rgrhuL An uneasy and in the stomach, some times attended with nausea and giddiness, frequently denotes the approach of this fever. In many cases, however, it is scarcely or not at all perceived, and the ' disease generally commences with lassi tude, languor, some of debility, horripilatio or sense of creeping, impair ed appetite, alternate and irregular heats and chills, anxiety about the precordia, and great dejection of spirits, accompa nied with frequent sighing. After these symptoms have continued for a few days, the patient is attacked with head-ach, or an uneasiness and confusion of head ; a deep-seated pain, or a sensation of cold ness, is perceived, particularly in the oc ciput; there is nausea, vomiting of insipid phlegm, andgreat prostration of strength; the heat of the body is but little increas ed ; there is little or no thirst ; the tongue i at the commencement of the disease is moist, and covered with a white crust ; in the more advanced stages it becomes dry, brown, and chapped ; the counte nance is pale and sunk, the pulse is small, weak, and frequent, the respiration is op pressed, and attended with great anxiety about the przcordia, the urine is pale, and secreted in tooat a quantity. The uneasiness and confusion ofhead increase with the debility; and prevent the patient from going to sleep or if he do, a t does not refresh him, and on the second or third night some degree ofdelirium comes on, which, however, goes off in the morning, and returns in a more severe manner every evening, and during the day he lies in a confused state, or is constantly muttering to himself. All these symptoms go on gradually increas ing, followed by tremor of the hands and tongue, muse= volitantes, picking of the bed-clothes, subsultus tendinum, and convulsions, which generally close the scene.
Causer. The depressing passions of fear, grief, and despair; all excessive evacuations ; a relaxed habit of body ; immoderate venery ; a sedentary and studious life; intemperance in eating and drinking ; fatigue ; the abstraction of the usual quantity of nourishing food ; conta gion, and paucity of blood.
Diagnosis. The stow and insidious ap pearance of this fever will distinguish it from the typhus &Taylor : the rigours are less severe; there is a considerably less degree of heat and thirst, and no bilious vomitine: there is also srreater mildness in the symptoms, even in the first stage ; the skin is pale, and has tl bluish and sunk appearance.
Prognosis. The favourable symptoms are, an universal warm moisture of the skin ; the tongue from being dry and foul becoming moist ; the pulse being ren dered more slow and full after a gentle diaphoresis, or the exhibition of cordials ; the appearance of an eruption about the lips and nostrils; a miliary eruption, neither preceded by, nor accompanied With, profuse deafness; a tem porary insanity; an increased secretion of saliva without aphthz ; a spontaneous but gentle diarrlices. The unfavourable symptoms are, a great degree of muscu lar debility ; the early appeirance and obstinate continuance of delirium ;•stu- pidity and listlessness of the eyes on the first days of the disease ; a morbid sensi bility of the surface, and of all the organs of sense ; profuse evacuations, attended with a weak pulse ; tremor of the hands and tongue ; feather-hunting ; a conside. cable degree of sighing, mumbling, and moaning ; constant watchfulness; coma, accompanied with fulness of the vessels of the tunics, *dilate, and dilated pupils ; a difficulty of swallowing, attended with hiccup ; an unconscious discharge of the urine and feces. Dr. Fordyce observes, in his third Essay on fevers, p. 111, that, if the respiration and deglutition be free, the prognosis is seldom bad, although the disease may be attended with alarming symptoms.
Treatment. The first step to be taken in this, as well as in most other febrile dis eases, is, to clear the prime viz of their crude and acrid contents, by the early ex hibition of an emetic, which, by the con cussion it gives to the whole system, dis solves the morbid catenation, and fre quently terminates the disease; in a few hours after that has ceased to operate, a cathartic of calomel should be adminis tered, mixed with a small quantity of con serve, honey, or mucilage, and it should be allowed to remain for a short time about the fences before it is swallowed ; throughout the whole course of the dis ease we must procure the regular expul sion of the feces, by means of the mildest laxatives, or by the injection of clysters every evening; the skin on every part of the body successively should be washed with cold water, or vinegar and water; wine and opium should be administered in small quantities, and repeated every three hours alternately ; the applisation of small repeated blisters will be of consi derable service ; the administration of oxygen gas will also prove an useful auxi liary. The symptoms which forbid the use of bark are, a hot and dry skin, and a parched tongue ; it mast, therefore, be our object of practice to remove those symptoms as early as possible, which will in general be accomplished by the admi nistration of the saline draughts in a state of effervescence. every two, three, or four hours, combined with the infusion or tinc ture of snake-root, with from twenty to thirty drops of xther in each draught ; warm pediluvia should be ordered in the evenings, or the lower extremities should be fomented ; whenever a general relaxa tion of the skin occurs, the bark, combin ed with a small portion of the confectio opiata, and a few drops of the muriatic or sulphuric acid in each dose, should be Oven frequently, taking care at the same time not to oppress the stomach. A table spoonful of yeast, either diluted or in its pure state, has been of late much employ ed, and with a considerable degree of success ; it should be given at least three or four times in the course of the day. At bed-time it will beproper to give an opiate, particularly if the patient is restless, and its effects will be promoted by combining h with about ten grains of the castor or camphor, or from fifteen to twenty grains of the compound powder of ipccacuanha, or a drachm of Iloffman's zther may be substituted, the last of which medicines, if It does not procure sleep, it does not, how ever, increase the heat or restlessness : if the hands and feet be at that time parch. ed, the effects of the opium or other wedies will be promoted by moistening them with cold or tepid vinegar. , If the bead-ach be very distressing, blisters should be applied to the temples : should subsultus tendinum supervene, either zther, camphor, carbonate of ammonia, castor, or the musk, should be adminis tered in large doses alternately with bark: the diet should be light and nourishing ; bottled porter and wine should be allow ed liberally, taking particular care that pot the smallest degree of intoxication ensues : sedative and antispasmodic re medies may also be employed externally -by means of friction ; they have in many instances produced the most happy ef fects Dr. Currie, in his ingenious and valua
ble --(irk, entitled " Medical Reports on the Effects of Water in Fevers and other Diseases," vol. i. p. 17, et seq. observes, when speaking of the aspersion or allusion of cold water, vinegar and water, or of a saturated brine," that the safest and most advantageous time for using either the aspersion or affnsion (the latter of which he prefers), is when the exacerbation is at its height, which is marked by increas ed flushing, thirst, and restlessness, or immediately after its declination is begun; and this has led me almost always to di rect it to be employed from six to nine o'clock in the evening ; but it may be safely used at any time of the day, when there is no sense of chilliness present, when the heat of the surface is steadily above what is natural, and when there is no general or profuse sensible perspira tion. It is at the same time highly neces sary to attend to the precautions which the employment of this valuable remedy requires : I. If the allusion of cold water on the surface of the body be used during the cold stage of the paroxysm of fever, the respiration is nearly suspended, the pulse becomes fluttering, feeble, and of an incalculable frequency ; the surface and extremities become doubly cold and shrivelled, and the patient seems to strug gle with the pangs of instant dissolution. I have no doubt, from what I have observ ed, that in such circumstances the repeat ed affusion of a few buckets of cold water would extinguish life. This remedy should,therefore, never be used when any considerable sense of chilliness is present, even though the thermometer, applied to the trunk of the body, should indicate a degree of heat greater than usual. 2. Neither ought it to be used when the heat, measured by the thermometer, is less than, or even only equal to, the na tural heat, though the patient should feel no degree of chilliness. This is some times the case towards the last stages of fever,when the powers oflife are too weak to sustain so powerful a stimulus. 3. It is also necessary to abstain from the use of this remedy, when the body is under pro fuse sensible perspiration, and this caution is more important in proportion to the con tinuance of this perspiration. In the com mencement of sweating, especially if it has been brought on by violent exercise, the affilsion of cold water on the naked or even immersion in the cold bath, may be hazarded with little risk, and sometimes may be resorted to with great benefit. After the sweating has continued some time, and flowed freely, especially if the body has remained at rest, either the allusion or immersion is attended with danger, even though the heat of the body at the moment of using it be greater than natural. Sweating is always a cool ing process in itself, but in bed it is often prolonged by artificial means, and the bo dy is prevented from cooling under it to the natural degree by the load of heated clothes. When the heat has been thus artificially kep; up,a practitioner, judging by the information of his thermometer only, may be led into error. In this situ ation, however, I have observed, that the heat sinks rapidly on the exposure of the surface of the body even to the external air, and that the application of cold water, either by effusion or immersion, is accom panied by a loss of heat and a deficiency of re-action, which are altogether incon sistent with safety." Under these restric tions, the cold effusion may be used at any period of fever, but its effects will be more salutary in proportion as it is used more early When employed in the ad vanced stages of fever, where the heat is reduced and the debility great, some cor dial should be given immediately after it, and the best is warm wine. Dr. Cur rie, when speaking of the internal use of cold water, vol. i. p. 92, etseq. directs that 1. Cold water is not to be used as a drink in the cold stage of the paroxysm of fever,however urgent the thirst. Taken at such times, it increases the chilliness and torpor of the surface and extremities, and produces a sense of coldness in the stomach, augments the oppression on the przcordia, and renders the pulse more frequent and more feeble. 2. When the hot stage is fairly formed, and the sur face is dry and burning, cold water may be drank with the utmost freedom. Fre quent draughts of cold liquids at this period are highly grateful ; they general-% ly diminish the heat of the surface several degrees, and they lessen the frequency of the pulse. When they are attended with these salutary effects,sensible perspiration and sleep commonly follow. Throughout the hot stage of the paroxysm, cold wa ter may be safely drank, and more freely in proportion as the heat is further ad vanced above the natural standard. It may even be drank in the beginning of the sweating stage, though more spa ringly. Its cautious use at this time will promote the flow of the sensible perspi ration, which, after it has commenced, seems often to be retarded by a fresh in crease of animal heat. A draught of cold water taken under such circumstances will often reduce the heat to the standard at which perspiration flows more freely, and thus bring the paroxysm to a speedier issue. 3. But, after the sensible perspire tion has become general and profuse, the use of cold drink is strictly to be forbid den. At this time I have perceived, in more than one instance, an inconsiderate draught of cold water produce a sudden chilliness, both on the surface and at the stomach,with a great sense ofdebility, and much oppression and irregularity of re spiration. At such times, on applying the thermometer to the surface, the heat has been found suddenly and greatly reduced. The proper remedy is, to apply a bladder filled with water heated from 110° to to the pit of the stomach, and to admi nister small and repeated doses of lauda num." Dr. Cullen divides this disease intotwo varieties ; typhus mitior, or low nervous fever, being that we have now described; and typhus gravior, jail,camp, or hospital fever, far more violent in its symptoms, rapid in its progress, infectious in its emu vium, and fatal in its tendency. It be comes the medical practitioner,therefore, to be proportionably more bold and ac tive : with which general observation, the same mode or treatment may for the most part be pursue4. The stimulant plan must be pushed to a much greater ex tent, and effusions of cold water are here of more use than in the,preceding variety, and of course ought to be employed with the most liberal and unhesitating atten tion.