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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[p. 291] 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[p. 293] 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.[p. 295] 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[p. 297] 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[p. 299] 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[p. 301] 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[p. 303] 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.

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