Vall d’Hebron University Hospital, Barcelona, Spain (Summer 2014)
Bust of Cicero, 1st century
Personal letters provide a window into the beliefs, perceptions, and patterns of interpersonal interaction within a society at a given period. Considering that health issues are part of humans’ daily concerns, epistles are a great testimony to the manner in which their writer perceived them. This is much more evident in antiquity, where epistolography was virtually the only literary genre in which the private life of the author was addressed.
The letters that Cicero wrote to his friends and relatives are unique. They allow us to penetrate the intimate world of one of Rome´s most remarkable statesmen, an outstanding figure whose legacy is still present in our contemporary civilization. They moreover are remarkable because of the variety of topics they tackle, the diversity of characters and public figures alluded to, and the political moment they record: the last years of the Roman Republic. They have been the object of extensive scholarly analysis, but the medical aspects they illustrate have received little attention. Particularly, the letters that Cicero wrote to his dear Tiro provide invaluable evidence of the socio-cultural reactions of the Roman elite to health problems3.
The letters written by Cicero wrote to his dear Tiro provide invaluable evidence of the socio-cultural reactions of the Roman elite to health problems3. In his medical anthropological theory about the social construction of reality, Kleinman wrote that “the real world, no matter its material basis, is also made over into socially and culturally legitimated ideas, practices, and things”. He argues that Illness, a layman’s subjective description of feelings or sensations that make him believe he is ill, and Disease – the reformulation of an illness made by a professional – are both socio-cultural constructs. In other words, the Illness experience is a consequence of learned responses to certain symptoms. Personal, interpersonal, and cultural factors influence the way in which each individual reacts to those feelings of discomfort and guide the steps that need to be taken to regain health. In this context these letters are still relevant today for doctors and patients.
Tiro was initially a domestic slave whom Cicero eventually freed. More importantly, he became his close and admired friend, and his resourceful secretary; not only did he invent the Tironnian notes (a shorthand system to write at the speed of speech, which was used for centuries thereafter), but he also edited part of his former master´s works. Indeed, judging by the content of the letters, there is every reason to believe that he was very dear to Cicero, and accordingly seems to have received the best available care.
The letters to Tiro are collected in the XVI book of the Epistulae ad Familiares, and were written between 53 and 44 BCE. Among other issues, they contain repeated references to three different health problems that Tiro suffered during that period. The first occurred in 53 BCE, while Cicero and Tiro where travelling from Rome to Cumas, on which occasion Tiro had to interrupt the journey. The second and most documented episode occurred at the end of 50 and beginning of 49 BCE. By that time, Cicero and Tiro were travelling back to Rome from the Orient, and again, Tiro had to stay in Patras because he fell ill and could not continue the journey. Finally, the date of the last process mentioned is not clear but probably happened during 47 BCE.
The clinical phenomenon
The most evident feature throughout these letters is the anxiety, uncertainty, and fear prompted by sickness of a close relative when he is away. Indeed, we can easily relate to Cicero’s insistent demands for responses to his letters (Ad Fam. XVI 2, 3 ,6, 11, 15) – he even arranges special couriers to have them delivered (Ad Fam XVI 5, 6). Whenever they do not arrive, or when there is a delay, the lack of information about the course of the illness causes anxiety, sleepless nights, and worries (Ad Fam XVI 7, 10, 12, 14, 15). At certain points, Cicero even seems to be reading between the lines to figure out how his friend is coping with his health problems: “your letter caused me mixed feelings; I was quite disturbed by the first page and slightly comforted by the second one” (Ad Fam XVI 4); “your letters did not inform me at all about your state, still I felt comforted” (Ad Fam XVI 14); “I received your letter with your shivery handwriting” (Ad Fam XVI 15); “I am expecting you in a state of suspended animation” (Ad Fam XVI 3).
Another hint of the way Romans envisaged the illness experience becomes clear through the constant allusions to resting, avoiding efforts, taking time off … not far from what we would nowadays call “common sense”. The aim was saving all the energy to fight the disease instead of worrying about obligations (Ad Fam XVI 3, 4, 6, 7, 8, 9, 10, 11, 18, 20). There is also an almost obsessive request to postpone sea trips for the sake of recovery (Ad Fam XVI 1, 4, 6, 7, 8). The sea seems to further endanger the “weakness” caused by the illness. Apparently, the reasons for such fear were the cold weather when sailing in the wrong season (Ad Fam XVI 1, 8), seasickness (Ad Fam XVI 8), and the length and hardships of sea journeys (Ad Fam XVI 9).
All in all, the perception Cicero transmits about the illness experience is that of a process that abruptly interrupts the normal course of life. It seems as though all aspects and activities of life need to be put on hold to save energy for the recovery: “put everything aside, take care of your body” (Ad Fam XVI 4); “I hope … these days you will take care of nothing else but convalescing” (Ad fam XVI 11). Again, this sounds like a sensible tip to our modern ears. An interesting exception to this kind of illness experience is found with depression: when a doctor diagnosed that Tiro´s disease was due to “low spirit”, Cicero suggested that he should “wake up [his] literary interests”, and “heal the spirit” to heal the body (Ad Fam XVI 14).
On a more practical level, illness seems to have cost a lot of money, and Cicero repeatedly insists on putting all his economic resources at Tiro´s disposition. “Just one thing I ask from you, dear Tiro, don´t cut down on any expenses that are necessary for your health. I wrote to Curio to give you whatever you ask for” (Ad Fam XVI 4). Moreover, there is a comment in Ad Fam XVI 14 that has been interpreted by the tradition as Cicero suggesting that the doctor’s fees were abusive: “Give the order to promise the doctor however much wages he asks for”. Indeed, the parallel with contemporary complaints about our expensive medicine is not difficult to draw.
At all levels, therefore, the illness experience is perceived as a postponement: the sufferer needs to defer his commitments and obligations until he is healthy again, the closest family are glad to postpone their wishes to see their relative when he has recovered (Ad Fam XVI 1, 2, 4, 6, 8, 9, 10, 11, 12); and finally, the unlimited offer of money – although not clearly stated – also must have put other projects on hold.
As far as the transactions with the health professionals are concerned, the first physician alluded to is criticised: “regarding the doctor … I completely disagree with his treatment: he shouldn´t have given you juice considering you have a bad stomach”. Most interestingly, not only does Cicero dare to disagree with the professional, but he also writes to him, presumably asking for an explanation (Ad Fam XVI 4). On other occasions, he does accept the diagnosis (Ad Fam XVI 14), or he even advises Tiro to listen to the doctor and obey him (Ad Fam XVI 20).
In any case, what becomes quite clear from these letters is that the doctor´s words could be questioned. An educated layman could perfectly disagree with a diagnosis or a treatment, and the doctor was expected to give explanations. It seems as though relatives challenging the doctors’ opinions is not necessarily a direct consequence of the Internet and our current easy access to information. Even in ancient Rome well-educated men felt entitled to question and argue with health professionals.
Regarding the healing process, different kinds of actions are undertaken. On the one hand, there is the strictly medical treatment normally – but not exclusively – prescribed by the practitioner, and on the other, the advice offered by the family and the community. In parallel with these medical interventions, Cicero mentions a whole series of arrangements he makes in order to ensure a successful convalescence: he sends slaves (Ad Fam XVI 5, 14) and a cook (Ad Fam XVI 15) to help Tiro, and he writes to his hosts and acquaintances in Patras to take care of him (Ad Fam XVI 4, 5, 12) and organizes his journey back (Ad Fam XVI 4, 5, 9, 12).
The structure of the clinical phenomenon that can be elucidated from these letters shows that the healing process is a mirror image of the illness experience. While at the individual level illness is experienced as a standstill in the life of the patient; at the family/community level, the healing process sets in motion the whole social network in order to bring about recovery: “Don´t you worry about anything else than your recovery, I´ll take care of the rest” (Ad` Fam XVI 5).
If we accept Kleinman’s idea that sickness is a socio-cultural construct, then we should agree that there is no natural or innate way to react to it, but instead each human group develops its own responses. This estranged look at the clinical phenomenon induces us to rethink our own reactions to health problems and to understand why we still nowadays read, relate, and even sympathise with Cicero’s concerns: because our feelings towards the ailments of our dear ones are not very different from his. At least since the Roman Republic, we have been reacting in a similar manner to health problems. Cicero’s letters should make us mindful to the fact that the anxiety, the uncertainty, and the urge for news that we feel are part of our cultural learning. Our natural way to react is with stress and concern. As doctors, these letters should make us more sympathetic when a patient or a relative questions our indications. Again, we should not think that they are personally challenging our expertise, but simply reacting according to their socio-cultural heritage.
- Hoffer 2007, pp. 87-88
- Wöhrle 2010, p. 160
- Kleinman 2010, p. 1519
- Kleinman 1978, p. 252
- Kleinman 1978, p. 254
- Kleinman 1978, pp. 255-7
- Menière 1862, p. 29
- Shackleton Bailey 1977, Vol II p. 385
- The letters are cited according to the traditional organization, rather than the chronological approach, which was first introduced by R.Y. Tyrrel and L.C. Purser in their edition of 1879. This traditional numbering is based on the topics tackled, the genres and the addressees. All the quotes are based on W.S. Watt’s edition and the translations are my own.
- Gourevitch interprets these allusions as a phobia of the sea that Cicero was projecting on Tiro. (Gourevitch 1984, p. 445)
- This involvement of Curio in financing Tiro’s treatment is also mentioned in a letter to Atticus. (Wohrle 2010, p.183)
- Gourevitch 1984, p. 450
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ANDRÉS D. PELAVSKI, MD, MPhil, PhD a consultant anesthetist in Spain, with six years of experience in a major university hospital. He also completed an undergraduate degree in Classics at the University of Barcelona, followed by a MPhil in Classics at the University of Cambridge. The topic of his research in the master’s programme was the ancient history of medicine. Currently he is doing a fellowship in cardiac anesthesia at Papworth Hospital, United Kingdom.