Praeceptiones

Time is that wherein there is opportunity, and opportunity is that wherein there is no great time. Healing is a matter of time, but it is sometimes also a matter of opportunity. However, knowing this, one must attend in medical practice not primarily to plausible theories, but to experience combined with reason. For a theory is a composite memory of things apprehended with sense-perception. For the sense-perception, coming first in experience and conveying to the intellect the things subjected to it, is clearly imaged, and the intellect, receiving these things many times, noting the occasion, the time and the manner, stores them up in itself and remembers. Now I approve of theorising also if it lays its foundation in incident, and deduces its conclusions in accordance with phenomena. For if theorising lays its foundation in clear fact, it is found to exist in the domain of intellect, which itself receives from other sources each of its impressions. So we must conceive of our nature as being stirred and instructed under compulsion by the great variety of things; and the intellect, as I have said, taking over from nature the impressions, leads us afterwards into truth. But if it begins, not from a clear impression, but from a plausible fiction, it often induces a grievous and troublesome condition. All who so act are lost in a blind alley. Now no harm would be done if bad practitioners received their due wages. But as it is their innocent patients suffer, for whom the violence of their disorder did not appear sufficient without the addition of their physician’s inexperience. I must now pass on to another subject.

But conclusions which are merely verbal cannot bear fruit, only those do which are based on demonstrated fact. For affirmation and talk are deceptive and treacherous. Wherefore one must hold fast to facts in generalisations also, and occupy oneself with facts persistently, if one is to acquire that ready and infallible habit which we call the art of medicine. For so to do will bestow a very great advantage upon sick folk and medical practitioners. Do not hesitate to inquire of laymen, if thereby there seems likely to result any improvement in treatment. For so I think the whole art has been set forth, by observing some part of the final end in each of many particulars, and then combining all into a single whole. So one must pay attention to generalities in incidents, with help and quietness rather than with professions and the excuses that accompany ill-success.

Early determination ofthe patient’s —since only what has actually been administered will benefit; emphatic assertion is of no use—is beneficial but complicated. For it is through many turns and changes that all diseases settle into some sort of permanence.

This piece of advice also will need our consideration, as it contributes somewhat to the whole. For should you begin by discussing fees, you will suggest to the patient either that you will go away and leave him if no agreement be reached, or that you will neglect him and not prescribe any immediate treatment. So one must not be anxious about fixing a fee. For I consider such a worry to be harmful to a troubled patient, particularly if the disease be acute. For the quickness of the disease, offering no opportunity for turning back, spurs on the good physician not to seek his profit but rather to lay hold on reputation. Therefore it is better to reproach a patient you have saved than to extort money from those who are at death’s door.

And yet some patients ask for what is out of the way and doubtful, through prejudice, deserving indeed to be disregarded, but not to be punished. Wherefore you must reasonably oppose them, as they are embarked upon a stormy sea of change. For, in heaven’s name, who that is a brotherly physician practises with such hardness of heart as not at the beginning to conduct a preliminary examination of every illness and prescribe what will help towards a cure, to heal the patient and not to overlook the reward, to say nothing of the desire that makes a man ready to learn?

I urge you not to be too unkind, but to consider carefully your patient’s superabundance or means. Sometimes give your services for nothing, calling to mind a previous benefaction or present satisfaction. And if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. For where there is love of man, there is also love of the art. For some patients, though conscious that their condition is perilous, recover their health simply through their contentment with the goodness of the physician. And it is well to superintend the sick to make them well, to care for the healthy to keep them well, but also to care for one’s own self, so as to observe what is seemly.

Now those who are buried in deep ignorance of the art cannot appreciate what has been said. In fact such men will be shown up as ignorant of medicine, suddenly exalted yet needing good luck. For should wealthy men gain some remission of their trouble, these quacks win reputation through a double good fortune, and if a relapse occurs they stand upon their dignity, having neglected the irreproachable methods of the art, wherewith a good physician, a brother of the art as he is called, would be at his best. But he who accomplishes his cures easily without making a mistake would transgress none of these methods through want of power; for he is not distrusted on the ground of wickedness. For quacks do not attempt treatment when they see an alarming condition, and avoid calling in other physicians, because they wickedly hate help. And the patients in their pain drift on a sea of twofold wretchedness for not having intrusted themselves to the end to the fuller treatment that is given by the art. For a remission of a disease affords a sick man much relief. Wherefore wanting a healthy condition they do not wish always to submit to the same treatment, therein being in accord with a physician’s versatility. For the patients are in need through heavy expenditure, worshipping incompetence and showing no gratitude when they meet it; when they have the power to be well off, they exhaust themselves about fees, really wishing to be well for the sake of managing their investments or farms, yet without a thought in these matters to receive anything.

So much for such recommendations. For remission and aggravation of a disease require respectively less or more medical assistance. A physician does not violate etiquette even if, being in difficulties on occasion over a patient and in the dark through inexperience, he should urge the calling in of others, in order to learn by consultation the truth about the case, and in order that there may be fellow-workers to afford abundant help. For when a diseased condition is stubborn and the evil grows, in the perplexity of the moment most things go wrong. So on such occasions one must be bold. For never will I lay it down that the art has been condemned in this matter. Physicians who meet in consultation must never quarrel, or jeer at one another. For I will assert upon oath, a physician’s reasoning should never be jealous of another. To be so will be a sign of weakness. Those who act thus lightly are rather those connected with the business of the market-place. Yet it is no mistaken idea to call in a consultant. For in all abundance there is lack.

With all these things it will appear strong evidence for the reality of the art if a physician, while skilfully treating the patient, does not refrain from exhortations not to worry in mind in the eagerness to reach the hour of recovery. For we physicians take the lead in what is necessary for health. And if he be under orders the patient will not go far astray. For left to themselves patients sink through their painful condition, give up the struggle and depart this life. But he who has taken the sick man in hand, if he display the discoveries of the art, preserving nature, not trying to alter it, will sweep away the present depression or the distrust of the moment. For the healthy condition of a human being is a nature that has naturally attained a movement, not alien but perfectly adapted, having produced it by means of breath, warmth and coction of humours, in every way, by complete regimen and by everything combined, unless there be some congenital or early deficiency. Should there be such a thing in a patient who is wasting, try to assimilate to the fundamental nature. For the wasting, even of long standing, is unnatural.

You must also avoid adopting, in order to gain a patient, luxurious headgear and elaborate perfume. For excess of strangeness will win you ill-repute, but a little will be considered in good taste, just as pain in one part is a trifle, while in every part it is serious. Yet I do not forbid your trying to please, for it is not unworthy of a physician’s dignity.

Bear in mind the employment of instruments and the pointing out of significant symptoms, and so forth.

And if for the sake of a crowded audience you do wish to hold a lecture, your ambition is no laudable one, and at least avoid all citations from the poets, for to quote them argues feeble industry. For I forbid in medical practice an industry not pertinent to the art, and laboriously far-fetched, and which therefore has in itself alone an attractive grace. For you will achieve the empty toil of a drone and a drone’s spoils.

A condition too is desirable free from the late-learner’s faults. For his state accomplishes nothing that is immediate, and its remembrance of what is not before the eyes is but tolerable. So there arises a quarrelsome inefficiency, with headstrong outrage, that has no thought for what is seemly, while definitions, professions, oaths, great as far as the gods invoked are concerned, come from the physician in charge of the disease, bewildered laymen being lost in admiration of flowery language spoken in continuous reading and instruction, crowding together even before they are troubled by a disease. Wherever I may be in charge of a case, with no confidence should I call in such men to help as consultants. For in them comprehension of seemly learning is far to seek. Seeing then that they cannot but be unintelligent, I urge that experience is useful, the learning of opinions coming far after. For who is desirous and ambitious of learning truly subtle diversities of opinion, to the neglect of calm and practised skill? Wherefore I advise you to listen to their words but to oppose their acts.

When regimen has been restricted you must not suppress for long a long-standing desire of the patient. In a chronic disease indulgence too helps to set a man on his feet again, if one pay the necessary attention to one who is blind. As great fear is to be guarded against, so is excessive joy. A sudden disturbance of the air is also to be guarded against. The prime of life has everything lovely, the decline has the opposite. Incoherence of speech comes from an affection, or from the ears, or from the speaker’s talking of something fresh before he has uttered what was in his mind before, or from his thinking of fresh things before he has expressed what was in his thoughts before. Now this is a thing that happens without any visible affection socalled, mostly to those who are in love with their art. The power of youth, when the matter is trifling, is sometimes supremely great. Irregularity in a disease signifies that it will be a long one. A crisis is the riddance of a disease. A slight cause turns into a cure unless the affection be in a vital part. Because fellow-feeling at grief causes distress, some are distressed through the fellow-feeling of another. Loud talking is painful. Overwork calls for gentle dissuasion. A wooded district benefits.