546 THE TREATMENT OF DISEASES. 



It is not always easy to say when the premonitory symptoms ceased, and the 

 actual disease began. The best method is to consider the day on which the patient 

 first became feverish as the first day of the actual disease. When this point cannot 

 be definitely determined, we may reckon the commencement of the disease from the 

 day on which the patient had to knock off work, or first took to his bed. 



In some cases, however, there are no warning symptoms at all, but the disease 

 begins suddenly in all its intensity. The patient is in the midst of his occupation, 

 or is on a journey of business, or perhaps pleasure, when he is seized with headache, 

 shivering, and fever, and is found to be suffering from typhoid. 



In the first week of the disease proper the patient is feverish, the skin is hot and 

 dry, and in the afternoons there are sometimes slight chills. The symptoms which 

 were present in the premonitory stage gradually increase in intensity. The headache 

 becomes violent, the pains in the back and joints are severe, and the patient feels 

 very ill, and is usually obliged to remain in bed. On attempting to stand he feels 

 dizzy and tottery. There is a great change in him, the expression of his face is 

 altered, he is silent, unwilling to think, sleepy, and not easily roused. His sleep is 

 disturbed by unpleasant dreams, and when in a condition between sleeping and 

 waking he is apt to wander a little, and to be partly delirious. There is complete 

 loss of appetite, but the patient is very thirsty. The tongue is at first moist and 

 coated, but later on it becomes drier, and the fur disappears, leaving smooth, red 

 streaks. Not unfrequently the nose bleeds freely at this stage. In many cases the 

 bowels are at first confined, the diarrhoea, which is always a prominent symptom of 

 this disease, often not appearing for a few days, or perhaps not till the end of the 

 first week. Just at first there is nothing particular about the stools ; they are brown 

 in colour, either thickish or watery, and are passed without pain, and usually with- 

 out straining. The abdomen gradually becomes swollen, tense, and tender, even on 

 the gentlest pressure, more especially on the right side. The spleen increases in 

 size, just as it does in ague, though not to the same extent. It may sometimes be 

 felt under the ribs on the left side, but as a rule it is not readily made out on 

 account of the swollen condition of the abdomen. The urine is diminished in 

 quantity, unless the patient drinks a great deal, and it is usually of a very high 

 colour. 



In the second week the fever continues high and the condition of the patient 

 shows how rapidly he is becoming exhausted. The headache is no longer complained 

 of, and the patient becomes apathetic and drowsy, but does not sleep soundly. He 

 is not inclined for conversation, but in answer to questions usually says that he is 

 very well and ails nothing. He seldom asks for drink, but drinks freely whatever 

 fluids are offered him. All movements are feeble and uncertain ; the tongue is put 

 out with difficulty, and only after repeated demands, and when protruded the 

 patient often neglects to withdraw it. The tongue is now dry, red, and cracked, and 

 in speaking is moved with such difficulty that it is no easy matter to understand 

 what is said. The patient usually lies on his back, hardly stirring, except to pick 

 at the bed-clothes and make other feeble movements with the hands ; the eyes are 

 half closed and he mutters unintelligibly, especially in the evenings. Sometimes 

 patients exhibit a more irritable mental condition ; they are restless ; disturbed by 



