De Medicina

12 Now shivering usually precedes those fevers which have a fixed cycle and a complete remission; hence they are the most safe, and specially admit of treatment. For when periodicity is uncertain,

neither clyster nor bath, nor wine nor other medicament, is administered at the right moment: for it is uncertain when the fever will supervene, so that if it comes on suddenly, it may happen that there is the greatest harm in what is intended to serve as an aid. And there is nothing else that can be one, except for the patient to abstain strictly for the first days, then, upon the decline of that paroxysm which is the severest, to take food. When, however, there is an assured cycle, all those remedies are more easily tried, because we are more able to inform ourselves of the alternations between paroxysms and remissions. In those fevers, however, which have become inveterate, starving is not of service; it is only in the first days that the fever is to be thus countered; later the treatment is to be divided, first to disperse the shivering, then the fever. Therefore, as soon as the patient shivers, and after the shivering grows hot, he should be given to drink tepid water with a little salt in it, and so made to vomit: for generally such shivering arises from a bilious sediment in the stomach. Likewise if shivering recurs at the next cycle, the same should be done; for often the fever is thus shaken off, and now we may learn to what class it belongs. And so in view of the possibility of the next paroxysm, the third which may be threatening, the patient should be conducted to the bath, and it should be do arranged that he is already in the solium at the moment for the shivering. If there also he feels chilled, yet none the less he should do the same again in view of a fourth paroxysm, for often in that way the shivering is shaken off. If there is no benefit even from the bath, before the paroxysm let him eat garlic, or drink hot water containing pepper; to see if these when taken excite heat which prevents the shivering. Further in the same way as prescribed for a chill before shivering can come on, the patient should be covered up, and the whole body surrounded with foments — but the stronger ones are to be used at once — and thoroughly encompassed by wraps which enclose hot tiles and cinders. If, notwithstanding, shivering breaks out, let the patient be anointed freely under the wraps with hot oil, to which add one of the heating elements: let rubbing be applied, so far as he can bear it, especially of the arms and legs, while he holds his breath. Nor should it be stopped even if he shivers; for often the pertinacity of the rubber overcomes the body's malady. If he vomits somewhat, tepid water is to be given him, and he is to be forced to vomit again; the same measures must be used until shivering comes to an end. But if the shivering is too slow in subsiding, in addition to the above, a clyster should be given; for that also is of good effect by unloading the body. The last remedies after these are rocking and rubbing. Now in such illness the food to be given is such chiefly as will secure a soft motion, meat glutinous, wine, when any is given, dry.

14 But if it be a tertian, when there are complete

intermissions, or a quartan, on the intermediate days the patient should make use of walking and of other exercises and of anointings. In this kind of malady, well before the paroxysm, a certain Cleophantus, one of the ancient physicians, poured over the patient's head quantities of hot water; and then gave wine. Asclepiades, although he followed many of this man's precepts, rejected this one, and rightly, for it is of doubtful effect. In the case of a tertian fever, Asclepiades said that on the third day following the paroxysm, the bowels should be moved by a clyster; on the fifth day after the shivering a vomit should be elicited; then, after the paroxysm, according to the custom of Cleophantus, patients whilst still heated were to be given food and wine, on the sixth day to be kept in bed; for so he hoped to prevent a paroxysm on the seventh day. It is likely that this may often happen. It is safer, however, so that we may use the exact order laid down, to try the three remedies, vomiting, clystering, and wine-drinking, on three several days, that is, on the third, fifth and seventh days, with this proviso that on the seventh day wine is not to be drunk until after the time for the paroxysm. But if a tertian fever is not dispersed within the first days, but is becoming chronic on the day that the paroxysm is expected, the patient should keep his bed; after the paroxysm he should be rubbed, then, having taken food, drink water; on the day following, which is free from fever, the patient should keep quiet, avoid exercise and anointing, and be content with water only. And that indeed is the best procedure; but if there is urgent weakness, he may both take wine after the paroxysm and a little food on the intermediate day.

15 In a quartan fever the same should be done. But seeing that unless it has been shaken off within the first days, it is a long while in terminating, we must be more careful from the very first to lay down what should be done in it. Therefore if a paroxysm has set in with shivering and has remitted, the patient ought to observe a regimen on the same day and on the following and on the third day; on the first day after the paroxysm he should take only hot water; on the next two days abstain if possible even from that;; on the fourth day, if the fever recurs with shivering, he should vomit, as was prescribed before; then after the paroxysm he should take a limited quantity of food and of wine four ounces. On the next two days he should fast, taking only hot water if thirsty. On the seventh day the cold stage should be anticipated by the bath; if a paroxysm recurs, the bowels should be moved by a clyster; having settled down after the clyster, the patient should be anointed and rubbed vigorously; then take food and wine as above; on the next two days abstain, and undergo rubbing. On the tenth day trial is again made of the bath; and if after that a paroxysm follows, he should in the same way be rubbed, and drink wine more freely. And it is likely that so many days of fasting, along with the other measures prescribed, will get rid of the fever. But if the quartan fever persists notwithstanding, a totally different line of treatment is to be pursued, the aim being that the body may easily bear what has to be borne for a long while. Therefore we cannot approve the practice of Heraclides of Tarentum, who said that in the first days the bowel was to be clystered and then there was to be abstinence until the seventh day.

Even supposing a man could endure this, yet if he does become freed from fever, he will have scarcely strength enough to recover; they themselves if there be more frequent recurrences of the fever he will sink. If, therefore, the disease shall remain on the thirteenth day, the bath should not be tried, either before or after the paroxysm, except occasionally when the shivering has been thrown off. The actual shivering is to be driven off by the measures above prescribed; then after the paroxysm it will be proper that the patient be anointed, and rubbed vigorously, and take food both nourishing and abundant, with as much wine as he likes; on the day following, when sufficiently rested, he is to walk, to take exercise, to be anointed and vigorously rubbed, then to take food without wine, and on the third day to abstain. On the day that a recurrence of the paroxysm is expected, he should get up beforehand, and so arrange the performance of the exercises that the time for the onset of the fever concurs with that of the exercise; for often in this way the paroxysm is thrown off. But if attacked during the exercise, he should thereupon return home to bed. In this kind of sickness the remedies are: anointing, rubbing, exercise, food, wine. If constipated, the bowels are to be clystered. But whilst the stronger patients can easily carry out the above, if weakness has supervened, rocking should replace exercise; if even that cannot be borne, nevertheless rubbing should be applied. If this also, when vigorous, is trying to the patient, treatment should be restricted to rest and anointing and food; care being taken that indigestion does not convert the quartan into a quotidian fever. For a quartan kills no one, but when a quotidian is made out of it, the patient is in a bad way; this, however, does not happen unless through the fault either of the patient or of the practitioner.

16 But if there is a double quartan fever, and those exercises which I have mentioned cannot be adopted, either the patient should rest entirely, or if that is difficult walk quietly, then sit with his feet and head carefully wrapped up; as often as a paroxysm has recurred and has remitted, he should take food in moderation and wine; for the remainder of the remission, unless there is urgent weakness, he should fast. But if two paroxysms are almost continuous, he should take food after both are over; then in the intermission he should move about a little, and after being anointed take food. Now since an inveterate quartan is seldom got rid of except in the spring, it is at that season especially that attention is to be given, lest something occur to hinder recovery. And it is of advantage in an old quartan to later now and then the class of diet, and change from wine to water, from bland food to acrid, from acrid to bland; to eat radish, then to vomit; to move the bowels by shell-fish or chicken broth; to add heating agents to the oil for rubbing; before the paroxysm to sip two cups of vinegar, or one cup of mustard in three of Greek salted wine, or pepper, castoreum, laser and myrrh in equal proportions in water. For by these and such-like remedies the system is to be stirred up in order that it may be moved from the state in which it is being held. When the fever has quieted down, for a long while it is well to keep in mind the day on which it occurred, and on that day to avoid cold, heat,

indigestion, fatigue: for fever readily recurs unless even a convalescent patient fears that day for some time to come.

18 The regimen of fevers has now been expounded; there are, however, other affections of the body which follow upon this, among which I subjoin in the first place those which cannot be assigned to any definite part.

I shall begin with insanity, and first that form of it which is both acute and found in fever. The Greeks call it phrenesis. Before all things it should be recognized, that at times, during the paroxysm of a fever, patients are delirious and talk nonsense. This is indeed no light matter, and it cannot occur unless in the case of a severe fever; it is not, however, always equally dangerous; for commonly it is of short duration, and when the onslaught of the paroxysm is relieved, at once the mind comes back. This form of the malady does not require other remedy than that prescribed for the curing of the fever. But insanity is really there when a continuous dementia begins, when the patient, although up till then in his sanity in his senses, yet entertains certain vain imaginings; the insanity becomes established when the mind becomes

at the mercy of such imaginings. But there are several sorts of insanity; for some among insane persons are sad, others hilarious; some are more readily controlled and rave in words only, others are rebellious and act with violence; and of these latter, some only do harm by impulse, others are artful too, and show the most complete appearance of sanity while seizing occasion for mischief, but they are detected by the result of their acts. Now that those who merely ave in their talk, or who make but trifling misuse of their hands, should be coerced with the severer forms of constraint is superfluous; but those who conduct themselves more violently it is expedient to fetter, lest they should do harm either to themselves or to others. Anyone so fettered, although he talks rationally and pitifully when he wants his fetters removed, is not to be trusted, for that is a madman's trick. The ancients generally kept such patients in darkness, for they held that it was against their good to be frightened, and that the very darkness confers something towards the quieting of the spirit. But Asclepiades said that they should be kept in the light, since the very darkness was terrifying. Yet neither rule is invariable: for light disturbs one more, darkness another; and some are met with in whom no difference can be observed, either one way or the other. It is best, therefore, to make trial of both, and to keep that patient in the light who is frightened by darkness, and him in darkness who is frightened by light. And when there is no such difference, the patient if strong should be kept in a light room, if not strong he should be kept in a dim one. Now it is useless to adopt remedies when the delirium is at its height; for simultaneously fever is also increasing. So then there is nothing else to do than to restrain the patient, but when circumstances permit, relief must be given with haste. Asclepiades said that in such cases to let blood is to commit murder; following the line of reasoning, that there was no insanity unless with high fever, and that properly blood was let only during the stage of remission. But he himself in these cases sought to bring on sleep by prolonged rubbing, though it is the intensity of the fever which hinders sleep, and it is only during the remission that rubbing is of service. Hence he ought to have passed over this remedy also. What then is there to do? Many things may be rightly done in imminent danger, which otherwise ought to be omitted. And fever also, when continuous, has times during which, although it does not remit, yet it does not increase, and this time, although not the best, yet is the second best time for remedies; and at this time blood ought to be let, if the patient's strength allow it. There can be less question as to whether a motion should be induced. Next, after a day's interval, the head should be shaved bare and then fomented with water in which vervains or other repressive herbs have been boiled; alternatively it is proper first to foment, then to shave, and again to foment; and lastly to pour rose oil over the head and into the nostrils; also to hold to the nose rue pounded up in vinegar, and to excite sneezing by drugs efficacious for the purpose. Such things, however, should be done only in the case of those who are not lacking in strength; but if there is weakness, the head is merely moistened by rose oil to which thyme or something similar has been added. Whatever the patient's strength, the two herbs, bitter-sweet and pellitory, are beneficial, if the head is wetted with the juice expressed from both simultaneously. When the fever has remitted, recourse should be had to rubbing, more sparingly, however, in those who are over-cheerful, than in those who are too gloomy. But in dealing with the spirits of all patients suffering from this type of insanity, it is necessary to proceed according to the nature of each case. Some need to have empty fears relieved, as was done for a wealthy man in dread of starvation, to whom pretend legacies were from time to time announced. Others need to have their violence restrained as is done in the case of those who are controlled even by flogging. In some also untimely laughter has to be put a stop to by reproof and threats; in others, melancholy thoughts are to be dissipated, for which purpose music, cymbals, and noises are of use. More often, however, the patient is to be agreed with rather than opposed, and his mind slowly and imperceptibly is to be turned from the irrational talk to something better. At times also his interest should be awakened; as may be done in the case of men fond of literature, to whom a book may be read, correctly when they are pleased by it, or incorrectly if that very thing annoys them; for by making corrections they begin to divert their mind. Moreover, they should be pressed to recite anything they can remember. Some who did not want to eat were induced to do so, by be placed on couches between other diners. But certainly for all so affected sleep is both difficult and especially necessary; for under it many get well. Beneficial for this, as also for composing the mind itself, is saffron ointment with orris applied to the head. If in spite of this the patients are wakeful, some endeavour to induce sleep by draughts of decoction of poppy or hyoscyamus; others put mandrake apples under the pillow; others smear the forehead with cardamomum balsam or sycamine tears. This name I find used by practitioners, but there are no tears on the mulberry, although the Greeks call the mulberry sycaminon. What in fact is meant are the tears of a tree growing in Egypt, which they call in that country sycamoros. Many foment the face and head at intervals with a sponge dipped in a decoction of poppy heads. Asclepiades said that these things were of no benefit, because they often produced a change into lethargy (III.20); but he prescribed for the patient that during the first day he should keep from food, drink and sleep, in the evening water should be given him to drink, after which he should be rubbed with gentleness, but the rubber must not press hard even with the hand (II.14); during the day following the same was to be done, then in the evening gruel and water should be given and rubbing again applied: for by this he said we should succeed in bringing on sleep. This does happen sometimes, and to such a degree that Asclepiades allowed that excess of rubbing may even cause danger of lethargy. But if sleep does not thus occur, then at length it is to be procured by the above medicaments, having regard, of course, to the same moderation, which is necessary here also, for fear we may afterwards not be able to wake up the patient whom we wish to put to sleep. Sleep is also assisted by the sound of falling water near by, also rocking after food and at night, and especially the motion of a slung hammock (II.15). If blood has not been let before, and the patient's mind is unstable and sleep does not occur, it is not unfitting to apply a cup over an incision into the occiput, which can produce sleep because it relieves the disease. Now moderation in food is also to be observed: for the patient ought not to be surfeited lest it madden him, and he should certainly not be tormented by fasting lest he collapse through debility. The food should be light, in particular gruel, and hydromel for drink, of which three cups are enough, given twice a day in winter, and four times in summer.

There is another sort of insanity, of longer duration because it generally begins without a fever, but later excites a slight feverishness. It consists in depression which seems caused by black bile. Blood-letting is here of service; but if anything prohibit this, then comes firstly abstinence, secondly a clearance by white hellebore and a vomit. After either, rubbing twice a day is to be adopted; if the patient is strong, frequent exercise as well: vomiting on an empty stomach. Food of the middle class should be given without wine; but as often as I indicate this class of food, it should be understood that some of the weakest class of food also may be given, provided that this is not used alone; and that it is only the strongest class of food which is excluded. In addition to the above: the motions are to be kept very soft, causes of fright excluded, good hope

rather put forward; entertainment sought by story-telling, and by games, especially by those with which the patient was wont to be attracted when sane; work of his, if there is any, should be praised, and set out before his eyes; his depression should be gently reproved as being without cause; he should have it pointed out to him now and again how in the very things which trouble him there may be a cause of rejoicing rather than of solicitude. When there is fever besides, it is to be treated like other fevers.

The third kind of insanity is of all the most prolonged whilst it does not shorten life, for usually the patient is robust. Now of this sort there are two species: some are duped not by their mind, but by phantoms, such as the poets say Ajax saw when mad or Orestes; some become foolish in spirit.

If phantoms mislead, we must note in the first place whether the patients are depressed or hilarious. For depression black hellebore should be given as a purge, for hilarity white hellebore as an emetic; and if the patient will not take the hellebore in a draught, it should be put into his bread to deceive him the more easily; for if he has well purged himself, he will in great measure relieve himself of his malady. Therefore even if one does of the hellebore has little effect, after an interval another should be given. It should be known that a madman's illness is less serious when accompanied by laughter than by gravity. This also is an invariable precept in all disease, that when a patient is to be purged downwards, his belly is to be loosened beforehand, but confined when he is to be purged upwards.

If, however, it is the mind that deceives the madman, he is best treated by certain tortures. When he

says or does anything wrong, he is to be coerced by starvation, fetters and flogging. He is to be forced both to fix his attention and to learn something and to memorize it; for thus it will be brought about that little by little he will be forced by fear to consider what he is doing. To be terrified suddenly and to be thoroughly frightened is beneficial in this illness and so, in general, is anything which strongly agitates the spirit. For it is possible that some change may be effected when the mind has been withdrawn from its previous state. It also makes a difference, whether from time to time without cause the patient laughs, or is sad and dejected: for the hilarity of madness is better treated by those terrors I have mentioned above. If there is excessive depression light and prolonged rubbing twice a day is beneficial, as well as cold water poured over the head, and immersion of the body in water and oil. The following are general rules: the insane should be put to fatiguing exercise, and submitted to prolonged rubbing, and given neither fat meat nor wine: after the clearance the lightest food of the middle class is to be used; they should not be left alone or among those they do not know, or among those whom either they despise or disregard; they ought to have a change of scene, and if the mind returns, they should undergo the tossing incident to travel (II.15), once a year.

Rarely, yet now and then, however, delirium is the produce of fright; this class of insanity, has similar sub-divisions, and is to be treated by the same species of dietetic regimen, except that, in this form of insaneness alone, wine is properly given.

19 That kind of affection which the Greeks call cardiac is a complete contrast to the foregoing

diseases, although insane persons often pass over into it; in those the mind gives way, in this it holds firm. Indeed the illness is nothing other than excessive weakness of the body, which, while the stomach is languid, wastes away through immoderate sweating. And it may be recognized at once by the exiguous and weak pulsation of the blood vessels, while sweat, at once unaccustomed and excessive and untimely, breaks out all over the chest and neck, and even over the head, the feet and legs remaining more dry and cold; and it is a form of acute disease.

The primary treatment is the application over the chest of repressant plasters; the secondary, to stop sweating. The latter is accomplished by bitter olive oil, or rose or quince or myrtle oil, with any of which the body is to be lightly anointed, then a salve made up of any of them is to be applied. If the sweating wins, the patient is to be smeared over with gypsum or litharge or cimolian chalk, or even powdered over with the same at intervals. A powder consisting of the pounded leaves of dried myrtle or of blackberry, or of the dried lees of dry and good wine, attains the same end; there are many simple materials, and if these are not at hand, it is useful enough to scatter on any dust from the road. In addition to this, moreover, in order that he may sweat less, the patient should be lightly covered and lie in a cool room, with the windows open, so that some breeze reaches him.

A third aid is to help his weakness whilst in bed by food and wine. The food, whilst not much in quantity, should be given often, as well by night as by day, so as to nourish without becoming onerous.

It should consist of the weakest class of materials and should be suitable to the stomach. Unless there is necessity, it is not well to hurry on to wine. But when fainting is apprehended, then there is given both bread crumbled into the wine and wine by itself dry indeed yet thin, undiluted, lukewarm, at intervals liberally, and if the patient is taking but little food, polenta may be scattered into the wine; and that wine should not be lacking in strength, yet not over-strong the patient may properly drink three quarters of a litre, and even more if of large build, in the course of a day and night: if he does not take his food, the patient should be anointed, should have cold water poured over him, and after that be given food. But if the stomach has become relaxed and retains but little, let the patient vomit as he will, whether before or after food, and after vomiting take food again. If even after that food is not retained, he should sip a cupful of wine, and another after the interval of an hour. If the stomach returns this wine also, he should be rubbed all over with pounded onions, which as they dry cause the stomach to retain the wine, and as a result, cause heat to return throughout the body, and a forceful pulsation to the blood vessels. The last resource is the introduction into the bowel from below of barley or spelt gruel, since that too supports the patient's strength. Should he feel hot, it is not inappropriate to hold to his nostrils a restorative such as rose oil in wine; if he has cold extremities, they should be rubbed by hands anointed and warmed. If we can by these measures obtain a diminution in the severity of the sweating, and a prolongation of life, time itself now begins to come to our aid. When the patient appears to have reached safety, rapid release into the same state of weakness is still to be feared; hence along with a gradual withdrawal of wine, the patient ought each day to take stronger food, until a sufficiency of bodily strength is gained.