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structions in the different viscera, particu- in its usual dose : the oxide of arsenic l'arly in the liver and spleen ; dropsy, dy, combined with opiates, either in solution or sentery, jaundice, and various species of in- in the form of pills
, will frequently succeed, flammation.
when bark and other remedies have been Treatment. In the paroxysms we are to tried without effect. If the disease should endeavour to shorten the different stages, and prove obstinate, and any pain can be perthus to obtain a final solution of the disease. ceived by the patient upon pressing the In the intermissions we are to prevent the right hypochondrium, small doses of the carecurrence of the paroxysms, and endeavour lomel, or friction with the unguentum hy. to obviate certain circumstances, which may drargyri, continued uirtil a slight soreness prevent the fulfilling, of either of the two of the mouth is induced, will, in general, be first indications
attended with the most beneficial effects, as The first indication will be accomplished its continuance is most commonly the conby the administration of an emetic at the sequence of obstructed viscera. commencement of the paroxysn, or during The circumstances which prevent our fulthe cold stage; for which purpose tartar filling the two first indications are, inflammaemetic is the best ; it should be given in di- tory diathesis, accumulation of bile in the vided, but pretty large doses, the patient stomach, and of that and fæces in the inshould at the same time be put to bed, kept testinal canal. The first circumstance will in warm blankets, and allowed warm di. be removed by blood-letting; and if, during luent, but not stimulating liqnors, except the paroxysm, any urgent symptoms indithere is a considerable degree of debility ; cate the presence of that diathesis, it will be and immediately the hot stage is formed, a attended with the greatest prospect of sucgentle diaphoresis will be excited, and a cess, if the operation is performed during final solution of the paroxysm procured, by the hot stage, when the excitement is most the exhibition of opiates, assisted by mo- considerable : the latter causes will be rederate dranglts of tepid, or, if the heat be moved by the administration of emetics and preternaturally great, of cold liquids, and cathartics: if there be a great degree of deby the neutral salts. In the intermissions, bility, the system must be strengthened by the bark should be administered in doses of a generous diet, the moderate use of wine, a drachm or more, every one, two, or three gentle exercise, the cold bath, and change hours, so that an ounce, or an ounce and a of air. As in this disease relapses very frehalf may be taken during the intermission ; quently occur, it will not only be advisable, when the apyrexy is long, as in the tertian, but necessary, to continue the use of the its exhibition may be delayed till within six bark in doses of a drachm four times a day, or eight hours of the time when the next pa. for two or three weeks, at the same time roxysm is expected, which will frequently the patient must most studiously avoid all more effectually prevent its return than the exciting causes, and every irregularity when given in small doses during a long in. in diet. Vernal are less liable than autum. termission ; but if there be a great degree nal intermittents, to become continued fe of debility, or where the intermissions vers, and are rarely attended with alarming are short, as in the quotidian, the bark symptoms, or followed by dangerous obshould be employed immediately after the structions. The taste of the bark will be termination of the paroxysm, at longer or concealed in a great measure, by exhibiting shorter intervals, until the return of the next it in milk, butter-milk, or infusion of liquofit, in such doses as the stomach will bear, rice ; and if the stomach should possess a and the urgency of the case may require : considerable degree of irritability, opium when this invalnable medicine purges, a few administered either by itself or combined drops of the tincture of opium may be with camphor, will, in general, succeed in added; and if on the other hand, it induce enabling that organ to retain the bark. costiveness, a few grains of rhubarb will The paroxysm may be generally prevented obviate it, and at the same time give tone by adnfinistering a full dose of the tincture to the stomach and bowels; it is sometimes of opium, in mulled wine or hot diluted of service to add about a scruple of snake spirits, about an hour previous to its exroot to each dose of the bark; where the pected return. stomach is habitually weak, it will be ad- Continued Fever. This is either inflamvisable to combine aromatics or bitters with matory (synocha) ; putrid or gaol (typhus) ; the bark, as calamus, or canella alba, &c. or mixed (synochus.) The sulphate of copper uzay be employed Symptoms of Synochd. This fever, which, however, withont topical inflammation, is in portion to the violence of the symptoms of this country a very rare occurrence, gene- increased excitement, strength, and former rally commences with short fits of cold and habits of life of the patient, and nature of heat alternating with each other, to which the prevailing epidemic; it, on the first succeed an intense burning heat, head-ach, blood-letting, the symptoms be consiaccompanied with throbbing of the temples, derably alleviated, and the pulse and heat or tinnitus aurium, pains in the back, loins, become nearly natural, it will not be ne. and joints, and the patient feels as if his body cessary to repeat it; if, on the contrary, had been severely bruised : the face is full the symptoms continue with but little or no and florid ; the eyes are inflamed and inca: abatement, it will not only be advisable pable of bearing the light; the skin, mouth, but indispensably necessary to repeat the and throat are dry; the tongue is covered operation, until we nearly reduce the pulsa with a white crust; the thirst is intolerable; and heat to the natural standard; the bloodthe respiration is frequent, hurried, gene. letting will be the more efficacious, the rally oppressed, and attended with a dry more suddenly we abstract the blood; an cough ; there is anorexia, nausea, vomiting, émetic should then be administered, and in restlessness, and delirium; the urine is se. a few hours after its operation has ceased, a creted in small quantity, and is high co- cathartic should be exhibited, for which loured; the bowels are costive ; the pulse is purpose the phosphate or sulphate of soda, frequent, strong, and hard, scarcely ever, or the sulphate of magnesia, combined with however, exceeding 120 strokes in a mi- the infusion of senna, with a small propornute ; the blood, when drawn, is covered tion of the tartarised antimony, will be with a whitish or yellowish crust. In this the most efficacious ; calomel is a precountry, after the symptoms have continued ferable medicine to the others; after the for some days, they begin generally to as- contents of the primæ viæ are sufficiently sume those of typhus, so that the whole evacuated, we should order the neatral disease is synochus.
salts, particularly the saline draughts every Causes. Suppression of the accustomed two or three hours, to each dose of which, evacuations ; cold by any means applied, as from twenty to thirty drops of antimonial exposure of the body to the cold air, when wine, with the same quautity of the spirit it is in a state of perspiration ; exposure to of nitre inay be conjoined with advantage ; the rays of the sun; intemperance in eating, cooling mucilaginons liquors acidulated but more particularly in drinking ; topical with the vegetable acids, or cold water, inflammation; intense study; great fatigue; sliould be freely allowed, when the heat of the premature repulsion of eruptions ; per- the surface of the body is steadily above the spiration suddenly checked, and violent natural standard. It is of the utmost con. passions of the mind.
sequence, throughout the whole course of Diagnosis. This fever will be readily this disease, that the alimentary canal should distinguished from the typhus mitior by the be kept clear of feculent matter; for which strength of the pnlse, the intense heat, great purpose the mildest laxatives shonld be em. thirst, violent pains in the back and joints, ployed, or perhaps mucilaginous clysters high coloured urine, and by the less de. would be preferable; all exercise, both of rangement of the mental functions.
the body and mind, must be studiously Prognosis. It frequently terminates in avoided, the patient must be kept quiet and a favourable manner abont the seventh in a horizontal posture, the light should be as day, either by hemorrhage, a profuse much as possible excluded, there should be diaphoresis, or by the urine depositing a a free circulation of cool air through the copious lateritious sediment; the termi- apartment, the floor of which should be nation by diarrlica is a much more rare oc frequently sprinkled with cold water, the currence. If the respiration be very labo- patient should be lightly covered with bed. rious, if the head-ache be very severe, at clothes, all excremental matters should be tended with delirium ferox, if the abdomi. speedily removed, and the patient should nal viscera be much affected, if the urine behave frequent changes of dry linen. If the pale or limpid, and the skin assumes a yel- pain of the head be very violent, accomlow tinge before the seventh day, we panied with delirium, or, if the patient is may generally expect an unfavourable oppressed with coma, blood-letting, both issue.
general and topical, will be necessary, proTreatment. The removal of this disease vided the strength of the patient is not too must be attempted by blood-letting, in pro. much exhausted ; catharties and laxative
clysters must be ordered, the head should the morning, and returns in a more severe be shaved, and cooling applications, as manner every evening, and during the day vinegar and water, or a solution of the vola- he lies iv a confused state, or is constantly tile salt of hartshorn in vinegar, and the muttering to himself. All these symptoms like, must be employed; blistering the go on gradually increasing, followed by head, and fomenting the lower extremities tremor of the hands and tongue, muscæ vo. will also be of service. If the respiration litantes, picking of the będ-clothes, subsulshould be much oppressed, and attended tus tendinum, and convulsions, which genewith a short, dry cough, we must immedi- rally close the scene. ately have recourse to blood-letting, both Causes. The depressing passions of fear, general and local ; blisters should be ap- grief, and despair ; all excessive evacuaplied to the thorax, and we should direct a tions; a relaxed habit of body; immoderate liberal use of mucilaginons diluents. Should venery; a sedentary and studions life ; inthe abdominal viscera be attacked in the temperance in eating and drinking; fatigne; course of the disease, the same general the abstraction of the usual quantity of means of blood-letting and blistering must nourishing food; contagion, and pancity of be employed, together with laxatives or blood, fomentation of the lower extremities. In Diagnosis. The slow and insiduous apthis climate, after a short period, the symp. pearance of this fever will distinguish it toms generally begin to assume the typhoid from the typhus gravior: the rigors are form, therefore some degree of caution will less severe; there is a considerably less be indispensably necessary in the liberal degree of heat and thirst, and no bilious employment of evacuations, lest we should vomiting; there is also greater mildness in indnce a degree of fatal debility.
the symptoms, even in the first stage; the Typhus.-Symptoms. An uneasy and pe skin is pale, and has a bluish and sunk apculiar sensation in the stomach, sometimes pearance. attended with nausea and giddiness, fre- Prognosis. The favourable symptoms are, quently denotes the approach of this fe. an universal warm moisture of the skin; the ver. In many cases, however, it is scarcely tongue from being dry and foul becoming or not at all perceived, and the disease ge- moist; the pulse being rendered more slow nerally co:nmences with lassitude, languor, and full after a gentle diaphoresis, or the some degree of debility, borripilatio or exhibition of cordials; the appearance of sense of creeping, impaired appetite, alter. an eruption about the lips and postrils ; a nate and irregular beats and chills, anxiety miliary eruption, neither preceded by, nor about the præcordia, and great dejection of accompanied with, profuse sweating ; deafspirits, accompanied with frequent sighing. ness; a temporary insanity; an increased After these symptoms have continned for a secretion of saliva without aphthæ ; a sponfew days, the patient is attacked with head. taneous but gentle diarrhea. The unfaach, or an uneasiness and confusion of head; vourable symptoms are, a great degree of a deep-seated pain, or a sensation of cold muscular debility; the early appearance ness is perceived, particularly in the occi- and obstinate continuance of delirium ; stuput; there is nausea, vomiting of insipid pidity and listlessness of the eyes on the first phlegm, and great prostration of strength; days of the disease; a morbid sensibility of the heat of the body is but little increased; the surface, and of all the organs of sense ; there is little or no thirst; the tongue at profuse evacuations, attended with a weak the commencement of the disease is moist pulse; tremor of the hands and tongue; and covered with a white crust; in the more feather - hunting; a considerable degree advanced stages it becomes dry, brown, and of sighing, mumbling, and moaning ; conchapped; the countenance is pale and supk, stant watchfulness ; coma, accompanied the pulse is small, weak, and frequent, the with fulness of the vessels of the tunica adrespiration is oppressed, and attended with nata, and dilated pupils; a difficulty of great anxiety about the præcordia, the swallowing, attended with hiccup ; an unurine is pale, and secreted in too great a conscious discharge of the urine and fæces. quantity. The uneasiness and confusion of Dr. Fordyce observes, in his third Essay on head increase with the debility, and prevent Fevers, p. 111, that, if the respiration and the patient from going to sleep ; or, if he deglutition be free, the prognosis is seldom do, it does not refresh him, and on the bad, although the disease may be attended second or third night some degree of deli. with alarming symptonis. rium comes on, which, however, goes off in Treatment. The first step to be taken in this, as well as in most other febrile dis. Jessness : if the hands and feet be at that eases, is to clear the primæ viæ of their time parched, the effects of the opium or crude and acrid contents, by the early ex- other remedies will be promoted by moishibition of an emetic, which, by the con- tening them with cold or tepid vinegar. If cussion it gives to the whole system, dis- the head-ach be very distressing, blisters solves the morbid catenation, and fre. should be applied to the temples: should quently terminates the disease ; in a few subsnltus tendimum supervene, either æther, hours after that has ceased to operate, a camphor, carbonate of ammonia, castor, or cathartic of calomel should be adminis. the musk, should be administered in large tered, mixed with a small quantity of con- doses alternately with bark : the diet should serve, honey, or mucilage, and it should be be light and nourishing ; bottled porter and allowed to remain for a short time about wine should be allowed liberally, taking the fances, before it is swallowed; through- particular care that not the smallest degree out the whole course of the disease we must of intoxication ensues : sedative and antiprocure the regular expulsion of the fæces, spasmodic remedies may also be employed by means of the mildest laxatives, or by the externally by means of friction ; they have injection of clysters every evening; the skin in many instances produced the most happy on every part of the body snccessively should effects. be washed with cold water, or vinegar and Dr. Currie, in his ingenious and valuable water ; wine and opium should be admini- work, entitled “ Medical Reports on the stered in small quantities, and repeated Effects of Water in Fevers and other Disevery three hours alternately; the applica- eases," vol. i. p. 17, et seg. observes, when tion of small repeated blisters will be of speaking of the aspersion or affusion of cold considerable service; the administration of water, vinegar and water, or of a saturated oxygen gas will also prove an useful anxi- brine,“ that the safest and most advantaliary. The symptoms which forbid the use geous time for using either the aspersion or of bark are a hot and dry skin, and a affusion (the latter of which he prefers), is parched tongue; it must, therefore, be our when the exacerbation is at its height, object of practice to remove those symp, which is marked by increased flushing, toms as early as possible, which will in ge. thirst, and restlessness, or immediately afneral be accomplished by the administra- ter its declination is begun; and this has led tion of the saline draughts in a state of ef- me almost always to direct it to be emfervescence, every two, three, or four hours, ployed from six to nine o'clock in the evencombined with the infusion or tincture of ing; but it may be safely used at any time snake-root, with from twenty to thirty of the day, when there is no sense of chilli. drops of æther in each draught; warm pe. ness present, when the heat of the surface diluvia should be ordered in the evenings, is steadily above what is natural, and when or the lower extremities should be foment. there is no general or profuse sensible pered; whenever a general relaxation of the spiration. It is at the same time highly skin occurs, the bark, combined with a necessary to attend to the precautions which small portion of the confectio opiata, and a the employment of this valuable remedy few drops of the muriatic or sulphuric acid requires : 1. If the affiision of cold water on in each dose, should be given frequently, the surface of the body be used during the taking care at the same time not to oppress cold stage of the paroxysm of fever, the the stomach. A table-spoonful of yeast, respiration is nearly suspended, the pulse either diluted or in its pure state, has been becomes fluttering, feeble, and of an incalof late much employed, and with a consi- culable frequency; the surface and extrederable degree of success; it should be gi. mities become doubly cold and shrivelled, ven at least three or four times in the course and the patient seems to struggle with the of the day. At bed-time it will be proper paogs of instant dissolution. I have no to give an opiate, particularly if the patient doubt, from what I have observed, that in is restless, and its effects will be promoted such circumstances the repeated affusion of by combining it with abont ten grains of a few buckets of cold water would extinthe castor or camplior, or from fifteen to guish life. This remedy should, therefore, twenty grains of the compound powder of never be used when any considerable sense ipecacuanha, or a drachm of Hoffman's of chilliness is present, even though the 'æther may be substituted, the last of which thermometer, applied to the trunk of the medicines, if it does not procure sleep, it body, should indicate a degree of heat do not, however, increase the heat or rest. greater than usual. 2. Neither ought it to be used when the heat, measured by the water may be drank with the utmost free thermometer, is less than, or even only dom. Frequent draughts of cold liquids at equal to, the natural heat, though the pa- this period are highly grateful ; they gene, tient should feel no degree of chilliness. rally diminish the heat of the surface several This is sometimes the case towards the last degrees, and they lessen the frequency of stages of fever, when the powers of life are the pulse. When they are attended with too weak to sustain so powerful a stimulus. these salutary effects, sensible perspiration 3. It is also necessary to abstain from the' and sleep commonly follow. Throughout use of this remedy, when the body is under the hot stage of the paroxysm, cold water profuse sensible perspiration, and this cau. may be safely drank, and more freely in tion is more important in proportion to the proportion as the heat is further advanced continuance of this perspiration. In the com- above the natural standard. It may even mencement of sweating, especially if it has be drank in the beginning of the sweating been brought on by violent exercise, the stage, though more sparingly. Its cautious affusion of cold water on the naked body, use at this time will promote the flow of the or even immersion in the cold bath, may be sensible perspiration, which, after it has hazai ded with little risk, and sometimes commenced, seems often to be retarded by may be resorted to with great benefit. After a fresh increase of animal heat. A draught the sweating has continued some time, and of cold water taken under such circumflowed freely, especially if the body has re. stances will often reduce the heat to the mained at rest, either the affusion or immer. standard at which perspiration Aows more sion is attended with danger, even though freely, and thus bring the paroxysm to a the heat of the body at the moment of using speedier issue. 3. But, after the sensible it be greater than natural. Sweating is al. perspiration has become general and proways a cooling process in itself, but in bed fuse, the use of cold drink is strictly to be it is often prolonged by artificial means, forbidden. At this time I have perceived, and the body is prevented from cooling an- in more than one instance, an inconsiderate der it to the natural degree, by the load of draught of cold water produce a sudden heated clothes. When the heat has been chilliness both on the surface and at the thus artificially kept up, a practitioner stomach, with great sense of debility, and judging by the information of his thermo- much oppression and irregularity of respirameter only, may be led into error. In this tion. At such times, on applying the thersituation, however, I have observed, that mometer to the surface, the heat has been the heat sinks rapidly on the exposure of found snddenly and greatly rednced. The the surface of the body even to the exter- proper remedy is, to apply a bladder filled nal air, and that the application of cold wa- with water heated from 110° to 120° to the ter, either by affusion or immersion, is ac. pit of the stomach, and to administer small companied by a loss of heat and a de- and repeated doses of laudanum." ficiency of re-action, which are altogether Dr. Cullen divides this disease into two inconsistent with safety.” Under these re- varieties : typhus mitior, or low nervous strictions, the cold affusion may be used at fever, being that we have now described ; any period of fever, but its effects will be and typhus gravior, jail, camp, or hospital more salutary in proportion as it is used fever, far more violent in its symptoms, more early. When employed in the ad. rapid in its progress, infectious in its effluvanced stages of fever, where the beat is vium, and fatal in its tendency. It becomes reduced and the debility great, some cor. the medical practitioner,' therefore, to be dial should be given immediately after it, proportionably more bold and active: with and the best is warm wine. Dr. Currie, which general observation the same mode when speaking of the internal use of cold of treatment may for the most part be parwater, vol
. i. p. 92, et seq. directs that sued. The stimulant plan must be pushed « 1. Cold water is not to be used as a drink to a much greater extent, and affusions of in the cold stage of the paroxysm of fever, cold water are here of more use than in the however urgent the thirst. Taken at such preceding variety, and of course ought to times, it increases the chilliness and torpor be employed with the most liberal and unof the surface and extremities, and produces hesitating attention. a sense of coldness in the stomach, augments Synochus.--Symptoms. This, as we have the oppression on the præcordia, and ren. already observed, is a fever compounded of ders the pulse more frequent and more fee- those that characterise the first stage of ble. 2. When the hot stage is fairly formed, synocha, or inflammatory fever, with which and the surface is dry and burning, cold it commences, and of those which constitute