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Homo Patiens -

Approaches to the Patient in the Ancient World


Studies in Ancient Medicine
Edited by

John Scarborough
Philip J. van der Eijk
Ann Ellis Hanson
Joseph Ziegler

VOLUME 45

The titles published in this series are listed at brill.com/sam


Homo Patiens - Approaches to
the Patient in the Ancient World

Edited by

Georgia Petridou and Chiara Thumiger

LEIDEN | BOSTON
Cover image: Patients arrived to consult a physician from a medieval manuscript now in Paris, Bibliotheque
Nationale cod. gr. 2243, fol. 10 verso. After fig. 1 from Medical Illustrations in Medieval Manuscripts
by Loren Carey MacKinney, Wellcome Historical Medical Museum,  London  1965.

Library of Congress Cataloging-in-Publication Data


 
Names: Petridou, Georgia, editor. | Thumiger, Chiara, editor.
Title: Homo patiens : approaches to the patient in the ancient world / edited
 by Georgia Petridou and Chiara Thumiger.
Description: Leiden ; Boston : Brill, [2016] | Series: Studies in ancient
 medicine, ISSN 0925-1421 ; volume 45 | Includes bibliographical references and index.
Identifiers: LCCN 2015032061| ISBN 9789004305557 (hardback : alk. paper) |
 ISBN 9789004305564 (e-book)
Subjects: LCSH: Physician and patient—History. | Medicine, Ancient. |
 Medical ethics—History.
Classification: LCC R135 .H66 2016 | DDC 610.9—dc23 LC record available at http://lccn.loc.gov/2015032061

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Contents

Acknowledgements ix
List of Figures x
Notes on the Contributors xi
Bibliographical Note xv

Introduction: Towards a History of the Ancient Patient’s View 1


Georgia Petridou and Chiara Thumiger

part 1
Medical Authority and Patient Perspectives

1 “This I Suffered in the Short Space of my Life”. The Epitaph for


Lucius Minicius Anthimianus (CIG 3272; Peek GV 1166) 23
Lutz A. Graumann and Manfred Horstmanshoff

2 Questioning the Patient, Questioning Hippocrates:


Rufus of Ephesus and the Pursuit of Knowledge 81
Melinda Letts

part 2
Case Histories in the Hippocratic Corpus

3 Patient Function and Physician Function in the Hippocratic Cases 107


Chiara Thumiger

4 Case History as Minority Report in the Hippocratic Epidemics 1 138


John Z. Wee

5 Voice Pathologies and the ‘Hippocratic Triangle’ 166


Colin Webster
vi contents

part 3
Patients and Psychological Illness

6 Galen’s Anxious Patients: Lypē as Anxiety Disorder 203


Susan P. Mattern

7 Experiencing Madness: Mental Patients in Medieval Arabo-Islamic


Medicine 224
Pauline Koetschet

part 4
Emotional Aspects of the Patient-Physician Relationship

8 Interpretations of the Healer’s Touch in the Hippocratic Corpus 247


Jennifer Kosak

9 Patience for the Little Patient: The Infant in Soranus’ Gynaecia 265


Lesley Bolton

10 Compassion in Soranus’ Gynecology and Caelius Aurelianus’


On Chronic Diseases 285
Amber J. Porter

11 Galen on the Patient’s Role in Pain Diagnosis: Sensation, Consensus,


and Metaphor 304
Courtney Roby

part 5
Material Aspects, Diagnostic Techniques and their Impact
on the Patient-Physician Relationship

12 The Μισθάριον in the Praecepta: The Medical Fee and its Impact
on the Patient 325
Giulia Ecca

13 The Practical Application of Ancient Pulse-Lore and its Influence


on the Patient-Doctor Interaction 345
Orly Lewis
contents vii

14 Images of Doctors and their Implements: A Visual Dialogue between


the Patient and the Doctor 365
Patricia A. Baker

15 Case Histories in Late Byzantium: Reading the Patient in John


Zacharias Aktouarios’ On Urines 390
Petros Bouras-Vallianatos

part 6
The Informed Patient: Self-Healing and the Patient as Physician

16 Treatment of the Man: Galen’s Preventive Medicine in the De Sanitate


Tuenda 413
John M. Wilkins

17 Literary and Documentary Evidence for Lay Medical Practice


in the Roman Republic and Empire 432
Jane Draycott

18 Aelius Aristides as Informed Patient and Physician 451


Georgia Petridou

19 “It may not cure you, it may not save your life,
but it will help you” 471
Katherine D. van Schaik

20 Epilogue: Approaches to the History of Patients: From the Ancient


World to Early Modern Europe 497
Michael Stolberg

Index locorum 519
Index rerum 543
Acknowledgements

All but one of the contributions included here were first presented in a three-
day international conference, which took place at Humboldt University in July
of 2012. The conference was organised by the editors under the auspices of
the ‘Medicine of the Mind—Philosophy of the Body, Discourses of Health and
Disease in the Ancient World’ research programme and was generously funded
by the Alexander von Humboldt Foundation.
We are extremely grateful to Philip van der Eijk, the director of the pro-
gramme, for supporting us throughout the process of organising the con-
ference and publishing the proceedings. We would also like to thank the
Alexander von Humboldt Foundation for its generous financial support, which
made both the original conference and the ensuing publication possible. We
are indebted to the speakers and the participants of the original conference for
making it an informative and memorable occasion. Special thanks are owed to
Brooke Holmes, Michael Fontaine, Carin Green, Ido Israelowich, Lesley Dean-
Jones, George Kazantzidis, Helen King, Karl-Heinz Leven for livening up the
discussion during the original event, but whose papers do not appear in this
volume. Finally, we are extremely grateful to Manfred Horstmanshoff for pro-
viding inspiration and expert advice on all matters related to ancient medicine
and patient history.
We are particularly grateful to all contributors to this volume for trusting
us with their work and bearing with us throughout the process of publication.
Michael Stolberg, the author of the only chapter which was especially commis-
sioned for this book, is especially to be thanked for accepting our invitation
to provide an expert discussion of approaches to the history of the patient in
early modern Europe.
Furthermore, we would like to thank the anonymous reviewers of the indi-
vidual chapters for their detailed comments and for helping us to improve the
quality of this volume. We are also grateful to Katharina Hess, Annette Schmidt
and Konstantin Schulz for their valuable assistance in formatting the book.
We are indebted to the Wellcome Trust, the University of Cologne database
(Arachne) and the Deutsches Archaeologisches Institut for their help with
sourcing the images. Special thanks are owed to Paul Scade for improving the
English in a number of places, to the ERC funded ‘Lived Ancient Religion’ pro-
ject Max-Weber Kolleg, University of Erfurt, and its director Jörg Rüpke, for
supporting Georgia Petridou during the final year of the preparation of this
volume. Finally, we should thank Richard Gordon for reading a draft of our
introduction and the editorial board of Studies in Ancient Medicine at Brill, as
well as Caroline van Erp, Tessel Jonquière, and Tessa Schild for their help and
assistance.
List of Figures

1.1 The Epitaph for Lucius Minicius Anthimianus (CIG 3272, Peek GV
1166) 29
10.1 Midwife birthing scene from the tomb of Scribonia Attice, Isola Sacra,
Ostia. Mid-second century AD 291
14.1 Roman Cupping Vessel. 1st–3rd century. Copper Alloy 384
14.2 A Greek medical relief located in the Archaeology Museum in Basel.
After Berger 1970, fig. 1. Drawing by L. Bosworth 384
14.3 Drawing of a fifth century BC aryballos depicting a doctor or surgeon
treating a patient 384
14. 4 Votive Relief from Piraeus, Greece. After Berger 1970, fig. 96. Drawing by
L. Bosworth 385
14. 5 Funerary monument of Jason the Doctor. Athenian, Second century
AD 385
14. 6 Relief from Ravenna. After Berger 1970, Fig. 79. Drawing by
L. Bosworth 385
14. 7 Fragment of a relief from the Asclepion at Piraeus, fourth century
BC 386
14. 8 Roman fresco painting of the doctor Iapyx treating Aeneas, Casa di
Sirico, Pompeii, first century AD 386
15.1 Bononiensis 3632 (mid-15th c.), fol. 20v, with permission of the
Bibliotheca Universitaria di Bologna. The miniature shows John
holding a urine vial with an inscribed motto derived from the opening
phrase of his work ‘On Urines’, reflecting the popularity of his uroscopy
treatise 401
Notes on the Contributors

Patricia A. Baker
(PhD, University of Newcastle upon Tyne, 2001), is a Senior Lecturer in Classical
and Archaeological studies at the University of Kent, Canterbury, UK. She has
published monographs, edited books and journal articles on ancient medi-
cine. Her most recent monograph is The Archaeology of Medicine in the Greco-
Roman World with Cambridge University Press (2013).

Lesley Bolton
(PhD, University of Calgary, 2015), is a Sessional Instructor in the Classics and
Religion Department at that university. She is currently preparing her disserta-
tion, a new edition and translation of Mustio’s Gynaecia, for publication, and
completing a textbook on medical terminology.

Petros Bouras-Vallianatos
has been recently awarded his PhD focusing on the late Byzantine medi-
cal author John Zacharias Aktouarios, and teaches medical history at King’s
College London. He has published several articles on Byzantine and Early
Renaissance medicine and pharmacology, including a new descriptive cata-
logue of the Greek manuscripts at the Wellcome Library in London. He is also
co-editing the Brill’s Companion to the Reception of Galen.

Jane Draycott
is Lecturer in Classics at the University of Wales Trinity Saint David. After
receiving her PhD from the University of Nottingham, she was 2011–12 Rome
Fellow at the British School at Rome, and Associate University Teacher in the
Department of Archaeology at the University of Sheffield. She has published a
monograph and a number of articles on the history and archaeology of ancient
medicine.

Giulia Ecca
(PhD, Humboldt-Universität zu Berlin, 2014) is currently working at the Berlin-
Brandeburgische Akademie der Wissenschaften. Her Ph.D dissertation (in
press) is a new critical edition with translation and commentary of the Pre-
cepts, a treatise included in the Corpus Hippocraticum. The main focus of her
current research is Galen’s Commentary on the Hippocratic Aphorisms.
xii notes on the contributors

Lutz Alexander Graumann


(PhD, MD, Philipps University Marburg, 2000), is a Paediatric Surgeon at the
University Hospital of Marburg. He has published several articles and his the-
sis on the case-stories of the Hippocratic Corpus, and contributed a paper on
ancient hermaphrodites in a volume co-edited by Laes, Goodey and Rose (Brill,
2013). He is now focusing on ancient children’s activities with medical implica-
tions for his forthcoming book, Children’s Accidents in the Roman Empire.

Manfred Horstmanshoff
(PhD, Leiden University, 1989), is Emeritus Professor of the History of Ancient
Medicine at that University and Research Fellow at the University of the Free
State, Bloemfontein. He was Fellow-in-residence at the Netherlands Institute
for Advanced Study and the Internationales Kolleg Morphomata, University
of Cologne, visiting scholar at the Humboldt University, Berlin, and the Max-
Weber Kolleg, Erfurt. He has published widely on ancient medicine and is now
studying the patient’s history in a comparative perspective.

Pauline Koetschet
CNRS-Aix Marseille Université, TDMAM UMR 7297, is a Researcher working
on Arabo-Islamic philosophy and medicine. She is currently involved in a pro-
ject that focuses on the critical reception of Galen in the formative period of
Arabic philosophy.

Jennifer Kosak
is an Associate Professor of Classics at Bowdoin College and Chair of the
Classics Department. She specialises in Greek language and literature. Her
particular interests include Greek tragedy, Greek and Roman medicine, Greek
intellectual history and gender studies. She is the author of Heroic measures:
Hippocratic medicine in the making of Euripidean tragedy (Brill, 2004) and
numerous other studies.

Melinda Letts
read Classics at St Anne’s College, Oxford and subsequently worked for
25 years in the UK non-profit sector, latterly at the helm of various health-care
policy and campaigning bodies. She returned to academic life in 2009, and
is now Lecturer in Greek and Latin at Jesus College, Oxford, while pursuing
doctoral work on Rufus of Ephesus. Publications include ‘Rufus of Ephesus
and the Patient’s Perspective in Medicine’, in British Journal for the History of
Philosophy 22.5 (2014): 996–1020, and ‘Psychological Factors in the Work of
Rufus of Ephesus’ (forthcoming).
notes on the contributors xiii

Orly Lewis
(PhD, Humboldt-Universität zu Berlin, 2014), is a Research Fellow at the
Excellence Cluster TOPOI, Humboldt-Universität zu Berlin. Her research
focuses on Greco-Roman anatomy, physiology and psychophysiology. Her dis-
sertation examined the theories of Praxagoras of Cos on pneuma and arteries.
She has also published on the ancient pulse theory and practice and on the
Ps.-Aristotelian treatise De spiritu.

Susan P. Mattern
(PhD, Yale University, 1995), is Distinguished Research Professor of History
at the University of Georgia. Her most recent book is The Prince of Medicine:
Galen in the Roman Empire (Oxford University Press, 2013).

Georgia Petridou
(PhD, University of Exeter, 2007), is a Research Associate at the Max-Weber
Kolleg, University of Erfurt. She works on classical literature, history of reli-
gions and Graeco-Roman medicine in its socio-cultural context. She is the
author of Divine Epiphany in Greek Literature and Culture (Oxford University
Press, 2015).

Amber J. Porter
(PhD, University of Calgary, 2014), is a Sessional Instructor in the Department
of Classics and Religion at that university. She is currently in the process of
preparing her PhD dissertation for publication with Ashgate.

Courtney Roby
is Assistant Professor of Classics at Cornell University. Her research includes
articles and a forthcoming book (Technical Ekphrasis in Ancient Science: The
Written Machine between Alexandria and Rome, Cambridge University Press)
on literary and cognitive aspects of ancient technical texts.

Katherine D. van Schaik


(MA, MD PhD candidate), is pursuing her MD at Harvard Medical School and
her PhD in Ancient History at the Harvard Department of the Classics. She has
published articles on health and disease in Greco-Roman antiquity, physical
and social anthropology, paleopathology, medical decision making, and medi-
cal education.
xiv notes on the contributors

Michael Stolberg
Univ.-Prof. Dr. is, since 2004, the Chair of history of medicine at the University
of Würzburg, Germany. He has published widely on learned medicine, the
experience of illness and concepts of the body in early modern Europe.

Chiara Thumiger
is a Research Associate at Humboldt Universität (Berlin) within the Alexander
von Humboldt Professorship Project ‘Medicine of the Mind—Philosophy of
the body’. She has previously worked on the representation of self and mental
facts in literary sources (especially tragedy) and published a monograph on
Euripides’ Bacchae (Hidden paths, London 2007) as well as a various articles
and chapters about tragedy. At the moment she is finalising her monograph
on mental disorder in early Greek medicine, and working on several projects
related to the study of ancient ideas about mental life.

Colin Webster
(PhD, Columbia University, 2014), is an Assistant Professor of Classics at UC
Davis. He has written on multiple topics in ancient science, including both
optics and medicine, and is currently working on a monograph about how
theorists in antiquity utilise material technologies as cognitive tools.

John Z. Wee
(PhD, Yale University, 2012), is Assistant Professor of Assyriology at the
University of Chicago. His book Knowledge and Rhetoric in Medical Commentary
and edited volume The Comparable Body are both forthcoming in Brill. He
has also authored several articles on the history of medicine, astronomy, and
mathematics in Mesopotamian and Classical antiquity.

John Wilkins
John Wilkins is Emeritus Professor of Greek Culture at the University of Exeter.
He has edited Galen and the World of Knowledge (with C. Gill and T. Whitmarsh,
CUP 2009) and Galien: sur les facultés des aliments (Budé 2013), among numer-
ous studies on ancient diet and nutrition.
Bibliographical Note

The abbreviations used for the ancient literature follow those given in the
H. G. Liddell, R. Scott and H. S. Jones, Eds. (19409) A Greek-English Lexicon,
Oxford. Supplement (1996), and S. Hornblower, A. Spawforth, A. and E. Eidinow,
Eds. (20124) The Oxford Classical Dictionary, Oxford.
There are a few easily recognizable exceptions, most notably for the
Hippocratic and Galenic texts, where the abbreviations of Fichtner are used:
G. Fichtner, (1992) Corpus Hippocraticum: Verzeichnis der hippokratischen und
pseudohippokratischen Schriften, Tübingen, and (1990) Corpus Galenicum:
Verzeichnis dergalenischen und pseudogalenischen Schriften, Tübingen. Of
course, Fichtner’s catalogues have been updated several times since 1992,
the most recent versions are on the CMG website at http://cmg.bbaw.de/
online-publications/hippokrates-und-galenbibliographie-fichtner.
References to Hippocratic texts generally contain the volume and page
number of the Littré edition: E. Littré, Ed., Oeuvres complètes d’Hippocrate,
vol. 1–10, Paris 1839–1861, repr. Amsterdam 1961–1963. Some authors have added
references to the editions used in the Loeb Classical Library. An analytical list
of the editions the individual authors have employed in their work follows
each of the chapters. References to Galenic texts contain the volume and page
number of the edition by Kühn: G. C. Kühn, Ed., Claudii Galeni Opera Omnia
1–20 (22 Volumes), Leipzig 1821–1833, repr. Hildesheim 1964–1965.
Introduction: Towards a History of the Ancient
Patient’s View

Georgia Petridou and Chiara Thumiger

This is a volume about the homo patiens in the Graeco-Roman world: the
ancient suffering man, woman, and child, their role in ancient medical encoun-
ters and in broader cultural contexts,1 as well as their relationship to the health
providers and medical practitioners of their time. The participle patiens is
used here in its etymological sense denoting the ‘afflicted’, ‘the suffering’ per-
son (who would be variously described in Greek as ho arrhōstos, ho nosōn, ho
kamnōn, ho trōtheis, ho katakeimenos, or simply ho paschōn) and, as far as pos-
sible, freed from any Foucauldian connotations.2 The title of this collected vol-
ume, Homo Patiens: Approaches to the Patient in the Ancient world, stresses our
particular interest in the ancient patient’s view, while simultaneously alluding

1  The concept of medical cultures—that is the notion of cultural systems of health and illness—
appeared for the first time in the late seventies in the work of Arthur Kleinman. Kleinman
with his 1978 Concepts and a Model for the Comparison of Medical Systems as Cultural Systems
(Social Science and Medicine 12, 85–93) and his 1980 Patients and Healers in the Context of
Culture: an Exploration of the Borderline between Anthropology, Medicine and Psychiatry
looked for the first time at something as ‘objective’ as medicine and the body, and attacked
the positive-reductionist views of clinicians and historians alike by re-­contextualising them
both and declaring them both to be as ‘subjective’ as any product of a cultural system.
2  Roy Porter (1985a). ‘The patient’s view. Doing medical history from below’, Theory and Society
14.2, 175–98 discusses Foucault’s position that modern patients are constructs of the ‘medical
gaze’ or ‘the medical glance’ (original French term “le regard”), criticizing it as misleading.
See also Foucault, M. ‘La politique de la santé au 18e siècle’, in Foucault, M. et al. (1976a). Les
machines à guérir. Aux origines de l’hôpital moderne, 11–21. Porter envisions a more active
role for the patient in the medical encounter and prefers less marked terms such as ‘the sick’
or ‘the sufferer’ (on which see below). For more information on the perennial question of
whether a ‘patient’ should exist in isolation, independently from the prying eyes of the exam-
ining or attending physicians, see Armstrong, D. (1984). ‘The patient’s view’, Social Science &
Medicine 18,737–44, and Cooter, R. (2007). ‘After-death/after-life: The social history of medi-
cine in post-postmodernity’, Social History of Medicine 20, 439–62; in addition, the excellent
discussion in Condrau, F. (2007). ‘The patient’s view meets the clinical gaze’, Social History of
Medicine 20.3, 525–40.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_002


2 Petridou and Thumiger

to ­influential recent works in history of medicine, such as Michael Stolberg’s


Homo Patiens. Krankheits- und Körpererfahrung in der Frühen Neuzeit.3
Our collection appears at an interesting time for the history of medicine
and the history of medical ethics: it coincides with the thirtieth anniversary of
Roy Porter’s programmatic plea for a patient-centered history of medicine, in a
seminal article with the explicit title The Patient’s View: Doing Medical History
from Below.4 Furthermore, it comes almost a decade after Roger Cooter’s 2004
groundbreaking manifesto about what he described as “the end of the social
history of medicine”.5 Most history of medicine, argued Porter, has been written
in the form of grand stories of scientific progress and expanding knowledge,
largely organised around a sequence of biomedical breakthroughs. Porter’s
article was the first call for a fundamental rewriting of the history of medi-
cine, shifting the perspective towards the patient’s point of view. Cooter, on
the other hand, went as far as to declare the end of the social history of medi-
cine and urged a radical re-consideration of the good old trusty categories of
knowledge, science, scientific breakthrough, disease, and even the biomedical
causes of death. Cooter’s extreme position can be explained and justified if we
consider the fact that the development of the history of the patient’s view has
in fact fallen far short of what was promised by Porter and others in the 1980’s.
It is the case, of course, that some steps in the right direction have been taken:
for example, in the field of medical ethics emphasis has increasingly been laid
on the ‘power relations’ between the sufferers and their healthcare provid-
ers—not least in certain areas of modern psychological theory. The move is
not only theoretical but has an influence on operational strategies too, as is
perhaps most evident in the area of psychotherapeutic and psychoanalytical
practices, whereby patient narratives are increasingly valued as a fundamental
diagnostic tool.6

3  Originally published in 2003, and translated into English in 2011 as Experiencing Illness and
the Sick Body in Early Modern Europe. Houndmills: Basingstoke, UK; New York, NY: Palgrave
Macmillan.
4  
Porter, ‘The patient’s View’, 175–98. Cf. also Porter, R. ‘Introduction’, in Patients and
Practitioners. Lay Perceptions of Medicine in Pre-industrial Society, 1–22.
5  Cooter, R. ‘ “Framing” the end of the social history of medicine’, in Huisman, F. and Warner,
J. H. (2004). Locating Medical History. The Stories and their Meanings, 309–37.
6  See Holmes, J. ‘Narrative in psychotherapy’, in Greenhalgh, T. and Hurwitz, B. (1998). Narrative
based medicine: Dialogue and discourse in clinical practice, 176–84; and Thumiger’s contribu-
tion (Chapter Three, 109–110 with n. 3. in this volume.). Power as problem, that is, how various
institutions exert power on individuals and groups of individuals, and how those latter resist
and affirm their own identity, is a central theme in Foucault’s historical and philosophical work.
See for instance, Foucault, M. (1962). Maladie mentale et psychologie; id. (1969). L’archéologie du
Introduction 3

Despite these promising starting points, “it is also undoubtedly true that
mainstream historiography has not incorporated the radical change of per-
spective for which Porter argued”.7 The dominant medical and historiographi-
cal discourses are still shaped by the physician’s view and, as such, they give
us inadequate access (if at all) as to how individuals experienced their bod-
ies, negotiated sickness, and signified their suffering to others. Indeed, at the
level of clinical practice the attention paid to the perspective of the patient still
leaves much to be desired. The diagnostic and therapeutic power of medical
action and theory may have advanced enormously in modern times, but this
advancement does not correspond with greater rapport, intimacy, nor empa-
thy between the suffering person and his or her healthcare provider. Advances
in clinical examination, pathological anatomy, and microbiology have had
the result of limiting close observation and reducing the time and attention
devoted to ‘taking history’. The effect of this has been to reduce the opportuni-
ties for physical and emotional intimacy between the patient and the physi-
cian, sometimes to the point of true estrangement between the two. To put it
in Edward Shorter’s words:

Advances in clinical investigation since the Second World War entailed


the downgrading of careful history-taking and physical examination. . . .
With the advent of such post-modern techniques of investigation as
computerized blood tests, computerized tomography scans, magnetic
resonance imaging, and ultrasonography, old-fashioned percussing,
palpating, and auscultating seemed increasingly irrelevant, for the new
techniques yielded far more information. The ‘history’ too became down-
played, and letting the patient talk was perceived as a waste of the busy
physician’s time.8

Awareness of this change can be seen not only in theoretical reflections about
the history of medical practices, but also increasingly in clinical environments.
Arthur Kleinman’s work on the illness narratives, as he called them, and his

savoir; and id. (1976b). Histoire de la sexualité, 3 vols. (La volonté de savoir, L’usage des plai-
sirs, and Le souici de soi, which was translated in English by Robert Hurley as = History of
Sexuality, 3 vols: Introduction, The Uses of Pleasure, and Care of the Self. The ‘power relation’
issue is given more prominence in Foucault’s 1963 book entitled Naissance de la clinique,
which was translated in English by Allan Sheridan as The Birth of the Clinic.
7  Condrau, ‘The Patient’s View’, 526.
8  Shorter, E. ‘The history of the doctor-patient relationship’, in Bynum, W. F. and Porter, R.
(1993). Companion Encyclopaedia of the History of Medicine, 794.
4 Petridou and Thumiger

raising awareness about the difference between medically defined illness and
“illness as lived experience” was undoubtedly a major step towards the radi-
cal redefining of the social history of medicine.9 Perhaps the most promising
recent development in patient-centered medical practice, inspired by the criti-
cal suggestions coming from social history of medicine and medical anthro-
pology, is the emergence of the so-called ‘Narrative-based Medicine’ (NBM),
which puts the patient at the center of the medical encounter.10 Narrative-
based Medicine lays emphasis on both the narrative structure of medical
knowledge and on narrative as a tool to gain access to the perspectives of
patient as well as caregiver. Furthermore, the epistemic value of the patient’s
view, and of the narrative he or she constructs, has risen to prominence in
discussions concerning palliative care, the area of healthcare focusing on pre-
venting and relieving the patients’ suffering.11 Providing relief for the sufferer
by tailoring the means of treatment and by ameliorating overall conditions of
life is especially relevant to those afflicted by chronic and incurable illness, as
is argued in Chapter Nineteen of this volume. These developments in clinical
practice have been spurred on and mirrored at the theoretical level by studies
examining the comparative history of the patient in the modern period, such
as Stolberg’s Experiencing Illness and the Sick Body in Early Modern Europe.
In this spirit, our volume hopes to further advance the theoretical and clini-
cal foregrounding of the patient as the protagonist of the medical encounter, by
offering a historical perspective on the contributions made by ancient patients
to the healing encounter. The socio-cultural contexts of these meetings are of
vital importance to the project of uncovering the perspective of the ancient
sufferers, and as such they are given a prominent place in several of our chap-
ters. Chapters Fourteen and Fifteen, in particular, focus on how the patient’s
social status affects not only the patient-physician relationship but also the
effectiveness of the medical treatment. Chapters Twelve and Fourteen, on the

9   Kleinman, A. (1988). The Illness Narratives: Suffering, Healing, and the Human Condition, 4.
10  The origins of this movement can be found in the late 1990s, when physicians like Rachael
Niomi Remen and Rita Charon emphasised the importance of narrative in general, and
patients’ narratives in particular for both the diagnostic encounter and the healing pro-
cess. See Greenhalgh, T. and Hurwitz, B. (1999). ‘Narrative based medicine: Why study
narrative?’ BMJ 318, 48–50 for further discussions.
11  The ultimate goal in palliative medicine, as opposed to curative medicine, is to provide
both the patient and his or her family with relief from both the physical and psychological
distress of disease and improve quality of life, regardless of the prognosis. The Preface in
Fins, J. J. (2006). A Palliative Ethic of Care. Clinical Wisdom at Life’s End provides an infor-
mative exposition of the subject. See also van Schaik’s contribution pp. 471–496 in the
present volume.
Introduction 5

other hand, emphasise the ambiguous social status of the attending physi-
cians and care-givers in Graeco-Roman antiquity.12 The cases of renowned and
popular physicians like Rufus and Galen seem to be the exception rather than
the rule.
The majority of our contributors examine the way ancient patients experi-
enced their bodies and illnesses; how they qualified and quantified pain; and
how they signified their suffering. All these feed into that enterprise which can
be described as ‘doing ancient medicine from below’, to echo Porter’s concerns
and apply them to the field of ancient medicine.
Although our focal point is the relationship between the ancient sufferer and
his or her healer, this volume hopes to move beyond past and current preoccu-
pations with the question of the significance or insignificance of the patient’s
personal narrative in the physician’s diagnostic quest.13 The theoretical and
methodological agenda of the volume foregrounds the contrast between the
views of medical experts and the perspectives of the ancient patients during
the diagnostic and prognostic process, and in the course of therapy; but it also
moves beyond that. By reminding ourselves how central the patient’s role is to
the dynamic of the so-called ‘power relation’ established with the physician or
healthcare provider, we want to invite a move beyond the medical practitioner’s
rhetoric of control and competence and delve deeply into the emotional range
of these relationships. Furthermore, we set out to explore the impact that
seemingly more superficial material aspects had on the psyche of the suffer-
ing person, such as the self-presentation of medical activity as profession and
privilege, the condition of the doctor’s medical apparel, the concrete issues of
fees and bed-side manners, as well as the diagnostic techniques. These issues
did not simply affect the patient’s psychology; they also influenced decisively
the progression of the illness and the healing process as a whole. Our concerns
do not lie exclusively with physical illness but address also the complexities
of mental disorder. Individuals suffering from mental illness are an especially
poignant example of the irreducibility of the patient. This is well shown well
by the discussions of Graeco-Roman and Arabic examples of the mentally ill
in the contributions included in the third part of the book, which explore the
sufferers’ attempts to qualify and quantify pain and seek help.

12  This is a topic that has been explored from various angles. See Ecca’s contribution
(Chapter Twelve), 323–344 in this volume.
13  There are many popular medical handbooks on how best ‘to take history’ from a patient.
See, for instance, Fishman, J. and Fishman, L. (2005). History Taking in Medicine and
Surgery. On the historical development of the concept of ‘taking a history’ and its appli-
cation in clinical praxis, see the chapters included in the first part of this volume.
6 Petridou and Thumiger

Ultimately, what we hope to have offered here is an example of how much a


patient-centered approach to the history of ancient medicine can deepen our
understanding of ancient societies and their medical markets, as well as enrich
our knowledge of the history of medical ethics. In other words, this volume is a
first attempt towards shaping a history of the ancient patient’s view, which will
be of use not only to the ancient historian, the student of medical humanities,
and the historian of medicine, but also to the historian of medical deontology
and ethics. Moreover, the contributions in our volume can also be employed as
stimulating comparative perspectives for medical students and practitioners
interested in the experience of the patient.
This volume brings together scholars from diverse methodological back-
grounds and with a wide range of expertise in medicine, ancient history, his-
tory of medicine, archaeology, history of religions, material culture, classical
literature and medical humanities. We aim to present a balanced combination
of established scholars and new voices, bringing together broad theoretical
reflections on medical ethics and cultural history, on the one hand, and practi-
cal concerns of such topics as laypeople’s medicine, on the other. As such, our
collection of contributions offers a new synthesis in the field of the history of
medicine, which has so far been dominated by an emphasis on the authority
and perspective of medical practitioners as the source of knowledge, and sets
out to unravel the ancient patient’s view.
Having outlined our general theoretical and methodological framework, it
is time to pose the all-important question: to what extent can we access the
ancient patient’s view?

1 Our Sources and Some Methodological Considerations

It has become more acceptable these days among the scholarly community to
expose the elusiveness of scientific biomedical certainties and the dominance of
the medical professional’s view in historical analysis and subsequently urge a new
perspective in the ancient history of medicine. That fact, however, has not made
our task any easier. Indeed, the efforts of the ancient medical historian to gain an
insight into the patients of the past, their views, voices and experiences of illness,
are often thwarted by well-known methodological challenges.
First and foremost, we are faced with the perennial problem posed by the
nature of the available sources. The social historian of ancient medicine has
access to an extremely limited quantity of personal testimonies such as patient
letters, personal correspondence, autopathologies and autobiographies, mate-
rials and resources to which the modern historian of medicine has much greater
Introduction 7

access.14 The bulk of the ancient material is, in fact, constituted by third-
person narratives, self-styled as objective reports or scientific treatises. These
narratives may address, with varying degrees of depth, the perspective of the
patient as it filters through the organising structure imposed by the medical
author; but they hardly attempt to shed light on the patient’s view in its own
right. How can one unravel the figure of the patient from the tightly knitted
‘rhetoric of power’ that operates in a large number of ancient medical texts,
most obviously from the second century AD, but also shaping to a large extent
the much more varied and less codified medical texts of the fifth and fourth
centuries BC? All history belongs to those who have written it and this remains
as true for the history of medicine as for any other field.
A number of our contributors deal with precisely these methodological
issues and examine our main textual corpora and the imposing authorial and
narrative personas of their authors with an eye to the ancient patients, their
views and feelings, as well as their dealings with their medical providers. This
problem is further exacerbated by the innumerable distinctions (chronologi-
cal, generic, textual transmission, etc.) one should bear in mind when deal-
ing with the individual works of the Corpus Hippocraticum, or with Galen or
any other prominent physician such as Rufus, Soranus and John Zacharias
Aktouarios. Chapters Two, Nine, Ten, Eleven, Twelve and Fifteen address these
challenges. Other contributions, such as Chapters Eighteen and Nineteen,
address analogous (and equally tantalizing) methodological problems in
accessing the ancient patient’s view in the case of highly elaborate and excep-
tionally self-conscious representations of patienthood. These narratives may
strike the modern reader as intimate, even autobiographical, but the extent to
which we can consider these literary creations by highly educated patients as
genuine autopathographies (comparable to modern patient diaries or letters)
remains a matter of debate.
Chapters One and Fourteen, on the other hand, expose well how data stem-
ming from sources of material culture are riddled with difficulties of their
own. Artefacts, inscriptional and sculptural alike, such as honorific and funer-
ary reliefs, contain highly stylised and formulaic patients’ narratives and, thus,
present us with a whole new set of conventions and constraints which need to
be discounted in a search for the ancient patient’s subjectivity.
Secondly, there is the equally important methodological caveat about apply-
ing modern conceptual categories and distinctions to ancient sources. Is this a
case of purely anachronistic and largely ahistorical application, or can modern
conceptual tools be used, with caution, to throw light on the ancient patient’s

14  More on these issues in Stolberg, Experiencing Illness, 1–4.


8 Petridou and Thumiger

view? Chapters One, Three, Four, Five and Six deal with, among other issues,
the recurrent methodological problems that result from turning to modern
categories and conceptual tools such as ‘anxiety’, ‘depression’, ‘placebo’, and
discuss the fallacy of retrospective diagnosis when it comes to the patient
of the past.
Even the very category of the ‘patient’ is problematic and has long been
called into question, in the wake of Foucault’s socio-historical critique.15 One
can only imagine how much more complicated things become when we relo-
cate this modern category, with its deeply structured socio-political implica-
tions (e.g. in relation to public health care systems, work exemptions, and so
on), to the much less categorised figures of the sick and the sufferer of the
ancient world. Porter rightly maintains that “it is probably preferable to speak
historically of ‘sufferers’ or ‘the sick’, some of whom opted (original empha-
sis) to put themselves into relations with medical practitioners”. As it becomes
obvious from the sixth part of our book (Chapters Sixteen to Nineteen), this is
especially true in the case of the ancient sufferers, who quite often put them-
selves not in the hands of an esteemed member of the medical profession
(whose social status, however, was far more complicated than it is nowadays),
but in those of a family member or close friend. Alternatively, some of the
ancient patients effectively took the role of the healer upon themselves and
opted for self-healing. Therefore, in both the introduction to this volume and
the individual contributions the term ‘patient’ is used rather loosely to refer to
the sufferer of the ancient world and is used in full-awareness of the method-
ological problems the strict application of the term entails. Likewise, the labels
‘physician’, ‘medical professional’, ‘care giver’ or ‘healthcare provider’ are used
equally loosely and encompass not only recognised medical experts (the iatros
or the medicus), but also the midwife and even the members of the familial
circle in their nursing roles.
In exploring this set of issues, our contributors also re-evaluate (and in
some cases reject) widespread—but not necessarily functional or helpful—
methodological frameworks that have much influenced previous scholarship
in the field, such as a narrow focus on the epistemic value of patients’ nar-
ratives in diagnosis and treatment, a fixed distinction between physical and
psychological health, or a reliance upon rigid binaries such as those of scien-
tific and sacred medicine. At the same time, the volume as a whole exhibits
a variety of approaches in an attempt to celebrate the diversity of our rich
source material.

15  More on this topic in n. 2.


Introduction 9

The common denominator in all the chapters of the present volume is the
shift of focus away from the authoritative voices and views of the ancient
health practitioners and historians and on to the medicine of the layperson
and the subjective experience of the sufferers, for the first time with specific
reference to the ancient world. As such, it refocuses this fairly recent theoreti-
cal and methodological development of foregrounding the patient and consid-
ering him or her as the center of the medical encounter in order to examine its
bearing on ancient medical texts and artefacts.

2 Earlier Work on the History of the Ancient Patient

To be sure, we are not claiming that a patient-focused ancient medical history


is our own theoretical and conceptual novelty. As this introduction, as well as
the rich bibliographical references in the individual contributions, reveals, the
present volume follows in the steps of earlier historiographical and method-
ological enterprises.
A classic on the topic of individual patients, their relationship to illness and
interaction with their attending physicians is the study by Danielle Gourevitch,
Le Triangle Hippocratique dans le Monde Gréco-Romain (1985). The book covers
a variety of related topics, from studies of famous sufferers like Cicero, Aelius
Aristides,16 and Galen’s Simulatores (those who faked illness), through dis-
abled and disfigured patients, and from those afflicted by gout, to the victims
of Pliny’s frightfully greedy and ruthless physician, who thinks nothing of poi-
soning his own patients.17
Also in 1985, Vivian Nutton offered ancient history’s response to Porter’s
call for a patient’s history across cultures and chronologies, when he wrote an
extensive article entitled Lay attitudes to medicine in classical antiquity.18 The
study expertly surveyed a plethora of what he calls “non-medical evidence”,
as opposed to the writings of the Hippocratic authors and the works of Rufus,
Soranus and Aretaeus. The second part of the paper, in particular, looked at
laypeople’s views and outlooks towards competent and incompetent medi-
cal practitioners. This is perhaps the closest we have yet come to a history of

16  On Aelius Aristides’ Hieroi Logoi as a patient-centred narrative, see the bibliographical
references in Petridou and van Schaik in the present volume.
17  More on this topic in Ecca in this volume.
18  Nutton, V. ‘Murders and miracles: lay attitudes towards medicine in classical antiquity’,
in Porter, R. (1985). Patients and Practitioners. Lay Perceptions of Medicine in Pre-industrial
Society, 23–54.
10 Petridou and Thumiger

the ancient patients’ view as envisaged by the editors of this volume. Nutton
is absolutely right in underlining the scale of the task and the impossibility
of seeking to cover in a single monograph the ancient patient’s perspective
while working on such extensive and disparate material, each piece of which
presents the student of ancient medicine with a different set of difficulties.
A collected volume, where various approaches to the patient’s history are pre-
sented, offers a more adequate forum for this sort of enterprise.
Other studies have paid particular attention to the history of the patient
in specific authors, works or media. Galen’s patients, for instance, have
received much scrutiny—as shown by articles such as those of Manfred
Horstmanshoff or thematic studies such as that published by Susan P. Mattern
in 2008.19 Specific aspects of ancient medical writings, such as the ‘case his-
tories’ in the Hippocratic Epidemics, the Galenic works, and the reception of
the Galenic case histories in the medical treatments of medieval Islamic writ-
ers have also attracted great scholarly interest.20 Other students of patient
history have focused on age- or gender-specific groups of ancient suffer-
ers, such as children, virgins, child-bearing mothers and old people. The
­parthenoi in the Hippocratic On the Diseases of the Virgins, or the women of
child-bearing age in Soranus’ gynecological treatises have also been stud-
ied most notably by Helen King and Lesley Dean-Jones, among others.21
Moreover, the patient and his or her involvement in the local healthcare has

19  Horstmanshoff, H. F. J. ‘Galen and his Patients’, in Eijk, Ph. J. van der et al. (1995). Ancient
Medicine in Its Socio-Cultural Context, vol. 1, 83–100; Mattern, S. P. Galen and the Rhetoric of
Healing. Other important studies of Galen’s patients include Ilberg, J. (1905). ‘Aus Galens
Praxis: Ein Kulturbild aus der römischen Kaiserzeit’, Neue Jahrbücher 15, 276–312; Garcia
Ballester (1995). ‘Elementos para la construcción de las historias clínicas en Galeno’,
Dynamis 15, 47–65.
20  On this aspect specifically, see Thumiger, Wee, and Webster in this volume, where more
bibliographical references can be found. See Lloyd, G. E. R. ‘Galen’s un-Hippocratic
case-histories’, in Gill, C. et al. (2009). Galen and the World of Knowledge, 115–31, for an
informative analysis of the case histories in the Hippocratic texts and Galen. On the
reception of Galenic case histories in Byzantine medical authors, see Bouras-Vallianatos
in this volume; on the receptions of Galenic case-histories in Islamic medical writers, see
Koetschet’s contribution in this volume.
21  E.g.: King, H. (1988). Hippocrates’ Women: Reading the Female Body in Ancient Greece; ead.
(2004). Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty; Dean-
Jones, L. (1994). Women’s Bodies in Classical Greek Science; and ead. (1992). ‘The politics of
pleasure: female sexual appetite in the Hippocratic Corpus’, Helios 19, 72–91. On Soranus’s
Gynaecology, see the contributions of Bolton and Porter in this volume.
Introduction 11

been the center of scholarly research devoted to specific media of textual


transmission, such as the medical papyri of the Fayum region.22
Finally, mental health is something of a separate chapter in the scholar-
ship, in which attention to subjectivity is, so to speak, embedded in the topic
from the very start. In fact, one may argue that the questions and concerns
of patient-centered medicine are necessarily part of the methodological chal-
lenges of a history of psychiatry, regardless of the approach one wishes to take,
thus making it a useful hermeneutical model. Key contributions to the study of
ancient medical ideas on mental health have been offered by Jackie Pigeaud:
La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tradition
medico-philosophique antique (1981); Folie et cures de la folie chez les medicines
de l’antiquité gréco-romaine. La manie (1987). Melancholiē and maniē, on the
other hand, have received much scholarly attention along with other aspects
of mental health in individual texts or authors. More recently, a volume edited
by William Harris (Mental Disorders in the Classical World, 2013) has brought
together numerous contributions with a broad range of topics and a theoreti-
cally-minded frame, in interrogating the subjectivity of the mentally ill both as
a problem and as a theoretical challenge.
The first original feature of the papers collected in this volume lies in the
explicitly programmatic character of its conception of ‘doing ancient medi-
cal history from below’, that is, its rejection of top-down approaches, which
offer bird’s eye view of the ancient sufferer and medical practitioner but miss
the specifics. The second innovative element of this volume is the extensive
chronological and generic distribution of the material covered in the indi-
vidual chapters of the volume. The layperson’s experience of illness and heal-
ing is examined in literary texts from the fifth and fourth century Epidemics
(Thumiger, Wee) and the writings of first century authors like Rufus (Letts) and
Soranus (Bolton and Porter), to the medical works of Galen (Mattern, Roby,
Wilkins); and from the post-classical Hippocratic writings (Ecca) and patient-
centered narratives like the Sacred Discourses of Aelius Aristides (van Schaik,
Petridou) to the writings of Byzantine medical writers (Bouras-Vallianatos)
and those of the medieval Islamic medical authors (Koetschet).
Some of the contributions take a more comparative look at laypeople’s med-
icine and the experience of suffering in the ancient world (Horstmanshoff and
Graumann, van Schaik, Stolberg); while others focus on the material aspects of
the patient-physician relationship (Ecca, Lewis, Baker), equally illuminating

22  E.g.: Hanson, A. E. ‘Greek medical papyri from the Fayum village of Tebtunis: patient
involvement in a local healthcare system?’, in Eijk, Ph. J. van der (2005). Hippocrates in
Context, 387–402. More on this topic in Draycott’s contribution (Chapter Seventeen),
432–450 in this volume.
12 Petridou and Thumiger

of the medical encounters of the past. Many of our contributors, finally, exam-
ine how the ancient patient’s experience of health and illness was shaped by
gender-related issues (Bolton, Kosak and Porter, for example).
Furthermore, this volume explores the patient’s perspective and experience
in a range of sources and media which have remained relatively unexplored to
this day: from sculptural artefacts (Baker) to papyri, ostraca, and tablets from
the Roman Republic and Empire (Draycott), and highly stylised and formu-
laic patients’ narratives, such as honorific and funerary reliefs (Horstmanshoff
and Graumann); and from the writings of Byzantine physicians like John
Zacharias Aktouarios (Bouras-Vallianatos) to those of the medieval Islamic
medical authors, such as Abû Bakr al-Râzî and Ishâq ibn Imrân (Koetschet).

3 Our Volume at a Glance

The first part of our volume, MEDICAL AUTHORITY AND PATIENT PERSPEC-
TIVES, revisits both inscriptional and literary sources for the patient history
in the ancient world and looks at them afresh with an eye to how understand-
ing the patient’s agency and identity in illness and health can help modern
patients, medical practitioners, public health officials, and indeed healthcare
policy makers in making their own choices. In Chapter One (‘ “This I Suffered
in the Short Space of my Life”. The Epitaph for Lucius Minicius Anthimianus’),
Manfred Horstmanshoff and Lutz Graumann focus on the child patient and
explore the harsh reality of childrens’ deaths in Graeco-Roman Antiquity. By
examining the funerary monument dedicated to the four-year-old Lucius,
Graumann and Horstmanshoff offer an original and inspiring argument for the
value of narrative medicine in conveying the marginalised voice of the patient,
complementing the approach with a reasoned and cautious discussion of the
possibilities of retrospective diagnosis. In a genuinely interdisciplinary fash-
ion, this chapter brings together the views of an eminent historian of medi-
cine and a distinguished physician, who establish a dialogue to discuss the
funerary inscription that relates the death of young Lucius and the grief that
his death brought upon his family, along with the possibility of a very much
culture-specific retrospective diagnosis of Lucius’s cause of suffering and
subsequent death.
Melinda Letts (‘Questioning the Patient, Questioning Hippocrates: Rufus
of Ephesus and the Pursuit of Knowledge’) argues that Rufus of Ephesus not
only did think that engaging patients in the epistemic process is a fundamen-
tal prerequisite of good medical practice, but that he was alone in devoting a
scientific treatise to the topic. By comparing Rufus’s conceptualisation of the
Introduction 13

relevance and use of questioning the patient, on the one hand, and that which
can be seen in the theoretical and descriptive works of Galen and the Hippo-
cratic authors, on the other, Letts puts forward the ground-breaking thesis that
Rufus exhibits an avant-garde grasp of the epistemic value of the patient’s per-
sonal narrative. More significantly, Rufus’s treatise On Questioning the Patient
shows resonances with some of the modern preoccupations of Western health-
care systems. Thus, this treatise is, as Letts maintains, of cardinal importance
not only for the historical debate between expert medical knowledge and the
layperson’s knowledge, but also because it can provide paradigms of fruitful
embedment of subjective information into the medical agenda of clinicians,
public health officials, public and private health policy makers.
The second section of the volume, CASE HISTORIES IN THE HIPPOCRATIC
CORPUS, concentrates on a key genre among ancient medical sources, and
one that has attracted much theoretical interest in contemporary medical dis-
cussions: the patient-report, or ‘case history’. All three papers in this section
discuss the rich, and often puzzling, information preserved by the Hippocratic
Epidemics, a collection of texts from the fifth- and early fourth century which
contains reports on a number of individual cases, whereby patients are even
named and vivid details are supplied. Chiara Thumiger (‘Patient Function and
Physician Function in the Hippocratic Patient Cases’) follows the strategies of
narratological and stylistic analysis to establish variations in the construction of
patient cases, between the reporting of a patient’s experience and the doctrinal
and operative influence of the visiting and writing physician. John Wee (‘Case
History as Minority Report in the Hippocratic Epidemics 1’) discusses one spe-
cific case, that of the patients of the first book of the Epidemics, addressing the
epistemological function of the individual case (usually taken as exemplum)
in the economy of the medical doctrine put forth by the doctor. The anecdotal
section, he argues, functions in this case not as illustration of a norm, but as an
exploration of the exception to it, a shift in perspective that further illuminates
what we know about the relationship between theory and observation-based
data at this early stage in the development of Greek medicine. Finally, Colin
Webster (‘Voice Pathologies and the Hippocratic Triangle’) tackles directly the
question of subjectivity by looking at what is perhaps its most direct expres-
sion in medical exchanges: the actual voice of the patient, an element closely
scrutinised by the doctor in these texts. The voice is an instrument of ver-
bal, articulate communication, central to the understanding of the patient’s
state; but it is also a signifier of health on a more basic level—its sound, its
strength, its quality deliver information about what is going on inside the body,
in a manner similar to the bodily excreta the Hippocratic doctor examines
and interprets.
14 Petridou and Thumiger

PATIENTS AND PSYCHOLOGICAL ILLNESS is a theme that occupies a spe-


cial place in the patient-centered perspective. That the specific case of the his-
tory of psychiatry and mental disorder, as we have suggested, may be seen as
providing the model, the archetype for any discussion about the subjectivity of
the medical experience and its deep rooting in any medical communication. This
section includes both a study of a specific topic in one specific author (the dis-
tress caused by anxiety in Galen) and a broader historical survey reaching into
the Arabic reception of Greek authors who discussed mental disorder. In the first
chapter (‘Galen’s Anxious Patients: Lypē as Anxiety Disorder’) Susan P. Mattern
explores Galen’s use of the term lypē as a marker of a specific form of distress, in
many ways comparable to what we may call ‘anxiety disorder’. Mattern explores a
wealth of Galenic examples for such forms of mental suffering, and offers a sensi-
tive discussion of the validity of current taxonomical labels of mental disorder
when approaching the ancient world. The second chapter, Pauline Koetschet’s
‘Experiencing Madness: Mental Patients in Arabo-Islamic Medicine’, takes us on a
journey through the work of two esteemed physicians of the early centuries of the
Common Era, Galen again and Rufus of Ephesus, reconstructing the reception of
their ideas about melancholy and mental distress in Arabo-Islamic medicine. The
key questions addressed here are how these physicians would recognise and cat-
egorise cases of mental illness, what the discussion of several individual patients
can tell us about the experience of mental illness in these contexts, and how men-
tal illness was represented in its social contexts.
The focus of the fourth part of our volume is entitled EMOTIONAL ASPECTS
OF THE PATIENT-PHYSICIAN RELATIONSHIP. Studies of ancient medicine
have fallen somehow behind in this recent wave of scholarly contributions, so
that the four essays in this section mark an important step in bringing medi-
cine into dialogue with the emotions as they are now studied in the ancient
setting. In this section we have grouped together papers that look especially
at the emotional level of the subjective experience of suffering, involving the
person-patient in a fuller sense, influenced by aspects of gender, social class,
age and authority. Jennifer Kosak (‘Interpretations of the Healer’s Touch in
the Hippocratic Corpus’) begins by addressing the act of ‘touching’ as healing
gesture, with the emotional and personal aspects it involves, and interrogates
the gender specifics one might expect to influence this part of the medical
encounter. Lesley Bolton (‘Patience for the Little Patient: the Infant in Soranus’
Gynaecia’) takes us to the realm of children patients, by looking at the work of
the great physician Soranus, whose work on gynecology and pediatrics have
come down to us. Bolton explores the attitudes of Soranus towards his child
patients, the display of tenderness and compassion towards the child as child,
and the attempt to address the little patient’s emotional needs and distresses.
Introduction 15

The emotions of both patient and physician are also the focus of Amber
Porter’s ‘Compassion in Soranus’ Gynecology and Caelius Aurelianus’ On Chronic
Diseases’. Porter looks at the work of Soranus, as well as the writings of late-
antique Caelius Aurelianus, a writer-physician who draws on a variety of earlier
sources to highlight a shift, in medical authors in the early centuries of the first
Millennium, towards the display of greater compassion and empathy towards
patients and their subjective suffering. The section is completed by a contribu-
tion that adds an important theoretical discussion to the picture, Courtney Roby’s
exploration of the conceptualisation of and reliance on pain as a diagnostic tool
in Galen (‘Galen on the Patient’s Role in Pain Diagnosis: Sensation, Consensus
and Metaphor’). This chapter not only surveys Galen’s views on the variations
and qualities of pain as well as its use as an indicator of health, but also poses
the difficult questions of the reliability and measurability of pain experiences in
medical procedures, a challenge with which the ancient doctors were familiar.
Bernhard Liehrsch, a well-known and well-documented nineteenth century
physician from Dresden, admonished his colleagues on the preliminaries of
medical examination with the following words: “You should never omit feeling
the pulse, and looking at the urine and the tongue. These are the three matters
to which every patient attaches value”.23 Part five of our volume (MATERIAL
ASPECTS, DIAGNOSTIC TECHNIQUES AND THEIR IMPACT ON THE PATIENT-
PHYSICIAN RELATIONSHIP) argues that the ancient medical provider had
analogous concerns about the impact diagnostic techniques had on his or her
rapport with the patient. The four chapters included here look closely at the
impact of these techniques on the sufferer’s psyche; they focus on the trust
and/or distrust, the relief or anxiety these diagnostic techniques caused to
the ancient patient. In short, this part of our volume argues that the quality
of the relationship between sufferer and medical expert was determined in a
significant way by certain material aspects, most notably by the medical prac-
titioners’ fees, as well by their medical utensils and equipment, professional
behavior and appearance. Giulia Ecca (‘The Μισθάριον in the Praecepta: the
Medical Fee and its Impact on the Patient’) examines the issue of financial
transactions and reciprocal exchange of favours between patient and physi-
cian, and its impact on their relationship as it emerges through a close reading
of the Precepts—an underappreciated Hippocratic treatise which deals with
issues of medical ethics. Orly Lewis (‘The Practical Application of Ancient
Pulse-Lore and its Influence on the Patient-Doctor Interaction’) investigates
the role of ‘the technē of the pulses’ in the process of (un)mediated transfer

23  Liehrsch, B. (1842). Bilder des ärztlichen Lebens, oder: die wahre Lebenspolitik des Arztes für
alle Verhältnisse, 148.
16 Petridou and Thumiger

of knowledge from the patient to the physician and the diagnostic process as
a whole. The main focus of the paper is Galen; Lewis, however, casts her net
more widely too, and looks at ‘pulse-lore’ (ancient theories of the pulse) in
medical texts attributed to physicians of the fifth century BC.
In the same vein, Patricia A. Baker (‘Images of Doctors and their Implements:
A Visual Dialogue between the Patient and the Doctor’) focuses on visual repre-
sentations of the ancient medical encounter, and how they might enhance our
knowledge of the ancient patient and his relationship with the medical profes-
sional. In this chapter, surviving images of Graeco-Roman doctors are critically
assessed to establish the patients’ perceptions of medicine and doctors. These
images, Baker claims, offer us a clearer insight into laypeople’s expectations
of what medical providers should look like and what sort of medical equip-
ment they should carry with them. In the final chapter included in this sec-
tion of the book, Petros Bouras-Vallianatos (‘Case Histories in Late Byzantium:
Reading the Patient in John Zacharias Aktouarios’ On Urines’) examines the
way in which the intimate relationship of Aktouarios and his patients unfolds
in his extensive urological treatise On Urines. This text, Bouras-Vallianatos
argues, contains a detailed chronicling of John’s visits to his patients, and thus
offers us a unique insight into the patient’s point of view, as well as glimpses
of how physical intimacy and gender-related variables affected the diagnostic
and therapeutic procedure.
All chapters included in this part of the book deal with topics that are of
cardinal importance for the history of medical ethics, such as appropriateness
of bed-side manners, the physician’s self-representation and the effect of these
factors on the patient’s psyche and the success of the treatment.
The focus of the sixth part of the volume (THE INFORMED PATIENT:
SELF-HEALING AND THE PATIENT AS PHYSICIAN) is twofold: it explores
the active role of the patient in a variety of medical contexts, while looking
at the key issues of wider availability and dissemination of medical knowl-
edge in Graeco-Roman Antiquity. The contributions included here revisit
key-themes of this volume, such as the multiple ways that effective commu-
nication between patient and healthcare provider, as well as a good grasp of
the patient’s socio-cultural background can affect not only the patient’s expe-
rience of their own body and illness, but also the efficacy of the treatment.
John Wilkins (‘Treatment of the Man: Galen’s Preventive Medicine in the
De sanitate tuenda’) offers us a discussion of Galen’s preventive medicine and
of the patients, who acquired for themselves a proactive, rather than a reac-
tive role in medicine and hygiene. Wilkins argues that Galen’s ideal patient,
as delineated in his treatise On Hygiene, does not become a patient at all, but
remains a healthy person able to maintain his or her health without need of
Introduction 17

remedies or other therapies. This chapter explores the extent to which the male
patient who is well-educated in medical matters can effectively function inde-
pendently of healthcare providers like nurses, trainers and masseurs and keep
his body and soul in balance. Georgia Petridou (‘Aelius Aristides as Informed
Patient and Physician’) focuses on an individual sufferer and his illness narra-
tive by close-reading sections of Aristides’ Hieroi Logoi. This knowledgeable
member of the second century socio-political elite, Petridou maintains, takes
the notion of self-healing one step further and presents himself not only as
an active agent in his own medical encounters with both earthly and divine
healers but also as intimately involved in the treatment of others, thus func-
tioning as a physician of sorts.
Jane Draycott’s focus is the lay medical practitioner of the Roman empire as
(s)he emerges from literary and documentary papyri, ostraca, and other docu-
ments from ancient Britain, Syria and Egypt. Draycott’s chapter (‘Literary and
Documentary Evidence for Lay Medical Practice in the Roman Republic and
Empire’) offers the reader a unique insight into lay medical practices, which
can be accessed far more satisfactorily if we move the scope of our investigation
away from ancient medical literature to other genres, and incorporate treatises
devoted to horticulture, agriculture, animal husbandry, and even religion and
magic. Documentary evidence, Draycott maintains, “gives voice not only to lay
medical practitioners diagnosing and treating their family members, friends
and acquaintances, but also to the patients who were experiencing these cures
alongside their health problems”. In the final chapter of this section, Katherine
van Schaik (‘It may not cure you, it may not save your life, but it will help you’),
both a physician-in-training and a historian of medicine, offers a comparative
study of the layman’s medical experience in the context of acute and chronic
disease between the patient of Graeco-Roman antiquity and the cancer-
sufferers in Western Australia. In particular, van Schaik considers the chal-
lenges faced by Indigenous palliative care patients and palliative care provid-
ers in Western Australia, as well as considerations of the challenges faced by
chronically or terminally ill patients as they determine their own treatment
preferences. In this rich, truly interdisciplinary and inter-cultural study, van
Schaik addresses the key-issues of the patient-physician relationship and that
of the cultural specificity of disease and its treatment. She also demonstrates
powerfully the significance of mutual trust and belief in the effectiveness of
the suggested medical treatment.
The EPILOGUE to this volume returns to some of the broader questions with
which the volume opened: ‘Approaches to the History of Patients: from the
Ancient World to Early Modern Europe’. Michael Stolberg is not only a practic-
ing physician, but also a distinguished advocate of the need to bring the patient
18 Petridou and Thumiger

more front-and-center in histories of medicine. This chapter takes a com-


parative look at the late medieval and early modern period and proceeds to
sketch a more general outline of the volume’s research agenda, connecting the
patient of the past with the patient of the present and tracing the main lines of
research that should shape future enquiries. Stolberg warns against the risks of
using physicians’ case histories to retrieve the patient’s experience of illness, a
procedure he sees as involving deeply rooted methodological problems, rather
than a specific difficulty with ancient sources such as the Hippocratic patient
cases. He also returns to the problem of retrospective diagnosis which has sur-
faced several times in a number of our contributions.
Our aim, of course, has not been to produce an exhaustive history of the
ancient patient’s view, nor to provide the final word on the theoretical discus-
sions we have just surveyed. We will however be satisfied if we have succeeded
in making a first step towards a history of the ancient patient, presenting here
a sample of the possibilities this field of research can offer, and contributing to
a dialogue not only within history of ancient medicine or classical studies, but
within the larger community of the history of medical ethics and the medical
humanities as a whole.

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Introduction 19

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20 Petridou and Thumiger

———. The Illness Narratives: Suffering, Healing, and the Human Condition, New York:
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———. Disease of Virgins: Green Sickness, Chlorosis and the Problems of Puberty,
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Body in Early Modern Europe, New York: Palgrave Macmillan, 2011.
PART 1
Medical Authority and Patient Perspectives


CHAPTER 1

“This I Suffered in the Short Space of my Life”.


The Epitaph for Lucius Minicius Anthimianus
(CIG 3272; Peek GV 1166)
Lutz A. Graumann and Manfred Horstmanshoff

Herewith we present an interdisciplinary study of the metrical funerary


inscription from the third century CE (CIG 3272; Peek GV 1166). This emo-
tional Greek epitaph reports the short life (from birth to death) of the
4 year old Lucius Minicius Anthimianus. This is the first detailed study
since the dissertation by Klitsch (1976). The inscription presents an ideal
case for a truly interdisciplinary study of the patient-history, in that its
interpretation involves the study of Greek literature and linguistics, epig-
raphy, social and religious history, and ancient medicine. It also offers
ample opportunity to show the contradictions inherent in proposing ret-
rospective diagnosis, without neglecting the relevant information mod-
ern medicine has to offer for the interpretation of this case history. We
argue that Lucius’ father was most probably a physician, that the text of
the inscription stems from expert knowledge of ancient medicine and
that the traditional retrospective diagnosis of this case, tuberculosis, is
an untenable hypothesis.

*  Although both authors accept responsibility for the text of this article it goes without say-
ing that sections 9–10 rely on the expertise of Lutz Alexander Graumann as an experienced
clinician. We would like to thank all, who have given us so many fruitful suggestions at the
public presentations of the growing content of this paper: in Mainz 2009, Calgary 2010, Tartu
2010, Marburg 2011, Cologne 2012, Berlin 2012–2013 and Erlangen 2013. Especially, we would
like to mention our editors Georgia Petridou and Chiara Thumiger, as well as Rita Amedick,
Joan Booth, Dietrich Boschung, Philip van der Eijk, Antje Krug and Peter Toohey. Further
thanks go to Carin Kruithof, Leiden, who has done great research work in the course of her
MA-thesis on the epitaph. We would also like to thank Gudrun Wlach, Österreichisches
Archäologisches Institut Vienna for her kind information about Josef Zingerle. Manfred
Horstmanshoff wishes to thank the Internationales Kolleg Morphomata, Cologne, for the
time he could spend on this project during his fellowship (2011/2012) and Philip van der Eijk
for arranging his stay as a visiting scholar at the Humboldt Universität zu Berlin in 2013. We
gratefully acknowledge the assistance of Cornelis van Tilburg in harmonising bibliography
and footnotes.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_003


24 Graumann and Horstmanshoff

1 Introduction

The cruel reality of children’s premature death in Graeco-Roman antiquity


has been a major topic in many recent historical discussions.1 Rather surpris-
ingly, there are hardly any new medical-historical contributions to this theme.
This fact has prompted us to undertake an interdisciplinary research project
on the funereal inscription for the four-year-old Lucius Minicius Anthimianus,
dating from the third century AD. The epitaph is a unique document permit-
ting insight into the social, cultural and religious life of children and families
during the Roman Empire. Furthermore, it offers an understanding of contem-
porary medicine in general and medicine for children in particular. During the
last century, this inscription has been interpreted without exception as a clas-
sical clinical picture of tuberculosis in childhood. This is a typical case of a ret-
rospective diagnosis that has not previously been called into question.2 Today
this single medical interpretation appears rather simplistic. We present here a
new interdisciplinary approach to this epitaph which contextualises it prop-
erly and adopts two main perspectives: a philological-historical and a medi-
cal one. It is our view that only such an interdisciplinary approach can really
advance our understanding both of this document, and of ancient patient-
history in general.

1  Golden, M. (1988). ‘Did the ancients care when their children died?’, Greece & Rome 35, 152–
63, esp. 153; Nielsen, H. S. (1996). ‘The physical context of Roman epitaphs and the structure
of the Roman family’, Analecta Romana Instituti Danici 23, 35–60; King, M. ‘Commemorations
of infants on Roman funerary inscriptions’, in Oliver, G. J. (2000). The Epigraphy of Death,
117–54; Rawson, B. ‘Death, burial, and commemoration of children in Roman Italy’, in Balch,
D. L. and Osiek, C. (2003). Early Christian Families in Context, 277–97.
2  Meinecke, B. (1927). ‘Consumption (tuberculosis) in classical antiquity’, Annals of Medical
History 9, 379–402 [our text: 385–86.]; Zingerle, J. (1928). ‘Ein Fall von Kindertuberkulose vor
1700 Jahren’, Zeitschrift für Kinderheilkunde 46, 440–44; Meinecke, B. (1940). ‘A quasi-autobi-
ographical case history of an ancient Greek child’, Bull. Hist. Med. 8, 1022–31; Klitsch, H. D.
(1976). Eine inschriftliche Krankengeschichte des 3. Jh. n. Chr.: Das Grabgedicht für den fünfjäh-
rigen Lucius Minicius Anthimianus, Med. Diss., Universität Erlangen; Grmek, M. D. (1983). Les
maladies à l’aube de la civilisation occidentale, 289; Gourevitch, D. (1968). ‘Une observation
pédiatrique pour épitaphe: Un texte inédit’, L’Écho medical au service du médecin, 145;
Gourevitch, D. (1969). ‘Déontologie médicale: quelques problemès’, Mélanges d’archéologie et
d’histoire 81, 519–36; 523–24 (“une tuberculeuse généralisée”); Gourevitch, D. (2001). I giovani
pazienti di Galeno: Per una patocenosi dell’impero Romano, 86–87; Mattern, S. P. (2008). Galen
and the Rhetoric of Healing, 36 also mentions the “famous inscription in Greek verse” of Lucius,
citing the works of Klitsch (1976) and Petzl, G. (1981). ‘GVI 1166—eine Krankengeschichte aus
Smyrna?’, Chiron 11, 303–08, but without offering any diagnosis.
the Epitaph of L. M. Anthimianus 25

The twentieth century has seen a paradigmatic shift in medical history, fol-
lowing analogous developments in society, where the position of the patient
in relation to the physician has become stronger.3 Whereas in the nineteenth
and early twentieth century the aim of contemporary medical history was to
describe the progress of medicine as a science, in the later part of that century
the focus has shifted more towards the practice of medicine and towards the
patient’s perspective, thus lessening the distortion caused by the traditional
physician-centered account.4 The consequence of this shift in focus was the
use of different sources: not only learned medical treatises, but also case his-
tories, patients’ diaries and letters.5 The history of ancient medicine has fol-
lowed this trend, albeit at a slower pace, and thus testimonies from papyri and
inscriptions have become more important in establishing an overall picture of
healing in Graeco-Roman Antiquity. Philip van der Eijk has summarised the
situation aptly: “From appropriation to alienation”, from Hippocrates as the
‘Father of Medicine’ to understanding ancient medicine in its social and cul-
tural context.6
“I have seen the patient”; these words, if spoken by a medical doctor, mean
a lot: the doctor has used his or her senses, insight, knowledge and experience;
he or she has ‘taken a history’. When a medical historian ‘takes a history’ of
individual patients from the past he or she makes individuals visible in his-
tory. Medical concepts, ideas and terminology played an important role in case
histories as they ‘dripped down’ into literature and society. In our research, we
address case histories in ancient Graeco-Roman medical writing, their func-
tion, form and medium, including the relationship between case descriptions
in medical and in non-medical writings and their visual representations. We
argue that patient history can make an important contribution not only to
the history of ancient medicine, but also to the study of ancient society and
mentality. Furthermore, the study of ancient case histories may serve as an
introduction for modern medical practitioners to ‘narrative-based medicine’.7

3  For an overview see Huisman, F. and Warner, J. H. (2004). Locating Medical History: The
Stories and their Meanings.
4  Ackerknecht, E. H. (1967). ‘A plea for a “behaviorist” approach in writing the history of medi-
cine’, Journal of the History of Medicine and Allied Sciences 22, 211–14; Porter, R. (1985). ‘The
patient’s view: doing medical history from below’, Theory and Society 14, 175–98.
5  See e.g. Stolberg, M. (2003, Engl. Trans. 2011). Homo patiens: Krankheits- und Körpererfahrung
in der Frühen Neuzeit.
6  Eijk, P. J. van der (2005). Medicine and Philosophy in Classical Antiquity, ‘Introduction’, 1–42.
7  Horstmanshoff, H. F. J. (2006). Patiënten zien: Patiënten in de antieke geneeskunde; Charon, R.
(2004). ‘Narrative and medicine’, The New England Journal of Medicine, February 26, vol. 350
No. 9, 862–64. On narrative-based medicine see also the introduction to this volume.
26 Graumann and Horstmanshoff

The document we examine offers a unique opportunity for such a new


approach. While reading it closely and carefully, we rediscovered the value
of Hans-Georg Gadamer’s Truth and Method as a tool for understanding.8 As
a health-care professional (Graumann) and a classicist (Horstmanshoff), we
are both historians of ancient medicine, but each with a different background
and set of values, each with a different intended audience or in Gadamer’s ter-
minology, a different ‘horizon’. “Historical consciousness is aware of its own
otherness and therefore makes a distinction between the horizon embedded
in the tradition and its own”.9 Attempting a historical reconstruction of the
event in its own right would be as futile as to apply present-day medical knowl-
edge to a past case history. We realise that to understand this text we have not
only to ‘fuse’ our individual ‘horizon’ of understanding with the horizon of its
author, but also with each other and with earlier interpretations. We enter into
a dialogue with the text.

2 The Slab

The slab is made out of white marble and presents an arched top adorned by
a wreath. It is a square, 56 centimeters long and 56 centimeters broad, and
is almost completely covered with text: 32 lines of Greek verse in capital let-
ters. The total number of Greek letters is 1149, with an average of 37 letters per
line (with the exception of the first and the penultimate line, which counts
46 letters). The stone is in good condition. Its present location is the Palazzo
Barberini in Rome, Via Quattro Fontane 13, where it is inserted in the inner wall
of the Palazzo’s courtyard. The original physical context is unknown. It may
have been part of a single grave or columbarium, at the side of some road near
Rome, perhaps the Via Appia, or in one of the catacombs.10 Although its origin

8   Gadamer, H. G. (2006). Wahrheit und Methode: Grundzüge einer philosophischen


Hermeneutik.
9   “Das historische Bewußtsein ist sich seiner eigener Andersheit bewußt und hebt daher
den Horizont der Überlieferung von dem eigenen Horizont ab”, Gadamer, Wahrheit, 311
(slightly revised translation suggested by Joan Booth).
10  Dietrich Boschung (Cologne) kindly suggested that the slab was originally part of a
columbarium. On the location, see McLean, B. H. (2002). An Introduction to Greek
Epigraphy of the Hellenistic and Roman Periods from Alexander the Great down to the Reign
of Constantine (323 BC–AD 337), 269: “Epitaphs that address passersby were especially
common on tombs located by the sides of the roads leading out of the city”. On funeral
practice and commemoration in imperial Rome, see Nielsen, H. S. ‘The value of epithets
in pagan and Christian epitaphs from Rome’, in Dixon, S. (2001). Childhood, Class and Kin
the Epitaph of L. M. Anthimianus 27

has been debated, there is now general agreement that it must have been writ-
ten in Rome.11 Commemorations of dead children below the age of five years,
independently of their gender, are most commonly found in the larger urban
centres of Rome and Ostia.12
Interestingly, any kind of iconographic representation is missing, with the
exception of a schematic representation of a wreath on the first line. The slab
may originally have been part of an ensemble, containing a family picture with
the traditional three-person grouping (father-son-mother) pictured above the
inscription, or only one stylised head of a child.13
The inscription is dated to the end of the second or the beginning of the
third century AD.14 Roman grave monuments were usually placed in promi-
nent positions, so as to be visible for the passersby (line 6), alongside path-
ways leading in and out of the city or in catacombs. They were meant to be a
memoria, a commemoration of the dead. This brings us to an important point:
for whom was this inscription intended? Who were its supposed readers? Were
inscribed epigrams really read by anyone? Nowhere in ancient literature is it
attested that passersby actually stopped to read an inscription, let alone such
an elaborate and difficult one.15 Our sepulchral monument is that of a single
family member, a male child’s tomb; and hence, a monument of private char-
acter. Although addressed to a passersby, it contains many private features.16

in the Roman World, 166. Antje Krug kindly proposed the idea of a location in a catacomb.
For more on this possiblity, see Liverani, P. et al. (2010). The Vatican Necropoles: Rome’s City
of the Dead.
11  For a long time it was supposed that the stele came originally from Smyrna. Major argu-
ments in favour of Rome can be found in Petzl, ‘Krankengeschichte’.
12  McWilliam, J. ‘Children among the dead: the influence of urban life on the commemora-
tion of children on tombstone inscriptions’, in Dixon, S. (2001). Childhood, Class and Kin
in the Roman world, 79.
13  See Backe-Dahmen, A. (2006). Innocentissima aetas: Römische Kindheit im Spiegel liter-
arischer, rechtlicher und archäologischer Quellen des 1. Bis 4. Jahrhunderts n. Chr. for the
usual forms of children’s grave stones from that period.
14  On the basis of the letter forms and the structure of personal names (tria nomina)
mentioned in the text, while no decisive internal evidence can be found; see McLean,
Introduction, 123.
15  Bing, P. ‘The un-read Muse? Inscribed epigram and its readers in antiquity’, in Harder, M. A.
et al. (2002). Hellenistic Epigrams, 39–66. Attitudes toward inscribed epigrams began to
change in the course of the Hellenistic period, due to the interest of poets and scholars.
We thank Rolf Tybout for the reference.
16  For example, it was clearly not a ‘consolation decree’-epitaph sponsored by the city/
dēmos/boulē for the consolation of deceased children of local civic (usually aristocratic)
politicians or benefactors; see Strubbe, J. H. M. (1998). ‘Epigrams and consolation decrees
28 Graumann and Horstmanshoff

On the other hand, “within the Roman necropolis (. . .) there is some evidence
of competition, for families using expensive sepulchral portraits in an attempt
to win attention.”17 Would this apply also to texts? Since we have no informa-
tion about the original location of the inscription, we will never know. An
informed guess would be that family and friends returned yearly to the grave,
where offerings were made and someone read the inscription aloud to com-
memorate the young heros.

3 Text and Translation

Text18
Θεοῖς (corona) Ἥρωσιν
Λούκιος Μινίκιος Ἄνθιμος καὶ Σκρει-
βωνία Φηλεικίσσιμα ἀτυχεῖς γονεῖς
4 Λ. Μινικίῳ Ἀνθιμιανῷ τέκνῳ γλυκυτάτῳ
καὶ θεῷ ἰδίῳ ἐπηκόῳ ζήσαν(τι) ἔτη δ’, μῆνας ε’, ἡ(μέρας) κ’.
Νήπιός εἰμι τυχὼν τύμβου τοῦδ’, ὦ παροδεῖτα.
Ὅσσ’ ἔπαθον δ’ ἐμ βαιῷ τέρματί μου βιοτῆς
8 ἐνκύρσας λαϊνεᾳ στήλλῃ τάχα καὶ σὺ δακρύσεις
μητρὸς ἀπ’ ὠδείνωμ <μ’> ὡς εἰς φάος ἤγαγον Ὧραι,
ἐκ γαίης με πατὴρ ἐμὸς εἵλατο χερσὶ γεγηθώς
καὶ μ’ ἀπέλουσε λύθρου καὶ εἰς σπάργανά μ’ αὐτὸς ἔθηκεν,
12 η{ε}ὔχετο δ’ ἀθανάτοις, ἅπερ οὐκ ἤμελλεν ἔσεσθαι
Μοῖραι γὰρ πρῶται περί μου κεκρίκεισαν ἅπαντα
καὶ μ’ ἔτρεφεν γενέτης μητέρα μου τροφὸν εἱλάμενος

for deceased youths’, L’Antiquité Classique 67, 45–75, especially 59–75. Of course, it should
be noted that any discussion about public or private character of epitaphs from this
historical period projects our own recent understanding of public and private into that
past where surely not the same image has predominated. On the distinction between
private and public monument in the Graeco-Roman world, see Ma, J. (2013). Statues and
Cities. Honorific Portraits and Civic Identity in the Hellenistic World. esp. Part 3, ‘Statues and
families’.
17  Mander, J. (2013). Portraits of Children on Roman Funerary Monuments, 152.
18  Earlier editions: Boeckh, A. (1828–77). CIG 3272; Hondius, J. J. E. et al. (1979). SEG 29, 1003;
Dübner, F. et al. (1864). Epigrammatum Anthologia Palatina 3, ch. 2, 637 (pages 196–97)
(with Latin translation and commentary); Kaibel, G. (1878). Epigrammata Graeca ex lapidi-
bus conlecta 314; Peek, W. (1955). GV 1166; Moretti, L. (1968–90). IGUR 4, 1702; Vérilhac, A. M.
(1978–82). ΠΑΙΔΕΣ ΑΩΡΟΙ 1, 165–68 no. 106; Pleket, H. W. (1969). Epigraphica II, Texts on
the Social History of the Greek World, nr. 55. For full references see infra Texts Used.
the Epitaph of L. M. Anthimianus 29

FIGURE 1.1 The Epitaph for Lucius Minicius Anthimianus (CIG 3272, Peek GV 1166), National
Gallery of Ancient Art of Barberini Palace, Rome.
Photo DAI-ROM-58.1431 Courtesy Deutsches Archäologisches Institut,
Rome.
30 Graumann and Horstmanshoff

αὐτίκα δ’ η{ε}ὐξανόμην εὐερνὴς καὶ πᾶσι ποθητός.


16 Ἐν δ’ ὥραις ὀλίγαις Μοιρῶν γὰρ σφραγεῖδες ἐπῆλθον,
αἵ με νόσῳ πῆξαν χαλεπῇ διδύμους πέρι
ἀλλ’ ὁ ταλαίφρων γεννήσας εἰάσατό μου νόσον αἰνήν
τοῦτο δοκῶν ὅτι μοῖραν ἐμὴν εἰάμασι σώσει.
20 Καὶ τότε δή μ’ ἑτέρα νόσος εἷλε κακίστη
τῆς προτέρης νούσσου πουλύ τι χειροτέρη·
σῆψιν γὰρ <λαι>οῦ πεδίον ποδὸς εἶχεν ἐν ὀστοῖς.
Εἶτ’ ἔταμόν με φίλοι γενέτου καί μου ὀστέ’ ἀνεῖλαν
24 λύπας καὶ στοναχὰς τοῖς τεκέεσσι διδόντα,
καὶ ταῦθ’ ὡσαύτως εἰάθην πάλιν, ὡς τὰ πάροιθεν.
Οὐδ’ οὕτως μου Γένεσις δεινὴ πλησθεῖσ’ ἐκορέσθη,
ἀλλ’ ἑτέραν πάλι μοι νόσον ἤγαγε γαστρὸς Μοῖρα
28 σπλάγχνα μου ὀγκώσασα καὶ ἐκτήξασα τὰ λοιπά,
ἄχρις ὅτου ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων.
Ταῦτ’ ἔπαθον βαιῷ τέρματί μου βιοτῆς, ξένε,
καὶ κατέλειπον τηκεδόνα στυγερὴν τοῖσί με γιναμένοις,
32 αἰνόμορος, λείψας τρεῖς συνομαίμονας ἀστεφανώτους.

Translation
We present here the established English translation by Bruno Meinecke from
1927/1940.19

Dis Manibus! [To the sacred spirits]


Lucius Minicius Anthimus and Scri-
bonia Felicissima, miserable parents,
4 for L[ucius] Minicius Anthimianus, their sweetest child
and for their own merciful god. He lived 4 years, 5 months and 20 days.
A helpless child am I who have reached this tomb, o traveller;
even you who have chanced upon my stony slab
8 will straightway weep at the suffering which I have endured in the brief
compass of my life.
When the Horae brought me into the light by the travail of my mother,
my father joyfully took me up in his hands from the earth,

19  Meinecke, ‘Consumption’, 385 = Meinecke, ‘Quasi-autobiographical’, 1023–24. Translation


in other languages: Latin (Boeckh, CIG; Cougny, AP); German (Zingerle, ‘Fall’); French
(Gourevitch, ‘Observation’, 14 = Gourevitch, ‘Déontologie’, 523–24, note 7; Vérilhac,
ΠΑΙΔΕΣ 1, 167); Italian (Gourevitch, Giovani, 86–87); Dutch (Hoefmans, M. (1967–68).
Bijdrage tot de studie der Griekse metrische grafschriften; Horstmanshoff, Patiënten).
the Epitaph of L. M. Anthimianus 31

and washed me clean of the impure blood, and he in person placed me


in swaddling clothes.
12 My father made prayers to the gods which were not to be;
for the Fates were the first to make all decisions about me;
and my father chose my mother as nurse and reared me.
Forthwith I grew lustily like a young plant and was beloved by all;
16 but in a few seasons the seal of the Fates came upon me,
who made me fast with a dread disease about the testicles;
but my distressed father healed my dire disease,
thus thinking to save my fate by medical treatment.
20 And then, moreover, another disease seized me,
most grievous by far, and many times worse than the former;
for the metatarsi of my (left) foot had sepsis in the bones,
and so my father’s friends performed an operation on me and took out
my bones
24 which were the cause of grief and groans to my parents,
and in this way I was healed again as before.
Not even thus did my ill-boding birth have its fill of smiting,
but fate again brought upon me another disease of the belly,
28 enlarged my intestines and wasted away the other parts,
until such time when my mother’s hands snatched life from my eyes.
This I suffered in the short space of my life, o stranger,
32 and I, doomed to a sad end, survived by three unwedded siblings, have
left the hated consumption to those who begat me.

4 Language, Style, Metrical Aspects and Structure of the Text

Grave epigrams were common at Rome, and they were written both in Latin
and in Greek. Latin carmina funeralia have a more formal structure than Greek
ones, mentioning full names, status, age and profession. Greek grave epigrams
are more freely composed and less elaborate. It might seem surprising at first
that a Greek inscription was made in Rome. Greek inscriptions were, however,
no exception there.20 Epitaphs for children appeared both in Greek and Latin,
and even bilingual ones.21

20  See IGUR; for this inscription: 4, 1702.


21  Rawson, ‘Death’, 350; cf. the epitaph for Quintus Sulpicius Maximus (who lived 11 years,
5 months and 12 days; after 94 AD), the verse-writing child prodigy, with texts in Latin and
Greek: IGUR 3, 1336, Kaibel EG 618, GV 1924; Vérilhac, ΠΑΙΔΕΣ 1, no. 78.
32 Graumann and Horstmanshoff

This epitaph combines two traditions: the old Greek epigrammatic tradition
and the Latin gravestone tradition of Rome as a virtually bilingual city.22 The
language is that of the Greek koine, but the detailed biographical information
about the child is reminiscent of the Latin inscriptions. The style is archaising,
interspersed with frequent allusions to the Homeric poems. We have adopted
the translation by the American classicist Bruno Meinecke who tried to emu-
late this style using a sort of biblical English.
The structure and part of the content of the poem are traditional. After
an introduction (titulus ll. 1–5), including the apotheosis (τέκνῳ γλυκυτάτῳ /
καὶ θεῷ ἰδίῳ ἐπηκόῳ ll. 4–5), follows the proper grave poem (carmen funerale
ll. 6–29). In l. 6 the παροδεῖτα, the traveller (Latin viator) is addressed, while in
l. 30 it is the stranger (ξένε).23 In l. 15 young Lucius is called πᾶσι ποθητός “beloved
by all”: the ever present theme of childish charm.24 Another conventional ele-
ment of the inscription is the so-called ‘boast’, (laudatio ll. 10–29) put into the
mouth of the deceased himself.25 In the case of the four year old Lucius this
is not a cursus honorum, nor an account of his bravery on the battlefield, but
rather a description of his birth and early years, and, contrary to the usual prac-
tice in children’s epitaphs, of his three illnesses as the causes of his death.26 In
adult Greek epitaphs, other causes of death are commonly mentioned, such as
accidents, war wounds etc., but only rarely diseases. It is conventional in grave
epigrams to mention the cruelty of death itself. Especially in cases of young
people or children, the dead are called ἄωροι “untimely”,27 and death itself is
thought of as mors immatura “unseasonable death”, and funus acerbum “a bit-
ter demise”. Supernatural causes of death are frequently stated, e.g. Tyche, or
like here (l. 16) the Moirai (the Fates).
The text is not devoid of literary aspirations e.g. ll. 10 and 29 form a moving
counterpoint:

22  Kajanto, I. (1963). ‘A study of the Greek epitaphs of Rome’, Acta Instituti Romani Finlandiae
2.3, 6.
23  Cf. e.g. Kaibel, EG 711; GV 1612.
24  Liddell, H. G. and Scott, R. (1978). A Greek-English Lexicon (LSJ) 1427, Suppl. 6, 253, s.v.
ποθητός; AP 7,467,5; IG 7, 3434; SEG 33, 1475 (Cyrenaica 1./2.); IG 5, 2, 491 (Megalopolis
second / third century AD); GV 958; GV 395. Cf. Laes, C. ‘High hopes, bitter grief: Children
in Latin literary inscriptions’, in Partoens, G. et al. (2004). Virtutis Imago, 58.
25  Lattimore, R. (1942). Themes in Greek and Latin Epitaphs, 288.
26  Backe-Dahmen, Innocentissima, 96.
27  For a discussion of the term, see Vérilhac, ΠΑΙΔΕΣ 2, 152–54.
the Epitaph of L. M. Anthimianus 33

l. 10 με πατὴρ ἐμὸς εἵλατο χερσὶ “my father took me up in his hands”


l. 29 ψυχήν μου μητρὸς χέρες εἷλαν “my mother’s hands took the life
 ἀπ’ ὄσσων  from my eyes”.28

There might even be an intentional juxtaposition between light and darkness


in ll. 9 (μητρὸς ἀπ’ ὠδείνωμ <μ’> ὡς εἰς φάος ἤγαγον Ὧραι) and 29 (ἄχρις ὅτου
ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων): it is the mother who gives birth, brings
the newborn baby “to the light” (εἰς φάος) and the mother’s hands who took the
light out of Lucius’ eyes. Is there an allusion to the same notion of light in the
name Luc-ius (Latin lux)?29
The last two lines (conclusio ll. 31–32) stand apart. Introduced by καί, con-
cluded with ἀστεφανώτους “unwedded”, they make up a special conclusion.
To conclude, the poem is carefully composed. Its length is exceptional and
so is the fact that it is devoted to a very young child; while the striking medi-
cal details—a description of three diseases on which see below—make it
unparalleled.

4.1 Latin Influence


Θεοῖς Ἥρωσιν (l. 1), the translation of Dis Manibus (DM), which is the usual
invocation of the gods of the underworld (spirits of the deceased), is the first
example of Latin influence.30 The phrase Θεοῖς Ἥρωσιν itself is quite rare; in
Rome there are only two other known examples.31 More commonly attested
as translation of Dis Manibus is Θεοῖς Καταχθώνιοις.32 The boy’s name, Lucius
Minicius Anthimianus, is quoted in full, and so is his age (ll. 4–5). The record-
ing of age in terms of years, months and days is another striking feature of
Latin influence.33

28  On the repeated use of εἵλατο, εἷλαν and related forms see above.
29  For frequent use of φώς cf. Vérilhac, ΠΑΙΔΕΣ 1, 134 no. 85, 145 no. 94. For the expression
cf. Hom., Il. 16.333–34 τὸν δὲ κατ’ ὄσσε/ ἔλλαβε πορφύρεος θάνατος καὶ μοῖρα κραταιή. On the
theme ‘light and darkness’: Griessmair, E. (1966). Das Motiv der mors immatura in den
griechischen metrischen Grabinschriften, 19–23.
30  The dedication Dis Manibus became customary only during the second century AD. The
spirits of the deceased are also often adressed as the Lemures (Kajanto, ‘Epitaphs’, 8–10).
31  IG 14, 1572 and 1795.
32  Vérilhac, ΠΑΙΔΕΣ 1, 167.
33  Cf. the epitaph for Secundus Glykytatos, 100–10 AD, who died at 5 years, 3 months, 19 days
(Kleiner, D. E. E. (1987). Roman Imperial Funerary Altars with Portraits, 190–91); Kajanto,
‘Epitaphs’, 13. See also the remark on the horoscope in n. 63.
34 Graumann and Horstmanshoff

4.2 Homeric Elements


Ἥρως (l. 1) has a Homeric tinge. In l. 6 the epic νήπιος “infant”, like Latin infans,
“not speaking”, is used instead of the more common ἄωρος (“untimely”). L. 24
λύπας καὶ στοναχὰς τοῖς τεκέεσσι διδόντα “which were the cause of grief and
groans to my parents” is reminiscent of the Homeric formula ἄλγεα τέ στοναχάς
τε.34 A keyword in this epigram is αἰνόμορος (“doomed to a sad end”) in l. 32.
It describes how the child (his parents are speaking through his mouth) sees
himself and is unmistakably Homeric.35 The same goes for l. 29: ψυχή here
means ‘breath’, ‘the breath of life’. If someone dies, his ψυχή leaves him usually
through his mouth.36 Here the mother closes her son’s eyes.

4.3 Metrical Aspects


The poem is written in rather clumsy Greek dactylic hexameters alternating
with pentameters.37 In some lines the meter is used to produce a special effect.
Exactly where the poet tells us that the boy’s life span was short in l. 7 (ἐμ βαιῷ
τέρματί μου βιοτῆς, “in the brief compass of my life”), there is a katalexis, that is:
the last element of the colon is missing, perhaps echoing Lucius’ abrupt end of
life.38 In l. 20 the dramatic tension becomes visible and audible. The metrum
stops suddenly: μ’ ἑτέρα νόσος εἷλε κακίστη “another most terrible disease seized
me”. A complete (metrical) foot is lacking, so that the expected hexameter is
cut down to a pentameter. “After Fate brought another disease, having caused
my innards to swell” (σπλάγχνα μου ὀγκώσασα, l. 28), a slow hexameter, comes a
halting pentameter in l. 29, ψυχήν μου μητρὸς χέρες εἷλαν ἀπ’ ὄσσων “my mother
took the life from my eyes”.39 The last two lines (conclusio ll. 31–32) have a
different metrical structure.

34  E.g. in Hom., Il. 2.39 or Od. 14.39, cf. GV 855,4.


35  Hom., Il. 22.481; Hom., Od. 9.53. Cf δύσμορος AP 9,158; Vérilhac, ΠΑΙΔΕΣ 1, 126 no. 79, 2 years
old, Rome; νήπιος ὠκύμορος in Vérilhac, ΠΑΙΔΕΣ 1, 190 no. 123, 4 years old, Rome.
36  Hom., Il. 5.696; 9.408.
37  Gallavotti, C. (1979). Metri e ritmi nelle inscrizioni greche, 48–50; Kruithof, C. (2010). ‘Dit heb
ik geleden in de korte tijd van mijn leven, vreemdeling’: Een interpretatie van het grafgedicht
voor de vierjarige Lucius Minicius Anthimianus (GVI 1166)’. Unpublished MA-thesis, 36–42,
gives a complete metrical analysis of the poem.
38  For τέρμα as ‘the end of life’, see A., Fr. 362; S., OT 1530; Eur., Alc. 643. On inscriptions for
παῖδες ἄωροι, see Vérilhac, ΠΑΙΔΕΣ 1, 190 no. 73; 114–15 no. 77; 129–30 no. 82.
39  On the repeated use of εἵλατο, εἷλαν and related forms see above p. 33 and n. 28.
the Epitaph of L. M. Anthimianus 35

5 Socio-Cultural Context

It was especially common among immigrants from Asia Minor to erect Greek
epitaphs in Rome. Most of them had a higher social status,40 and many of them
mentioned a medical profession in their inscriptions. This should not surprise
us, since the majority of the physicians in the Western part of the Empire and
also in Rome itself were of Greek origin. Many of them had acquired a medical
education in Ephesus and Smyrna in the second century AD.41
Epitaphs for children are generally rare, especially among the upper classes.
It was rather unusual in that historical period that children should hold any
socially relevant office as persons. Still, their role within the familial context
was important:42 12 % of all known Latin pagan funerary inscriptions of a liter-
ary kind are dedicated to children; while 67 % of the Latin epitaphs for chil-
dren belong to the class of the liberti (freedmen). An explanation of the fact
that liberti apparently devoted grave epigrams to young children more often
than the elite might be found in the steadfast belief of the upper classes that
it was not appropriate to grief overtly for the death of a child. We know that
liberti were more prone to extravagant expressions of funerary sarcophagi and
inscriptional texts precisely because they could not hold public offices in real
life. Through epigraphic dedications they could make public the fact that their
children were freeborn.43

5.1 Onomastic Criteria


The dedicators are Lucius’ parents, Lucius Minicius Anthimus and Scribonia
Felicissima. The tria nomina (praenomen, nomen gentilicium and cognomen)
indicate that the father was a Roman citizen.44 Women usually had no
praenomen. The name of the father indicates that he had probably been
­manumitted. The individual praenomen Lucius is a very frequently attested

40  Kajanto, ‘Epitaphs’, 6.


41  Nutton, V. ‘Murders and miracles: Lay attitudes toward medicine in classical antiquity’,
in Porter, R. (1985). Patients and Practitioners, 23–53, especially 27, 33. Nutton, V. (2013).
Ancient Medicine, 263: “In the city of Rome itself in this period more than 90 per cent of
the names of doctors are Greek”.
42  Schörner, G. ‘Saturn, Kinder und Gräber: Zur Beziehung von Götterverehrung und Kinder-
bestattungen im römischen Nordafrika’, in Rüpke, J. and Scheid, J. (2010). Bestattungsri­
tuale und Totenkult in der römischen Kaiserzeit, 215–35.
43  Laes, ‘Hopes’, 47–48; Wypustek, A. (2013). Images of Eternal Beauty in Funerary Verse
Inscriptions of the Hellenistic and Greco-Roman Periods, 55–57.
44  But, there is of course a “real possibility of error” about the social status (free, freed, or still
slave) of Lucius’ father; McLean, Introduction, 131.
36 Graumann and Horstmanshoff

name.45 The freed father (libert[in]us) adopted the name of his former mas-
ter (patronus), Lucius Minicius, as his praenomen and nomen adding his own
(originally Greek) personal name Anthimos as his cognomen.46 Even as freed-
man, he may have stayed with his own ‘family’ in the household (domus) of his
patron.47 Lucius, the little boy who died prematurely, was his freeborn son. To
underline this, he was given his own tria nomina: Lucius Minicius Anthimianus.
The praenomen Lucius was taken from his father, most probably because he
was his eldest (and only) son, while the cognomen Anthimianus was derived
from his father’s cognomen Anthimus, meaning “son of Anthimus”.48 The
Prosopographia Imperii Romani, the ‘Who is who?’ of the Roman Empire, gives
evidence of quite a few Minicii (gens Minicia), who could have been the master
of our little boy’s father. There is no unequivocal evidence, however, pointing
with certainty at one identifiable person. We can only speculate about their
family connections. The father may have moved to another family after manu-
mission.49 In the Hellenistic tradition even behind a Greek name there could
be a non-Greek (e.g. an Egyptian) person.50
Apparently the father, Lucius Minicius Anthimus, and the mother, Scribonia
Felicissima, originated from two different households. It is conspicuous that
the mother is not called γυνή, the equivalent of Latin uxor. This could be
interpreted as an indication that Lucius’s mother was still a slave at the time
of the erection of the inscription. The background of the mother remains,
thus, rather difficult to fathom: her name could be interpreted as Scribonia
Felicissima, meaning “the daughter of Scribonius Felicissimus”, or as “daughter
of Scribonius” with the added cognomen Felicissima, possibly for being mother

45  McLean, Introduction, 119 (Lucius meaning “born by day” from luce natus).
46  ἄνθιμος “flowering” from ἄνθος “flower”; LSJ, s.v. Many Greek slaves are known to have had
‘flower-names’; McLean, Introduction, 103. Are we allowed to speculate further about the
not uncommon ornamental corona in line 1: does it symbolise something like an heraldic
family-sign? Cf. GV 1244. For personal names of the former patronus used as cognomen
see McLean, Introduction, 128.
47  Mattern, Galen, 22: “Many physicians were slaves in aristocratic households; as freedmen,
they also formed part of their patron’s entourage”.
48  McLean, Introduction, 119; 121.
49  Rawson, B. ‘Degrees of freedom’, in Dasen, V. and Späth, T. (2010). Children, Memory, and
Family Identity in Roman Culture, 213–14. A possible candidate for Anthimus’ patron is
Thrasea Priscus (Roman senator and consul of 196, who died under Caracalla in 212;
D. C. 78 (77) 5,5), full name Lucius Valerius Publicola Messal(l)a Helvidius Thrasea Priscus
Minicius Natalis; PIR2 5, 95, AE 1998, 280.
50  Kudlien, F. (1986). Die Stellung des Arztes in der römischen Gesellschaft: Freigeborene
Römer, Eingebürgerte, Peregrine, Sklaven, Freigelassene als Ärzte, 120.
the Epitaph of L. M. Anthimianus 37

of at least three children: our Lucius and three other (perhaps female) chil-
dren. Their social status (free, freed, or slave?) remains entirely unclear.51
Συνομαίμονας (line 32) could be said of sisters or brothers, hence “siblings” is
the preferred translation, as in the German Geschwister. We surmise, however,
that sisters are meant. By sheer accident a grave epigram has been preserved
for a fifteen year old girl, daughter to a certain Lucius Anthimus, so probably
the same parents lost a second child.52 We may conclude that the parents had
four liveborn children, so they had the ius trium liberorum. When, probably,
the only male heir, our Lucius, died, his three sisters were still alive. The fact
the last line begins with αἰνόμορος and ends with ἀστεφανώτους “unwedded” is
not a coincidence.53

5.2 Social Status


We venture then to explore the hypothesis that our little boy was the son of a
freedman of relative wealth, relatively high social status and erudition, a phy-
sician, originating from Asia Minor, who had high expectations from his son,
perhaps—but this is speculation—as his successor.54 Véronique Dasen aptly
pictures the expectations of parents, who cultivated the ambition to compen-
sate a lack of prestigious ancestors by investing on their descendants, thus,
placing their pride in their future, as opposed to their past lineage: “The child
is a substitute for powerful patrician ancestors. Freeborn children, who may be
still alive, become ancestors.”55

6 Religious Aspects

The inserted corona, the wreath or crown, is a conventional, almost ornamen-


tal epigraphical symbol. It could symbolise some funeral sacrificial offering,

51  McLean, Introduction, 127.


52  IG 14, 2037.
53  Cf. Kaibel, EG 314, 27; Vérilhac, ΠΑΙΔΕΣ 1, 27 (p. 49).
54  On physicians as slaves or freedmen in ancient Rome in general, see Korpela, J. (1987).
Das Medizinpersonal im antiken Rom: Eine sozialgeschichtliche Untersuchung, 110–13; as
men of culture, see e.g. Samama, É. (2003). Les médecins dans le monde grec, 155, where a
wedding epigram with mythological content for a physician’s daughter drawing from the
Oresteia. For a discussion of arguments in favour of this hypothesis, please see below.
55  Dasen, V. ‘Wax and plaster memories: Children in elite and non-elite strategies’, in Dasen, V.
and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 136. Cf. also
Backe-Dahmen, Innocentissima, 80 “[die Freigelassenen] projizieren die eigenen Hoffnungen
auf einen gesellschaftlichen Aufstieg auf die Kinder.” In general: King, ‘Commemorations’.
38 Graumann and Horstmanshoff

or more specifically refer to the cult of a deity,56 or it could be interpreted


as a heraldic family sign. Perhaps one could draw a connection with l. 32
ἀστεφανώτους “unwedded”, said of Lucius’ sisters.
Literally ἐπήκoος in l. 5 (καὶ θεῷ ἰδίῳ ἐπηκόῳ) means ‘listening to’. The word
is very common in inscriptions from Asia Minor and is often associated with
healing deities like Asclepius, Apollo, Zeus Hypsistos, Hercules.57 It is never
used in a grave inscription, except here, and so is in itself proof of Lucius’
apotheosis. We read καί here as explicative, “that is their own god, giving ear
to them”, in Meinecke’s translation “merciful”. He will act as a kind of guard-
ian angel for the family. It is remarkable that this apotheosis is added to the
more conventional γλυκυτάτος, Latin dulcissimus “sweetest”), one of the most
frequently used epitheta in funeral inscriptions for very young children, espe-
cially in Asia Minor.58
The three Ὧραι (l. 9), goddesses of the hours, daughters of Zeus and Themis,
called Eunomia, Dike, and Eirene, are in the Homeric Iliad the keepers of the
heavenly gate. They watch over the seasons, and especially over the right time
of birth. They symbolically induce life. Μοῖραι (l. 16) means implicitly the three
Moirai (Latin Parcae), Clotho, Lachesis and Atropos.59 Γένεσις (l. 26) is quite
rare in funerary inscriptions. Its literal meaning is, of course, “birth”, but here
she is personified: Fate, like the Μοῖραι.60

7 Emotional Aspects61

Even though the wording is sometimes formulaic the text of the inscription is
an emotional roller coaster: from pride and joy at the start, to alternating hope

56  Backe-Dahmen, Innocentissima, 103.


57  Weinreich, O. (1912). ‘ΘΕΟΙ ΕΠΗΚΟΟΙ’, Mitteilungen des Deutschen archäologischen
Instituts; Athenische Abteilung 37, 21 no. 104, and 37–38; Chaniotis, A. (2011). Ritual
Dynamics in the Ancient Mediterranean, 274, n. 39.
58  Kajanto, ‘Epitaphs’, 35–36; Backe-Dahmen, Innocentissima, 90; Vérilhac, ΠΑΙΔΕΣ 2, 37, no. 110.
59  Them., Or. 32 describes their activities elaborately. Only Klotho is twice mentioned
explicitly in child epitaphs: Vérilhac, ΠΑΙΔΕΣ 1, 113 no. 76,1, Mysia second century AD, and
1, 217 no. 145,2, Rome, second-third century AD.
60  Cf. Vérilhac, ΠΑΙΔΕΣ 1, 233 no. 160, Tomis, v.9; Vérilhac, ΠΑΙΔΕΣ 2, 90; IG 12, 3,870, l. 14.
A striking Latin parallel is offered by Laes, ‘Hopes’, 52: D(is) I(nfernis) M(anibus)/ Aurelie
Aureliani| a(nnos) n(atae) XXXV et Bono fi(lio)| a(nnos) n(ato) X / Quem mihi | crudelis
Genesis| abstulit de scola| immerentem, / Et| Iuste filie a(nnos) n(atae) V,| Que erat ingressa |
atminestrare pa|rentibus dulcissi|mam aetate(m).
61  On emotions in Greek Antiquity: Konstan, D. (2006). The Emotions of the Ancient Greeks:
Studies in Aristotle and Classical Literature; in inscriptions: Lattimore, Themes; in Latin
the Epitaph of L. M. Anthimianus 39

and sadness at every new onset of disease, to fatalism at the end. From line 6
onwards, the child becomes his own spokesperson. The emotions of the child,
however, remain in the dark. As readers we share the pride and hope of the
parents, who (including their three daughters) were still alive when the stone
was erected. In l. 4 the tria nomina of “their sweetest child” (τέκνῳ γλυκυτάτῳ)
take pride of place. In l. 10 the father lifts up his son “joyfully” (γεγηθώς), a son
who is “beloved by all” (πᾶσι ποθητός l. 15). When the illnesses hit the child, the
father remains hopeful: “thinking to save my fate” (δοκῶν ὅτι μοῖραν ἐμὴν (. . .)
σώσει l. 19). Even after the second illness there is still hope that Lucius will be
healed “as before” (ὡς τὰ πάροιθεν, l. 25).
We get involved in their despair and sadness. In l. 3 the coupling of the
Latin nomen Φηλεικίσσιμα (Felicissima) and the clichéd Greek epithet ἀτυχεῖς
(corresponding to Latin infelices), traditionally said of bereaved parents, is rhe-
torically impressive and probably not accidental.62 There is even more sadness
in l. 8: καὶ σὺ δακρύσεις “even you (traveller) will straightway weep”. In l. 18 the
father is ταλαίφρων “distressed” and l. 24 describes the λύπας καὶ στοναχάς the
“grief and groans” of the parents after the operation.
In l. 26 we find a trace of an emotion that is formulated more clearly in other
funerary inscriptions: envy. Οὐδ’ οὕτως μου Γένεσις δεινὴ πλησθεῖσ’ ἐκορέσθη,
“Not even my Genesis (the goddess of my Birth) was completely satiated”. The
goddess, a kind of Fate, or Moira, almost a personified horoscope, is envious
of human happiness and is only satiated after she has destroyed a young life.63
Hatred against the disease is expressed in the epithet στυγερήν “hated”
(l. 31), referring to the corpse of the child that is wasted away, now lifeless, not
anymore the embodiment of Lucius.64

inscriptions: Pikhaus, D. (1978). Levensbeschouwing en milieu in de Latijnse metrische


inscripties: Een onderzoek naar de invloed van plaats, tijd, sociale herkomst en affectief klimaat.
62  Backe-Dahmen, Innocentissima, 90.
63  In some epigrams like GV 1732. In Merkelbach, R. and Stauber, J. (1998–2004). Steinepi-
gramme aus dem griechischen Osten (SGO) (3), no. 14/13/05 the personified Greek Φθόvος
(Envy) is clearly to be blamed for the premature dead of a child or youth, see Strubbe, J. H. M.
‘ “Niet Tijd maar Nijd. . . . . .”: Dood en hiernamaals in de Griekse en Romeinse grafinscrip-
ties’, in Horstmanshoff, H. F. J. (1994). Pijn en Balsem, Troost en Smart: Pijnbestrijding en
Pijnbeleving in de Oudheid, 138–39. In SGO (1), no. 01/12/15, an inscription from the tomb of
a three year old boy, Marcus Audius, in Halicarnassus in Caria, presents Hades as a divine
being that is pleased by sacrifices being made of people and children, of death and tears.
On horoscopes see Barton, T. S. (1994). Power and Knowledge: Astrology, Physiognomics,
and Medicine under the Roman Empire; the precise age recording of years, months and
days in l. 5 may point in this direction.
64  Cf. Samama, Médecins, fragments 023; 072; 155; 175. Tηκεδόνα στυγερήν does not refer here
to the surviving parents’ hateful old age, but to the effect of the disease.
40 Graumann and Horstmanshoff

The parents may have found consolation in the idea that the young boy
henceforth will watch over them θεῷ ἰδίῳ ἐπηκόῳ, like “their own hearkening
god”. Such elements are common in grave epigrams.65 There is an element
of comfort too, in the idea that a traveller might check his paces to read the
inscription and show compassion (ll. 6–8, 30). Furthermore, the making and
erecting of the slab itself, and possibly the yearly commemoration, would have
been an effective part of the mourning process.66
The prevailing emotion in the poem, however, is fatalism: so much is clear
as early as the first appearance of the Horae (l. 9). The decision of the Fates
(Μοῖραι, l. 13) makes all prayers (l. 12) and even medical treatment (l.19) futile.
Their seal is inescapable (l. 16).
This feeling of fatalism is accentuated by linguistically contrasting the
terms γονεῖς “parents” (l. 3), γενέτης “father” (l. 14), γεννήσας “father” (l. 18), and
γιναμένοις “those who begat me” (l. 31) with the all-conquering divine Γένεσις
“Birth”, who prevents Lucius’ parents from claiming their own son for them-
selves. He belongs to the Moirai rather than to his genitors. His mother gave
birth to him; his father assisted actively in the process and intervened bravely
when his son was ill, but none of these mortal parents could claim real owner-
ship of Lucius, who thus is imagined to have joined the divine world. He leaves
his parents and his siblings behind, twice expressed in κατέλειπον (l. 31) and in
λείψας (l. 32).67
In ll. 10 εἵλατο (the father) “took up”, 14 εἱλάμενος (the father) “chose”, 23
(the friends) ἀνεῖλαν “took out”, and 29 (the mother) εἷλαν “took” (life from
my eyes) the same verb and verbal forms occur. The verb refers to a very
‘hands-on’ approach to Lucius’s birth, upbringing and course of life in general.
Unfortunately, and despite the family’s interventionist approach, the Moirai
or the Genesis get hold of little boy, a rather pessimist view of human fight-
ing against fate. When Fate brought down a third disease on him (l. 27), there
could only be one conclusion: this boy was αἰνόμορος, “doomed to a sad end”
(l. 32), the leitmotif of the poem.

65  Rawson, ‘Death’, 362.


66  Yearly commemoration of the dead as a social act was common in mid second century AD,
and was a product of Roman mourning rituals. Cf. McWilliam, ‘Children’; and King,
‘Commemorations’.
67  Cf. AP 7,467,8; 7,662: a daughter follows her brother.
the Epitaph of L. M. Anthimianus 41

8 Medical Context

8.1 The Perspective of Ancient Medicine


It is not easy to describe the course of the disease(s) in this inscription from
the perspective of ancient medicine. We only have a few clues in favour of the
idea that specialised medical knowledge was involved. Ancient physicians
were generally reluctant to treat children.68 Lucius died at a very young age
of only 4 years old. Numbering of an exact age length (“4 years, 5 months and
20 days”, ll. 4–5) does not necessarily mean that the exact age of Lucius was
really known. Age rounding was not uncommon in Roman antiquity, and as,
for example, Galen’s extant writings suggest, exact age calculations were of no
particular medical significance.69 The chronological details in this particular
case were important—perhaps because a horoscope was or had been cast for
the baby more or less at birth.
Attending a birth was in Antiquity, as in many cultures, women’s business.70
From ll. 10–11, however, it may be deduced that the father was not only present,
but performed in person several tasks usually destined for a midwife. He took
the baby from the earth, washed it and swaddled it.71 Αὐτός (“in person” in l. 11)
emphasises the special character of this action72 L. 14 tells us explicitly that the
father chose the mother as nurse (τροφὸν εἱλάμενος) and reared the infant him-
self. This was quite exceptional: even among the less well-to-do the common

68  Children should not be treated like adults, Celsus, Med. 3.7.1. On diseases of children in
ancient medicine in general: Bertier, J. ‘La médicine des enfants à l’époque impériale’, in
Temporini, H. and Haase, G. G. W. (1995). ANRW 2.37.3, 2147–2227; Hummel, C. (1999).
Das Kind und seine Krankheiten in der griechischen Medizin: Von Aretaios bis Johannes
Aktuarios (1. bis 14. Jahrhundert).
69  Mattern, Galen, 106; on a possible reference to a horoscope see above n. 63.
70  See the contributions of Porter (Chapter Ten) and Bolton (Chapter Nine), 285–303 and
265–284 in this volume.
71  “The environment [of birth], human and divine, is entirely female”, with Dasen, V. (2009).
‘Roman birth rites of passage revisited’, Journal of Roman Archaeology 22, 204; cf. also
Dasen, V. ‘Le pouvoir des femmes: Des Parques aux Matres’, in Hennard Dutheil de la
Rochère, M. and Dasen, V. (2011). Des Fata aux fées: Regards croisés de l’Antiquité à nos
jours, 115–39. On duties of (medical) men attending especially difficult births in coopera-
tion with midwives and their female helpers, see Hanson, A. E. (1994). ‘A division of labor:
Roles for men in Greek and Roman births’, Thamyris 1, 157–202.
72  This may not have been so unusual: the poet Statius reports in two of his Silvae both his
own and his friend Melior presence at the birth of a child (Stat., Silv. 2,1,78–81; 5,5,69–72);
see also, Laes, C. ‘Delicia-children revisited: The evidence of Statius’ Silvae’, in Dasen, V.
and Späth, T. (2010). Children, Memory, and Family Identity in Roman Culture, 265. Dasen,
‘Pouvoir’, 122, points out that Cato Maior attended in person the washing and swaddling
of his son (Plut., Vit. Cat. Mai. 20,4–5).
42 Graumann and Horstmanshoff

practice was to employ a wet nurse, often a slave woman. Only a few voices
were raised in favour of being breastfed by the baby’s own mother.73
However, the father’s active involvement in Lucius’ life continues. The father
healed (εἰάσατο l. 18) with medicaments (εἰάμασι l. 19) his son’s disease about
the testicles. Eἰάμασι is a general medical term, which could encompass ban-
daging as well as medicaments.
The Roman encyclopedist Celsus mentions the treatment of testicle
problems, with medicaments, and even with surgery or bandaging.74 In the
Hippocratic and Galenic tradition, children were classified as having “hotter” ’
and “wetter” qualities than adults, which required correspondent treatment
in case of sickness.75 Galen advises ‘moistening and cooling’ with specific
salves against inflammations of the genitals.76 The Byzantine physician Paulus
Nicaeus in his manual several treatments of testicular inflammation describes
using dressings soaked with honey, vinegar and different types of oil.77
As to the operation following the second disease (ll. 22–23), a comparable
case is described in the Hippocratic Epidemics: fatal gangrene of middle foot
in the female slave of Aristion.78 Generally, any surgical intervention was the
‘treatment of last resort’.79 Celsus recommends excision, or finally amputation,

73  One of them was the medical author Soranus (second century AD), Sor., Gyn. 2.16–18.
On Soranus, see Bolton and Porter in this volume. More specific information about new-
born’s feeding: Bradley, K. (1994). ‘The nurse and the child at Rome’, Thamyris 1, 137–56;
Gourevitch, D. (1998). ‘L’ alimentation du petit enfant romain’, Revue internationale de
pédiatrie 289, novembre–décembre, 43–46; Wiesehöfer, J. ‘Selbstsüchtige Mütter und
gefühllose Väter? Bemerkungen zur Ernährung und zum Tod von Neugeborenen und
Säuglingen in der Antike’, in Mauritsch, P. et al. (2008). Antike Lebenswelten: Konstanz-
Wandel-Wirkungsmacht, 503–31.
74  Treatment with medicaments: Celsus, Med. 6.18.6, with surgery: 7.18–19, with bandaging:
7.20.
75  Gal., De plac. Hipp. et Plat. 8.6 (K. 5.692–93 = De Lacy CMG V, 4,1,2, 516). On children in
Galen’s works, see Byl, S. ‘L’enfant chez Galien’, in López-Férez, J. A. (1991). Galeno: Obra,
Pensamiento e Influencia, 107–17.
76  Gal., De meth. med., 10.9 (K. 10.702–03 = Johnston and Horsley 62–65); De tumor. praeter
nat., 15 (K. 7.729): terminology of swellings relating to the scrotum and its content.
77  Paulus Nicaeus, De re medica 85 (Ieraci Bio 172–73).
78  Epid., 5.41 (L. 5.232.6 = Smith 172 = Jouanna 20): ὁ ποὺς ἐσφακέλισε κατὰ μέσον τοῦ ποδὸς
ἔνδοθεν, “the foot spontaneously ulcerated in the middle of the foot”. The illness was
diagnosed by M. D. Grmek as metatarsal osteomyelitis caused by staphylococci; cf. also
Jouanna, 147. In this very short case-story, therapeutical measures are not mentioned.
Eventually the patient dies.
79  Nutton, Ancient Medicine, 246.
the Epitaph of L. M. Anthimianus 43

if a bone is really rotten.80 Elsewhere he calls gangrene therapy not difficult


in the initial phases, utique in corpore iuvenile, “especially in young patients”.81
The father was supported by his friends or colleagues, who were surgeons
themselves: ἔταμόν με φίλοι γενέτου ‘my father’s friends performed an opera-
tion on me’ (l. 23). Was he a partner within a medical group practice? There is
evidence for medical group practices in the ancient world,82 as there is for col-
legial friendship, membership of a collegium and master-pupil relationships in
a kind of guild. From the first century AD onwards, there were colleges, ‘clubs’
of physicians at Rome, but it was not until 368 AD that a kind of super-elite
guild, the ‘College of Physicians in Rome’, was established by law.83
There is some technical language in the inscription. In l. 22 two termini tech-
nici are used: σῆψις, “putrefaction” and πεδίον ποδός, “part of the feet next the
toes”,84 also known as the ‘midfoot’. Galen advises in a comparable situation:
“but if some part of what is suppurating seem to have putrefied (σεσηπέναι),
it is necessary to cut this out.”85 The combination πεδίον ποδός—which itself
may have evolved from the metaphor of a ‘ploughed field’—is only found in
medical authors of the second and third century AD, like Rufus, Galen and
Oribasius.86 But we may interpret this term more broadly in a less ‘anatomi-
cally’ correct way: at the time there was not yet an international standard on
human anatomic terminology. Πεδίον ποδός may simply mean some external
part of the foot namely the back of the foot (dorsum pedis).

80  Celsus, Med. 7.33; 8.2.5.


81  gangrenam vero, si nodum plane tenet, sed adhuc incipit, curare non difficillimum est, “But
gangrene, when not yet widespread, but only beginning, is not very difficult to cure, at any
rate in a young subject”, Celsus, Med. 5.26.34.
82  Nutton, V. ‘The medical meeting place’, in Eijk, P. J. van der et al. (1995). Ancient Medicine
in its Socio-Cultural Context, 3–25.
83  Samama, Médecins, 68; Nutton, Ancient Medicine, 256.
84  LSJ 1352, s.v.
85  Gal., De meth. med. 13.5 (K. 10.886 = Johnston and Horsley 336).
86  Ruf., De ossibus 39 (Daremberg-Ruelle, 193); Onom. 125 (Daremberg-Ruelle, 149); Gal., De
ossibus (K. 2.777.7); De usu part. (K. 3.194.18); Orib., Med. Coll. 25.22.6.2 (CMG VI, 2,1 Raeder);
Theophilus Protospatharius, De corp. hum. fabr. 1.20.6 a.o.; See the detailed discussion
in Michler, M. (1961). ‘Zur metaphorischen und etymologischen Deutung des Wortes
Pedíon in der anatomischen Nomenklatur’, Sudhoffs Archiv 45, 216–24; and Skoda, F.
(1988). Médecine ancienne et métaphore: Le vocabulaire de l’anatomie et de la pathologie en
grec ancien, 49–50.
44 Graumann and Horstmanshoff

Further on, we find more technical words: ἐκτήξασα “wasted away” (l. 28),
and τηκεδόνα “consumption” (l. 31), both from the verb τήκω, have medical con-
notations.87 Τὰ λοιπά probably refers here extremities and the thorax.88
Furthermore, the word νόσος, “disease” is mentioned four times (ll. 17, 18, 20,
27). Τhere is a chronological description of disease evolution, comparable to
those archetypical ancient case histories of the Hippocratic Epidemics.89 The
whole story, with its focus on the three ailments of the little boy, has a ‘morbid’
character, almost unbearable for a layperson, but not for a physician. Remarks
on prognosis (e.g. based on qualitative signs like fever, pulse, urine), typical
for case histories, are lacking,90 but no one would expect them in an epitaph.

8.2 Conclusion
Does the content and the language of our epigram point towards a possible
medical profession for the father-narrator? The presence of the father at birth,
his active role immediately after the birth and his decision to choose the
mother as nurse could be explained by assuming that the father had at least
something more than superficial medical knowledge. The fact that he healed
the first disease by himself (l. 18–19) and was supported by his friends in oper-
ating on his child’s foot (l. 23), as well as the use of some technical terminology,
all point in the same direction.
These arguments put together favour the hypothesis that the father was
indeed a physician.91 None of them is completely convincing if taken on its
own, but the cumulative evidence might tip the scale. After all, we know of
several manumitted physicians with tria nomina originating from Asia Minor,

87  For reasons explained in sections 9–10, the anachronistic translation “tuberculosis”
should be avoided.
88  Klitsch, Krankengeschichte, 207–08; Zingerle, ‘Fall’, 442.
89  Graumann, L. A. (2000). Die Krankengeschichten der Epidemienbücher des Corpus Hippo-
craticum: Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven Diagnose;
νόσος as a divine punishment is mentioned repeatedly in the so called confession inscrip-
tions from Asia Minor, but they contain no technical medical language, see Chaniotis, A.
‘Illness and cures in the Greek propitiatory inscriptions and dedications of Lydia and
Phrygia’, in Eijk, P. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context,
323–44; Petzl, G. (1994). Die Beichtinschriften Westkleinasiens.
90  On the meaning and importance of ancient prognosis, see Graumann, Krankengeschichten
64–66.
91  Zingerle, ‘Fall’, 443–44; Meinecke, ‘Quasi-autobiographical’, 1026–27. Meinecke’s argu-
ment is partly based on his belief in the Smyrnean origin of the slab and its presupposed
connection to a Greek medical school.
the Epitaph of L. M. Anthimianus 45

who practised their profession in the higher classes of Rome during the
second and third centuries AD.92 The father, Lucius Minicius Anthimos, may
have been one of those freedmen.93
On the other hand, there is no explicit mention of any physician in this
text (ἰατρός or χειρουργ(ικ)ός); neither the father nor his friends are called
physicians.94 The father himself might have been non-medical, but with medi-
cal friends in his narrower relationship.95 Even the father’s friends could have
been some sort of “amateurs of medicine” (φιλίατροι) who were practicing
medical procedures only based on general knowledge.96
Nevertheless, it may be argued that this text is a dedication to the child,
not to the father, much less to his friends. The child is in the centre of the
story, and this leaves remarks about professions understandably to the
background.97 At any rate, in case of manumitted physicians the omission
either of the professional title or of the manumitted state (libertus) on grave
stones is far from being a rare finding.98 In the special case of Greek physicians
in Rome, even a tria nomina could be interpreted as a strong sign of assimila-
tion (Romanisation), of a freeborn, not enslaved Greek physician after receiv-
ing the full civis Romanus.99

92  Korpela, Medizinpersonal, 110–13.


93  Unfortunately, there is no other contemporary epigraphic evidence for a physician with
the name ‘Anthimos’ in Rome or in other Roman cities. To our knowledge, there is only
one inscription by a military physician named ‘Lucius Fabius Anthi[mus]’ dated to ca.
the end of second century AD from Großkrotzenburg, Germania Superior: CIL 13, 7415;
Rémy, B. (2010). Les médecins dans l’Occident romain (Péninsule Ibérique, Bretagne, Gaules,
Germanies), 162–63.
94  We may expect some wording like “friends who are doctors” (φίλοι ἰατροί), as those found
in Galen: see Mattern, Galen, 20, 209, n.43 and 211, n.62. Long before, Georg Kaibel (1849–
1901) had expressed some doubts EG 314, 120.
95  Mattern, Galen, 22.
96  Salazar, C. F. (2000). The Treatment of War Wounds in Graeco-Roman Antiquity, 91. Nutton,
Ancient Medicine, 259, speaks of “learned lay men and women”. Mattern, Galen, 25 on the
example of Galen and his ‘friends and companions’. One of Galen’s own patients could
serve as an exemplary case (De meth. med. 5.12 (K. 10.362): “The patient himself was not
inexperienced in medicine, but rather was one of those who is experienced at therapy
from practice and exercise [of the art]”; trans. Mattern, Galen, 125.
97  In Greek child epigrams the father’s profession is rarely mentioned; Vérilhac, ΠΑΙΔΕΣ 2,
96 presents only five cases, none of them features a physician.
98  Kudlien, Stellung, 133 and 149.
99  Kudlien, Stellung, 62–64.
46 Graumann and Horstmanshoff

The particular use of ἰάομαι, especially in both lines 18 and 19, does not auto-
matically mean that the described act of healing is exclusively performed by a
physician.100 Discussing medical content was not confined to medical special-
ists. There was indeed an ongoing and informal cultural interchange between
medical professionals and laymen, and it is generally believed that both cat-
egories shared the same language and explanatory models.101 There was no
secret medical wisdom, and a specific medical vocabulary was not yet fully
established.102 The practice of medicine, in fact, was much more of a public
(agonistic) art.103 We will end in a somewhat circular argument without any
objective conclusion: the father is a physician, so he uses medical descrip-
tion; the father uses medical description, so he must be physician. If we argue
a contrario, the father himself probably was a well-trained, sophisticated Greek
teacher, a sort of a medical autodidact, and simply interested in medicine as a
caring father.104

100  Samama, Médecins, 579, citing: Brock, N. van (1961). Recherches sur le vocabulaire medical
du Grec ancien: Soins et guérison, 42 (ἰάομαι only means doing some healing, but does not
automatically imply a physician).
101  For ‘explanatory model’ as concept in medical anthropology, see Kleinman, A. (1980).
Patients and Healers in the Context of Culture: An Exploration of the Borderland between
Anthropology, Medicine, and Psychiatry; Nijhuis, K. ‘Greek doctors and Roman patients’, in
Eijk, P. J. van der et al. (1995). Ancient Medicine in its Socio-Cultural Context, 49–67.
102  Nutton, ‘Murders’, 32; Jori, A. (2009). ‘Medizinische Bildung für Laien’, Sudhoffs Archiv 93,
67–82. Mattern, Galen, 24: “The works of several aristocratic laymen of the first and sec-
ond centuries AD [. . .] display medical erudition or a keen interest in (some might say
obsession with) health and medical matters.” On Galen, Mattern states: “Galen believed
that educated aristocrats should know something about medicine, and he values [. . .]
patient’s medical expertise”; Mattern, Galen, 125. Eventually, one may refer to the anec-
dote in the second century author Aulus Gellius (Gell., NA 18.10.8) about the common
medical knowledge in his lifetime and his remark: turpe esse ne ea quidem cognovisse ad
notitiam corporis nostri pertinentia, “not to know even such facts pertaining to the knowl-
edge of our bodies”, trans. Rolfe 1952.
103  Cf. Nutton, ‘Murders’, 37: “medicine in classical antiquity was an open science”. See also,
Nutton, Ancient Medicine, 270; Mattern, Galen, 26. We may only refer to the famous exam-
ple of Celsus’ unclear medical profession.
104  Barton, Power, 167. Gourevitch, D. ‘The sick child in his family: A risk for the family tradi-
tion’, in Dasen, V. and Späth, T. (2010). Children, Memory, and Family Identity in Roman
Culture, 273–92, here 290: “Good and bad fathers (those at least we know) [in the Roman
Empire] were genuinely interested in medicine”. One may think of the exemplary case in
Galen: Piso observes and intervenes in the medical treatment of his own, severely injured
child; Gal., De ther. ad Pis. 1 (K. 14.212–14).
the Epitaph of L. M. Anthimianus 47

9 The Perspective of Modern Medicine

9.1 Medical Historical Discussion


Why is it important to interpret this sad story from the perspective of mod-
ern medical science? What does it add to its general interpretation apart from
what we know about its historical, philological and archaeological context? We
have a linear, chronological description of an illness with a beginning and an
end, but we miss a final, explicit medical diagnosis. The sophisticated reader is
tempted, almost urged, to make a retrospective medical diagnosis.105

9.2 Retrospective Diagnosis: Overview


There have been several modern attempts for retrospective diagnostic.
Verdicts are surprisingly in unison from 1927 to 2001: Lucius suffered from
tuberculosis.106 The three diseases of Lucius have been interpreted as: urogeni-
tal tuberculosis (testicle disease), tuberculous osteomyelitis (foot disease), and
fatal tuberculous peritonitis (belly disease). It is remarkable that only two of all
the ‘diagnostic experts’ listed here namely Klitsch and Grmek, were themselves
professional physicians.107

9.3 Tuberculosis (TB) and its Standard Clinical Symptoms among


Children
Tuberculosis (TB) is first of all a lung disease (pulmonary TB) with prevailing
respiratory symptoms, but it is also a multi-organ infection potentially spread-
ing in all tissues and organs other than the lungs (extrapulmonary TB).
One of the classical symptoms of pulmonary TB is the chronic, more than
two or three weeks persisting, non-remitting, partly agonising cough. This

105  Graumann, Krankengeschichten, 125–26. Of course, we are not the only recent investi-
gators performing retrospective diagnosis on ancient epigraphical material; see for
example: Prêtre, C. and Charlier, P. (2009). Maladies humaines, thérapies divines: Analyse
épigraphique et paléopathologique de textes de guérison grecs, and Charlier, P. (2009). Male
mort: Morts violentes dans l’Antiquité.
106  We have considered before a few ancient diagnoses. See the discussion above. Modern
diagnoses: Meinecke, ‘Consumption’/‘Quasi-Autobiographical’; Zingerle, ‘Fall’; Klitsch,
Krankengeschichte; Grmek, Maladies, 289; Gourevitch, ‘Déontologie’; ead., Giovani.
107  At the time of publication of his work, Klitsch (born 1948) had still limited experience as a
clinical practitioner. This discussion was his medical doctoral thesis. Only then he started
working as a practising physician. Grmek, although educated as a physician, turned his
research interests to philology and history of sciences already in the course of his medical
training. See Fantini, B. (2001). ‘Obituary Mirko Dražen Grmek’, Medical History 45, 273
and 275.
48 Graumann and Horstmanshoff

cough may be sometimes associated with coughing up blood (haemoptysis).108


Checking the narrative on our stone, there is no hint of coughing or cough-
ing up blood in the chronicle of Lucius’ diseases.109 In childhood, especially in
early childhood (0–5 years), symptoms of (pulmonary) TB may be rather sub-
tle, non-specific, or even absent. The same holds true for cough. Only the com-
bined presence of persistent, non-remitting cough of more than two weeks’
duration, an objective weight loss over three months with failure to thrive, and
fatigue in children over 3 years of age provides a ‘good’ diagnostic tool for pul-
monary TB.110
Today, TB is a rather endemic disease, especially in children. From the
perspective of Europe and the USA, however, TB is a ‘historical’ disease, van-
ished from the limelight, or perhaps re-emerging with changing patterns due
to increasing drug-resistance.111 Malnutrition, poverty, poor hygiene, badly-
ventilated narrow and overcrowded living spaces are all factors that predispose
children in particular toward the infection.112 Just before the advent of che-
motherapy in the 1940s, a decline in tuberculosis has been noted in Western
countries.113 Taking the example of modern Germany in 2008, only 124 chil-

108  “Coughing up blood” as the classic symptom of (pulmonary) tuberculosis is interestingly


also mentioned by non-medical authors like Mattern, Galen, 6. Note, however, that medi-
cal authors already at the beginning of twentieth century have mentioned that haemop-
tysis is not significant at all. E.g., Much, H. (1923). Die Kinder-Tuberkulose: Ihre Erkennung
und Behandlung. Ein Taschenbuch für praktische Ärzte, 49: “Blutspucken spielt so gut wie
keine Rolle.” Moreover, the sign of haemoptysis especially in children is noted very rarely
by ancient medical authors: Hummel, Kind, 209 refers only to Cael. Aur., TP 2.12.138; cf.
also 139.
109  Cough may have been so common in childhood in this period that it was not worth men-
tioning. Can this be interpreted as an argument from silence?
110  Marais, B. J. et al. (2006). ‘A refined symptom-based approach to diagnose pulmonary
tuberculosis in children’, Pediatrics 118, 1350–59.
111  TB is endemic in Eastern Europe, Southeast Asia, India, Thailand and the Philippines.
TB in Europe with special reference to children: Walls, T. and Shingadia, D. (2007). ‘The
epidemiology of tuberculosis in Europe’, Archives of Disease in Childhood 92, 726–29. On
drug-resistance (Iranian perspective), see: Velayati, A. A. et al. (2009) ‘Emergence of new
forms of totally drug-resistant tuberculosis bacilli: Super extensively drug-resistant tuber-
culosis or totally drug-resistant strains in Iran’, Chest 136, 420–25.
112  Roberts, C. A. and Buikstra, J. E. (2003). The Bioarchaeology of Tuberculosis: A Global
View on a Reemerging Disease, 54–61; Connolly, C. A. (2008). Saving Sickly Children: The
Tuberculosis Preventorium in American Life, 1909–1970, 56.
113  This was probably due to improved nutrition and healthier living conditions, especially
due to the introduction of standard pasteurisation of milk by which the risk of cow-
borne TB (infection with Mycobacterium bovis through cow milk intake) was minimised.
the Epitaph of L. M. Anthimianus 49

dren under the age of fifteen were diagnosed, while the incidence for children
below five years of age was only 1.8 (per 100.000), with about eighty per cent of
those children suffering from pulmonary TB.114 Today, there is a close correla-
tion of TB with malnutrition and immunologic compromise, especially in case
of AIDS/HIV.
Children could be infected at a very young age through inhalation (pulmo-
nary disease) after being in contact with an infected adult, or through inges-
tion of infected animal milk, or even breast milk. Congenital TB (infection
before birth) is also possible.115 In the natural course of TB (without antibiotic
treatment), infected children would develop pulmonary symptoms impairing
their lungs or tracheo-bronchial tree within one year at a rate of about sixty
or eighty per cent;116 up to a quarter of the cases would develop extrapulmo-
nary symptoms, most commonly in the lymph nodes (mainly cervical), the
bones, the joints, the pleura, and the meninges,117 but also in the abdominal
and genitourinary tract.118 Extrapulmonary tuberculosis is reported to be more
widespread among children younger than three years of age, because of their
immature immune system, which translates effectively to a higher frequency
of lymphohaematogenous spread.119 Prolonged household exposure to the dis-
ease (such as close contact with a person with open pulmonary tuberculosis,
e.g. an infected mother) makes up the eighty per cent of the risk factor for
children.120 Especially young, infected infants are at high risk of severe dis-
ease progression and death. Without any antibiotic treatment one third of all

Alternatively, this decline may also be due to a kind of natural (long lasting) epidemic
cycle. More on this topic in Roberts and Buikstra, Bioarchaeology, 12; Connolly, Saving, 7.
114  Robert-Koch-Institut, Germany. http://www.rki.de/cln_151/nn_274324/DE/Content/InfAZ/
T/Tuberkulose/Download/TB2008.html (received on 31.05.2011).
115  Roberts and Buikstra, Bioarchaeology, 49.
116  Marais, B. J. and Donald, P. R. ‘The natural history of tuberculosis infection and disease in
children’, in Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical
Reference, 136.
117  Wang, P. D. (2008). ‘Epidemiological trends of childhood tuberculosis in Taiwan 1998–
2005’, International Journal of Tuberculosis and Lung Disease 12, 250–54. Interestingly,
a high local incidence of bone and joint tuberculosis in up to 56% of extrapulmonary
symptoms is reported in Taiwan: Nong, B.-R. et al. (2009). ‘Ten-year experience of children
with tuberculosis in Southern Taiwan’, Journal of Microbiology, Immunology, and Infection
42, 516–20.
118  Graham, S. M. et al. ‘Clinical features and index of suspicion of tuberculosis in children’, in
Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 154.
119  Reuter, H. et al. ‘Overview of extrapulmonary tuberculosis in adults and children’, in
Schaaf, H. S. and Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 377.
120  Marais and Donald, ‘History’, 133.
50 Graumann and Horstmanshoff

patients (adults and children alike) will die out of TB (pulmonary or systemic
failure). In our case, Lucius has suffered and survived his disease complex for
nearly five years. If we compare the three supposed types of TB in Lucius (in
the testicles, the midfoot and the abdomen) to recent descriptions of the ill-
ness we can assert that:

1) Genitourinary TB, such is for example the TB of the epididymis, is usually


caused by haematogenous spread from any other primary infected organ (sec-
ondary TB). The illness usually presents itself as scrotal swelling, which later
develops into a hard, craggy epididymis and sometimes results in a draining
sinus on the scrotum. The disease in this case is usually not confined to the epi-
didymis, it often includes the testicle (‘epididymo-orchitis’); while on occasion
it can lead to specific tissue necrosis (‘caseation necrosis’) of both, epididymis
and testicle. Antibiotic administration set aside, the treatment nowadays con-
sists primarily in epididymectomy (i.e. the excision of the epididymis).121 But,
the same disease can manifest itself very obscurely, for example as isolated TB
only of the testicular sheath.122
2) Skeletal or bony TB, especially in metacarpal (midhand) or metatarsal
(midfoot) bones (spina ventosa or tuberculous dactylitis), is nowadays rarely
seen. It occurs usually as a secondary disease of primary pulmonary tuberculo-
sis, which has gone undiagnosed.123
3) Abdominal TB in children mostly manifests itself with abdominal disten-
sion, pain or else painlessness (with or without peritonitis). Other symptoms
include: fever, weight loss, night sweats, diarrhoea, bloody stools, and jaundice,
but may vary considerably, thus, mimicking clinically many other diseases and

121  For an Indian perspective with an overview of 9 cases of genitourinary tuberculosis in


children, see Chattopadhyay, A. et al. (1997). ‘Genitourinary tuberculosis in pediatric
surgical practice’, Journal of Pediatric Surgery 32, 1283–86. Cf. also Fishberg, M. (1932).
Pulmonary Tuberculosis, 188–89.
122  In this case, the physician can be led to the wrong diagnosis of acute scrotum, which
results in unnecessary surgery of the testicle. See, for instance, the report of a 2-year-old
child, who was misdiagnosed as suffering from testicular torsion, and for that reason “mis-
takenly” operated upon in Sookpatorom, P. et al. (2010). ‘Isolated tuberculosis of tunica
vaginalis in a child’, Pediatric Surgery International 26, 763–65.
123  Roberts and Buikstra, Bioarchaeology, 108. Exemplary case: Patel, N. C. et al. (2000).
‘Tuberculous dactylitis (spina ventosa) secondary to pulmonary tuberculosis’, Applied
Radiology 29, 34–35 (the case of a 6-month-old Asian girl with a draining sinus from the
right foot). In their discussion, the authors name as differential diagnosis syphilis and
pyogenic infection. The most common affected bone in children’s TB is neither hand nor
foot, but the tibia (shinbone): Roberts and Buikstra, Bioarchaeology, 98.
the Epitaph of L. M. Anthimianus 51

making diagnosis extremely difficult even nowadays. In up to twenty per cent


of the cases it manifests itself as solid organ disease (liver, spleen or pancreas).
Untreated cavitary (=open) pulmonary TB is strongly associated with gastroin-
testinal TB via prolonged exposure to swallowed infected secretions.124

9.4 Tuberculosis: Exact Diagnosis?


Another pitfall when diagnosing TB lies in its clinical reality. Sometimes diag-
nosis itself could be a very difficult task. Signs and symptoms, especially in the
sick child, are seldom clear from the beginning due to the great variety of the
ways they manifest themselves. The symptoms of TB may be similar to those of
other diseases. Precisely because TB is able to mimic other diseases, it can also
have rare and unusual clinical presentations. In Lucius’ case, the complex of
the three diseases described could easily be interpreted as set of symptoms of
three different diseases. On the other hand, it is equally possible that the indi-
vidual symptoms of TB can be related to different, non-tuberculous diseases,
and this holds true even in the case of chronic cough, e.g. cough as sign of
bronchial asthma. Even the so-called ‘classical signs’ of TB could be mimicked
by other, non-tuberculous diseases, such as syphilis.125
Retrospectively, one has to admit that prior to microbiological diagnosis,
the discovery of x-rays, the established use of the diagnostic skin test in chil-
dren (epidermal tuberculin test), and the introduction of antibiotics a number
of patients, especially children, were victims to other diseases not clearly dis-
tinguishable from TB. Their symptoms, due to lack of the appropriate diag-
nostic tools were confused and interpreted as symptoms of TB. Such was, for
instance, the case with the Hodgkin’s disease, when it was combined with cer-
vical adenitis, fever, and weight loss. Even nowadays, the diagnosis of TB and
its subsequent treatment with antibiotics presupposes careful microbiologi-
cal testing (using some kind of tissue specimen, most commonly sputum) in
addition to positive tuberculin skin test (the intradermal Mendel-Mantoux),
and positive chest x-ray findings in conjunction with newly developed immu-
nological tests, and occasionally it must even be supported by animal testing
(artificial infection of animals).126 Unfortunately, diagnosis of TB in children

124  Fishberg, Tuberculosis, 239; Reuter, ‘Overview’, 382–83.


125  Reuter, ‘Overview’, 387: “Extrapulmonary TB [= tuberculosis] may involve almost any body
organ system and like syphilis is a great mimic of many other diseases”.
126  In Germany, the medical reference paper is: Schaberg, T. et al. (2001). ‘Richtlinien zur
medikamentösen Behandlung der Tuberkulose im Erwachsenen- und Kindesalter’,
Pneumologie 55, 494–511. New tests in children: Detjen, A. et al. (2006). ‘Immunologische
Diagnostik der Tuberkulose-Interferon-γ-Tests’, Monatsschrift für Kinderheilkunde 154,
52 Graumann and Horstmanshoff

is extremely complicated for many practical reasons, not least because in chil-
dren a sufficient amount of sputum and other respiratory specimens are more
difficult to collect and microbiological tests yield poorer positive results than
in those made on adults. The tuberculin skin test is not specific enough and
may be positive in non-tuberculous mycobacteria, too.127 Blood tests still are
not able to diagnose childhood TB accurately. Even more difficult is diagnosis
in immunocompromised children, such as HIV-infected children. Clinicians
call that a ‘diagnostic dilemma’.128 Some physicians actually have stated that
even today most cases of TB in younger children are only diagnosed either clin-
ically (by physical examination), or by successful trial of antibiotic treatment
(“who heals is right at all”).129

9.5 The TB Complex and the Concept of its Evolution


A sometimes underestimated topic, but fairly important in human diseases
caused by bacteria, is the very fact of biological evolution. Bacteria like other life
forms are not static. Though mycobacteria are very resilient bacilli, recent sci-
entific research has demonstrated that the prevalent strain of Mycobacterium
tuberculosis emerged only one millennium ago in human pathological history.
This does not automatically mean that this strain could cause other symptoms
than Mycobacterium tuberculosis two millennia ago, but the possibility for a

152–59. Historically, it was not long before 1916 that standardised diagnostic criteria for
tuberculosis were available in the USA, and before that “physicians relied on their own
experience and judgment to make the diagnosis”: Connolly, Saving, 38.
127  Non-tuberculous mycobacteria, like Mycobacterium avium, can cause lymphadenitis, but
not TB; Magdorf, K. (2006). ‘Tuberkulose im Kindesalter: Pathogenese, Prävention, Klinik
und Therapie’, Monatsschrift für Kinderheilkunde 154, 126.
128  Marais, B. J. et al. (2006). ‘Childhood pulmonary tuberculosis: Old wisdom and new chal-
lenges’, American Journal of Respiratory and Critical Care Medicine 173, 1078–90. Similar
difficulties in diagnosis were noted already at the beginning of twentieth century.
Connolly, Saving, 37. E.g., Maurice Fishberg (1872–1934) begins his chapter on diagnosis of
tuberculosis in infants as follows: “The diagnosis of tuberculous disease in infants is not
an easy matter”; Fishberg, Tuberculosis, 25.
129  Driver, C. R. et al. (1995). ‘Tuberculosis in children younger than five years old’, The Pediatric
Infectious Disease Journal 14, 112–17. It may be added, that also the interpretation of chest
radiographs in children with suspected tuberculosis is far from being easy, and its clinical
utility is even questioned today in some settings (e.g., in asymptomatic children): George,
S. A. et al. (2011). ‘The role of chest radiographs and tuberculin skin tests in tuberculosis
screening of internationally adopted children’, The Pediatric Infectious Disease Journal 30,
387–91.
the Epitaph of L. M. Anthimianus 53

changing pathological picture over time (also known as pathomorphosis) even


in the case of Lucius remains.130
Moreover, TB in humans is not only caused by a single bacillus, but by a group
of bacilli, the so-called Mycobacterium (M.) tuberculosis complex: besides the
most common M. tuberculosis, there is M. bovis, a cattle-borne pathogen which
can be transmitted via infected raw dairy products (first of all milk), meat or
inhalation of infectious droplets from the cattle or goat.131 The clinical pat-
tern of M. bovis TB in humans is indistinguishable from M. tuberculosis TB.132
Bone or joint TB (such as the midfoot disease in Lucius) is more likely to have
been caused by infection of M. bovis than by M. tuberculosis.133 However, the
epidemiological impact of M. bovis in the past remains unclear.134 Especially
in Roman times, cow milk was not consumed regularly, beef was eaten very
rarely, and cattle contact in the ancient urban setting was less often. All this
renders Lucius’ infection by this route quite improbable.135

9.6 Lucius’ Retrospective Diagnosis Revisited


Moving back to the sad story of young Lucius, we should first reconsider ‘hard
medical facts’, i.e. the medical status of ‘our patient’. We are dealing with a male
child, breastfed by his own mother, born in a probably unspectacular way at
home in the presence of his father. The child may have been born after (and
later survived by) three more living children (his unwedded sisters).136 The
boy seem to have developed well in the beginning, but many further medi-
cal questions about Lucius’ development and his environment remain unan-
swered. For instance, there is no information about the health status of other

130  Hirsh, A. E. et al. (2004). ‘Stable association between strains of Mycobacterium tuberculo-
sis and their human host populations’, Proceedings of the National Academy of Sciences of
the USA 101, 4871–76.
131  M. tuberculosis complex: M. bovis (with its subspecies bovis and caprae), M. africanum,
M. microti, M. pinnipedii and M. canettii. M.bovis has recently shown to be also (re-)trans-
mittable from human to cattle: Fritsche, A. et al. (2004). ‘Mycobacterium bovis tuberculo-
sis: From animal to man and back’, International Journal of Tuberculosis and Lung Disease
8, 903–04. Cattle-borne TB (pearl disease, German ‘Perlsucht’) was not known before 1895;
Connolly, Saving, 46.
132  Roberts and Buikstra, Bioarchaeology, 5.
133  Roberts and Buikstra, Bioarchaeology, 88.
134  During early twentieth century researchers claimed that more children with TB suffered
from M. bovis than from M. Tuberculosis. Today, this opinion is questioned. Cf. Connolly,
Saving, 46. Roberts and Buikstra, Bioarchaeology, 77; 84.
135  Gourevitch, Giovani, 121, n.30.
136  See above p. 37 n. 53.
54 Graumann and Horstmanshoff

family members, Lucius’ father, his sisters and his mother. Lucius may have
been in prolonged direct household contact with his mother, who was per-
haps herself suffering from open TB. Concrete information is lacking about the
nutritional status of the baby Lucius (possible malnourishment, vitamin defi-
cit, or insufficient calcium intake), his birth weight, the exact duration of his
mother’s pregnancy (full-term or preterm baby). There is no hint for the season
of the sickness’ first occurrence (perhaps in winter time?), as well as for the
exact duration of each of Lucius’ illnesses. Furthermore, we have no informa-
tion about any possible contact with animals, his living conditions (perhaps in
overcrowded Rome?), and, more importantly, the epidemic or endemic state of
TB in Rome at the time. We also do not know of the sickness’ first occurence, a
fact that makes it impossible to draw any connections with the disease’s evolu-
tion, as we know it today. Again, we only know of three disease patterns recog-
nised as different disease entities, and that Lucius finally died in the fifth year
of his life in the course of the third disease, and after an unknown period of
suffering.137 All in all, we haven’t got any other additional material evidence,
no portrait of the boy, nor do we possess his human remains (bones or ashes)
to conduct further palaeopathological examinations so as to collect evidence
for specific diseases.138 At the moment, we can consider four possibilities: the
described three diseases patterns could have been caused by:

137  More precisely, from contemporary view only signs of illness recognised by the father-
narrator are described. Nevertheless, we will further speak of ‘disease pattern’ keeping
this in mind.
138  In human remains it is possible today to show TB infection by detecting mycobacterial
DNA, though this says rather little about the ways disease evolves in an individual or in a
specific population. TB in Egyptian mummies: Nerlich, A. G. et al. (2002). ‘Paläopathologie
altägyptischer Mumien und Skelette: Untersuchungen zu Auftreten und Häufigkeit spe-
zifischer Krankheiten in verschiedenen Zeitperioden der altägyptischen Nekropole
Theben-West’, Der Pathologe 23, 379–85. On the quality of palaeopathologic detec-
tion of Mycobacterium tuberculosis DNA, see Zink, A. R. et al. (2005). ‘Molecular identi-
fication of human tuberculosis in recent and historic bone tissue samples: The role of
molecular techniques for the study of historic tuberculosis’, American Journal of Physical
Anthropology 126, 32–47. Compare Roberts and Buikstra, Bioarchaeology, 49 “However,
even if tuberculosis has been identified and the person’s skeleton is aged accurately, it is
almost impossible to ascertain when the disease started in the individual’s life and when
the bone damage started occurring”; and Roberts and Buikstra, Bioarchaeology, 107: “Even
if a positive tuberculous ancient-DNA result has been established for a skeleton with rib
lesions, this does not indicate that TB [=tuberculosis] caused them”. There is only the
spectacular ‘Grottarossa mummy’, excavated 1964 in Rome, the remains of a 8-year-old girl
from second century, who died of pneumonia (unsure detection of TB): Ascenzi, A. et al.
the Epitaph of L. M. Anthimianus 55

1) a single contemporary disease (like TB)


2) two different contemporary diseases
3) three different contemporary diseases
4) or, finally, they could have been caused by one or more unknown caus-
ative factors.139

First, we have to ask ourselves, what degree of medical accuracy can be


expected. The described nosological facts remain implicit, whereas the
explanatory medical model remains in the dark.140 Typical children’s diseases
from the same historical period are not mirrored in the poem’s description.141
Classical symptoms like fever, secretion or excretion of body fluids (cough,
feces, urine, blood, phlegm) are not reported here, and we just can’t conjecture
missing symptoms.

9.7 First Disease (l. 17): αἵ με νόσῳ πῆξαν χαλεπῇ διδύμους πέρι
Beside testicular TB, there is a plethora of other diagnostic scenarios that could
match the description: inguinal hernia (possibly incarcerated, but reducible),
hydrocele, torsion of testis, torsion of Morgagni’s hydatide, epididymitis (non-
tuberculous; viral, bacterial, or chemical via reflux), orchitis (viral, such as
mumps, or bacterial), scrotal abscess (staphylococceal) and idiopathic scrotal
edema (a benign, full reversible skin affection). Further possiblities include:
malignant tumor of testis (teratoma or seminoma), leukemia, lymphoma, sar-
coidosis (bilateral granulomatous orchitis), primary (idiopathic) or second-
ary (due to some, perhaps malignant intra-abdominal process) varicocele,
secondary scrotal swelling (edema) caused by abdominal, retroperitoneal
tumor (benign or malignant), scrotal or testicular metastasis of any other
malignant tumor.
A brief look at this list of ten possible diagnoses other than TB quickly
reminds us that TB is not an unquestionable candidate. From the inscription
we hear of some affection around the testicles or around the scrotal area, for
which Lucius was treated. There is, nonetheless, no explicit description of

‘The Roman mummy of Grottarossa’, in Spindler, K. et al. (1996). Human Mummies:


A Global Survey of their Status and the Techniques of Conservation, 205–17.
139  Graumann, Krankengeschichten, 79.
140  Compare Graumann, Krankengeschichten, 57–61. Classic example: the ‘standard’ inter-
pretation of cyclic fever in antiquity as sign of malaria may be misleading; Graumann,
Krankengeschichten, 104; Mattern, Galen, 155–58.
141  See the meticulous analysis of diseases in children described by second century physician
Galen in Gourevitch, Giovani.
56 Graumann and Horstmanshoff

this ‘treatment’: as mentioned above ἰάομαι is a general medical term that can
denote treatment by medicaments (e.g. ointment or purgatives) or bandaging
without cutting or cauterising. This does not preclude the possibility that some
invasive procedure was involved: such as incision of a scrotal abscess that could
even include (semi-)castration of the child, or venesection (following ancient
medical methodology) to drain any surplus of pus.142 The text gives the impres-
sion that in the eyes of the father-narrator the illness was successfully treated.
However, if there is any connection between the first illness and those that
followed, how could one speak of a ‘successful’ treatment? The notion of cure
remains vague and implicit, and the possibility of it serving as a literary device
to raise the dramatic tension should not be excluded. As medical historians we
should be aware of our own historical horizon and not simply superimpose our
own horizons on either those of the father-speaker in the inscription or those
of subsequent generations of interpreters. Neither should we try to dissemble
our modern knowledge and experience in attempting to reconstruct a medical
event in the past. Such a (pseudo-)reconstruction would be nothing more than
a value-avoiding, lifeless description. We should try, however, to build a bridge
of understanding between the past and the present, inviting the reader to walk
with us over that bridge, to and fro, gaining new knowledge and insights into
the past, the present and the future.143

9.8 Second Disease (l. 22): σῆψιν γὰρ λαιοῦ πεδίον ποδὸς εἶχεν ἐν ὀστοῖς
Even in this second disease pattern, a kind of purulent necrosis in the left
midfoot,144 many diseases other than TB fit the description: osteomyelitis
(non-tuberculous; staphylococceal), primary osseous tumor (benign or malig-
nant), posttraumatic wound infection, secondary (malignant) metastatic
tumor, syphilis, haemoglobinopathia (such as thalassaemia), dactylitis (in

142  Mattern, Galen, 142.


143  Gadamer’s hermeneutics can be successfully applied to present day medical ethics,
see Widdershoven, G. A. M. and Metselaar, S. (2012). ‘Gadamer’s truth and method and
moral case deliberation in clinical ethics’ in Kasten, M. et al. (2012). Hermeneutics and the
Humanities. Dialogues with Hans-Georg Gadamer, Leiden, 287–305.
144  The explicit mention of σῆψις in the ‘left’ (λαιοῦ) side of the foot may have no further func-
tion in the whole description of disease than providing precision. Prima facie, it appears
as an unnecessary piece of information. But, if we reconsider the Greek background of
the narrator, we could interpret the disease on the left side as disease on the weaker, on
the ‘bad’ or ‘unlucky’ side of the child, which may confirm the fatality of disease in the
eyes of the narrator. See Wirth, H. (2010). Die linke Hand: Wahrnehmung und Bewertung in
der griechischen und römischen Antike. On λαιός and σκαιός and their Latin counterparts
laevus and scaevus, see especially his broad discussion in 14–48.
the Epitaph of L. M. Anthimianus 57

sickle cell disease),145 or aseptic necrosis of metatarsal bone (Köhler’s disease)


with subsequent bacterial superinfection. The features of illness as described
in our inscription are by no means pathognomonic for tuberculous osteomy-
elitis: no swelling is mentioned while no specific information is given about
the surrounding tissue, the part of bone involved (the diaphysis, that is the
shaft of the bone, the epiphysis, that is the tip of the bone, or the whole bone),
and whether σῆψις was accompanied by pain or not. At least, who could argue
against a symptom of (perhaps congenital) syphilis here without any micro-
biological counter-evidence?146

9.9 Third Disease (l. 27–28): ἀλλ’ ἑτέραν πάλι μοι νόσον ἤγαγε γαστρὸς Μοῖρα
σπλάγχνα μου ὀγκώσασα καὶ ἐκτήξασα τὰ λοιπά
Here, personal experience in contemporary paediatric medicine teaches us
that a sure and single diagnosis is not possible. Apart from the diagnosis of a
fatal tuberculous peritonitis, the incomplete list of possible fatal diseases (all
combined with sudden or slow onset of the clinical picture of an ileus)147 in
this age group starts with congenital abdominal anomalies, acute and chronic
inflammatory diseases, and ends up with malignant diseases of different
kind, such as: volvulus (that is gut strangulation based on congenital mal-
rotation of intestines), duplications of intestinal tract, mesenteric or omen-
tal cyst, symptomatic Meckel’s diverticulum (that is perforation, or also gut
­strangulation), appendicitis (quite possibly perforated), abdominal typhus,

145  A form of vaso-occlusive crisis most common in young infants (mostly under age 2 years)
with sickle cell disease associated with vaso-occlusion of the nutrient arteries, which supply
the metacarpal and metatarsal bones See, Friday, J. H. ‘Hematologic and oncologic emer-
gencies’, in Selbst, S. M. and Cronan, K. (2001). Pediatric Emergency Medicine Secrets, 178.
146  Compare the differential diagnoses of tuberculous dactylitis in Storm, M. and Vlok, G.
‘Musculoskeletal and spinal tuberculosis in adults and children’, in Schaaf, H. S. and
Zumla, A. I. (2009). Tuberculosis: A Comprehensive Clinical Reference, 502 and in Roberts
and Buikstra, Bioarchaeology, 108 (congenital syphilis, osteomyelitis, sarcoidosis, sickle
cell anemia). Going further back in time, syphilis has always been riddled with diag-
nostic difficulties: Karewski, F. (1894). Die chirurgischen Krankenheiten des Kindesalters,
148: “[Mit der Tuberkulose] konkurriert fast nur die Syphilis und in der That ist die
Differentialdiagnose von dieser Krankheit häufig recht schwer”. In this first German
manual of paediatric surgical diseases, 214 pages out of 780 pages are dealing exclusively
with the topic of tuberculosis in childhood! It is even possible that both diseases, syphi-
lis and tuberculosis, could co-exist in the same person. More on this topic, in Fishberg,
Tuberculosis, 202.
147  We indicate that the usual Greek word εἰλεός or ἰλεός, “intestinal obstruction” is miss-
ing from the inscription. On ἰλεός in childhood in ancient medical authors, see Hummel,
Kind, 231–32.
58 Graumann and Horstmanshoff

intussusception, Hirschsprung’s disease (intestinal aganglionosis), infantile


Crohn’s disease, mesenterial infarction (thrombosis, metastatic vessel occlu-
sion), Non-Hodgkin-lymphoma (also known as Burkitt’s lymphoma), neuro-
blastoma, Wilms’ tumor (or nephroblastoma), abdominal lymphangioma or
haemangioma, hepatoblastoma, hepatocellular carcinoma, and rhabdomyo-
sarcoma.148 Accurate (‘lege artis’) diagnosis today is only possible by diagnostic
tools like radiological imaging (conventionally, sonography, CT, MRI), specific
blood tests (e.g. microbiological examination, tumor markers), histopathologi-
cal examination (of excised tumor material), and, of course, many years of
clinical experience.

9.10 The Context of the Initial Diagnosis of Tuberculosis: Medical and


Historical Considerations
After so many different, plausible possibilities for a medical diagnosis one may
wonder: why in the light of so much uncertainty have people in the past con-
sidered tuberculosis as the only diagnostic possibility?149 One reason could
be that a historian of medicine who is not a practising physician bases his
dogmatic theoretical medical diagnosis only on manuals and misses insight
into the uncertainties of daily medical practice. This must lead to misconcep-
tions. The other important reason could be found when this sort of diagnosis
is placed in its own historical context. Following many different scientific con-
tributions about the infectious character of TB as disease entity in the early

148  Compare the differential diagnoses of abdominal tuberculosis in children in Rey Nel, E.
de la ‘Abdominal tuberculosis in children’ in Schaaf, H. S. and Zumla, A. I. (2009).
Tuberculosis: A Comprehensive Clinical Reference, 435. The thought experiment of the
diagnosing a malignant disease in Lucius’ case may run as follows: the diagnosis of Wilms’
tumor (nephroblastoma) is based on the first disease being interpreted as primary symp-
tomatic inguinal hernia or varicocele, the second disease as osteogenic metastasis with
osseous necrosis, and the third disease as growing abdominal (in fact, retroperitoneal)
tumor (which would have been the original tumor of nephroblastoma) combined with
ileus and followed by death by starvation. The diagnosis of rhabdomyosarcoma: primary
paratesticular tumor, osseous metastasis with necrosis, ileus and death by abdominal
metastasis (in the liver?). The clinical image on which the diagnosis of neuroblastoma is
based includes primary adrenal tumor with scrotal metastasis, osseous metastasis, and
finally death caused by ileus. Cf. the recent case report by Reed, R. C. and Casale, A. (2011).
‘Metastatic neuroblastoma presenting as a scrotal mass in an infant’, Journal of Pediatric
Urology 7, 495–97.
149  The inscription is mentioned as part of a broader discussion about ancient case-­histories
in Mattern, Galen, 36, too, and it is classified as famous medical history, but without
any further statements about a probable diagnosis. She only cites Klitsch and Petzl; see
Mattern, Galen, 216, n.115.
the Epitaph of L. M. Anthimianus 59

nineteenth century, TB was redefined as specific microbial, germ-borne infec-


tious disease since the discovery of M. tuberculosis in 1882 by Robert Koch,
thus, rendering possible this new, germ-disease-based possibility of retrospec-
tive diagnosis.
The first scholar known to have written of retrospective diagnosis of TB in
modern context was Bruno Meinecke in 1927, in his broad and twenty four
pages long article, which was entitled ‘Consumption (tuberculosis) in classical
antiquity’ and published in the Annals of Medical History.150 Meinecke himself
was a Michigan-based classical philologist of German origins with a general
interest in ‘consumption’ in ancient literature. His brother was a physician.151
In Meinecke’s view, TB was one of the most common diseases of classical
antiquity.152 Thirteen years later, in 1940, when he was an established member
of the faculty at the University of Michigan and a member of the American
Association for the History of Medicine, Meinecke re-diagnosed TB in a sin-
gle ten pages long article entitled ‘A quasi-autobiographical case history of
an ancient Greek child’, which was published in the Bulletin of the History
of Medicine.153 In 1928 and independently (as far as we know) Josef Zingerle
also diagnosed TB as the cause of Lucius’ death.154 Despite being a classical

150  Meinecke, ‘Consumption’, 385–86. His presentation and discussion of the grave stele and
the inscription takes up one whole page of his article. He is citing Georg Kaibel (no. 314)
and August Boeckh (CIG 3272), but does not reveal wherefrom he acquired his knowledge
of the inscription. The article was based on his own doctoral dissertation at the University
of Michigan. He was also the first who translated the Lucius’ inscription in English.
151  Dunlap, J. E. (1966). ‘Commemoration (Bruno Meinecke)’, Classical Journal 62, 142–44.
In his 1927 article, Meinecke acknowledges in an introductory note (p. 379) especially
his brother, who was a physician: “I desire, too, to record my thanks to my brother,
H. A. Meinecke, M. D., of Detroit, who gave me many valuable suggestions and whom I
often consulted to verify my own conclusions”.
152  Meinecke, ‘Consumption’, 399.
153  Meinecke, ‘Quasi-autobiographical’. On page 1028, Meinecke is citing his own article of
1927 extensively. The result of his own “fascinating game of diagnostic speculation” (1027)
reads as follows: “we may be reasonably sure that this Greek child had tuberculosis of the
|testicles, of the bone, and of the intestine, whether as a primary or secondary factor”; cf.
also pages 1029–30.
154  He was the son of the famous Austrian classical philologist Anton Zingerle. Josef Zingerle
was an experienced epigraphist with a special interest in Greek epigraphy. He was also
a member of the Austrian Archaeological Institute: Wlach, G. ‘Die Direktoren und wis-
senschaftlichen Bediensteten des Österreichischen Archäologischen Institutes: Josef
Zingerle (1868–1947)’, in Kandler, M. (1998). 100 Jahre Österreichisches Archäologisches
Institut 1898–1998, 122–24; Schauer, C. ‘Die ‘Sekretäre’ des Sekretariats Athen und ihre
60 Graumann and Horstmanshoff

philologist and not a physician—initially he had wished to study medicine and


had attended some medical lectures—he published this spectacular article
entitled ‘A case of a child suffering from tuberculosis 1700 years ago’ in the inter-
national renowned German paediatric journal Zeitschrift für Kinderheilkunde.155
Both, Meinecke and Zingerle, lived and published their papers in the
Interbellum, in the 1920s. At that time, childhood tuberculosis was the major
topic in the medical circles and in general in the Western developed societies of
Europe and the USA. Around the fin de siècle, international scientific research
revealed that most infections with tuberculosis took place in early childhood.156
Since 1907, and after the introduction and the institutionalisation of the tuber-
culin skin test, it was possible to elucidate TB-related infections, especially in
children before any symptoms of disease appeared. Active measures to pre-
vent TB in children were taken and infected children were separated from their
‘tuberculous families’ in sanatoria and preventoria. Moreover, food and water
supply and common hygiene were improved including the wider application
of technologies like pasteurisation.157 At the end of World War I, however, and
especially in Germany the incidence of TB had risen again dramatically, before
it was reduced once again by half at the beginning of the 1930s.158 Between 1921
and 1924, the first active immunisation with the live attenuated (weakened)
strain of M. bovis, the Bacille Calmette Guérin, was introduced by which the
risk of active TB could be reduced. But, the real, causal treatment was not pos-
sible until after the introduction of antibiotics like streptomycin, and certainly

Tätigkeit: Josef Zingerle (1901–1902)’, in Mitsopoulos-Leon, V. (1998). Hundert Jahre


Österreichisches Archäologisches Institut Athen 1898–1998, 38–39. In 1928, Zingerle held the
office a ‘Hofrat’ (court counsellor) and was vice-president of the Austrian Archaeological
Institute in Vienna, two very prestigious positions, which may have opened the doors
for him to publish in a rather specialised medical journal, despite not being himself a
paediatrician.
155  His publication takes only five pages of this journal, under the rubric “Kleine Mitteilungen
und Kasuistik” (‘short communications and case-stories’). Maybe the publisher’s motive
was to broaden the scientific spectrum of his highly specialised journal.
156  Connolly, Saving, 25. The most famous promoter of that idea was the first ever Nobel Prize
winner in medicine, Emil von Behring (1854–1917): Connolly, Saving, 97. Compare the slo-
gan of the famous German paediatrician Arthur Schloßmann (1867–1932) in 1910: “Der
Kampf gegen die Tuberkulose setzt in der Kindheit ein” (‘the fight starts in childhood’):
Schlossmann, A. ‘Die chronischen Infektionskrankheiten: Tuberkulose’, in Pfaundler, M.
and Schlossmann, A. (1910). Handbuch der Kinderheilkunde. Ein Buch für den praktischen
Arzt, 533. We thank Ulrike Enke, Marburg, for her kind remarks on Behring.
157  Connolly, Saving, 49–60.
158  Gloser, C. (2007). Die Tuberkulosebekämpfung in Thüringen in der Zeit von der Entdeckung
des Erregers bis 1933, 66; 85.
the Epitaph of L. M. Anthimianus 61

not before 1944.159 It is our view, that in this specific historical, pre-antibiotic
setting the view that TB had been an analogously great threat for the children
in antiquity was quite widespread among scholars.160
Meinecke, in 1927, reflects contemporary medical knowledge regarding
childhood TB in his statements. He is not citing any specific medical literature,
but at the end of his long article there is a ‘general bibliography’ with mainly
medical monographies about TB and medical history; while his bibliographi-
cal references consisted in primarily German titles.161 In his investigation of
the Lucius’ case, Meinecke used und gave special emphasis to an 1896 German
monograph about TB in children.162 For instance, he declared that Lucius’
death was a typical case of sepsis in systemic tuberculosis,163 that tuberculo-
sis in children was mostly a disease of early age,164 that tuberculosis was the
result of an intestinal infection in up to a thirty per cent of the cases,165 and,
finally, that fatal tuberculosis infection may be caused by another co-infection
typical of children’s diseases like whooping cough, or measles.166 Meinecke

159  Connolly, Saving, 114. The next antibiotic agent, the isoniazid, was introduced in 1954:
Connolly, Saving, 118. Today’s standard combination chemotherapy against tuberculo-
sis was developed as early as in the 1960s; Harries, A. D. (2008). ‘Robert Koch and the
discovery of the tubercle bacillus: The challenge of HIV and tuberculosis 125 years later’,
International Journal of Tuberculosis and Lung Disease 12, 241–49.
160  Good examples of that “historical trend” in that specific era follow: Baumann, E. D.
(1930). ‘De phthisi antiqua’, Janus 34, 209–25; Major, R. H. (1939). Classic Descriptions of
Disease: With Biographical Sketches of the Authors [on tuberculosis: 58–81]; Ebstein, E.
(1932). Tuberkulose als Schicksal: Eine Sammlung pathographischer Skizzen von Calvin bis
Klabund 1509–1928. Even the famous classicist Arthur Stanley Pease had spent some time
on this trend topic: Pease, A. S. (1940). ‘Some remarks on the diagnosis and treatment of
tuberculosis in antiquity’, Isis 31, 380–93. Based on a presentation at the Harvard Medical
School in 1939, besides a philological discussion this article contains a list of famous
Roman victims of suspected tuberculosis.
161  29 titles from 1828 (Medicinisches Wörterbuch, Berlin) to 1917 (L. Cobbett, The Causes of
Tuberculosis, Together with Some Account of the Prevalence and Distribution of the Disease,
Cambridge); Meinecke, ‘Consumption’, 402.
162  Dennig, A. (1896). Über die Tuberkulose im Kindesalter. Dennig was at the time resident in
internal medicine at the University Hospital of Tübingen.
163  Meineke, ‘Consumption’, 386.
164  Meineke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 8–9.
165  Meineke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 236–35., who differentiates
between “tuberculous peritonitis”, “intestinal ulceration”, and “mesenterial lymph node
tuberculosis.”
166  Meinecke, ‘Consumption’, 386. Cf. Dennig, Tuberkulose, 17, who mentions measles,
whooping cough, pneumonia, scarlet fever, and typhus.
62 Graumann and Horstmanshoff

­ resupposed that unhygienic behaviour and in particular the ingestion of


p
infected (tuberculous) milk made children prone to TB.167 Again, in 1940, in
his second article on the inscription, he reinterprets the case-story “in the light
of modern observation and experience” as “manifestations of a general tuber-
culosis”, and repeats verbatim his line of argumentation from 1927.168 In that
article, Meinecke did not cite any medical literature.169
Back in 1928, Zingerle also cited very little medical literature170 although
he did use very broad medical terminology and contemporary knowledge
throughout his work despite not being a doctor. In particular, he cited the med-
ical pathologist and historian of medicine Walter Pagel, who at that time was
a TB expert.171 But, following Zingerle’s argumentation and terminology is very
much like reading a TB manual of that time, and often reminds the reader heav-

167  Meinecke, ‘Consumption’, 386 = Meinecke, ‘Quasi-autobiographical’, 1029 “This [=inci-


dence of tuberculosis in young children] undoubtedly can be explained by the fact that
in early childhood children convey the infectious material to their mouths by their fin-
gers, inasmuch as they play on their hands and knees during that period, and also by the
fact that at this time infected milk would be taken most freely.” Cf. the preventive mea-
sures which suggest following a strict infant’s hygiene and only using boiled cow milk in
Dennig, Tuberkulose, 251.
168  Meinecke, ‘Quasi-autobiographical’, 1029 = Meinecke, ‘Consumption’, 386. Interestingly
enough, Meinecke did not used or cited recent literature on the topic. One would have
expected to find, for instance, the US standard work of reference Tuberculosis among chil-
dren (1938) written by the famous Lymanhurst ‘tuberculosis crusader’ Jay Arthur Myers;
cf. Connolly, Saving, 106.
169  Meinecke reflects in his introduction on some early twentieth century-thoughts about
scientific progress, as put forward by the German physician Hans Much (Das Wesen der
Heilkunst, “The essence of medicine”). Meinecke probably knew that Much himself was a
specialist in TB in children and had published the often reprinted manual on that topic,
which was translated in English in 1921: Much, H. (1920). Kinder-Tuberkulose, 3rd–5th ed.
1923; Much, H. (1921). Tuberculosis in Children. In this manual Much also emphasised
the role of immunity during the infection and the progress of tuberculosis, which was
negatively influenced especially by systemic co-infection by measles, whooping cough,
influenza and scarlet fever: “Von den Krankheiten, die das allgemeine Gleichgewicht plöt-
zlich verschieben, sind für uns die gefährlichsten Masern, Grippe und Keuchhusten. Auch
andere, wie Scharlach kommen in Frage.”; Much, Kinder-Tuberkulose, 23.
170  In an article that contains no footnotes, Zingerle cites both prime sources and secondary
bibliography only very sparingly.
171  Pagel, W. (1927). Die allgemeinen pathomorphologischen Grundlagen der Tuberkulose,
29–31; id. (1927). ‘Die Krankheitslehre der Phthise in den Phasen ihrer geschichtlichen
Entwicklung’, Beiträge zur Klinik der Tuberkulose und spezifischen Tuberkuloseforschung,
66–68.
the Epitaph of L. M. Anthimianus 63

ily of Pagel’s own literary style.172 Especially his usage of the two terms ‘meta-
static’ (for haematogenic or lymphatic dissemination of bacteria) and ‘virus’
(for the tubercle bacillus) were extremely common at that time. Nowadays both
terms are deemed obsolete.173 Zingerle speculates, that the progress in Lucius’
disease as shown by him contracting TB in the bones may have been induced
by some typical undercurrent infectious disease like measles, or scarlet fever,174
and mentions en passant high mortality rates in children, who were infected
in the first year of their life.175 He equates the father of Lucius to an (ancient)
internist, who has knowledge of pulmonary signs of TB and would not, while
practicing meticulous anamnesis, have overlooked symptoms,176 and who con-
sults his surgical colleagues in a skilled manner.177 By that, Zingerle is retroject-
ing uncritically and anachronistically modern ideas on to the past. In order
to support his retrodiagnosis of tuberculosis, Zingerle presupposed a constant
pathomorphology of tuberculosis since antiquity,178 and pronounced the huge
scientific medical progress in diagnosing and treating TB in his time.179 He also
lamented the ancient inability to understand the microbiological origin of TB180
and criticised the wrong treatment of the bone affection.181 Again, Zingerle
here neglects the historical fact, that it was only in his lifetime that extrapul-
monary manifestations of TB were proved by detection of tubercle bacilli
in extrapulmonary tissues, and were integrated into the whole new defined
paradigm of TB disease complex as a general or systemic disease, whose
onset is attributed to an infection in early childhood.182 Moreover, surgical

172  Zingerle, ‘Fall’, 441–43. Cf. Pagel, Grundlagen 77.


173  The term ‘metastasis’ today is reserved for dissemination of cancer, ‘virus’ is confined
today to the DNA-, or RNA-based infectious pathogens. Compare ‘virus’ as term of the
tuberculous germ in Pagel, Grundlagen, 77, 86, 91, and 95. On ‘metastasis’, see also Pagel,
Grundlagen, 77: “lympho- und hämatogene Metastasen.”
174  Zingerle, ‘Fall’, 442.
175  Ibid., 443.
176  Ibid., 443.
177  Ibid., 444.
178  Ibid., 443, using his own retrospective diagnosis of tuberculosis as proof of the persistent
existence of tuberculosis in his days: a circular argumentation!
179  Zingerle, ‘Fall’, 443.
180  Ibid., 443.
181  Ibid., 442.
182  Spitzy, H. ‘Die chirurgische Tuberkulose’, in Pfaundler, M. and Schlossmann, A. (1910).
Handbuch der Kinderheilkunde: Ein Buch für den praktischen Arzt, 195: “Die tuberkulöse
Infektion wird hervorgerufen durch den Tuberkelbacillus (Robert Koch). Durch diese Ent-
deckung wurde die Zusammenfassung einer ganzen Reihe von Erkrankungen verschiede-
ner Disziplinen ermöglicht und auch durch die Verfeinerung der Untersuchungsmethode
64 Graumann and Horstmanshoff

i­nterventions with fatal outcomes were still practiced in the early twenti-
eth century.183 By excluding any accidental coincidence of three different
diseases184 and narrowing his thought experiment to one single cause,185
Zingerle unconsciously projected his own contemporary knowledge of the
extrapulmonary character of TB into the ancient past, when such knowledge
was both unavailable and unattainable within the ancient mental framework.186
Zingerle’s beliefs in the possibility of reaching an accurate and certain medical
diagnosis on the basis of the fragmentary information of our inscription are
mirrored in multiple statements like “explicit diagnosis”, or “prosaic-meticu-
lous objectivity”.187
In their statements about the unequivocal diagnosis of tuberculosis both
Meinecke and Zingerle reflect contemporary, naïve beliefs in progress, superi-
ority and objectivity in the biomedicine of their own time. This renders both
men typical representative of the “epidemic trend” of embarking on unreflec-
tive, microbiologically grounded retrospective diagnoses in the early twentieth
century.188 Eventually, their interest in the sick child and his possible tubercu-
lous disease can also be seen as a typical result of the new child-saving ethos of
the early twentieth century.189
Successive interpreters of Lucius’ case such as Klitsch, Grmek, and
Gourevitch have all followed and cited Meinecke und Zingerle with their retro-
spective diagnosis of TB, partly combined with a more or less growing inclusion

eine Anzahl von chirurgischen Erkrankungen der Gelenke und Knochen, die früher als
getrennte Krankheitsbilder beschrieben wurden, ihrem Wesen nach erkannt und in die
Gruppe der tuberkulösen Erkrankungen eingereiht.”
183  Connolly, Saving, 38. See the overview of trends in surgical treatment of tuberculosis until
1910 in Spitzy, ‘Tuberkulose’, 197–99.
184  Zingerle, ‘Fall’, 441 “ist die zufällige Koinzidenz dreier pathogenetisch selbständiger
Affektionen auszuschließen.”
185  Zingerle, ‘Fall’, 441 “Das Syndrom von Hoden-, Knochen- und Bauchaffektion ist so chara-
kteristisch, daß unter Ausschluß differentialdiagnostischer Erwägungen kurzweg auf
Tuberkulose als dem gesamtkomplexe übergeordnete ätiologische Einheit geschlossen
werden darf.”
186  Interestingly, although cited by Zingerle, Walter Pagel came quite close to realising that
the term ‘phthisis’ did not imply the same concept of disease in early nineteenth century
was comparable to that of his own time. Similarly, Pagel claimed to have found a timeless,
constant leitmotif in tuberculosis: Pagel, ‘Krankheitslehre’, 67, 91.
187  Zingerle, ‘Fall’, 440: “alle Elemente für die Erstellung einer eindeutigen Diagnose”;
“nüchtern-pedantische Sachlichkeit”.
188  Graumann, Krankengeschichten, 132.
189  Connolly, Saving, 14.
the Epitaph of L. M. Anthimianus 65

of other diagnostic possibilities (e.g. leukaemia, malignant tumors).190 While


the retrospective diagnosis of TB persisted in the scholarly pages, TB itself was
vanishing from the public eye and people’s awareness thanks to long and suc-
cessful post-war anti-TB campaigns.191 Simultaneously, the medical experts
observed in their life-time a pathomorphosis, a changing clinical picture of TB
in children.192 Therefore, both the careful medical discussion undertaken by
Klitsch in 1976 and the shorter medical discussion by Grmek in 1983 have now
only historical value. One must remember, however, that by that time there
was no longer such a great public interest in TB as in the times of Meinecke
and Zingerle.
In sum, from our own current perspective based on the illness’ low inci-
dence, TB may be still a possible diagnosis, but it is not the only diagnosis.
Lucius’ symptoms as described in our inscription could be interpreted as the
symptoms of a wide range of different diseases known to us today. There may
be descriptions of disease which overlap with our modern concept of TB, thus
allowing us to diagnose it as TB, but nothing is for sure. From the historical per-
spective of early twentieth century, TB has been regarded as the most probable
diagnosis mainly due to the broad and public interest of that specific period
in the illness. Many out of our contemporary well-known and defined disease
entities that could mimic symptoms of TB were unknown, or not yet ‘well’
defined at that time. The issue of whether TB was indeed a common disease
in childhood in Rome of Imperial times remains open to discussion, because
we do not have at our disposal (and quite possibly we will never obtain) robust
epidemiological data of that specific era.193 Thus, the retrospective diagnosis

190  Klitsch, Krankengeschichte 129–30, who uses the now outdated medical terminology of a
paediatric textbook of 1972 as main reference; cf. Grmek, Maladies, 289, who remains very
vague in his medical terminology, but includes the possibility of dealing with three differ-
ent diseases in Lucius’s case.
191  In Western Germany, in 1976 there was a reported drop of in-hospital treated children
with open TB from 26.794 in 1953 (incidence 245.3: 100.000 children) to 2.994 in 1973 (inci-
dence 24.6), also a major decrease in mortality from TB in children from 449 in 1953 to
only 6 cases (4,1: 100.000 resp. 0,04). Cf. Spiess, H. (1976). ‘Kindertuberkulose einst und
jetzt’, Praxis der Pneumologie 30, 406.
192  Spiess, ‘Kindertuberkulose’, 406. In fact, this was almost true at the beginning of the
1960s with the disappearance of former classical symptoms like spina ventosa (bony
TB in metacarpals or metatarsals in children): see Brügger, H. (1964). ‘Das veränderte
Erscheinungsbild der Tuberkulose des Kindes und des Jugendlichen in den letzten 35
Jahren’, Der Landarzt 40, 310–18.
193  This, at least, admits Grmek, too: Grmek, Maladies, 290. We may add that even the nice
diagnostic try to identify signs of tuberculosis in Roman children’s portrait sculpture
66 Graumann and Horstmanshoff

of TB made by so many different authors in the past is in itself a historical


diagnosis.

9.11 Conclusion
We have clearly shown that a single retrospective diagnosis of tuberculosis is
not unequivocal. In theory, there are innumerable other diagnostic possibili-
ties with tuberculosis being only one option. Bearing in mind the low inci-
dence of children’s tuberculosis in contemporary Western developed societies,
TB seems like a rather a simplistic, less probable option, and, moreover, itself
an historical diagnosis. To put it simply, today we cannot really say of what
kind of disease Lucius ultimately died. We have to abandon the image of dis-
ease as trans-historical, cross-cultural entity. The diagnostic process, even the
retrospective one, changes and differs over time. Retrospective diagnosis could
only serve as point of orientation within its own framework. It is, ultimately, a
contingent explanatory tool.194
Beside the medical aspects, what remains is a quite expensive marble arte-
fact which survived almost two millennia, and preserved a very long, sophisti-
cated, and carefully composed text to the purpose of granting eternal memory
to young Lucius.195 This tombstone and, of course, our own discussion here
counteracts the negative impression of fading names on withering stones as
was famously lamented by the fourth-century author Ausonius in his epigram
37,9–10: monumenta fatiscunt,/mors etiam saxis nominibusque venit, “tomb-
stones decay, death comes even to stones and the names on them”.196 Reporting
to us a single life event in the historical context of Roman antiquity, this text
conveys how much loved and valued this particular boy, Lucius, was by his own
parents (especially his father). It offers some kind of consolation, an attempt

(= iconodiagnostic) is based on unsound ground (e.g., Backe-Dahmen, Innocentissima,


106, where the author critically mentions this diagnostic interpretation of a boy’s sculp-
ture from second century AD with narrow chest and slight upper arms).
194  Graumann, L. A. ‘Die Krankengeschichten in den “Epidemien” des “Corpus Hippocraticum”.
Retrospektive Diagnosen als ein Beispiel für Kontingenz’, in Labisch, A. and Paul, N.
(2004). Historizität. Erfahrung und Handeln—Geschichte und Medizin, 118–19.
195  McWilliam, ‘Children’, 86: “Yet taking the trouble to erect a permanent burial-marker for
a child (and for many members of the Roman society this would have involved consider-
able expense) implies a strong motivation for doing so”.
196  Cf. the full of pathos poetic example in Statius (Silv. 2.1.54f.; ca. 90 AD): cuncta in cineres
gravis intulit hora | hostilisque dies; nobis meminisse relictum, “A heavy hour, a hostile day
has brought all to ashes: to us is left a memory”. Trans. Shackleton Bailey 2003. Vérilhac
has collected many funeral inscriptions for children, which contain the same idea of eter-
nal memory: ΠΑΙΔΕΣ 1, 126–27 no. 80, 196 no. 126, 218 no. 146, 232 no. 159.
the Epitaph of L. M. Anthimianus 67

to cope with grief, a ‘Trauerarbeit’. Simultaneously, it must have served as tra-


ditional, socially expected and public means of self-representation (a status
symbol) for Lucius’ parents as manumitted citizens.197 With this putative med-
ical background in mind, we may further speculate that the father-narrator has
perhaps also implicitly hoped, by writing down the medical history of his own
child’s fate, that there would come a time when physicians will be able to heal
similar illnesses. Did he have Thucydides in mind, who wrote his history as a
κτῆμά τε ἐς αἰεί, “a possession for all time”, and his description of the plague in
order that “from the study of it a person should be best able, having knowledge
of it beforehand, to recognise it if it should ever break out again”?198 We are
fully aware of the fact that considering our text as a sort of ‘physician’s testa-
ment’, that is a plea for medical research from the past, cannot rise above the
level of speculation. This is not history on a grand scale, but miniature family
history.199 Mourning for one’s own deceased children seems to be a constant
in human history, no matter how much rituals might differ. We cannot say
if people in antiquity mourned more or less emphatically or intensely, than
today. But we know that they mourned in their own way and with their own
possibilities of expression.200

10 Epilogue

This unique Roman pagan epitaph has been erected to commemorate the
individual existence of one deceased and beloved child with his individual sad
story of sickness. Beside its own undeniably funereal context, it provides us
with some medical information by describing the course of the diseases and
their treatment. Retrospective diagnosis of this pattern of sickness is feasible,
but has to be regarded only as a relative, self-reflecting and tentative thought-
experiment limited by its own historical context. To focus only on a single
diagnosis like tuberculosis is oversimplifying the complex, very contingent
phenomenon of sickness itself.
While reading this ancient poem we realised that not only our horizons
and those of Lucius and his parents differ, but that there have already been

197  McWilliam, ‘Children’, 91: “a mark of social prestige.”


198  Respectively, Th. 1.22.4 and 2.48.3.
199  Dixon, S. ‘The “other” Romans and their family values’, in ead. (2001). Childhood, Class and
Kin in the Roman World, 13.
200  Golden, ‘Ancients’, 159–60: “The way we shape our feelings is culturally determined, the
feelings have some physiological and even biological basis”.
68 Graumann and Horstmanshoff

encounters in the past between them and many generations before us, each
with its own horizon. Through engaging in dialogue with the text and with
earlier interpretations of it, we are changed, and so too, in a way, is the text.201
In confronting the past and in taking due note of the tradition from which we
come, we had to test our own prejudgements.202

Texts and Translations Used

Inscriptions
l’Année épigraphique. Revue des publications épigraphiques relatives à l’antiquité
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Corpus Inscriptionum Graecarum (CIG). Ed. A. Boeckh, vol. 1–4. Berlin: Reimer,
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Corpus Inscriptionum Latinarum (CIL). Consilio et auctoritate Academiae litterarum
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Epigrammatum Anthologia Palatina (AP). Ed. F. Dübner, E. Cougny et al., vol. 1–3. Paris:
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Griechische Vers-Inschriften (GV). Ed. W. Peek, Grab-Epigramme, vol. 1. Berlin:
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Inscriptiones Graecae (IG). Ed. Academia Scientiarum Berolinensis. Academia
Scientiarum Brandenburgensis. Berlin: Reimer, 1873–, later: Berlin: De Gruyter.
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Steinepigramme aus dem griechischen Osten (SGO). Ed. R. Merkelbach and J. Stauber,
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Die Beichtinschriften Westkleinasiens. Epigraphica Anatolica 22. Ed. G. Petzl. Bonn:
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Prosopographia Imperii Romani saeculi 1, 2, 3 (PIR2). Consilio et auctoritate Academiae
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201  Gadamer, Wahrheit, 311, English translation 305; Frank, R. ‘On the field’, in: Engen, J. van
(1994). The Past and Future of Medieval Studies, 204–16, especially p. 210.
202  Gadamer, Wahrheit, 290, Engl. Translation, 305.
the Epitaph of L. M. Anthimianus 69

Epigraphica 2, Texts on the Social History of the Greek World. Ed. H. W. Pleket. Leiden:
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Samama, É. Les médecins dans le monde grec: Sources épigraphique sur la naissance
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Supplementum Epigraphicum Graecum (SEG). Ed. J. J. E. Hondius et al., vol. 1. Leiden:
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CHAPTER 2

Questioning the Patient, Questioning Hippocrates:


Rufus of Ephesus and the Pursuit of Knowledge

Melinda Letts

Rufus of Ephesus’ short treatise, Quaestiones Medicinales, the only


ancient medical work that takes as its topic the dialogue between doctor
and patient, has usually been seen as a procedural practical handbook
serving an essentially operational purpose. In this paper I argue that the
treatise, with its insistent message that doctors cannot properly under-
stand and treat illnesses unless they supplement their own knowledge
by questioning patients, and its remarkable appreciation of the singular-
ity of each patient’s experience, shows itself to be no mere handbook
but a work addressing the place of questioning in the clinical encounter.
I illustrate some of the differences between Rufus’ conceptualisation of
the relevance and use of questioning and that which can be seen in the
theoretical and descriptive writings of Galen and in the Hippocratic cor-
pus, and show how apparent resonances with some of the preoccupa-
tions of modern Western healthcare can be used judiciously to elucidate
the significance of those differences.

1 Introduction

Rufus of Ephesus, who worked around the time of Trajan,1 was for more than
a millennium considered one of the great names in Greek medicine. The great
majority of his work having disappeared, he has less of a reputation today. It is
probably fair to say that his modern image is that of a competent, essentially
practical physician who, though praised by Galen, was ultimately effaced by
his overpowering successor.2 The epithets attached to his name do not tend to

1  The date is provided by the Suda, s.v. Ροῦφος. Biographical details about Rufus are scanty; for
a summary, see Pormann, P. ‘Introduction’, in id. (2008). Rufus On Melancholy, 4; or, for a full
discussion, Abou Aly, A. (1992). The Medical Writings of Rufus of Ephesus, 15–55.
2  See for example Eijk, P. J. van der ‘Rufus’ On Melancholy and its philosophical background’, in
Pormann, Melancholy, 159–60, and, in the same volume, Nutton, V. ‘Rufus of Ephesus in the
medical context of his time’, 140.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_004


82 Letts

include words like ‘innovative’, ‘bold’ and ‘controversial’. Yet Rufus did some-
thing that no-one else did, so far as we know: he wrote a treatise urging the
systematic questioning of patients. The subject matter of this work is unique in
the extant corpus of ancient medical writing,3 and, of Rufus’ undoubtedly pro-
lific output, it is one of only four authentic treatises to have survived in Greek.4
Unlike other works of Rufus, it receives no attention from Galen.5
The treatise originally attracted my attention because, after studying classics
as an undergraduate, I had spent two decades leading UK advocacy organisa-
tions that worked on behalf of people with long-term conditions, persuading
health care professionals and policy makers to recognise the unique and trans-
formative effect of the patient’s narrative on the clinical encounter. Returning
to classics I was naturally drawn to ancient medicine, and became aware of
the comparative dearth of material (both primary and secondary) that showed
much interest in the patient’s perspective. The understudied status of Rufus’
treatise is a case in point. Often characterised as a practical manual,6 the work
is surely more than that, with its lucid and insistent message that the doc-
tor does not know enough on his own and that information elicited from the
patient is a sine qua non of successful diagnosis and therapy. It is a message that
captures one of the central preoccupations of the politics of modern western
healthcare remarkably well. What I want to offer here are some ideas prompted
by wondering why Rufus, and apparently only Rufus, should have been moved
to devote a treatise to the topic. What could he have been aiming to achieve?
Though we may not be able to isolate the definitive factors behind an author’s
decision to write something, there is obvious value in considering what those
factors might have been, and forcing ourselves to distinguish elements of our
hypothesis that anachronistically reflect our own pre-occupations from those
that might illuminate the ancient text or help it to illuminate others.

3  Gärtner, H. (1962). CMG Suppl. IV, 19–20 and 106; Abou Aly, Rufus, 192–93. See also Jouanna, J.
(1992). Hippocrates, 135. A hypothesis advanced by both Wellmann and Gossen that two
Herophileans, Callimachus and Callianax, wrote works on the same topic that have not sur-
vived is dismissed by Gärtner (ibid. 19–20).
4  Nutton, ‘Medical context’, 139–40.
5  References to Rufus—some complimentary, some less so—are scattered across several of
Galen’s books. No doubt attaches to the authenticity of this treatise. Galen may have sim-
ply not considered it a significant work. Initiatives to improve the delivery of care routinely
attract less attention and fewer resources than pushing back the frontiers of medical knowl-
edge (see for example Westfall, J. et al. (2007). ‘Practice-based research: “Blue highways” on
the NIH roadmap’, Journal of the American Medical Association 297.4, 403–06). The study of
ancient medicine is not immune from this tendency; see next paragraph.
6  See for example Nutton, V. in Brill’s New Pauly, s.v. Rufus [5]: “a handbook for doctors on the
questions to ask their patients”; cf. Nutton, V. (2004). Ancient Medicine, 209.
Questioning the Patient, Questioning Hippocrates 83

I shall refer to Rufus’ treatise as On Questioning the Patient, the title of my


new translation. Quotations from the text are taken from Hans Gärtner’s
Teubner edition of 1970.7 All translations in this paper are my own unless oth-
erwise specified.8

2 More than a Manual

On Questioning the Patient (henceforth QP) is clearly more than a practical


handbook. Rufus does not merely cover what doctors should ask about, but
insists repeatedly (eleven times in the course of this short work) that unless
they ask, and listen, their knowledge will be inadequate to the physician’s task.
The idea is articulated in a variety of ways, but the running theme is clear: any
doctor who fails to incorporate questioning into his clinical practice must nec-
essarily operate in ignorance of a range of crucial factors, none of which can
be discovered by any other means, and, even when there are indicative signs
(σημεῖα) to point the way, he will greatly improve the quantity and quality of
his knowledge by asking questions.9 Rufus disagrees with others who hold dif-
ferent views. He is exasperated by a school of thought that expects doctors to
be able to tell whether a patient has eaten by touching him rather than asking
(§ 37), and downright critical of “the physician Callimachus”10 for having pro-
nounced it unnecessary to ask any questions at all:

7  These references are identified by the letter ‘G’. This text is an improved version of
Gärtner’s 1962 edition, which was published (with commentary and German translation)
as CMG Suppl. IV.
8  My translation, which forms part of my doctoral thesis, is the first complete English ver-
sion. For a partial English translation, see Brock, A. (1929). ‘Rufus of Ephesus: On the
interrogation of the patient’, in id. Greek Medicine, Being Extracts Illustrative of Medical
Writers from Hippocrates to Galen, 112–24. For a French translation, see Daremberg,
Ch. and Ruelle, Ch. É. (1879). ‘De l’Interrogatoire des Malades’, in id. Oeuvres de Rufus
d’Éphèse. Texte collationné sur les manuscrits, traduit pour la première fois en Français, avec
une introduction, 195–218. For Gärtner’s German translation, see note 7. A Dutch transla-
tion appeared as this article was being finalised: Haak, H. (2013). Rufus Ephesius: medicus
gratiosus, 40–59.
9  For example, ἐγὼ δὲ ἡγοῦμαι μὲν καὶ παρ’ <ἑ>αυτοῦ δύνασθαί τινα πολλὰ τῶν ἐν ταῖς νόσοις
ἐξευρίσκειν, κάλλιον δέ γε καὶ σαφέστερον ἐν τοῖς ἐρωτήμασιν (‘I think that although one can
certainly find out a lot about illnesses by oneself, one can do so better and with greater
clarity by asking questions): QP 22, G. 6.8–10. See also §§21, G. 5.22–24; 23, G. 6; 26, G. 7; 33,
G. 8; 34, G. 8; 37, G. 9; 38, G. 9; 40, G. 9–10; 64, G. 14; 73, G. 16.
10  Probably the late 3rd/early 2nd century BC Alexandrian, Callimachus of Bithynia. See
Gärtner ad loc., CMG Suppl. IV, 64–65.
84 Letts

ὥστε ἔγωγε θαυμάζω Καλλιμάχου τοῦ ἰατροῦ, ὃς μόνος τῶν ἔμπροσθεν, ὧν γε


δὴ καὶ λόγον ἄν τις ποιήσαιτο, οὐκ ἔφασκε δεῖν ἐρωτᾶν οὐδὲν οὔτε περὶ τὰς
ἄλλας νόσους οὔτε περὶ τὰ τραύματα, καὶ μάλιστα τὰ τῆς κεφαλῆς· ἀρκεῖν γὰρ
καὶ τὰ ἐφ’ ἑκάστῳ σημεῖα τό τε πάθος σημῆναι καὶ τὴν αἰτίαν αὐτοῦ, ἐξ ὧν καὶ
προγινώσκεσθαι πάντα καὶ θεραπεύεσθαι ἄμεινον. ἐπεὶ μηδὲ τὰς ἡγουμένας
προφάσεις τῶν νόσων [καὶ] ἀναγκαίως ἐρωτᾶσθαι, οἷον διαίτης τε ἀγωγὴν καὶ
τὰ ἄλλα ἐπιτηδεύματα καὶ εἰ κοπιάσαντι συνέβη νοσῆσαι καὶ εἰ ψυγέντι· μηδὲν
γὰρ ἂν τούτων μαθεῖν <δεῖν> τὸν ἰατρόν, εἰ τὰ σημεῖα ἀκριβῶς ἐκμελετήσαι τὰ
συμπίπτοντα ταῖς νόσοις.11

I am amazed, then, by the physician Callimachus, who alone of earlier


doctors—at least of those whom one would take seriously—denied the
need to ask questions about illnesses, including wounds, and especially
head-wounds. He claimed that the signs in each case were sufficient to
indicate both the condition and its cause and should preferably be used
as the basis of all prognosis and treatment. He said there was no need to
ask even about the immediate causes of illnesses—such as the regimen
being followed, and the other habits of life, or whether the person was
tired or cold when he fell ill—on the grounds that the physician had no
need to learn anything from these factors if he considered carefully and
accurately the signs occurring along with the illnesses.

He also criticises Hippocrates. In the treatise’s closing section, Rufus defends


himself against a putative charge of un-Hippocratic thinking with the counter-
charge that his illustrious predecessor did not go far enough:

εἰ δέ τις φησειέ μέ ἐναντίον γιγνώσκειν Ἱπποκράτει, ὃς δὴ τέχνην ἔλεγεν


ἐξευρηκέναι, δι’ ἧς δυνήσεται ὁ ἰατρὸς ἀφικόμενος εἰς πόλιν, ἧς ἄπειρός ἐστι,12
περὶ τῶν ὑδάτων εἰδέναι καὶ περὶ τῶν ὡρῶν, ὅπως τε τοῖς ἀνθρώποις αἱ κοιλίαι
ἔχουσι, καὶ εἰ φιλοπόται εἰσὶ καὶ εἰ ἐδωδοί, καὶ περὶ τῶν νοσημάτων ὁποῖα
ἐπιδημεῖν εἴθισται, καὶ αἱ γυναῖκες ὅπως πρὸς τοὺς τόκους διάκεινται, καὶ ὅσα
ἄλλα ἐκεῖνος ὑπέσχετο τῇ τέχνῃ, μηδένα ἐρωτῶν τῶν ἐπιχωρίων, ἀλλὰ παρ’
ἑαυτοῦ, μανθάνειν· ταῦτα δὲ εἴ τις προ[σ]φέρων ἐπιμέμφοιτό μοι ὡς τῷ ἀρίστῳ
τῶν ἰατρῶν περὶ τῶν μεγίστων <οὐ> συγγιγνώσκοντι, λέγω πρὸς ἐκεῖνον οὐδέν
με[ν] τῶν ἐκείνου ἀτιμάζειν, ἀλλὰ τὰ μέν τινα καὶ οὕτως εὑρεθῆναι περί τε

11  QP 21, G. 5.24–6.8.


12  Rufus quotes recognisably, if loosely, from Aer. 1.12–13 (L. 2.12.9–10), ἐς πόλιν ἐπειδὰν
ἀφίκεταί τις ἧς ἄπείρός ἐστι; thereafter his paraphrasing of the Hippocratic work is inexact
and even misleading.
Questioning the Patient, Questioning Hippocrates 85

ὡρῶν καταστάσεως καὶ φύσεως σώματος καὶ διαίτης τρόπων καὶ ὑδάτων τὴν
κοινὴν ἀρετήν τε καὶ κακίαν καὶ νοσημάτων τὴν κοινὴν [καὶ] ἰδέαν, τὰ[ς] δὲ
[δι’] ἱστορίας τῆς παρὰ τῶν ἐνοικούντων εἰς τὴν διάγνωσιν χρῄζειν, καὶ μάλιστα
ὅσα ἄτοπα καὶ ξένα ἑκάστοις ὑπάρχει. τοῦ μὲν σοφίσματος καὶ πάνυ ἄγαμαι
τὸν ἄνδρα καὶ πολλαχῇ καλῶς αὐτῷ ἐξεύρηται, παρακελεύομαι δὲ μηδὲ τῶν
ἐρωτημάτων ἀφίστασθαι τὸν μέλλοντα ὀρθῶς ὑπὲρ ἁπάντων γνώσεσθαι.13

If someone were to say that my thinking was opposed to that of


Hippocrates, who as you know said he had invented an art by means of
which a doctor could, on arrival at a city with which he was unfamiliar,
have knowledge of the waters, the seasons, the condition of the inhabit-
ants’ bowels, whether they enjoy drinking and eating, what disorders are
endemic there, how the women experience childbirth, and everything
else that Hippocrates professed to find out by the art, not by questioning
any of the inhabitants but off his own bat; if anyone, citing this, were to
find fault with me for disagreeing with the greatest of doctors about the
most important matters, I say this: I do not disparage any of Hippocrates’
theories, and some things are certainly discovered by his method—things
to do with the character of the seasons and the constitution of the body
and modes of life, as well as the general advantages and disadvantages
of the waters and a general picture of diseases—but there are other things
that require research among the inhabitants in order for diagnosis to be
made, especially anything unusual or strange that is present in them indi-
vidually. I admire the man unreservedly for the cleverness of his method,
and he used it to make good discoveries in many places; but I urge anyone
aiming for accurate and complete knowledge not to reject questioning.

How strong a criticism this constitutes is something on which recent authori-


ties have disagreed, with assessments ranging from Nutton’s that it is “an
extension, not a criticism, of Hippocrates’ views”, through that of Gärtner, who
called it “slight criticism”, to Jouanna’s description of Rufus’ desire to defend
himself against the hypothetical accusation of un-Hippocratic thinking as
“significant”.14 There is not enough space in this paper to discuss this aspect
in detail, but criticism of other doctors, including Hippocrates, was perfectly

13  QP 72–73, G. 15.23–16.18.


14  Nutton, Ancient Medicine, 210, arguing that Rufus was a faithful Hippocratic; Gärtner ad
loc., CMG Suppl. IV, 65, drawing a contrast with the “distinctly polemical” character of the
attack on Callimachus; Jouanna, Hippocrates, 135.
86 Letts

normal practice, and Rufus is not averse to engaging in it elsewhere.15 Though


the critique is undoubtedly polite, it is firm: the method by which Hippocrates
claimed to acquire his knowledge was clever but, in its disregard of question-
ing, inadequate to the task of identifying particular, rather than just universal,
complaints. Combined with the other criticisms and the frequent repetitions
of his point, this emphatic closing statement suggests that QP constitutes a
counter-argument to ideas or practices with which Rufus disagreed.

3 “Things that Even Laymen are Capable of Knowing”: An Enduring


Debate

What lay behind this difference of opinion? Was it something as simple and
timeless as poor practice: sloppy, lazy doctors not bothering—or perhaps
lacking the time—to do something that Rufus considered a priority?16 Or was
there some weightier point of principle at stake, a methodological or episte-
mological difference perhaps, or disagreement over what sorts of knowledge
were relevant to understanding the workings of the body and where that
knowledge might be found? On this latter possibility Galen, as so often, proves
instructive. Though he postdated Rufus by a generation or two, he is close
enough in time to stand witness to broadly contemporary patterns of medico-
philosophical thinking. Not only do his writings betray a somewhat differ-
ent attitude to dialogue with patients from Rufus’ own, as we shall see, but
he explicitly articulates the view that “things that even laymen are capable
of knowing” are incompatible with the Art and out of place in a medical

15  See for example QP 40, G. 9–10, on the praiseworthiness of physicians who are prepared to
admit their own ignorance. Professor C. Pelling believes this sounds “particularly . . . ago-
nistic, taking on an opposite view that may explicitly have been formulated” (personal com-
munication, 2012). H. von Staden (1989, Herophilus: the art of medicine in early Alexandria,
481 with note 3) notes Rufus’ “polemical posture” towards some of the Alexandrians, cit-
ing his attack on “Egyptians who speak Greek poorly”. Nutton on the other hand (‘Medical
Context’, 140) describes him as “eirenic”. On traditions of criticising other doctors, see
Lloyd, G. E. R. (1991). Methods and Problems in Greek Science, 398 with note 3 (Galen claim-
ing to have improved on Hippocrates: De praecogn., K. 14.665.5–6 = CMG V, 8.1, 134.3–4;
De meth. med. K. 10.420.10–13 and 425.1–11) and 401 with notes 11 and 12 (a wealth of ref-
erences for criticism of Hippocrates by Celsus, Soranus, Ctesias and Diocles); see also
Nutton, ‘Medical Context’, 148.
16  Nutton (Ancient Medicine, 201) points out that in a city as large and busy as Ephesus there
could have been considerable merit—for both patient and doctor—in keeping consulta-
tions short by following Methodist principles.
Questioning the Patient, Questioning Hippocrates 87

treatise. This sharp conceptual distinction between what we might today call
“expert” and “common” knowledge is of a piece with the intellectually com-
petitive atmosphere of the first and second centuries,17 and it seems plausi-
ble to hypothesise that Rufus’ views on the importance of learning from the
patient may not have been widely shared. The liveliness of this same debate in
our own era should not mislead us into considering it a uniquely modern one;
indeed its diachronic nature can be nicely illustrated by a brief excursus into
medieval scholasticism. In the late thirteenth century, Taddeo Alderotti, cel-
ebrated professor of medicine at the University of Bologna, proposed a series
of quaestiones18 concerning the epistemological role of patients and lay people
in the production of medical knowledge, including “Whether the doctor ought
to question the patient about all his symptoms and write a book about them”
(utrum medicus debeat interrogare infirmum de omnibus accidentibus et de eis
facere librum) and “Whether any of the things that are known to laymen ought
to be added to the art of medicine” (utrum aliqua nota vulgo, arti medicinali
addenda sint);19 and he chose to illustrate his discussion with quotations from
Hippocrates and Galen. It was, then, legitimate within the thirteenth cen-
tury European academic medical tradition not only to debate whether or not
“things known to laymen” carried epistemological validity in medicine but—
importantly for our purpose—to assume that the question had also taxed the
minds of ancient physicians.20

17  The intellectual competitiveness of the “Second Sophistic” is succinctly described by


Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 9–11. On competitiveness between
doctors specifically, see also Hankinson, R.J. ‘Galen on the limitations of knowledge’ in
Gill, C. et al. (2009). Galen and the World of Knowledge, 239–42.
18  The use of quaestiones to explore important matters of principle was a standard tech-
nique of medieval scholasticism.
19  Thaddei Florentini Expositio in arduum aphorismorum Ipocratis volumen, In divinum pro-
nosticorum Ipocratis librum, In preclarum regiminis acutorum Ipocratis opus, In subtilissi-
mum Joannitii Isagogarum libellum (Venice, 1527), fol. 247v, cited and discussed by Siraisi, N.
(1981). Taddeo Alderotti and his Pupils: Two Generations of Italian Medical Learning, 124–
25. On medieval academic medicine more generally, see Siraisi, N. (2001). Medicine and
the Italian Universities, 1250–1600.
20  On the whole, despite valuing the patient’s narrative, medieval physicians “felt obliged
to mistrust” it because laymen lacked medical training, according to Siraisi, N. (1990).
Medieval and Early Renaissance Medicine: An Introduction to Knowledge and Practice, 124.
Taddeo himself defended the inclusion in learned medical tracts of information acquired
from patients, and considered both Hippocrates and Galen mistaken on this point (Siraisi,
Taddeo, 125).
88 Letts

Taddeo’s Hippocratic quotation, from the opening paragraph of Regimen in


Acute Diseases, rebukes the authors of the (now lost) Cnidian Maxims for hav-
ing written too much about patients’ experiences and too little in the way of
expert commentary:

οἱ συγγράψαντες τὰς Κνιδίας καλεομένας γνώμας ὁποῖα μὲν πάσχουσιν οἱ


κάμνοντες ἐν ἑκάστοισι τῶν νοσημάτων ὀρθῶς ἔγραψαν καὶ ὁποίως ἔνια
ἀπέβαινεν· καὶ ἄχρι μὲν τούτων, καὶ ὁ μὴ ἰητρὸς δύναιτ’ ἂν ὀρθῶς συγγράψαι,
εἰ εὖ παρὰ τῶν καμνόντων ἑκάστου πύθοιτο, ὁποῖα πάσχουσιν· ὁπόσα δὲ
προσκαταμαθεῖν δεῖ τὸν ἰητρὸν μὴ λέγοντος τοῦ κάμνοντος, τούτων πολλὰ
παρεῖται, ἄλλ’ ἐν ἄλλοισιν καὶ ἐπίκαιρα ἔνια ἐόντα ἐς τέκμαρσιν.21

The authors of what we call the Cnidian Maxims correctly recorded the
sorts of things patients experience in individual diseases, and the out-
comes of some of them; even a non-doctor would be able to do that, if he
was well informed by patients about each illness and their experiences.
But much of what the doctor ought to know besides, without a word from
the patient, is omitted—different things in different cases, including
some that are important for the interpretation of symptoms.

Galen’s commentary on this passage goes further, leaving no room for doubt
that he regarded laymen’s and doctors’ knowledge as very different things
and thought that a work too liberally supplied with the former could not be
regarded as a proper medical tract:

οὐ μόνον οὐδὲν ὧν οἱ κάμνοντες πάσχουσι παρέλιπον οἱ τὰς Κνιδίας γράψαντες


γνώμας, ἀλλὰ καὶ περαιτέρω τοῦ προσήκοντος ἐνίων ἐμνημόνευσαν, ὡς ὀλίγον
ὕστερον δείξω. καὶ οὔπω τοῦτο τέχνης ἔργον, εἰ μηδὲν παρέλιπον τῶν καὶ τοῖς
ἰδιώταις γνωσθῆναι δυναμένων· οὐ γὰρ οὗτος ὁ σκοπὸς τοῖς τεχνίταις ἐστίν,22
ἀλλὰ τὸ τὰ χρήσιμα πρὸς τὴν θεραπείαν ἅπαντα γράφειν, ὥστε καὶ προσθεῖναί
τινα δεήσει πολλάκις, ὧν μὴ γινώσκουσιν οἱ ἰδιῶται πάντως, ἀφελεῖν τε πολλὰ
τῶν γινωσκομένων αὐτοῖς, ἐὰν μηδὲν φαίνοιτο συνεργοῦντα πρὸς τὸ τῆς τέχνης
τέλος.23

21  Acut. 1 (Loeb II.62.1–10 = L. 2.224.2–9), the first of three paragraphs criticising the Cnidian
authors.
22  This is Kühn’s punctuation; Helmreich punctuates . . . γνωσθῆναι δυναμένων, (οὐ γὰρ οὗτος ὁ
σκοπὸς τοῖς τεχνίταις ἐστίν), ἀλλὰ τὸ τὰ χρήσιμα. . .(for reference see next footnote).
23  Gal., In Hipp. Acut. comment.1 (K. 15.419 = CMG V, 9.1, 117.11–19).
Questioning the Patient, Questioning Hippocrates 89

Not only did the authors of the Cnidian Maxims include every detail of
what patients suffer, but they actually mentioned more than what was
appropriate, as I shall show a little later.24 This is not yet the point of the
medical art,25 if they omitted none of the things that even laymen are
capable of knowing; the goal for practitioners of the Art is not this, but
recording everything that is useful for therapy. This means that one will
often need to include things of which laymen have absolutely no knowl-
edge, and to exclude much of what they do know, unless it seems to con-
tribute something to the fulfilment of the Art.

4 “We Try to Tell Without Asking”: Galen and the Art of Questioning

Galen’s concern with what was conducive to the telos of the Art is entirely
characteristic. His work is permeated by a marked interest in the integrity, sta-
tus and nature of medicine and in the assertion of his self-image as its guard-
ian and protector, as well as by an overriding enthusiasm for order and control
manifested variously, but consistently, in the content and organisation of his
writings, in the opinions he expresses about the technē of medicine, in his tele-
ological concept of the body, and in his concern with maintaining the author-
ity of the physician.26 In his commentary on Hippocrates’ Epidemics 6.2.24 he
discusses at length the value of questioning patients.27 He begins by explain-
ing that it is particularly useful in cases where one does not have previous

24  Galen kept his promise but we are not, unfortunately, able to benefit from it; after the tan-
talising words “I said earlier that the Cnidian authors wrote . . .” the text is irrecoverably
corrupt (K. 15.427 = CMG V, 9.1, 121. 22).
25  My translation is influenced by van der Eijk’s observation that Galen often refers to “the
principal job (ergon) or aim (skopos) of the medical art” (Eijk, P. J. van der ‘Therapeutics’,
in Hankinson, R. (2008). The Cambridge Companion to Galen, 283).
26  Concern with status and nature of the technai: Mattern, Rhetoric, 23; need for order and
control, and image as protector of the integrity of the Art: Flemming, R. ‘Galen’s impe-
rial order of knowledge’, in König, J. and Whitmarsh, T. (2007). Ordering Knowledge in the
Roman Empire, 241–77; teleological approach to the body: Holmes, B. ‘Medical knowl-
edge and technology’, in Garrison, D. H. (2010). A Cultural History of the Human Body in
Antiquity, 101.
27  Gal., In Hipp. Epid. 6 comment. 2.45 (K. 17.1.995–99 = CMG V, 10.2.2, 115–117). For a discus-
sion of the cognitive ability of lay people to report physical and mental symptoms and
pain in Galen’s work, see Courtney Roby, ‘Galen on the patient’s role in pain diagnosis’
(Chapter Eleven) 304–322.
90 Letts

knowledge of the patient, for the things a sick person says can reveal his state
of mind, enabling one to judge how to behave towards him, and in particular
how truthful one can be without frightening the nervous or encouraging dis-
obedience in the over-confident:28

φρόνιμον μὲν γὰρ εἰ γνωρίσαις εἶναι τόνδε τινὰ τὸν ἄνθρωπον ἔτι τε μὴ δειλόν,
ἀληθεύειν πειραθήσῃ μηδὲν ὑποστελλόμενος τῶν κατὰ τὴν νόσον ἐσομένων·
ἄφρονα δὲ καὶ δειλόν, ἐξ ὧν ἂν εὐθυμότερος γένοιτο, πάντα ταῦτα ἐρεῖν μετὰ
τοῦ μηδὲν μέγα ψεύδεσθαι. . . . τὰ γὰρ πλεῖστα τῶν ἐπισφαλῶν νοσημάτων
ἀνατρέπει τοὺς κάμνοντας ἀπειθοῦντας τοῖς ἰατροῖς . . . ἀλλὰ καὶ θαρρήσαντες,
ὡς ἀκινδύνως νοσοῦντες, οἱ πλείους τῶν ἀνθρώπων οὐ πάνυ κατήκοοι γίνονται
τῶν ἰατρῶν.29

If you find the patient has presence of mind and courage, by all means
try telling the truth, holding back nothing of what is going to happen
during the illness; but if he is witless and cowardly then say whatever will
improve his spirits, without telling any major untruths. . . . Mostly, dan-
gerous illnesses destroy patients when they disobey their doctors . . . And
besides, most people become less than obedient to their doctors if they
are confident that they are not dangerously ill.30

Secondly, where one has some prior knowledge, questioning affords the oppor-
tunity to draw conclusions about the patient’s mental stability from his man-
ner, for example if he speaks differently from normal.31 Thirdly, the voice itself
can contain important diagnostic clues such as hoarseness, shrillness, lisp-
ing and hesitancy.32 Finally, skilful choice of questions based on the patient’s
physical appearance will allow one to show off one’s medical skill by asking

28  K. 17.1.995–97 = CMG V, 10.2.2, 115.23–116.20.


29  K. 17.1.995–97 = CMG V, 10.2.2, 115.28–116.17.
30  On disobedience as the most likely cause of a poor outcome, see also de Arte 7 (L. 6.10–
12). On the risk implied for the physician, see Decent. 14 (L. 9.240.15–16): when patients
fail to follow instructions and then die, “their behaviour is never admitted, but the physi-
cian gets the blame” (αὐτῶν μὲν οὐχ ὡς ὁμολογίην τρέπεται τὸ ποιηθέν, τῷ δὲ ἰητρῷ τὴν αἰτίην
προσῆψαν). On Galen’s insistence on obedience see Mattern, Rhetoric, 145–49.
31  K. 17.1.997 = CMG V, 10.2.2, 116.21–26. For the idea that boldness in a normally mild-man-
nered patient is a bad sign, cf. Rufus, QP 2, G. 1; also Prorrh. 1.44 (L. 5.522.6): ἐκ κοσμίου
θρασεῖα ἀπόκρισις κακόν.
32  K. 17.1.997–98 = CMG V, 10.2.2, 116.26–117.1. The patient’s voice as a diagnostic and prognos-
tic tool in Hippocrates’ Epidemics is discussed by Colin Webster, ‘Voice Pathologies in the
Hippocratic Corpus’ (this volume, Chapter Five) 166–199.
Questioning the Patient, Questioning Hippocrates 91

questions which indicate a preternatural level of prior knowledge about his


complaint and its attendant circumstances, while avoiding those that might
suggest the opposite:33

ἐὰν γὰρ τὰ προγεγονότα καὶ τὰ προγινωσκόμενα τῷ τε κάμνοντι καὶ τοῖς


ἀμφ’ αὐτὸν ὁ ἰατρὸς πυνθάνηται, θαυμάζουσιν εὐθέως αὐτόν, ὥσπερ κἂν εἴ
τινα τῶν ἐναντίων τοῖς γεγονόσιν ἐρωτῴη, καταγινώσκουσιν. ἀλλὰ καὶ τῶν
συμβεβηκότων τοῖς κάμνουσιν ἔνια, πρὶν ἀκοῦσαι παρ’ αὐτῶν, ἐν μέσῳ σχήματι
λέξεως ἐρωτήσεώς τε καὶ ἀποφάσεως ἐὰν εἰπὼν ἐπιτύχῃ, θαυμάζεται. λέλεκται
δ’ ἅπαντα ταῦθ’ ἡμῖν ἑτέρωθι.34

For if the doctor enquires about things that have already happened, and
things that the patient and his companions already know, they imme-
diately admire him; similarly, they condemn him if he asks about any-
thing that is the opposite of what has happened. And if in the middle
of the question-and-answer process he happens to mention some of the
things that have befallen patients before they tell him themselves, he is
admired. All this I have said elsewhere.

As a statement of Galen’s attitude to dialogue with patients, this whole com-


mentary is rich and revealing. His interest in maintaining control and exciting
admiration comes through very clearly. A modern taxonomy of question types
characteristically includes a range such as open, closed, factual, probing, hypo-
thetical, reflective and leading questions.35 Galen conceptualises questioning
in a way that today appears limited and superficial: in his account, q­ uestions

33  K. 17.1.998–99 = CMG V, 10.2.2, 117.4–19. The Hippocratic author of Prorrhetic 2 advises that
doctors “make their predictions, if they are sensible, only after the disease has become
fixed”, adding that “when you are successful in making a prediction you will be admired by
the patient you are attending, but when you go wrong you will not only be subject to hatred,
but perhaps even be thought mad”, Prorrh. 2. 2 (L. 9.8–10); tr. Potter, Loeb vol. 8, 219–221.
34  K. 17.1.998–99 = CMG V, 10.2.2, 117.13–19.
35  For a contemporary list, see http://www.changingminds.org/techniques/questioning/
questioning.htm (accessed 23rd August 2015). For a scholarly discussion, see Dillon,
J. T. (1990). The Practice of Questioning, especially chapters 5, ‘Clinic Questioning:
Medicine’ and 10, ‘Notions of Questioning’. Dillon (p. 54) quotes research demonstrat-
ing that “physicians commonly believe that questioning skills are unnecessary” and
comments “But . . . the way they ask questions can clearly affect both the information-
gathering and therapeutic value of the interview”. For a discussion of how the content
and timing of a question affects the answer, see Loftus, E. F. (1975). ‘Leading questions and
the eyewitness report’, in Cognitive Psychology 7, 560–72.
92 Letts

are tools through which the doctor can assert control, manipulate the patient’s
behaviour, secure obedience, conjure up signs36 (the patient’s manner and
voice) and, if he deploys them cleverly enough, demonstrate the accuracy
of his initial suppositions. The respect and trust which, according to the
Hippocratic authors of Prognostic 1 and Decorum 11, flow from successful prog-
nosis have in Galen’s analysis been transmuted into a kind of bedside shock
and awe. There is a marked bias towards what today we call closed, leading
and factual questions, the latter to be asked in specific symptomatic circum-
stances, as opposed to using questions throughout the consultation as a way
of probing from different angles in order to penetrate the heart of the patient’s
complaint. The injunction against questions that might suggest poor prognos-
tic ability is highly significant, for it disallows the use of process of elimination
as a diagnostic tool.37 So far as the patient’s answers are concerned, Galen is
much more interested in delivery—the opportunity that questioning provides
to observe the respondent’s behaviour and voice—than in content. In sum,
his grasp of the use of questioning as a clinical technique seems to a modern
eye narrow and underdeveloped, not to say self-serving,38 and, like his remarks
about the Cnidian Maxims, devoid of the interest a modern doctor would be
expected to show in the patient’s narrative.
Three well-known case histories in Galen’s On Prognosis will serve for prac-
tical illustration at this point:39 those of the insomniac woman,40 the anxious
slave, and the feverish son of Boethus. Each presents an initially baffling case,
the first two involving psychosomatic symptoms and the third secretive behav-
iour on the part of a boy. All three cases, to modern sensibilities, cry out for
careful, sensitive questioning of the patient. Yet despite emphasising his own
appreciation of the relationship between body and mind, Galen mentions
questioning the patient only once, in the case of the insomniac woman, when
he simply says he asked about “all the things that tell us insomnia is present”;

36  On the importance of signs (σημεῖα) in ancient medicine, see for example Holmes,
‘Medical knowledge’, 90 and Hankinson, R. J. (1998). Galen on Antecedent Causes, 39–43;
cf. Jouanna, Hippocrates, 291.
37  Contrast Art. 47 (L. 4.212.4–5), on the instructive value of describing failure.
38  Cf. Lloyd on Galen’s aim of presenting himself “as the most successful prognosticator and
therapist of all time” (Lloyd, G. E. R. ‘Galen’s un-Hippocratic case-histories’, in Gill, T. et al.,
Knowledge, 131).
39  Lloyd points out (‘Un-Hippocratic’, 118) that although there are case stories “scattered
through the oeuvre of Galen”, it is in On Prognosis that he chose to set out his “most con-
centrated collection of case-histories”. It must therefore be reasonable to turn to it for
insights into his handling of the medical encounter.
40  This episode is also discussed by Mattern in ‘Galen’s Anxious Patients: Lypē as Anxiety
Disorder’ (chapter six, 203–223.).
Questioning the Patient, Questioning Hippocrates 93

he ascribes his success to his own powers of observation, natural intelligence


and well trained logical faculty.41 The theoretical rationale for his interactions
with patients is given in On Therapeutics to Glauco, where he explains that
the way to resolve the tension between universal medical theory and messy
individual reality is to employ logic, in the form of diairesis, a rebarbatively­
complex process which, if done properly (and most doctors usually fail, of
course), will lead to faultless endeixis.42 Questioning the patient should not
need to feature: “we try, as you know, to tell patients the preceding cause with-
out waiting to ask them, and the acquisition of such an ability is the best indi-
cation that one is not mistaken” (ἡμεῖς δὲ, ὡς οἶσθα, πειρώμεθα λέγειν αὐτοῖς τὸ
προηγησάμενον αἴτιον, οὐ περιμείναντες ἐρέσθαι τὸν κάμνοντα, καὶ ἔστι μέγιστον
σημεῖον εἰς τὸ μηδὲν σφάλλεσθαι τὸ τοιαύτην τινὰ πεπορίσθαι δύναμιν).43

5 On Questioning the Patient

Galen’s advice on questioning implies an essentially hierarchical concep-


tion of knowledge. I refer not to the difference between technical and non-
technical knowledge—Galen expected all educated men to possess medical
knowledge44—but to his apparent disregard for the diagnostic and therapeu-
tic value of the empirical perspective that is available from, and only from,
the person who inhabits the ailing body. Today it is recognised that the best
understanding of an illness and how to treat it is likely to proceed from com-
bining the patient’s empirical knowledge with the theoretical and empirical
knowledge of the doctor.45 This chimes remarkably well with Rufus’ opening
statement: ἐρωτήματα χρὴ τὸν νοσοῦντα ἐρωτᾶν, ἐξ ὧν ἂν καὶ διαγνωσθείη τι τῶν
περὶ τὴν νόσον ἀκριβέστερον καὶ θεραπευθείη κάλλιον (“You must ask the patient

41  Gal., De praecogn. 6–7 (K. 14.630–41 = CMG V, 8.1, 100–110). Emphasis on body-mind
connection: 6.15 (K. 634 = CMG, 104.14–18).
42  Gal., Ad Glauc. de meth. med. K. 11.4.7–5.11. For a new edition and translation, see Dickson, K.
(1998). Stephanus the Philosopher and Physician: Commentary on Galen’s Therapeutics
to Glaucon. For helpful discussions, see van der Eijk, ‘Therapeutics’, and Hankinson,
‘Limitations’, 231–33; cf. also Hankinson, R. J. (1991). Galen on the Therapeutic Method,
Books 1 and 2. On Galen’s preference for deductive rather than inductive routes to knowl-
edge, see Lloyd, ‘Un-Hippocratic’, 130, referencing in particular Galen, In Hipp. Epid. 1 com-
ment. 1 (K. 17.1.251–53 = CMG V, 10.1, 126.11–127.17).
43  Gal., Ad Glauc. de meth. med. (K. 11.10.13–16). On ‘antecedent’ and ‘preceding’ causes, see
Hankinson, Antecedent Causes, 24 with note 104, and 43–45.
44  Mattern, Rhetoric, 24–25.
45  See for example Malterud, K. (1995). ‘The legitimacy of clinical knowledge: towards a
medical epistemology embracing the art of medicine’, Theoretical Medicine 16, 183–98.
94 Letts

questions that will lead to more precise recognition of any of the factors sur-
rounding the illness, and to better treatment”).
Having set out his stall right at the start, Rufus proceeds immediately to
explain that priority must be given to questioning the patient himself, because
of the possibility this affords for combining observation of voice and manner
with the gathering of information. If this is not possible (if the patient is deaf,
or physically or mentally prevented from speaking, or is too young, too old, or
a foreigner) then one must direct one’s questions to his or her companions. A
series of areas for questioning is advised, which we can group under fourteen
headings:

1. Timing of onset (11–14)


2. Whether or not the complaint is a new one (15)
3. The patient’s nature (φύσις) and habits (ἐθισμούς) and any current diver-
gences from his norm (16–23)
4. Distinguishing between obvious and hidden causes (24–27)
5. The quantity and quality of urine, faeces and saliva compared to dietary
intake (27)
6. Current patterns of sleep compared to the patient’s norm (28)
7. Visions and dreams (29–33)
8. Congenital diseases: patterns of recurrence, presentation, previous
attacks (34–35)
9. Current dietary and therapeutic regimes, and their effects (36)
10. Current food consumption, preferences and reactions (37–40)
11. Pain, especially the distinction of genuine pain from histrionics (41–43)
12. Ease or otherwise of bodily waste processes (44)
13. When treating animal bites, whether or not the beast was rabid (46–49)
14. When treating wounds, the type of weapon and wound and the patient’s
subsequent reactions (50–62).

All this might be considered unremarkable. Good Hippocratics question their


patients in order to flesh out their own observations, improve their interpreta-
tion of signs, and enlist the patient’s co-operation.46 Is Rufus’ treatise, then,
simply a particularly forceful articulation of Hippocratic adherence, designed
to encourage the same in others? I think that there are some significant factors
that set it apart, a couple of which I want to highlight briefly.

46  Jouanna, Hippocrates, 135–36; cf. Nutton, ‘Medical Context’, 147.


Questioning the Patient, Questioning Hippocrates 95

First, although questioning is implied or recommended by a number of


Hippocratic authors,47 they tend, like Galen in the commentary discussed
earlier,48 to prescribe specific questions to be asked at specific moments or
under specific circumstances. A good example is the sequence of questions
recommended in Prognostic 2, shown opposite in diagrammatic form to illus-
trate the algorithmic nature of the process.49
This type of questioning is not part of a free-flowing conversation where
the physician follows interest to build his knowledge incrementally, as modern
doctors are trained to do when taking a patient’s history;50 rather, it forms part
of a procedural protocol for the doctor to use at prescribed junctures when
his own visual observations yield insufficient signs for diagnosis or prognosis.
For Rufus, on the other hand, questioning the patient is a primary and indis-
pensable activity, and the process he implies is comparatively fluid, and con-
ducive to a greater variety of question types. Where the author of Prognostic
supplies a script, Rufus takes us on a tour of the areas the doctor ought to
ask about, supporting each of his recommendations with an explanation of
how the information thus acquired will enhance the doctor’s knowledge. The
questioning recommended in Prognostic starts from the disease and implies
a kind of standardised mechanics of the body; Rufus’ starts from the person
and emphasises individuality. As he puts it, “things the physician might fear,
thinking them the hardest to prevent and the most resistant to treatment, may
be unproblematic in the case of this individual, or not unfit for treatment in
the present illness. . . . for we are not all constituted the same; on the contrary,
we are completely different from one another, in every respect whatsoever”.51

47  See notes 55–57 below.


48  In Hipp. Epid. 6 comment. 2.45 (K. 17.1.998.7–13 = CMG V, 10.2.2, 117.5–11).
49  Progn. 2 (L. 2.112–18); cf. also 7 and 16 for similarly prescriptive questioning
recommendations.
50  See Hatton, C. and Blackwood, R. (2003). Lecture Notes on Clinical Skills, 8: “Try, if feasible,
to conduct a conversation rather than an interrogation, following the patient’s train of
thoughts”. This handbook for medical students covers the history-taking process in con-
siderable detail (see chapter 1, pages 6–25); for a summary of the structure of a patient
history, see http://www.gpnotebook.co.uk/simplepage.cfm?ID=-2120613880 (online
resource, accessed 23rd August 2015).
51  ἅπερ ἂν καὶ δείσαι ὁ ἰατρὸς <ὡς> χαλεπώτατα [καὶ] διακωλῦσαι καὶ οὐ[τε] προσφόρως
θεραπευόμενα οὔτε χαλεπὰ τούτῳ <γε> τῷ ἀνθρώπῳ ὄντα οὔτε ἀνεπιτηδείως τῇ παρούσῃ
νόσῳ θεραπευόμενα . . . οὐ γὰρ πάντες πεφύκαμεν τρόπῳ τῷ αὐτῷ, ἀλλὰ καὶ πάνυ ἀλλήλων
διαφέρομεν εἰς ὁτιοῦν χρῆμα. (QP 15–16, G. 4.16–24). Rufus goes on to observe, “there is no
single theory to explain the actions of all these substances [foodstuffs and medicines]”, a
theme echoed a little later in § 40. For a fuller discussion of Rufus’s thinking on patient
96 Letts

His purpose is not to provide a script or a check-list, but to outline a method


that doctors can adapt for themselves:

ἤδη οὖν μοι σαφὴς ἡ γνώμη ἐστίν, †ὅτι ἂν ἀφικέσθαι βούληται†. τὰ μέντοι
σύμπαντα οὔτε λόγος αὐτάρκης οὔτε χρόνος ἱκανὸς σημῆναί τε καὶ ἐξευρεῖν.
τὸ δὲ κεφάλαιον τῆς γνώμης εὑρεθὲν καὶ ὑποβληθὲν τῷ ἰατρῷ ἔχοι ἂν πάμπαν
τὸ δέον.52

So now my thinking is clear. . . . A speech is not, of course, sufficient for


explaining or learning everything, nor is there enough time.53 But if the
doctor grasped the essence of my thinking and based his work on it, it
would contain everything he needed.

Secondly, the Hippocratic texts are not noticeably concerned about who
exactly supplies the answers to the questions. This has considerable bearing
on how we think about the information that is elicited. Bystanders (παρόντες)
are a familiar feature of the ancient bedside scene.54 Sometimes they are
explicitly drawn into Hippocratic texts by having questions addressed to
them.55 Sometimes the patient himself is named as the interlocutor.56 But
quite often neither is specified.57 To appreciate the implications of this, we

individuality, see Letts, M. (2014). ‘Rufus of Ephesus and the patient’s perspective in medi-
cine’, British Journal for the History of Philosophy 22.5, 1009–1012.
52  QP 71, G. 15.18–22.
53  Q P was, I argue in my thesis, probably composed for oral delivery.
54  For example Epid. 6.2.24 (L. 5.290); Gal. De praecogn. 3.3 (K. 14.614 = CMG V, 8.1, 82.19);
Rufus, 3, G. 2; 9–10, G. 3; 21, G. 5.22–24; 63, G. 13.25. See also Mattern, Rhetoric, 88–92.
55  For example Prorrh. 2.2.10 (L. 9.30.7–8): “most of the people who look after the chil-
dren will, if you ask them, agree” (οἱ μὲν πλεῖστοι τῶν τρεφόντων τὰ παιδία ἐρωτώμενοι
ὁμολογήσουσι).
56  For example Fract. 5 (L. 3.432.9, cf. 434): after bandaging a fracture, “ask the patient if it
is tight” (ἐρωτώης αὐτὸν εἰ πεπίεκται); Progn. 16 (L. 2.152.10–11): while the patient is lying
on his good side, “ask him if it feels as if there is a weight hanging down from above”
(ἐρωτᾷν εἴ τι αυτέῳ δοκέει βαρὺ ἀποκρέμασθαι ἐκ τοῦ ἄνωθεν); Acut. (spur.) 9 (L. 2.436.8–
438.1): ὀκόταν δὲ ἔρῃ αὐτὸν καὶ διασκέψῃ ταῦτα πάντα, “when you are questioning him and
examining everything carefully”.
57  For example Aff. 37 (L. 6.246.16–18): “when you reach a patient, you must ask carefully
about what he is experiencing, from what cause, for how many days, whether his bowels
are moving, and what regimen he is following” (ὅταν δὲ ἐπὶ νοσέοντα ἀφίκῃ, ἐπανερωτᾶν χρὴ
ἃ πάσχει, καὶ ἐξ ὅτου, καὶ ποσταῖος, καὶ τὴν κοιλίην εἰ διαχωρέει, καὶ δίαιταν ἥντινα διαιτᾶται);
Progn. 7 (L. 2.126.12–128.2): “Such patients also experience nosebleed in the first period,
Questioning the Patient, Questioning Hippocrates 97

Presentation: appearance of facea


bnormal, nose sharp, eyes hollow,
temples sunken, ears cold with lobes
turned outwards, facial skin hard,
tense and parched, with yellow or
black colour

At beginning If illness has


of illness lasted longer
than three days

Examine the
other signs

Examine signs
If conjecture in bodyand eyes
Make your conjecture
not possible

ASK if patient has had Certain signs are listed


insomnia, loose bowels, that indicate imminence
or hunger of death

YES NO

Recovery may If no recovery


Little danger;crisis likely
occurafter a day after a day and a night
after a day and a night
and a night

Expect death
98 Letts

must recognise that there are significant limits to an intermediary’s ability to


represent a patient’s experience. The insertion of a rapporteur or interpreter
into a dialogue—no matter how much integrity the intermediary brings to the
task—alters its dynamic, circumscribing the scope of the doctor’s enquiry and
compounding the risk of misinterpretation by a factor of two. By way of illus-
tration, if the question “has there been a headache?” is answered by a third
party—“yes, she complained of headache the night before the fever began”—
the doctor can do little more than tick the question off on a check-list; but in
an unmediated conversation with the patient, supplementary questions can
be posed, such as “Had you done or felt anything unusual beforehand? Was it
a dull pain or a throbbing one?” and so on. The mediated response forces a
schematic approach to diagnosis, one that does not lend itself to probing and
has been shown by modern research to tend towards mistaken diagnosis.58
The patient’s subjective response, on the other hand, may spark discussion of
symptoms that might not otherwise have come to light, encouraging unfore-
seen lines of enquiry.59 The process is still abductive, but with a potentially
much richer base of factors from which the physician can draw inferences.60
To a greater or lesser extent, then, relaying information via a third party
compromises the subjectivity of that information. Even if the patient is pres-
ent but simply unable to speak the language, there is an almost inevitable
degree of contamination, given how hard it is for an interpreter’s choice of

which is very helpful; but you must also ask if they have headache or visual impairment,
for if one of those is the case, the illness will fall in that direction” (γίγνεται δὲ τουτέοισιν ἐν
τῇ πρώτῃ περιόδῳ καὶ αἵματος ῥῆξις ἐκ τῶν ῥινῶν, καὶ κάρτα ὠφελέει· ἀλλ’ ἐπανέρωτᾷν χρὴ, εἰ
τὴν κεφαλὴν ἀλγέουσιν ἢ ἀμβλυώπέουσιν· ἢν γάρ τι τοιοῦτον εἴη, ἐνταῦθα ἂν ῥέποι).
58  Patel, V. et al. ‘Thinking and reasoning in medicine’, in Holyoak, K. (2004). The Cambridge
Handbook of Thinking and Reasoning, 739–40. Pain, Rufus advises, should not be taken at
face value, since “many people, through softness and weakness, play the part of being in
pain more elaborately than tragic actors groaning on the stage” (QP 41 G. 10.16–18).
59  For an eloquent discussion of the importance of effective dialogue in the clinical
encounter, see Geisler, L. (1991). Doctor and patient—a partnership through dialogue, espe-
cially ‘Introduction’ and ‘Discussion techniques: general principles’; see also Malterud,
‘Legitimacy’, especially 184 and 187–88. For a fuller discussion of Rufus’s interest in subjec-
tivity, see Letts, ‘Patient’s Perspective’, 1012–16.
60  This is one of the reasons why retrospective diagnoses—though diverting both for the
doctors who make them and for the rest of us, to whom they offer vicarious thrills and
a frisson of human interest—are of limited value. Retrospective diagnosis is a one-way
conversation, an example par excellence of traditional, top-down, evidence-driven medi-
cal process. It cannot be considered a form of narrative-based medicine, because the nar-
rative on which it relies is static and incapable of being developed.
Questioning the Patient, Questioning Hippocrates 99

words, or even his or her facial expression and body language, to have no
impact on the tenor and direction of the conversation.61 Indifference as to
whether questions are answered by the παρόντες or directly by the patient
implies that the author assumes them to be materially equivalent. For Rufus
there is no such equivalence. His treatise begins by emphasising the primacy
of questioning the patient himself. His opening declaration, ἐρωτήματα χρὴ τὸν
νοσοῦντα ἐρωτᾶν62 (“You must ask the patient questions”, §1), is swiftly followed
at the start of the next sentence by πρῶτον δὲ ἐκεῖνο ὑποτίθημι τὰς πεύσεις αὐτοῦ
τοῦ νοσοῦντος ποιεῖσθαι63 (“That is my first principle: put your enquiries to the
patient himself” §2). Only after restating the importance of questioning the
patient at the very end of this section does he admit of the alternative, second-
best option: πρῶτον μὲν δή, ὡς εἴρηται, αὐτόν τινα χρὴ τὸν νοσοῦντα ἐρωτᾶν περὶ
ὧν χρὴ εἰδέναι, ἔπειτα δὲ καὶ τοὺς παρόντας, εἰ κωλύματα εἴη παρὰ τοῦ νοσοῦντος
μανθάνειν64 (“First, as I have said, you must question the patient himself about
the things you need to know; then, if there are obstacles to learning from the
patient, you must question his companions as well”, §9). I have not (so far)
found this kind of hierarchical preference articulated in any Hippocratic texts.
Taken together, the prescriptive questioning model and the apparent lack of
concern about who provides the information suggest that, in the Hippocratic
Corpus, questioning is conceived as essentially an extension of, rather than
supplementary to, the collection of signs through observation. Seen in this
light, Rufus’ clear preference for subjective information gained directly from
the patient does not appear accidental.

6 Conclusion

In conclusion, my point is not that Galen and the Hippocratic authors do not
discuss questioning patients; obviously they do. Nor do I doubt the importance
that, in their own ways, they attach to this aspect of the medical encounter.
What this paper is concerned with is how different physicians conceptualise

61   See for example Angelelli, C. (2004). Medical Interpretation and Cross-cultural
Communication, a study of the role of medical interpreters in situations where health-
care providers and patients do not speak the same language. Angelelli argues that the
interpreter, far from being a passive conduit for language, has significant power over the
medical encounter and the relationship between patient and provider.
62  QP 1, G. 1.3.
63  QP 2, G. 1.5–6.
64  Q P 9, G. 3.6–8.
100 Letts

the questioning of patients: how they think about it and understand its place
in their practice; and, by extension, how they think about the patient, both as
a person and in relation to the doctor. To quote one respected modern author-
ity, “The medical dialogue is the fundamental instrument through which the
paradigmatic battle is waged: the patient’s problem will be anchored in either
a biomedical and disease context or a broader and more integrated illness con-
text that incorporates the patient perspective.”65 I have referred to contem-
porary discussions of doctor-patient relations at several points in this paper,
not because they are necessarily transferable to analysis of how these things
worked in the ancient world but because, in whatever age or culture, the clini-
cal encounter reflects the enduring nexus of negotiated power represented by
doctors’ specialist knowledge and the use that patients, and society, permit
them to make of that knowledge. Studying how that plays out can illuminate
the expression and resolution of tension between common knowledge and
expert power in a community or society, while also providing insight to dif-
ferent ways of perceiving the human body.66 I find it hard to avoid seeing in
Galen’s case studies a view of the patient as essentially a collection of symp-
toms, a malfunctioning physical entity that forms a convenient backdrop for
the great physician’s own heroic role in the narrative.67 From the Hippocratic
texts there emerges a greater uncertainty, indeed a frequent sense of perplex-
ity as authors wrestle to draw valid inferences from a bewildering plethora of
possible signs. Absent from both is any clear recognition of the value of prob-
ing the patient’s subjective experience through the kind of unstructured dis-
cussion advocated by Rufus. Today, the right of patients to be heard, and the
importance of their experiential knowledge to the development of medical
understanding, are increasingly recognised in western medicine, supported
by both grass-roots campaigns and a growing academic literature. But when
these issues first forced their way onto the policy agenda it was in reaction to
institutionalised patterns of behaviour that were recognisably similar to the

65  Roter, D. (2000). ‘The enduring and evolving nature of the patient–physician relationship’,
Patient Education and Counseling 39.1, 6.
66  Is it, for example, a machine that ‘goes wrong’? An intricate system of interdependent
humours and qualities needing to be kept in equilibrium? A complex psycho-somatic
organism some of whose responses to physical and mental challenge are uniform and
predictable while others are highly individual?
67  I refer, of course, to how Galen chooses to present his conduct of the clinical encounter,
rather than making any claim to know how those encounters were actually conducted.
Cf. Lloyd’s opinion that the strategic purpose of Galen’s case studies was “to validate his
claim as the most successful prognosticator and therapist of his time” (‘Un-Hippocratic’,
131); see above, p. 92.
Questioning the Patient, Questioning Hippocrates 101

authoritarian, disease-focused clinical style projected by Galen.68 Perhaps part


of the value of Rufus’ treatise lies in its ability to highlight the existence of an
alternative paradigm subsequently overwhelmed by the Galenic tsunami, and
thus to underline the challenge involved in achieving constructive, productive
balance between expert knowledge and that of the person or people in rela-
tion to whom the expert wields his—or even her—power.

Texts and Translations Used

Galen. Opera omnia. Ed. C. G. Kühn. Leipzig: Cnobloch, 1821–33.


———. On Prognosis. (De praecogn). Ed. V. Nutton. CMG V,8,1. Berlin: Akademie-Verlag,
1979.
———. Commentary on Hippocrates On Diet in Acute Diseases (In Hipp. Acut. com-
ment.) Ed. G. Helmreich. CMG V, 9.1, Leipzig and Berlin: Akademie-Verlag, 1914.
———. Commentary on Hippocrates Epidemics 1. (In Hipp. Epid. 1 comment). Ed.
E. Wenkebach. CMG V, 10.1. Leipzig: Teubner, 1934.
———. Commentary on Hippocrates Epidemics 6 (In Hipp. Epid. 6 comment.) Ed.
E. Wenkebach. CMG V 10,2,2. Berlin: Akademie-Verlag, 1956.
Galen. On the Therapeutic Method, Books 1 and 2. Trans. R.J. Hankinson. Oxford:
Oxford University Press, 1991.
Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris: J.-B.
Ballière, 1839–61.
———. Regimen in Acute Diseases (Acut.). Ed. W. H. S. Jones. Hippocrates Vol. II. Loeb
Classical Library. London: Heinemann and Cambridge, Massachusetts: Harvard
University Press, 1923.
Rufus. Oeuvres de Rufus d’Éphèse. Texte collationnée sur les manuscrits, traduit pour la
première fois en Français, avec une introduction. Daremberg, Ch. and Ruelle, Ch.
É. Paris: L’Imprimerie Nationale, 1879.
Rufus von Ephesos. Die Fragen des Arztes an den Kranken. Ed. H. Gärtner (CMG
Supplementum IV). Berlin: Akademie-Verlag, 1962.
Rufus Ephesius. Quaestiones Medicinales (On Questioning the Patient, QP). Ed. H.
Gärtner. Leipzig: Teubner, 1970.

68  For accounts of what was considered normal behaviour by physicians before pioneer-
ing voices began to demand change, see for example Millenson, M. (2011). ‘Spock, femi-
nists, and the fight for participatory medicine: a history’, Journal of Participatory Medicine;
Boston Women’s Health Book Collective et al. (1978). Our Bodies Ourselves, 535–37;
Malterud, ‘Legitimacy’.
102 Letts

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Part 2
Case Histories in the Hippocratic Corpus


CHAPTER 3

Patient Function and Physician Function in the


Hippocratic Cases

Chiara Thumiger

This chapter looks at the patient cases of the Epidemics as testimonies to the
interaction between the physician and the patient. My corpus of reference
is the patient cases in fifth- and early fourth-century medical texts, mostly
the more elaborated examples offered by Epidemics 1 and 3. A patient case
collects information from various sources: the patient’s observable behav-
ior and state; his or her account of her disease, its history and the patient’s
lifestyle; the contribution given by relatives and friends; and, of course, the
physician with his judgment, his agenda, his terminology and didactic aims.
What remains elusive and hidden is the viewpoint of the patient and his
personal experience within, or under the authoritative report compiled by
the physician. In this chapter, I survey key stylistic features of these reports,
which I see as significant to the reconstruction of the point of view of the
ill in his or her encounter with the doctor. My main aim is to extract from
these texts as much as possible information about the experience of suffer-
ing and patienthood in antiquity. In my analysis I look at the text not only,
and not primarily as a definitive pronouncement stemming from the physi-
cian’s legislating mind, and from the material author’s ‘pen’, nor observa-
tions from by-standers and helpers in the sick room, nor even as the plaintive
cries from suffering patient, but as a composition in which all the principal
actors in the drama of a sickness must contribute.

*  I should like to thank the Alexander von Humboldt foundation which has supported
my research and Philip van der Eijk for his ongoing help and advice; the audience at the
Homo Patiens conference, and in particular Peter Singer, and Manfred Horstmanshoff; my
colleagues in the AvH research group, for commenting on a final version; Petros Bouras-
Vallianatos for important bibliographical suggestions. I also benefited from discussions dur-
ing the conference with Brooke Holmes and Helen King (unfortunately not included in this
volume). Last and not least, I thank Annette Schmidt and Konstantin Schulz for their help
with bibliographical researches.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_005


108 Thumiger

1 Introduction

In this article I explore the interaction between patient and physician in


the patient cases from the seven books of Epidemics, already a part of the
Hippocratic Corpus—that collection of early medical writings among which
Epidemics have figured prominently for the past two thousand years. I use the
label ‘patient case’ in a comprehensive sense: a report focussing on one specific
individual, mentioned by name or, in any case, identified as unique subject. A
patient case in the strict sense generally narrates his or her illness in a promi-
nent manner, from the beginning to the end or for a significant portion of time;
but there is interest for our topic also in the brief mention of an individual in
association with a pathology which is being discussed, or in analogy to a previ-
ous case.
My aim is to assess the form that patient cases take in choice of words,
stylistic features, syntax and narrative structure, for variation of these quali-
ties within patient cases from the Epidemics offers clues as to the balance of
power within exchanges of medical information. I propose to weigh patient
functions in each exchange with doctor functions, and, by weighting patient
experiences as of equal importance to the doctor’s medical knowledge, I hope
to gain access to the suffering patient, the homo patiens. I leave aside distinc-
tions among the seven books of Epidemics and fasten my gaze exclusively on
patient and physicians, and how they interacted during the late-fifth and early-
fourth centuries. My interpretive approach will be primarily narratological, as I
inspect the building blocks out of which patient cases were constructed. I shall
consider these texts as speaking entities, individual voices rather than as the
medium through which a controlling authorial voice purposefully organised
and trumpeted his own medical knowledge.1 In this sense, I diverge substan-
tially from Webster’s take in this volume, and his attention to the authors of
Epidemics (and other texts) as organising minds and self-conscious speakers.2
This approach, as shown below, far from being an abstract digression into liter-
ary theory, is firmly rooted into a patient-centred project.

1  Narratology is a development of structuralist and, before that, formalist approaches to lit-


erature, therefore by nature interested in the text and its stylistic features, structures and
mechanisms as text as opposed to external aspects such as a supposed authorial intention.
2  Webster in this volume, especially 166–168.
Patient Function and Physician Function 109

2 Patient Cases: Historical and Theoretical Issues

Theoretical reflections on the patient in the so called ‘casuistry’ (the report-


ing on individual patient cases) and the importance and challenges of giving
space to the voice of the sufferer therein, are at the heart of the project of this
volume and central in current trends in the history of medicine and devel-
oping clinical approaches alike. There are thus three methodological aspects
here: one (a) is theoretical and applies more generally to medicine and medi-
cal theory, concepts of patienthood and patient-narrative; the second (b) is
historical, and has to do with ancient medical texts in connection with the
doctor-patient relationship; finally (c), there are the issues implied when we
try to bring (a) into dialogue with (b).
The first point is a trans-historical and methodological one. The importance
of considering the patient as active participant in the medical act has increas-
ingly taken center stage in current medical practices (most notably psycho-
therapeutic and psychoanalytical,3 but not only so).4 History of medicine has
responded to this shift. From Porter’s call onwards5 medical stories and histo-
ries have been increasingly scrutinised as testimonies to the voices of the ill,
resiliently filtering through to the reader despite the normative control exerted
by official medical figures, however all-mighty and pervasive they might seem
to be.6 Personal narratives (not necessarily first-person) appeared from the
start to be the privileged locus of expression of these voices, in opposition
to the physician-centred doctrinal accounts, with their lists of signs, their

3  The leading psychiatrist Kächele (2011) for example, speaks of “the discovery of a narrative
science” in his discussion of “single case study” as useful tool to “bring together clinicians and
researchers” (‘The single case study approach as a bridge between clinicians and research-
ers’, Annual Meeting of the Rapaport-Klein Study Group. Austen Riggs Center); on the side of
theoretical reflection, see Frank, A. W. (1995). The Wounded Storyteller for a reflection on the
intertwining of illness and storytelling, describing the embodied narrative offered by suffer-
ing patients.
4  See Brody, H. (2003). Stories of Sickness, 11 and 16–17 on the “joint construction of heal-
ing narratives” as cooperation between patient and physician. See also, from earlier days,
Kleinman, A. (1988). The Illness Narratives: Suffering, Healing and the Human Condition.
Kleinman’s distinction between disease and illness (psychiatric, but not only so) points also
at the gap between the biology of dysfunction and the subjective experience of a pathology,
that is not a mere epiphenomenon to the biological datum, but indeed the ‘real thing’.
5  Porter, R. (1985). ‘The patient’s view: doing medical history from below’, Theory and Society
14, 175–98. For a practical illustration see his 1987 A Social History of Madness, a collection of
case histories of mental patients aimed at foregrounding the point of view of the patient.
6  On the excesses of Foucault’s views on this matter, see Porter, ‘Patient’s view’, 197.
110 Thumiger

technical language and theoretical generalisations. Narrative as seriously rel-


evant to humanity in medical contexts, and not an accidental by-product or
pre-scientific endeavor is thus taken as ineliminable part of medical knowl-
edge in its fieri.7 Clinical medicine has long recognised this: Brody’s 1987 Stories
of Sickness was among the pioneering contributions to the field; Montgomery
Hunter”s 1991 Doctor”s Stories emphasises explicitly the application of the meth-
odologies of the humanities for “understanding what it is that clinicians do”,
proposing to look at the interactions between physicians (and patients too) as
“literary” phenomena.8 She speaks firmly against hard-core “epidemiological”
models of medicine, claiming that medicine is “not a science” but an interac-
tive practice,9 to be studied “as narrative activity”.10 In addition, Epstein looks
at case histories and case fictions, maintaining that “human understanding is
finally achieved through narrativity”.11 All these reflections have in common
the resort to literary approaches as trait d”union between an anthropologically
minded medical history and the interpretation of textual material. DelVecchio
Good, in particular, looks at “competence” in American medicine as a “social
product”, which medical narrative well illustrates in terms of literary analysis:
narratives are characterised by “plot” (the facts), ‘emplotment’ (the way the
facts are turned into a story), and “narrative time”,12 three features to whose
creation patient and physician must cooperate.13 Good develops these topics
in a similar direction,14 using textual analysis, and comments insightfully on
what he calls “subjunctivising” elements in illness narratives.15 Narrative, he

7  Brody, Stories of sickness, 8–11 for a summary of the rehabilitation of the scientific value of
casuistry.
8  Hunter, K. M. (1991). Doctors” stories: The Narrative Structure of Medical Knowledge, 13–14.
See Brody Stories of sickness, 3, 4, with n. 2, who, discussing modern patient narratives,
speaks of the opportunity to eliminate the gap between fictional and real case: research
must bring together “amateurish literary criticism” and “a philosophical inquiry into the
nature of sickness”. On the operative side in the field of psychiatry, Kächele (see n. 5)
includes in his clinical procedure an operative stage of “linguistic and computer-assisted
text analysis” where levels of discourse, vocabulary, metaphors used by the patients, and
as small print as “meaning structures” and “the use of pronouns” are investigated (9–10).
9  Hunter, Doctors” stories, 17.
10  Ibid., 21.
11  Epstein, J. (1995). Altered Conditions: Disease, Medicine, and Storytelling, 25; 31.
12  DelVecchio Good, M.-J. (1995). American Medicine: The Quest for Competence, 178–79.
13  Ibid., 180 speaks of a “therapeutic emplotment” in which the “ongoing experience of dis-
ease and treatment is created by clinicians and patients as they engage each other and
interpret the impact of treatment on disease”.
14  Good, B. (1994). Medicine, Rationality, and Experience.
15  Ibid., 153.
Patient Function and Physician Function 111

observes, aims to “subjunctivise” reality, i.e. to make the reader enter the world
of the narrative: “to be in the subjunctive mode is . . . to be trafficking in human
possibilities rather than in settled certainties”.16 It is in the nature of narrative
to introduce elements of possibility, hypothesis and openness to the reader.
These elements reflect a tension in the very creative genesis of a text, the inter-
action between the two (or more) parts at work.
In short: medicine is interactive, and has an irreducible narrative, human-
istic component, most evident in patient’s narratives as the basic feature of
medical epistemology. These narratives are best approached not (or not only)
by the standards of scientific factuality, but through literary lenses.
This hermeneutic agenda naturally fits medical testimonies that are con-
ceived to reflect the point of view of the patient from the start: diaries, epis-
tolography, autobiography, and so on. Most of the modern thinkers we have
just quoted look at these kinds of sources to build their argument on patient
narratives. A quick glance at the material we have from antiquity easily reveals
that no such evidence remains from the ancient period, with Aelius Aristides,
a rhetorician of the Second Sophistic being the first exception.17
As far as the Epidemics are concerned, the inquiry into doctor-patient inter-
action in them is inseparable from the question of their aim and composition
in the first place. As records of a patient-physician encounter, how and why
did they become a written text? This is a huge topic that has received lengthy
discussion,18 and we shall not dwell on it here, if not to remind ourselves that

16  Ibid., quoting Bruner, J. (1986). Actual Minds, Possible Worlds, 26, here and above.
17  Steger, F. (2007). ‘Patientengeschichte—eine Perspektive für Quellen der Antiken
Medizin? Überlegungen zu den Krankengeschichten der Epidemienbücher des Corpus
Hippocraticum’, Sudhoffs Archiv 91, 230–38 emphasises this point, 231, “doch ist für die
Antike eine Autobiographie im engeren Sinn gar nicht auszumachen”; when we move to
ancient medical texts, and to the Epidemics, the question is to what extent the material
“einen Einblick in das Innere der Patienten läßt und damit Antworten auf die Fragen
zuläßt, wie die Patienten empfanden, dachten und reagierten . . .” (234). On Aelius
Aristides as patient and author see Petridou and van Schaik (Chapters Eighteen and
Nineteen) in this volume 452–495.
18  On oral culture and medical texts see Lonie, I. M. ‘Literacy and the development of
Hippocratic medicine’, in Lasserre, F. and Mudry, P. (1983). Formes de Pensée dans la
Collection Hippocratique; Miller, G. (1991). ‘Literacy and the Hippocratic art: reading,
writing and epistemology in ancient Greek medicine’, Journal of the History of Medicine
and Allied Sciences 45, 11–40 for the status quaestionis; Eijk, P. van der ‘Towards a rheto-
ric’, 93–99 for an important correction; and Langholf, ‘Structure and genesis’, 222, who
improves on the Havelockian comparison with Homer and exposes in these fifth- and
fourth century ‘Hippocratic’ texts modes of communication that have still much in com-
mon with oral delivery.
112 Thumiger

there are considerations of oral style, on the one hand, and history of com-
position and transmission, on the other that we must discount when giving a
formalist interpretation of these ancient texts.
This takes us to the last point. To what extent can we apply the method-
ological observations offered by the exciting developments in (a) to the
non-autobiographical material of the Epidemics, given the specifics of com-
position we have briefly mentioned in (b)? Scholarship has often emphasised
Hippocratic medicine as disproportionately siding with the authoritative phy-
sician, his doctrine and theories (in nosological or theoretical texts, for exam-
ple), and offering a top-down account of the suffering patients (in the clinical
texts). It is sometimes even taken for granted that Hippocratic medicine “laid
the groundwork for a practice of medicine in which the physician does not talk
to the patient” from the start.19 Very recently, Steger looked at the seven books of
the Epidemics as a whole to conclude that, in their primary focus on ‘ “descrip-
tions of signs of disease” ’ they do not reveal ‘ “how the patient lived his (or her)
disease, how he viewed the way it had been dealt with”, and offer “no insight
into the experience of the doctor in exchange with the patient, leaving the
experience of the patient entirely precluded to us”.20 Other readers have been
more nuanced in this respect. Allowing for a distinction within Hippocratic
texts and ‘genres’ (if I may call them so), Jori explored how the importance of
the information the patient can provide was recognised already by the physi-
cians of the fifth and fourth centuries.21 It is undeniable that it would be the
other model, the one based on theoretical knowledge totally dismissive of the
patient’s view, which would shape the Western dominant medical culture. For

19  Cassel, E. J. (1976). The Healer’s Art, 56; in Brody, Stories of Sickness, 8; in a similar spirit
Webster in this volume, 167 “in short, patients in this text (Epid. 1) are constructed essen-
tially as sick bodies emitting verbiage, not as interlocutors contributing speech”. Entralgo
concedes a little more (Entralgo, P. L. (1970). The Therapy of the Word in Classical Antiquity,
158–70) as he focuses on communication from the other side and explores the presence of
a “suggestive word” (what he calls “psychotherapy”) in the Hippocratic texts as conducive
to the “active cooperation of the patient”, albeit with “paucity and vagueness” (161, 165);
Letts (Chapter Two), especially 85–86 in this volume recognises talk and even questions
and answers as important in Hippocratic medicine, but opposes it to Rufus’ attentiveness
to the patient’s viewpoint.
20  Steger, ‘Patientengeschichte’ 234, 237, my translation and emphasis. See instead already
Pigeaud, J. (1981). La maladie de l’âme. Étude sur la relation de l’âme et du corps dans la tra-
dition medico-philosophique antique, 11 who emphasises how Ancient Medicine in particu-
lar inaugurates a view of ancient medicine grounded onto dialogue . . . “la collaboration
du médecine et du malade”.
21  Jori, A. (1997). ‘Il medico e il suo rapporto con il paziente nella Grecia dei secoli 5 e 4 A.C.’.
Medicina nei secoli. Arte e Scienza 9/2, 189–222.
Patient Function and Physician Function 113

the Hippocratic material, still, we could distinguish (with Jori) between two
options: what he calls an “Hippocratic Model”, open to the view of the patient,
and a “doctor-centred model”, exemplified for Jori by De Arte.22 The first is alive
in the several instances in which the patient is called upon through question-
ing, or reports that appeal directly to his or her viewpoint. In the Prorrh. 2, for
instance, the advice is repeatedly given to ask the patient, ἐπανερέσθαι; consider
also Morb. 2, 51 (L. 7.78.16–17 = Jouanna 188, 10–12), καὶ ἢν ἐρωτᾷς αὐτόν, φήσει
οἱ . . . (“if you ask him, he will tell you that he . . .”). References to patients being
questioned by the physician are explicit, and frequent. Moreover, it is not only
a matter of opposing a theoretical text like De Arte to clinically-minded ones.
There is in fact a more radical objection to readings such as Steger’s: however
much one might wish to portray the ‘doctor-centred model’ as authoritarian
and insensitive to the patient’s viewpoint, the voice of the ‘oppressed’ patient
still resists elision. Jori highlights contradictions and cracks even in the vertical
authorial posture of De Arte, for example, when the author is shown to rely on
the sensations of the patient for the formulation of his doctrine.23 In this way,
even in a text in which the silencing of the patient appears to be programmatic,24
his or her presence is to a degree ineliminable. So, we are not only legiti-
mised, but obliged to look at the interaction between patient and physician in
ancient medicine, and especially in the case reports of the Epidemics, from two
perspectives.25 From a historico-philological point of view (b), as these texts in
the specific are the products of the long-lasting interaction between different
voices: those of the authors which contributed to every stage from note-taking
to draft, compilation and reworking; the speaking patient; the attending audi-
ence of professionals and/or relative and friends; the layers of tradition and
commenting. Secondly, from a socio-methodological point of view (a), con-
sidering the constructedness of medical pathology, its being inseparable from
the subjective experience of the sufferer which is not epiphenomenal. The
sufferer’s experiences necessarily form the substructure on which a patient

22  Ibid., 191. This useful dichotomy (as Jori is well aware of) is useful precisely because we can
see it eroded in different ways.
23  Ibid., 195 on De Arte 5, 35 (L. 6.8.3–12 = Jouanna 228, 12–229, 6) “intima incrinatura”.
24  Jori, “Il medico e il suo rapporto”, 204–06: “Il silenzio del terapeuta”.
25  See Leven, K.-H. ‘ “Mit Laien soll man nicht viel schwatzen, sondern nur das
Notwendige”—Arzt und Patient in der hippokratischen Medizin’, in Reinhard, W. (2007).
“Krumme Touren”—Anthropologie kommunikativer Umwege, 47–61, for a perceptive dis-
cussion of the specific conditions under which patienthood and authority were realised
in ancient, and in particular Hippocratic doctor-patient encounters; on the patient cases
of the Epidemics see also Graumann (2000).
114 Thumiger

case is to be narrated.26 No patient history can really be written despite the


patient, or entirely over his or her head; all medical discourses, on the other
hand, contain a literary element that cannot be eliminated.

3 The Epidemics: The Material Circumstances of the Doctor-Patient


Encounter27

We have some reliable information about the activities of the itinerant physi-
cians in the fifth and early fourth centuries preserved in many of the texts of
the so-called ‘Hippocratic Corpus’.28 Hippocrates and his entourage, as well as
other doctors travelled around the Aegean visiting various locations in main-
land Greece and Asia Minor, plausibly operating in the company of students
and helpers. The activity of the doctor as itinerant is traditional to the medi-
cal profession in Greek culture;29 the very title Epidemics, perhaps given to
the texts at a later stage, if surely before Galen, is taken to mean ‘visits to the
city’, ‘visit to the people’ on the part of the physician, to underline the con-
textual (geographical and seasonal) nature of the texts, but also its nature as
encounter.
Visits to a place could last from weeks to months. The physicians would
return time and again to visit the same patient, as it is sometimes stated explic-
itly. The chronology and topography of these visits are neat and clear in their
details only in Epid. 1–3, while in the other books duration and location may
be left uncertain.30 In terms of frequency, visits might occur every day, or even
more times in the same day or for longer time for a week or more; or with lesser
frequency altogether.

26  Kleinman, A. (1991). Rethinking Psychiatry, 25.


27  See Langholf, ‘Structure and genesis’, 249 on individual books and blocks of books;
Jouanna, J. (1999). Hippocrates, 387–90 on 1–3; Smith, W. D. ‘Generic form in Epidemics 1
to 7’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 27 for a summary;
Leven, ‘Mit Laien soll man nicht viel schwatzen’, 52–58.
28  On Hippocratic therapeutic practices, see Jouanna, Hippocrates, 112–40, 25–36 and
Nutton, V. (2004). Ancient Medicine, 87–102.
29  See the famous passage in Odyssey 17, 383–86 on calling a doctor from a faraway land;
Langholf, V. (1990). Medical Theories in Hippocrates, 36, 135–231; Nutton, Ancient Medicine,
40–41, 87; Horstmanshoff, H. F. J. (1990). ‘The ancient physician: craftsman or scientist?’,
The Journal of the History of Medicine and Allied Sciences 45, 177–79; 188.
30  See Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen’,
in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 9–19; Smith, ‘Generic
Form in Epidemics 1 to 7’, in Baader, G. and Winau, R. (1989). Die Hippokatischen Epidemien,
144–58 for a survey of these aspects.
Patient Function and Physician Function 115

The number of cases in each book varies greatly: as opposed to Epid. 1–3 and
5–7, Epid. 2, 4, 6 largely contain crowds of names listed to illustrate doctrinal
points.31 As one might expect, this reflects in the very different degree of devel-
opment of individual cases. We can then propose various typologies (without
strict categorisation): a) cases proper, including previous circumstances (the
so-called ‘anamnesis’), present illness, prognosis, outcome, and stretches of
daily report; b) long narratives, which may be missing some of the elements
just listed; c) short cases, focused on a particular element of relevance, cover-
ing only a segment of the illness; and finally, d) mentions of names to substan-
tiate a general point, or to add statistically to an event described.
In the case of longer reports, interaction between patient and physician may
offer examples of intimacy and familiarity. First of all, let us consider the ana-
graphics: great precision in giving name and family connections, address and
time of the year (especially in Epidemics 1 and 3), or a rather different kind of
labelling, with anonymous but elaborate indications, to distinguish one individ-
ual from the next or offer a token for future recollection and re-elaboration, espe-
cially in Epid. 2 and 4. E.g.: “the wife of the leatherworker who made my shoes”, or
“the woman with pain in the hips” in Epid. 2.2, 17 and 18 respectively (L. 5.90.7–12;
90.13–92.2). There are adjectives and qualitative comments about the patient, his
or her condition and life, his or her appearance and so on, such as “the pretty
virgin, the daughter of Nerios . . .”, ἡ παρθένος ἡ καλὴ ἡ τοῦ Νερίου (Epid. 5, 50,
L. 5.236.11= Jouanna 23, 15). At the other end of the spectrum, we find quicker
mentions that advertise no deep acquaintance, referring simply to the occa-
sion of contact with the physician, or to the doctrinal reason for mentioning the
patient. These variations reflect varying degrees of actual interaction, and inter-
est in reporting on the interaction (or lack thereof). This is indeed an impossible
and ultimately unnecessary distinction to make, insofar as we are looking at the
text as text, and not trying to reconstruct a specific biographical fact.
The recollection of the patient’s past circumstances is an important indica-
tor: the narrative about the patient’s larger context and relevant past, his or
her general lifestyle, past pathologies, and so on—in short, all the information
that cannot be apprehended by the physician through the use of his senses
upon the observation of the present state of things. The duration, frequency
and intensity of the exchange, and possibly a role played by friends and family
to convey information can be gathered from these anamnestic sections.
On a parallel level, over the head, so to speak, of the patient-physician dia-
logue, there is the noise of professional talks that offer a background to the

31  Epid. 1–3 offers a limited number of articulated patient cases that are given exemplary
prominence: 13 cases (plus 14 names listed in the constitutions) in Epid. 1 and 28 in
Epid. 3, as against around 460 named individuals in the other books.
116 Thumiger

condition of the patient: competitions, doctrinal reflections and debates,


(self)-criticism, and comparisons between therapies and outcomes.

4 ‘Doctor Function’ versus ‘Patient Function’: A Stylistic and


Narratological Approach

On these premises, let us turn now to an analysis of the texts. There is an ele-
ment of abstraction in our programme, of course, implicit in the very label
‘function’. This is inevitable, since it is not the actual autopathography we are
considering, or a clinical report drafted by a doctor in a hospital of nowadays,
a process whose routine, conventions, and interactive ratio we know well, at
least in its broad lines. In the case of the Epidemics, these two actors, patient
and physician, can only be approached as textual entities, and thus as liter-
ary functions. On the other hand, there is also a theoretical legitimisation to
such a move: the literary approach advocated for by those scholars who have
reflected on the clinical reality of modern and contemporary patients. As we
have explored, several observers of the dynamics of case taking and patient
reporting insist on the literary, narratological nature of patient stories.
While in contemporary Western practice doctors produce narratives that
are (at least, supposed to be) intelligible to the patients by incorporating the
stories uttered by them, mostly in a way that makes that input clearly distin-
guishable (for instance, using explicit indirect speech markers), the patho-
graphies of the Epidemics are authored by a third-person narrator who only
exceptionally indicates his external source of information. More importantly,
the cases of the Epidemics have been revised at several stages, and are aimed
at professional audiences of largely unknown size and shape. So, our herme-
neutic task is more complex and the object further removed. Still, if we suc-
ceed in avoiding a mechanicistic application of discourse analysis the tensions
between the two forces, or ‘functions’, of patient and physician can be uncov-
ered to some degree.

5 The Patient Function

5.1 Explicit Embedded Focalisation32


Perhaps the most evident way of voicing the perspective of the patient is
the syntax of subjunctivisation and reported opinion, introduced by verbs

32  Embedded focalisation: “the representation by the narrator in the narrator-text of a


character’s focalisation, i.e., perceptions, thoughts, emotions, or words (indirect speech).
Patient Function and Physician Function 117

of thinking and especially of saying. In general, it is true that no sense of the


importance of reproducing the patient’s words with precision is found in the
ancient texts, as opposed to what current clinical practice recommends.33
Nonetheless, seemingly quoted speech is sometimes reported, although in
ways that are not without problems and ambiguity: embeddment of this kind,
in fact, can be equally a feature of channeling the point of view of another,
or a way of conquering his or her space through an omniscient narratorial
posture.34 Let us explore some of these possibilities.35 The incidental ἔφη, or
ὡς ἔφη (a marker of explicit embedded focalisation) often indicate a received
information on which doubt is cast, as at Epid. 4, 6 (L. 5.146.11–12), ἄρσεν δὲ καὶ
ἄλλο πρὸς τὰς εἴκοσιν ἔφη, εἰ ἀληθέα, οὐκ οἶδα, “she said that she had lost another,
a male, towards the twentieth day. Whether it was true, I don’t know”, or Epid. 4,
20 (L. 5.160.6–7), ἡ Τενεδίη τεταρταίη ἀπέφθειρεν, ὡς ἔφη. . ., “the woman in

Embedded focalisation can be explicit (when there is a shifter in the form of a verb of
seeing or thinking, or a subordinator followed by a subjunctive or optative, etc) or implicit
(when such a shifter is lacking)”. Here and below, I employ the useful glossary that intro-
duces De Jong, I. J. F. (2001). A Narratological Commentary on the Odyssey, xi–xix.
33  See Epstein, Altered Conditions, 32 on this point; 35. To counterbalance the general impres-
sion, that the value of faithfulness to the wording of the patients is generally not recog-
nised, we may quote here the checklist of items to observe at Epid. 6, 8, 7 (L. 5.346.6–7 =
Manetti-Roselli 172, 11–12) which includes “speech, silence, saying what he wishes. The
words with which he speaks: loudly or many, unerring or moulded (with Smith’s English)”,
λόγοι, σιγή, <μὴ> εἰπεῖν ἃ βούλεται· λόγοι, οὓς λέγει, ἢ μέγα, ἢ πολλοί, ἀτρεκεῖς, ἢ πλαστοί. Not
all items here have to do with the quality of the voice: in particular ἀτρεκεῖς, ἢ πλαστοί,
which Manetti and Roselli translate as “se veri, se falsi”, may belong to a ‘literary’ apprecia-
tion rather than an evaluation in terms of veracity: “whether the words are precise/strict
or instead built up/involute”: this would suggest an interpretative effort to understand the
wording style of the patient.
34  Focalisation is notoriously a problematic theoretical point: does embedded focalisa-
tion express even more the view point of the narrator, who goes as far as fabricating his
characters’ words, or withdraws it to really introduce that of someone else? See Rood, T.
(2002). Thucydides: Narrative and Explanation, 294–96 for some important points, and
Hühn, P. et al. (2009). Point of View, Perspective, and Focalization: Modeling Mediation in
Narrative for a status quaestionis on the debate in narratology; to our purpose here, it is
important to note that focalisation effectively does both, signaling the will of the narra-
tor to report on someone’s words, and power of decision; and at the same time reporting
these words.
35  Relevant here is the contract that joins patient and physician (on which Ecca, Chapter
Twelve in this volume, 325–44). On the necessary trust and trustworthiness between
patient and physician see Jouanna, Hippocrates, 136–42; and van Schaik (Chapter
Nineteen) in this volume, 477–479; 486–489.
118 Thumiger

Tenedos aborted on the fourth day, or so she said, . . .”.36 These idiomatic


phrases oppose the statement of the patient to the unreliability the physi-
cian attributes to it, although he nonetheless mentions it. More interesting is
the patient quoted at Epid. 5, 74 (L. 5.246.25–48.1 = Jouanna 34, 6–7) and 7.36
(L. 5.404.18–19 = Jouanna 74, 11–12): γλώσσης οὐ πάντ᾿ ἔφη δύνασθαι ἑρμηνεύειν
(“problems with the tongue: he said he could not articulate everything”). Here
the patient is reported uttering his own inability to utter properly, a passage
that at first sight seems to expose its own fictionality but reveals, in fact, the
complex interweaving of patient’s words on the one hand, and interpretation
and final synthesis in the narrative, on the other. There is no way (unless we
wish to suppose a malignant intention to fabricate facts) that a physician could
write these words independently of an utterance from the patient. Genuinity
is sometimes supported by the subjective and idiosyncratic content prevalent
in most of these instances: Nicanor, at Epid. 5, 81 (L. 5.250.12 = Jouanna 37, 10)
is quoted as he qualifies further his phobia as being more severe in the night,
μόλις ὑπομένειν ἔφη ὅτε εἴη νύξ (see also Epid. 7, 86 with a very close wording),
and Democles, his fellow patient, at Epid. 7, 87 (L. 5.444.18 = Jouanna 102, 4–5;
see also Epid. 5, 82) is quoted on his own gephyrophobia (‘fear of bridges’): “he
said he could not go along a cliff . . .” (καὶ οὐκ ἂν παρὰ κρημνὸν ἔφη παρελθεῖν). In
these examples of indirect speech, we are led to take the words that follow as
close in content, if not identical, to those of the patient.
A special sub-group of shifters is constituted by verbs of seeming. The case
of δοκεῖ and its forms is a central, and difficult one, as such verbal forms eas-
ily become ambivalent in respect to who their subject is. As Good explores
with some sophistication, “narrative discourse” (made of reported opinions or
judgments, and the modulation of intersecting perspectives) has the effect of
“recruit[ing] the reader’s imagination” by enacting the different points of view
in the text, and leaving it open notwithstanding its neat closure.37 The Greek
form δοκεῖ does exactly this in cases when no dative is specified, and no overtly
technical term signals the physician as source. Such openness is often left unre-
solved, as it is impossible to definitely assign a source to the judgment conveyed.
Take Epid. 5.82 (L. 5.250.14–15 = Jouanna 37, 13–14), our Demοcles’ phobias of
height: ὁ μετ’ ἐκείνου ἀμβλυώσσειν καὶ λυσισωματεῖν ἐδόκει (“Democles appeared
to be/felt to be blurred in vision and slacken in the body”). What follows is the
report on a subjective fear, so that we are invited to take ἐδόκει as subjective
(“he felt”, “it seemed to him”—although Smith translates with the impersonal
“seemed to”). Likewise at Epid. 5, 83 (L. 5.250 = Jouanna 38, 5–6): τὸ Φοίνικος· ἐκ

36  See also Epid. 4, 1, 22 (L. 5.162).


37  Good, Medicine, 153.
Patient Function and Physician Function 119

τοῦ ὀφθαλμοῦ τοῦ δεξιοῦ τὰ πολλὰ ὥσπερ ἀστραπὴν ἐδόκει ἐκλάμπειν (“Phoinix’s
problem. (To him) it seemed to see flashes like lighting in his right eye”). Once
again, what seems to be a subjective report could be the interpretation of the
physician as much as the patient’s impression. A description of a patient at
Mul. 2, 174 bis (L. 8.356.2–5) could be also compared here as clear instance of
subjectivity. The passage depicts a typology of patient with psychological suf-
fering: δυσθυμέει τε καὶ αἰολᾶται τῇ γνώμῃ (“she is depressed and restless in her
mind”), and later δοκεέι θανεῖσθαι (“it seems (to her) to be dying”): in the frame
of her despondency, we can take the verb as describing the woman’s own feel-
ings of fear and weakness.
Many other cases, however, remain ambiguous as to whether they refer to
patient and physician, in irreducible ways.38 Such is the case found at Epid. 7, 29
(L. 5.400.12–13 = Jouanna 70, 6–7) ὁπότε ἀπεμέσειεν, ἐδόκει ῥηΐων εἶναι, (“when-
ever he vomited, he seemed/he felt easier”); or at Epid. 7, 5 (L. 5.372.23–74.1 =
Jouanna 53, 11–12) ἡ θέρμη λῆξαι ἐδόκει καὶ ἡ ὀδύνη, (“the heat and the pain
appeared to abate”)—to the patient, or to the observer? And, a bit further, τῇ
ἑβδόμῃ ὡς ὑγιής, (“on the seventh day seemingly/slightly improved”): does this
ὡς subjectivise the doctor’s, or the patient’s view? Or is it perhaps supposed to
oscillate in between, being an expression for the undefinable experience of
suffering, in which the patient becomes spectator of himself and the doctor,
to some degree, a sufferer himself?39 A last and striking example of the two-
way traffic between the one who suffers and the one who cures behind these

38  In her paper delivered at the original Homo Patiens conference Brooke Holmes engaged
with these topics, and noticed the exemplarity of δοκεῖν with its ambiguity. The transmis-
sion of our texts reflects that this must have been a point of tension also for earlier read-
ers. At Morb. 2, 51 (L. 7.78.16–8 = Jouanna 188, 10–12) Jouanna has φήσει οἱ ἄνωθεν ἀπὸ τῆς
κεφαλῆς κατὰ τὴν ῥάχιν ὀδοιπορεῖν οἷον μύρμηκας, “he says that like ants walk from his head
down the neck”, while Littré prints κατὰ τὴν ῥάχιν κατέρχεσθαι δοκεῖν οἷον μύρμηκας, with
δοκεῖν restitutum al. manu. At Epid. 7, 114 (L. 5.462.8–9 = Jouanna 113, 11–12) ἐπελιδνώθη
πάντα κύκλῳ καὶ σαπρά· ἐδόκει ἀμείνον· ἀπέθανεν, “it all became livid in a wide circle and
rotten; he seemed/felt to get better; he died”. In this passage ἀμείνον is omitted by the Ald.
and I, where we have then σαπρὰ ἐδόκει, “they seemed rotten”. Several textual ambiguities
appear around these ἐδόκει et sim.; which shows that an ambiguous nature is inherent to
them, and not only our modern problem.
39  The sympathy and co-suffering of the physician with the patient is evidently present
in the awareness of the Hippocratic physician, as stated famously in Flat. 1 (L. 6.90.3 =
Jouanna 102, 3–4), whereby the medical art is described as one of those which are ἐπίπονοι
(“painful”) to those who practice them, while bringing great advantage to their receivers.
The physician “sees terrible sights, touches unpleasant things, and the misfortunes of oth-
ers bring a harvest of sorrows that are peculiarly his” (ὁ μὲν γὰρ ἰητρὸς ὁρεῖ τε δεινά, θιγγάνει
τε ἀηδέων, ἐπ’ ἀλλοτρίῃσί τε συμφορῇσιν ἰδίας καρποῦται λύπας (L. 6.90.4–6 = Jouanna 2,
120 Thumiger

expressions, their being an interface between patient and physician, is offered


at Epid. 6, 5.7 (L. 5.318.1–4 = Manetti-Roselli 110, 1–4), a case of placebo effect.
The text: ἢν οὖς ἀλγέῃ, εἴριον περὶ τὸν δάκτυλον ἐλίξας ἐγχεῖν ἄλειφα θερμόν, ἔπειτα
ἐπιθεὶς ἔσω ἐν τῷ θέναρι τὸ εἴριον, τὸ οὖς ἐπιθεῖναι, ὡς δοκέῃ τί οἱ ἐξιέναι, ἔπειτα
ἐπὶ πῦρ ἐπιβάλλειν· †ἀπάτη†, (“if the ear aches, wrap wool around your fingers,
pour on arm warm oil, then put the wool in the palm of the hand and put it
over the ear so that something will seem to him to come out. Then throw it in
the fire. †A deception†”). This passage has at the center the doctor, acting out
what might seem to be a patronising ploy to provide the patient with psycho-
logical comfort; on the other hand, it is the deceived subjectivity of the patient
that brings about the improvement, for he is the one upon whom the outcome
depends (δοκέῃ . . . οἱ, “it will seem to him”).

5.2 Character Language40


Character language as indicator of the patient’s viewpoint is detectable in
the use of unique imagery for the expression of subjective feeling. Take as
exemple Epid. 7, 11 (L. 5.382.15 = Jouanna 58, 23). This case offers a rich and
detailed report on a female patient’s mental disturbance. At the very opening
we read καὶ τὴν καρδίην οἱ γυιοῦσθαι ἔφη (“and she said that her heart had been
damaged”).41 Even if the term at stake here is a conjecture,42 it serves nonethe-
less as an instructive example. The verb γυιόω (“to be weak, lame”) is associated
with γυῖα, limbs, and indicates a state of physical weakness, ‘to limp, to suffer
a damage in the limbs or joints’.43 The expression would be therefore heav-
ily metaphorical, ‘my heart is limping’, as opposed to technical, and as such
unique: all these would strongly support the authenticity of the phrase as lit-
eral word choice of the patient. To confirm this point, a few lines below, the
patient’s verbal communication emerges again, and more explicitly: μετὰ τὰς
πρώτας ἡμέρας ἐρωτωμένη οὐκ ἔτι κεφαλὴν ἀλλ’ ὅλον τὸ σῶμα πονεῖν ἔφη (“after the
first days, when asked, she said that no longer only the head, but now also her

102.7–103.2). On touching in ancient medical practice, see Kosak (Chapter Eight) 248–264
in this volume.
40  Character-language: “words which are typically used by characters, i.e., which occur
mainly or exclusively in speeches and embedded focalisation”.
41  With Smith’s translation for γυιοῦσθαι.
42  Coray’s conjecture for M ὑγιᾶσθαι (which makes no sense).
43  Cf. Il. 8, 402 γυιώσω . . . ὑφ’ ἅρμασιν ὠκέας ἵππους, (“I shall break the horses’ legs underneath
the chariot”), says Zeus planning to sabotage Hera and Athena’s journey.
Patient Function and Physician Function 121

entire body ached”).44 A second (and analogous) example is another female


patient, Polemarchus’ wife at Epid. 5, 63 (L. 5.242.10–11 = Jouanna 28, 14–29, 1):
καὶ κατὰ τὴν καρδίην ἔφη τι ξυλλέγεσθαι αὐτῇ (“and she said that something was
gathering to her in/on her heart”). Here the image is less extraordinary than in
the previous case, but what is clearly at stake is again an irreducibly subjective
experience: not only because the location in the καρδίη is invisible and impos-
sible to guess from the outside, but also because of the psychological and emo-
tional suggestions it carries traditionally in Greek culture.45 Interestingly, in
the version of this case found at Epid. 7, 28 (L. 5.400.4–5 = Jouanna 69, 14–15),
καὶ κατὰ τὴν καρδίην ἔφη δοκεῖν τι ξυνάγεσθαι ἑωυτῇ, the verb in the ‘quoted’
patient words is a different one, although the sense of the image used (‘to
gather’, ‘to collect’) is the same. This semantic agreement works in support for
the ‘gathering’ image as original, regardless of which verb was used. At Epid. 7,
45 (L. 5.414.2–5 = Jouanna 80. 1–5) we find a patient with an important sub-
jective pathology, phobic anguish: οὐκ ἐξιέναι ἤθελεν ἀλλὰ δεδιέναι ἔφη· εἰ τέ τις
περὶ νοσημάτων χαλεπῶν διαλέγοιτο, ὑπεξῃει φόβῳ· ἔστι δ’ ὅτε προσπίπτειν αὐτῷ
πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη καὶ τῶν ὀφθαλμῶν μαρμαρυγὰς παρακολουθεῖν
(“he did not want to go out, but he said he was afraid; if someone spoke to him
about severe diseases, he would withdraw in fear; he said sometimes that heat
fell on his hypochondria and that sparks before his eyes continues”).46 The
content of the patient’s utterance is his subjective experience of fear and anxi-
ety, although the physician might be adding his own interpretation to it. The
expression προσπίπτειν αὐτῷ πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη, with heat falling
onto the patient’s chest is more likely to reflect the patient’s representation of
a sensory experience than the physician’s view of it.

44  Verbs of saying and those others denoting the experience of pain (therefore, the sub-
jectivity of the patient in reporting) are associated in a very clear way in Prorrh. 2, 24
(L. 9.54.22), αὗται φήσουσι κεφαλὴν ἀλγέειν; 42 (L. 9.72.11), φήσει πολλάκις ἀλγέειν; 42
(L. 9.72.21–22), ἐπανερέσθαι καὶ κεφαλὴν εἰ ὀδυνῶνται· φήσουσι γάρ. Pain is an experience
where the patient’s (and the physician’s) choice of words become especially pregnant.
For further discussion on this topic see Roby (Chapter Eleven), 304–322 in this volume.
45  Representatively, see Sullivan, S. D. (1995). Psychological and Ethical Ideas: What Early
Greeks Say; id. (1997). Aeschylus’ Use of Psychological Terminology: Traditional and New;
id. (1999). Sophocles’ Use of Psychological Terminology: Old and New; id. (2000). Euripides’
Use of Psychological Terminology for a survey of tragic and early philosophical usage of
καρδία respectively.
46  See Mattern (Chapter Six in this volume) on patient anxiety in ancient medicine, 203–223.
122 Thumiger

5.3 Actorial Analepsis/Prolepsis47


Some passages are narratologically even more complex; the impression is that
these are cases in which psychology, emotions and moods are foregrounded.
Parmeniscus, a patient whose report offers an instructive illustration of depres-
sive mood, appears in both Epid. 5 and 7. It is here interesting to compare
the shortened and probably derivative passage in Epid. 5, 84 (L. 5.252.5–6 =
Jouanna 39, 1–2) with the ‘longer version’ and speculate on the strategies of
reporting at work in it. The short version: Παρμενίσκῳ καὶ πρότερον ἐνέπιπτον
ἀθυμίαι καὶ ἀπαλλαγῆς βίου ἐπιθυμίη, ὁτὲ δὲ πάλιν εὐθυμίη (“to Parmeniscus it had
happened also before to have low mood and desire to take his own life, and
then again positive mood”). In the longer version at Epid. 7, 89 (L. 5.446.7–17 =
Jouanna 103, 6–18) we find a recapitulative section in the second part, in which
Parmeniscus is shown to discuss his previous state after the improvement:
even though he lay still and facing away (he appears to be pointing out after-
wards), he was vigilant and could recognise people all along (ἔφη δ᾿ ὕστερον
ἐπιγινώσκειν τοὺς ἐσιόντας. In this small ἔφη δὲ ὕστερον, (“but he said afterward”)
every word deserves italics: the particle δέ that establishes a correction, or a
requalification of what the doctor had noted; the verb ἔφη that foregrounds
communication of an otherwise inaccessible fact; and the adverb ὕστερον that
gives us a glimpse of a therapeutic process that is ongoing, lasts across a long
period of time, and contemplates post eventum discussion between patient
and physician.

5.4 Anamnesis
There are practical pieces of information that would arguably remain inacces-
sible without the direct cooperation of the patient. The best example is the
anamnestic narrative—or aspects of anamnesis—the material that has to be
provided by the patient or his or her entourage. In this sense, anamnesis is a
form of extended analepsis. An example of extraordinary expansion is that at
Epid. 5, 25 (L. 5.224.6–13 = Jouanna 15, 16–26), a female patient with a gyneco-
logical complaint:

Ἐν Λαρίσῃ ἀμφίπολος Δυσήριδος, νέη ἐοῦσα, ὁκότε λαγνεύοιτο περιωδύνει


ἰσχυρῶς, ἄλλως δὲ ἀνώδυνος ἦν. ἐκύησε δὲ οὐδέποτε. Ἐξηκονταέτης δὲ
γενομένη, ὠδυνᾶτο ἀπὸ μέσου ἡμέρης ὡς ὠδίνουσα ἰσχυρῶς· πρὸ δὲ μέσου

47  Analepsis: “the narration of an event which took place before the point in the story in
which we find ourselves”. Prolepsis: “the narration of an event which will take place later
than the point in the story in which we find ourselves”. Both analepsis and prolepsis can
be narratorial (made by the narrator) or actorial (made by characters).
Patient Function and Physician Function 123

ἡμέρης αὕτη πράσα τρώγουσα πολλά· ἐπειδὴ ὀδύνη αὐτὴν ἔλαβεν ἰσχυροτάτη
τῶν πρόσθεν, ἀναστᾶσα ἐπέψαυσέ τινος τρηχέος ἐν τῷ στόματι τῆς μήτρης.
ἔπειτα, ἤδη λειποψυχούσης αὐτῆς, ἑτέρη γυνὴ καθεῖσα τὴν χεῖρα ἐξεπίεσε
λίθον ὅσον σπόνδυλον ἀτράκτου, τρηχύν· καὶ ὑγιὴς τότε αὐτίκα καὶ ἔπειτα ἦν.

In Larissa, the servant of Dyseris, when she was young, whenever she had
sexual intercourse suffered much pain, but otherwise was without dis-
tress. And she never conceived. When she was sixty she had pain from
midday onwards, like strong labour pain. Before midday she had eaten
many leeks. When pain seized her, the strongest ever, she stood up and
felt something rough at the mouth of her womb. Then, when she had
already fainted, another woman, inserting her hand, pressed out a stone
like a spindle top, rough. She was immediately and henceforth healthy.

This case is a great concentrate of patient information. The pathological past


in a realm that is especially sensitive (sex life, conception), with subjective
notes (pain during intercourse, lack of distress); as well as the intrusion of the
physician—she could not herself compare the pains to those of labour, having
never conceived (or was it suggested by someone else?)—and the pain, “the
greatest ever”, registered seemingly in its present insurgence.

5.5 Implicit Embedded Focalisation


Finally, in the portrayal of the patient stand out those internal bodily experi-
ences that must come directly from the experiencing patient, and cannot be
the object of the physician’s direct appraisal—a separation, here, between the
fabula and the main story:48 καὶ τὰ σπλάγχνα δοκεῖ οἱ κρέμασθαι, for example, at
Vet. Med. 10 (L. 1.592.17 = Jouanna 131, 2–3), “it seems to him that his intestines
are hanging”, in the description of a typology of patient, is one such example.
Along similar lines, the common use of the verb δάκνω, (“to bite”), for stinging
pain, or terms such as νυγμός (“sting”, a symptom repeatedly found in the gyne-
cological texts) fall under this category.
Other topics have by their own nature a subjective core that cannot be
imposed externally: volition (i.e. wanting, desiring, or refusal) and awareness;
refusal to communicate, silences; emotions, sensorial perceptions and their
metaphors, as well as the sense of one’s bodily presence. These are there to
remind us of that ingredient in the patient cases that resists organisation into

48  Fabula: “all the events which are recounted in the story, abstracted from their disposition
in the text and reconstructed in their chronological order”. Main Story: “the events which
are told by the narrator”.
124 Thumiger

a pre-ordained schema. Even if intentionality and drives are not at the fore in
these accounts, or perhaps precisely because of this, when they are found, they
place an emphasis onto the patient as focaliser. Let us give some examples: at
Epid. 7, 10 (L. 5.382.10–11 = Jouanna 58, 18–19) a patient is presented as φάμενος
δὲ θέλειν τι ἑωυτῷ ὑπελθεῖν (“saying however/still that he wanted something to
be put under him”). At Epid. 7, 5 (L. 5.374.22–23 = Jouanna 54, 13–15) we read
τῇ δὲ φωνῇ κατὰ τὸν χρόνον τοῦτον εἰ μὲν σφόδρα ἀπεβιάσαιτο εἶπεν ἂν τελέως ἃ
ἐβούλετο, εἰ δὲ προχείρως, ἡμιτελέα, “with his voice in this period, if he was very
forceful, he succeeded in saying what he wished, but if it was casual, it was
imperfect”; at Epid. 7, 11 (L. 5.384.17–19 = Jouanna 60, 11–13) παρηκολούθει δὲ τὸ
ἀγριοῦσθαι καὶ τὸ θυμαίνειν καὶ κλαίειν εἰ μή οἱ ταχέως ὅ τι βούλοιτο ῥεχθείη, “ . . but
she persisted in her wildness, her anger and tantrums if what she wanted
was not done for her quickly”. Another case to consider is the ability (or lack
thereof) to recognise one’s family and friends as indicator of health or illness,
as in the case of Cydis’ son, a patient who, we read, could at times not recognise
anyone (οὐκ ἐπεγίνωσκεν οὐδένα, Epid 7.5, L. 5.374.7 = Jouanna 53, 20–21).
Anger, fear, sadness and despair are the dominant emotional spectrum of
the Epidemics patient. If anger has a strong physiological, therefore visible,
component, fear and especially grief and hopelessness are deeply introverted
and inner emotions. At Epid. 3.17, case 11 (L. 3.134.2 = Kühlewein 241, 4–5) the
patient is a γυνὴ δυσάνιος (“a refractory/uneasy woman”), whose illness is ἐκ
λύπης μετὰ προφάσιος, “following a grief for a reason” (i.e. a loss, as opposed to
general, unmotivated depression). Such remark suggests that the doctor knows
perhaps about a loss the patient has suffered, and about her mental reactions
to it.49
On a different level, sensorial abilities are meticulously reported in the
Epidemics. If blindness and deafness proper could be a diagnosis that does
not necessitate the voicing of a patient’s experience, the full range of visual
impairment and disturbances these physicians took care to describe—ἀμβλύς,
ἀμαυρόω, οὐ/οὐκ ὀξέα ὀρᾶν/βλέπειν, σκοτόδινος (which we can translate with
vertigo), δῖνος (whirling, swooning),50 μαρμαρυγή (“flashes of light”/“sparks”),
ἀστραπή, ἰλλαίνω and cognates and auditive phenomena (e.g. οὐκ ἀκούειν,
κωφός, βαρυήκοος, βαρυηκοΐα, βαρυηκοέω; ἦχος, βόμβος, ψοφός)—must reflect an
attempt to create order among the various self-reports the patients would give.

49  Likewise, at Epid. 3.17, case 15 (L. 3.142.7 = Kühlewein 244, 1–2) we find a woman whom a
“fever with shivers and of the acute kind took hold of, following a grief”, πυρετὸς φρικώδης,
ὀξύς, ἐκ λύπης ἔλαβεν.
50  Also Acut. (spur.) 17 (L. 2.426.8 = Joly 76, 5), δῖνοι.
Patient Function and Physician Function 125

6 The Physician Function

6.1 Explicit Embedded Focalisation


The self-fashioning of the doctor, narrator and main focaliser51 is natu-
rally more straightforwardly detected. Perhaps the most evident, and saf-
est indicators of the physician function are those items which we might call
‘epistemological’ or ‘meta-cognitive’, which expose, that is, the process of
thinking, evaluating, formulating an opinion, or knowing the medical truth
about the patient.
These emerge through the use of pronominal expressions or functionally
equivalent features by which the narrator (and, here, focaliser too) is exposed
and through the use of relevant verbs, especially forms of οἶδα (“I know”) and
forms of δοκεῖ (“it seems to him/her”). The emphatic ἐγώ occurs only seven
times across all seven books of the Epidemics, and in six occurrences it is used
in conjunction with such forms: οἶδα (four times), οἶμαι (once), εἶδον (once).
We can definitely see it as forceful insertion of the author adopting a scientific
posture.52 The emergence of the first person more generally has an epistemo-
logical value—it is a marker of scientific inquiry and possess of knowledge
but also, in negative, can indicate the physician’s presence through failure,
impasse or pure and simple ignorance of facts. Some examples: at Epid. 2, 2.3
(L. 5.84.8–9), οὐκ οἶδα ποσταίῃ, “I do not know for how many days”; likewise at
Epid. 4, 13 (L. 5.150.22), ποσταῖος οὐ γινώσκω; at Epid. 4, 6 (L. 5.146.11–12), “how
many months pregnant, I don’t know”, ὁποσάμηνον οὐκ οἶδα. . .; “she said that
she had lost another baby, a male, towards the twentieth day. I do not know
whether that was true”, εἰ ἀληθέα οὐκ οἶδα‘; at Epid. 4.26 (L. 5.170.9), εἰ δὲ καὶ
εἶχέ τι νήπιον, οὐκ οἶδα, “whether she was carrying a baby, I do not know”; at
Epid. 7, 24 (L. 5.394.5 = Jouanna 66, 2), “I don’t remember which of the two
cheeks was red”, ὁποτέρη οὐ μέμνημαι. Not only ignorance, but even mistake
is conveyed through the explicit first person.53 Such is the case in Epid. 5, 27
(L. 5.226.10–11 = Jouanna 17, 1–3), τοῦτο παρέλαθέ με δεόμενον πρισθῆναι· ἔκλεψαν

51  Narrator: “the representative of the author in the text (the primary narrator-focaliser)”;
Narrator-text: “those parts of the text which are presented by the narrator, i.e. the parts
between the speeches”. Focaliser: “the person (the narrator or a character) through whose
eyes the events and persons of a narrative are seen”.
52  The dative μοι occurs five times in the seven books, always with forms of δοκέω; the accu-
sative με occurs four times, all used as direct object of verbs of visiting (with reference to
the doctor).
53  On admission and discussion of errors in Hippocratic medicine see Lo Presti, R. ‘The phy-
sician as teacher. Epistemic function, cognitive function and the incommensurability of
errors’, in Horstmanshoff, M. (2010). Hippocrates and the Medical Education, 137–68.
126 Thumiger

δέ μευ τὴν γνώμην, (“it escaped my notice that I should trephine; because it
failed my understanding . . .”). The effect might be at times merely to express
caution, e.g. when giving an approximation on irrelevant facts, as at Epid. 2,
2.18 (L. 5.92.2), “she lived, ὡς ἐγὼ οἶμαι, in Archelaos’ property”; or when report-
ing unsure details, as in the case of Epid. 7, 42 (L. 5.408.22 = Jouanna 77, 12),
“I believe around the fourteenth day”, ὡς οἶμαι. Occasionally, this feature
exposes more radical tentativeness: “he was practically without fever and pain,
because his seat was inflamed—or so I interpret it”, τοῦτο λέγω (Epid. 4, 41,
L. 5.182.15): in this last case, the doctor explicitly puts his hands up as he passes
judgment on the patient’s lack of pain and its causes.
δοκεῖ (“it seemed (to me) that”) returns here in its capacity as expression
of external judgment, and conveys the doctor’s point of view. Consider some
examples: at Epid. 1, 13, case 1 (L. 2.682.8–9 = Kühlewein 202, 15–16) τρίτῃ . . . ἔδοξε
γενέσθαι ἄπυρος, (“on the third day . . . he appeared to have lost the fever”);
or in Epid. 3, 1, case 2 (L. 3.34.8 = Kühlewein 216, 6), πάντα ἔδοξε κουφισθῆναι
(“he seemed to be relieved in all respects”); in Epid. 2.3, 13 (L. 5.114.17), μὴ ἑστάναι
ἔδοξεν ἀπόστασις (“there seemed to be no apostasis that stayed”); and Epid. 5,
50 (L. 5.236.16 = Jouanna 23, 22), ἔδοξεν ἄμεινον ἔχειν (“it seemed to get better”),
as well as in Epid. 7, 25 (L. 5.394.15–16 = Jouanna 66, 13–14), πέμπτῃ πρωΐ ἐδόκει
ἠπιώτερος εἶναι (“early on the fifth day the fever seemed milder”); and so on. All
these are potentially ambiguous from a syntactical point of view—the patient,
in theory, might also be the subject of these impressions. In some cases, how-
ever, the reference to the physician as the source of the opinion expressed here
appear undoubtedly to be the most plausible: the past tense for the assess-
ments of pathological severity, especially concerning fever; the use of the
technical term apostasis, where the aorist expresses the evaluation of the phy-
sician and in particular caution at an optimistic prognosis in a case that than
develops badly. However, a statement such as “it seemed to get better” must
remain open.
The focalising role of the physician is explicit in those cases in which a
contrast between prevision and outcome is made. See, for instance, Epid. 5, 31
(L. 5.228.20–21 = Jouanna 18, 18–19), καὶ παρέκοψε καὶ ἔθανεν· ἐδόκει δ’ ἂν ἐκφυγεῖν
τὸ νόσημα (“he was deranged, and died; while it had seemed he would escape
the disease”); or Epid. 4, 3 (L. 5.146.3–4), ἐδόκει ἔμπυος ἔσεσθαι, οὐκ ἐγένετο
(“it appeared he would become purulent; he did not”). Ιn this last case, the
technical term ἔμπυος reinforces that this is the doctor’s and not the patient’s
impression to be disproven by facts. Both examples contain an element of pro-
lepsis as well as one of ‘if-not’ situation that heighten suspense and intensity.54

54  ‘If not’ situation: “there X would have happened, if Y had not intervened”. Often a pathetic
or tension-raising device.
Patient Function and Physician Function 127

All these elements work as proleptic “seed”55 presented after the outcome, and
in negative, with a pathetic effect, thus allowing for a didactic function: the
students or colleagues in the audience should beware of interpreting the given
sign or ‘seed’ in that way, or univocally in that way. The use of technical terms
in association with evaluative expressions, thus, is always a key signal for a
physician’s viewpoint. Such is the case at Epid. 5, 87 (L. 5.252.16–17 = Jouanna
40, 2), ἐκ μελαγχολικῶν δοκεόντων εἶναι καὶ τοιούτων καὶ τοσούτων. . . (“after what
seemed to be a melancholic affection of that kind and degree . . .”), or explic-
itly at Epid. 5, 14 (L. 5.212.20–21 = Jouanna 8, 19–20): Ἱπποσθένης περιπλευμονίῃ
ἐδόκει τοῖσιν ἰητροῖσιν ἔχεσθαι. ἦν δὲ οὐδαμῶς (“Hipposthenes seemed to the phy-
sicians to have peripleumonia; but that was not the case”).56

6.2 Character Language


An important indicator is the use of technical as opposed to non-technical
language. Hunter remarks that this important and indisputable indicator of
a physician’s contribution to the dialogue is increasingly obfuscated in many
contemporary patient reports, as nowadays laymen (in Western urban con-
texts, at least) tend to appropriate language and concepts of science (to what
degree of true understanding, is a matter of debate).57 This was not in any
way the case for our ancient patients. Hence, the use of terms we can clearly
detect as technical should be safely taken as reflective of the doctor as focaliser.
The use of expressions that appear to be out of the ordinary, like ἵδρυσις, for
instance, a metaphorical usage of a term coming from architecture to indi-
cate composure and calm (e.g. at Epid. 3, L. 3.138.13 = Kühlewein 242, 24), or
παρακρούσις, common for derangement in Epidemics and not found much any-
where else: all these contribute to a ‘character language’ typifying the physician,
in a way different from what we expect from technical vocabularies, but to a
similar effect.

55  Seed: “the insertion of a piece of information, the relevance of which will only later
become clear. The later event thus prepared for becomes more natural, logical, or plau-
sible (a form of prolepsis)”.
56  Similar cases are found at Epid. 7, 26 (L. 5.398.5–6 = Jouanna 68, 13), ἐδόκει ῥηγματώδης
εἶναι (“he appeared to have some fissuring”), or Epid. 4, 30 (L. 5.174.6–7): ἰσχίου δὲ καὶ
σκέλεος, ὑστερικὰ ἦν, δοκέοντα ἀλγήματα εἶναι (“pains that seemed to be related to the state
of the womb appeared in her hip and leg”).
57  Hunter, Doctors’ stories, 14: “the existence of these two narratives [the physician’s and the
patient’s, i.e.] is obscured by the adoption of the terms of scientific medicine into the folk
beliefs of Western culture”.
128 Thumiger

6.3 Rhythm58
Rhythm, the way in which the narrative relates to the fabula, to the actual facts,
is also a focalising feature that can only stem from a source that posits itself as
external and authoritative. Rhythm can be detected in the very chronologi-
cal frame of the report: the varying choice of which days to observe, and the
consequent organisation of anamnestic elements, prognosis, present pathol-
ogy and post-eventum comments in succession. The use of adverbs and expres-
sions of intensity and the comments denoting progress and deterioration all
contribute to imparting structure and pace to the narrative.

6.4 Managing the Patient’s Utterances


The references to whether patients speak or not—a matter entirely differ-
ent from our earlier discussion of what they say—are also worthy of consid-
eration. The decision about which silences and voices deserve mention is
an important underlying element of control. Most explicitly so are the ques-
tions directly posed to the patient, found also outside the Epidemics: frequent
examples come from Prorrh. 2, e.g. 42 (L. 9.72.16), ἐπανερέσθαι οὖν περὶ τῆς τοῦ
αἵματος ῥήξιος, “but ask about the blood”. This information on communication
or lack thereof points to overt occasions in which the patient has the chance
to contribute his or her information to the report, but also marks the reaffir-
mation of the physician’s strong role as focaliser of the story, since embedded
focalisation, the introduction of a viewpoint internal to the story, participates
notoriously in both. The given information on speaking or not speaking feeds
also into this aspect: the common expressions πολλὰ λέγει, (“s/he says many
things”), λόγοι (πολλοί), παραλήρειν or λῆρος, and even φλυαρεῖ (“delirium,
s/he talks nonsense”) and, at the other end of the spectrum, the silences and
the refusal to talk (σιγή, σιγάω, οὐκ ἀποκρίνετο, ἀναυδίη), but also the refusal
to reply:59 all these expose the filter of the physician who decides, at a given
moment, to tune the narrative onto the patient and his/her communication,
or lack thereof.
When, at Epid. 2, 3, 2 (L 5.104.9) the writer says ἐῶ τὰ πλεῖστα, (“I pass over
most things”)—not in a patient case however, but here discussing drugs—we
have a glimpse of what must be continuously happening in a teaching context
where a didactic agenda dictates topics and creates focus. Accordingly, not all

58  Rhythm: “the relation between text-time and fabula-time. An event may be told as a
scene (text-time=fabula-time), summary (text-time<fabula-time) retardation (text-
time>fabula-time) or ellipsis (no text time matches fabula time)”.
59  Like at Epid. 3, 1 case 2 (L. 3.36.6 = Kühlewein 216, 13–14), διαλέγεσθαι οὐκ ἠδύνατο; Webster
177–179 in this volume.
Patient Function and Physician Function 129

information is regarded as valuable. At Prorrh. 2, 3 (L. 9.12.11–12), for instance,


the author devotes a section to comment on how one can detect the import of
patient disobedience in the case of patients lying ill in a fixed place (ἄνθρωπον
κατακείμενον ἐν τῷ αὐτῷ, 10–11): the physician later dismisses ‘confessions’ or
reports of petty infractions as preposterous and of no consequence, so irrele-
vant that he listens and laughs when they are announced to him, τὰς δ’ ἀκριβείας
κείνας ἀκούω τε καὶ καταγελῶ τῶν ἀπαγγελλόντων (Prorrh. 2, 4 (L. 9.14.10–11).60

6.5 Professional self-reflectiveness


References to the professional frame (such as engagement with colleagues
and comments on the medical acts performed) are also significant for our pur-
poses. In several cases, for exemple, the physician makes prognosis (prolepsis,
narratologically) or reflects backwards on the ‘roads not taken’ or on previous
false impressions (analepsis). Especially in Epid. 2, 4 and 6 this professional
and competitive component is very strong.61 The work of colleagues is men-
tioned, pondered, rated and often plainly criticised. A few good examples can
be found in Epid. 7, 123 (L. 5.468.5–6 = Jouanna 118, 4), ὁ ἱητρὸς οὐ ξυνεῖδεν, (“the
doctor did not realise” (and the patient died); in Epid. 5, 14 (L. 5.212.20–21 =
Jouanna 8, 19–20), “it seemed to the doctors that it was peripleumonia, but it
was false”; at Epid. 5, 28 (L. 5.226.20=Jouanna 17, 14), on the other hand, “it was
rightly recognised as needing trephination”, ἐγνώσθη ὀρθῶς. One could men-
tion several remarks in which ἐδόκει or analogous expressions refer to the false
impressions received by a physician, or to surprising outcomes; implicitly, even
a case like the one found in Epid. 5, 46 (L. 234.10 = Jouanna 22, 8, παραδοξότατα
ἐσώθη, “he survived against all expectations”) inserts a strong focalisation
of the point of view of the professional health provider.62 ἐδόκει can also

60  See also Prorrh. 2, 2 (L. 9.10.13–15) on ‚hearing‛, καίτοι γε ἀκούω καὶ ὁρῶ οὔτε κρίνοντας ὀρθῶς
τοὺς ἀνθρώπους τὰ λεγόμενά τε καὶ ποιεύμενα ἐν τῇ τέχνῃ οὔτ’ ἀπαγγέλλοντας, “and indeed I
know, both by what I hear and by what I see, that people neither judge correctly what is
said and done in medicine, nor report it accurately”.
61  See Manetti, D. (1990). ‘Data-recording in Epid. 2, 2–3: some considerations’, in Potter, P.
et al. (1990). La Maladie et les Maladies dans la Collection Hippocratique, 149 on some
important questions on the topic, with reference to Epid. 2.
62  The same posture can be conveyed by other means, of course, that we cannot exhaus-
tively review here: even only the particle δέ can bring in a world of disattended prognosis,
as in the case of Timocrates in Epid. 5, 2 (L. 5.204 = Jouanna 3, 2–5), ἐν δὲ τῷ ὕπνῳ οὐκ
ἐδόκει τοῖσι παρεοῦσιν ἀναπνεῖν οὐδὲν ἀλλὰ τεθνάναι, οὐδ’ ᾐσθάνετο οὐδενὸς οὔτε λόγου οὔτ’
ἔργου· ἐτάθη δὲ τὸ σῶμα καὶ ἐπάγη. ἐβίω δὲ καὶ ἐξήγρετο: the patient “did not seem in his
sleep to those who were there to be breathing, but to have died. He perceived nothing,
speech or action, and his body was stretched out and rigid. But he survived and waked
up”. Within three lines of text three subjectivities appear, kept together by that δέ, which
130 Thumiger

underline one’s viewpoint for caution or modesty—“I, for one, thought that . . .”,
like at Epid. 5, 95 (L. 5.254 = Jouanna 42, 5–7): ἐδόκει δέ μοι ὁ ἰητρὸς ἐξαιρέων τὸ
ξύλον ἐγκαταλιπεῖν τι του δόρατος κατὰ τὸ διάφραγμα. Αλγέοντος δὲ αὐτοῦ, πρὸς
τὴν ἑσπέρην ἔκλυσέ τε καὶ ἐφαρμάκευσε κάτω, “it seemed to me that the physi-
cian who took out the wood left a piece of the shaft in the diaphragm, and the
patient thought that too. The physician gave him an enema towards the eve-
ning and a drug by the bowel . . .”. We have here a first narrating physician and
his own judgment, a second physician who had underperformed his operation,
and a third one at work—whether this last is identical to either of the first two,
it is impossible to say; perhaps, as the texts seems to suggest,63 we might even
have the viewpoint of the patient in agreement with the narrator. The result
is an especially rich example of the narratological complexity these texts can
reach. At Epid. 6, 8, 32 (L. 5.356.12–15 = Manetti-Roselli 194, 10–14), instead, the
verb of opinion serves the purpose of depicting a medical consensus about the
therapy to apply. This move, if it does not entirely lift individual responsibil-
ity for the ensuing failure, may make it lighter: ἐδόκει δὲ πᾶσι τοῖσιν ἰητροῖσιν,
οἷσι κἀγὼ ἐνέτυχον, μία ἐλπὶς εἶναι τοῦ γυναικωθῆναι, εἰ τὰ κατὰ φύσιν ἔλθοι· ἀλλὰ
καὶ ταύτῃ οὐκ ἠδυνήθη, πάντα ποιούντων, γενέσθαι, ἀλλ’ ἐτελεύτησεν οὐ βραδέως,
(“it seemed to all doctors, among which I also found myself, that there was only
one hope to restore her womanhood, if normal menstruation would occur: but
in her case too it was not possible, though we did everything, but she died
quickly”). Sometimes the judgment a posteriori is left open (a case of ‘if-not’
situation), as in Epid. 5.15 (L. 5.214.18–19 = Jouanna 10, 7–8), ἐδόκει δ’ ἂν πλείονα
χρόνον διενεγκεῖν εἰ μὴ κατὰ τοῦ φαρμάκου τὴν ἰσχύν (“it seemed that he would
have survived longer if not for the strength of the medicine”).

6.6 The Third Parties


At Epid. 6, 2, 24 (L. 5.290.4–6 = Manetti-Roselli 46, 1–3) we find a list of aspects
on which a medical inquiry should be conducted: “what is explained, what kind
of things, how it must be accepted; the reasoning/words; what relates to the
patient, what relates to those who are present, and to people elsewhere” (ἡ περὶ

convey respectively the lack of consciousness, or sensorial perception, on the part of the
patient; the insight of those present; or the narrating physician, who (wrongly) expected
death or continuation of the comatose state.
63  Jouanna corrects MV’s δοκέοντος here with ἀλγέοντος, found in MV for the homologous
case in Epid. 7, 121 (and kept by Smith); he explains why we should consider Epid. 7 closer
to the original in 13–15. See n. 39 above.
Patient Function and Physician Function 131

τὸν νοσέοντα οἰκονομίη καὶ ἐς τὴν νοῦσον ἐρώτησις· ἃ διηγεῖται, οἷα, ὡς ἀποδεκτέον,
οἱ λόγοι· τὰ πρὸς τὸν νοσέοντα, τὰ πρὸς τοὺς παρεόντας, καὶ τὰ ἔξωθεν).64
There is an additional element in the ways these cases are narrated: the ‘oth-
ers’, the third parties, who are far from being mute spectators and are impor-
tant, at times crucial, sources of information, elements of interaction, and
actors in the scientific debates or recipient of the doctor’s didactic gestures.
This composite internal audience has not often been given the prominence
it deserves by scholarship on these cases and on the practice of Hippocratic
medicine, which focused more on the so-called “triangle” ’65 that joins disease,
patient and physician in a Spiel of effort and counter-effort (ὁ ἱητρὸς ὑπηρέτης
τῆς τέχνης· ὑπεναντιοῦσθαι τῷ νουσήματι τὸν νοσεῦντα μετὰ τοῦ ἰητροῦ). The tri-
angle becomes thus rather a ‘quadrangle’, or, in any case, a schema of greater
complexity and much less clear internal relationships.
A net of competing centres of attention emerges in the background of the
Epidemics. First, the family and friends of the patient. For example, at Epid. 1,
13 case 5 (L. 2.694.4–6 = Kühlewein 206, 17–19) the reference to the bystand-
ers as source becomes explicit: Ἐπικράτεος γυναῖκα. . .περὶ τόκον ἐοῦσαν, ῥῖγος
ἔλαβεν ἰσχυρῶς, οὐκ ἐθερμάνθη ὡς ἔλεγον (“the wife of Epicrates . . . when near
her delivery was set with sever rigor without, it was said, becoming warm . . . ”.
In the case of the daughter of Euryanax, the reference to what others said is
used rather to express caution, ἔλεγον δὲ γευσαμένην βότρυος, “they said that
she suffered this after having eaten grapes”—as the eating of a specific food
is proposed as possible cause for an illness with fever and delirium (Epid. 3, 2,
case 6 (L. 3.50.11 = 220, 15–16 Kühlewein). Even when the reference is not explicit,
however, the contribution of the family is visible. In the reports on sleep, for
example, especially when they are daily (or even offered several times a day)
and stretch over longer periods the imput of family members must have been
necessary. Long anamnestic sections also lead us to third cooperating voices,
like in the case of Apollonius in Epid. 3, 17, case 13 (L. 3.140.10 = Kühlewein 243,
9), where the narrative opens with the patient’s suffering, including pieces of
information such as “he was ailing for a long time”, or “he adopted a thoroughly
bad regimen”, which seem difficult to have been gathered from him, especially
as he lay prey to forgetfulness and delirious throughout (διὰ τέλεος). We should,
therefore, often count for this additional dimension, that of a co-authoring

64  See Manetti-Roselli ad loc. on this passage as expressive of the importance of the patient’s
words.
65  Epid. 1, 5 (L. 2.634.6–636.4 = Kühlewein 189, 24–190, 3–6); cf. the classic D. Gourevitch
(1984), Le triangle hippocratique dans le monde gréco-romain: le malade, sa maladie et son
médecin.
132 Thumiger

internal audience participating in the creation of the main story. Sometimes


this audience is illumined as if by a flash of lightning: at Epid. 5, 95 (L. 5.256.2 =
Jouanna 42, 9–10), the patient “seemed to the physician and others to be bet-
ter” (ἐδόκει καὶ τῷ ἰητρῷ καὶ τοῖσιν ἄλλοισι βέλτιον ἔχειν). This is a case where
we have already noticed a polemical engagement among physicians, with the
narrating voice possibly coming from a third party. We have here possibly the
additional presence of a group of bystanders comprising family members or
students of the attending physician (οἱ ἄλλοι seems to suggest a categorical
difference from ὁ ἱητρός). Another example is a patient we have already men-
tioned, that of Epid. 5.2 (L. 5.204.13–15 = Jouanna 3, 2–5). He is at the center of a
web of perceptions—his own, and that of others: “in sleep he did not seem to
those who were present to be breathing, but to have died. He perceived noth-
ing, speech or action, and his body was stretched out and rigid” (ἐν δὲ τῷ ὕπνῳ
οὐκ ἐδόκει τοῖσι παρεοῦσιν ἀναπνεῖν οὐδὲν ἀλλὰ τεθνάναι, οὐδ’ ᾐσθάνετο οὐδενὸς
οὔτε λόγου οὔτ᾿ ἔργου· ἐτάθη δὲ τὸ σῶμα καὶ ἐπάγη). The patient and οἱ παρέοντες
are symmetrical focuses from which the medical scene is observed: lack of sen-
sorial feeling, from the first and corpse-like appearance, in the second case.
The case of very young patients is also to the point: in these cases the partici-
pation of family is greater and even necessary in the case of smaller children.
This intrusion, however, is not always declared. See for example Epid. 7, 117
(L. 5.462.21–23 = Jouanna 114, 7–10): τῷ Δεινίου παιδίῳ ἐν Ἀβδήροισι μετρίως
ὀμφαλὸν τμηθέντι συρίγγιον κατελείφθη· καί ποτε καὶ ἕλμις δι’ αὐτοῦ διῆλθεν ἁδρή·
καὶ ἔφη, ὅτε πυρέξειε, χολώδεα ὅτι καὶ αὐτὰ ταύτῃ διῄει, “Deinias’ child in Abdera:
when a small incision was made at his navel a small fistula was left behind.
Once a full-sized worm came through it. And he said that whenever he was
feverish actual bilious material came out of it . . . ”. Who is this last speak-
ing part? Not the child, surely. Perhaps it is a parent, if we can attribute to
him knowledge and use of the seemingly technical concept of “bilious mate-
­rial” (χολώδεα); unless, this is a reported information from a relative recasted
by the physician in the language of the profession—a case of ‘simultaneous
translation’ into professional idiom that is always at work in patient reports
(ancient and contemporary), and surely is active everywhere in the texts we
are examining, even when not signaled like in this case. Alternatively, the ‘he’
could be a professional interlocutor, another physician the writer is in dialogue
with; although no other reference to him is made. A counterexample to such
explicit reference to the voice of the patient or his family could be found in
Epid. 7, 52 (L. 5.420.20–21=Jouanna 84, 14–16), the case of an infant patient who
ἀρρωστέων δὲ αἰεὶ τῇ χειρὶ κατῆγε κατὰ τοῦ βρέγματος. . .οὐκ ἤλγει δὲ τὴν κεφαλήν
(“while he was sick he kept drawing down with the hand from the front of his
Patient Function and Physician Function 133

head . . . but he had no pain in the head”): the latter is an impossible assump-


tion to make about the behaviors of others and their causes, and all the more
in the case of a baby.
This additional audience, as mentioned above, is not only a familial one
but can be also constituted of students, or colleagues. We have seen men-
tions of interaction among competing or cooperating physicians. There are
also elements of a didactic or epideictic nature that evoke a teaching context,
especially in the form of questions. These are especially frequent in Epid. 2, 4
and 6,66 where they are inserted into the discussions of individual patients.
One such case is the one at 2, 9 (L. 5.88.11–12), ἐρωτήματα· ἤρεον γὰρ αὐτοὺς ἀεὶ
πληροῦσθαι ποτοῦ καὶ σίτου; “question: is it easier always to satiate with drink or
with food?”. This question reads like a general reflection, and may be an addi-
tion made at a later stage in the redaction of the text, but may also equally have
generated from the specifics of the encounter with the patient, with the debate
and didactics the visit could include. Likewise, at Epid. 2, 2, 10 (L. 5.88.13–14)
the author asks “how can one recognise very serious pains by seeing them?”
(ὀδύνας τὰς ἰσχυροτάτας, ὅτῳ τρόπῳ διαγνοίη ἄν τις ἰδών;). If these questions
may sound more general, there are also clinical ones attached more tightly to
individual cases which evoke more unequivocally the context of the medical
encounter, such as Epid. 2, 3, 11 (L. 5.116.8–9= Smith 56, 7–8), if we take, with
Smith, the phrase as interrogative: “does such excrement indicate crisis, like
in the case of Antigenes?”, τὸ τοιοῦτον ἦ κρίσιμον, ὅτι καὶ τὸ Ἀντιγένεος;). These
features of openness and dialectic are absent from Epid. 1 and 3 (as, in general,
is explicit professional self-reflectiveness), and echo directly the interaction
between a physician and an audience of students—during the visit, at a later
stage or both. In this way, the patient cases in books 2, 4 and 6 expose openly
the in-and-out traffic, so to say, in the creation of these patient narratives: not
only the disease, the patient, and the physician; but also a complication of
competing medical voices, professional and belonging to students, as well as
coming from family and bystanders of unclear status.

66  See Alessi, R. (2010). ‘Research program and teaching led by the master in Hippocrates
Epidemics 2, 4 and 6’, in Horstmanshoff, M. (2010). Hippocrates and Medical Education,
119–36 on the didactic milieu we can reconstruct from Epidemics 2, 4 and 6. See, in addi-
tion, Epid. 7, 57 (L. 5.424.5–6 = Jouanna 86, 4–6) (and 5, 77), ἧρά γε ἐν πᾶσι τοῖσιν ἐμπυήμασι
καὶ τοῖσι περὶ ὀφθαλμὸν ἐς νύκτα οἱ πόνοι, “is it true that in all suppurations, including these
around the eye, the distress comes towards night?”.
134 Thumiger

7 Conclusions

This analysis has hopefully shown that these texts can in no way be simplis-
tically seen as blind to the point of view of the patient. Yes, they are more
explicitely reflective of the systematising intentions of the physician, with his
knowledge and agenda. In almost every paragraph of the Epidemics, however,
we can find a shift from the physician’s function to the function of the patient
which undermines this opposition. In addition, there is a degree of depth and
complexity to these texts which involves a third part, a supplementary audi-
ence of professionals or family that does not always come to the fore, and yet
contributes to the authoring of the narrative to an important extent.
Our narratological observations will have served their aim if they have
managed to illustrate a more general fact, valid outside the interpretation of
the patient cases of the Hippocratic Epidemics: that it is indeed impossible to
write about someone’s suffering without the writer making space, in a way or
another, for the voice of the suffering individual. This is a hermeneutic model
well-known to scholars who have engaged with the recovery of the voice of
marginalised groups in various literatures (with feminist and gender studies
serving perhaps as the best example). This methodology has been taken on
variously, as we have seen, by current studies of patient case taking, bringing
together the interpretation of texts as humanistic act and the interpretation
of illness stories as practice of medical ethics. Its application to the history of
ancient medicine is bound to yield exciting results.

Texts Used

Hippocrates. Ancient Medicine (Vet. Med.). Ed. and trans. J. Jouanna. Hippocrate. De
l’ancienne medicine, Collection des universités de France. Paris: Les Belles Lettres,
1990.
———. The Art; Breaths (Art., Flat.). Ed. and trans. J. Jouanna. Des vents, de l’Art,
Collection des universités de France. Paris: Les Belles Lettres, 1995.
———. Diseases 2 (Morb. 2). Ed. and trans. J. Jouanna Maladies 2, Collection des univer-
sités de France. Paris: Les Belles Lettres, 1983.
———. Epidemics 1 (Epid. 1). Ed. H. Kühlewein. Hipp. Opera Omnia 1, 180–245 (CMG).
Leipzig: B. G. Teubner, 1894.
———. Epidemics 3 (Epid. 3). Ed. H. Kühlewein. Hipp. Opera Omnia 1, 180–245 (CMG).
Leipzig: B. G. Teubner, 1894.
———. Epidemics 5 and 7 (Epid. 5, 7). Ed. and trans. J. Jouanna. Epidémies 5 et 7,
Collection des universités de France. Paris: Les Belles Lettres, 2000.
Patient Function and Physician Function 135

———. Epidemics 6 (Epid. 6). Ed. and trans. D. Manetti, A. Roselli. Ippocrate. Epidemie.
Libro sesto. Firenze: La Nuova Italia Editrice, 1982.
———. Epidemics 2 and 4 (Epid. 2, 4). Ed. and trans. W. D. Smith. Hippocrates, vol. 7.
The Loeb Classical Library 477. Cambridge, MA: Harvard University Press, 1994.
———. Nature of Woman (Nat. Mul.). Ed. and trans. F. Bourbon. Nature de la femme,
Collection des universités de France. Paris: Les Belles Lettres, 2008.
———. Prorrhetikon 2 (Prorrh. 2). Ed. and trans. P. Potter. Hippocrates, vol. 9. The Loeb
Classical Library 482. Cambridge, MA: Harvard University Press, 1995.
———. Regime in Acute Diseases, Appendix (Acut. (spur.)). Ed. and trans. R. Joly
Du Régime des maladies aiguës, Appendice. De l’aliment. De l’usage des liquids.
Cambridge, MA: Harvard University Press, 1972.
For all other Hippocratic texts, I have used Littré’s edition (Œuvres completes
d’Hippocrate. Ed. and trans. É. Littré, vol. 1–10. Paris: J.-B. Ballière, 1839–61.

References

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Brody, H. Stories of Sickness. Oxford: Oxford University Press, 2003.
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De Jong, I. A Narratological Commentary on the Odyssey. Cambridge: Cambridge
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Frank, A. W. The Wounded Storyteller. Chicago: University of Chicago Press, 1995.


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Jori, A. ‘Il medico e il suo rapporto con il paziente nella Grecia dei secoli 5 e 4 A.C.’
Medicina nei secoli. Arte e Scienza 9.2, (1997): 189–222.
Jouanna, J. Hippocrates. Baltimore and London; Johns Hopkins University Press, 1999.
Kächele, H., Schachter, J., Thomä, H. From Psychoanalytic Narrative to Empirical Single
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———. Rethinking Psychiatry. From Cultural category to Personal Experience. New
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———. Medical Theories in Hippocrates. Berlin: Walter De Gruyter, 1990.
———. ‘Structure and Genesis of Some Hippocratic Treatises.’ in Magic And Rationality
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Mnemosyne, (2014): 1–24.
CHAPTER 4

Case History as Minority Report in the Hippocratic


Epidemics 1

John Z. Wee

Instead of being self-evident depictions of sickness, ancient medical texts


were narratives created from certain points of view and for intended pur-
poses. As a guide for the physician travelling to an unfamiliar commu-
nity of people, the treatise Airs, Waters, Places anticipated “communal”
conditions resulting from seasonal changes, while admitting the pos-
sibility of “personal” sickness due to individual lifestyles. Even with its
geographical situatedness, Epidemics 1 continued to prioritise population
narratives, subsuming sickness within the experiences of the anonymous
majority whenever possible. In both its constitutions and case histories,
however, patients whose conditions deviated from majority expectations
were identified for forensic purposes, so that case histories functioned as
minority reports rather than exemplars of how sickness behaved. Such
reports guarded against surprising deviations from the rules of prognosis,
which could present a threat to the physician’s credibility and livelihood
as a consequence.

Why is there a patient in the medical text? Are patient identities really neces-
sary in medical writing? Large portions of the Hippocratic corpus, in fact, do
a coherent job describing the human body without identifying it with any his-
torical patient. The treatise Regimen in Acute Diseases, as we will see, employs
the invented persona of a patient for the sake of illustrating how sickness
behaves, while avoiding the capricious experiences of actual patients who do
not always fall sick in the manner they are expected to.1
This point should give us pause to think about the complexity of using real
patients as exemplars in medical writing. In the precise nosological schemes
of the Hippocratic Epidemics, for example, where events such as crises,

1  Acut. 46 (L. 2.320.5–324.4 = Joly 56.3–18). The author of Regimen in Acute Diseases acknowl-
edged that the same sickness could manifest itself differently in different regimens and com-
plained about the practice of attaching a new name to every variation of the same sickness.
See Acut. 3 (L. 2.228.2–6 = Joly 37.7–10).

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_006


Case History as Minority Report 139

paroxysms, and intermissions are assigned to fixed days, and where their
occurrences on even or odd days carry predictive significance, it may not have
been that difficult to find patients who broke the rule in one way or another.2
We know today that different patients can respond differently to the same
disease, whether due to their individual genetics, immunity histories, aller-
gies, nutrition, or psychological states. To be sure, the notion of the patient
as variable is not completely foreign to the Hippocratic writings, though we
typically encounter patient groups (e.g. athletes, the elderly, women, and chil-
dren) rather than named and identified individuals. Perhaps more so than
other texts, the fourteen case histories of Epidemics 1 show us how personal
narratives can perform important roles in supplementing, or even contradict-
ing, systematised accounts about the behaviour of sickness.

1 Place, Time, and Patient

Modern medical authors have credited the treatises of Airs, Waters, Places
and Epidemics 1 and 3 for making the early distinction between ‘epidemic’
and ‘endemic’ disease.3 These writings date to the second half of the fifth cen-
tury BC, and they were considered authentic Hippocratic works in Erotian’s
Glossary.4 The modern impression of Airs, Waters, Places may have been
influenced by the words ‘endemic’ and ‘epidemic’ in W. H. S. Jones’ accessi-
ble English translation, though, in what may be a typo, ‘endemic’ is curiously
used for the Greek expression ἐπιδημεῖ in one instance.5 Many have noted the
ambiguity of the term ἐπίδημος itself, which could have referred not only to

2  For discussion on ‘Critical Days’, see Langholf, V. (1990). Medical Theories in Hippocrates: Early
Texts and the ‘Epidemics’, 79–118.
3  Buck, C. et al. (1988). The Challenge of Epidemiology: Issues and Selected Readings, 3, 18–19;
Wilkinson, L. ‘Epidemiology’, in Bynum, W. F. and Porter, R. (1993). Companion Encyclopedia
of the History of Medicine, vol. 2, 1263; Morens, D. M. ‘Epidemiology’ and Parascandola, M.
‘Epidemiology’ and ‘Epidemiology, History of’, in Byrne, J. P. (2008). Encyclopedia of Pestilence,
Pandemics, and Plagues, vol. 1, 201, 205.
4  περὶ τόπων καὶ ὡρῶν (line 11) and ἐπιδημίαι ζ´ (line 18) in Nachmanson, E. (1918). Erotiani
vocum Hippocraticarum collectio cum fragmentis, 9.
5  See Jones’ translation “endemic” (p. 77) for ἐπιδημεῖ at Aer. 4 (L. 2.20.4 = Jouanna 193.6–7). It
is tempting to understand ἐπιδημεῖ here as an error for ἐπιχώρια, which appears in a similar
context in Aer. 3 (L. 2.18.1–2 = Jouanna 190.13–14). The reading ἐπιχώρια, however, does not
appear as a variant for ἐπιδημεῖ (Aer. 4) in attested manuscripts.
140 Wee

a ‘visiting’ sickness, but also to ‘visiting’ medical practitioners.6 Our interest


here extends beyond the title Ἐπιδημιῶν to the Greek terms appearing in the
narrative, which reveal to us the heuristics employed for the identification and
classification of sickness.
The word that corresponds to ‘endemic’ or ‘native’ conditions in Airs, Waters,
Places is ἐπιχώριος, which designates “space” or “place” (χώρα or χῶρος) as its
defining factor.7 This variable of geography is, in fact, the primary concern of
the treatise, which goes on to set up contrastive dichotomies between north
and south, and between east and west. We might suspect that much in such
paradigms derives from correlative theory rather than empirical evidence,
though the narrative presents its conclusions as self-evident. There is aware-
ness, moreover, that geography alone cannot fully account for all conditions
affecting the population:

These sicknesses are native (ἐπιχώρια) for them. And, besides, if any com-
munal (πάγκοινον) sickness should take hold due to a change of the sea-
sons, they also share in this (Aer. 3, L. 2.18.15–17 = Jouanna 192.5–8)
For the men, these sicknesses are native (ἐπιχώρια). And, besides, [there
are] communal ones (πάγκοινον) which take hold due to a change of the
seasons (Aer. 4, L. 2.22.1–2 = Jouanna 194.10–12).

In the above references to seasonal changes, we do not find the term ὡραῖος
(“seasonable”) or any other word that reflects a time aspect. Instead, the word
used is πάγκοινος (“communal”), which draws attention to the means by which
such sicknesses are recognised. Aristotle famously argued that “one swallow
does not make a spring”.8 The single manifestation of a medical condition does

6  Smith, W. D. ‘Generic form in Epidemics 1 to 7’, in Baader, G. and Winau, R. (1989). Die
Hippokratischen Epidemien, 145; Langholf, Medical Theories in Hippocrates, 78–79; cf.
Graumann, L. A. (2000). ‘Die Krankengeschichten der Epidemienbücher des Corpus
Hippocraticum. Medizinhistorische Bedeutung und Möglichkeiten der retrospektiven
Diagnose’. Med. Diss., Universität Leipzig, 35–36; Eijk, Ph. J. van der ‘Exegesis, explanation
and epistemology in Galen’s commentaries on Epidemics, books one and two’, in Pormann, P.
E. (2012). Epidemics in Context: Greek Commentaries on Hippocrates in the Arabic Tradition, 29.
7  For ἐπιχώρια as a description of sickness, see Aer. 2 (L. 2.14.4 = Jouanna 188.9); Aer. 3 (L. 2.18.1–2 =
Jouanna 190.14; L. 2.18.15 = Jouanna 192.6); Aer. 4 (L. 2.22.1 = Jouanna 194.11). The word also
describes ‘native’ winds in Aer. 1 (L. 2.12.7 = Jouanna 187.1); Aer. 4 (L. 2.18.20 = Jouanna 192.12);
Aer. 15 (L. 2.62.8 = Jouanna 227.5) and ‘native’ persons in Aer. 22 (L. 2.76.14–15 = Jouanna
238.9).
8  E N 1.1098a.18–19 = Bywater 11.18–19. Of course, Aristotle’s concern here is ethical rather than
medical, though the principle articulated is more broadly applicable.
Case History as Minority Report 141

not link it to any specific time or season. Correlation between sickness and
season requires the widespread occurrence of such medical phenomena in the
local community at particular times of the year. This supposition also under-
lies the heuristics recommended at the beginning of Airs, Waters, Places:

For if one (the physician) should know these things well, preferably all or
at least most of them, when he arrives at a polis with which he is unfa-
miliar, he would not be unaware of either the native (ἐπιχώρια) sicknesses
or the nature of the common ones (τῶν κοινῶν; alternative reading: τῶν
κοιλιῶν, “of the bellies”) . . . As time and the year advances, he would be
able to tell what communal (πάγκοινα) sicknesses will take hold of the
polis, whether in summer or in winter, and what personal ones (ἴδια) will
become hazardous to the individual due to a change of lifestyle, Aer. 2
(L. 2.14.1–10 = Jouanna 188.6–189.3).

Again, πάγκοινος (and perhaps κοινός) appears as a variable related to time


(“whether in summer or in winter”) and distinct from geography (i.e. ἐπιχώριος).9
Furthermore, the ‘communal’ aspect of πάγκοινος stands in contrast to any “per-
sonal” (ἴδιος) sickness of specific patients that cannot be adequately attributed
to seasonal changes.10 Before the physician arrives at an unfamiliar polis, he
may anticipate ‘native’ sicknesses based on the polis’ location and its proximity
to the winds and water. Knowing the effects of heat, cold, wetness, and dryness
on health, he may also predict how seasonal changes would affect the popu-
lace. Such predictions could be later corroborated or refined by the physician’s
own encounters with ‘communal’ sicknesses while residing in the polis. Any
‘personal’ conditions unexplained by geography and time, however, depended
on interactions with specific patients and could not be addressed beforehand
in a preparatory treatise like Airs, Waters, Places. On the other hand, as we will
shortly see, the situatedness of Epidemics 1 and its grounding in actual local
experiences presented material for the expression of the ‘personal’ in the form

9  Note the use of ξύντροφος instead of πάγκοινος when seasonal changes are not significant
(“both in summer and in winter”) at Aer. 7 (L. 2.28.3–4 = Jouanna 200.9–10). Fever is cat-
egorised as either κοινός (instead of πάγκοινος) or ἴδιος in Flat. 6 (L. 6.96.23–98.2 = Jouanna
109.5–8).
10  Priority given to the variables of place and time (i.e. seasonal change) in the classification
of sickness could even cut across traditional or natural groups within a population. “Being
women is a less unifying factor in etiology and nosology than is climatic exposure”, since
slave women and men shared similar vulnerabilities due to their exposure outdoors, in
contrast to free women who remained indoors. Hanson, A. E. ‘Diseases of women in the
Epidemics’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 39.
142 Wee

of case histories. The statements below reveal similar ways of thinking about
sickness in Books 1 and 3 of the Epidemics:

And it is necessary to learn well the constitution of the seasons, each


one11 accurately, as well as (each case of) sickness: any good feature that
is common (κοινόν) during the constitution or among (manifestations of)
the sickness, any bad feature that is common (κοινόν) during the constitu-
tion or among (manifestations of) the sickness . . ., Epid. 3.16 (L. 3.102.2–5 =
Kühlewein 1.232.10–14)12
. . . learning from the common (κοινῆϛ) nature of all and the per-
sonal (ἰδίηϛ) (nature) of the individual . . ., Epid. 1.10 (L. 2.668.14–670.2 =
Kühlewein 1.199.10–11)

The first selection implies that the beneficial or harmful quality of a feature
in any constitution or sickness can be determined when the feature consis-
tently produces the same effects in repeated cases, so that such effects may
be described as “common” (κοινός) among the cases. The injunction “to learn
well the constitution of the seasons, each one accurately,” suggests that what
is ‘common’ can vary with time and must therefore be re-evaluated at dif-
ferent times. The next selection sets forth a contrast between the ‘common’
(or ‘communal’) and the ‘personal’. Though notions of the ‘communal’ in the
Hippocratic Epidemics are not as exclusively associated with seasonal change
as in Airs, Waters, Places, temporal variation is included as one of the factors

11  The question is whether ἑκάστην in Epid. 3.16 (L. 3.102.3 = Kühlewein 1.232.11) refers to τὴν
ὥρην (“season”) or τὴν κατάστασιν (“constitution”). If the former, this would be a direct
implication that what is ‘common’ changes with the season. The latter option, however,
might be the more natural grammatical interpretation and finds support in the subse-
quent pairing of κατάστασιϛ and νοῦσος, Epid. 3.16 (L. 3.102.3–5 = Kühlewein 1.232.12–13).
Even if one understands this as an injunction to learn well “each constitution of the
seasons” (rather than “the constitution of each season”), it is still more likely that this
passage refers to constitutions that change with each season, rather than constitutions
that change with each year of seasons. Finally, Littré’s edition reflects the reading τὴν
κατάστασιν τῶν ὡρέων ἑκάστης, “the constitution of each of the seasons” (L. 3.102.2–3),
where it is unambiguous that “common” conditions vary with seasonal change.
12  My translation reflects the switch in Kühlewein’s edition from νόσημα “(a case of) sick-
ness”, Epid. 3.16 (Kühlewein 1.232.12) to νοῦσος “(manifestations of) the sickness”, Epid. 3.16
(Kühlewein 1.232.13–14) when the author refers to common features shared by separate
manifestations of the same kind of sickness. Littré’s edition has the noun νοῦσος in both
instances (L. 3.102.3–5).
Case History as Minority Report 143

accounting for ‘group’ conditions.13 Here again, our physician performs the
work of a statistician, reasoning inductively from repeated and widespread
observations to general conclusions about their value for medical practice and
prognosis. These methods might even account for the eventual formulation of
medical aphorisms.14 A good illustration of such means of generalisation is the
following rule of thumb:

In this constitution, they (the patients) recovered particularly due to four


signs—either (1) a good bleeding through the nostrils, or (2) much urine
from the bladder having much proper sediment, or (3) bile from disor-
dered bowels at the right time, or (4) by becoming dysenteric, Epid. 1.9
(L. 2.656.7–658.2 = Kühlewein 1.195.21–196.2).15

In antiquity and in modern times, scholars have recognised the affinity


between Books 1 and 3 of the Epidemics. Both books clearly demarcate sections
of their text by the titles κατάστασις (“constitution”) and ἄρρωστοι (“(case his-
tories of) sickly ones”). Both are meticulous in their attention to date and time
references, to the patient’s development even over the period of a month or
months, and to the designation of the final outcome as death, crisis, or recovery.
For all their similarities, however, the precise relationship between Epidemics 1
and 3 is less clear. Littré considered Books 1 and 3 of the Epidemics to be origi-
nally a single work divided into two and proposed that they should be read in
the order of “the four annual constitutions one following the other,. . .[and]
finally, the forty-two individual histories without interruption”.16 This proposal
to disregard manuscript forms and to group together all the constitutions and
all the case histories was adopted by Sticker in his translation.17 Deichgräber

13  For a survey of ‘types’ and ‘groups’ in the Epidemics, see Langholf, Medical Theories in
Hippocrates, 194–208.
14  Thivel, A. (1981). Cnide et Cos? Essai sur les doctrines médicales dans la collection hippocra-
tique, 148–49; Roselli, A. ‘Epidemics and Aphorisms: Notes on the history of early trans-
mission of Epidemics’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien,
182–90.
15  To be sure, we find aorist optative verbs (αἱμορραγήσαι, ἔλθοι, γενοίατο) in this passage,
rather than the ‘gnomic’ or ‘empirical’ indicative aorist forms one might expect for
aphorisms in the Epidemics. Langholf, V. ‘Generalisationen und Aphorismen in den
Epidemienbüchern’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien,
137–39.
16  Littré, É. (1840). Oeuvres complètes d’Hippocrate, vol. 2, 537–38, 588–89 [translation mine].
17  Sticker, G. (1923). Der Volkskrankheiten erstes und drittes Buch, 37–85. More recently, all
forty-two case histories of Epidemics 1 and 3 were studied as a group without ­differentiation
144 Wee

drew attention to thematic and perhaps even intertextual links between the
Hippocratic work On Prognosis and Books 1 and 3 of the Epidemics, suggesting
that On Prognosis was composed prior to the Epidemics.18 Arguing for a pro-
gressive development of medical doctrine within Epidemics 1, Lichtenthaeler
proposed that Book 3 preceded Book 1, and that On Prognosis followed after
both books.19 Dugand relied on this chronological sequence to reconstruct
the travels of Hippocrates through Larissa, Meliboea, Abdera, and Thasos
(places mentioned in the case histories of Epidemics 3) before his three-year
stay at Thasos (the location of the constitutions in Epidemics 1).20 Langholf
declared such a reconstruction “too speculative”, and his important study on
the Epidemics follows the usual approach today of treating Books 1 and 3 as a
single group without specifying their exact relationship with each other.21
All things considered, there may be good reasons to respect existing
manuscript forms and to avoid conflating both books of the Epidemics as a
single work. In Book 1, each of the three constitutions begins with the label
“in Thasos”, while the vast majority of case histories are silent about their
locations and seasons of occurrence.22 This silence is remarkable, since the

in Hellweg, R. (1985). Stilistische Untersuchungen zu den Krankengeschichten der


Epidemienbücher 1 und 3 des Corpus Hippocraticum; Potter, P. ‘Epidemien 1/3: Form und
Absicht der zweiundvierzig Fallbeschreibungen’, in Baader, G. and Winau, R. (1989). Die
Hippokratischen Epidemien, 9–19.
18  Deichgräber, K. (1933, repr. 1971). Die Epidemien und das Corpus Hippocraticum:
Voruntersuchungen zu einer Geschichte der koischen Ärzteschule, 17–23.
19  Lichtenthaeler, Ch. (1960). Sur la vocation universitaire de l’histoire de la médicine, leçon
inaugurale. Le troisième Épidémique d’Hippocrate vient-il vraiment après le premier?,
40–67; id. (1989). Das Prognostikon wurde nicht vor, sondern nach den Epidemienbüchern 3
und 1 verfasst. Zweiter Beitrag zur Chronologie der echten hippokratischen Schriften, 121–26;
id. (1994). Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch
des Hippokrates, 16–17.
20  Dugand, J.-E. ‘Hippocrate à Thasos et en Grèce du nord’, in Joly, R. (1977). Corpus
Hippocraticum, 233–45; id. (1979). ‘Les adresses de malades d’Épidémies 1 et 3 et les preuves
tant archéologiques qu’épigraphiques du séjour d’Hippocrate à Thasos, capitale de l’île de
ce nom’, Annales de la Faculté des Lettres et Sciences humaines de Nice 35, 131–55.
21  Langholf, Medical Theories in Hippocrates, 77–78. Skepticism at Lichtenthaeler’s scheme
was also voiced by Hankinson, R. J. (1991). Review of Das Prognosticon wurde nicht vor,
sondern nach den Epidemienbüchern 3 und 1 verfasst. Zweiter Beitrag zur Chronologie der
echten Hippokratischen Schriften by Charles Lichtenthaeler, Isis 82.2, 365–66. Note the
opinion that “eine Klärung der Frage nach dem Entstehungsverhältnis dieser Texte allein
aufgrund stilisticher Befunde . . . unmöglich” in Hellweg, Stilistische Untersuchungen, 225.
22  Only two exceptions in the case histories (cases 4 and 9) mention “Thasos” and, as we
will see shortly, at least three more cases (1, 2, and 10) can be identified with individuals
described in the Year #3 constitution of Thasos in Epidemics 1.
Case History as Minority Report 145

constitutions emphasise the idea that medical conditions were noteworthy to


a greater or lesser extent depending on when they occurred. The case histo-
ries were likely intended to be read in tandem with their preceding constitu-
tion, which supplied the geographical and seasonal background information
missing in the case histories themselves. By contrast, the constitution in Book
3 curiously lacks a toponym (“Thasos” or otherwise), while the case histories
after this constitution are careful to specify their patients’ locations, moving in
rotational order from Thasos, to Larissa, to Abdera, and on to other sites (i.e.
Cyzicus or Meliboea).23 One might wonder whether the absence of a single
toponym served to portray the constitution in Epidemics 3 as a description of
the larger Aegean coastal region, which encompassed the disparate locations
mentioned in its case histories.
It is clear, in any case, that variables of geography, time, and patient were
defined and prioritised differently in Books 1 and 3. Of the two, it is Epidemics 1
that corresponds more fully to the heuristic recommended in Airs, Waters,
Places. Instead of understanding Epidemics 1 as a bipartite division of ‘constitu-
tions’ versus case histories, we might do better to view it as a tripartite account
of three years at the island of Thasos.24 The usual assumption that the years
are consecutive is plausible, especially since the seasonal description at the
end of Year #2 (i.e. the return of much rain with northerly winds near the rising
of Arcturus) appears again at the beginning of Year #3.25 The constitutions of
Years #1 and #2 do not name any patients and include no case histories, while

23  The case histories at the end of Epidemics 3 may perhaps be interpreted in terms of the
following cycles: #1) Thasos (cases 1–3 or 4?)—Larisa (case(s) 4? and 5)—Abdera (cases
6–10); #2) Thasos (case 11)—Larisa (case 12)—Abdera (case 13)—Cyzicus (case 14); #3)
Thasos (case 15)—Meliboea (case 16). The sequences here are unexpected, because they
seem to disregard the close geographical proximity between Thasos and Abdera, and
between Larisa and Meliboea. In contrast, the twelve case histories preceding the consti-
tution in Epidemics 3 are largely silent about their location, though it is uncertain how or
whether they relate to the constitutions in Books 1 and 3 of the Epidemics.
24  In fact, scholars already tend to assume that the case histories of Epidemics 1 pertain par-
ticularly to the Year #3 constitution, rather than to all three constitutions. See, for exam-
ple, Deichgräber, Die Epidemien und das Corpus Hippocraticum, 11; id. (1982). Die Patienten
des Hippokrates: Historisch-prosopographische Beiträge zu den Epidemien des Corpus
Hippocraticum, 8–11; Dugand, ‘Hippocrate à Thasos et en Grèce du nord’, 234; Hellweg,
Stilistische Untersuchungen, 10; Lichtenthaeler, Neuer Kommentar, 90.
25  Epid. 1.4 (L. 2.616.4–5 = Kühlewein 1.184.15–16); Epid. 1.13 (L. 2.638.8–9 = Kühlewein
1.190.22–23). Note also the mention of a “previous constitution” (τῆς πρόσθεν καταστάσιος)
in the Year #1 constitution, Epid. 1.1 (L. 2.598.11 = Kühlewein 1.180.11–12), which has been
omitted from Epidemics 1 for rhetorical or other reasons.
146 Wee

Epidemics I

Year #1 Year #2 Year #3

Constitution Constitution Constitution 14 Case Histories


(No Names) (No Names) (Names) (Names)

the Year #3 account identifies many of its patients in the constitution and con-
cludes with fourteen case histories of named patients.
As we remember, Airs, Waters, Places begins by settling upon a single geo-
graphical location, thus eliminating the variable of place and giving definition
to what is “native” (ἐπιχώριος). In Epidemics 1, the location chosen is the island
of Thasos. Whereas Epidemics 3 seems to portray an itinerant physician in the
midst of his travels, both Epidemics 1 and Airs, Waters, Places envision him at
the commencement of a residency intended to last for at least a year or years.
The seasonal traits given prominence in Aer. 11 (L. 2.52.1–6 = Jouanna 218.13–
219.5) are the same ones that govern the organisation of the constitutions in
Epidemics 1, in which each year begins and ends around the season of Arcturus,
the equinox and the setting of the Pleiades are major autumnal events, the
summer and winter solstices herald constitutional changes, and the Dog Star
is linked to the hottest days (i.e. ‘the dog days’) of summer.26 In Airs, Waters,
Places, seasonal sicknesses are said to be “communal” (πάγκοινος), because
their widespread occurrence at particular times is what suggests the corre-
lation between sickness and season. Conditions of individual patients that
cannot be conflated with such communal descriptions are, instead, labelled
as “personal” (ἴδιος). In Epidemics 1, the same heuristic is evident in the effort
to distinguish medical conditions of ‘the majority’ from those experienced by
only ‘some’ or by single named individuals.

26  “The meteorological approach of Epidemics 1 and 3 is considerably more flexible than the
one of Airs, Waters, Places (and of On the Sacred Disease); but the traditional method is
not criticised; instead, the new method of Epidemics 1 and 3 is formulated in a way that
no contradictions to the older one can occur.” Langholf, Medical Theories in Hippocrates,
172–79, 211–12.
Case History as Minority Report 147

2 Patterns of Identity and Anonymity

Airs, Waters, Places served as a preparatory guide for the physician who arrives
at a polis “with which he is unfamiliar”, Aer. 1 (L. 2.12.9–10 = Jouanna 187.4–5);
Aer. 2 (L. 2.14.3 = Jouanna 188.8–9). The absence of “personal” (ἴδιος) accounts
agrees with this portrayal of the physician as one who has not yet encountered
actual patients in the polis. Epidemics 1, on the other hand, represents a narra-
tive situated in place and time, whereby the physician’s experience of a single
year (i.e. Year #3) at Thasos yielded the information needed for the writing of
“personal” case histories.27 Indeed, for us to appreciate the local significance
of medical signs observed in these histories, we may have to view them in the
narrowly prescribed context of their constitution.28 How might Epidemics 1
appear to us if, for a change, we consider it primarily as a physician’s interpre-
tation of the historical incidence of medical phenomena in a single year and
at a single place? What if we allow that medical signs in Epidemics 1 need not
always concur with the manifestations, distribution, and frequencies of signs
known from comparable diseases today or from those of other Hippocratic
writings, e.g. the other books of Epidemics and On Prognosis?
Three case histories in Epidemics 1, in fact, have been identified with indi-
viduals named in the Year #3 constitution, and they reveal how case histories
function in the rhetorical context of their constitution.29 Philiscus (case 1) and
Silenus (case 2) are the patients named in the following passage:

. . . those most likely to recover were those who had good and copious
bleeding from the nostrils, and I know no one who died in this constitu-
tion, if he had a good bleeding. For Philiscus and Epameinon and Silenus,
who died, dripped (only) a little from the nostrils on the fourth and fifth
days, Epid. 1.8 (L. 2.642.5–10 = Kühlewein 1.191.19–24).

27  I refer here to the physician in the singular, though of course it is possible that more than
one physician was responsible for Epidemics 1, or that the author utilised notes composed
by other physicians.
28  Even if one thinks the same author wrote Books 1 and 3 of the Epidemics, “sa tâche propre
consiste à adapter ce cadre général aux caractéristiques particulières des maladies dans
une constitution donnée.” Demont, P. ‘Les facteurs aggravants de la troisième constitu-
tion de Thasos’, in Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien, 204.
29  Deichgräber, Die Epidemien und das Corpus Hippocraticum, 11; Lichtenthaeler, Neuer
Kommentar, 90.
148 Wee

As we noted earlier, repeated observations had suggested the rule of thumb


that “a good bleeding through the nostrils” predicted the patient’s recovery,
Epid. 1.9 (L. 2.656.7–658.2 = Kühlewein 1.195.21–196.2). The three patients here,
however, seemed to question the validity of this rule, since they died even
after a nosebleed. The solution was to argue that what happened in the case
of Philiscus, Epameinon, and Silenus did not count as a “good bleeding”, but as
“a little” dripping. There was, of course, a degree of subjectivity involved in
classifying a nosebleed as “good” versus “a little”, and we cannot be certain that
such labels were always attached to medical signs before the patient’s final
outcome was known. In two other passages of Epidemics 1, instances of nose-
bleed that ended with the patient’s death were likewise qualified as “a little”
dripping.30 In the final logic of the treatise, distinctions on types of nosebleed
served to buttress the paradigm of prognosis adopted in the constitution.
Another patient, “the Clazomenean” (case 10), is more fully addressed as
“Hermippus the Clazomenean” in the constitution:

The painful swellings by the ears during fevers, for some, neither subsided
nor suppurated when the fever left with a crisis. These were relieved,
when they had bilious diarrhea or dysentery or a sediment of thick urine,
as in the case of Hermippus the Clazomenean, Epid. 1.9 (L. 2.660.1–5 =
Kühlewein 1.196.19–23).

The reference to “some” implies that, for most patients, ear swellings did
indeed disappear along with their fevers after times of crisis. This impression
is confirmed elsewhere in the Year #3 constitution. One passage describes how
“near the crisis . . . swellings by the ears disappeared”, Epid. 1.8 (L. 2.646.2–3 =
Kühlewein 1.192.21–22). Another text resembles Hermippus’ case even more
closely, revealing that “some had (swellings) by the ears, had a crisis on the
twentieth day, and, for all these, (the swellings) subsided and did not suppu-
rate, but were diverted to the bladder”, Epid. 1.9 (L. 2.664.12–666.3 = Kühlewein
1.198.3–5). Hermippus the Clazomenean also experienced a crisis on the twen-
tieth day, exactly when one might have expected his ear swellings to subside,
but they did not do so until the thirty-first day of his sickness.
In short, Philiscus, Silenus, and Hermippus represent instances where
the behaviour of sickness deviated from expectations suggested by compa-
rable medical cases. One might have anticipated recovery after nosebleeds
by Philiscus and Silenus, but they ended up dying instead. One might have

30  See σμικρὰ ἔσταξεν, Epid. 1.18 (L. 2.654.1 = Kühlewein 1.195.6) and σμικρὰ ἀπὸ ῥινῶν ἔσταξε,
Epid. 1.13, case 11 (Kühlewein 1.212.6); ἔσταξε σμικρὰ ἀπὸ ῥινῶν (L. 2.710.3).
Case History as Minority Report 149

predicted that Hermippus’ ear swellings would subside with his fever, but they
remained for at least eleven more days. As a matter of fact, the identification of
the patient in such contrary cases is not surprising, for the practice is aligned
with patterns of identity and anonymity widely attested in the Year #3 consti-
tution. Let us look at the following examples:

Example #1: Women and maidens share all the above-written signs. And
those for whom any of these (signs) occurred properly, or copious men-
struation appeared, through these (signs) they began to recover and had
a crisis. And I know no one who perished, for whom any of these (signs)
occurred properly. For the daughter of Philo died despite a violent flow
from the nostrils, because she dined unseasonably on the seventh day,
Epid. 1.9 (L. 2.658.6–12 = Kühlewein 1.196.6–13).

Example #2: For the majority, menstruation appeared during the fevers
and, for many maidens, it was the first time then. Some bled from the
nostrils. Sometimes both (bleeding) from the nostrils and menstrua-
tion appeared at the same time, as in the case of the maiden daughter
of Daitharses, where there appeared at that time her first (menstrua-
tion) and a violent flow from her nostrils, Epid. 1.8 (L. 2.646.13–648.4 =
Kühlewein 1.193.10–16).

With the daughter of Philo in Example #1, we are again confronted with the sit-
uation where the patient’s nosebleed is followed by death. Unlike the case with
Philiscus and Silenus, however, the “violent flow” that issued from this woman’s
nostrils could not be easily rationalised as “a little” dripping. Instead, the phy-
sician resorted here to the vague explanation that she had “dined unseason-
ably”, hence vindicating the prognostic value of nosebleed as a sign of recovery
under normal circumstances. We should take note that the many “women and
maidens” whose medical conditions ratified this prognostic rule are unnamed,
whereas the daughter of Philo is identified precisely because she deviated from
the rule. The same concern for the atypical is evident in Example #2, where the
majority of women who menstruated during fevers are not specified. Even the
minority group with nosebleeds instead of menstruation remains unnamed.
A subset of women within this minority group, however, who simultaneously
experienced nosebleeds and menstruation, finds representation in the person
of Daitharses’ daughter (Example #2).

Example #3: The majority had bleeding, especially youths and those in
their prime. And most of those who did not have bleeding died. But older
150 Wee

people had jaundice or disordered bowels, as in the case of Bion who


lay down at the house of Silenus, Epid. 1.8 (L. 2.644.7–11 = Kühlewein
1.192.10–14).

Example #4: For the majority, urine was well-coloured, but thin and
having few sediments . . . But I will recall those whose urine was very
watery, clear, and thin, but for whom both sediments and other aspects
ameliorated after a crisis: Bion who lay down at the house of Silenus,
Cratis who lodged with Xenophanes, the slave of Areto, and the wife of
Mnesistratus . . ., Epid. 1.8 (L. 2.648.6–650.3 = Kühlewein 1.193.19–194.5).

Example #5: The majority had a crisis on the sixth day, an intermission of
six days, and a crisis on the fifth day after the relapse. . . . Some had a crisis
on the sixth day, an intermission of six days, an attack for three days, an
intermission of one day, an attack for one day, and a crisis, as in the case
of Euagon the son of Daitharses. Some had a crisis on the sixth day, an
intermission of seven days, and a crisis on the fourth day after the relapse,
as in the case of the daughter of Aglaïdas, Epid. 1.9 (L. 2.662.3–664.4 =
Kühlewein 1.197.7–16).

Both nosebleeds and bile from disordered bowels, if we remember, were


considered signs that the patient would recover, Epid. 1.9 (L. 2.656.7–658.2 =
Kühlewein 1.195.21–196.2). In Example #3, however, the manifestation of one
sign over the other seems to have been determined by the age of the patient.
The majority were young persons who suffered bleeding on their way to recov-
ery, while the fewer older patients experienced jaundice or disordered bow-
els instead. No names appear here from the young majority, whereas Bion is
mentioned as a representative of the older group. In Example #4, the major-
ity of patients with well-coloured urine are likewise anonymous. The text, on
the other hand, meticulously lists the identities of Bion, Cratis, the slave of
Areto, and the wife of Mnesistratus, because their “very watery” and “clear”
urine marked a departure from the usual observations. Example #5 is interest-
ing for showing the importance of the timing of crises and intermissions in the
scheme of Epidemics 1. When compared with others, Euagon and the daughter
of Aglaïdas each experienced one additional day of intermission at different
points in their sicknesses. This variation was sufficient to warrant the mention
of their names, in contrast to the nameless majority who supposedly followed
the typical pattern of crises and intermissions.
These examples and others show that common medical conditions were
described under the rubric of an anonymous “majority” (οἱ πλεῖστοι), whereas
Case History as Minority Report 151

more unusual or peculiar medical signs were designated as the experiences


of ‘some’ or of specifically named individuals.31 Though there are a couple
of exceptions to this rule, the general pattern of identity and anonymity is
clear.32 To express this in the language of Airs, Waters, Places: Medical con-
ditions that were “communal” (πάγκοινος) could be described anonymously,
as occurrences validated by the experiences of ‘the majority’ and thought to
derive from seasonal changes. Medical conditions that were “personal” (ἴδιος),
however, had greater need for the evidence of individual testimony, whereby
the names and identities of patients took on forensic importance. ‘Personal’
sickness, moreover, was linked to individual lifestyle and individual responses
to therapy, which could vary from person to person.33
The relationship between the “communal” (πάγκοινος) and the “personal”
(ἴδιος) deserves our careful attention. The ‘personal’ is defined by the ‘com-
munal’, and not the other way round. We might even say that the ‘personal’
exists because of its failure to assimilate into the ‘communal’. To be sure, it
may appear counterintuitive to say that ‘personal’ case histories derive not
only from their individuals’ experiences, but also from those of the community
of patients. In the first place, however, the selection of individuals for patient
narratives and the choice of content for their case histories were shaped by
manifestations of sickness in the wider community. Patients whose conditions
could be adequately described in ‘communal’ terms were simply addressed
as part of the anonymous majority, rather than given prominence in separate
case histories. Conversely, this means that identified patients are by definition

31  The word translated “the majority” in all these cases is not οἱ πολλοί with its possible politi-
cal overtones, but οἱ πλεῖστοι, which expresses proportion without necessarily suggesting
value judgments about majority or minority attestations.
32  We are not certain why Teleboulus’ daughter was mentioned as an example of death
after childbirth, Epid. 1.8 (L. 2.646.11–13 = Kühlewein 1.193.7–10), though her case history
was evidently not considered noteworthy to be preserved in Epidemics 1. Another pas-
sage relates that “the majority died on the sixth day in these sicknesses, as in the cases
of Epameinondas, Silenus, and Philiscus the son of Antagoras”, Epid. 1. 9 (L. 2.664.10–12
= Kühlewein 1.198.1–3). These were probably not the same persons as Philiscus and
Silenus mentioned earlier: in the case histories, Philiscus is not qualified as “the son of
Antagoras”, while Silenus dies on the eleventh, not the sixth, day. In any case, judging
by other accounts in the constitution and case histories, “Epameinondas, Silenus, and
Philiscus the son of Antagoras” seem to exemplify a situation (i.e. death on the sixth day)
that was normative only in a rather prescribed context.
33  Similarly, in Flat. 6.3–7.3ff. (L. 6.96.23–98.16ff. = Jouanna 109.5–111.1ff. ), “common” (κοινός)
fevers come from the population’s shared exposure to harmful wind, whereas “personal”
(ἴδιος) fevers result from the individual’s bad regimen of food and exercise.
152 Wee

non-­representative medical cases, at least according to the heuristic schemes


of Epidemics 1 and Airs, Waters, Places. We should therefore question the view
that the case histories here “may have been conceived as exemplary pieces
of evidence for the general exposition of the καταστάσεις” in Epidemics 1.34
Philiscus, Silenus, and Hermippus are known to us from the text, not because
they exemplified the behaviour of sickness in its constitution, but because they
contradicted majority expectations of how sickness is supposed to behave.
As a matter of fact, the labelling of a patient narrative as “exemplar”
(παράδειγμα) does occur in Regimen in Acute Diseases, where, perhaps tellingly,
a hypothetical rather than a real patient is described:35

It is sufficient to write a certain exemplar (παράδειγμα) of all these things:


for, if a certain one, who receives a wound on the lower leg that is nei-
ther severe nor slight, . . . is treated immediately from the start while lying
down and never raising the leg, . . . he would recover much more quickly
than if he wanders about while being treated. If, however, on the fifth or
sixth day or later still, he wishes to arise and step forth, he would suffer
more than if he had wandered about immediately from the start while
being treated . . . Finally therefore, all these things testify (μαρτυρεῖ) with
each other, that all things that suddenly deviate much from the mean in
either direction are injurious, Acut. 46 (L. 2.320.5–324.4 = Joly 56.3–18).

The language of proof (παράδειγμα and μαρτυρεῖ) implies that even the imag-
ined behaviour of a hypothetical patient could present a persuasive argu-
ment to the ancient audience. What were the benefits of imagining such a
hypothetical patient, rather than quoting from the experience of an actual
named individual? Here, anonymity not only took for granted the plausibil-
ity of the situation described, it also suggested that the principle illustrated

34  Hellweg, Stilistische Untersuchungen, 10 [translation mine]. Silenus’ case was viewed “as
illustration of [the author’s] general description of the third catastasis” in Smith, ‘Generic
form in Epidemics 1 to 7’, 147. The question whether case histories served to validate any
hypotheses held by the ancient author was considered in Potter, ‘Epidemien 1/3: Form
und Absicht’, 17.
35  Perhaps ‘exemplar’ here may recall Thomas Kuhn’s idea of analogical ‘models’ of imag-
ining scientific objects or processes and representative puzzle-solving solutions known
as ‘exemplars’. Kuhn, Th. S. (1977). The Essential Tension: Selected Studies in Scientific
Tradition and Change, 297–98. These ‘models’ and ‘exemplars’, while certainly relatable
to real world situations, may also include clearly hypothetical features such as frictionless
surfaces and speed-of-light travel.
Case History as Minority Report 153

was ­universally valid and not limited to specific named cases. Furthermore,
by using a hypothetical narrative, the author could isolate a single point in
the patient’s experience (i.e. pain from a leg wound), without concern for a
whole array of other medical signs that might unnecessarily—in the author’s
view—complicate his argument. These reasons present the flip side to what
we observe in Epidemics 1, where patients were named because the behaviour
of their sickness could not be taken for granted, and where detailed case histo-
ries were preserved in order to fully document such conditions that deviated
from the majority of cases.

3 The Imperative of Prognosis

Our methodology has departed from most previous scholarship on the case
histories of Epidemics 1 in three important ways. First, in respect for existing
manuscript forms, we have focused exclusively on Epidemics 1 as a self-con-
tained narrative, without conflating or grouping it together with Epidemics
3. Secondly, we have adopted a narrowly contextual reading of the medical
signs in the case histories, viewing their manifestations, distributions, and
frequencies as incidental phenomena of a single historical year (Year #3) at
Thasos, while resisting attempts to define them as products of sicknesses
known in modern times or in closely affiliated works such as the other books of
Epidemics or On Prognosis. Finally, in clarifying the relationship between con-
stitution and case histories, we have avoided the usual practice of emphasizing
similarities between the two, as if case histories represent simple illustrations
of sicknesses addressed in their constitution. Instead, we have prioritised
the differences between constitution and case history, in line with our argu-
ment that ‘personal’ case histories exist because they cannot be assimilated
with ‘communal’ descriptions in the constitution. All three points are, in fact,
related: it is only when we insist on reading the case histories of Epidemics 1
exclusively through the lens of the Year #3 constitution, that it becomes obvi-
ous how much dissonance there is between case histories and constitution.
The non-representative nature of the case histories in Epidemics 1 explains
why scholars have found it so difficult to connect them to the constitution(s).
Furthermore, the exact point of relevance between the case histories and
their constitution is not always clear. On the one hand, parts of the case his-
tories of Philiscus (case 1) and Hermippus (case 10) play critical roles in the
argument of their constitution, providing counterexamples to the experi-
ences of the majority of patients. Parallels in language may even suggest that
these case histories or their Vorlagen served as textual sources for the Year #3
154 Wee

constitution.36 To give one example, the form σμικρόν is used in the consti-
tution and in the case histories to describe “a little” nosebleed by Philiscus,
whereas similar constructions elsewhere in Epidemics 1 seem to prefer the
form σμικρά.37 On the other hand, the vast amount of detail in these same case
histories appears to be of only tangential relevance to the constitution.38 Why
record the entire case history of Philiscus, for instance, if the only feature that
mattered was his nosebleed? Indeed, there are many patients named in the
constitution that do not have their case histories preserved. In the end, we may
not be able to give a definite answer. It bears reminding, however, that ‘per-
sonal’ (ἴδιος) medical conditions did not arise arbitrarily, but from a specific
set and combination of factors in the individual’s life, and therefore required a
holistic consideration of the individual’s history.39
After all, the case history of Philiscus was intended not merely as a historical
record of past events, but as a pattern that could be consulted for future com-
parisons. We earlier noted the subjectivity involved in classifying a nosebleed
either as ‘good’ or ‘a little’. Imagine a patient with an indeterminate amount
of nosebleed on the fifth day. The physician might say, the patient has a good
nosebleed that will lead to his or her recovery. Or the physician might say, it
is going to turn out the way it happened with Philiscus. Indeed, if the patient

36  Compare the language of τὰ παρὰ τὰ ὦτα . . . οὔτε καθίστατο οὔτε ἐξεπύει, Epid. 1.9
(L. 2.660.1–3 = Kühlewein 1.196.19–21) with τὰ δὲ παρὰ τὰ ὦτα οὔτε καθίστατο οὔτε ἐξεπύει,
Epid. 1.13, case 10 (L. 2.706.15–708.1 = Kühlewein 1.211.9–10). Compare also σμικρὸν ἀπὸ
ῥινῶν ἔσταξεν, Epid. 1.8 (L. 2.642.9 = Kühlewein 1.191.24) with σμικρὸν ἀπὸ ῥινῶν ἔσταξεν
ἄκρητον, Epid. 1.13, case 1 (L. 2.682.14–15 = Kühlewein 1.202.21–22).
37  In descriptions of Philiscus, the form σμικρόν appears as an adjective (modifying ἄκρητον)
at Epid. 1.13, case 1 (L. 2.682.14 = Kühlewein 1.202.21), and either as a substantivised adjec-
tive or an adverb at Epid. 1.8 (L. 2.642.9 = Kühlewein 1.191.24). The adverbial form σμικρά
is preferred in similar constructions at Epid. 1.9 (L. 2.654.1 = Kühlewein 1.195.6); Epid. 1.13,
case 11 (L. 2.710.3 = Kühlewein 1.212.6); Epid. 3.17, case 7 (L. 3.122.14 = Kühlewein 1.238.3). See
discussion of syntax in Langholf, V. (1977). Syntaktische Untersuchungen zu Hippokrates-
Texten: Brachylogische Syntagmen in den individuellen Krankheits-Fallbeschreibungen der
hippokratischen Schriftensammlung, 76. But note the attestation of σμικρόν at Epid. 3.17,
case 1 (L. 3.104.5 = Kühlewein 1.233.3).
38  In fact, the case history of Silenus (case 2) omits altogether the crucial point of his
nosebleed.
39  Lloyd was correct when he spoke of “seeing the case histories not so much as a resource
for generalisation about what particular signs (for example, “thin” urine or “sleepless-
ness”) might mean but, rather, as underlining the need to take every sign in its collocation,
namely, as part of a history to be viewed and interpreted as a whole.” Lloyd, G. E. R. (1995).
Review of Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3. Epidemienbuch
des Hippokrates by Charles Lichtenthaeler, Isis 86.3, 469.
Case History as Minority Report 155

also manifests semen-like urine, deep and intermittent breathing, a swollen


spleen, and other signs shown by Philiscus, the physician would be able to say
on firmer grounds that history (or case history) was repeating itself. The works
of Deichgräber and Lichtenthaeler have long drawn attention to the relation-
ship between the Epidemics and the treatise On Prognosis. The characters
associated with case histories in Epidemics 3 further testify to the importance
of prognosis, since these characters end with either Υ or Θ, which, accord-
ing to Galen, signified “recovery” (Ὑγείαν) or “death” (Θάνατον).40 It has been
argued that case histories served “less to facilitate diagnosis, than to provide
information that would help the doctor to predict the outcomes of diseases,
especially whether the patient would die or recover”.41 Our imagined scenario
with the physician above suggests what is at stake for the medical profes-
sion. In the absence of formal medical certification, accurate prognosis was a
means of winning the patient’s trust and building the physician’s r­ eputation.42
Unexpected deviations from the usual rules of prognosis, therefore, presented
a potential threat to the physician’s credibility and livelihood. This imperative
of prognosis may give us a key to understanding the case histories.
There are four more case histories in Epidemics 1 that can be meaningfully
related to parts of the Year #3 constitution. The two case histories on pregnant
women (cases 4 and 5) are natural candidates for the following passage in the
constitution, which is specially devoted to the topic of pregnancy, delivery, and
post-natal sickness:

Many women became sick, though they were fewer than men, and fewer
died. The majority suffered in childbirth and fell sick after delivery, and
these especially died, as when the daughter of Teleboulus died on the
sixth day after delivery. . . . And if those who were pregnant happened to
become sick, to my knowledge, all had miscarriages, Epid. 1.8 (L. 2.646.9–
648.6 = Kühlewein 1.193.6–18)43

40  See Jones’ notes (p. 213–15) before his translation of Epidemics 3.
41  Lloyd, G. E. R. (1979). Magic, Reason and Experience: Studies in the Origin and Development
of Greek Science, 154.
42  A particularly clear statement of this notion may be found at Progn. 1 (L. 2.110.1–112.11 =
Alexanderson 193.1–194.9). On prognosis and the medical profession, see also Jouanna, J.
(1999). Hippocrates, trans. M. B. De Bevoise, 100–11.
43  For the medical meaning of ἀπέφθειραν here as “to have a miscarriage”, see also descrip-
tions of “miscarriage” (ἀποφθορά) elsewhere at Epid. 3.1, cases 10 and 11 (L. 3.60.2, 10 =
Kühlewein 1.222.6, 14).
156 Wee

The wife of Epicrates (case 5) offers a challenge to the above description at


every level. Though she was seized with strong rigors two days before “she gave
birth” (ἔτεκεν), the delivery “went according to plan” (κατὰ λόγον ἦλθε), and the
language here seems to imply that the child survived.44 It is not entirely clear
how to reconcile this fact with the author’s statement in the constitution that,
to his knowledge, “all had miscarriages”.45 Furthermore, though her sickness
was aggravated immediately after delivery, she avoided the fate of the major-
ity of women, and experienced a complete crisis after a long period of eighty
days. Her case history may have served as a caution to any physician who might
prematurely predict the deaths of women in similar condition.
More in line with expectations, the wife of Philinus (case 4) fell sick only after
delivery and eventually died like the majority of women. The delivery itself,
however, was normal, and she was in good condition prior to the sickness. The
point of controversy, however, is this: the wife of Philinus appears to have been
fitted into the paradigm of death from post-natal sickness, though the first
signs of any sickness only occurred fourteen days after the delivery. This is a
significant gap when one compares her experience with other women, such as
the wife of Dromeades, Epid. 1.13, case 11 (L. 2.708.6–710.11 = Kühlewein 1.211.15–
212.14), the woman by the Liars’ Market, Epid. 3.1, case 12 (L. 3.62.11–66.11 =
Kühlewein 1.223.3–224.5), and the woman in Cyzicus, Epid. 3.17, case 14
(L. 3.140.14–142.4 = Kühlewein 1.243.13–25) who all fell sick immediately or a day
after delivery, the woman by the Cold Water, Epid. 3.17, case 2 (L. 3.108.5–112.12 =
Kühlewein 1.234.3–235.6) who developed acute fever three days after deliv-
ery, and the woman at the house of Pantimides, Epid. 3.1, case 10 (L. 3.60.1–8 =
Kühlewein 1.222.6–13) and the wife of Hicetas, Epid. 3.1, case 11 (L. 3.60.9–62.10 =
Kühlewein 1.222.14–223.2) who both fell sick immediately after their miscar-
riages. In other words, the case of Philinus’ wife warned against the presump-
tion of well-being, even if a woman’s sickness did not manifest itself for a full
thirteen days after childbirth, more than double the time it took the daugh-
ter of Teleboulus to die from post-natal sickness! Just as Epicrates’ wife repre-
sents the minority experience in the Year #3 constitution, the wife of Philinus

44  It is less likely that the expression κατὰ λόγον ἦλθε (“went according to plan”) refers to the
miscarriage of the child in accordance with prognostic expectations. In cases 1.10 and 1.11
of Epidemics 3, the women who had miscarriages are not described as having “given birth”
(ἔτεκεν).
45  Was the case history of Epicrates’ wife not taken into account in the composition of the
constitution, but included later? Did the author consider sickness to commence only
with the onset of acute fever, which occurred the day after the wife of Epicrates delivered?
Case History as Minority Report 157

illustrates the unusual extent to which the event of childbirth can remain rel-
evant in cases of female mortality.
The case histories of Meton (case 7) and Erasinus (case 8) relate to another
passage, which includes a description of medical signs remarkably similar to
their own:

About the equinox until (the setting of) the Pleiades and during winter,
though kausos-fevers continued, phrenitics became majority at that time,
and the majority of these died. . . . There were signs for those who suffered
from kausos-fever at the beginning, for whom the fatal signs concurred.
For right from the beginning, there were acute fever, slight rigors, sleep-
lessness, thirst, nausea, slight sweats . . . much delirium, fears, depres-
sion, very cold extremities—toes and especially fingers. The paroxysms
were on even days; for the majority, the pains were greatest on the fourth
day, . . . Their urine was slight, black, thin, and their bowels were stopped.
They did not bleed from the nostrils . . . or else they dripped (only) a lit-
tle. . . . They died on the sixth day with sweating. Phrenitics shared (alter-
native reading: did not share) all the above-written (signs), and their
crisis was generally on the eleventh day . . ., Epid. 1.9 (L. 2.650.9–654.5 =
Kühlewein 1.194.13–195.10).

Erasinus (case 8) seems to closely mirror the picture of fatal kausos-fever


here.46 He was seized with fever at the beginning of his sickness, experienced
sleeplessness, a mild thirst, sweat, delirium and wandering, fear, cold extremi-
ties, black urine, and no nosebleeds, though he did pass excrement from the
bowels. He had a paroxysm on the second day, became worse on the fourth day,
and finally died with sweat and convulsions around the beginning of the sixth
day (i.e. around sunset on the fifth day). Meton (case 7) displayed similar signs,
but with some at different times. He too was seized with fever from the start,
suffered during the night, passed black urine, and had only a little nosebleed.
He experienced his paroxysm on the fourth day, but his sickness was instead
resolved by a crisis on the fifth day, after which he suffered from sleeplessness,
wandering, and frequent nosebleeds. As with Philiscus, Silenus, and the wife of
Epicrates, Meton’s history bore certain resemblances with comparable medi-
cal cases (i.e. of kausos-fever) but provided an alternative outcome that contra-
dicted prognostic expectations (i.e. he did not die on the sixth day).

46  Note that Philiscus (case 1) too is mentioned in the constitution as suffering from kausos-
fever, Epid. 1.8 (L. 2.642.4–5, 8 = Kühlewein 1.191.19, 22), and that much of his case history
agrees with the description of this sickness here.
158 Wee

A major difficulty in interpretation stems from the ambiguous manuscript


evidence whether or not phrenitics “shared all the above-written (signs)” of
fatal kausos-fever.47 All things considered, it is likely that the two conditions
were similar to each other: phrenitics either shared all the described signs
of those suffering from fatal kausos-fever, or they shared many (but not all) of
these signs.48 The case of Erasinus, which otherwise appears to be an unre-
markable example of fatal kausos-fever, may therefore take on special signifi-
cance in the argument of the constitution. We are in a season when cases of
phrenitis are “majority”, but when we also need to be reminded that kausos-
fevers exist. Due to their similarities, kausos-fever was liable to be mistaken
for the more common sickness (i.e. phrenitis). In Example #3 earlier, Bion was
named not because his condition of “jaundice or disordered bowels” was in
itself extraordinary, but because it was less common when compared to the
majority of patients who were young and suffered “bleeding” instead, Epid. 1.8
(L. 2.644.7–11 = Kühlewein 1.192.10–14). Likewise, Erasinus is important here
not necessarily as a deviant case of kausos-fever, but because kausos-fever rep-
resented the minority condition at this time. Indeed, during this season, suf-
ferers of kausos-fever are described as dying on the sixth day, while phrenitics
may expect a crisis on the eleventh day. In the case of Erasinus, we may have
an example of a sickness that had the potential to be misidentified, and which
could therefore lead to a misguided prognosis.
Other case histories in Epidemics 1 cannot be related to the Year #3 constitu-
tion with the same degree of clarity and, at this stage, it would be too specula-
tive to map every single case history onto the constitution. The account of days
thirty to eighty of Cleanactides’ sickness (case 6), for example, seems to focus
on the colour and sedimentation of his urine, which happens to be the theme
of a distinct section in the constitution (see Example #4 above). Other condi-
tions, however, such as Crito’s painful toe (case 9), worms in stools (case 12), and
the nosological pattern of initial fever, intermission on the seventh day, and a
crisis on the eleventh day (cases 13 and 14) cannot be definitely linked to parts
of the constitution, though the omission of such descriptions in the constitu-
tion may indicate that these too represent less typical cases. Furthermore, we

47  See critical apparatus to L. 2.654.3 and Kühlewein 1.195.8–9. Littré has οὐ ξυνέπιπτε in the
main body of his edition, while Kühlewein prints συνέπιπτε without the negative particle.
48  The option that phrenitis had nothing or not much in common with fatal kausos-fever
fails to satisfactorily explain the following: 1) the implied comparison of the two condi-
tions in the passage, 2) the need for the qualifier πάντα (‘all’), and 3) the absence of any
subsequent description of bodily signs of phrenitis other than days of its crises that dif-
fered from those for kausos-fever, even though “phrenitics became majority at that time”.
Case History as Minority Report 159

should remember that the case history of Silenus (case 2) does not even men-
tion the crucial point that he experienced a slight nosebleed on the fourth or
fifth day, though the constitution is explicit about the relevance of that detail.
Such omissions may indicate that the author was familiar with the patient’s
history to an extent that is not always preserved in our textual accounts.
The chart below suggests that, up to a point, the case histories in Epidemics 1
appear in an order parallel to the narrative of the Year #3 constitution, though
there are still too many gaps here to be absolutely certain of this picture.
Regardless of how closely we wish to connect the textual structures of constitu-
tion and case histories, it at least seems likely that our case histories functioned
as companion texts to their constitution, providing alternative perspectives or
counterexamples to general trends of sickness described in the constitution.

Case Histories of Epidemics 1

Case Patient Feature Under Related Section in Relevance for


Consideration Constitution Constitution

1 Philiscus A little Epid. 1 8.12–18 = Named in


nosebleed L. 2.642.4–10 = Constitution
Kühlewein
1.191.19–24

2 Silenus (A little Epid. 1 8.12–18 = Named in


nosebleed) L. 2.642.4–10 = Constitution
Kühlewein
1.191.19–24

3 Herophon ? ? ?

4 Wife of Childbirth & Epid. 1 8.1–15 = Topic of


Philinus sickness L. 2.646.9–648.6 = childbirth &
Kühlewein 1.193.6–18 sickness

5 Wife of Childbirth & Epid. 1 8.1–15 = Topic of


Epicrates sickness L. 2.646.9–648.6 = childbirth &
Kühlewein 1.193.6–18 sickness
160 Wee

Case Histories of Epidemics 1

6 Cleanactides Urine colour & Epid. 1 8.1–12 = Topic of urine


sedimentation? L. 2.648.6–650.4 = colour &
Kühlewein sedimentation?
1.193.19–194.7?

7 Meton Signs of Epid. 1 9.1–28 = Topic of


kausos-fever/ L. 2.650.9–656.1 = kausos-fever /
phrenitis Kühlewein phrenitis
1.194.13–195.14

8 Erasinus Signs of Epid. 1 9.1–28 = Topic of


kausos-fever/ L. 2.650.9–656.1 = kausos-fever /
phrenitis Kühlewein phrenitis
1.194.13–195.14

9 Crito ? ? ?

10 (Hermippus) Ear swellings Epid. 1 9.1–6 = Named in


the persisting after L. 2.660.1–5= Constitution
Clazomenean crisis Kühlewein
1.196.19–23

11 Wife of ? ? ?
Dromeades

12 Man ? ? ?

13 Woman ? ? ?

14 Melidia ? ? ?

4 Concluding Thoughts

We conclude our study here with a few final thoughts. First, although the
categories of ‘communal’ and ‘personal’ are distinct enough conceptually,
the assignment of particular cases to one category or to the other relied on
Case History as Minority Report 161

the Hippocratic author’s interpretive judgment. Whereas patients identified in


the case histories and the Year #3 constitution were acknowledged to be atypi-
cal, it does not mean that other patients addressed as part of the anonymous
‘majority’ necessarily conformed to the same degree to majority paradigms.
Since the observation of medical signs is a theory-laden enterprise, the ten-
dency would have been to interpret medical phenomena in line with estab-
lished patterns of sickness behaviour, and to smooth over minor discrepancies
wherever possible. Case histories represent instances where, for whatever rea-
sons, the dissonance between observation and expectation proved too difficult
to ignore.
Secondly, the factors that classified a medical condition either as ‘communal’
or ‘personal’ were its frequency and distribution in the community of patients,
rather than the specific mechanism of sickness. In other words, variables of
place, time, and patient represent different ways of organizing a narrative
about sickness in a local population, rather than different immediate causes of
sickness. Though Epidemics 1 is not always explicit about humoral theory, there
is nothing here against the view that both seasonal change and individual life-
style were understood in terms of their effects on bodily humours.49
Thirdly, though the case histories of Epidemics 1 were products of a selec-
tion process that emphasised the ‘personal’, this criterion probably applied to
the preservation of recorded histories, rather than to their initial composition.
Some of the case histories in Epidemics 1 and 3, in fact, span a period of up to
forty, eighty, or even a hundred and twenty days, and it is natural to assume
that some record was undertaken from the beginning, even when it was not
entirely clear how the sickness would develop. It is possible, therefore, that dif-
ferent Hippocratic case histories served various purposes or represent written
records at different stages of formulation. We cannot expect all case histories
to adhere to the heuristic of those in Epidemics 1, especially when they are not
presented together with a constitution as an integrated narrative. That being
said, there are several examples in the Epidemics where patients experiencing

49  The term κατάστασις “can be used for the ‘state’ of a disease as well as for the ‘condi-
tion’ of the weather”, and “the semantic ambiguity is due to the underlying medical doc-
trine of a close interrelation between the weather and the diseases, which both form one
‘system’ ”. Langholf, Medical Theories in Hippocrates, 169–70. Cf. Temkin, O. (1928). ‘Der
systematische Zusammenhang im Corpus Hippocraticum’, Kyklos 1, 15, 29–31; Demont,
‘Les facteurs aggravants’, 204. Note the mention of “humor” (χυμός) responsible for
ear swellings, Epid. 1.8 (L. 2.646.1 = Kühlewein 1.192.20), as well as the implication that
this is diverted to the bladder when ear swellings subside, Epid. 1.9 (L. 2.664.12–666.3 =
Kühlewein 1.198.3–5).
162 Wee

different medical signs are nonetheless implied as suffering from versions of


the same condition, revealing attempts to account for varied sickness behav-
iours in systematised ways.50
Finally, our arguments here on case histories as minority reports, which
deviate from the experiences of the majority, should enter into larger discus-
sions about the definition and classification of diseases in ancient Greece. The
polemic in Regimen in Acute Diseases against the Cnidian Sentences is well
known, which includes the complaint about the absurdity of attaching a new
name to every variation of the same sickness.51 Galen’s commentary on this
work and the nosological treatise of Internal Affections seem to illustrate this
practice, with their enumeration of three consumptions, four kidney diseases,
four jaundices, and three tetanuses, among other disease categories.52 Viewed
in this light, the heuristic in Epidemics 1 may represent an alternative strategy
of classification, whereby differences in the manifestation of sickness were
attributed, not to variant forms of the same disease, but to the patient instead
as the variable.

Texts and Translations Used

Aristotle. Nicomachean Ethics. (EN). Ed. I. Bywater. Oxford Classical Texts. Oxford:
Clarendon Press, 1894.
Hippocrates. Œuvres completes d’Hippocrate. Ed. and trans. E. Littré, vol. 1–10. Paris:
J.-B. Ballière, 1839–61.
———. Airs, Waters, Places. (Aer.). Ed. J. Jouanna. Collection des universités de France.
Paris: Les Belles Lettres, 1996.
———. Airs, Waters, Places. Trans. W. H. S. Jones. The Loeb Classical Library 147.
Cambridge, MA: Harvard University Press, 1923.
———. Breaths. (Flat.). Ed. J. Jouanna. Collection des universités de France. Paris: Les
Belles Lettres, 1988.

50  Unlike Timenes’ sister, Menander’s vinedresser did not shiver during his crisis on the sev-
enth day because of his upset belly, Epid. 4.25 (L. 5.168.3–5 = Smith 110). In place of the
eye problems experienced by other patients, the slave/child of Apemantus’ sister suffered
joint problems due to his fatigue, Epid. 4.27 (L. 5.172.1–5 = Smith 114). There are also other
cases where differences between patients being compared are not explicitly stated.
51  Acut. 3 (L. 2.228.2–6 = Joly 37.7–10).
52  See, for example, Int. 10 (L. 7.188.26 = Potter 102); Int. 14 (L. 7.202.1 = Potter 118); Int. 35
(L. 7.252.17 = Potter 188); Int. 52 (L. 7.298.11 = Potter, 250).
Case History as Minority Report 163

———. Epidemics 1. (Epid. 1). Ed. H. Kühlewein. Hippocratis opera quae feruntur omnia,
2 vols. Leipzig: B. G. Teubner, 1894–1902.
———. Epidemics 3. (Epid. 3). Ed. H. Kühlewein. Hippocratis opera quae feruntur
omnia, 2 vols. Leipzig: B. G. Teubner, 1894–1902.
———. Epidemics 3. Trans. W. H. S. Jones. The Loeb Classical Library 147. Cambridge,
MA: Harvard University Press, 1923.
———. Epidemics 4. (Epid. 4). Ed. W. D. Smith. The Loeb Classical Library 477.
Cambridge, MA: Harvard University Press, 1994.
———. Internal Affections. (Int.). Ed. P. Potter. The Loeb Classical Library 473.
Cambridge, MA: Harvard University Press, 1988.
———. Prognostic. (Progn.). Ed. B. Alexanderson. Studia Graeca et Latina
Gothoburgensia 17. Stockholm: Almquist and Wiksell, 1963.
———. Regimen in Acute Diseases. (Acut.). Ed. R. Joly. Collection des universités de
France. Paris: Les Belles Lettres, 1972.

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Lloyd, G. E. R. Magic, Reason and Experience: Studies in the Origin and Development of
Greek Science. Cambridge: Cambridge University Press, 1979.
Case History as Minority Report 165

———. Review of Neuer Kommentar zu den ersten zwölf Krankengeschichten im 3.


Epidemienbuch des Hippokrates by Charles Lichtenthaeler. Isis 86.3, (1995): 469.
Morens, D. M. ‘Epidemiology.’ in Encyclopedia of Pestilence, Pandemics, and Plagues,
Volume 1, ed. J. P. Byrne, 200–204. Westport, CT: Greenwood Press, 2008.
Nachmanson, E. (ed.) Erotiani vocum Hippocraticarum collectio cum fragmentis.
Collectio Scriptorum Veterum Upsaliensis, 1918.
Parascandola, M. ‘Epidemiology’ and ‘Epidemiology, History of.’ in Encyclopedia of
Pestilence, Pandemics, and Plagues, Volume 1, ed. J. P. Byrne, 204–07. Westport, CT:
Greenwood Press, 2008.
Potter, P. ‘Epidemien 1/3: Form und Absicht der zweiundvierzig Fallbeschreibungen.’ in
Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 9–19. Sudhoffs Archiv
Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989.
Roselli, A. ‘Epidemics and Aphorisms: Notes on the History of Early Transmission of
Epidemics.’ in Die Hippokratischen Epidemien, ed. G. Baader and R. Winau, 182–90.
Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner Verlag, 1989.
Smith, W. D. ‘Generic Form in Epidemics 1 to 7.’ in Die Hippokratischen Epidemien, ed.
G. Baader and R. Winau, 144–58. Sudhoffs Archiv Beiheft 27. Stuttgart: Franz Steiner
Verlag, 1989.
Sticker, G. Der Volkskrankheiten erstes und drittes Buch. Klassiker der Medizin 28.
Leipzig: Verlag von Johann Ambrosius Barth, 1923.
Temkin, O. ‘Der systematische Zusammenhang im Corpus Hippocraticum.’ Kyklos 1,
(1928): 9–43.
Thivel, A. Cnide et Cos? Essai sur les doctrines médicales dans la collection hippocratique.
Paris: Les Belles Lettres, 1981.
Wilkinson, L. ‘Epidemiology.’ in Companion Encyclopedia of the History of Medicine,
Volume 2, ed. W. F. Bynum and R. Porter, 1262–82. London: Routledge, 1993.
CHAPTER 5

Voice Pathologies and the ‘Hippocratic Triangle’


Colin Webster

Hippocratic authors frequently utilise silence, babbling, lisping and other


verbal signs to diagnose a variety of physical illnesses and predict their
course. This chapter examines these ‘voice pathologies’ and evaluates
their impact on the dialogue between patients and Hippocratic physi-
cians. In short, Hippocratic authors treat patients’ voices in two disso-
nant ways. On the one hand, physicians promote some form of discourse,
implicitly relying on patients to report internal sensations resulting from
illnesses. On the other hand, they develop extensive techniques to dimin-
ish and downplay this reliance. As a result, Hippocratic authors treat
patients’ mouths not so much as the loci of potential subjective expres-
sion, but as orifices secreting verbal discharges. They weaken the distinc-
tion between the (sonic) effluvia of the mouth and those of other bodily
outlets, thus bringing verbal output into close conceptual proximity with
other types of discharge. Words come to be scrutinised for their quantity,
quality and consistency as though they were quasi-excreta of the mouth.

λέγειν τὰ προγενόμενα, γινώσκειν τὰ παρεόντα, προλέγειν τὰ ἐσόμενα·


μελετᾶν ταῦτα. ἀσκεῖν περὶ τὰ νοσήματα δύο, ὠφελεῖν ἢ μὴ βλάπτειν. ἡ τέχνη
διὰ τριῶν, τὸ νόσημα καὶ ὁ νοσέων καὶ ὁ ἰητρός· ὁ ἰητρὸς ὑπηρέτης τῆς τέχνης·
ὑπεναντιοῦσθαι τῷ νοσήματι τὸν νοσέοντα μετὰ τοῦ ἰητροῦ.

Announce what has happened, discern what is happening and foretell


what will happen; attend to these things. Practice two things concerning
diseases: help or do no harm. The art consists of three parts: the disease,
the diseased and the physician; the physician is the servant of the art; the
diseased fights against the disease with the physician (Hipp., Epid. 1.5,
L. 2.634.6–636.4 = Kühlewein 189, 24–190, 6).1

1  Many thanks to the editors of the present volume, Georgia Petridou and Chiara Thumiger,
for their helpful comments and continual patience. All translations are my own unless other-
wise noted.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_007


Voice Pathologies 167

1 Introduction

The famous ‘Hippocratic triangle’ outlined above establishes the three main
components that comprise the art of medicine: the disease, the diseased and
the physician. Yet, even construing these three elements as a ‘triangle’ implic-
itly invokes the idea of equilateral angles and shared status. In fact, many schol-
ars interpret this passage as though it were granting all but equivalent agency
to both a physician and his patient, constructing them as two subjective agents
allied together in combating the disease. Scholars then tend to assume that
this type of partnership extends throughout the Hippocratic corpus. Jouanna,
for instance, speaks about a “conversation” whereby the physician initiated
a dialogue “for the purpose of collecting information about the diagnosis or
prognosis of the illness, or possibly about the course of treatment.”2 Likewise,
Nutton insists that the doctor’s success in treating the disease was just as
dependent on the patient’s cooperation as an “informant” as it was on the
patient’s compliance with the doctor’s advice.3 Despite these claims, however,
the case studies in Epidemics 1 present patients who are consistently unreliable
partners in dialogue, report very little information and are often incapacitated
by fevers. To be sure, their verbal emissions are recorded, but mainly insofar as
they babble and produce nonsense—or simply remain speechless. In short,
patients in this text are constructed primarily as sick bodies emitting verbiage,
not as interlocutors contributing speech. As a consequence, if the above pas-
sage of the Epidemics were in fact suggesting a triangle, it would need to be
deeply acute, rather than equilateral.4
Difficulties surrounding the medical use of patient voices are not unique
to the Epidemics. Across the corpus, Hippocratic authors frequently utilise
silence, babbling, lisping and other verbal signs—what I call the ‘voice pathol-
ogies’—to diagnose a variety of physical illnesses and predict their course. In
this paper, I propose to examine the use of these voice pathologies as litmus to
test the potential for dialogue between patient and physician and to ­examine

2  Jouanna, J. (1992, rev. ed. 1999). Hippocrates, 135. For similar interpretations of the Hippocratic
triangle, see Bourgey, L. ‘La relation du médecin au malade dans l’écrits de l’École de Cos’, in
Bourgey, L. and Jouanna, J. (1975). La Collection Hippocratique et son rôle dans l’histoire de la
médicine, 215; Gourevitch, D. (1984). Le Triangle Hippocratique dans le monde gréco-romaine:
le malade, sa maladie et son médecin.
3  Nutton, V. (2004). Ancient Medicine, 88.
4  Cf. Hipp., Progn. 1 (L. 2.112.1–3 = Alexanderson 194, 1–3), which reflects a similar type of asym-
metry, insofar as in this passage it is the physician alone who “fights against” (ἀνταγωνίσασθαι)
the disease with his art.
168 Webster

the construction of the patient within Hippocratic texts. How do ancient phy-
sicians use the voice in a medical context? What are the consequences of these
practices?
To begin to answer these questions, I argue that Hippocratic authors treat
the patient’s voice in two dissonant ways. On the one hand, physicians do
engage in some form of discourse, implicitly relying on patients as agents who
can ‘give voice’ to the internal sensations resulting from illnesses—I call this
listening to the patient’s subjective voice.5 In this way, patients provide valu-
able medical information otherwise hidden from sight. On the other hand,
physicians also develop extensive techniques to diminish and downplay this
reliance on secondhand testimony. These techniques are quite valuable: they
allow physicians to consolidate their own authority and demonstrate their
own expertise, while also helping to stabilise what constitutes medically
relevant information. We should not underestimate the importance of such
codification in a context where multiple healing practices compete with one
another, and different traditions disagree over what constitutes a disease in
the first place. Hippocratic physicians operate in a world where dreams can
be just as medically significant as flatulence, the direction of the wind and the
orientation of one’s city. Thus, what information gets brought into the medical
arena is far from obvious, and regulating this information is quite important.
Yet, while controlling the patients’ subjective voices is useful, it has its conse-
quences, namely, it undermines their agency, thereby rendering them as epis-
temic objects—diseased bodies to be inspected and examined—rather than
true partners in the therapeutic process. We can see this dynamic reflected in
the way in which Hippocratic physicians treat patients’ mouths: not as the loci
of potential subjective expression, but as orifices secreting verbal discharges.
In other words, by constraining the voice’s capacity to relate subjective sensa-
tions and focusing instead on the diagnostic usefulness of vocal emissions—
what I call the ‘literal voice’6—Hippocratic authors collapse the distinction
between the (sonic) effluvia of the mouth and those of other bodily outlets.
They thus bring verbal “secretions” into close conceptual proximity with other

5  The subjective voice is identified with the actual linguistic content—that is, the verbal infor-
mation supplied by the voice.
6  The literal voice encompasses two types of information: 1) the sonic qualities of the voice,
such as roughness, smoothness and pitch; and 2) the qualitative and quantitative aspects of
how a patient says what he says, what he chooses to say, how much he says, etc. Both aspects
of the literal voice relate meta-linguistic information not supplied by the actual verbal con-
tent. We could also think of the subjective voice as the message and the literal voice as the
medium—with the obvious blurring between the categories to be discussed below.
Voice Pathologies 169

types of discharge. Words come to be scrutinised for their quantity, quality and
consistency as though they were quasi-excreta of the mouth.

2 Prognosis and Dialogue

As a simple medical practice, ancient physicians must have asked their patients
who they were and when they had become ill. Textual evidence confirms
this and suggests that sick patients supplied considerable information about
symptoms7 to which the physician would not have had direct access. For
instance, Hippocratic authors frequently list internal sensations such as dim-
ness of vision, thirst, hunger and heaviness in the limbs and body, and Epidemics
7.45 states that Mnesianax saw sparks around his eyes as he was walking around
the marketplace—a detail that the author could not have known if Mnesianax
had not himself mentioned it—and indeed, in this instance the author actu-
ally flags it as reported information.8 Other Hippocratic texts also occasionally
describe pains so specific—some radiating across the left side of the body and
into the ear, others shooting along the shoulder blades to the collarbone—
that the patients simply must have been the ones describing them.9 Despite
often utilizing information derived from patient reports, however, Hippocratic
authors only rarely give indication that their data has been collected from sec-
ondhand testimony.10 Instead, throughout the corpus authors list symptoms

7   The term symptom comes loaded with conceptual baggage, insofar as it implies that
observable afflictions are effects of some underlying disease. The distinction between
sign and disease is not always so transparent in the Hippocratic corpus. As such, I use the
term symptom, but it should be understood to refer to the perceptible afflictions either
accompanying or resulting from disease—in other words, medically relevant data.
8   Hipp., Epid. 7.45 (L. 5.412.19–414.5 = Jouanna 79, 7–80, 5). This entry includes a report from
Mnesianax: “He said that at times heat fell upon his hypochondria and sparks followed
his eyes” (ἔστι δ᾽ὅτε προσπίπτειν αὐτῷ πρὸς τὰ ὑποχόνδρια θερμασίην ἔφη καὶ τῶν ὀφθαλμῶν
μαρμαρυγὰς παρακολουθεῖν). For other patients reporting visual flashes, see Hipp., Epid.
5.83 (L. 5.250.18–252.4 = Jouanna 38, 5–15); Epid. 7.88 (L. 5.444.22–446.6 = Jouanna 102,
9–103, 5).
9   Cf. Hipp., Epid. 2.3.4 (L. 5.106.3–108.6 = Smith 50); Morb. 3.15. (L. 7.136.11–15 = Potter 82,
22–25). An especially marked case of a self-reported affliction is that of Nicanor, who
said that he was terrified by the sound of the flute at nighttime symposia; see Epid. 7.86
(L. 5.444.13–16 = Jouanna 101, 10–102, 2).
10  Although examples can be found in other texts, the majority of explicitly marked patient
reports comes in Epidemics 5 and 7. In several instances, however, when these reports
are mentioned, the Hippocratic authors couch them in the language of ‘seeming to the
patient’, which has the effect of distancing the author from the observed data; cf. Hipp.,
170 Webster

without commenting on whether they were reported by the patients them-


selves, or simply gleaned by other outward means. In fact, there are a surprising
number of symptoms that the physician could have easily learned by simple
inquiry, but for which Hippocratic authors employ extensive visual signs. For
instance, there are visual, outward signs for discomfort,11 delirium12 and dim-
ness of vision.13 Diagnosing pain is a particular point of anxiety for Hippocratic
physicians,14 and while they propose many outward, visible signs, including
body position,15 rapidity of breathing,16 sleep patterns,17 drawn-up testicles,18

Epid. 5.21 (L. 5.220.14–19 = Jouanna 13, 18–25); Epid. 5.22 (L. 5.220.20–222.11 = Jouanna 14,
1–18); Epid. 5.43 (L. 5.232.17–22 = Jouanna 21, 11–18); Epid. 7.2 (L. 5.366.10–11 = Jouanna
49, 7); Epid. 7.25 (L. 5.394.15–18 = Jouanna 66, 13–17). Holmes remarks that the use of “it
seemed to the patient” (δοκεῖν ἑαυτῷ) does not always imply that the author necessar-
ily thinks the patient is incorrect; see Holmes, B. (2010). The Symptom and the Subject:
The Emergence of the Physical Body in Ancient Greece, 149, n. 2; cf. the chapter of
C. Thumiger in this volume, 107–137 (Chapter Three).
11  For instance, rather than simply asking the patient how he is feeling, Hipp., Progn. 3
(L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11) provides an elaborate description of how a
patient should look if he is feeling healthy—he should be leaning on either of his sides,
holding his arms, neck and legs slightly bent and lying in a healthy manner.
12  Hipp., Progn. 3 (L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11); Progn. 5 (L. 2.122.11–17 =
Alexanderson 199, 6–11); Progn. 10 (L. 2.134.5–12 = Alexanderson 205, 9–206, 2); Progn. 11
(L. 2.134.13–138.14 = Alexanderson 206, 3–208, 3); Coac. 159 (L. 5.618.9–11 = Potter 140);
Coac. 485 (L. 5.694.3–7 = Potter 224); Epid. 6.7.6 (L. 5.340.8–12 = Manetti and Roselli 156,
1–158, 6). The movement of the patient’s eyes is especially telling, for instance at Progn. 7
(L. 2.126.3–8 = Alexanderson 201, 2–9), where rapid eye movements and a throbbing hypo-
chondrium indicate madness; cf. Pigeaud, J. (1987). Folie et cures de la folie chez les méde-
cins de l’antiquité gréco-romaine, 23, 31. Galen, too, notes that madness can be detected
from visual signs as easily as from verbal signs. For instance, see Gal., In Hipp. Prorrh.
comment. 1.2.53 (K.16.630.13–631.11); cf. Ciani, M. G. ‘The silences of the body: Defect and
absence of voice in Hippocrates’, in ead. (1987). The Regions of Silence: Studies on the
Difficulty of Communicating, 154.
13  Hipp., Int. 48 (L. 7.284.8–19 = Potter 230–232); Dieb. Judic. 3 (L. 9.300.11–22 = Potter 302–304);
cf. Boehm, I. ‘Inconscience et insensibilité dans la Collection hippocratique’, in Thivel, A.
and Zucker, A. (1999). Le Normal et le Pathologique dans la Collection hippocratique, 259.
14  Cf. C. Roby’s paper in this collection, which examines Galen’s response to patients report-
ing their own pain, 304–322 (Chapter Eleven).
15  Hipp., Progn. 3 (L. 2.118.7–122.4 = Alexanderson 197, 3–198, 11).
16  Hipp., Progn. 5 (L. 2.122.11–17 = Alexanderson 199, 6–11).
17  Hipp., Progn. 9 (L. 2.134.5–11 = Alexanderson 205, 9–206, 2).
18  Hipp., Progn. 10 (L. 2.134.5–11 = Alexanderson 205, 8); cf. Coac. 484 (L. 5.694.2–3 = Potter 224).
Voice Pathologies 171

patients rubbing their sore parts19 and the sound of flatulence,20 the author of
Epidemics 2 still asks how someone would distinguish the strongest pains, for
which he offers cowardice and unique, individualised fear as outward signs.21
As was mentioned above, identifying symptoms from within a strict set of
prescribed visual signs allows physicians to objectify what could otherwise be
unstructured information and to stabilise what constitutes medically relevant
information.22 Yet, the extensive use of outward signifiers should also cause us
to reconsider what we might have otherwise identified as reported informa-
tion. Even seemingly straightforward internal sensations are now externalised,
objectified and made directly accessible to the physician’s senses.
The Hippocratic author of Regimen in Acute Disease reveals his particular
anxiety about relying on patients to report their own internal sensations, argu-
ing that collecting such testimony is the mark of an amateur:

οἱ συγγράψαντες τὰς Κνιδίας καλεομένας γνώμας ὁποῖα μὲν πάσχουσιν οἱ


κάμνοντες ἐν ἑκάστοισι τῶν νοσημάτων ὀρθῶς ἔγραψαν καὶ ὁποίως ἔνια
ἀπέβαινεν· καὶ ἄχρι μὲν τοῦτων, καὶ ὁ μὴ ἰητρὸς δύναιτο ἄν ὀρθῶς συγγράψαι,
εἰ εὖ παρὰ τῶν καμνόντων ἑκάστον πύθοιτο, ὁποῖα πάσχουσιν· ὁπόσα δὲ
προκαταμαθεῖν δεῖ τὸν ἰητρὸν μὴ λέγοντος τοῦ κάμνοντος, τουτῶν πολλὰ
παρεῖται, ἄλλ᾽ ἐν ἄλλοισι καὶ ἐπίκαιρα ἔνια ἐόντα ἐς τέκμαρσιν.

Those who compiled the so-called ‘Cnidian Sentences’ wrote down cor-
rectly what sort of things sick people suffer in each of the diseases, as well
as the ways in which some turn out. But this much, even a non-physician
would be able to compile correctly, if he should learn from each of the sick
people what sort of things they suffered. But all the things the physician
needs to understand beforehand without the sufferer saying anything, the
majority of these things [the Cnidian authors] omit, some in some cases,
others in other cases and some even though they are pertinent for judg-
ing from signs (Hipp., Acut. 1, L. 2.224.1–8 = Joly 36, 1–10, emphasis mine).

19  Hipp., Epid. 5.17 (L. 5.216.11–19 = Jouanna 11, 4–14). This visual sign seems to identify when
children have pain in their genitals; cf. Aer. 9.4–6 (L. 2.38.13–42.6 = Jouanna 209, 11–211, 11).
20  Hipp., Progn. 11 (L. 2.138.6–10. = Alexanderson 207, 7–10); cf. Coac. 485 (L. 5.694.3–7 =
Potter 224).
21  Hipp., Epid. 2.2.10 (L. 5.88.13–14 = Smith 33). The entry also mentions two other signs of
serious pain—“solutions” (αἱ εὐπορίαι) and “experiences” (αἱ ἐμπειρίαι)—although what
these denote is unclear.
22  On the difficulty of classifying medical information, especially as regards mental afflic-
tions, see Simon, B. ‘ “Carving nature at the joints”: The dream of a perfect classification of
mental illness’, in Harris, W. (2013). Mental Disorders in Classical Antiquity, 27–40.
172 Webster

While this passage clearly denigrates dialogue with the patient for the purpose
of gaining insight into their symptoms, it also suggests that not all physicians
shunned this practice outright.23 In fact, the author of the ‘Cnidian Sentences’
seems to have engaged in it.24 More than that, however, this passage betrays
the author’s somewhat schizophrenic treatment of the patient, insofar as some
level of questioning must take place at least in practice if there are any pieces
of information that fall outside of the heading ‘things the physician ought to
understand beforehand’—which clearly must be the case for the category to
have any meaning (i.e. if this were not the case, everything should be under-
stood beforehand). Regardless, this Hippocratic author is suggesting that
ideally a physician should recognise most of what patients are experiencing
‘without them saying anything’. Therefore, Hippocratic physicians do not sim-
ply disregard the subjective voice altogether, but nevertheless display manifest
anxiety about relying on patients to articulate their own experiences.
Although this preference for visual signs is displayed across the Hippocratic
corpus, the prognostic texts exhibit it most thoroughly.25 They also display a
unique response to this anxiety, insofar as they articulate a set of strategies

23  See M. Letts’ paper in this volume (81–103) which examines the great importance given
by Rufus of Ephesus to the questioning of patients. The fact that he needs to argue for the
benefit of questioning his patients demonstrates that it was not taken for granted as a
standard practice.
24  Cf. Hipp., Praec. 2.2–11 (L. 9.254.4–5 = Jones 314), which argues that the physician “should
not hesitate to question non-physicians” (μὴ ὀκνεῖν δὲ παρὰ ἰδεωτέων ἱστορεῖν). It is unclear
whether these non-physicians are reporting their own past experiences, or those of others.
In any case, it shows that some physicians were occasionally willing to ask questions to
others and incorporate their answers into the construction of generalities. Nevertheless,
it shows that Hippocratic authors did not all assume that asking patients questions was
valuable; see G. Ecca (Chapter Twelve, 325–344 in this volume) on the Precepts and the
patient-physician relationship described in it.
25  Texts that include prognostic practices: Progn., Prorrh. 1, Prorrh. 2, Coac., Dent., Aph., Aer.
and Epid. 2, 4–7. The same type of visual signs also appears in Morb. 1–3. Grmek illustrates
that Epidemics 1 and 3 also place an emphasis on prognosis rather than diagnosis; see
Grmek, M. (1983). Les maladies à l’aube de la civilization occidentale. Similarly, Nutton,
Ancient Medicine, 89, 92 sees Epidemics 1 and 3 as representing an ‘intermediary stage’
between case studies designed to collect prognostic information and a text designed to
describe and catalogue various constitutions. For a similar account of the Epidemics,
see Baader, G. and Winau, R. (1989). Die Hippokratischen Epidemien; Langholf, V. (1990).
Medical Theories in Hippocrates, 222–54; Robert, F. ‘La prognose hippocratique dans les
livres 5 et 7 des Épidemies,’ in Bingen, J. et al. (1975). Hommages à Claire Préaux, 257–70;
Jouanna, J. (2000). Hippocrate, Épidemies 5 et 7. See also J. Wee’s paper in this volume
(Chapter Four, 138–165) on cases and constitutions.
Voice Pathologies 173

whereby patients confirm rather than describe certain symptoms. This provides
the physician with access to valuable diagnostic information, while simultane-
ously neutralizing the destabilizing effect of actual patient subjectivity within
the medical arena.26 These techniques thus control the output of the patient’s
voice by filtering it through a set of established questions rather than letting it
sound on its own. This leaves the physician as the sole authority narrating the
course of a disease. Although it can be found throughout many texts, a single
example from Prorrhetics 2 will suffice to illustrate the technique. In the con-
text of a long description of sciatica, the author states:

oἷσι δὲ τὸ νούσημα τοῦτό ἐστι μὲν ἐν τῇ ὀσφύι καὶ τῷ σκέλει, βιάζεται δὲ οὐχ
οὕτως ὥστε κατακέεσθαι, ξυστρέμματα σκέπτεσθαι μὲν εἴ που ἐν τῷ ἰσχίῳ, καὶ
ἐπανερέσθαι εἰ εἰς τὸν βουβῶνα ἡ ὀδύνη ἀφικνεῖται· ἢν γὰρ ταῦτ’ ἔχῃ ἄμφω,
χρόνιον τὸ νούσημα γίνεται· ἐπανερέσθαι δὲ καὶ εἰ ἐν τῷ μηρῷ νάρκαι ἐγγίνονται,
καὶ ἐς τὴν ἰγνύην ἀφικνοῦνται· καὶ ἢν φῇ, αὖθις ἐρέεσθαι, καὶ ἢν διὰ τῆς κνήμης,
ἐπὶ τὸν ταρσὸν τοῦ ποδός. ὁπόσοι δ’ ἂν τούτων τὰ πλεῖστα ὁμολογέωσι, εἰπεῖν
αὐτοῖσιν ὅτι τὸ σκέλος σφὶν τοτὲ μὲν θερμὸν γίνεται, τοτὲ δὲ ψυχρόν.

For those who have the disease in the loins and leg, but who are not so
oppressed that they remain in bed, examine whether there are tumours
anywhere in the hip joint and ask whether pain extends down into the
groin; for if both are the case, the disease becomes chronic. And ask
whether numbness is present in the thigh and extends to the upper leg.
And if he says yes, ask again whether it also extends through the lower leg
to the bottom of the foot. For all those who answer yes to the majority of
these questions, say that their leg will sometimes become hot, sometimes
cold (Hipp., Prorrh. 2.41, L. 9.70.20–72.4 = Potter 284).

In instances such as this, the patient’s voice is reduced to its capacity to affirm
or deny specific symptoms; it does not engage the physician in a general dia-
logue about the course of the illness. Rather than allowing the subjective expe-
riences of the patient to guide him to a prognosis, the physician uses his own
general prognostic framework to structure the appropriate symptoms for the
patient to be experiencing. As a result, instead of acting as a true partner, the
patient becomes little more than the raw input for the medical formula to cal-
culate. One could say that prognostic techniques supply both the vocabulary

26  It should be said that it is hard to discern whether controlling the patient’s voice in this
way reflects a simple textual practice—perhaps an idealised scenario—or a reflection of
how medical encounters actually transpired.
174 Webster

and grammar of suffering, and the patient can only speak according to this
rigidly prescribed set of rules.
Beyond structuring the patient’s experience of disease, the practices of
prognosis claim even more authority over the subjective symptoms to which
the patient could have otherwise been expected to ‘give voice.’ As Holmes
has shown, Hippocratic patients bear very ambiguous relationships to their
own bodies. In fact, Hippocratic authors often attempt to divorce sick indi-
viduals from their own somatic sensations and instead assume that they pos-
sess a more intimate knowledge of what patients are experiencing than even
the patients themselves.27 For instance, Hippocratic prognosis is supposed to
reveal not only what will happen to the patient during the course of a disease,
but also what he has experienced—as well as what he is currently experienc-
ing. As part of this program, the Hippocratic author of Prognostic 1 states that
the physician should foretell “the things that are happening in the present,
the things that have happened in the past, and the things that will happen
in the future” (τά τε παρεόντα καὶ τὰ προγεγονότα καὶ τὰ μέλλοντα ἔσεσθαι).28
Similarly, the author of Prorrhetics 2.1 mentions that prophecy can be correct
about both present and past symptoms (ἐπὶ πᾶσι τούτοισί τε καὶ τοῖσι προτέροισι
χρόνοισι προφητίζειν καὶ πάντα ἀληθεύειν).29 The author of the Precepts even
seems to remind physicians of the need to make a “display” (ἐπίδειξις) of the
relevant signs to the patient, rather than advocating any dialogue or sustained

27  Holmes, Symptom, esp. 167–71. Holmes argues that the physician places himself as the
true authority over the sensations that the patient feels (or is supposed to be feeling) and
that the patient can only truly experience his or her own body by adopting the role of a
physician. My argument aligns with hers in many ways, except insofar as I argue that the
ubiquity of the voice pathologies provide a slight difficulty for this account, since in most
cases a patient is fundamentally unable to hear his own voice as the physician would. For
examples in which authors claim explicit authority over what a patient is actually feeling,
see Hipp., de Arte 7 (L. 6.10.15–12.13 = Jouanna 231, 1–232, 11); de Arte 11 (L. 6.18.14–22.14 =
Jouanna 237, 4–239, 14); Morb. 1.20 (L. 6.178.5–180.7 = Wittern 54, 15–58, 6).
28  Hipp., Progn. 1 (L. 2.110.2–3 = Alexanderson 193, 2–3). The quotation goes on to say “tell-
ing in detail as many as the patients leave out, [the physician] would be more trusted to
know the predicaments of the sick” (ὁκόσα τε παραλείπουσιν οἱ ἀσθενέοντες ἐκδιηγούμενος
πιστεύοιτο ἂν μᾶλλον γινώσκειν τὰ τῶν νοσεόντων πρήγματα) (Hipp., Progn. 1 (L. 2.110.3–5 =
Alexanderson 193, 3–5). This once again demonstrates the schizophrenic treatment of
patient reports, which the physicians need in order to understand the basic parameters
of most diseases, but which they also try to downplay; cf. Epid. 1.5 (L. 2.634.6–636.4 =
Kühlewein 189, 24–190, 6), quoted above. See also Langholf, Medical Theories, 232–54 for
the connection between this type of prognosis and divination.
29  Hipp., Prorrh. 2.1 (L. 9.6.13–14 = Potter 216).
Voice Pathologies 175

q­ uestions designed to elicit reports from them.30 Even the so-called “recollec-
tion” (ἀνάμνησις) of the symptoms in On Ancient Medicine seems to come from
the physician rather than the patient.31
In part, as Edelstein suggests, prognosis of this type is used for its ‘psycho-
logical effect’, insofar as physicians can demonstrate incredible competence
and skill by being able to identify symptoms that the patient is experiencing
before actually being told of them. Moreover, they can detect when patients
break from their prescribed regimens, much to the astonishment (and per-
haps chagrin) of the offending party.32 In short, prognosis garners trust.33 Such
trust can be an incredibly powerful tool to attract and keep patients within a
crowded marketplace of healers, and it can help ensure that patients adhere to
their doctor’s orders, potentially improving the chances of recovery. That being
said, the trust gained through visual prognosis has its consequences, namely,
that by providing the physician with a set of visible signs to perceive internal
sensations, prognosis also continues to remove the patient’s authority over his
own body and actions. By privileging visual diagnosis, Hippocratic physicians

30  Hipp., Praec. 11 (L. 9.266.14–15 = Jones 326); cf. Praec. 9 (L. 9.264.8–266.8 = Jones 324–326).
31  Hipp., VM 2 (L. 1.572.9–574.7 = Jouanna 119, 12–120, 15). In this passage, the physi-
cian tells the patient what symptoms he suffers, and the patient only ‘recollects’ them
(ἀναμιμνήσκειν) after he has heard them described by someone else, pace Wittern, who
suggests that ‘anamnesis’ reveals the subjective symptoms of the patient; see Wittern, R.
‘Diagnostics in classical Greek medicine’, in Kawahita, Y. (1987). History of Diagnostics,
69–89.
32  Hipp., Prorrh. 2.1–4 (L. 9.6.1–20.15 = Potter 216–232).
33  Edelstein, L. ‘Hippocratic prognosis’, in Temkin O. and Temkin, C. L. (1967). Ancient
Medicine: Selected Papers of Ludwig Edelstein, 87–100. More recently, Nutton, Ancient
Medicine, 88–89 takes the same position. While trust can certainly be gained through
these prognostic displays—and this is certainly how the Hippocratic author of the
Prorrhetics justifies his program cf. Progn. 1 (L. 2.110.1–112.6 = Alexanderson 193, 1–194,
5)—both Edelstein and Nutton paint an overly rosy picture of the potential accuracy of
prognosis. That is, the competence that the Hippocratic physician could display through
correctly declaring what symptoms patients are suffering surely must be weighed against
the danger of getting the symptoms wrong. While correctly identifying present symptoms
can gain the patient’s trust, accurate prognosis in the long term—and therefore greater
sustained confidence in a physician—could certainly be better served by true and thor-
ough dialogue, rather than simply asking for confirmation of what the physician already
feels he knows. For a recent discussion of prognosis and the purpose of the Prorrhetic 2 as
a text to gain students, see Stover, T. ‘Form and function in Prorrhetic 2’, in Eijk, Ph. J. van
der (2005). Hippocrates in Context, 345–61. See also K. van Shaik’s contribution (Chapter
Nineteen, 471–495 in this volume), which explores how prognosis engenders trust,
whether in the Hippocratic texts or the indigenous populations of Western Australia.
176 Webster

elevate visible signs over any declarations of the patient. Authority over the
patient’s personal actions is thus granted to the physician, who begins to speak
as the true spokesman of the patient’s body.34
Once we acknowledge that prognostic practices devalue questioning and
control patient reports, the construction of the patient within the so-called
Hippocratic triangle looks very different—especially when we recognise that
the author of Epidemics 1, quoted above, advocates the same triad of progno-
sis—that the physician should announce “what has happened, recognise what
is happening and foretell what will happen” (λέγειν τὰ προγενόμενα, γινώσκειν
τὰ παρεόντα, προλέγειν τὰ ἐσόμενα)—directly before he establishes that the dis-
ease, the diseased and the physician are the three components of medicine.
That is, this Hippocratic author introduces the relationship between the physi-
cian and his patient only after having endorsed the very practices of prognosis
that would have greatly reduced any subjective voice potentially available to
the sick party.35
Up to this point, we have examined the anxiety that Hippocratic authors
display about using the patient’s subjective voice as an access point to the
body. In contrast, Hippocratic physicians frequently utilise the literal voice
as a repository of diagnostic information without any such hesitancy. In fact,
when articulating his diagnostic method in a well-known programmatic pas-
sage, the author of the Epidemics 1 provides a list of the fields that are medi-
cally relevant:

τὰ δὲ περὶ τὰ νοσήματα, ἐξ ὧν διεγινώσκομεν, μαθόντες ἐκ τῆς κοινῆς φύσιος


ἁπάντων καὶ τῆς ἰδίης ἑκάστου, ἐκ τοῦ νοσήματος, ἐκ τοῦ νοσέοντος, ἐκ τῶν

34  At a textual level, therefore, the potential agency of the patient finds expression not
through dialogue, but only in troublesome disobedience. Some irony may be found in
the fact that employing prognosis in order to gain a patient’s trust implicitly recognises
patients as subjective individuals outside the text, insofar as they are seen as capable of
choosing another physician or other kinds of healers. In other words, the fact of needing
the patient’s trust recognises him as a subjective customer. Yet, at the same time, the very
practices used to engage with the patient as a customer and win his trust have the effect
of reducing him to an agent-less set of symptoms inside the text, a vector of bodily pains
and affections to which he himself no longer has unique access.
35  As a result, ὁ νοσέων in the introductory quotation above ought to be closer identified with
a ‘suffering body’ mutely fighting against the disease rather than an ‘embodied sufferer’
able to articulate his own somatic experiences; cf. Holmes, Symptom, esp. 143–47. This is
not to argue that we cannot reconstruct moments within the text where patient agency
and subjectivity filter through, only that we cannot take this as guaranteed by any hypo-
thetical Hippocratic triangle.
Voice Pathologies 177

προσφερομένων, ἐκ τοῦ προσφέροντος—ἐπὶ τὸ ῥᾷον γὰρ καὶ χαλεπώτερον


ἐκ τούτων—, ἐκ τῆς καταστάσιος ὅλης καὶ κατὰ μέρεα τῶν οὐρανίων καὶ
χώρης ἑκάστης, ἐκ τοῦ ἔθεος, ἐκ τῆς διαίτης, ἐκ τῶν ἐπιτηδευμάτων, ἐκ τῆς
ἡλικίης ἑκάστου, λόγοισι, τρόποισι, σιγῇ, διανοήμασιν, ὕπνοισιν, οὐχ ὕπνοισιν,
ἐνυπνίοισι, οἵοισι καὶ ὅτε, τιλμοῖσι, κνησμοῖσι, δάκρυσιν, ἐκ τῶν παροξυσμῶν,
διαχωρήμασιν, οὔροισιν, πτυάλοισιν, ἐμέτοισι. . .ἐκ τούτων καὶ ὅσα διὰ τούτων
σκεπτέον.

The things concerning diseases, from which we recognise them, learning


from the common nature of all and from the individual nature of each
person; from the disease, from the diseased person; from the things being
applied, from the one prescribing them—for from this it is either easier
or more difficult—from the condition of the whole and according to the
parts, from the heavens and from each place; from the character; from
the regimen; from practices; from the age of each person; by means of
words; mannerisms; silences; thoughts; by their sleeping and not sleep-
ing; by what sort of dreams and when; by pulling out hair; by scratching;
by tears; from paroxysms; by bowel movements; by urines; by expectora-
tions; by vomits . . . from these, one ought to examine all the things that
occur because of them and all that results because of these fluids (Hipp.,
Epid. 1.10 (L. 2.668.14–670.15 = Kühlewein 199, 8–200, 2, emphasis mine).

We can note that alongside other signs, such as bowel movements and urines,
the author mentions “words, mannerisms, silences and thoughts” (λόγοισι,
τρόποισι, σιγῇ, διανοήμασιν). Although the consideration of “thoughts” would
require some discourse with the patient, the investigation of “words” and
“silences” would demand a very different type of listening. That is, for these
symptoms the physician would attend to the actual manner in which the
patient speaks, while also noting the times at which he does not speak.
Epidemics 6 makes this explicit:

τὰ ἐκ τοῦ σμικροῦ πινακιδίου· σκεπτέα, δίαιτα γίνεται πλησμονῇ, κενώσει


βρωμάτων, πομάτων· μεταβολὴ τούτων ἐξ οἵων οἷα ὡς ἔχει. ὀδμαὶ τέρπουσαι,
λυποῦσαι, πιμπλῶσαι, †πειθόμεναι† μεταβολαὶ ἐξ οἵων οἵως ἔχουσι. τὰ
ἐσπίπτοντα, ἢ ἐσιόντα πνεύματα [ἢ καὶ σώματα]. ἀκοαὶ κρέσσονες, αἱ
δὲ λυποῦσαι. καὶ γλώσσης, ἐξ οἵων οἷα προκαλεῖται. πνεῦμα †τὸ ταύτῃ†
θερμότερον, ψυχρότερον, παχύτερον, λεπτότερον, ξηρότερον, ὑγρότερον,
πεπληρωμένον, μεῖόν τε καὶ [τὸ] πλεῖον· ἀφ’ ὧν αἱ μεταβολαί, οἷαι ἐξ οἵων, ὡς
ἔχουσιν. τὰ ἴσχοντα, ἢ ἐνορμῶντα, ἢ ἐνισχόμενα [σώματα]. λόγοι, σιγὴ, <μὴ>
εἰπεῖν ἃ βούλεται· λόγοι, οὓς λέγει, ἢ μέγα, ἢ πολλοί, ἀτρεκεῖς, ἢ πλαστοί.
178 Webster

Things from the small tablet that one ought to examine: regimen
resides in repletion and evacuation of food and drinks; changes in these
things—from what to what, and what happens. Smells: pleasant, painful
and filling; changes from what things and what happens. The stuff going
in or breath going in, or bodily things as well. Noises: stronger, but some
painful. And of the tongue, what is called forth from what. Breath: hotter,
colder, thicker, thinner, drier, wetter, more filled up, to a greater and lesser
degree; what sort of changes result from what sort of things, and what
happens; the bodily things that bind or encourage or are bound. Words,
silence, saying what he wants; words: which ones he says, either loudly,
or many, or accurate or affected (Hipp., Epid. 6.8.7 (L. 5.344.17–346.7 =
Manetti-Roselli 166, 1–172, 12, emphasis mine).36

Once again, verbal articulations are listed alongside other bodily affections,
including things that either constipate or encourage bowel movements. The
voice, however, was considered a uniquely important marker of a patient’s
health. When speaking of the development of the fetus, the author of Epidemics
2 claims that “one’s nature is similar to one’s utterances” (ἡ γὰρ φύσις τῇ φθέγξει
ὁμοίη),37 and Theophrastus even goes so far as to say that “the majority of signs
in sick people are located in the tongue” (. . .σημεῖα πλεῖστα τοῖς κάμνουσιν ἐπ᾽
αὐτῆς εἶναι).38 Still, adopting “words” as a symptom has two major effects. On
the one hand, it recognises the role that the voice plays in the construction
of the patient as an individual,39 implicitly acknowledging the patient has a
set of normal speech patterns against which any current articulations must

36  For other similar statements, see, Hum. 2 (L. 5.478.6–13 = Jones 64–66); cf. Prorrh. 2.3
(L. 9.10.16–14.6 = Potter 220–224).
37  Hipp., Epid. 2.6.4 (L. 5.134.2–5 = Smith 76); I am following Smith’s text; Littré reads λύσις,
not φύσις; cf. Montiglio, S. (2000). Silence in the Land of Logos, 229, n. 53.
38  Thphr., Sens. 43. There is a possibility that Theophrastus means this quite literally,
although Greek physicians do not promote tongue-diagnostics as extensively as tradi-
tional Chinese medicine, and the ‘tongue’ is often used as a metaphor for speech.
39  Montiglio, Silence, focuses on the social aspects of ‘speechlessness’, although she overem-
phasises the symbolic or cultural meaning of the symptom at the expense of recognizing
voice pathologies as fundamentally physical in nature. Holmes, Symptom, 155–62 has a
more measured approach, speaking about voice and physical comportment as signs that
pertain to the construction of the patient as a social agent, while also acknowledging that
these are physical symptoms that allow a window into the internal struggle between the
φύσις of the body and the φύσις of the disease.
Voice Pathologies 179

be weighed.40 On the other hand, examining the literal voice as a repository


of diagnostically valuable information further fractures the possibility of the
patient ever acting as such an individual, since the main vehicle for subjectiv-
ity, namely his or her words, must now constantly be scrutinised to see whether
they betray any pathological significance. Is the patient talking too much? Too
little? Is he rambling? Do his words sound distorted in any manner? In this
way, the scrutiny of the voice’s potential pathological content would have pro-
duced a barrier that prevented any actual dialogue from taking place, since the
voice no longer truly belongs to the patient as an individual, but primarily as
a diseased body. It therefore must now be run through a medical gamut in the
same way as the other effluvia, being tested and examined for signs to which
the patient does not himself have access.

3 Voice Pathologies

Having established that Hippocratic authors restrict and devalue the subjec-
tive voice in the medical arena while having also emphasised that they utilise
the literal voice for both diagnosis and prognosis, we can now turn to examine the
conceptual apparatus at work behind the voice pathologies themselves—and
indeed, the ubiquity and the diversity of voice symptoms are considerable.
While many appear completely comprehensible to a modern reader, others
betray significant foreignness.41 Nevertheless, in all cases the voice pathologies

40  Several scholars discuss how symptoms such as changes in voice and behavioural
alterations implicitly express the individuality of the patient; see Pagel, W. (1939).
‘Prognosis and diagnosis’, Journal of the Warburg Institute 2.4, 382–98; Diller, H. (1964).
‘Ausdrucksformen des methodischen Bewusstseins in den hippokratischen Epidemien’,
Archiv für Begriffsgeschichte 9, 133–50 (repr. in Diller, H., 1971. Kleine Schriften zur anti-
ken Medizin, 106–28, see esp. 136); Hall, T. S. (1974). ‘Idiosyncrasy: Greek medical ideas
of uniqueness’, Sudhoffs Archiv 58, 285–90; Bourgey, ‘La relation’, 128, 195–210; Pigeaud,
Folie, 23–24; Wittern, ‘Diagnostics’, 86–88; Schubert, C. ‘Menschenbild und Normwandel
in der klassischen Zeit’, in Jouanna, J. and Flashar, H. (1996). Médecine et morale dans
l’Antiquité, 121–55; Andò, V. ‘La φύσις tra normale e patologico’, in Thivel and Zucker, Le
normal, 97–122; Giambalvo, M. ‘Normale versus Anormale?: lo statuto del patologico nella
Collezione Ippocratica’, in Thivel and Zucker, Le normal, 55–96; Von Staden, H. ‘Ὡς ἐπὶ τὸ
πολύ: “Hippocrates” between generalization and individualization’, in Thivel and Zucker,
Le normal, 23–24; Nutton, Ancient Medicine, 89, 92.
41  For example, while we might consider the nasal voice of a cold and the incapacity to
articulate a thought as symptoms belonging to two very different medical categories,
Hippocratic physicians treat both as pathologies of the voice. “Swearing” (αἰσχρομυθεῖν)
180 Webster

refer to aspects of the literal voice—in other words, voice pathologies concern
the voice as a medium. Ciani has provided the most in depth general taxonomy
of such verbal signs,42 and although I follow her approach in many respects, I
wish to focus on a few pathologies in particular, even as I slightly recast her cat-
egories. For the purposes of this paper, I focus on a set of pathologies dealing
with the sonic quality of the voice, such as roughness, smoothness, pitch and
clarity of articulation, and a set of pathologies dealing with the verbal quantity
of vocal emissions, such as babbling and speechlessness.43 Of course, there is
a distinct qualitative element to evaluating the verbal aspects of voice pathol-
ogies (i.e. whether what is said constitutes coherent speech) and keeping a
strict wall between sonic and verbal pathologies would be misleading, since
the Hippocratic physicians use both to the same end (namely, to evaluate the
status of the battle being fought inside the patient’s body). Nevertheless, exam-
ining the pathologies while using these rough categorisations will allow us to
recognise how Hippocratic authors interpret the ‘outflow’ of the voice through
a conceptual rubric related to the other bodily effluvia.

4 Sonic/Qualitative Pathologies

4.1 Roughness and Smoothness


On the Art 12 names the “clarity and roughness of the voice” (φωνῆς λαμπρότης
καὶ τρηχύτης) as the paradigmatic voice pathologies—in fact, the very first
symptoms to which a physician has recourse when signs of illness are not

is treated as a symptom for those who do not normally use foul language; see Hipp., Epid.
4.1.15 (L. 5.152.20 = Smith 96); cf. Coac. 51 (L. 5.596.11–13 = Potter 116). Yet, because this
case takes into consideration the normal behaviour of the individual patient, it does
not fall under the typical paradigm of verbal ejections. Some scholars, such as Wittern,
‘Diagnostics’, have argued that the Coan treatises that include these symptoms are thus
more ‘patient focused’, whereas the Cnidian treatises are more ‘disease focused’. Langholf,
Medical Theories, dismantles such distinctions.
42  Ciani, ‘Silences’. Ciani, however, structures her taxonomy according to modern medical
explanations, rather than categories more relevant to the conceptual framework of the
Hippocratic texts. See also Gourevitch, D. ‘L’aphonie hippocratique’, in Lasserre, F. and
Mudry, P. (1983). Formes de pensée dans la collection hippocratique, 297–305, who deals
with ἀφωνίη in particular.
43  An impediment arises from trying to classify and comprehend the voice pathologies,
since it is often unclear whether attendant symptoms are supposed to be understood as
expressing the cause of the voice pathologies, or whether they should simply be taken as
a group of associated signs; cf. Pigeaud, Folie, 21.
Voice Pathologies 181

directly visible.44 A scratchy, harsh voice is perhaps the most immediately


comprehensible of the voice pathologies, and Hippocratic physicians often
associate “rough” (τρηχέα), “hoarse” (βραγχώδης) and “rasping” (ῥέγκος) voices
with throat infections.45 Still, voices can be rough by nature rather than sim-
ply by disease, and even this natural roughness can help predict diseases46—
something which modern physicians might be more hesitant to assert. In
addition, the smoothness of the voice can also help forecast the course of an
illness. For instance, the author of Coan Prenotions 208 suggests that a “weaker
and smoother voice” (ἀσθενεστέρη καὶ λειοτέρη) indicates that a patient will
undergo remission,47 while those with naturally soft voices (αἱ μαλακαί) are
less prone to certain problems.48 As such, although evaluating the roughness
and smoothness of the voice may seem like a comprehensible practice, the
way this information is used within the Hippocratic texts already betrays a
type of strangeness that becomes even more visible with the other pathologies.

4.2 Pitch
Both high- and low-pitched voices can provide valuable diagnostic informa-
tion as regards both the physical state of the respiratory system and the men-
tal stability of a patient. For instance, speaking in a low-pitched voice (βαρὺ
φθέγγεσθαι) is a bad sign, indicating diseases of the lung,49 while “high-pitched”
and “shrill” voices are even worse and can indicate psychological disorders,
such as mania.50 Yet, even pitch-diagnosed mania should not be seen as a sim-
ple mental evaluation. Rather, the symptom is understood within a nexus of

44  Hipp., de Arte 12 (L. 6.24.2–7 = Jouanna 240, 5–6).


45  For examples, see Hipp., Epid. 2.1.8 (L. 5.80.1–4 = Smith 24–26); Epid. 6.8.32 (L. 5.356.8 =
Manetti-Roselli 194, 6); Epid. 7.7 (L. 5.378.9 = Jouanna 56, 8); Morb. 2.50 (L. 7.76.10 =
Jouanna 186, 13).
46  For example, see Hipp., Epid. 2.1.8 (L. 5.80.1–14 = Smith 24–26).
47  Cf. Hipp., Hebd. 46 (L. 8.663.18–19 = Roscher 69); cf. Dieb. Judic. 2 (L. 9.298.17–19 =
Potter 302).
48  Hipp., Epid. 2.1.8 (L. 5.80.3–4 = Smith 26). Similarly, the author of Aer. 5 (L. 2.24.2 =
Jouanna 197, 4) suggests that inhabitants of a place where springs face east are “clear-
voiced” (λαμπροφονοί), more intelligent and better tempered.
49  Hipp., Morb. 2.48 (L. 7.72.6–13 = Jouanna 183, 5–13); Morb. 3.16 (L. 7.150.21–23 = Potter 50);
Prorrh. 2.35 (L. 9.66.11–15 = Potter 278–280); cf. [Arist.], Pr. 11.3, 11.11.
50  Hipp., Coac. 98 (L. 5.604.3–6 = Potter 126); Coac. 252 (L. 5.638.10–12 = Potter 162); Prorrh.
1.17 (L. 5.514.10–12 = Polack 77, 1–3); Prorrh. 1.19 (L. 5.514.14–516.1 = Polack 77, 6–8); Epid.
6.7.6 (L. 5.340.8–12. = Manetti-Roselli 156, 1–158, 6). Prorrhetic 1.47 (L. 5.522.8–9 = Polack
80) makes the broader, and simpler, claim: “a high-pitched, broken voice is a bad sign”
(ὀξυφωνίη κλαυθμώδης κακόν).
182 Webster

bodily affects, since delirium-indicating sharpness of the voice accompanies


the tightening of the hypochondrium.51 Indeed, most scholars acknowledge
that Hippocratic physicians never establish a strict division between the mind
and body, or between mental and physical afflictions, and instead see mental
illnesses as part of a larger somatic physiology. In fact, even when authors such
as Plato and the author of the Anonymous Londiniensis papyrus articulate a
distinction between mental and physical diseases, they still attribute many
defects in cognition to underlying somatic causes.52
Thus, by using pitch to determine both physical and mental health, as well
as by conceptualizing mental illness as part of a larger psychosomatic contin-
uum, Hippocratic authors illustrate that we should not consider sonic patholo-
gies as bodily and verbal pathologies as mental. Rather, both aspects form a

51  Hipp., Coac. 51 (L. 5.596.11–13 = Potter 116).


52  Pl., Ti. 86b1–2 argues that there are diseases of the body and diseases of the soul; cf. Anon.
Lond. 1.36, et al. (see Manetti, D. ‘The role of doxography in the Anonymus Londiniensis’,
in Eijk, Ph. J. van der (1999). Ancient Histories of Medicine, 95–141; cf. Hipp., Epid. 6.8.31
(L. 5.354.19–365.3 = Manetti-Roselli 192, 1–194, 5). In all these cases, the authors still attri-
bute “soul-” or “mind-” afflictions to somatic causes, such as excess bile, or heat and cold
destabilizing the function of the mind, etc. See also Sassi, M. M. ‘Mental illness, moral
error, and responsibility in late Plato’, in Harris, Mental, 413–26, who cites Plato’s distinc-
tion as evidence that he essentially ‘invented’ the concept of mental illness; cf. Jouanna, J.
‘The typology and aetiology of madness in ancient Greek medical and philosophical writ-
ing’, in Harris, Mental, 97–118. Although Plato certainly contributed to the conception of
mental afflictions as disturbances in the soul rather than the body, authors prior to Plato
had already begun to mark cognitive/behavioural disorders as a category in their own
right, even if they were not yet separated from bodily causes; cf. Harris, W. ‘Thinking about
mental disorders in classical antiquity’, in Harris, Mental, 1–23. For general investigations
into the emergence of mental illness as a category and the hazy boundary between body/
soul and somatic/psychic afflictions in ancient medical thought, see Pigeaud, J. ‘Quelques
aspects du rapport de l’âme et du corps dans le Corpus hippocratique’, in Grmek, M. D.
(1980). Hippocratica, 417–33; Singer, P. ‘Some Hippocratic mind-body problems’, in López
Férez, J. A. (1992). Tratados Hipocraticos: estudios acerca de su contenido, forma e influencia,
131–43; Gundert, B. ‘Soma and Psyche in Hippocratic medicine’, in Wright, J. P. and Potter, P.
(2000). Psyche and Soma: Physicians and Metaphysicians on the Mind-body Problem from
Antiquity to the Enlightenment, 13–35; Bartoš, H. (2006). ‘Varieties in the ancient Greek
body-soul distinction’, Rhizai 3, 59–78; Eijk, Ph. J. van der ‘Modes and degrees of soul-
body relationship in On Regimen’, in Perilli, L. et al. (2011). Officina Hippocratica. Studies
in Honour of Anargyros Anastassiou and Dieter Irmer, 255–70; Eijk, Ph. J. van der ‘Cure
and (in)curability of mental disorders in ancient medical and philosophical thought’, in
Harris, Mental, 307–38; Lo Presti, R. ‘Characterizing epilepsy in Greek scientific discourse’,
in Harris, Mental, 195–222; Holmes, B. ‘Disturbing connections: Sympathetic affections,
mental disorder, and the elusive soul in Galen’, in Harris, Mental, 147–76.
Voice Pathologies 183

larger group of voice signs that collectively address the status of the patient and
the disease. For the present, however, it is important to note that by allowing
the tenor of a patient’s voice to determine his mental and physical stability, the
physician puts up a barrier between himself and the person whom he treats;
he no longer listens to the patient’s voice for its verbal content alone, but now
scans it instead for its meta-linguistic information. In effect, the patient’s voice
ceases to function as a vehicle for subjectivity, but becomes redeployed as a
substance whose quality and consistency reveals the inner fight between body
and disease. As Ciani states, the voice “becomes an expression of the state of
health, the voice of the body, rather than the expression of the thoughts and
the mind.”53 Moreover, although the voice certainly can be used to gauge the
mental stability of the patient, the delirium associated with shrillness of the
voice tends to be linked to certain bowel symptoms as well: “Cases of delirium,
shrillness in the voice and spasms in the tongue: when these people also trem-
ble, the person will become beside themselves; constipation is a fatal sign for
these people” (αἱ παρακρούσιες, φωνῇ κλαγγώδεες, γλώσσῃ σπασμώδεες, καὶ αὐτοὶ
τρομώδεες γινόμενοι, ἐξίστανται· σκληρυσμὸς τούτοισιν ὀλέθριος).54 In fact, this is
the first in a series of associations between the ‘excretions’ of the mouth and
the effluvia of other orifices, which may allow us to see a greater conceptual
link between these different sets of pathologies.

4.3 Trembling Voice (τρομώδης)


The connection between voice defects and the bowels is explicit with the
trembling of the voice (φωνὴ τρομώδης), which sounds as if the patient is shiv-
ering. Coac. 39 claims that this is a “bad sign”,55 and, as if demonstrating this
fact, the symptom occurs at Epid. 4.55 shortly before a patient’s death. Like
pitch, vocal trembling can be used to evaluate the patient’s mental stability—
nevertheless, even when it is associated with delirium, it still remains linked to
other bodily effluvia. For instance, Coac. 228 states: “Trembling tongues cause
liquidity in the bowels for some; and if their tongues are also black, they sig-
nify a quick death; is a trembling tongue a sign of the mind not being settled?”
(αἱ τρομώδεες γλῶσσαί τισι καὶ κοιλίην καθυγραίνουσιν· μελανθεῖσαι δ᾽ἐν τούτοισι,
ταχὺν θάνατον σημαίνουσιν· ἆρα τρομώδης γλῶσσα σημεῖον οὐχ ἱδρυμένης γνώμης).56

53  Ciani, ‘Silences’, 159.


54  Hipp., Coac. 98 (L. 5.604.3–6 = Potter 126); cf. Prorrh. 1.17 (L. 5.514.10–12 = Polack 77).
55  Hipp., Coac. 39 (L. 5.594.11–14 = Potter 114).
56  Hipp., Coac. 228 (L. 5.634.14–17 = Potter 158); cf. Coac. 253 (L. 5.638.12–13 = Potter 164);
Coac. 625 (L. 5.728.19–23 = Potter 264), Coac. 636 (L. 5.732.4–5 = Potter 268). Similarly,
Coac. 312 (L. 5.652.9–11 = Potter 178) asks whether trembling is also a bad sign for those
184 Webster

However strange the association of trembling tongues and diarrhea may seem,
Hippocratic authors frequently make connections—both pathological and
conceptual—between verbal effluvia and the outflow of the anus. Worman has
demonstrated the links between mouth and anus in Athenian rhetorical prac-
tices, whereby the two often stand as metonyms for each other, as orators pur-
posefully conflate their respective appetites and excretions.57 And, while the
Hippocratic authors never do so explicitly, the pseudo-Aristotelian author of
Problemata 11.45 even calls the voice a “flow” (ῥύσις).58 In fact, the Problemata
treats the voice pathologies as though they were completely physical symp-
toms, operating within the same system as the rest of the body’s ailments—so
much so that the text explains stammering not as some mental affliction, but
as the effect of the voice cooling, cured by the heating action of wine. Such
associations can help us understand how the physiological function of the
voice operates in close conjunction with the physical, somatic discharges flow-
ing out of the other orifices.

4.4 Stuttering (ψελλός), Mumbling and Lisping (τραυλός)


“Stuttering” (ψελλότης) is characterised by the inability to articulate one’s
words, especially the incapacity to join one word to the next. It can be caused
by paralysis and general weakness,59 or even dryness of the tongue.60 Rather
than reflecting defects of either the mind or mouth alone, it belongs to a nexus
of physical and psychis systems, just like trembling. To give a few examples,
stuttering can signify that a patient will become empyemic and start collecting
pus in a given cavity.61 When stuttering occurs in bald people whose “chests
are saturated” (κατακορέα τὰ στήθεα), it can indicate mania.62 Baldness is often
associated with the voice, and in turn both are connected to the testicles.63

with pains in their loins; cf. Prorrh. 1.42 (L. 5.522.2–4 = Polack 80, 4–7); Prorrh. 1.19
(L. 5.514.14–516.1 = Polack 77).
57  Worman, N. (2008). Abusive Mouths in Classical Athens.
58  [Arist.], Pr. 11.54. Similarly, Pr. 11.12 considers how the sound of the voice is tied to the
moisture levels of the body; cf. Pr. 11.30, 35, 36, 38, 54, 55, 60.
59  Hipp., Epid. 7.8 (L. 5.378. 22–23 = Jouanna 56, 23–25).
60  Hipp., Epid. 7.105 (L. 5.456.7–8 = Jouanna 109, 14–15).
61  Hipp., Epid. 2.5.2 (L. 5.128.7–11 = Smith 70); cf. Judic. 43 (L. 9.290.9–11 = Potter 292–93).
62  Hipp., Epid. 2.6.14 (L. 5.136.2–5 = Smith 80); I am here following Smith’s translation of
κατακορέα (see Smith, Loeb 81, n. b.); cf. Epid. 2.6.22 (L. 5.136.14–18 = Smith 82).
63  Cf. Hipp., Coac. 160 (L. 5.618.11–15 = Potter 140–42).
Voice Pathologies 185

Related to stuttering are “mumbling” (ἰσχνοφωνίη) and “lisping” (τραυλότης,


ὑποτραυλότης). These are two separate affections,64 but are often paired
together as a set. As with stuttering, lisping can be a congenital disorder, or
can be caused during the course of a disease, either by a dry mouth or exces-
sive shouting.65 And, like stuttering, muttering and lisping are associated
with a related assortment of symptoms. Mumbling can indicate epilepsy in
a child who also has shooting pains in the belly and has recently gotten in an
accident,66 while the author of Epid. 2.5.1 states that mumbling can be cured
when veins in the testicles enlarge. This latter claim should recall the asso-
ciation of the voice and testicles above, as well as the claim: “when a testicle
has swelled from coughing, it is a reminder of the connection between the
chest, breasts, genitals, voice” (ὄρχις οἰδήσας ὑπὸ βηχωδέων ὑπόμνημα κοινωνίης
στηθέων, μαζῶν, γονῆς, φωνῆς).67 The remainder of the passage at Epid. 2.5.1 goes
on to assert that “mumblers” (ἰσχνόφωνος) and “lispers” (τραυλός) are melan-
cholic when they are also bald or hairy. The link between mumblers, lispers
and melancholic diseases also appears at Epid. 2.6.1, where a similar set of
physical categorisations comes up again, where lispers with large heads and
small eyes are “quick to anger” (ὀξύθυμοι). Moreover, the lispers and “fast talk-
ers” (ταχύγλωσσοι) are melancholic and intense, while someone with a small
head will neither be a lisper nor bald unless his eyes are grey.68

64  Ciani, ‘Silences’, 149–50 notes how difficult it is to discern the precise semantic ranges
of ψελλός, ἰσχνοφωνός and τραυλός. [Arist.], Pr. 11.30 considers “lisping” (τραυλότης) to be
the inability to articulate a certain letter, “stuttering” (ψελλότης) the inability to join one
syllable to another and “mumbling” (ἰσχνοφωνίη) the inability to control the tongue, as
is often the case with children; cf. Schmidt, J. H. H. (1876). Synonymik der griechischen
Sprache, 369–73. Ciani identifies these as ‘congenital defects’, but they also occur during
the course of an illness and are thus sometimes pathological as well.
65  Hipp., Epid. 7.2 (L. 5.368.3 = Jouanna 50, 1–2); Epid. 7.43 (L. 5.410.11–13 = Jouanna 78, 2–5);
Epid. 7.22 (L. 5.393.13–14 = Jouanna 65, 7–9); Epid. 7.11 (L. 5.386.21–22 = Jouanna 61, 23–24).
66  Hipp., Prorrh. 2.10 (L. 9.28.26–30.9 = Potter 242); cf. Coac. 157 (L. 5.618.4–7 = Potter 140).
67  Hipp., Epid. 2.1.6 (L. 5.76.15–16 = Smith 22); cf. Epid. 2.6.2 (L. 5.132.21–22 = Smith 76); Epid.
4.61 (L. 5.196.19–21 = Smith 140); Hum. 10 (L. 5.490.9–16 = Jones 80–82). These connec-
tions could reflect the observation that castrated males do not undergo a deepening of
the voice during puberty, or could reflect the common idea that the testicles were part
of the vascular system, connecting to the veins leading down from the head from which
semen was derived; see Hipp., Oss. 14–15, 17 (L. 9.186.17–190.9, 9.192.3–16); cf. Arist., HA
3.1.510a12–35; 3.4.514b29–515a5; GA 2.2.735a29–736a23. Celsus, Med. 6.18.6; 7.22.5 mentions
castration, but it is unclear what he thought its consequences were aside from the loss of
the capacity to procreate, see König, J. (2013). ‘Ancient Greco-Roman views of the testicle
in Celsus and beyond’, Rosetta 13, 104–10.
68  Hipp., Epid. 2.6.1 (L. 5.132.15–21 = Smith 76).
186 Webster

This association of inherent physical features, cognitive/behavioural afflic-


tions and particular speech pathologies can indicate a patient’s potential sus-
ceptibility to certain diseases. For example, the author of Epid. 1 lists a group
of people who died in large numbers, including “those who have lived care-
lessly and are lazy, the mumblers, the rough voiced, the lispers, the passionate”
(οἱ εἰκῇ καὶ ἐπὶ τὸ ῥᾴθυμον βεβιωκότες, ἰσχνόφωνοι, τρηχύφωνοι, τραυλοί, ὀργίλοι).69
Lastly, Aphorism 6.32 declares: “lispers will be especially afflicted by terrible
diarrhea” (τραυλοὶ ὑπὸ διαρροίης μάλιστα ἁλίσκονται μακρῆς).70 These examples
demonstrate that the quality of the patient’s voice belongs to a psychosomatic
system of signs and afflictions, where mental disturbances remain tied to a
larger physiological conception of the body, one that involves passages, fluids,
heat, coldness, wet and dry. Moreover, while the particular physiological rela-
tionship remains undefined, the voice pathologies are frequently connected to
disrupted bowel movements. That is, the body’s inability to control the outflow
of one orifice (the mouth) signifies that the patient is unable to control the
outflow of another (the anus).

5 Verbal/Quantitative Pathologies

While many voice pathologies deal with the sonic qualities of articulation,
another set deals with the meta-linguistic information related by verbal utter-
ances. On the one hand, these verbal pathologies evaluate certain qualitative
aspects, determining whether utterances constitute meaningless, inappropri-
ate speech (e.g. nonsense). On the other hand, the two most prevalent sets of
verbal pathologies deal largely with the quantity of speech—that is, whether
patients produce speech in excessive amounts, which generally indicates men-
tal and physical instability, or in deficient amounts, through either periodic
silence, or physical voicelessness. Scholars have often examined these pathol-
ogies within the context of mental illness.71 Nevertheless, while identifying

69  Hipp., Epid. 1.9 (L. 2.656.4–6 = Kühlewein 195, 18–19).


70  Hipp., Aph. 6.32 (L. 4.570.10 = Jones 186).
71  For the most recent examination of the taxonomy of madness, see Thumiger, C. ‘Early
medical vocabulary of insanity’, in Harris, Mental, 61–96; cf. Berrettoni, P. (1970). ‘Il lessico
tecnico del 1 e 3 libro delle Epidemie ippocratiche. Contributo alla storia della formazi-
one della terminologia medica greca’, Annali della Scuola Normale Superiore di Pisa 39,
27–106, 217–311. The bibliography on ancient mental illness is vast, but for the most recent
contributions, see Harris, Mental, many of which have already been cited. For investiga-
tions that incorporate the voice and breath in particular, see Clarke, E. (1963). ‘Apoplexy
in the Hippocratic writings’, Bull. Hist. Med. 37, 301–14; Pigeaud, Folie, 14–40; Pigeaud, J.
Voice Pathologies 187

babbling and nonsense can certainly help establish a patient’s mental state,
there are many instances where the psychological implications are far from
evident—and, if the mind/body distinction is already unclear for mental ill-
nesses, as mentioned above, we should consider whether the same is the case
for mental symptoms. Thus, given the pathological connection between cer-
tain voice defects and troublesome excreta, we can also draw a conceptual con-
nection between how symptoms such as rambling and incoherence map onto
physiological conceptions of surfeit and lack.

5.1 Nonsense and Excessive Speech


Hippocratic authors have a number of different words for ‘nonsense’, and
they can include both verbal emissions that are nonsensical by nature and
those that are nonsensical in context. In the first category we can include
“talking gibberish” (φλυηρεῖν), which seems to occur while a patient is inca-
pacitated by drink,72 deliriousness from pain,73 or in a state of lethargic semi-­
consciousness.74 Similarly, patients can be said to “babble” (λαλεῖν) while in a
similar state of lethargy.75 In these instances, the words that come out of the
patient’s mouth seem devoid of any particular meaning, and instead operate
merely as random phonemes, perhaps even associated with animal noises.76
Along with this type of nonsense, we might also include the symptom listed as
“many words” (πολλοὶ λόγοι), or simply as “words” (λόγοι), which again seems
to indicate when a patient is producing words of no discernible value, which
may however—as in all these cases—include snippets of actual speech. For
instance, Silenus, struck by a fever, gets worse on the third day: “feces thin,
dark; urine turbid, dark; no sleep at night; many words, laughing, songs; he was
unable to hold back” (διαχωρήματα λεπτά, ὑπομέλανα, οὖρα θολερά, ὑπομέλανα,
νυκτὸς οὐδὲν ἐκοιμήθη, λόγοι πολλοί, γέλως, ᾠδή, κατέχειν οὐκ ἠδύνατο).77 Similarly,
in Thasos, the wife of Philinus suffered complications from birth, and on the
fourteenth day: “spasm all over the body, many words, a little bit lucid” (παλμὸς

(1989). Maladie de l’âme, 100–07; Duminil, M.-P. “Les maladies ‘frappés’ ”, in Férez López,
Tradatos, 215–24. See also Benedetto, V. d. (1986). Il medico e la malattia, 43–50, who exam-
ines how voice symptoms function in terms of the soul and perception.
72  Hipp., Morb. 2.22 (L. 7.36.14–38.5 = Jouanna 156, 10–157, 10).
73  Hipp., Morb. 2.67 (L. 7.102.4–25 = Jouanna 205, 17–206, 18).
74  Hipp., Morb. 2.65 (L. 7.100.1–7 = Jouanna 204, 3–10); Coac. 355 (L. 5.658.23–660.3 = Potter
186). For an example of fever correlated with and episode of gibberish, see Hipp., Morb.
3.13 (L. 7.132.18–134.7 = Potter 26).
75  Hipp., Epid. 7.11 (L. 5.382.19–21 = Jouanna 59.5–7).
76  Cf. [Arist.], Pr. 11.30.
77  Hipp., Epid. 1.13, Case 2 (L. 2.686.1–7 = Kühlewein 203, 23–204, 1).
188 Webster

δι᾽ ὅλου τοῦ σώματος, λόγοι πολλοί, σμικρὰ κατενόει).78 More than babbling or
gibberish, when the Hippocratic physicians classify “words” as a diagnostically
valuable pathology, they functionally strip the patient’s voice of all linguistic
content and instead reduce the emissions of the mouth to a raw material being
excreted. Purged of any possible verbal meaning, the voice becomes a crude
emission, a substance to be scrutinised and examined.
Related to “words” is “nonsense” (λῆρος), as can be seen on the fifth day at
Epidemics 1.13, Case 1, where Philiscus has a distressing night with little sleep and
suffers from both “words” and “nonsense.”79 Although not exclusively verbal,80
the vast majority of instances of “producing nonsense” (λῆρος, λήρησις, ληρεῖν,
παραλήρησις) seem to involve something akin to the babbling that takes place
while a patient is asleep. The term appears throughout the Epidemics as a
symptom suffered by feverish, disturbed patients whether they are awake, or
unconscious.81 For instance, at Epid. 1.13, Case 3, Herophon suffers acute fever,
cannot sleep and on the fifth day becomes delirious (παρεφρόνησεν) with a
tighter hypochondrium.82 On the sixth day, “he produced nonsense, sweats
in the night, chills, the nonsense remained” (ἐλήρει, ἐς νύκτα ἱδρώς, ψύξις,
παράληρος παρέμενεν).83 We might consider what it means for the physician to
be consistently measuring the level of nonsense the patient produces whether
or not he or she is awake. These voice pathologies (or quasi-voice pathologies)
such as gibberish and nonsense certainly help determine the mental stability
of a patient if he is awake, but if the patient is asleep, nonsense offers a far

78  Hipp., Epid. 1.13, Case 4 (L. 2.692.16–17 = Kühlewein 206, 13–14).
79  Hipp., Epid. 1.13, Case 1 (L. 2.684.3 = Kühlewein 203, 3).
80  Hipp., Epid. 7.85 (L. 5.444.1–12 = Jouanna 100, 16–101, 9) describes Androthales as suf-
fering from ἀφωνίη, ἄγνοια, παραλήρησις, and it is unclear whether these symptoms
occur in alternation, or whether the “nonsense” in this case is non-verbal; cf. Epid. 5.80
(L. 5.248.23–250.9 = Jouanna 36, 7–37, 6). Nevertheless, λῆρος and φλυαρία are paired by
both Plato (Hp. Ma. 304b5) and Aristophanes (fr. 62, ln. 18, Austin), and like φλυαρία the
term λῆρος most often refers to verbal nonsense; cf. Ar., Th. 880, Pl. 518, Nu. 359, Ra. 1497;
Pl., Hipp. Maj. 298b8–c1, Tht. 176d4. That being said, Ar., Pl. 589, refers to a wreath as a
λῆρον, which suggests that the term could also denote non-verbal instances of nonsense
as well.
81  Pigeaud, Folie, 17–18 takes λῆρος as an indication of delirium displayed through speech on
par with παραλέγειν.
82  Hipp., Epid. 1.13, Case 3 (L. 2.688.10–16 = Kühlewein 204, 20–205, 2). Given the associa-
tion seen above at Hipp., Coac. 51 (L. 5.596.11–13 = Potter 116), tight hypochondrium =
high-pitched voice = delirium, we might consider whether this case draws on the same
supposition.
83  Hipp., Epid. 1.13, Case 3 (L. 2.688.15–16 = Kühlewein 205, 2–3).
Voice Pathologies 189

clearer window into the internal fight of the body.84 We could say that while
conscious, deranged patients speak gibberish; while asleep, sick bodies secrete
nonsense.

5.2 Voicelessness and Silence


As seen in the passages above, the authors of both Epidemics 1 and 6 list
“silences” alongside words and mannerisms as a symptom with potential med-
ical relevancy. In fact, “voicelessness” (ἀφωνίη) is the most common of all the
voice pathologies, appearing 109 times within the Hippocratic corpus.85 For
the most part, the symptom indicates devastation of the most severe type, fre-
quently appearing as the last outward sign that the patient displays as he or
she nears death.86 The case of Philinus’ wife at Epidemics 1.13, Case 4 could eas-
ily serve as a typical example: “Around the fourteenth day there was a spasm
all over her body, many words, a little rational, but after a short time deranged
again; around the seventeenth becoming voiceless; on the twentieth, death”
(περὶ τεσσαρεσκαιδεκάτην ἐούσῃ παλμὸς δι᾽ ὅλου τοῦ σώματος, λόγοι πολλοί,
σμικρὰ κατενόει· διὰ ταχέων δὲ πάλιν παρέκρουσεν. περὶ δὲ ἑπτακαιδεκάτην ἐοῦσα
ἄφωνος. εἰκοστῇ ἀπέθανε).87 For this reason, Montiglio calls silence the sound
of “the state of dying.”88 Nevertheless, while voicelessness is never a positive
thing, Montiglio does not emphasise the wide range of illnesses in which it
plays a crucial prognostic role.
Though they are rare, some cases of voicelessness, or “stopped voice”, rep-
resent actual physical constrictions. For instance, at Epid. 7.100, Polemarchus’

84  Montiglio, Silence, 228 claims that delirium and silence are worrisome, especially since
the physician “urgently needs his patients’ words in order to understand the nature of
their illnesses.” As we have seen, however, this is an overstatement and the information
conveyed by the sign “nonsense” can be just as powerful for prognosis as any patient-
revealed information.
85  Related to “voicelessness” ἀφωνίη is “speechlessness” ἀναυδίη. In fact, despite any overlap,
Hipp., Epid. 3.17, Case 3 (L. 3.114.3 = Kühlewein 235, 13) lists “speechless, voiceless” (ἄναυδος,
ἄφωνος) as consecutive symptoms on both the second and fourth days. Although it is
difficult to discern a strict difference between these two pathologies in the Hippocratic
corpus, Gal., In Hipp. Epid.1 comment. 3.74 (K. 17a 758.11–16) considers ἀναυδίη to be the
paralysis of the tongue and the inability to articulate words, whereas ἀφωνίη is the com-
plete loss of vocal capacity.
86  Montiglio, Silence, investigates the cultural meaning of silence and emphasises the rela-
tionship of speechlessness and death in the Hippocratic corpus; cf. Holmes, Symptom,
158; Boehm. ‘Inconscience’, 269.
87  Hipp., Epid. 1.13, Case 4 (L. 2.692.15–694.2 = Kühlewein 206, 12–16).
88  Montiglio, Silence, 229.
190 Webster

wife suffers post-menopausal pain in her hip, and, after she drank beet juice
“her voice was stopped through the night until midday; she heard and was
lucid, and signified with her hand that the pain was around her hip” (ἔσχετο
ἡ φωνὴ νύκτα καὶ ἐς μέσον ἡμέρης· ἤκουσε δὲ καὶ ἐφρόνει· καὶ τῇ χειρὶ ἐσήμαινεν
ἀμφὶ τὸ ἰσχίον εἶναι τὸ ἄλγημα).89 In most instances, however, voicelessness
arises from some type of general incapacitation. Often this includes mental
incapacitation, sometimes caused by trauma to the head,90 sometimes follow-
ing a sudden pain,91 sometimes as a result of epilepsy,92 but most often when
accompanied by intense fever. In many of these cases, the patient is com-
pletely weakened, lethargic and perhaps even functionally unconscious and
without senses (ἀναίσθητος).93 Galen even complains that Hippocrates often
classifies those who are in a state of torpor (κάρος) as voiceless.94 One such
instance occurs at Epid. 1.13, Case 2, on the eighth day of Silenus’ illness: “His
extremities warmed up a bit, little sleep, deeply lethargic, voiceless, thin, clear
urine” (ἄκρεα σμικρὰ ἀνεθερμαίνετο, ὕπνοι λεπτοί, κωματώδης, ἄφωνος, οὖρα λεπτὰ
διαφανέα).95 When reviewing this type of voicelessness, Ciani states that is has
“no particular import except in so far as it is connected with the comatose state

89  Hipp., Epid. 7.100 (L. 5.452.25–454.3 = Jouanna 108, 4–8). Hippocratic authors list other
peculiar physical signs that occur along with ἀφωνίη, including hiccoughs and jaundice;
cf. Hipp., Coac. 194 (L. 5.626.6–10 = Potter 150); Prorrh. 1.32 (L. 5.518.3–8 = Polack 78, 9–13).
90  Cf. Hipp., Epid. 7.32 (L. 5.400.22–402.5 = Jouanna 71, 3–10); Epid. 7.77 (L. 5.434.9–15 =
Jouanna 93, 13–94, 4); Epid. 5.50 (L. 5.236.11–20 = Jouanna 23, 15–24, 2); Epid. 5.55
(L. 5.238.11–16 = Jouanna 25, 6–13); Coac. 489 (L. 5.696.2–5 = Potter 226); Aph. 7.58
(L. 4.594.10–11 = Jones 206).
91  Hipp., Morb. 2.21 (L. 7.36.1–13 = Jouanna 155, 10–156, 9); Morb. 2.6 (L. 7.14.8–22 = Jouanna
137, 9–138, 5); Aph. 7.40 (L. 4.588.8–9 = Jones 202); Epid. 4.12 (L. 5.150.14–15 = Smith 94).
These cases of speechlessness seem to arise from a stroke or an aneurism, a category
which Ciani, ‘Silences’, 152 calls “cerebral disturbances”. Still, we should be weary of nor-
malizing this pathology to fit modern physiological explanations, especially when Aph.
7.40 regards this sudden paralysis of the tongue as a type of melancholic illness.
92  Hipp., Morb. Sacr. 7.2–5 (L. 6.372.4–374.22 = Jouanna 15, 5–22); Morb. Sacr. 10.3 (L. 6.380.4–7 =
Jouanna 20, 5–9).
93  Hipp., Epid. 7.1 (L. 5.366.1–6 = Jouanna 48, 15–49, 2); cf. Epid. 7.108 (L. 5.458.13–16 = Jouanna
111, 10–15). At other times, such as Prorrh. 1.83 (L. 5.530.13–532.1 = Polack 85), the voiceless
patients remain at least conscious enough to be considered “deranged” (παρενεχθεῖσαι)
and continue vomiting.
94  Gal., In Hipp. Aph. comment. 5. (K. 17b 788.7–9); cf. Ciani, ‘Silences’, 155. We should note
that being κωματώδης does not mean being outright comatose or unconscious, merely
severely lethargic or drowsy; cf. Pigeaud, Folie, 16, n. 13.
95  Hipp., Epid. 1.13, Case 2 (L. 2.688.1–2 = Kühlewein 204, 12–13). Similar cases occur where
patients are voiceless after fainting or while attended by tremendous lethargy, ending
Voice Pathologies 191

and, therefore, with a more or less drastic drop in the level of consciousness.”96
Despite Ciani’s claim, however, the very fact that Hippocratic physicians
describe incapacitated patients as voiceless has considerable import for the
way in which the voice is seen as a repository of diagnostic information. That
is, it is not being used simply to gauge whether or not the patient is deeply
lethargic—this is already known. Rather, a deficiency of the voice is seen as a
symptom in its own right. This has considerable consequences, since we could
certainly make sense of voicelessness as an affliction caused by incapacitation,
especially incapacitation resulting from fever, but it makes little sense to see
it as a symptom in addition to incapacitation unless we are already examining
the products of the voice for their quantity and quality as a unique and inde-
pendent marker of illness.
This point can be further stressed by recognizing the sheer speed at which
patients transition between speaking and becoming voiceless. For instance,
consider the case of the woman in Thasos who gave birth to a daughter with-
out an afterbirth:

ἑξηκοστῇ. . .κωματώδης· παρέλεγε καὶ ταχὺ πάλιν κατενόει· πρὸς δὲ τὰ


γεύματα ἀπονενοημένως εἶχεν· σιηγὼν μὲν ἐπανῆκε, κοιλίη δὲ χολώδεα σμικρὰ
διέδωκεν, ἐπύρεξεν ὀξυτέρως, φρικώδης· καὶ τὰς ἐχομένας ἄφωνος καὶ πάλιν
διελέγετο.

On the sixtieth day . . . comatose; she babbled and was quickly rational


again; towards food she was without sense; jaw slack; her bowels produc-
ing a little bit of bilious stool; she was acutely feverish, shivering; and
on the following days she was voiceless and then conversed again (Hipp.,
Epid. 3.17.2, L. 3.112.2–9 = Kühlewein 234, 22–235, 3).

The rapid transition between coherent dialogue and voicelessness should


strike us as at least somewhat strange, especially if the loss of speech denotes
outright incapacity, since it seems unlikely that a patient wavers so swiftly
between complete verbal incapacitation and coherent dialogue. Coac. 254
alludes to similar rapid transitions: “frequent voicelessness with extreme tor-
por are early signs of a consumptive attack” (αἱ πυκναὶ ὑποκαρώδεις ἀφωνίαι
σύστασιν φθινώδεα προσημαίνουσιν) (emphasis mine).97 Frequently losing and

in sleep; cf. Epid. 7.24 (L. 5.394.3–7 = Jouanna 65, 24–66, 4); Epid. 7.118 (L. 5.464.3–11 =
Jouanna 114, 14–115, 5).
96  Ciani, ‘Silences’, 154.
97  Hipp., Coac. 254 (L. 5.638.13–14 = Potter 164).
192 Webster

gaining one’s capacity to speak while continuing to suffer from the same torpor
seems odd—one would expect genuine torpor to predicate all but consistent
speechlessness. Yet, rapid transitions between silence and verbal outbursts
seem to have been a wider culture trope of illness. Euripides’ Medea presents
just such a case, insofar as Creon’s daughter, Glauce, swiftly shifts between
speaking and silence, as she writhes and screams in agony as a result of the
caustic potions of Medea: she suddenly falls speechless (ἄναυδος), then rouses
again before death.98 The ‘speechlessness’ in these instances blurs the line
between a patient’s inability to speak and a patient’s simple failure to speak,
perhaps even for a short duration of time.99 Such rapidity betrays the close
attention Hippocratic physicians must have paid to even subtle changes in
articulation, as they waited to hear whether and when the patient would speak.
This becomes especially clear in cases of “silence” (σιγή, σιγεῖν), which does
not seem to denote strict incapacity, but when the patient simply fails to speak.
The author of Coac. 65 makes a clear distinction between the two patholo-
gies: “Silent trances in fevers for a patient who is not speechless are fatal”
(αἱ ἐν πυρετοῖσιν ἐκστάσιες σιγῶσαι μὴ ἀφώνῳ, ὀλέθριαι).100 Both of these ele-
ments come together at Epidemics 7.89, where Parmeniscus, who was peri-
odically afflicted with depression and thoughts of suicide, took to his bed. By
operating right on the pivot of psychological and somatic symptoms, this case
allows particular insight into the use of the voice as a prognostic tool:

ἄφωνος κατέκειτο ἡσυχίην ἔχων, βραχύ τι ὅσον ἄρχεσθαι ἐπιχειρέων προσειπεῖν·


ἤδη δέ τι καὶ διελέχθη καὶ πάλιν ἄφωνος. ὕπνοι ἐνῆσαν, ὁτὲ δὲ ἀγρυπνίη· καὶ
ῥιπτασμὸς μετὰ σιγῆς καὶ ἀλυσμὸς καὶ χεὶρ πρὸς ὑποχόνδρια ὡς ὀδυνωμένῳ,
ὁτὲ δὲ ἀποστραφεὶς ἔκειτο ἡσυχίην ἄγων· ἀπυρετὸς δὲ διὰ τέλεος καὶ εὔπνοος·
ἔφη δὲ ὕστερον ἐπιγινώσκειν τοὺς ἐσιόντας.

He lay down, voiceless, keeping silent, hardly attempting to begin to say


something; then he said something, and again voiceless. Sleep came on,
but he was sometimes awake, and tossing in silence and anguish, and
his hand on his hypochondrium as though he were in pain. Sometimes,
turning away, he lay there keeping silent. He was feverless throughout,
and breathing was easy; he later said that he recognised those coming in
(Hipp., Epid. 7.89, L. 5.446.9–14 = Jouanna 103, 8–15).

98  Eur., Med. 1183–84.


99  For similar arguments, see Gourevitch, ‘L’aphonie’ 297–305; Ciani, ‘Silences’, 156–57 and
Montiglio, Silence, 228–33.
100  Hipp., Coac. 65 (L. 5.598.9–10 = Potter 120).
Voice Pathologies 193

The Hippocratic author seems to be careful to distinguish between silence and


strict voicelessness, although we might ask how he discerns the difference,
especially when the speed of these transitions is taken into consideration.
Is the physician or his assistant actually asking the patient to speak, thereby
intervening into the display of symptoms? Or is the information gained from
Parmeniscus failing to speak just as potentially valuable for prognostic pur-
poses? That is, would the physician ruin potentially valuable medical informa-
tion by the very attempt to engage the patient in the type of dialogue required
for even a bare minimum of partnership? Does any such dialogue only come
after the patient has recovered, as the above case seems to indicate? In any
case, once the amount of speech and its particular qualities matter as much to
the physician, if not more, than any potential subjective information conveyed
by the voice, the patient’s verbal emissions become more of a raw material to
be scrutinised than the articulations of an interlocutor to be engaged.

6 Conclusion

This paper has made two related arguments. First, Hippocratic authors do not
treat their patients as true partners in any hypothetical ‘triangle’ and instead
maintain a somewhat dichotomous relation to those for whom they care—
that is, these authors rely on subjective patient reports at the same time as
they construct medical strategies to reduce and eliminate any such depen-
dency. Second, Hippocratic physicians promote the literal voice as a means of
detecting another set of pathological information—encoded in the quality of
the voice and the amount that flows from the mouth. Value is placed on this
second type of information, and, as a result, the (vocal) medium becomes per-
haps the primary message.
Having demonstrated that the voice pathologies belong to a nexus of physi-
cal and mental afflictions, I have also suggested that the conceptual apparatus
underlying voice symptoms bears many similarities to the physiology of fluids
and discharges: the voice can flow in excess and defect; it can be distorted; it
accompanies diarrhea. Words are treated as a raw emission. Nevertheless, it
still remains unclear whether sublimating patient testimony is a true diagnos-
tic practice enacted in reality or simple textual practice deployed in writing.
It could be quite possible that Hippocratic physicians made substantial use of
patient testimony, but simply did not report it. In this way, they could prevent
the ‘diseased’ content of the voice from infecting any of the other symptoms
that they wished to establish as objective in nature. Yet, we should avoid fall-
ing back on this position automatically. We may take it for granted that it is
194 Webster

­ edically beneficial for a physician to engage his patient in a conversation


m
about their symptoms. This presumes, however, that both parties hold a con-
siderable amount of knowledge in common. While we may not all be medi-
cal experts, the vast majority of westerners have (roughly) similar ideas about
what constitutes a disease, what symptoms look like and what type of things
medicine can accomplish. This makes asking the simple question ‘what seems
to be the problem?’ a potentially useful endeavour. Even still, modern physi-
cians must frequently lament the unruliness of patient reports, which can spi-
ral in all directions and need to be understood within standardised categories
in order to be medically informative.
Whether it is a textual or diagnostic practice, however, the result is the
same: the pathological value of the voice puts pressure on its linguistic con-
tent. Although the voice potentially functions as the most important locus of
individuality and subjectivity, when the Hippocratic physicians treat it in their
texts, noting its abnormalities and measuring its amount, they scrutinise it as a
quasi-excretum of the body, as though it were an effluence to be examined for
its quantity, quality, consistency and timbre.

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PART 3
Patients and Psychological Illness


CHAPTER 6

Galen’s Anxious Patients: Lypē as Anxiety Disorder


Susan P. Mattern

Galen describes a syndrome he associates with an emotion called lypē,


with specific symptoms and a course that may lead to humoral imbal-
ance, disease, and death. Lypē is an emotion that encompasses distress
at a loss, as the death of a close friend or the destruction of one’s books
by fire; but Galen also associates it with chronic worry about a future
threat, and a physiology between the emotions of worry and fear (that
is, ‘­anxiety’). Lypē can cause a progressive syndrome characterised by
insomnia, fever, pallor, and weight loss that can kill patients or degen-
erate into psychotic illness. This syndrome can be described in modern
terms as an anxiety disorder.

Studies of psychology in antiquity pay little attention to the idea of anxiety,


either as an emotion or as a factor in mental illness.1 Today, anxiety disorders
are the most common category of psychiatric disorders in the world, by a wide
margin,2 and it would be interesting indeed if pathological anxiety did not
exist in antiquity or if medical writers did not address it. But modern schol-

1  Anxiety appears not to be discussed in any of the works on the emotions in antiquity
I am aware of, save that of Konstan, D. (2006). The Emotions of the Ancient Greeks: Studies
in Aristotle and Classical Literature, 149–50. It is not specifically addressed in Pigeaud, J.
(1981). La maladie de l’âme: Étude sur la relation de l’âme et du corps dans la tradition medico-
philosophique antique, or in ead. ‘La psychopathologie de Galien’, in Manuli, P. and Vegetti, M.
(1988). Le opere psicologiche di Galeno, 153–84. Stok, F. (1996). ‘Follia e malattie mentali nella
medicina romana’, ANRW 2.37.3, 2283–2410 includes a brief section on “Le nevrosi” (2322–24),
discussing some potential retrospective diagnoses of neuroticism in modern Western psy-
chiatry, neuroticism is mostly considered a personality factor and is not a diagnosis in the
DSM-5 or the ICD-10, although the latter retains a broad category of “Neurotic, stress-related
and somatoform disorders”.) Among the articles in Harris, W. V. (2013). Mental Disorders in the
Classical World, only one is relevant to the theme of anxiety and anxiety disorders: King, H.
‘Fear of flute girls, fear of falling’, 265–84. She discusses two patients in the Hippocratic
Epidemics 5 and 7 who appear to suffer from “phobias”.
2  W HO World Mental Health Survey Consortium (June 2, 2004). ‘Prevalence, severity, and
unmet need for treatment of mental disorders in the World Health Organization World
Mental Health Surveys’, Journal of the American Medical Association 291.21, 2581–90.

© koninklijke brill nv, leiden, ���6 | doi ��.��63/9789004305564_008


204 Mattern

arship has not discovered any such disorder in ancient medical literature,
and has barely addressed the more basic concept of anxiety—the emotion of
‘apprehensive expectation’—at all.3
What do I mean by an ‘anxiety disorder’? In the current, fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders (=DSM-5), published in
2013, the category of “anxiety disorders” includes Generalized Anxiety Disorder
(GAD), by far the most common diagnosis, and also Social Anxiety Disorder,
Panic Disorder, Agoraphobia, Specific Phobias, and certain disorders mostly
affecting children.4 Because scientists, clinicians, grant funding agencies, and
insurance providers all require a common language for mental disorders, the
categories of the DSM are the ones normally used, even by scientists in cross-
cultural studies. But most scientists agree that, among other problems and con-
troversies, the DSM and the closely related “Mental and Behavioral Disorders”
section of the International Classification of Diseases (ICD, now in its tenth edi-
tion, = ICD 10) are more useful for industrialised, Western European popula-
tions than for other cultures,5 a problem which the DSM-5 tries to address in
its section on “Cultural Formulation” (749–59).6 Just as some anxiety disorders
may be under-reported in non-Western cultures because they present varia-
tions that do not conform well to the criteria of the DSM, we should be sensitive
to the idea that these and other mental disorders may have looked different in
Galen’s (pre-industrial and pre-Western) world than they do in ours.
I will argue that modern cross-cultural research in abnormal psychology
provides a new context in which to understand certain problems that Galen
described—not as quaint folktales or urban myths, hyperbolic anecdotes or
literary traditions, nor even “culture-bound syndromes” (the latter idea has
undergone substantial evolution in recent years and is becoming obsolete);

3  ‘Apprehensive expectation’ is often used in psychiatric literature to describe states of anxiety.


Thus Generalized Anxiety Disorder is “excessive anxiety and worry (apprehensive expec-
tation), occurring more days than not for a period of at least six months . . .” (DSM-5, 222).
MacNally, R. J. ‘Anxiety’, in Sander, D. and Scherer, K. R. (2009). The Oxford Companion to
Emotion and the Affective Sciences, 42–44, offers “an aversive emotional state prompted by the
prospect of future threat”.
4  The DSM-4 included Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder
among anxiety disorders, but these have been removed and given their own categories in the
DSM-5.
5  See e.g. Marques, L. et al. (2011). ‘Cross-cultural variation in the prevalence and presentation
of anxiety disorders’, Expert Review of Neurotherapeutics 11.2, 313–22; Lewis-Fernández, R. et al.
(2010). ‘Culture and the anxiety disorders: Recommendations for DSM-5’, Depression and
Anxiety 27, 212–29.
6  This section replaces the DSM-4’s brief appendix on “Culture-Bound Syndromes”.
Galen ’ s Anxious Patients 205

but as manifestations of a common, possibly fundamental or universal


response to psychic distress, one that takes different forms depending on cul-
tural context. Psychologists are learning to recognise these culture-specific
forms of anxiety or distress disorders, and their findings can provide insight
into phenomena opaque to historians with no exposure to them. But also,
because research on non-industrialised populations is difficult today, histori-
ans of the pre-modern world can contribute to the current understanding of
anxiety disorders among psychologists.
Although scholars often remark on the attention Galen pays to psychiat-
ric symptoms,7 especially because some of the most relevant stories are in his
entertaining and accessible treatise On Prognosis, they have underestimated
the precision with which he defines certain conditions. In the example I will
discuss here, Galen describes a state of mental distress, perhaps even a specific
syndrome, with a dangerous course that can lead to death, recognizable (as I
argue) to modern cultural psychologists as a type of anxiety disorder. He asso-
ciates this syndrome with the emotion he calls lypē (λύπη). I will also suggest
that other phenomena described in ancient medical literature, such as hysteri-
cal suffocation or lovesickness, might be interpreted as culture-specific forms
of anxiety disorders, and I hope to publish on those arguments in the future.
When I noticed that modern English translations of Galen’s word lypē did
not always capture his full meaning, and that the word ‘anxiety’ might be the
best translation in some contexts, I began to appreciate the role of this emo-
tion—something different from fear or worry, but related to both—in Galen’s
work. For this reason I begin with a study of the term lypē as Galen uses it. Lypē
and its derivatives are extremely common in Greek.8 Most occurrences of the
verbal form (lypeō), especially in the active voice, simply mean “to harm,” and
Galen often uses it this way—referring for example to the λυπῶν χυμός, the
“damaging humor”.9 In the passive or middle voice it can signify a disturbed
emotional state—lypeisthai, “to be distressed”. The noun can refer very gener-
ically to pain; or it can refer to psychic pain as distinct from physical pain.
Thus the sophist Antiphon is supposed to have invented and practiced an

7  On psychiatry in Galen a full bibliography would be quite long; see especially Pigeaud,
‘Psychopathologie’; and more recently Nutton, V. ‘Galenic madness’, in Harris, Mental
Disorders, 119–28; and Boudon-Millot, V. ‘What is mental a illness, and how can it be treated?
Galen’s reply as a doctor and philosopher’, in Harris, Mental Disorders, 129–46.
8  On psychological meanings of lypē see Konstan, Emotions, 245–46; Harris, W. V. (2001).
Restraining Rage: The Ideology of Anger Control in Classical Antiquity, 342–44.
9  E.g. De facult. natur. 2.8; 3.13 (K. 2.113; 192); De sympt. caus. 2.6 (K. 7.197); De loc. aff. 1.4; 3.10
(K. 8.38; 192) and passim; Ad Glauc. de meth. med. 2.4 (K. 11.98), etc.
206 Mattern

art he called alypia, the cure of lypē; a sign he posted at his house near the
marketplace of Corinth promised to relieve his clients’ (psychic) distress with
words “just as diseases are cured by physicians”.10
The Stoics, by whom Galen’s thoughts on psychology were deeply influ-
enced, divided the emotions (the pathē) into four broad categories, namely
lypē; phobos, or fear; epithymia, or desire; and hēdonē, or pleasure.11 Lypē as
used by the Stoics and others is often translated into English as “distress” to
preserve its generic meaning. But it could also signify more specific emotions,
including distress at a loss, especially the death of a loved one, an experi-
ence with which Stoics and other Hellenistic philosophical traditions were
much concerned. It is therefore often translated as “grief”. Lypē often carries
this meaning “grief for a loss” in Galen, although he does not emphasise the
death of loved ones in his most substantive discussions of lypē. These discus-
sions occur in his treatises On Diagnosing and Curing the Passions of the Soul
(K. 5.37–57) and Avoiding Distress (Περὶ ἀλυπίας).12 In both, Galen purports
to respond to someone who marvels that no loss or setback seems to distress
him. Here Galen associates lypē mainly with two types of loss: that of property
such as animals, money, or slaves, and including intellectual property, as when
books burn (Avoiding Distress was written after Galen lost his most precious
possessions in the fire that burned the Temple of Peace in 192); and loss of
honor or reputation, shading into what we might today call shame.13 Thus we
may feel lypē if we fail to live up to the virtues of our noble ancestors (Protrept.

10  [Ps.-Plut.], Vitae decem Oratorum 833 C–D; Harris, Restraining Rage, 343; Furley, W. D.
(1992). ‘Antiphon der Athener: Ein Sophist als Psychotherapeut?’, RhM n.s. 135, 198–216.
Galen seems to contrast lypē with physical pain in De an. aff. dign. et cur. 7 (K. 5.37): “Lypē,
like physical pain (πόνος ἐν τῷ σώματι), seems bad to everyone.”
11  Many works on the Stoic emotions could be cited. For a sophisticated study incorporating
modern psychology, see Nussbaum, M. (2001). Upheavals of Thought: The Intelligence of
Emotions. Brief introductions include Becker, L. C. ‘Stoic Emotion’, in Strange, S. K. and
Zupko, J. (2004). Stoicism: Traditions and Transformations, 250–76; and Brennan, T. ‘Stoic
moral psychology’, in Inwood, B. (2003). The Cambridge Companion to the Stoics, 257–94.
12  An edition of the sole surviving manuscript of Περὶ ἀλυπίας, discovered in 2005, is avail-
able in Boudon-Millot, V. and Jouanna, J. (2010). Galien, vol. 4: Ne pas se chagriner.
13  De an. aff. dign. et cur. 8 (K. 5.43–44); 9 (K. 5.48–51); De indolentia, passim. De indolentia
(1–37) focuses mostly on the loss of material and intellectual property and slaves. In these
passages Galen always discusses slaves as lost property, not as lost friends or loved ones,
although his attitude toward slavery, and especially toward his enslaved patients, is com-
plex; see Mattern, S. P. (2008). Galen and the Rhetoric of Healing, 116–19, and ead. (2013).
The Prince of Medicine: Galen in the Roman Empire, 271–72. Galen mentions doxa at 65 and
81, and other miscellaneous calamities at 72, 74–75, and 78.
Galen ’ s Anxious Patients 207

7 = K. 1.12). For this reason, and probably showing a debt to the Epicurean tradi-
tion on this point, Galen connects grief with insatiability (aplēstia) and greed
(pleonexia) or excessive desire (epithymia); the pursuit of fame, or wealth
beyond what is necessary for self-sufficiency, causes distress when these things
are unattainable or lost.14 Finally, although Galen does not seem as interested
in this kind of grief as some of his contemporaries were, lypē can also be the
emotion one feels when someone dies (In Hipp. Progn. comment. 1.4 = K. 18b
19). Citing Chrysippus, Galen writes that lypē is what Achilles felt for Patroclus,
for example. Here Galen relates grieving or being distressed (lypeisthai) to
weeping, mourning, groaning, and wailing (De plac. Hipp. et Plat. 4.7.26, 44 =
K. 5.422, 426).15 It is also possible or likely that Galen used the word lypē to
describe the emotion of the mother of Nasutus the Jurist, who died after hear-
ing of the death of her best friend; the passage survives only in Arabic.16 When
Nasutus’ mother heard the news, she became unable to sleep, she lost weight,
became feverish, and died in four days.
Galen does not consider it unusual to die of grief, a point the story of
Nasutus’ mother is supposed to illustrate, and he names other examples in the
same passage. Among them is a grammarian named Callistus who died after
his books perished in the fire of 192: “He grieved because of this and could
sleep no more. First a fever began, and then in no long time he wasted away to
such an extent that he died.”17 In Avoiding Distress (7), Galen names another,
apparently distinct grammarian named Philides who died “consumed by
despondency (dysthymia) and grief (lypē)” after the fire. In On the Composition
of Drugs, by Type (6.1 = K. 13.861) Galen mentions that some physicians died

14  De an. aff. dign. et cur. 9–10 (K. 5.48–54); De indolentia 42, 48; Boudon-Millot and Jouanna,
Galien: Ne pas se chagriner, 56–58.
15  Other places where Galen seems to connect lypē with active mourning such as weeping/
wailing (klaiein, klauthmos) are De san. tuenda 1.8 (K. 6.40) and De difficult. respir. 3.10
(K. 7.941).
16  Wenkebach, E. and Pfaff, F. (1956). Galeni In Hippocratis Epidemiarum: Librum 6
Commentaria 1–8, 2nd Edition (CMG V, 10.2.2), 486–87. Books 6.5.6–8 of In Hipp. Epid. 6
comment. do not survive in Greek and are here translated into German from the Arabic
of Hunain ibn Ishaq. The CMG does not print the text of Hunain’s Arabic translation,
either here or in Pfaff’s index of Arabic words (Pfaff, F., 1960. Galens Kommentare zu
den Epidemien des Hippokrates, Indizes der aus dem Arabischen übersetzten Namen und
Wörter = CMG V, 10.2.4). It is clear from this index, however, that Pfaff believed that his
word Kummer (50, 17) translated the ancient Greek lypē and that Angst translated the
ancient Greek phobos. The Arabic text survives in a single manuscript and has never been
published.
17  Wenkebach and Pfaff, 486.
208 Mattern

from grief at the loss of their specially prepared medicines; Galen’s own store
of these was also demolished in the fire, along with many of his most precious
manuscripts. Grief in Galen is not a passive emotion, but a desperate, agitat-
ing force that drives its victims to extremes, like Homer’s Achilles or the dead
grammarians.18
The word lypē in Galen does not always signify a reaction to loss. In many
cases it appears to signify anxiety about some future contingency (‘apprehen-
sive expectation’). In On Prognosis Galen recounts the story of a slave steward
who has lost or embezzled his master’s money and expects to have to give an
accounting soon. He is lypoumenos (Galen uses this participle twice in close
succession and the verb, in the middle voice, once); he is sleepless because of
worry (ὑπὸ τῆς φροντίδος ἠγρύπνει).19 Galen also says he is afraid (phoboito) of
the upcoming audit. I am translating phrontis as “worry” throughout this paper
(although it can have slightly different meanings in some contexts, discussed
further below), agrypnia as “insomnia”, and phobos as “fear”. All of these contrib­-
ute to the slave’s distress or lypē, which might thus be translated as “anxiety” in
this context.
Galen very frequently uses the word lypē in close connection with fear,
worry, insomnia, or all of these, as in the case of the slave steward.20 Thus in
On the Causes of Symptoms, insomnia is often caused by lypai or phrontides
(1.8 = K. 7.144). Moreover, in On the Affected Parts, Galen explains that the delu-
sions of melancholia have their origins in fear, but can also be caused by fever,

18  Examples of cross-cultural studies comparing concepts of sadness or grief in Western and
other societies include Postert, C. et al. (2012). ‘Beyond the blues: Toward a cross-cultural
phenomenology of depressed mood’, Psychopathology 45, 185–92 (on Hmong society) and
Schieffelin, E. L. ‘The cultural analysis of depressive affect: An example from New Guinea’,
in Kleinman, A. and Good, B. (1985). Culture and Depression: Studies in the Anthropology
and Cross-Cultural Psychiatry of Affect and Disorder, 101–33.
19  De praecogn. 6 (K. 14.633–35).
20  Other examples: in De opt. corp. const. 3 (K. 4.742), lypē, insomnia, worry, and exhaustion
(kopoi) are listed as examples of external causes of humoral imbalance. In De loc. aff 3.10
(K. 8.185), an over-accumulation of black bile might result from lypē, insomnia, or worry
or the combination of these (and cp. De atra bile 6 = K. 5.126). In De praesag. ex puls. 3.8
(K. 9.388), worry, lypē, and chronic insomnia are among the causes of hectic fever (along
with labor, famine, travel, and old age). In De cris. 2.3 (K. 9.649), labor, insomnia, worry,
and lypai cause too much yellow bile; in De cris. 2.13 (K. 9.698), lypē and worry cause dry-
ness. In De meth. med. 8.3 (K. 10.555), one should treat patients suffering from insomnia,
lypē, or worry with moisture and sleep. In In Hipp. Progn. comment. 3.23 (K. 18b 273), lypai
and worry are among many external factors causing fever. Many more examples could be
given; see also n. 22.
Galen ’ s Anxious Patients 209

inflammation of the head, or of the brain (phrenitis), or by phrontis, or lypē,


when these are combined with insomnia. In On Crises (2.13 = K. 9.697–700),
psychic causes of fever include worry, fear, thymoi, and lypai, here discussed at
some length.
The idea of phrontis is prominent in Galen, this word and its derivatives
occurring more than two hundred times in his work; it means “worry” as well as
simply “thought”, and Galen often associates it with intellectual activity more
generally.21 In most places where he lists emotions or pathē, Galen is describ-
ing agents that imbalance the temperament and thus cause disease. Contrary
to philosophical tradition he tends to name phrontis along with lypē, two types
of anger (orgē and thymos), fear, sometimes pleasure, and sometimes envy as
the basic pathogenic emotions, and also tends to mix psychic causes indis-
criminately with ‘somatic’ causes of disease in these lists.22 Insomnia is often
closely linked to the emotions of lypē and worry not only as a result of psychic
disturbance, but as a cause of temperamental imbalance or disease.23

21  De cris. 2.13 (K. 9.697) (“those worried because of study or contemplation”); and
cf. Mattern, Galen and the Rhetoric of Healing, 133.
22  Ars med. 24 (K. 1.371): orgē, lypē, thymos, fear, envy, and worry. De temper. 2.6 (K. 1.633):
worry, thymoi, lypai. Thras. 40 (K. 5.885): worry and thymos. De san. tuenda 1.5 (K. 6.28):
thymoi, worry, lypai. De san. tuenda 1.8 (K. 6.40): thymos, klauthmos, orgē, lypē, and worry.
De cris. 2.13 (K. 9.695–700): lypē, fear, thymos, and worry. De meth. med. 8.2 (K. 10.535):
insomnia, thymos, lypē, worry. De meth. med. 8.7 (K. 10.585): lypē, worry, thymos. De
meth. med. 10.2 (K. 10.666): thymos, lypē, insomnia, worry. De meth. med. 10.4 (K. 10.679):
insomnia, orgē, lypē, worry. De meth. med. 10.6 (K. 10.692): lypai, agōniai, thymoi, and worry.
In Hipp. Nat. Hom. comment. 17 (K. 15.162): heatstroke, insomnia, worry, lypai, thymoi,
lack of food. In Hipp. Epid. 6 comment. 1.10 (K. 17a 852): insomnia, worry, lypai, thymoi. On
these lists see also Manuli, P. ‘Le passione nel De Placitis Hippocratis et Platonis’, in Manuli, P.
and Vegetti, M. (1988). Le opere psicologiche di Galeno, 193–97. In his works on the pulse,
Galen tends also to include hēdonē (pleasure) among the emotions with a characteristic
pulse. Thus in De puls. ad tir. 12 (K. 8.473–74) he discusses pleasure, lypē, and fear; in De
caus. puls. 4.2–6 (K. 7.157–62) he discusses anger, pleasure, lypē, and fear. See Manuli, P.
‘Le passione’, 195–201 on the emotions and the pulse in Galen. Finally, in De an. aff. dign.
et cur. 5.7 the pathē are thymos, orgē, fear, lypē, envy, and epithymia. At K. 5.24 Galen gives
a more traditional list of lypē, orgē, thymos, epithymia, and fear. Worry is not discussed
per se in this more philosophical treatise or in De plac. Hipp. et Plat., but is much more
prominent when Galen is discussing pathē as causes of disease. Galen seems to use singu­
lar or plural forms of all the pathē interchangeably (he also often writes of ‘insomnias’).
On different Greek and Latin words for ‘anger’ and their subtle distinctions, see Harris,
Restraining Rage, 50–70.
23  E.g. De san. tuend. K. 6.40, K. 6.217, K. 6.225; and see examples in nn. 20 and 22.
210 Mattern

Lypē is closely related to fear in its physiology. Here Galen’s ideas partly
reflect a complex dependence on Stoic concepts of the pathē, in which both
fear and lypē are responses to the apprehension of something bad and both are
what some would call today avoidance emotions (versus approach emotions).
In particular, lypē seems to be a chronic and less intense form of fear. Both
lypē and fear will cause blood to retreat to the depths of the body (De praesag.
ex puls. 3.7 = K. 9.375). For this reason the skin of those who are afraid may
feel cold to the touch, their pulse becomes irregular and small, and they may
suffer rigors, or shivering fits; lypai cause similar but less intense symptoms
(De sympt. caus. 2.5 = K. 7.191–93).24 While people may die suddenly of fear
or, paradoxically, joy,25 lypē takes longer to kill (De loc. affect. 5.1 = K. 8.302),
a point we will return to. Furthermore, lypē has exactly the same pulse as
chronic fear (De puls. ad tir. 12 = K. 8.474). Compared to phrontis however,
lypē is more intense. Thus both worry and lypē will cause weight loss, pallor,
and hollowness of the eyes; but these symptoms are more prominent in those
afflicted with lypē than in those who are “worried (phrontisantes, here per-
haps “stressed” is a better modern translation) from study or contemplation”
(De cris. 2.13 = K. 9.698).26 Lypē, worry, and insomnia all have similar effects on
the pulse; and the pulse, as Galen adds, is the most accurate way to diagnose
any illness caused by emotion, providing the emotion is still present.27

24  In this passage Galen also distinguishes an emotion between anger and fear, with a
distinct pulse, which he calls agōnia and which Johnson translates as “anxiety”. Galen
uses the word agōnia rarely in his work (about two dozen times), and does not normally
include it in lists or discussions of emotional causes of illness. The main exceptions are
a passage in De meth. med. 12.5 (K. 10.841), a list of psychic affections that can dissipate
or destroy the pneuma; and a passage in De plac. Hipp. et Plat., where Galen’s interlocu-
tor is Chrysippus, who seems to have used the word in his discussion of emotions (3.7 =
K. 5.335–36). De Lacy has also translated the word as “anxiety” in the CMG edition of this
text (De Lacy, P. (1984). Galen on the Doctrines of Hippocrates and Plato = CMG V, 4.1.2
ad loc.). Galen’s usage in De sympt. caus. and elsewhere suggest a state of disturbance and
agitation. ‘Anguish’ may be more accurate than ‘anxiety’, although the concepts are not
mutually exclusive, and seem to come together in the story of Justus’ wife at De praecogn.
6 (K. 14.632).
25  De meth. med. 12.5 (K. 10.841); De sympt. caus. 2.5 (K. 7.193).
26  See also Ad Glauc. de meth. Med. 1.2 (K. 11.12); and In Hipp. Epid. 6 comment. 2.47
(K. 17A.998), where insomnia, lypē, fasting, or exhaustion might cause the hollow-eyed
appearance of the facies Hippocratica.
27  “We now begin the discussion of the psychic affections, worry and fear and thymos and
lypē. If the examination takes place while the affections of the soul remain, try most of all
to diagnose them through the pulse, as I have written in the [books] about the pulse; and
after this, proceed to the diagnosis from the other things.” On the pulses of the emotions
Galen ’ s Anxious Patients 211

Thus Galen sees lypē as an emotion related to worry and fear, but stronger
than worry, and both less intense and more chronic than fear. Again, “anxiety”
is an appropriate translation, although we should be aware that Galen’s lypē is
a more flexible concept, specifically encompassing grief as well. Here it is help-
ful to remember that distinctions among the emotions in modern psychology
are also problematic.28
It is most of all by studying Galen’s case histories that one can appreciate the
significance of anxiety in his work. His most famous story is in fact about lypē
and not, as he twice insists in an apparently futile effort to explain, about love,
as many of his followers believed. For love neither has a characteristic pulse
by which it can be diagnosed29 nor, as he seems to say elsewhere, is it a direct
cause of disease: rather, love can be an antecedent cause if people become
distressed (lypountai) as a result of it, and this will result in the characteristic
symptoms of insomnia, wasting, fever, and skin color change (In Hipp. Progn.
comment. 1.4 = K. 18b 18–19).30
The case of Justus’ wife (De praecogn. 6 = K. 14.630–33) is one of Galen’s
favorite stories, and he refers to it several times in his extant works, comparing
himself to Erasistratus, who had made a similar diagnosis in the rather more
elevated case of Seleucus’ son Antiochus I.31 According to legend Erasistratus
diagnosed the cause of the young prince’s illness as love for his father’s new
wife, or in Galen’s version, for his father’s concubine. He did this by feeling
the patient’s pulse and detecting a so-called erotic pulse (as mentioned, Galen
explains that the legend is wrong, for there is no such pulse).

see also De cris. 2.13 (K. 9.697–98,700); De praesag. ex puls. 1.8 (K. 9.268); Ad Glauc. de meth.
med. 1.2 (K. 11.12–13); In Hipp. Progn. comment. 1.8 (K. 18b 39–41). On the pulse see also Orly
Lewis, ‘The practical application of ancient pulse-lore and its influence in the patient-
doctor interaction’ (Chapter Thirteen) in this volume, 345–364.
28  No consensus has been reached on any of the several theories of the definition and clas-
sification of emotions. For a concise discussion, see Scherer, K. R. ‘Emotion theories and
concepts (psychological perspectives)’, in Sander, D. and Scherer, K. R. (2009). The Oxford
Companion to Emotion, 145–50.
29  De praecogn. 6 (K. 14.635), In Hipp. Progn. comment. 1.8 (K. 18b 40).
30  However, in In Hipp. Epid. 2 comment. (Wenkebach, E. and Pfaff, F., 1934. Galeni In
Hippocratis Epidemiarum Libros 1 et 2 = CMG V, 10, 1.1), 208, surviving only in Arabic, Galen
names love or “love-grief” as the cause of Justus’ wife’s illness. The main point of the pas-
sage in In Hipp. Progn. comment. is to argue that there are no divine causes of illness or
death, not even in cases where death is attributed to love.
31  De praecogn. 5 (K. 14.625–26); 6 (K. 14.630–33, 634); 7 (K. 14.640); 13 (K. 14.669); In Hipp.
Epid. 2 comment. 206–07 Wenkebach and Pfaff; In Hipp. Progn. comment. 1.8 (K. 18b 40).
212 Mattern

The main symptom from which Justus’ wife suffers is insomnia. Galen
decides after questioning her and eliminating other possible causes that she
suffers either from depressed mood—dysthymia—caused by black bile, or she
is distressed (lypoumenē) by something she does not want to confess. Later he
determines from her maid that she is worn out by some grief, lypē.
One day someone happens to mention in the patient’s presence that Pylades
is dancing in the theater. Galen notices the following symptoms: change of
gaze and of the color of her face, and her pulse became suddenly irregular.
“The same thing”, he says, “happens to those who are about to contend over
something”, using the verb agōnian. He detects not love, but distress, a feeling
like the feeling one might have when one is about to compete in a contest, or—
as Galen also writes—like the feeling the slave steward had, who was “similarly
afflicted” (De praecogn. 6 = K. 14.633). As I have mentioned, Galen argues else-
where that lypē has a distinct pulse different from the pulses typical of anger
or (acute) fear but very similar to those of chronic fear, insomnia, and worry.
There is no erotic pulse, but there is an anxious pulse.
Lypē can be fatal. Thus Galen tells the story of Maeander the augur, who
died after predicting his own death. This passage survives in a portion of his
commentary on Book 6 of the Hippocratic Epidemics surviving only in Arabic,
and printed in German translation in Wenkebach and Pfaff’s edition.32 Galen
writes that

He [Maeander] went from the bird-flight area back to the city demol-
ished, wretched and yellow in color, so that everyone who met him asked
him whether he had some bodily illness . . . Then he began to lie sleepless
at night while distress (Kummer) oppressed him all day, so that he dete-
riorated entirely. Finally a light, gentle fever appeared. When the fever
began, his soul became so disturbed, that he was no longer himself and
had to stay in bed. Two months after his birthday he died because his
body gradually wasted away to such an extent that he entirely dissolved.

Here “distress” (lypē?) leads to insomnia, fever, yellow skin color, weight loss,
behavioral changes, and finally to death.33
In this story and in those that follow—an anonymous man in distress after
losing money; the mother of Nasutus mentioned above, distressed at the
death of her friend; the grammarian Callistus, also mentioned above; and a

32  In Hipp. Epid. 6 comment., 485–86 Wenkebach and Pfaff. On the Arabic text and the word
Kummer see above, n. 16.
33  In Hipp. Epid. 6 comment., 485–86 Wenkebach and Pfaff.
Galen ’ s Anxious Patients 213

patient whose story Galen tells at greater length in another passage also sur-
viving only in Arabic (this time from his commentary on the second book of
Epidemics), namely a man who thought a ghost was calling him by name from a
cemetery34—all of these patients show a progression of symptoms similar
to those of the slave steward and the wife of Justus. They develop insomnia
and fever; they may change skin color (to yellow or pale, possibly a result of
the accumulation of hot, dry yellow bile); they lose weight and waste away,
sometimes even until they die. As I have mentioned, Galen states many times
that lypē, worry, and insomnia (in some combination or all together) can cause
disease, particularly humoral imbalance (they cause drying and heating), and
fever.35 One female patient from On the Method of Healing, for example, “began
to be feverish from insomnia and lypē, and she suffered through most of the
winter” (De meth. med. 10.5 = K. 10.687). Lypē and worry can cause other kinds
of illness too, such as epilepsy. The grammarian Diodorus suffers seizures
when he fasts or works too late at his intellectual labours, or when he becomes
angry or suffers from phrontis or lypē.36
It is also possible for lypē to lead to the psychotic form of the disease Galen
and other ancient medical writers call melancholia, which might occur if black
bile over-accumulated in the brain from any of several causes.37 In On the
Affected Parts, in a passage probably indebted to Rufus of Ephesus’ lost work
on melancholia, Galen explains how yellow bile, when burnt, can transform
into black bile and cause what he calls “bestial hallucinations” and other psy-
chotic symptoms.38 Humoral imbalance leading to melancholia may be caused
by diet, or people of certain temperaments may be naturally susceptible to
it; but also, Galen writes, “lypai, insomnias, and worry” can be factors (3.10 =
K. 8.184–85). Pernicious, chronic melancholy, as he writes, tends to arise in
those who have suffered from the burning fever called kausos in Greek, or from

34  In Hipp. Epid. 2 comment., 208 Wenkebach and Pfaff.


35  See above, n. 20 and 22.
36  De san. tuenda 6.14 (K. 6.448–49); De loc. aff. 5.6 (K. 8.340–41); De venae sect. adv.
Erasistrateos 9 (K. 11.241–42).
37  I use the word ‘psychotic’ in its technical sense, meaning that the symptoms of delusions,
hallucinations, and/or disorganised thought are present. Any over-accumulation of black
bile could be called melancholia, and in ancient medical texts the disorder often affects
the stomach, but when it reached the brain it was thought to cause bizarre neurological
symptoms.
38  3.9 (K. 8.178); “bestial hallucinations” is van der Eijk and Pormann’s translation of θηριώδεις
παραφροσύνας in Pormann, P. E. (2008). Rufus of Ephesus On Melancholy, 267. For a com-
ment on this phrase see their footnote 4. On ancient melancholia a large bibliography
could be cited, but Pormann’s book is a good, recent introduction.
214 Mattern

an inflammation in the head, or from phrenitis, by which Galen meant delu-


sions or hallucinations accompanied by fever; “or it follows from worries or
lypai or insomnias” (3.1 = K. 8.193), probably because these could generate the
yellow bile that, when burnt, became the black bile of melancholia.
Chronic fear—a condition, as I have argued, that Galen might call lypē—
had long been considered a crucial element in melancholia. A Hippocratic
aphorism, very influential on ancient ideas of melancholia, states that “if fear
or depressed mood (dysthymia) persist for a long time, it is something melan-
cholic” (Aph. 6.23). Galen, commenting on this aphorism,39 distinguishes fear
caused by an apparent or obvious reason from fear that is not caused by some-
thing obvious—this idea of irrational fear evokes the modern psychological
concept of phobia or, perhaps more appropriately in light of Galen’s other
descriptions of melancholic symptoms, persecutory delusions. Galen believes
that irrational fear has a darker prognosis, but even fears that seem reasonable
can signify melancholia, if they are chronic—that is, anxiety in the sense of
‘chronic fear’ can indicate a very serious illness (In Hipp. Aph. comment. 23 =
K. 18a 35–36).
This, Galen says elsewhere, has happened to one of his patients: the patient
worried about Atlas. This patient’s story occurs in Galen’s commentary on the
sixth book of Hippocratic Epidemics, in the list of examples of people who died
or wasted away from mental distress (the same list that includes the story of
Maeander and of the mother of Nasutus); and Galen also tells it elsewhere, in
his commentary on the first book of Epidemics. The Atlas patient is an espe-
cially fascinating example of an anxiety disorder in antiquity:

I know a man from Cappadocia, who had gotten a nonsensical thing into
his head and because of that declined into melancholy. The idea that
he had got into his head was completely ridiculous. His friends saw him
weeping and asked him about his distress (Kummer). At that he sighed
deeply and answered, saying that he was worried that the whole world
would collapse. His distress was that the king, about whom the poets
relate that he carries the world and is called Atlas, because of the long
time that he had carried it, would become tired. Thus there was a danger
that the sky would fall on the earth and smash it.40

This patient’s totally irrational (in Galen’s view) and presumably chronic
anxiety about Atlas gives rise to melancholia, as Galen’s discussion in On the

39  Konstan, Emotions, 149–50 believes Galen is drawing on an Epicurean tradition here.
40  487 Wenkebach and Pfaff. On Kummer see above, n. 16.
Galen ’ s Anxious Patients 215

Affected Parts suggests that it might. Galen tells the same story in another
passage, in his commentary on the first book of the Epidemics, this time surviv-
ing in Greek:

For when someone was in our presence in the morning, as was his cus-
tom, he said in response to an inquiry of him that he had lain awake the
whole night, considering [the question, that] if it should occur to Atlas,
being sick, that he could no longer hold up the sky, what would happen?
And when he said this, we deduced that this was the beginning of melan-
cholia (K. 17a 213–14).

Here Galen considers worrying about Atlas a conclusive sign of melancholia.


He probably considered his diagnosis conclusive based on a passage from
Rufus of Ephesus, who had also described such a patient. Galen’s On the
Affected Parts contains a lengthy discussion of melancholia, based largely on
Rufus of Ephesus’ lost work on that subject.41 Patients suffering from melan-
cholia, he writes, will have fearful delusions; one thinks he is a mollusk liable
to be crushed underfoot at any time; another crows like a rooster; still another
is afflicted by the “fear, that somehow Atlas, who holds up the world, having
become tired will shrug it off, and thus he would be smashed himself and we
all would perish with him” (K. 8.190). Two medieval sources (the later appar-
ently derivative of the earlier) attribute this passage with its references to
rooster, mollusk, and Atlas to Rufus of Ephesus; adding the detail that the Atlas
patient was an astronomer.42 One possibility of course is that Galen invented a
fictitious patient based on the reference in Rufus. But Galen is consistent and
precise about his relationship to the stories he mentions; both his formulation
“I know a man” (in the first version of the story above) and his use of the first
person (in the second version) normally indicate first-hand experience, and
no other cases of his inventing a story are known.43 It seems more likely that

41  De loc. aff. 3.9–10 (K. 8.176–93). This passage is reprinted with editorial revision and trans-
lated by P. van der Eijk and P. E. Pormann in Pormann, Rufus of Ephesus, 265–88.
42  Fischer, K.-D. (2010). ‘De fragmentis Herae Cappadocis atque Rufi Ephesii hactenus igno-
tis’, Galenos 4, 173–83. I am grateful to Pauline Koetschet and Klaus-Dietrich Fischer for
drawing my attention to this reference.
43  For an extended discussion of this point see Mattern, Galen and the Rhetoric of Healing,
37–40. A couple of examples of supposedly fictitious case histories in Galen are some-
times adduced, but I address them in that discussion. On the debate over fictitious
patients in Galen, see also Pauline Koetschet, ‘Experiencing Madness: Mental Patients in
Arabo-Islamic Medicine’, Chapter Seven, 224–244 in this volume.
216 Mattern

Galen met a patient with a delusion similar to what Rufus had described, and
made an easy diagnosis from that indicator (as the second version of the story
implies); this interpretation would be more difficult if Galen had insisted that
his own patient was an astronomer, like the patient in Rufus, but he does not.
Does Galen’s idea of anxiety (for him, a condition of chronic fear or intense
worry that can unbalance the temperament toward heat and dryness, caus-
ing a constellation of progressive symptoms including insomnia, fever, weight
loss, a characteristic pulse, and skin color change, and potentially ending in
death or psychosis) reflect ideas prevalent in his culture and in ancient medi-
cal science more generally? Or did he make it up? While a full discussion of
anxiety in Greco-Roman literature cannot be attempted here, I make a few
suggestions, some of which may merit further study.
a) As I have mentioned above, Galen himself points out that lypē causes
symptoms often attributed to lovesickness, apparently holding the view that
lovesickness is really a form of lypē. Lovesickness in ancient literary sources
often produces wasting, insomnia, and skin color change (although a substan-
tial tradition of a more manic form of lovesickness is also attested).44 Perhaps
lovesickness in antiquity should be interpreted as a distress or anxiety
syndrome.
b) Introducing the story of Maeander, Galen writes that

I know a large number of people whom fear of death overcame, and


whom this fear first made sick, and then drove to death. Some of them a
dream plunged into this fear. In some cases this fear was produced by an
idea or an omen or a strange apparition that they had, or by a lightning
strike. Some were driven to it by signs that they found in the entrails of
sacrificial animals, or by an augury of some kind of bird . . . (In Hipp. Epid.
6 comment., 485–86 Wenkebach and Pfaff).

That is, Maeander represents a number of people known to Galen who wasted
away and died after their deaths were presaged by dreams or omens. Galen
further writes that he knows a large number of people wasted by “grief or a
bad state of the soul”, like the mother of Nasutus; “I limit myself to a couple
of cases, because their number is too great.” That is, he seems to consider the
syndrome he describes rather common.
Finally, some of Galen’s examples derive from other sources or from oral tra-
ditions. The story of Maeander, who hailed from Mysia and lived in Pergamum,
may be a folktale indigenous to Galen’s homeland; the hero of the story about

44  Toohey, P. (1992). ‘Love, lovesickness and melancholia’, Illinois Classical Studies 17, 265–86.
Galen ’ s Anxious Patients 217

a man afraid of a ghost was Erasistratus (In Hipp. Epid. 2 comment., 207–08
Wenkebach and Pfaff); Rufus of Ephesus saw a patient worried that Atlas
would drop the world, as Galen apparently also did, unless he lifted the story
from Rufus.
If it is true that Galen’s idea of anxiety and of a progressive anxiety syndrome
reflects something in his culture more generally, how should we interpret it?
As a literary tradition or folk belief? As a ‘primitive’ psychiatric theory, to be
compared to the DSM to see what Galen ‘got right’? Neither of these methods
is appealing, but there is another option. Cross-cultural approaches to psy-
chology pioneered by Arthur Kleinman have led to a deeper understanding of
how anxiety disorders manifest in different cultures today.45 In particular, phe-
nomena once dismissed as quaint “culture-bound syndromes” and relegated
to a brief appendix in the DSM-4 are now studied as culturally specific distress
syndromes. In Western culture, for example, Generalized Anxiety Disorder
may present as an extended period of worry together with some combination
of fatigue, restlessness, irritability, difficulty concentrating, muscle tension
and insomnia.46 Someone suffering from neurasthenia in China47 might
complain mainly of fatigue along with restlessness, muscle aches, dizziness,
headache, irritability, and indigestion. The patient might attribute his or
her symptoms to weakened heart or kidneys, and might meet DSM criteria
for Generalized Anxiety Disorder (GAD), Panic Disorder, Major Depressive
Disorder (MDD), Anxiety Disorder NOS (Not Otherwise Specified, a psychiatric
catch-all term), or none of these. A patient suffering from the Korean condi-
tion of hwa-byung or fire sickness, on the other hand, which usually afflicts
women, might complain primarily of intrusive angry thoughts, sensations
of heat, indigestion and abdominal pain, palpitations, or a feeling of stifling
or pressure in the chest, and on interview might meet DSM criteria for GAD,
MDD, Somatization Disorder, Panic Disorder, some combination of these, or

45  Kleinman has published very prolifically. I cite here his groundbreaking study of 1982,
‘Neurasthenia and depression: a study of somatization and culture in China’, Culture,
Medicine and Psychiatry 6.2, 117–90.
46  DSM-5, 222–26.
47  Shenjing shuairuo, weakness of the nerves; the term was introduced from the West in
the late nineteenth century and is a psychiatric diagnosis in the current editions of the
International Classification of Diseases and the Chinese Classification of Mental Disorders.
See Kleinman, ‘Neurasthenia’; Lee, S. and Kleinman, A. (2007). ‘Are Somatoform Disorders
Changing with Time? The Case of Neurasthenia in China’, Psychosomatic Medicine 69,
846–49.
218 Mattern

none of these.48 In this case the patient may believe that suppressed anger
accumulated over a long time has solidified in the abdomen, leading to somatic
symptoms in some ways similar to the “hysterical suffocation” of Greco-Roman
antiquity, a condition that probably also should be interpreted as an example
of a culturally specific distress syndrome.
While the diagnosis of neurasthenia is declining in China in favor of Western
diagnoses of anxiety or mood disorders,49 in a parallel movement, psychiatry
is recognizing new disease categories based on the study of non-Western dis-
orders, and developing assessments and treatments for them, for example in
the case of hwa-byung.50 Non-Western disease categories do not correspond
exactly to DSM categories, and may overlap affective disorders, anxiety dis-
orders, and even psychotic disorders. Here it is important to emphasise that
despite the pragmatic tradition of referring to DSM categories in cross-cultural
research, its system of classification is not considered particularly authorita-
tive. Western psychiatry struggles with the classification of mental diseases,
which is the subject of much debate and constantly in flux,51 many cross-
cultural studies make the point that DSM categories need to be revised in light
of their findings.

48  On anxiety disorders across cultures see recently the syntheses of Hinton, D. E. et al.
(2009). ‘Anxiety disorder presentations in Asian populations: a review’, CNS Neuroscience
& Therapeutics 15, 295–303; Marques et al. ‘Cross-cultural variation’; Lewis-Fernández
et al. ‘Culture and the anxiety disorders’. On the comorbidity of hwa-byung see further
Min, S. K. and Suh, S.-Y. (July 2010), ‘The anger syndrome Hwa-byung and its comorbidity’,
Journal of Affective Disorders 124.1–2, 211–14. The authors find that comorbidity with MDD
and GAD is very common but not universal in hwa-byung patients. They suggest creating a
category of internalizing distress disorders or of affective disorders, to include MDD, GAD,
and anger syndrome.
49  Lee and Kleinman, ‘Are somatoform disorders changing?’
50  Min, S. K. et al. (2009), 'Symptoms to Use for Diagnostic Criteria of Hwa-Byung, an Anger
Syndrome', Psychiatry Investigation 6, 7–12; Roberts, M. E. et al. (2006). ‘Development
of a scale to assess Hwa-byung, a Korean culture-bound syndrome, using the MMPI-2’,
Transcultural Psychiatry 43, 383–400.
51  For discussions of the problem see e.g. Blashfield, R. K. and Livesley, W. J. ‘Classification’,
in Millon, T. et al. (1999). The Oxford Textbook of Psychopathology, 3–28; Widiger, T. A. and
Samuel, D. B. (2005). ‘Diagnostic categories or dimensions? A question for the Diagnostic
and Statistical Manual of Mental Disorders—Fifth Edition’, Journal of Abnormal Psychology
114.4, 494–504. For comment on this subject by historians of antiquity, see Simon, B.
“ ‘Carving nature at the joints’: the dream of a perfect classification of mental illness”, in
Harris, Mental Disorders, 27–40; and Hughes, J. C. ‘If only the ancients had had DSM, all
would have been crystal clear’, in the same volume, 41–60.
Galen ’ s Anxious Patients 219

In many cross-cultural presentations of anxiety disorders, somatic symp-


toms are more prominent than psychological symptoms such as worry. Somatic
symptoms in patients meeting the criteria for GAD, for example, vary substan-
tially and may include items not mentioned in the DSM, such as sweating, indi-
gestion, dizziness, and palpitations. Galen’s patients presented the somatic
symptoms of fever, skin color change, weight loss, insomnia, and a weak, irreg-
ular pulse; that these are not identical to DSM symptoms associated with GAD
or other anxiety disorders is not especially significant in cross-cultural context.
Causes of anxiety also vary substantially; for example, worries about physical
symptoms vary depending on the perceived cause of the disease (‘ethnophysi-
ology’). Thus Cambodian patients imagining that a buildup or blockage of
wind in the body is a dangerous condition will be especially sensitive to, and
worried about, symptoms of dizziness, nausea, coldness in the extremities,
pain in the neck, or abdominal sensations. Other causes of worry, such as the
rebirth status of deceased family members in Buddhist populations,52 are also
obviously culture-specific and remind us not to dismiss the fears of Maeander
or even of the Atlas patient as folkloric inventions, even if one or both of these
particular patients is fictional.
Studying Galen’s idea of lypē as a cross-cultural anxiety or distress disor-
der offers several insights. First, it suggests that anxiety and distress disorders
existed in Greco-Roman antiquity, and that Galen’s lypē-syndrome might be
best understood as one of them. The Atlas patient, for example, might meet
DSM criteria for Generalized Anxiety Disorder and perhaps also for Major
Depressive Disorder, which is characterised by prolonged depressed mood
or anhedonia and which may involve weight change and sleep disturbance
as prominent symptoms. It is interesting to note that GAD and MDD are very
often co-morbid today and respond to the same drugs, and it is often suggested
that they are aspects of the same disease.53 Galen describes an identical pro-
gressive syndrome for people suffering from lypē in the sense of ‘grief’ or ‘sad-
ness’ (the mother of Nasutus) and those suffering from lypē in the sense of
anxiety (Maeander; the Atlas patient; the wife of Justus). His taxonomy is argu-
ably more accurate than that of the DSM on this point. Furthermore, the com-
parative perspective I propose here suggests that other conditions described

52  Hinton, D. E. et al. (2011). ‘Worry, worry attacks, and PTSD among Cambodian refugees: a
path analysis interpretation’, Social Science and Medicine 72.11, 1821.
53  E.g. Minenka, S. et al. (1998). ‘Comorbidity of anxiety and unipolar mood disorders’,
Annual Review of Psychology 49, 377–412; Watson, D. (2005). ‘Rethinking the mood and
anxiety disorders’, Journal of Abnormal Psychology 114, 522–36.
220 Mattern

in ancient sources, such as hysterical suffocation, might be better understood


as anxiety syndromes.
This perspective also suggests mechanisms for how anxiety disorders
worked in Galen’s patients: modern anxiety syndromes create a positive-
feedback cycle in which the anxious patient pays more attention to the symp-
toms believed to be associated with his or her syndrome; these symptoms
increase through ‘attention amplification’; the patient becomes more worried,
and so forth. Often symptoms are interpreted as indicating, or potentially caus-
ing, dangerous conditions such as a weakened heart or an attack of pathogenic
wind. These “catastrophic cognitions” amplify the feedback loop.54 Galen
and presumably his patients believed that anxiety could be fatal; Maeander
becomes intensely distressed at the appearance of the ominous symptom of
fever. Also, analysis of Galen’s stories can suggest an important correction to
modern psychology, which for the most part has not considered the role of
the physician in generating culturally specific expressions of distress. Some
of the somatic indicators Galen describes—skin color change