A Treatise on Fever

by Southwood Smith

4. There are cases in which the pain of the head is equally severe as in synochus: but this may be justly considered as rare. In general it is less acute. Dullness, confusion, stupor, giddiness, are more common than severe pain, and are often the substitutes for it. Though some degree of pain be generally present, yet it is by no means uncommon for one or more of these sensations to occupy its place completely. Question the patient as much as you please, and he will tell you that he has no pain; but it is evident, from his aspect and his manner, that he has little sensation of any kind. The eye is dull, heavy, stupid, without lustre: the old English word “lac-lustre” expresses its character truly and strikingly. But it is remarkable, that while the pain in the head is only slight, the pains in the back, loins, and extremities, and, as the patient himself says, in the bones, are severe.

5. When pain is present it diminishes sooner and disappears more completely than in synochus: when it is not present, the advancement of the disease is indicated by increasing insensibility, and by the rapid transition of dullness or confusion into a state of stupor approaching to coma. The eye is already muddy, and it soon becomes injected and suffused. The skin over the body is generally warm, sometimes hot: over the head it is often hot. The face is usually pallid, but the pallidness frequently alternates with flushing. The change of dullness into insensibility more or less profound sometimes takes place as early as the second or the third day: it is seldom that it is as late as the seventh or the eighth: it is postponed, when not prevented, by active and appropriate treatment.

6. There is little or no sleep; the restlessness is great; there may be no violence; but there is abundance of inquietude.

7. Delirium is more constantly present than in synochus; and when it comes it comes earlier: its presence is not unusual as early as the sixth or the seventh day; and it may appear still sooner, but that is rare. It consists of low muttering incoherence rather than of loud and violent talkativeness; and is expressed in moaning rather than in screaming.

8. The connexion between delirium and muscular tremor, between muscular tremor and subsultus tendinum, and between both, and the passing of the stools and the urine unconsciously, has already been pointed out. Like delirium, muscular tremor is much more constantly present in typhus than in synochus; and its relation to delirium is so close that it is sometimes observed to supervene on the very same day; frequently on the day following; and, if it appear at all, it is seldom longer absent than the third. Its degree likewise is commonly in proportion to the violence of the delirium; and though early and great delirium may appear without it, yet it very rarely appears without delirium; and in general all these symptoms form one series or train; pain disappearing, confusion of mind increasing, muttering incoherence supervening, and muscular tremor and involuntary and unconscious stools rapidly succeeding.

9. In the commencement of typhus the pulse is sometimes of good strength, and it may not exceed 90 in frequency; but as the disease advances it uniformly becomes weaker, smaller and quicker; so that death rarely takes place before it has reached 120. In the severer cases it is weak, quick, and easily compressed at a very early period.

10. The respiration is often not very obviously affected, but if it be attentively observed it will usually be found to be shorter and quicker than natural.

11. The tongue is always foul on the first or second day; it seldom continues moist longer than three or four days; it is often quite dry as early as the fourth, especially on the body and at the root; the apex and the edges sometimes remain moist a day or two longer; but in a short time the whole tongue becomes perfectly dry and of a brown colour; as the disease advances the colour often changes to a darker and darker hue until it becomes quite black; it is then frequently fissured into deep chaps, while the lips and teeth soon become covered with a black sordes. Were the sensibility not greatly altered, such a condition of the mouth and tongue must be attended with insatiable thirst; yet thirst is often not felt, although at other times it is considerable.

12. In the early stage of typhus the skin is frequently hot; as the disease advances the heat lessens: through the greater portion of the disease it is moderately warm; towards its termination it becomes cool, and some days before death it falls below the natural standard. It is always of a darker colour than in synochus: the whole surface is of a dull and dusky tinge. Sometimes it is covered with dun coloured petechiæ, at others with petechiæ of a florid colour.

13. During its progress, erysipelas, first appearing on the face, then extending over the scalp, and often down the shoulders and back, is very apt to occur. Excoriation on the back and hips often form sloughing sores of great malignity and extent, while enlargement, inflammation and suppuration of glands situated in different parts of the body frequently appear.