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,
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indigestion, fatigue: for fever readily recurs unless even a convalescent patient fears that day for some time to come.
17 But if a quotidian has been made out of a quartan fever, since this may have happened from mismanagement, the patient ought to fast for two days, make use of rubbing, and be given only a drink of water in the evening: it often happens that on the third day there is no paroxysm. But whether or not, food should be given after the time for the paroxysm. But if this fever persists, a two days' fast should be enjoined so far as the system can bear it, and rubbing used every day.
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
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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
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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.
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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
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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
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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
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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
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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
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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.
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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
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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.
20 There is also another disease, a contrast in a different way to the phrenetic. In the latter sleep is got with great difficulty, and the mind is disposed to any foolhardiness; in this disease there is a pining away, and an almost insurmountable need of sleep. The Greeks name it lethargy. And it also is an acute sort, and unless remedied, quickly kills. Some strive to excite these patients by applying at intervals medicaments to promote sneezing, and those which stimulate by their offensive odour, such as burning pitch, unscoured wool, pepper, hellebore, castoreum, vinegar, garlic, onion. Moreover, they burn near them galbanum, hair or hartshorn, or when that is not at hand, some other kind of horn, for these when burnt give out an offensive odour. One Tharrias said, indeed, that this affection is a sort of feverish paroxysm, and that the patient is relieved when that remits, hence those without keep on irritating such patients do harm uselessly. But the important point is whether the patient wakes up with the remission; or whether the fever is either not relieved, or else it is relieved and yet sleep still oppresses him. For if the patient wakes up, it is needless to treat him as if in a stupor; for he is not made better by keep in him awake, but if he is better he keeps awake of himself. If the sleepiness in us interrupted the patient must certainly be aroused, but only at those times when the fever is of the slightest, in order that he may both make a
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natural evacuation and take food. Now a most powerful excitant is cold water poured suddenly over him; therefore when the fever has remitted, and he has been anointed freely, he should have three or four jarfuls poured over his head. But this measure should be employed only when the patient's breathing is regular, and the parts below the ribs soft: otherwise those are to be preferred which have been mentioned above. Such is the most suitable procedure, so far as concerns sleeplessness.
But in order to cure, the head is to be shaved, and then fomented with vinegar and water in which laurel or rue leaves have been boiled. On the following day castoreum may be applied, or rue pounded up in vinegar, or laurel berries or ivy with rose oil and vinegar; mustard put to the nostrils is particularly efficacious both for arousing the patient, and when put on the head or forehead for driving out the disease itself. Rocking is also advantageous in this malady; and most of all food given opportunely, that is in the greatest degree of remission that can be found. Now gruel is most fitting until the disease begins to decrease; so if there is a severe paroxysm every day, it is given daily; if every other day, after a more severe paroxysm, gruel, and after a slighter paroxysm, hydromel. Wine is also of no mean service, when given at the proper time all with suitable food. But if this kind of torpor attacks the body after prolonged fevers, all the other measures are to be carried out, in the same way, and in addition three or four hours before the paroxysm castoreum is administered, mixed with scammony if the bowels are costive, if not, then by itself in water. If the parts below the ribs are soft, food should be given more freely; if hard,
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the patient must subsist on the gruel mentioned above, whilst something is to be applied to the parts below the ribs to repress and mollify at the same time.
21 Now the foregoing is indeed an acute disease. But a chronic malady may develop in those patients who suffer from a collection of water under the skin, unless this is dispersed within the first days. The Greeks call this hydrops. And of this there are three species: sometimes the belly being very tense, there is within a frequent noise from the movement of wind; sometimes the body is rendered uneven by swellings rising up here and there all over; sometimes the water is drawn all together within, and is moved with the movement of the body, so that its movement can be observed. The Greeks call the first tympanites, the second leukophlegmasia or hyposarka, the third ascites. The characteristic common to all three species is an excessive abundance of humour, owing to which in these patients ulcerations even do not readily heal. This is a malady which often begins of itself, often it supervenes upon a disease of long standing, upon quartan fever especially (III.15, 16). It is relieved more easily in slaves than in freemen, for since it demands hunger, thirst, and a thousand other troublesome treatments and prolonged endurance, it is easier to help those who are easily constrained than those who have an unserviceable freedom. But even those who are in subjection, if they cannot exercise complete self-control, are not brought back to health. Hence a not undistinguished physician, a pupil of Chrysippus, at the court of King Antigonus, held that a certain friend of the king, noted for intemperance, could not be cured, although but moderately affected by that
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malady; and when another physician, Philip of Epirus, promised that he would cure him, the pupil of Chrysippus replied that Philip was regarding the disease, he the patient's spirit. Nor was he mistaken. For although the patient was watched with the greatest diligence, not only by his physician but by the king as well, by devouring his poultices and by drinking his own urine, he hurried himself headlong to his end. At the beginning, however, cure is not difficult, if there is imposed upon the body thirst, rest, and abstinence; but if the malady has become of long standing, it is not dispersed except with great trouble. They say, however, that Metrodorus, a pupil of Epicurus, when afflicted with this disease, and unable to bear with equanimity necessary thirst, after abstaining for a long while, was accustomed to drink and then to vomit. Now if what has been drunk is then returned, distress is much reduced; but if retained in the stomach, it increases the disorder; and so it must not be tried in every case. But if there is also fever, this is first of all to be overcome by the methods which have been prescribed concerning possible relief in such cases (III.4‑17). If the patient has become free from fever, then at length we must go on to those measures by which the disorder itself is usually treated. And here, whatever the species, so long as the disease has not taken too firm a hold, the same remedies are required. The patient should walk much, run a little, and his upper parts in particular are to be rubbed while he holds his breath. Sweating is also to be procured, not only by exercise, but also by heated sand, or in the Laconicum, or with a clibanus and such-like; especially serviceable are the natural and dry sweating places,
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such as we have in the myrtle groves above Baiae. The bath and moisture of every kind is wrong. Pills composed of wormwood two parts, myrrh one part, are given on an empty stomach. Food should be of the middle class indeed, but, of the harder kind; no more of drink is to be given than to sustain life, and the best is that which stimulates urine. But that, however, is better brought about by diet than by medicament. If, nevertheless, the matter is urgent, one of those drugs which are efficacious is to be made into a decoction, and that given as a draught. Now this faculty seems to belong to iris root, spikenard, saffron, cinnamon, cassia, myrrh, balsam, galbanum, ladanum, oenanthe, opopanax, cardamomum, ebony, cypress seeds, the Taminian berry which the Greeks call staphis agria, southernwood, rose leaves, sweet flag root, bitter almonds, goat's marjoram, styrax, costmary, seeds of rush, square and round (the Greeks call the former cyperon, the latter schoinon): whenever I use these terms I refer, not to native plants, but to such as are imported among spices. The mildest of these, however, are to be tried first, such as rose leaves or spikenard. A dry wine is beneficial, but it must be very thin. It is good besides to measure every day with string the circumference of the abdomen, and to put a mark where it surrounds the belly, then the day following to see whether the body is fuller or thinner, for the thinning shows a yielding to the treatment. Nor is it unserviceable to take the measure of his drink, and of his urine; for if more humour is evacuated than taken in, then at least there is hope of recovery. Asclepiades has put it on record that for a patient who had lapsed from a quartan into dropsy, he employed for two days abstinence and
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rubbing, on the third day, the patient having all become freed from both the fever and the water, he gave food and wine.
So far the prescription can be common to all the species; if the disease is more severe, the method of treatment must be different. For instance, if there is flatulence and owing to that pain is frequent, a vomit is beneficial, either daily or on alternate days, after food; hot and dry foments are to be applied. If the pain is not ended by these, dry cuppings are needed, but if the torment is not relieved even by these, skin incisions are made and then the cups applied. If cupping does no good, the last resource is to infuse hot water copiously into the rectum and draw it out again. Nay even vigorous rubbing with oil and any one of the heating agents should be carried out three or four times a day, but in this rubbing the abdomen is to be left out; but to this mustard should be applied repeatedly until the skin is excoriated; and ulcerations are to be set up in many places upon the abdominal wall by means of the red hot cautery, and the ulcers to be kept open for some time. It is useful also to suck a boiled squill bulb; but for a long while after such attacks of flatulence the patient should abstain from everything that causes it.
But if the affection is that named leukophlegmasia, the swollen parts should be exposed to the sun, but not too much lest feverishness ensue. If the sun is over-strong, the head is to be covered, and rubbing is to be used with hands just moistened with water to which salt and soda and a little oil is added, taking care that the hands of children or of women are employed, for theirs is a softer touch; and this ought to be done, should the patient's strength
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allow of it, for a whole hour before noon, or for half an hour after noon. Repressing poultices are of benefit, especially for the more delicate. Also an incision should be made our fingers' breadth above the ankle on the inner side through which humour may discharge freely for some days, and the actual swellings ought to be incised by deep cuts; the body also is to be shaken up by much rocking (II.15); then after the incisions have formed a scab, both exercises and food must be increased, until the patient is restored to his former state of health. The food should be nutritious and glutinous, mostly meat. The wine, when the stomach permits of it, should be rather sweet, but should be drunk alternately with water every two or three days. The seeds of the wolf's-milk plant, which grows to a large size on the seacoast, may be advantageously administered in a draught with water. If the patient is strong enough, he should suck a boiled squill bulb as noted above. There are many authorities who would have the swelling beaten with inflated ox-bladders.
But if the form of the affection is that in which much water is drawn into the belly, the patient should take walks, but with much more moderation, and have applied a dispersive poultice, covered with three folds of linen, bandaged on not too tightly; a practice begun by Tharrias, which I see many have followed. If the liver or spleen is plainly affected, a fatty fig bruised with honey should be put on over it: if the belly is not dried up by such remedies, and in spite of them the humour is in large amount, aid must be given in a quicker way, by giving issue to it through the belly itself (VII.15). I am quite aware
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that such a way of treatment was disapproved of by Erasistratus, for he deemed the disease to be one of the liver, that therefore it was the liver which had to be rendered sound, and that it was of no use to let out water which, if that organ is diseased, will continually be reproduced. But firstly, the disease is not primarily one of that organ alone; for it occurs when the spleen is affected, and there is a general diseased condition of the body; further, granted that it begins from the liver, the water unnaturally collected there, unless evacuated, injures both the liver and all the rest of the internal organs. And it is agreed, nevertheless, that the body generally has to be treated; for the mere evacuation of the humour does not restore health, but it affords an opportunity for medicaments which the accumulation within impedes. And indeed it is not in dispute that not everybody with this affection can be so treated, but only the young and robust, in whom fever is wholly absent, or who have sufficiently long intermissions. For those are unfitted for this treatment whose stomach is corrupted, or who have lapsed into the malady owing to black bile, or who have a diseased condition of body. But food on the day the humour is first let out is not needed unless strength fails. On the days following, both food and wine, undiluted indeed, but not overmuch in quantity, should be given; little by little the patient should be submitted to exercise, rubbing, sun-heat, sweating, a sea voyage, along with a suitable diet, until he has completely recovered. Such a case requires a bath seldom, more often an emetic on an empty stomach; in summer a swim in the sea is beneficial. For a long while after his recovery, however, the practice of venery is unsuitable.