De Medicina

4 Such for the most part is the account of fevers; but there are different sorts of treatment in accordance with what is held by the several authorities. Asclepiades said that it is the office of the practitioner to treat safely, speedily, and pleasantly. That is our aspiration, but there is generally danger both in too much haste and too much pleasure. But what moderation must be shown, in order that as far as possible all those blessings may be attained, the patient's safety being always kept first, will be considered among the actual details of the treatment.

Before everything is the question as to what regimen the patient should keep to during the first days. The ancients tried to ensure assimilation by administering certain medicaments, because they dreaded indigestion most of all; next by the repetition of clysters they extracted the matter which appeared to be doing harm. Asclepiades did away with medicaments; he did not clyster the bowel with such frequency but still he generally did this in every disease; but the actual fever, he professed to use as a remedy against itself: for he deemed that the patient's forces ought to be reduced by daylight, by keeping awake, by extreme thirst, so that during the first days he would not allow even the mouth to be swilled out. Therefore those are quite wrong who

believe that his regimen was a pleasant one in all respects; for in the later days he allowed even luxuries to his patient, but in the first days of the fever he played the part of torturer. Now in my opinion medicinal draughts and clysters should only be administered occasionally; and I consider that they should not be used as to pull to pieces the patient's strength, since the greatest danger is from weakness. There ought to be, therefore, only such a diminution of superfluous matter as is dispersed by natural processes when nothing is being added afresh. Hence for the first days there is to be abstinence from food; the patient is to keep in the light during the day unless weak, for this also clears the body; and so he ought to lie up in a room as . . . as possible. As regards indeed thirst and sleep, it should be so managed that he keeps awake during the day; at night as far as possible he should be at rest; and he should neither drink much nor be too much distressed by thirst; his mouth also can be swilled out when dry, if he has a bad taste in it, even though that is not the time suitable for a drink. And Erasistratus said appropriately that often whilst the inside does not require fluid, the mouth and throat require it, and it does not help to keep the patient in suffering. And for the first days, such ought to be the regimen.

But his best medicament is food opportunely given; the question is when it should first be garden. Most of the ancients gave it late, often on the fifth, often on the sixth day of illness, which the climate of Asia or of Egypt may perchance permit. Asclepiades, after he had for three days harassed the patient in every way, destined the fourth day for food. But Themison, recently, took into account

not when the fever began, but when it ceased, or at any rate was alleviated; and awaiting the third day from that time, if there was no return of the fever, gave food at once; if fever recurred, he gave food when it ceased, or if it obstinately persisted, he certainly gave it if the fever abated. But on none of these matters is there actually an invariable precept. For it may be that the first food should be given on the first day, it may be on the second, it may be on the third, it may be not until the fourth or fifth day; it may be after one paroxysm, it may be after two, it may be after several. For it all depends upon the kind of disease, the patient's body, the climate, his age, and the time of year; where circumstances differ so greatly, there cannot be an invariable rule of time by any means. In the case of a disease which takes away more of the patient's strength, food is to be given earlier, and the same in a climate in which he uses up more. Hence in Africa it seems right that a patient should never fast over a day. Food should also be given sooner to a child than to an adolescent, sooner in summer than in winter. There is one thing that should be observed, always, and everywhere, that the patient's strength should be continually under the eye of the attending practitioner; and so long as there is a superfluity, he should counter it by abstinence; if he begins to fear weakness, he should assist with food. For it is his business to see that the patient is neither burdened by superfluous material nor rendered weak by hunger. And this I find also in the writings of Erasistratus; who although he did not direct when the bowels should be emptied, or when the body in general, nevertheless, by saying that such things should be seen to, and food given when it was needed by the body, showed sufficiently that food should not be given while the strength was in excess, but that care should be taken not to let it become deficient. Hence it can be understood that it is not possible for many patients to be cared for by one practitioner, and provided that he is skilled in the art, he is a suitable one who does not much absent himself from the patient. But they who are slaves to gain, since more is to be got out of a crowd, are glad to adopt those precepts which do not exact a sedulous attendance, as in this very instance. For even those who see the patient but seldom find it easy to count days or paroxysms; a physician must always be at hand, if he is to see the one thing that matters, the point when the patient is about to become too weak unless he gets food. The fourth day, however, is generally the most suitable date for beginning to give food.

But there is another uncertainty which concerns even the days themselves, since the ancients chiefly preferred the odd days and termed them critical, as though then the fate of the sick man was decided. These were the third, fifth, seventh, ninth, eleventh, fourteenth and twenty-first days, the most importance being attached to the seventh, next to the fourteenth and then to the twenty-first. Therefore they administered food to their patients as follows: they awaited paroxysms on odd days, and after that they gave food, as though slighter paroxysms were impending, insomuch that Hippocrates, when the fever desisted on any other than an odd day, was accustomed to fear a recurrence. Asclepiades has justly repudiated this as false, and he said that no day was more or less dangerous

to patients for being even or odd. For sometimes even days are the worse, and it is more suitable to give food after paroxysms on these days. Sometimes even in the course of the same fever the daily order changes, and that day becomes graver which had wont to have more of a remission; and besides, the fourteenth day itself, which the ancients confessed to be of great importance, is an even day. Since they held that the eighth day had the character of the first day, because from it began the second numbering of seven, they contradicted themselves in not giving more importance to the eighth, tenth and twelfth days, for they gave more to the ninth and eleventh. After doing this without any rational probability, they went on from the eleventh, not to the thirteenth, but to the fourteenth day. There is even in Hippocrates this statement, that the fourth day is the gravest in the case of those whom the seventh day is to liberate. So according to that very authority, there may be on an even day both a graver fever and a certain sign of what will happen. In another passage the same authority regarded each fourth day, namely, the fourth, seventh, eleventh, fourteenth, and seventeenth, as the most effective in both respects. Thus he passed from an odd system of reckoning to an even one, yet did not, even then, keep to his proposition; for the eleventh is not the fourth day after the seventh, but the fifth. It is clear enough that by whatever reasoning we view this numbering, there is to be found nothing rational in that authority at least. But in these matters indeed the Pythagorean numbers, then quite famous, deceived the ancients, since here also the practitioner ought not to count days, but observe the actual paroxysms, and from these infer when food should be given.

But it is much more pertinent to this subject to know whether food should be given when the pulse has well quieted down, or while remnants of the fever still persist. For the ancients proffered food when the bodies were as far as possible from fever: Asclepiades did so when the fever was beginning to abate although present. In this he followed false reasoning; not that food may not be given earlier sometimes, if another paroxysm is feared soon, but it certainly ought to be given when the patient is at his soundest: for food is less corrupted when introduced into a body free from fever. Nor however, is that true, which Themison held, that if the patient was likely to be free from fever for a couple of hours, it was better to give food then, in order that the food might be distributed when the body was as far as possible fever-free. For if it were possible for it to be distributed so quickly, that would be the best plan; but since that short time does not allow of it, it is better that the first food should be received by a declining fever, rather than

that remnants of food should be received by a recommencing fever. In this case, if the favourable time is longer, it should be given when the body is as free as possible; if short, even before it becomes quite free. But what also holds good for a full freedom does so also for a remission, which can occur, especially in the course of a continuous fever.

And there is the further question, whether it is necessary to wait for the same number of hours as the fever lasted, or if it is sufficient to suffer the first part of them to elapse so that the food may settle down more comfortably for the patient, if sometimes there is no intermission. It is safest, however, first to let pass the period of the whole preceding paroxysm, although in the case of a prolonged fever the patient may be indulged earlier, provided that half at least of that time has first passed. And this is to be observed not only in the fever just mentioned but in all.

5 The foregoing rules are rather of general application to fevers of all sorts: now I pass to their particular kinds. If, therefore, there has been only one paroxysm, then an intermission, and the fever arises either from the groin, or from fatigue, or from hot weather, or some other similar thing, and so that it gives no apprehension of a more internal cause, then on the day following, when the time for the recurrence of a paroxysm has elapsed without any disturbance, food can be given. But when there supervenes a deeply seated heat and a sense of weight, whether in the head or in the parts below the ribs, and it is not evident what is disturbing the system, even although freedom follows upon a single paroxysm, nevertheless the third day is to be awaited because a

tertian is to be apprehended; and when the time for such a paroxysm has passed, food is to be given, but in small amount, because a quartan may yet be apprehended; and not until the fourth day, if the body is still free, may it be used with confidence. But if on the second, or third, or fourth day fever has recurred, the disease can be recognized. But tertian and quartan fever in which there is both a definite cycle ending in freedom from fever, and ample periods of quiet, are most quickly dealt with, and of these I will speak in their proper place (III.14, 15). Now, however, I will explain the treatment of those fevers which cause trouble every day. Food, therefore, is more suitably given to the patient upon alternate days, in order one day to diminish the fever, the other to recruit his strength. But if it be that sort of quotidian fever in which there is a complete intermission, food should be given immediately upon the body becoming fever-free: if, although there are no paroxysms, the fever is nevertheless continuous and daily increasing, but with remissions that are not complete, food should be given when the system is in that state that no major remission is expected; if the paroxysm on one day is more severe, on the next day milder, food is to be given after the more severe paroxysm. But if the fever continues without ever becoming milder, and it is necessary to give food, there is a great controversy as to the time when it should be given. Some, because patients generally have more of a remission early in the morning, think that food should be given then. But if this answers, the reason for giving food is not the fact that it is morning, but the fact that the patient has more of a remission. But if the patient has no relief even in the morning, it becomes all the worse time for food, just because, although by itself that time should be better, owing to the fault of the disease it is not so; and at the same time, it is followed by midday, after which generally patients become worse, and so it may be feared that the patient may become more distressed than usual. To such a patient, therefore, others give food in the evening: but since at that time those who are ill are generally at their worst, there is fear that any action we may then take may exasperate the fever somewhat. For these reasons I delay until midnight, that is, when one critical time is over, and the next furthest off, whilst the hours which follow before dawn are those during which all patients generally sleep the most; after that comes early morning, naturally a period of greatest relief. If, however, fevers are erratic, since there is apprehension that paroxysms may immediately follow food, whenever a patient begins to have relief after a paroxysm, then food ought to be taken. But if several paroxysms occur on the same day, it should be noted whether they are equal in all respects, which can scarcely ever be the case, or unequal. If they are equal in all respects, food should be given rather after any paroxysm which does not desist between midday and evening. If they are unequal, it is to be considered in what way they differ; for if one is more severe and another slighter, food should be given after the more severe; if one lasts longer, another a shorter time, after the longer; if one is more severe, another more prolonged, it is to be observed which of thetwo causes more distress, the former by its severity, or the latter by its length, and food must be given after the one which causes the most distress. But what matters almost more than anything is, how long and of what kind are the remissions between them: for if after one paroxysm shivering persists, after another the body is free from this, the more suitable time for food is when the body is free. If a slight feverishness persists all the time, but a longer period of remission occurs at one time than at another, that is the time to be selected; so that, when paroxysms are continuous, straightway, when the first one has begun to pass off, food may be given. For it is the general rule to which every pan of treatment should be directed, to give food always as long as possible before the next ensuing paroxysm, and while keeping this rule, to give the food when the body is most free from fever. This should be observed not merely with two paroxysms but also with several. But although it is most proper to give food on alternate days, yet if the system is weak, it should be given every day; and far more so if the fevers continue without remissions, inasmuch as they distress the patient more; or when two or more paroxysms occur on the same day. This occurrence renders it necessary that immediately from the first day, food must be administered daily if the pulse has immediately become weak, and several times on the same day, if in the course of several paroxysms there is progressive diminution of the bodily strength. However, in these cases we must keep to this rule, that less food is to be given after paroxysms of such a kind that no food at all would be given after them if the bodily condition allowed it. When, however, a fever threatens, begins, increases, continues stationary, declines, then persists at a low level, or terminates, it should be recognized that the best time for food is after the fever has terminated; next, when it is continuing at a diminished level; and thirdly, if need be, whenever there is a decline; all other times are dangerous. If, however, there is urgent necessity on account of weakness, it is better to give some food when the increase in the fever has become stationary, rather than whilst it is increasing, better whilst the paroxysm is as yet imminent, rather than after it has commenced, nevertheless with this proviso, that there is no time at which a patient who is failing should not be supported. Most emphatically, it is not enough for the practitioner to pay attention merely to the actual fevers, but also he must look to the habit of the body as a whole, and direct treatment to that, whether patients have superabundance or deficiency of strength, or whether there are other intervening affections. While, however, it is always of advantage for patients to be free from care, so that they may suffer in body alone, and not also in spirit, it is so especially after food has been taken. Therefore if there are any things which might exasperate their emotions, it is best to withhold these from notice whilst they are ill: if this cannot be done, nevertheless to keep all back after food, until the time of sleep, and to tell them when they wake up.