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THE NEW SYDENHAM
SOCIETY.
INSTITUTED MDCCCLVTir.
VOLUME XLIX.
♦ •.,
ON THE
TEMPERATURE IN DISEASES:
A MANTTAI OF
MEDICAL THEEMOMETEY.
BY
DR. C. A. WUNDERLICH,
PEOFESSOB DER KLINIK AN DER UNIVERSITAT XEIPZIG-, E!. SACHS GEHEIMEN
MEDICINAIEATH, COMTHXTR UND EITTEE, ETC.
TRANSLATED FROM THE SECOND GERMAN EDITION
BY
W. BATHUEST WOODMAN, M.D.,
ASSISTANT-PIIYSICTAN TO THK LONDON HOSPITAL, AND PHTSICfAN TO TIIR NQRTH-F.ASTKKN
HOSPITAL FOR CIirT.DKEN.
y r7> f-^
WITH FORTY WOODCUTS AND SEVEN MTHOGEAPHS.
THE NEW SYDENHAM SOCIETY,
LONDON.
MDCCCLXXI,
SEEN BY
PRES£RVAT!OM
SERVsCES
DATF:.
l'-»-T'"-'*°-*--'— •-"—****"
76"
till
PRINTED BY
J. E. ADLAHD, BARTUOLOMEW CLOSE, E.G.
AUTHOE'S PREFACE
TO THE
F lU S T EDITION.
I MAY^ perhaps, be allowed a few words of introduction to the
following pages. Eor the last sixteen years my attention has been
uninterruptedly directed to the course pursued by the temperature
in diseases of various kinds. The thermometer has been regularly
employed at least twice daily, and in febrile patients from four to
eight times a day, and even oftener, in special circumstances, for
all the patients in my wards. I have also experienced the applica-
bility of this method of investigation in very numerous cases in
private practice. In this way I have gradually got together a mate-
rial which comprises many thousand complete cases of thermometric
observations of disease, and millions of separate readings of the
temperature. The more my observations were multiplied the more
fiimly rooted did my conviction become of the unparalleled value
of this method of investigation, as giving an accurate and rehable
insight into the condition of the sick.
Not a few of the results obtained have already been published,
partly by myself and partly by my assistants and the students who
attended my clinique.
Erom many quarters, and repeatedly too, I have been urged to
collect them together in a complete and connected form. I have
at last resolved to do so, though recognising fully the extreme diffi-
culty of the task ; to abstract and formulate well-founded general
principles from the mass of separate cases, whose enormous number
vi author's preface to the first edition.
makes it simply impossible to devote special consideration to each
case, and to present a coup d'lcil of these intricate and complicated
a (lairs.
For altliough theoretical questions as to human temperature and
kindred subjects must not be overlooked, and well deserve to be
explored, my immediate purpose has been to write a practical book,
and to lay before my medical brethren as impressively as I could
the eminent usefulness of thermometric observations. A knowledge
of the course of the temperature in disease is highly important to
the medical practitioner, and, indeed, indispensable : —
Because all the phenomena of the sick are deserving of study ; —
Because the temperature can be determined with a nicety which is
common to few other phenomena ; —
Because the temperatui'e can neither be feigned nor falsified ; —
Because we may conclude the presence of some disturbance in
the economy from the mere fact of altered temperatures ; —
Because certain degrees indicate that there is fever ; —
Because the height of the temperature often decides both the
degree and the danger of the attack ; —
Because thermometric observation may serve to aid in the dis-
covery of the laws regulating the course of certain diseases, and
may enable us to learn them ; —
Because when once the normal course of certain diseases has been
determined, thermometry is able to simplify, confirm, and certify the
diagnosis ; —
Because thermometric investigations indicate most rapidly and
most safely any deviations from the regular course of the disease ; —
Because the behaviour of the temperature during the progress of
the disease discovers to us both relapses and ameliorations before we
should otherwise recognise them ;—
Because in this way thermometry is able to regulate the results
of our therapeutical efforts ; —
Because it puts us on our guard against the injurious influences
which affect our patients in the course of their illness ; —
Because it is able to indicate the transition from one stage of the
author's PllEFACE TO THE FIRST EDITION. vii
disease into another j and particularly the commencement of conva-
lescence and its complete establishment; —
Because it reveals the existence of complications, and shows how
far recovery is from being yet complete ; —
Because it generally reveals the fact of a fatal termination being
imminent ; —
Because it often announces the impossibility of a continuance of
life, and thus gives an absolutely fatal prognosis with great dis-
tinctness;— ..' ' '
And lastly, because it furnishes a certain proof of the reality of
death, when this is otherwise uncertain.
If I succeed in diffusing yet more widely the conviction of the
truth of these propositions, and if I am able to offer to my medical
brethren a useful and usable clue to enable them to discover the
true value of thermometric data, the object of my work is already
obtained.
Dr. WUNDEELICH.
LfilPSlC; March, 1868.
AUTllOK'S PllEFACE
TO THE
SECOND EDITION.
A Second Edition having become necessary^ I have revised the
text to the best of my abihty, and have once more carefully com-
pared the propositions it contains with the original observation.*^,
and have added also a considerable quantity of new material, partly
original, partly selected. I hope that my book is thus not only
bigger but better, and that this new Edition will meet with as friendly
a welcome as the former one.
W.
Leipzig; Feb., 1870.
THE
TEANSLATOU'S PEEEACE.
I REGRET the delay which has occurred in the publication of this
volume.
It has been partly due to the alterations necessary to make the
translation correspond with the Second German Edition, and partly
to the nature of the work itself, which abounds with numerals and
foreign proper names. The translation has been done by me in the
midst of other engagements, and with somewhat feeble health.
Some few Germanisms and a few errors of the press have, it is to
be feared, escaped notice. As to the rest, I have not aimed at fine
writing, but simply at conveying the Author's meaning, as I under-
stood him, to the Enghsh reader.
Professor Wunderlich, in a letter acknowledging the receipt of the
first eight sheets, stated that he had no additional matter which
he could incorporate with this Edition, the whole of his time being
devoted to the supervision of three military hospitals for the wounded
in the present Eranco-German war.
The Centigrade scale has been retained for two reasons —
ist. Because in this way the original diagrams have been pre-
sented without any alteration, except some slight improvements in
their execution, for which I have to thank the artist, Mr. Tuffen
"West; and
2nd. Because the convenience of this scale will probably shortly
X Till: TKANSLATOHS I'RKFACK.
load to ils general adoption by all scientific men, and then tin-
value of this work for rrferencc will still be unimjiaircd.
I have quoted Knglisii authors but sparingly, because I considered
that the readers of the New Sydenham Society did not need more
than a general reference to such. Had ray task been to continue
the History of Thermometry, the names of Drs. CHfford Allbutt,
Aitken, Sydney Einger, Grimshaw, E. Long Fox, and many others,
would have occupied a larger space in these pages.
To Mr. Hutcliinson, whose own researches on the effects of nerve-
section are amongst the most interesting and important recent con-
tributions to our knowledge, I am indebted for many kind and
valuable suggestions.
Two new woodcuts (Nos. 39 and 40) have been specially designed
for this Edition.
W. B. W.
10, FnfSBtrET PArEMENT, E.C.;
February, 1871.
TABLE OF CONTENTS.
Fundamental Principles
HiSTOEY AND BIBLIOGRAPHY
CHAPTER I.
CHAPTER II.
CHAPTER III.
Value of Thermometer in Medical Practice
PAGES
1- 19
19— 48
48— 58
CHAPTER IV.
The Art of Medical Thermometry
. 58— 80
CHAPTER V.
On the Temperature in Health
. 80—120
CHAPTER VI.
Causes of altered Temperature in Disease
. 120— IGO
CHAPTER VII.
Local alterations of Temperature in Disease
160—170
CHAPTER VIII.
Typical Forms with altered Temperatures
170—203
CHAPTER IX.
Diagnostic Value of Single Observations
202—226
CHAPTER X.
Daily Fluctuations of Temperature in Disease .
. 226—241
CHAPTER XI.
The Course of the Temperature in Febrile Diseases
241—288
Ml
rO.NTKNTS.
CHAPTKn Xll.
Ov TIIK TEMrF.RATt'UK IN SPECIAL DiSKASES
I. — AlKiominal Typhus (Eiilciic Fcvn)
II. — Exantlicnmtic Typhus
III. — Relapsing Fever
IV.— Variola (Smallpox), &c.
Varicella
v. — Measles
VI.— Scarlatina
VII.— Hubeolffi
VIII. — Erysipelas
IX. — On a peculiar Kcniittcnt Fever
X. — Febricula and Traumatic Fever
' XI. — Pyscmia
XII.— Catarrhal Affections of Mucous Membranes
XIII. — Croupous and Diphtheritic Inflammalious
XIV. — Pneumonia
XV. — Amygdalitis (Quinsy)
XYl. — Parotitis (Mumps)
XVIT. — Meningitis
XVIII.— Pleurisy, Endo- and Pcri-carditis, and Pciitonitis
XIX. — Acute Rheumatism
XX. — Osteo-myelitis
XXI. — Nephritis and Briglit's Disease
XXII. — Hepatitis and Yellow Fever .
XXIII. — Lues (Constitutional Syphilis)
XXTV.— Glanders and Farcy
XXV, — Acute Miliary Tuberculosis .
XXVI. — Acute Phthisis
XXVII. — Trichinosis
XXVIII. — Malarious Diseases (Ague, &c.)
XXIX.— Cholera .
XXX. — Injuries of the Spinal Cord
XXXI. — Neuroses
XXXII. — Chronic Disorders of Blood, Tissues, and Secretions
I'AliE
28S, &c.
292
327
im
Ul
312
34()
351
351
354
355
3G1
365
367
368
385
387
388
391
394,
403
404
404
405
408
409
410
415
416
419
423
424
427
CHAPTER XIII.
On the Effects of altered Temperatures on the System
436
Appendices on Influence of Rest and Work, and Atmo-
spheric Pressure — Table of Thermometric Equivalents
— temperatltie of animals — effects of plnchlng —
Respiration — and Supplemental Bibliography
445
MEDICAL THERMOMETRY,
> , , CHAPTEll I.
It*-'
FUNDAMENTAL PRINCIPLES.
§ I. — There are two well-ascertaiued facts, which not only justify
us in endeavouring to determine the temperature of the body in
diseases, and render the use of the thermometer both a duty and a
valuable aid to diagnosis, but form the basis of all our investiga-
tions. The first fact is the coustaticj/ of tem2)erature hi healtki/
jjersoits, or, in other words, that healthy human beings of every age
and condition, in all places and in all circumstances, and exposed to
all kinds of influences, provided these do not impair health, have an
almost identical temperature.
The second fact is the variation of temperature in disease, for in
sick persons we are constantly meeting with deviations from the
normal temperature of the healthy.
§ 2. — The average nonaat tt'iiiperaiare of the liealthy human
body in its interior, or in carefully covered situations on its surface,
varies, according to the plan of measurement, from 98-6° to 99*5^
Pahr. (37° to 37'5° C). It is about 98-6° in the well-closed axilla,
and a few tenths of a degree higher ('5 — i^ or 2° Fahr., 7° Eahr.
average) in the rectum and vagina.^
§ 3. — The temperature of healthy persons is almost constantly
the same, although not absolutely so. Indeed, there are sponta-
neous variations in the course of every twenty-four hours, but these
seldom exceed half a degree of the Centigrade scale (= '9° Tahr.)
' Tlie arrow to iudicate the normal temperature is placed at 98. t^ Ealir, 011
most English thermometers ; from numerous observations, and conipar'iAOu ol
various statements, lam inclined to believe that the author is correct in placing
it higher. — [Trans.]
1
2 FUNDAMENTAL I'HINCIPLKS.
for i-acli imliviilual. rmisual comlitions, ami external iiilluenccs,
may iiuleed cause variations of temperature, but. tliesc arc never very
great, as long ns they produce no disturbance of health. Any
elevation of the axillary temperature above 99*5° {^T5° ^-t "^
any depression below 97'i° {i^'5° C.) is always very suspicious,
and whether it ai)pear to be spontaneous or induced by external
circumstances, can only be considered normal when all the facts of
the case are known, or in very exceptional cases.
The maintenance 0/ a normal temperature under varying conditions,
or, in other words, a constant temperature of the body in any indi-
vidual, is a proof of a sound constitution.
§ 4. — A normal temperature does not necessarily indicate health,
but all those whose temperature either exceeds or falls short of the
normal range, are unhealthy.
§ 5. — There are certain limits, which are rarely exceeded, in the
range of temperatures observed in disease. The highest tem])eraturc
yet met with in a living man, noted by a trustworthy observer,
amounted to 1 12'55° Fahr. (= 4475^ C), whilst the range of lower
temperatures is less accurately determined. But if we put aside cases
which are quite exceptional, the range of temperature in the most
severe diseases is between 95° Fahr. {^^^ C.) and 108-5° F. (420° C),
and it is very seldom that it exceeds io9"4° Fahr. (43° C), or sinks
below 9 1 -4° F. (33° C).
§ 6. — Deviations from the normal course of temperature are cer-
tainly to be regarded as significant, and as never occurring without
due cause, whether we regard their origin, their amount, the course
which they pursue, or their cessation. Many of these deviations
may be referred to fixed laws or rules, even now (which I may call
pathological thermonomy), but we sometimes fail to discover these,
because in disease even much more than in health, animal heat or
the temperature of the body is the result of many different, and, in
fact, mutually antagonistic, factors. Besides the essential pheno-
mena of disease, many accidental and collateral influences may
alter the sick man^s temperature.
§ 7. — Influences which in no ways disturb the temperature of a
healthy man, have often a very remarkable effect in causing varia-
FUNDAMENTAL PllINCIPLES, 3
tions of temperature in diseased conditions of bodj^ although the
diseased condition itself may affect this but slightly. Moh'ility of
temperature as the result of external influences is, therefore, a sign
of some diseased condition of body. The discover}^ of abnormal
temperatures in men who have previously exhibited a normal degree
of heat is, therefore, a means of discovering or confirming the
existence of latent disease.
§ 8. — Alterations of temperature may be confined to special
regions of the^\hody, which are the seat of diseased actions (local
inflammations), whilst the general temperature remains more or less
normal. These circumscribed variations, in topical diseases, are of
very little practical moment. They consist for the most part of
elevations or depressions of temperature of very moderate extent,
seldom exceeding a degree Centigrade (i"8°, or less than 3° Fahren-
heit), over a larger or smaller area. These local changes are almost
invariably accompanied with other obvious phenomena, which, in a
practical point of view, are far more useful for diagnostic purposes
than the locally abnormal temperature.
§ 9. — The general temperature of the body (blood-heat), regis-
tered by the thermometer in interior parts, or in perfectly sheltered
spots on the surface, not locally afi'ected, is the exjiression of the
result of a number of processes, which on the one hand tend to the
production of heat (chemical processes, so-called tissue-changes),
and on the other hand promote the giving up of heat (cooling by
various means and apparatus, changes of heat into motion). How-
ever varied the combinations of these processes, and however their
several values may change almost momentarily, so that they appear
dependent on almost countless accidental circumstances ; yet expe-
rience shows, not only that the final result (the animal heat, or
specific heat of the body) remains almost always the same, in health ,•
but also that in disease the variations of temperature, if not abso-
lutely trustworthy, are yet the safest standard for estimating the
condition of the whole body. Variations of temperature coincide
with other functional and structural disturbances of the diseased
organism, but none of them can be determined and measured with
such accuracy as the temperature. None of them are so inde-
pendent (comparatively speaking) of trifling and subordinate sur-
rounding influences as the temperature. Very often these variations
4 lUNDAMKNTAl- I'lM Ni. 1 1'1-KS.
of tem|)c'ra(uiv nro conspicuous long belorc either I'liiictioiial or
t^tructural changes can be recognised.
§ 10. — 'J'he average (emperalnie or specilic heat of the whole
body may be normal in disease, or increased or diminished, whilsl
the distribution of heat is unequal as regards various regions of the
body. .-/ normal icmperalurc in ftic/r/wss Is onlij (o be considered as
a relative sign, as a symptom which may exclude certain forms of
disease, and may justify, but never by itself liad to a positive
diagnosis. A fall of temperature below the normal range is persistent
in very few diseases onlj', but occurs as a temporary ])licnomenon in
many favorable and unfavorable circumstances, rrccisely parallel is
the case of an unequal distribution of animal heat. In a majority of
cases, however, this must be considered an unfavorable symptom.
Abnormal derations of temperature furnish the most imjjortant
material for purposes of diagnosis and prognosis.
§ II. — Abnormal variations of temperature, except such as are
only momentary, are generally associated Avith certain common typical
states of (ill) health (modalities, or typical forms.)
A rapid increase of the temperature of the body from a chill, or
in the normal warmth of the hands, feet, nose, or forehead, is com-
monly associated with strong feelings of chilliness and convulsive
movements {" cold sJiivers ;" rigors ; "fever frost").
A more or less permanent and noticeable rise of temperature
amounting to J 01*3° Fahr. (38'5°) or more, is generally accom-
l)anied with subjective feelings of heat, and lassitude ; and usually
with thirst and headache, as well as with increased frequency, and
rapidity of the pulse ; and after lasting a little longer, with diminu-
tion of body- weight {" Feverishness ;^' pyrexia; fever; fever-
heat) .
Any considerable diminution of warmth in the extremities or in
the face, or in separate exposed parts ; with a high or simultaneously
falling temperature of the trunks is generally associated with a small
pulse, sunken features, feelings of weakness, and nausea (Unlust),
Avith much sweating, especially local, principally on the cold parts
of the skin {Collapse).
% 12. — The amount of temperature changes, the relation of these
changes to one another, and their alterations in the course of the dis-
FUNDAMENTAL PIUNCIPIiES, 5
ease [Quantity, type, and relation], although often modified by
accidental influences, are commonly determined hij the nature of the
disease : and, indeed, the more typical and well-developed the dis-
eased processes are, the more certainly is this tlie case. Many
separate kinds of disease correspond to loell-marhed ti/pes of altered
temperature. These answer to well-known varieties of disease.
In opposition to these there are certain (7(///;/(?«^or irregular forms
of disease, in which the temperature also is irregular. The contrast
between typical and atypical forms is, however, not always sharply
defined, so that many affections may be considered as standing on a
sort of neutral grouiid, between typical and ill-defined forms.
True ti/p'jcal states of disease, that is, those which almost inva-
riably show more or less clearly a characteristic type, and in which
there is seldom if ever a complete deviation from the typical form,
are illustrated by enteric fever (abdominal typhus), true exanthematic
typhus, and apparently by relapsing fever, smallpox, measles, and
scarlatina, primary (croupous or lobar) pneumonia, and recent
malarious fevers.
The group of apiiroxhriativelij typical forms of disease, in which,
indeed, characteristic types may be certainly recognised in the abstract,
but which, although in certain stages they exhibit great regularity,
yet occasionally deviate very widely from the typical, and almost
constantly display a great breadth and laxity of behaviour is less
easily defined. Yet we may include under it febricula, pyremia,
and septicaemia, varicella and rubeola notha, facial erysipelas, acute
catarrhal inflammation, tonsillitis (cynanche tonsillaris), acute rheu-
matism (rheumatic fever), basilar meningitis, and meningitis of the
superior convolutions; cerebro-spinal meningitis, parotitis (mumps),
pleurisy, acute tuberculosis, fatal neuroses in their last stages, and
the trichina disease.
Another groiip) is formed by those diseases which in certain cir-
cumstances conform to a regular type, but which generally run their
course without fever: when, however, fever supervenes a regular type
is generally displayed. To this group cholera, acute phosphorus-
poisoning, acute general fatty degeneration, and syphilis especial! v
belong.^ Even diseases which we are forced to include under the
designation of atypical or irregular do occasionally, in exce])-
tional cases, show a close approximation to typical forms in their
^ Under tliese lieadiugs some observations will be made in llie notes, which
will, I belipve, tend to show that tliis gronp is probably superfluous. — [Traxs.]
6 FUNHAMKNTM, IMMNCl Pl.K^^.
proi^rrs^. Of tliesc \vc may mention diphtlicria, dysentery, peri-
carditis, peritonitis, aente and chronic snppurntions (abscesses), and
phthisis.
^ 1 :}. — The conrsc of the teinperatiirc in many special diseases
almost invariably folhnvs a single ty|)ical form [monotj/picol or
uni/onn diseases).
Other maladies, according to their intensity, or from other special
causes, follow varions types of t(Mnperature {mnUiform, or pleoliipic
diseases) . The stndy of thermometry can define these variations of dis-
ease far more accnrately than has vet been done, and thus enable us
to discover and dilTercntiatc varying types of the same disease.
Smallpox, enteric fever, scarlatina, pneumonia, and malarious fever,
are diseases which occasionally assume the multiform type [j^Ieo-
iypis))}), although as a rule they decidedly follow a single pure type.
Those diseases which usually exhibit only an approximatively typical
course of temperature, show still greater tendencies to assume a
multiplicity of ill-defined types.
§ T4. — Any disease, however fixed may be its typical form, may
exhibit deviations from this in special cases [irregularities.] They are
determined by more or less lasting individual peculiarities and
circumstances (idiosyncrasies), by external conditions, or therapeutical
influences, whether favorable or unfavorable, and by the supervention
of complications. These irregularities are circumscribed within
certain hmits, and their form and extent are more or less determinate.
By means of the thermometer it will be possible to learn more of
these irregularities than is yet known, to assign them to their
proper causes, and give them their due weight in prognosis. And
it will help us better to fix the time when a patient's disease,
which has appeared to run an irregular course^ reassumes a typical
form.
§ 15- — -^ single ohservation of an abnormal temjierature, how-
ever great, or however small the deviation from the normal mav be,
is not L)j itself conclusive as to the kind of disease from which the
patient suffers. All we learn from it is —
1. That the patient is really bodily ill.
2. TThen there is considerable elevation of temperature^ we know
that there is fever.
rUNDAMENTAL PRINCIPLES. 7
3. When there are extremes of temperature^ wc know that there
is great danger.
We may indeed assign the following general significance to single
observations of temperature (in a conventional sense) .
A. Tcmjjeratures much below normal [collapse temperatures),
below 96-8° F. (36° C).
{a). Deep, fatal algide collapse, below 92*3° F. (33'5°C.).
{h). Algide collapse, 92-3° F. to 95° F. {o,^-^ 0.-35°), in
which it is possible for life to be saved, but which indicates the
greatest danger.'
(e). Moderate collapse, 95°— 96-8 F. (35 — 36° C), in itself
without danger.
B. Normal, or almost normal temperatures.
{a). Sub-normal temperatures, 96" 8° to 977° F. (36 —
36-5° C.).
[tj). Really normal temperatures = 97-88° to 99'i2°F. (36-6 —
37-4° C.).
(c). Sub-febrile temperatures := 99"5° — 100-4° F. (37-5 —
38° C).
C Febrile temperatures.
[a). Slight febrile action = 100-4° ^o iot'I2° F. (38 —
38-4° C).
(li). Moderate degree of fever, 101-3° to 102-2° F. (38-5 —
39° C.) . in the morning, and rising to 103-1° (39-5° C.) in the evening.
(c). Considerable fever, about 103-1° F. (39'5° C.) m'(\\Q, morn-
ing, and about 104'° in the evening (40-5 C).
id). High fever is indicated by temperatures above 103-1°
(39-5° 0.) in the morning, and above 104-9° (40'5) "^ the
evening.
D. Tetnperatures which hi every known disease, except relapsing
-fever, in all probability indicate a fatal termination = 107-6 F.
(42° C.) or more. (Hyperpyretic temperatures.)
§ 16. — By taking into consideration other circumstances and
symptoms of the sick, a single observation of temperature may
sometimes lead to a diagnosis, or serve to exclude the existence of
a supposed malady.
And a single observation of temperature (due regard being
had to all the circumstances of the case) may sometimes help
us to pronounce on the severity, or if the temperature of the
K ir\i)\MKA TAi. nnNciri Ks.
(lisenso lie nol dantrorously liitrli, on tin- rninpnralivo sn/i'ti/ of the
at I nek.
^ 17. — As (luMc arc rarialioiitt of tcinpcratiirc in t lie. course of
twcniv-four hours in /lealtfi, so also Ihoy occur in diKcaite. The
iJaili/ /! IK'/ 1' 11/ /OILS' ill Jls'caw aiv coiuMiotily wiic/i f/reo/er than ///
heallli. Tlicsc arc subject to rule— aiul ])ar(ly (Icpciitl (in fclirile
disease) upon the Kind, statje, and degree of severity of the disease,
and upon these iuiprovement (or crisis) depends. If the daily tem-
perature deviates from the normal type, it is generally due to the
individual circumstances of tiie ])a(i(iit, to an abnormal type of
disease, to complications and sudden relapses, to constipation or
diarrhoea, to sudtlen emj)tying of an over-distended bladder, to a
spontaneous or therapeutic loss of blood, to ])rofuse perspirations,
to moving the patient, or his over-fatiguing himself, to mental
excitement or to sleep, to errors in diet and thermal influences,
or the operation of medicines and other therapeutic agencies.
§ 18. — The daily fluctuations may be either simply ascending or
descending, but almost always describe a curve with one or more
elevations of tem})erature [dailij exucerhaiions) and intercurrent y^/i^/.y
of iemperaiure (daily remission fs). The number of degrees (or parts
of them — the extent of the excursus) between the daily maximum
and the daily minimvm is the daily difference or ravge of tempera-
ture : and when the difference is trifling, Ave call the course of tem-
perature continual ; when the daily fluctuations are considerable, mc
call it remitting. The wean between the maximum and minimum
temperature is the averayc daily temperature, and the height of this
shows the intensity of the fever. Typical forms of disease have, for
the most part, during their intensity, a determinate average daily
temperature, and seldom sink below a certain minimum or rise above
a certain maximum, unless shortly before death.
§19. — Coniinual oh scr rations of temperature, repeated several
times a day, through the whole course of a disease, or for a consi-
derable period of its duration, afford the best materials for diagnosing
and prognosticating the nature and results of any disease, when
this is associated with considerable elevations of temperature We
learn from them what is conformahle to laio or normal in the course
of febrile diseases, thus gaining a solid basis for diagnosis in indi-
vidual cases. They may often, in themselves considered, afford a
rUNDAMKNTAL rRINCIPLES. 9
perfectly correct diagnos'ifi of tlie k'nid of disease ; or, to say the
least, they furnish the most important and trustworthy materials for
a diagnosis, and are sometimes the only possible means of deciding
in doubtful cases.
They point out to us the stages or periods in the course of a dis-
ease, and show the transition of one stage into another.
They afford the best means of judging as to the severity of a
disease, and of recognising ameliorations and exacerbations. We
learn from them the irregularities displayed by the disease in its
course — dependent' partly on accidental causes, partly upon compli-
cations, and partly upon the influence of therapeutic agents. They
therefore furnish us criteria for the progress of the disease, and are
checks or controllers of our therapeutics. By means of these daily
observations we know when the diseased actions have come to an
end ; and very often, from the way in which this happens, we can
decide (by looking at the chart of the temperature) upon the kind
of disease, and whether it has been complicated or not, and judge of
the restoration to healtli whether perfect, or as yet incomplete.
Either in combination with other symptoms, or sometimes by them-
selves alone, the temperatures point out the approach of ?i fatal ter-
mination', and they either give assurance of undisturbed convales-
cence, or give the first signals of tlireatened relapses.
§ 20. — In the course of febrile diseases, we may distinguish the
following stages or periods in the range of temperature :
A. 'Periods preceding the termination of the disease.
1. The period of development (initial period or pyrogenetic
stage), which may be longer or shorter, but must be considered at
an end with the development of a locahsed process, or when the
lowest average daily temperature characteristic of the disease is
reached.
2. The period of full development of the disease (the acme, the
fastigium), during which the fever maintains the characteristic daily
elevations of temperature.
3. The period of perturbation (amphibolic or doubtful stage) usually
follows this in severe diseases, in which the temperatures generally
show a more or less irregular course.
B. Periods in cases which recover,
] . The crisis (perturbatio critica, or stage of decrement) or period
of decided, but as yet insufficient, decrease.
10 ITNOAMKNTAl, PKINCin.ES.
2. The ppiidd of rotiirn to normal temperature (stnge of defcrves-
rence or coolint,').
3. The epicrilical period and the j)eriod of eonvalosccnce, in which
the temperature is normal, or below normal, or sometimes even u
little above the normal.
r. Periods of the fatal termination.
1 . The pro-agonistic period (period preceding tlic death struggle),
during wliich the more or less peculiar character of tlie temperature
or other circumstances point out tlie commencement of a fatal
termination.
2. The agony or death struggle.
3. The aci 0/' (fj/iiiff and the post-mortem changes of temperature.
Very often these several stages are very brief, and escape observa-
tion more or less entirely.
»
§ 2 I . — The initial period in many forms of disease has a con-
stant and characteristic type, but very commonly escapes observa-
tion, on account of its brief duration. The type is varied by the
fact of tlie fever either preceding or following a localised inorbid
])roccss.
In those cases where a patient is previously ill and already
feverish, the type of the stage preceding a new attack is very vague
and undetermined.
The iniensHi/ of the symptoms (temperature, &c.) in the initial
period will only lead to a correct decision on the intensity and de-
gree of danger of the disease it ushers in, in cases of quite exceptional
severity.
§ 22. — The next period, ov fasti f/ in m, affords us characteristic
(lata for a correct diagnosis in three ways — {a) from the height of
the temperature, [h) by the alterations it undergoes, (<?) and by the
duration of this stage. It is especially by the positive elevation of
ternj^eratnre, by its long continuance at abnormal heights, and by
deviations from the normal type (irregular ])rogress), that we learn
the intensity and degree of danger of a disease. On the other hand,
when the elevation of temperature is moderate, when the duration of
the maxima (high temperatures) is short, and the remissions occur
early, we judge that the disease is of a mild type. Irregularities in
the course of the temperature, even when they indicate an abatement
of fever, must generally be regarded as unfavorable, and can only
FUNDAMENTAL PRINCIPLES. 11
be considered as signs of a mild attack in certain special cases. A
rise of temperature toioards the end of this stage generally betokens
some complication of the original malady.
§ 23. — The amphibolic or doubtful stage (of perturbations) is
seldom absent in cases which, without terminating fatally, take a
severe form, and the more regular the course in the fastigium the
more plainly is this stage to be recognised. It is a period of im-
provement, marked , by variations, sometimes easily traced to their
source, at other times apparently capricious. During this stage we
often get complications ushered in by noticeable elevations of tem-
perature. This period of p)erturt)atio7is is vA\\d.j% a sign of a severe
form of disease, and should always indicate a guarded prognosis as
long as it lasts, whether this be only a few days or some weeks.
The occurrence of an exceptionally high or low temperature on a
single occasion is less signijicanf, but its recurrence, or the fact that
the temperature remains abnormally high or at a moderate elevation,
renders a relapse or convalescence probable.
§ 24. — At the conclusion of either the fastigium or the amphibolic
period there is very commonly a final rise of temperature, which
more or less exceeds those met with at an earlier stage, sometimes
taking place in an afternoon, or is even shown by a slighter morning
remission, but in many cases lasts two or three days. This rise of
temperature is always associated with other marked symptoms, and
gives in every way a deceiving impression that there is a relapse, or
even that danger is imminent — perturhatlo critlca. It is, indeed,
quite impossible to predicate its favorable character, which can only
be judged of by the further course of the temperature and the pro-
gress of the case.
§ 25. — The stage of decrement, the period of preparatory mode-
ration, is wanting in many cases of recovery, for in these the
fastigium or doubtful period terminates the febrile process suddenly or
after a critical disturbance.
The first time the temperature fails to reach its previous elevation,
rather than any sudden change, is a characteristic of this stage. This
may occur cither at the evening exacerbation, or in the morning tem-
peratures, or with both. It is not unusual in this stage to observe a
single sudden descent of temperature even helo^o 977° {?,^'5° C,),
12 1 rNDAMKNTAL PinNClPI.KS.
which is very often associatrd willi all tlio syin])toins of collapso.
It may occur only once, and the Icniijeraturo may return to its
former, perhajis moderate elevation, or it may repeat itiself daily,
M'liile the intervenini' exaeerhations are still hut sliirlitlv moderated.
§ 26. — The period of defervescence or eooliiiL;; may conclude the
fastigium or the amphiholii^ stage, or follow a critical disturb-
ance, or he ushered in hy a ])criod of preparatory moderation. The
temperature in this stage returns io the normal, and there are
tiro vcU-niarlrd and different t//pes, although one may possibly
sometimes pass into the other. Defervescence taking place rapidly,
perhaps in a .single night, or, at all events, in about thirty-six hours : —
rapid defervescence or crisis ; or the fever may abate gradually, the
process occupying several days even — protracted defervescence or
t^sis.
The defervescence may consist of either a continuous fall in tempe-
rature, which, however, when it lasts more than twelve hours, is less
marked in the afternoon ; or of a fall in a remittent fashion, that is,
interrupted by daily evening exacerbations. It is very common to
meet with a state of collajhse in the course of the defervescence, in
which the extremely low temperature is accompanied with other
deceptive and seemingly very dangerous symptoms. These cases,
however, although protracted, constantly end in recovery.
§ 27. — The more rapid and complete the stage of defervescence
has been, the more clearly defined is the epicrilical 2'>criod (com-
mencing convalescence). Sometimes the temperature returns com-
pletely to the normal, and exhibits the same daily fluctuations as in
health. But there is generally increased mobility, and a certain
fickleness in the behaviour of the temperature. Once now and then
the temperature remains below the average normal level. In some
cases, and regularly in many diseases (especially in polyarticular
rheumatism), it keeps above the usual height. Besides this, we
sometimes meet with isolated, transient, but very significant rises of
temperature (of 2, 3, or more degrees Centigrade, = 4, 6, or more
degrees Fahr. nearly), of which the causes are sometimes nearly un-
known, or seem but trifling. Eeal relapses, and secondary diseases,
which also very frequently develop themselves at this special period,
are also speedily recognised by the renewed rise of temperature. The
duration and termination of the epicritical stage is not to be deter-
FUNDAMENTAL PRINCIPLES. 13
mined by the course of the temperature, because the actual true
convalescence occurs without material alteration of temperature.
^ 28. — In the convalescent stage, or period of recovery, when
this has been fairly entered upon, and the disease has left no sequelre
or complications, the temperature is much the same as in healtli.
Every rise of temperature above normal, and every abnormal fall,
shows that the convalescence is imperfect or deceptive. A^ery sudden
elevations of temperature indicate a fresh complication, or a new dis-
ease; and slighter;, continuous elevations are the expression of the
fact that the disease has left a residuum [sequelre] behind it.
§ 29. — In cases which terminate fatally there is generally some
siign of the approaching end (pro-agonistic stage), which may either
succeed the fastigium, or the amphibolic period (period of perturba-
tion), or may unexpectedly develop itself during convalescence. The
temperature is then very variable, sometimes rising, sometimes falling,
sometimes continuing as before, sometimes wholly irregular. Other
symptoms, such as the state of the pulse, will serve to denote this
period..
§ 30. — Daring the ayony or death struggle, the temperature either
niters Ijid little, or remains at its former elevation; or it sinks con-
siderably, either to normal or even below it (especially in death by
starvation) ; or it rises very rapidly to more or less enormous heights,
to heights which in the previous course of the disease it has never
i-eached, and, perhaps, not even approached.
§ 31. — Just about the moment of death the temperature '^Qm&>-
times /alls ; but commonly, even in cases where it has been rapidly
rising for some time before, it continues to rise till death, and in
some persons for some minutes, or even an hour or more after
death. In the first class of cases the temperature falls rapidly
after death ; in the latter the process of cooling is tedious, so that
even twelve hours after death the warmth of the corpse may be coii-
siderably greater than that of a healthy man.^
■^ 32. — In reviewing the course or progress of febrile diseases^
' This section has reference (as will be seen bj the context) to cases of disease.
It has, therefore, but slight bearing on cases of homicide, or suicidal deaths, of
which more will be said further on. — [fuAxs.]
14 FUNDAMENTAI, lUlNCll'LES.
wc liiul tliat the iluratioii and succession of the I'tbrilc pluMiouieiia
constitute live j)iinci))al groups.
I. Cases of fever running a short course (I'cbricula, ephemera,
and terniinal fever.
z. Fevers wliich are essentially coniinuous in their course (con-
tinued fevers), which exhibit but slight daily dirtereuces of tempera-
ture during their fastigium or acme, aud defervcsce rapidly (by crisis) .
3. Acute fevers, which have an essentially remittent course or cha-
racter, wliich when their intensity is not too great, exhibit even
at the height of the disease, or at least in the connncnccment of
defervescence, considerable daily differences of temperature (mostly
evening exacerbations and morning remissions), aud only fail to do
so when complicated, or if there is a tendency to death. Their
defervescence is also of a remitting type (gradual, or lysis).
4. The intermitting and relapsing types of fever.
J. Chronic or protracted forms of fever, which extend over
several weeks, or even months, sometimes in an uniutcrru[)tcd, but
generally in a remittent or intermittent type, or sometimes with con-
siderable intervals (free from fever).
§ 33. — Febricula and ephemeral fevers are those which last but
a brief time, are moderate in degree, and terminate rapidly.
The temperature in these cases may rise, with or without rigors,
to as much as 104 or 104*9° (^4*^° ^^ 4'^' 5^ C), or even more, but
seldom exceeds this ; aud sinks in rapid defervescence, in all cases,
with a short unbroken line of descent. The fever lasts from half a
day to two or (seldom) three days. This type occurs in traumatic
fever, in the brief childbed fever [ephemera or weed of llamsbotham.
Trans.], during convalescence in slight cases of catarrh, and in mode-
rate inflammatory changes in tissues, and in many other occasional,
and more or less recognisable circumstances. The paroxysim of
intermittent fever assume this type.
In other cases the temperature rises but little at first, and either
returns to normal after a day or two, or rises gradually after from
two to five days to its culminating point, which seldom exceeds
104° ("40° C), and terminates rapidly in defervescence. This type is
seen under similar circumstances to the former, but never occurs in
intermittent fever.
§ 34. — levers which terminate a disease (terminal fever).
FUNDAMENTAL PRINCIPLES. 15
though widely different in their significance, much resemble those
described above.
In the period shortly before death, of apyretic diseases, or in the
death struggle itself, there is a rapid elevation of temperature at the
point of culmination, or after a slight fall during the last moments,
death ensues. This type is found at the conclusion of fatal neuroses,
and in many cases of poisoning, and the temperature may thus reach
a great elevation, even above that in life.
§ ^^. — Eevers-'With continued elevation of temperature usually
begin suddenly, with rigors and shivering. During the fastigium
(or height of the fever) the average temperature varies (according to
the severity of the case) between iot%° and 104° Tahr. (39 and
40° C), and seldom much exceeds or falls short of this. The difference
between the daily maximum and minimum is only exceptionally
above 1° Centigrade (i*8° Eahr.), more commonly it is only half a
degree Cent. ("9 Tahr.) . The length of this stage is usually less than
a week; Defervescence is commonly rapid, or at least tolerably so.
The most perfect representative of this group is primary uncompli-
cated croupous (lobar) pneumonia (although this disease sometimes
assumes other types). A similar course obtains in the eruptive
fever of smallpox, in scarlatina (in w^liich, however, defervescence is
less rapid), in parenchymatous tousilhtis (cynanche tonsillaris), in
meningitis of the convolutions (of the convexity), and in typhus fever
(exanthematic typhus), but in this case the fever lasts longer; in
the beginning of facial erysipelas ; and lastly, but very frequently,
in very intense febrile diseases of all kinds (acute diseases), in
which the temperature, previously remittent, assumes a continuous
type simultaneously with the increase of heat.
§ 36. — In fevers with a remittent course of temperament, the
initial period or stage of incubation may be either short or protracted.
The average daily temperature is very varied, because both slight
and severe forms assume this type, and maybe either 101-3° (38-5°
C.) or less, or may rise to 104*9° (40'5° ^■) o^" ^°^^' ^^ *^^^ \-Mq\-
case, so to speak, exacerbations may occur, but no true remissions,
because the minimtcm temperature always continues truly febrile.
The duration of the remittent type of fever temperature is less
limited than that of the continued, and may occupy several weeks.
Defervescence is generally by lysis, and of a remittent type.
10 FUNDAMENTAJ. IMU NCll'LES.
Tvj)lu)i(l or enteric fever (abdominal typhus) is the best rejjie-
^entalivl'ol" this u;rou|). A reniiltent i\\)i.' is also displau'd by febrile
catarrhal aU'eelions, inllucnza, catarrhal pncumoniaj fi'brilc rheunuitic
aflections, by measles, by the conunenceinent of basilar meningitis,
in acute tuberculosis, and often, at least, by acute (pulmonary)
I'hthisis, and in acute trichinosis, iVc.
IJ :}7. — IntcniiitUiii and rvlujDsunj tyiies of disease have this
peculiarity, that in the Inlerrah of the brief, or, at all events, not
protracted accessions of fever (paroxysms), there are periods of
completely normal temperature. In the intermittent fevers, the
actual paroxysms of fever are always short, and seldom extend
through a whole day, and the temperature rises higher than in any
other disease of similar intensity, where there is similar absence of
danger; that is, temperatures of 105*8^ F. (41° C), or 1067°
Kahr. (4rj'^) are common, and sometimes there are one or two
tenths (Cent.) more (= -f to --^ Tahr. nearly). The intermis-
sions (apyrexiic) are also short, yet vary from a lew hours to three
days. Paroxysms and intermissions alternate with each other, with
more or lesss regularity, and this periodicity is the distinguishing
feature of these diseases.
In the rdajiis'incj forms the paroxysm is of less limited duration,
and the temperature in this stage varies ; the intermission is longer,'
and the relapse or repetition of the paroxysm commonly happens
i^nee only, sometimes Uc'ice, and more rarely a fjrcaler nnniher of
Itiiiei!'.
Malarial fever (ague) is the best example of the intermittent type,
whilst relapsing fever (tievre a rechute) is the best representative of
the recurrent form. But manv diseases seem with more or less
regularity to approximate to one or other of these types, especially
pytcmia, erysipelas, true smallpox, many cases of lobar pneumonia,
and not unfrcquently acute tuberculosis, basilar meningitis, and
acute phthisis.
^ 38. — C/iroHic diseases, and those marked by keette, are distin-
guished by their long duration, and cases are not wanting in which
the fever has apparently ])ersisted whole years.
Their course is sometimes very irregular, yet they generally approach
some definite type, which although, perhaps, exchanged for another
in the course of the disease, is still marked for a considerable space
FUNDAMENTAL PRINCli'J.KS. 17
of time with considerable regularity. Their type is usually remit-
tent, with one or two exacerbations in the course of every clay.
These exacerbations are sometimes slight, but sometimes severe or
even extremely so, so that the temperatures daily or twice daily reach
a similar elevation, and in the remission fall again to normal or even
below it. Sometimes there is what I may call a tertian rhythm, or,
in other words, there may be intervals of a day between the exacer-
bations, or the rhythm may be still more extended. When death
approaches, or when complications occur, the remitting type often
changes into a continuous one. This is best recognised in those
chronic inflammations of the lungs and bronchi which are classed
together clinically as phthisis, chronic ulcerations of the bowels,
prolonged suppuratioiis, in chronic inflammations of serous mem-
branes, and in prolonged admixture of embolic or infecting materials
with the blood.
§ 39. — An elevated temperature^ be the cause what it may, has
undoubtedly in itself an influence on the functions of the hodij, on
the nutrition of the tissues, and upon secretions.
When the temperature is only slightly raised, it is not possible to
distinguish the amount of this in particular cases. When the
elevation of temperature, however, is considerable, the most certain
result will be a diminution of the weight of the body. Besides this,
the pulse and respiration will be accelerated, the brain will exhibit
functional disturbances, the secretions of the skin, and the elimina-
tion of urea will be increased. There will be tendencies to local con-
gestions, and their results ; perhaps, also, to rapid fatty degenerations,
and even destruction of tissue (mortification). Yet these results
are not proportionate to either the amount, duration, or rapidity of
the elevation of temperature, and their absence is not an unusual
circumstance. The most remarkable elevated temperatures are
incompatible with the continuance of life. The reason of this is at
present unknown.
§ 40. — Very sudden alterations of temperature may influence the
functions of the body. Very rapid rises of temperature, especially
when the warmth of the trunk considerably exceeds that of the
extremities, are commonly associated with rlf/ors : with rapid falls of
temperature, where this has ])reviously been high, we tind severe
disturbances of health, dyspucea, delirium, or appearances of
collapse.
18 I'UN DA MENTAL I'lUNCIPLES.
^ 41. — DJ.'ioascs wliicli, instiail of diii|)lauiig clcvulioiis of lompi'-
raturo, arc cliaractcrlsetl, 011 the contrary, by an abnormally low
temperature, never conform to regular rules as regards the course
of the temperature, which is never constant.
^lany cases of inanition, of sclerema, cancer, clironic intoxication,
autl of serious metital disease, belong to this category.
Exceedingly low temperatures arc, however, very commonly met
with in the following cases :
In the remissions of a remittent fever;
In consequence of loss of blood, or powerful evacuations ;
la the course of defervescence, when this is excessive ;
And sometimes in the death -struggle.
Abnormally low temperatures may seriously disturb the various
functions of the body ; and when the fall is very considerable, it may
render the continuance of life impossible.
CHAPTEE II.
HISTORY AND BIBLIOGRAPHY.
§ I. — In the earliest ages of medicine the significance of tem-
perature as a symptom of disease was fully recognised. By Hijjpo-
crates, in common with most of the ancient writers, and those of the
middle ages, and even of comparatively modern times, the heat of
the body was deemed to be the chief and most diagnostic sign of
acute diseases. Most of them considered heat as a pathognomonic
symptom of fever, and the Greek and Latin names signifying
fever point to the elevation of temperature as of the greatest impor-
tance.
It is somewhat remarkable that after the lapse of two tliousand
years, during which an increased temperature was recognised as a
characteristic and important symptom of fever, without any contro-
versy, the true significance of the phenomenon should first fail to be
recognised, and as it were, fall into the background, in an age in
which accurate themometry first became possible by means of instru-
ments, and that in a school which introduced the study of physical
signs into pathology, and by which the use of the thermometer in
the observation of disease was first recommended and introduced.
We can, however, explahi this. The latro-mechanical theories of
medicine directed the chief attention of observers to the phenomena
presented by the altered conditions of the circulation in fevers, and,
moreover, these were precisely the symptoms which most exactly
agreed with the current theories of disease. And further, as modern
medicine developed itself, it so happened that as observation became
more precise and difficult, attention was diverted from those common
symptoms, which were difficult to determine precisely, to those
:J() lllSTum AM) lill51,U)tillAl'llY.
topical changes which had been neglected by earlier ol)servers. The
increasing number of aids lo diagnosis, which were continually being
discovered and perfected, and thus revealed local alterations of struc-
ture, seemed to give such a certainty of diagnosis, that in con-
templating this positive gain one forgot the loss sustained by
neglecting to observe the amount of general disturbance of the
bodily functions. And in this way, just as accurate thermometry
was rendered possible by the discovery of instruments for determin-
ing the degree of heat, the study of temjieraturc was more and more
neglected, oidy a few isolated observations being taken here and
there, till it had fallen quite into oblivion^ and has only lately been
revived.
^ 1. — Sanclorhiis (died about 1631S), the fore-runner of the latro-
mechanical school, was the first to apply a thermometric instrument
of his own discovery and manufacture, to the determination of tem-
perature. It is interesting to notice that Sanctorius was fully aware
of the importance of determining the hod^-weigJit as well as the
h'mperaiure, and considered these the two priucij^al criterions for the
changes affecting the whole body. [He invented a weighing- chair,
and strongly advised the use of the balance in other ways, in the
study of disease. He was Professor of Medicine at Padua, and
afterwards practised at A'enice. His treatise ' Ars de Statica
Medicina' was published in 1614. — Trans.] Another century,
however, passed before the measurement of temperature was again
revived — with improved and i)ractically perfect instruments.
The great Boerhaave was the first to profit by this. iVlthough he
sought for the essential nature of fevers in disturbances of circula-
tion, and amongst other things, remarks in his 581st Aphorism,
" A elocior cordis contractio, cum aucta resistentia ad capillaria,
febris onmis acuta? ideam absolvit •/' ^ yet he remarks in the 673rd
Aphorism, " Calor febrilis thermoscopio externus sensu aegri et
rubore urinae internus cognoscitur.^' -
Va/i Swieien, one of Boerhaave^s pupils, speaks yet more plainly ;
for although lie too, in his second book of ' Commentaries on Boer-
haave's Aphorisms ' (Leyden, 1 745), p. 'zC'>, says, " Signum patho-
^ "An increase in the rapidity of the heart's coutraction.s, aud an increased
resistance of the capillaries, complete our idea of every acute fever."
■ "External febrile heat is recognised bj the tiierinoinclcr; iulcruai by the
bcnsalions of the patient, aud by the redness of tlic urine."
HISTORY AND BICLIOORAPH Y. 21
G;nomoiiicum omnis febris est pulsus auct.i vclocitas," ^ yet he adds
to the other aphorism of Boerhaave's the note, " The estimate of
temperature by the hand is uncertain/' ^ "Omnium ergo certissima
mensura habetur per thermoscopia, qualia hodie pulcherrima habentur,
et portalia quidem^ fahrenheitiana dicta a prirao inventore : accuratis-
sima imprimis ilia sunt, qure argentum vivum loco alterius cujuscuncjue
hquidi continent. Tali thermometro, prius mensuratur calor hominis
sani, et plerumque in indice affixo ille gradus notatus est ; deinde hoc
cognitOj si idem thermometrum a febricitante segro manu teneatur^ vel
bulbus ejus ori i-mmittatur, vel nudo pectori aut sub axillis appli-
cetur per ahquot minuta horac, apparebit pro varia altitudine
ascendentis argenti vivi, quantum calor febrilis excedat naturalem et
sanum calorem." And in the commentary on section 47 6^ "Datur
in corpore hominis sani caloris gradus, thermometris mensurandus,
a quo nee liquidis nee solidis aliquid noxre accidit. Earo etiam in
fortissimis hominibus calor ille nonagesimum sextum gradum ther-
mometri Eahrenheitiani excedit. Ubi vero ultra centesimum gradum
in morbis ascendit, incipit sanguis ejusque serum ad coagulationem
disponi; si autem centesimum et vigesimum gradum sequat calor,
serum sanguinis coagulatur/''
In contrast with these limited researches another celebrated pupil
of Boerhaave's, and a colleague of Van Swieten's, de Haen, the
first clinical teacher at Vienna (and indeed in all Germany), greatly
extended the practical application of thermometry in disease.
Although he too defined fever, as a disease Avhich was commonly to
be recognised by a more or less quickened pulse, yet he availed
1 "Increased rapidity of pulse is the special diagnostic symptom of every
fever."
- "By far tlie most accurate measurements of heat are by thermometers,
whicli are now to be had both elegant and portable, and are called after Falircn-
lieit, tlie first inventor of them. Tliose which contain quicksilver instead of
other fluids are the most accurate. When such a thermometer, first used on a
lieallhy man, and marlced accordingly on the scale, is either held in the liand of
a fever patient, or tlic bulb placed in his mouth, or laid on his bare chest, or in
his axilla, for some minutes, the ascent of the mercury to different elevations
will show liow far the fever heat exceeds the natural and healthy." "Let it be
granted that the degree of heat, to be measured by the thermometer, in liealthy
men, is one at which no injury accrues to either liquids or solids; for it is rare
indeed, in even the strongest man, to find the temperature exceed 96° F. But
wlien it rises above 100° in diseases, the blood and its serum are disposed to
coagulate. If, however, the temperature equals 120° the serum of the blood is
coa2;ulated."
22 HISTORY AM) nilU.IOfiH.MMIV.
liiin'=;rlf of t lie use of iho (lun'moiinitT in (ho observation of febrile
(liscaso viTV extensively.
His methotl of thcrniomclrv was very peculiar, because lie was
accustomed to leave the iustrument seven and a half minutes inftHv,
and then add i° or 2° F. to the tenpcrature registered, because he
had found that the mercury would rise as much if left longer. In
spite of this imperfect method of ])rocedure, the thermometer
afforded him very valuable data, which for the most part have been
confirmed or even re-discovered in modern times. His researches are
dispersed through the fifteen volumes of his 'Ratio ]\fedcndi.^
Those chiefly deserving notice are: torn, ii, cap. 10, " De supputando
calore corporis huinani;'^ torn, iii, cap. 3, "De sanguine humano,
ejusdemque calore ;" torn, iv, cap. 6, " De sanguine et calore humano ;
tom. vii, cap. 5, " Varia," § 3; torn, x, cap. 1, " De febribus inter-
mittentibus; cap. 2, " De morbis acutis ;" tom. xii, cap. 2, " Historia
pulsus," &:c.
De Haen made a number of observations of temperature on healthy
people of various ages, and very numerous investigations in sick
people, so that he could fairly judge of its significance. " Non
antcm semel deciesve, sed pluries ipsissima experimenta iterata sunt
et semper idem docuerunt.''^ ^ He remarked constantly the remarkable
fact of the high temperature of the aged. In various parts of his
work we discover how valuable an aid to prognosis and diagnosis de
Haen found thermometry to be. He was aware of the morning
remission and evening exacerbation of temperature in fevers ; the rise
of temperature during febrile rigors (ficber frost) (tempore frigoris
homini intolerabilis cum pulsu contractiore minore, thermometum
signat octo gradus ultra calorem uaturalera," tom. ii, p. 142.)
He was familiar with the elevations of temperature, after inter-
mittent fevers have been apparently cured, which are often unaccom-
panied with any other noticeable symptoms (torn, iii, p. 326) ; he
was aware of the discrepancies between pulse and temperature in
many patients, the common contrast between subjective feelings of
warmth (or the reverse), and objective elevations of temperature ; he
used the changes of temperature as a controller or director for his
1 " Not once only, nor even ten times, but very many times were the experi-
ments repeated, and always with the same result."
- "During the cold stage, so intolerable to the patient, along with a
diminished force of the pulse, the thermometer registers eight degrees above
the natural heat,"
HISTORY AXD BIBLIOGRAPHY. 23
therapeutics^ aud regarded tlie return to a normal temperature as a
proof of convalescence.
The causes of animal heat were discussed by him at considerable
length, and with some ardour, in opposition to any mechanical theory
of its origin.
In spite of the influence of this celebrated Vienna Professor, his
contemporaries appear to have neglected medical thermometry.
§ 3. — In England, however, about the year 1740, Ch. Martin
published the first accurate observations on temperature in healthy
men and animals ('' De animalium calore^).
The followers of Ilaller also turned their attention to this subject.
{Haller-Marcard, ' Dissert, de generatione caloris et usu in corpore
liumano,' Gottiugen, 1741. Roderer, 'Dissert, de animalium calore
observ.,^ Gottingen, 1758.) A dissertation by PicJcel is also quoted,
' Experimenta mecl. physica de electricitate et calore animah,'
Wiirzburg, 1778, in which experiments on the influence of batliing
in rivers on the temperature are recorded.
One of the most remarkable and important facts of physiology, as
regards temperature, was, however, established in 1774, Blagden
('Philosophical Transactions,' I775j P- h^) demonstrated the main-
tenance of temperature of healthy men in rooms heated to the
boiling point of water (212°), and Bohson remarked the same at a
still higher temperature. These communications led John Hunter,
the great surgeon and physiologist, to publish his experiments, begun
in 1766 (Philosophical Transactions, 1775 — 78). He showed that
animals were able to resist external cold, because they produced in
themselves heat enough to counterbalance the loss.
John Hunter also, who was the first to remark local elevation of
temperature in inflammation (first after an operation for hydrocele,
Hunter's Works, edition 1837, vol. iii, p. 338), combatted the
view that the temperature was produced by the circulation of the
blood. He says, " It is very evident that warmth depends on a
different principle, which is intimately connected with life itself, and
is a power which maintains and regulates the machine, iudei)endent
alike of the circulation, the will, and of sensation. However, he was
not fortunate enough to discover the seat of this power, and he was
inclined to locate it in the stomach.
Shortly after this, the celebrated work ' Sur la chalcur, mem.
de I'academie' (1780) was published in Prance, by the celebrated
:2I' lllSTOIiY AM) iniU,l()fiUAP!lV.
jMrois'irr, tlio (lisoovcMvr of owLCcn, ami llu' rcfDnnn' of clinnislry. '
Tu conjunction with Iriplafc, lie iiivcstitfatcd (lio causes of aniiital
licit, and ascril)C(l it. to the chemical combinations of oxyi^on with
liydrojjon and carhon in resi)iration. lie says, ''The niiinial
machine has three rei^idators : res|)iration, which consumes hydrogen
and carbon, and produces heat; transpiration, which according
to the necessity of the case, lowers the temperature and cools the
body ; and digestion, which restores to the blood what it has Inst.
Although he considers the combustion of hydrogen and carbon to be
sources of animal heat, he does not entirely exclude other chemical
processes. lie places the seat of warmth production Ccombustion)
in the lungs. An Englishman also, Crawford (' Dc calorc aniiiiali,'
1 779, ' Experiments and observations on animal heat,' 17H6, and
second edition, 1788) seeks the source of heat in the chemical pro-
cesses in the lungs, whilst he admits that there may be an overplus
of heat, because the capacity of the atmospheric air for heat may
exceed that of carbonic acid for the same. He also turned his
attention to some pathological changes of temperature, and also to
the temperature of si)ecial inflamed parts, seeking to explain what he
found by the help of his theory.
§ 4. — Towards the conclusion of the last century (1797) there
appeared a work which was singularly free from mere theories, and
in the highest sense of the term, practical. For the first time since
the observations of de Haen, temperature observations were made
available for medicinal purposes, especially for the therapeutic in-
dications they afforded, and as a means for controlling therapeutic
experiments. This was James Currie's ' Medical Reports on.
ihe effect of neater, cold and warm, as a remedy in fever and other
diseases'
Observations of temperature are almost invariably added to the
clinical reports of the cases, and thermometry pervades the whole of
Carrie's practice. lie tests the action of warm and cold baths, of
digitahs, opium, alcohol, and restricted diet, by the alterations of
temperature they produce. He regards perspiration as a regulating
apparatus for temperature (p. 620). The value which Currie set
upon temperature as diagnostic and prognostic in the case of fevers,
will appear from the following passage (which the German translator
' Oxygen was so named by Lavoisier, but was discovered in 1774 by Sclieele
in Sweden, and Dr. Priestly in England, independently. — Trans.
HISTORY AND RIBT-IOGRAPHY. 25
]Ic(/eu-il--ich says lie should have suppressed, were it not that it
ajipeared to him a " glaring instance " in proof of the miserable state
of medicine in England ! ): —
"Though I am far from thinking that fever, properly so called,
consists merely of a series of phenomena originating in a morbid
nccumulation of heat in the system, yet this symptom evidently
occurs more or less early in that disease,^' (p. 624), and further,
"that some advantages are to be obtained from a strict attention to
tlie state of the l^eat in fever, and to the proper function of the
perspiration, this "volume affords, if I do not deceive myself, impor-
tant proofs. A careful attention to the changes of the animal heat,
and to the state of those functions on which it depends, and by which
it is regulated, though more requisite in febrile diseases, perhaps,
than in others, is however of importance throughout the whole circle
of diseases^' (p. 631). Although Cnrrie's work ran through several
editions in England, and was very favorably reviewed, yet it influenced
his contemporaries and countrymen but httle. Its influence in
Germany was still slighter. Mkhaeliis translation of the first part
fell almost still-born from the press, and Ilegeioitsch, who undertook
to translate the second part, complained that the first part was
almost unknown amongst German medical men. A similar fate
befell himself, as regards his share in the translation, and it was not
till half a century later that Huf eland again rescued Curriers work
for a brief space from the oblivion into which it had fallen.
§ 5- — Whilst practical men in various countries, with the excep-
tion of those above named, concerned themselves but little with the
temperature of the sick, physiologists for the most part were quite
satisfied with the chemical theory of warmth-production, as explained
by Lavoisier. It is true there were one or two exceptions, as Vacca
BerlingJiieyi {" e%?imQ della teoria di Crawford'^), Buntzen, and others.
But the experiments of Coleman (' Dissertation on suspended
respiration,' 1 791), and (Saimy (' Recherches sur la physique des
animaux hybernans,^ 1808) adduced some interesting facts which
appeared to contradict this chemical theory.
8ir Benjamin Brodie, in 181 1, entered the Hsts as an opponent of
the theory of the production of warmth by respiratory processes (see
his paper on '' Some physiological researches respecting the influence
of the brain on the action of the heart, and on generation of animal
heat,'' 'Philosophical Transactions,' tSit, p. 36, and also "Further
2G iiisTonv AM) nini,if)(;ir\riiv.
pxperimcnls and observations on the inlliuMicc of the l)rain in the
generation of animal heat," 'I'hil. Trans.' i(Si2, ]). ;]7<^). Jlis experi-
ments had shown him that, in decajjitated animals, uhen tlie cervical
vessels were ligatnred,nnd artificial respiration ^vas maintained for some
hour?, in sjjitc of the conversion of venous into arterial blood, main-
tained for so long a time, the temperature of the body sank more
rapidly than in those cases in which (after decapitation) artificial
respiration was not tried. lie deduced the conclusion that no heat
was evolved in the conversion of venous blood into arterial by respira-
tion, and that the source of heat must be sought for in the nervous
system. This explanation led not only to a lively discussion but to
further investigations as to tcmi)crature. Dallon at once opposed
Brodic, and JohiiDary, in particular ('Philosophical Transactions,'
1814, p. 590), published experiments on the capacity of arterial and
venous blood for heat, and comparative researches on the temperature
of both kinds of blood, as well as that of different parts of the
body. A communication of Hale's (in Meckel's ^Archives,' iii,
429), and one \>y Legallois (Ibid., 436) may also be mentioned.
(3n the other hand, Nasse, the translator of Brodie's tractate
(Rcil &: Auteurietli's ' Archives,' 1815, Bd. xii, 404 — 446) pro-
nounced strongly in favour of Brodie.
Earle also believed that Brodie's theory was supported by patho-
logical observations.
CJiossat (see 'Mem. sur I'influence du systeme nerveux sur la
cbaleur animale.' These de Paris^ 1820) considered the opinion
that the source of animal heat was to be sought in the sympathetic
nerve, established by a great number of exjieriments. In the course
of this discussion the Prench Academy offered a prize for a treatise
on the source of animal heat. The essay of Didong (read
December, 1822), and that of Despretz (read January, J 823) were
published. Both of them decided for Lavoisier's theory. They
estimated the oxygen absorbed by animals, and the carbonic acid
which they exhaled, ascribed the overplus of oxygen absorbed to
formation of water ; estimated the total production of heat by tb.e
combination of oxygen and carbonic acid^and that of the ascertained
excess of oxygen combined with a calculated quantity of hydrogen,
in proportion to form water, and compared these results with the
total heat-production in animals^ as determined by calorimetry (now'
for the first time made use of for determining physiological ques-
tions) ; as, however, an excess of heat was found to be produced (as
niSTORY AND BIBLTOGRAPHY. 27
compared ^vitll the estimated amount), the conclusion was arrived at
that there must be other sources of heat than the combustion-processes
of the animal body.
§ 6. — During these theoretrical discussions but few observations
were made of temperature in human beings. Gentil, however,
published some on the variations of temperature according to age,
sex, temperament, and the time of day (' Diss, sur la chaleur animale,'
quoted by Dei/eux in ' Annales de Chimie,' xcvi, p. 45). Thomson also
reported on the prodilction of heat in an inflamed part (communicated
in Meckel's ^Archives/ v. 405).
Shortly after, two practical works appeared in Germany, which
followed Currie's plan. Ilnf eland, in 1821, offered a prize for the
demonstration of Currie's experiments on the influence of the water
treatment of febrile diseases. One of the requisitions of the giver of
the prize was, that the essays should contain " a series of original
experiments, in order to moderate febrile heat by the external use of
water, by Currie's method. The use of the thermometer before and
after the application of water, and counting the pulse, appears to be
an essential part of the experiments.''^
These prize essays were published in Hufeland's ''Journal' for
1822. The third of these (by PitscJiaft) appears to be valueless.
On the other hand, the one by Anton FrdJdich (of Vienna), and
that by Reim (of Aschaffenburg) both contain many valuable con-
tributions to pathological thermometry. Some thermometric observa-
tions are contained in Lucas' Dissertation at Bonn, ' Experimenta
circa famem/ 1824.
Baill^ wrote a " Memoire sur Talteration de la chaleur animale
dans les fievres algidcs'' {' Revue Med.' 1825, ^'^ 3^4)-
Sir Everard Home (in ' Philosophical Transactions/ 1825, p. 257),
in a paper '' On the influence of nerves and ganghons in producing
animal heat,'' adduced some incredibly high temperatures (as much
as 118° Eahr. = 477° C), which GrainviUe asserted to have ob-
served in the uterus during labour.
Edimrds, in 1824 (' De Tinfluence des agents physiques sur la vie ')
gave a resume of all that was then known about temperature.
§ 7. — Daring these thirty years only a few methodical or com-
prehensive observations on the relations of temperature to health and
disease were pubhshed.
The celebrated researches of Becqiterel and Brescliet (published in
I-3S IIISTOHV AM) lUIU,Ioni!.MMIV.
iS?-, in \\\c 'Aniialcs dcs pci'imiccs imtiircllos,' sccnnd series,
'* ZouIoi,'ie/' torn, iii, iv, nnd ix) bcloiii^; (o this cali'Ciory, alliiough tl'.cy
rfuardcd j)atlit)Iogical ronditions but slijflitly. They tested the varia-
tions of leniperalure in dillerent ])arts of llie bodies of animals, by
means of extraordinarily sensitive thermo-electric ajiparatus. These
experiments found tlie teinj)crature of inllamed parts to be higher
than tliat of the rest of the body.
Another work, wliicli concerned itself still less with pathology,
was the zoo-physiological treatise of Ik-rger, which treated of the
determination of temperature in various species of animals ("Faits
relatifs a la construction d'une ('chelle de degres do la chaleur
animale," in the ' j\Iemoires de la societe de physique et histoiro
naturelle de Geneve/ torn, vi, part z, p. 257; and 1836, torn, vii,
Erhcardf) furnished a comprehensive article in ' Todd's Cyclopsedia,'
vol. ii, p. 648, 1836 — 39.
The specially medical publications of this period were far less
valuable.
CoJlard de Mari'ujnij,'vQ. 1836, wrote, 'Del'influence dela circula-
tion generale et pulmonaire de la chaleur du sang, et de celle de ses
lluides sur la chaleur animale/ in the 'Journal Conplenation,' torn,
xliii, p. 286.
The article on warmth in the thirty-volume 'Dictionary' of 1834
had for its authors, for the physiological part V. H. Berard (torn,
vii, p. 175), and for the pathological part (p. 212) Chomel, then the
first practitioner of his day in Trance. Chomel laid great stress
upon temperature, but believed the hand to be the only proper
instrument to determine it, and that the thermometer only gave im-
perfect ideas of its elevation, and was unable to give any indications
of its special modifications.
Bouillaud, however, declares that he made more than three
hundred thermometric observations (' Cliuique j\led,' i, 294, and iii,
428).
Bonne ('Archiv. General:' 2 serie, ix, 129) investigated the
temperature in various diseases, and compared it with the pulse and
res^iirations.
Fiomj (1838, 'Traite de la diagnostic,' iii, p. 28) recognises the
necessity of a measurement of the skin temperature " dans plusieurs
cas," and cites the following from Blot, " Lorsq'un voit tant de
resultats obtenus par le seul secours d'un peu de mercure enferme
s.
o
HISTORY AND BIBLIOGRAPHY. 29
dans un tube de verre, et qu'on songe qu^un morceau de fer suspendu
sur un pivot a fait decouvrir le nouveau monde, on concoit que rieu
de ce qui pent agrandir et perfectionner les sens de I'liomme, ne
doit etre pris en legere consideration/' ^
Piorry had a thermometer added to his stethoscope^ and speaks
very judiciously on the vakie of thermometiy, only he gives so many
cautions and difficult directions as to the use of the instrument as
almost to deter people from using it. Notwithstanding this^ his
own observations are entirely untrustworthy, and indeed fabulous
He found the tem"perature in the axilla in healthy persons to be 33
Eeaumur, and even more (= 104° Fahr.), and in a number of sick
people, temperatures of 34 — 36° E. (=108-5° — 113° Fahr.) and
even 38° R. (=117-5° i'ahr.) in a case of typhus. In a case of
prurigo, free from fever, he found a temperature of 34° E.
(=108-5° Pahr.) in the axilla, and 35° E. (=110-75° Fahr.) at the
epigastrium ! He took temperatures in ninety-one individuals, but
only once in any single case, and his observations were in various
parts of the body. It is, therefore, obviously impossible to deduce
any conclusions from observations so little comparable with each other.
Sir Benjamin JBrodie made known his experiments on elevation of
temperature after division of the spinal cord, and his case of trau-
matic haemorrhage in the upper part of the cord, with enormous eleva-
tion of temperature, in the year 1837 ("Pathological and surgical
observations relating to injuries of the spinal cord," in the ' Mcd.-
Chir. Transactions,^ vol. xx, p. T18).
In the same year (1837) a somewhat valuable dissertation by
IFistingkausen was published at Dorpat {' De calore animali
qusedam^) treating of the sources of animal heat, and the causes of
its constancy.
Fricl-e, of Hamburgh (' Zeitschrift fiir d. gesammte Med.,'
1838), made experiments on the axillary and vaginal temperatures
before and during menstruation, and found a slight elevation of
temperature during the How of the catamenia.
Friedrich Nasse published in 1839 (in ' Untersuchungen zur
Physiologie and Pathologic,' von P. and Hermann Kasse, Pd. 2,
Heft i, p. 115), some new experiments on the dependence of animal
^ " When ouc sees such results obtained by the sole aid of a little mercury in
a glass tube, and reflects that the discovery of the New World was owing to a
little bit of iron suspended on a pivot, surely nothing which can siipplenient or
perfect the operations of our senses should be held in slight estimation."
30 IIISTOIIV AND niBLlOGUAlMlY.
lii-at upon the nervous system, and Ilermanti Nasse (Ibid., \). lyo),
" On the dependence of animal lieat on the brain and spinal cord."
Gavarret ('Journal rexperience,' 1839), conlirmed what de
Uaen had already found, although it was even then not generally
known that the temperature of the trunk during the rigor of
fever (Ficber-frost), was much elevated, and not less than in the hot
stage (Fieber-hitze). AVe are indebted to Dr. John Davi/ for the
most important additions to the facts of thermometry, at least in
healthy jjcrsons at this period, lie republislicd his earlier statements
in * Physiological and Anatomical llesearches' (1839).
But during the whole of these forty years, the work done in
animal temperature was but scanty, and //. Nasse (loc. cit. supra),
has very justly remarked of this period : " For some years ])ast the
science of thermometry has been more neglected than formerly, and
indeed remains aluiost in statu qiio.^^
% 8. About the year 1840, there commenced in good earnest a
series of not-again-interrupted painstaking investigations on the
temperature of the body both in health and disease. The facts re-
lating to temperature in both these conditions were now first collected
in greater numbers, and in a much more methodical manner. As
regards the practical application of thermometry to clinical observa-
tion, which holds itself free from all theories, we find several ob-
servers had already recognised the importance of thermometric ob-
servations in order to decide on the severity of a disease or its
amehoration or exacerbation (diagnosis and prognosis), whilst others
had considered an elevated temperature worthy of notice, either by
itself or in relation to other single symptoms (the pulse, &c.) ; but
no one, since the time of Currie, had made the attempt (or even be-
lieved in its possibility), to evolve practical laws from the course of
the temjierature, and, as it were, to map tliem out for others (und sie
auschaumg zu bingen). Anclral (whom we consider as in everyway
the leader of the march of progress in his day), first recognised the
aspect of medical thermometry, and in the year 1841 he formulated
a considerable number of fixed rules for the elevation of tempera-
ture in disease, in his ' Lectures on general pathology.'
Still more valuable was the dissertation by Gierse which appeared
in 1842. The medical faculty at Halle had ofi'ered a prize for an
essay on the question " Qusenam sit ratio caloris orgauici partium
inflammatione laborantium, investigetur experimentis accuratius
HISTORY AND BIBIJOGRAPHY. 31
facieiidi^.'^ [The cause and reason of organic heat in inflamed parts
to be investigated by careful experiments.]
Gierse extended his subject^ and carefully measured the tempera-
ture, not only in artificially or spontaneously induced inflammations
of the skin and mucous membranes, but also in various febrile afi'ec-
tions (intermittent fevers, scarlatina, measles, &c.), not once but
several times, and also the temperature during menstruation and
pregnancy, making observations on his own temperature at various
times of the day, and adding thermometric observations on plants.
Gierse' s observations" have long been regarded and quoted as the
best comparative ones, and are not devoid of value at the present
time.
Not less important, although somewhat neglected, were the ob-
servations of Hallmann scattered through his treatise on the proper
treatment of typhus (' Tiber eine zweckmiissige Behandlung des
Typhus^), 1844. He was deeply impressed with the importance of
thermometry in medicine, and the necessity of its introduction into
clinical researches, and has not only incorporated the result of his
observations on the variation of temperature with his recommenda-
tions of the water treatment of fevers, but has also added a number
of observations on the variations of temperature in the healthy, under
various conditions and circumstances (p. 54) .
In France, Chossai's " Experimental researches on inanition,''' which
were for the most part communicated in 1838, were repubhshed
during the year 1843. (' Memoires de Pacademie royale des sciences,'
tom. viii, p. 438.) In the second part (p. ^0,1 et seq.), he inves-
tigated the influence of starch on animal heat, and incidentally dis-
cussed carefully the daily fluctuations of temperature in the normal
condition. Chossat regards the difi'erence between the day and night
temperatures, as a proof that " les combinaisons d'ou resultent les
degagements de la chaleur animale, se font essentiallement sous Fin-
fluence nerveuse" (p. 554) } He investigates the decrease of tem-
perature in complete starvation, as well as in the case of imperfect
nutrition, and gives the lowest point to which the temperature falls
in fatal cases of starvation.
The investigations of Henri Roger, although they have a limited
basis, and are not guarded by those precautions necessary to perfectly
trustworthy results, are yet highly important. {^'De la tem])eratiire
' " The conibiuatious which give rise to auimal heat are esseutially under
the iuflueuce of the nervous system."
32 lllSTOKY AM) lUlU.KX.KVni V.
cfie: les lufauts a Vviat phjjs'wlvijiquc et paf/toloy'iquc," published in
1S44 in the ' Archiv Genor./ scric 4, torn, iv — ix, [and republislicd
st>p;irati'l\ . 'J'horo is u co])y in Ihe Obstetrical Society's library, of
wiiich 1 have availed myself. — Trans.]). After some preliminary
observations on the methods of thermometry, Jiof/cr adduces obser-
vations on the normal tcm})eraturc of children (at birth, during the
tirst seven days, and at a later period), as well as in ephemera, in-
termittenl, and t vphoid fevers, smalli)ox, scarlatina, measles, erysipelas,
rheumatism, pericarditis, cardiac hy])ertroi)liy, stomatitis, enteritis,
dysentery, meningitis, encephalitis, laryngitis, bronchitis, pleurisy,
and pneumonia ; and still further, in tuberculosis, hooping-cough,
chorea, dro])sies, rickets, and paralysis; not to mention thrush and
the oedema (sclereme) of newly born infants.
finally, at pp. 261 — 297 of torn, ix, he sums up the results
obtained in a very practical manner, in their application to diagnosis
and prognosis. Such a wealth of thermometric fact had never
before been accumulated, and Roger himself was well aware of the
practical importance of his experiments. If, however, we are forced
to confess that his great work does not express the full value of
pathological thermometry, the explanation must be sought in the
fact that the observations were not reported sufficiently often in the
several cases (very often the temperature was only taken once in the
disease), and especially in the fact that Roger strove rather to esti-
mate and compare the positive rise or fall of temperature in various
diseases, than to indicate the course of the temperature in any given
disease, which is far more important. ]\'oue the less, on this
account, are Roger'' s summaries and deductions of great interest
even in the present day, and they contain many fine observations.
Demarquay published a contribution to experimental pathology,
in which he investigated the influence of pain, of loss of blood, of
the ligature of blood-vessels, of traumatic inflammations, of ob-
struction of the bowels, and of various toxic agents on the tempe-
rature of animals. (Recherclies experimentales sur la temperature
Dissert., 1847), and conjointly with JJumerr'd, '^Experiments on the
elTect of ether and chloroform in lowering temperature'^ (it548,
'Arch. Gener.,' 4 serie, tom. xvi, p. 189.) About this time, George
Ziinmermann , an army surgeon at Hamm, began to make very
numerous observations on temperature. His first publications are
to be found in the 'Med. Zeiting d. A^ereins f. lleilkundc in
Preussen,' i'^^6, Nos. jO and 40, and almost immediately after.
HISTORY AND BIBLIOGRAPHY. 33
very numerous ones in the same journal for 1847, Nos. 19, 21, and
^^, ofi; in the ' Archiv fiir physiologische Heilkuncle/ 1847, p. 735,
and in the ' Prager medicin. Yierteljahrschrift/ 1847, Bd. 4, p. i.
In the "^Archiv fiir Chemie und Mikroskopie/ 1847, ^^^ ^^ ^^^^
paper, 'Uber die Analyse des Blutes/ 1847, further observations will
be found.
In the year 1850, this surgeon published a new series of papers ;
first, in the 'Archiv fiir physiologische Heilkunde/ 1850^ p. 283;
next, in the first part of his own ' Archivs fiir Pathologie und The-
rapie,' 1S50, in the ■' Deutsche KKnik,^ 1851,^0. 36, and 1852,
No. 9, in the ' Prager medicin. Yierteljahrschrift,^ Bd. 4, p. 97 ; in
'Med. Zeitung des Vereins f. Heilkunde in Preussen," 1853, but
especially in a brochure which he published, entitled, 'Khnische
Untersuchungen zur Pieber-Entziindungs-und Krisen-Lehre,' 1854
(' Clinical Researches in Pevers, Inflammations, and Crises ').
Zimmermann undoubtedly rendered a great service to medical
thermometry by his untiring observations, made at a time when its
importance was generally neglected by medical men. His harsh
and fearless denunciations of his colleagues, for neglect of so im-
portant, a means of observation, were not entirely unfounded. Be-
sides, he has furnished a great number of very valuable facts. The
very copiousness of his works has, however, deterred people from
following in his steps. Inde]3endently of the mass of facts which
they contain, his works are, however, of value, because he first
especially pointed out the dependence of elevated temperature upon
local processes of inflammation, and the rise of temperature deve-
loped in them.
It is almost certain that the dissertation of J. Peter Schnitz,
whicli appeared at Bonn, in 1849, '^^ calore in morbo,^ and
contained about 300 observations of temperature in various diseases,
owed its publication to the influence of Nasse, who was almost the
only German clinical teacher who took a lively interest in the subject
of temperature.
"\Ye ought, perhaps, to supplement this catalogue with the further
observations of Dr. John Davy, on the temperature of healthy
persons, as ofi'ering a simple basis for other observations, free from all
theoretical propositions. He had published a number of papers from
the years 1844 to 1850, of varying value, and in 1863 he published
them in a collected form in his ' Physiological Eesearches.' They treat
of the temperature in advanced age, of the influence of various
3
34 IIISTOHY AND lU Ul.KXJHAl'JI Y.
tcmporatures of the external nir on animal heat; of the diurnal lluc-
tuations, the iiitlucncc of seasons, of active and jwssivc movements,
of concentrated attention, of increased alimentation, and of the
effects of sea-sickness on tlie teni])cratur(', and all these points are
discussed as regards tropical as well as northern climates, and inci-
dentally many other less important subjects arc considered. Although
not, perhaps, the most exact observations possible, they are collec-
tions of materials of great value.
Other pathologists devoted their attention to special features of
animal temperature. Fourcanlt, Flonrens, and especially Magend'ic,
made experimental researches on the physiology of temperature.
Bergman)!, although a chemist, furnished a contribution of a
physical character to the literature of the subject in his " Ikitrag
zur Kritik dcr Lehre von Calor Animalis" in Miilkr's ' Archiv,' 1845,
(p. 300), and again in 1847 {' Gottiugen Studien,' p. 59,5), he pub-
lished a treatise, " Uber die Verhaltnisse der Wiirmeokonoraie der
Thiere zu ilirer Grcisse^' [" On the size of animals as affecting their
comparative temperature.)"
In 1846, HelmJwHz published a very valuable and comprehensive
article on warmth, in the Berlin ' Encyklopadische Worterbuch der
medicinischen "NYissenschaften,' Bd. 25, p. 323, and in 1848, the
same investigator furnished a demonstration of the production of
warmth by muscular movements. In 1847, there appeared a trans-
lation from the Dutch of Bonders on '^The tissue changes as a
source of heat in both ])lants and animals."
Friedrich Nasse's treatise on ' Yerbreunen und Athmen,' 1846
(' Respiration and Combustion^), belongs to the physiological series.
§ g. But the greatest advance was made at this time, in respect
to the theory of warmth, and of animal heat in particular. New
principles are developed which appeared at first to influence opinion
but slightly, but soon acquired an indisputable supremacy over all
views which had been previously entertained.
This appears to me the place to mention the views of Lieh'ig upon
the sources of animal heat, views founded less upon direct experiment
than upon a bold and original conception of genius. He considers the
source of animal heat to be the combination of the constituents of the
food, with the oxygen carried by the blood-streams (v. ^ Die orga-
nische Chemie in ihrer Anwendung auf Physiologic und Pathologie,^
1842). Although some of LieUg's conclusions are untenable, and
the distinction drawn by him between tissue-forming (histo-genetic)
HISTORY AND BIBLIOGRAPHY. 35
material; and warmth-producing (respiratory^ thermo-genetic) food,
extremely difficult to maintain in its strict signification (althougli
still accepted by many), and although his inroads upon the province
of pathology have not all been successful, yet the deliberate reference
of the ultimate source of animal heat to chemical processes, and
especially to a slow combustion (eremacausis), maintains its ground.
The basis laid by Lavoisier was extended and fortified, as well as
adorned, by Liehig,
The recognition of the essential unity of the so-called impon-
derables (of chemical forces and of motion) ; the reference of all
chemical processes to a single force or power, which sometimes
appeared as light from the sun, its unquenchable source ; was some-
times continued as chemical difference, sometimes changed into heat,
sometimes into a mechanical effect (motion), and sometimes trans-
posed into electricity, preserving all the while in inorganic as in
organic nature, a constant magnitude — this doctrine of the unity
and correlation of forces was a perfectly new idea, which we owe to
Br. J. R. Mayer, a surgeon practising at Heilbronn, who first pub-
lished this idea, which marks an epoch in physics, in a short
pamphlet, ' Bemerkungen liber die Krafte der unbelebten Natur,^ in
' Wohler und Liebig's Annalen,^ May, 1842, and afterwards in a little
book, ' Die organische Bewegung in ihrem Zusammenhang mit dem
Stoffwechsel,' 1845. His teachings in regard to motion as the mecha-
nical equivalent of heat, although disregarded at first, were gradually
recognised in all their correctness and grandeur of conception, and
are now the basis of the views entertained on the nature of heat,
and especially on the forces of nature, as regards their mutual
equivalency and preservation. And although they had but little
influence in changing the current theories of heat-production till ten
years afterwards HelmhoUz had expressed substantially the same
ideas, yet almost every one in the present day agrees that Mayer w^as
the true discoverer of the mechanical theory of the forces of nature.
'' Ex nihilo nil fit, nil fit ad nihilum " (says Mayer, ' Die Organische
Bewegung,^ p. 5). '^The effect equals the cause : the operation of
force is again force in its turn. In real truth there is but one single
force, w^hich runs through an eternally changing round, in dead as
in living nature. There, as here, there is no progress, unless the
force changes its form (p. 6). Heat is a force, it becomes changed
into motion (p. 10). Chemical difference is a force (p. 28), the
changing of chemical difference into heat results from combustion
36 mSTOUV AM) lUHLIOORArilY.
(j). 35). Ill all chemical ami physical changes the i^ivcii power
always maintains a constant magnitude (j). 32). The sole cause of
animal heat is a chemical process, a kind of oxidation (p. 46). The
chemical force, uhich is contained in the food ingested, and in the
oxygen inhaled, is the source of two manifestations of power, viz.,
motion and warmth; and the sum of the ])hysical power of any
animal is e([uivaleut to that of the simultaneously produced chemical
processes (]). 45). Since that time these views have been generally
and fully accepted in physics, as well as in physiology, and they
must doubtless be accepted in pathology, although their application
to the ceaseless complications of disease processes is extremely
diflk'ult. In the pamphlet quoted, Mayer has very lucidly discussed
the application of his theory to some pathological and many physio-
logical processes.
lie has also attempted a further application to pathology in his
treatise on fevers (' Archiv der lleilkunde,^ J862, p. 385).
Soou after Ma^er, Joule, of ^lanchester, experimentally demon-
strated the absolute and unchangeable relation between heat and
mechanical power, and showed that a given quantity of power pro-
duced a determinate quantity of heat, as on the other side, that the
quantity of heat which would raise a given quantity of water one
degree in temperature, would perform exactly a certain amount of
mechanical work. The use, and indeed the name of the word
kilogrammeter, originates from this principle in order to designate
the mechanical power which is equivalent to, and necessary for
raising 1000 grammes to i meter in height, or i gramme to 1000
metres, for he found that the heat which would raise i kilogram of
water i degree (Centigrade) will raise 424 kilogrammes i metre;
and if converted, the same mechanical power which produced the
latter effect will raise the temperature of a kilogramme of "water 1°,
or in other words, that the mechanical equivalent of the heat (that
required to raise a kilogramme of water, 1° in temperature being
taken as a unit) is 424 kilogrammes.^
' Or, in another form : — That tlie quantity of heat capable of increasing the
temperature of one pound of water (weighed in vacuo, between 55° and 66°)
by 1° Fahr., requires for its evolution the expenditure of a mechanical force
represented by a fall of 772 pounds, through the space of i foot. Or, the heat
capable of increasing the temperature of r gramme of water by i" C. is equivalent
to a force represented by the fall of 42355 grammes through the space of i
metre. This is consequently the effect of "a unit of heat." See Towne's
'Chemistry,' loth Ed., p. 64. — [Tiu:ks.]
HISTORY AND BIBLIOGRAPHY. 37
Him, in Colmar, showed by direct experiments, that whilst at
work the production of heat never corresponded to the oxygen con-
sumedj much of it being changed into work. Whilst during perfect
rest 30 grammes of oxygen were consumed in an hour, and 155
units of heat produced, it was found that work equivalent to 27450
kilogrammetres done in another hour led to 132 grammes of oxygen
being consumed, whilst only 251 units of heat were produced. One
was increased four and a half times, the latter only one and two-
third times. But in place of the missing heat so much work was
done.
It would occupy too much space to discuss this subject in further
detail. Enough has been said to indicate the direction which
Mayer's initiation has given to the theories of warmth-production.
§ 10. In the beginning of 1850, medical thermometry entered
on a new phase of development. Two medical men in Germany
published some highly important, and, as regards medical thermo-
metry, novel observations in the years 1850-51. Their names were
Bcwensprung and Trauhe.
It i^ somewhat doubtful which of them can claim priority.
Trauhe, indeed, published his first measurements of temperature
in his treatise on the effects of digitalis, and especially on the in-
fluence of that drug on the temperature of the body in febrile
diseases, (*■ Annalen der Charite,'' 1850, p. 622), but it appears
from other local publications of the same year, that in March and
even up to June, he had never taken the temperature in pneumonia.
His first case, in which measurements of temperature were given,
was a case of typhoid fever, of the date 18th June, 1850.
Biirensprung's work " Untersuchungen liber die Temperatur
verhiiltnisse des "Fotus, und des erwachsenen Menschen in gesunden
und kranken Zustande,'-" appeared in 1851 in Miiller's 'Archiv,^
at a later date than Trauhe's publication. But a careful considera-
tion of his cases leads to the conclusion that his investigations were
commenced at an earlier date than Traube's. Any decision as to
priority, however, is unimportant. Both investigators doubtless
commenced their observations independently, and the important
services rendered by each remain the same, whoever may have been
the first in the field.
Bdren&pruiu/ s treatise is an eminently classical w^ork. He has
determined all the principal points of thermomctric experience.
38 HISTORY AND ninLTOnil API! V.
and (lisplayoil tlicir manifolil relations', so that the accuracy of
his results has becu confirmed 1)\ liter observations. What was
previously known only in an im})erfect, unsatisfactory, and fratjinen-
tary form, as regards single instauces, has been raised by liiin to
the dignity of a comprehensive, well constructed, and, in many
respects, complete doctrine. The reason of his failure in inilucucing
the medical profession in a degree corresponding to its merits,
must be soui'ht for in the fact that it is somewhat too miiml(>
and circumstantial, and surrounded willi too many precautions,
(pialities, however, which arc imperatively required in a scien-
tific observer. His use of two decimal places in his measure-
ments of temperature, the importance he attributed to deviations of
one tenth of a degree (centigrade = 4-° Fahr. nearly) or even less,
and the recommendation of em])loying half an hour for every
thermometrical observation, were slight recommendations of ther-
mometry in general practice, rendered the use of the instrument too
burdensome, and, indeed, almost impossible in ordinary medical use,
and only exceptionally possible in hospital practice.
On the other hand, Tranbe's thermometrical investigations, which
are evidently those of an earnest questioner of nature, had for their
object the decision of questions which, though partly theoretic, were
also very practical (the effects of digitalis, crises, and critical days,
&:c.), and have clearly shown that the thermometer is a most valuable
means, and often the only one, of deciding difficult and debated
questions in the art of medicine.
§ II. Ever since October, 1851, i, myself, induced by Trauhe's
spoken recommendations, have introduced the use of the thermo-
meter in my clinique.
Used at first only in a few selected cases, an increasing appre-
ciation of its value has led to its more extended and rational
employment. For the last fifteen years there have been no patients
in my hospital wards whose temperature has not been taken ; and,
although at first this w^as only done twice a day, for the last ten
years from four to six daily observations have been made in cases of
fever, and in special cases even more frequently. The number of
cases of illness in which thermometric observations have been taken
in my clinique, amounts to nearly 25,000, and the number of single
observations to some millions.
The object which I had in view at first, w'as to determine the
HISTORY AND BIBLIOGRAPHY. 39
actual facts as regards tlie temperature of the sick, uninfluenced by
special theories, and irrespective of special questions and objects in
order, by accumulating a mass of observations, to eliminate the influ-
ence of accidental circumstances. When the number of observations
fairly reached more than 100,000, they appeared to me to furnish
a basis for the determination of to me the most important and most
decisive question in pathology : the question, namely. Do certain
diseases in their progress obey fixed laws or rules, and can tins
he determined and displayed hy the course of the temperature ?
The affirmative. answer to this question was first afforded by our
commonest form of severely acute disease, abdominal typhus (enteric
or typhoid fever), and also by a shght epidemic of exan thematic
typhus, imported into Leipsic, which was almost entirely under my
own observation, and of short duration only. But afterwards, the
regular course of other forms of disease was evident to me, after
most careful consideration, and most painstaking observations : and
the conviction of the immense and almost incalculable value of the
thermometer in a practical point of view, hitherto unrecognised, took
fast possession of me, a conviction which I am bound to endeavour
to wakfe and confirm in the minds of others.
I considered, however, that it was not well to publish observa-
tions of such importance in a crude form, or before they had been
carefully tested. On this account, with the exception of the com-
munication of my former assistant {I)r, Thierfelder) on Abdominal
Typhus, and my own on the subject of True Typhus, and the refer-
ences to the importance of the thermometer in special forms of disease,
in my ' Ilandbuch der Pathologic und Therapie' (2nd edit.), I waited
six or seven years from the commencement of thermometric observa-
tions in my clinique before communicating the most important
results and considerations to the common stock. Since then, how-
ever, I have constantly sought to adduce fresh examples of the
practicability and usefulness of this method of investigation in the
varied domains of pathology, and the innumerable questions of
medical diagnosis.
The collection of this immense mass of observations now at my
disposal, which has rendered it possible for me to determine com-
mon principles, and to discern what is normal and regular in
disease, would have been impossible had I not been aided by a host
of faithful and accomplished assistants, who worked day and night
with the greatest devotion, taking and superintending thermometric
40 HISTORY AM) inui.ior.H.MMiv.
observations. .Many of those have themselves eliiciclatetl si;viral
important (jneslions, partly by their own inclcpcntleiit observations,
antl j)artly by the comparison of the results of sixteen years' mate-
rials collected together in the archives of my clinical wards.
I must especially express my thanks for their aid to m}' former
assistants, Drs. T/ii erf elder (now Clinical Professor at llostock),
Uhle* (first Clinical Professor at Dorpat, and afterwards at Jena),
Friedeniaun ^ (in general practice), Jh)Her, Na/cotiz, Geiss/er^' (Tutor
and Clinical Assistant), llo/jl', Blaftx, Thomas (at present Director of
Polidinik), Siegel (now District Surgeon in Leipzig), Sc/icnkel, and
Treihmann, Drs. Fr'iedldnder and Heiiize, as also to my present
assistants, Drs. Ilenbner, Slechcr, and Hankel, as well as to a great
many earlier students, who have published valuable contributions to
medical thermometry, especially to Drs. Seume, Michael, and Jfilhler.
I cannot omit saying that our labours have not been in vain. The
thermometric observations wliich, ou their first publication, many
thouglit fit to ridicule, and which a French critic declared to be an
empty wind-bag (lit. cine unfruchtbarc diiftalei), which could only
amuse physicians in those little German hospitals where the num-
ber of the staff almost equalled that of the patients, these measure-
ments are now customary in every clinical service in Germany, in
the majority of hospitals, and with a great number of busy practi-
tioners, and are regarded as an essential part of the observation of
every case of fever. Let the scope and importance of this brancli
of science be regarded as it is now, and as it was itri years ago, and
it will be seen to have reached a development which few tlieories
have attained in so short a time.
The circumstances affecting the temperatur of the body, and its
relations to other phenomena, have attracted the greatest attention
from those who have investigated this subject.
The variations of temperature in healthi/ people, and the influences
which cause them, have been to a great extent determined by the
beautiful experiments of 7?. Lichienfels and R. Frohllch (see Biblio-
graphy, p. 45) ; and further contributions to our knowledge have
been made by Dami'osch, Knauthe, Dr. W. Ogle, and JUrgensen (for
titles see p. 45).^
* Those marked thus are since dead.
^ See also a pajier by Drs. Sydney E-iuger and A. P. Stewart "On the
Temperature of tlie Human Body in Health," in the ' Proceedings of the Royal
Society,' vol. xvii. No. 109, p. 287; and another by ^Ir. A.. H. Garrod "On
HISTORY AND BIBLIOGRAPHY, 41
The moditications of temperature induced hy jnegnanci/, delivery,
and the pod-partum i^eriocl, as well as those met with in the newly
horn, have all been very carefully investigated, as will be seen in further
chapters. And the behaviour of the temperature in cases of inpiries,
has been investigated with equal care, especially by Billroth and 0.
Weher. Thermometry has been introduced into surgical practice,
not for a day or a year, but " for all time'' (lit. fiir alle Zeiten) .
As regards internal diseases, very many observations of tem-
perature have been published. And although perhaps no very great
discovery has been' added to the facts established by Bdrensprung,
Tranhe, and those of my own clinique, yet the confirmation, by nume-
rous observers in different places, of the principles already laid down,
are of great value, and have served still further to elucidate some spe-
cial points. Details will be found under the several diseases treated of.
Drs. Jenni, Wolf, and JJhl and Wagner have all published compre-
hensive abstracts (see on pp. 46 and 47 for titles) .
The application of the thermometer to patients has undoubtedly
had an influence in inducing a rational use of cold baths in abdo-
minal typhus (enteric fever), and some other diseases. Towards pro-
moting the cooling treatment of febrile diseases, after Brand (of
Stettin) had once broken the ice (lit. die Bahn gebrochen hat) ,• ^a;-/<?/^,
Jiirgensen, Liehermeister, Ziemssen, Obernier, Wald, Barth, Hosier,
and Immerniann, have all contributed, especially the two former.
Into other European countries also [besides Germany] medical
thermometry has been introduced. The ice has been broken, so to
speak, in Holland, Russia, Prance, Italy, and England, as well as in
North America ; and although I find my communications and those
of my pupils and assistants simply reproduced (sometimes with
acknowledgment, sometimes not !) in not a few publications in all
these countries, yet in all there are independent and original workers.
In Russia, especially, there are celebrated medical men, of German
extraction, who have jniblished important material, which must
receive more detailed notice further on. In Holland, the observa-
tions of Fokker (see on p. 46) deserve special mention.
In France, besides numerous theses by Maurice, Spielmann,
Fouque, Aronssohi, Hardy, Buclos, Sec, other distinguished prac-
titioners, well acquainted with German literature, have recognised
some of the Minor riuctuations in the Temy)eratiire of tlie Human Body when
at rest, and their Cause," ' Proceedings of the Royal Society,' vol. xvii^ No.
112, p. 419. — [Trans.]
1'2 HISTORY AN11 ni lU-lOORAm Y.
ll e gnat valiu' of llicniioinclry at the; sick bctl, especially Charcul
(in nuiiuTous works), and -liu'coud (in his * Lcc;ons dc Cliiiique
Mt'tlicalr,' 1S67, and liis 'Trailc (U- I 'at hoi. iiiliTno,' iiS6y, pp. 72-
92). Ladr, of Geneva, has pnhlislu-d a good book (sec p. 47).
Laihiiiic, of Ncuehatel, lias also pnblished a work, called ' Le thor-
nionietre au lit du nialade, recherches j)h}'siologiqnos et pathologiques
.'inr la temp, del'homnio." in ^13ull. de la Societc dcs sc. naturoUos
de Nenchatel, 1866,' In .///^vvVrz, according to Lcwick (' i'enn-
slyvauia Hospital Hcports, tS68,' i, p. 3H2), Beniuil-Doxoler, of
New Orleans, had already in 1851 made a number of "Experimental
researches into animal beat in the living and dead body,'' and
published them in the July nimibcr of the ' New York Medical
Gazette/ as well as later ones (in 1856) in the 'New Orleans Med.
and Surgical Journal.'
Segmn, in particular, has made our experience avcU known in
America (Oledical Eecord,' i. 51 f^); and since then tlicrmoractry
has been still more extended and recognised there.
In Enfjland, John Simon at first, and Sidney Hhiger in particular
(especially in his work ' On the Temperature of the Body as a means
of Diagnosis in Phthisis and Tuberculosis,' 1865), and Aitkin (who
quotes my observations and curves in almost all febrile diseases, in
his ' Science and Practice of Medicine'), have all declared most
strongly the practical value of thermometry, and introduced its
significant results to their countrymen. Medical thermometry has
in recent times found great acceptance with a host of intelhgent
medical men, towards which, no doubt, the Germans practising there,
particularly Weber and Bav.mler, have contributed not a little. Com-
pare the articles of Comj)ion ('Dublin Journal/ August, 1866),
Grimshaw (Ibid., May, 1867), Warier (since dead, in 'St. Bartho-
lomew's Hospital Pieports/ 1866), MeCormacIc ('Medical Times and
Gazette/ 1866), Gibson ('British Medical Journal/ 1866), and
Smith ('Edinb. Medical Journal/ 1866), and many others. [See
also the Supplemental Bibliography. — Teans.]
§ 12. — The number of newer works on thermometry is so great
that it is impossible for me to enumerate them all. But it may not
be superfluous, at the end of this short historical resume, whilst
overlooking those occupying themselves with special circumstances
and forms of disease, which will be mentioned in their place here-
after, to introduce the following works to the reader's notice, as ap-
HISTORY AND BIBLIOGllAPIIY. 43
peariiig in the last fifteen years^ as being generally important and
necessary to complete one^s knowledge of human temperature in
both health and disease. The following comprehensive works, ab-
stracts, and pamphlets on Heat itself, and particularly on Animal
Heat, may be noticed :
H. Nasse, on "Animal Heat/' in Rud. Wagner's ' Handworter-
buch der Physiologie,' 1853, Bd. iv, p. i.
Gavarret, 'T)e la Chaleur produites par les etres vivants,' 1855.
A. FicJc, ^ Medicinische Physik/ 1856, p. 162.
G. A. //«■;?,.•'■' ]l-echerches sur Tequivalent mecanique de la
Chaleur,' Colmar, 1858 ; 2nd edition, 1865.
G. Zeuner, 'Grundziige der mechanischen Warmetheorie, mit
besouderer Eiicksicht auf das Verhalten des Wasserdampfes,-" t 860,
(2nd revised edition, 1866).
C. Ludivig, ' Lehrbuch der Physiologie des Menschen/ 2nd edition,
1861, Bd. 2, p. 719-758.
B. Claiisius, 'Abh. iiber die mechan. Warmetheorie,' 1864.
John Ti/ndaU, "Heat considered as a mode of Motion/' (French
translation, by the Abbe Moigno, 1864).
Berthelot, "Sur la chaleur animale" (1865), in Eobin's 'Journal
de Fanatomie et de la physiol. normale et pathologique/ ii, 652,
and ' Gazette Med. de Paris/ C. xx, 474.
Onimi/s, "De la theorie dynamique de la Chaleur" (1866) in
' Comptes rendus de la Soc. des Sciences Biologiques/
H. Mayer, ' Mechanik der Wiirme' (Collection of his earlier pub-
lications, 1867). Compare also the abstracts of the subject in the
more recent text books of medicine and physiology.
The theory of the Relations of Animal Heat (to other forces) has
been especially the subject of numerous and increasing discoveries.
The influence of the nervous system on the production of warmth,
the question of warmth-regulators, and the further elucidation of
Mayer s theories of the conservation of forces, have all been the
subject of numerous works. The most important of these are —
Claude Bernard, "De Pinfluence du systeme nerveux grand
sympathique sur la chaleur animale" (1852), in "■ Comptes Rendus,'
xxxiv, 472. "Experimental researches on the vascular and
calorific nerves of the great sympathetic (1862), in Ibid., Iv, 228,
and in the ' Journal de Physiologic,' v, 383 ; " On the influence of
the great sympathetic in calorification" (1853), in the 'Memoires de
la societe de Biologic/ p. 84; "Eecherches sur le grand sympa-
•I ^ HISTOHV AM) UIBLIOGRAI'llK
thiqiu^, it sprciak'nu'iit sur rinlliuMice t|uc l;i section do co ncrf
oxorcc snr la chaleur aninialc/' i S ■;4 ; " liC(;ons sur la physiologic
ct la patliologio du systoino norveux," ^^S^> ^' J "Logons sur les
proprit^ti's physiologiqucs et Ics alterations patholog. des li([uidcs do.
rorganismo," i8j9, i, 50-162 ; " Ivcclierches sur le grand sympa-
thique" (1863) ; in the ' Ann. dcs Sciences nalnrelles Zoologie/ xix,
p. 101.
Brflwn-Si'qunrd, " Ijxpcriniental Researches a])plied to LMiysiology
and Pathology/' t8 33 ; especially in the abstract *' On the increase of
animal heat after injuries of the nervous system/' p. 73 : besides an
immense nuinlun- of papers in the ' Medical Examiner' of Phila-
del])hia; in the 'Journal de Physiologic/ &c.
M. Scliijf, "J)q Tintluence du grand sympathique sur la produc-
tion dc la chaleur animale, et sur la contractilite musculaire/^ in the
'Gazette hebdom./ 1854, p. 421, and his " Untersuchnngen zur
Physiologic des Xervensystcms mit Beriicksichtigung dor Patho-
logic/'' 1 8 -55 (especially the 2nd abstract); " Uber den Einilusz
der Nervenliihmungj auf die Erhohung dcr thicrischen AYiirme/'
p. 1 24-228 ; " Neue Yersuche iiber den Einlluss der Nerven auf die
Gefasse und die thierische "Warmc" (1856) in the ' i\[ittheilungen der
Natur forschen den Gesellschaft/ of Bcrn^ p. 69/'Ubcr die Eicberhitze
(1859)/^ in 'AUg. AViener med. Zeitung/ Nos. 41 and 42.
Knoch, ' De nervi syrapathici vi ad corporis temperiem/ Diss
Dorpat^ 1^55-
J'ati der Beke Callenfels, " Ueber den Einfluss deu vasomotor-
ischen Nerven auf den Kreislauf und die Temperatur" (1855), in
the * Zeitschrift fiir rationelle Medicin/ N. E. vii, 157.
Kussmaul and Tenner, " Ueber den Einfluss der Blutstromung in
den grossen Gefiissen des Ohrs beim Kaninchen, und ihr Ver-
hiiltniss zu den AYiirmeveriinderungen^ welche durch die Lahmung
und Reizung des Sympathicus bedingt werden" (1856), in 'Mole-
schott's Untersuchungen/ i^ 90.
Lieherrneister : " Die Eogulirung der "Wtirmebildung bei Thieren
von constanter Temperatur" (in 'Deutsche Ivlinik/ 1859), and
" Physiologische Untersuchungen iiber die quantitativen Veran-
derungen der "Warmeproduction/' (in Eeichert's 'Archives/ i860 —
62.
J. Beclard : " De la contraction musculaire dans ses rapports
avec la temperature animalo/' 1861 ('Archives generales/ E. xvii^
34).
HISTORY AND BIBLIOGRAPHY. 45
Heiclcnham : ' Mecliauische Leistung, Warmeentwickling und
Stoff-umsatz bei der Muskelthiltigkeit/ 1864.
Kemig : ' Experimentale Beitrage zur Kentniss der "Warmeregu-
lirung beim Mensclien ' (1864).
/. Vogel : " Uber die Temperatur-Verlialtnisse des Menscblichen
Korpers mit besonderer Riicksickt auf ihre Ursacb.e und auf die
Versucbe, den Werth der Letzeren numerisch zu bestimmen/' in
the ' Arcbiv. des Vereins flir wissenscb. Heilk./ 1864, p. 441.
Waltlier of Kiew : " Studien im Gebiete der Tbermopbysiologie/'
in ' Eeicbert's ArcbiV/ 1865, p. 25.
Achermann: "Die Warmeregulation ini boberen tbieriscben
Organismus" (1866), in the ' Deutscb. Arcbiv fur Kliniscbe
Medicin/ ii, 359.
TscJ/eschichin, " Zar Lebre von der tbieriscben Wilrme/^ in
' Eeicbert's Arcbiv/ 1866^ p. 151.
Falkland : " On tbe source of muscular power/' Koyal Institu-
tion of Great Britain^ weekly evening meeting, 8tb June^ 1866.
Bupui/ : "Dq la cbaleur et du mouvement musculaire" (1867),
in tbe 'Gazette Med. de Paris/ Nos. 33, 34, 37, 38, 42, and 44.
Tbe 'subject of temperature in bealtby persons^ witb its fluctua-
tions^ and the circumstances which affect it, were investigated by —
Rud. LicJdenfels, and Rud. Frdhlich, "■ Beobacbtungen iiber die
Gesetze des Ganges der Palsfrequeuz und Korperwiirme in den
normalen Zustiinden, sowie unter dem Einfluss bestimmter Ur-
sachen/^ in tbe 'Denkscbrift der Wiener Academic, 1852, Matbem-
uatur-wissenscbaft classe/ Bd. iii, Abt. 2, p. 113.
DamroscJi, "Ueber die tiiglicben Schwankuugen der menscbl.
Eigenwiirme in gesunden Zustand,'-* in the ' Deutsche Klinik,' 1853,
P- 317-
Roppe, "Ueber den Einfluss des Wlirmeverlustes auf die Eigen,
temperaturen warmbliit. Tbiere,'' in ' Virchow's Arcbiv,' 1 857, xi,
P- 453-
KnautJie, " Halbstiindliche und Viertelstiindlicbe temperatur
curven von Gesunden," in tbe 'Zeitscbrift fiir Medicin,' 1865.
Heft 8.
If. Ogle, '^ On tbe diurnal variations in the temperature of tbe
human body ;" ' St. George's Hospital Eeports,' 1866, i, 221.
JUrgensen (1867), in 'Deutsches Arcbiv. fiir klin Med./ iii, 165.
As regards tbe thermometry of disease, with comprehensive obser-
vations and discoveries of abnormal temperatures (exclusive of
\(i llISTOliV AND UIKLlOfiKAI'll V.
treatises on special fi)rins of disease, or on some special ([ueslionj, the
following books may be consulted with advantage :
Joc/itnaiin, 'lU'obachtungen iiber die Korpcrwurmc in clironischen
fieberhaftcn krankheitcn/ 1H53.
/'/>c7/(>/^', article "Ecver/' 1854, in Mlandbucli der spec. Pathnlo-
gie und Thcrapie, i, p. 26.
Lasii/iw, " Dc la temperature du corps dans Ics maladies/'
(i8-)6), a retrospective article in the 'Archives Gen. de Medccine/
Maurice, " Des modifications morbidcs dc la temperature ani-
male dans les affections febrilcs" {' Dissertation/ 1 853) ; and /^j/f /-
mann, ''Des modifications dc la temperature animale dans les maladies
febriles aigues et cbroniques" ('Dissert./ 18-/)). (Both drawing
chiefly from German sources).
U'underl'ich, "Die Thermometrie bei Kranken/' in the 'Archiv.
fur physiolog. Heilkunde/ i 857, and " Ueber den Normal Verlaui'.
einiger typischen Krankheitsformen'^ (Ibid., 1858).
Fouqne's Dissert. "Du Thermometre en Medecine/' 1858.
Aronssohn's Dissert. "De la Tievre/' 1859.
Hardy s Dissert. " De la temp, animale dans quelques etats
pathologiqucs/' i8_;9,
ll'nnderUch, " Ueber die Nothwendigkeit einer exacteren Beach-
tuug der Gesammtcoustitution/' in the 'Archiv. d. Pleilk./ i860, and
his " Yorlegung einiger Elementarthatsachen aus der praktischen
Thermometrie und Auleitung zur Anweudung der "Warmemessung in
der Privatpraxis'^ (Ibid.).
Jenni, " Beobachtungen iiber d. Korperwiirme in Ivrankh.,''
i860.
Smoler, " Ueber das Verhtiltniss von Pulsfrequenz, Eespiration,
und Temperatursteigeruug in einigen acuten Krankheiten/' i860, in
' Prager A'irtaljahrschaft,' Ixvii, p. iii.
John Simon, article " Inflammation," in Holmes' ' System of
Surgery,' i860, vol. i, p. 40—53-
Billroth, in the 'Archiv. fiir klinsche Chirurgie,' 1862^ and 64.
Forster, " Ueber Thermometermessung ber Kindern," in ' Journal
fiir Kinderkrankheiten/ 1862.
Tranbe, " Zur Pieberlehre," in * Allgemeiner medic. Central-
zeitung/ 1863, 1864.
Fokker, "Over de Temperatuui' van den Mensch.,' in 'gezonden
en zieken. toestand/ 1863.
Beh>se, "Beitrage zur Lehre vom Pieber/'' 1864.
HISTORY AND BIBLIOGRAPHY. 47
Duclos, '' Quelques recherclies sur Tetat de la temp, dans les
maladies'^ ('Dissert./ 1864).
Wolf, " Eiickblick auf die bisherigen Temperaturbeobachtungeu/'
in the ' Archiv. des Vereins fiir wissenschaft Heilk./ 1864.
0. IFeher, " Ueber die Wiirmeentwicklung in Entziindeten
Theilen^ und experimentelle Studien liber Pyiimie, Septicamie, und
Pieber/' in ' Deutscher Klinik./ 1864, and 1865, and article on
Fever in 'Pitha and Billroth's Chirurgie/ i, 1865.
Liebermeister, "Kliniscbe Untersucliungen liber das Pieber,"
(1865X in the ' Prfiger Yierteljahrschr/ Ixxxv, 1, and Ixxxvii, i.
W'aclmmdh, " Zur Lehre vom Fieber," 1865^ in 'Archiv. der
Heilkunde/ vi^ p. 192.
TJhle and Wagner's " Handbuch der allgem. Pathologie/' 3rd
edit., p. 537— 560 (1865).
Wunderl'ich, " Vortriige liber Krankeu-thermometrie/^ 1865 to
1867, "^ 'Archiv. der Heillmude/ vi — viii.
Lade, "De la temp, du corps dans les maladies/' Geneva,
1866.
Frese, '^ Experimentalle Beitriige zur Aetiologie d. Fiebers/'
1866. ^
TscheschicJiin,_ ''Zur Fieberlehre/' 1867, in "Deutsche Archiv.
fiir klinische Medicin/ ii, 588.
Note. — It has been thought best for the purposes of reference, not to trans-
late the titles of books in the Bibliography. The respective questions discussed
by each author will appear froni the body of the book, and a supplemental list
of still more recent works will be found at the end. — [Tkans.]
CllAPTER HI.
Tin: VAUK OF TIIK THERMOMETER IN MEDICAL PRACTICK.
^ 1. — The tendency of modern medicine to set the highest value,
for diagnostic and ])rogiiostic purposes, upon objective symi)toms,
and amongst these upon what are called plnjsical signs, is un-
doubtedly a step in the right direction.
Now, the temperature of a sick patient is both an " objective"
and " physical" symptom, and the use of the thermometer must be
classed with the " physical diagnostic'^ methods of percussion, aus-
cultation, &c. ; and whatever may be claimed for these as regards
their significance and practical value may be claimed for thermo-
metry with equal justice.
Thermometry, however, has this advantage over all these ap])lica-
tions of acoustics, an advantage of almost priceless value, inasmuch
as it gives results which can be measured, signs that can be expressed
in numbers, and offers materials for diagnosis which are incontestable
and indubitable, which are independent of the opinion or the
amount of practice or the sagacity of the observer — in one word,
materials which are physically accurate. Amongst all the phe-
nomena of disease there is scarcely another which admits of such
accuracy or is so reliable as the temperature.
The results afforded by thermometry have yet another advantage
over those of the other physical methods of diagnosis. Whilst the
latter aids to our judgment indicate, for the most part, somewhat
permanent changes, or at all events slowly changing phenomena, the
measurement of the temperature gives us a peep, as it were, into a
sce7ie of continual changes — changes, indeed, which, in the normal
states, are but as slight oscillations of a pendulum, which in disease,
by its sudden and powerful swing, points to similar perturbation in
the domestic economy. The temperature is both a more accurate
and a more delicate mensme of the changes undergone by the animal
VALUE OF THE THERMOMETER IN MEDICAL PRACTICE. 49
organism than other symptoms, which may slowly become evident,
perhaps at a much later period of the disease.
There remains a third advantage in favour of thermometry, which
amply vindicates its claim to a liigh position amongst physical
methods of investigation.
Whilst nearly all the other methods of this kind have for their
object the discovery of topical changes only, their indications are
summed up, as it were, by thermometry, which presents to our
judgment d. phenomenon dejiendent upon the whole of the vital pro-
cesses of the entire^hodi/'; and whilst it places accurately measured
observations at our disposal, opens up to us for our investigation
regions of pathology (literally, ^' a domain of sick life^') which were
inaccessible to other methods of exploration. Indeed, thermometry
renders these general changes available for prognosis, and the im-
portance of this is great in proportion to the amount and signifi-
cance of the general morbid processes.
The nse of the thermometer in disease is, therefore, an objective,
physical method of investigation, which gives exact and accurate
results, in signs which can he measured and expressed numerically ;
which is delicate enough to follow every step of the changing pro-
cesses of the organism, and places at the disposal of the practitioner
•A. phenomenon dependent upon the sum total of the organic changes
ill the body.
§ 2. — The determination of the patient^s temperature in disease
may be regarded as a valuable contribution to pathology from three
different points of view.
(a) It appears desirable and necessary p)er se, because any devia-
tion from the normal or healthy condition is an essential element of
the study of disease (des Krankseins, the state or condition of the
sick), and of all deviations surely that which may be determined
with objective physical accuracy.
{b) So far as the temperature obtained is a phenomenon common
to the whole body, equally diffused, and apparently a result of the
entire processes of life, its variations are symptoms of general dis-
turbance of function, and its determination is the more important as
it is the only speedy, accurate, and delicate method of following
some of the sudden alterations of the general morbid condition.
(c) As the temperature affords us indications which can be mea-
sured of the general disturbances of function, however sudden, or
4<
aO VALUi: OF TIIK THEll.MOMliTlill IN MEDICAL PRACTICE.
whenever they may occur; it also enables us, by a comparison of its
course in a muUitutle of similar cases, to decide the question, " Js
there not, In mani/ forms o^' disease, a Jiced law which regulates the
course of the general disturhancc / and as a corollary to this to discuss
what deviations from the given law may occur, and by what they arc
occasioned.
In deciding upon the practical value of thermometry in disease,
we must not lose sight of this threefold aspect of the ques-
tion.
The human body has a temperature of its own, almost independent
of the medium in which it is placed. A simple and accurate pro-
cedure shows us that this temperature does not remain at the same
degree in certain conditions of health and disease. 13y further trials
we learn that in health the temperature remains nearly the same
under all circumstances, whilst in disease, with certain limits, we
iind considerable variations.
These facts are of the highest interest in themselves alone. We
are almost impelled to serious reflection when we see that the tem-
perature of the human body cannot be much increased or diminished
without more or less injury to health, and that the temperature
varies only within the limits of a few tenths of a degree (Centigrade),
however the quantity or quality of the ingesta, of muscular or mental
activity may vary, in all sorts of atmospheres, by any process of
waste and expenditure, whatever the age, temperature, stature, body-
weight, or other outward influences, so long only as health is not
impaired.
On the other hand, is it less wonderful to see in the manifold
varieties of disease, alterations of temperature occurring more or less
suddenly, and to observe that the very presence of a diseased process
gives rise to a speedy alteration of temperature, or at the least
confers on the body an aptitude to exhibit fluctuations of tempera-
ture, under the influence of varied, but in themselves unimportant,
circumstances ?
If any facts at all relating to the organism deserve our attention,
surely this contrast between the temperature of the sick and the
healthy deserves it ; and even if at present it appeared entirely
devoid of practical results, we could scarcely be indifi'erent to so
remarkable a circumstance. But the fact is the practical importance
of this phenomenon is almost incalculable. This is strikingly evi-
dent (sie erhellt sofort) when Ave consider the bearings and relation
1
VALUE OF THE THERMOMETER IN MEDICAL PRACTICE. 51
of this phenomenon to the various processes carried on at one and
the same time in various parts of the body.
If we admit the proposition, that the general condition of the
system, or, in other words, the sum of the tissue changes in dis-
ease, is of considerable importance for diagnosis, it must surely be
of the highest importance to avail ourselves of a simple physical phe-
nomenon, the shghtest changes of which admit of easy measurements
which can be expressed in number, and thus give an index or a
gauge of these otherwise recondite processes. The value of this
symptom for the estimation of tissue changes would indeed appear
entirely illusory, if we considered that the height of the temperature
did not depend on the production of warmth in the body or indi-
cate the result of chemical processes, and it would be still more
difficult to come to an accurate conclusion if the radiation or giving
off of heat were to be disregarded. The degree of heat (die Hohe
der Eigenwiirme) in an animal is a complex phenomenon, produced
by the most varied, often incalculable, and partly antagonistic
factors. On this account the immediate theoretic application of
temperature-relations in disease is almost completely nugatory, and
all endeavours in this direction are, a jmori, hopeless and illusive.
On this account it is possible that the opinion may be entertained
that, although alterations of temperature do indeed generally betoken
a disturbance of the customary order and regularity of the economy, all
further deductions from them, and especially from any given degree of
temperature, are worthless. But experience teaches a different lesson.
For this reason the greatest gain accruing to thermometric obser-
vation was undoubteclly the discovery that the alterations of tempe-
rature in disease are subject to fixed laws ; or, in other words, the
value of pathological thermometry is chiefly determined hy the evi-
dence afforded hy an extended experience, founded on very nnmerous
observations, that the alterations of tem/peratiire, however slight and
insignificant, are determined by strict Urns. In fact, the circumstance
that the body is warmer or colder than in health, whether the
change be great or small, must not be considered in the same way
as the indication that one weighs so much or more, feels strong or
weak, sleeps well or badly, coughs frequently or but seldom, has
much pain or the reverse, &c., &c., but the deviation from the
normal temperature is to he considered, in more than one aspect, as
closely related to the various ^processes going on in the body generally
(im organisraus).
.")•.' XAI.l'K til I'ltK TIIKllMO.MKTKR I.N MKDICAL PRACTICE.
As soon as tliorniometry attains lo llio discovery of these laws, il
conquers a fresh territory for))athoh\t;y, and reveals a " new woiKl/'*
vainly sought by other routes, and declared, indeed, by many who
have attempted to reach it by other methods as the sanguine dream
or fabled region of adventurous spirits — the domain of laio in
One ditliculty meets us at once, when we endeavour \o draw
rigorous conclusions or to estimate the value of the data in given
cases, and that is, that the alteration of temperature in disease is
sometimes due to the morbid process, and sometimes to accidental,
and perhaps only momentary, influences afl'ecting the sick man's
constitution. This ditliculty is sometimes very great, but it may be
conquered by increasing the number of observations, and by a
proper use of our judgment and careful consideration of the sur-
rounding circumstances.
AVhen once these difficulties are overcome, thermometry will,
doubtless, lead to entirely new views of many diseases, and no small
part of our pathology will have to be " radically reconstructed."
§ 3. — The true position of thermometry in medicine clearly
appears from these considerations. It is a part of our method <f
diagnosis or observation of disease which is indispensable in all the
cases where the temperature varies, very useful in many doubtful
cases, and an auxiliary in almost every case. The medical attendant
who undertakes to decide a case of fever or febrile disease, without
knowing the facts of thermometry, and without taking the tempera-
ture, is like a blind man trying to find his way in a fresh locality.
With much practice, if very intelligent, he may often find it out cor-
rectly, but he will be more often deceived, and, at the best, will only
discover, with much difficulty and very imperfectly, that which is
patent to those gifted with sight.
But thermometry can and must do more than this ; it ought to
discover the laws which regulate the cause of disease ; and when it
has fullv attained this — when thermometrv becomes thermonomv,
then, and not till then, will the strictly practical applications be
attained in their full development.
§ 4. — After thus attempting to portray the true significance of
• " Uuerreiclibares Ziel." "^Tundeilich has cLanged the metaphor here. I
have ventured to restore the original simile. — [Tkans.]
VALUE OF THE THERMOMETER IN MEDICAL PRACTICE. 53
tliermometry as it truly exists, althougli only partially known as yet,
it is perhaps not quite superfluous to mention some of the really
practical applications of this method of observation.
[a) A normal temperature is no proof of health, p)<^^' ^C} but t/ie
maintenance of a normal temperatitre under varied conditions and
influences, or, in other words, a constant normal temperature, may be
regarded as an evidence of a sound constitution. A healthy man
may have scanty or luxurious fare, he may fast or feast, drink water
or stimulating liquprs, he may remain quiet, or exert himself vigor-
ously, both bodily " and mentally, and do other things of the like
kind, and yet have almost the same temperature, as long as his
health is unimpaired. Even taking medicines and losses of blood, if
he remains well, do not influence his temperature much, for in such
circumstances the variation is only a few tenths of a degree (Centi-
grade) . The less a man^s temperature is disturbed by various modes
of living and numerous other influences, the more confidentlv mav
we pronounce him to be healthy.
[b) In actual every-day life there are numerous occasions on
which it is necessary, or at least desirable, to ascertain whether a
jjartictilar person is really ill, or at least indisposed. Taking the
temperature, when it shows a deviation from the normal, is one of
the most rapid means of ascertaining the existence of some disturb-
ance in the economy. It is an objective symptom, applicable to
every one, very convincing, and often of almost incalculable value.
Suppose a patient's complaints are vague, and his account of his
symptoms confused, if we find an abnormal temperature, we may be
quite sure that he is neither imposing on us, nor over-anxious about
himself, and that his complaints are deserving of further investiga-
tion. We may find patients unwilling to confess that they are
really ill, or whilst still suffering from the dregs of a disease they
consider themselves quite cured, but if the thermometer still shows
an elevated temperature, we may confidently affirm that they really
are ill, or that they are only partially convalescent, as the case
may be.
Not only does the surgeon himself obtain indications for his
future guidance, but he may also by this means be able to convince
the patient of the necessity of caution and of further treatment.
[c) In general, however, we wish to know more than the mere
fact of the existence of disease, we want to know the importance or
degree of severity of the affection. Very often the thermometer
5t VALUE OP THE THERMOMETER IN MEDICAL TRACTICR.
enables us to do this with an accuraey quite unattainable by other
methods. If the temperature remains normal, or only slightly ele-
vated, we may, after making allowance for any entirely local affec-
tion, which may generally be easily recognised, regard the general
condition without alarm, l^ut if, on the contrary, wc find the tem-
perature markedly abnormal, the case is to be considered far more
serious. In this way the thermometer becomes an invaluable aid in
accurately prognosing the severity or slight nature of a complaint.
For example, in the frequently occurring cases of obscure symptoms
in young children, the physician is either impelled to superfluous or
over-vigorous treatment, or loses valuable time, or at least defers
active treatment to a late period of the disease. The thermometer
will clearly show in these cases whether the symptoms are of little
consequence, or, on the other hand, indicate the development of a
serious iUness ; and, indeed, in the hands of an intelligent nurse or
relative, may serve as a useful criterion to judge whether it is neces-
sary to summon the doctor instantly, or whether his visit may be
postponed to a later period. Very often the thermometer alone in-
dicates serious and yet latent disturbances. If a patient feels only
'' a little poorly,'^ but shows a very high temperature, the attack is
never to be slighted, as it generally masks the commencement of a
very serious illness.
{d) When the malady has developed itself, and sometimes even in
the first day or two of illness^ a certain diagnosis of the kind of dis-
ease may be made from the course of tlie iem/perature. And still
more frequently^ when a concurrence of symptoms appear to indicate
a special disease, the thermometer decides our diagnosis ; or in other
words, gives certainty to otherwise doubtful cases. There is no
other aid to diagnosis which gives so many trustworthy indications,
none which can so frequently correct premature conclusions ; and
further (a matter of great interest), when we have the complete map
or course of the temperature before us, we can often, by this means
alone, determine from what disease the patient has been suffering.
[e] But the mere making of a diagnosis or giving a name to the
disease is far from being the most important or only matter on
which the practitioner has to decide.
The varied modifications diseases exhibit, the passage of one stage
into another, the times of exacerbation and remission, the develop-
ment of com]}lications, the severitg of the attack, and the amount of
danger, are at least of equal importance.
VALUE OF THE THERMOMETER IN MEDICAL PRACTICE. 55
Thermometry in these cases serves as a clue or indicator to the
practitioner at an earher period, and more trustworthUy than any-
other method of investigation.
(/) As long as the temperature conforms to a normal ty2^e, in the
course of any disease which admits of recovery, the practitioner may
almost always be confident that everything is going on favorably,
and may often dispense with any further investigations ; and, on the
other hand, whenever an unusual alteration of the course of the tem-
perature occurs, this, is an important symptom, and very often the
first signal of danger, and ought to induce a careful search for the
causes of the irregularity.' Complications which would be otherwise
unnoticed may often be discovered in this manner.
{g) During co}walescence the course of the temperature is equally
available, as the most certain method of discriminating between real
and apparent improvement, and of recognising what seems to a
careless observer to be a relapse — as a stage in the process of
recovery. When there is improvement in all the other symptoms,
bat the temperature still continues high, complete recovery is far
from being attained. On the other hand, a favorable "turn^^ (or
crisis) is often accompanied with such alarming symptoms, that only
the accuracy with which the temperature indicates the commence-
ment of recovery makes us confident that this is really the case, in
spite of the impression made by the severity of the rest of the
patienf s symptoms.
{h) Observations of temperature are exceedingly valuable as con-
trollers of our therapevtics, or, in other words, as enabling us to
judge of the real efficacy of medication in many diseases. Acute
diseases, which contain in themselves the conditions of compensa-
tion (die Bedingungen zur Ausgleichung, or vis medicatrix naturae),
and therefore generally tend to spontaneous recovery, render it very
difficult for us to demonstrate the advantages of medication.
No other method of observation except temperature affords so
certain a means of proving the favorable influence of therapeutic
agencies, or, on the other hand, of showing their failure to influence
the disease.
Even in cases which terminate at a later period in death, observa-
tion of the temperature is often able to prove that the remedies
applied have at least initiated a curative action. All active medica-
tion in febrile diseases must be tested, and judged almost entirely
by the results of thermometric observations.
."»n VAT. IK OF Tin; TIIKiniOMl-.Tl'.U IN MEDICAL VKArTICF..
These examples must sulTice for the jjrcscnt; i( woulil he fasy
to mulliply (hem i,'reatly; but the practical advantages of ther-
mometry, in almost every aspect of the ([iiestion, will be further
elueidateil when we come to the consideration of special diseases.
§ 5. — There arc many persons who freely admit the advantages
of thermometry in hosjiital practice, and for clinical teaching, but
who think it little suitable for i)rivatc practice, or consider that it
cannot be made use of in the latter.
The number of these sceptics is much diminislicd of late years, for
there are a great many places where the general introduction of tlu;
thermometer into private practice has been already accomjilishcd by
energetic and accomplished practitioners. That the cost of instru-
ments is by no means excessive, and that the use of them ofFcrs no
insuperable difiicultics, is now generally admitted. How far tlie
time required for the observation may be abbreviated, so as to render
the use of the thermometer possible for the busiest practitioners, will
be considered under tlie heading of " The Methods of Observation,"
and no one maintains that the busy practitioner must take the tem-
perature of every case he sees, or at every visit.
In a certain sense, however, t/ie thermometer may he said to he a
saver of time, for the observations of this one phenomenon will often
lead to conclusions which could scarcely be arrived at otherwise,
or only by lengthy interrogations and investigations. Indeed, we may
safely afiirm that just in the same way as one who is well versed
in percussion and auscultation can dispense with their use on account
of the lessons they have taught him, so the surgeon who has attained
to great experience in thermometry can safely draw conclusions, in
many cases of illness, without using the thermometer at all, from other
diagnostic signs — conclusions which it would have been impossible
to arrive at without his previous experience of temperatures.
The difficulties on the part of patients anticipated by many are
entirely without foundation. Similar objections were made at first,
as regards percussion and auscultation ; but now-a-days our patients
are scarcely satisfied unless these methods of exploration have been
employed, so thoroughly is the general public imbued with a sense
of their necessity.
Just in the same way the laity (if I may so call them) are deeply
interested in observations of temperature, which can be taken with-
out fatiguing the sick, and without any violations of propriety.
VALUE OF THE THERMOMETER IN MEDICAL PRACTICE. 57
Tlie}^ derive satisfaction, not only from the little inconvenience tliis
method of observation causes, but also from the favorable results
which they experience from a diminution of febrile temperatures.
Everywhere the thermometer has speedily become popular whenever
it has been introduced, and there has never been any objection to its
use on the part of the public.
To render thermometry generally useful we must next consider
the methods to be employed, in order to secure trustworthy results
from the observation of the temperature in disease ; and we must
not neglect the lessons derived from experience as to the temperature
of the healthy.
CllAriER IV.
THE ART OF MEDICAL THERMOMETRY.
§ I. — Various instruments and methods may be employed to
determine the temperature of the human body. In order to secure
trustworthy resultSj or at least to form a judgment as to the degree
of accuracy secured, it is necessary to consider the sources of fallacy
in observation, and to know the general rules which enable us to
avoid them.
Absolute accuracy of observation is vnailainable, and if it were
possible to secure it, it is unnecessary for the purposes of medical
thermometry ; and indeed the apparatus, and the precautions re-
quisite to secure absolute accuracy, would be unsuitable for the
practical applications demanded by the medical art. Whilst it is
quite certain that unless we can secure trustworthy observations, no
useful results can be obtained, and it will be impossible to deduce
any rules for practice from them, it would, on the other hand, be
absurd to require, or even to apply^ an invariable method, of what I
may i^tva. ])ainfal accuracy, in all sorts of cases.
"Whilst requiring that the observations should be exact, and trust-
worthy, ice must ahoays bear in mind what is required by the circum-
stances of the special case, for there is no single method which is
equally good and approjiriate in every case. It is therefore requisite
to have clear ideas as to the degree of exactness required for par-
ticular purposes.
Eepeated observations of only moderate correctness, may be more
valuable for some purposes, than single or scanty observations of
irreproachable accuracy. And for many practical uses, a rapidly-
secured indication is more desirable, however imperfect, than one
which, while anxiously guarded from errors, is prodigal of time.
Methods of investigation which make too excessive demands, have
the effect of preventing the application of this method of research,
and in endeavouring to give "sharpness^' to the results, make the
number of the observed facts too small to afford a safe basis for
THE ART OF MEDICAL THERMOMETRY. 59
experience, and render any deduction of general principles im-
possible.
If we are only anxious to ascertain quickly tohetJier a patient has
fever or not, and lohetlier the fever he mild or severe, in order to
satisfy our minds as to tlie nature of the case^ or to learn the neces-
sity for more careful supervision, a somewhat superficial examination
suffices.
Hox practical pirpo^es generally , — that is, to determine the nature
and progress of any disefise; or in other words, to form the usual
diagnosis and prognosis, — a somewhat greater degree of care is re-
quired; but even in this case, the frequency of the thermometric
observations, and the degree of accuracy required, must vary with
the special circumstances of the case. So long as the course of the
diseases varies little from that of which we have previous experience,
so long as nothing unusual or unfavorable occurs, so long as the
diagnosis is clear, and the disease runs its usual course, approxima-
tively accurate observations, repeated at considerable intervals of
tjme, may suffice. Errors which do not exceed half a degree Cen-
tigrade ("9° Eahr.), are scarcely worth mention in this point of view;
and if the proper time of day be chosen, twice a day, or sometimes
even once, is often enough to take the temperature. But even in
general practice, in cases where the thermometer is used to clear up
a difficult diagnosis, or a doubtful prognosis, or to prove 2,^^ regulate
the worhing of therapeutic, agencies, greater accuracy of observation,
and more frequent repetitions of the process, are required. But even
in this case, generally speaking, errors of one or two tenths of a
degree Cent. ("2 — '4° Tahr. nearly) do not much matter. Only if the
temperature reaches unusual elevations (about 41° C.= 105*8° T.),
a tenth of a degree Centigrade ("3° Fahr. nearly) becomes worthy of
notice, and especially so as regards prognosis. But the necessity
of accuracy, and of frequent repetitions of the observations, becomes
greater if we propose to formulate our observations into rules, and
to lay down the laws of disease, or to criticise those previously
deduced.
As regards questions of this kind, all those whose measurements
of temperature have been made but seldom, and are not sufficiently
accurate, must simply be ignored (haben einfach zu schweigen) ;
yet frequent repetition of the measurements in the course of the day
is to be insisted upon, more than the absolute accuracy of the obser-
vations. Errors of observation whicli only amount to one or two
GO TIIK AKT OF MF.DICAT, THKHMOMKTllY.
tenths of a (l(\i:jrec Ccnligrado (:='2 — "4° Falir. nearly), or soiiir-
timcs a trille more, mav be uniinporlant, as soon as one accumulaUs
a mass of observations, either of similar kinds of disease, or madi;
under tolerably similar circumstances ; and these observations may
be valuable, if we set out with the principle, that not the absolute
heic;ht of the temperature, but its course (the curve of temperature
in the chart), is the object we have in view, i^ut observations of
temperature made at rare intervals give a distorted and unfair im-
pression of the progress of the temperature in cases of disease.
Pinally, there arc qveaiiom of pureli/ scientlfc interest, for the
solution of which the highest possible accuracy is required, and con-
sequently every kind of error in observation is to be carefully
avoided. In such cases, the slightest deviations are of great signifi-
cance.
But as I have said before, absolute freedom from error is unattain-
able, and for practical purposes is not to be expected. AVe must not
require impossibilities ; and in thermometry, as in all other afiairs of
hfe, we must be content with possibilities.
§ 2. — The means or instruments for determinvtuj the temperature of
the hocly differ much in their value and suitability ; but every one of
them may, under varying circumstances, find its place and applica-
tion in medicine. The use cf the hand as a standard (f temperature
is hy no means a reliable method. Any one unaccustomed to ther-
mometric observations, may very easily be most grossly deceived by
this method ; and even after many years' experience, corrected by
continual verification by the thermometer, one is often enough de-
ceived, and can scarcely estimate a quarter of a degree Centigrade
{=-i^^ Fahr.) correctly. If the observer's hand is cold, no con-
fidence can be placed in its sensibility to heat, and the most expe-
rienced may make mistakes amounting to half a degree, or even a
whole degree Centigrade (= '9 to 'I'S^ Eahr.).
However, the use of the hand to estimate the temperature of the
skin, may afford a superficial knowledge of its warmth, and may
serve to indicate the necessity or otherwise of taking a thermometric
observation. Bat for this purpose it is never enough to feel the
hands or face only of the patient, but parts of the body protected by
clothing must be handled, because only these will give a correct
indication a? to elevation or otherwise of the temperature.
THK ART OF MEDICAL THERMOMETRY. 61
§ 3. — The only observations of temperature which can furnish trust-
worthy results, are those made by instruments for the purpose.
{a) The best instrument for ordinary medical purposes, is a good
mercurial thermometer, which need not be too delicate, but such as,
only rightly applied, can satisfy all practical requirements, though
it fails to measure very sudden changes of temperature. This is to
be preferred to a spirit thermometer, because the latter is not re-
liable when the temperature is much elevated.
The following are desiderata in a thermometer which is to be used
in medical practice : —
The reservoirs of metal [i. e, the bulbs) must be neither too large,
nor too small. If the bulb is too large, it is wanting in sensitive-
ness ; if too small, it is difficult to retain it in close apposition to
the body. A diameter of about .1- — f of a centimetre {^-^.^ — \ of an
inch nearly), seems the most convenient size. A globular form
should be preferred for measurements in the axilla, or at least if the
bulb be cylindrical, the long axis should not greatly exceed the
shorter, but should approach to the form of a spherical bullet. Tor
measurements in the rectum and the vagina, a conical reservoir is
to be preferred, for a contrary reason, and the lower end should be
tapering. A hemispherical form, with the fiat surface downwards,
is recommended for investigations on the surface of the skin, and is
very convenient for any purpose, but the results are not trustworthy,
and indeed scarcely of any use. The glass of the bulb should not
be too thin, or it will be easily broken, or squeezed flat ; but if too
thick, the instrument loses in delicacy.
The tube or stem of the instrument must have an even bore
throughout, and be of such a diameter that the distance between
any two-tenths of a degree C. can be easily divided by the eye into half
and quarter parts (so that -^\° to ^V° Pahr. can be easily read). The
length of the tube must be such that the degrees on the stem are
at least 12 centimetres (4^; inches nearly) from the bulb, in order
that the height of the mercury may be easily read /// sUil. For the
sake of portability, however, it is well not to have too long a stem ;
and it will be found sufficient to have a tube a little longer than the
probable height to which the mercury will rise when applied to a
living human being. The zero may very well be placed in the reser-
voir (or bulb), and it is quite unnecessary to have the tube long
enough to mark the boiling point of water (3ia° F. = 100° C.) ;
and it will be ([uite sufficient, even for bathing purposes, if the stem
62 THK AUT Dl' MKDICAl- TIll'.R.MOM I'/rRY.
comprises from 32*5'^ — 4')°(-'- (= 90*.")°— "3° J^'-)= or perhaps cvoii
44° (= 1 1 1-2° Valir.) may be enough^ if the 35° Ceut. [= 95° P.]
is 12 centimetres (about 4^ inches) from the bulb.
Only tlic degrees given above (90° — 113°) need be marked on
the scale. "Whether one uses Reaumur's or Celsius' (the centi-
grade) division is quite indifTercnt. On the Continent, Fahrenheit's
scale, which was formerly cmjiloyed, is quite gone out of use.- It
is quite sufficient for ordinary medical purposes if the scale is divided
into fifths of a degree centigrade [= '36' Fahr. nearly, or about two
fifths].
The marks for both the degrees and their divisions should be
clearly defined and legible, and those for the degrees should be longer
than those for their component parts.^
' "Etwa noch der 24 Grad," in my copy, which seems a misprint for 44. —
[TiuNS.]
^ Keaumur's seale is only used in Russia, Sweden, and some parts of
Germany. Fahrenheit's scale has been, and still is very generally used in all
parts of the British Empire, and in the United States. It is, however, not
generally understood on the Continent, and it is greatly to be wished tiiat
Eoglish medical men would learn to use the Centigrade Seale, which is almost
universally employed by chemists and other physicists. (Messrs. Casella,
Negretti and Zambra, Harvey and Reynolds, and others, supply thermometers
with both notations, to facilitate the acquirement of this scale. See note in
appendix. — [Trams.]
^ The thermometers made for medical use by English makers are generally
divided into fifths of a degree Fahreniieit = {■^q° Centigrade nearly), and can
easily be read to half of that = ~^^° Fahrenheit ; their range is from 85° or
yO° Fahrenheit (29-4' or 32-2° Centigrade) to 110° or 115° Fahrenheit
('13'3° — -16"1^ Centigrade). They vary in length, from about 5 to 10 inches,
or more. Nearly all the surgical instrument makers supply them ; but Messrs.
Casella (at the suggestion of Dr. Aitkin), I believe, were the first to make a
registering maximum thermometer for medical use, by enclosing a little air
between the mercury in the bulb and that serving as the index. To use these
thermometers, the index must first be set, i.e. the mercury in the bulb should
first be warmed (either between the thumb and forefinger, by warm water, or
otherwise, so that the mercury rises about an inch above the bulb — then, hold-
ing the instrument in the hand, with the bulb a little lower than the other end,
raise the hand to the shoulder, and bring it down again to the side with a
smart swing — repeating this once or twice if required, till the index is about
95° (or sometimes lower) ; or, holding the upright thermometer lightly in the
right hand, tap the bulb gently on the palm of the left a few times, which will
shake down the index. Care must be taken not to shake the index down into
the bulb, and it is better to carry the thermometer upside down in the pocket.
I have tried the thermometers of Messrs. Casella (Hatton Garden), Negretti
THE ART or JIERICAL THERMOMETRY. 63
An indispensable condition for accurate investigation by means of
any instrument is, that tlie instrument itself should be accurate.
The accuracy of a thermometer, however, depends more upon the
perfect equality of the divisions npon the stem than upon the num-
bers affixed to them ; it is desirable, indeed, that the degrees should
be marked correctly, but it is easy to correct any error in this re-
spect, for it is only necessary to compare the thermometer for each
degree by placing it in a water-bath with a correctly marked (or
standard^ thermometer, and to notice the difference, if any, which
exists between them, and make the necessary correction when the
former is used. If the difference between the thermometer employed
and the standard instrument is the same for every degree, we are at
once aware how much is to be added or subtracted for each degree,
and then the results, after this correction, will be as accurate as if
the standard instrument itself were employed. In this way instru-
ments of moderate price may be made useful, which renders thermo-
metry accessible to men of moderate means. This is especially
important, because for practical purposes it is far more desirable to
have a 'considerable number of thermometers than to possess a few
of absolute accuracy. Only care should be taken by the observer to
be perfectly acquainted M'ith the necessary corrections to be made
for each instrument. But if, on the contrary, the scale is so badly
divided (<''. e. the degrees marked so unequally) that the error varies
for each degree, the use of such an instrument becomes very awk-
ward, and it is better not to make use of it at all, since it is difficult
to avoid errors if a separate calculation has to be made for every
degree.
Even the best instruments, with the most correct markings,
should be tested again by a standard instrument about a year after
they are made, and occasional testings should be had recourse to as
long as the instrument is made use of for medical purposes, for even
the glass of which it is made is subject to slight (molecular) changes
in its condition by the lapse of time, until an equilibrium is esta-
blished, if indeed that is ever attained. In this way the calibre of
the bulb or reservoir is altered ; and it may happen that a thermo-
meter, which was perfectly correct in its markings at first, differs
and Zambra (Holborn), Harvey and Reynolds (of the Briggate, Leeds, the first
to make a six-inch portable thermometer of this kind, at Dr. Clifford Allbutt's
suggestion, although the Casellas were the inventors), and find them very
good. — [Tkans.]
^1 TMK ART OK MKDICAI- Til KR.MOM ICTK V.
from a standard one by onr or two tenths of a degree (Centigrade
= one or two fifths Fahrenheit nearly) after a year or so. It is
possible, also, that the handling it undergoes for medical purposes,
and pressure upon a tliin bulb, may cause a slight dimiiuition of the
size of the reservoir in the course of time. On this account the
more frequently clinical thermometers are cm])loyed the more often
they will bo found to rctjuire occasional comparison with a standard.
LSomctimes it is well, when meeting with an exceptional and hardly
credible temperature in the course of observation, to test the instru-
ment, in order to make certain that it has received no damatre. It
is scarcely necessary to observe that we must always be on our guard
against obvious injuries or accidents to the instrument, such as divi-
sion of the mercurial column or loss of the mercury [or the index
being lost in the bulb in registering thermometers. — Trans.]
It is always well to iisc the same thermomcler, ifjwssiblcjfor anij
f/iven imtlent, and to note the number of the instrument in the
clinical notes, or on our memoranda. In this manner it becomes
easy, should any errors be discovered at a later date in the instru-
ment, to see what observations are untrustworthy. It is always
requisite to have a considerable number of good instruments, and to
mark each with a number. In private practice, a thermometer
should be left with every patient who requires continuous observa-
tions of temperature. In hospitals, it greatly facilitates thermome-
tric observations if there are a sufhcient number of thermometers to
allow of one being applied to every patient in the ward at the same
time.
As a standard, it is quite enough to have one accurate (normal)
thermometer, which may be occasionally compared with another
standard instrument (say one belonging to a meteorological obser-
vatory or a philosophical institute, Src.) . For many purposes it is
convenient, or may even be necessary, to possess one or more histru-
ments on which hundredths of a degree (Centigrade = J-^, Fahren-
heit nearly) can be easily read. But for private practice this is quite
superfluous, and, indeed, for really practical questions has hitherto
appeared unimportant.
(Jj) Very considerable accuracy of observation may be attained
(more, indeed, than is required in private practice) by the use of the
metastatic thermometer of Walferdin. The mercurial reservoir of
this is very small, and the very narrow tube is divided at pleasure
into equal divi;>icn?. To the upper end of the tube, namely, that
THE ART OF MEDICAL THERMOMETRY. 65
opposite to the reservoir^ another bulb is affixed, and where it joins
the capillary tube there is a narrowing of the latter. The calibre of
the instrument is such that a variation of 3° or 4° (Centigrade = 5*4°
to 7*2° Eahr.) expands the mercury so as to fill the whole of the tube.
The quantity of mercury in the instrument must be such that at the
lowest temperature one intends to experiment with, the reservoir, the
whole tube, and a part of the upper bulb shall be filled, and that with
I ° or 2° over the hig|iest temperature expected the whole of the upper
bulb shall be filled' {i. e. the whole instrument). Eor instance, if it is
only desired to measure temperatures under 42° C. (io7'6° F.), the
instrument is to be warmed a httle above 42°. The quicksilver fills
the whole tube and a great part of the upper bulb; then one sets it in
a bath of 42^, leaving it there till the mercury is expanded corre-
spondingly to this degree. Then it is taken out of the bath, and given
a smart ia^, which causes the quicksilver to part or be divided at the
narrow part of the tube, whilst that in the rest of the tube retracts con-
siderably, in which it is not followed by the mercury in the upper bulb,
and the metal is not again united till it is again exposed to a tempera-
ture of 42°. The instrument is now ready for all observations under
42° (ioy6°), and the only requisite now is to compare the degrees
with those of a standard thermometer in a water- bath. The only
advantage of this thermometer is the length of the single degrees
(allowing of very fine divisions), with its comparative cheapness. Wal-
ferdin made metastatic thermometers in which one degree centigrade
(i"8° Eahr.) corresponded to a length of ten centimetres (= nearly
four inches) . As we are able with the unassisted eye to conveni-
ently distinguish distances of half a millimetre {--^ irVth inch nearly),
we are thus enabled to read off ^Voth of a degree Centigrade with
the naked eye, or -roVo° even by the help of a lens (= x-troth and
, i-gth Eahr, nearly). Such minimal differences of temperature are of
no practical moment in thermometry in cases of disease, and it is
doubtful, even for purely scientific or theoretical purposes, how far
they are of use.
(c) The thermo-electric apparatus offers considerable advantages
for many investigations. The principle on which this is founded is,
that in any metallic circuit, composed of two different metals sol-
dered together, there is an electric stream or current produced when-
ever the two points of junction, or places of soldering have different
temperatures; and although the difference may be very slight, the
current may be rendered visible, and even measured by the magnetic
5
CO THE AHT Ul' MKDICAL TllEllMOMETllV.
noetlle. Bccquercl was the fir.^t to use such au apparal us for j)liysiolngical
cx]KTini(Mits, csjiccially for asccrfaiuiut^ lln' (lillV-rcnccs of tc'nii)craturc
bctwttMi (lilVcrent parts of tho body, and 7^ ////vW/tV perfect I'd it. Tliey
used only a simple pair (iron and copper), vi\\\hilIehu/iollz (Miiller's
*Archiv/ 184S, )). 147) einj)loyed three elements joined tocjethcr (of
iron and virgin silver) . Not only is the delicacy of the thermo-electric
ajiparatus very considerable (Dutrochet's apparatus registered -^\i\\
of n degree Centigrade = ^'„° Falir. nearly), but if the solderings
are sharpened to a jioint, it allows the difference of tcnij)erature be-
tween any two points of the surface of the body to be estimated with
an accuracy of which the mercurial thermometer is incapable, because,
in a])i)lying the latter, it is necessary to cover the skin and protect
it from loss of heat by radiation, which alters the condition of things,
and furnishes erroneous results.
Lombard {' Archives de la Physiologic normale et Pathologique,'
1868, I, 498) describes (but not very clearly) an apparatus with
which he accurately indicated differences of temperature amounting
to '00025° Centigrade (= ~7Tr° Pahr. nearly).
Gavarret has recommended that thin plates (of copper and bis-
muth) soldered together should be used instead of the needles for
estimating the temperature of superficial parts. The thermo-electric
apparatus is especially useful in indicating sudden changes of tem-
perature, and serves for the measurement of heat of individual parts
of the skin ; and besides, as the needles can be introduced into in-
ternal organs, the temperature of these can be determined, and thus
the thermo-electric apparatus is applicable where the mercurial
thermometer cannot be introduced.
[See also some observations by Dr. Edward Montgomery with a
platinum and steel apparatus, in the article on Inflammation, by
Mr. John Simon, in Holmes's ' System of Surgery,' vol. i, p. 18.]
{(I) In order to make contlmious ohservations of temperature, and
to secure the accurate and automatic registration of these by the in-
strument employed, 21. Ilarey has invented a therraograph (^'Le
thermographe, appareil enregistreur des temperateures,'' 1865, in
Robin's ' Journal de I'Anat. et de la Physiologic normal et patholo-
gique,' ii, 182). It is an aeV- thermometer, the copper chamber of
which is connected by means of a very small-bored copper tube (}rd
millimetre in diameter = —i-oth inch nearly), with a glass tube, bent
in a half circle, which is open at one end, and fastened to a metallic
wheel moving easily on its axis, the glass tube having a globule of
THE AllT OF MEDICAL THERMOMETRY. 67
mercury just filling its calibre. As soon as the air becomes warm,
it is expanded and moves the mercury, and as this always seeks the
lowest level, it moves the wheel and tube, and this gives motion to
an indicator or needle, which inscribes or registers the changes of
temperature on ruled paper, moved by clockwork at a regular rate
of motion. The use of this instrument in cases of disease has not
as yet been tested, and it is doubtful whether we can expect it to be
practically useful,, since it is to be feared that when placed on any
part of the body, without any one to superintend the process, some
hitch might occur in the working of the instrument, which might
destroy the whole value of the observations. Tor similar reasons
the electric registering thermometers, invented, for example, by
Zecchi and General Ilorin, are hardly likely to be introduced into
practice.^
§ 4. — The determination of units of heat or caloric-units, that is,
of the quantity of heat required to warm a given measure of distilled
water (say one grain or one kilogramme, or so many ounces or
pounds, as one chooses) one degree (Centigrade or Fahrenheit) is
quite a different thing to measurements of the degree of temperature.
These investigations, interesting as they are from a theoretical point
of view, and much as they would add to our knowledge of warmth-
production in disease, are yet, on account of the many details in-
volved, and because, in spite of the precautions taken, absolute
accuracy has not yet been attained — not available for practical
purposes.
If one shows the increased warmth of the water of a bath, in
which a living body is immersed, during a given period of time ; one
obtains the warmth given off by the body in the given time (or more
properly only a portion of this) : in this manner endeavours have
been made to estimate the warmth-production of the body during
this time, by comparing the height of the temperature at the beginning
and end of the experiment. Such calorimetric investigations have
been industriously made by Liehermeister, Kernig, v. Wald, Leyden,
and Eemhold.
^ A portable and easily applicable apparatus wliich could be worn for stated
periods of time, and consist of a registering maximum and a registering mlnimtim
thermometer seems to be the greatest practical desideratum in Medical Ther-
mometry. The latter appears the chief diflaculty. It would then be easy for
the general practitioner to take the daily excursus, or extremes of temperature
in any given case. — [Teans.]
C)8 Till', ART or Mr.DlCAL TlIKiniOMKTRV.
§ 5. — Tho most siiifdhfc place for tin' apjil'wittion of the iiist rumen t
is h\ 110 ineans invariably the same under all circumstances, and,
according to the i)nr[)osc the observer has in view, he may select one
or another spot at pleasure.
When the object is to take the temperfitiire of a particular part
of the body, the measurement must naturally be taken at the place
in question. If this is on the surface of Ihc bodv, the indications
of the mercurial thermometer are always somewhat uncertain, because
if the instrument is exposed (uncovered) during the observation the
external air will continually tend to cool it; but if, on the other
hand, the instrument and the part are covered, the warmth-relations
(so to speak) of the latter, or the circumstances of the case, are
materially modified. For this purpose, therefore, the thermo-electric
apparatus is to be preferred.^ But if, as generally happens, we want
to determine the general temperature of the body (or blood-heat),
the mercurial thermometer is the most j)ractical instrument ; but it
must be so disposed that it is surrounded on all sides (as far as
regards the bulb) by some portion of the body. We may avail our-
selves of several places for measurement of temperature, of which
each spot has its advantages and disadvantages, and may be chosen
according to circumstances. The introduction of tlie thermometer
into the well-closed axilla appears to be the most convenient method
in the great majority of cases. Its use in this situation is attended
by scarcely any difficulties, does not fatigue the patient, and no objec-
tion can be made to it on the score of decency. On the other hand,
in very thiii people or restless patients, the results are uncertain,' and
besides this, the axillary temperature is a trifle lower than that of
most of the other accessible spots, and on this account its indications
are less delicately sensitive than those of mucous membranes. If
these imperfections, which may sometimes be very evident under
certain circumstances may sometimes lead us to prefer other places
for the thermometer, yet, in the majority of cases, the axilla
will be found the most suitable place. The application of the
instrument in the inside of the rnoulh apparently affords uncertain
■ indications, because the cool air inspired may easily lower the tem-
^ It appears to me that the author's objections do not apply to observations
made on parts of tlie surface nsuallj/ covered (e. g. the abdomen or thorax), nor
to comparative observations on parts equally exposed, as, for example, two ears,
two bands, &c. &c., when the object is to determine the difference rather than
the absolute height of the temperature. — [Tkaxs.]
THE ART OF MEDICAL THERMOMETRY. 69
perature, and in cholera especially, it gives lower readings than
many other places of observation. However, the mouth must be
employed, if other regions are inaccessible (as, for example, in baths,
or in patients who are "packed" or closely swathed for any pur-
pose, &c.).^
Taking the temperature in the rectum, so warmly advocated by
many observers, is repulsive, can seldom be repeated often enough
to satisfy the exigenpies of the case, may provoke the action of the
bowels, and perhaps produce prejudicial chills by the necessary ex-
posure. Besides this, if the bulb, as may happen, should be pushed
into a mass of fpeces, a false impression would be given of the tem-
perature. And Billroth avers that powerful contractions of the
rectum may be induced by the mere introduction of the instrument,
which may thus affect the result. On the other hand, it is generally
allowed that the mercury registers the maximum temperature more
quickly in the rectum than elsewhere, and that this method may be
advantageously employed in new-born infants, little children, very
emaciated patients, and in collapse, when the peripheral temperature
often differs greatly from that of internal organs ; and in some
other special circumstances.^
Still less suitable is the introduction of the thermometer into the
vagina, except for special reasons (as in Obstetrics). Although
certainly more trustworthy than observations in the rectum, there
are very few individuals in whom it could be repeated sufficiently
often. It seems most applicable to cholera cases, and when the
temperature of the internal genital organs is to be estimated.
Levier took temperatures in the groin, for a special purpose,
which, however, is scarcely more suited for general use than Mante-
' 111 Germany it is still customary amongst the lower orders, at least, to roll
young infants up in "swaddling bauds" — a custom winch still prevails in some
country districts in England, and perhaps Ireland. Whilst agreeing with the
author as to the general objections to the mouth, I believe that for auto-
thermometry (as by Dr. Ogle, Dr. Garrod, and others) it gives good results for
comparative observations. — [Trans.]
" My own experience (which I am glad to see confirmed by Dr. Piiilayson) is
strongly in favour of this method, when a single observation has to be n.ade in
a young child, for diagnostic purposes. I find that if the child be in short
clothes, it is only necessary to lay it comfortably on one side (the left usually)
on the mother's lap, and the bulb of the thermometer, slightly oiled, can gene-
rally be introduced without giving any pain, often without tcakiiif/ the child
even. — [Tkans.]
70 THE ART OF MEDICAL THERMOMETRY.
gatza's proposal to take the temperature of the freslily passed urine
ns a standard.
Holding the thermometer in the closed fst, is an entirely unre-
liable method of ascertaining the general temperature, but may bo
valuable as a means of comparing the temjjerature of the trunk with
tliat of the extremities, or of comparing that of the two sides of the
body.
[The clefts of the fingers and toes (in cases of paralysis of one
nerve-trunk), and the elbows, and popliteal spaces, may, under specinl
circumstances, and for special objects, be chosen as the places of ob-
servation. For similar reasons, the thermometer may be introduced
into sinuses, wounds, the bladder, &c., &c., in special cases. Wun-
derlich's object, however, is to recommend those methods which will
(apjiroximatively) give the average general temperature of the body.
— Trans.]
§ 6. The mode of using the instrument may contribute much to
the accuracij ; or, on the contrary, the vmrtlilessness of the observa-
tions. The following precautious must be observed, when the tem-
perature is taken in the axilla.
TThen there is much perspiration, the axilla must first be carefully
wiped dry. It is then advisable, as Liebermeisiei'has recommended,
to keep the axilla closed (by bringing the arm to the side) some
time befo)-e the thermometer is put there. He has pointed out that
the time taken by the mercury to reach the maximum, was reduced
by this means to from four to six minutes ('Prager Yierteljahrsch.'
Ixxxv. p. 13). But sometimes this preliminary closure of the axilla
may cause loss of time. The thermometer should first be w^armed a
little in the hand (to 85° or 90° F. in most cases^ and if a regis-
tering one, the index must he set — see note, p. 62), then introduced
deep into the axilla (under the anterior or pectoral fold), and the
axilla closed, by close pressure of the arm against the thorax, which
always gives the arm an inclination towards the breast [i. e. to the
median line).
If the thermometer does not keep its position nicely, — if the
patient is restless, unruly, sleepy, or forgets himself, or if he be very
much emaciated, the arm and thermometer must be kept in appo-
sition by the person who takes the temperature. In any case, it is
well to make sure occasionally that the instrument is in good
position.^
' The pons asinorum oi young observers is generally fonntl in the necessity
THE ART OF MEDICAL THERMOMETRY. 71
We can often judge whether the mercury is likely to rise to any
considerable height, by the rapidity or slowness of its ascent during
the first minute or two ; and even the first few seconds often enable
us to give a good guess as to the presence of fever, or its intensity.
The mercurial column seldom becomes stationary, in measurements
taken in the axilla (unless that has been kept closed for some time
before) in less than ten minutes, or oftener a quarter of an hour,
sometimes it takes twenty minutes, or even longer. It is noticeable,
as regards this, that the mercury rises more quickly at first than
afterwards, and for the' last one-tenth of a degree, the time occupied
in rising from one tenth to another tenth may even occupy some
minutes.-^ In order to make accurate observations, it is therefore
desirable to allow the thermometer to remain some minutes after
the mercury remains stationary. This period, however, must not be
unduly protracted, for it appears that in many sensitive sick people,
the forced and uncomfortable position of the arm, and perhaps the
persistent contraction of muscles, cause slight elevations of tem-
perature after the mercury has (apparently) attained a stationary
pointy quite independent of fluctuations due to the disease. Besides
this, in some minute investigations, it must not be forgotten that in
some cases, chiefly on account of the not inconsiderable daily variation,
the mercury never comes to rest at all. In such cases, therefore, these
changing values must be noted for a given number of minutes. Tor
that the thermometer should be quite free of the clothes (which are bad conductors),
and in contact with the shin alt round. I have known mistakes of 3 — 4° Eahr.
easily made in this way, where the arm-hole of the dress was tight. — [Trans.]
^ See a very interesting paper in the 'British Medical Journal,' August 21st,
1869, "On some Points concerning the Method of observing the Temperature
of the Body," by Dr. Charles Biiumler, who finds from various experiments
that the time required in the axilla for the mercury to ''settle" or become
steady, varies from eleven to twenty-four minutes. In the rectum from three to
six minutes only were required. He quotes Dr. Liebermeister as follows : —
"When a thermometer is placed in the axilla, its temperature gets there as
quickly as in the rectum or any otiier place of application, into equilibrium with
the surrounding temperature, and after a few minutes that point is reached
which corresponds to the temperature of the unclosed axilla. Meanwhile, how-
ever, the axilla has, by enclosing in it the thermometer, been transformed into
a closed cavity; its temperature therefore begins at once to rise, and continues
rising until the temperature is reached, which would correspond to that of a
point of the body lying in the same depth under the surface. The mercury too
must therefore continue to rise until the temperature of the axilla has become
that of a closed cavity."
72 niK AUT ov .Mi:uic.\L tukkmomktky.
juost purposes, the obsiTvation may be loniiinah'il wlicn the luir-
cury has remained stationary for five minutes. In general practice,
it is sufficient to wait for two or three miimtes after it has ajjpeared
to stop rising.' It is scarcely necessary to observe (that except in
the case of register} uj thermometers) it is necessari/ to read the inslru-
ment in sit it ; and yet 1 have known men of some eminence commit
this mistake, and then criticize thermometry !
Tt is possible to shorten somewhat the time required for investi-
gation, although at expense of accuracy, by previously warming the
bulb, before introducing it, a few degrees higher tlian the expected
temperature. However, there is not much to be gained by this, for
Liebermeister has shown that unless the axilla has been previously
closed for some time, the mercury first sinks below the temperature
of the body, on account of the cooling of the axilla, and then begins
to rise again. "Wlien there is much elevation of temperature, how-
ever, this disadvantage is less considerable ; and the method (of
previously warming the thermometer) may be recommended as sufli-
ciently accurate in these cases, whilst in lower temperatures it is less
advisable, unless the axilla has been closed beforehand.
If the thermometer is used in the month, the bulb should be placed
under the tongue, the mouth closed, and breathing should be carried
on through the nose. In observations of temperature made in the
vagina and the rectum, it is enough to introduce the well-oiled bulb
about two inches ;- and it stands to reason that care must be taken
to guard against such a mishap as the instrument breaking because
it was not strong enough, or for want of some other precaution.
§ 7. A few cautions must be added as regards the taking of obser-
vations.
If the patient a short time previously, or just before the observa-
tion, has been affected by any unusual circumstances, — if he has had
^ This direction is very different from tlae directions placed on some tbermo-
meters, directing tlicm to be retained for three minutes only (altogether). I
cannot but, think that this direction is well-calculated to bring the instrument
into contempt, if not disuse. — [Tkans.]
- Thomas (iu the ' Jahrbuch f. Kinderheilk,' N. F. II, 239) gives the useful
advice, to warm the thermometer two or three degrees (Centigrade = 4 — 6" F.
nearly) above the temperature expected, and to introduce it quickly, in which
way useful results are obtained in from a quarter to half a minute. This does
not apply to registering thermometers. Tiiese, however, may be warmed to 98
or 100^ F. before introducing, by which lime is saved.
THE ART OF MEDICAL THERMOMETRY. 73
copious stools, or hajmorrhage, or has vomited, or just had a meal,
or taken a considerable quantity of any heating or cooling drink, or
if he is perspiring at the time, all these circumstances must be care-
fully considered and estimated, because they may all affect the tem-
perature.
It is generally unimportant to note the temperature of the sur-
rounding air at the time, because most observations are taken in
temperatures whicli, vary but little (i. e., in a sick chamber, which
commonly has a" temperature of 15° — 20° Centigrade = 59° — 68°
Eahr.) It is only when the temperature of the surrounding air is
very hot, as sometimes happens in summer, that it may be as well to
note this also.
For a similar reason, any consideration of the barometric pressure
is unimportant in the majority of cases where the thermometer is
used in disease.
On the other hand, it is desirable to note carefully both the day of
the tnonth, and the time of day at which the observation is taken, as
without this the whole of the observations may be useless.
§ 8. The circumstances of the case, and the objects sought to be
attained, must decide the question of the time, and the frequency of
repetition of the observations. Under most circumstances, it is
desirable to repeat the observations, at a similar time of the day ;
and for most medical objects, it is enough to make observations twice
a day, which is best done between seven and nine a. m., as probably
the time of the lowest daily temperature; and in the evening, be-
tween four and six o^clock, as being probably the time of highest
daily temperature. But if experience has shown that the daily
remissions and exacerbations of a given case occur at other periods,
the measurements should be taken at such times.
In cases of great importance, or when any special question has to
be decided, the measurements should be repeated every two or four
hours, especially in very acute diseases ; and sometimes in the very
commencement of a disease, in order to find out the periods of exa-
cerbation and remission; in cases of doubtful diagnosis; and in cases
where variations from the normal course or type of the temperature
occur.
And besides this, the temperature should be taken whenever any-
thing special is noticed in the patient, or occurs to affect him.
In order to learn accurately the real course of temperature in any
74. TIIF, ART OF MKDICAI, TIlKiniOMETRV.
illness, it is not enough to take observations only twice a day ; they
should be taken at least four, perhaps six or more times daily. For
these observations, the following times are most suitable : — From
seven to eight, and nine to ten in the morning ; from twelve to one
at noon ; from three to four and from six to seven in the afternoon ;
and from ten to cloven at night. To these may be added an obser-
vation in the early morning hours, if the fever be very severe, or
its course exhibits great fluctuations of temperature. When very
sudden changes of temperature occur in a disease, — as, for example,
in a rapid crisis, or in a case of intermittent fever, — hourly or half-
hourly, or even continuous observations may be required to exhibit
the actual progress of the case.
Such severe demands upon time seldom concern the private prac-
titioner, but must be met, if it is desired to speak authoritatively
on the laws of disease, or the course of a malady.
§ 9. The question — By whom shall the observations of temperattrre
he taken ? — is not an unimportant one.
Although it might appear that only the results obtained by a
practised medical man, or a trustworthy medical assistant, could be
relied upon, we must remember that this devolves an immense amount
of labour upon the medical man.
The chief objection which has been made to the practical useful-
ness and applicability of thermometry to medical uses, rests on the
supposition that the doctor must always take the observations him-
self,— a measure which is considered to involve too much expen-
diture of time.
So long as only one or two daily observations are taken, even in
severe cases, this objection is of little value, since almost any
medical man can afford to spare a couple of quarter-hours, for very
acute cases, which do not occur so very often in private practice. If
he cannot spare this amount of time, he had better not undertake
the cases. The logic of this objection is scarcely better than that
of an accoucheur, who would not wait to the termination of a diffi-
cult labour he had undertaken, for want of time !
But, on the other hand, it is quite certain that no busy practi-
tioner can make six or seven daily observations in the same patient,
except as a very exceptional thing indeed, and it is not very often
that he would be able to ^^ersonally take observations twice daily in
the same cases. But indeed it is not necessary that he should do so.
THE ART OF MEDICAL THERMOMETRY. 75
It is only necessary that he should know by whom, and how the
observations were taken, and that his knowledge of pathological
thermonomy should be sufficient to enable him to control (or rightly
estimate) the results obtained.
Any trustworthy, honest, and intelligent man, with good sharp
sight, or provided with spectacles if necessary, can be very quickly
taught to take temperatures with sufficient accuracy. The role of
the surgeon is not merely taking observations, but the superinten-
dence, control, and 'right interpretation of them. The mere reading
of thermometer degrees helps diagnosis no more than dispensing
does therapeusis.
Even in observatories and meteorological stations, the thermo-
metric and many other observations are often made by those who
have no direct interest in their interpretation. A trustworthy,
attentive man, with good will, and conscientiousness, without any
special medical knowledge, will indeed often make less errors than
many a medical man. He will have no preconceived opinions to
prejudice him, as many practitioners have, and thus he will take
cognizaiice of things as they really occur.
In this way trustworthy and well-trained attendants on the sick,
in private practice, or intelligent relatives, make very good and useful
colleagues for the work of medical thermometry. I have generally
found that the relatives quickly appreciate the value of these ob-
servations, and go to work with painful anxiety; and are often
inclined, if they err at all, to do so by disturbing the patient too
frequently to take his temperature. But whoever may be entrusted
with the thermometer, must be carefully taught how to use it, and
assiduously overlooked. Any carelessness on their part is a sign that
they are not fit for their post ; and the medical man ought to be so
familiar with whatever regards medical thermometry, that any
deviation from customary routine may be regarded as an indication
for care, and as requiring that he should personally repeat the taking
of the temperature. It is easily to be understood, that the indica-
tions thus obtained, although sufficient for private practice, cannot
be considered satisfactory data for enunciating general principles or
laws of disease. If the facts thus ascertained appear to be in
contradiction to those obtained by better {i. e., more accurate) obser-
vations, we must at least wait until we are convinced that such a
deviation often occurs as the result of laws learnt by other means,
or is in accordance with the other circumstances of the case.
7<'i TllK AKT OF MKDICAr, Til KKMOM KTKV.
§ lo. — The n/iorlvst (1)1(1 s'luijjfcut met hod of obtaining useful re-
sults also varies witli the circumstanees of the case and the objects
sought.
\\\ prlvaie 2)r(ictice the axilla will almost always be chosen as the
place for the thcrnioracter. The medical attendant should place the
thermometer there as soon as he comes to the bedside. The axilla,
if necessary, is to be first wiped dry, and the thermometer previously
warmed slicrhtlv by the hand. Great care mui^t be taken to avoid
the linen [or other underclothing] getting between the skin and the
bulb of the thermometer; or directions may have been given that it
should be so applied a quarter of an hour before his visit. The
moment of introducing the thermometer should be noted by a watch
or clock. AVhile the thermometer is thus lying in the axilla, the
doctor can ask the necessary questions, feel the pulse, see the tongue,
and inspect the dejecta or excreta. If he has himself placed the
thermometer iu the axilla, he may, after about two minutes, look to
see if the mercury is quickly rising, or if the thermometer is in good
position.^ It is advisable, for many reasons, to look every two
minutes or so, and if from three to five minutes have elapsed since
the mercury became stationary, the instrument may be removed and
the observations concluded.
In private practice it is seldom necessary to know the absolute
height of the temperature, and therefore the observations may be
made more quickly than if we had to determine this. A fifth of a
degree Centigrade (= V° Fahrenheit nearly) minus the ])roper tem-
perature affects our diagnosis or prognosis very little. Just as in
regard to the pulse, it is generally of little moment whether a patient
has a pulse of 80 or 84, of 100 or 104, of 140 or 150 a minute, so
for the questions which arise in private practice, except in cases of
extremely high temperature, one or two tenths of a degree Centigrade
(= two to three tenths Fahr. nearly) usually matter but little. The
physician should know when it is of importance, and when not, and
so, very often the time for taking a temperature may be still more
abbreviated. In private practice the thermometer may be previously
warmed, which can be quickly done by a match, and the mercury
allowed to fall to the temperature of the body. In this way, two or
three minutes may suffice to give, not very exact, but quite satisfac-
tory results. "When it seems desirable, in private practice, to repeat
1 One finger will feel if the bulb is all right, without opening the axilla, and
a glance at the stem is generally all that is necessary. — [Traxs.]
THE ART OF MEDICAL THERMOMETRY. 77
tlie observations more frequently than the surgeon himself can co]i-
venicntly do (as, for examjile, in all severe cases of fever, in inter-
mittents, and in chronic forms of fever), the duty should be entrusted
to an intelligent relative, first informing him or her of the import-
ance of the results thus obtained for guiding our treatment of the
sick and judging of his condition. When he has been shown and
told how the manipulations are effected, he must be allowed to take
some temperatures under supervision, and then he may be allowed
to make the observations independently, the surgeon testing (so to
speak) his accuracy, by occasionally repeathig the observation, espe-
cially if anything unusual has happened, or any startling result has
been procured. The attendant must put down his reading of the
degrees, the thne at which the temperature was taken, and how long
the thermometer was kept in the axilla. Such observations become
a great help to private practice, and if nothing further were learnt
from them than the times at which remissions and exacerbations
occur, they would serve as a very useful finger-post to indicate the
necessity of further visits and thermometric observations. But much
more iifiportant lessons can be learnt from them without much
danger of self-deception, for by means of these we may often get the
first indication of tendencies (or complications) in the disease, the
early knowledge of which is of the last importance, and not to be
attained at an equally early period by any other means of observa-
tion,
I need hardly say that the thermometer left with the patient must
be an instrument which is in good order, and has been previously
tested.
In the wards of large hosintals a methodical process, with the
view of saving time, is even more necessary than in private practice.
For the regular daily observations, the same time must be chosen.
Before the doctor enters the ward, a thermometer should be applied
to every patient in it, and he should go round quickly, and ascer-
tain that the instruments are in good position, correcting them
when necessary. Whilst making other observations (pulse, &c.),
he may from time to time correct the position of the thermometer
or of the patient^s arm, &c. If a patient is inclined to be restless, or
let the thermometer slip out of his axilla (which very seldom
happens in patients possessing consciousness, who generally show-
deep interest in the temperature being properly taken), a nurse or
other attendant rnav attend to the instrument. After about twentv
7S TlIK A HI' Ol'' MIIJIL'AI, TH KRMU.M l-'/nn .
minutes, a clinical iissistiuit, or :\n inlclligont nurse or wardsnmn,
goes round (|uick]y, and notes tlic temi)cratur(! of every case.
^[eanwhile the instruments are left in llie patients' axilkc for
about live miiuiles more, when the doctor reads the temperature for
liimsclf. If the degrees he observes diiTer from those obtained just
before, the thermometer in the given case is left still longer, till the
mercury has become stationary. In this manner, the temperature
of every patient in a ward containing twenty beds, can be accurately
determined in less than an hour, and much of this time can also be
usefully employed in simultaneously making other observations
[pulse, tongue, res]nrations, questions, &c.]. In a well-organised
corps of attendants on the sick, there will always be some found
who make perfectly trustworthy readers of temperature, and their
services may be made use of at least for cases of ordinary kind, and
for times when no medical or surgical visit is to be expected. We
must always remember that a physician who has much therraometric
ex])erience, will not be very easily, or at least for long together,
deceived by false results, or imperfect takings of temperature, and
that only the novice in thermometry has to fear being much misled
by others.
Naturally enough, there will still be some cases which require
more time to be devoted to them, either because the ascertained tem-
peratures appear on some grounds suspicious, or because the special
circumstances of the case render a more than common amount of
accuracy and care desirable. We must devote more time and care
to these, in thermometry, just as in other ways, some patients both
claim and secure more detailed investigation of their cases than
others do.
He who has learnt the value of thermometry wUl not reckon either
his time or his trouble in these cases thrown away.
§11. "\Thatever the nature of the thermometric observations, if
they are to be of any use at all, it is essential that the results ohtainecl
should he conthmov.sJy recorded. This can be best done, and the
course of the disease rendered most evident, by indicating it on a
chart, or ruled map, as a coni'nmous curved line. On this charts
both Reaumur^s and Celsius' (the Centigrade) degrees may be
marked. [Those used in this country generally have the Centigrade
and Fahrenheit scales instead.] It is convenient to note the
frequency of the pidse^ and the number of the respirations, in a
THE ART Ob' MEDICAL THERMOMETRY. 79
similar manuerj but in different colours. This may be conveniently
done by coloured pencils. Other memoranda, of other symptoms
and appearances which are highly important, may be exhibited on
the same chart. (See Model, Plate I.) In this way the entire
course of the disease, with all its fluctuations, complications,
tendencies, and changes can be seen at a single glance. No memory,
however retentive,, however life-like and true to nature, affords so
^'speaking" a likeness of the course of the disease as such a chart.
The comparison of many such charts together exhibits the unifor-
mity of the general course of diseases, lets the laws of disease promul-
gate themselves, so to speak, and exhibits all the variations and
irregularities of the malady, and the working of therapeutic agents
in so striking a manner, that no unprejudiced mind is able to resist
such a method of demonstration.
CHAPTER V.
ON TIIM TKML'Kll.VTURE IN HEALTH.
1. It is almost self-evident tliat our knowledge of the ienqiera-
lure of healthy human beings must be the basis of all our conclusions
as to the temperatures met with in disease. Altliougli observations
of temperature in healthy persons have now become very numerous,
yet the facts are still insufficient in number, and as yet far from
sufficiently reliable, to completely satisfy our wishes on all the points
which it is desirable to elucidate.
These observations are for the most part concerned with differences
of only a few tenths of a degree \jj\° Centigrade =-iV^„° rahr.=-i-°
nearly] .
Very often indeed, we may fairly question, whether the persons
who are the subject of experiment Vixe. j^eifectlj/ healthy or not; and
particularly in those cases, when the supposed healthy temperature
is tested under the influence of unusual conditions and circumstances,
it may be doubted whether these influences and conditions have
affected the health of the subject of experiment — whether the in-
fluences to which he is exposed have proved overpowering in them-
selves, or that the individual subject to them has not been sufficiently
healthy to withstand the effects of a novel diet, or prolonged baths,
and such like. And it is no less true that whole series of personal
observations have become of doubtful value, owing to the subsequent
illness of the experimenter fas for example those of Gierse) ; and in
many cases the unusual deviations from the recognised standard
allow us confidently to assert that the experimentees were not in
perfectly sound health. In this way, facts and observations made
with the greatest care and precision, as regards the method of obser-
vation, are subject to considerable drawbacks when regarded as
materials for judgment on the temperature of health. Many of these
observations, however, have been somewhat negligently made, and
the precautions which are rightly considered essential for pathological
ON THE TEMPERATURE IN HEALTH. 81
thermometry have been neglected in the experiments made on the
temperature of the healthy. It is, however^ essentially wrong to found
our principles of physiological thermometry upon materials so scanty.
If a great number of observations, under all sorts of circumstances were
accumulated, many errors would thus be compensated or eliminated.
Instead of this, it has been attempted to solve the problem by a few
isolated observations, or by observations made on a few persons, a
solution which cannot be accepted unless farther confirmed by general
laws.
It is easy, too, to comprehend that it is difficult to pursue these
investigations on normal temperature through a sufficiently ex-
tended period of time — most of the furnished data referring only to
brief periods. It is equally necessary to accumulate a long series of
facts in medical thermometry, only it is easier to find materials.
Physiological thermometry generally tries to decide important
questions in short periods of time, and on a small number of facts,
which could not be accepted as a basis for conclusions as to the tem-
perature in disease. We must not overlook the fact that it is
difficult to get a sufficiently large number of thoroughly healthy
people for our experiments, and even if we could secure them, it is
more difficult to guard them from undue extraneous influences than
it is in the case of sick persons confined to their beds in a hospital
ward.
In the absence of a sufficient number of healthy persons to serve
as subjects of experiment, recourse might be had to observations on
animals; but those which are generally chosen for this purpose
(dogs, rabbits, &c.) do not exhibit an equal constancy of tempera-
ture with healthy men, or in other words their normal temperature is
not confined to such narrow limits ; and therefore the results of
observations on them cannot be accepted as conclusive in the case of
human beings, without further investigations. The restdis of ])hjsio-
logical thermometry, as regards trustworthiness, and the number
of experiments on which, they are founded, must be considered to
lag greatly behind the principles which the observations of the
last twenty years have estabhshed as regards the temperature of the
sick.
§ 3. — But even when every precaution has been taken in making
the observations, it is mposs'ihle to draw a hard and fast line to
indicate ly the temperatnre the exact limits of health and disease.
G
S.',' ON THi: TKMFEUATUUli IN lIliALTll.
So long as no otlior sii^ns of disoaso are i)rcst'iit, the decision as lo
what degree of temperature is normal appears to be quite an arbitrary
one. All that justifies the establishment of such a limit is the fact
that the occurrence of temperatures which exceed certain limits, is
generally quickly followed by symptoms of disease, even when none
such are observed at the time of using the thermometer. But we
cannot always determine absolutely that such and such evidences of
disturbed health are really symptoms of a disease. However, this
dilliculty in disease is only met with occasionally. It only occurs
when man, or some other of the mammalia is brought under the
effect of unusual circumstances, or powerful influences are brought
to bear on them. In such cases, a physiological effect may simulate
a pathological one, and it is, in fact, often difficult to say whether
the compensatory-heat of healthy bodies is much affected by outward
intluences, or whether the insufficient compensation is to be con-
sidered a sign of a really diseased, although artificially induced con-
dition. "\Te may perhaps be justified in considering the effect to be
normal or healthy, when the normal temperature is very speedily
restored, immediately after the disturbing element is eliminated,
provided no other signs of functional or textural mischief present
themselves. But such cases of experiment must often be considered
to be on the border-land between health and artificially-induced
disease. A similar remark applies to certain cases not yet regarded
as diseased conditions ; for example : extreme fatigue, menstruation,
pregnancy, and parturition, and the more doubtful we are as to the
absolute healthiness of the individual, the more difficult does it
become to decide on the category to which these belong.
§ 3. — The untrustworthiness of the observations of healthy tem-
perature, owing to the difficulty of excluding previously existing
slight, or (although latent) serious disturbances of health in the
subjects of experiment, and the impossibility of sharply severing
pathological effects from physiological ones, prevent our positively
determining the range of temjjerature in healthy human leings ; yet we
may accept, as not far from absolute truth (supported as it is by the
very numerous observations we have the opportunity of making in
convalescence), the statement that the range of normal temjjerature
in the axilla is from 97"25° Fahr. (36*25° C.) to 99*5° Fahr.
(37*5° C.) and that the mean normal temper ature^^^'(f P. (37° C).
At least anything above or below this must be looked upon as
ON THE TEMPERATURE IN HEALTH. 83
suspicious, and only considered normal under special circumstances
and conditions.
Since the temperature of the human body can only be considered
as the result of continual production and losses of heat, of varying
amounts, it appears a very remarkable fact that the sum total (Facit)
should always remain so nearly the same (under the operation of so
many, and doubtless every moment changing processes and in-
fluences), that the internal temperature varies by little more than a
degree Centigrade( = i"8° Fahrenheit).
"What Lavoisier has said of the body-weight — " Quelle quantite
d' aliments que Fon prenne, le meme Individ u revient tous les jours
apres la revolution des 24 heures au meme poids a peu pres qu'il avoit
la vielle, pourvu qu^il soit d'une forte sante, que sa digestion se fasse
bien, qu'il ne s'engraisse pas, qu'ilne soit pas dans unetat decroissance,
et qu'il evite les exces,"i may be said with still greater propriety of
the temperature of the body. So long as the bodily health is good, it
maintains the same temperature in spite of slight fluctuations, or
quickly returns to the same degree of heat ; and even when special
influences have determined a greater deviation, the normal tempera-
ture is soon reached again, if health is not injured ; and even when
an illness has been thus induced, as soon as ever recovery takes
place, the temperature is again found to be normal. Human beings
are not shigular in this respect. Many other animals, and especially
those nearest related to us in structure, exhibit the same pheno-
menon.
A specific temperature is indeed a peculiarity of every living-
being. Every animal, although subject to the laws which regulate the
difi'usion of heat, has the peculiarity that as long as it retains life it
does not necessarily acquire the same temperature as the bodies with
which it is brought into contiguity, or in other words, the tempera-
ture of the fluids or gases in which it is placed; under normal con-
ditions it has a higher temperature than that of the medium which
surrounds it, and if it happens, as it may exceptionally, that the
temperature of this medium exceeds 104° or io7'6° Fahr. (40°=
42° C.) it does not acquire this temperature.
^ " Whatever the quantity of food taken, the person taking it will be found
to have regained almost exactly his original weight after the lapse of twenty-
four hours, provided that he has done growing, that his health is good, and his
digestion vigorous, that he is not getting corpulent, and that he avoids other
excesses."
SI
ON THK TKMPKRATUllK IN HEALTH.
]\rainni:ilii\ niul birds exhibit the still more remarkable pcculiarily
of a more or less coii.sfdnf, temperafi(rc ; that is their temperature is
imlepeiul'Mit, or almost independent of the warmth of the medium
in which they are placed, whilst oilier animals arc very materially in-
lluenccd by this.
The expressions " warm-blooded " and " cold-blooded " animals
are intended to denote this, but it is more correct to indicate the dis-
tinction between them by the terms, animals with ''constant" tem-
perature, and those with " t'cyva^d'tf" temperature.' This constancy
of temjjcrature is however by no means absolute, and indeed many
animals whose temperature is generally constant, exhibit considerable
alterations of their specific heat, under certain circumstances — for
example, amongst mammalia the hibernating animals closely approxi-
mate to the temperature of the surrounding medium during their
winter-sleep, or hibernation. Man belongs to the class of creatures
in which the constancy of temperature is almost invariable — yet this
must not be understood absolutely — in every man there are slight
variations, under many different conditions, and in some persons,
under special circumstances there are wider deviations from the
normal, and this may be more ])articularly manifest in disease, which
sometimes exhibits a great breadth of such deviations.
' From a comparison of statements by various authors, I believe that the
temperatures given below are a fair average of the results of various experi-
ments : —
Mean temperature.
105-8°— 111-25° F.
(41= - 43^ C.)
Animal.
Birds
Mammalia .
Fish,
Reptiles, and
Amphibia
= {
= {
<^(i' — 105^ F.
(35-5°- 40-6^ C.)
= {
(10°
- 52° F.
13-6^ C.)
'Or two or three de-
grees only higher than
the surrounding me-
-dium (air or water).
Molluscs and other
Invertebrata
"^ A few fractions of a degree higher
3 than tlie surrounding media.
Insects, when excited, gain from 2° — lo"" Fahr. (= '^'G'— 18° C.) in heat. A
hive of bees has been known to have a temperature of 48-5° Falir., wiiilst the
surrounding air was 345°, and when annoyed the temperature of the hive rose
to 102°. (Newport.)
The following temperatures are taken chiefly from Dalton's ' Physiology,'
P- 255 :
ON THE TEMPERATURE IN HEALTH.
85
§ 4. — This phenomenon of specific heat^ and its constancy, is the
result, on the one hand, of the continual production of loarmth, which
occurs in almost every part of the body, and on the other hand of
the ceaseless loss of heat, processes which are always going on simul-
taneously, whilst life remains.
The fact that heat is generated in the human body, especially
during life, is easily understood. There is no doubt that there is no
other source of independent heat in the body except those processes
which are called chemical. A fresh creation of heat no more happens
in the body than a fresh creation of material — it is an exchange of
forces which occurs in the organism. The forces which are changed
into heat in the body, are the chemical affinities of its own sub-
stance, and of the materials introduced into it from without. In
every process in which stronger affinities than before come into
play, and are, so to speak, saturated, or satisfied (gesattigt),yt»f(?e is
liberated (in the form of heat or motion). Since the tissues of the
body, find the materials introduced into it, enter into fresh chemical
combinations, which possess much less chemical power of com-
bination (Sj)annkraft) or none at all ; since the oxidisable ingesta
(food of all kinds), and the inspired oxygen, are combined into car-
bonic acid, or eliminated as oxidised excreta, their previously existing
chemical affinities are changed into (or pass over as, iibergehen) heat
Animal.
"" Swallow .
Heron
Birds '
Raven
Pigeon
Towl
L Gull
' Squirrel .
Goat
Cat .
Hare
Mammalia -
Rabbit .
Dog. .
Guinea-pig
Ox .
Ape ,
Reptile
Toad
Fish
f Carp
I Perch
Jlean temperatui
Fahren leit.
e.
. 111-25°
. 111-2°
. io8-5°
. 107-6°
. 106-7"
. ioo-o°
. 105-0°
. 102-5°
■ 101-3°-
102'
. 100-4°
• 103-0°
. 99-4° —
lOI
. 1020°
• 99-5°
• 95-9° -
. 51-6°
98
■ 51-25°
52-10°
[T[!AN.S.]
HG ON THK TEMl'EllATUllE IN HEALTH.
;u\il motion. 1 The uniumerable chemical processes going on iji the
system, and especially the coml/iiuifions ol* the alimenlari/ materials
converted into blood and, althougli in a less degree, of the tissues,
with the ori/gen inspired, the oxidation of this material, the so to
speak, continuous slow combustion of the blood, and of all the
materials introiluced into the body, or of those in it capable of
oxidation — these are the sources for a ceaseless, and indeed copious
development of heat.
The blood, on account of its capacity for takuig up oxygen, is in
every case the agent of heat-production. It is also, on account of its
circulation through the entire body, the means of assimilating the
unequal temperatures of dilTereut regions, and thus equalising the
general temperature of the body. Whether the blood itself is not
the principal seat of this interchange of chemical affinities which
produces warmth, and wdiether the generation of heat in the
parenchymatous tissues is due to this, and in what degree, is for
the present of much less consequence. Maijer says, that " Not a
hundredth part of the combustion-processes goes on anywhere else
but in the blood-vessels themselves,^' and physiology has already
begun to justify the statement. Yet it is generally admitted, that
with the exception of the horny tissues (hair, nails, epithelium, &:c.),
all parts of the body contribute to the production of heat, by the
changes their substance undergoes. The glands, the intestines, and
the muscles, are the especial seats, or furnaces, (lleerde,) so to speak,
of this process, although it is not possible to assign the exact share
due to each.
It is equally impossible to express accurately in figures the suvi-
total of all the warmth produced in a given time in a healthy man
under ordinary circumstances (that is, [amount of caloric, or] the
number of warmth-units which are furnished by the human organism
in any given time), because the loss of warmth in the same space of
time can neither be prevented, nor exactly estimated ; and further,
because the attempt to estimate the warmth produced, by calcu-
lating from the products of metamorphosis, or from the combustion-
heat of the materials of nutrition (that is, the amount of heat pro-
1 It may perhaps be objected that this (although a description of a physical
process) is couched in somewhat metaphysical language, and that a rather vague
meaning is attached to the term affinities. This is, however, inseparable from
the imperfection both of our knowledge and of language itself. Compare
Groves ' On the Correlation of Forces,' and Professor Tyndall on ' Heat con-
sidered as a mode of Motion.' — [Tbans.]
ON THE TEMPERATURE IN HEALTH. 87
duced by their combustion), is beset with almost insuperable diffi-
culties; and last of allj because the oxygen consumed is no measure
of the warmth produced^ since the materials to be oxidised have not
all the same combustion-point ; and because the whole of the force
set free by oxidation, does not give rise to heat, but some of it
appears as motion [Arbeitsleistung] , and is to be calculated as so
m.uch zvorlc. Thq estimates we sometimes meet with, of the amount
of heat jaroduced by human beings in a given time, appear for the
most part to rest on arbitrary data. Por example, Helmlioltz (in
the ' Berlin. Encycl. Worterb.,^ xxxv, p. ^^^) calculates that a man
weighing 83 kilogrammes (or about 13 stone) produces daily
2,732,472 "Calorien," or heat-units {i.e., '' Gramm-C2i\ovm\" or
heat-units in the sense of the quantity of warmth required to make
I gramme [= 15*44 grains nearly] of distilled water 1° Centigrade
[= i'8°rahr.] warmer than before) ; or, in other words, that every
gramme of his body-weight produces dail// sufficient heat to raise
the temperature of 33-;V grammes of distilled water by 1° Centigrade
(= £'8° Fahr.), or in one hour enough to warm one gramme of
distilled water about 1*4° Centigrade (= 2-52° Fahr.)^.
§ 5. — As there is a continual production of heat in the body,
there is also a continuous giving off or loss of heat. This loss of
heat occurs —
By radiation (from the surface),
By conduction, or transmission to other bodies.
By evaporation of secretions in a gaseous form ;
And lastly, by the furnishing of mechanical work (or change of
heat into motion).
' Wunderlicli's figures are 38^ grammes and i'G° respectively, instead of
333 grammes and i'4'^ as above ; but a simple calculation appears to show that
this is a clerical error. Tor the English reader the statement may be more
familiarly put by saying that every pound of body weight produces heat enough
in every 24 hours to make 6 gallons of water 1° Fahr. hotter than before ; iu one
hour enough heat to warm a quart of water to the same extent. Beclard esti-
mates that a man produces daily heat enough to raise 55 lbs. (5! gallons) of
water from 32" to 212° Fahr., which indeed differs but slightly from the former
statement. Other calculations by Despretz, Dalong, Barral, Nassc, and others,
are referred to in Dr. Otto Funke's ' Lehrbuch der Physiologie,' Band I, pp.
492 — 508. See also Dr. Carpenter's ' Principles of Human Physiology ' (edited
by Dr. H. Power), pp. 437-8, where, apparently on the authority of Scharliug,
the daily number of heat-units is estimated at 2,464,154, or heat enough, if
converted into mechanical force, to raise 1,166,000 kilogrammes (= 11472
tons) I metre (= 39'37 inches') high. — [Tbans.]
88 ON TllK TEMl'KllATLlliK IN IIKAI.TII.
Tlir cliii't' sc;it of the losses of heat, and conso(|iuMiily of llie cool-
int^ process, is the surface of the body. It is lierc that the losses by
radiation, and by transmission of licat to the surrounding media, and
finally the loss of heat by the evaporation of water (perspiration)
take place. The quantity of heat lost from various ])arts in this
way depends partly upon the nature of the surroundings (IJnige-
bung), their relative coldness, or conducting-j)o\ver, &c.; and next on
the form of the organs — (the nose, ears, fmgcrs, quickly grow cool).
But it depends also on the thickness and quality of the epidermis,
and especially on the fulness, or otherwise, of the blood-vessels, and
especially on the moisture of the skin, and the amount of per-
spiration. There is also a loss in the air-passages by the air w4iich
is inspired abstracting heat, and also by evaporation of water from
the lungs. As, however, the air-passages are also the chief seats of
heat-production, loss and gain are constantly going on together in
them. In a less degree, there is also a loss of heat in the stomach
(at such times as cold substances are introduced into it, correspond-
ingly to their quantity and temperature), and in the rectum (by
masses of faeces). Tinally, in the action of" muscles, a part of the
heat is changed into movement (mechanical effect) ; but here again
the account is balanced to some extent, by the production of heat in
muscular contraction. It is estimated that from 60 to 70 per cent,
of the heat lost must be assigned to radiation and conduction from
the surface (from the skin), from 20 to 30 per cent, to evaporation
of water, from 4 to 8 per cent, to loss through the air respired, i to
2 per cent, to loss in the excretion of urine and faeces, and about
2 per cent, to the introduction of cold articles of food.^ The sum
total of loss in a given time, cannot be determined any more certainly
than the sum total of production ; this only we know, that in health
.one is equivalent to the other.
c
' Barral, on somewhat arbitrary data, makes the calculation that in a man of
29 years of age, in an atmosphere of 20° C. (68° Eahr.), tlie amoimt of heat
production and loss amounts to the following figures : —
Ileat-units produced = 2,706,076.
Loss of heat, in units and in per centages of the production : —
By evaporation, 699,801. 25'85 per cent.
By warming the air inspired, 100,811. 372 per cent.
By warmiug the food and drink taken, 52,492. i'94 per cent.
By the solid and liquid excrements, 33,020. 1*22 per cent.
By radiation, conduction, and mechanical work, 1,819,952. 67^22 per cent.
See Funke's ' Physiologic,' loc. cU. — [Tea>-s.]
ON THE TEMPERA'lURE IN HEALTH. 89
§ 6. — Although tliere is now pretty general agreement, and but
little doubt as to the condition of warmth production, and the
processes by which heat is given off, or lost; yet the real causes wdiich
maintain an even temperature in the body, or in other words, the
regulators of warmth, are not at all well known.
As regards this, it is indeed quite conceivable that the production
of heat is regulated^ by the concurrent increase or diminution of the
losses of heat ; and that man is instinctively led, when he loses much
warmth, to try and limit this (by better covering himself) and to
recover the lost heat by a richer production (through taking in food) ;
or that, on the other hand, when the heat produced is excessive, he
may seek to reduce it by such means as cold drinks, washing,
bathing, &c. It is also conceivable that a number of contrivances
may exist in the body, which unknown to the individual himself,
come to the help of his instinct ; as for example, in increased pro-
duction of heat, the circulation is quickened, the blood-vessels of
the skin become fuller, and the consequent loss of warmth from the
skin greater, which is augmented by perspiration ; the respiration is
also quickened, and the consequent loss of heat from the difference
of temperature of the inspired air becomes greater : whilst on the
other hand, when the production of heat is less, the cutaneous vessels
contract, become less rich in blood, and in this way the loss of heat
from the skin is diminished. An uncompensated [einseitige = one-
sided] alteration of warmth-production, or an uncompensated change
in the amount of heat lost, quickly induces, and indeed necessitates
an alteration in the height of the temperature. But in a state of
liealth, when the respective apparatus for heat-production, and heat-
destruction [if one may use such a term], are in good order; or in a
word, when the organism is under normal conditions, the com-
pensatory changes are so suddenly made, that an equilibrium is
quickly reestablished. Any considerable (uncompensated) increase
of temperature is generally followed by a somewhat excessive loss of
heat, and any unusually considerable loss is generally more than
compensated by an over-production, so that after either a rise or fall
of temperature, the temperature fluctuates somewhat, in opposite
directions, till an equilibrium is attained. But all this does not
make it any more evident, why the temperature in health so con-
stantly maintains a particular degree, why this degree in human
beings should be just about 37° C. (= 98*6° Fahr.) ; why other
creatures, also provided with apparatus for the production, and means
00 0\ THK TKMPERATURR IN HKALTII.
for gettinj; rid of licat, should litlicr less perfectly, or not at all,
maintain an equally constant temperature with man; or Aviiat these
contrivances, so intimately blended one with another, really are,
hy •whose instantaneous and correct co-ordination, or working
together, the constancy of temperature (/. e. the regulation of it)
really depends.
Even Lvdw'ig ('Physiologic/ II, 754), who sets out with the
" Means for the preservation of the normal degree of temperature,"
allows, that although the organic conditions, which determine the
balance between gain and loss of heat can be at least partially dis-
covered, the mechanism of this connection is yet quite unknown.
There still remains this remarkable enigma, that these various and
changing factors in the healthy body, constantly produce so uniform
a result, as regards the degree of heat; and that thus, however
varied the amount of heat production, or whatever the amount of its
loss, there is constantly in the healthy body a regulator, which in-
stantly steps in, and never allows it to rise much above, or sink
much below a determinate limit. The problem is not simplified by
our observing that this regulator only displays its full power in the
healthy, and that any disturbance of health makes itself known to
some extent by disturbing this regulating power also.
Yet, on the whole, the process is scarcely more mysterious than
that by which the blood maintains a constant similarity of compo-
sition in health, notwithstanding the varied ingesta and secretions ;
or that in which the totality of organic life, all the conversion of
tissue-materials to the composition (building up) of definite organic
forms, all compensation in living nature, whether in great things or
in little, all preservation of the individual, the equality ' (number-
relations) of the sexes, and the preservation of species (in spite of
slaughter, losses, and accidents), all alike depend. So long as the
organism is healthy, every 7;/%* on the one side is met by this
regulating power, Avith a minus on the other : and in health
the warmth production exactly compensates the amount of heat
lost through outward influences or in other ways, and in just a
similar way if the production of heat is either excessive or dimin-
ished, very numerous contrivances soon rectify the account. Just
as it is necessary for the due and orderly continuance of life that the
balance should be maintained between the/00^ ialien in [ingesta] and
the excreta, so it is with regard to this force. The undisturbed
continuance of hfe demands an equality as regards the production
ON THE TEMPERATURE IN HEALTH. 91
of heat, and its loss or application in other ways, and on this
equilibrium of heat health depends.
Tor this orderly arrangement (Ordnung) there is no need of special
regulating apparatus^ or organs for the purpose, or of any mystical
working of these on the chemical processes of the economy, any
more than the regularity of the rest of the system depends entirely
on the domination ;of any special part of the body. The mainte-
nance of the accustomed order depends much more upon the in-
tegrity of the function of all the parts where tissue changes are
carried on, or, at least, on their practical (approximate) integrity,
for the organism is fashioned with such artistic perfection, that a
slight injury of one part sometimes disturbs the order of the whole
body. But as regards the maintenance of the general functions of
the body in their accustomed order, all parts of it are not of equal
importance ; so as regards an equilibrium of temperature, the in-
tegrity of some parts is much more important than that of others.
Yet it must be allowed, indeed, that if there be (whether acciden-
tally or designedly [artificially] induced,) too considerable hin-
drances to compensation; if the operation of single important
organs deviates too widely from the necessary standard, there may
then be very serious disturbances in the balance of production and
loss of heat, and thus very considerable deviation from the normal
temperature may occur. It will then depend upon the extent and
duration of these deviations, whether we should consider them as
within the limits (Breite) of health or not. Up to a certain point,
indeed, we may choose to call it so, as has been said before, but it
is no less true that with any considerable or continuous alterations
of temperature, other signs of disturbed health are not long in
making their appearance.
It is almost self-evident that such disturbances of the accus-
tomed order may arise from various points and different processes of
the economy. But that anomalies in the working of the nervous
system (Anomalien der Thatigkeit der Nerven), are generally con-
cerned in them, is easUy understood, when we consider the extra-
ordinary, complicated, and sensitive influence of this apparatus
over all parts of the body. This, however, does not justify us in
attributing to the nervous system or to any part of it, the function
of regulating exclusively the heat of the body. The nervous system
is, indeed, concerned in this function of regulation, first, because it
is a part of the body ; but it is especially concerned in it, and in a
«)? ON Till". rr.MPl'.HATUnK IN IIKALTIF.
hiu;h clef»rco, just because its rclalions with all the remainiiiif parts
of the body are so numerous, manifold, and important (einlluss-
reiehe) ; ami it is further particularly concerned in the disturbances
of equilibrium, because its own anomalies even when they are but
slight, generally extend further than those of most other parts of the
body ; and because the change in the calibre of the smaller vessels,
and, consequently, the blood-supply (Blutfiille) of all the organs,
depends ujxm one part of the nervous system itself.
^ 7. Constant as the temperature remains in healthy men, when re-
garded as a whole (im Groben und Ganzen), yet, it admits of some
slight fuctuatiojis {lit. of a certain breadth of movement).
Many facts have been discovered which show the causes producing
the minor deviations from the normal temperature, which are con-
stantly occurring within certain limits.
The temperature of different j^arts or places of the same body,
taken at any given time, is not quite uniform.
The temperature of any part of the body depends —
(i) On the amount of heat it receives.
(2) On the amount of heat generated in the part itself (an Ort
und Stelle).
(3) On the local losses of heat.
As these conditions are not identical at any one time, in all the
various parts of the body, since the copious or more sparing access
of warm blood, the stronger or weaker local production of heat,
and the topical radiation of heat, and cooling of the part may be
more or less considerable, so the temperature of various parts will
vary at one and the same time.
The blood itself, in different parts of the circulatory system ex-
hibits variations of temperature. The cutaneous veins generally
have the blood less warm than that of the arteries of the extremi-
ties ; whilst, on the other hand, the venous blood of the kidneys
and liver is warmer than the blood which is brought to these organs.
The blood in the mucous membrane of the intestines is sometimes
warmer, sometimes cooler, than that of the vena porta, and that
of the veins of the salivary glands and muscles, in relation to their
arterial blood, exhibits similar changes.
The blood of the jugular vein is warmer than that of the carotid
artery.
The blood of the inferior cava is warmer than that of the supe-
ON THE TEMPERATURE IN HEALTH. 93
rior, and than the mixed blood of the right side of the heart ; but
the latter is warmer than the blood of the veins in the extremities.
The contents of the right ventricle are warmer than those of the
left.
It is clear that in organs in which much warmth is generated^
the venous blood leaving them is warmer than the arterial blood
they receive; whilst jn, parts which give off a good deal of heat,
the converse holds good. The arterial blood becomes colder in
the extremities, whilst, on the other hand, the blood which passes
through the organs of the abdomen, returns from them warmer than
before, and make the blood of the inferior cava warmer than that
of the superior, and even warmer than arterial blood itself.
Although these facts have no immediate practical valuer yet they
])oint, so to speak, to the furnaces (auf die Heerde,) where vital
heat is produced, as well as to the refrigeration of the economy
(die Stellen der Abkiihlung) ; and now and then they may be used
for purposes of comparative physiology. The following are the
most important of the numerous investigations and experiments on
the temperature of the blood in different blood-vessels : Those of
Becquerel {' Gavarret, de la Chaleur,' p. 107); G. Liebig {'Vhtx
die Temperaturunterschiede des venosen und arteriellen Blutes,
Giessen thesis,' '^'^53)} ^^' Bernard (' Comptes Eendus,' xl, p.
331 and 561, and his "Lecons sur les proprietes physiologiques et
les alterations pathologiques des liquides de I'orgauisme," 1 859, i,
p. 54) ; Savory/ (^Lancet,' April, 1857), and WurlUzer {' ^\\e&\s, ai
Greifswald,' i^o^)- Colin, however, has obtained somewhat different
results by means of very delicate Walferdin's maximum (metastatic)
thermometers, as regards the blood of the heart. In 93 comparative
measurements of the temperature of the blood in the two sides of
the heart in horses, ruminants, and dogs, he found the temperature
identical on both sides in 21, the blood of the right heart warmer
in 45, and that of the left M^armer in 27. He explains the latter by
the production of heat in the lungs. He admits, however, that
the temperature of the heart depends not only on that of the blood
it receives, but also upon the varying conditions as to warmth of
the stomach and intestines (' Annal. des Sciences, Zoologie,' vi, 83 —
103.
As regards the temperature of internal organs in healthy
human beings, we can easily understand that direct experiment is
wanting.
04 ON THE TE.MPKRATUKK IN HEALTH.
It is sujiposcd, widi some reason, that Ihey have about the same
Icmperature as accessible, but well sheltered spots.
Jacobson and Bernhardt (' Central blatt/ 1868, p. 643), found
the left heart in llfteeu cases about '12° to '42° Centigrade (= ^° to
-5-° Fahr. nearly) M'armer than the right., and the same temperature
only in two cases. They found normal pleural cavities about •1'' to
'2^ Centigrade (= -^° to -]° Fahr.), cooler than the abdominal cavity,
and about -2° to -5° Cent. ( = -\° to -,''.,° Fahr. nearly), cooler than
the left heart.
The (inferences of tenqierature in those jiarts wh\ch are most
capahJe of serving ns in practical investigations are apparently very
slight when carefully measured. Amongst these, the temperatures
of the vagina and the unloaded rectum are the highest, being from
one to four tenths of a degree Centigrade ( = -ith to -r^ths of a
degree Fahr. nearly), higher than that of the axilla.
The temperature of the interior or cavity of the mouth, if there
is no disturbing element, occupies an intermediate position (between
the axillary and vaginal or rectal) . We may safely allow that when
the mean temperature of the axilla in a healthy person is 37°
(98-6° Fahr.), that of the month will be 37-1° to 37-2° (9878° to
98'96° Fahr.), and that of the vagina, or imloaded rectum 37\3° to
37"5° (99'i4°to 99*5° Fahr.). Yet the results of various observers
are somewhat contradictory. Compare on these points L. Fick
(" Temperaturtopographie des Organismus'^ in Miiller's ' Archiv,'
1853, P- 408). Winckel (in the ' Monatsschrift fllr Geburtskunde
und Frauenkrankheiten,^ 1862, xx, 473). Zlemssen ('Pleuritis
und Pneumonie im Kimdesalter,^ 1862, p. 10). Schroder (Vir-
chow^s 'Archiv,' xxxv, 253.)^
The differences between the temperatures of imperfectly protected
situations on the surface of the body are far more considerable. As
cooling takes place to a greater and more fluctuating extent, the
differences observed in customary measurements are almost value-
less for practical purposes. "We learn, however, from thermo-electric
determinations of temperature of various parts of the skin, that
' In some diseases (notably in cholera, pneumonia, pelvic and abdominal dis-
eases, &c.) much greater differences will sometimes, as might be expected, be
found. This is also the case occasionally in parturition. From 2' to 3" Fahr.
(= 3"6° to 5'4° C.) difference between the axillary and vaginal or rectal tem-
peratures occurs in some of these cases. Some of the discrepancies which have
been recorded are, however, doubtless due to the methods of observation being
imperfect. — [Tra:^s.]
ON THE TEMPERATURE IN HEALTH. 95
there are constant variations of temperature, in one and the same
place; within certain not very considerable limits, corresponding with
the amount of blood-supply, and that this ebb and iiow is almost
continuous, and determined by various circumstances. For example,
Lombard has found such variations in the temperature of the skin
of the occiput produced by the influence of moderate mental ex-
ertion (Experiments on the relation of heat to mental work[s] —
analysis by Brown-S^quard in ' Archiv de Physiol. Normale et Path.,'
1868, i, 670).
§ 8. The variations in the temperature of healthy persons under
varying conditions are very shght, and are comprised in the limits of
a few tenths or fractions of tenths of a degree. [This is true,
whether we take the Centigrade or Fahrenheit scale.] With very few
exceptions the temperature in the axilla, in health, under the most
varied circumstances and influences, moves between 36*2° and 38°
(Centigrade = 97-16° to 100*4° Fahr.), and if it exceed this a
little, does so only for a moment. Br. W. Ogle (On the diurnal
variations in the temperature of the human body, ' St. George's
Hospital Reports/ 1866, ii, 221,) gives a somewhat lower minimum,
and a somewhat higher maximum temperature; however, he found
the minimum at 36-1° (96*98° Pahr.), on a winter morning, and
the maximum at 38'i° (100*58°) in a Turkish bath. In some in-
dividuals (healthy in other respects) of greater delicacy, especially
women and children, the mobility of temperature is somewhat
greater, and under corresponding conditions the variations may
somewhat exceed the above limits.
It must, however, always be remembered, when we find more
considerable deviations, that the apparently healthy cannot always
be safely considered as really so. Very numerous observations have
been made in the effect of varied circumstances and influence on the
temperature of the healthy. Any extended resume of these would
be unsuitable for my purpose, on account of the very varying value
and importance of these observations. In the following pages,
notice will only be taken of the most important observations and
experiments.^
' Mr. A. H. Garrod (in ' Proceedings of the Koyal Society,' vol. xvii,
No. 112), publishes a series of observations which are intended "to show that
the minor fluctuations in the temperature of the human body, not including
those arising from movements of muscles, mainly result from alterations in the
96 ON THE TKMi'KRATUlU'; JN llEAJ/l'll.
§ y. The inlluencc of age upon temperature. — Before birth the
infant's temperature is a trifle higher than that of the mother's
uterus or vagina (Hiirensprung). The diflrrence, all hough very
amount of blood exposed at its surface to the influence of external absorbing
and conducting media." He sajs : " It has long been known tliat cold con-
tracts and beat dilates the small arteries of the skin, respectively raising and
lowering the arterial tension, and thus modifying tiic current of blood in the
cutaneous capillaries. But modifications in the supply of blood to the skin
must alter the amount of heat diffused by the body to surrounding substances;
and so we should expect that by increasinr/ the arterial iemion, thus lessening
the cutaneous circulation, the blood would become hotter, from there being less
facility for the diffusion of its heat, and that by lotcering the tension, thus in-
creasing the cutaneous circulation, the blood would become colder throughout
the body, from increased facility for conduction and radiation." The jiaper is
accompanied with sphymographic tracings to show that "by stripping the
warm body of clothing, in a cold air, when the tension was low (bounding,
weak pulse), the temperature and tension rose at the same time the surface of the
body became colder. Simply heating the feet in warm water of iio^ — 114'
Fahr. f43'3^ — 45'6° C), lowers the temperature and tension together, and is
accompanied with feelings of chilliness." The subject of the experiments was
a young man, aged 22, and thin. The temperatures taken in the mouth (usually
for five minutes), the temperature of the external air never over 66'^ Fahr.
( = i8'9°C.) ; and the skin was uniformly dry.
The following are examples :
No. I, sitting in room of 66', temperature in mouth from 10.30 — 11 p.m.
= 98'7' Fahr. (37"i° C). He then stripped, and remained nude till 11.40.
Fifteen minutes after stripping, his temperature was 99° Fahr. (37'2' C). He
then (at 11.40) covered the skin with a warm blanket, and at 11.55 the tempe-
rature was again 98-7^ Fahr. (37"2^ C).
No. Ill, same subject standing in room, the temperature of air in which was
52° Fahr. (ii-i° C), from 11 to 11.30 p.m., the temperature of mouth was
p8'75° Fahr. (37"i9° C). He then stripped, and by 11.50 p.m. his tempera-
ture = 99"5'' Fahr. (37-5° C). He went to bed at 12.2, and by 12.30 his
temperature was only 98° Fahr. (367° C).
It fell to 97-75" Fahr. (36-5= C) by 12.50 a.m.
No. V, sitting in a room (temperature of air 58' Fahr. (14" 9' C), all the
time, warmly clad till 11 p.m. Temperature in mouth = 9775° Fahr. (36-5,
C). Nude at 11.2. From 11. 15 to 11.45 p.m. the temperature varied from
99° to 99-4° Fahr. (= 37'23° to 37*45'' C.). After putting on warm flannel,
and sitting in front of fire, it fell again by 11.55, P-™-> to 9775" Fahr.
(360= C).
This author explains the facts obtained by Dr. Ogle, Sydney llinger, and
others, as to the temperature falling at night, and being lowest at from 12 —
I a.m., and then beginning to rise by the loss of heat, though going to bed,
given to cold bed-clothes, which gradually become warm, &c. [But this fall
will take place without going to bed at all, or stripping at all, and in a warm room
ON THE TEMPERATURE IN HEALTH. 97
slight, is significant in a theoretic point of view : it indicates not
only that the upborn infant has its own pro])er sources of heat, but
iilso, that widely as the foetus differs from the adult, as regards the
means of cooling, or getting rid of heat, the sum total, or final
result, is not much different from what is found in the maternal
organism. During birth (according to Biireusprung, children exhibit
an average temperature (in the rectum) of 37'75° C. (= ioo° F.
nearly) . Of thirty-seven newly born infants twenty-six had a tempera-
ture exceeding 37"5° Cent. (= 99*5° P.), and only one under 36"75°
Cent. (= 98-15° P.) ScMfer (' Greifswald Thesis,' 1 863) found the
rectal temj)erature of new-born children_, before the division of the
funi^ in twenty-three cases, higher than the vaginal temperature
of the mother in sixteen cases, and lower in only two cases ; and
the average temperature of these cases was 37*8° C. (1 00-04° ^O
with an average temperature of 37*5° C. (99'5° F.) in the maternal
vagina. (See also Wiirster, Berlin. Klinische Wochenschr^ 1869,
No. 37.)
Soon after birth, especially after the first ablutions, infants lose
on an average from 7 to '8 of a degree Centigrade (= i'26° to
1*44° Fahr.) ; and exhibit an average temperature of 37° C.
(= 98-6° Fahr.) Of twenty-two new-born children, there were
only three whose temperature was above 37*5° C. (99*5° F.), and
eight of them were under 3675° C. (98* 15° F.), according to
BarenspruDg. In the next ten days the rectum temperature again
rises somewhat, and pretty constantly remains between 37*25 C.
or a cold one indifferently almost; also iu summer or winter, as I have often found
by experiment, — which is confirmed by a number of observers.
Drs. Sydney Ringer and the late Andrew Patrick Stuart ('Proceedings of
the Royal Society,' vol. xvii, No. 109, p. 287), have drawn the following con-
clusions as to the temperature in health. " The average maximum temperature
of the day in persons under 25 years of age is 99" 1° I'ahr. (= 37-3° C.) ; of
those over 40, 98"8° Pahr. (37'i° C). The highest daily point =: 9 a.m. until
6 p.m. About this time it slowly and continuously falls, till between 11 p.m.
and I a.m. it again rises, and reaches nearly its highest point by 9 a.m. The
diurnal variation in persons under 25 equals about 2"2° Pahr. (i"2'' C.) In
persons between 40 and 50 it is very small, the average being not greater than
o'87° Pahr. ( = f ° C. nearly), or on some days no variation whatever occurs.
In young persons the diurnal fall occurs at night, in older persons at any
hour. They do not believe in the iniluence of food as causing diurnal varia-
tions. Nor do hot or cold baths, although at the time the former may i-educe
the temperature to 88'" Fahr. (31 '1° C), and the latter inciease it to 103^ or
104' Pahr. (39-5° to 40° C.).— [Tkans.]
7
98 ON THE TEMl'KRATUllE IN HEALTH.
(99-05° F.) and 37-6° C. (99-68° E.). or ^ trifle higher than that of
grown-up people. Prom the sixth to the eighth day after birth, it
is very common to meet with temperatures even a httle higher than
this. (See also Furster in the 'Journal fiir Kinder-Kr./ 1862).
Besides this, the variations of iemperature met with in different
observations, made at various times on newly horn children, are
much greater than those met with in observations made on adults.
Even the act of crying will cause a rise of temperature. New-born
infants very commonly show an evening rise of -i- a degree Centigrade
(= -9° Fahr.), and a still greater elevation at noon. In apparently
healthy new-born infants, although but rarely, we sometimes meet
with elevations of temperature amounting to as much as 2° C
(3-6° Fahr.), which are not found in healthy adults. This may
be explained either by supposing that they exhibit less constancy of
temperature than adults, or that they are subject to disturbances
of health which are more easily overlooked {i.e. less easily dia-
gnosed) .
Throughout childhood the same mobility of temperature may be
recognised.
Br. Fmlaijson ('On the Normal Temperature of Children/ 1869)
remarks that the daily fluctuations of temperature in children are
greater than in adults.^ As the age increases, there is but little
1 Dr. Einlayson places this daily range at from 2°— 3°F. (= I'l' — 1"6° C).
He lays especial stress on a fall of temperature in the evemng,as always occurring
in healthy children, amounting to 1°, 2°, or 3°r. (= -9°, r8°,and 2-7° C.); and
states that this usually commences about 5 p.m., but is most strikingly seen
between 7 and 9 p.m.— it often begins at 5 p.m. and continues till after mid-
night. The minimum temperature in children is usually reached at or before
2 a.m. ; between 2 and 4 a.m., whilst still sleeping soundly, it begins to rise, and
fluctuates between 9 a.m. aud 5 p.m., but only slightly. The observatious of
M. Eenri Roger on newly born infants and young children, agree in the main
with those of Bdrensprung given in the text. Thus, at the moment of birth, he
found the temperature from \° to 1° C. (= -9° to rS" F.) ahove that of the
mother [axilla). The mean of 33 new-born children (1—7 days after birth)
was 37-08° C. (= 98-75 F.) ; in 13 children from 4 months to 6 years, a mean of
37-21° C. (= 98-97° F.), and in 12 cases varying from 6 to 14 years, a mean of
37-31° C. (= 99.15° F.)."—^/'c///y. General, vol. v. Series 4, p. 293.
" Br. Flnlayson found a mean of 99-41° F. (37-4° C. nearly) in 21 cliildren under
6 years, the temperature being taken in the rectum between 7.30 and 9 a.m.,
before breakfast. Dr. Cassel's average = 97-75° to 97-47° ^- at an earlier
hour." — Glasgow Med. Journ.^ Feb., 1867.
See also an interesting paper by Dr. William Squire, on " Infantile Tempera-
I
ON THE TEMPERATURE IN HEALTH. 99
appreciable difference between the temperature of healthy indivi-
duals— the most that we can say being, that the average temperature
falls one or two tenths of a degree Centigrade ('2 — '4° P. nearly),
from early infancy to puberty, and from j)uberty to fifty or sixty
years of age, in about the same proportion ; but about the sixtieth
year it begins to rise again, and notably about the eightieth year the
mean temperature approaches that of infancy. This relatively h'ujli
temperature of the aged, is a very remarkable circumstance, when we
take into consideration the varieties (not inconsiderable in them-
selves) of respiration, of tissue changes, of the quantity of carbonic
acid exhaled, and the traditional notions (Vorstellungen) as to the
degree of vitality (Lebensactivitut) belonging to this period of life.
This may perhaps depend on diminished loss of heat from the skin^
on account of this being less supplied with blood (mehr anamischen
BeschafFenheit). See JDr, John Bavy on the ' Temperature of very
Aged Persons ' ('Philosophical Transactions,'' 1844, p. 59).
§ 10. The Influence of 8ex. — No noticeable difference of tempera-
ture can be ascribed to sex. It may be that grown up women are a
trifle warmer than men of an equal age ; but the number of observa-
tions is insufficient to enable us to lay down a safe general rule on
this point. However Davy arrived at an opposite conclusion, from
a very small number of facts ('Medical Times,' v. 24, Sept., 1864).
[Dr. Ogle's continuous observations of a single case, in the day-
time only {i.e. from 9 a.m. to 12 midnight), made hi the summer
months, confirm Wunderhch as to a slightly higher temperature in the
female, never exceeding ^° P. (= "45° C.) (' St. George's Hospital
Reports,' vol. i.) — [Trans.]
§ II. Influence of Mace, Station in Life, and Occupation. —
Livingstone ('Travels in South Africa,' p. 509) has observed that the
temperature of Africans was 3° P. (= i"8° C.) less than his own.
On the other hand Thomsen (' Ueber Krankheiten und Kraukheits-
verhaltnisse auf Island und den Paroerinseln,' p. 24) makes the
temperature of the Icelanders somewhat higher (on an average
37-2° C. (= 98-96° P.) under the tongue).
There are scarcely any facts, up to the present time, which
justify us in ascribing any differences in temperature to the situation
ture in Health and Disease," in the ' Transactions of the Obstetrical Society/
vol. X, p. 274.
100 ON TIIK TEMPBRATUllE IN HEALTH.
in lilV, as, for example, to the diircrence between the jioor aud the
Mell-to-do, notwithstanding tlieir dillercnt diet.
lu the same way different occupations, so long as health is not
impaired, appear to be entirely without iiilluence on temperature.
Consequently we must conclude that the almost certain difference
in the amount of \\Qni producediw differing circumstances of life, is
compensated in health, by a corresponding difference in the amount
of heat given off.
§ 12. Individual Peculiarities, or Idiosyncrasies. — Apart from
age, sex, race, and all accidental modes of hfe, and incidental influ-
ences, it appears that the mean (average) temperature of healthy
persons is not absolutely identical in every individual. In this point
of view observations in sufficient numbers of absolutely healthy
people are wanting. But if I may be allowed to draw any conclu-
sions from the circumstances of those who have been ill, but have
perfectly recovered, all living under similar circumstances, as for
example^ all in the same ward of a hospital, and taking the same
diet, &c. I must conclude that the mean temperature of different
individuals is not absolutely identical, and indeed may vary from
^6'^° C. (977° P.) to 37-25° C. (99-05° F.) I have not been able
to associate this somewhat considerable difi'erence of average tempera-
ture in various individuals with any other special peculiarity of con-
stitution, or habit of body. But it is of some practical importance to
remember, that we may not make the mistake of ascribing what
may be only an idiosyncrasy^, to a continuous, or latent pathological
condition. In experiments on animals, still greater differences of
temperatures have been noticed, between individual animals of the
same kind, than occur in the human subject.
§ 73. The Daily Fluctuations of Tem/perature in the Healthy. —
The temperature varies a little even in healthy persons, according
to the time of day. Many observers have directed their attention to
the fluctuations of temperature, occurring in the healthy, during the
course of a day. According to Lichienfels and Frohlich (loc. cit.)
these amount, on an average, to scarcely half a degree Centigrade
{= -9° Tahr.) They state that the loioest temperatures occur in
the night between 10 p.m. aud i a.m., and in the morniug hours,
between 6 and 8 a.m. ; the highest temperature occurs between
4 and 5 o'clock in the afternoon.
ON THE TEMPERATURE IN HEALTH.
101
According to Damroscli ('Deutsche Klinik/ 1853, p. 317) the
temperature rises in the morning from 7 to 10 o'clock, about ^° C.
(•9° F.); falls till' I pirn, about J/ to t\° C. (-2°— -4° ^- nearly).
From thence till 5 p.m. it rises from -f/ to tI° C. (= -4° to -6° T.
nearly), and then falls again till 7 p.m. by about -fV° ^o -j%° C.
(= -6° — '9° E.) Occasionally the afternoon fall is absent. The
morning elevation of temperature (7 to 10 a.m.) and the evening
fall (from 5 to 7 p.m.) are the most constant. The temperature
at 7 in the evening is sometimes the same, sometimes lower than
that of the same hour in the morning.
According to Ogle {' St. George^s Hospital Reports,' 1866, i, 221)
the temperature is lowest about 6 a.m., and then a rise begins,
which continues till late in the afternoon. This rise and fall is
independent of sleep.
Jilrgensen (in the 'D. Archiv fiir Klin. Med.,' 1867, iii, 165) says
that the daily marimum occurred between 4 and 9 p.m. ; the daily
minimum between 2 and 8 a.m.^
> As Dr. Ogle's observations were continued for many months, and appear
to liave been exceedingly carefully made, the chief results obtained have beeu
tabulated, as follows :
Time of day.
Male.
Female.
9 — II a.m. ; before
breakfast.
II a.m. — 2 p.m.
3 p.m. — 5 p.m.; lunch
at 3 p.m.
Time of day.
97'73
98-2°
98'36=
6.30 p.m.— 7.30 p.m. ; 1 98-63°
dinner at 7 p.m.
9 p.m.— 10 p.m.
98-
12 p.m. — 12.30 p.m. 97*96"
98-
98-56°
9875^
98-6°
98-45°
98-°
12.30 a.m. — I a.m.;
bed at i a.m.
3 a.m. — 5 a.m.
5.30 a.m. — 6.30 a.m.
8 a.m. — 9 a.m.
Male.
Female.
97'9°
-..J
fcn
.^
i-»
3
'TS
97-5°
G
a -
~ tn
c^ ":^
a "
0
97-2-
03
>
f-(
<U
OT
rQ
0
97-66°
0
^
The temperatures were taken under the iovgue. The day observations in
summer. The nigJd in winter. The numbers given in the table are the mecnis
of the monthly results.
Dr. Ogle finds the average variation to be \^ Fahr. (= |° Centigrade.) He
found the minimum = 97° F. (36'i°C.) at 5.30 a.m. on a winter's morning,
and the maximum ioo-6° F. (=■ 38-25° C.) in a Turkish batii, a variation of 3 J° F.
(= i'94°C.) He found the morning rise 7iot to be due to the temperature of
lO?. ON THE TEMPKRATUKE IN HEALTH.
§ 14. — Itijhioice of menstruation y of pregna)ic]), and of tlte puer-
peral state (Wochenbett) upon temperature. Normal menstruation,
ill healthy women, according to the observations of all trustworthy
observers (which agree with what I myself have found to be true), is,
as a rule, without any influence at all upon the general temperature of
the body. On the other hand, we sometimes find elevations of
temperature during the flow of the catameuia, which cannot be con-
sidered as anvthincc but decidedlv febrile, and which are sometimes
accompanied with other functional disturbances, and sometimes not,
without any special pathological process being either indicated or
induced (sich anschlosse) .^
Pregnancy has next to no influence (so gut wie keinen) on the
bodily temperature. Only during the last two months the vaginal
temperature appears to be slightly elevated : the morniwi mean
being 38-15° C. (100-5° F.), ^^^ minimum 37-9° C. (100-3° F.), and
the maximum 38-35° C. (100-9° P.) ; whilst the evening mean is
38-22° C. (ioo-8°r.),the minimum 38-i°C (100-5° I"-), tte maxi-
mum 38-65° C. (101-5° 1\).
Schroder {' Virchow^s Archiv,^ xxv, 253) estimates that the tem-
perature of the gravid uterus is about -3° C. (4-° Fahr. nearly)
higher than that of the axilla, and on an average about -15° C. (^°
Fahr. nearly) warmer than the vagina, which is doubtless independent
of the warmth of the foetus.
Immediately before the beginning of the labour pains, no eleva-
tbe room, but coincident with increased CO^ exhaled, and urea excreted (see
Dr. E. Smith's Paper, in 'Proceedings of Royal Society,' 3olhMay, 1861). It
was not due to light.
General conclu&mis. — Miniimtm at 6 a.m. Maximum late in afternoon. A
rise produced by both food and exercise. Tea retards the fall. Alcoliol causes
a fall, but probably the reaction reaches a higher temperature than if no alcohol
were taken. — [Trans.]
^ In young women, otherwise healthy, who suffer from dysmenorrhcea, or
sometimes in the T^rs^ menstruation, I have often found swelling, redness and
pain in the fauces and tonsils, with temperatures of 103^ 104°, and 105'^ P.
(=39 '5, 40^, and40'6"j, with extreme depression, restlessness, perhaps semi-
delirium, and occasionally vomiting, without being able to trace any scarlatinal
or other febrile poison. These cases differ from scarlatina in their sudden onset,
their equally sudden recovery (being well as soon as the catamenial flow ceases,
or \5 fully established), and their having no desquamation of the cuticle, or other
sequelae. The sympathy between the tonsils and the generative organs has been
known from great antiquity, but I do not know that this pseudo-amygdalitis
has ever been described before. — [Trans.]
ON THE TEMPERATURE IN HEALTH. 103
tion of temperature is noticed. During the pains there occurs a rise
of some tenths (Centigrade) 'a to '25 (i to -^ Pahr. nearly), in
such a way that ih the pains^ and immediately after, the temperature
rises somewhat ; and in the pauses hetioeen the pains it falls again.
However, the daily healthy fluctuation is not much affected by
labour. The temperature during labour exhibits a mean rise of
•18° C. (4-°r.) in the morning hours, and -250. (t"/ F.) in the
evening hours, as compared with the preceding period, and in the
second stage of labour about '07° {-^ 1\) above the temperature of
the first stage. According to Hecker, the elevation of the tempera-
ture is proportionate to the intensity of the pains, and the quick-
ness with which they succeed one another. However, his materials
afford too scanty data to settle this point.
Schroder found that during labour the excess of the uterine tem-
perature over the axillary and vaginal was somewhat greater than in
pregnancy: "83° C. (= i'49° I".) more than in the axilla, and
•175° C. ("32° r ) more than in the vagina. In a later work
he considers thf temperature of women in labour to be very
changeable, and expresses a strong opinion that this chiefly depends
upon the amount of heat lost in various ways being more or less.
Immediately after deliver?/ a fall of temperature has been observed
by Barensprung, even as low as 36*2 C. (= g'j'16'^ F.), and on an
average about 37*1° C (98"78° F.) and, indeed, especially when
the birth happened between midnight and mid-day ; while Witickel
has onlv verified this fall in those cases where the birth fell within
the time of the daily remission.
Schroder found the lowest temperature in those who had given
birth to children at eleven in the morning.
In the first twelve hours after delivery Winchel found a moderate
rise, in the second period of twelve hours a corresponding fall.
The average minimum of the normal lying-in period is estimated
by Griinewaldt at 37° (98-6° P.). Amongst 57 lying-in women
he found temperatures of 36*6° C. (97'8° F.) three times, of 36"8°C.
(98*24° F.) nine times, and of 37° C. (98'6° F.), or more, forty-five
times. The maximum temperatures often exceeded 38° C. (ioo"4°F.)
especially in cases of constipation, and when there was distension of
the mammary "lands, but the above-named observer considers that all
temperatures above 30-2 E. (= 100° Fahr. or 37-8 Cent.) in lying-
in women are very suspicious. Schroder points out that lying-in
women, even when they have subsequent puerperal mischief, may
104 ox THE TKMrERATURK IN HEALTH.
exhibit a perfectly normal temperature in the first period {i.e., a few-
hours after the birth).
lie further remarks that the course taken by the temperature
after delivery is composed of two factors; on the one hand, of the
regular daily iluctuatiou (a rise towards 5 p.m., a fall from then till
I a.m.), on the other hand of the rise induced by the process of
labour in the first twelve hours, and the fall in the second period of
twelve hours. On this account the course or curve of the tempera-
ture will vary with the hour at which birth occurs, so that if the
birth happens in the forenoon, the temperature will reacli its highest
point from 5 to 8 p.m. ; the lowest about midnight, when the birth
has fallen within the early morning hours, because, in the first
instance, the daily rise and the first puerperal elevation, in the latter
case the daily fall and the first puerperal diminution coincide.
IFincl-el further propounds that at the end of the first four hours,
after the beginning of the fall of temperature, the temperature begins
to rise slowly again, and the evening temperature is on this account
commonly higher than the morning, but the daily excursus (or amount
of variation) less, so that as a rule the rise of temperature keeps
pace with the secretion of milk, and on this account is most evident
on the third, fourth, or fifth day, and that as soon as the draught
or flow of milk is established : or, if the mother does not suckle,
with the drying up of the milk a gradual decrease of temperature
is noticeable; further, that nursing women^ and those who do not
suckle, primiparce and multiparas do not differ from one another
as regards their temperature, and that normal after-pains are with-
out any influence at all ! Lastly, that the mean temperature of
puerperal women is a trifle higher than the average normal tempera-
ture of other healthy women.
In so far, however, as the puerperal state is admitted to exhibit a
great mobility of temperature, it must be considered as belonging
to pathology. However, according to Winclcel, the differences between
the axillary and vaginal temperatures in lying-in-women are wholly
without parallel, even in cases of disease of the uterus or vagina.
Schroder found that in puerperal women the difference between the
temperature of the uterus, as compared with the axillary and vaginal
temperatures, amounted to only '28° C. ("5° P.) above the axillary,
and "11° C. ('19° C.) more than the vaginal.
See also besides Earensprung the following authors on the tem-
perature in pregnancy, labour, and the puerperal state — llecker.
Ox\ THE TEMPERATURE IN HEALTH. 105
' Annalen des Charite-Krankenliauses/ 1 854, p. 333 ; Wind-el,
"Temperatur Studien bei der Geburt und im Wochenbctt ^^ (in the
' IMonatsschrift fi,ir'Geburtskunde/ 1862^ Bd. 30, p. 409, and 1863,
Bd. 22, p. 321) ; Griinewaldt, "Uber die Eigenwiirme Gesunder
und Kranker Wochnerinnen/^ in the ^ Petersburg Med. Zeitung/
1863, Bd. 5. p. I ; ''Oscar IFoIf, " Beitriige zur Kenutnisz der
Eigenwarme im "Wochenbett," Marburg Thesis, 1866; Baum-
/elder, " Beitrag zu den Beobachtungen der Korperwarme, der
Puis und Respirations, frequenz im Wochenbette/' Leipzig Thesis,
1867; Schroder (loc. cit., and especially in ' Schwangerschaft,
Geburt, und Wochenbett/ 1867, p. 117; Squire, in the 'Lancet/
1867, No. 10, and in the 'Obstetrical Transactions/ vol. ix,
p. 129.^
§ 15. — The Influence of Rest, of Muscular Activity, and of Worh
(Arbeit) upon the Temperature,
The contrast between movement and rest, as regards their respec-
tive influence upon temperature, is by no means a simple fact, nor
can it be elucidated by a bare recital of facts.
It has been shown by Helmholtz that the contraction of a muscle
is accompanied by a rise of temperature, and in later times especially,
Solger, Ileidenhain, Meirstein, and Thiry have investigated it, and
found, amongst other results, that in the flrst moment of stimula-
tion the muscle itself actually becomes a little colder (negative
warmth- variation, afterwards contradicted by Heidenhain) , and then
begins to grow warmer, but that the degree of warmth generated is
never entirely proportionate to the mechanical work done; and,
' Dr. Squire's temperatures were taken in the vagina. After the sixth
month of pregnancy he finds the temperature to be a little over 99° F.
(=37-3"C.).
He considers the vaginal temperature and the axillary to differ by only
i° or i° except during labour. He found the temperature to gradually rise till
the birth of the child, and soon after to slowly decline during the 24 hours
after, to normal, or even below it. The most constant disturbance ushers
in, and accompanies the formation of milk — it attains a certain prominence
48 hours after delivery. As soon as milk flows freely there is a considerable
fall.
He objects to the axilla as not furnishing trustworthy details after labour.
It is probable that he omitted to dose the axilla previousli/, as recommended
by Wunderlich. The whole paper, however, is well worthy of study. —
[Trans.]
lOG ON THE TEMPERATURK IX HEALTH.
further, that the muscle when stimidafed develops more heat, if its
contraction be hindered (or resisted) than when this is not done,
and that with equal weiglits, the lieat developed by continuous con-
tractions decreases as the muscle gets " tired out," and this more
quickly than the mechanical results would lead us to suppose, and
that by increasing the weight the heat increases up to a certain
point, and then decreases again.
According to the theory of J. R. Mayer, we must admit that
during rest the chemical affinities (spannkriifte) or combining
forces, which are set free through the combination of oxidisable
substances with oxygen, are perfectly changed into heat, whilst
during work of any kind, some part of these summed-up forces
are translated into mechanical results by means of them. There-
fore, during rest, the heat produced should be greater, to which
must be added that the loss of heat by respiration, and transpira-
tion, is also less during rest. Indeed, Mayer quotes from Bouville,
the fact that the latter found a temperature of 40*2° C. (io4"36° F.)
in a negro, who lay lazily basking in the sun, Avhilst the temperature
of the same man, when hard at work in the sun, was only 3975° C
(io2'88°F.). AA'hilst, however, during active bodily work, a part of
the force set free by chemical processes, is so far lost, as regards
the production of heat, by being changed into mechanical results,
and producing motion; so, on the other hand, there is a simultaneous
diminution of the amount of tissue-changes, the amount of oxygen
is increased by the quickening of respiration, and by the more rapid
circulation of the blood, the number of blood-discs brought within
the range of the oxygen in a given time is increased, as well as
the chemical action, on which the warmth-production depends, more
complete and more rapid, and indeed the increased production is
not entirely compensated by the conversion of a part of the total
force into mechanical results ; but the force generated or liberated
by the action of the muscles, through the coincident increased
chemical action is doubtless in general greater than that consumed
by conversion into work done (Arbeit). In addition to the
mechanical results there is therefore an overplus of warmth. Ilini,
whilst at rest, produced 155 calorien (or heat-units) per hour, and
251 whdst working in the treadmill. But a long series of con-
trivances carries off the overplus of heat in a healthy man. This
is effected by more rapid breathing, quicker circulation of the blood
through the skin, and therefore quicker cooling there, and by sweat-
ON THE TEMPERATURE IN HEALTH. 107
ing, &c. And so it comes to pass that the opposing conditions of
the loss of force (kraft-summe) by mechanical work, and by quicker
cooling, and, On the other hand, the overplus through augmented
chemical action, is compensated in health, so that the final diference
of temperature during rest and during labour is extremelij trifling,
John Davy made numerous direct experiments on the effects of
bodily movements upon the temperature. He found, after active
exertion, under widely differing circumstances, that the temperature
under the tongue was between 987° F. and 99*4° P. (37° and
37 "5° C.) j whilst in travelling in a conveyance (in wagen) the
temperature remained between 97° and 97"7° F. ( = 36° and
36-5° C). In tropical climates, after active exercise, the tempera-
ture sometimes rose still higher, whilst in travelling in a waggon
the minimum reached was almost the same, and, on the other liand,
reached a maximum on one occasion of 997° F. (37*6° C).
Breschet and Becqtcerel [loc. cit.) found by means of the thermo-
electric apparatus, that the elevation of temperature in the working
muscle, after 5 minutes^ work, was about 1° C. (i'8° F.) In
Sjjeck's experiments (1863 ' Archiv des Vereins flir WissenschaftL
Heilkunde') it appeared that during strenuous continued muscular
action the ten:iperature of the body rose somewhat. From the con-
siderable increase of the elimination of carbonic acid, one might
expect to see the body produce considerably more heat.
The sudden fall of temperature with cessation from exertion
proves, also, how instantaneously the equalisation of the general
temperature occurs ("dasz die Momente zur Ausgleichung der
Korpertemperatur rasch und intensiv wirkten.'''') A moment ago,
the body was, so to speak, taken by surprise, but how soon the
cooling processes have brought back its normal temperature, or even
reduced it below the normal. In a few other experiments, in which
there was no perspiration during the exercise, there was but little
elevation of temperature, and the maximum degree of heat occurred
in those trials in which there was most sweating.
According to Kernig ("Experim. Beitriige," p. 41), the tempe-
rature in the axilla, when quietly lying down, was less by a few
tenths of a degree (Centigrade) than it had been before, or was after
in the erect or sitting posture.
Oheruier has lately (' Der Hitzschlag.,' p. 80, published in
1867) made experiments on the influence of bodily exercise upon
temperature. Marching for 30 to ^^ minutes raised the tempe-
lOS 0\ THE Tr.MPI'.RATUHK IN UKAl/lH.
raturc about half a degree C. (= "9° ¥.) or less, wliilsl (lie pulse, one
case excepted, when there was no effect produced, was much more
strikingly allectcd — rising from 20 to 44 beats. A " quick niarch'^
of ItV hour raised the temperature 1° to i*a° C. (1*8° to 3-16° ¥.),
(the pulse 30 to 48 beats). An observation made at the same time
in a pedestrian, in which after a very fast walk of i hour, a tempe-
rature of 3Q'6°C. (= 103*28° r.), was observed ought not properly
to be placed with the effects of muscular exertion on the temperature
of the healthy, since this performer exhibited other evident signs of
imperfect health. According to Mayer's theory, when muscular con-
traction brings about a mechanical result, it rather diminishes the pro-
duction of heat by tissue changes (erhiilt eine Abzugs-quelle) . Beciard
has confirmed this ingenious proposition by actual observations.
He found {" de la contraction musculairc dans scs rapports avec la
temperature normale,'' in 'Arch. Gen.^ 1861, xvii, p. 21 — 40, 157 —
180, and 257 — 279) that the amount of heat generated by muscular
contraction is greater when the muscle contracts statically; that is,
independently of mechanical work, than if the contraction produced
a mechanical result (travail raecanique utile) ; and further, that the
amount of heat which escapes (verschwiudet) from a muscle in a
mechanical effort, is in direct proportion to the mechanical effect (or
work done) ; and he arrives at this further conclusion, that the
products of muscular contracfnon, i. e., the heat, and the mechanical
results, are conjointly the expression or equivalent of the chemical
action which goes on in the muscle.
Liebermeister denies that voluntary changes in the depth and
frequency of the respirations have any influence on the temperature
(' Eeichert's Archiv.,' 1862, p. 66i)}
§ 16. — The influence of mental exertion on the temperature is
even less than that of bodily exercise. According to Dr. JoJni Davei/,
the temperature during mental exertion in northern climates reached
a height of only 98° to 987° F. [= ^6-6° and 37° C.) ; while on the
other hand, under similar circumstances in tropical climates, the
temperature reached a much greater elevation, as much as 98' 1° to
104° F. (=367° to 38° C).
According to Lombard ("Experiments on the Relation of Heat to
Mental Work" [s], Anal, in 'Archiv. de la Physiologic,^ I, 670),
^ That the temperature is momentarily affected in this way, is, liowever,
readily shown by a delicate thermometer. — [Tkans.]
ON THE TEMPERATURE IN HEALTH. 109
(luring a state of mental repose (Ruhe), the fluctuations of tem-
perature were frequent, although inconsiderable (-01° C = -18 or
i°E. nearly).-' ^^verything which excites the attention causes a
slight rise. Very active mental exertion causes the temperature to
rise from a quarter to half a degree Centigrade ( = 7/77° — -^f
Tahr.)
Sleep, in itself, so far as is known, has no influence on the tem-
perature of healthy people ; in other words, production and loss of
heat preserve their mutual relations even in sleep.
§ 17. Thermal influences, and the effects of air, ivaler, and
moishire. The influence of external cold and heat on the tempera-
ture of the healthy body, simple as it may appear, really offers for
the most part a complicated problem for our investigation, and we
must separate the accompanying influences from one another, before
we can rightly estimate the results of experiments. For, generally,
it is not simply heat and cold which affect the organism, but they
are connected with a medium, the simultaneous working of
which must not be overlooked. With regard to hot and cold baths,
the influence of the water in cold or warm atmospheres, their dry-
ness, or the degree of their moisture, their movement, and their
(barometric) pressure ; in cold and warm drinks, the water and the
other constituents of the solution must be taken into account, and it
is not always easy to accurately determine how much is due to the
thermal influences, and. how much to collateral circumstances.
But, setting all these aside, there is much to be considered as
regards the effects of cold and warm applications only. Their results
are, indeed, far from simple ; they are manifold and complicated.
The phenomena of thermal influences are not only complex, but
appear in succession.
The first phj/sical effect, the direct and immediate operation of
cold, is to abstract heat and to cool, whilst the effect of higher
degrees of heat is to hinder cooling, or indeed to impart heat.
Accordingly the temperature of the body may be lowered by cold,
and raised by heat.
But in close conjunction with the immediate physical effect, is a
simultaneously operating physiological one, which produces conse-
quences more or less opposite to the former.
The impression made by cold brings about a constriction of the
minute vessels of the skin, through which they become partially
110 ON THE TEMTERATUKK TN HEALTH.
emptied of tlicir blooil ; in tl\is way the cooling of the blood, wliicli
now circulates less through the superficial parts of the body, is
hindered, and in this way the direct cooling operation of the out-
ward cold on the general temperature of the body is considerably
diminished. The oj)eration of external warmth, on the other hand,
is followed by dilatation of the blood-vessels (of the skin) by which,
as long as the external heat is less than that of the blood, the
cooling of the blood, and thus of the whole body is promoted. More-
over, by the influence of warmth, the secretions of the skin, and the
evaporation of water is promoted — another powerful method of
cooling.
And indeed any remaining overplus of cooling by the operation
of [external] cold is soon compensated, so long as the organism
retains its normal condition or anything approaching to it, by an
increased production of heat, whilst in reduced or diminished cooling
the production of heat is lessened.
Every diminution or elevation of temperature which momentarily
occurs through thermal applications, is therefore only transient, and
and is speedily neutralized by the altered warmth-production. It
does not follow that there is an immediate restoration of the status
quo ante, more often the increased production of heat, which follows
an artificial coohng, is greater than necessary [for mere compensa-
tion], and therefore the depression of temperature is followed by
increased heat. And when artificial means have been made use of
to limit the loss of warmth, the production of heat generally becomes
less in amount than is necessary to restore an equilibrium of tem-
perature, and so it may easily happen that a fall succeeds the
elevated temperature induced by the influence of higher degrees of
external heat. Thus, for example, a high temperature (of the body)
commoidy follows a cold bath, and after a warm bath on the other
hand increased coolness is noticed, and in tropical countries, and
very hot seasons, no means of cooling is so lasting as a bath, or a
douche ^Uebergiessung) of very warm water. This secondary efi'ect
(lit. back-stroke-working) is indeed partly compensated by the fact
that the cutaneous blood-vessels are dilated by the reaction after
the cold, and thus favour the giving off of the overplus of heat
which exists; but comparatively insignificant circumstances may
assist either the one effect or its opposite, and thus suffice to induce
disturbed action. The effect may be more or \qss joermaneyit, although
very healthy individuals, gifted with the power of resistance, may
ON THE TEiMPERATURE IN HEALTH. Ill
not show it, because their temperature still remains normal, whilst
under opposite circ^imstances the effect would be evident in further
deviation from normal temperature. Still further differences arise
from the fact that the influence of thermal operations differs much
according to the place of application (parts to which hot or cold
water, ice, or poultices, &c., are applied), but extends from that to
subjacent and neigJihourinr/ parts, and then to the tvhole organism,
and the parts remotest from the place of application; and as
commonly these operations on the different parts are not exactly
similar, the combinations will be very numerous [i.e. the factors
combining to produce the sum total will be many, and thus the
operation of thermal application is complex] .
Lastly, we must notice that individual constituiion (Dispositionen
des Individuums) of the subjects of thermal experiments must not
be left out of consideration, or indeed in estimating the effects of
other external influences. It is true that there is more diversity of
constitution apparent amongst sick people, but still the influence of
'constitution (Diathesis) makes itself evident even in health, and as this
occurs in regard to the direct or primary operation of thermal
influences (baths, &c.), it does so still more as regards their secondary
operation.
If moist air, or a solution is the vehicle (der Trager) of the
thermal influences, the circumstances are still more complicated.
Solutions of low temperature, or moist air, in contact with the surface
of the body, abstract warmth from it far more than dry, cold air
does, and their cooling effects are far more evident than those of
the latter — and the secondary (opposite) effects may be still more
considerable. Further, very much depends on the duration of the
[thermal] influence on application on its remaining the same, or
changing, and on the cooling medium being in a state of repose,
or motion. In this way the results as affecting the temperature of
the body may be much modified in various ways.
All these things go to prove that the effects of thermal influences
are by no means so simple as they might at first sight appear.
This consideration affords a key to the numerous contradictions
met with in the results of different observers, and also serves to
indicate that one should hesitate, before formulating as laws, the
results of even careful observations on man, or on animals, chosen
for experiment.
A few of the more important observations on the effects of
112 ON THE TEMl'EUATUllE IN HEALTH.
heat and cold are adduced here more as exam])lcs of what lias been
done than as exhausting the subject.
As regards the outward application of cold water, for instance,
Fleuri/ found the temperature in a cold bath sink to 34°, or even
29° Centigrade (= 93'2° or 84-2 Fahr.) Speck (in the Archiv fiir
gemeinschaftliche ArheiteU; i860, p. 422) found at the beginning of
the application of a cold shower bath a slight rise of temperature,
but after to minutes' continuance of the bath (at 22°C.= 7i'6° E.)
there was a decrease in the temperature of the mouth of about
i"23° C. (= 2*2° F.) Liebermeister has made the most painstaking
investigations and observations on the influence of baths. lie
found that as regards the influence of cold water on the surface of
the body of a healthy man, the other conditions of whose life were
normal, that during a moderate length of exposure to this influence,
the temperature in the well-closed axilla never sank at all. This
resulted from the increased warmth-production. In a bath of
20° — 23° C (= 68° — 73° r.) the production of heat was three or
four times more than usual; in a bath of 30° C. (86° F.) double the
ordinary mean product. In a bath at blood-heat the warmth-pro-
duction is very slightly more than usual. Kernig has made very
extended experiments on the production of warmth in baths of 257°
to 36° C. (78-26° to 96-8° F.) and comes to the conclusion, that
the more heat is lost (the colder the bath) the greater is the amount
of heat generated [in the body], and vice verm (Experimentalle
Bcitriige zur Kenntniss der Warmeregulirung beim Menschen, 1864,
p. 169). Schuster, of Aix-la-chapelle (in the ' Deutsche Klinik,' 1846,
I\o. 22) found in some trials with baths at 37*6 to 41° (= 997 to
io5"8° F.) made on himself and an assistant, that during the baths
the rectum temperature rose considerably. He published further
observations in Yirchow's 'Archiv,' 1868, xliii, 60.
On the other hand the cooling influence of baths on completely
exposed parts of the body (nose, forehead, hands, and feet) is much
more considerable, and may amount to 6° or 7° C. (= to"8 to i2'6°
Fahr.), and, indeed, TJiolozan and Broivn-Sequard ('Journal de
Physiologic,' J., p. 497) found that one hand immersed in water of
alow temperature lost in a few (3 — 17 minutes) from 10 — 18° of
heat (C. = 18° — 34° Fahr.), and that it required far longer time to
regain the lost heat (for 3 minutes' immersion 38 minutes, for
10 minutes' immersion in ice-cold water more than an hour); and
on the other hand that the influence of this lowering of [local]
ON THE TEMPERATURE IN HEALTH. 113
temperature is quite unnoticeable as regards the general temperature,
andj indeed, sometimes seemed to raise that ; but that the hand
which remained' ifree in the air generally became cooler, in propor-
tion as the impression of the cold on the hand immersed became
painful. Bilrensprung has shown that running water abstracts more
heat from the body than water at rest, and that wet clothes, fluttered
by the wind, produce the greatest amount of cooling. Ho])pe
(Virchow's 'Archiv,-' xi, 462) observed that moisture diminishes
warmth production, by hindering evaporation, and that on the other
hand, a loss of heat excites fresh production. He found further,
that in a dog who was set in a strong current of air of 60° — 70° C.
(140° — 158° E.) the temperature in the rectum rose after ;^^ minutes
about 1° C. (1-8° P.), after 41 minutes about 2-i° C. (31° F.).
After retiring into common air, the temperature had fallen in a
quarter of an hour to its original height, after a few minutes it was
even below normal. The same fall below the normal was shown
after a warm bath; and, indeed, the temperature fell more quickly,
and to a lower level, in proportion to the height it had previously
obtained. Finally, he remarked that persistent considerable losses
of heat keep the blood temperature at its maximum, but continued
losses of heat of less amount allow it, on the contrary, to fall below
normal.
LeJimanii, BocJcer, and Kirejeff have studied the effects of local
(Sitz) baths. The latter (see Yirchow's ' Archiv,' xxii, 496) found a
slight elevation of the general temperature in a warm Sitz-bath ; after
the bath was over the temperature returned directly to its usual
height. In a cold Sitz bath the general temperature fell about 3°
(3-6° Palir.), but when the bath was over, it began to rise, over-
topped the normal, and reached, after two or three hours, its highest
point, which was 1° C. (i-8°F.) higher than the normal, and \° C.
[='(f Pahr.) higher than the maximum temperature previously
reached by the subjects of experiment on days when they did not
bathe.
Hagspiel has shown that ice-bags applied to the body lower the
temperature of the abdominal contents, and of the rectum (' Leipzig
Dissertation,' 1857). The temperature of the rectum, after an hour's
application of ice, fell from 37*25 C. (99'05 Eahr.) to 36-5° C.
(977° Eahr.), the temperature of the abdominal cavity from 37° C.
(98-6° Eahr.) to 35-25 C. (95-45° ^^ahr.).
According to Bim (' Beobachtungen zur innern Klinik,' 1865,
8
Ill ON THE TEMPERATURE IN HEALTH.
p. 159), ice-bags applied to the belly caused a rapid fall of the
mercury in a thermometer introduced bcneatli the abdominal wall,
but no alteration of the temperature in the rectum.
The effect of drinhing cold water on tlie temperature has been
investigated by Lichtenfels and Frohlich, who observed a slight
diminution of temperature, with a " Seidcl " ( = I2'4 oz. nearly)
at 18° C. [=64-4° Fahr.] after six minutes, about -,\>' C. [=1°
Fahr. nearly] ; with the same quantity at 16-3° C. [=61-3° Fahr.],
about -V° C, [ = f o-° Fahr. nearly] in the same time. Some others
also have made similar experiments, and particularly Winternitz
('Oesterr Zeitschrift fiir prakt. Heilkunde,' 1865, p. 130). In one
experiment, after the enjoyment of 6 "Seidel " ( = 3t pts. nearly)
of water at 40'48^ Fahr. (4'6° C.) at intervals of ten to fifteen
minutes, in the course of seventy minutes the temperature was
lowered about 2*5° Fahr. (1*4° C.) j but pathological symptoms
followed (tendency to vomit, eructations, &c.). In another trial (p.
168) after four "Seidel" (=2^ pts. nearly) of 67° C. (44° Fahr.)
had been drunk in divided portions, at intervals of fifteen and twenty
minutes, within one and a quarter hours, the temperature sank about
I "44° Fahr. ("8 C), eructations being again produced.
In the summer the temperature of the human body is a trifle
(about -jV to -fg.0 C.=:i to i° Fahr. nearly) higher than in winter.
In very hot summers this elevation may be still more considerable.
Johi Davy found in the transit from a hot climate to a temperate
one, with a mean difference of ii'ii° C. (=20° Fahr.) a decrease of
temperature of '88° C. (=i'58° Fahr.). Brotvn-Sequard ('Journal
de Physiologic,' ii, 551) found, in a journey from France to the Isle
of France, that eight healthy people, between seventeen and fifty-five
years, whose temperature was taken under the tongue, whilst travell-
ing in an atmospheric temperature of 8° C. (46*4° Fahr.), a mean
body temperature of q,6'6%^° C. (97*9° Fahr.). Eight days later,
with the temperature of the air at 25° C. (77° Fahr.), the body tem-
perature was 37*428'^ (99'4° Fahr.), and still further nine days later,
under the equator, with an atmospheric temperature of 29*5° C.
(=85-1° Fahr.) a mean temperature of 37*9° C. (=ioo'22° Fahr.)
was shown, and six weeks later, in 37*4° S. latitude, with the ex-
ternal air at 16° C. (=6o-8° Fahr.), the mean temperature had sunk
to 37*23° C. (=99-04° Fahr.). E//doiix and Souleyet observed rather
smaller differences (' Comptcs rendus de FAcad. des Sciences,^ 1838,
vi, 456).
ON THE TEMPERATURE IN HEALTH. 115
Johi Davy (" On the Effect of Air of Different Temperatures on
Animal Heat/' in 'Philosopli. Transact./ 1845, p. 61) has made some
observations on temperature during long continuance (aufenthalt)
in over-heated rooms, and believes that a considerable elevation is
caused by this circumstance. His data are, however, scarcely
sufficiently numerous or accurate to enable us to formulate a general
law.
The same observer made observations on temperature in Constan-
tinople at a time when the temperature of the air ranged between
31° and 94° Pahr. ( — 0*9 C. and 34*5° C), and observed differences
of temperature under the tongue, varying from 97° to 99° Fahr.
(=315 — 37 '3 C). In his treatise ("On the Temperature of Man within
tho Tropics,' ' *■ Philosophical Transactions,' 1850), he arrives at this,
amongst other conclusions, that the average temperature in tropical
climates is one degree Fahrenheit (='9 C.) higher than in temperate
regions, and that the daily fluctuations are not identical. For
further remarks on the effect of external temperature, see also the
next chapter on the causes of altered temperature in disease.^
§ 18. Variations in Atmospheric Pressii^re appear to have no
important effect upon human temperature ; which does not vary with
the changes of the barometer. Yet Fivenot (Jahrbuch der Gesell-
schaft der Aerzte zu Wien, xi, 113 — 146) found by experiments in
a chamber where the air was compressed, that tlie temperature rises
about '4° C. (—1-° Fahr. nearly) during the rising of the atmo-
splieric pressure, whilst during the maximum of pressure in the
chamber it falls again, and may finally fall to a lower degree than at
the commencement of the experiment.
^ 19. The kind and amount of Ntitritmis Material introduced
into the body, although indeed this is the chief means of warmth
production, have very slight effect upon the temperature, so long as
the body remains healthy. Beyond a doubt the very different kinds,
bulk, and amount of ingesta [taken by different persons] must
^ Dr. Ogle (in St. George's ' Hospital E.eports,' vol. i), points out that the
value of Dr. John Davy's numerous and laboriously collected observations,
scattered through the 'Philosophical Transactions' from 1845 — 50, is seriously
impaired by numerous and serious arithmetical errors — partly typograpliical,
and partly perhaps errors of calculation. For instance, the means and ave-
rages given do not correspond with the data assigned as their sources. As,
no
ON TllK TKMPKRATURE IN HEALTH.
very greatly alToct ami, inilced, determine the amount of heat pro-
duced, but manifestly this is compensated by a corresponding diller-
cnce in the amount of heat got rid of, and the balance of production
and loss is cither not at all or but slightly disturbed. In healthy
people taking a meal has only' a moderate edect on the temperature.
According to Biirensprung, after dinner, between 2 and 6 p.m., the
temperature rises, on an average about -ff C. (= i° Fahr. nearly).
But even vhen no dinner is taken, there is a rise about this time.
5«7);jtT (or an evening meal taken at 8 p.m.) is more likely to hinder
the customary fall of temperature at this time in the evening.
Ogle remarked that the normal rise (in the daily fluctuation) was
most evident after a good breakfast, less after lunch, and that the
evening dinner (or principal meal of the day) only caused a delay
in the fall which otherwise took place at this time of day.
The daily fluctuations are only slightly affected when the customary
liowcver, those published in 1863 (founded on the others) are often quoted, I
subjoin them.
Observations on Jiimselfin England August 1844, to April, 1845.
Time of day.
Temperature
under tongue.
Pulse.
Respiration.
Temperature of
Room.
Remarks.
7—8 a.m.
3-4 p.m.
12 at night.
9874°
98-52°
97-92°
57-6
55-2
54-7
156
T5"4
15-2
50-9° "
54-7°
62-°
-Dinner at 5p.m.
J
Observations in Barbadoes
, July, I
845, to November, 1848.
Time of day.
Temperature
under tongue.
Pulse.
Respiration.
Temperature of
Room.
Remarks.
6 — 7 a.m.
12 — 2 p.m.
9 — II p.m.
98-07°
98-09''
99-°
[?98775]
54-4
56-
603
i4'4
15-4
15-
76-7°
83-6°
79-°
Breakfast, 9 a.m.
Dinner with wine
at 5 p.m.
Tea, 7 p.m.
Evening temperature lower than morning in England by o-82° F.
„ „ higher „ in Barbadocs by o-93' (? 0-705°).
ON THE TEMPERATURE IN HEALTH. 117
meals are postponed. If a meal produces a different effect it may
be taken for granted that the individual in question is either not
quite healthy or under entirely normal conditions ; or that the meal
itself has a detrimental effect upon health.
Jilrgensen found, that a hearty meal taken after prolonged fasting
is likely to cause a considerable elevation of temperature (rather
more than 4-° C. = i° Fahr. nearly) ^Deutsches Arcliiv fur klin.
Med./ iii, 177. Bep-hatlon of food has no considerable effect on
the temperature, until the general health begins to suffer. According
to Lichtenfels andrrohlich, from the loth to the 15th day of fasting
the temperature fell pretty continuously with strong subjective
feelings of chilliness, about yij° — -ro° C. (="9° to i'44° ^O^ ^^^
tlien rose again spontaneously, with cessation of the chilly feelings
till about the 20th day of fasting, about -fV° C. (= VV° ^■)'
The further effects of inanition through deprivation of food, first
elucidated by Chossat fall appropriately into the pathological
department.
§ 20. Effects of ardent spirits and other luxuries (Genussmittel)
on the temperature. — In experimental trials with various kinds of
these we must not forget the simultaneous action of the higher or
lower temperature of the medium or vehicle.
According to Lichtenfels and Trolilich, the use (genuss) of beer,
containing from 3 to 4 per cent, of alcohol in quantities of a half
" maas " to a " maas " [a " maas " is the German equivalent for
our English "pot,'' and its size varies with the part of Germany
where it is found — it averages a little over a quart — but may some-
times be found to contain about half a gallon Enghsh. The measure in
the text probably means about 50 oz. (2-^ pints)] lowered the tempera-
ture about -A- a degree Centigrade (= "9° Eahr.) in not more than a
quarter of an hour's time, and it remained thus low for i^ hour.
In the same way wine and brandy have a lowering effect upon the
temperature. Yery numerous observers, the latest of whom is
Cuni/ Bouvier (Pfliiger's 'Archiv,' 1S69, p. 370), have confirmed this
fact and confuted the contrary opinion.^
1 To the best of my belief, Demarquay and Dumeril were the Grst to clearly
point out the lowering effects of alcohol on the temperature, although Orfila,
Ogston, Percy, and others, had noticed in general terms the coldness produced
by poisonous doses. The translator had also (' Med. Mirror,' Feb. 1866)
formulated the results of numerous experiments in the words, " The secondary
lis ON THE TRMPFRATrilK IN llEATTII.
Bonvicr has found that small doses of alcohol invariably lower the
temperature of the body (whilst increasing the frequency of the
pulse), but the eflcct does not last long; larger doses lower the
temperature almost immediately several degrees (the pulse at
the same time becoming fuller and more frequent). See also his
latest work, * tjber die "Wirkung des Alkohols auf die Temperatur,'
1869, and also GocJ/ri7i,''De I'alcool, son action physiologique, ses
applications therapeutiques,' 1869. The cause of this effect of
alcohol is not certainly known. It appears partly to depend on a
retardation of the tissue chaiiges, partly on an increased loss of
warmth from the su])erficies of the body ; but here the physiological
and pathological (toxic) effects can scarcely be separated. Refer,
therefore, to the next chapter.
"Warm alcoholic drinks, on the other hand, may raise the tempera-
ture; punch about 50° C. (= 123° F.) raises the temperature about
•1 to "3 of a degree 0. (= i to ^° F.) for -A- to i hour.
Carbonic acid (sherbet powders, &c.) causes a lowering of tem-
peratui'e equal to about Vo or one or two more tenths of a degree
(4-° to 4-° r.) which is com])ensated in about half an hour. Strong
coffee causes an elevation of temperature, which in about an hour
reaches its maximum (2 — 4 tenths of a degree C.= 1° — ^° Fahr.)
Tea (drunk at blood-heat) acts in the same way, but less powerfully,
and for a shorter time [compare Sydney Einger, Anstie, &c.].
§ 21. The effects of losses of blood on the temperature of the
healthy are not very considerable. But after a moderate venesection,
the temperature rises a few tenths, and gradually returns to the
normal after a day or two, and may even at a later period, sink
below the normal (Barensprung). After very copious bleedings
(in animals) the temperature sometimes sank a great deal {Marshall
Hall) . According to Frese (Virchow's ' Archiv,' xl, p. 303) imme-
diately after a moderate bloodletting, a fail of temperature of about
1° C. (['8° F.) ensued; but a few hours after the temperature
effect of alcohol appears to be invariably a great fall iii temperature."
Tscbescliichia (Reichert's 'Arcbiv.,' 1866, pp. 151 — 179) published a cou-
firmalion as regards auimals poisoned with alcohol. lu this country Drs.
Anstie, B. Ward Kichardsou, Walter Rickards, Sydney Ringer, and others
liave further confirmed the statements in the test. Dr. Ogle also (Joe. cit.)
says, that alcohol at first lowers the temperature, and then raises it (perhaps
higher than before).
ON THE TEMPERATURE IN HEALTH. 119
began to rise and generally exceeded the temperature before the
bleeding. , ■
Unfortunately it is not easy to determine these facts by experi-
ments on healthy men ; indeed, it is now impossible [except in
Italy ?— Trans.]
§ 23. As stated in the introduction, all fluctuations in the height
of the temperature in health, are very trifling (fast durchans
minimal). Whether they arise spontaneously, or are induced by
internal influences, these deviations from the mean (average) tem-
perature are only transient. As soon as ever the temperature takes an
upward or downward direction, a tendency to return to the opposite
direction soon manifests itself. "Whenever the production of warmth
is increased in a healthy body, not only is the loss of warmth greater
but there remains for some time after, a tendency to diminished
generation of heat. When the production is very small the losses
also are limited ; when these are slight production is lessened ;
when these losses are excessive they are compensated by an
increased warmth production.
Herein is the mystery of the organism, that so long as it is
healthy, everything goes on in it with wonderful regularity (Ordnung)
and all accidental disturbances are immediately and spontaneously
compensated.
CIIArTER VI.
THE CAUSES OP ALTERED TEMPERATURE IN DISEASE.
§ i. Thermometric observations show us liow narroio are the
Vnnits betiveen health and disease, and hoio imperceptilily one passes
into the other (wie sie untrcnnbar in einander iibergehcn).
From temperatures which fall within the limits of health, to
those which are decidedly morbid, the transition from the very
first step is entirely undistinguishable ; neither in theory nor in
any given case can we discriminate a point where health ends and
sickness begins. A sort of neutral territory, of no great width,
intervenes impartially between the normal track, and that over the
morbid nature of which no doubt can be entertained.
Just so it is with the causes which determine alterations of
temperature. There are some influences which are nearly certain
to produce morbid changes of temperature in those exposed to
them.
But in a great number of other cases the effect produced de-
pends very much on the constitution (disposition) of the subject
exposed to the influence, and very often upon quite accidental
circumstances. These influences, which in one healthy man either
produce no effect upon temperature, or such effects only as fall
within the range of health, may, in another healthy person, with
less powers of resistance, or in a sickly person, whose temperature
was not previously affected, cause more or less considerable, and
more or less decidedly morbid alterations of temperature.
Various circumstances which influence temperature must be con-
sidered not only as converting normal temperatures into abnormal
and diseased ones, but also as modifying temperatures which were
previously abnormal. The self- same influences and circumstances
which affect the normal balance of temperature, and thus prove
causes of pathological temperature-changes, are able when the
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 121
balance has once been disturbed, to induce further deviations from
the standard. The causes of these cannot be severed one from
the other, they may indeed be identical. But their effects on him
whom they make ill, in the first instance, and on him who is
previously ill, and constantly has an abnormal temperature, are by
no means always ahke ; and the effect produced upon the sick is
throughout to be distinguished, not only as regards the kind of in-
fluence brought to bear on him, but also from the effect produced by it
on the healthy. As regards every kind of influence, the effect depends
much, and indeed chiefly, upon the previous condition of the
patient, and upon the " epidemic constitution " of the prevailing
type of disease, upon the regularity or irregularity and intensity
of the sickness, upon the degree of its development — in one word,
upon the sum-total or aggregate of all the circumstances of the
patient. And if, indeed, the effect of an influence affecting tem-
perature and causing disease in a previously healthy person, in no
ways depends upon the nature and degree of this influence alone,
but very much upon the individuality, surroundings, and other
conditions of the subject, and may be determined in part by acci-
dental circumstances; so, also, in estimating the results of any
influences affecting temperature in patients already abnormally
warm, must the whole closely interwoven " complexity " of morbid
conditions be taken into consideration.
On this account one and the same influence may possibly induce
very different and even opposite effects.
§ 3. The common basis of the operations [or community of
working] of those influences which affect temperature, does not
depend on their increasing or diminishing either the production or
the loss of heat, but rather on the fact that the regulating potoer is
less perfect (die Eegulation unvollkommener ist) than in health.
Even in health there may be a greater or less production of heat,
but the giving ofi^ of heat regulates itself {so to speak) according to
the plus or minus of production. The loss of heat may also be
more or less than usual, even in health, but the warmth generated is
proportionate to the amount lost. Therefore in health the sum total
(Facit), or the height of the temperature, remains at a determinate
point, just in the same way as the body-weight, the average daily
quantity of urine secreted, the number of respirations, the composi-
tion of the blood, and the whole organism in its various parts, and
133 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
as regards its most important groups of functions, remains sub-
stantially the same.
When we perceive in a patient whose general temperature con-
forms to the standard, a deviation from the normal temperature,
produced by inllucnccs which do not affect the temperature of the
healthy, we may conclude that the power of regulating his tempera-
ture possessed by him is sufficient for all ordinary pur])oses, but
becomes inefficient under somewhat strange influences. Such great
mobility of temperature in patients whose ordinary temperature is
normal, may closely approximate to the fluctuations met with in
health ; but the " excursus " or curve of the temperature (vide § 18,
chap, i) will be striking and exceed ordinary bounds, just in propor-
tion as the resistance or controlling power is less or the influences
overpowering. Influences which produce a morbid alteration of
temperature in a healthy man either produce in him so considerable
an uncompensated alteration of heat-production, and its loss, as makes
compensation become impossible, or they excite an illness, which has
for one of its elements an imperfect regulation of the balance between
heat-production and the loss of heat. For every deviation of
temperature is a proof that the compensation between production
and destruction of heat is imperfect. There is still compensation,
but the power of maintaining the normal constancy of temperature
is lost. Sometimes heat-production and heat-destruction (or loss)
are so evenly balanced that a certain equality is maintained between
them — an equality, however, which stands on a different level
(niveau) from that of the healthy, and an equahty which it is always
far more easy to disturb than it is in the case of good health.
§ 3. It is quite conceivable that the defective balance (Equilibri-
rung) of many functions which compensate each other in health may
arise from very different sources (Ausgangspunkte), and from widely
differing reasons.
The loss of heat may be so considerable that the most extreme
over-production, or at least the greatest rise in production possible
to the individual, may not compensate it.
The giving off (or radiation) of heat may be so much hindered in
the bulk (in dem maase) that with a limited production of heat, or
in a special case with even a diminished amount of it, an accumula-
tion (Stauung) of temperature is certain.
The production of heat may be so much increased that all the
CAUSES OF ALTEPvED TEMPEUATURE IN DISEASE. 123
contrivances to carry it off^ or at least aU the available contrivances
in the organism in question, may not suffice to compensate the
overplus. Or the generation of heat may be so much diminished
that although the giving off of heat is limited in every possible way,
no satisfactory compensation is attained.
Increased production of heat and diminished loss of it, or increased
giving off of warmth and diminished warmth-production, may also
be combined together, in different degrees, and their disturbing
influences may accumulate. They may, even in different parts of
one and the same organism, show themselves in different ways.
The antagonistic compensating processes, instead of going on
swiftly and promptly in their relative order (Beziehung), may be
hindered, interrupted, and dilatory.
And besides all this it is very evident that in sickness we have not
to do with merely ^ ]}lus or a minus of the heat-production (or loss)
in health, but that there 2ive fresh sources (Quellen) of heat-produc-
tion developed unknown to the healthy body. And, on the other
hand, 2oa?/s of getting rid of heat offer themselves, which are wanting
in the healthy body.
Amongst such new sources of heat-production, we may reckon
the more or less rapid destruction of tissues, which we can only
conceive of as chemical processes, the formation of abnormal che-
mical products of the metamorphosis of tissues (^Mf/-producte —
such as oxalates, cystin, &c. &c.) ; and finally, it is not at all impos-
sible, that independently of the oxygen in the body, some kind of
fermentative process may be excited, which may become a fresh
source of heat, as happens indeed external to the organism (so also
perhaps in zymotic diseases) . To the new methods of abstracting
heat we must refer copious losses of the fluids of the body, and the
deposit of larger, but less vitalized (belebter) masses, such as
exudation and extravasation products in the body, in which warmth
is not produced, but only expended, &c.
But even when the equilibrium is disturbed in disease, there is an
adjusting power in the body which guards against a mischievous
anarchy (iNIaassloswerden), and is able after a longer or shorter inter-
val to bring about a restoration of the equilibrium — sometimes by a
return of the excessive heat-production (or loss) to the normal, or
even below the normal, and sometimes by the gradual strength-
ening of the active compensatory processes, till they become suffi-
ciently strong for the purpose, and sometimes by the opening of new
1:2 !■ CAUSES OF ALTERED TEMPERATURE IN DISEASE.
sources for llic production of heat, or for its distribution. The
[animal] organism is indeed full of tlic most varied and ingenious
(sinnrcichsten) contrivances and combinations for this purpose. For
example, increased heat quickens the movements of the heart, which
propels the warm blood more quickly through the vessels to the
surface of the body, through which in a given time, a greater quan-
tity of blood comes into contact with the surrounding coolness, and
so becomes more rapidly cooled. Heat also increases the need of
breathing [bcsoin de rcspirer], the movements of the respiratory
organs arc quickened, and the cooling air is introduced in greater
quantity. Anremic peo])le, with diminished blood corpuscles, ])ro-
duce less warmth, but their superficial vessels are contracted, and
thus the cooling of their blood is less rapid. Other examples might
easily be adduced.
Even in disease there is a certain amount of regulation, hut with
more extended limits of JI actuation, and in this way, when the
original causes of the disturbance of equilibrium, or in other words,
the sources of the disease, are exhausted, and no new ones have
arisen in the course of the malady, the return to a state of equili-
brium is provided for, and actually introduced.
When these natural aids (Selbsthiilfen) are wanting, and arti-
ficial means prove powerless, and therefore the disturbance of the
equilibrium between the production and the giving off of heat, proves
overwhelming in power, then no restoration occurs, and the excessive
disproportion, and extreme deviation towards one extreme or the
other, as regards temperature, must terminate in death.
These propositions, which in the abstract are almost indu-
bitable, can however very seldom be demonstrated in individual
cases.
As it has already been shown that it is not practicable to deter-
mine accurately the sum total of the warmth produced, or eliminated
(weggeschafften) in a healthy man in a given space of time, so it is still
less possible to indicate even approximatively the sources, or amount
of the heat production, or the quantity of heat lost, or to determine
the several shares of the different parts in which the generation or
dissipation of heat occurs, in any special form of disease, or any
given case of sickness, or in any determinate part of the course
of the disease. The combinations are so numerous, and so subject
to almost momentary [instantaneous] change, and are generally, at
any given time, built up, as it were, of such contrary-working forces
I
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 125
(Momenten), they partly concern such inaccessible regions of the body,
and both the greater and the lesser modifications in the products
[Leistungen] df the various organs are so manifold, and compli-
cated, that even the loosest and most superficial calculations become
either impossibilities or fiction.
We are therefore only in a position to determine the result
or sum-total, the alteration in the height of the general temperature ;
the factors composing this result elude direct observation, and at the
best can only be estimated approximately by conjectural methods.
Since then we are unable, and doubtless never shall be in a posi-
tion to trace back the alterations of temperature to their true
conditions, as a matter of accurate calculation; it is all the more
necessary to endeavour, as far as possible, to determine accurately in
an empirical manner the connection between the course of the
temperature in disease, and determinate influences, conditions, cir-
cumstances, and processes.
§ 4, The primitive causes (Ursachen) which may lead to morbid
changes of temperature, or modify those already existing, may be —
{a.) External influences.
(b.) The circumstances (surroundings) and constitution of the
individual.
(c.) The processes going on in the organism itself.^
In any given case, these primitive causes may be very variously
combined, and it would seem impossible, on account of their intricacy
(Unentwirrbarkeit) to disintangle, from the combination of such
varied influences and cii'cumstances, the exact share of any one force,
or to reduce these operations to elemental forms, or make them
evident as matters of simple necessity (in ihrer einfachen Nothwen-
digkeit auschaulich zu machen). And since the final decision as to
the operation of primitive causes of temperature-disturbance, falls to
the share of clinical observation, the latter is still further justified by
the fact, that ever since the earliest period of observation of thermal
phenomena in the organi:?m, experments, or the artifical produc-
tion of simple morbid phenomena, have been made subservient to
discovery.
The results of experimenls on the influence of various circum-
1 " Aussere Einfliisse,
Die Verbaltnisse und Aulagcu des ludividiiums,
Die A^orgiiuge in dem Orgauisnius selbst."
126 CAUSES OF ALTERED TEMPERATURE IN DISEASE,
stances on the temperature of animals or healthy men, in tlicmselves
of the highest and most undoubted interest, must however be
estimated with the greatest caution and circumspection [Vorsichl,
uud BesoniicnJieii) when applied for the purpose of drawing conclu-
sions as to the behaviour of the human orijanism under external
injuries, or in diseases. Many of the results of experiments corre-
spond exactly, or at least exhibit a close analogy with influences
which make a healthy man ill when he is exposed to them, or are
able to modify his temperature when already morbid.
But we must not forget to use caution when applying to man
the results obtained in experiments on healthy animals — for human
beings exhibit slighter normal fluctuations of tem]icrature than
most other mammals. Amongst these, for example, rabbits may
give very deceptive results, because they show very extreme variations
in temperature — and such are induced even by merely trying them
securely [for experiment].
The same caution must be employed as regards experiments made
on healthy men. It is indeed highly useful and important to study
the operations of therapeutical agents on the healthy, but we must
be cautious how we transfer results so obtained to the organism in
sickness — for there the results may possibly be quite different, and
are especially likely to vary with the pathological conditions. In
many diseases conditions exist which cannot be induced experi-
mentally. But experimental results serve capitally to direct
attention to special operations — to afford us analyses as it were, of
complex phenomena, and to prove selected theories from patho-
logical facts — but if we except traumatic and toxic influences, for
which they are apparently able to furnish us safely with pure
analogies, the remainder must always be controlled by clinical
observations
1
* Even in toxicology, the comparative immunity of certain animals to the
poisonous effects of alkaloids must not be forgotten. See a paper by Dr. W.
Ogle "On the Comparative Harmlessuess of Atropine to Rabbits," apropos of the
case of Regina v. Sprague ('Med. Times and Gazette,' i, 1867, p. 466), where
he shows that a middle-aged rabbit can live for six days at least on Belladonna
leaves only, without inconvenience (See also ' Pharmaceutical Journal,' 2nd
series, vii, 127, and the newspapers for 1866).
Pigeons also, and perhaps most birds, possess a capacity/ of resisting the
effect of morphia, first pointed out by Dr. Weir Mitchell (CJ. S.) and confirmed
bv Dr. B. \V. Richardson. It is also well known that some dogs will take
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 127
The amount of clinical material, setting forth general facts re-
garding tlie opei;ation of certain influences, which induce morbid
alterations of temperature, and regarding accidental circumstances
incidental in the course of the disease, but not an essential part
of it, yet influencing the track of the temperature, is indeed
extraordinarily great; yet it is for the most part fragmentary,
and therefore often unreliable. It requires great attention,
and much thermometric experience, to evolve the simple facts
from the conflict of combined circumstances. Amongst other
things we must remember to separate the effects of accidental cir-
cumstances upon the temperature of the sick from the effects of such
influences as immediately induce a true amelioration or deterioration
in the sickness itself, or in its principal symptoms. It is clearly not
the same thing, whether after some incidental operation the whole
malady is bettered or made worse, or whether, without any special
effect on the disease, only the course of the temperature is affected.
In the same way we must seek to determine whether, after a result
obtained on the temperature of a previously healthy person, this is
the pure result of the experiment^ or whether it depends upon the
development of a determinate form of disease, of which an abnormal
temperature is an essential element.
§ 5. The influences which operate as dejn'essors of temperature do
so either {a) by abstracting heat from the body, and especially
increasing the amount of heat lost, [b] or by hindering or hmiting
the access of the (normally, sub-normally, or unusually) warm blood
to the parts under observation, {c) or chiefly by diminishing the
production of heat in the body.
It is not always easy to exactly determine of what kind the
temperature-depressing influence may be, and no doubt one and the
same cause often operates in different ways.
The very same cause may at one and the same time, or successively,
operate in opposite ways — that is, it may even raise the temperature.
In this way it may happen that the efiPect is so compensated that the
height of the temperature remains apparently unaffected. On the
other hand, the compensation must remain imperfect whenever
through the influence of the original cause the temperature is
depressed.
large doses of Prussic acid. It has recently been showu that some monkeys
resist comparatively large doses of stryclmia. — [Tkans.]
1.^8 CAUSES OF ALTERED TEMTERATUllE IN DISEASE.
Experimental and cliuical experiences of elevated temperatures are
far more numerous^ botli as regards the general temperature and
that of special regions.
Any elevation of general temperature above the normal must have
as its basis cither an over-production or a diminished loss of warmth,
or both combined ; but in elevated temperatures the respective shares
of these conditions are not to be determined any more easily than in
diminished temperatures.
Since, moreover, the very same causes which originally raise the
temperature operate immediately on those which tend to depress
it, and the effects of over-production, or diminished giving off of
heat may be compensated in this manner, the [absolute] height of
the temperature may be the result of very complicated, and widely
differing factors.
In local elevations of temperature, especially when this is deter-
mined by observations made on the surface of the body \i. e., with
the ordinary thermometers], it is by no means always certain
whether the temperature observed is a real elevation of temperature
or only a relative addition to the [local] warmth ; produced by the
part, as compared with the general surface, having received a greater
quantity of the warmth-bringing [although in itself of normal heat]
blood — or whether the giving-off of heat is diminished in the spot
where the temperature is measured.
§ 6. Extreme degrees of external cold are the most certain means
of abstracting warmth from the body, and may, when their operation
is very intense, and long-continued, depress the temperature so
greatly that death becomes inevitable. A. WaWier, of Kiev, has
investigated the results of artificial cooling (Virchow's 'Archiv,'
1865, p. 25). The lowest point to which he could depress the
temperature in rabbits, before they died was 9° C. (= 48*2° Fahr.)
Animals which were cooled down to 1 8° or 20° C. (= 64*4° or 68°
Eahr.), and then brought into a medium not warmer than their own
temperature, were found to have lost the power of regaining their
normal temperature. But on the other hand they were restored to
their normal heat by artificial respiration. Some of the animals
which had been thus cooled, and again artificially warmed, displayed
for some days a febrile elevation of temperature (42° C. (= 107*6°
Eahr.) or more).
As regards the direct effect of cold in producing disease in healthy
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 129
men, accurate observations are wanting. Apparently death from
cold (congelation) takes place in a similar way to the death of
Walther's rabbitsj although perhaps by much less extreme degrees
of cold. Diseases which result from the influence of cold are
always complicated with other circumstances ; and the temperature
in these must not be regarded as the immediate consequence of the
operation of cold. On the other hand the results of experience of
the effects of cold on men whose temperature \%felnle are far more
reliable, and are of the highest moment, since cold is available as
one of the chief antipyretic and antiphlogistic remedies, and has been
applied as such^ in modern times, in febrile, especially typhous and
exanthematic diseases, and that most extensively.
The effect of cold drinks and cold injections on a morbidly
elevated temperature is transient, and indeed rapidly so. Con-
stantly repeated applications of very cold water (washings), ice-bags,
or cold compresses, and cold sitz-baths are far more effective. Yet
their influence extends but little beyond the place where they are
a])plied, and the general temperature is but little or not at all
affected.
Unlike these, the effect of the application of water, more or less
cold, in the form of packing (Einwicklungen) in wet sheets, of full
(complete) baths, and of douches, is far more considerable, intense,
and permanent. The advantages of an energetic and more or less
methodical treatment of high degrees of fever with these measures
have been abundantly proved since the zealous recommendations of
Brand,, and although without doubt there is another and an adverse
side (Kehrseite) to this question, which at present is not fully dis-
covered, yet this much is certain, that the effects are exceptionally
potent, and that there is no therapeutic method which is capable of
inducino; such favorable modifications in the course of a severe
fever, with equal power and trustworthiness (see Abdominal Typhus
or Enteric Fever) . It may be freely conceded that the conditions,
and indeed the very causes (Griinde) of the effect of cold in lowering
febrile temperatures, and in shaping the course of the disease, are by
no means accurately determined ; and as regards the immediate and
remote effects of this method, much remains to be done (sind noch
Keineswegs die Akten geschlossen — the curtain has not yet fallen).
Certainly much depends upon the kind of application, the tempera-
ture of the water used, and the duration of the operation ; and on the
other side upon the morbid conditions themselves, on the intensity
9
130 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
{ind fonn of the disease, its stage, &c., &c. And the operation is by
no means uniformly simple. At the moment of application, or when
applied in an ineflicient manner, the cold often causes the tempera-
ture to rise, and only after continual application, the temperature
begins to fall. If repeated too seldom, reaction (lit. back-stroke-
working) takes place the more certainly, in proportion to the
intensity and newness of the disease, and the definitive (or desired)
effect is only to be attained by a very energetic and continued appli-
cation of the method. The true cause of the effects of the cold
treatment has not yet been explained. It is no doubt an error to
believe that the benefits derived in cases of fever depend simply upon
the mere abstraction of a detrimental [over] plus of heat.
Sell ruder {' Dcutsches klinischcs Archiv,' vi, 385) has found that
cold baths in typhus diminish the ehraiuation of carbonic acid and
urea, and retard all the tissue changes.
WaJil (' Petersburg, med. Zcitung,' 1867, xii) attributes the chief
influence of cold baths to their influence on the nerves and the
nervous centres ; says that they fail whilst the temperature is still
rising, and recommends that the cold should be chiefly applied in
the remissions, or in extremely high temperatures, because the
carrying away of the extremely accumulated heat acts beneficially.
The reaction which takes place after the external apphcation of
cold is so powerful, that we may very safely use short but energetic
applications in order to raise an abnormally low temperature, or in
other words, the temperature of collapse.
^ 7. Temperatures above Mood-heat, or even approximating closely
to this, have, when long continued, a decidedly morbid influence, and
cause the temperature of the body to rise.
Claude Bernard ('Gazette Medicale,' xiv, p; 562, 1859) has
found that animals exposed to a high external tem])erature, suc-
cumbed to the effects of the heat, whilst their own temperature rose,
as soon as the latter exceeded their normal temperature, by
4_5° C. (= 7-2°— 9° Fahr.). Ohermer ('Der Hitzschlag,' 1867)
has determined the rise of temperature in animals which were
exposed for a lengthened period to the effects of an elevated external
temperature. The temperature of animals generally fell at first
(about -ro° C. = 4° I^ahr. nearly) when the surrounding temperature
was raised continually for some time. "When the surrounding
temperature reached from 30^ — 35° C. (= 86° — 95° Fahi-.) the
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 131
animal heat began to rise also, and commonly to a few degrees above
that of the surrounding atmosphere. AVhen the animal heat
reached from 44'^ to 45° C. (= in-2°— 113° Fahr.) the animals
generally died, although the air in which the animal was placed did
not exceed about 40°— 41° C. (= 104° to 105-8° Fahr.) The
temperatures rose, post mortem, a few tenths of a degree in most
cases. Animals whose temperature was raised to 41*6° or even
43'8° C. (= io6-88° or 1 10-84° Fahr.) might still be recovered.
A. Walther exposed rabbits, securely confined, to a direct solar
heat of 30° — 34° C. (= 86° — 93-3° Fahr.). The temperature rose
to about 46° C. (= 114-8° Pahr.). After death the temperature
continued to rise till it reached 50° C. (== i2a° Pahr,). The
autopsy sho'vved anaemia of the internal organs, but the lungs were
hyperaemic, and the muscles rigid, as if cooked. Walther con-
siders that the elevation of temperature in these experiments is
only the result of diminished giving off of heat, and he attributes
the post-mortem rise of temperature and the rigidity of the
muscles to a development of heat (Bulletins of the Petersburg
Academy, in the 'Berliner Centralblatt,^ 1867, p. 391). A morbid
elevation of temperature may often he observed in human beings
as a consequence of unusually high atmospheric temperatures. In
the hot summer of 1865 many of my fever patients exhibited
unusually high temperatures, the cause of which, I have no doubt,
was to be traced partly to the impossibility of keeping the sick-
ward sufficiently cool, and partly to the insufficiency of the neces-
sary giving off of heat by the patients themselves. From the
5th of July to the ist August of that year, during which time
the average temperature of the air at % p.m. was 26-6° C.
(= 79*9 Tahr.), and was only six times less than 25° C. (= 77°
Ifahr.), whilst it exceeded 30° C. (= 86° Palir.) on six occasions,
the maximum being 34° C. (= 93-2), 1^ patients in my clinique
died. In 23 of them the temperature was taken at the moment of
death ; and of these six had normal or collapse-temperatures (3 cases
of phthisis, I of heart-disease, J of marasmus, and i of small-
pox); 3 sub-febrile and moderately febrile temperatures (2 cases
of phthisis and i of cancer); and 14, which is more than half of
the cases, exhibited temperatures of 40° (= 104° Tahr.) or more.
The particulars of these cases are as follows : —
A case of pseudo-rheumatic osteomyelitis had a temperature of
40° C. (= 104 Fahr.) at moment of death.
132 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
2 cases of peritonitis a temperature of 40'5° C. (= I04"9° Falir.).
2 cases of ty])lioitl fever =41-375° C. (= 106-47 i'^il"'-)-
1 case of delirium tremens = 4i'75° C. (= 107-15 Ealir.).
I case of pneumonia and i case of a girl, aged 23, ^vllo died
after a few days' severe fever, without any localised symptoms,
and at whose autopsy no anatomical lesions of any kind were dis-
covered, had temperatures of 42° C. (= 107-6° Fahr.).
I case of typhoid fever, and 1 case of delirium tremens =
42-25° C. (=108-05° Fahr.).
I case of cholera (choleraic diarrhcca) (= 42-875° C. ( =
109-175 Fahr.).
1 case of insulation (coup de soleil) =: 43-25°C. = 109-85 Fahr.).
I case of puerperal septicsemia and i of cerebral softening =
43-75° (= 110-75° I'ahr.). Never, either before or since, have I
seen so many high temperatures at the moment of death compressed
within so short a space of time. Many observers have noticed
sudden and remarkable elevations of temperature, in cases in which
the complex symptoms of insolation (sunstroke) have been met
with. Schneider [' Inaugural Dissert, on Sunstroke,' 1867) observed
a temperature of over 40° C. (above 104^ Fahr.) in a fatal case
2| hours after admission to the hospital. TIelbig ('Leipzig Disser-
tation on three cases of Sunstroke,' 1868) observed the same,
Ferher ('Archiv der Heilkunde,' ix, 487) observed 40° C. (= 104°
Fahr.) in a case which recovered. 5a«w^/^r (' Medical Times and
Gazette,' Aug. i, 1868) observed a temperature of 42*9° C. ( =
109-22° Fahr.) in a fatal case one hour after admission. According
to LevicJc C Heat Fever in Pennsylvania Hospital Eeport,' 1 868,
\, 369) a case in a man of fifty-five, who recovered, showed a
temperature of 42*8° C. (= 109-04 Fahr.); a similar case in one
aged forty, the same. He also communicates a number of similar
observations, amongst which one by Bowler is said to have reached
as much as 45° C. (=113° Fahr.).i
On the other hand, it is a matter of every day experience, that in
1 See also a letter of Dr. Baiimler's in the 'Lancet,' August 6\h, 1870,
calling attention to the great benefit derived from rubbing with ice in case of
sunstroke, as recommended and practised byDr. Levick in the cases mentioned
above : the same means proved successful in my hands in some cases admitted
to the London Hospital, when I was resident medical officer there, witli tem-
peratures of 103^, 104°, and 105° (the latter temperature seems not uncommon),
a few hours after the first attack. Tor another paper by Dr. Levick, see the
' American Journal of Medical Sciences,' vol. xxxvii, p. 40.— [Tkans.]
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 133
those whose temperature is sunk below the normal, bringing them
into a warm medium or surrounding them with warmth-giving
materials [hot-watet bottles^ &c.] is able to raise the temperature
of their bodies.
§ 8. The application of external irritants (Reizmittel) appears to
have the effect of lowering the general temperature rather than of
raising it. Mantegazza (Eeference in Schmidt's ' Jahrbuch/ 1867,
i; p. 153) observed that pain had a tendency to lower the tempera-
ture both in man and other animals. Most observers agree that
there is no elevation of temperature in places rendered hypersemic by
mustard, and Naumann (Prager's 'A^iertelj.,' 1867, xciii, 133) even
states that he has found a lowering of the general temperature
consequent upon the application of mustard. Heidenhain com-
municated to the Innspruck Natural History Congress, that accord-
ing to his experiments irritation of sensory nerves constantly and
suddenly lowered the temperature except after division of the
medulla oblongata from the spinal cord, or when fever was
present.
§ 9. When a considerable hyperemia of any part is artijJcially
induced the temperature of the part may become elevated, and an
artificial impediment to the access of blood to a part may diminish
the temperature.
Kiissmaul and Tenner (loc. cit.) have shown that ligature of the
arterial trunks which diverge from the vessels leading to a given
part, the part receiving a greater blood supply in consequence of
the operation (as, for example, the head, after ligature of both
subclavians), induces not merely congestion in the part, but an
elevation of temperature. Brown-Sequard {' Comptes Eendus,'' 1 854,
xxxviii, p. 117) found that when animals were hung up by the
hind legs, with the head hanging down, the temperature in the
head became raised.
On the other side narrowing, or compression of the vessels, has
on similar grounds the result of lessening the temperature in the
part concerned.
Therapeutics has long known how to turn to advantage the
results of artificially increased or diminished fulness of blood on the
temperature, [e.g. Local and general bloodlettings — influence of
position and compression, &c., on inflammation — ligature of arteries
134 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
for ditto (as suggested and carried into effect by Mr. l^Faundcr) —
the effect of topical astringents — local warmth, Sec, and cold, may
be adduced as examples. It must be remarked here, however, that
although the immediaic effect of Hgature of either arteries or veins
leading to or from a part is as full of temperature, there is a rise
again (often considerable) as soon as the collateral circulation is re-
established . — Tkans.]
§ 10. Large losses of hlood, both in healthy people and in sick
persons, generally cause a rapid lowering of temperature, which is
however compensated pretty generally, after a few hours or days,
unless ending fatally, or, as may sometimes happen in the course of
a disease, terminating in a crisis. Marshall Hall observed the
temperature fall from 37*5° C. (99-5° Fahr.) to 29-45° C. (85° Eahr.)
in a house dog weighing 17 lbs., from whom he took 32 oz. of blood,
and the animal died. From another dog, weighing 19 lbs., he took
30 oz., and the temperature sank to 31 "65° C. (= 88-97° Fahr.).
i^r^^e'* experiments with moderate bleedings (see page 118) may
be contrasted with these.
After a copious hsemorrhage from the lungs, stomach, intestines,
or uterus, there ensues an almost immediate and very considerable
sinking of the temperature, even amounting to collapse-tempera-
tures, when there has previously been a high febrile range. It
depends upon the circumstances of the case whether, how soon, and
to what degree the temperature again rises. Even a moderate
spontaneous loss of blood [such as epistaxis, &c.] causes a dispro-
portionate fall of temperature in most fever cases.^
General bloodlettings in suitable cases of disease, and in a less
degree local abstraction of blood, have similar effects, and it not
seldom happens that the temperature, which just before was con-
siderably elevated, or in other words, febrile, becomes normal, or
very nearly so just after. But the reaction is generally far from
insignificant. In most cases the temperature soon rises again to its
previous height, or even exceeds it. The temperature will remain
^ For example, a girl under my care, aged 12, on the tenth day of typhoid
fever, had a morning temperature of 104' ; pulse, 130 ; Ft. 24. In the evening,
after a moderate bleeding from the nose, the temperature was only 100° ;
pulse, 100 ; H. 24 ; whereas the evening temperature of this disease is gene-
rally from 2" — 3' higher than the morning, and was so in this case when there
was no epistaxis.
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 135
reduced just in proportion to the actual improvement which has
taken place in the patient's condition (lit. in dem Krankheit s process,
in the process .of ' the disease) at or after the bleeding. It appears
not to be very material whether the blood flows from capillary
vessels, or from those of a larger calibre; but it is far more impor-
tant, on the other hand, that the course of the disease should be
sn^cientlj fonvard to allow of a lasting impression being made upon
it by the abstraction of blood. ^
If menstruation occurs in the course of a disease, we find it more
commonly preceded by a rise of temperature than is the case in
healthy people. The loss of blood itself is sometimes followed by a
diminution of the previously elevated temperature induced by the
disease. And besides this, the occurrence of the catamenia has
often a disproportionate disturbing influence, especially on women of
a nervous temperament, and may cause a previously high tempera-
ture to rise as well as causing greater mobility of temperature, and
in some very susceptible individuals it may be associated with a
species of febricula [see note to page 102]."
§ II. C/iossafs valuable researches and experiments on the effects
of deprivation of food in lowering the temperature, were the first
published on this subject (1843, 'Eecherches experimentales sur
Pinanition. Mem. presentes a Tacad. des sciences. Sc. mathem. et
physiques,' viii, p. 438), and on the effects upon temperature, further
see page 532. Besides this Schnidt, LicJitenfels, and FrdJdich
^ Dr. Christian Baiimler (''Clinical Society's Transactions,' vol. ii, read Peb.
12, 1869) lias called attention to the rise of temperature which takes place
■within a few (one or two) days after haemoptysis, and to the necessity for
watching such cases and keeping them quiet, even when occurring in previously
healthy people. The paper is illustrated with several cases, and a chart of the
temperature. There can be no doubt that this is a very important practical
observation.— [Tkans.]
- It may not be out of place here to draw the reader's attention to the
eminently practical therapeutic results and indications to which Wunderlich
refers here and elsewhere, as the fruit of thermometry applied to medicine. I
Avould especially single out the author's remarks on alcohol, bleeding, baths,
calomel, digitalis, diet, ice, and purgatives [see this, and the preceding and
follo\ving chapters, and many other places passim, for which I must beg the
reader to consult the index]. It appears to me that the effect on the candid
reader's mind, however radical or revolutionary his pathology and therapeutics
may be, will be to make him endorse the Horatian maxim, *' Vixere fortes ante
Agamemnoua multi."
136 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
liavc cxpcriinontod on the innuonoc of hunger upon tlic teinporaturc,
and it has thus been cstabUshed that by continuous deprivation of
food, moderately extensive diminutions of temperature may be ])ro-
duced, without necessarily producing thereby any intercurrent rela-
tive elevations of temperature. In disease the effects of diminished
diet are never simple, and therefore observation of this kind upon
sick people are of little value. ^
§ 12. The \ntrochidlon of nutritious material, contrary to the
rule of health, is often remarkable in its operation upon the sick.
Not only those patients who have a more or less elevated tempera-
ture, but even those whose temperature is entirely normal, or has
again become so, may exhibit very striking elevations of tempera-
ture consequent on taking nourishment ; and for these we do not
need any special error of diet, or an increase of nourishment before
the appetite is restored, but they may occur on the introduction of
very moderate quantities: sometimes with the first enjoyment of
animal food, durhig convalescence, at a time when the appetite is
extremely sharp (in hohem grade lebhaft), it is not uncommon to
meet with a rise of temperature of two or more degrees (Centigrade
= 3"6° F.), and it may remain at this height for two or three
days or more.
§ 13. Constipation, if it lasts a few days, and sometimes even the
absence of an alvine evacuation for only twenty-four hours, especially
after previous diarrhoea or catharsis, may give rise to elevations of
temperature in disease. Betention of urine and suppression of the
catamenia have a similar effect. So when a pathological haemorrhage
occurs, the temperature usually rises a few hours previously.
Very relaxed motions generally lower the temperature, and when
artificially induced, more than when they are spontaneous. Even a
single copious evacuation may do this, if there has been long-
standing constipation, and the temperature has been previously high.
After the relaxation however, the reaction is generally considerable,
1 For a very interesting account of various experiments of Bidder and
Schmidt's, and others, on the effects of starvation, see Otto Fuuke's ' Lelirbuch
der Physiologie,' i, 607. See, also, Dr. Carpenter's 'Principles of Human
Physiology,' pp. 54— 56, 434— 5, sixth edition, and Taylor's 'Medical Juris-
prudence,' p. 742. Also the medical journals of the current vear on the case
of Sarah Jacobs, " the Welsh Pasting Girl."— [Traxs.]
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 137
and the subsequent rise may exceed the height of the previous
temperature. The kind of purgative, however, appears to have but
shght infiuenc.e ou either the amount or the permanence of the
depression of temperature.
Vomiting depresses the temperature far more than the action of
the bowels. Indeed the act is often accompanied or followed by
collapse-temperature. In this case also there is, for the most part,
a certain amount of reaction, inducing a rise of temperature.
§ 14. The lowering of temperature consequent on the toxic effects
of alcohol agrees with what has been said before of its effects iti
health, although as long as health is unimpaired the effects are far
slighter (see page 117).
With poisonous doses of alcohol the depression of temperature
may be very considerable,^ as Dumeril and Demarquay first pointed
out, and many others have confirmed. It appears that the ingestion
of alcohol diminishes or retards the tissue changes. Yet we must
notice that after the employment of brandy the fall of temperature
is usually followed by a very strong reaction. But in febrile con-
ditions the effect of alcohol is to lower temperature, as several
English observers have announced, from clinical observations, and
C. Bonvier has lately proved by experiments (Pfliiger's 'Archiv/
1869, p. 381). Habitual '' soakers ^^ have as a rule, under parallel
circumstances, a lower temperature than other persons, and collapse-
temperatures are met with in them, both in different kinds of fever
and in non-febrile diseases also, very commonly, and the collapse is
often very marked. This is not incompatible with the fact that very
high temperatures are often met with at the termination of fatal
cases of delirium potatorum (D. tremens). A variety of other more
or less poisonous substances depress the temperature. Demarcpiai/
has demonstrated this as regards Ether and Chloroform. Brown-
Sequard (1849, ' Comptes rendus des seances de la Societe de
Biologie,^ Nr. 7, p. 102) reckons opium, hydrocyanic acid, hyoscy-
amus, digitalis, belladonna, tobacco, euphorbium, camphor, acetic
acid, oxalic acid, sulphuric, nitric, and hydrochloric acids, amongst
the agents which lower the temperature.^
^ In cases of acute alcohol poisoning admitted to the London Hospital, I
have several times noted a temperature of only 90° T. (32"2° C.) in cases which
recovered. — [Trans.]
' Chloral-hydrate must also be reckoned amongst temperature-depressors.
138
CAUSES or ALTERED TEMPERATURE IN DISEASE.
Mauy medicines, when administered to patients sufTering from
fever, have the effect of lowering the previously elevated temperature.
This is most certainly correct as regards digitalis (employed in
quantities amounting to from 3 to 6 grammes (grs. 46 to 93) in
See Dr. Otto Liebreich's monogram, 'Das Chloral Iljdrat/ &c., Berlin>
1S69. Also papers and notices by Mr. Spencer Wells, Dr. B. W. Eichardson,
and others, too numerous to mention, in the ' Edinburgh Medical Journal,'
'Lancet,' ' Medical Times and Gazette,' ' The Practitioner,' 'Pharmaceutical
Journal,' and other medical publications at the close of 1869 and commence-
ment of 1S70.
I may also specially mention a paper on its use in tetanus, by Mr. Waren
Tay, in the ' British Medical Journal' for April 2, 1870, p. 329); other papers
in same journal, pp. 301, 433, and 413. It is not at all uncommon for the tem-
perature to fall 3^ or 4° Fahr. (= I'di" to 2"2°C.), or even more after a full dose
(40 — 80 grains) of chloral hydrate.
Dr. E.. P. Oglesby, of Leeds, has made a series of experiments on various
animals (cats, dogs, rabbits, and guinea pigs), which tend to prove that the
action of morphia and atropine, administered hypodermically, is almost identical,
regard being had to the difference of activity (see the ' Practitioner ' for
January, 1870). He finds that the first effect is to lower the temperature, but
it rapidly rises again ; and he believes that in these drugs, so used, we have a
reliable remedy for the collapse of cholera, summer diarrhcea, &c. The follow-
ing examples may serve to explain and illustrate his statements.
No. I. — A young cat. Temp, in rectum ioi° before operation; -J- gr.
bimeconate of morphia at 9.30 p.m.
10 p.m. Temperature 99'!°
11 p.m. „ 99'o°
12 night „ 99-4°
1 a.m. Temperature ioo"3"
2 a.m. ,, i02"i°
4 a.m. „ io2'3°
No. 2. — A terrier. Temp, in rectum I02"3^; igr. morphia at 4.30 p.m.
7.0 p.m.
8.0 p.m.
9.0 p.m.
Temperature i02"i'
„ 102-4°
1031
o*
5.0 p.m. Temperature ioi'4°
5.30 p.m. ,, ion'
6.0 p.m. „ 1011°
6.30 p.m. „ ioi"4°
* In spite of vomiting, this temp, continued several hours.
J. Temp, in rectum ioi"2'; ^ gr, bimeconate of
No. 3. — A guinea ph
morphia at 4.0 p.m.
4.30 p.m. Temperature 101*2
5.0 p.m.
5.30 p.m.
No. 4. — A cat.
6.15 p.m.
I02'2
6.0 p.m.
8.0 p.m.
Temperature io3'o°
„ 104-1"
„ 102-4'
Temp, in rectum 103°
Temperature 102 '4'
6.30 p.m. „ 102-3°
7.0 p.m. „ 102-3° 1-30 P-"i-
7.30 p.m. „ 102-2°
Similar results were obtained in rabbits. — [Trans.]
j^j gr. atropine at 6 p.m.
8.30 p.m. Temperature 103-1°
11.30 p.m. „ 1040°
104-0
CAUSES OF ALTERED TEMPERATURE IN DISEASE, 139
divided doses, spread over some days), veratria, quinine, antimony,
and calomel. Aqids, saltpetre [potassium nitrate], and other salines
show this action less decisively. But children and delicate women
exhibit greater sensitiveness than other patients in this respect, and
exhibit more clearly the temperature-depressing effects of these
remedies.
[Hence the old-fashioned treatment of fever by salines, and
the more modern use of mineral acids both find a justification.
Dr. Eobert Barnes, who has paid great attention to therapeutics,
expresses himself very strongly on the beneficial effects of salines
('Lectures on Obstetric Operations,^ p. 493, and elsewhere).
Liebermeisfer of Bale has published in the 'Deutsches Archiv
f. Klinisch Medicin,' vol. iii, parts 5 and 6, on the effects of Quinine,
to which he ascribes a decided and almost invariable temperature-
reducing effect. Dr. P. Stabell in the ^ Eeport of the Medical
Department of the Eoyal Hospital, Christiana," for the year 1867
{' jN'orsk Magazin for Lcegevidensk Aben,' xxiii Bd., i Heft) gives
details of two cases supporting the same view. In one woman,
aged thirty-one, a case of fever, with rose spots and petechia, without
diarrhcea, the temperature fell 8°, 5°, and 9° nearly after three doses
of 3j each of quinine. Dr. Baumler, however {' Kliuische Beobach-
tungen iiber Abdominal-typhus in England '), found but slight effects
from quinine, except perhaps in the last period of enteric fever;
indeed 3j doses of quinine had no effect at all in one case in
which that dose was several times administered.
Dr. Baumler's paper also contains remarks on the effect of port
wine, calomel, and other medicamenta, and is full of interesting
observations on the course of the temperature in enteric fever, &c.' —
Tkans.]
§ 15. On the other hand, a great many distances have a direct
effect in raising the temperature, which are partly to be observed
after " toxic incorporation" in healthy people, and partly in diseases
when the temperature is either abnormally high or depressed.
Coffee, musl:, and campJior, belong to this group. The effects of
curare (Woorara) have been most accurately investigated. After Claude
Bernard had made the discovery that it acted on the vaso-motor
nerves first, and that then the temperature rose, Voisin and Liou-
ville C Gazette des Hopitaux,' 1866, Nr. 109 and 11 1, and 'Journal
de PAnatomie ct de Physiologic,' 1867, p. 114), by means of sub-
1 10 CAUSES OF Af-TKRl-.D TKMPKll ATUUE IN DISEASE.
culancous injections of tliis drug, induced a complete artificial fever
in human beings, uith rigors, heats and sweatings, the temperature
rising to 40*4'^ C. (io4"H° F.), accomj)anied with all the signs
of febrile circulation and secretion, and disturbance of the nervous
system. TscJiescIiicJiin, on the contrary, found that in animals, some
)ninutcs after the injection of curare, there was a slight decrease of
temperature, which continued till cramps set in, when the tempe-
rature began to rise unmistakably. Fleischer, however (Pfliiger's
'Archiv,' 1869, p. 441), confirmed the effect of curare in raising
the temperature.
§ i6. Billroth and Hafschnidt, 0. Weber, and Frese, have all
pointed out the temperature-raising (pyrogonic) effects of certain
animal substances, when introduced into the circulation.
Billroth and Rufschnidt ('Archiv fiir klin. Chir.,' vi, 392)
found that in all the cases in which putrid solutions (jauchige
Fliissigkeit), or recent pus, were injected into the subcutaneous
cellular tissue, or into the blood, there was a rise of temperature in
the rectum, which was considerable even within two hours after the
injection, and reached its maximum in from two to twenty-eight
hours ; that the minimum exceeded the normal temperature by
r6°C. (2-88° F.), and the maximum by 2-2° C. (3-96° F.) ; and
that if the injection were only done once, a rapid defervescence
generally set in, shortly after the acme had been reached ; whilst, on
the other hand, after repeated injections, death constantly occurxed,
generally with very high temperatures.
Soon afterwards, 0. Weber (in 1864, 'Deutsche Khnik,' p. 495,
and 1865, p. 13, 21, 33, ^'^ determined by similar experiments the
pyrogonic (and phlogogonic, or in other words, heat-producing and
inflammatory) effects of pus injected subcutaneously, or into serous
cavities, or into the blood; of fluids from inflamed tissues, and
further, of the injection of pysemic and septicsemic blood, and even
of the blood of an animal merely suffering from simple inflammatory
fever. However, in the last case, the elevation of tem[)erature was but
slight, and amounted to only 0-65° to 1-15° C. (i'i7° F. to 2"07°F.).
Frese (1866, 'Experiment. Beitrage zur ^tiologie des Fiebers.
Diss.'') made still more numerous experiments. He showed that
the blood of animals suffering from fever, whatever kind of fever it
might be, when introduced into the circulation of a healthy animal of
the same species, induced a rise of temperature.
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 141
This followed tlie injection pretty speedily ; in one case, after two
hours and a half, the temperature was already i° higher (= I'S E.).
Yet according 'to Trese, the rise of temperature was by no means
enormous. In the three cases uncomplicated by accidental intro-
duction of part of the injurious blood into the connective tissue (which
then set up local inflammation) the temperature only exceeded the
maximum temperature of healthy animals by 07 to i"3°C. (=: i"i6°
to 2'34° Eahr.). The rise of temperature lasted only a short time
(il, 4,'r, and 6 days), and thus only attained the very minimum
period held to constitute a state of fever in the human subject.
Frese further discovered or confirmed —
(i) That products of decomposition and of inflammatory tissue-
destruction, when introduced into the circulation, induce a rise of
temperature — whether they are obtained from the body experimented
upon or from that of another animal.
(2) That this depends not upon the pus-corpuscles, but upon the
serum of the fluid.
(3) That even boiling and subsequent filtration does not destroy
this property.
(4) That very recent fresh serum of pus possesses this property
in a high degree.
(5) That no fever is induced by the injection of healthy blood,
but that the blood of an animal suffering from fever has pyrogonic
effects (induces rise of temperature).
(6) Since beating up (" whipping," German ^' Qairlen ") of the
fever blood and subsequent filtration does not deprive it of this
property, the efi'ect cannot be due to the fibrin.
More recently E. Bergmaim (1868, ' Petersburger med. Zeit-
schrift') has made a great number of experiments on the effects of
decomposing and inflammatory products, and has found that after
the injection of a moderately small quantity (according to circum-
stances) of the deleterious material, there is always induced a very
exact and identical typical alteration of the course of temperature
(an immediate rise after the injection, a maximum attaiiied in from
3 — 5 hours, and a return to the normal in 3 — 6 hours). Local
disturbances thus originating may hinder the process of restoration,
and cause modifications of the course of the temperature. All the
experiments are parallel, whether decomposing materials, or products
of inflammation, or only the results of the customary tissue changes,
are injected. Indeed it aj^pears to this observer (p. 84) that after
142 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
the injections of large quantities of water^ or smaller quantities of
irritating substances, there may be a very similar (analogous) altera-
tion of tenq)erature^ to that which occurs after the injection of
solution of decomposing or inflammatory products.
Those unknown influences which excite specific morhul processes
in the person attacked must have something in common (schliesseu
sich an) with those results of experiments on the pyrogonic action
of animal substances introduced into the system. However, except
in the case of pya3mia and septicsemia, the resemblance is not very
close [lit. die Achnlichkeit ist doch nur eine beschriinkte] .
Our knowledge is still very far from being in a position to clearly
comprehend the peculiar course of the temperature produced by the
operation of these unknown but doubtless specific influences, or
to be able to trace clearly the connection between the original
specific causes and the altered temperature.^
' The conclusions arrived at by M. Andral on tlie relation of the constituents
of the blood, &c., to temperature, are stated as follows in tlie 'Medical Times
and Gazette' of January ist, 1870. ist. As to fibrine. When the blood con-
tains more than xoW^^^s of this, the temperature rises, and in a correspoudinff
ratio. Tims, of all diseases, pneumonia is marked with the greatest increase of
iibrine, and is the highest in temperature of all the phlegmasisB. In 85 cases
in only 13 was the temperature below 39° C. (i02"2°E.) ; in 44 it was between
39° and 40° C. (i02-2° F. and 104'' F.); in 26 between 40° C. (104^ F.) and
41° C. (105-8° F.) ; and in 2 rose to 41-2° C. (= io6-i6°F.). In acute pleu-
risy, in which there is always less fibrine, the temperature only once reached
41° C. (i05'8° F.), and usually oscillated between 38'5' C. (= ioi'3'' F.) and
39'5° C. (i03'i° F.). M. Anclral, however, admits exceptions, as in erysipelas,
when there have been only yoVo^I^s of fibrines, the temperature has been
4i"8° C. (io7"24° F.). Still there are high amounts of fibrine never seen with-
out a corresponding rise of temperature — thus the fibrine never exceeds 10 parts
in a thousand without the temperature exceeding 40"^ C. (104° F.). But he
does not consider these as cause and effect, for in pyrexiae, where there is no
excess of fibrin, the temperature is as high or higher than in phlegmasitE.
Thus 42-4° C. (io8'32" F.) has been reached in typhoid ; 42° C. (107-6° F.) in
the onset of smallpox, the hot stage of ague, and in glanders, &c. Indeed, the
highest degrees are reached in. diseases when there is the least fibrine in the
blood.
2. The number of red globules does not much affect it. In a woman
exhausted by hsemorrhage, with only 21 parts of globules in the blood, the tem-
perature was maiutained at 37° C. (98-6° F.), and a chlorotic patient with only
^^o globules kept a temperature of 37-9° C. (100-22° F.). Of 20 cases with
38 — 117 per 1000 globules, the temperature varied from 37° to 38-4" C.
(98-6° to iori2°F.).
3. VThen the albumen escapes in the urine, theory would lead us to expect
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 143
§ 17. Breschet and Becquerel (Session of the Academie des
Sciences, 1 8th Oct,, 1841) were the first to point out the remarkable
depression of temperature in animals, the surface of toliose hody is
covered witli an imjoermeahle coating. They made the communication,
diminished temperature. More facts are wanted, however, to establish this.
Of 7 cases, the temperature was diminished in 5, and 2 had intercurrent
inflammation.
4. On the relations of the amount of zirea in the urine to the temperature,
M. Andral considers that the increased temperature generally means an increased
amount of urea in the uriue. Notably in fevers. He considers 10 — 15 per 1000
normal. lu 53 patients whose temperature was normal, tlic urea did not
exceed xo^th in more than 8 cases. In 45 others with non-febrile diseases it
ranged from 4 to 12 — loooths. But in 23 analyses in intermittent fevers, the
urea ranged from 13 — 32 per 1000. In pneumonia 20 — 29 per 1000, &c. Urea
is increased also in cirrhosis of the liver."
With regard to the artificial production of tuberculosis in animals, by
inoculations, and the injection of various irritants, the scope and purpose of
this work do not allow me to do more than refer the reader to the following
sources of information.
For an account of M. Fillembi's experiments communicated to the French
Academy in 1865—6 see the 'Edinburgh Medical Journal,' Feb. 1867, pp.
756—765.
For further experiments, English and Foreign, see also—
Dr. Wilson Fox, — 'The Artificial Production of Tubercle in the Lower
Animals.' (Macmillan, 1868.)
Dr. J. Burdoii Sanderson, — 'Appendices to Reports of the Medical Officer
of the Privy Council,' 1868 — 9, and his article, " Recent Researches on Tuber-
culosis," ('Edinburgh Medical Journal,' Nov. 1869, p. 385.) See also —
'British and Foreigu Medico-Chirurgical Review,' April, 1870, p. 389,
("Tuberculosis and Pulmonary Consumption.")
Niemeyer's ' Clinical Medicine,' American edition. (Henry Lewis, Gower
Street).
Niemeyer's 'Clinical Lectures,' (translated by Dr. Biiumler, New Sydenham
Society).
The number of German and French writers, and other contributors, is too
great to allow of more than mentioning the names of Virchow, Cohnheim,
Buhl, Ziemssen, Bastels, Chaveau, Cornil, Ranvier, and Petersen, and quoting
the following titles :
" Die Tuberculose, die Lungenschwindsucht, und Scrofulose, &c.," von Dr.
L. Waldenhurg, Berlin, 1869.
"Manuel d'Histologie Pathologique," MM. Cornil and Banvicr, p. 204.
Dr. Julius Pelersen's "Thesis for M.D.," Copenhagen, 1869, entitled,
"Lungesviudsotens og Tuberculosens omtvistede Contagiositet og Inocu-
labilitet."
This appears to me a fitting opportunity of doing justice to the labours of
two of our own countrymen, who have been somewhat unfairly neglected (per-
144 CAUSES OP ALTERKD TEMPKllATUllE IN DISEASE.
tliat rabbits whose shaved skin was covered with a coatirif^ of glue,
or taUow and rosin, lost from 14 — 18° C. [25*2° — 32*4° Tahr.] of
tlicir pro])or temperature, in the course of i or i ,V hour, and soon
after died. Tliese observers themselves remarked that what they
thus propounded was apparently contradictory to the received
notions about the functions of the skin. However, the observations
themselves have been lately fully confirmed by Gerlach (in Mailer's
'Archiv/ 1851, p. 467), Valentin (in ' Archiv fiir Physiologische
Heilk.,' 1858, p. 433). Edenhuizen (in ' Zeitschrift fiir rationellc
Med./i863, p. 25).'
Valentin has also shown that in animals thus treated, the respira-
tory movements are diminished to a third or even a quarter of what
they Avere. The taking in of oxygen and the giving out of carbonic
acid became diminished in a greater degree (to jV^h) ; but that on
the other hand, if the air which the animals breathe is raised in
temperature the refrigeration is checked, the breathing becomes
stronger, the animals become more lively, and the fatal termination
is retarded although not prevented. Edenhuizen found that the
animals [rabbits] perished after only a part of the skin was thus
treated, as soon as more than -^th or -^th of their superficies was
thus covered. The more the surface was thus coated, the quicker
and more remarkable was the sinking of the temperature, and the
more rapidly death set in. When a considerable portion of the
surface was left free, the temperature, pulse-frequency, and frequency
of respirations were all diminished at first; but the first two soon
recover again, and may even exceed the normal, while the frequency
of respiration still remains lessened. If a yet larger surface
(-]ths to l^rds) was left uncovered, the frequency of res[)iration was
diminished at first, but soon became increased, but did not exceed
the normal so long as the temperature and pulse did. If only
-^th to -^th of the surface was covered in this way, the quickened
breathing was the chief symptom, whilst the temperature and the
frequency of the pulse were less afiected. Laschkewitzch explains
]iai)S by accident) by tlie writers of some of the arliclcs referred to — I mean
Dr. Andrew Clark, and Dr. Edwards Crisp. A paper by the latter will be
found ia the ' Transactions of the St. Andrew's Med. Grad. Association,' vol. i,
p. 1 10. "With regard to Dr. Andrew Clark, I can state from personal know-
ledge, that his experiments on the artificial induction of tubercle were carried
on long before the publications of those who have ignored his labours. —
[Tkaxs.]
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 145
these symptoms by the increased loss of warmth in consequence of
paralytic dilatation of the cutaneous vessels.
§ 18. Very numerous experiments and investigations have been
made with the view of elucidating the hifluence of the nervous sij stem
iqmi temperature. Numerous very remarkable facts have been
added to our knowledge, partly by experiments and partly by means
of clinical observations. It is however not possible as yet to deliver
a comprehensive and satisfactory judgment on the mode in which
the nerves affect the temperature. Long ago there were numerous
observations, showing that after experimental division of the spinal
cord, or after severe injuries of it, there followed a peripheral ele-
vation of temperature, particularly by Clwssat (1820, ^Mem. sur
Influence du System. Nerveux sur la Chaleur Animale'), by Sir B.
Brodie (1837, ' Medico-Chirurg. Trausac./ XX, 146^), by Macartny
(1838, 'Treatise on Inflammation,'' p. 13), by Tr. Nasse (1839,
' Untersuchungen zur Physiologie and Pathologic/ II, 115), and
especially by H. Nasse (ibid. II, 190).
In opposition to these. Flour ens and Magendie observed, that the
temperature fell after injuries to nerves, and this fall was local when
nerve trunks only, general when nerve centres were damaged.
Claude Bernard gave in his adhesion to the latter proposition, which
he erroneously considered a constant phenomenon, when he published
his astonishing discovery of the effects of dividing the cervical sym-
pathetic (1852, 'Comptes Kendus dc I'Acad. des Sciences,^ XXXIV,
p. 472). He discovered that after the division of the connecting
branches betM^een the superior and inferior cervical ganglia, there
commenced an immediate increase of heat in the whole corresponding
side of the head, which could be especially well seen in the ear of a
rabbit. He also found that merely laying bare, or disturbing, or
pressing on the ganglia of the sympathetic nerve was followed by
great congestion, and increased development of heat. More lately
('Comptes Eendus,' Iv, 232) he made further communications,
according to which section of the lumbo-sacral plexus, or [of the
sciatic nerve, was followed by an elevation of temperature in the pos-
terior limb thus treated, and also that section of the brachial plexus
about the first rib, was followed by a rise of temperature in the
' Sir B. Brodie's first paper was in the ' Pliilosopliical Transactions ' for
181 1. It is referred to by tlie auilior, p. 25.— Tkaks.
10
146 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
corresponding anterior extremity. Bernard built upon these results
the theory of a special iullucuce of the sym])atlu.'tic on the blood-
vessels, and upon calorilication, and distinguishes the sympathetic
system from the motor and sensory nerves, as being vaso-motor, and
calorific nerves.
In his " Le9ons sur la Physiologic et la Pathologie du Systemc
Nerveux, ii, 490" (1858). Bernard formulated his ideas as
follows : —
1. La section des nerfs du sentiment outre I'abolition du senti-
ment, produit la dimimition de la temperature des parties.
2. Celle des nerfs du movement outre I'abolition du mouvement
donne lieu cgalement a un refroidissement des parties paralysees.
3. La destruction du nerf sympathique qui ne produit ni Timmo-
bilite des muscles, ni la perte de sensibilite amene une augmentation
de temperature constante et tres considerable.^
The most important questions arising out of these results of
experiment are : —
(j .) Whether the increased heat is proportionate to the excess of
blood in the part which occurs when the sympathetic is divided ?
(2.) Although the temperature (as compared with the other ear,
and with its height before the section of the nerve) may be consider-
ably increased^ does it remain within the range of temperature
which is proper to the internal organs of animals ? If these ques-
tions are answered in the affirmative, this phenomenon has only a
subordinate, mediate, and almost insignificant relation to the pro-
duction of heat. In that case, the section of the nerve merely acts
by producing a hypersemia, and the consequence of this hypersemia
is, that the normal blood heat is more perfectly attained and
exhibited by the parts thus more richly supplied with blood.
(3.) Pinallyj this question arises — Are they really the proper
fibres of the sympathetic, or those which although mixed with it,
are derived from the spinal cord^ upon which the phenomena
depends ? Is the sympathetic the special vaso-motor nerve (as
a
I. Division of nerves of sensation, besides producing anaesthesia, dimi-
nishes the temperature of the parts supplied.
" 2. Division of motor nerves, besides causing paralysis, gives rise also to
coldness in the pamli/sed parts.
" 3. Destruction of the sympathetic nerve, which neither produces muscular
paralysis nor loss of sensation, is accompanied with a constant and very con-
siderable elevation of tempei"ature."
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 147
Bernard supposes) or are the movements of the vessels dependent on
the cerebro-spinal centres ?
On all these. points, the majority of experimenters have decided
against Bernard. Brown-Sequard first entered the lists against
Bernard's conclusions. Before the publications of the latter in the
'Comptes Eendus/ the former had communicated the experiment
that galvanization of the divided portion of the cervical sympathetic
caused contraction of the vessels in the corresponding part of the
head, and in consequence of that, ansemia, and diminution of tem-
perature and of sensation (in 1852 in the 'Medical Examiner of
Philadelphia/ p. 486, of the vol. for that year). Shortly after
(in 1853, ^^ 'Experimental Researches/ p. 9) he expressed the
opinion, that the results of section of the cervical sympathetic ought
to be attributed only to a paralytic dilatation of the cephalic blood-
vessels, and the increased warmth referred to the increased congestion,
through the larger amount of blood flowing to the part. He pointed
out that hanging up the animals by their hind legs had almost
the same effect as division of the sympathetic. He concludes the
abstract {' On the Increase of Animal Heat after Injuries of the
Nervous System') as follows (p. 77) : —
(i.) An injury to the nervous system may cause either an increased
or diminished temperature in the parts which are paralysed, by it.
(2.) It appears that the respective shares of the sympathetic and
cerebro-spinal nervous systems in producing these, cannot well be
determined.
(3.) The degree of temperature of paralysed parts depends on the
quantity of blood which they contain, and this quantity varies with
the condition of the arteries and capillaries of the part.
(4.) It is a matter of fact, hitherto unexplained, that the arteries
and capillaries of paralysed parts may be either dilated, normal,
or contracted.
S?w/^(/ (1853. ' Comptes Rendus/ xxxvi, 377, and 'Med. Ztg.
von dem Yereiu fiir Heilkunde in Preussen,' xxii, 149) has pointed
out, that this elevation of temperature is not only produced by divi-
sion of the sympathetic, but that injuries of that part of the spinal
marrow which lies between the seventh cervical and the third
dorsal vertebra, which thus includes the eighth cervical, and the
first and second dorsal nerves, has the same effect on the tempera-
ture of the head.
Waller also ('Comptes Rendus/ xxxvi, p. 378) attributes the rise
118 CAUSES OF ALTKRED TEMPERATURE IN DISEASE.
of t("m])cralurc simply to the ))aralysis of the circular fibres of the
siiialliT arteries, and the hvpcrajinia thus induced, caused by the
section of nerve.
De Riii/fer ('Dissert, de actionc Atroptc belladonnje/ 1H53)
remarked also, that he had noticed no alteration of temperature
which could not be explained by the increased access of blood ; and
Uonders (' Aanteekingen van het Utr. Gen.,' 1853) remarks that
in these experiments the temperature of the ears very seldom
exceeds that of the rectum, that it is high just in proportion to
the amount of blood sent to the ears — that it diminishes when
they are congested — and that after ligature of the carotid the
temperature of the ear on the side of the section is no higher than
that of the other side, and that if the ears are forcibly rubbed
the temperature in both is alike.
Sc/iiJ' discussed the question from the most advanced point of
view, and made a number of fresh experiments (1855, 'Untersi^;- <a
chungen zur Physiologic des Nerven Systems,^ i, 124). He has
observed that the difference of temperature of the two sides of the
head (of the ears) may be very considerable, and may amount to
even 12° or 16- C. {^ 21-6° to 28-8° Pahr.); that the difierence of
temperature was proportionate to the difference in the quantity of
blood in the parts, and that when (as exceptionally occurs) the
section of the cervical sympathetic has no effect on the vessels of
the ear, there is also no elevation of temperature. lie seeks to
prove that the increased fulness of the vessels depends upon paralysis
of the blood-vessels, and that the larger quantity of blood circu-
lating through the part, causes the local elevation of temperature.
He also propounds that the sympathetic is not the sole and exclusive
vascular nerve of the head, but that the cervical auricular, the
facial, and the trigeminus nerve have their share; and also that the
part of the vaso-motor nerves of the head, which is actually con-
tained in the sympathetic, consists entirely of the spinal nerve
fibres contained in it ; that the vaso-motor nerves pass through the
spinal cord, and that a part of the medulla oblongata must be
regarded as a centre for the vaso-motor nerves, because those of the
head and trunk both meet there. He maintains that in complete
spinal paralysis of a part, the temperature of this must be elevated,
whilst in incomplete («'. e., paralysis of motion only) the temperature
must be diminished (p. 226) ; a conclusion which has since been at
least partially confirmed by pathological facts.
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 149
A further very important conclusion of ScMff's in its relation to
the pathology of feyer^ is this, which he claims to have established
by experiments V that the vaso-motor nerves of the face, and of the
distal portions of the extremities on the one hand ; and those of the
trunk, the arm (above the elbow), and the u])per part of the thigh,
on the other hand form two distinct groups, which keep perfectly
separate in their course through the spinal cord, so that the latter
group of vascular nerves, decussates laterally, as does the corre-
sponding group of the other half of the body, which those of the
first group fail to do ; and further, that when one cuts across the
left half of the spinal cord near the medulla oblongata, the vascular
nerves of the skin of the face, of the hands and feet, and the lower
part of the forearm, and of the leg (below the knee) of the left side,
and on the other side (the right) those of the trunk, the arm (above
the elbow), and the upper part of the thigh are paralysed.
Some further experiments of Schiff's which he published after-
wards in the ^Allgern AViemer Med. Zeitg.,' 1859, p. 318, are of
very great interest. He excited fever by injection of pus into the
pleura, or into the vascular system, in animals in whom he had
previously divided the left cervical sympathetic, or resected the
nerves of one extremity. As soon as the fever set in, the parts
unaffected by the section of the nerves began to rise in temperature,
whilst in the parts suffering from vaso-motor-paralysis, which were
previously warmer, the temperature either did not rise at all, or only
very slowly ; and when the febrile temperature was fully established,
the organs which before were warmest (the nerves of which were
divided) were colder than the corresponding parts of the other
(uninjured) side. He concluded from this, that the [paralytic]
hyperpemia (Blutiiberfiillung) induced by the nerve-section, and that
induced by fever (and congestion) do not depend on the same pro-
cess ; that the latter is of a much more active nature, and that there-
fore (as for that matter, Claude Bernard himself admits, as regards
the submaxillary glands, see 'Comptes Rendus,^ 1858) there must
exist in the nerves of the blood-vessels, such elements as, when
stimulated, cause [an active] dilatation (durch ihre Erregung eine
Erweiterung bedingen) ; but that, after section of the nerves, this is
no longer possible.
Knmnaul and Tenner's researches (in Moleschott's 'Untersuch-
uncjen zAir Naturlehre des Menschen und der Thiere,' 1856, i,
90 — 132) had considerable influence in again referring the pheno-
150 CAUSES OF ALTKRKD TKMPERATURR IN DISEASE.
mcna of warmth to the amount of blood contained in the vessels.
They obtained the important result, of constantly reducing the
increased warmth of the ear of the side on which the sympathetic
was divided, below that of the other car, and even lower than its own
temperature before the section, as soon as (in addition to ligaturing
or compressing the carotid on the same side) they also ligatured the
two subclavians at their origin, and thus prevented the establishment
of the collateral circulation. On the other hand they procured an
elevation of temperature if they only ligatured the subclavians, and
thus increased the lateral pressure of the blood in the carotid. The
effect of compression of the carotid on one side, after previous liga-
ture of the subclavians, had parallel results, whether the sympathetic
were previously divided or not, and the section of the sympathetic
produced no greater increase of heat than the increased pressure of
blood. However, both Lussana and Ambrosoli ('Gazz. Lombarda,^
1867, Nos. 25 — 33), after suspending animals by their hind legs, did
not find so great an increase of temperature in the ears as they did
after division of the sympathetic ; and they think that in the latter,
a local i)athological process of blood-dissolution (decomposition)
induced by the section of the sympathetic, causes the elevation of
temperature, and not mere hypersemia, or increased functional
activity.
Broioi-Sequard (^Experimental Researches, applied to Physiology
and Pathology,' p. 73) discovered also that complete division of
one lateral half of the spinal cord in the dorsal region was followed
by a rise of temperature in the hinderextremity of the corresponding
side, and a fall of temperature in the opposite limb.
iiSc?/^/^ (^ Untersuchuugen,' p. 1 96) confirmed this, but attributes
the (low) temperature of the opposite extremity to an accidental
injury of one half of the spinal cord in performing the section of the
other half.
TschescJiicM/i, after complete section of the spinal cord in a
variety of situations, has always observed a suppression of the active
operations of the vessels, and a sinking of the general temperature,
in addition to the loss of voluntary movements (Reichert's 'Archiv,'
i865, p. 152); and he considers the primary cause of this dimifiis^ed
warrathy to consist in the paralytic dilatation of the vessels, their
overfullness of blood (and especially in the veins), in the hindrance
to the free circulation of the blood, and consequently in the increased
radiation [or loss] of heat. He found that the rapid sinking of the
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 151
internal temperature after division of the spinal cord might be dimi-
nished or even prevented, by enveloping the body in bad conductors
of heat [wool, -cotton, &c.], and thus hindering the loss of heat from
the surface of the body. When Tscheschichin, however, divided the
medulla oblongata in a rabbit, near to its junction with the pons, he
found that immediately after the operation, the general temperature
began to rise, and the pulse and respirations were greatly quickened.
After half an hour, the temperature was from 39*4° to 40" 1° C.
(io2-92°to 104-18° P.); after an hour it rose to 41-3° C.( I o6- 1 6°P.),
whilst the respirations ranged from 78 to 90, and the pulse became
uncountable. Immediately after the operation, the reflex pheno-
mena began to be unusually evident, and reached so extreme a
point, that the least touch excited convulsive movements of the
whole body of tlie animal. After an hour and a half, the tempe-
rature reached 42*2° C. ( 107*96° P.) ; after two hours 42*6°
(io8"6S°F. ; more rapid breathing and convulsions set in, under
which in half an hour more the animal died.
TscJiesc/dchin connects these facts with the theory of centres of
control (Moderationscentren) which have their seat in the brain,
in order to regulate the activity of the spinal cord. By the ceaseless
activity of these, the intense activity of the spinal cord is diminished;
when they are destroyed or isolated, the activity of the spinal cord is
morbidly increased, and for some time exhibits itself in excess of
functional activity (increased reflex action, quickened respiration,
acceleration of the cardiac systole (Herzschlag), and increased
animal heat) .
Naunyn and QuincJce (Reichert's ^Archiv,' 1869, p. 174),
asserted that after crushing of the upper part of the (spinal) cord,
remarkable elevations of temperature were only met with when
the animal was prevented from losing heat, otherwise there was
always a rapid sinking of temperature, lasting till death. They
propound the view that injuries to the cord have a two-fold opera-
tion— an increase of warmth production, and an increase in the
amount of heat given ofp. By these contrary forces they explain the
contradictory results obtained by difl'erent observers. They further
observed, that when the cervical portion of the medulla was divided,
the rise of temperature was more rapid than when the section was in the
dorsal portion. Naunyn and Quincke have lately published other in-
teresting experiments, and have shown, that after division of the spinal
cord, the temperature can be kept at a low degree by means of
152 C.VUSKS OF ALTKHKI) TK.M PrK ATUllK, IN DISKA^K.
([uiniiic [by limiting the wannth-production]. Fischer (' Einfliiss
ilcr Riickenmarksvcrlctzungcu auf d'w Kiirperwiirino.' ( )rig. Mittlnil
itn Centralblatt, 1869, p. 259), believes that he has met with cases
which justily him in concluding that there is a centre in the cervical
portion of the cord for limiting the temperature [cin Temperatnr-
hemmungscentrum], by irritating which we get a decrease of
temperature; by paralysing it there is increased heat obtained; and
that this centre is to be looked for in the anterior fibres of the
cervical portion of the spinal cord.
Remotely, and one might almost say negatively related to all these
experiments are those of Bre?ier :\nd Chrohah (1867, 'Wiener medic.
Jahrbiicher/ xiv, p. 3) who have investigated the question whether
the nerves of a part supply the stimulus which causes the febrile
elevation of temperature in an inflamed part; by means of experi-
ments on animals, in whom they have as far as possible divided all
the nerves of one part of the body. After the injuries caused by
the operation have healed, they have set up local inflammations
in the nerveless part; and they think themselves justified in con-
cluding that the fever of the traumatic inflammation is independent
of the nervous connections of the inflamed part witli the nerve
centres.
Clinical ohservations furnish us with only a few cases exactly
analogous to the results of experiments on the relations of the
nervous system to the temperature of the body. However, we may
consider the following as analogous spontaneous conditions : —
(i.) The local alterations of temperature in neuralgias, during the
paroxysms of pain.
(2.) Observations on temperature in paralysed parts.^
(3.) Observations on variations of temperature in those forms of
disease which are considered as vaso-motor neuroses.
(4.) The effect of mental exertion, or excitement in elevating the
temperature in cases of disease, the effect of different kinds of delirium,
and the moderation of febrile temperature, which is sometimes
observed after a quiet sleep.
* Mr. Earle published a paper entitled " Cases and Observations lUustraliiig
tlie Influence of the Nervous System in Regulating Animal Heat," in vol. vii,
of the ' Medico- Chirurgical Transactions ' (1816), in which the following cases
appear sufficiently interesting to justify quotation: —
Case I. — A sailor had paralysis of the left arm after an injury. The
temperature of the right (uuinjured) hand was 92^ (F.), of the left (or paraly-
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 153
(5.) The great elevation of temperature in acute (rapid) inflam-
mation of the brain.
(6.) The midre enormous elevation of temperature in injuries
destructive of the spinal cord.
(7.) The very disproportionate rise of temperature at the end of
tetanus and other fatal neuroses.
These facts are indeed very favourable (vollig geniigend) to the
theory that a large share in the regulation of heat belongs, at least in
tic) hand only 70" (F.) ; after electricity for ten minutes it rose to 74° (F.). On
another occasion the temperatures were,
r Hand
Paralysed limb < Arm (at elbow)
L Axilla
r Hand
Healthy limb < Arm (at elbow)
(.Axilla
Before electricity. After eleetricity.
71^ ■ 77°
80° 83^
O O
92 93
92° 92°
96' 96°
Case II. — Excision of portion of ulnar nerve (about one inch) for neuralgia.
Five years after the cleft between little and ring fingers of that hand = 57° ;
other parts of hand 62". Between little and ring fingers of other hand 60° ;
other parts of hand 62^, as before.
He also states that a friend of his examined twenty-five cases of paralysis in
the Bath Hospital, and always found the paralysed limbs colder than normal.
See, also, a paper by Dr. Yellohj in vol. iii of same 'Transactions.'
More recently Mr. Jonathan Hutchinson has published a series of accurate
observations on temperature (inter alia) after injuries to nerves in the 'London
Hospital Reports,' vol. iii, p. 305 — 324. The following results seem especially
worthy of selection.
Case III. — Injury to median nerve supplying the forefinger. Difference of
10° F. (5"5° C.) between that and adjacent thumb.
Case IV. — Section of ulna and median nerves of right hand — latter partial
only. Temperatures — Fourteen weeks after the accident the following re-
n\arkable difference was noted : " Cleft between little and ring-fingers, left 83 ;
right (paralysed) 64'"' = 19° F. = 104 C. Twenty-one months after there
was still lo"" difference in this situation, and 5° between the right and left hands
in the cleft between fore and middle fingers — the paralysed parts being that
much colder.
He records other cases with a difference of 2°, 4°, 5^ 9°, 10", 11°, &c. See
also a case of injury to cervical spine, in a boy aged 6, under Dr. Fraser's care
(in the 'Loudon Hospital Reports,' vol. ii, p. 365). I myself saw a case of
division of the median nerve, in which nine months after there was a difference
of 13° between the healthy and paralysed hand (between the middle fingers—
the paralysed = 75°, the other 88°). Dr. Powell kindly verified this for me. —
[Tkans.J
154 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
complex cases, to the nervous system. The influence of certain
nerve-tracks on the activity of the heart on the one side, and on the
circulation on the other, is indeed indubitable. On this account it
may be safely assumed, that alterations in the amount of blood in
the peripheral vessels, influence in more ways than one the warmth
of the places concerned, and of the general temperature also.
A great part of the pathological phenomena of warmth, may
be only the expression of the action (verhalten) of the vaso-
motor nerves. And, perhaps, even in actual diseases of the
nervous system, the fluctuations of temperature, particularly if
slight, must be attributed to an alteration in the circulation. But
we learn from another series of observations, those namely with
enormous elevation of temperature, that some hitherto unknown
power has sway over animal heat, since the most remarkable
alterations of temperature occur with profound disturbances of the
nervous system, without corresponding anomalies of circulation, and
it is perhaps not too much to affirm that the integrity of certain
parts of the central nervous apparatus is more necessary for the
regulation of animal heat, than that of any other parts of the body.
§ 19. Muscular exertions generally cause a very considerable
rise of temperature, in cases where there is any previously existing
morbid condition, however slight. On this account toe are quite
justified in feeling anxiety ahout the health of any one lohose tem-
perature exceeds the normal after only moderate exercise, however
cheerful and apparently vjell he may seem in other respects.
During convalescence, however, the temperature generally rises
one or more degrees (Centigrade :^ i-8° Fahr. or more) on the first
occasion of rising from bed, and sitting up, even when this has not
been permitted at all too soon. If the sitting up has been dispro-
portionate to the strength of the patient \i. e., too long at any one
time], the temperature generally rises again, so that in this way we
have a useful criterion as to how far we may allow the patient to
relinquish his couch. In confirmation of my own publications on
the enormous elevation of temperature in the fatal termination of
cases of tetanus, Ley den in 1863 ('Beitrage zur Pathologic des
Tetanus,^ in Yirchow's ' Archiv,' xxvi, 538), and Billroth and Fich
in the same year ('Versuche liber die Temperaturen bei Tetanus,' in
the 'Schweizerische Vierteljahrschrift,' viii, 427) instituted experi-
ments on animals, which they artificially tetanised, and found that
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 155
the teinperatare in these cases was increased as much as 5° or 6° C.
(=9°__io-8°rahr.).
Tlie removal' of a sick person^ and the sum-total of the in-
fluences then brought to bear upon him [?". e., the mental and
physical conditions induced by the transfer of the patient], have
almost always a disturbing effect upon the temperature, and it is
about equally common to find a rise of temperature, or a reduction of
a previously high one. It may therefore be laid down as a rule, that
an observation of temperature taken immediately after the removal of
a patient to a fresh place [admission into a hospital ward, or after
a journey of any kind] is by no means decisive.-^
An athlete, who whilst running a (foot) race, became faint and
insensible, and was brought into my wards, showed a very remarkable
rise of temperature in consequence of his strenuous muscular ex-
ertions. His temperature was 40*5 C. (io4"9° ^O* ^'^^ ^^i^ pulse
128 per minute. The urine contained TTrth of its volume of albu-
men. Two hours afterwards the temperature had fallen to 39"i°0.
(to2'38°P.) On the second morning the temperature was normal,
and remained so, whilst the albumen in the urine rapidly diminished,
and after a few days entirely disappeared."
On the sliare which post-mortem rigidity of muscles takes in the
temperature of the dead body, see further on.
§ 20. It seems almost superfluous to remark, that this enu-
meration of the influences which aS'ect the temperature is by no
means exhaustive. For not only is the material furnished us by
1 The author does not of course mean tliat no importance is to be attached to
a high temperature, or a low one, after removal of a patient — the preceding
paragraph (iu italics) forbids tliis — but simply that for purposes of prognosis,
or even diagnosis, we must reject such temperatures, or at all events give them
a subordinate value — since the mere transport of the patient is sufficient, iu his
weak condition, to disturb his temperature — either from the muscular exertion,
or the mental excitement — or the exposure to cold or heat, &c. — [Tbans.]
5 Dr. Robert Barnes, in his clinical lectures at the London Hospital, laid
special stress upon the development of a febrile state, by excessive uterine
(muscular) action — especially in delicate women — and adduced this as one of
the best arguments for skilled interference in protracted labour. I remember
a lad of nineteen who walked seventy miles in two days, who had a temperature
of 105°, with a pulse of 130 next day, with enormous quantities of lithates in
the urine. In three days his temperature was normal. Another youth, a
little older, walked from Dover to London iu about the same time, and
was similarly affected. — [Trans.]
l.")''» CAUSES OF ALTKIIED TEMPERATURE IN DISEASE.
oxporiinent and clinical observation to he regarded in all its detail,
and in every i)os:'iblc point of view \/iL in its infinite nnances], bnt
there are also, no doubt, numerous real causes (Ursachcn) of
alteration of temperature, as yet quite unknown, or only partially
auticijiated.
This is especially true of the original causes of altered tempe-
rature in the diseases M'hieh are said to arise spontaneously, and also
in many which originate in contagion (Infectionskrankheitcn). It
is very evident that the more or less extensive tissue-changes which
occur in severe diseases, and especially those complete destructions
of the parenchyma of organs, which have lately become accessible, as
it were, to improved methods of research, must have a very important
share in the production of high temperatures. It is, however, very
difficult to accurately investigate them, on account of the complexity
of the phenomena. It is also very apparent that changes in the
l/loocl itself, processes akin to fermentation, often occur, which are
equally capable of increasing the amount of heat produced ; as,
on the other hand, some things in the blood may contribute
to limit the chemical processes on which the warmth-production
depends, and either to hinder or promote the giving off or loss of
heat.
But from this general idea of the possibility or probability of the
influence on the temperature of morbid processes in the tissues or
blood no jiarticular good results at present. We cannot indicate
the special chemical processes which influence the production of
heat ; we cannot say why the temperature is such and such in one
form of disease, or why it differs from that of another disease. We
ask in vain why in many severe disturbances in the economy, accom-
panied with very extensive (reichlicher) tissue changes, the tem-
perature, as a rule, remains normal. Sometimes the absence of any
influence on the temperature appears to depend upon the slow and
tedious development of the changes, and in such cases the com-
mencement of a change in the temperature either heralds the approach
of a complication, or indicates the more rapid development of a
previously existing morbid process.
On the other hand, in some affections of remarkable chronicity,
alterations of temperature may be noted for months, and even vears,
and these not inconsiderable ('Forms of Chronic Fever').
Moreover, we must not forget, that for the most part we are
accustomed to observe only the results of two factors, namely, that
CAUSES 01' ALTERED TEMPEUATURE IN DISEASE, 157
of warmth-production, and that of the giving-ofF, or loss of warmth,
and not the factors themselves, so that many a case of over-pro-
duction of heat 'may escape observation, because the giving-off of
heat is simultaneously increased. So that a previously existing over-
production of heat may suddenly become noticeable on account of
some subordinate intluence on the parts which give off heat,
whereas before it had been latent, on account of a satisfactory
compensation.
§ 31. Besides the external influence mentioned, and in addition to
processes occurring in the organism itself, there are also individual
circumstances and surroundings, which have their share in causing
deviations of temperature, and especially in affecting the facility with
which they occur, and the extent of the variations themselves.
Whether the disease which affects the patient necessarily modifies
the temperature in itself or not, we may remark in almost every sick
person, a greater sensitiveness to accidental influences. Even when
the temperature has been unaffected by the disease, the most varied
influences will seem to disturb the equilibrium, and may sometimes
cause very considerable rises or falls of temperature. Tiiese may
either be partial, or extend over the whole body. Diseases in which
the temperature is always affected, exhibit a similar sensitiveness and
mobility of temperature. Yet there is a great difference in the
degree of sensitiveness to accidental influences. The more decidedly
typical, regular, and uncomplicated the course of a disease is, the
less is it affected by accidental influences. On the other hand, in a
typical form of disease, in slight cases of illness, and in such as con-
stantly admit of deviations from other causes, accidental influences
operate most markedly. The severity and stage of the disease affects
the stability of the temperature ; or in other words, its dependency
upon accidental influences. At the real commencement of an acute
typical disease^ outward influences affect it but little; the less decisive
the symptoms which usher it in, the greater effect external influences
will have. Mild cases of disease are chiefly thus aftected from their
commencement, to about their acme. In the further progress of the
disease, there is also a distinction as regards the mobility of tempe-
rature, in response to external influences. The more variations the
disease itself exhibits, the longer convalescence is protracted, the
greater effect of these on the temperature, whilst in rapid recovery
very powerful external influences are often quite powerless to disturb
158 CAUSES OF ALTERED TEMPERATURE IN DISEASE.
the temperature. lu convalescence, tlic outward influences often
become once more of consitlerable importance, but especially when
convalescence is only partially establishetl, and when the embers of
the disease are, as it were, still smouldering.
The direction in which an accidental influence tends, is not unim-
portant [/. e.f whether it tends to raise or lower the temperature] . If
this is in the same direction as the natural course of the disease at the
time, the effect is all the more certain : if the operation of the cause
is in an opposite direction, the effect is less certain. Even the "daily
fluctuation'' has an influence in this point of view. Circumstances
which raise the temperature operate most certainly at noon, and in
the afternoon, whilst those which depress the temperature, act most
surely at night or in the early morning.
§ 22. Apart from all previously existing or special morbid condi-
tions, the degree of sensitiveness to accidental influences on tempe-
rature is very varied in different persons.
In children the temperature exhibits great mobility in disease. Not
only do slight ailments induce a great amount of disturbance, and
not only are the daily fluctuations greater than in older patients, but
influences of all kinds also have a more powerful effect.
In the female sex, even in adult life, there is a resemblance to
children in this respect. Indeed great mobility of temperature is
most perfectly developed in women. Apparently causeless elevations
of temperature occur in them with the rapidity of the recoil of a
spring, and outward accidents exert a wholly unusual influence.
This is especially seen in those individuals who exhibit the nervous
temperament (hysterical persons, and the like).
In the male sex, also, we find certain individuals, whose tem-
perature is far more impressionable by external influences than
that of others, and in general these also are of the nervous tem-
perament.
Men of advanced age differ in this respect from younger adults.
It is more common to meet with a sluggish course of temperature ui
them, than with increased susceptibility. In very old people, it is
common in various diseases, to find the temperature half a degree or
more (C. = -^2^° Fahr.) lower than is common in similar circum-
stances in younger people.
Individual susceptibility is also sometimes strongly shown under
certain influences, and but slightly under others. This may depend
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 159
upon many personal peculiarities (idiosyncrasies) ; and it appears
very clear that, on tlie one hand, repetition of certain influ-
ences may augment the sensibihty of the temperature, whilst on
the other hand the repetition of certain influences may weaken, or
blunt this susceptibility.
CHAPTER Vll.
ON LOCAL ALTERATIONS OF TEMPERATURE; AND ALTERA-
TIONS OF THE GENERAL TEMPERATURE IN DIFFERENT
DISEASES.
§ I. The variations from tiie normal temperature occurring iii
sick people, are partly local^ confined to special regions of the body,
and partly general; that is, extending more or less over the whole
body.
This antithesis must not be interpreted too strictly. It is very
seldom, perhaps never the case, that with any considerable local
alteration of temperature, that of the whole body remains perfectly
normal in all respects, not only as regards its absolute height, but as
regards its stability and freedom from fluctuations (Eestigkeit und
Unveriinderlichkeit), notwithstanding adverse influences.
On the other hand, when the general temperature is much aff'ected,
it is very seldom that the increased heat is distributed quite impar-
tially over all the difl'erent regions of the body. Indeed, in the com-
mencing period of the disturbance of temperature, and afterwards
when it is still more affected, the contrast, as regards warmth, between
various ])arts of the same body, is often well-marked.
But the contrast between local and general alterations of tem-
perature is sufficiently indicated by the fact, that sometimes the one
and sometimes the other is the most important.
§ 2. Since even in health, different parts of the same body differ
from one another in their temperature, in disease the contrasts are
still more marked.
The temperature may be locally elevated, in contrast with other
parts of the body, or with even the general temperature; or it may
be lower in one part than that of the rest of the body. Although it
has been rendered indubitable by separate observations, that some
CAUSES OF ALTERED TEMPERATURE IN DISEASE. IGl
local elevations of temperature in parts specially atfecteJ, actually
exceed the temperature of the blood, although only very slightly, yet
in other cases it is certain, and in very many others at least possible,
that the local rise of temperature is only apparent, and that the parts
with liigh temperature only exhibit the degree of blood-heat more
perfectly thau other accessible regions of the body. We must not
overlook the fact, that we do not accurately know the temperature of
the blood, and that that is possibly even higher than our observa-
tions taken in the most sheltered spots appear to show; and if
Brown-Sequard's previously quoted opinion on the true temperature
of human viscera be confirmed, this will very seldom be found
exceeded by any local elevation. The local increase of heat in so far
as it is a more complete exponent of the true blood-heat, may depend
either on a freer access of blood to the part, or of a less perfect degree
of cooling, or on both combined.
§ 3. Local elevations of temperature have been met with in the
following conditions —
(a). In inflammations.
According to theory, and the subjective feelings of the patient,
and even when estimated by the objective method of laying the
observer's hand on the inflamed part, there is a very considerable
elevation of temperature in a part which is inflamed, and this opinion
has gained general credence. Direct measurements [by the thermo-
meter] have however shown that this does not always occur, and that
the local elevations of temperature which are sometimes met with, are
even then very moderate in amount.
We owe the first observation of increased local temperature from
inflammation to John Hunter, as has been remarked previously.
After an operation for hydrocele, he found the temperature of the
tunica vaginalis to be 92° E. (== 33"33° C.). ''The cavity was
filled with lint, dipped in salve.'^ The next day the temperature was
found to be 984°!'. (=37*i°C.); which was indeed a very con-
siderable elevation of temperature, yet not exceeding that of the
blood.
John Hunter made many similar observations, yet in experiments
which he made on animals, after artificially induced inflammation, he
did not discover any alterations of the local temperature.
Numerous examples of locally elevated temperatures were pub-
\\A\tKi\i^ Breschet and Becqiterel (in 1835, loc. cit.) They were
11
lCt2 CAUSHS OK Al/l'Kin;i) TKMl'KKATURK IN DISKASK.
furnished by a thermo-electric apparalus. In n scrofidous girl, the
tein[)erature of whose mouth was 37'5°C. (99'5° ^•), they remarked
ill au intlamed glandular swelling in the neck a temperature of 40°C.
{104° F.) In other cases there was also a dillVrcnce between the
heat of inllaincd j)artSj and the general temperature. Yet it was
always much less than that above. j\[any doubts however have been
raised against the accuracy of these experiments.^
Gierse's experiments show an increase of heat in iuflamcd parts
amounting to half or even a whole degree Centigrade (= "9 to
1-8° F.).
Barensprnng iowwdi no rise of temperature in an artificially induced
erythema, but in a case of crural i)hlcbitis he found the temperature
in the j)atieiit's diseased thigh, at the lower part, 1° R. (= 2*25° Fall.)
hotter than in the healthy limb.
Juhn Simon has ])ublished some very important observations in
Holmes' 'System of Surgery/ i860, article, "Inllammation/' vol. i,
j). 43 [2ud edition, 1870, vol. i, p. 18, &c.] They were made by
the help of a thermo-electric apparatus [of platinum and iron,
connected with a galvanometer, devised by Dr. Edward Montgomery] .
Mr. Simon found —
(i). "That the arterial blood supplied to an inflamed limb is less
warm than the focus of inflammation itself;
(2). "That the venous blood returning from an inflamed limb,
though less warm than the focus of inflammation, is warmer than the
arterial blood supplied to the limbs ; and
(3). "That the venous blood returning from ^w inJIamedWmh,
is warmer than the corresponding current on the oj)posite side of
the body ."2
Billroth and Hufschmldt only obtained negative results. The
figures are added up incorrectly in the original. But it appears
from the observations themselves, that in 37 comparative measure-
ments of temperature in a wound and in the rectum, the heat of the
wound was less than that of the rectum 28 times ; the two tempera-
tiire were alike 8 times, and the temperature was only once higher
* Especially by Helmholtz, and Ludwig. See note to J//-. Simon's article,
quoted above.
- Mr. Simon's article on "Inflammation" gives a very interesting resume of
what is known of the relations of temperature and inflammation. The same
volume of the 'System of Surgery' also gives charts of the temperature in
tetanus, traumatic fever, &c., &c.
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 163
in the wound (by o'3° C. = 0*54° E.) than in the rectum^ after the
wound had been irritated by turpentine.
In 9 comparative observations on the temperature of an inflamed
vagina and that of the rectum^ the temperature of the vagina was
5 times lower than the rectal ; both temperatures were alike 3 times,
and once the temperature of the vagina was -f^° C. (= o"36° F.)
higher than that of the rectum.
Billroth remarks, that although hypersemic parts may on that
account appear warmer, because there is greater fullness of the
blood-vessels, than in healthy parts, yet there is not necessarily any
greater production of warmth in the inflamed parts.
In four observations on a man suffering from a very extensive
difl'used abscess in the subcutaneous connective tissue (diffused
cellulitis) the temperature of the wound was lower than that of the
rectum or axilla.
0. Weber in 1864 published a number of observations in the
'Deutsche Klinik' (Nos. 43 and 44), which, however, furnish
equally dubious results. In 12 thermometric observations on men
suffering from wounds (from operations) the temperature of the
wounds was six times higher, three times lower, and three times the
same as that of the mouth and the axilla. However in the first
class of cases the temperature was only -{\j° C, (= i"o8° F.) in
favour of the wound. It was also noticeable that the temperature
of the wound was most markedly elevated where the superficies of
the wound lay somewhat protected, and towards the interior ;
whereas when the wound was in an exposed part, it was much less —
owing perhaps to cooling and evaporation. He also remarked that
with continued and profased suppuration, the temperature of the
wound decreased.
In a series of 31 experiments on dogs and rabbits, the thermo-
metric observations showed the warmth of the wounds (or inflamed
parts) to be higher than that of the rectum 9 times, equal to it
6 times, and less warm 15 times. The maximum difference in
favour of the wound was 1° C. (i-8° F.) in rabbits, and 0-3]° C
(=0-63° F.) in dogs. Besides this, 0. Weber has repeated and con-
firmed Simon's experiments, and agrees with Simon's conclusions.
We may at least conclude from these exi)erimeiits that the
greatest heat in inflamed parts only exhibits a moderate rise of
temperature — and it still remains open to discussion, how much is
due to hyperajmia, and how much to true local production of heat.
IT)! CAUSKS OF AI-TKUKD TKMPERATUllE IN DISEASE.
res|)ectivclv. In a >i;ri-:it nuinbcr of cases there was no increased
heat in the wound, and it was niuch more coinmon to meet with a
lower temperature than that of the rectum,
Jacobson and Bernhardt (1868, 'Centralbl. Orig. Mitth./ p. 643)
have also pointed out that the temperature in in (lamed serous cavities
(pleura and j)eritoueum) may be lower than the heat of the same
parts when healthy, or than the temperature of the heart.
So also Laicdieti (1869, ' Centralblatt Orig. Mitth., p. 291)
found that the temperature of the skin, however deeply inllamed,
and that of the muscles, even in their deepest layers, was never
so high as the temperature of the interior of the body, and he
found [in opposition to Simon] the temperature of tlie arterial
blood higher than that of the focus of inllammation to which it
was streaming.
{b). That au elevated temperature may be caused by simple
hyperemia, or at least a temperature relatively high under the
circumstances, in relation to other parts of the surface of the body,
appears from the above quoted experiments on division of the
sympathetic, with ligature of the subclavian, and of suspending
animals by their hind legs. In the human subject, however, we
have no trustworthy observation of a rise of temperature through
simple hypereemia : and it is particularly to be noted, that the
local ap])lication of mustard does not cause a rise of temperature.
(c). In the exanthema la, the inflamed parts of the body appear to
show a higher temperature than those parts free from the ex-
anthem, as the experience of Gierse and Biirensprung indicates.
{d). In neuralgia, and local cram^js, the temperature of the skin
of the painful or cramp-affected part, appears to be somewhat raised;
which generally coincides with great reddening of the skin, and must
apparently be attributed to increased afflux of blood, but perhaps
also to local diminution of cooling, although in cramps there may
very well be increased warmth-production.
{e) . As regards paral//sed parts, Schmitz has observed a slight
diminution of temperature ; Bdrensprung also, in four cases, found
the temperature of the paralysed parts less in three cases, and a trifle
higher in one case, than in the healthy parts. Nothnagel (Berliner
'Klinische AYochenschrift,' 1867, p. 537) found in the hollow of the
hand of a paralytic arm a temperature of 2° C (= y6° P.) loioer
than in the healthy side. [See also note to page 153 for experi-
ments of Earle, Hutchinson, and others.]
CAUSES OF ALTERED TEMPERATURE IN DISEASE. Ifij
On the other hand, Folet {in the 'Gaz. Hebdoin./ Nos. 12 and
14 for 1867) made continuous observations on hemiplegic patients,
and came to the following conclusions —
(i). In the immense majority of cases, the commencement of
hemiplegia is accompanied with an increased temperature on the
affected side ; both sides are very seldom ahke, and a diminished tem-
perature on the diseased side is hardly ever noticed.
(2). The rise of temperature varies between -f^° and -p-„° C.
(•54° and 1-63° F.) but seldom exceeds 1° C. (= i-8° F.).
(3). The presence or absence of contractions has no influence on
the thermometric results.
(4). The thermometric difl'erence may be greatly augmented by
various primary causes.
(5). The original cause of the hemiplegia has no effect upon the
result (?).
(6). Recovery from the paralysis tends to equalize the tempe-
rature again : if the paralysis continues, the height of the tem-
perature varies greatly, and in one case may return to the normal
in a few months ; in others, may continue unec^ual for even years
together.
(7). Undoubtedly paralytic atrophy necessitates depression of
temperature.
(8). In an old hemiplegia, when the affected side exhibits a high
temperature, and the other side becomes paralysed at a later date,
either the two sides become equalized in temperature, or the side
last paralysed now becomes considerably hotter.
(9). The general temperature of hemiplegic patients is not usually
above the normal, but exhibits an average height of 37° C.
(98*6° r.), except in the last hours of hfe, when it generally rises.
I/epine ('Gazette Med.,^ 1868, p. 501) states that he has
found —
{(() . That in a recent case of hemiplegia, the paralysed limb is at
first warmer than the liealthy one; and on exposure to a certain
amount of cold, loses more heat than the sound one ; with a still
greater degree of cooling, however, it loses less heat than the
other.
{/j). On the other hand, in a very old case of hemiplegia, the
paralysed limb appears colder than the other, but remains relatively
warmer than the healthy oiie when exposed to cold, and with artificial
heat becomes less warm than the sound limb, thus exhibithig less
160 CAUSES OK ALTERED TEMPEHATURE IN DISEASE.
extensive lluctuations eitlier upwards or downwards under exlernal
lliernial inlluences.^
1^'iG. 1. § 4. An incn'dftcd Icmpera-
tiire extending all over one
half of the bodj/ witliout any
evidence of any local diseased
j)rocess going on on either
side of the body, has been
many times, and very ])er-
sistently observed by rae, in
a person sufi'ering from a])pa-
reutly hysterical p])inal dis-
ease.
This girl, who was 18 years
old, was often attacked with
partial [i. e., right-sided)
hyperaemias,and urticoid erup-
tions, local sweatings, and
very changeable and varied
symptoms in different internal
organs. Besides this, at other
times than the local hyperrc-
mias of the skin, she exhibited
all over the surface of the
body, from i to i C. (= -36°
to '9° r.) higher temperature
than in the vagina ; in the
' If these observations should
be confirmed by further experience
(as I believe they will, for the
most part), it is clear that our
means of diagnosis in cases of
feigned or doubtful paralysis, have
received a valuable addition. I
believe, myself, that the tempera-
ture mainly depends on the amount
of cerebral or spinal irritation, or
in other words, on the more or less
active changes going on in the
central portions of the nervous
system, at or around the scat of
the lesion.— rTRAMS.l
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CAUSES OF ALTERED TEMPERATURE IN DISEASE. 167
right axilla (as well as in the right groin) there was a persistently
higher temperature than in the left ; the difference being sometimes
only a few tenths of a degree (Centigrade), sometimes as much as
i'°C. (=37°F.).
There were occasional, apparently purposeless (unmotivirte)
elevations of temperature as much as to 3 9 '5° C. (i03*i° F.) ;
through which the temperature of the two sides was sometimes
approximated, and sometimes still more discrepant.
This very remarkable beliaviour of the temperature, which lasted
almost a year (and of which the accompanying curve (fig. i),
represents a short period) could scarcely mean anything else but a
disturbance of the vaso-motor nervous system, which whilst it
affected both sides, affected the right much more than it did
the left.
§ 5. More or less extensive partial depressions of temperature,
occur pretty commonly, especially in mortified (gangrenous) parts,
also in oedematous and indurated conditions, and in disused parts
of the body [ausser Activitat gesetzten Korperstellen — probably
the author means in limbs disabled by accident, or paralysis, or
purposely kept inactive, as in the limbs tied up by fakirs, or
impostors], and especially whenever the access of blood to a part is
diminished, or its cooling becomes excessive. In direct contrast to
the internal temperature which is often excessively high, the surface
of the body often shows more or less extreme depression of tem-
perature, particularly after cold applications, in febrile rigors, and
in all collapsed conditions. It would however be very erroneous
to regard the partial depression of temperature in these cases as an
isolated phenomema, it ought indeed rather to be regarded as part
of a very complicated process.
§ 6. It need scarcely be remarked that alterations of the general
temperaliire are the most important phenomena in pathological
thermometry whether we regard them theoretically, or practically.
The temperatures taken in either the axilla, vagina, or rectum
(provided these are not affected by any local processes of disease)
approximate as closely as is possible in a living man, to the tem-
perature of the blood, and also to the general temperature of the
individual.
This general temperature (Temperatur des Gesammtkorpers)
in its manifold, and ol'ten extremely ra])id changes, is not tlie only
108 CAUSES Ol- AJ/rKRKD TEMPERATURE IN DISEASE.
staiidartl we possess, but it is at least a very drlicate gauge
(]\[ass-stab) for the general condition of the system (Allgemeinver-
lialten) in disease.
Then the question immediately occurs — what importance ought
we to attach to the general condition of the system? and further,
what are the processes which are connected with the temperature?
The general condition in diseases (setting aside new growths
[neoplasms]), and the loss or severe injuries of parts essential or
very important to life, and the obliteration or closing of channels
(CaniUen) which cannot safely be dispensed with [urethra, alimen-
tary canal, thoracic duct, &c., &c.], and some other conditions of
overwhelming local importance (Einflusse), is of all other things the
most important in furnishing us with rules for safely prognosticating
and judging of the fate of a patient, or the course and duration of
Ids disease, and his prospect of recovery or dissolution. And it
is just the same in practical therapeutics, which has its strongholds
(Angriffspunkte) not in the local disturbances which so frequently
give a name to the disease \_e,g. pneumonia], but in the general
condition of the system, which our therapeutic helps must assist and
direct. Here also exceptions must be made, as regards determinate
(causalen) urgent symptomatic, and specially important topical indica-
tions. (I may refer here to my treatise ' Ueber die Nothwendigkeit
einer exacteren Beachtung der Gesammtconstitution bei Beurthei-
lung und Behandlung der Kranken," in the ' Arcliiv der Heilhmde'
i860, Bd. i, 97. [On the importance of particular attention to
the General Constitution of the Patient, in the diagnosis and treat-
ment of Disease.] When all this has been more or less fully
conceded, we are still met by the difficulty of discovering how
far the fluctuations of the general temperature depend upon certain
organic processes. On what fixed laws does the temperature
depend? How can we explain the fact that some disturbances
which undoubtedly affect the whole organism do not alter the
temperature? whilst on the other hand others invariably do so?
What forces (Motive) determine the varieties of temperature ?
Where are the regulators which, even in sickness, keep these
within certain Hmits? In my opinion no definite answer can be
given as yet to these questions,^ and we must be satisfied for the
' Nach mciner Meinung siud alle diese Pragen niclifc spruchreif.
CAUSES OF ALTERED TEMPERATURE IN DISEASE. 169
present to deduce empirical rules from the copious stores of experi-
ence. But only the most painstaking and comprehensive study of
the special details of the subject can place us in a position to
extract from them the common principles which are illustrated by
the normal course of disease.
CHAPTER VI I r.
ON THE TYPICAL FORMS OF CONSTITUTIONAL AFFECTIONS
ASSOCIATED WITH ALTERATION OF TEMPERATURES.
§ I. Ill many diseased conditions, the anomalies of temperature
consist solely in its increased mobility. Very slight influences
suffice to determine very considerable deviations from the normal
heat of the body ; the daily fluctuations show a wider " excursus "
[or range of temperature] ; and when slight accidental disturbances
of general health occur^ they are associated with unusual, though
brief elevations of temperature, or with similar depressions; and the
increase or decrease of heat often takes place in an apparently
spontaneous, and purposeless manner, either as an isolated pheno-
menon, or recurring in an entirely anomalous fashion. Such
changes often vanish as casually, and as inexplicably as they
appeared. The diseased conditions in which the temperature
exhibits this behaviour, are very numerous — and do not consist
merely in well-marked, definite diseases to which we can give names,
but also in very many conditions in which no accurate diagnosis is
possible, and in which it is only possible to recognize a disturbance
in the general health. Cases of slight illness (Kranklichkeit),
general irritability, persistent feelings of lassitude, slight disturb-
ances of all the [bodily] functions, impaired digestion, imperfect
respiration, convalescence, &c. The actual and well-defined diseases
in which these occur, are usually chronic in their nature, confined
within certain limits, or so slightly developed, that extreme anomalies
of temperature do not occur, or they are brief intervals of not
quite undisturbed repose intervening between the phenomena of
severe disease (nicht ganz reinenPausen — "not quite pure pauses'^);
or the ''residua^' (so to speak) of various morbid affections; or
they may be diseases of short duration and of moderate severity ; or
lastly, they may be fresh complications, which do not conform to
TYPICAL FORMS WITH ALTERED TEMPERATURES. 171
rule, and only produce lasting or considerable alterations of tempera-
ture, when they become intensified,
§ 2. It is not unusual to meet with cases, in which the tempe-
rature of a ]i(itient remains a little above the tiorrnal, either persis-
tently, or in the form of a nightly rise.
In addition to this, we may have the increased mobility previously
mentioned, and also isolated and apparently causeless elevations of
temperature. This " course '^ of temperature also occurs in ill-
pronounced disturbances of health, in convalescents (especially after
articular rheumatism) ; in the decline of various affections, as for
example, after the exacerbations which occur in phthisis, as well as
in many sub-acute, and pre-eminently atypical forms of disease.
It is far less common to meet with cases in which the temperature
takes the descending type, and remains constantly helow the normal,
or is so at least in the morning hours. And in these cases also,
either with or without recognized cause, the temperature may
sometimes exhibit intercurrent elevations. This form of tempera-
ture also is met with in chronic, and declining diseases, principally
in such as are marked with the character of inanition, in marasmus,
cases of cancer, in diabetes, and extreme degrees of ansemia, only
exceptionally in phthisis ; in cases of mental disease according to
Williams ('Medical Times,^ 1867, No. 896) both in the stage of
depression, and in chronic, uncomplicated, though incurable
forms ; and, according to Wolff, especially in melancholia attonita
[Lypemania].
§ 3. In real, though not very apparent relation to these less con-
spicuous alterations of temperature (?". e., approximating to these
through their "middle term," which one may place either above or
below the normal line) we may consider those constitutional affections
which are connected with alterations of temperature, which assume
definite- and characteristic types. These are generally much more
strongly marked, and are generally separated by a sharp line of
demarcation from the ordinary course of health.
Such definite general types, in which constitutional anomalies
specially afi'ect the temperature, are illustrated by —
(«). lligors (Fieberfrost) .
{h). Fever-heats [flushings, hot stages of fever], pyrexia.
(<?). Collapse.
ir.O TVl'ICAl, FORMS WITH Al.TKRKl) TEMPERATURES.
ll would 1)1' a groat error to su})posc ihnt alterations of tcm-
])i"ratinv are the sole characteristics of these j)atholotrical ))roccsses.
Kach of them forms a complex assemblage of manifcjld and more or
less essential plienomcna. Every one of them is a condition of the
entire body, in which every organ and every particle (Punkt) of the
body has its share, and the share of each is infinitely " many-sided"
(und dieser Antheil bietet unendlich viele Seiten dar) . The physiology
of rigors, of febrile heat (pyrexia), and of collaj)se, is as compre-
hensive, and as little comprehensible, as the physiology of healthy
men ; indeed far less so, because confirmation from experiments is
almost entirely wanting. In this com])lexity, our pur[)ose is chiefly
to regard the part played by temperature. As to other j)henomena,
they will only be considered so far as is necessary to the compre-
hension of the subject.
§ 4. During a rigor (Eieberfrost) when well marked, we usually
find the general temperature of the body very greatly increased
(amounting usually to about 40° C. (104°), or even more) ; on the
other hand, the parts of the extremities which are farthest from the
trunk (the hands, forearm, feet, and the legs below the knees), and
also parts of the face (nose, chin, ears, and frequently the forehead),
very commonly show more or less considerable decrease of warmth.
Along with this contrast of the high temperature of the trunk, and
the heat of the body generally, with the coldness of the parts named
above, there is experienced a subjective feeling of chilliness (shivers),
which is often very extreme.
Several other phenomena are associated with this, the most con-
stant being pallor of the skin, with bluish (cyanotic) coloration of the
nails and some other parts, automatic and convulsive movements
(yawning, chattering of the teeth, tremblings, &c.), thirst, headache,
and extreme malaise, and colorless, watery urine.
As a rule, rigors occur in the beginning of a febrile disease, or of
an accession of fever, but by no means exactly at the commencement
of the rise of temperature in the trunk, the increased temperature
generally preceding the rigors a little (see fig. 2.) As soon as the
heat has exceeded the previous temperature (whether that has been
normal, sub-normal, or sub-febrile), either a little, or it may be by
nearly 2^C. (3*6° T.), during which the warmth of the extremities,
and of certain parts of the face, has not kept pace with that of the
trunk, and has indeed even fallen ; the phenomena of chilliness set in,
TYPICAL FORMS WITH ALTERED TEMPERATURES.
173
and increase in intensity with the rise of temperature of the trunk, till
the increased heat has extended to the nose and the fingers and toes.
Then the phenomena of the
" cold stage "" disappears.
Shortly after they cease ; they
can, however, be rapidly re-
induced, simply by exposure
of the hands, arms, or feet,
which causes rapid cooling.
When the temperature,
after reaching its maximum
(which may occur in the rigor
itself, or in the succeeding
hot stage), begins to fall
again, there is, as a rule, not
a trace of the feelings of chilli-
ness, or of the phenomena pe-
culiar to rigors ; and it seems
to make no difference in this
respect, whether the sinking
is rapid or protracted, whether y^e 2
the temperature becomes nor-
mal or remains above it, or whether it sinks below normal, and
the case goes on into collapse.
This is the usual progress (Verhalten) of a rigor ["cold stage'^],
especially in those cases in which it attains its fullest aiul most
decided development, and runs a well-defined course of half an hour
to two hours.
But in forming a right opinion on the subject of rigors, we must
not overlook those forms which are less marked in their commence-
ment (initial stages) and their indications ; those rarer modifications,
and less perfect forms, which often occur. In overlooking these, we
lose, as it were, the key to the whole process.
We must bear in mind those rigor-like phenomena, which occa-
sionally occur in very nervous people, without any alteration of tem-
perature at all (nervoser Frost). We may grant that the latter
pursue no definite course, and therefore our experience of these gives
us little insight into the actual significance of the phenomenon ; but at
least they show us, that all the other phenomena of rigoi's may occur
without any objective alteration of temperature.
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17 1 T\ri('AI, lUUMS WITH AI/ir.UKD TKMl'KUA'rUllKS.
Willi thrso we must associate tliosc cases, in wliich a sincere
riffor occurs after any sudden iini)ression made on some sensitive
spot (which most commonly occurs during the passing of a catheter).
In this case, there are either no objective alterations of temperature,
or they are at all events inconsiderable, and these cases must also be
ranked with nervous rigors.
Yerv similar symjjtoms often show themselves immediately after
the introduction of toxic agents into the blood, without actual
objective alteration of temperature.^ So also in slightly indi-
cated and rudimentary developments of a true rigor (chilliness,
shiveriugs, "cold water running down the back,'' &c.), the ob-
jective coldness of the extremities is very often wanting, or but very
trilling, whilst the rise of temperature in the trunk makes rapid
progress. Pallor of the skin is often absent : and indeed there
is sometimes nothing at all objective to be noticed about the patient,
whilst he himself has a decided feeling like a rigor : and these, in
dehcate and susceptible personages, may easily pass into severe
rigors under the influence of slightly unfavorable circumstances.^
But rigors also occur occasionally with falling temperatures —
collapse, rigors ; these are, however, for the most part, imperfectly
developed, or have some other origin than the fall of temperature,
probably identical with that of nervous rigors.
But there are some cases of rigors which occur in the very midst
of an elevated temperature, occasionally without any fresh exciting
cause, and usually without the extremities being chilled, as for exam-
ple in pyemic patients. It must specially be noticed, that whilst the
' The convulsions of epilepsy, and [the so-called] uramic poisoning, ought
clearly to be reckoned in this category. I have traced the history of very many
epileptics in whom there was no history of convulsions before puberty, and have
found that tlie first "fit" followed the ingestion of an inordinate quantity of
alcoholic stimulants in a very large proportion of the cases. — [Trass.]
- It is exceedingly common to meet with imperfect rigors in middle-aged
patients living in malarious districts, and in some places not commonly reckoned
as such [notably in the East of London] : as many of tliese patients are women,
in whom the catamenia are beginning to be irregular, or ceasing, and the rigors
are very imperfectly marked, being chiefly subjective, and described as "heats
and flushes ' (the chilliness being often absent or very transient), these
symptoms are very commonly attributed to "the change of life" even by
their medical attendants; and the patient is led to believe that they are either
incurable, or at least of uterine or ovarian origin, whereas I believe this patho-
logy to be erroneous, and 1 know that the symptoms can gcneially be cured by
either quinine, arsenic, or a change of residence. — [Tkass.]
TYPICAL FORMS WI I'll ALTERED TEMPERATURES. 175
temperature remains liigb, and in those periods of the disease in
which it is making progress, rigors occur more easily than in those
periods which- either precede or constitute convalescence. The more
recent a disease is, the more easily does mere stripping of the body,
or a draught of air, prove distressing ; and in delicate and sensitive
individuals, at such times, rigors are easily and suddenly thus induced,
in spite of the high temperature.
Very complete rigors may also occur when the temperature rises
rapidly, although the rise may take place from an abnormally low
temperature, and may never rise above the normal level. I have
seen cases of chronic starvation, in which, so to speak, habitual col-
lapse-temperatures of about '^^° C. (= 95° F.) were met with, but
there was a rise of about 3° to 3° C. (= 3"6° to 5*4° E.) occurring
every evening, which raised the temperature just to normal. This
evening-rise was very commonly accompanied with strong sensations
of cold, shiverings, and "chattering'^ of the teeth, in spite of the
fact that the rise of temperature was only relative. Nor on the other
hand, must we overlook the fact, that the temperature of the trunk
may rise with equal rapidity, and to as great a height as in a com-
plete rigor (Schiittelfrost), without being accompanied with any
subjective feelings of chilliness, and without any other particular
phenomenon except that of increased heat. Such simple elevations
of temperature very commonly occur once or twice after an inter-
mittent fever has been apparently cut short by quinine ; and they
may also be noticed in transient accessions of fever, during conva-
lescence, and in many other conditions. The temperature may even
rise as high as 41° C. (io5*8°F.) with equal suddenness, and in a
similar manner to a complete rigor; and in intermittents, as well as
in the former, may again as rapidly fall. In like manner objective
coldness may often be noted in the forearms and hands, the lower
})art of the legs and feet, along with more or less increased heat in
the trunk, without the least feeling of chilliness [on the part of the
patient]. It is not therefore the coldness of the extremities and
remote parts which causes the feeling of chilliness and the other
phenomena of rigors. The extremities may be very cold without a
rigor, and they need not be cold (in spite of the one-sided statements
often made) even although rigors are present, and indeed this is often
the case. Nor is it the increased heat of the trunk which causes a
rigor. This may be present to a very great extent, quite as much as
in a febrile rigor without this phenomenon. And on the other hand
17() TYIMCAI, I'OUMS WITH ALTKRKI) TKM IM-'.UATUUKS.
a ri^or may occur in casscs where the temperature is normal only, or
hut slightly above it.
Nor ilo rigors depend merely on the contrast between the high
temperature of the trunk and the low temperature of the extremities,
'riiis may occur ecpially in collapse without the feeling of chilliness.
And it is absent in nervous rigors,
AVhen the dilVerence between the coldness of the hands and feet
and the temperature of the trunk sets in suddenly and continues to
increase, this appears to play a far more imj)ortant part in the con-
stitution of a rigor. It is not when the hands and feet are cold,
whilst the trunk is excessively warm, but when the temperature of
the trunk rises rapidly, whilst that of the hands and feet remains
stationary, or even falls, that a rigor occurs ; and especially when
with a rapid rise of the internal temperature the warmth of the
surface of the body, and particularly of the extremities, is ra])idly
abstracted in great quantity ; then a rigor follows almost instanta-
neously.
People who go to bed at the very commencement of a severe
febrile attack are often attacked with very severe rigors, because the
cold bed rapidly abstracts the heat from the surface of their bodies,
and thus the contrast between the heat of the interior of their bodies,
and the coldness of their extremities and surface (Peripherie) is very
quickly intensified.
Yet even the sudden increase of the difference between external
and internal temperature will not explain everything ; and there are
cases of rigors, with both normal and abnormal temperatures, in
which there is no fluctuation or alteration of temperature during the
rigors (nervous rigors).
All this undoubtedly indicates that a febrile rigor is a complex
phenomenon, the several elements in which, viz. the altered tempera-
ture, the subjective sensations, and the remaining functional pheno-
mena, do not pursue a parallel course, and are thus not necessarily
dependent one upon another. The more perfect, or so to speak
normal, the process is, which constitutes a rigor; so much the more
perfectly are all the elements not only present, but developed ; any
one of these may, however, be wanting, whilst the rest may be very
strongly developed.
Those cases of rigors where there is a rapid rise of the temperature
of the trunk to decidedly febrile or extreme degrees of heat, are
usually followed by a longer or shorter hot stage. In the
TVPICAL FOUMS AVITH ALTERED TEMPERATURES. 177
remaining forms of febrile rigors this may be either present or
absent.
§ 5. The pyrexia {" hot stage ^^ or fever heat^ Fieberhitze) may
follow a well-marked rigor, or slight feelings of chilliness ; but it
may also develop itself out of a normal temperature without the
slightest indications of either of these. kSometimes the pyrexia affords
no other result to our means of observation than the mere increase of
temperature, which not uufrequently amounts to a rise of a° to 3° C.
(3"6°=:5'4° r.) or more (as for example in the ephemeral (transientj
febrile attacks of convalescence, and in the paroa'j/sms of temperature,
after the apparent cure of an intermittent fever, &c.). There may
be no subjective feeling of discomfort whatever, no thirst, nor
languor (at least if the patient lies in bed), no quickening of the
pulse, nor any change in that, nothing luiusual in the peripheral cir-
culation, or in the respiration, no altered secretions, and no change
in the functions of the nervous system, only the altered temperature.
These are facts which all who have used the thermometer much at
the bedside must have verified ; and facts which are of extreme value
in a theoretic point of view.
In other cases, however, besides considerable elevations of tem-
perature, there may be indications of particular complications, which
may be easily overlooked on account of their being slight in degree ;
yet still the phenomenon of abnormal heat bears no special relation
to the other symptoms.
In both classes of cases it appears that although the temperature
may reach no great height under conditions of perfect repose, and
the absence of external influences, yet it generally rises greatly as
soon as functional forces [disturbances], or powerful external in-
fluences come into play ; and then we generally find other and complex
phenomena superadded.
In contrast to the cases where there is only an elevation of tem-
perature, we find in the great majority of diseases a complex group
of other disturbances of the general health, of functional anomalies,
and of varieties of impaired nutrition. Of these the most striking
are alterations of the pulse, of the urinary secretion (which becomes
scanty, and, therefore, concentrated), and of respiration; and added
to these, subjective feelings of heat, thirst, and loss of appetite, loss
of power, malaise, disturbed sleep, and interruption to the con-
tinuity of mental operations ; the muscular system is affected, and
13
178 TYPICAL FORMS WITH ALTERED TEMPERATURES.
digestion is also impaired — there is a decrease in the iminber of
blood-corpusclcSj and in the body-weight. These are the phenomena,
•\vhicli without special disease of the organs concerned, generally
accompany the morbid elevation of temperature, and are grouped
together by the general name oi fever.
But in opposition to the loudly expressed opinions of many, I
would most emphatically assert that there is generally no exact
parallelism between the height of the temperature on the one haiul,
and the kind and degree of the remaining phenomena on the other,
neither regarded as a whole, nor yet as concerns any single pheno-
menon : that neither the feeling of depression, nor the thirst, nor
the quality or frequency of the pulse, nor the pallor or injection of
the skin, nor the amount or quality of its secretions, nor the fre-
quency of respiration, nor the quantity or quality of the urine or of
any of its ingredients, nor the functions of the nervous system, nor,
finally, the diminution in the weight of the body, usually stands in
any definite general proportion to the rise of temperature. It is only
in a few special forms of disease, that we can establish a relation
between the height of the temperature, and this or that morbid
symptom, so long as the course of the disease is normal; but the
experience and rules obtained from any special form of disease, cannot
be applied indiscriminately to other forms of disease.
This want of congruity between the temperature and the other
symptoms of febrile diseases might lead to the conclusion, that the
temperature is either no guide at all, or a very deceptive one, to the
general condition of the system ; but experience shows, that what-
ever the kind of sickness may be, a careful observation of the tem-
perature, and of its course, offers a far more reliable stand-point
(Auhaltspunkte), or basis for judging the progress of a disease, than
any other phenomenon, or even than all the other complex pheno-
mena of fever united. All mere theoretical considerations must be
put to silence by this simple empirical fact, although we may be quite
unable to explain it.
In the pyrexia of fevers we commonly meet with a general
elevation of temperature, but this does not preclude some parts of the
body from both appearing and really being warmer than other parts.
Not only is the trunk often warmer than the extremities, because they
cool more rapidly, but we also notice (what seems contradictory) a
similar increase of heat commonly occurring in the head, the ears,
the cheeks, and the hands, especially in the palms of the hands. Not
TYPICAL FORMS WITH ALTERED TEMPERATURES. 179
only can the increased heat of these parts be noticed earher than in
other ])laces, in contrast to the still slight elevation of the heat of the
trunkj and especially so in the cases in which the pyrexia has not
been preceded by rigors ; but when the febrile movement is only
moderate^ it is often limited^ or almost entirely so to these parts,
which generally appear colder during a rigor. During the pyrexia,
the height of the temperature may be very varied. Tliis depends,
as will be subsequently shown, not only on the intensity of the disease,
but also very materially on the kind or type of the disease ; and so
much so, that in certain kinds of disease, however mild and favorable
their course, the temperature reaches an elevation which in other
diseases never occurs, or only when the case is exceptionally severe.
The conditions which regulate the height of the temperature (die
Bedingungeu fiir das Niveau der Temperaturhohe) seem therefore to
be partly determined by the specific nature of the progress of the
actual disease. Tree perspiration generally diminishes fever-heat
very considerably ; indeed, in parts which sweat much, the tempe-
rature of the skin may fall below normal. But this is a purely local
effect, and it entirely depends on circumstances, whether the
increased blood heat itself is diminished, or remains the same, or
only returns to the normal height with the cessation of the per-
spiration.
There are some cases of enormously increased temperature, which
deviate in many ways from the usual course of pyrexiee. They are,
partially at least, cases of disease in which there is often [for some
timel either no pyrexia or but very little, and the tremendous
increase of heat generally occurs with the near approach of a fatal
termination — the subjective phenomena which generally accompany
the pyrexia, are wanting; the functional disturbances of the heart
indicate the beginning of paresis, the products of tissue-changes are
deficient in the urine. It is doubtful whether we ought to regard
these cases as extreme degrees of pyrexia, on account of their fre-
quent and sudden development out of cases where there is no
previous fever — or whether we ought to exclude them altogether
from the category of fevers.
§ 6. Collapse sometimes occurs by itself (isolirt), sometimes in the
middle of pyrexias of various degrees, very often in the sequelse of
fevers, very seldom during rigors, although these have many pheno-
mena in common with collapse
ISO TYl'lCAf. I'OUMS WITH ALTEUKI) TEMPKRATUKES.
Collapse is not a disease any more tlian a rigor, or pyrexisc. It is a
more or less isolated process, occurring in the course of a disease ;
vet, ulicn it attains a certain degree of severity, it may temporarily
ac([uire an all-absorbing interest, may demand every available remedy
for its treatment, and rightly cause us to Avholly forget for the
moment the disease under which the patient is labouring.
"Without doubt, collapse is a symptom which never occurs without
very sullicient reasons, but these are such as for the present, receive
no elucidation from direct anatomical investigation.
Like rigors and pyrexiae, it is a general disturbance, affecting the
whole of the system. But in spite of its character as a con-
stitutional anomaly, the alterations of temperature occur in collapse,
as they do in rigors and pyrexia?, at first locally only, make them-
selves visible only in particular places, and extend to the whole body
only when the phenomena of collapse are fully developed.
Collapse is more transient and less eventful than pyrexia or even
rigors, and v\hen it is relatively protracted, it still forms only an
episode, or the last act [of a drama] of relatively short duration.
It presents a contrast to pyrexia in many of its phenomena, but it is
not essentially the opposite of this, for it may occur in the middle,
as it were, of pyrexia, and the fever, although modified by it,
pursues further course in company with it.
In the slighter degrees of collapse, the patient con])lains of
nothing particular, there is no special alteration in his appearance ;
in company with the preceding period, the fever may persist, or
may have ceased; the pulse and respiration present no particular
deviation from the previous course, nor does the general condition ;
but the nose and cheeks are cold, often only locally, and perhaps on
one side only, and the coldness may be noticed in the forehead, ears,
and hands and feet. iUthough the circulation in these parts need
not be visibly interfered with, although they may not always have
been exposed to any greater degree of external cold, than the rest of
the body, their temperature is often considerably diminished, with-
out the patient being himself conscious of it. From this first and
shghtest degree of collapse, there is an almost imperceptible transition
(accompanied with an access of more and more numerous and severe
symptoms) and extreme degrees of collapse, in which the patient lies
pale, sunken, motionless, and almost without signs of life — like a
corpse, and perhaps soon to be one in reality ; icy-cold, so to speak,
both in the head and limbs, and sometimes in the trunk also — with
TYPICAL FOUMS WITH ALTERED TEMPERATURES. 181
an almost imperceptible pulse, feeble action of tlie heart, and scarce
visible breathing, whilst the skin, which has lost its plumpness, is
bedewed notwithstanding, and bathed with a copious perspiration
which stands on it in big drops, and almosts pools of sweat — (in
grossen Tropfen und Laclien) . Unpleasant subjective sensations are
sometimes met with in the slighter degrees of collapse, sometimes at
the very commencement of the severer forms. Not pain indeed, nor
rigors, but generally still more disagreeable feelings — the feeling of
tlie most extreme weakness and faintness (Unmacht), with anxiety,
and a sense of oppression (suffocation), with a "beaten feeling" in
the limbs, and often thirst also, giddiness, with disordered vision and
hearing, and confusion of thought. Collapse often occurs as the
immediate sequel to particular events, such as vomiting, profuse
diarrhoea, after losses of blood, and with perforations of serous mem-
branes. The collapse in these cases is significant in itself, only
just in the degree in which the circumstances which cause it
involved anger; when this is not the case, it usually passes off
quickly, without any after-consequences. In the same manner
the significance of the collapse which accompanies extreme debility
(Unmacht) depends upon the original causes which produced it,
and upon the particular bodily disorders which accompany it. The
collapse of [Asiatic] cholera is generally unusually severe and
protracted ; it may indeed occur in sporadic cases, both in children
and adults, but much more frequently in epidemic and infectious
cholera.
In chronic diseases, also, collapse is often observed, either transient
or prolonged, and it is not unfrequently repeated.
The kind of collapse which occurs in acute febrile diseases, is of a
much more peculiar character. In such cases its beginning is almost
imperceptible to the patient; but occasionally he feels a slight
shivering, or a general feeling of malaise; and it is generally only
when the collapse is deep that very distressing sensations are com-
plained of. In the very beginning of collapse, we may recognise it
only by the nose, the chin, the forehead, and the extremities
becoming cold ; but as soon as the collapse becomes deeper, the face
becomes very pale, sometimes yellowish or livid (blue) and the inte-
guments lose their elasticity. The face appears flaccid and sunken,
the eyes look hollow, and the features deformed ; the posture and
movements of the patient indicate extreme feebleness, his voice is
weak and has no timbre (no ring in it), and his skin is either dry or
IS*} TYPICAL rORMS WITH ALTKRliD TEMPERATURES.
more or less bcilcwcd with sweats, particularly noticeable on the
forehead, which is covered with numerous big drops of moisture.
TVhilst, however, the face and the extremities appear more or less
cold, the temperature of the trunk may be cither increased, or
normal, or diminished. This distinction is very important, yet a
prognosis can scarcely be founded on this alone, for collapse with
diminished temperature, and that with increased temperature may
be equally dangerous, although in different ways. The temperature
in both may be equalised, and this again happens in various ways.
Cases of collapse with a falling temperature in the trunk are those
most commonly met with in febrile diseases, and these require to be
watched with the most painstaking care. The previously more or
less high temperature sinks near to or quite to normal, and very
often indeed more or less considerably below it (most often between
^f and 37° C. (95° and 98-6° E.)). The fall is usually sudden,
within a few hours^ and often in still briefer time.
The diminution of temperature, in the course of half a day, may
amount to as much as 6° or 8° C, or even more (= lO'S^ to 14-4°
F.) . Cases of collapse with sub-normal temperature may last a few
hours only, or be prolonged through several days ; and the tempe-
rature may either become normal or rise to a more or less consider-
able degree of pyrexia?, or the patient may die in the collapse.
Such cases of collapse in which the temperature of the trunk falls,
occur : —
(a) During the stage of defervescence, most commonly in pneu-
monia, but also in acute exanthems and other diseases ; in these
cases the condition of the patient may give rise to more or less
anxiety, but is generally quite devoid of serious danger ;
{b) During the remission of fevers, most common in enteric fever
(abdominal typhus) ;
{c) In the transition stage from intermittent fever to an apyretic
condition, especially in pernicious forms of malarial fevers, and in
pycemia ;
{d) During rigors, especially in pernicious forms of malarial
fevers, and also in other very severe diseases, or in very delicate
and susceptible individuals ;
(e) As accidental (spontaneous) or artificially induced Episodes
(Epistrophen), especially after bloodlettings, vomiting, very copious
evacuations, and also after overloading the stomach, and with
extreme nausea, w ith extreme degrees of pain, very rapid or copious
TYPICAlj FORMS WITH ALTERED TEMPERATURES, 183
exudations^ and perspirations — perforations of the pleura^ or peri-
toneum— and the formation of coagula in the heart ;
(/) In many 'kinds of intoxication (poisoning of various kinds),
and in the cold stage of cholera ;
{g) In the pro -agonistic period, and in the [death] agony
itself.
Cases of colhapse with elevated temperature in the trunk are
scarcely to be met with except in severe cases of fever, and it
appears as if a very elevated temperature directly predisposed to
sncli collapses (Geneigtheit nnd Veranlassung geben konne).
Eefer to the following abstracts on the subject of collapse, and
especially to a treatise by the Authors, entitled, *Der Collaps
in fierberhaften K rankheiten ^ (1861, ^Archiv der lieilkunde/
II, 289).!
§ 7. If the course of the temperature in relation to these three
general forms of constitutional disturbance be compared, and the
whole summed up, the following is the result. The temperature
may be above the normal in all sorts of cases : it is always high in
pyrexia, highest of all in febrile rigors, and generally above normal
in collapse.
No distinction can be drawn between them from the mere height
of the temperature. Normal and sub-normal temperatures often
occur in collapse, but only exceptionally in cases of incomplete
rigors.
The extremities (peripheral parts) are always cold in collapse,
and generally so in rigors.
A rapid rise of the temperature of the trunk, with coldness of
the extremities, is generally associated with rigor.
A rapid and very considerable fall of the temperature of the
trunk generally goes along with collapse.
^ The internal temperature (as measured in the rectum and vagina, in the
collapse of cholera), is often very high, relatively to that of the axilla. See
some very interesting observations by assistant-surgeon P. M. Mackenzie, in
vol. iii 'Lond. Hosp. Reports' (for 1856), p. 457. For instance, in a female,
fct. 35, with an axillary temperature of 90"2° P., that of the vagina and rectum
was i02'4° P. In a female, set. 32, the temperature in the axilla was 93" F.,
and tiiat of the vagina I02'8° F., &c. &c. See also other papers in the same
volume, and Dr. Sutton's Report in the 'Ninth Report of the Medical Officer
of the Privy Council.' — [Tbaks. ]
18 1 TYPICAT, FORMS WITH ALTKRKD TKMPF.R ATUHKS.
The recurrence of warmth in particular parts of the boily
whilst the temperature of the trunk remains high, is peculiar to
collapse.
§ <S, We arc met by insu])erable difTiculties when we try to
cx])lain theoretically the true meaning of all these varieties of
temperature. Previous attempts at explanation have concerned
themselves entirely with the theory of " Tever/' and have in so
doing ignored the mteresting and practically important condition
of collapse.
Even as regards attempts to explain fevers, many of them
have been very partial. ^Imy persons, setting out with the
opinion that fever is identical with elevation of temperature, have
only regarded the latter in framing their theories. This view is
repelled by logic as well as by facts. Some have taken rigors, and
others again pyrexia, as the basis of their several explanations, and
thus only one-sided views have been promulgated. The theories
of others have been founded upon the course of very perfectly
developed cases of fever only, and their conclusions therefore are
not suitable to slighter and less typical forms. Indeed, so infinite
have been the "practical judgments,'^ founded on a mere observa-
tion of the circumstances of temperature in febrile diseases, that
one might almost doubt whether the theory of fever has made any
real progress through thermometric observations. Indeed, we can
hardly help doubting, when we see how widely divergent, and even
directly contradictory to one another many of the theories are ; and
how many of them are not only one-sided, but stand in direct
opposition to the facts of every day experience ; and how strong an
inchnation there is to reintroduce that old, and frequently recurring
fallacy (Irrweg) of medicine, — the attempt to explain the complex
phenomena of the organism by one simple and short {" cut and
dried ") formula.
An unprejudiced consideration of the phenomena of fever leads
us rather to ascribe the chief share in them to the agency of the
nervous system, than to lay particular stress [Hauptaccent] on the
increased heat. (See my' treatise, 'Das Fieber,' 1842. ' Archiv
fiir Physiolog. Heilkunde/ ii, p. 6.)
After the great significance of temperature in febrile conditions
had been incontrovertibly demonstrated by thermometric observa-
tions, Thdioio's theory of fever^ and his explanation of the mutual
TYPICAL FORMS AVITH ALTERED TEMPERATURES. 185
relations of the phenomena (propounded in 1854, in his ' Handbuch
der Spcciellen Pathologic und Therapie/ i, p. 33, ff. ), agreed very
"tvcU with the_ .general views^ because he distinguished the rise of
temperature as the most constant phenomenon of fever, and again
ascribed it to increased combustion of the blood-constituents; and
also prominently insisted that the rise of temperature in fevers Avas
not merely increased heat, but an increase of heat from a special
cause, and that this cause could be found nowhere else but in the
nervous system.
This explanation appeared to give general satisfaction; and
Zlmmermann'' s theory, which ascribes pyrexia to local centres (foci)
of inflammation, was almost entirely disregarded. Fever was held
to be a process produced by increased tissue- decomposition, leading
to increased heat, and the influence of the nervous system on this
process, although it could not be determined with precision, remained
undisputed.
Claude Bernard, in an article on fever (communicated in the
' AUgemein Wiener med. Zeitung' for 1859, Nos. 33 and 24),
has sought to utilize his experiments on the effect of section of the
sympathetic nerve upon animal heat, and to apply them in explana-
tion of fever. He considers that whatever may be its origin, a
fever must be regarded as a purely nervous phenomenon, and
indeed as a transient and incomplete paralysis of the sympathetic
system (which, according to him, is the sole vaso-motor nervous
apparatus) .
Certain transient impressions produce feelings of chilliness, i.e.
a disturbance of common sensation ; a reflex activity of the sympathetic
causes a rigor, and to this succeeds a relaxing (Erschlaffung) of
the nerves, which entails increased activity of circulation, tempera-
ture, perspiration, &c. He is inclined, therefore, to look upon a rigor
as a general irritation, and upon pyrexia as a general weakening
of vascular nerves of the whole surface of the body.
The rigor is accordingly looked upon as the primary condition,
and, in fact, the only active process, the heat being only the result
of the activity, a sort of sequel to it, and in some sort a new
creation of the other.
Schiff opposed these views in an article contained in Nos. 41 and 42
of the ' Algem. Wiener med. Zeitung,^ 1^59' He very justly pro-
pounds, that rigors and heat (pyrexia) are two separate (inde-
pendent) phenomena, and that the former does not explain the latter.
180 TYriCAI. FORMS WITH ALTKIIRD TKMrEH ATl'RES.
nnd that any theory wliich represents the one as the necessary
consequence of the other is incorrect and incomplete. He comes
to the conclusion, that the vaso-moter nerves (which according to
him arc by no means to be regarded as fibres of the sympathetic
nerve only), by which the vessels are contracted, also contain
V ithin themselves an active clement, by which the vessels can be
dilated, and that pyrexia is an active condition, an increased activity
of those dilating nerves ; whilst in a rigor a portion of the con-
tracting fibres are in activity {i.e. those which do not decussate in
the spinal cord, the vaso-motor fibres belonging to the face, hands,
and feet. He propounds, further, that both contracting and dilating
fibres go to the medulla oblongata, where accordingly all vaso-motor
nerves find a point of reunion ; that powerful and direct impres-
sions chiefly excite the activity of the contracting nerve-fibres,
rather than that of the dilating, and thus excite a rigor, but that
the dilating nerves are more easily excited in a reflex manner by
slighter impressions than the contracting ones require, and are more
persistently active than these, which require powerful irritants.
But whilst Sc/nff ilms believes in an active condition in both rigors
and pyrexia, he expressly declares that he does not deny that there
may be pathological forms of increased temperature, which may be
due simply to paralysis of the vaso-motor nerves.
AYhilst either by silence, or by express declination, there was a
general consent to the doctrine that the increased heat in fever
was to be regarded as the immediate (Wesentlichen) consequence
of an increased production of heat, Trauhe (who had shared the
same opinion in 1855, 'Deutsche Kliuik,' No. 46, for the year
1866) asserted, in opposition to all previous theories, that he con-
sidered the essence of fever to consist not in increased 2^1'oduction
of heat, but in diminisJied giving off of the same {' Algemein medic.
Centralzeitung' for 1863, xxxij. Nos. 52, 54, 102). He says: —
" The elevated temperature, and the other phenomena of fever are
induced as follows : Under the influence which the primary cause
exciting fever exerts upon the vaso-motor nervous system, which
I regard as a stimulating (erregende) influence, the muscular fibres
of the vessels, which are well known to be most developed in the
small arteries and arterioles, are thrown into stronger contraction.
This diminished calibre of the small arteries and arterioles must
have a twofold result : it reduces the quantity of blood which
the capillaries receive in a given period of time (Zeiteinheit) from
TYPICAL rORMS WITH ALTERED TEMPER ATUxvIlS. 187
the systemic circulation ; and simultaneously with this, it diminishes
the pressure on the interior of these minute vessels. From the
first movement' there results (along with a decreased access of oxygen
to the tissues) a diminished cooling of the blood by conduction
and radiation to the surface (periphery) of the body : from the
second movement we get diminished transudation of liquor sanguinis^
by which I mean the fluid which is forced through the walls of the
capillaries by the pressure within them, and which furnishes to every
tissue not only the oxygen, but other vital necessaries, especially the
materials appropriate for furnishing to the secreting apparatus
materials for both secretions and excretions. The diminished supply
of water to the superficial layers of the skin, and mucous membrane
of the lungs (Lungenschleimhaut) , is necessarily followed by a
diminished transpiration on both these surfaces, which is another
cause for the diminished cooling of the body.'"' In continuation,
he endeavours to explain the varied circumstances and phenomena
of fever in harmony with this theory. In this way Trauhe has
taken a rigor with its tetanic contraction of the smaller vessels as
the starting point of his theory of fever. He explains the rise of
temperature preceding a rigor, and the commencement of fever
without rigors, by supposing that the agents which excite fever act
with varying intensity on the vaso-motor nervous system; so that
in the first case the dose (quantum) of the primary fever-excitant is
but small at first, and therefore is only able to excite a slight degree
of contraction in the vessels ; and, on the other hand, when it is
more potent, stronger contraction is induced ; and in cases of fevers,
which begin without rigors, he supposes that the fever-poison
itself is less active.
The results arrived at by Behse partly coincide with this view.
(See his 'Beitrage zur Lehre vom Tieber,^ 1864.) He sums up his
views in the following words : — '' By fever we must understand an
increase of tissue-changes, induced by alterations in the nervous
system, and connected with a general disturbance, in which the
temperature-regulating machinery of the body, which is dependent
upon the nervous system, is so affected, that the loss of heat is
diminished in proportion to the amount of warmth produced."
Auerhacli combatted Trauhe's theory, and criticised it sharply,
with considerable completeness and pertinency (Erwagungen iiber
die Ursachen cler Eigenwiirme, in the 'Deutsche Klinik,' Nos.
22 and 23 for 1864). He points out that the full force (Moghch-
188 TYPICAL rORMS WITH ALTFni',1) TKM PKU ATURES.
kc'itcn) of the original causes of an increased temperature in fevers
cannot be explained simply by the alternative of increased produc-
tion or diminished loss ; that the contraction of the smaller arteries
in fever has never been demonstrated, and particularly that the
pallor of the skin may arise from contraction of its own muscles ;
and that this arterial contraction is especially inaj)plicablc to explain
the hot stage of fever, and that the increased heat in this stage has
been scarcely ex])lained in any way by Trauhe, and that the length
of time usually occupied by this stage makes it impossible for us to
derive its increased heat from the preceding short stage of rigors ;
and that even in the latter the economy of warmth from the con-
traction of the small arteries is affected by a variety of circumstances,
and can never be sufficient to produce the increased height of
temperature. Aiierhack finally comes to the conclusion that during
fever, especially in chronic febrile diseases, the relative amount
{BnicMheile) of heat generated in the body of an animal, exceeds
the normal, perhaps very greatly, on account of the combustion
of hydrogen, and that the absolute amount of heat generated
by the combustion of hydrogen in fever greatly exceeds the
rormal.
The proposition that fever depends upon a diminished cooling of
the body was also combatted by Liehermeister (Prager Vierteljahr-
schrift, 1865) and Immermann (1865 Deutsche Klinik, Xos. i
and 4), who attempted to show by calculations that during the stage
of rigors (cold-stage) the temperature rises more than could be
accounted for by a mere diminished loss, and that therefore there
must of necessity be an increased production of heat.
WachsmvAh, on the contrary, explained (in the ^ Archiv der Heil-
kunde' for 1865, vi, p. 211) that neither increased production nor
diminished loss of heat constitute fever, or at least neither occurring
by itself, but that fever depends upon a disturbance of the regulators
of warmth — that this is the essentia fehr'ium. Fever, according to
him, is the result of at least two influences, one of which increases
heat-production, and the other paralyses the nervous system.
In opposition to all these theories which seek to explain fever by
regarding it from one point of view only, Billroth endeavours to
explain the varied forces which may cause an elevated temperature,
and thus constitute fever (see the ' Archiv fiir klinische Chirurgie '
for 1864; vi, p. 429). According to him, the following conditions
mav be met with :
TYPICAL rORMS WITH ALTERED TEMPERATURES. 189
I. The heat-supplies may be increased, the conditions which
determine the giving off of heat remaining identical, and for the foci
(lit. furnaces) of increased heat-production, may be: —
(A) . Local only ; or,
{£). All the processes of oxidation may be increased, either by (a)
an increased amount of oxygen in the inspired air, or the nutritious
material ingested, or {b) by an increased amount of oxidisablc tissues
(material) in the body, or (c) by an increase in the capacity for
oxidation of all the materials in the body which generally take up
the oxygen, or lastly (d) by an increased rapidity of change
(Bewegungsgeschwindigkeit) in the oxidisable materials.
(C). Amongst subordinate forces seeming to maintain a constant
temperature in the body, are the friction of the blood and the walls
of the vessels, friction in the joints, of the muscles on one another,
&c., &c. Of far more importance is the development of warmth pro-
duced by muscular contractions.
II. The circumstances which conduce to the giving off of warmth
may be less favorable, and thus heat may become accumulated in
the body, and so the blood-heat may be increased.
Billroth further investigated the conditions which are able to
excite fever. According to him, three kinds of excitants of fever
are conceivable : —
[a). Decompositions may arise in the blood without any particular
action of the nervous system, which may allow of increased com-
bustion, or bodies may be introduced into the blood which may
excite and maintain such decompositions ;
((5/). The poisoned (lit. intoxicated) blood may irritate the nerve
centres, and thus excite fever ; {<:(ci) the poisoned blood may irritate
the trophic nerves (nerves of nutrition) and the latter may operate
directly to produce increased oxidation of tissues ; (Jjh) the poisoned
blood may stimulate all the vaso-motor centres, and thus (a) in every
part of the system the tissue-changes, and processes of oxidation may
be augmented ; (B) contraction of the small arteries and arterioles
may ensue, tissue-changes may be diminished, and thus the general
temperature may rise in consequence of the conditions being un-
favorable to the giving off of heat ;
(c). Or the blood may have nothing to do with the origination of
fever, it may be caused by a direct specific irritant (Reiz) acting on
peripheral nerves, by which the vaso-motor nerves may be excited in
a reflex manner.
11)0 TYPICAL rOllMS WITH ALTKRED TKMPERATUllIiS.
This somewhat diar'ramrnatic analysis lias at least the merit of
calling attention to the great niultij)licity of circumstances which
mav possibly be concerned in the production of fever.
0. V'eber, in 1H65 (' Pitha uud Billrotli's Ilaudbuch der allg. und
spec. Chirurgie/ i., 599), explained fever as a general increase of the
tissue changes, associated with elevation of temperature, which is
produced by a poisoning of the blood by the products of tissue
decomposition, which operate after the manner of ferments, and
induce a rapid decrease of the weight of the body. How one-sided
and partial this explanation is, is self-evident (liegt auf der Hand).
However \vell it may suit some cases of fever it suits others just as
little.
On the other hand, TscItescJiicJiin has propounded some ideas
which deserve the most careful consideration : {" Zur Ficberlehre "
in the ' Deutsch. Archiv filr KHn. Medicin' for 1867, ii, 5'SH).
He considers fever to be a morbidly increased activity of the spinal
centres in consequence of an affection (weakening or paralysis) of
the moderating portions of the brain, by which a number of chemical
processes are increased to an extent which is never attained under
normal conditions of the functions of the brain. Without being
entirely reliable as regards fever in general, this hypothesis sheds
considerable light u])on certain of its processes, and is well worthy
of consideration in some cases of extreme febrile temperatures at
the close of severe diseases of the nervous system (such as tetanus)
or of pernicious infections.
More recently two works deserve special mention in reference to
the relations of the production and loss of heat to fever : —
Senator (Yirchow's 'Archiv/ xlv, 351), adopts Traube^s theory^
whilst Lej/den ('Deutsch. Archiv/ v, 273), arrives at the following
conclusions by calorimetric investigations. The loss of heat in fever
is greater than usual, and this is true whether the temperature
remains the same, or rises, or falls. An increased generation of heat
must, therefore, undoubtedly occur. In very high fever the loss of
warmth is from one and a half to almost double the normal amount.
It is most extensive in the stage of crisis with a rapidly falling
temperature ; it then amounts to two or two and a half, or even
three times the normal quantity (lost). The defervescence always
occurs with well marked perspiration and exhalation of water, whilst
in increasing fever no evaporation of water can be demonstrated
even under an impenetrable covering.
TYPICAL AFOllMS WITH LTERED TEMPERATURES. 191
§ 9. These varied attempts to explain the primary cause and pro-
cesses of fever, widely differing as they are, do certainly throNv light
on many points connected therewith. Most of them fail because
they take such partial (one-sided) views of the process, and almost
all are spoilt by dwelling upon some one special phenomenon of
fever which they seize upon, and whilst seeking to explain this,
the authors fancy they explain the whole process of fever, and they
all omit one important circumstance, the impossibility of explaining
all the phenomena ! In the foreground is the question, " On what
does the abnormal temperature depend ?'^ But this is by no means
identical with the question — what constitutes fever ?
Pever is a complex assemblage of very varied phenomena, of
which one of the most important is the increased temperature,
if, indeed, this be not the most important ; whilst it is not possible
to derive all the other phenomena from the elevation of temperature.
The true value and significance of the several symptoms must be
first separately determined before we are in a position to comprehend
them in their complex entirety.
As regards the course of the temperature more particularly, it is
very varied, and on this account also may well have very varied
determining causes (Ursachen). Even when the course of the tem-
perature is identical [in two cases of fever] it by no means follows
that both originate in the same way. It is, on the contrary, highly
probable, that the opposing circumstances of production and loss [of
heat] in different cases, or at different periods in the same case, and
even with an identical height of temperature may vary greatly. It
is more pertinent to inquire. What are the primary causes of a given
degree of temperature in a given individual, at any given time ? or,
to say the least, what are the true reasons of the course taken by
the temperature in a given form of disease at any one period ? and
when progressing in any particular manner (bei einer bestimmten
Artung), than it is to ask, why is the temperature altered in fever ?
These questions can certainly only be answered as regards particular
cases and special forms of disease, by careful consideration of the
possible conditions by which alterations of temperature may be
produced during life, a method which up to the present time has
only been hit upon (eingeschlagen) by Billroth, and by further re-
flecting on the particular share which the varied primary causes
affecting temperature have in different pathological cojiditions.
Amongst those alterations of tcm])eraturc which must be con-
19:2 TYlMCAIi roRMS WITH AI/rEUED TEMPKUATUUES.
sidercd as signs of constitutional disease, \\c may coni^ider the
following :
(i) A general rise of temperature (all over the body).
(2) An increased temperature in the greater part of the body,
with diminished temperature in certain parts of it.
(3) A general diminution of temperature all over the body.
•^ JO. As far as our present knowledge extends, a;^ increase (>/'
temperature all over the hodij (which is the commonest phenomena
of a fairly commenced febrile disease which is still running its course)
is determined bv :
(a) An accumulation of heat caused by deficient abstraction of
warmth. Diminished giving off of heat may itself be determined by
a varietv of causes. Yet we can scarcely admit that during a long
continued duration of febrile heat any such circumstances could be
continuously realised as a considerable accumulation of normally
produced warmth, and we cannot but admit that if any such storing
of heat supervened on the customary methods by which it is dissi-
pated, either the production would soon decrease or new methods of
getting rid of it would present themselves ; and it is a matter of
every day experience that those suffering from fever make all tlieir
bedding, and whatever surrounds them, quite hot, however often
these are changed. On the other hand, it is quite conceivable that
a transient case of fever might arise from accumulated heat, and that
durinfT a ria'or the deficient coolinejof the blood throu2;h the anaemia
of the skin may have a great share in causing the increased heat of
the internal organs. It is further very apparent that in many
cases the accumulation of heat, through deficient carrying off of
warmth, may assist iji producing the high temperature.
{Ij) It is further conceivable, when a local centre or focus of in-
creased warmth-production is set up in any part of the body, that
from this the overplus of heat is communicated by means of the
circulation to the entire body ; and thus the latter has its own
temperature increased. Such centres (foci) let the mode of increased
production of heat be what it may (centres of inflammation or
hyperseraias) are always very limited in comparison to the bulk of the
whole body, and it can at the most only be admitted that the local
overplus of production may effect a very moderate increase in the
general temperature, which moreover, unless special disturbing in-
fluences come into play, is easily and speedily compensated through
TYPICAL FORMS WITH ALTERED TEMPERATURES. 193
the means of giving off heat in the same manner as very considerable
physiological over-plusses of heat are got rid of through these
channels. Besides this, in contradiction to any view ascribing the
origination of every fever to local processes, we have the fact that it
is just in the very cases where the highest febrile temperatures are
met with, that is in the severest forms of fever, that the pyrexia
generally precedes the occurrence of localised disturbances, whereas
when it follows the latter the temperatures observed throughout the
disease are, on an average, very moderate in height. We must not
say that local over-production of heat contributes nothing to the
general elevation of temperature ; but the contribution is by no
means large, and where it is at all considerable there must be com-
plications at work which hinder the compensation [which would
otherwise occur] of the local overplus of warmth.
(c) A general elevation of temperature may arise from increased
activity of the normal processes for the production of heat. Here,
too, it is very evident that the means of giving off heat will prevent
this disproportion from lasting long, or becoming very great, unless
further complications in the organism arise to hinder the activity of
the heat-abstractors. And it must be remarked that there is not a
single fact which would warrant us in concluding that in any case of
fever the simple circumstance of increase or acceleration of the normal
chemical processes is present ; and, on the other hand, the results of
direct determination of the normal products of decomposition in fever
patients (of the carbonic acid exhaled, and of the urea excreted) are
by no means uniform, and indeed only very partially correspond with
the amount of increase in the temperature ; and, again, the weight
actually lost by the body in fever corresponds just as little with the
amount of destruction of the constituents of the body which might
have been preconceived as resulting from the increased production
of heat.
{d) A general elevation of temperature may also occur through
an extensive over-production of heat, resulting from chemical pro-
cesses which are more or less unknown (fremd) in the healthy body
(Leben), by means of which so much heat may be generated that
the channels of heat-abstraction are quite unable (ausser Stande sind)
to compensate it, whilst in these also, through the extension of the
disturbance, irregularities and anomalies may be developed. Very
much, indeed, may be said for this, and something of this sort occurs
in very many cases of fever ; but we are still very far from being
13
104. TYPICAL FORMS WITH ALTERED TEMPERATURES.
able to determine with precision \Yhat actually happens, or to calcu-
late its exact share in the production of warmth. It appears, how-
ever, that the following special processes may occur : an increased
combustion of hydrogen in fevers which, from the very high com-
bustion heat of hydrogen (which is more than fourfold that of carbon)
may tend very greatly to raise the temperature {Aiierbach) ; a widely
diffused sudden organic decomposition (Zerfall), by which it is possible
free caloric may be produced, a circumstance, however, which is so
suddenly deadly that it can only be realized at the conclusion of a
fatal illness, with the dying rise of temperature, or in terminal fever ;
an over-production of heat by violent, persistent, muscular contrac-
tions not furnishing any mechanical results (tetanic spasms), which,
however, only occurs in a few special cases, and, as shown by
experience, also only towards the fatal termination of the disease, and
so doubtless concurrently with other conditions, is uncompensated,
and thus induces a rapid elevation of temperature (der Eigenwarme).
The development of new combinations of the constituents of the
body, associated with increased generation of heat, but not necessarily
dependent on increased oxidation {^Gdhrungen, zymoses, fermentative
processes), which cannot indeed be exactly demonstrated ; but whose
occurrence is very ])robable, although we cannot always tell what
diseases to rank in this class : for example, should the development
of fever by the transfusion of fever-blood, by the introduction of
products of inflammation and of tissue destruction [pus, and putrid
materials] be attributed to zymotic (fermentive) processes ; and how
far are we justified in accepting the theory of fermentation (zymosis)
in cases which terminate in recovery ?
{e) Alterations in the degree of activity of the vaso-motor
nerves must, if they are sufficiently extensive and persistent, almost
necessarily have an influence upon temperature, and that in more
ways than one, and quite as much by altering the conditions of pro-
duction, as by affecting the giving off, or loss of heat. In reahty,
many phenomena indicate that the blood-vessels are in an abnormal
condition, not merely hi the stage of rigors (cold stage) but also
during pyrexia, and it is scarcely possible to attribute this entirely
to the changes in the contraction of the heart, or to the temperature
itself in other ways. It would rather seem that in many cases the
condition of the vessels was rather the prime cause of the increased
temperature than its consequence. But we are met by insuperable
difficulties in ascribing warmth to the activity of the vaso-motor
TYPICAL rORMS WITH ALTERED TEMPERATURES. 195
nerves as long as we suppose that an isolated direct stimulation of
the vascular nerves absolutely determines (feststeht) the contraction
of the smaller-arteries. For active contraction (Zusammenziehung) of
the smaller arteries can only be considered certain in a very brief
space of time during the course of a fever^ and if their dilatation,
which results in hypersemia and increased calorification, is made to
depend simply upon paresis or upon debility and exhaustion, this
explanation may easily be accepted in the case of certain fevers of
great intensity ; but for many other cases, indeed for the majority,
it is unsatisfactory.
A great part of the difficulty would be removed, should Schiff^s
conclusions be confirmed, that besides the contractile elements in
tlie vascular nerves, there are also such as induce a dilatation of
the vessels when they are stimulated. It is easily explicable, on this
hypothesis, that on the first onset and determined attack (Zurwir-
kuugkommen) of the primary cause inducing the disease, such an
excitation of the central vaso-motor organs may ensue, as may give
predominance to those elements which produce contraction of the
vessels ; and that at a later period, or when the primary causes of
fever are in less force, more gradual in their approach, and milder
in their operation, the influence may be such as may chiefly make
itself manifest in the dilating elements of the vaso-motor nerves,
just as under powerful stimuli applied to the motor (locomoto-
rischen) nerves, the action of the extensor muscles usually prepon-
derates, whilst with a less powerful, or longer continued stimulation,
the contractions are principally shown in the flexor muscles, and
their previous antagonists appear inactive. Further opinions of
Schiff as to the two distinct properties or functions (Gebieten) of
vaso-motor nerves, are no less striking. According to him, the
state of vascular contractions is not generally met with at any given
time all over the body, but is probably limited to the face and
extremities (Extremitatenendeu, — hands and feet) ; and this view
agrees extremely well with many pathological conditions; as for
example, with the distribution of warmth and cold on the surface
of the body, even without rigors, and with the spread of many
exanthems [the evolution of the eruption], &c. &c.
{f) Elevation of temperature may occur in consequence of a
morbidly increased action of the spinal centres, in consequence of
loss of power in the moderating portions of the brain, — a process,
however, which we can scarcely be confident in accepting as true,
10(3 TvricAL roH.Ms wiiii altered temperatures,
imless we meet M-ith other symptoms of a suspension of the normal
influence of the brain during the course of tlie ilhiess. This
cxphination deserves some consideration in very severe diseases, in
lesions of the upper part of tlic sj)inal cord, and in many terminal
fevers. On the other hand, it is not applicable to moderately severe
cases of fever, in which there is often no indication at all of any
brain disturbance.
(y) The rise of temperature is doubtless brought about by
several of these conditions combined, or in varied succession ;
indeed, it is probable that such combinations occur in the majority
of cases ; and thus the precise determination of the relative shares
of the primary causes becomes quite im])Ossible (eine reine un-
moglichkeit) ; and, indeed, the mere indication of the several
causes in operation may become for the most part hypothetical.
When we consider the probability, and for many cases indeed
the certainty of the co-operation of more causes than one [for
the production of febrile heat], we can understand that in two
different cases, or at two separate periods of the same case, one
and the same high degree of temperature may have a very varied
significance. The same height of temperature may indicate very
different amounts of over-production of heat, according as the
amount of heat given off is diminished, normal, or increased ; and
it is very apparent that the consequences, i. e. the disturbances of
functions, and the waste of tissue (consumtion), may be very
different in one case where the high temperature remains, in spite
of larcje losses of heat bv the usual channels, from another case
which maintains a similar height, but in which the production of
heat is only moderate, and the result is attained by simultaneous
retention or accumulation (stauung, ht. stowing) of heat. In this
way we may explain the fact, that in some cases of long-continued
high temperature the final products of tissue changes [urea, &c.]
are greatly increased, and the body loses a great deal of weight,
whilst other cases, with equally long-continued, and equally high
temperature, waste but little, and furnish but few such products.
The hand of the observer laid upon the patient does not always
receive the same sensation (adequate to the degree of heat) from
the same temperature in fevers when there is great increase of heat.
Sometimes, without being really higher than at other times, there
is a peculiar and lasting impression of a " burning " quality in the
heat (calor mordax). It is conceivable that this phenomena of
TYPICAL FORMS WITH ALTERED TEMPERATURES. 197
calor mordax belongs to those cases in which the high temperature
chiefly depends upon increased production of heat, and in which
the hand of the observer is therefore less able to place itself in
equilibrium with the heat of the patient's skin, because the con-
tinual over-production compensates for the heat lost by conduction ;
and the fact that the phenomena of calor mordax is chiefly met
with in zymotic diseases agrees very well with this view ^.
§ II. An elevated temperature which extends over the greater
part of the body, whilst the temperature of certain parts is lowered
may arise from
[a] . An unequal distribution of the heat produced in the body ;
or,
(b). From an unequal cooling, through variations in the amount
of heat lost in various parts, especially on the surface of the body,
in contrast to the continual increase of warmth-production in
internal parts.
(c). But especially from unequal fulness of the (blood) vessels.
The very common distinction which is, however, by no means uni-
formly present between the temperature of the trunk^ the (upper)
arms and the thighs, on the one hand, and of the forearms and
legs (below the knees), on the other hand [see page 149], is well
explained by ScMff's view of the different centres, and different course
pursued by the corresponding vaso-motor nerves ; and it is easy to
understand that in the first beginning of an illness, and again in a
sudden relapse during its course (as in the collapse of defervescence),
both groups of vaso-motor nerves may not be affected in the same
way, or in the same degree, and that thus there may be an actual
contrast between the blood-vessels influenced by them, and so of the
warmth of the parts to which they are distributed. Schiff's theory,
indeed, does not explain a rigor, for this may occur without this
contrast, but it does explain one of the phenomena of rigors,
which is, indeed, very common, viz. the contrast between the coldness
of the forearms, and (lower part of the) legs, with the high tem-
perature of the trunk.
' By many English observers this pungent heat of skin, at least in its most
characteristic form, is believed to be almost pathognomonic of pneimotiia. I
have myself been accustomed to attribute it to increased acidity of the cutaneous
secretions. It is best recognised by a slightly moist hand, and the almost pain-
ful feeling induced, sometimes requires the hand to be washed to get rid of it.
193 TYPICAL FORMS WITH ALTERED TEMPERATURES.
It is further very evident that the great variety of causes of un-
equal distribution of warmth vary greatly in tlieir importance as
regards the functions and special relations of the organism gene-
rally. A patient in a rigor, and a patient in collapse, feel very
dillorently notwithstanding the fact that the contrast between the
temperature of the trunk and that of the extremities may be iden-
tical. It may be conjectured that it depends more upon the dif-
ferences in the original causes than upon the degree of their opera-
tion, as to what further symptoms may accompany the phenomena
of difference of heat, and one may even venture to affirm that when
no difference of temperature is manifest, because the exciting cause
has operated too feebly, yet other corresponding special effects arc
associated with the cause in question.^
§ 12. ^ loioering of temj)eraU'..re all over the body, can only be
induced (bedingt) by
{a). Diminished warmth-production, or,
{b). Increased loss of heat, or,
(c). Both these conditions together.
Such a depression of temperature below the normal warmth, may
occur after a previously normal temperature of the bodj'^, or after
this has been previously above normal. In the latter case, in some
points of view, a fall of temperature which does not even reach
the normal level (Niveau), may have the same significance, and be
followed by similar results, as a descent below the normal tem-
perature would have under other circumstances.
In most cases, if not in all, it is quite impossible to assign the
respective shares of diminished production or increased loss, with
anything like accuracy. But we may sometimes arrive at tolerably
correct conclusions, as to the chief cause of the decreased heat,
from the circumstances of the case, from the suddenness with which
the temperature falls, and from the mode in which certain remedies
act when applied.
§ 13. The remaining phenomena of rigors, of collapse, and of
1 Ir, is scarcely necessary to remind the reader that fsecal accumulations, and
pelvic or abdomiual tumours, &c., may cause coldness of the lower ex/reiuides.
It is also no less true that in such cases the corresponding parts of the
vpper extremities are also affected. The former from diminished blood-supply —
the latter by sympathy (?) — [Trans.]
Ti'PICAL FORMS WITH ALTERED TEMPERATURES. 199
pyrexia, present us v/itli a very complex assemblage of functional
disturbances, and in part also of chemical and textural changes.
Although, indexed, many of these may be attributed to the altered
temperature itself, a great number of them still remain which indi-
cate that in the three conditions named above, the different organs
of the body are placed at once in abnormal conditions, by the im-
mediate operation of the original exciting causes (Ursachen), and
the disturbing effect of the complications thus induced is so pene-
trating (innig) and complete, that a variety of interdepending and,
perhaps, opposite circumstances arise, which, however the tempe-
rature may affect them (or whatever its relations to other special com-
plications may be), undoubtedly affect the temperature. For ex-
ample, if increased temperature effect certain definite changes in the
movements of the heart and respiratory organs, it is just as certain
that an altered rhythm and force of the heart, and changes in the
respiration aflfect the temperature. An inexplicable interdepen-
dency of influences and operations, and, therefore, incalculable results
and consequences might fairly be expected to ensue, were it not
that even disease itself is a part of the '^domain of law" which
we can discover by oft repeated and laborious observations, but
apparently never succeed in codifying [lit. ergriinden].
§ 14. Thus, a rigor presents itself as a complex Initial — very
rarely as a process complete in itself — in certain types of disease,
and recurring paroxysms. In the one case its occurrence is the
rule ; in the other case it requires for its production a certain in-
tensity of the disease (as regards its exciting causes) or a certain
predisposiiiou on the part of the individual attacked. If this predis-
position be highly developed, forms of disease which usually exhibit
no cold stage may set in with one, and a rigor may even occur in the
midst of their course, although usually it only marks the commence-
ment of fresh disease or new attacks of old ones.
There is no doubt that a rigor is most sure to be developed when
the temperature of the trunk rises so rapidly that it soon creates a
considerable contrast with the slowly rising or perhaps falling
warmth of the extremities.
But this condition is not inseparable from a rigor, and even when
it exists, there may be no rigor. In men who are not very impres-
sionable, or in such as have their capacity for impressions diminished
by medicines {quinine) or by disease, no rigor may ensue, in spite of
200 lYiMCAT, FORMS WITH ALTF.UF.D TKMPER ATURKS.
sudilcn rising of (lie trunk temperature. In very sensitive ])coi)lc,
on tlie other jiand, it does not recjuirc any very marked contrast to
induce a rigor, and the same condition (stimmung) of internal ])arts
uhich is brought about by tlie contrast of temperature, may doubt-
less be induced in other methods and by other primary causes. For
even in health, a sensation like a rigor (feelings of chilliness, &c.)
is induced by slight but sudden changes in the objective warmth of
the media in which we find ourselves (a draught of cold air, or in
summer, passing out of an atmospheric warmth of 30° C. (86° F.)
into a room at 22° C. (72° F. nearly) ; but tlierc is a very remark-
able difference between one person and another even as regards the
predisposition to shiver under such circumstances.
§ 15. If we regard a rigor as an expression signifying the rapid
development of new conditions, and especially of such as are accom-
panied with a rise of temperature, we must look on pyrexia as a
state in which these conditions have arranged themselves more or
less in a kind of relative equilibrium — not indeed an equilibrium on
the same plane (niveau) as in health, but such a balance of power
as is brought about by the pathological processes which are occurring
— an equilibrium in which the temperature either remains persistently
high, or exhibits daily fluctuations with more or less considerable
excesses over the normal daily maxima of health. It is not difficult
to understand that in those cases in which tiiis relative equilibrium
is very gradually brought about, or in which the increase of tem-
perature always keeps within certain limits (maass) and remains
tolerably constant, the transition from health into the febrile con-
dition may occur without any rigor or " cold stage," aTid the " hot
stage " (pyrexia) may begin at once — or at least only slight indica-
tions of a rigor (chilliness and the like) may precede it. The
maintenance of a certain equilibrium of temperature in the course of
a disease, does not prevent the occurrence of " changes of level" in
the temperature. If they do not occur too suddenly, they generally
have no other consequence than an increase or decrease of the other
symptoms. TThen a fresh and rapid rise of temperature sets in, and
the temperature in other parts of the body does not keep pace with
it, a fresh rigor may occur.
§ 16. CoUajJse may occur relatively as a primary phenomenon,
(after the operation of certain causes and influences), or as an
TYPICAL FORMS WITH ALTERED TEMPERATURES. 201
episode of brief duration in the course of pyrexia, and also in the
fatal close of a disease ; or, lastly, in its transition into health. The
relatively prim-jlry collapse, to which also belongs the collapse of
rigors (that is, the kind of collapse which sometimes occurs in very
intense cases of rigors), doubtlessly depends essentially upon an
effect produced on the nervous system, and with this we find rapid
losses of warmth (generally with very profuse perspiration), uncom-
pensated by increased production of heat.
The kind of collapse which occurs as an episode during pyrexiae is
sometimes only the result of special influences, or occurrences, or of
predisposition on the part of the individual, or it may be induced by
circumstances in the course of the disease, which induce greater losses
of heat than can be immediately compensated all over the body,
particularly at its periphery, owing to imperfect circulation ; not-
withstanding, an overplus of heat may be actually produced. It is,
therefore^ chiefly met with where there is much sweating, along with
a feeble contraction of the heart.
Pro-lethal collapse may rest on similar grounds, and it is even pos-
sible that the production of warmth in disease may actually fall
below the normal.
Collapse during the transition from disease to health only occurs
when a rapid fall of the previously high temperature sets in—
whether this fall be definitive or followed by a fresh rise of tempe-
rature. An overplus of heat has nothing to do here ; but, doubtless,
at the same time the means of giving off heat are greatly increased.
(Perspirations, &c.). The favorable nature of the process in these
cases is guaranteed by the fact, that in the closing periods of the
sickness, compensation for the losses of heat by normal production
very soon becomes established, because the increased temperature
itself is no longer continuously fed by morbid processes.
CHAPTER IX.
THE DIAGNOSTIC VALUE OF SINGLE (DETACHED)
THERxMOMETRIC OBSERVATIONS.
§ I. A single observation of temperature is always an imperfect
and unsatisfactory standard — and taken by itself must almost always
lead to incorrect conclusions. It may chance to coincide with a
point of time, in which the state of temperature is of the highest
importance (entscheidende) ; but, on the other hand, it may just as
■well happen at a moment when the temperature is no standard at
all. Notwithstanding this, however, detached observations claim
our first attention for the following reasons : —
(rt) A single observation may enable us to decide whether a
person is fairly (wahrscheinlich) healthy, or decidedly unwell;
•n-hether the complaints of the patient are probably feigned, or un-
doubtedly justified by circumstances, although the disorders may
be mistaken, or even appear improbable.
(3) It may enable us to form a decided opinion upon the severity
and urgency of a general disorder (Sturung), which occurs sud-
denly, although dependent on a previously existing and undoubtedly
local disease.
(c) Supposing it to be the first thermometric observation in a
given case of illness, it is still of considerable value; for when certain
precautions are taken, it assists us in diagnosing the kind of disease
which is present, and in excluding some forms of disease, with even
greater certainty.
(f/) And sometimes, especially when the other symptoms and
circumstances of the case are taken into consideration, a single tem-
perature may itself enable us to make both a diagnosis and a
prognosis.
((?) The divergence (heraustreten) of a single temperature from
the general course of the temperature in a given disease, is of very
great importance, and may furnish us with many valuable aids [in
ISOLATED OBSERVATIONS, ETC. 203
treatment ; lit., wertlivolle Anlialtspankte] when gnided by the rules
of experience.
[f) PinalljTj it is necessary to form a right estimate of separate
observations, because the whole course of the temperature in a given
disease [as known to us] is composed of a consecutive series of
single [thermometric] observations ; and because, of necessity, the
separate observations thus become the very foundation (das letzte
Fundament) of all empirical rules.
The conclusions derived from a single temperature will be reliable
in proportion to their extent, and to the precautions observed against
deception.
Although in ordinary cases^ when continuous observations of tem-
perature are taken, very extreme accuracy is not so important in a
practical point of view ; it may easily be understood that, v/hen a
single temperature is to be made a diagnostic or prognostic basis,
the correctness of our conclusions must chiefly depend upon the
accuracy of the observation. In such cases every precaution against
deception in taking the temperature, both as regards the instrument
and the method, must be used, if we are to attach particular import-
ance to the single thermometric reading. Yet it is consolatory to
know, that even here we need not concern ourselves much with
hundredths of a degree ; and indeed, in the majority of cases, an
error of observation amounting to one or sometimes even two tenths
of a degree (Centigrade = •3-°to i° Fahrenheit, nearly) is of no great
consequence, and will not materially affect the practical value of our
conclusions.
§ 2. It has already been remarked (in § 5, Chapter I) that, with
very fev/ exceptions, the temperatures observed in human beings
during life are limited to a range of about 8° (Centigrade = less than
15° Fahrenheit).
The extreme minimum of the general temperature, or that of the
blood, can scarcely be determined with even approximate accuracy.
It is precisely in the lower degrees of temperature that errors of
observation are most likely to occur, and the observations made in
accessible situations, even when such parts are fairly sheltered, do
not allow us to conclude that the temperature of the blood, or that of
internal organs, is precisely similar. In the great majority of cases,
the temperature of the well-closed axilla exceeds ^^° (C. =: 95° F.),
and indeed it is very seldom that we observe a depression of tempe-
204 ISOLATED OBSERVATIONS,
raturo there as low as 33° C. (9r4°F.) or 32^ C. (^9-6° l\) ; and
although in certain cases of cholera, temperatures of 26°C. (78*8° F.),
or even lower, have been observed on the surface of the body, we may
be almost sure (from other observations in the same disease) that the
rectal and vaginal temperatures were considerably higher.^
Very recently Lowen/ianU has published four cases of insanity, in
which lower temperatures occurred than any hitherto observed (see
the 'AUg. Zeitschrift fiir Psychiatrie' [for ]868] XXV, 685).
Before death, and indeed for several days, they showed temperatures
of 25°, 29-5°, 2375°, and 28° Centigrade ! (= 77°> «5-i^ 747°.
and 82*4° Fahr.) They were very old people, who got out of bed in
the coldest time of the year, and ran about naked, and from their
dirty habits were constantly being bathed, and who took hardly any
food — in one case the pulse was only 45, in another only 23 strokes
per minute. Ma(fna7i ('Gazette des Ilopitaux' for 1869, No. 82)
states that he found that the vaginal temperature of a drunken woman
who laid out exposed to sleet all night, was only 26° C. (78*8° F,).
After two days it became normal.
The maximum of temperature has hitherto never been accurately
observed to be higher than 4475° (ii2"55°F. in a case of tetanus
measured by myself). Even approximative degrees (leaving fabulous
accounts out of sight) are very seldom observed. But Cicrrie found
a temperature of 44'45° (112° F.) in a case of scarlet fever." Simon
('Charite Annalen,' XIII, B. 8, 1865) observed 44-5° C. (ii2-i°F.)
in a case of variola hsemorrhagica, although indeed the temperature
■was taken after death. Lehnann (Schmidt's ' Jahrbiicher,' C.
XXXIX, 236) noted 44*4° C. (iii'9°F.) in a tetanus case just
before death; Quincke ('Berlin. Khn. Wochenschrift,' 1869, No.
29) 44'3° C. (11174° F.) in a case of acute rheumatism; Brodie,
^ Reference has previously been made (p. 183) to the observations of assistant-
surgeon P. M. Mackenzie and others on the vaginal and rectal temperatures
in cholera. Confirmatory evidence will be found in the third vol. of the
' London Hospital Reports,' and in the ' Ninth Report of the Medical OfEcer
of the Privy Council,' from the Observations of Drs. Sutton and James
Jackson, Mr. J. McCarthy, Drs. Bathurst Dove, N. Heckford, and myself. —
[Trans.]
- In the 'Medical Llirror' for February, 1865, I have put on record some
fa{al cases of scarlet fever, iu -which the temperature amounted to 115° E.
(= 46'!° C). The observations were made with one of Negretti and Zambra's
thermometers, divided into fifths, whicli had been recently compared with a
standard. — [Tbaxs.]
THEIR VALUE AND SIGNIFICANCE. 205
in his case of destruction of tlie lower cervical portion of the spinal
marrow^ 43-9° C. (ill -02° P.). I myself have seen several cases
where the tempi^rature reached 44° C. = iii"2°F., or approached it
very closely. Just after death the temperature may sometimes be
still higher : 57 minutes after death, the temperature in the case
of tetanus I mentioned above, amounted to 45*375° C. (i 1^-6^^° F.).
Even temperatures between 42*5° and 43'5° C. (io8'5° and
iio"3°F.) are exceptional (gehoren zu der Seltenheiten), and only
occur under special circumstances. In the great majority of cases,
the temperatures met with in disease, even when they prove fatal, do
not exceed 41*5° C. (1067° P.).
Narrow, however, as the limits are within which the temperature
ranges, very decisive conclusions can be derived from them.
§ 3. All possible precautions having been taken to ensure
accuracy, the fact of the temperature being apyretic (or, in other
words, the axillary temperature being less titan 38° C. (= 30*4° E.,
or 1 00*4° F.)), is of the greatest importance [in a diagnostic point of
view] ; it proves the absence of fever at the moment of observation
at all events ; yet it must be borne in mind, that the nearer the
temperature approaches the confines of fever-degrees, the more pro-
bable is it that it may soon overstep the boundaries. Whenever,
therefore, a given temperature nearly approaches fever-heat, it is
important to repeat our observations at short intervals. Yet there
is no sharply defined line of demarcation dividing the febrile con-
dition from the non-febrile. It may depend entirely upon other
circumstances in the case, whether we admit that there is fever or
otherwise. If the comparatively high temperature be observed in
the morning, before taking food, and after having been in bed some
time, fever is far more probable than with a similar degree observed
in the evening, or after the mid-day meal, or after the enjoyment of
alcoholic beverages, or after exertion, &c. So that the complexion
(ausdruck) of the complementary phenomena must be studied
before making the diagnosis of fever.
All tew/per atures which exceed 38° C. (ico'4°F.) must be looked
upon with sitsjncion, as probably febrile. We may consider one of
38*4° C. (ioi'i° F.) as indicating a mild febrile movement; anything
over this indicates decided fever. To determine whether very
moderate, considerable, or extreme degrees of fever are present,
regard must be had principally to the time of day at which the tern-
206 ISOLATKD OBSERVATIONS,
perature is taken. The very same temperatures may be important
or otherwise, according as tliey occur iu the morning, and at the
usual times of remission (ebb-tides) or otherwise.
Sometimes very high temperatures occur, which exceed, sometimes
even considerably, those common in high fever, which cannot,
liowever, in spite of this, be regarded as the true expression of an
unusually severe degree of fever, for they often occur under circum-
stances where there is no corresponding development of fever. Either
other symptoms are wanting, of those which we are accustomed to
group together under the general name of fever, or they are at all
events not develo])ed in a corresponding degree to the height of the
temperature. On this account, such temperatures may fairly be
called Itypcr-pyreilc.
"U'henever the temperature exceeds 41° C. (io5"8° P.) we may
suspect that we no longer have to do with a simple case of fever ; as
the temperature rises, this suspicion will be strengthened, and
indeed becomes a matter of moderate certainty with temperatures
above 41-5° C. (1067° F.)
The circumstances under which such high temperatures occur, differ
widely from one another:
[a] They occur in some specific forms of disease, which doubtless
depend upon infection ; but which, in spite of the high temperature,
are some of them quite free from danger, and others by no means so
dangerous, as might be inferred from the enormous elevation of
temperature. Malarious intermittent fever (ague) and relapsing
fever, are examples.^
In these, the temperature often rapidly rises, and generally
more than once in the same cases, to 41° C. (105-8° P.), or even
more, without being at all dangerous. In cases of relapsing fever
which recover, rises of temperature to 42° C. (107 "6° T.) may occur,
and even a few tenths more. In this disease the temperature may
remain rather longer above 41° C. (io5'8° F.) than in ague, but
not often for more than about a day.
(^) In other diseases of a favorable type, terminating in recovery,
1 With every respect for the opinion of so illustrious an observer as Professor
Wunderlicli, I caunot but feel that he speaks rather lightly of the danger of
intermittent fevers. Although ^ first attack in youug healthy adults is perhaps
never fatal, it is far otherwise with the very young, the aged, the enfeebled, or
those who have suffered from repeated attacks of ague, or the swamp-fevers of
Europe, Asia, and Africa, to say nothing of the American Continent. — [Tkans.]
THEIR VALUE AND SIGNIFICANCE. 207
Kit is mucli more exceptional to meet with temperatures of 41 C.
(io5"8° F,), or more ; and when they do occur, it is only for a briefer
time.. 'No satisfactory explanation of this occurrence can be
. given ; they sometimes immediately precede the crisis (perturbatio
I critica).
I (c) There are some diseases, of which the chief common charac--
teristic is best designated by the term malignanci/ ; some of these are
)■ specific infections, whilst in others we are unable to prove the pre-
sence of any infection : in such diseases it is very common to meet
with very high temperatures, and it remains open to doubt whether
these should be regarded as the cause of this mahgnancy, or merely
as its expression (Grund oder Ausdruck) . Such cases most commonly
occur in typhus, acute exanthems [scarlatina, measles, &c.] pysemia,
parenchymatous hepatitis, malignant pneumonia, puerperal fever,
meningitis of the convexity, and fatal rheumatic affections. The
rise of temperature in these cases sometimes happens somewhat
abruptly (ziemlich schroff, lit,, rather rudely)^ and it seldom remains at
this height for any number of days. The degree of temperature very
commonly decides the prognosis in these cases. If the temperature
rises to 41*5° C. (io67° F.), the prospect of recovery is always
small; and if it rises to 4i'75 C. (io7'i5° F.), death is almost
certain.
[d) In many cases of disease, even such as are not febrile in
themselves, during the last hours of life the temperature rises
enormously, generally by a sudden spring, to over 41° C. (io5"8° F.)
up to 42'5° C. (108-5° ^O^ ^^ more, or even above 44° C.
(111-2° F.)
They are generally diseases in which the central nervous system
is seen to be implicated, and generally severely so, before the rise
of temperature. Tetanus, in particular, pursues such a course,
and so do epilepsy and hysteria when terminating fatally ; and so,
also, inflammatory affections of the brain and medulla spinalis, as
well as injuries of the upper part of the medulla -, and once, now and
then, diseases in which there had been no previous evidence of the
nervous system being implicated.
As regards collapse-temperatures we must not forget, that
collapse itself is not identical with collapse-temperatures — for these
may occur without the special phenomena of collapse, and symp-
toms of collapse may occur, with an elevated temperature of the
trunk.
208 ISOLATED OBSERVATIONS,
^ 4. Anv special diagnostic or prognostic value based upon tii^^'
nbso/ufe height of a given tcmporaturo niorcly, apart from wliat \\-\i
previously been stated, is in every way doubtful (niisslicli). OAly
extreme degrees of liigii or low temperature can be regarded as in
themselves certain iiulications of ilanger, or even of the certain
api)roach of death, Mith this limitation, that in certain formes of
disease, extremely high degrees of temperature, which in other casfe'^-
would signalise a death-agony, may in them ])ermit a favorable
prognosis. In both typhus and typhoid fevers, higher temperatures
are borne [safely] than in i)neumonia, and higher in scarlet fever"
than in measles ; yet, whilst in all these types of disease a degree of
temperature above 42° C. (io7'6° P.) allows us scarcely any hope — in
relapsing fever, such an occurrence is almost free from danger in
itself. The highest temperature noted in a case of recovery, in recent
times, is given by Mader (Session of the [Vienna] Imperial Surgical
Society, June 5, 1868). In a soldier returned from Mexico, pre-
viously suffering from an irregular intermittent, after repeated
hiemorrhages, and the most extreme debility and deafness, the tem-
perature rose to 43*3° C. (i09"94° F.) (?). Transfusion of blood
saved him, and the next day the temperature was almost normal
(' Wiener "Wochenblatt.,' xxiv, 233.) Cases of sun-stroke with
temperatures of 42*8° C. (i09"04 Y.), ending in recovery, have been
published hjZevicl- (see page 132.) In cases observed by myself, I
can only remember two (of relapsing fever) with a temperature of
42*2° C. (io7'96'F.) which ended in recovery; all the rest, Avhich
exceeded a temperature of 42* 125° C. (io7"825° P., occurring in the
rigor of abdominal typhus) ending fatally.
It is less easy to define the limits of temperature in a downward
direction. The lowest temperature I find recorded amongst those cases
of mine which recovered, is 33*5° C. (= 26"8^ R., or 92*3° Fahr.),
the pulse at the same time being only 62 per minute (in the collapse
of defervescence in a case of enteric fever) .
§ 5. In all less extreme degrees of temperature particular atten-
tion must be paid to the other circumstances of the case.
The idiosyncrasy (Individualitilt) of the patient is to be chiefly
regarded.
In CHILDREN* the significance of temperature in disease is in the
mahi identical with that of adults, but children much more frequently
exhibit sudden and extensive changes of temperature than those of
THEIR VALUE AND SIGNIFICANCE. ■ 209
i:_^i-e advanced age. They show more sudden '^plunges" (Spriinge),
nid in febrile diseases an earlier rise, and a somewhat higher tempe-
latjre all through, than grown-up people.
Their temperature is affected more rapidly and more considerably
l;y accidental influences. So that if we note a high febrile temperature
'Is. a child, it has not generally the same serious import as it generally
J ,3 in the adult, but may, apart from malarious intermittent fever,
belong to a brief, paroxysmally occurring affection, and may occur
without much danger in diseases in which, in the grown-up person,
.- would almost warrant a fatal prognosis. Yet any considerable
elevation of temperature in a child must always call for the most
careful and anxious supervision ; although we see often enough, that
considerable rises of temperature, occurring after a few hours' illness,
give place either to normal or moderate degrees of heat, after some
twelve or twenty-four hours.
' ases of ephemeral fever, without any very serious foundation
(bcdeutungsvolle Begriindung), are particularly characteristic of the
period of childhood. Therefore in children's diseases, even when we
find a very high temperature, we must be very careful in drawing
coi/clusions from the first [or a single] observation. At this age
a^so more or less high temperatures may occur at stages [Punkten]
IS? the course of a disease in which we generally find very moderate or
iO'rmal temperatures in the adult. And even in convalescence, espe-
', ially after muscular exertions, very considerable elevations of tempe-
lature are sometimes met with in children.^
On the other hand, very old people and aged men very often show
temperatures in disease, which are from a half to a whole degree C.
(=•9 to i"8°r.) under the average height, or even under the
iiiinimum height exhibited by the same disease in younger people —
and this kind of advanced age (betagte Alter) occurs in febrile disease
somewhat sooner than we generally reckon ; at a time, indeed, which
a healthy man considers as his prime of life, though earlier in some
than in others. Between forty and fifty the majority of men begin
to exhibit the senile character in the degree of temperature in febrile
diseases, and in not a few this modification of age begins to show
1 If any confirmatiou were wanted, I might mention that I have several
times found a temperature on the second day of a child's illness, of 106° T.
(41.1° C), whilst on the third or fourth day tlie temperature was not only
normal, but the child was also to all appearance well, and continued so.—
[TllANS.]
14
210 ISOLATED OBSERVATIONS,
itself about their fortieth year. This senile character is so peculiar,
that the nature of the disease being previously deterinined, one cnii
diagnose the age with tolerable certainty, merely by a glance at tlu'
course of the temperature. On the other hand, if we disregard iliis
[physiological] age of the patient, the moderate elevation of tempe-
rature may easily lead us into error, as to the kind and degree of
danger of the disease, especially in a first observation, or before the
diagnosis is otherwise determined. On the other hand, aged men
are much addicted (incliniren) to collapse-temperatures, and in them,
these often sink to a very low level. For some details on the condi-
tions of temperature in fevers, in very old people, consult Charcot
(de I'etat febrile chez les vieillards, in Nos. 69 and 74 of the
'Gazette des Hopitaux,' 1866) and Bergeron ('Recherches sur 1
Pneumonic des Vieillards,' 1866.)
Many women, and sometimes also men, of delicate, somewhic
feminine build and constitution, occasionally exhibit a similar cou
of temperature to that shown by children. They are generally dp ..-.
cate, sensitive, nervous natures, and those of hysterical temperaro .lli
in whom we meet Avith sudden elevations of temperature, 0 or
reaching high degrees on slight provocation, and sometimes a^ iar
rently without any "motive" [any apparent cause], degrees oft a-
perature which they sometimes exhibit for unusually prolont n
periods. In such persons, when no other decisive symptoms a
present, we must suspend our judgment for awhile. But a
unusual height of temperature must always afford a good reason 1 <i
careful and continued supervision of the case. 'i
§ 6. In estimating the diagnostic value of a thermometric reac/
ing, the time of day at which it is taken must never be left out of
consideration. (Refer on this subject to the sections on Daily
Fluctuations of Temperature.)
The period of digestion, which generally causes a more con-
siderable rise of temperature in sick people than in the healthy,
and other accidental influences, must always be considered, even
in a solitary observation. We must particularly remember that
thermometric readings, just after the removal o^ a patient, are
always untrustworthy, since the mere act of removal (transport) is
just as hkely to raise the temperature as to depress it.
§ 7. It is especially important [although we may not be able
*1. .«"fV «*
THEIR VALUE AND SlGNli'IC'ANCE. TJ^I
(o draw absolutely decisive conclusions from a single tliermometric
reading] to devote special attention to the other sym^itoms of the
patient, and particularly to consider whether they agree or contrast
with the temperature we discover.
In order rightly to estimate the relations of temperature to the
other symptoms discovered in the patient, we must endeavour to
realise how varied and many-sided these relations may be.
{a) The altered temperature may be produced by a disease of
some organ, which in itself gives rise to more or less striking
symptoms. The behaviour of the temperature in such a case is
the result of the topical malady.
{]j) The altered temperatures, and a larger or smaller number of
)ther symptoms may be the common result of one definite primary
"use, e.g. of an infection (contagion), of an intoxication (poisoning),
I other external morbific operation.
((?) Alterations of temperature, especially such as greatly exceed
normal, or are of long duration, in themselves produce very
erous functional disturbances in most portions of the body,
\ even alterations in the tissues, if very long continued ; so that
I in high degrees of fever and in collapse the foundation may
laid for a copious semeiology, which may base itself on the
ered temperature, and exhibit itself in changes in the circulating,
spirating, secreting, and nutritive systems, as well as in the
!ictions of the nervous system. But it must not be forgotten that
ere is in no way an exact parallelism between the morbidly
ivated or depressed temperatures on the one hand, and the
^ecial symptoms on the other; but empirically we learn that the
aost important indications (Kundgebungen), particularly as regards
the nervous system, coincide not with the actual height, or the
equivalent condition of the temperature, but with rapid changes of
the same.
(r/) [Almost] innumerable circumstances and conditions may
cause a discrepancy between some one or more of thepatient^s other
symptoms, and the course of the temperature.
In particular cases it is first necessary to carefully consider how
far the temperature observed agrees with the remaining symptoms.
If the temperature harmonizes with the patient's whole condition,
and with all the rest of the several symptoms, and with the
diagnosis derived from them, as to the kind, degree, and character
ISOLATED OUSKllVATIONS,
of the disease, it is, as regards this diagnosis, simply an additioniil,
but indeed verv valuable and decisive conlirmatioii. \]
§ 8. If, on the other liand, we notice a [\nnr\ie(\'\con/i'asf between
the temperature, and the rest of the symptoms, we ought, in those
cases in which the contrast is considerable, to lay the chief stress
upon the temi)erature. On the other hand, if the temperature be
less than we should expect from the other sym])toms, our first duty
is to verify the tliermometric reading, and having done so, to con-
sider, as far as we can, what accidental, therapeutic, and other
influences and events have occurred, which may cither depress
the temperature, or exalt the other symptoms. And in con-
sidering the a])parent contrast between the sliglit deviation of
temjierature, and the severity of the other symptoms, we must!
inquire whether the type or stage of the disease may not be 1
concealed cause which is signalised by this course of tempeaturre.
If no such explanation is possible, the contrast between 1
temperature and the other symptoms generally furnishes us wi
proof, either that no very pronounced type of disease is present.]
that an advanced stage of it has been reached, or that some pecur
development is masked; or perhaps the lowness of the tempei^
ture may even indicate that the patient is just bordering up
collapse.
§ 9. Although the temperature may contrast strongly with fl^
general feelings of the patient (Allgemeinbefinden), even shoul
these be more or less uncomfortable (schlechte), still if the hca(
of the body is only normal, or slightly abnormal, there may indecc
be some irregularity or disturbance in the economy ; but it is at^
most not very acute; and sometimes, if the disease has only lasted
a short time, the association of loud and varied complaints with
normal temperature gives us good reason to suspect simulation
or exaggeration.
If, on the other hand, the subjective condition [i.e. the patient's
own feelings] and the temperature exhibit a considerable contrast
(Abweichung), we are at once justified in concluding that the
disease is probably severe and extensive. In ty^Jtious and other
infectious diseases the contrast between subjective feelings of com-
fort (Wohlbefindens), and a high temperature is not unfrequently
met with.
THEIR VALUE AND SIGNIFICANCE.
213
At the very moment of a favorable crisis of severe febrile diseases a
very miserable (unbeliagliclie) feeling sometimes occurs with normal,
or even sub-normal temperatures, especially when defervescence
degenerates into collapse. We should not allow ourselves to be
easily deceived in these cases by the uncomfortable (schlechte) feel-
ings of the patient, but may safely conclude that convalescence has
commenced.
§ lo. There is very often a contrast betw^een the temperature
and ihcfreciuencif of the pulse.
AVe may lay down as a rule for febrile conditions in grown-up
people that slight febrile temperatures coincide with a pulse of
80 to 90, moderate degrees of fever with one of 90 to 108, con-
siderable fever with a pulse of 108 to 120, and that in more
extreme degrees of fever the frequency of the pulse exceeds 120
per minute. Yet these numbers have only an approximate
value.^
In children and very delicate and nervous individuals this
relation is materially altered, and the frequency of the pulse is
generally much greater.
1 Dr. Aitkiu (' Science and Practice of Medicine') says, " As a general rule
the co-relation of pulse and temperature maybe stated as follows: namely,
" A7i increase of temperature o/"one degree F. above C)%° F. correspo7idstcifh an
increase o/te'S beats of the pulse per minute, as in the following table :
Temp. Talir. [Centigraile.] Con-esponcl to a Pulse of
. 60
• 70
. 80
. 90
. 100
. no
. 120
• 130
. 140
[[ have added the Centigrade equivalents for convenience sake.]
Liebermerster gives the following numbers \J Schmidt's Jixhrbuch.,' Bd. 142,
pp. 42,91]:—
Pulse.
F.
F.
98°
z=.
[36-6°]
99°
=^
[37-2°]
100^
—
[37-8°]
101°
1=
[38-4°]
102°
^
[38-8°]
103°
=
[39-9°]
104°
^
[40-0°]
105°
i::z
[40-6°]
106^
z=
[41.1°]
Pulse.
Temperature.
786
37° c. = 98-6
88-1
38° C. = 100-4
97-2
39"^ C. = I02-2
41° C. = 105-8" F.
F. 121-7 42° C. = 107-6° F."
Both statements substantially agree with the author's in the text.— [Trans.]
1053
109-6
121-7
Temperature.
40' C. = 104° F.
214 ISOLATED OnSKKVATIONS,
Somotimcs very great contrasts occur between pulse and tem-
perature,— the former gcnoraWy follows the temperature when there
is any improvement ; and increased frequency of the pulse generally
precedes the rise of temperature in exacerbations.
A somewhat infrequent pulse, as compared with the temperature,
may be regarded as a favorable sign, as it indicates a tranquil
nervous system; a disproportionately low pulse-frequency with a
high temperature, allows us, on the contrary, to predicate the
presence of some special conditions, which must be discovered by
some other method, c.ff. pressure on the brain, biliary constituents
in the blood, medicines which affect the pulse (depressants), and
such like. A temperature which is disproportionate to the great
frequency of the pulse, points to local complications in the heart,
or to mischiefs arising from the organs of respiration, the thorax,
or the pelvis, or to the heart being influenced by the nervous
system; we must, however, not forget that any movement, how-
ever slight, will accelerate the pulse considerably in many of our
patients.
On all these grounds the frequency of the pulse, taken by itself,
is a bad guage of the amount of fever present.
In general that which affords us the best standard, is the cir-
cumstance (Moment) which appears the most unfavorable, "With
rapid pulse and moderate temperature the former, with slower
pulse and high temperature the latter — and this rule (Verhalten)
will be found most applicable when the contrast between the two
is greatest, A sub-normal temperature co-existing with a not ex-
cessive frequency of pulse does not, however, indicate an unfavorable
prognosis.
§ II. The miniber of respirations per minute corresponds "o-ith
the temperature far less than the frequency of the pulse. In collapse-
temperatures there is generally increased frequency of respiration, but
it cannot be laid down as a universal rule.
It is equally impossible to apply any rule in this respect to hyper-
pyretic temperatures, whilst on the one hand respiration may be
much accelerated, on the other it is not uncommon to meet with
cases in which it is less rapid than normal. When the temperature
is nearly normal, and in moderate degrees of fever, respiration is
scarcely influenced at all ; only in children, even with moderate
fever, there is sometimes increased frequency of breathing. [In
THEIR VALUE AND SIGNIFICANCE. 215
others] when we meet with quickened respiration, we must look foi-
local causes. In ordinary degrees of fever there is generally a
moderate increase in the number of respirations, amounting to some
20 or more respirations (Ziigen) per minute, and in children even to
40 or 50 in the same time. In considerable, and extreme degrees of
fever, the number of respirations generally rises to 30 or more,
and in children even above 60 per minute, without the organs of
respiration being specially implicated.^ The frequency of respiration
in fever-patients is also considerably increased by every movement of
the body.
§ 13. Between the temperature, and cerehral ST/m/ptoms, there is
sometimes a certain parallelism (correspondence), and at others
there is a considerable contrast to be noted. With regard to these
brain-symptoms, no doubt individual peculiarities play the most
important part. In slight or moderate degrees of fever, in grown-up
people, the brain is usually but little implicated ; but in children and
very old persons much more striking cerebral symptoms are met with.
Even with more considerable degrees of fever in adults, the functions
of the brain are not generally so much disturbed as to produce
confusion of ideas, or involuntary utterances during the daytime.
Delirium and special disturbance of brain-function chiefly occur with
very high degrees of fever. If, therefore, there is a moderate tem-
perature, with considerable symptoms on the part of the brain, we
must attribute the symptoms to a local and independent affection of
this organ, in the case of most patients, but not if the patient be
either a child or a very old person.
This conclusion is justified in proportion as the temperature
approaches to normal, and the less "peculiarities" mark the
individual.
When the temperature is falling rapidly, as occurs in collapse, and
in many cases of defervescence, there sometimes occur, during the
change, alarming cerebral symptoms, particularly fierce delirium and
maniacal outbreaks, which under these circumstances have far less
1 It is scarcely necessary to reniiud the reader, tliat much of this is due to
diminished muscular power, and more perhaps to the fact of the mechanical dis-
advantages under which much of the work of respiration is performed, and the
increased work thrown upon tlie lungs, owing to other organs being hors de
combat. These remarks apply of course to fevers ^'ithout special pulmonary
complications. — [Trans.]
2\G TSOLATI'.D OnSKRVATlOKS,
iiiiportaiicc tliau those not familiar with the circumstance wouhl
ascribe to them. However, it is no less true, that similar symj)toms
occur during the collapse preceding death (Agonie-collaps.) And
here the distinction between the two sets of cases must be made ujiou
other grounds [than mere tem])crature or delirium].
§ 13. Significance of (lie result of a single thermomeiric observation
in a person considered to be healtlnj. — The fluctuations, which gene-
rally occur in such, are very trifling. Yet there are cases, in which
one finds very considerably excessive temperatures. During men-
struation and lying in (Wochenbett), during suckling, during
dentition, unusually rapid growth, in conditions of extreme fatigue,
of psychical depression, and such like, the temperature is often
increased. In such circumstances, therefore, the maintenance of a
normal temperature is a capital guarantee of the resisthig powers
[Widerstaiidsvermogen, staying powers, or capacity of endurance]
of the organism, and therefore that no pathological process is going
on. On the other hand, when the normal hmits are exceeded, the
significance depends on the amount of excess, and upon the idiosyn-
crasies of the patient. In every case, every deviation from the normal
should be a motive for further careful observation,
A sub-normal temperature in ap])arently healthy people is, as a
rule, without much importance ; although it will always raise the
suspicion that either some unfavorable influence is working upon
the individual in question,^ or that the apparent health masks some
concealed disorder.
The commonest deviation from normal temperatures which occurs
in apparently healthy people, without any very exceptional circum-
stances, is a sub-febrile temperature. It indicates that the subject
of it is not quite in good order, and that at all events there is a
morbid susceptibihty (Empfindlichkeit).
In children, particularly, the younger they are, such temperatures
can generally be caused through slight external influences, by move-
ments, &c. In adults, particularly, if they seem pretty robust,
such febrile temperatures render it very probable that some latent
mischief exists. When such are found, they should urge us to
further examination, particularly of the lungs, heart, bowels, renal
secretion, &c., and to continued vigilance, and particularly to repeat
^ The temperature is often sub-normal in chronic alcoholism, saturnine in-
toxication, and the intermissions of malarious fevers. — [Tkans.]
TITETR VALUE AND SIGNIFICANCE. 217
the application of the thermometer. Pebrile temperatures occur
pretty frequently in men reputed healthy, but certainly as a rule
only moderately febrile degrees. They are a sure sign of some
existing mischief, — either of some anomaly from the operation of
an external cause, or the beginning of some acute disease, which
has not yet revealed itself in any other way, or finally, that some
chronic mischief, although present, is concealed (latent).
It need scarcely be remarked that such a state of things calls
for the most vigilant supervision.
§ 14. Significance of a single observation of temperature in cases
of apparently slight indisposition.
Cases of indisposition, which afford as yet no diagnosis in other
ways, exhibit the value of the thermometer as a rapid method of
acquiring information (zu einer raschen Orientirung) in a very
striking manner. When the temperature is found to be normal,
the slight character of the illness is confirmed ; yet it is well in
all cases of indisposition with normal temperature to use the
thermometer again a few hours after, and particularly at such
times as are commonly marked by exacerbations (in disease).
Even a sub-normal or sub-febrile temperature allows us to
conclude that the malady is not very serious, provided the observa-
tion is not taken at the very commencement of the disorder.
But as soon as the temperature reaches the fever limit, increased
vigilance is necessary. Yet such a febrile elevation need not
necessarily entail a severe illness; for children, women, delicate
persons, those suffering from chronic diseases and phthisical
patients, commonly show a transitory febrile temperature during
slight attacks of indisposition.
But a very high temperature should at least always prepare our
minds for the development of a serious illness. Under these cir-
cumstances, therefore, the patient should be confined to bed, and
requires at least prudence and vigilant nursing.
§ 15. A diagnosis is seldom possible at the very commencement
of an acute febrile disease.
If we find the temperature normal, or the fever only moderately
high, we may with tolerable certainty exclude acute true pneumonia
(croupcise lobare Pneumonic), small-pox, and scarlatina.
If the temperature is normal, or only slightly febrile, the illness
2 IS ISOT,ATi:n OBSERVATIONS,
is certainly not iyplioid fever (so ist die Erkrankung kciii Typhus).
[Our pctccliial ty])hus is rare in Germany. — Trans.]
If, ou the other hand, witli the development of the other early
symptoms, the temperature at once shows considerable fever, the
"area of probabilities " is ranch more extended, and includes the
exanthemata, acute tonsillitis, pneumonia, pleurisy, intermittent
fever, ephemera (febricula), ])ya3mia, meningitis of the convexity
of the brain, petechial typhus, S:c. ; but we may at least conclude
with great certainty that there is no enteric (typhoid) fever present.
Influenza (eine Grippe) is also improbable, and so is diarrha-a,
except some special injurious influence has attacked the bowels.
In the same way acute articular rheumatism is very improbable
when the temperature is very high at the onset of a disease.
§ i6. In many cases, the diagnosis of an acute disease is still very
doubtful during the first half of the first weelc. Thermometry is
sometimes able to assist in the diagnosis, by means of a single
observation, but not always. Subnormal and collapse temperatures
only occur in diarrhoea, cholera, haemorrhages, perforations occurring
internally [as of intestine], sometimes with gastritis from toxic
agents, and even in peritonitis.
If in spite of symptoms suggesting the idea of fever, one finds on
any of the early days, particularly in the evening, a normal tempe-
rature, we are justified in suspecting an intermittent fever to be
present ; at all events, such a course of disease excludes both typhus
and typhoid (enteric) fevers, and acute exanthems before the erup-
tions (except measles, rubeola notha [rotheln], and varicella.) The
development of severe inflammations is also improbable under such
circumstances ; and above all, a normal temperature in the evening
in the early period of the disease, points to a speedy termination of
the process. If the morning-temperature is also found normal,
unless some special circumstance operates to keep the temperature
low, we may conclude against any disease at all with tolerable
certainty.
Catarrhal affections, measles, pleurisy, acute tuberculosis, granular
(tuberculous) meningitis, and acute rheumatism, may however be
present with a normal morning temperature. Sub-febrile tempe-
ratures, and those of a slight febrile movement have about the same
sicrnificance, except that on either the first or second morning they do
not exclude the possibility of abdominal typhus (enteric fever).
When acute exanthems are very rudimentary [in the early stage].
THEIR VALUE AND SIGNIFICANCE. 219
especially in measles, sucli moderately febrile temperatures may occur
before tha •ei-'uptiou. In catarrhal and rheumatic affections they are
the rule for the first few days ; on the other hand, we do not find
them in intermittent fever, unless we accidentally take the observation
at the beginning or end of a paroxysm.
A considerable or high febrile temperature, when it is observed as
early as the first or second day, renders enteric fever improbable, or
proves that it began longer ago than the other symptoms seem to
indicate. This conclusion is still more probable if the high tempe-
rature be found in the morning. For the rest, a single observation
of temperature indicating a high degree of fever, scarcely allows us to
form a conclusion as to the kind of [morbid] process going on, for
the first few days ; but if we are able to exclude the possibility of an
intermittent fever, we may with great probabiHty expect a very severe
illness.
If, however, the diagnosis of the disease can be made from other
data (Momenten) during the first few days, the degree of the tempe-
rature obtained may enable us to form tolerably accurate conclusions
as to severity of the case, since extreme temperatures indicate a
severe form, whilst a temperature less than the mean {vul(/o, average)
temperature of the disease at any given hour of the day, indicates the
probabiUty of a mild course of the disease.
" § 17. Even in the second half of the first week of illness of a
febrile character, the diagnosis may still be very uncertain. We
may have to do with the protracted [initial or] prodromal fever of
an exanthem, with abdominal or exanthematic typhus [ij^his or
i)']ihoid fever] , relapsing fever, a tardily developing pneumonia, severe
influenza, capillary bronchitis, acute miliary tuberculosis, inter-
mittent fever, tubercular meningitis, epidemic cerebro-spinal me-
ningitis, hepatitis, internal suppuration, osteo-myelitis, acute lues
[syphilis.]
A solitary reading of temperature can give us but scanty aid in
forming a diagnosis in such cases. If we find, however, the evening
temperature normal, sub-febrile, or moderately febrile only, and no
temperature-depressing influence has been at work, we may correctly
assume that neither the prodromal fever of an exanthem nor typhus
is present.
If we find a considerable, or very high degree of fever heat, we
can Avith great probability exclude tubercular meningitis.
2'20 ISOLATED 0T5SERVATI0NS,
If a liypcr-pyrctic temj)orature is present, cither an intermittent
fever, or some malignant form of infectious disease is masked, and
there is imperative necessity for further anxious supervision and
renewed application of the thermometer. Temperature is in all
these cases a valuable auxiliary) in diagnosis, but to remain satisfied
M'ith a single observation of the thermometer, must always lead to
imperfect results, and we ought to be particularly careful not to
found rash conclusions on such.
§ 18. When an exanthem [eruption] appears, in cases when the
diagnosis has previously been doubtful, its kind and the symptoms
while occupying it must naturally be the groundwork of our dia-
gnosis ; but we may sometimes still be uncertain for a little while,
whether we should consider the commencing eruption to be that of
small-pox, measles, scarlet fever, exanthematic [true] typhus or a
syphilide. In these cases the thermometer may help us to a dia-
gnosis, at least, so far as this, if the symptoms have been very
severe, and after the eruption the temperature becomes low, we
may conclude for small-pox, and, indeed, if it become perfectly
normal, we may be almost sure that we have modified small-pox
(varioloid). With a syphilitic exanthem the temperature falls also,
but the distinction is that the preceding fever-symptoms are mode-
rate also in that case. In measles, scarlatina, and exanthematic
[true] typhus, the fever continues, on the contrary, at the commence-
ment of the eruption.
§ 19. During i\\efiiriJier course of an acute febrile disease, when
the diagnosis appears certain, or is so, the temjperature continues
to afford most important and desirable information on which to
found our conclusions, only this thermometric observation must be
continual and consecutive.
Yet sometimes a single thermometric observation may be of
great importance : it may serve to confirm a diagnosis ; it may re-
move or mitigate a doubt ; it may decide on the severity of the
disease, and may indicate its modifications, as well as the dangers
and complications which attend it.
In order to avail ourselves of the full value of a single thermo-
metric observation, we ought to be well acquainted with the usual
course of temperature of the disease which is present. A high
degree of temperature, in proportion to the remaining symptoms.
THEIR VALUE AND SIGNIFICANCE. 221
must especially be regarded as a sign of a severe attack, even when
it is oidj noticed once. Comparatively low degrees of temperature
are not, however, corresponding signs of safety, or of a mild form
of the disease, because even in the worst cases a temporary improve-
ment may occur, the cause of which is sometimes evident, some-
times unknown.
An isolated observation of temperature taken in the course of a
disease, only allows us to form just conclusions, after the most careful
consideration of all the other circumstances and symptoms of the
case.
We can scarcely admit the presence of typhus [enteric ?] fever,
when at any time between the third and tenth davs of the disease
the temperature is not at least moderately febrile, and considerably
so in the evening (at least 39'6° C. (i03'38° F.) unless some strong
fever-moderating influence has been at work just before (such as
copious hsemorrhage, diarrhcea after previous constipation, &c.), or
when the patient is aged. A low temperature, contrasting strongly
with the previous course of the temperature, may at once raise the
suspicion of internal haemorrhage, before any blood has appeared
externally. Even later, and up to the middle of the third week,
enteric fever is very doubtful if the evening temperature (apart from
the influence named above), is less than 39° C. (io2'3° F.). High
febrile morning temperatures (which approach 40° C. (104° P.), or
even evening temperatures of 41° C. (io5"8° P.), are, in this disease,
signs of great severity and threaten danger. And the danger is
very great, if the temperature of the trunk is very high along with
symptoms of collapse. But a normal temperature in the morning,
at a later period, is in no way a sign that the fever is over [for it
still rises in the evenings].
In measles it is a sign of a threatened or existing complication,
when temperature remains febrile, after the eruption begins to fade
and even a sub-febrile temperature is suspicious.
In scarlatina the same rule applies, although at a little later date.^
' I liave found the noon temperature of typical non-malignant scarlatina in a
great many cases to be nearly as follows : —
Day of Temperature,
eruption. Fahrenb. Centig.
iGt . . 105° = 40"5
2nd . . 104° = 40°
3rd . . 103° = 39-5
Bay ot Temperature,
eruption. Fureiih. Centig.
4tli . . 102° = 38'9
Sth . . 101° = 38-4
6th . . 100° = 37'8
About two dai/s more being required to regain the normal. — [Tuans.]
223 ISOLATED OBSERVATIONS,
111 sniall-j)o.r, when the temperature still continues febrile after the
eruption has fairly come out, a variola vera (/. e. the disease with
the stage of su))purative fever), or a complication may be predicted
uith great certainty.
In primary croupous and lobar [true] pneumonia, the occurrence on
a single occasion of a normal or sub-febrile temperature is no proof
that the [inflammatory] process is over. All high-febrile tempera-
tures in pneumonia are deserving of consideration, and must cause
the cases in which they occur to be regarded as very severe. If
they are found in the later period (after the sixth day) this is still
more true. Only it must be borne in mind that a striking rise of
temperature sometimes precedes the favorable crisis. In the ad-
vanced stage of jme?c?nonia, in spite of alarming symptoms, if the
temperature shows [itself normal or sub-febrile, there is, usually
speaking, no danger, and one may predict [favorable] termination of
the process with great confidence.
In facial erysipelas a febrile temperature indicates that the process
is still going on, and that further extensions or complications will occur.
In wfluenza and hronchitis considerable or high- febrile tempera-
tures are always very suspicious, and the more so if they occur in
the morning or later on in the course of the disease. They indicate
with great probability an extension to the finer bronchi, or the
supervention of pneumonia; but they also sometimes occur in cases
in which the bronchitis simply masks the deposit of acute [gray or
miliary] tubercle.
In liooping cough any febrile temperature indicates a complica-
tion, the first period of its development being excepted.
In acute [articular) rJieumatism a single observation of tempera-
ture aids diagnosis hardly at all, not even to discover the existence
of complications. Very high temperatures, however, in this dis-
ease, generally show the case to be a dangerous one.
TThen symptoms of menhuj'dis are present, a considerably febrile
or high-febrile temperature points specially to disease of the con-
vexity or summit of the brain. Weak febrile, or apyretic temperature,
on the contrary, indicates the granular form of meningitis of the
base of the skull.
In cerebro-sjnnal meningitis the temperature may reach [almost]
any height.
In pleurisy, pericarditis, endocarditis, and peritonitis, a high
febrile temperature always indicates great danger at whatever time it
THEIR VALUE AND SIGNIFICANCE. 223
may occur, whilst a tolerably moderate degree of fever, or even an
apyretic temperatm-e by no means ensures a favorable prognosis. In
presence of a g astro-intestinal catarrh, if the patient has been pre-
viously in good condition and not exposed to any special prejudi-
cial influences, a single observation if it shows us a high temperature
must always excite a suspicion of enteric fever (abdominal typhus),
or of some latent inflammation. Yet a second thermometric obser-
vation of a high temperature is required to make us certain that a
severe disease is present.
Unless the temperature at the conclusion of the cold stage (rigor)
or the commencement of the hot stage reaches nearly 41° C.
(io5"8° P.), or more, it is very doubtful whether we have to do
with an intermittent fever. But if it exceed a height of 41*8° C.
(107 "24° r.), the diagnosis of an intermittent is again very im-
probable. And the diagnosis is further doubtful unless the tempe-
rature be normal in the apyrexise (intermissions). Although the
attacks (paroxysms) may have ceased, and no other morbid symptoms
are present, as long as the temperature still shows itself febrile the
intermittent is not cured.
^ 20. During defervescence, isolated observations of temperature
afford no satisfactory results, although a low temperature occurring
in the evening is in some sort a proof of the cessation {lit. winding
up) of the fever. When the fever is just about to take its de-
parture, and shortly after, the temperature often exceeds the normal
bounds, especially in severe illnesses, and in weak, sensitive indivi-
duals, often falls for hours together, or even for a whole day, to a
depth which may easily cause anxiety. These collapse [conditions]
are sometimes associated with other symptoms, more or less severe,
and sometimes can only be recognised by the temperature. The
closer to the crisis such a collapse occurs, the less danger does it
indicate, and the more safely can it be pronounced to be the collapse
of defervescence.
§ 21. After the termination of the disease, and in true convalescence
(Pteconvalescenz) the temperature is generally normal, but conva-
lescents are rather subject to transitory collapse-temperatures. They
are not without special significance, and the more so, the farther off
they are from the crisis ; and in that case, we must endeavour to
determine whether an internal haemorrhage, or perforation of the
bowel has caused the collapse. Simple subnormal temperatures
2:li i>;OL.\Ti:i) obskuvations,
often occur during convalescence, without any special unfavorable
!?ignilicance, yet they indicate that tlic convalescence is not yet con-
solidatcdj and leave room for suspecting that nourishment is not pro-
portionate to the necessities of the case.
^loreover, the temperature of convalescents is very mobile, and
easily all'ected by insignilicant influences^ so that we may not unfre-
quently be sur[)rised by more or less considerable elevation of
temperature at this period. Such rises of temperature indicate that
convalescence is not quite complete (lit. rein.), or that it has been
interrupted.
If we find a febrile temperature in convalescence, it may depend
upon subordinate influences.
{a) From some relative errors in diet, especially a premature
use of flesh-meat, or spirituous liquors, or from overloading the
stomach.
{b) From some exertion too much for the strength of the patient ;
from too early leaving, or too long staying out of bed ; and many
convalescents show an immediate rise of temperature on first get-
ting up.
(c) From constipation.
{d) From other more or less trifling influences to which the con-
valescent has been exposed.
{e) But it may be caused by serious, it may be persistent, although
not yet diagnosable disordered conditions (such as imperfect
resolution (Abheilung) of the diseased process, partial extensions of
the disease, latent chronic affections, or a fresh disease) ; but a single
observation is not decisive on these points, and can only serve as a
beacon or sign-])ost, to point out the necessity of further ob-
servations, and of the most watchful solicitude.
^ 2 2. ^Alien any considerable change (Wendung) occurs in the
course of an acute febrile disease, a single observation of temperature
may sometimes decide whether a fatal termination is imminent or not.
Such an event is very probable, if the temperature is hyperpyretic, or
if, on the contrary, it is moderately febrile, or falls to normal, or
even below it, whilst the remaining symptoms exhibit great
severity.
§ 23. In diseases which are not in themselves of a febrile charac-
ter, the discovery of an elevated temperature is always specially
noteworthy.
THEIR VALUE AND SIGNIFICANCE. 225
111 affect'ions of the nervous system (epilepsy, chorea, hysteria,
tetanus, neuralgias and apoplexies) it may depend on the super-
vention of a- new febrile disorder, or be the beginning of a fatal
termination.!
In jaundice a high febrile temperature is always a very suspicious
circumstance. In diseases accompanied by vomiting, diarrhoea, and
particularly collapse, a febrile temperature of the trunk indicates the
commencement of reaction. And in all these non-febrile diseases
the occurrence of a febrile temperature may indicate an exacerbation
or complication.
On the other hand, in all these affections, collapse temperatures,
if they are very extreme, are of very great importance.
§ 24. — In chronic cases, with persistent fever, it is naturally to
be expected that nothing important as regards diagnosis will flow
from a single observation of temperature. Continuous observations
must, therefore, be made as soon as the results of a single observa-
tion are observed to be divergent from the iisual course of the
disease.
If collapse temperatures occur in chronic diseases they are more
significant than in acute cases, unless such subnormal temperatures
correspond to the kind of disease present.
^ 111 some cases of chorea, and perhaps of epilepsy, the high temperature is
probably to be regarded as the result of muscular action, or iu other words of the
metamorphosis of the muscular tissue, and not in itself unfavorable. — [Teans.]
15
CHAPTER X.
THE DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE.
§ I. In disease the height of the temperature varies more or less
even in the course of one day. It never remains stationary at any
one point for twenty-four hours continuously, and observations ^vhich
represent the temperature as remaining a whole day at the same
elevation are undoubtedly false.
The daily fluctuations of temperature, which have already been re-
marked as occurring even in health, are still more evident in disease.
In sick persons the temperature commonly varies from i to i-^°
Centigrade (= i"8° to 27° Fahrenheit), and it may very well change
as much as 5° or even 6° (= 9° to io"8° Tahrenbeit), or more.
When the temperature is rather high, or very high, and the daily
variations are very slight, the course of the disease will be more or
less continuous, and, cater'is paribus, a severe attack of illness is
indicated.
The daily fluctuations in different diseases, and in different patients
suffering from the same disease, assume very different forms {lit.
form a varied picture), yet they all have certain ])oints of agreement,
and are regulated by certain laws. The daily fluctuations when
projected diagrammatically take the form of waves, with crests and
farrows [lit. hill and dale], or not infrequently of combinations of
waves. The daily fluctuation is a curve, with one, two, or even
more secondary curves. In order to become acquainted with it, it
is clear that numerous observations must be taken in the course of
the day. According to the purpose one has in view, and partly
according to the nature of the case, it may sometimes suffice to take
from two to four temperatures in a day — sufficient at least to form
an opinion on the special case in accordance with general prin-
ciples previously learnt. Indeed, beginners are sometimes puzzled
by the complex combinations of curves (Wellensystem) derived from
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 227
very frequent observations, and don^t know how to find tlie longi-
tude of the case, so to speak [sich zu orientiren], whilst they easily
do so from double or fourfold daily observations^ which must, how-
ever, of course be taken near the periods of daily exacerbation
and remission. But such sparse observations must make us over-
look and fail to recognise many very important and critical events
[Momenta]; and very numerous observations, six or eight at least
in tlie course of a day, and in some conditions even a continuous
observation of temperature, is indispensable if we want to learn the
laws or, in other words, the common facts of the daily fluctuations
in disease.
§ 3. The average value of all the temperatures of a given day, or
(which is less accurate but more practical) an equal division of the
sum of the daily maximum and daily minimum is the mean dally
temperature. This must be considered in the first place if any con-
clusions are to be drawn from the daily fluctuations.-^
The daily difference is the extent of the excursus between the
maximum and minimum temperature of the day.
All the elevations of temperature which occur in the course of
the day, and exceed its mean temperature, may be designated its
exacerbations, whilst all falls of temperature below the daily mean,
may be called its remissions.
The moment (during an exacerbation) in which the rising tem-
perature changes to a falling one (which is thus, as it were, the
crest of the wave), is the acme of exacerbation (Exacerbations-
gipfel).
The temperature may happen to fall the moment it has reached
its highest point, = pointed or acute exacerbation ; on the other
hand, it may chance to linger at the height attained before
sinking = less-acute {lit. broad-topped) exacerbation. Sometimes
the exacerbation shows a sinuous outline, caused by two or more
1 Vol. xi of the New Sydenham Society (pubh'shed in i86i) contains some
interesting papers on "Tiie Importance and Value of Arithmetic Means and
their A])plicaf ions to Medicine," by Professor Radicke, of Bonn; translated
by Dr. P. T. Bond from Wuuderlich's ' Archiv. fiir Pliysiologische lieiikunde,'
new series, vol. ii, part 2, 1858, as well as other papers by Professor Carl
Vierordt of Tiibingen, and Dr. F. W. Benecke, of Marburg, translated from the
same source, and bearing on the same subject, by the same accomplislied trans-
lator. The reader is referred to them for explanations of the difference
between a simple average, or arithmetic mean, and the true value.
228 DAILY rT.rCTUATIONS OV TEMPERATURE IN DISEASE.
slight falls interrupting the ascent = double or triplc-pcakcd ex-
acerbation. The highest point in such cases is i/ie inaximinn of ike
cxaccrhalioii. "When several exacerbations occur in the course of
one clay, Iherc may be maxima of exacerbation which need not
coincide with the maximum of the day. [Tliesc phrases refer to
the curves projected by the temperature on the charts.] The
moment during a remission at which the falling temperature reaches
its lowest point, is the depth or nadir of the remission. AVhen
several remissions occur in the course of one day, these low-points
may differ, and the lowest of them corresponds with the day's
minimum. The time between the moment at which the rising
temperature exceeds the daily mean, and the moment in which the
once more falling temperature again touches the same point repre-
sents the extent of the exacerbation; and just in the same w^ay
the period between the moment in which tbe sinking temperature
oversteps the daily mean, and that in which by its again rising from
the lowest point of remission it reaches the same point again, shows
the extent of the remission.
There is a great difference in different cases between the Icngtli
of time in which the temperature remains near to the high or low
points respectively ; sometimes it remains a long time high (or low),
sometimes only a very short time : = duration of proximity to the
high (or low) point.
The moment the temperature begins to rise from the low-point
of the remission, it has begun its true ascent. This ascent (the
daily ascendance) is sometimes moderate, sometimes extreme, and
interrupted, sometimes tedious, at other times very sudden.
The daily descent begins the moment the highest point of the
exacerbation is reached. If the line of exacerbation presents two
or more elevations, the beginning of the descent is to be reckoned
from the last elevation, even when this is somewhat lower than the
former one. The descent may be gradual or precipitous, and may
be interrupted ; it may take place slowly or suddenly.
Through the occurrence of two or more exacerbations in the course
of a day, morning, noon, or evening descents may be met with.
§ 3. The form assumed hy the daily fluctuations depends —
(A.) Upon the elements which constitute the morbid jn-ocesses,
and chieflv.
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 229
(a.) on the kind of disease ;
(d.) on its intensity ;
{c.) on the 'stage it has reached ;
(d.) on the regularity or irregularity, or other peculiarities of its
course ;
(e.) on the improvement or relapses of the patient ;
(/.) on the occurrence of complications or special events ;
(ff.) on the progress towards health ; or,
{/i.) on the fatal crisis.
(B.) It may also depend —
{a.) on the idiosyncrasy of the patient;
(Ij.) on interstitial external influences ;
[c.) on therapeutic agencies.
Thus the daily fluctuations exhibit very complex phenomena j
but notwithstanding this, they furnish us with very numerous and
valuable indications.
In cases where the diagnosis is tolerably clear, the daily fluctua-
tions greatly extend our bases of observation, and our means of
forming a judgment, but in obscure cases they are far less reliable.
The mere observation of the fluctuations of one day of twenty- four
hours, only permits us to draw satisfactory conclusions under special
circumstances. It is generally necessary to watch them for some
days, in order to either a safe diagnosis or prognosis ; and a com-
parison of one day with another, of variations, or of their symme-
trical repetition, gives the surest and the plainest indications. We
can never positively determine the nature of the disease from seeing
the temperature-curves of a single day, but it is sometimes possible
to exclude the presence of an otherwise probable disease from such
an examination. But a single day's fluctuation may often suffice to
determine the degree of severity of a disease wliich has been
diagnosed in other ways.
It may also afford a tolerably ample means of judging the staff e
of certain forms of disease.
In the same way an irregular course of the malady may be some-
times learnt from a single day's curves, whilst the regularity of the •
course indicates that the disease will probably be of some days'
duration. An examination and comparison of the curves of several
days is necessary in order to decide as to ameliorations or relapses.
In general, more than one day's fluctuations are needed to esta-
230 DAILY FLUCTUATIONS OP TEMPERATURE IN DISEASE.
blisli the presence of coin])lications, \vliilt>t tlic coinmeiiccmcnt of
convalescence may be sometimes recognised in ilie lluciuations of a
sinirle day.
In like manner, in special cases, a fatal termination may be pro-
gnosticated from the curves of a single day, especially when corrobo-
rated by other symptoms.
But the individual peculiarities of a patient can scarcely be de-
termined from only one day's fluctuations.
And the operation of accidental external causes can only be
recognised by a comparison of the day's fluctuations with those of
preceding days.
The operation of therapeutic agencies also requires a comparison
of one day with another for its determination. Notwithstanding
these limitations, the daily fluctuations are an important element in
the general constitution of diseases, and form, so to speak, a very
solid substratum on which the remaining circumstances of the case
are superimposed.
^ 4. The conclusions to be drawn from the average iemjperaliire of
a single day.
An important distinction must be made, between fluctuations upon
a high level and those of a medium or loM^er level. Whilst
the base-line, or plane (Darchschnittsniveau) of the daily iluc-
tuations in health is 37° C. (98-6° P.), it is seldom so low in disease,
bnt generally more or less elevated ; and it is only in a few forms of
disease, which are distinguished by their low temperatures [such as
cholera], or in advanced stages of others, where there is a casual
sinking of temperature below the normal, or in cases attended by
collapse, that the mean daily temperature of the sick is found to be
lower than that of health.
The daily mean temperature furnishes us at once with tolerably
certain indications as to the degree of fever present.
In moderate degrees of fever, the mean daily temperature should
not exceed 39° C. (i02"a° F.) ; and when the average temperature of
a day is between 39° and 40° (i02"3° — 104° F.) the fever must be con-
sidered somewhat high; indeed, this is the case in remittent types
with a mean of 39° to 39*5" C. (io2'2° — i03'i° ^•), and in con-
tinuous fevers with one of 39'5° — 40° C. (103-1'^ — 104*^ F If the
average temperature of the day exceeds 40*^ C. (104° F.), a very high
degree of fever is present.
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 231
Many diagnostic and prognostic conclusions depend upon this.
Highly febrile daily-means above 40^^ C. (= 104*= P.) are met
with in pernicious (malarial) fevers ; in typh«,y and typho?V^ fevers,
in their fastigium ; in relapsing fever, and in severe cases of pneu-
monia. All these, notwithstanding the height of the temperature,
may possibly terminate in recovery. On the other hand, when a like
average daily temperature is met with in other diseases, we may rea-
sonably conclude that death is imminent.
A considerably febrile daily mean-temperature (39*^ — 40° C.
= loa'a"^ to 104^) is generally met with in all w-ell-developed forms
of pyrexia, and in many inflammatory diseases during the fasti-
gium ; and in general the only safe conclusion to be drawn is, that a
very severe febrile affection is present, yet there are certain forms of
disease in which such a temperature deserves the most careful consi-
deration, and is of the highest importance. In this category we must
include all forms of catarrh, acute (polyarticular) rheumatism,
cerebro-spinal meningitis, all the neuroses, the post-choleraic stage
of cholera, trichinosis, diphtheria, dysentery, pleurisy, pericarditis,
peritonitis, and all the diseases which are suspected to be tubercular
or phthisical.
Daily-mean temperatures which are only moderately febrile, may be
of very varied significance. They occur in continued and remittent
febrile diseases, when these attain only a rudimentary development ;
also in tlie commencement (initial period) of such diseases, or on the
contrary, when a favorable crisis has occurred ; but chiefly in cases
in which in the course of a single day, the temperature sinks from a
considerable heiglit till nearly normal, or even subnormal ; as well as
in many favorable and unfavorable irregularities which occur in the
course of these diseases, after an uncompensated fall of temperature
in consequence of some potent influence, as in febrile collapse, and so
forth ; as well as in most inflammations of mucous membranes, rheu-
matic affections, and inflammations of serous membranes ; and not
infrequently in the death-agony itself, especially when this is brought
about by pressure on the brain, suifocation, anaemia, or inanition, or
occurs during collapse.
When the daily-mean is much aifected by some special occurrence,
or some momentary alteration is induced by active remedial measures
very great caution must be exercised, if we attempt to draw any
conclusions from it.
23:1 DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE.
§ 5. The (laifif-diD'crence, or the extent of the excursus
between the maximum and minimum of the day, may vary greatly,
and the siguillcance of tiie same number of degrees may be very
diirereut, in proportion as the daily mean at the same time is high
or low.
In a daily mean of 37° C. (98-6° F.), daily excursus of 1° C.
(i'8° r.) are of no importance — they seem at most to show only very
slight disturbances of health, and may even occur in quite healthy
people. On the other hand, if they amount to i^° C. (27° P.)
they are at least suspicious.^ When the daily mean is 37*5° 0.
(99"5° F.), daily excursus of 1° C. (i-8° T.) indicate disordered
condition with far more certainty; and such as amount to i|°C.
(27° r.) undoubtedly show some disease to be present, although
not always a decidedly febrile one.
If the daily mean temperature is as much as 38*5° C. (101*3° E.),
or more, the daily difference becomes of far higher importance. If
the daily difference is less than ^° C. ('9° F.) a continued fever is to
be diagnosed, when less than i°C. (i*8'' F.) a sub-continual fever.
The fever must be considered remittent when the difference is
more considerable, especially when, at the same time, the day's
minimum does not exceed 39*5 C. (99*5° F.) .
But when the daily minimum remains at a considerable fever
height, even when in the exacerbations this is only exceeded by about
1° C. (i*8°r.), or a little more, such a course has no longer the same
significance as that of a truly remittent fever ; it is rather a sign of a
very high degree of fever, in which there is yet no trace of a disposi-
tion to a favorable termination ; and it is far preferable in such cases
to denote such a course by the phrase of an " Exacerbating daily
fluctuation."
If the daily minimum reaches the normal, there is, in truth,
an Intermission introduced into the febrile curve of the day, yet
we are not generally accustomed to reckon such cases with inter-
mittent forms of fever, but generally class them with remittent,
more particularly when such daily minima first occur when the dis-
' As I wish to render Prof. Wunderlicli's meaning perfectly clear to every
reader, I will put tliis in another form : — If the average temperature of the
day {i.e., the sum of the highest and lowest, divided by the number of ob-
servations) be normal, i.e., 98*6 F., then a range of nearly two degrees
Tahreuheit {i.e., anything between 977° and 99*5', or in the same proportion)
is quite compatible with health. But excursions of more than 2' Fahr. are
probably morbid.— [Tkaxs.]
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 233
ease has readied its acme; and convalescence has commenced. In
like manner we are accustomed not to admit an intermittent type
when the lowest degree falls under the normal, although there may-
be more or less considerable degrees of exacerbation, although the daily
difference may thus amount to 6° C. (io"8° F.), or more. Such an
event indicates collapse, which may actually be an excessive remis-
sion, or a true intermission, which may, however, be intercurrent in
the course of a fever of continuous type.
Eeal intermissions are only to be admitted when all the symptoms
of fever abate and the return of febrile symptoms assumes a
paroxysmal form; they are founded on the whole course of the
disease, and not upon the fluctuations of a single day. (See the
next chapter.)
Whenever, in a fever of tolerable severity, the daily differences are
but slight, they are generally a sign either that the disease is in an
early stage, or that exacerbations or complications are present.
The occurrence of remissions during the height of an illness
almost always indicates an improvement, or the transition towards
convalescence. A continuance of the remissions, and especially an
increase in the amount of the daily difference, proves that conva-
lescence is progressing, whilst an interruption to the remissions, com-
bined with a continuance of a febrile daily mean, indicates either a
relapse or a complication.
When the difference becomes greater, by the daily minima falhng
more and more (increasing difference, with a decreasing mean tem-
perature), this is a sign, in acute diseases, that convalescence has
made good progress.
But when the difference is augmented so that the elevations [lit.
peaks) "on the charts become more acuminated (increasing differ-
ence with rising daily means), this is, on the contrary, a sign of the
patient^s getting worse.
When the difference is augmented, through the temperature
becoming sub-normal in the period of remission, it may be either a
favorable, indifferent, or dangerous symptom.
When the remissions are unduly protracted, in relation to the
customary course of the malady, this indicates a tendency to pro-
tracted defervescence and to sequelae. Especially is this the case
when the patient in all other respects [except temperature] seems
fairly convalescent, for then the continuance of a remitting tempera-
23 t DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE.
lure is a sign that disease has still a hold upon him, and that true
rocoven- is yet incomplete.
A diminuticm of the daily difference is a favorable sign when the
exacerbations become less severe at the same time (decreasing difl'cr-
ence with decreasing daily-means) ; it is an unfavorable symptom
when the remissions are less marked (decreasing dilference with
increasing mean temperature) ; whilst when both exacerbations and
remissions are more limited in range (decreasing differences witli
stationary means), the significance is doubtful. The differences may
remain the same, in spite of the progress or diminution of the dis-
ease ; in the first case, because the exacerbations rise to a height cor-
responding to the fall of the remissions (stationary difference with
increasing means) ; and in the second case, by the exacerbations
decreasing in proportion to the increashig depth of the remissions
(stationary difference with decreasing means).
The daily difference is usually slight, or in other words, a continuous
or sub-continuous type is met with in the following diseases : in very
severe typhoid fever (abdominal typhus), in true (exanthematic)
typhus, in the prodromal stoge of smallpox and its congeners, in
scarlatina at its height, in the majority of cases of croupous and lobar
(true) pneumonia, in the last stage of acute fatty degeneration, in
facial erysi])elas, in meningitis of the convexity of the brain, and in
the last stai(e of fatallv-endina; neuroses.
On the other hand, the daily differences are generally considerable
in typhoid fever of moderate or even medium severity, and even in
severe cases for the first few days, and again when they are begin-
ning to convalesce, sometimes in the recovery from true typhus, in
the suppurating stage of smallpox and its allies, in measles, and all
catarrhal affections, in acute polyarticular rheumatism (rheumatic
fever), in basilar meningitis and acute tuberculosis, in pleurisy,
pericarditis, in acute and chronic suppurations, in pyaemia, the
various forms of phthisis, and in trichinosis.
Dailv differences which alternate between normal and sub-normal
and considerable or high febrile temperatures, occur in the advanced
stage of recovering typhoid, sometimes in the suppurating stage of
small-pox and its aUies, occasionally towards the end of lobar pneu-
monia, in all malarial diseases, in pyaemia and septicsemia, and
sometimes in acute tuberculosis and chronic forms of fever.
Such a change may also occur in the course of a single day's
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 235
fluctuations^ through some special occurrence or seizure (after haemor-
rhages and such like.)
Daily differences between moderately high temperatures^ and such
as are normal or subnormal, are extremely common in many fevers
of moderate severity, especially those progressing towards recovery,
or with a protracted defervescence (lentescirenden) .
§ 6. In the majority of cases we find on a single day, i.e., in 24
hours, only one exacerbation, [whose curve] displays one, two, or
three peaks, and one remission with one minimal descent. This,
which is the simplest form, is by far the commonest in all sorts of
diseases. Only in complicated cases of intermittent fever the fluctua-
tion, which comprises the paroxysm with the apyrexia or intermis-
sion, has ordinarily a duration of 48 hours (tertian type) .
We generally find the remission begin in the time between the
late evening and the early morning ; and last through the later hours
of the morning (morning-remission). The exacerbation begins in
the late morning-hours, or even the first hours of the afternoon ; and
lasts till late on in the evening, till midnight perhaps, or even later
(evening exacerbation) . The remission generally reaches its lowest
point from 6 to 9 o'clock in the morning., and the daily maximum
generally occurs in an afternoon, or early hour of the evening (3 to
6 p.m.) sometimes indeed at noon, and once now and again near
midnight. Such is the general course of the temperature in almost
all kinds of diseases in all stages ; with the exception of malarial
fevers, which far most frequently have their exacerbations at other, or
at alternating times of the day, and also pycemia, the paroxysms of
which are confined to no hour of the day. Sometimes, also, we
must include with these the hectic of phthisis and tuberculosis,
which also not infrequently shows morning exacerbations. Occa-
sionally, too, in particular cases of other kinds of disease, we
meet with a diS'erent arrangement, l. e., the rise of the tempe-
rature in the early morning hours, or at least after midnight, and
remissions in the afternoon. If this only happens on a particular
day, we may regard it as an irregularity, which often indicates the
approach of a relapse, or a complication, although it may sometimes
herald, or occur in the very moment of a favorable crisis. Yet we
meet with cases in which, without affecting the results, the daily
fluctuations are misplaced (as regards the time of their occurrence)
throughout a considerable period, or even through the whole course
230 DAILY FLUCTUATIONS OF TEMrEllATURE IN DISKASE.
of a remittent fever (in tj])lioicl fever, or in influenza for instance),
the exacerbations occurring in the morning, and the remissions in the
evening — individual peculiarities which at least sometimes result
from the habits and mode of life of the patient — when during healtli
they have slept by day, and worked by night (as bakers do^ for
example).
In cases of collapse, also, we may meet with an extraordinarily
low minimum in the evening.
§ 7. The time at which the dail)/ riiaxhnnm and daily minimum
occur, may be available for diagnosis and prognosis, when we can
compare several consecutive days' fluctuations. When the daily
maximum occurs very early (about noon) it is generally a sign of the
disease being nearly at its height, and also of its being a very severe
one, whilst the occurrence of the maximum late in the day indicates
that the disease is already moderated, or is of a trifling character, in
the majority of cases. The occurrence of the daily minimum at an
early hour, may be considered a sign of improvement, although it is
not infrequently brought about by collapse in the evening, and before
midnight, and cannot by itself be regarded as a decisive element for
prognosis.
Tar more important than the mere moment at which the maximum
or minimum is reached, are the periods in the daily fluctuations,
especially if they are preponderating in either direction, when the daily
rise of temperature legins (ascent) on the one hand, and when the
temperature begins again to fall (daily descent) on the other hand.
The more punctually (when the rhythm of the fluctuations is not
otherwise disturbed) the ascent begins in the course of the day, the
more intense is the disease, and the more remote from convalescence.
It is therefore always an unfavorable sign, when even in the early
morning hours (before 9 a.m.) the temperature begins again to rise
considerably ; and if, from comparison of several days' fluctuations,
we find that the moment of rising becomes earlier day by day, an
increase of the disease may be anticipated with great probability.
On the other hand a postponement of the ascent is decidedly
favorable. It shortens the duration of the exacerbation, especially
if in the evening hours there is a gradual moderation (remission),
and we may with great probability conclude that there is improve-
ment, although the daily maximum is yet in no degree diminished.
On the other hand the later the exacerbation begins to decline (as
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 237
for example first towards midnight or even later) the more severe and
extreme will the .disease generally be.
§ 8. The suddenness with which the daily rise or fall occurs, may
sometimes afford materials for judgment, especially when the daily
differences are considerable. ^\\q first rise of temperature is generally
gradual, and some hours are occupied in rising a few tenths of a
degree only, then a rapid rise occurs, and towards the conclusion of
the process, the rise is again very gradual.
An unusually rapid rise occurs in the early stages of acute
diseases, and principally in very severe ones, but especially in the
cases in which intense fever-paroxysms interrupt the course of an
apyrexia (or intermission) without, in the latter case, necessitating
an unfavorable prognosis. On the other hand, when a rapid rise
occurs half-way on in the course of a remitting disease, this is unfa-
vorable, unless the remissions at the same time become more
decided ; this indicates either a great intensity of the disease, or
some accidental influences causing the temperature to rise, relapses,
or complications, and the like, and must in all cases call for the most
careful and continued observation of the case. Just before a
favorable crisis, we not infrequently meet with an unusually pro-
tracted rise of temperature, which is then generally the last of its
kind, and immediately precedes defervescence. In such cases the
ascent is sometimes broken by a short descent. A very rapid fall of
temperature may occur in cases of convalescence, or may on the other
hand be due to collapse. When the fall of temperature occurs very
slowly, it is to be feared that the next day's remissions will be less
marked, or entirely absent. Defervescence may be inferred with
considerable probability, when we find the morning-fall interrupted
in the afternoon by either a stationary temperature or a slight rise,
but again resuming the descent in the evening.
In fevers of some severity the temperature generally lingers less in
the vicinity of the lowest temperatures, than it does at the higher
degrees ; and it may therefore be regarded as a favorable symptom,
when the extreme points (peaks) of temperature are very quickly
attained, and very suddenly again deserted.
^ 9. The duration of the variations of temperature above the daily
average, the latitude of the exacerhations, is in slight and even mode-
rately severe cases, but inconsiderable, as is also the duration of the
238 DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE.
daily movement below the daily averngo {(he latUnde of the re-
mission^ If tho former be longer than tlic latter, the case is to be
regarded as severe, without further evidence. This hajipcns particu-
larly in the early stages of severe diseases. The more a disease,
approaches to recovery, the more equality is evident, and it is there-
fore no slight matter, when in spite of a late period of the disease,'' the
latitude of the exacerbations preponderates. In advanced conva-
lescence the [curves of the] remissions become daily broader and
broader, whilst [those of] the exacerbations become more pointed
(steep curves). Exacerbations of great extent generally show
[curves with] double or multiple summits ; these elevations especially
occur about midday, the early hours of afternoon, the late hours of
the evening, and after midnight. If there are only two elevations (or
summits) they generally happen at noon, and in the evening — some-
times in the evening, and after midnight. In the double-peaked
exacerbation the evening elevation is generally the highest ; in the
triple-pointed the maximum-point is sometimes the first, sometimes
the second, but verv seldom the third of them.
These many-crested (mehr-spitzigen) daily fluctuations generally
indicate a considerable exacerbation, and are therefore unfavorable ;
if, however, during the preceding days, the exacerbations have pre-
sented an unbroken line, their occurrence may be regarded as a sign
that the fever is moderating.
§ lo. Those cases in which two or more exacerbations succeed one
another in the course of twenty-four hours [duplex and triple exacer-
lafions), are closely related to these multiple-peaked exacerbations
just described. In many forms of disease, the afternoon exacerbation
is followed by another about midnight. Yery commonly the evening
remission in such cases occurs with all due punctuality, and may be
erroneously taken as a favorable symptom, although an observation
at night would indicate a fresh exacerbation. In general a daily
fluctuation, which is marked by several waves, is a sure sign that the
course of the disease is complicated, or influenced by some special cir-
cumstance, or has some special tendency.
It occurs principally in very severe cases, and these are always
more or less complex. It occurs in a relapse, yet it may be the
prelude to convalescence; yet, indeed, the two cases present a different
aspect. It is often induced by some special, and powerfully ope-
rating symptom of the disease itself, or is preparatory to such :
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE. 239
constipation, or very copious stools, vomiting, hsemorrhages,
nervous disturbances, and sleeplessness. It may be a consequence
of some injurious influence, of a more or less unsuitable diet, of catch-
ing cold, or of undue exertions in proportion to strength. It may also
be induced by therapeutic operations.
The nature of a daily fluctuation marked by several waves, especially
requires the most careful simultaneous investigation of all the other
circumstances of the case, in order to a right estimation of its signi-
ficance. Its meaning varies :
{a) According to the degree of tlie daily difference ;
{b) According to the type of the fever, whether that be con-
tinuous, exacerbating, or remittent.
(c) In proportion to the height of the daily mean, whether that
indicates a very high, considerable, or moderate degree of fever, or
shows a sub-febrile condition.
{d) In proportion as the general tendency is either to a rise of
temperature or to a fall, or the disease has already entered on the
period of defervescence.
In fevers exhibiting a continuously high degree of temperature,
the daily fluctuations have no special (prognostic) significance, and
therefore their waves, however numerous, assist us little in forming
our judgment. It is only when one of the waves much overtops the
other, or when, on the contrary, an unusually deep depression occurs,
that one is able to draw an unfavorable conclusion from the former,
and a favorable one from the latter.
In exacerbating fevers of great intensity, in which the lowest
temperatures are still considerable, and the intercurrent elevations
enormous, a repetition of such elevations in the course of one twenty-
four hours is always more unfavorable than one solitary rise. In
remittent fevers of great intensity, in which the remissions may de-
scend to moderately febrile, or even sub-febrile, temperatures, whilst
the exacerbations are very strongly marked, the occurrence of a
duplex daily exacerbation, the preceding fluctuations having been
simple, is an unfavorable symptom.
If the exacerbations, on the other hand, are dupHcated from the
very commencement, the type of disease is generally mixed, and of
itself affords grounds to suspect complications.
In moderate degrees of fever, a daily fluctuation marked by nume-
rous waves is always a suspicious symptom, and either causes us to
suspect complications and disturbing causes, or at least indicates
240 DAILY FLUCTUATIONS OF TFMrEBATURE IN DISFASE.
great susceptibility on the part of the individual alTcctcd. Their
occurrence, uhcn we might otherwise ]io])e fur a favorable tcrniiiui-
tion, must always render this doubtful.
In the period preceding death (pro- agonistic stage) the fluctua-
tions of temperature arc often marked by a wavy outline, and we
must be careful not to deceive ourselves by false hopes in such
cases.^
■ Tlie whole of tliis chapter requires freriucnt reference to the cliarts of tlio
temperature iu various diseases, wliich arc pk\ccd at the end, aud to tlic dia-
grams, in order to understand the allusions to the varied types of tlie daily
fluctuations.— [Teans.]
CHAPTER XL
THE COURSE OF THE TEMPERlTUllE IN FEBRILE DISEASES.
§ I . Febrile diseases exhibit great variety as regards the course
pursued by the temperature^ but, in spite of all their differences, we
can recognise certain rules as regulating their behaviour ; and it is
also true that the very differences they exhibit furnish us with most
important data for distinguishing the several forms of disease and
their varieties.
The temperature in febrile diseases may remain continuously above
the normal, at least till they have passed their maximum develop-
ment, or only descends below it from some special accidental cir-
cumstances, in which case it speedily regains its abnormal height ^=
coniinued fever. Or the elevations of temperature are interrupted
once, or several times, by apyretic temperatures = intermittent and
relapsing fever. In such cases each interval of time, separated by
the period free from fever (apyrexia), may be regarded as a fever in
itself, and all that belongs to continuous fever may be attributed to
this fever-abstract (so to speak) ; for although the disease is by
no means terminated by this single paroxysm of fever, yet the
paroxysm itself behaves exactly as a longer or shorter course of con-
tinued fever, and exhibits all the peculiar characters which are com-
mon to such cases.
The fever is an essential part of the disease, at least in a part of
its course, in so far as it is never absent in the given forms of dis-
ease, except under very exceptional individual circumstances.
Sometimes the elevated temperature is more accidental, depending
on the severity of the disease, on idiosyncrasies of the patient, and
on numerous collateral circumstances.
These differences affect the course of the fever in a decided maimer,
16
212 THE TEMPERATURE IN FEBRILE DISEASES.
since in the former case this is dceicled by the type of disease^ and
in the latter principally by accidental circumstances.
The category of diseases in which fever is an essential part includes
most well-marked types^ besides many others which are only approxi-
matively typical. Many of the latter, however, only show occasional
elevations of temperature. This is equally true of diseases which
are occasionally typical and of those which are atypical.
§ 2. The course pursued by the temperature in febrile diseases
may be determined, first, by the nature of the disease ; the more
typical the form assumed by the disease, the more preponderating its
influence on the course of the temperature. This influence is, indeed,
not the only one, even in typical forms of disease, but it has greater
force in proportion as the disease shapes itself in a pure, uncompli-
cated, and, so to speak, normal fashion ; that is, in proportion as a
previously disposed healthy individual is attacked by the original
specific cause of disease without admixture of other injurious influ-
ences, and the less other disturbing influences come into play during
the course of the disease. (Refer to Fundamental Principles, §§ I3
and 13.)
Secondly, the course of the temperature is determined by the
intensity of the disease. Even in typical forms of disease this con-
siderably modifies their course, and may sometimes prove the cause
of a particular variety of type. It is still more decisive in approxi-
matively typical diseases, but has only a partial influence in atypical
forms.
Thirdly, the course of the temperature may be determined by
individual circumstances. These are of limited influence only
under certain conditions, e.g. in little children deviations of tempe-
rature are very frequent ; in aged persons alterations of temperature
are tardy, and the height of temperature under otherwise similar cir-
cumstances remains less considerable ; whilst a freshly acquired febrile
affection has very great influence on the course of the temperature
of a previously existing fever ; and, lastly, certain peculiar modifica-
tions of constitution, as, for example, the hysterical temperament,
very commonly modify the course of the temperature.
rourtlily, the course of the temperature may depend qvl accidental
influences, under which we must include many therapeutic under-
takings ! The degree in which these operate depends on the one side
upon the potency of the influence itself, and on the other hand on
THE TEMPERATURE IN FEBRILE DISEASES. 243
the susceptibility of the individual, or of the form of disease from
which he suffers. As regards the latter, truly typical forms of dis-
ease are capable 'of being thus influenced in only a very slight degree.
Not only do accidental influences very commonly fail in influenchig
the course of the temperature at all in typical forms of disease, but
even when they do affect it they do so in this way — either that the
alteration induced by the accidental influence is only temporary, or
that the modification of the course thus induced itself takes on this
type of the disease.
Fifthly and lastly, the course of the temperature is especially modi-
fied hjcomjoUcationssuT^evvemngon the disease, and these are sometimes
able entirely to obliterate the original type of the temperature, and, in-
deed, to destroy all appearance of type of any kind ; whilst they some-
times introduce a new and peculiar type of their own, and lead to mixed
conditions ; whilst sometimes their effect is only transient. An inti-
mate knowledge of special details is required in order to estimate the
working value of complications in themselves and in their relation to
special diseases, and to decide in a complicated case of disease what
is to be attributed to the original and essential disease and what to
the particular complications which have occurred.
§ 3. The course of the temperature in febrile diseases may be
divided into a number of periods or stages, which vary much in
their significance, as well as in expression, and can be very clearly
recognised in the form assumed by the course of the temperature.
(See Fundamental Principles, § 20.)
In many diseases, and in many special cases, these stages are very
strongly marked, whilst in others the lines of demarcation are very
indistinct.
§ 4. The pyrogenetic stage, or initial-period, the first development
of fever in a patient, assumes various forms, depending somewhat on
the fever either preceding the development of the local affection, or run-
ning its course almost without any localised disease, or succeeding to
a local morbid process. In the first case the fever begins more or
less severely, and very commonly reaches a considerable height even
before the appearance of any local disturbances. In these cases the
initial-period generally terminates as soon as the lowest daily average
temperature characteristic of the type of disease is reached, or as soon
as the local affection is developed.
In the second case (if there are hardly any localised morbid pro-
211
THE TEMPERATURE IN FEBRILE DISEASES.
cesses) the beginning of the pyrogcnctic stage is very indistinct, and
in tlic same way the boundary line between it and the fastigium is
more or less arbitrary, especially in less typical forms of disease.
AVe can easily understand that the material for observations in this
stage is but scanty, from the nature of things, since few patients seek
medical aid till their disease has made some ])rogress. As re-
gards the form of the initial stage, different cases of disease vary.
{a) There are forms of disease with a short pyrogenet'ic stage. The
temperature rises suddenly, and in one line, or at least in a short
interrupted line, and reaches the characteristic height in a few
hours, or from one day to a day and a half. (See figs. 3 and 4.)
Fig. 3.
Fig. 4.
Cent.
40"5
40-
39'5 -
39'
38-5 -
38-
37*5
/
Fahr.
104-9
104-
1031
1022
lOIV-
ioo'4
— 99*5
Cent.
40-5
40-
39'5
39"
38-5
38-
37'5
/
/
^
/
/
V
/
/
Fahr.
104-9
104-
1031
102-2
IOI-3
ICO-4
99'5
In these cases the temperature generally rises more rapidly in the
trunk than in the extremities, particularly as regards the fore-
arms, hands, legs (below the knees), feet, and even face. These parts
still appear cold, whilst the temperature of the trunk has already
risen considerably (see p. 149). In such cases there is therefore
very commonly a strong feeling of chilliness, with shuddering move-
ments (shivering and shaking), chattering of the teeth, and the like,
to be met with, which ceases as soon as the temperature of the
THE TEMPERATURE I\ FEBRILE DISEASES.
215
extremities has approximated to the elevated temperature of the
trunk.
Attacks of illness which begin with a short pyrogeuetic stage
have for the most part but short paroxysms of fever, lasting from a
few hours to a few days, with a sharp elevation of temperature
(akmeartiger), or with a continuous course, not lasting more than a
week, and terminated by death or by a fall of temperature. The
latter happens in such cases with great rapidity (by crisis) if no dis-
turbing influences come into play. On the other hand, these cases
often exhibit a proclivity to repeated accessions of fever, or these may
be a principal feature of the kind of disease present.
This kind of initial-stage is commoner in some forms of disease
than in others, whilst there are forms of disease in which it never
occurs at all.
Cent.
40-5
40-
39"5
39"
38-5
Fig. 5.
Fig. 6.
3T^
fi
/
j\
u
i\
/
R
1
^
r
^
1
Fahr.
104-9
103-1
I02"2
101-3
100-4
99o
Cent.
r
4u-
1
39 5
39'
t
1
1]
38'5
\
1
\
38-
1
\
1
\
375
I
)l
Fahr.
104-
103-1
102-2
101-3
100-4
95.'
•r.
It is the rule in variolous affections (smallpox, &c.), in scar-
latina, in primary croupous and lobar [true] pneumonia, in malarial
attacks, in pyaemia, and in relapsing fever. It is excessively
common in true exanthematic typhus, in febricula, in facial
erysipelas, in tonsillar angina, and meningitis of the convexity of
the brain.
It never occurs in abdominal typhus [angUce typhoid fever), in
216
THE TEMPERATURE IN FEBRILE DISEASES.
basilar meningitis, in catarrhal affections, nor in acnte ])olyarti-
cular rlieumatism.
(i) Forms of disease with ]}^'of''racte(l pijrogenetlc stage. The rise
of temperature generally happens thus : it begins to ascend in the
evening, in the morning hours it moderates again, to rise again more
considerably the following evening (fig. 5). It may thus happen
that the normal temperature is again reached in the morning of the
first day (fig. 6), or even that the initial-stage is interrupted by a still
longer interval free from fever (apyrexia, fig. 7) .
Fig. 7.
Cent.
Fahr.
40-5 r
40-
39'5
39"
38-5
38-
37" '
i
t
\
i04'9
104'
103- 1
I02"2
101-3
100*4
986
In this type the initial-stage lasts three or four days, but seldom
more than a week. If the temperature is not high by that time, the
illness will remain slight, and quickly pass away ; if the temperature,
on the other hand, rises to a considerable height, we must not expect
so sudden a termination to the illness.
This type occurs most constantly in typhoid fever, and so much
so that the diagnosis can be safely based upon the initial- stage only
[the other symptoms being conformablel.
This kind of initial-stage is common enough in some other diseases,
such as -measles, acute bronchial catarrh, catarrhal pneumonia,
basilar meningitis and cerebro-spinal meningitis, in acute tuber-
culosis, in polyarticular rheumatism (rheumatic fever), as well as in
THR TEMPERATURE IN FEBRILE DISEASES.
247
most of those cases in which fever begins to supervene on an already-
existing local affection^ supposing the next type to be mentioned is
not predominant;
(c) In many cases the development of fever is more insidious.
Such attacks of illness do not generally conform to rules, or have at
best only an approximatively typical course (fig. 8).'
Tig. 8.
This is the common type in acute (polyarticular) rheumatism, in
pleurisy, in pericarditis, in peritonitis, in lues,^ in chronic cases of
suppuration, and phthisical affections, as well as in numerous atypical
afi'ections, particularly when the fever only depends upon the gradu-
ally increasing severity of the local disturbances.
§ 5. The fasttgium (or acme) is that period in which the fever
is most fully developed. In this stage, more especially, the tempe-
rature of the sick exhibits great variations, which may depend on a
variety of influences — in fact, on all those which affect the course of
the fever.
(a) The variations in the height of the temperature in the fasti-
1 Sypliilis has become a name so commonly known that the author prefers to
use the name of Lues for its secondary and tertiary manifestations, as less
calculated to produce domestic misery, in case our observations on a patient's
case arc overheard or our diagnosis read by unprofessional readers. — [Trans.]
218 THE TEMPERATURE IN rEBRII-E DISEASES.
gium may be in relation to tlic Jic'igJil of the maximum temperature
(of the highest poiut reached by the tenij)eraturc in the given case
of disease), which depends in part upon the kind of disease, and
partly on the degree of its severity ; yet this circumstance, on which
people were at first inclined to lay the chief stress, is really of sub-
ordinate importance, since an isolated rise of temperature to unusual
heights may be induced by accidental collateral circumstances. Of
course, if the temperature be one incompatible with life, or even
indicating great danger — as, for example, a temperature of 42° C.
(107-6° F.), or above this — it must greatly affect our judgment of
the case.
In special forms of disease it may be worth while to deter-
mine the maxima of numerous separate cases, in order to learn the
limits between which the maxima may vary in individual cases, in
order to determine, for purposes of diagnosis, that any elevation of
temperature above those Hmits excludes the presence of a given form
of disease. The lower ranges of the maxima of a special form of
disease must always be less useful and less trustworthy, because one
can be by no means certain, in an individual case, whether one has
obtained the maximum temperature from the observation. Yet (for
example) by the careful observation of a brief accession of fever
one may be pretty sure that the case is not one of intermittent fever,
if the lower range of maximal temperature of intermittent fever has
never been reached. In like manner, by very painstaking observation
of a case we may exclude typhus [and typhoid] fever if a tempera-
ture of 39'5° C. (i03"i° F.) has never been met with.
(b) The variations in the height of the dally means (average daily
temperatures) are far more important. Like the former, they also
depend on the kind and severity of the disease, and also on a multi-
plicity of other influences which modify the course of the disease.
The sum (total) of the daily means furnishes us with the general
average height of the wdiole fastigium, which is far more sympto-
matic than the mean of single days.
The general average height of the temperature in the fastigium
fashions itself somewhat as follows, according to the kind of dis-
ease : —
[a) In typhoid fever (abdominal typhus), according to the severity
of the case, it is between 39° and 40-2° C, ( = io2'2° and
104-36° F.).
THE TEMPERATURE IN FEBRILE DISEASES. 249
{h) In typhus fever (petechial, or true typhus), between 39*2° and
40-5° C. (102-56'' and 104-9° ^•)-
[c) In the eruptive fever of smallpox and its allies, between 39°
and 40° (102-2° and 104° F.).
{(I) In measles about the same, yet very commonly somewhat
lower, on account of the extent of the morning remissions.
((?) In normally developed scarlatina, about 40° C. (104° T.).
{/) In primary croupous (true) pneumonia^ from about 39-2°
t0 4O°C. (102-56° to 104° r.)-
{g) In meningitis of the convexity (of the brain), to 40° C.
(i04°F.), or more.
{It) In articular rheumatism, without complications, generally from
about 38-5° to 39-5° C. (101-3° to 103-1° r.).
(i) In acute influenza, from 38*5° to 39-2° C. (101-3° ^o
102-56° F.).
[j) In facial erysipelas, from 39*5° to 40° C. (103-1° to 104° F.).
{k) In parenchymatous tonsillitis, somewhere about 39-5° C.
(103-1° F.).
Meanwhile the general average height of the fastigium tempera-
ture may very easily be modified by the circumstance that, especially
when this stage is short, a single accidental remission may essentially
depress the general average, whilst a single accidental exacerbation
may considerably raise it. It is better, therefore, to entirely disregard
such manifestly intercurrent variations of temperature, when seeking
to determine the general average height.
Within certain limits the degree of average height is the chief
factor in determining the intensity of the disease. The hmits
liere set down relate only to such cases as are pretty perfectly de-
veloped. Unusually slight cases, and, on the other hand, very
malignant ones, may much exceed or fall short of the limits assigned
above to their average temperatures.
(c) The most valuable data, for both diagnosis and prognosis,
are obtained from the general course of the temperature during
the fastigium.
The course of the temperature during the fastigium is [when pro-
jected on a chart] —
{a) Either acuminated in form, and consists in the rapid reach-
ing of a point at M'hich it rapidly begins to fall, or which termi-
nates fatally; or —
250
THE TKMrERATURE IN FEBRILE DISEASES.
(/;) It is a continuous persistence at a given height (which does
not, however, preclude shght fluctuations, not exceeding i° C.
(■9<^F.); or-
{r) The course is interrupted by considerable fluctuations in a
single day, or by differences manifesting themselves in the course
of different days.
(a) An acuminated course of temperature during the fastigium
occurs in all one-day fevers, and in some whose duration is only a
few days, as well as in all paroxysms of intermittent fever of short
duration ; in ephemeral fever, in malarial fever (ague), in pyremia,
sometimes in erratic erysipelas, seldom in pneumonia ; also in herpetic
eruptions and varicella, as well as in many of the daily attacks of
fever in acute tuberculosis and chronic fever, and, lastly, in all
terminal fevers. The fastigium may thus exhibit only a single
pointed summit (fig. 9), or it may show a broad-topped maximum
Fig. 9
Pig. 10.
Cent.
40-5
40-
39*5
39"
38-5
A
1
^\
\
\
\
\
^
\
*
\
Fahr.
104-9
104'
103-1
I02'2
101-3
^ ioo'4
(fig. 10), or the heights may have several peaks (fig. u). The dura-
tion of this kind of fastigium is generally only a few hours, but not
infrequently it extends over more than one day.
The pyramidal fastigium either ends in death, as Jiappens in ter-
minal fever (fig. 12), or a downfall of temperature occurs soon after
THE TEMPERATURE IN FEBRILE DISEASES. 251
reachiug its acme, which under such circumstances is generally very
rapid. In the latter case there are generally two or even more
attacks of fever (paroxysms) to be expected. Such repetitions of
the fever are sometimes more or less essential to the special form of
ElG. II.
Fig. 12.
Cent,
103-1
T I02"2
101-3
Cent.
42-
4i'5
41*
40-5
40-
39"5
39*
A
Fahr.
1076
106-7
105-8
104-9
104-
103-1
102-2
disease, e. (j. malarial fevers, pysemia, intermittent pneumonia ; often
customary in erratic erysipelas, acute tuberculosis, and chronic
fevers ; and, moreover, when a fever terminates so abruptly a relapse
very frequently occurs.
{Jj) A continuous course of temperature during the fastigium
seldom consists in an absolute and perfectly steady persistence of
Fig. 13.
Cent.
40"o
40-
39"5
?
A
\
I'
v^
■■J\
v^
I
Falir.
104-9
104-
103-1
<W <-/ .V
THE TKXirEUATUllK IN FEBRILE DISEASES.
the iompcraturc at one and the same lioiglit, but it is
fur more general to meet Avitli !>liglit iluetuationS; and they
may very well amount to i° C. (9° 1\), or even a little more
(fig- 13)-
A contbmed course [of temperature] occurs in the fastigium —
(fl) In every very severe acute disease.
[b) In most cases of severe complications supervening on a previous
disease.
{c) And also in very mild cases of almost all kinds.
Besides this there are some diseases in which there seems to be a
predilection (so to speak) for this type of fastigium, which is some-
times perfectly developed, sometimes only partially so, and always in
proportion to their severity, for when they are milder the fastigium
fashions itself after a non-continuous type. The forms of disease in
which a continual course of temperature predominates are especially
true exanthematic typhus, scarlatina, primary croupous (true) pneu-
monia, the prodromal stages of variola and its allies, and acute severe
secondary pneumonia, facial erysipelas before it begins to extend,
parenchymatous tonsillitis (angina), meningitis of the convexity of
the brain ; severe general febrile affections, in which, although not
localised, slight microscopic patbological lesions are sometimes dis-
covered ; and chiefly diseases which have a short initial stage of
rigors.
AVhen diseases which usually exhibit a remittent or non-contmuous
course assume a continuous type, it must always be regarded as an
unfavorable symptom.
The height of the average temperature is of great importance in
forming a judgment of the intensity and danger of the disease in such
as have a continuous type. The continuous course of temperature is
either persistent at one level, or in favorable cases descending (fig.
Fig. 14.
Cent.
40-
39"5
A
/
^^^
\A
nA
V
^•'
\
Fahr.
104"
1031
THE TEMPERATURE IN FEBRILE DISEASES.
253
14); or sometimes at first, and in unfavorable cases, ascending (fig. 15) .
It is often broken into two distinct parts, of which the first is gene-
rally the more severe, and the second milder.
Fig. 15.
Cent.
4i"5 —
41"
40 5 —
40-
Eahr.
They are generally divided by a considerable fall of temperature
{jjseiido-crisis).
The continued course of temperature usually lasts but a short
time, seldom more than a week.
It either terminates fatally or remissions set in, which are for the
most part a sign of improvement, provided that the exacerbations do
not much exceed the previous height of the temperature ; but these
remissions may sometimes announce the commencement of a fatal
end, or the continuous course may merge into defervescence, which
is generally rapid, though sometimes protracted. This defervescence
may either immediately succeed the continued fastigium, without any
further change, or it may be divided from this by a period of critical
perturbations, or by a preparatory decrease of temperature {Ij/sis) .
This continuous course of temperature may sometimes be repeated,
and is then interrupted either by a more or less lasting and con-
siderable moderation of temperature, or sometimes by a remitting
course.
{c) In the great majority of diseases the course of the temperature
is non-conihmous during the fastigium.
This is the rule in many diseases, as in abdominal typhus (typlio'ul
fever), catarrhal affections, catarrhal and putrid pneumonia, measles,
polyarticular rheumatism, osteo-myelitis, meningitis without much
254
THE TEMPERATURE IN FEBRILE DISEASES.
afTectiou of the suiiunit of the brain, pyremia, suppuralion-fevcrS; the
secondary fever of variolous affections, trichinosis, lues (constitutional
syphilis) , and chronic fevers, and more or less commonly so in other
diseases.
The fluctuations between most of the evening exacerbations and
morning remissions may be more or less considerable, and, therefore,
the absolute height of the daihj maxima may be very varied. In
cases of moderate severity the morning remissions fall more or less
below the average height of the fastigium of tlie particular disease
(remittent type, fig. 1 6), whilst in severe cases the morning remissions
Fig. i6.
I02'2
generally remain above the average level of the disease in question,
or rather of its stage of fastigium, whilst at the same time the evening
exacerbations are more or less considerably removed from, and rise
above, this average level (type with exacerbations, fig. 17).
Cent.
41'
40-5
40-
Pig. 17.
^
*
r
■>A
/\
\/
•
1
y
V
\
i
\
Fahr.
105-8
104-9
104"
THE TEMPERATURE IN FEBRILE DISEASES. 255
The extent or excursus of the fiuctuatlons between the morning
and evening temperatures may be very varied^ ranging from f ° to 3
or 4 degrees Centigrade (=1-35° to 5*4° or 7*3° Eah.). See fig. 18.
Tig. 18.
Cent.
X
1
41
\
w
1
1
405
w
w
l\
\
40
\
1
\
p
r
\
dyt;
\
\l
w
\i
\
39
1
fc
\
i
i
38-5
Fahr.
I05-8
104-9
104-
103-1
102-2
101-3
The alternations {lit. exchange) between exacerbations and remis-
sions are sometimes more or less regular, and, indeed, in acute
diseases may repeat with the utmost regularity the same daily height
of exacerbations and depth of remissions for a whole week together,
or even more ; and in chronic fevers this regular alternation may go
on even for months with perfect, or nearly perfect, identity. Yet
this does not preclude the occurrence of two periods, even in the
non-continuous fastigium, the first with slighter and the second with
more extended excursions or fluctuations [or inversely as the con-
tinuous type] . But occasionally, and especially in complicated or
otherwise abnormal cases, as well as in special forms of disease
(particularly in pyaemia), the non-continuous course of tem])erature
exhibits more or less stvikiug irref/7ilajiiles. Sometimes it continues
an even course for only a few days preparatory to abnormalities.
Such irregularities may occur from accidental influences, individual
circumstances, and many other conditions. These irregularities may
consist in —
(a) The remissions and exacerbations occurring at irregular times
256 THE TEMPERATUUE IN FEBRILE DISEASES.
— sumctimes earlier, sometimes later iu the day, or lasting for a
longer or shorter time on a given clay.
{6) Or iu a want of correspondence between the dej)tli of the
remissions and the height of the exacerbations.
(c) Or of intercurrent and })Owerful retrograde movenienis of
temperature, sometimes taking the form of isolated falls of con-
siderable extent, sometimes of more or less lasting, but not strongly
marked decrease of temperature, such as often occurs through
favorably operating influences, and is induced by many accidental
events. In some diseases, however, this may often occur spontane-
ously, and must not then be regarded as a favorable symptom.
{d) In intercurrent elevations of temperature, which either occur
once or consist in more or less lasting intercurrent rises of tempera-
ture, which are for the most part the result of unfavorable influences
or the development of comphcations.
{e) And occasionally, though but seldom in this stage, the irregu-
larities consist in intercurrent collapse.
Generally speaking, the irregularities proceed from a combination
of two or more of these ; and when once irregularities have broken
in upon the regular course, and destroyed its typical character,
the regular tvpe is seldom resumed again, or only imperfectly.
Sometimes the course of the temperature appears quite anomalous,
fluctuating hither and thither with sudden elevations and equally
sudden falls, and with occasional alternations of the continuous and
non-continuous type (commonest in pysemia).
The varieties in the non-continuojis course of temperature duriiig
the fastigium result, for the most part, from the nature of the disease
and the degree of its severity. But the absence or presence of com-
plications, events occurring perhaps only once, accidental and also
therapeutical influences, and finally the individuality (idiosyncrasy)
of the patient himself, all contribute their share in determining the
nature of the fastigium in the non-continuous type.
Of all the diseases which exhibit a non-continuous course in their
fastigium, abdominal typhus (typhoid fever) is the most clearly
typical. It has clearly defined minimal limits to its exacerbations
(39'j C. = 103'!° F.); tolerably well-marked limits to the daily
excursus (which does not much exceed i|° C. — 2*7 1\) ; an ex-
tremely regular course (at least in normal uncomplicated cases) ; and
a very accurately defined limit to the duration of its fastigium (not
under eisht nor over seventeen davs). This disease mav, indeed, be
THE TEMPERATURE IN FEBRILE DISEASES. 257
affected by individual circumstances, but these do not easily affect
the range of its temperature, and still less often its duration.
All the remaining forms of disease, with a non-continuous type of
fastigiura, exhibit greater varieties, and the influence of collateral
circumstances is more strikingly shown.
The absolute /leight of the maxima of the exaeerlatlons is generally
very considerable in the non-continuous part of the course of recur-
rent fever, in the suppurating fever of variola, in measles, catarrhal
pneumonia, pysemia, osteo-myelitis, facial erysipelas, and acute tuber-
culosis. On the other hand, it depends more upon the severity of
the attack, or upon the existence of severe complications, whether
the height of the exacerbations is considerable in the following
diseases : — Influenza, polyarticular rheumatism, pleurisy, cerebro-
spinal meningitis, trichinosis, lues, and acute suppuration. The
maxima of the exacerbations may remain inconsiderable in spite of
very severe disease, in acute fatty degeneration, basilar meningitis,
dyphtheria, dysentery, pericarditis, and peritonitis.
The da'ilij difference, or the width of the excursus of the fluctua-
tions, depends on the form and severity of the disease. Sometimes
the extent of the excursus approximates closely to the type of inter-
mitting fever (pseudo-intermittent), and sometimes the smallness of
the difference imitates the continuous course. Cases of the latter
kind must generally be considered severe, whilst the former (pseudo-
intermittent), especially if the temperature is very high in the
exacerbations, must be at least suspected of malignancy {liickisch-=
tricksy) ; they give rise to the suspicion of latent pysemic or septic
infections, or of successive embolisms, and are generally connected
with secondary deposits [in the tissues], and particularly so in the
suppurating fever of smallpox, in parotitis, acute rheumatism, endo-
carditis, pleuritis, inflammatory affections of the liver and spleen,
suppuration in any part, whatever the original cause ; and always
more so the higher the temperature goes in the exacerbations. Such
latent self-infecting processes may occur also in other diseases, and,
since many of them are, at least occasionally, impossible to diagnose,
the development of remissions which almost amount to intermis-
sions, followed by exacerbations of considerable height, becomes of
very great importance, and must always make us dread danger, and
more especially so when such a course lasts several days without the
exacerbations moderating. This does not set aside the fact that in
many of these cases recovery may occur without any subsequent
17
258 THE TEMPERATURE IN FEBRILE DISEASES.
coufirmation of the suspicion, yet in such cases it will generally be
found impossible to discover any other ground for such a course
of tcmj)crature. Exacerbations reaching a very high degree with
almost, or entirely, apyretic remissions, occur in the fastigium, with-
out any special danger, most frequently in the prodromal fever of
measles, in severe influenza, in erratic erysipelas, and also in lues
[constitutional syphilis] . On the other hand, if the temperature
nearly reaches normal in the remissions, whilst in the exacerbations
it exceeds the limits of moderate fever only slightly, or not at all,
one may generally consider the case to be a mild one, unless, from
the nature of the disease, great and perhaps unavoidable danger
exists, apart from fever altogether. For this reason, moderate exacer-
bations, with almost perfect absence of fever in the mornings, do not
justify a favorable prognosis in the following diseases : — Acute fatty
degeneration, acute capillary bronchitis (bronchiolitis), basilar- and
cerebro - spinal meningitis, acute tuberculosis, diphtheria, severe
dysentery, peritonitis, and acute parenchymatous nephritis. Perfect
regularity of alternation between exacerbations and remissions, as to
both time and height, must not be expected in any other form of
disease mentioned here, except abdominal typhus; or, in other
words, no particular importance as a symptom is to be attributed
to such irregularities in any other disease except abdominal typhus.
The following diseases chiefly and generally exhibit more or less
regularity of course : — Influenza, catarrhal pneumonia, on which
account both may assume a great resemblance to typhoid fever
(abdominal typhus) during their fastigium, polyarticular rheuinatism
(in which the temperatures are generally not so high in the ex-
acerbations as in typhoid fever), pleurisy, cerebro-spinal menin-
gitis, trichinosis, suppurations, lues, phthisis, and chronic fevers.
Sub-acute tuberculosis sometimes follows a very regular course for
some time, although just as often it shows most remarkable irregu-
larities.
With so great a predisposition in the non-continuous fever-course
towards irregularities, very trivial occurrences suffice to make their
course irregular. This principally occurs from complications from
special events in the course of the disease, and through influences
and cu'cumstauces of either a favorable or an unfavorable nature.
Complications generally affect a non-continuous course, in such a
way as to render the course of the temperature either temporarily or
persistently continuous, or approximating to that type, although
THE TEMPERATURE IN FEBRILE DISEASES.
259
sometimes they change the remittent course into an exacerbating
one.
Isolated events principally induce sudden springs or plunges^
sometimes rises of temperature^ sometimes— indeed^ very often — falls
of the samCj and even collapse ; the latter is particularly wont to be
induced by haemorrhages, vomiting, strong diarrhcea, immoderate
perspirations, and perforations of serous cavities.
Influences of either a favorable or unfavorable kind may have
either a temporary or a lasting effect. It is possible, in many cases,
after long experience, to recognise a definite typical course as the
result of certain therapeutical influences, at least in certain kinds of
diseases, in this way ; in typhus (enteric fever ?), calomel, digitalis,
and cold-water treatments each furnish us with, so to speak, typical
and definite modifications in the course of the disease, and so does
bloodletting in pneumonia.
The direction taken ly the temperature when the course is non-
continuous may in like manner differ ; the fastigium may either
continue to assume a uniform character, or sometimes it takes an
ascending, sometimes a descending direction; (of the course modi),
which in most cases sufficiently accurately corresponds with the
severity and dangerousness of the disease.
The ascending direction may consist —
{a) In an increase in the height of the daily averages of tem-
perature (fig. 19).
Cent.
40-5
40-
395
39"
385
38-
EiG. 19.
K
1\
1
\
\
l
'J
V.
I.
■
> /
y
1'
V
\
V
I
rahr.
1049
104-
1 03- 1
I02'2
101-3
100-4
XMU) TIIH TKMPEUATUUE IN l-ElilULE DISEASES.
[d] Or ill the remitting typp npproximating- to a contiiiuuus or
exacerbating one (fig. 20).
Flu. 20.
Cent.
405
40-
39'B
39"
38-5
38-
1
K
h
A
, /■
1'
P'
1
v
V
/
\l
\l
i
V
't
1
Fahr.
1049
104'
103- 1
I02'2
101-3
ioo"4
The descending type is to be recognised by exactly opposite symp-
toms. A change in tbe direction of the fastigium usually happens
gradually and easily, but sometimes suddenly and rudely, and is
generally led up to by very brief irregularities.
The fastigium may be broken into two abstracts, or phases, more
or less sharply defined, through an abrupt change of direction, and
these not infrequently correspond to a whole week, or half of one.
"When the fastigium lasts longer the various characteristic phases can
be clearly recognised by the curves, and if an ascending direction is
succeeded by a uniform course, and then a descending one makes
itself evident, we are warranted in a favorable prognosis ; but when,
on the other hand, a uniform progress is lost in an ascending direc-
tion, the case is bad, although not yet on this account a lost one.
The duration of the fastigium in the non-continuous type is, on an
average, longer than in the continuous one, and very often depends
on the kind of disease, and on the other hand very much on its
severity. It is obvious that in most (that is, not suddenly fatal)
cases a short duration of the fastigium indicates that the cases are
not very severe. "When the fastigium is much prolonged, it is always
noteworthy.
THE TEMPERATURE IN FEBRILE DISEASES. 261
The prodromal stage of measles^ in favorable cases^ has a par-
ticularly short fastigium.
In influenza, bronchitis, cynanche, tonsillaris, parotitis, catarrlial
pneumonia, wandering erysipelas, the suppurating fever of smallpox,
in peritonitis, and the reaction fever of cholera, the fastigium cannot
last more than five or six days without the case becoming dangerous.
The fastigium lasts one to two and a half weeks in abdominal typhus
(enteric or typhoid fever).
Even in favorable cases the fastigium is, comparatively speaking,
prolonged in polyarticular rheumatism, in pleurisy, in trichinosis, in
suppuration, in cerebro-spinal meningitis, and in lues (constitntional
syphilis) .
In basilar meningitis the probability of a fatal termination is little
affected by the length of the fastigium.
In septicsemia and pyaemia a protracted fastigium is rather a
hopeful indication, and the same may be said of acute tuberculosis.
In phthisis and other chronic febrile affections the fever may per-
sist in a remitting course for a great length of time, for months and
even years, with great uniformity ; although it may sometimes be
spontaneously interrupted for some weeks, or in consequence of some
influences brought to bear upon it, the former fluctuations often recur
with great regularity, and with an identical height of the daily tem-
perature.
(d) In most diseases the fastigium is simple ; on the other hand,
it may be doubled or repeated more than once in the following affec-
tions : — In typhoid fever with successive relapses, in relapsing fever,
in smallpox, in irregular exanthems, in many cases of pneumonia
(relapsing forms), in pyaemia and septicemia (with apparent improve-
ment intervening), in facial erysipelas (following an apparent re-
lapse), in polyarticular rheumatism (in complicated cases), in basilar
meningitis, cerebro-spinal meningitis, pleurisy, and phthisis.
When the fastigium repeats itself, the first differs from the second
and successive stages. Continuous, remittent, and paroxysmal types
may alternate with each other. The more continuously elevated
these later stages are the more unfavorable, generally speaking.
(e) The close of the fastigium is sometimes clearly defined, some-
times it is indistinctly marked and merges into the other stages.
Sometimes a brief rise of temperature occurs at the close of the
fastigium. This was particularly noticed by the physicians of
TllK TEMPERATUUE IN rKIHlILE DISEASES.
old lime?, and clesignalccl by them as the periurhai'w crifica
(fig. 2l).
Fig. 21.
Cent, "Fahr.
40-5
40-
395
104-9
o'
8-5
103-1
102-2
101-3
In other cases we meet with a considerable fall of temperature ==
preparatory decrease. In the prodromal stages of smallpox the fas-
tigium ends as soon as the eruption becomes "shotty^' (Erhebung
zu Kuotchen).
In measles it terminates when the eruption is at its height.
In scarlatina when the exanthem begins to pale.
In pneumonia when hepatization is completed, seldom before the
third, or after the ninth day.
In true petechial typhus, towards the end of the second week, some-
times in the middle of the third week.
In abdominal typhus, or enteric fever, in mild cases in the
middle or at the end of the second week, in severe ones in the
middle or at the end of the third week, and sometimes not till the
fourth week.
In influenza it generally ends after a few days.
In parenchymatous tonsillar angina after lasting from three to
seven days.
In the remaining diseases the termination is more or less uncertain.
§ 6. The periods of development and completion of most diseases
come to an end with the fastigium ; that is, they either pass on at
THE TEMPERATURE IN FEBRILE DISEASES. 2G3
once to a fatal termination, or immediately begin the convalescent
stage. Yet the fastigium is frequently followed by a stage of
indecision.
This period of indecision [ampJdboUc stage) is most evident when
the course of the temperature is most regular in the fastigium, whilst
with an irregular course of temperature in the fastigium it becomes
difficult to separate this from the amphibolic stage. Cases which,
without quickly proving fatal, run a very severe course, almost
always have an amphibolic stage. This is most strikingly severe and
lasting in bad cases of enteric fever. It also occurs in severe and
lingering cases of pneumonia, in exanthems with severe compli-
cations, in petechial typhus under similar conditions, in polyarticular
rheumatism of great severity, and in epidemic cerebro-spinal
meningitis.
The amphibolic period displays more or less want of regularity,
and is marked by isolated changes of temperature, or such as last
for a few days, and exacerbations and remissions of varying degree;
the remissions, indeed, generally occur in the morning, but fre-
quently at other times also, and the exacerbations are not limited to
any hour of the day. Intercurrent collapse is often met with. The
temperature rises suddenly, either from some recognised cause, or as
it were casually, and slight improvements take place 4n a similar
manner, and both sometimes last only a few hours, or frequently a
few days, whilst now and again alterations take place on alternate
days, generally in a very irregular fashion. Sometimes, when the
amphibolic stage lasts some time, we notice on certain days of the
disease, at the middle or end of a week (of the illness), certain special
changes, which do not, however, last long enough to modify the general
character of the course.
Notwithstanding all these irregularities, however, the temperature
keeps within limits which permit some definition, and the separate
temperatures seldom reach the maximal heights of the fastigium.
The amphibolic stage may last from a few days to a week or even
more. It lingers longest in severe cases of abdominal typhus.
§ 7. When a disease is at its height, and in the amphibolic stage,
the fever is more or less easily ivjluenced by processes in the
organism itself, or by causes which operate on it from without, some-
times injuriously and sometimes with benefit to the patient. It may
be stated generally that those processes and influences which cause
264. THE TEMPKRATURE IN FEBRILE DISEASES.
the ])rcviously liit^h temperature to rise still higher are projiulicialj
whibt, oil the contrary (although not invariably), those which tend
to moderate the temperature are beneficial. Therapeutics should
therefore aim at utilising the latter, and also strive to greatly mul-
tiply them, but, above all, to determine as far as possible their true
powers, and how far they may be safely employed. A rise of tem-
perature may be induced in febrile patients by mental excitement, by
movements of the body, by being kept too warm, by errors in diet, by
persistent constipation, and by the occurrence of complications.
A diminution of the high temperatures can be brought about
in the fastigium and in the amphibolic stage by the following
causes :
By spontaneous haemorrhages (v. p. 134).
By copious stools, by vomiting, and profuse perspirations.
Also by the respiration becoming impeded and imperfect, by
paralysis of the heart, by pressure on the brain, and by starvation.
Sometimes, but by no means always, by tranquil sleep.
Still further by the proper application of cold to the body of the
patient.
By medicinal bloodlettings ; and finally, by the ingestion (incor-
poration) of a number of medicines, amongst which the following are
already recognised as antipyretic : — ]\Iercury (calomel), antimony
(tartar-emetic), lead, digitalis, veratria, quinine, acids, and the so-
called " cooling" salts, laxatives, and emetics.
The amount and safety of their operation is, however, by no
means the same in all cases having a similar temperature, and
the suceptibility of single cases is even yet more varied. One
fever patient is very susceptible of their influences, and therefore
quickly responds to the action of medicines and well-chosen thera-
peutic procedures. In other cases the fever has more resistance (so
to speak), and all methods of procedure remain altogether, or at
least for a time, -without any effect.
The temperature is most easily affected when the fever is at its
height and in the amphibolic stage, principally in children, in dehcate
individuals, in diseases of moderate severity, after spontaneously
occurring falls of temperature, in temperatures with a non-continuous
course, and in the natural daily remission. Eobust adults, very
severe diseases at their onset, and complicated maladies, the con-
tinuous type of fever, and the hours of daily exacerbation, on the
contrary, exhibit more or less resisting power.
I
THE TEMPERATURE IN FEBRILE DISEASES. 265
§ 8. The course taken by the temperature during convalescence
may be more or less peculiar.
Diseases differ' very considerably in the mode in which recovery
from them generally takes place^ and the difference is most charac-
teristic when the course of disease is least complicated and, so to
speak, most normal. In one disease the morbid process appears
almost instantaneously exhausted and terminated, and what follows
is merely compensatory, without being serious — the return to the
old order of things follows quickly, and without hindrance. Such
a course may be noted in petechial typhus, in varioloid, varicella,
and measles, in primary croupous, lobar and uncomplicated pneu-
monia, in febricula, in relapsing fever, in facial erysipelas, in
parenchymatous tonsillar angina, in the fever of cholera-reaction
without parenchymatous degeneration of the kidneys. In other
forms of disease such alterations in the texture of the parts are
induced by the morbid process itself, so many new products stand-
ing in organic relation to another, and so much destruction of tissues
is brought about, that there is need of long and laborious processes
of reparation, easily permitting of renewed damage and dis-
turbance, in order to restore again more or less of pristine order and
regularity.
To such a category belongs enteric fever (abdominal typhus), and
for the most part scarlatina, true smallpox, acute polyarticular
rheumatism (rheumatic fever), all forms of meningitis, trichinosis,
pleurisy, pericarditis, dysentery, &c.
That which occurs in these last-named diseases, from the essential
nature of the morbid processes, may also be brought about by com-
plications and unfavorable circumstances in the first class, although
in a normal way recovery from them is sudden and without difficulty.
Naturally enough, there are cases intermediate between these two
types of rapid recovery and protracted and tedious reparation.
The course of the temperature corresponds to these varied re-
lations, and therefore this allows us to draw conclusions as to the
mode of recovery.
In cases of laborious convalescence very considerable rises of tem-
perature may occur in the midst of the healing processes. This
harmonises with the fact that in certain forms of disease the patient
is most, and most often exposed to danger just at the very period of
recovery.
2CG
THE TF.MPKRATURE IN rKinULE DISEASES.
On the other hand, in those diseases in which there ore no great
obstacles to recovery the fever also passes away with the disease.
The course of the temperature during the process of recovery
may be divided into — (a) The period of decided, but still insuflicient,
decrease of temperature (stadium decrementi) .
(i) The period of cessation of the fever, for which I have intro-
duced the now generally accepted term " defervescence/'
{c) And the period after defervescence, epicrital period, and
recovery.
§ 9. The first stage in the restorative process, the period of
decided, but still insuihcient, decrease of temperature, cannot, indeed,
be observed in all cases. AVhen it is present it either closely suc-
ceeds the fastigium or immediately follows the amphibolic period,
or after a precursive rise of temperature; then immediately suc-
ceeds for a day or two a slight fall, which is at once followed
by unmistakable defervescence (see fig. 22). This preparatory
Fig, 22.
Cent.
40"5
40-
39'5
39"
38-5
38-
/.
A
*
/
■V
V'
.A
\ *
i
\
\
Fahr.
104-
103-1
I02"2
101-3
ioo'4
process of slight decrease of temperature may be gone through so
imperceptibly, in acute cases, that it may be difficult to define the
commencement of true defervescence. This preliminary decrease
may amount to half or even a whole degree (Centigrade = 9 to
I '8° Fahr.) in very high fevers and pseudocriscs ; in the latter,
indeed, it may even reach 3° C. (= 5*2° F.) or more. Sometimes it
THE TEMPERATURE IN FEBRILE DISEASES. 267
consists in a moderation, or perliaps entire absence, of the customary
evening exacerbation, in such a manner that on the day of decrease
the daily fluctuation is absent, and the morning elevation of tempe-
rature persists cojitinuously ;
Or it may consist of a greater morning remission, whilst in the
evening the temperature reaches its previous height ;
Or it may happen that the morning remission is more con-
siderable, and the evening exacerbation is less marked, thus making
the daily difference the same, whilst the average temperature of the
day appears lower ;
Or it may consist in a pseudo-crisis followed by a slight rise of
temperature. It not infrequently happens that in this way for
several days, or even a whole week, the daily averages may be
actually lower than in the preceding time of the fastigium or of the
amphibolic period^ whilst at the same time a moderated febrile
condition persists for several days, or subsides very slowly, before the
proper defervescence.
Such a course is easily distinguished from.the amphibolic stage,
for in that which we are now describing no fresh aggravations occur,
and the rises of temperature in the evening hours are nothing else
but the expression of the daily fluctuations ; they have no unfavor-
able significance, provided the morning remissions occur regularly.
There are no forms of disease in M'hich such a stadium decrement!
may not be met with, and defervescence may succeed it either rapidly
or lingeringly. Therapeutic efforts often manifestly hasten its com-
mencement. On the other hand, the length of this stage varies with
the kind of disease. In abdominal typhus the stadium decrementi
may last from several days to a week or more, and the same may
occur in the suppurating stage of variola. It is shorter in petechial
typhus and in scarlatina, and shorter still in measles and lobar
pneumonia. In forms of disease which are only approximatively
typical the length of this stage may be very various, and affords less
warrant for believing that it will be immediately followed by defer-
vescence. And in these, without any fresh complications occurring,
the temperature may begin to rise again, and the course once more
assume the characters of the fastigium. In these cases a state of
diminished fever has intervened between two periods of fastigium,
and gives a deceptive appearance of recovery. Just such wholly
deceptive and false moderations of temperature are met with in
pyEemia and in the amphibolic stage of many diseases.
208
THE TKMPERATURK IN FEBRIT.K DISEASES.
§ lo. The most clearly (Icfmctl distinctions arc met Avith in the
period of defervescence, according to tlie kind of disease; and the
deviations from the proper type of the special form of disease all'ord
us very safe indications as to the anomalies and imperfections of the
recovery.
(a) Defervescence may occur quite suddenly (rapid defervescence,
crifiis) in such a way that it is complete in four, twelve, twenty-four,
or at the most thirty-six hours ; the temperature falls during this
time from 2° — 5° C. ( = 3*6° to 9° F.), and, indeed, sometimes
more than that, reaching to normal, or even below that (tigs. 23
and 24).
Cent.
Fig. 23.
V *
ilO'". ^
•
4"-' .) ^
v/
a
39'5
">0'
■38-
6°
37 5
/
3/
1/
Fahr.
105-8
104-9
104'
103-1
102-2
IOI-3
100-4
995
98-6
Ftct. 24.
Cent.
40-5
40-
39"5
39"
385
38-
37"5
37'
\
>
Fahr.
104-9
104-
103-1
102-2
101-3
1004
1
-^ 98-6
In this way the fever may terminate in the time between morning
and evening, or in the course of a night, and already next morning
perfectly normal temperatures may be reached ; but the end of the
fever is not to be assumed until we see that no fresh rise of tempera-
ture takes place on the next afternoon and evening. Such a rise is
THE TEMPERATURE IN FEBRILE DISEASES.
269
not uncommon, but it does not reach the height of the day before,
and definitely passes on into the feverless condition on the next night.
This rapid defervescence may often extend over twenty-four hours.
The temperature fall? in the early morning more or less rapidly ; in
the course of the ' afternoon it falls still more, but more slowly, or
the temperature remains the same, or even rises afresh, and the nor-
mal temperature is first attained on the morning after. It may also
happen, even on the second evening, that the temperature rises
again a little, but this rise is generally very trifling (see fig. 25).
Ceut.
40-5 r
EiG. 25.
40-
39'5
39"
38-5
38-
37"5
V
Tahr.
104-9
104-
103-1
I02'2
101-3
100-4
99*5
98-6
It ha])pens, occasionally, that there is no disposition to 'defer-
vescence to be remarked in the morning hours, or at most only a
very moderate depression, and often, indeed, an unaccustomed height
of temperature, and that defervescence begins in the afternoon or
evening. In such cases the decrease is seldom considerable ; very
commonly the defervescence is to be recognised by the absence of the
evening exacerbations, or instead of this a slight fall, amounting to
Tuto-rV°C. (about 4- to ^° F. or a little more), upon which the
270
THE TEMPERATURE IN FEBRILE DISEASES.
defervescence on the following evening may be based, or even then
may require twenty-four hours in the way just described for its
completion (see fig. 26).
Fig. 26.
Cent. Fahr.
405
40-
395
39"
58-5
38-
37o
37"
y
— 104-9
104-
103-1
102-2
- 101-3
1004
— 99"5
.: 98-6
The temperature often falls below the normal, either almost to
36° C. (96-8° F.), or even below that, when defervescence is very
rapid, and this is especially apt to be the case when therapeutic
efforts have been made to reduce the temperature. But even such
an immoderate depression gives no guarantee that the tempera-
ture may not rise again, and we cannot make sure of defer-
vescence, unless the temperature on the next evening confines
itself within normal limits. Symptoms of collapse are often met
with in cases where there has been a very rapid fall from a pre-
viously extreme height of temperature, and the general disturbance
in the economy is so great that the patient and those around him
often consider the situation more critical than even at the height
of the fever, and when it was really dangerous. By means of the
thermometer we are able in such cases to recognise the transition
towards health in these unpleasant and apparently unfavorable cir-
THE TEMPERATURE IN FEBRILE DISEASES. 271
cumstances. Generally speaking, this uncomfortable condition,
which may be accompanied by delirium, only lasts a few hours,
yet it may continue for a day or two; and if the temperature
continues to be normal, or subnormal, there is nothing at all to
dread, unless the fall of temperature, instead of depending on the
termination of the illness, is the result of the intervention of some
severe and easily recognisable event, such as a copious hsemor-
rhage, perforation of the intestine, or perforation of the lung, &c.
There is generally rapid defervescence (crisis) in those cases and
forms of disease in which there is a very rapid rise of tempera-
ture in the initial stage, and which are thus for the most part
free from complications of special cases. Relapsing fever exhibits
the most striking and constant rapid defervescence, and the excur-
sus is the widest (5° or 6° C. = 9° or iO'8° P., or more, in a few
hours), and this is as true of the first attack as of the relapse.
It is the rule in the uncomplicated cases of primary croupous pneu-
monia which do not last more than a week, in varioloid diseases and
typical measles. It occurs also in ephemeral fever (febricula), in all
fevers and febrile cases of acute kind (Akme-artig, i. e. in which
the temperature assumes a pointed or a pyramidal outline). It is
the rule in parenchymatous tonsillar angina, and also occurs in facial
erysipelas, but is no guarantee in the latter that a new fever may
not begin with further extension of the cutaneous inflammation. It
also occurs very often in petechial typhus, less often in scarlatina and
catarrhal fevers.
{b) In an opposite class of cases, defervescence takes place more
slowly, in an extended line, or by I//sis, and this may be —
(i) Either in a continuous but tedious fall of temperature, in
which this generally falls rather less from morning to evening than
it does from evening to morning, or may even remain stationary,
or rise a little [during the day] . In this manner the decline occu-
pies two to four days, and sometimes a whole week (fig. 27, on
page 272).
This is particularly the case in scarlatina (see page 22 1), in pete-
chial typhus, and sometimes in pneumonia, if the course of this
disease is not quite normal or lasts over a week. This mode of
defervescence only occurs exceptionally in abdominal typhus, and
occasionally in catarrhal forms of fever.
Or lysis may exhibit a remiiterd type, in which morning remis-
• )?>>
Tin; TEMl'EKATUllE IN FEBRILE DISEASES.
sious alternate witli evening exacerbations, but on the whole either
the daily maximum or the daily average is less from day to day.
Ceut.
405
HO-
395
39*
385
38-
37 5
37
Fiii. 27.
A
\
\
\/\
^
V\
\
u
V
\
V
— *—
Fuhr.
' 104-9
1 04"
103-1
1022
101-3
100 4
995
98-6
In this way it may happen that the evening exacerbations con-
tinue to reach their previous high degrees for some time, whilst the
morning remissions become more marked from day to day, till at
a later period the exacerbations also decrease in severity (fio-.
38, on page 273).
Or the daily differences remaining the same, both the morning
and evening temperatures may become lower (see fig. 29, on page
274) ; or the evening exacerbations may become less severe, and
gradually approximate to the morning remissions (fig. 30, on
page 275).
These various forms may succeed one another, and in this way the
transition from one to the other may be sudden and abrupt (stoss-
und schub-weiser).
Remitting defervescence may last from three or four days to a
whole week or more, and interruptions to the regularity of its
course are very commonly met with.
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 273
It is the characteristic type iu enteric fever (abdominal typhus),
is customary in the suppurating fever of variola, and very com-
FlG. 28.
J 98-6
monly met with in severe forms of catarrhal disease. It also occurs
frequently in acute polyarticular rheumatism, as well as in trichinosis,
pericarditis and peritonitis.
Collapse not infrequently occurs in remitting defervescence, at
least in severe diseases ; and the way in whicli it happens is by the
morning temperature falling considerably below normal, whicli is
succeeded by the other symptoms of collapse. This state of affairs
may last for several days.
§ 10. In the epicritical period, and especially in convalescence,
when this has undoubtedly commenced, and remains undisturbed,
the temperature is normal both in the morning and in the evening ;
and only the normal daily fluctuations which are met with in health
occur. This behaviour of the temperature is the safest guarantee
18
274 DAILY FLUCTUATION OF TEMPERATURE IN DISEASE.
that the healing process AviU be jierfected. As long as ever such
febrile temperatures are met with in the evening hours, convalescence
is still imperfect ; vhilst if the temperature is above normal in the
morning hours, it is a still greater argument against satisfactory
convalescence having set in. Yet in special cases, and in many
diseases, we find that the daily fluctuations, far on in the course of
Cent.
41'
40-5
40-
39"5
39'
38-5
38-
375
37-
Fig. 29.
I
f
A
It
\/l
J\
A
i
V
\/^
a
y
\/\
I
y
v\
•
y
1/^
V
\^
V
\
Fahr.
- 105-8
104-9
104-
1031
ior3
1004
99'5
986
convalescence, are on a somewhat elevated plane of daily averages,
without the prospects of recovery being materially affected ; for
example, this is very common in articular rheumatism.
The temperature of convalescents is, however, almost always more
mobile, and more easily influenced, than that of healthy people, and
the daily fluctuations are somewhat greater than in health. Outward
influences, little ailments, trifling errors in diet, little muscular
exertions, such as the first rising from bed, cause sufficiently notice-
able rises of temperature, and sometimes they occur without any
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 275
assignable cause. For example, a rise of temperature is often met
with when the convalescent is allowed animal food for the first time,
especially if this be given a little too soon. (Fig. 31 on page 376.)
Cent.
Fig. 30.
Fahr.
40-
39'
38-
A
I04"0
I
•
104'
1
\
l\
f
103-1
I 1
r
/\
^
102 2
1
\i
\r
>/'
f^
101-3
100*4
99'5
nS-6
J
\
V
V
\/'
f
\/\
^ "
id
37-
Such shght elevations of temperature, however, only last a very
short time, and disappear after one or two days, or so^ when every-
thing else is as it should be.
AValking about will again induce temporary rises of temperature,
amounting to ^ a degree Centigrade ( == -j^ Fah.), or a little more,
which speedily compensate themselves when the patient lies down
again. AYhenever the temperature remains elevated, however shghtly,
and generally when the temperature rises still more, we may con-
fidently assume that the healing process is yet incomplete, or that a
fresh malady, a sequela, or a hypostrophe is being developed. And
the incompleteness of the recovery generally shows itself either
in continued evening exacerbations, or in the temperature re-
maining abnormal in the morning, or in occasional strongly marked
relapses into fever, extending over several days, which often exhibit
themselves only in the elevated temperatures. The beginning of an
27G DAILY FLUCTUATION OF TEMPERATURE IN DISEASE.
acu(c alToction (wliitlicr a relapse, or some other complication)
during couvalcsccnce, is generally shown by a suddenly occurring
rise of temperature after the type of the new affection.
Fig. 31.
Cent.
-lo-
39'
38-
31
1
,t
1
1
1
t
\A
i
u
Fall!-.
104-
103-1
I02'2
101-3
100-4
99'5
)8-5
§ II. If an illness^ instead of recovering, or directly terminating
fatally, is followed by sequela, the course of temperature just
described as belonging to recovery may go on towards convalescence,
and the sequela may set in after a longer or shorter duration of the
convalescent stage, with or without a fresh occurrence of fever.
Yet in almost all these cases the healing process is imperfect,
retarded, intcrruj)ted, and exhibits many deviations from the normal;
for instance, in forms of disease which generally recover with rapid
defervescence, the fever in these cases terminates by lysis ; and in
such as are accustomed to end in lysis, the process is protracted,
fresh rises of temperature intervene, and there are pauses in the
progress towards recovery ; or even in apparent convalescence, the
temperature does not become normal, or rapidly rises again without
obvious cause.
The transition to a consecutive disease (sequela) may occur during
the amphibolic stage, the stage of decrement, or at any point in the
defervescence. The sort of thing that generally occurs is this :
— after some slight and deceptive remissions of temperature have
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 277
occurred (or even more considerable oncs^ tliougli not equalling
those which might fairly be expected^ and it may be not easily trace-
able to any special influences), and have held out false hopes for a
short time, the apparent lysis is proved to be only apparent, by a
fresh elevation of temperature or the failure of further progress
towards improvement. The further course is determined by the
nature of the sequelse, and the preceding disease has hardly any
influence on the course of the fever which may accompany the
consecutive disease.
§ 12. A fatal termination is often preceded by symptoms lasting
for a longer or shorter interval, which are for the most part of an
unfavorable and casual kind, but in other cases may easily be inter-
])reted as apparent ameliorations. When such symptoms set in, we
are seldom able to obviate the tendency to death by even the most
powerful means at our command.
The pro-agonistic stage is very far from being simple ; its halite
so to speak, differing more or less according to circumstances, from
the earlier course of the disease, as it does also from the death
agony itself. Its duration may be long or short. Thermometric
observations aid our prognosis most, especially when the remaining
symptoms are also taken into consideration. The course taken
by the temperature, as well as the other phenomena in the pro-
agonistic period, partly depends upon the actual disease and the
extent of its development, and partly upon the numerous compli-
cations and terminal disturbances which generally accompany severe
and fatal illnesses, although perhaps but slightly connected with the
original aflFection.
If we take the course of the temperature as our clue, we shall
find the pro-agonistic stage assume varied forms. The temperature
rises continuously, although there may be morning remissions, until
the occurrence of the agony, and it may be the very moment of
death = the ascending form of the pro-agonistic stage; in such
cases the commencement of this period may be more or less obscure,
if the preceding course of the disease has had the same character,
or even if an amphibolic stage has preceded.
Its commencement is however sharply defined if the disease has
passed into the period of convalescence, or made more or less progress
towards recovery, or when the temperature has been artificially
affected by therapeutic agencies which lower the temperature. It is
278 DAILY FLUCTUATION OF TE:\irF,RATURE IN DISEASE.
■well uiarkcd also when the previous course of tlie temperature lias
been continuous. But it is most sharply defined when a pro-agonistic
period begins with a very rapid rise, in a disease which was previously
marked by no fever or by slight feverishness only.
In this ascending form we generally note the temperature conti-
nuously rising higher and higher, yet seldom quite uuinterrui)tcdly
so, far more generally iu a zig-zag fashion, so that in tlic morning
hours there is a slight decline of temperature, which is however fol-
lowed at the next evening exacerbation by a still higher rise; thus the
daily average height of the temperature increases, and the daily
maxima increased at the same time (fig. 32).
Pig.
Cent.
41"
40-
A
r
y
-ji
A
y
Fahr.
105-8
104-9
104"
In this way it may sometimes happen that the temperature which
had already shown a more or less constant tendency to rise, continues
to do so with more or less regularity all through the pro-agonistic
period. This is however comparatively rare ; or the rise may first
begin when the pro-agonistic stage itself begins — these cases also
are uncommon.
Or the decided rise of the pro-agonistic stage succeeds an irregular
course, or follows the fluctuations of the amphibolic stage.
Or the pro-agonistic elevations of temperature occur, after a
previously moderate or not truly febrile condition, or after more or
less favorable events have occurred in the course of the disease, or
even after convalescence has made considerable progress.
Or the pro-agonistic stage may set in after a fall of temperature
which approximates closely to normal, or even descends below it,
after a deceptive remission, or a state of collapse has existed for a
short time.
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 279
In contradistinction to this steady rise of temperature it is
common enough to find cases with rapid and extremely remarkable
elevations in the pro-agonistic period, and they may occur either
when the temperature is previously very high or when it is moderate,
or when it is low rind all fever is absent.
In the first case, which is common enough, the temperature before
the beginning of the pro-agonistic stage has reached a height of
40° to 41° (C. =; 104° to io5"8°rahr,) or more, when a further rise
of 1 to 2 degrees (C. = i"8° to y6° Fahr.) sets in : in this case the
pro-agonistic stage is shorty and imperceptibly merges into the death
agony (fig. 33).
Tig. 33.
Cent.
41"
40-
\
+
/
r-^
H
1
/
^
i
Talir.
ioy6
105-7
105-8
104-9
104-
Cent.
41'
Fig. 34.
40-
39"
38- I.
/
r't
1
1
\
\
Falir.
105-8
104-
I03'2
100-4
In the second case it may be an open question whether the fall of
temperature which precedes the last elevation ought to be included
in the pro-agonistic stage or not. The final rise is often very con-
siderable when compared with the preceding fall, yet the absolute
height is not always remarkable per se ; in these cases, too, the pro-
agonistic period merges at once into the final agony (fig. 34) .
Lastly, in the third category, to which terminal fever and hyper-
pyretic rises of temperature in fatal neuroses and diseases of the
brain free from fever (non-inflammatory diseases) belong, we may
consider the whole period in which the temperature is rising as the
280 n.\lT-Y FLUCTUATION 0? TEMPERATURE IN DISEASE.
})ro-ngonistic stage. Tiic rise is generally moderate in the beginning,
but suoji becomes rapid^ and in the death-agony reaches enormous
heights (fig. 35).
Cent.
4^'
41"
40-
3S-
37'
Fig- 35-
/V
Fahr.
io7'6
1058
I04"
I02"2
ioo'4
98-6
(b.) Far more common than the ascending form of the pro-
agonistic stage is that with decrease of temperature (descending
type), and it is much more important to regard this form, inasmuch
as a superficial and partial consideration of the temperature only,
might lead us to consider its decrease as a sign of amendment.
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 281
A careful attention to the state of the pulse is our best safeguard
against this gross deception, for in such cases, along with the fall (f
temperature, the frequency of the pulse increases in the most striking
manner.
Sometimes the pro-agonistic stage is very short in such cases, the
fall of temperature occupying from twelve hours to about two days,
and amounting as a rule to about i° (C. = i*8°F.) ; yet sometimes
the decrease extends till even the normal temperature is reached, and
then it often happens that immediately after such a pro-lethal
moderation of temperature, there is a sudden and extremely striking
rise of temperature in the death-agony itself, and the extremest
ranges of fatal temperature are attained. With these must be
associated the cases, where in consequence of some occurrence not
essential to the disease (such as considerable haemorrhage from the
lungs or intestines, or perforation of the peritoneum) the temperature
is much diminished, and the patient either dies at once, or may just
before death exhibit a rapid rise of temperature (fig. 'ifi).
Fig. 36.
Cent.
Fahr.
40"
<\
'3Q'
+
'^S-
/
0"
/
-?'?•
u
104-
I02'2
I00'4
986
In other cases the remissions are periodical, and may be repeated
282 DAILY FLUCTUATION OF TEMPERATURE IN DISEASE.
several times, uliilst they arc interrupted by fresh elevations of tem-
perature. A certain irregularity is uoticeable in these cases. It is
not the quiet, although zig-zag descent of defervescence by lysis, but
there are plunges up and down ; sometimes the descent is absent, at
another time it is very marked. This form occurs in all sorts of
diseases, especially in cases where complications set in at an early
stage, or uhcn nervous symptoms arc unusually predominant, also
with bad nursing, or after (he use of strong remedies.
Sometimes the combinations of rising and falling temperature
in the pro-agonistic stage are tolerably regular. The period begins
with a very decided fall, which may last one and a half or two and a
half days, but then the temperature rises again nearly to its ])revious
height, or may even exceed that. The approach of death may be
heralded in these cases by a still higher rise, or through an exceptional
fall of temperature.
But sometimes (and these are indeed the most difficult cases for
prognosis) the temperature for some days pursues a descending
course, whilst all the other severe symptoms continue. The patient
dies, whilst the temperature still continues to fall ; or the temperature
suddenly sinks still deeper, or changes itself at once to a more or
less considerable fatal perturbation, in Mhich the death-struggle can
no longer be overlooked (fig. 37). Such a course is common
Fig. 37.
Cent.
40-
39"
.-A
+9
^A
J
Tahr.
104-
— I02"2
enough in almost all cases of long protracted disease — in basilar
meningitis, in exanthematic and abdominal typhus (typh?/^ and
typhoid fevers), in acute exanthems with complications, and espe-
cially in scarlatina, but very seldom in jmeumonia ; and indeed there
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 283
are cases which, in their very onset, are distinguished by their
ferocity, and may be considered in themselves as almost necessarily
fatal, and cases in which death follows the very beginning of a tempe-
rature depressing. treatment (such as venesection).
{c.) In rare cases the course of temperature in the pro-agonistic
stage is not materially aifected, and w^e must found an unfavorable
prognosis on other data, especially on continuous rise of the pulse,
which is not followed by a corresponding rise of temperature. Such
are the cases particularly where, at the end of the disease, cyanosis
occurs through insufficient respiration, although in these it is
much more common to meet with the descending type of the pro-
agonistic stage.
{d.) Lastly, the pro- agonistic stage is sometimes marked by very
extraordinary fluctuations of temperature, repeating themselves more
than once in the course of twenty- four hours, in which deep descents
and enormous elevations of temperature suddenly alternate with one
another, and the death agony sometimes begins during the fall, some-
times during the rise. Pysemic affections, and those diseases which
induce very energetic therapeutic measures on account of their great
severity and almost certain hopelessness of cure, are those which
more especially display such a course of temperature (fig. 38). For
details on the course of the temperature during the pro-agonistic
period, I may refer to my treatise, '^ Das pro-agonische Stadium in
fieberhaften Krankheiten," in the '' Archiv der Heilkunde" for 1868,
Band ix, 1.
§ 13. In the deat/i agony the course of the temperature is very
varied.
In not a few cases the patient^s temperature during the death
struggle exhibits no particular peculiarity, and may even show the
daily fluctuations very clearly. The patients usually die with a
somewhat rising temperature, if the death-struggle occurs in the time
of daily exacerbation ; and on the other hand, if the death takes
place daring the time of the daily remission, the temperature at the
moment of death will be rather moderate.
In most patients previously suffering from fever, w^e may note an
elevation of temperature amounting to half a degree or a degree
(^ths to I '8° P.) during the agony. If the fatal rise be only mode-
rate, there is very commonly a recession of temperature amounting
to a few tenths during the last few hours. As regards this,
281. DAILY FLUCTUATION OT TliMPKUATURE IN DISEASE.
there arc two very remarkable ami by no means uncommon ex-
ceptions.
In not a few cases, whether the previous temperatures have been
febrile, normal, or sub-normal, there occurs a full of temperature in
Fig. 38.
Cent.
f
41
■
>
A.
I
1
40
A
r
1
1
I
39
\
'■\
1
t
\ "
1
38-
I
1
i
i
I'ahr
io.i'8
104"
I02'2
ioo'4
the death-agony, which, when the preceding temperatures have been
above normal, may be rapid and very considerable : the patient dies
in collapse. This happens in many cases of consumptive diseases, in
death from inanition, as well as after profuse haemorrhages, very
copious evacuations of the bowels (cholera flux), and also when death
rapidly follows perforation of the intestine, and sometimes also under
other circumstances.
On the other hand, in other cases a rapid rise of temperature to
extraordinary degrees occurs in the death-agony itself, both in
patients who have before shown highly febrile degrees of warmth,
and also in those whose illness has furnished us before with no re-
markable elevations of temperature, or indeed with no febrile
temperatures at all. Of these we have on the one hand, patients
DAILY FLUCTUATION OP TEMPERATURE IN DISEASE. 285
with malignant febrile affectionSj in wliicli the diagnosis of an
infectious character is very probable, especially abdominal typhus,
exanthematic or true typhus, scarlatina, variola, pyaemia, septic-
Eemia, and also. sunstroke; also measles, tliough less commonly,
pneumonia, endo-carditis, general acute fatty degeneration, malignant
peritonitis, facial erysipelas, malignant rheumatic fever (even if
uncomplicated), osteo-myelitis, acute miliary tuberculosis ; in all
these cases very severe cerebral disturbances are often met with, but
are by no means essential, in order to induce the excessive tempe-
rature in the death-as-onv : and it would rather seem that exten-
sive (dill'used) chemical processes, of a zymotic nature, w^ere the
causes.
On the other hand there are diseases in which the affection of the
nervous centres appears to determine the essential, or one of the
essential disturbances — partly coarse anatomical changes : e.g. me-
ningitis of the convexity, softening of the brain ; partly diseases
without definite tissue changes : tetanus, epilepsy, hysteria, and
other so-called central neuroses ; diseases in which the tempera-
ture generally begins to rise for the first time in the last days of
life, and very rapidly reaches enormous heights. In these cases it
may be questioned whether the fatal rise of temperature is a symptom
and effect of the death-agony (and the processes which go along
with it), or is this rise (and the processes which form its basis) the
original cause of the agony, that is, of the fatal termination ?
Senator (Virchow's ' Archiv,^ xlv, 412) thinks the latter is true,
and says we may pretty safely conclude that the agony and death
occur because from some cause or other the temperature rises to
a height incompatible with life. However, the thing scarcely
seems so simple. The high temperatures of the agony must be
differently estimated, according as they take their point of departure
from an immediately preceding highly febrile process, or on the
other hand attain suddenly to enormous heights after preceding
moderate temperatures. However, it must be conceded that a fresh
state of aifairs is inaugurated, a final process, which is indeed very
frequently thus early and thus undoubtedly prejudicial from no
other cause so much as from the enormous elevation of temperature.
§ 14. The moment of death is not indicated by any special altera-
tion of temperature.
When the temperature is only moderate, or even low, in the
286 DAILY FLUCTUATION OF TEMPERATURE IN DISEASE.
ac^ony-pcriod, it generally sinks most in the few last moments of
life.
AVhcn the temperature is Ligli during the agony, it often reaches
a height at the very moment of deatli higher tlian any ever before
attained; yet in some cases there is a minimal diminution of
temperature just at the fatal moment, compared with what it was
just before.
§ ^5- ^^''^'* death/m the majority of cases, the temperature begins
to fall, and the decrease is slow and tedious at first, then more or
less quickened, and in general much more sudden when the patient
has died with a low temperature than when the temperature was high
at the time of death, and the rapidity of coohng increases as it
goes on.
In a good many cases, however, a moderate rise of temperature,
seldom amounting to more than a few tenths of a degree, may be
observed after death, and this may continue from a few minutes to
an hour, and then a short pause ensues, which is followed by a very
tedious sinking of temperature, which afterwards becomes more and
more rapid.
This 'post-mortem rise of temperature sometimes occurs in cholera,
but especially in cases of disease which have terminated with hyper-
pyretic temperatures, and most especially in those in which the rise
of temperature has continued to the very moment of death, yet it
is met with in cases in which a slight and short-lasting pro-lethal
decrease has moderated the hyperpyretic temperatures a trifle. Con-
sult Thomas (1858, in the ' Archiv d. Heilkunde,' ix, 31).
This remarkable phenomenon of post-moHerii rise of temperature
is based on two causes.
"When death occurs, the cooling that goes on by the introduction
of air (in respiration) and by perspiration, comes to an end, whilst
the warmth-producing processes of the economy are not so imme-
diately terminated. And new sources of warmth are opened after
death, by changes in the substance of the muscles, and h^ posl-
morteni decomposition, two sources which are foreign to the living
body, and which are sufficient to maintain the corpse for a short time
at an equilibrium of temperature, against the losses of heat it suffers,
and sometimes even to raise the temperature a trifle. Compare on
23ost-mortem temperatures : Seume's ^ Leipzig Thesis, 1 856 ' (" de
Calore corporis humani in Morte observato "), Wunderlich (" Bemer-
DAILY FLUCTUATION OF TEMPERATURE IN DISEASE. 287
kungen bei eineiii Fall von spontanem Tetanus, i86i/Mn ' Arcliiv
der Heilkunde/ ii, 547)j Jiuppert ('Uiber die Ursaclie der post-
mortalen Temperatursteigerung, 1867/^ ibid, viii, 3^1 )j Thomas
("Klinische Bemerkungen zur Tliermometrologie, 1868/' ibid, ix,
17), Fich and Dyhkoicshj (* Centralbkatt/ 1868, i97)j Scldfer
('Eeichert's Archiv/ 1868, 442j, Ad. Valentin (1869, 'deutsches
Archiv/ vi, 200), which indicate that post-mortem production of
heat is a process common to all corpses, and when it is more con-
siderable than the simultaneous losses of heat it gives rise to the
i:>henomenou of post-mortem elevations of temperature.
[Drs. Taylor and Wilks collected observations on the cooling of
the dead body in 100 cases (' Guy^s Hospital Reports/ October,
1863, p. 184). The temperatures were taken in the dead-house, by
placing the bulb of a thermometer on tlie abdomen. The bodies had
probably been washed before removal from the wards. The fol-
lowing summary is taken from Dr. Taylor's ' Principles and Practice
of Medical Jurisprudence,^ p. 6 :
Number of ob
servations
Maximum tein
perature of
the body .
Minimum tem-
perature of
the body .
Average tempe
rature
First period, a — 3
hours after deatli.
76
F.
94°
60°
77^
C.
34-4"
Tfr°
^5 5
25-0°
Second period, 4—6
hours after death.
49
r.
86'
62°
74°
c.
30-0'
i6-6'
23"3°
Third period, 6—8
hours after death.
29
E.
C.
80°
266°
60'
i5'5
70°
21-1°
Fourth period, li
hours after deatli.
35
P.
79°
67°
C.
26-1°
19-4°
In cerebro-spinal meningitis, temperatures of 104° — 111° F. have
been observed just after death. Smon observed 104° — 113° after
death from variola. Assistant-Surgeon F. M. Mackenzie observed
io6'2° in rectum after death from cholera {' Lond. llosp. Reports,^
vol. iii, p. 454). — Trans,]
CHAPTER XII.
ON THE TEMPERATURE IN SPECIAL DISEASES.
§ 1. A complete insiglit into the course of tlie temperature ia
disease can only be obtained by comparison of the curves of many
thousand separate cases. It is only thus that the mind awakes to
the conviction of their harmony one with another, and gains the
faculty of finding itself at home in the manifold modifications and
deviations which occur in the temperature of the sick.
"When one studies the rules which may be deduced from the
comparison of separate cases, one never feels quite satisfied, although
they may be derived from one's own extended experience. These
rules, however cautiously they may be drawn from a great number
of separate observations, are never a complete, exhaustive or exact
expression of the facts. All the faults of empirical abstractions
are common to them : they fail to bear the stamp of inevitability, and
fresh experiences of another kind may probably modify, and possibly
overthrow them.
Tlie fact that abstractions are to be deduced from a material which
consists of definite quantitative values, is not in itself an advantage,
but raises a very peculiar difficulty. We might imagine that the
greatest exactness might be attained by calculating, in a statistical
manner, the arithmetic means of corresponding numbers of single cases
of the course of a given form of disease, and putting these forward
as the expression of the average course of the temperature in the
given form. Such a course, however, is quite inadmissible, and if
practised must lead to quite erroneous and delusive results. The
true characteristics are not to be sought in the absolute height of the
temperature on a given day, but in the orderly succession of the
temperatures in the whole course of the disease, or during a definite
portion of it, in the rise of the temperature to a certain height at a
casual moment, and in its fall to a certain depth at an equally occa-
ON THE TEMPERATURE IN SPECIAL DISEASES. 289
sioual or fortuitous time. A mere statistical estimation of the curves
in the gross mass must obhterate all the peculiarities of the course
followed by the temperature, and a mere numerical treatment of the
numbers of different cases can only afford trustworthy data for the
answer of certain definite questions.
In order to extract the general facts from separate observations,
we must look less to the numbers than to the form, that is, to the
varied outline of the wave-systems which each separate curve fur-
nishes us. Only in this way are we able to construct a sort of model
curve, which may approximatively express the peculiarities of single
cases. Yet even these, and the general rules of which they are the
image (so to speak), can never adequately express or attain to the
concrete actualities of the case. Whenever I strive to formulate
such rules, I am perfectly convinced of the deficiencies and short-
comings incident to them, and it is only the copious stores of material
at my command, and constantly repeated proofs of the correct-
ness of my principles which allow me to hope that they do not
caricature or contradict nature. Although I do not arrogate to
myself the right to declare them to be the laws of pathological
action, I still believe they may serve as a very useful clue to those
who interest themselves in the thermometry of disease.
In order to present the reader with a solid foundation for the
exercise of his own judgment, a number of different cases are figured
in the tables (see lithographs at end) ; and although these are nume-
rous, they are indeed only a very scanty selection from thousands of
observations, and can only furnish a partial view of the actual pro-
cesses of disease. The varieties met with in the thermometric
symptoms of disease are multipHed, like every other symptom, in
proportion as one follows them into detail. It cannot be doubted
that a critical {lit. epicritical) exploration of individual cases is of the
highest utility. But this is the province of clinical instruction.
Medical literature cannot concern itself with individual cases, when
these amount to many thousands, each of which has its own pecu-
liarities.
Tiie different types of disease, and their principal varieties, are the
only details which can be discussed in such a method of repre-
sentation. I do not ignore the dangers of such a mode of regarding
diseases, a danger which especially consists in the fact that the so-
called special forms of disease are for the most part merely ab-
stractions which find but slight justification in the actual facts, and
19
290 ON THE TKMl'ERATURE IN SPECIAL DISEASES.
too often comprchciul things which differ under the same name, and
doubtless rudely separate things which are really closely related to
one another. But these abstractions are useful enough as current
categories, which may be employed without anv great danger of
being misunderstood.
§ 2. Amongst the different forms of disease there are many in
which each scjjarate case of the same general form of disease exhibits
more or less correspondence with others of the same kind, in the
general course of the malady, in the parts of the body affected, in the
complications which occur, and in their symptomatic manifestations.
No unprejudiced person can deny this fact, and there is nothing
contrary to reason or illogical in designating such forms of disease
as ti/pical, although the reason of such correspondence and harmony
of symptoms may be quite inexplicable, and although the cor-
respondence may vary greatly in degree. These forms of disease
may be to a great extent units based on some special cause, i. e.,
depending upon some specific cause, which modifies and directs all
the vital processes, so as to bring them within the control of one
particular and definite force ; or at least we are justified in assuming
with considerable probability the presence of such primary causes and
conditions.
The course of the temperature in these forms of disease exhibits a
similar correspondence as regards the special cases, a harmony of
type which is sometimes more marked, and sometimes less so than is
the case with other symptoms. The notion of typical forms must
therefore be extended so as to embrace the course of the tempe-
rature. "We are quite ignorant of the real cause of this agreement
in the course and behaviour of the temperature ; we know neither
more nor less of it than we do of the reason w4iy the contagion of
smallpox generally produces pustules, why that of measles produces a
patchy eruption on the skin, or why in the latter case the respiratory
track, whilst in the contagion of scarlet fever the pharynx is mostly
attacked, or why idiopathic erysipelas generally fastens itself upon the
face ; or lastly, why the primary cause of abdominal typhus should
cause disease of the glands of the intestines.
The typical course of the temperature in many forms of disease
is no mere speculation, but an acknowledgment of undeniable facts.
It is only doubtful and, perhaps, optional, how many diseases may
be included in such a classification.
ON THE TEMPERATURE IN SPECIAL DISEASES. 291
When once we have admitted the fact of this typical behaviour of
the temperature, we are confronted with the idea that there are such
things as normal diseases (Krankeitsnormen) . Those, namely, which
most perfectly correspond to the abstract type of uncomphcated
cases of the given form of disease.^
As far as I know, the distinction between normal and abnormal
cases of typical form of disease was first introduced into modern
})atliology in the classical and incomparable treatise of liill'iet and
Barthez on the diseases of children, with a full consciousness of the
practical significance of this distinction.
These authors established it with great ingenuity in the varied
forms of disease, as far as the symptoms they could then recognise
allowed; and logically and correctly expounded the conception of
normal courses of disease, that is of such as represent the uncom-
plicated results of a specific primary cause, in a previously healthy
individual, and which appear as such to every reflecting mind ; and
Rilliet and Barthez rendered the practical value of this distinction
between normal and abnormal cases very evident.
Above all other phenomena, the course of the temperature is able
to distinguish what is normal and characteristic in the course of
diseases, and thus to establish, confirm, and extend the distinction
between normal and abnormal cases.
The fact that there are numerous cases which exhibit deviations
from the typical course, and cannot be brought into harmony with
it, and that even when one sharply defines the normal form of any
form of disease, the abnormal cases may exceed the normal in
number, will not appear to any reflecting mind as a valid objection
against the reception of a type, or against the conception of normal
diseases. It is so easy to weaken such objections by analogies derived
from any other province of science not founded upon mathematics,
that no space can be spared for its discussion.
But it is necessary to remember that in different forms of disease,
the limits of the normal are sometimes boldly defined, sometimes
faintly, and sometimes merge obscurely into others, and that, whilst
fully recognising the principle, one cannot force all forms of the
disease to conform to any given type.
1 The reader who is familiar with the origiual will see that iu this chapter, as
elsewhere, I have occasionally altered the form, and sometimes the order of the
author's language, with a view of conveying to the English reader what I believe
to be the real meaning. — [Trans.]
X'92 ON TlIK Tl'.MPERATUllK IN SPECIAL DISEASES.
I. Abdominal Typhus.
{Tiiphohl or enteric fever, Dothinenler'il'is)
§ I , Abdominal typhus fever pursues its course witli unmistakcable
regularity. It is almost impossible to resist this conclusion when
we compare a number of charts or curves of temjierature of this
form of disease, and next to relapsing fever and interinittents this
disease affords the best proofs and the best justification of the theory
of types.
In spite of this recognition of the typical character of abdominal
typhus, it must be conceded that the course of particular cases may
be very dissimilar, and yet, in spite of their differences, it is possible
to recognise amidst them all the marvellous and noteworthy order
and regularity of its course.
I will go further and say that in this pre-eminently typical disease
not a single rule can be laid down which is not subject to exceptions,
although these may, as regards some rules, be extremely' rare. It
must, however, be remarked that when a case proves to be an
exception to some well-founded rule in some single point, it shows
an agreement in all others, or at least in a great many others. The
type is there, although it must clearly be understood that it is not
to be considered as a model to be slavishly copied in all cases and at
all times. On the contrary, deviations may occur in any segment,
but they are neither so numerous nor so out of proportion in any
given case as to prevent the typical peculiarities from being re-
flected in the greater portion of its progress, provided the observations
are made with sufficient accuracy, and extend over a considerable
period of the actual course of the disease.
But even where very painstaking observations are made, cases of
abdominal typhus do occur, in which, so to speak, the disease remains
latent, and where the nature of the fatal illness is first recognised in
the dead body. Such cases are generally those in which the com-
mencement of the disease is uncertain, generally secondary cases,
and moreover irregular, or with severe complications.
There are also cases in which, although there is a suspicion of
abdominal typhus being present, the diagnosis remains doubtful and
cannot be decided until recovery, or even up to the time of death,
especially cases of acute tuberculosis, many cases of basilar menin-
THE TEMPERATURE IN ABDOMINAL TYPHUS. 293
gitisj and epidemic cerebro-spinal meningitis, of true petechial typhus,
sometimes cases of pygemia, whether puerperal or otherwise, cases
of protracted catarrhal pneumonia, and severe influenza, trichinosis,
and also cases of very decidedly localised disease, which have
not declared themselves in life, and whose presence is not in-
dicated by the sum total of the symptoms (for example, cases of
myocarditis, endocarditis with ulceration of the valves, abscesses
of the liver, acute affections of the kidney, &c.), all of which
closely simulate abdominal typhus, as regards their course, especially
resembling the more or less irregular forms, often so closely that the
diagnosis is often impossible. Still more difficult is it to be sure
whether abdominal typhus has supervened upon some other special
severe form of disease. Even thermometry cannot resolve our doubts
in some of these cases, but it can settle many a doubtful diagnosis
which could not otherwise be decided. It can raise questions which,
apart from thermometry, would scarce have been entertained. It
may often confirm and certify our suspicion that the suspected ab-
dominal typhus may be another form of disease, or that abdominal
typhus is complicating another severe disease ; and it especially
determines our power of replying to questions as to the diseases, and
furnishes us with a standard for judging of the apparent propriety
of the answers.
§ 2. In order to gain the full, practical value of thermometry in
abdominal typhus, attention must be paid to the following points :
A single thermometric observation is never sufficient, ^;^r se, for
the diagnosis of abdominal typhus.
A single observation, made at certain times, may, however, con-
travene the presence of this disease, or at least make it very impro-
bable. We may with great probability assume.
That abdominal typhus is not present, when even on the first day,
or on the second morning of the disease, the temperature rises to
40° C. (104° F.);
We may exclude abdominal typhus, when between the fourth and
sixth day, the evening temperature in a child, or adult under middle
age, never reaches 39.5° C. (103.1° ¥.), and indeed if it has failed
to do so two or three times ;
Abdominal typhus may be excluded when as early as the second
half of the first week considerable or progressive diminutions of the
evening temperature are met with.
201 THE TEMrERATURE IN ABDOMINAL TYPHUS.
Very often the tlicrmometric observations alone raise the suspicion,
or help to justify it, that abdominal typlius is latent :
As in cases of slight subjective severity ;
In cases where an unaccustomed localisation of the disease directs
all our attention to the part affected, but the course of the tempera-
ture is able to show that the fever is not dependent upon the given
local manifestation ;
In the first week, or three or four days at least of the course of
abdominal typhus ;
In cases where this disease attacks one who was previously ill
from some other cause, or who was just convalescent.
Only morning and evening temperatures, taken for several days,
can decide the presence of abdominal typhus — in the beginning of
the fever about three days', but in the fastigium from four to six
days' observations, and in convalescence about the same time is
required.
The temperature indicates the severity of the disease in most cases
about the second week, generally at its middle, and only rarely as
early as the first week. A single observation of temperature affords
no certain sign as to the severity of the disease, but a whole day's,
still more two or three days' temperatures often give very valuable
indications.
Irregularities in the course of the disease are best and earliest
known by thermometry.
The thermometer indicates complications at a period of the disease
when they are recognisable by no other means of observation.
It is the first means of recognising a relapse after the patieiit has
begun to recover ;
The thermometer warns us of the tendency to death.
Thermometry is able to regulate the potency of therapeutic
operations.
Thermometry shows the transition to convalescence with very
great definiteness.
Thermometry points out complications during convalescence, and
affords the only sure sign, by which we can certify ourselves of tlie
patient's convalescence.
The disorders of the convalescing period, relapses, and new diseases
are recognised earliest and most certainly by the thermometer.
We must not overlook the very important fact, that a large
tliermometric experience in abdominal typhus first gave us a
THE TEMPERATURE IN ABDOMINAL TYPHUS. 295
full insight into the course of this disease, and rendered possible a
certainty of diagnosis and prognosis in such cases (even sometimes
without using the thermometer at all), which without thermometry
would have been quite unattainable by any previous means of
observation.
§ 3. Ahdommal typhus is c/iaracferised hy a fever wTiicli lasts for at
least three weeks, unless we include very exceptional cases, and even
those which rapidly terminate fatally, seldom do so in less than a
week. The maximum temperature, with rare exceptions, is not less
than 39"6°C. (io3'28° F.), and is more commonly between 40° and
41° C. (104°, and 105-8° F.), although it may rise to hyper-pyretic
degrees, but not easily above 43*5° C. (iio"3° F,), and except
in fatal cases it is rare to meet with temperatures above 41*5° C.
(To6-7°)._
The daily course of the disease varies very much according to its
intensity and the period of the disease. It is either
Continuous, but with highly febrile daily elevations of temperature
when the disease is at its height, in severe cases ; or
Sub-continuous, or continuous without any considerable inter-
current elevations of temperature at the height of the disease, or at
any part of its height in severe cases ;
In all cases it is fairly remittent in type at the beginning of the
illness, and in moderately severe and in slight cases it is so even at
the height of the disease; sometimes it may almost be considered
remittent even when severe cases are at their height; and lastly, it is
so in all cases where they begin to convalesce ;
The type of the disease is decidedly remittent (with sharp curves)
during the period of recovery, in the most severe as in the milder
cases ;
The course sometimes repeats itself irregularly in many of the
severe cases, both at critical periods and after the occurrence of ])arti-
cular events, or the operation of special influences.
Accordingly the daily average, on which the daily fluctuations are
based, varies a good deal : in the continued form with exacerbations
it is 40'5°C. (104*9° F.) or more; in the sub-continuous, and con-
tinued forms, about 40° C. (104° F,), or a few tenths more or less ; in
the milder remittent form seldom above 39*5° C. (i03'i° F.), in slight
cases even as low as 39*2° C. (io2"56°F.) at the commencement,
and in convalescence still lower ; in the former with sharp curves
between 38° C. (100-4° F.) and 38-5° C. (101-3^).
29Ci THE TKMPERATnn: IX MiDOMINAT. TYPHUS.
When the llnotuations are irregular, the daily average is uncertain,
and alTords no indications. In the great majority of cases the dail^
maxima occur between noon and 1 1 p.m., most commonly between 4
and 7 p.m., or at least between 2 and 9 p.m.
The extent of the exacerbations is very considerable in severe
cases and at the height of the disease, and the rise begins as early in
the morning as between seven and nine. At the height of the disease,
the exacerbation is generally a single-peaked curve, with a broad
summit, yet it may sometimes be two, three, or four-peaked. From
tlie third week on, the form with two or more peaks prevails, and the
single peaks again in the period of advanced convalescence, and the
peaks are more pointed, and thus the extent of the exacerbations is
very considerably diminished.
In the form with curves of multiple peaks, the first peak or rise
is between 9 a.m. and 4 p.m. ; the second between 2 and 8 p.m.,
most commonly about 6 p.m., the rise at night is between i and 5
a.m. Sometimes the rise at night is doubled, one occurring about
1 1 p.m., the second between i and 5 a.m. In double-peaked exacer-
bations, we sometimes find the first the higher one, but sometimes
vice versa (in tlje period of increase the second is generally the higher
one) ; wlien the exacerbation has more than a double summit, the
first and third peaks are generally the highest. [These descriptions
of the curves will easily be understood by a reference to the lithographs
at the end.] The lowest point of the remission occurs between
midnight and 10 a.m., most often between 6 and 8 a.m., and not
seldom between 6 and 8 or 9 a.m. It is not very low, and assumes
an acute curve (lasting only a few minutes) in severe cases as well as
in recent ones, but increases in breadth with the progress of con-
valescence.
The rise of temperature is sometimes gradual, sometimes sudden,
and sometimes one segment of it is tardy, the other rapid. The daily
descent is slow, as a rule, and takes the form of an easel (Staffel-
formig), and is only rapid when the curves are sharp, or when there
are irregularities. On the subject of the daily curves in abdominal
typhus the following authors may be consulted :
Thomas (Mrchiv der Heilkunde, v, 456, and viii, 49), Jurgensen
(1866, 'Klinische Stiidien," p. 56), Zianssen and Immermann
(1870, 'Kaltwasser behandlung des Typhus abdominalis,' p. 33),
Immermann {' Zur Theorie : Deutsches Archiv fiir klin. Med.,' vi,
561). [Bdumler ('Deutsches Archiv fiir klin. Med./ iii, Bd.
THE TEMPERATURE IN ABDOMINAL TYPHUS. 297
xxvii, p. 527, &c.) For references to English authors see ' Supple-
mentary Bibliography/]
§ 4. Abdominal typhus has two principal types, which agree with
each other at their beginning, and again at their end, but differ from
each other by the fact that one type has a brief and steady course,
generally terminating at the end of three weeks ; whilst the other, on
the contrary, has a longer period of intense fever and fluctuations
interposed between its commencement and its decline, by which its
course is extended to four or four weeks and a half, and very com-
monly to five or six, or sometimes even to eight or ten weeks. These
two principal distinctions correspond sufficiently closely to the
anatomical changes met with, since the former, which lasts but a
short time, occurs in those cases where only slight infiltrations of the
plexus of glands in the intestines are met with [plaques molles),
whilst, on the contrary, the longer fever corresponds with those cases
ill which copious and extensive deposits are developed in the bowel,
and in which indeed there are often successive deposits. In the one
the restorative process is simple, and occurs easily by restorative
retrograde metamorphosis ; in the others, on the contrary, there is
need of complicated processes of elimination, in order to dislodge the
deposits ; ulcers follow this dislodgment, and their healing may be
more or less protracted. As the period of febrile development is from
its very nature most intense in these cases, so the process of restora-
tion affords numerous opportunities for renewed extensions and
intercurrent febrile attacks, for unfavorable events, for complications
and dangers.
In characteristic cases, these two types exhibit a very pregnant
difference (see Table II) ; but there are many cases which occupy a
middle ground between these two forms, and sometimes resemble
one, sometimes the other form most closely ; and the anatomical
changes may exhibit very different characters in different parts of the
intestine, sometimes healing with facility, whilst in other spots, on
the contrary, they take such a development that they can only
undergo tedious and extensive processes of reparation. An interme-
diate type of fever may also be shown in the course of cases when
there are successive deposits in the bowel.
Sometimes there is a difference between the two forms even at the
very commencement of the fever, but they are generally seen in the
period when its development has reached its height, and in the stages
298 TllK TEMPERATURE JN ABDOMINAL TYPHUS.
of repair and restoration of the afTectccl portions of the intestine.
Whilst the hitter process can be finished in a week in tlie mihl and
brief form, in tlie longer and severer form it may be very protracted,
and many unfavorable and dangerous events may occur, so that at
this period the life of the patient is indeed threatened on almost every
side. The duration {lit. rapidity) of these two forms may vary in
diflerent places, and certainly varies at different times in the same
place. The mortality [of an epidemic] depends chiefly upon the
jireponderance in numbers, of one or the other type, and all con-
clusions as to the results of therapeutic measures require to be modi-
fied in accordance with this rule.
§ 5. Besides these two principal distinctions, complications, and
the circumstances of individual cases may cause many hTegulaniie^
and deviations from the normal course of the fever. These, how-
ever, are less frequent, and of far less significance in the rapid form
of abdominal typhus than in the protracted type.
It is noteworthy, that the most perfect typical course of the rapid
form of abdominal typhus occurs in those who are again attacked at
the close of a typhous fever after convalescence has commenced, or
seemed about to do so. The relapse of abdominal typhus when its
commencement dates from the period when the fever of the first
attack has just left the patient, is marked by all the characteristic
features of a normal attack of abdominal typhus.
A regular course of the fever is generally met with in persons
whose previous health has been good, and whose age is from eighteen
to twenty-eight, provided other circumstances are normal, and the
fever is not of great severity, and provided also that they are not
subject to other injurious influences.
Ou the other hand, in children (and the younger they are the
more so), in people of more advanced age, whom the fever attacks
first in their thirty-fift,h or fortieth year, in those sick of some other
disease (especially sufferers from phthisis and hysteria), in puerperal
and scarlatinal cases, and those simultaneously suffering from any
pronounced local disorder of any kind (especially endo- and peri-
carditis, pleurisy, and parenchymatous nephritis), the typical cha-
racter of the course of the fever of abdominal typhus becomes
more or less obliterated.
In particular epidemics, and at certain times, it is more common
to meet with irregularities in the fever course than at other times,
THE TEMPERATURE IN ABDOMINAL TYPHUS. 299
as has been remarked also of the remaining symptoms of abdo-
minal typhus.
Extremely slight cases, as well as those of great severity, and
cases which run a very rapid course, are for the most part irregular.
The character of the fever-course may also be more or less altered
and affected by injurious influences, to which the patient may have
been exposed cither before or at the beginning of the attack ; by
defects in nursing ; through gross mistakes, and continued muscular
exertions ; and by special events of great influence (very severe
hsemorrhages, perforation of the bowels, and by complications of
overwhelming severity) .
Some therapeutic measures have also the power of modifying the
type ; and that in a way which is beneficial to the patients.
With the approach of death, the peculiarities of the course are
often lost.
These deviations and irregularities are, however, not extravagant
and unbounded ; indeed, some indications of the reign of law may
be recognised even here, and, above all, we can usually (unless a
fatal termination be imminent), recognise a tendency to resume the
normal course, or to run a course with certain modifications of
the type agreeing "with the definite circumstances of the case.
§ 6. Both in regular and in irregular cases, but most constantly in
the former, we observe the course of the disease to be divided into
more or less clearly defined periods or stages. Two well-marked
periods may be distinguished as clearly separated from each other,
and capable of being recognised by the thermometer with great
certainty, in the course of typhoid fever ; the first corresponds to
tlie deposition of the exudation and infiltration (in the intestinal
glands), whilst the second corresponds to its elimination, and the
restoration and repair of the diseased parts.
But both of the principal periods or stages are marked by points
at which an alteration of the general fever course occurs, althougli
no corresponding change in the anatomical characters can be recog-
nised. These points can also be more clearly recognised hy the
the thermometer than by any other means of diagnosis.
It is, however, noteworthy, that in a very large number of cases,
especially such as run a perfectly regular course, the duration of
the separate periods or stages of the course pretty accurately corre-
sponds in time with the division into weeks and half weeks, and that
alterations in the complexion of the course, and transitions from
300 Tin: TEMPKHATfRK IN ABDOMINAL TYPHUS.
one stage into another, generally occur at the beginning or end of a
week of the disease, or else in the very middle. This hebdomadal
type is most decidedly shown in the brief and mild form of tyi)hus
(abdominalis) ; in the severer and longer form it is less clearly
marked, or is preserved only in the third and fourth weeks. Com-
plications also, and other irregularities may completely obliterate
this weekly type, or, at least, disturb it for a time.
§ 7. The period which appears to be the initial stage of abdo-
minal typhus, does not always perfectly represent the first commence-
ment of morbid symptoms. In not a few cases it is preceded for a
longer or shorter time (corresponding, doubtless, to the period of
incubation, according to the original causes in operation), by slight
and generally interrupted phenomena, which display themselves in
disorders of the bowels or of the head, or of the respiratory mucous
tract, or of the whole system, and even slight febrile movements, and
occasionally rigors may occur off and on as a kind of prologue to
the proper course of the disease. But all these symptoms are too
slight and too transitory to afford opportunity for careful medical
observation, and we have, therefore, to begin at a point from which
an unbroken series of pathological phenomena take their origin.
This initial stage of abdominal typhus, although for the reasons just
mentioned not always properly called so, runs its course with great
regularity.
Its course is always identical, whatever complexion the case may
afterwards assume.
The temperature always takes an ascending course, in a zig-zag
fashion, in such a way that during the three or four days occupied
by this stage it always rises about 1° — 1|° C. (i"8° — 27° F.) from
every morning till evening, and falls again, from every evening till
the next morning, about \° — f° C. (-9° — 1-3° F.) till, on the third
or fourth evening, a temperature of 40° C. (104° F.) is reached, or
a little exceeded.
The formula for this ascent is nearly as follows :
First day, morning, ^f C. (98-6° F.) ; evening, 38-5' C. (101-3'' F.).
Second day, „ 37-9" C. (100-22' F.) ; „ 39-2' C. (io2'56° F.).
Third day, „ 387' C. (ioi-66"^ F.) ; „ 39-8' C. (103-64° F.).
Fourth dav, „ 39-2° C. (102-56' F.) ; „ 40-3' C. (104-54° F.).
It is very seldom indeed that an attack of abdominal typhus,
THE TEMPERATURE IN ABDOMINAL TYPHUS. 301
occurring in a healthy man, or even one free from fever, does not
closely approximate to this type in its initial stage.
It is still more rare for any other form of disease except abdo-
minal typhus to show a similar pyrogenetic stage. This course in
the first half of the first week is thus in itself alone tolerably deci-
sive for diagnostic purposes. In other words :
If the temperature in the evening hours of the second, third, or
fourth day is only approximatively normal, we may exclude abdo-
minal typhus ;
If the temperature on the first three evenings, or only on two of
them, is the same height, the disease is not abdominal typhus;
If the temperature on two of the first three mornings is alike, it
is almost certain not to be abdominal typhus :
If the temperature on the first two days rises to 40° (104° F.) or
more, abdominal typhus may be excluded with great probability ;
If the temperature displays a retrograde course only once on any
successive mornings of the first half week, or on any successive
evenings, we must exclude abdominal typhus.
The positive diagnosis is so much more certain in proportion as
the course of the temperature in the first four days follows the
formula given above.
Meanwhile we must not overlook the fact that here and there
exceptions to this type of the initial period are met with.
The rise of temperature may very occasionally be completed by
the end of two days, or, on the contrary, may take five days for its
completion ; in both events a severe course must be expected, and
in the latter a favorable turn (crisis or lysis) must not be looked for
before the middle of the third week. The temperature may some-
times return to the normal on the second morning, which is suc-
ceeded by a still greater rise on the second evening, than that of the
first.
The rise of temperature on the first and second day is sometimes
less, and then it is so much more on the third and fourth.
The height reached by the temperature on the third or fourth
day is not always 40° C. {= 104° F.), but may be a few tenths less ;
more often, however, it is a few tenths higher, and, indeed, may be
a whole degree more (=41° C. or 105-8° F.).
When typhoid fever is a secondary disease attacking those already
ill, and already suffering more or less from fever, the initial stage is
very often obscure and unrecognisable.
302 THE TEMl'ERATURK IN ABDOMINAL TYPHUS.
The initial period decides nothing as to the mihhiess or severity
of the subsequent course of the disease, for it is the same in mild
cases as in severe. In the majority of cases, however, this stage
does not come under medical observation ; the disease has generally
lasted some days before medical advice is sought for. Eut if the
initial stage does not come under our notice, our diagnosis is de-
prived of a very powerful proof, and a longer period of the disease
must be watched in order to make a positive diagnosis of abdomi-
nal typhus by means of the thermometer, with anything like the
same accuracy.
However, we must remember also to guard ourselves against
deception in respect to the day on which the illness began, since
defects of memory often lead the patient into error as to the begin-
ning of the disorder.
§ 8. Id the second half of the first tveek, and in the first half of
the second tveeJc, the course of the temperature, in the majority of
cases, is pretty tolerably uniform ; but it must be specially remarked
that nothing decisive can be predicted from the course of the tem-
perature, or the height to which it rises, as regards the intensity of
its further course.
At this time, and, indeed, very often in the second half of the
first week, the cases reach the maximal height of their temperature,
which happens most commonly on the fourth or fifth, more rarely,
in cases left to themselves, on the sixth, still more rarely on the
seventh or eighth day, and generally amounts to between 40° and
4i*5° C. (104° and 1067° P.); most often between 40'a° C.
(104-36° r.) and 40"8° C. (105*44° Y.). This maximum is gene-
rally reached on one day only (usually between noon and evening),
but sometimes on two days, rarely on three ; in the latter case the
third maximum is commonly reached on the seventh or some later
day. During all the second half of the first week the maxima of
the daily exacerbations remain in the neighbourhood of the general
maximum temperature. All this time the morning temperatures, as
a rule, are from ^° — 1^° Centigrade (= "9° — 27° F.) lower than
the evening ones, seldom less than this; greater differences may
occur sometimes, but not often, except that sometimes, on a par-
ticular day, a transient deeper remission may show itself.
The first half of the second week, although agreeing in main with
the course of the preceding half w^eek, is very often marked, at least
THE TEMPERATURE IN ABDOMINAL TYPHUS. 303
in cases which show a favorable course^ by its exacerbations being a
trifle less severe than those of the preceding period ; the remissions
also show a teiidejicy to become somewhat more marked (deeper), so
that in such cases the fastigium divides itself into two segments — the
first distinguished by more severity in the exacerbations and less
considerable averages in its remissions, and the second by more
moderate exacerbations and somewhat more considerable remissions.
The end of the first half stage of the fastigium most commonly
falls on the seventh or eighth day, more rarely on (he sixth, or
perhaps not before the ninth or tenth day.
During this course of the fastigium temporary diminutions of tem-
perature often occur, generally on a single morning, once and again
in an evening.
Sometimes they are met with as early as the first w^eek, most
generally not before the tenth day ; are most common when the
course is mild, but by no means ensure such a course. Especially
must it be remarked that this period oflPers nothing decisive as to
the further progress of the disease, for from the middle of the first
week to the middle of the second week the course may be severe,
and yet be followed by speedy convalescence ; or be mild, and yet
lead to a severe and protracted course at a later date. Yet some-
times cases occur which vary from this type ; sometimes the form
of the disease is mild, sometimes more severe ; and then the further
development of the case may no doubt be predicated with tolerable
probability.
§ 9. Sometimes, indeed, cases occur ivith an unusuallij mild course
between the fourth and eleventh days.
The evening temperatures generally remain comparatively low
(39-6° — 39'8° C. = 103*28° to io3'64° F.), or considerable inter-
current moderations of temperature may occur on particular
evenings.
Or the morning remissions maybe more considerable (i^° to 2° C.
= 27° to 3-6° r.).
Or the course appears to be cut short, and a retrocedent type
finds a very early expression, which may lead to complete defer-
vescence even in the beginning of the second w^eek.
In not a few cases it happens, after therapeutic measures at
the beginning of the disease, that this takes the desired turn very
early, even after a laxative. If the disease were previously well
30i TllK TKMl'EllATUlll': IN ABDOMINAL TYPHUS.
pronounccil, tliis termination is no reason fur altering,' the dia-
gnosis. But such early convalescences and mild forms of the
disease may occur spontaneously, although much more rarely.
Sometimes, in such mild cascs^ we notice a moderation of all the
symptoms, whilst the course of the disease maintains the minimum
duration of normal cases (three weeks), or only a little less.
In other cases a prejudicial increase of the fever again occurs,
and we may then conclude that tlie typhous changes happened suc-
cessively, on account of the tirst dej)osits (in tlie glands) being slight,
and the later ones more intense. If, on the other hand, recovery
takes place unusually early, the question may remain doubtful
whether abdominal typhus has been present or not, Posl-morlem
confirmation cannot be obtained, and the remaining symptoms are
not suflBciently decisive, and in such mild cases many of them are
often absent.
In such circumstances ought we to pronounce the case one of
abortive or exceptionally mild abdominal typhus, or should we
admit some other disorder, such as febrile intestinal catarrh, and such
like? This question is not only a difficult one in concrete cases^
but is difficult to decide even in the abstract.
No one is quite certain that the course of abdominal typhus must
have a fixed duration, or that it cannot occur without a certain
number of the symptoms usually reckoned as pathognomonic. We
can only say that in our times and our country it is, comparatively,
very rare for a well-characterised case of abdominal typhus to
exhibit any shortening of the febrile course to less than two and
a half weeks, unless in consequence of powerful therapeutic measures ;
and still more, in the vast majority of cases, even a mild course of
the disease does not terminate in decided defervescence before the
twenty-first day.
Meanwhile it is quite possible that two essentially different dis-
eases, very similar in many of their symptoms and in their
anatomical relations, may be included under the common designa-
tion of abdominal typhus ; the one may be a general disease,
produced by infection, although localising itself in the glandular
apparatus of the bowels; the other may be a local enteritis in
which only for individual reasons the follicular apparatus of the
bowels is attacked in a similar manner as in abdominal typhus,
and thus a series of symptoms like those of the first form are
evolved. "What happens in scarlatina supports this, for not only
THE TE.MPERATUEE IN ABDOMINAL TYPHUS. 305
do alterations in the follicles of the bowels occur in that disease
similar to those of abdominal typhus, but during the period of con-
valescence a variety of symptoms and the course of the temperature
closely resemble the latter disease, whilst without doubt no abdo-
minal typhus is present. Analogy with many other diseases leads
to the same conclusion, for example, with cholera, in which the
epidemic disease induced by contagion may be perfectly simulated by
forms of disease arising from purely local conditions. Now it is very
conceivable that in the second forms, the further typhous development
of tlie anatomical changes and of the general course may halt and
stop at any given point, and that thus we may get affections begin-
ning like typhoid fever, but ending much earlier. Such cases must
include merely intestinal catarrh, without any very precise limita-
tions.
But even in the disease which originates in infection, we have
no reason to deny that, provided the original causes were not
very potent, or when the deposit is slight, rudimentary forms of the
disease may be developed, as may be often observed in the case of
other infectious diseases. All this, however, only complicates the
question for diagnosis ; thermometry alone cannot settle it, yet it
may give us considerable aid in the solution. The Betiology, the
circumstances of the special case, the remaining symptoms, must be
taken into consideration. Thermometry itself may afford the follow-
ing aids to diagnosis in unusually mild cases ;
If the temperatures, without any other particular reason, several
times reach the evening ranges of abdominal typhus, this, especially
if it occur with good nursing, is an argument for abdominal
typhus.
Even if the temperatures are somewhat below the characteristic
ranges, but still approximate to them very closely, and the general
course resembles that of abdominal typhus, this is also an argument
in its favour, and so much more so if the patient is more than thirty
years old, or a child, or suffering from anaemia. If such a type of
disease lasts for a whole week, without special and satisfactory rea-
sons, this is a powerful argument for the presence of abdominal
typhus.
§ lo. However characteristic the fastigium stage maybe, errors of
diagnosis may occur very easily when the initial period has not been
20
30() TIIK I'KMl'KKATUKK IN AllPOMINAL TVl'llUS.
under observation, and still more easily wlien no information as to
the commencement of the attack can be obtained, and we arc thus
h'ft in ignorance as to the time the disease has already lasted.
These errors are likely to be most numerous when our observa-
tions are made on only a brief period of the fastigium. At this
l)eriod it is common enough to confound abdominal typhus with the
following diseases :
(a) With pneumonia, especially in cases where hepatization
takes place slowly, and for two or three days at least it is impossible
to difTerentiate such cases from abdominal typhus simply by the
temjicrature. Even in cases of pneumonia, where the physical ex-
ammation of the chest has determined the presence of changes in
the lungs, it may still remain doubtful whether abdominal typhus
may not co-exist with pneumonia. In such cases it is not possible
to form a correct diagnosis, except by several days^ observations.
{b) With acute exanthems, in which, liow"ever, it is very rare for
a high fever temperature to persist longer than the fifth day, without
either the exanthem or some local manifestation declaring itself.
{c) With exanihemat'ic iijphus, which sometimes is indistinguish-
able from abdominal typhus, as far as the temperature goes, during
the fastigium; in general, however, the elevation of temperature is
greater in true typh?^s than in typho/V/ fever, and the morning remis-
sions especially are less considerable in the former.
{(l) With cerebrospinal meningitis, in which the observations of
a few days only afford little aid to diagnosis.
{e) With acute osteomyelitis, which may run a very similar course
to abdominal typhus, but differs from it by intense local phenomena
developing themselves in the joints.
(/") With acute tuberculosis, which may sometimes exhibit a
similar course to that of typhoid fever for several days together.
{g) With tricJiinosis, which, like the preceding, may exhibit a
similar course of temperature.
{h) With abscess of the liver and pymnia, which for some little
time cannot be diagnosed from the fastigium of abdominal typhus.
(i) "\^ ith intestinal catarrh ; with moderately good nursing, how-
ever, this shortly exhibits a lower range of temperature than abdo-
minal typhus.
{j) With influenza; like the preceding, however, with good
nursing, it does not long maintain the high temperatures of typhoid
fever, unless associated with catarrhal pneumonia.
THE TEJLPERATURE IN ABDOMINAL TYPHUS. 307
Although thermometry does not always succeed in mastering the
difficulties of diagnosis iu these cases at this stage^ yet it often
enough does so, and by itself is able to procure us a means of decision,
and to exclude ■ abdominal typhus — (i) in young adults, when
during the fastigium (especially if the other symptoms are severe)
the evening temperature keeps under 39'6° C. (103*28° F.) ; (2) iu
all cases in which, during the severity of the symptoms, the tem-
perature sinks to normal at any time of day (unless from powerful
causes, suchi as copious hsemorrhages, perforations, &c.), which
certainly happens in severe, or pernicious intermittent fever resem-
bling abdominal typhus, does often at least happen in pysemia, and
sometimes occurs in pneumonia and acute tuberculosis.
Most certainl// one is jusUfied in pos'it'ively diagnosing abdominal
tT/phns in illnesses of moderate severity during the fastigium, when
previously/ healthy persons of youthful or middle age, after being
ill about five days or perhaps a week, exhibit evening tempera-
tures of y)"]° — 40*5° C. (to3*46° — 104"9° '^•)' ^^' ^ Utile higher,
alternating toith morning temi^eratures, which are f° — 1^° C. (i"35°
— 2*7° F.) lotoer ; unless some other disorder of any sort can be dis-
covered to explain the height of the fever, or unless they have been
the subjects of gross neglect immediately before coming under observa-
tion.
In children, or persons who have been much neglected, and very
old people, and where considerable local disorders are recognisable,
even where the course of the temperature is conformable, the curves
of the second week must be waited for, if the diagnosis cannot be
established by other means than the thermometer.
§ II. If the period of fastigium is marked by very extravagant
temperatures, or, indeed, either by specially high temperatures (41°
C. (= io5"8° E.) or more), or the morning remissions are wanting,
this may depend, in the first place, upon the severity of the case, or
on the want of proper care in nursing, or on manifold mistakes of
various kinds, but less often at this period on the occurrence of com-
plications.
In such cases, the same doubts and errors of diagnosis are pos-
sible as in cases of moderate severity, but the diagnosis is certainly
more difficult in those extremely severe cases. But very extrava-
gant temperatures are rather against than in favour of abdominal
typhus. A positive diagnosis of abdominal typhus on the basis of
308 Tin; TK.MPERATLKH IN ABDOMINAL TYl'IIUS.
tliermoinetric observation can sometimes, under such circumstances, |
be obtained only by watching the case for a longer period.
§ 12. In the m'ldiUe of the second wed-, between the ninth and
twelfth da\s, slight and severe cases show a well defined difference.
In sligltl cases of abdominal typhus the fastigium then shows a
tendency to terminate. Sometimes a brief perturbation, an unusually
liigh evening tem])erature, or an absence of the morning remission,
immediately precedes the crisis; more commonly, however, the
decrease of fever immediately follows the fastigium. The favorable
crisis (Wendung) generally happens from the tenth to the twelfth
day of the disease, or even earlier now and again, especially after
remedial measures have proved successful. On tlie tenth day, or
most commonly on the twelfth, in favorable cases, the first consider-
able morning remission is wont to occur, and contrasts most satis-
factorily with those which have preceded it. On the following day
the remission may indeed again appear less considerable, but soon
the remissions steadily increase in amount, whilst the exacerbations
at the same time decrease in severity ; the daily ascent begins later,
and the corresponding fall begins earlier ; the height of the exacer-
bations generally diminishes a little, a decidedly descending direction
is taken by the temperature, and already at the end of the second
week, or at the beginning of the third, the decrease of the evening
exacerbations shows that convalescence is fairly establislied.^
The conversion of the short daily curves of the fastigium into the
steep daily curves of the period of convalescence, when it occurs in
the second week, may be regarded as a sign (which seldom deceives
us) that the case will be a mild one. It is true it gives no absolute
pledge as to the termination; for dangers threaten even in the
mildest course of this disease, dangers which cannot be foreseen :
perforations, haemorrhages, cerebral irritations dependent on indi-
vidual peculiarities, complications from the organs of respiration,
^ It is iuteresting to notice Low the thermometric results obiained by tlie
aullior in many liundred cases of abdominal typhus and other fevers, confirm
the observations of Hippocrates on critical days. The Father of Medicine con-
sidered the 3rd, 5th, 7th, ptb, iitb, 14th, 17th, and 2oih as the critical days in
fevers, and if allowance be made for the diiFereuce iu the Oriental and modern
methods of reckoning (by including both the dayy/w« which we date, and the
day on which the change happens) we shall find his observation fully confirmed
by our author's. — [Traxs.I
THE TEMPERATURE IN ABDOMINAL TYPHUS. 309
and so forth. But if the essential process assumes a favorable
shape — and thermometry only guarantees this — the probability of
such degenerations and accessory disorders becomes incomparably
lessened, and to a great extent the patient may be guarded from
such dangers by a careful vigilance.
Less favorable and less trustworthy than this transition of the
temperature into steep curves, is a temporary considerable sinking of
temperature, a considerable decrease of the evening exacerbations
occurring unusually early, so that they approximate to the unaltered
morning temperatures, or an apparently rapid transition into defer-
vescence ; in all these cases the course is usually irregular, and fresh
elevations of temperature may be expected.
The commonest course taken by the temperature during improve-
ment and convalescence, is that of increasing remissions in the
morning hours, which are succeeded by exacerbations of less severity,
so that in the course of from six to ten days the temperature ap-
proaches to normal in a sort of zigzag fashion. The difference
between the morning and evening temperatures may thus remain
the same for several days, or even a Aveek, or it may become increased,
through the morning remissions rapidly becoming greater. Then the
daily differences become less, through the continuous diminution of
the evening exacerbations, and at the end of the third week we
generally find both the normal temperature and convalescence at-
tained together.
If the course described above be taken, there can be hardly any
doubt as to the diagnosis. Catarrhal pneumonia and very severe
influenza may indeed recover in similar fashion, but they do so
much more quickly, and the fever does not last to the end of the
third week. On the other hand, when high temperatures are met
with in recovering cerebro- spinal meningitis and trichinosis, con-
valescence indeed occurs in a remitting fashion, but it is more
protracted, and is more commonly interrupted. Otlier affections
which recover in this remitting type are distinguished by not reach-
ing the same heights of temperature during the fastigium as abdominal
typhus does. Deviations from the prescribed form of defervescence
do indeed occasionally occur, and may make the diagnosis doubtful.
"With these we must reckon the accelerated return to freedom from
fever, which happens once now and then in such a way that in the
middle, or even in the beginning of the third week, normal tem-
peratures are met with in the evening. This generally occurs after
310 THE TKMPKRATURE FN AnnOMINAL TVPIIUR.
judicious therapeutic measures, atul seldom, if ever, without them.
In such cases, the diagnosis of the disease must not have been made
from the general symi)toms only, but from (he temperature also, if
it is to be maintained after such a recovery.
Other varieties of defervescence are less common when recovery
takes place in the course of the third week. Sometimes the variation
is only apparent. We are deceived by false statements of the patient
jis to the duration of his disease. If all the remaining conditions
are perfectly en regie, we are often o,ble to determine, from the
course of the temperature, that the patient has deceived himself as
to the beginning of his disease, and this thermomctric indication is
often subsequently confirmed when further demands are made upon
the memory.
In such a course of temperature during convalescence we seldom
meet with much trouble from complications, unless the })atient was
in a condition of im])crfect health before being attacked ; or special
injurious influences induce them, or the " epidemic constitution "
exhibits a temporary tendency to such complications. If a compli-
cation occurs, there results at some point of the course an arrest of
the decrease in temperature, or a fresh elevation of temperature.
Sometimes an unusually sudden and deep fall of temperature precedes
this change, and is always suspicious.
On the other hand, it is not unusual in such cases, and especially
in diseases which run a very mild course, to meet with relapses, and
recrudescence of the morbid processes. There is here an essential
distinction in the course and danger of the case, whether the renewal
of the process begins in places which have hitherto remained intact,
so long as the earlier deposits have not yet begun the healing process,
or have made but little progress in it (recrudescence, typhous after-
stroke, or relapse) ; or whether recovery has, on the other hand,
made considerable progress, and freedom from fever has been ob-
tained. In the former case, the commencement of recrudescence is
either indicated by the temperature rising above the previously
moderate height ; or we observe all at once an alteration in type
instead of the constantly descending course, the daily remissions
begin to be more imperfect, the daily exacerbations begin earlier,
become somewhat higher, and last longer, and in general a very
severe and irregular course succeeds, which brings many dangers to
the sick in its train. It is quite otherwise with the relapses, properly
so-called, v.hich begin after the joatient is free from fever, and
THE TEMPErxATURE IN ABDOMINAL TYPHUS. 311
sometimes even in convalescence. They have (as has ah-eady been
said), as a rule, a very normal, and generally favorable course, which
usually terminates with the twenty -first day from the beginning of
the relapse, more particularly when they occur after a mild primary
attack.
§ 13. We may always, with great probability, expect a severe
course of the disease as soon as morning temperatures above 39*5° C.
(io3"i° F.) are persistently met with, and evening temperatures of
40*5° C. (i04"9F.) are reached or exceeded, and the daily exacerba-
tions occur with great punctuality, or prolong themselves beyond mid-
night, whilst the daily differences are slight, and so the course of the
disease is sub-continuous, but the daily minimum exceeds the lowest
limits of the range of typhus exacerbations (39*6° C. = io3'38° P.);
and finally when moderation of the temperature does not occur about
llie middle of the second week, or at the latest about the twelfth day.
All irregularities in the second week are suspicious. All uneven
elevations of temperature, as well as purposeless and excessive falls
of temperature, and although a tolerably rapid recovery is possible
in such cases, relapses, fresh elevations of temperature, complications,
and hypostrophes are very common. The irregularity is especially
unfavorable when no indication of an increase in the remissions is
met with in the second week, although the evening temperatures
per se may remain substantially inconsiderable, or even when the
morning temperatures are higher than the evening.
It is an almost certain sign of a severe course when the morning
temperatures reach 40° C. (104*^ F.), and those of the evening-
exceed 41° C. (105-8° F.), and especially when, towards the close
of the second week, increasing rises of temperature are met.
The most unfavorable circumstance of all, however, is the occurrence
of apparently purposeless fluctuations, along with such a course as
has been described, even when such fluctuations consist in a sudden
decrease of temperature not proper to abdominal typhus.
§ 14. It is in severe cases more particularly, that we meet with a
complicated cotirse.
The least dangerous form is that in which, without any particular
or at least much moderation of temperature at the beginning of the
second half of the second week, the evening exacerbations remain
considerable (over 40° C. = 104° F.), and on particular evenings
312 TIIK TRMPKRATURE IN ABDOMINAL TVIMIUS.
reach above 41^ C. (105*8° F.) ; and on tlie other hand, mornint^ re-
missions ninounting to one degree, or a degree and a half Centi-
grade (= 1*8^ or 27° r,)> or even more, are met with ; and thus the
course goes on into the third week, or even to its ver}' end, with
scarcely diminished severity. Bat if no complications occur, it is
most customary, even in such cases, to Ihid the exacerbations a trille
less in amount from the middle of the third week, and now and then
a more considerable remission occurs, preparatory to a decided
decrease of fever heat.
Sometimes, however, the temperature moderates in this way — the
high temperatures of the second week do not recur, the temperature
especially remaining about {-° C. (-V° ^') lower than in the second
week, but still a high degree of fever remains, and the remissions
continue to be inconsiderable. However, even in cases which may
be considered pretty favorable, it is not infrequently the case that
considerable remissions of temperature are postponed to the fourth
week. Or the temperature may still remain as high as in the second
week, or even rise still higher, and continue so till at least the
middle of the third week, and often to the middle or even end of the
fourth week. In such cases the evening temperatures continue to
show themseh'es as high or almost so as in the earlier stages, the
remissions are less, and the daily difference is commonly not above
-^°C. (Yi7°r.), except when the exacerbations exhibit an exorbitant
height of temperature. The morning temperatures, in particular,
generally range between 39*5° and 40° C. (103-1° and 104° F.),
or perhaps between 40° and 40"5° C. (104° and 104*9° '^■)> ^'^^ ^^'^
seldom above this, whilst in the periods of exacerbation the tempe-
rature sometimes exceeds 41^0. (105*8° F.), or may reach and even
surpass 42° C. (107*6° F.). The mean daily temperature is gene-
rally over 40° C. (104° F.). The extent of the exacerbations is
thus increased, and the daily rise of temperature begins in the
morning, even as early as 9 or perhaps 8 a.m., and the high tempe-
rature continues till midnight or even later, commonly with two or
more peaks [to the curve of elevation]. The morning remission is,
correspondingly, of very brief duration, and lasts only an hour
or two.
Or irregularities may occur in the course of the fever, which
usually draw other irregularities in their train. Not infrequently
these irregularities result from the severity of the case, from unfa-
vorable conditions surrounding the patient, individual pecuharities,
THE TRMPERATURE IN ABDOMINAL TYPHUS. 313
or the prevailing character of the epidemic. But in many cases the
irregularities result from complications. If the complications are of
a local inflammatory nature, such as intense bronchitis, pneumonia,
parotitis, and such like, either the temperature rises notably, or at
least the previous morning remissions, which have probably been "
considerable, become much less so.
When a patient suffering from abdominal typhus becomes attacked
with Asiatic cholera, the course of the temperature is very peculiar.
Cases of this, observed in my wards, have been published by
Fnedlander (in 1867, in ^Archiv der Heilkunde,^ viii, 439). He
has not only shown that cholera exerts a powerful influence in de-
pressing the temperature, but also that in the patient suffering from
typhoiV/ fever, the first unmistakable fall of temperature occurs even
thirty to thirty-six hours before the collapse of cholera, and as much
as twelve to twenty-four hours before copious diarrhoea commences,
and this fall of temperature therefore serves as the first symptom of
cholera infection in such cases.
If severe hemorrhages supervene in the course of abdominal
typhus, particularly haemorrhages from the bowels, a considerable fall
of temperature may be met with, even to below normal ; but the
temperature usually rises again speedily to the previous heights, or
even above them.^
The momentary elevations of temperature in the former cases, and
its momentary falls in the latter cases, are by no means the sole
effects of the complications : beyond this, they more or less com-
pletely destroy the normal characters of the course, and the numerous
irregularities may themselves prove injurious even when the compli-
cations which caused them have been happily overcome.
In some special, and in many respects extraordinarily severe cases,
considerable falls of temperature occur at the supreme moment of
danger, without any particular collapse, and without assignable
cause ; these are by no means to be looked upon as favorable, but are
on the other hand connected with an increase in other threatening
symptoms, with weakness of the cardiac contractions and of the
sounds of the heart, with enormous frequency of the pulse, severe
delirium, and automatic muscular movements (floccitatio, carphology,
subsultus tendinum, kc), with coma, and the most extreme pros-
tration, and bear the strongest resemblance to the fall of temperature
in the pro-agonistic period, which will be described presently. They
^ See page 134 and tlie foot-note. — [Trans.]
31 !■ TIIF. TK^r^KRATrRK T\ ARDOMINAT, TYPHUS.
do not accurately ro})rcsciit. any favorable crisis of the disease; yet
it sometimes hai)))ens tliat the fatal cud, Avhicli seemed so imminent,
is averted by energetic measures — upon wliicli the temperature recurs
to its previous heights, or even rises as the patient gets better. AVe
may call these cases of pro-letho/V/ (pro-agoniform) fall of tempe-
rature. But even in cases which have become severe and irregular,
the typical course recurs, as soon as affairs begin to mend. This
does not so often happen at the height of the disease (or in the
fastigium), but generally begins first during convalescence.
Unless death succeeds, all severe cases have this in common, that
the fastigium period and the whole course of the disease is pro-
tracted. And therefore, in very many cases, there occurs, on a
tolerably fixed day of the disease, a transitory moderation, and in
others a particular elevation of temperature. The remissions seem
to prefer the last days of the week, or the middle of a week (of the
disease) ; the rises of tem])erature immediately l/f/ ore those, days, or at
the beginning of a fresh week. The commonest event of all is to
observe, in such protracted cases, a striking rise of tem])erature about
the twenty-fifth day, or sometimes a day earlier or later. This rise
of temperature becomes more conspicuous, because about this time
the course exhibits a visible remission, and the fever has even begun
to decrease ; and this decrease is very commonly interrupted on the
twenty-fiftli day by elevations of temperature which are wont
to exceed the height attained on the preceding day by -^° C. (-pV ¥.)
or more.
At this stage the diagnosis is seldom doubtful ; only exceptionally
acute tuberculosis, or cerebro-spinal meningitis, may be suspected,
and particularly when the latter is epidemic, at which times especially
many more or less striking cerebro-spinal symptoms are generally asso-
ciated Avith typhoid fever, and thus increase the resemblance of the
two diseases. On the other hand, the prognosis is an affair of
practical interest at this period. Thermometry cannot always afford
certain data on which to found them, but may give us very valuable
hints (literally vji?ih) .
Generally speaking, every case is a dangerous one in which this
(protracted) form of the disease is met with.
There is very great danger, as soon as the temperature reaches a
height of 4T'2° C. (ic6'i6° E.), and the best that can be hoped for
is a very tedious recovery. "With a temperature of 41 '4° C.
(to6"52° 1\) the fatal cases are always nearly twice as numerous as
THE TEMPERATURE IN ABDOMINAL TVPHUS. 315
the recoveries. With 41 '5° (107-15° E.) and ]iigher degrees, reco-
very is a rarity.
Fiedler ('Deutsch. Archiv. f. khn. Med./ i, 534) declares
4175° C. (io7-i5°'r'.) to be the maximum temperature admitting
of recovery, which occurred in two such cases, all the rest with the
same, or a higher, temperature ending fatally. However, in one of
my cases of typhoid fever, recovery took place after a temperature of
43-5-° C. (=33'7°R. = •107-825° P.) had been reached (during a
rifjor in the course of the disease).
A repeated rise of temperature to very considerable heights
(41° C. = 105-8° F.) increases the danger considerably. Yet these
are much better borue by the patient if, in the morning hours, or
intercurrently, there are considerable falls of temperature. Very high
temperatures with intercurrent remissions of temperature are less
danijerous than somewhat lower heights which continue both
morning and evening with scarcely any break. If tlie tempe-
rature exceeds 41° C. (105-8° r.) in the morning hours, death is
almost certain.
If the temperature in the third week is higher than in the second,
or when an ascending direction is assumed in the third week, it must
always be considered noteworthy.
All gross irregularities afford a bad prognosis ; or, at least, one
must be prepared for further complications.
§ 15. It is quite the exception for the course of a severe case to
immediately terminate favorably by crisis ; for more often there in-
tervenes a period of changing fortunes — a period of uncertainty :
the amphibolic stage.
This stage often intrudes into cases which seemed in the com-
mencement to be of only slight severity, but which, in any case,
must excite the suspicions of the well-informed practitioner ; as
particularly in cases of abdominal typhus of aged persons ; in cases
of previous ill-health; in cases of relapse, occurring before decided
progress towards recovery has been made; in cases which displayed
great irregularities at a very early stage, unless these necessitate an
extreme mildness of the attack ; in patients continuously exposed to
injurious influences, or who are forced to make great muscular
exertions in the earlier part of the illness; and such like. The
amphibolic stage generally begins in the middle, rarely so early as
the com-mencement, of the third week ; sometimes in the beginning
31G THr, TEMrERATUUF, IN ABDOMINAL TYniUS.
of the fourtli week, and is preceded in many cases by a rcmisision of
unusual extent, or even by collapse, and makes itself known by
more or less considerable irregularities, apparently casual improve-
ments or purposeless relapses. lu general the evening temperatures
are still pretty high in this stage, although less so on the average
than in the fastigium. And although on particular days the maxi-
mum of the fastigium may be reached or even exceeded, yet in the
majority of cases the temperature in the evenings remains a trifle
lower. Considerable remissions, which may extend to the evening,
occur intercurrently, but exhibit no steadiness ; and whilst the symp-
toms for several days may appear strikingly favorable, all at once
relapses again occur. It is by no means common to find the inter-
current falls of temperature in this stage going on into collapse,
without further and dangerous reasons for such a course ; and, when
such falls of temperature occur, they are almost always dangerous,
or are at least followed by a fresh and striking rise of temperature.
Sometimes exacerbations of stationary height alternate for a longer
or shorter time with deep remissions of temperature, which go down
to normal or even below it ; in the latter cases, symptoms of collapse
are often met with. Although defervescence may estabhsh itself by
a gradual decrease of the exacerbations, after such an alternating
course has lasted a whole week ; yet what generally occurs is this —
that after some time, the remissions become less, and even approxi-
mate to the exacerbations. In special cases, deep falls of temperature,
or even collapse temperatures, occur even in the time of the exacer-
bation. It is not very rare to meet with a postponement of the
times of exacerbation and remission — so that the former occurs in
the morning hours, and the latter in the afternoon — which seems to
have no bearing upon prognosis.
Yery many complications commonly occur in this stage; most
frequently their effect is not simj^ly to raise the temperature, but also
to abolish or at least mask the remissions.
Sudden and considerable falls of temperature are only observed
with severe haemorrhages and perforations in this stage.
Not infrequently recrudescence of the course takes place, with a
renewal of the symptoms in the fastigium, apparently caused by a
renewal of the anatomical lesions. It is in these cases, more par-
ticularly, that dangerous and fatal haemorrhages and perforations are
to be dreaded.
Piigors sometimes set in, with great rise of temperature; they
THE TEMPERATURE IN ABDOMINAL TYPHUS. 317
generally indicate the occurrence of fre.sli complications (pysemic
and septicemic processes) .
This amphibolic stage sometimes lasts only three or four days
(half a week), generally a week, or a week and a half; sometimes
even longer.
§ 1 5. If the disease is tending towards death, the pro-agonistic
stage generally commences with deceptive depressions of teoipe-
rature, which, however, for the most part not only exhibit a contrast
to the remaining symptoms, but also show a certain amount of
irregularity.
In other cases, on the contrary, there is an unusual and persistent
rise of temperature, particularly in the morning, which exceeds
41° C. (1058^ F.); or tliere ensues a sudden increase of temperature,
amounting even to 42*5° C. (= 108-5° E.) , or even more, only seldom
reaching 43° C. (i09'4°F.), or above that;
Or there occurs a sudden deep full of temperature, accompanied
with symptoms of extreme collapse.
The death-agony is not always preceded by a recognisable pro-
agonistic stage. Sometimes, on the contrary, death happens very
suddenly and unexpectedly in this stage. In the death-agony, and
in the actual moment of death, the temperature may, according to
circumstances, be very low, highly febrile, or even hyper-pyretic ;
which apparently depends chiefly upon the kind of condition which
immediately determined the fatal result.
If the temperature rises in the death-agony, this generally happens
with rapidity in pro])ortion to the near approach of death, amounting
sometimes to a degree and a half hi a single hour (= 27° F.).
Death generally happens between 42° and 43° C. (io7'6° and
109-4° E.).
Post-mortem elevations of temperature are met with, but they are
generally inconsiderable, and only last a few minutes.
§ 17. "When severe cases of tlie disease tend towards recover ij,
this generally occurs after a critical perturbation, which may be
noticed for only a few hours, or may extend itself over a longer
period, even lasting several days.
More commonly, however, a preparatory moderation of tempe-
rature precedes, in which case the commencement of true recovery ia
less clearly defined.
318 THE T K.Mr EK ATI' KK IN A15UO.M1NAE TVIMIUS.
This preparatory moderation allows itself either in a singhi re-
mission, somewhat deeper than others, or in a slighter exacerbation,
or in a slightly clesceuding direction taken* by the temperature,
which may spread over several days, by means of which, in severe
cases, the type always remains sub-continuous, and the daily mean
may continue about 40° (104° F.). iSuch a gradual descent may
last for a half, or even a whole week, before any decided amendment
occurs.
The amendment generally announces itself by a considerable fall
of temperature, which commonly happens at the time of the daily
remission, and is generally somewhat lower than the remission of the
day which succeeds it.
The beginning of decided improvement in cases of moderate
severity often occurs about the middle of the third week, but in. very
severe ones only seldom at the end of the third week, most often in
the middle of the fourth week (immediately after the rise of tempe-
rature on the twenty-fifth day), and sometimes even later.
Defervescence occurs after the remittent type, just as in cases
which recover at an earlier period, but the defervescence takes a
longer time in most, but by no means in all cases.
The remissions are not infrequently so excessive as to induce col-
lapse more than once.
Defervescence often induces a *' stand-still/^ or even a slight
relapse in the patient^s condition.
Sometimes its even course is broken by single moderate or colossal
fluctuations, sometimes through a solitary evening rise of tempe-
rature of considerable amount, sometimes by several such, between
wliich, however, the temperature every morning returns to the
normal, or sometimes the defervescence is interrupted by several days'
subcontinuous elevation of temperature.
But actual relapses are often enough observed during the de-
fervescence.
§ 18. Sometimes, instead of exhibiting a tendency to death, or
instead of passing on into recovery, the amphibolic stage terminates
in a protracted process (lentescirende^ Process), which generally
depends on continuous ulceration in the bowels, sometimes on
' " Lenlesco, to cleave or slick like pitch, to grow gentle or supple." —
AlNSWOKTU.
THE TEMPERATURE IN ABDOMINAL TYPHUS. 319
suppurative bronchitis, aud other tardily recovering local affections,
and once now and again by marasmus, it depends on advanced
marasmus.
The course of the fever is chronic in such cases, with daily more
or less high evening exacerbations and morning remissions, which
reach even to normal. The duration of this stage is quite in-
definite.
§ 19. Complete recover)/ in abdominal typhus is only to be
admitted when the temperature shows complete freedom from fever
in the evenings. The beginning of recovery is therefore to be esta-
bhshed only by the thermometer, and we can only be assured of it
when the lower temperatures have been met with for at least two
successive evenings.
Yery commonly, however, during reconvalescence, the temperature
is actually somewhat loiver than in the normal condition, being from
36° to 0^6'^ C. (96-8° to 977° F.) in the morning, and under 37°
C. (98*6° r.) in the evening, which rather indicates the safe cha-
racter of the recovery than any unfavorable course.
But very often the period of recovery is complicated.
The least significant disturbance consists in a brief, although often
very considerable, elevation of temperature, occurring after the first
indulgence in animal food, or other nutritious substances, or very
often in abdominal typhus after the visit of a friend.
In many cases of abdominal typhus, and more commonly in severe
cases than in milder ones, febrile movements or febrile relapses are
met with without any known cause, and last from one to three days.
They are not dangerous in themselves, but they retard recovery, and
unless the patient be treated accordingly may have other injurious
consequences as a sequel. The temperature is generally the only sign
by which they can be certainly recognised, and it also indicates their
termination most accurately. Sometimes it shows that at a certain
period in the course of an epidemic the recovery of almost every case
is interrupted by such relapses into fever, which may be repeated
once or twice in one and the same individual.
Yery frequently, in many periods, and less frequently at other
times, true relapses or repetitions of the typhoid process occur during
convalescence, and can generally be recognised only by the temperature
for the first few days, since in general no other symptoms call atten-
tion to the relapse during the period.
3:20 THE TK.MrEll.VTLUE IN ABDOMINAL TITHUS.
They are rather to be dreaded if elevations of temperature above
normal occur during convalescence, and may be developed eight days
or even more after convalescence has occurred. AVith timely care
and supervision they are not generally dangerous^ and they furnish
us, as already stated, with the must perfect example of a simple,
favorable, and quickly recovering typhoid process.
Various hypostroplics^ may occur during the recovery from typhoid
fever, which are generally to be recognised earliest by a fresh rise of
temperature; the kind of fresh complication can generally be deter-
mined after a few days.
On this account continued thermometric observations of conva-
lescents from abdominal typhus, at least once every evening, are of
the greatest practical value, and its usefulness becomes all the more
evident when we reflect on the difficulty or impossibility of making
a daily examination into all the sym])toms, and that this easy method
indicates with the greatest accuracy tlie moment at which it becomes
desirable once more to make a more careful examination of the patient
Mho was recovering.
§ 20. In childhood, particularly in very young subjects, the course of
the temperature in abdominal typhus is generally somewhat irregular.
The commonest irregularity is a course of extreme mildness, yet
in these cases the temperature for the first few days rises more sud-
denly than in the adult, and during the first week its average height
is very considerable.
Cases of typhoid fever pass more quickly in the child into the
remitting period, and the course of defervescence is usually more
sudden. But complications are often met with, and where they show
themselves the height of the subsequent temperatures may be very
considerable.
These irregularities of temperature may render the diagnosis of
abdominal tvphus very difficult in children [and hence it is seldom
made in England. Infantile remittents and a host of other spectres
being conjured up in its stead. — Trans.].
§ 21. When peoi^le over forty years of age are attacked by
tvphoid fever, their temperature is commonly lower than that of
• ' YTTotrpo^Vj a return, a going back, the act of turning round or turning
buck — a relapse.
THE TEMPERATUilE IN ABDOMINAL TYPHUS. 321
young adults. Even during the fastigium the height reached by the
exacerbations is only from 39° to 39'5°C. ( = 102*2° to 103-1° F.) ;
40° or more (104° P.) being quite exceptional, and in the morning
hours it falls below 39° C. ( i02-2° F.)
More irregularities are met with in its course than in younger
individuals.
The fastigium seldom lasts over the second week, but an amphi-
bolic stage succeeds, or at least the period of recovery is protracted
and inclined to complications. Collapse often occurs, and the tem-
perature more often falls below normal during convalescence and in
recovery than it does in younger people. The beginning of the fever,
even in fatal cases, is often mild and deceptive, but later on the tem-
perature may reach considerable heights. Death sometimes occurs
with a high, still more often with a moderate or low, temperature.
Such a course of temperature is \'ery common in persons of forty
years of age or more, and occurs in about half of those attacked at
this age, and is generally absent only in those who are very well
preserved in spite of their age ; it is far less frequent in men of
thirty-six to forty years (only in about one seventh of the cases),
and still less frequent in men between thirty-one and thirty-five
years (in about one tenth of the cases).
Compare Vhle (1859, in the ' Archiv fiir physiolog. Heilkunde,^
xviii, 95).
§ 22. Ancemic people, especially when their anaemia is not too
extreme, exhibit a modified course of abdominal typhus as a rule,
and recovery happens comparatively early. This does not preclude
ansemic people being greatly endangered by comphcations, or the
temperature from shaping itself unfavorably in certain events — such
especially as hEemorrhages (although not in themselves severe), aff'ec-
tions of the lungs, severe brain-symptoms, parotid-gland aftections,
bed-sores, all of which have a more dangerous significance and a
greater influence in ansemic people than in others.
§ 23. Previously/ existing diseases, of almost any considerable kind,
which persist through the whole course of abdominal typhus, render
its course irregular, with scarcely a single exception; and the irregu-
larities may be so great that we may be doubtful of the diagnosis
right through the disease, and even up to the time of death. In most
cases of this kind the course is not only irregular, but at the same
21
322 TllK TKMPEHATUllK IN ABDOMINAL TYPHUS.
time very severe. High temperatures are not very often met with in
the eveiiiiii; ; remissions, and indeed very profound ones, arc often
seen, but the suecession of events in the course is disorderly and
obscure, and the lluctuations of tlie amphibolic stage are met with
almost at the beginning of the course. The principal diseases which
have this effect are pulmonary phthisis, extreme degrees of emphysema,
diseases of the heart, catarrh of the stomach, ulceration of the intes-
tines, chronic nephritis when considerable, the htcmorrhagic dia-
thesis, chronic alcoholism, chronic lead-poisoning, high degrees of
hysteria ; and amongst the acute diseases in whose course abdominal
typhus supervenes are peritonitis, scarlatina, and cholera.
Pregnancy and the puerperal state have a similar tendency, but
not by any means in all cases.
§ 24. The energetic application of cold in the form of repeated
more or less cold baths, very cold douches, continued ice, cold
compresses over the trunk, or frequently repeated envelopment of
the body in cold wet sheets (so-called cold-wnter treatment) is in-
contestably the most powerful means of influencing the temperature
of abdominal typhus as yet known to us.
Besides the numerous other results which the above applications
produce on other symptoms of the disease, they have the following
effects, provided they are sufficiently often and energetically
applied.
{a) A more or less considerable, and more or less lasting depres-
sion of temperature after each application. A slight rise of tem-
perature for the first few moments sometimes precedes the depression
of temperature ; this is not, however, by any means invariable, for
sometimes it falls immediately after an energetic ap])lication; for
instance, after a complete immersion in a cold bath for a quarter of
an hour, after an hour's application of ice-bags, &c., the temperature
measured in the rectum is either very triflingly (a few tenths only)
or not at all elevated; generally speaking, however, one finds a
quarter or half an hour after the application of cold, that the tem-
perature has fallen about i to 3 degrees Centigrade (= i*8° to
5'4° r.), and sometimes considerably more; after this it begins for
the first time to rise again, and after from two to six hours, or even later,
it reaches intense febrile heights. Very often, under special favorable
circumstances, it never again reaches its previous elevation. These
varied effects depend partly on the kind and intensity of the applica-
THE TEMPERATURE IN ABDOMINAL TOPHUS. 323
tiou, and partly^ on the other hancl^ upon the surroundings of the
case, and the form and stage of the malady.
The effect is in general greater and more durable in complete cold
bathsj and quickly repeated cold wet packs, especially in children ;
when the course of the fever is mild and remittent, in the absence
of complications, in the later periods of the disease, and when the
application is made at the time of the natural remission. The effect
is less marked, or entirely wanting, when the applications are less
energetic, also in grown-up people in the earlier stages, and when
the disease is of a severe sort, when its course is sub-continuous, or
complicated, and during the previously described daily ascent of
temperature, or at the height of the daily exacerbations.
{h) The type of the course is more or less materially altered by
an energetic and sufficiently frequent application of cold. Pirst the
natural daily remission becomes obscured, and the exacerbations are
commonly enough dislocated.
It is quite an exceptional thing to have the course actually
shortened, it is perhaps rather prolonged, but, on the other hand,
very commonly rendered milder. The highly febrile exacerbations
are at once interrupted, and a fresh rise of temperature is hindered ;
it is true indeed that as a rule, the latter recurs when the applications
are left off prematurely. It also appears that when the course is
sub-continuous, a repeated and consecutive application of cold
causes a transition to the remittent type, though the form of this is
perhajDs anomalous at first, and the further progress is secured and
accelerated by the occurrence of the remission.
As regards this, it is already evident that severe accidents and
sequelae of abdominal typhus may be guarded against, and moderated,
and great dangers successfully combated, and thus many lives
saved in abdominal typhus by the cold-water treatment. The
other effects of this method of cure do not belong to my subject,
but I may add that by the common consent of all observers, and in
my own trials of the method, the mortality of the disease is very
considerably diminished, and that in some desperate cases, favorable
terminations which could scarcely have been anticipated have been
obtained.
Consult on this subject Kallmann {loc. cit.), Brand ('die Hydro-
therapie des Typhus,^ 1861, and 'die Heilung des Typhus/ 1868),
Liebenneister and llagenhach (' Beobachtungen und Versuche iiber
die Anvvendung des Kalten Wassers bei iiebcrhaften Krankheiten,^
3.21 TIIK IK.MPKKATUKK IN AIIDOMINAL TYl'llUS.
iiS68), Jiirgcnxcd (' Kliiiisclio Studicn iibcr die Ik'liandluiig dcs
Abdoininaltyj)liU!> mit kaltt'ui \\ as^^cr/ 1866), Z'lemswn and
Immertiidnn ('die KaUwasscr-beliaiidlung des Tv[)hus Abdoiiii-
iialis/ 1870).
§ 25. The early (/". c. in the first week) internal use of calomel m
doses sullicieiitly large (30 Centigrammes, =4v gi'^- i^^arly), and
although less certainly the use of other laxatives,^ iiillucnce
the course cliiefly ; producing especially an immediate more con-
siderable remission than is accustomed to occur spontaneously at
this period. After this fall, however, the temperature rises again,
but not commonly to the former height ; and in a tolerable number
of cases, defervescence follows on the few days^ modified course
induced by these means, in the usual remittent fashion, and sometimes
even more rapidly, and recovery takes place earlier than it does on
an average in cases left to themselves, however mild. If calomel be
given very early (/. c, in the middle of the first week), a great
remission takes place almost directly, but the rise of temperature
which succeeds is sometimes (although not in the majority of cases)
more considerable, and may exceed the temperature before the dose
was given. It appears that by the early use of calomel the tem-
perature is sometimes delayed in reaching the usual maximum
heights, at least in such cases the maxima occur on the seventh or
eighth day, or even later, and the efficacy of the method must gene-
rally be regarded as doubtful if temperatures of more than 40*5° C.
(104*9° E.) ^^^ observed after its use. If calomel is not given till
the second week, or later still, considerable remissions immediately
succeed its use, but it is exceptional to find it affect the general
course of the disease, and it does so less and less frequently the further
advanced the disease was at the time it was exhibited.
Consult my treatise, 'Priifung der Calomelwirkung beim en-
terischen Typhus' (1857, ' Archiv fiir physiol. Heilkunde,'
xvi, 367.)
§ 26. JJigitalis, in the quantity of two to four grammes (553 — 5J
nearly), or even more (in divided doses, extending over from three to
live days), given in the second and third week of a severe abdominal
^ Dr. W. Teiiuant Gairdner, who has had considerable success in the trcat-
meut of typhoid, spealis highly of the use of sulphate of magnesia in small
doses. — ['Tra>"s.]
THE TEMPERATURE IN ABDOMINAL TYPHUS. 325
typlmSj immediately produces a slight moderation of temperature in
a great number of cases; or perhaps a considerable fall of temperature,
which during the time of the exacerbation may amount to two degrees
or more (C. = 3 '6° F.) This fall does not generally last more than
about a day after the exhibition of the remedy. Then the tem-
perature rises again, and in cases favorably affected, does not again
attain the previous height, but remains stationary, with very power-
fully depressed pulse, at moderate heights, whilst defervescence takes
place as usual ; and the pulse first recovers itself from its artificial
retardation, about four days after the use of the digitalis, whilst
convalescence has meanwhile advanced.
Compare my article, ' Ueber den Nutzen der Digitalisanwendung
beim enterischen Typhus' (1862), in the ' Archiv d. Heilkunde,'
iii, 97); Ferber (1864, in ' Virchow's Archiv,' xxx, 290), and
Thomas (1865, 'Archiv d. Heilkunde,' vi, 329).
§ 27. Quifiine, in tolerably large doses (i*2 — 1*8 grammes =3j
5SS nearly) divided into three doses given within a few hours, has a
powerful effect in lowering the temperature in typhoid fever. The
first who made observations on this was Wacltsmuth, who gave 0'6
grammes {^= 9I grs. nearly) every three hours, on three oecasions,
and observed a rapid fall of temperature from 40*25° C. (104*45° F.)
to 36"75° C. (98'i5° F.) After two days, the evening temperature
rose again to 40*2° C. (104*36° F.), but in the remission it again
reached the normal, and defervescence soon began and was rapidly
completed. In one of my cases in which one to two grammes of
quinine (3j nearly) were given, when the temperature between 5 and
12 p.m. had reached a height of 41° (105*8° F.), a rapid fall of
temperature resulted in the night after toxic symptoms [cinchonism],
and on the following morning there was a temperature of 37*1° C.
(98*8°), and at noon it was actually only 36*25° C. (97*25° F.) In
the evening it rose again to 40* 1° C. (104* 1 8° F.) A fresh exhibition
of I gramme (15*44 grs.) in divided doses, spread over forty-eight
hours, again depressed the temperature to 36*9° C. (98*42°), after
which it rose again, but the disease from that time preserved a mild
course. The use of quinine in large doses does not however aff'ord
us any certainty of a favorable issue. It is noteworthy, too, that
Qaincke has communicated to the Berlin ' Klinische Wochenschrift,'
1869,^0. 29), a case in which a girl who was suffering from an
attack of abdominal typhus, which did not appear of any great
.'i'jn rilK THMPKRATUUK IN AHDOMINM. TVlMirs.
severity, ^vas treated for several evenings witli v)j doses of quinine,
and died suddenly in the third week of the disease with an ex-
icssivtly high temperature (43'4° C. = i JO^'is^E.) More mode-
rate doses of quinine (o'6 to o'cS gramme =9 — 13 grains nearly)
may also cause the temperature to be reduced in abdominal ty])hus,
but cannot be relied upon. [Compare p. 139, where the views of
Dr. r. Stabell and Dr. C. Baiimler are recorded. The former thinks
the quinine ought to be given in large doses^ with which the author
seems to agree. — Teaxs.]
See also Wachsmuth (1863, 'Archiv der Ileilkuude/ iv, 74),
Thomas (1864, ibid, v, ^^^), Liebermeister (1867, 'Deutsches
Archiv/ iii, 26).
§ 28. There is no other form of disease in which such numerous
investigations and facts are accumulated as there are in abdominal
typhus. Amongst the first which deserve mention are the already
quoted works of Gierse, Kallmann, Roger, Zmmermann, and espe-
cially Biirensjirung and Traube, which either touch upon the course
of the temperature, or are more or less exhaustive. Its thermome-
tric relations are also treated of, inter alia, in most of the more
recent accounts of abdominal typhus, as well as in most modern
text-books, amongst which, besides my own treatise [JVunderVicli s
' llaudbuch der Pathologie und Therapie,'' and edit., 1 856;, I may
especially mention Griesinger' s account in his ' lufectionskrank-
heiten,^ 2nd edit., 1864, as based upon very numerous independent
thermometric observations. I may also mention the following :^ —
Thierfelder' 8 article, from observations made in my wards (in 1855,
' Archiv flir physiologische HeilkuTide, xiv, 1 73), Wnnderlich ( 1 857,
ibid, xvi, 367, and 1858, xvii, 19), TJhle (1859, ibid., xviii, 76),
Wunderlich (i86i, 'Archiv der Heilkunde,' ii, 433, and 1862, iii,
97), Fiedler (ibid., iii, 265), Wacksmutk (1863, ibid., iv, ^^), Thomas
(1864, ibid., V, 431 and 527 ; and 1847, ibid., viii, 49), Lade (' De
la Temperature du Corps dans les Maladies et en particulier dans la
Fievre Typhoide, 1866), Biiumler (1867, ' Deutsches Archiv fiir
klin. Med.' iii, 365, which treats of typhoid fever in England),
8eidel (1868, ' Jena'sche Zeitschrift.^ iv, 480). Besides these, nume-
rous notices of special points, or confirmations of previous state-
ments, will be found scattered through various periodicals, &c.
See the Charts at the end. Tables I, II, and III, and the supple-
mental bibhography.
THF- TEMPKRATURK IN EXANTHEMATTC TYPHUS. 3.27
II. — EXANTHEMATIC TyPHUS.
(Sjiolied fever — petechial or true tijplms.)
§ I. As far as can be gatliered from very accurate altliongh not
very numerous observations, the fever in exantliematic typlius has a
very definite typical character, which can be recognised best in mild
cases, and those of medium severity. The fever in this disease
differs from that of all other diseases, and particularly from that of
abdominal typhus (or ti/pJioid fever), with which, however, it dis-
plays certain points of correspondence.
The fever of exanthematic typhus is of shorter duration than the
shortest normal fever course of abdominal typhus ; it lasts longer,
however, than the fever in all the rest of the acute diseases which
nm a typical course.
In exanthematic typhus the initial stage, the fastigium (in which
two distinct divisions can be distinguished), and the period of defer-
vescence, are all characteristic. Observation of the temperature
alone through any one of these stages sometimes allovvs us to dia-
gnose typhus fever with great probability, whilst a continuance of
such observations through any two of these periods almost always
renders the diagnosis perfectly certain.
The course of the temperature furnishes a means of distinguishing
mild cases, cases of moderate severity, and dangerous cases witli
tolerable certainty.
But in very severe cases the type sometimes becomes difficult to
recognise, and this, or observation of only a brief period of the
disease, may sometimes render the diagnosis, es])ecially from other
severe diseases, very difficult, and sometimes impossible.
Irregularities in the course, with or without complications, also
occur in exanthematic typhus, but the sparseness of undoubtedly
correct observations has hitherto made it impossible to characterise
them more precisely.
§ 3. In the heg'mniug of the illness, the temperature generally
rises more suddenly than it does hi typhoid fever, especially in cases
which commence with a rigor.
The temperature generally reaches 40° — 40'5°C. (104° — 104*9" -^O
as early as the first evening, On the following morning it recedes
3'3R TIIF. TEMPKRATURi: IN EXANTIIEMATIC TYPHUS.
somewhat, aiul sometimes even aijjiroxiinates to the normal tem])era-
turc, but most generally ri'maiiis between 39\5° and 40° (i03"i° and
104*^ ¥.). On the second evening it rises afresh, and often enough
exceeds 40*5*^ C. (i04'9° ^')' ^^^ °'^ ^'^^ third evening it has risen
to a still greater height, even to 41 "5" C. (1067° F.).
This increase continues at least till the fourth evening, on which
the temperature is seldom under 40*5° (i04'9°), generally about
41° C. (105*8° F.), and often more, and this indifferently in cases
which die as in those which recover.
At this period of the disease, neither thermometry nor the re-
maining symptoms, however carefully weighed, are able to make a
certain diagnosis ; and in particular it is impossible to differentiate
the disease from relapsing fever. On the other hand the diagnosis
from typhoid fevers is very definite, because in the latter the tem-
perature rises less suddenly. The positive diagnosis of true typhus
can only be made with tolerable accuracy, by a consideration of the
etiology (proofs of infection) during this stage.
§ 3. In moderate cases, and such as take a favorable course, the
temperature has already reached its summit on the fourth day, and
in the course of the second half of the first week, on the fourth,
fifth, or sixth day, there occurs a turning-point, which, indeed, is
announced by only a very trifling decrease of temperature. A some-
what greater remission succeeds, in favorable cases, on the seventh
or eighth day. The temperature, it is true, rises again immediately
in the second week, but only for a few days, and as a rule, in favor-
able cases, does not again reach the maximal heights of the first
week.
This rise of temperature, in pretty nearly all the cases, begins
about the eighth or ninth day, seldom later, and may be from
4-° to 2° C. (^° to 3'6 ° F.). In favorable cases it lasts only a very
short time, it may be only one day, or two to three days, and the
temperature begins slowly to descend again. On the twelfth day,
in fortunate cases, there commonly occurs a more decided, and, so
to speak, preparatory remission, which sometimes lasts half a day,
at others for two successive mornin2;s.
A third, but generally very brief rise of temperature may succeed
this, having the character of a perturbatio critica, and terminating
immediately in definite defervescence.
Or defervescence may immediately follow the first inconsiderable
THE TEMPERATURE IN EXAiNTHEMATIC TYrilUS. 329
diminution of temperature, which occurs in the middle of the second
week, without any further rise of temperature intervening.
In these slight cases, the diagnosis generally remains doubtful
during the fastigium, unless the etiology confirms it. Thermometry
only affords a fair probability in favour of exanthematic typhus, and
against the presence of typhoid fever, based on the temperatures
being uniformly higher in the second half of the first week, and not
much less in the first days of the second week. The probabilities
are essentially strengthened, when with these high temperatures, the
cerebral symptoms are considerable, and the remaining phenomena
relatively unimportant. The other symptoms indeed, taken by
themselves, furnish a number of points in confirmation, but certainly
afford no certainty of diagnosis. However, if the case has been
under observation from the very beginning till the first half of the
second week, we may generally make the diagnosis with great con-
fidence, merely from the thermometric course.
There is indeed one other disease, besides typhus fever, which
begins in a similar way, and exhibits the same course during its
fastigium, and, especially after high continuous fever, may even extend
into the second week without any severe localisation ever taking place.
The disease thus easily confounded with petechial typhus, is relaps-
ing fever, although this happens but seldom. ; for in the great
majority of cases of relapsing fever, the fever, properly so-called,
does not extend into the second week.
§ 4. In severe or neglected cases of typhus, the continuous ascent
in the height of the exacerbations continues all through the first week,
and attains very considerable degrees (41 "3° — 41 '6° C. = io6-i6^
— io6"88° F. or more). The remission on the seventh day is absent,
and the high fever persists through the whole of the second week,
or at least for a great part of it, at very considerable heights, and
in an exacerbating type; so that the morning temperatures are about
40° C. (104° r.) whilst in the evenings the heat may rise a degree
or more higher (= I'S*^ P. or more). In such severe cases, even
the remission on the twelfth day is wanting, or is present only in a
much less degree, and although in severe cases which recover, the
temperature may become a trifle lower towards the end of the second
week, yet very high degrees of temperature are met with both in the
mornings and evenings till the beginning of the third week.
In severe cases the diagnosis during the fastigium is almost always
.'^;30 TIIF, TKMIM'.RATIIKK IN lA AM'll KM ATIC TVIMIUS.
more iliilicnlt than in the niiklcr cases, especially the diagnosis from
abilominal typhus : for severe cases of tyi)h«.y and ty])ho/V/ are in
every respect more alike in the fastiniuni than milder cases of these
diseases. The daily maxima of temperature are, liowever, as a rule,
higher than even in severe abdominal typhus ; the tendency to con-
siderable remissions is far less, but these are mere quantitative dill'er-
ences, which are generally not sufhcient to decide. If we add to this,
that there may be a very great correspondence between the recurring
symptoms of these two diseases in severe cases — that, for example,
the rose spots may be very copious in typlio?V^ and very scanty in
typhus,^ that the brain symptoms may be equally severe in iy\)]ioid,
and that in typh?/.? liquid stools and profuse diarrhcea are sometimes
present ; it is easy to understand the necessity of great care in
making a diagnosis.
§ 5. The stage of defervescence is usually very characteristic in
cxanthematic typhus.
In the great majority of cases defervescence is preceded by a
critical perturbation, which lasts only a very short time (one to two
evenings), and consists in a rise of temjjerature amounting to from
a few tenths to 2° C. {y6° I\), or more, above that of the preceding
evening, and often contrasting still more strongly with the already
modified temperature of the morning of the same day.
Defervescence may either succeed this immediately in a precipitous
manner, or in rarer cases the rise of the perturbation is immediately
followed by a brief fall of moderate amount, and then a rapid
descent.
In cases where there is no critical perturbation the temperature is
usually moderated to a medium intensity as early as the second half
of the fastigium.
Defervescence most commonly occurs between the thirteenth and
seventeenth days, less frequently between the twelfth and thir-
teenth, and still more seldom at an earlier date.
Postponed terminations are rare and doubtful, unless the fever is
> To those wlio are familiar with typhus, this uote may seem superfluous,
but as the eruptions are so badly described in most text-books, it is perJiaps
not really out of place to remark, that the Jirst appearance of the typhus
rash is not only strikingly like the typhoid, but absolutely indistinguish-
able in some of the cases, both as to colour, form, and fading on pressure. —
[Trans.]
THE TKMPKRATURR IN EXANTHEMATIC TYPHUS. 331
protracted on account of complications. Defervescence follows a
rapid course in the majority of cases. In many the temperature in
tiie course of a single night falls from a height of 40° C. (104° 1\),
or even from higher degrees, down to normal; or falls from a°
to 3° C. (3"6° to 5*4° E.) or so, and from this time no longer rises
to febrile height [crisis]. But rather more commonly, especially in
severe cases, this happens : that the morning temperature after the
first evening decrease does not quite reach normal, but about 38° — •
38-5" C. (ioo'4— ioi"6'^ F.) ; on the following evening it rises again
to 38-8° or 39"2° C, and reaches the normal point for the first time
on the following morning.
More rarely the defervescence continues during the night, although
the line of its march is extended, or it descends in the pattern of an
easel [see diagrams at end], and reaches the normal after a second
twenty-four hours ; or a somewhat slower though almost continuous
fall of temperature continues for some days, so that from three to
five days are occupied in reaching the normal temperature.
It is, however, quite exceptional for the defervescence to resemble
that of typhoid fever, because that exhibits remissions. And in these
cases also the normal temperature is in fact reached much more
quickly than in typhoid fever.
These varieties of defervescence distinguish exanthematic from
abdominal typhus in the most striking manner ; and although other
diseases may defervesce in a similar fashion (cases of pneumonia,
variola, measles, scarlatina, &c.), yet the course and duration of the
fastigium is essentially different in these. Typhus on the other hand
is distinguished by the defervescence itself from relapsing fever,
because the decrease of temperature in the former is never so colossal
as in the latter. Defervescence, therefore, taken in connection with
the preceding course, may serve to distinguish exanthematic typhus
from every other form of disease with great accuracy ; and the cases
are quite exceptional in which complications during defervescence
weaken the potency of this method of proof.
§ 6. Fatal cases of exanthematic typhus generally announce them-
selves even from the very beginning by the enormous height of the
temperature (41*2° C. = io6'i6° F., and even more). The tran-
sient remission at the end of the first week is wanting in these
cases.
Death may occur in the second week with continual high tem-»
333 THE TEMPERATUUr, IN EXANTHKMATIC TYPIIUS.
pcratiircs. If (he case enters the tliiril wcek^ some remission may
show itself on the fourtecntii day, but this must not be rcprardcd as
a favorable symptom, and is very soon compensated.
Yet even in fatal cases the temperatures in tlie third week arc not
so high as at the earlier periods, at least till iiear the death agony.
The daily maxima do not exceed 40*8° C. (10744° !'•)» ^"t are, for
the most })art, moderate. The danger to life during this third week
is indicated not by the height of the fever, but by its continuance.
Just before death, and in the death agony, the temperature con-
stantly rises in exanthematic typhus. In all my cases in which it
was possible to make observations, there was a rise of temperature
during the agony of at least 1*25° C. = 2\° Y., in one case of even
3'6° (6*48°) ; and on an average about 1 "8° C. (3*24° T.). During the
agony the temperature was seldom so low as 40° (104° F.); more
usuallv it was about 41 — 42° C. (105-8° C. — 107-6° F.), and once
43° d (109-4° F.).
§ 7. The course of the fever in exanthematic typhus was first
demonstrated by myself in my article, ' Beobachtungen liber den
exanthematischeu Typhus,' (1857, in the ' Archiv f. physiol. lleil-
kunde,' IS". F. Bd. i, 177). My conclusions were contirmed in all
essential points by Griesinger's Observations (1861, ' Archiv der
Heilkunde,' ii, 557), by Moers (1866, in the 'Deutsche Archiv fUr
klinische Medicin,' ii, 0^6), and by Murchison (in the 'Lancet' of
Dec. 8th, 1866). Even the readings obtained by Gnnmhaw
('Dublin Journal,' 1867), unsatisfactory as they are, for he only
took the temperature once a day and noted too many whole
degrees, and adduced as they are by him as a contradiction to
my conclusions as set forth by Aitkin, show clearly, at the first
glance on the charts, that with all their imperfections they simply
represent and confirm the views I have set forth.
[Dr. Gnmshav) ('Medical Press and Circular,' 1866) speaks of
Collapse temperatures of 95° and 96° F. preceding death in many
cases of typhus. Dr. FaIvAii Long Fox thinks lysis the most common
mode of defervescence. He thinks the author places the typhus
temperatures too high ('Medical Times and Gazette,' February 5th,
1870), and Mr, Square)/ ('Med. Chir. Transactions,' 1867), seems
to be of the same opinion. He states that the evening temperature
rarely exceeds 105° F. in the evenings. Whilst fully admitting that
all cases are not alike, I can only account for the different results
THE TEMPERATURE IN RELAPSING FEVER. 333
obtained by these observers and some other English ones, by sup-
])osing that the cause was the same as that mentioned in the note to
page 105, or that the thermometer was retained for only tliree or
four minutes. My own observations entirely confirm those in the
text. — Trans.]
See the curves of tem])erature in Table IV at the end.
III. — Relapsing Fever.
[Ti/ijhiis recurrens ; famine fever ; fievre a reckule.)
^ 1. Eecurrent or relapsing fever shows itself in two forms — as a
sim])le recurrent fever [relajosivg fever of English writers) and as
bilious tijphoid (first introduced into pathology by Griesiuger).^
The course of the fever in the simple relapsing form is in the
highest degree typical, and is quite peculiar from the fact that two,
sometimes three, seldom four, attacks of fever running a continuous
course of several days, with very remarkable heights of temperature,
are interrupted by intervals free from fever, which also last for several
days ; so that this disease pre-eminently deserves to stand as a model
of the relapsing fever type.
In the other far rarer form of bilious typhoid the course of the fever
has been far less accurately studied, but the type of the course may
correspond pretty well with that of the other. Yet both in fatal
cases and in those v/hich recover, the second attack of fever is often
wanting, and so the peculiar apyretic interval or interruption is
wanting, and the peculiar character of the type is thus lost.
§ 2. The disease generally begins with the symptoms of a rigor
with rapid rise of temperature, and thus on the second day the
temperature commonly exceeds 40° C. (104^ E.) or even 41° C.
(105-8° E.)
The further course of the first stage of the fever is pretty prac-
tically continuous, although interrupted by solitary /j^aZ'.s of exacer-
bation, which may occur at any hour of the day, and may extend
to between 41° and 42° C. (io5'8° and 107*6° E.) Tw^o elevations
of temperature on one day arc not uncommon. Actual remissions,
' Is not this the true " bilious fever" of our own older writers '1 [TiLV>'s.j
ooi TllK Tli.MrKllATUKi; IN KKIiAPSlNG FEVKH.
I.e., a downfall of tcmpovaiurc as low as 39*8° C. {ioy6^° Y.) do
not occur during the ])rincipal part of the fever paroxysm, which as
a rule lasts from five to seven days, or less frequently three to four, or
eight to thirteen days. A decidedly descending direction is first per-
ceived on the last, or last day but one, or if the paroxysm be pro-
tracted, on the third or fourth day before the critical period. This
descending direction announces itself by a lasting, and considerable
fall of temperature, or sometimes by the remissions becoming more
marked, and being succeeded by slighter exacerbations. More par-
ticularly a very marked remission descending to nearly 38° C.
(ioo'4^F.) sometimes occurs, just the day before the crisis, after
which the temperature rises again more or less, but generally not to.
the height of the exacerbation of the preceding day, though some-
times it may even exceed this.
The height of the temperature immediately before the crisis is
commonly between 39-8° and 40-5° C. (= 103-64° to 104*9° F.), and
is thus actually less than the maximal heights, and it is only
exceptionally that the heat rises immediately before defervescence to
the level of the earlier maxima, in the manner of a critical pertur-
bation. The downfall now occurs with extreme rapidity, with or
without the co-operation of perspiration, so that within less than
twelve hours the temperature falls in an unbroken line from 4° to
6° Centigrade (7-2° — io-8° P.), and seldom less than 3° C.
(= 5*4° F.), and hence it generally reaches sub-normal degrees.
According to Zoni, the fever does not run so high in the
lilious form, as it does in the simple, although it is obviously
severe. The mercury seldom rises above 41° C. (io5"8° P.), but
generally fluctuates between 39° and 40*5° C. (102*2° and
1 04*9° F.), and it is common for peripheral parts to feel even cold,
which is an immediate indication of a dangerous attack. In the
bilious form, very many cases prove fatal even in the first attack.
A similar rapid fall of temperature appears sometimes to determine
a cessation of the fever in bilious typhoid ; this sometimes happens
after a fresh rigor, and with copious perspirations. Yet this is not
the normal course. Some cases end at once in death, without any
further progress, others have a protracted defervescence. Herrmann
remarks, that either accidental complications or more profound
localizations are to be dreaded in cases in which the perspirations
are not critical, and lysis takes place, interrupted by fresh exa-
cerbations.
THE TEMPERATURE IN RELAPSING FEVER. 335
§ 3. A period free from fever (apyrexia) follows the defervescence,
and generally lasts from a half to one and a half weeks, rarely only
one to three days^ and sometimes as long as two to two and a half
weeks. It is, however, exceptional for this period to exhibit a con-
tinuous course of normal temperatures, marked by healthy or conva-
lescent daily fluctuations. As a rule, it is far more common to meet
with interruptions to this even course of temperature, from more or
less considerable elevations.
Very shortly after the temperature at the conclusion of defer-
vescence has reached its lowest point, it rises again more or less
rapidly, in many cases, not only from sub-normal to normal, but very
commonly also to the level of a febrile movement, or even to
moderate fever heat (38-5° C. = 101-3° -^O ^^^^^ ^'"^^^i ^^^^ of
temperature is usually ephemeral ; after a few hours it falls again
for half or a whole day till it reaches the normal. Sometimes a
second, but less considerable elevation occurs on the next day, and
these fluctuations may continue for as much as three to five days,
whilst in other cases these rises of temperature are absent entirely,
or do not transgress the limits of normal temperature, or the tem-
perature may even remain below normal for several days.
Let the course of the temperature during the intermediate, or
apyretic, stage be what it will, there almost always occurs about the
middle of the stage a brief, sharply pointed (akme-artige) elevation
of temperature, sometimes only amounting to about one degree C.
{= rS° P.), but sometimes to as much as 2° or 3° C. (= ^'6° to
5*4° P.). The freedom from fever soon recurs, and very often it is
only completely seen after the episodal elevation ; at other times,
however, the temperature is as truly normal before this as after.
This rise of temperature generally divides the apyrexia into
two almost equal portions, of which the former has a special cha-
racter of its own.
The apyrexia is indeed not wholly devoid of danger, and even in
simple recurrent fever death may once now and again occur at this
period, whilst in bilious typhoid such a termination is pretty fre-
quently met with.
§ 4. The second attack or relapse is more often met with in the
simple form than in the bilious, and in the former almost invariably
in cases which recover, whilst, according to Zorn, it occurs only in
about half of the bilious cases.
330 'I'lIK TKMI'IHAH UK in UKLAI-SIXG VKVKIl.
Tlu> l)ri:iiuiiiig of the scrond alfack is generally inorc or less
ra])iil. It is sometimes preceded by a t^lij,'ht rise of teiiij)! latiiic.
Then the rise occurs in an abrupt line, and sometimes in ;i very few
hours, or in other cases within twenty-four hours, the temperature
has already reached its previous heitfht. This, as a rule, amounts to
from 40° to 41° C. (104° to 105-8° 1\), but is almost always con-
siderably under the maximum of the second fever period.
This second stage of the fever generally occupies three to four
days. The temperature generally takes an ascending course, with
more or less deep remissions ; sometimes it is continuously ascend-
ing, more rarely it is actively intermittent with a tertian, or some
other type, with two to four paroxysms ; or rarely a solitary, short,
and acutely pointed elevation of temperature.
The jjeah, of which there is generally only one in the course of
the day, though sometimes there are two, generally grow higher and
higher: and the last usually represents the maximum of the second fever
period, which is commonly rather higher than that of the first attack,
and is seldom. less than 41° C. (105-8° F.), generally between 41 '4°
C. (io6-6°F.) and 42° C. (107-6° F.), and sometimes even still
higher (in two of my cases it reached 42-2° C. = 107-6° F.).
Hardly any other kind of disease exhibits such high temperatures
in cases which recover.
The intercurrent remissions are sometimes very inconsiderable, but
in the majority of cases, one or more of the remissions (most usually
the first or the last) is considerable, so that the temperature may fall
about 2° or 3° C. i:^-6° to 5-4° F.) within a few hours. 13ut it
immediately begins a fresh ascent, and very rapidly exceeds the level
from which it had fallen. In the intermittent form only do the in-
tercurrent lower temperatures last somewhat longer, whilst the
paroxysms rise higher than in ordinary malarial intermittent fever
or ague. The last elevation, which is generally also the highest
point, is very often reached in the morning hours. Defervescence
immediately succeeds, with or without pcrs]nratiou, by a rapid and
unbroken fall of temperature ; that is, in the course of half a day
it falls from 4° to 7° C. (7*2° to i2-6° F.), and very seldom less
than 3^° C. (6-}° F.), generally even below the normal, which may
occur without any symptoms of collapse. Isolated fluctuations are
sometimes met with at the end of the fall.
The disease generally terminates with this second defervescence,
which exhibits a greater fall of temperature than any other disease.
THE TEMPERATURE IN SMA.LLPOX, 337
Once now and then some inconsiderable fluctuations of temperature
succeed^ which slightly surpass normal temperatures, but in general
convalescence is definitively reached. Sometimes death may occur
even after the cessation of the fever. Once now and then, after a
fresh interval of apyrexia (generally lasting one to four days) a
third or tveudi fourth attack (second or third relapse) may succeed.^
But these renewed attacks are generally wanting ; they occur but
seldom in simple relapsing fever, and still more rarely in the bilious
form. When they do occur they have the same character as the
first two, but are generally less acute, and the temperatures are not
so high, but are no less fatal on this account.
In cases which recover, the third attack lasts from two to four
days, seldom more. Defervescence is rapid, but the fall of tempera-
ture is less considerable. Owing to the fever temperature being less
extreme, the fall amounts only to from i*6° to about 3° C. (a*88° to
5-4° r.).
§ 5. As regards i\\Q fatal termijiation, which may occur under
various conditions, sometimes in the fiercest paroxysms of fever, at
other times in the extremest collapse, or it may be under many other
conditions, thermometric data are wanting. In the only fatal case
observed by myself the second attack was succeeded by an amphi-
bolic stage of fluctuation, which lasted a whole week, and the tem-
perature finally rose again to 41*4° C. (106-52° F.).
As regards the fever in relapsing typhoid, I would specially refer
io Herrmann (' Petersburg. Zeitschrift,' viii, 14), Zorn (ibid., ix,
16), m^ own account (in the ' Archiv fiir Heilkunde\for 1869, x,
314), IFi/ss and Bock ('Studien iiber Febris recurrens," 1869), and
numerous other authors.
[The English reader will find a good resume in Dr. Russell
Eeynolds^s and Dr. Aitkin^s works on medicine previously quoted.
— Trans.]
See the charts in Table IV.
IV. — Vaeiolous Diseases.
§ I. The fever in variolous diseases exhibits tivo dldinct Ij/pes,
which closely correspond, however, at their commencement.
' Dr. AVarburtor. Begbie (Reynolds's 'System of Medicine') and Dr. Aiikiu
(• Practice of Medicine ') state that a fourth or fifth relapse is, although rare,
sometimes met with. — [Tkans.]
22
338 THE TEMrEllATURE IN SMALLPOX.
These two types correspond to the two chief modifications of
smallpox ; one a brief continuous form, belonging to the moderated
and modified disease, or varioloid, occurring chiefly, although not
exclusively, in vaccinated or inoculated persons ; the other a relaps-
ing tvp^"* which characterises the complete form, which runs its
course with fever in the suppurating stage, or variola vera, which,
for the most part, though not always nor only, attacks the unvacci-
nated. The course of the fever does not distinguish variolous dis-
ease from all others ; in the initial stage more particularly, and in
modified smallpox, the fever course may resemble that of some other
diseases, and particularly that sometimes met with in pneumonia.
On the other hand, the course of the fever at the time of the
eruption is so peculiar that this, taken in combination with the out-
break of the exanthem, even whilst this has not yet presented
any distmctive characters, is able to afford a perfectly correct
diagnosis.
Nor will the course of the temperature in the initial stage suffice
to distinguish between variola vera and variolois. But as soon as
the exanthem develops itself the course of the temperature is not
only the most certain, but the only certain criterion by which true
smallpox may be distinguished from the modified form. Not only
is the occurrence of a more or less developed secondary fever (fever
of suppuration) the most trustworthy means of diagnosis between
the two forms, but the mode of defervescence of the eruptive fever
gives an almost infallible indication as to the kind of further course
we have to expect.
During the initial stage the temperature affords no aid in de-
ciding on the severity of the disease, but the course after the
eruption aids us very much. Complications^ also, for the most ])art,
may be recognised by the temperature, when occurring after the first
commencement of the eruption.
§ 2. The initial period is common to both types. On the first
or second day of the disease the temperature has already attained a
considerable height (40° C. = 104° F., seldom below this, some-
times above it). This may, perhaps, occur in an unbroken line
and with extreme rapidity (in which case there is generally a rigor
and shivering), or perhaps it may occur more slowly, and reach this
elevation in the second evening, after a retrocession on the morning
of that day.
THE TEMPERATURE IN SMALLPOX. 339
lu patients previously ill {e.g. phthisical cases) this rise may be
more protracted and less considerable.
On the second day the temperature may have already attained its
maximum, or may still exhibit a moderate increase on the third or,
indeed, on the fourth day, with which only very slight remissions
occur in the morning hours.
The maximum temperature of the initial stage or prodromal fever
is only exceptionally less than 40° C. (104° F.), generally somewhat
above that, sometimes even 41° C. (io5*8 P.), or, indeed, a few
tenths more.
When the maximum has been reached a slisiht fall immedialclv
ensues, which geiierally lasts only one day. At this time we may
commonly notice the first traces of the eruption in tlie form of spots.
This stage lasts from two to five days, and it is not possible at this
time, from the course of the temperature, to discriminate smalljiox
from exanthematic typhus, relapsing fever, or from a pneumonia
which as yet afi'ords no local evidence of its presence; and even
when the other symptoms are taken in conjunction, it is seldom that
we can speak with complete certainty. Yet, on the one hand,
every day that the fever lasts without the lung symptoms renders
pneumonia less probable ; and, on the other hand, if the fifth day
of the disease pass over without any eruption making its appearance
the presence of smallpox must be considered very doubtful.
§ 3. Soon after the first development of the variolous papules
the te7n,]}erat%ire falls more or less raindly. In rare cases of the
disease this defervescence occurs as early as the second or third day
of the disease, but generally from the fourth to the sixth day. The
downfall either lasts only twenty-four hours or less, in which case it is
continuous ; or two, or, indeed, even three days, when it is generally
not continuous or, in other words, it is interrupted by a moderate
evening exacerbation.
In cases of uncomplicated varioloid the temperature quickly
reaches normal by this defervescence, or falls even a trifle below
it, and thenceforth remains normal, or pretty nearly so, unless the
occurrence of some complication causes a fresh rise, which is but
seldom the case.
When the eruption in modified smallpox (varioloid) is very
copious there may sometimes occur a slight, scarcely febrile, and
seldom decidedly febrile elevation of temperature at the time when
310 THE TEMrEUATUllE IN SMALLPOX.
the pustules arc desiccating, but this does not last long in any case.
This fall of temperature is the best characteristic of varioloid, espe-
cially when regard is had to the fact that the defervescence is not
simultaneous with the full devflo[)incnt of tiie eruption, but occurs
soon after that begins, even at the time the spots begin to be
])aj)ular, or to be distinctly felt as elevations. When this occurs,
and the temperature begins to fall in this way with the beginning of
the eruption, one may pronounce for smallpox with great certainty
if the question be between smallpox or measles, or between the
former and exanthematic typhus.
In the same way, one may be perfectly certain that not the so-
called variola vera, or true smallpox, but a modified disease or
variolois is present, if a normal temperature is very quickly reached
during this defervescence.
§ 4. In variola vera the falling temperature after the prodromal
stage either never gets down to normal, sometimes remaining sub-
febrile, but generally at decidedly febrile degrees, and continuing in
this fashion for several days, with or without considerable daily fluc-
tuations ; or the normal temperature is reached, if at all, tediously,
and defervescence is by lysis.
With the beginning of the renewed congestion of the skin intro-
duced by the suppuration of the eruption, the temperature again
begins to rise.
The secondary fever (suppurating fever) is of indefinite duration,
varied, indeed, according to the intensity of the disease ; and at the
same time its course and the height of the temperature diff'er
according to the danger and severity of the disease. In smallpox of
moderate severity the temperature in this stage scarcely reaches
39° C. (io2*2° F.) in general, and very rarely 40° C. (104° F.) or
more; there are morning remissions, and the duration is usually only
a few days. In severe cases the temperature is considerably higher;
the course is sometimes remittent with very marked exacerbations,
and sometimes continuous with occasional isolated elevations of
temperature.
Irregular fluctuations very often mark its course. If during the
fever of suppuration the temperature several times exceeds 40° C.
(104° r.) it is a sign of great danger. In cases not fatal the
duration of the secondary fever is seldom less than a week.
In favorable cases the fever defervesces by lysis, in a very gradual
THE TEMPERATURE IN VARICELLA. 341
manner, and sometimes at the time of scabbing there is an occa-
sional prejudicial but brief rise of temperature, or the fever may
even continue till desiccation, and it may be even longer.
In fatal cases the temperature may rise rather quickly from
moderate heights to very considerable degrees, and death may occur
at 42° C. (107 "6° F.), or even more, although during this stage the
patient may sometimes die with only very moderate elevation of
temperature. Simon {' Charite Annalen,'' xiii, Bd. v) has published
cases in which the temperature (which was, however, measured
after death) was 43*75° and 44*5° C. respectively (11075° ^^^^
112-1° F.).
§ 5. Serious complications may cause intercurrent attacks and
irregularities in the temperature, which, however, presents nothing
specially characteristic of smallpox.
Compare ?;?y oivn account of the disease (1858, in the 'Archiv
fiir physiol. Heilkunde,^ N. F. ii, 18) and a communication by Zeo
on an epidemic of smallpox in my wards (in 1864, in ' Archiv der
Heilkunde,' v, 481); FroMicli (1867, ibid., viii, 420); and
Kbrher ('Petersb. Zeitschrift,' xiii, 303). For the curves of vario-
lous fever see lithographs. Table lY.
Varicella.^
Thomas states (in the 'Archiv der Heilkunde,' viii, 376, and the
'Archiv fiir Dermatologie und Syphihs,^ i, 309) that sometimes
even in the incubation stage of varicella there are slight elevations
of temperature, and that at the time of the eruption in many cases
the rise of temperature is very trifling. In the majority of cases,
however, sometimes at the beginning of the exanthematic period and
sometimes after a copious eruption had been developed, he found a
sudden and relatively considerable elevation of temperature, some-
times indeed only a few tenths over 38° C, or about 101° F. ; in
rather severe cases 38*5° C. (101-5° F.) to even 40° C. (104° F.), but
1 I have removed this from No. VII, where the author places it with
rubeola, and assoeiated it with its congeners, because the experience of several
epidemics of smallpox (in London, Herts, Warwickshire, and Hants) more
and more forces upon my mind the essential identity of variola and varicella,
a conclusion which is warmly contended for by Ilebra (see Dr. Hilton Fagge's
translation, New Sydenham Society).— [Trans.]
312 THK TEMTKRATURE IN MEASLES.
seldom more. The high stage lasted from two to five da} s^ and the
fever was rcinilteiit, and as regards the height of the temperature
corresponded pretty accurately witli the copiousness of the eruption.
The maximum temperature occurred sometimes in ilic fiisi; liutmore
often ill the second half of the fastigium, and the morning remissions
after the maximum were sometimes somewhat more considerable than
they had been before. Defervescence was rapidj and commonly over
in half a day. [I have nothing to add to this very accurate
account, except that my own notes confirm it in every respect. —
TllANS.]
Y. — Measles.
§ T. The disease known as measles presents us with a fever
■which precedes the exanthem, and accompanies it to its fullest
development. Its typical character is pretty strongly marked.
But inasmuch as measles is subject to manifold irregularities
of extraordinary number, and more especially so in certain epidemics,
when they seem to accumulate, it cannot be expected that the
course of the temperature should be absolutely regular and free from
deviations.
Still further, since measles is a disease which principally attacks
children or very young people, and since the temperature in childhood
is more susceptible of variations from accidental influences than at
any other age, it is perfectly easy to understand that one often
stumbles upon cases which exhibit more or less deviation from the
typical form which occurs when uncomplicated measles attacks pre-
viously healthy although predisposed individuals, who are not too
delicate and sensitive. The very beginning of measles has many
characteristics, and so have the maxima of temperature attained in it.
But the mode and the time of defervescence of the fever is particu-
larly characteristic in measles, and very definitely distinguishes it
from other acute exanthematic diseases.
Even the forms which deviate from the normal show more or less
clearly some traits of this type of defervescence ; and on the other
hand the imperfect correspondence of the descending temperature
with the type, or the. irregularity of the defervescence in special cases,
affords us data for prognosis, and is an indication that the case is
abnormal.
§ 3. Even before the proper fever-stage in measles, in even the
THE TEMPERATURE IN MEASLES. 313
stage of inmlalion, and therefore at a time in which, although the
infection has been taken, no ordinary means of observation suffice
for its recognition, Thomas states that there is, in many cases, a
short preliminary fever-course in the form of an ephemera, or of an
ephemera protracta, in which the maxima of temperature are about
38-8° C. (102-84° E.) to 39-8° C. (103-64° F.), and that this is
followed by a pause or interval of several days quite free from
fever.^
§ 3. Decided and connected symptoms of the disease commence
with a rapid and more or less considerable rise of temperature
(initial-fever) which is complete in from twelve to twenty-four hours,
and by which in the great majority of cases a temperature of 39-1°
to 40° C. (102-38° E. to 104° E.) is attained in the evening; it is
far less frequent to find only 38-1 to 39° C. (ioo"58° to 102-2°)
according to Thomas. Yet it is exceptional for this first rise of tempe-
rature to reach the maximum temperature of the entire fever-period
of measles. On the other hand, the degree of temperature attained
in this preliminary elevation allows us to forecast the subsequently
occurring elevations with very great probability, since these, on an
average, are wont to exceed the height of the initial rise by about
~ to 1° Centigrade = i"5° to 1-8° Fahrenheit, and only exceed this
a trifle even when most extreme.
The initial rise of temperature is pretty constantly followed by an
immediate downfall on the next night, so that in the morning the
temperature is normal, or only just a fev/ tenths above it, and very
seldom exceeds 38° (100-4°), except in very severe or anomalous
cases.
This depression of temperature sometimes lasts for a few hours
only, and sometimes a whole day (through an entire evening and the
following morning).
The rise and fall of temperature in this initial stage are so rapid
' Dr. Wui. Squire (if I understood him correctly) expressed a similar opiiiiou
at fi recent meeting of the Obstetrical Society, but extended it to a variety of
other febrile diseases of childhood. Should this be generally conflrmed (as
I fully expect it will be), it is clear that in large schools or families, during an
epidemic, a rise of temperature in a previously healthy child, accompanied, per-
haps, by trifling symptoms of indisposition, may afford a seasonable warning
and indications for precautionary measures, but the great mobility of childish
temperatures must preclude our founding au absolute diagnosis or prognosis
upon such a slender foundation.— [Tkans.]
'Ul TiiK TKMrr.n vrrHK in me\si,ks.
that tlie case might be taken for an intcnnittciil, did not ilic tcm-
])crature remain rather too low to allow of this idea. On the other
hand, it may easily be confounded witli an ephemeral fever, and if
the succeeding normal temperature lasts a little longer than usual
the opinion may easily gain ground that the disease is already over!
But in most cases the marked existence of other symptoms (])arti-
cularly the ocular and pulmonary ones) allows us to recognise the
disease which is developing itself.
§ 4. The true eruptive fever begins with a fresh rise of tempe-
rature, which henceforward till the exanthem is fully developed
either exhibits no return towards normal or only very temporary
remissions.
In most cases this eruptive fever is divided into two sections, a
moderately febrile stage and the fastigium or acme.
The moderately/ febrile stage generally lasts from thirty-six to forty-
eight hours, seldom less, and is made up of one or two exacerbations
of moderate extent (38° to 39° C. = 100-4° to 102*2° F.), which do
not generally reach the high level of the initial fever. When there are
two exacerbations the second is the higher, and the morning
remission which intervenes commonly descends less low than the
retrocession after the initial fever, yet even at this stage the normal
temperature may be reached on a single occasion.
The stage o'i fastigium is characterised by a considerable and
])ersistent rise of temperature, which, leaves behind for some time the
preceding normal or moderately febrUe temperatures {Thomas). The
commencement occurs early in the day in some cases, in others in the
evening. In the former case the evening temperature rises still more,
which may or may not be followed by a trifling remission on the
next morning, and the maximum occurs the next evening.
If the rise of the fastigium begins in the evening, there is simi-
larly, the next morning, either a very slight remission or none at all.
But in rare cases rather considerable remissions may be met with
during the fastigium.
The maximum temperature of the fastigium, and also generally
speaking that of the disease itself, is chiefly observed in normal
cases at the very time when the exanthem reaches its maximum of
development and extension. Yet there is a tolerable number of cases
which are so far exceptions that the temperature reaches its maximum
shortly after the first appearance of the eruption, and so between its
THE TEMPERATURE IN MEASLES, 345
beginning and its highest development; when the latter has been
])erfectcd^ the temperature has already begun to sink somewhat.
But the maximum of temperature almost always occurs closer to the
maximum of the exanthem than to its beginning. And even if the
maximum has been reached whilst the eruption is still progressing,
the decrease of temperature up to the time of the fullest development
of the eruption is almost always very slight. Moreover, it is not
improbable that complications may contribute their share towards
accelerating the acme of temperature. The maximum temperature
usually occurs in the evening hours ; and if it occur in the morning
hours there is only a moderate fall the same evening ; and it seems
an optional thing whether we should yet call this the beginning of
defervescence.
The whole fastigium lasts from one and a half to two and a half
days, and thus the complete eruptive fever occupies from three to
four and a half days. Its course may, however, be prolonged by
complications.
§ 5, Decided defervescence begins, according to rule, in the night,
and for the most part, and in normal cases, runs a rapid course.
Either the temperature on the next morning has already fallen to
normal, or even below it ; or the fall during the night is less com-
plete, and the descent continues, although less rapidly, all through
the day, or the temperature rises again in the evening, and first
reaches the normal on the following morning. In uncomplicated
and normal cases the normal temperature is at least reached on the
second morning, and from that time continues thus. One or two
slight evening exacerbations rising to sub-febrile heights are the
most that occur.
Very severe bronchitis, or complications, may protract the course
of the defervescence. In the same way, cases of measles M'hicli
begin irregularly may have an abnormal defervescence. Nor must
it be forgotten that in young children trifling causes may suffice to
elevate the temperature.
Sometimes a recrudescence of the fever is caused by a second
attack (nachschub = after-stroke or recoil) of the exanthem. In
this the elevation of temperature may almost or quite equal the
height of the previous maximum, but if no other complication be
present this rise of temperature is very transient.
§ 6. Complications may induce alterations in the course of tern-
34G TIIK TEMPERATURE IN SCARLATINA.
pcratiire of measles, which in sucli cases shapes itself according to
the kiml of complication, and is no longer subject to the sway of
the original disease. Only, if the complication jirccedes the develop-
ment of the cxanthrm, there generally occurs along with and imme-
diately after the eruption a further elevation of temperature, which
is, doubtless, due to the exanthera. Since the fatal termination in
cases of measles which go on to death undoubtedly always depends
upon complications, the temperature in such circurastauces is deter-
mined by the kind of complication present.
On the subject of the type of fever in measles, consult my oion pub-
lication, " Ueber den Normal-verlauf einiger typischen Krankheits-
formen" (1858), in ' Archiv filr physiol. lleilkunde/ B. ii, 14) ; S'legel
("Beobachtungen liber Maseru 1861 ausfilhrliche Bearbeitung dcr in
meinerKliuik vorgekommenen Fillle,'' in 'Archiv der lleilkunde,' ii,
521); Ziemsseu and Krabler (1863, ' Greifswalder Beitrilge,' i) ; wy
own remarks on them in 1863 (in 'Archiv d. lleilkunde,' iv, 331) ;
PfeilsiicJcer ('Beitriige zur Pathol, der Masern,' 1863); Monti
{' Jahrbuch fiir Kiuderheilk.,' vii, 21 ; and especially Thomas (1867,
in the ' Archiv der Heilkunde,' viii, 385) .
For the curves of the fever in measles see lithographs, Table V.
VI. — SCAIILATINA.
{Scarlet fever ^
§ I. Scarlatina conforms far less closely and regularly to its type
than the previously mentioned diseases do to theirs. Yet there is con-
siderable correspondence in the course of the temperature even in
cases which diti'er widely in other respects, and in this point of view
the deviations appear to compose a minority of the cases.
§ 2. Cases of an abnormally mild course are tolerably common,
and the symptoms of indisposition are sometimes so trifling that,
especially at their commencement, they never become objects of medical
care at all, although, indeed, in many such cases this want of care
is punished by subsequent severe or even fatal sequelae. I cannot
from my own experience state whether any of these cases arc so ab-
normally mild that either no alterations of temperature or next to
none occur, because in cases which run a mild course all through I
never had an opportunity of observing the commencement of the
disease. Thomas, on the other hand, has lately stated, in a commu-
THE TEMPERATURE IN SCARLATINA. 347
uication to the ' Arcliiv d. Heilkuncle/ Heft ii (1870), that he has
seen cases which in the early stage, i. e. before or at the beginning
of the eruption,, have not shown any febrile temperature. However^,
I also know cases in which it was most strenuously asserted by their
guardians that the scarcely noticed and very slight eruption, which
was afterwards followed by desquamation, and indeed by severe
kidney-symptoms, occurred at first without any uncomfortable
or unusual feelings at all. But the course of the fever is very
often quite characteristic when the infection of scarlatina develops only
a rudimentary disease, or even only an angina without any eruption.^
§ 3. In all cases of scarlatina which are tolerably severe the
first symptom wdiich shows itself, or, at all events, one of the first,
for other symptoms may accompany it or even sometimes precede
for an hour or two, is a rapid and continuous elevation of tempera-
ture, by which in the course of a few hours this reaches a consider-
able height (39*5° to 40° C. = 103*1° to 104° P)., generally accom-
panied by the phenomena of a more or less intense rigor or shivering.
Sometimes the commencement of the exanthem dates from imme-
diately after this first rise, but the eruption commonly begins the next
morning (on the second day). If this delays to come out, the tem-
perature continues to rise slowly, with very shght morning remis-
sions, beyond the considerable height it obtained at first. It generally
^ I think it possible that one explanation, applicable to some of the cases
alluded to above by Thomas, lies in the fact that just as there are some persons
who all through life have a relatively slow pidse, so there are others who all
through life have a relatively low temperature, or, in other words, their line of
normal temperature must be drawn one or two degrees Fahrenheit, or even
more ("9° to nearly 2° Centigrade), loicer than the average normal temperature
of 37^ C. or 98'6T. I feel strongly convinced of this, and on looking over my
notes I find charts of several cases of scarlatina, measles, typhus, and typhoid,
in which the temperatures all through were at an unusually low level, although
other symptoms were fairly marked, e.rj. SeliuaF — , a girl of 18 (said to have
been always very cold from infancy), had well-marked rash of scarlatina, sore
throat, and afterwards desquamation, albuminuria, &e. Her temperature was
never above 101° F, (38"3° C), and when she recovered remained at or a little
below 97^ F. (36- 1° C), although watched for several months,
J. A — , a man who died of typhus at 30, never had a temperature above
I02"2° F. (39° C.) all through the fever, although there was no sign of collapse,
nor any hseniorrhage nor other symptoms to account for it, I also know one or
two people, apparently in good health, whose average temperature is 96-8° F,
(36° C).
318 THE TEMPERATURK IN SCARLATINA.
remains persistently high, or continues to rise strongly, till the exau-
them has reached its maximum and covered the whole hody, and
sometimes even whilst the parts first attacked by the eruption have
begun to grow pale. The duration of this rise may be very varied,
and may continue from only half a day to four days.
The height finally reached by the temperature in this fashion is
almost always above 40° C. (104° E.), very commonly over 40*5° C.
(104*9° !•)> b^^ seldom in cases which terminate favorably exceeds
41° C. (105-8° F.).
In general the height of the temperature stands in tolerable paral-
lelism with the intensity of the exanthem. Yet there are cases in
which the eruption is but slight or almost wanting, with a very high
temperature, but very few cases of copious eruption go with mode-
rate fever.
The continuous course of the rising temperature, or when the
eruptive stage is protracted, its dwelling upon almost stationary
heights (disregarding the insignificant, and often enough totally
absent, remissions), is only exceptionally interrupted by a solitary
fall of temperature, which seems by preference to occur in cases where
the eruption comes out in successive crops (Stossen). No definite
moderation of temperature is generally met with before the eruption
has attained at least the greater part of its development.
The rapid rise of temperature at the beginning of the disease on
the one hand^ and its remaining continuously high without any
proper remissions on the other hand, allies scarlatina with many
other diseases, and the diagnosis cannot therefore be made from this
behaviour of the temperature taken by itself.
But scarlatina may indeed be very well distinguished by this course
of the temperature from those affections with which, on account of
the other symptoms, it is most easily confounded, and more particu-
larly from measles (morbilli) and rubeolse (Kubeola notha — Eotheln,
or the so-called hybrid between measles and scarlatina), and, pro-
vided no exanthem can be noticed, from abdominal typhus, diphtheria,
simple angina, and acute parenchymatous nephritis.
§ 4. When the eruption has passed its maximum, defervescence
commences. The progress of this is not always the same. In cases
with moderate elevation of temperature it may happen, although only
exceptionally, that the temperature falls ra])idly and reaches the
normal height in half a day.
THE TEMPERATURE IN SCARLATINA. 349
But in an overwhelming majority of cases defervescence is pro-
tracted, and requires from three to eight days for its completion. As
a rule, it occurs in this fashion, that from day to day the temperature
gets gradually lower, and slopes like an easel, or almost easel-like
(Staffelweise), or goes down with trifliug remissions, falling more
especially at night, remaining about the same from morning to even-
ing, or perhaps sinking a little till it reaches the normal. Sometimes
elevations of a few tenths of a degree (Centigrade = ^ to ^ E. or a
little more) in the evening break the fall, in which case the nightly
descent is rather greater.
But it is only very seldom that a remitting defervescence pro-
duces a remote resemblance to that which is peculiar to abdominal
typhus.
When defervescence is considerably delayed the downfall on the
first, second, or even third day is often very slight, and a rapid fall is
not noticed till afterwards.
Complications may still further retard defervescence, or even give
rise to fresh elevations of temperature.
A sub-normal temperature is pretty commonly met with before
the definite return of normal temperatures, and other symptoms of
collapse may also be associated with this. The sub-normal tempe-
rature, however, seldom falls below 36° C. (96-8° F.), but often lasts
for some days.
This form of defervescence, although not invariably met with, is
tolerably characteristic of scarlatina, at least it does not so often
occur in any other disease. A close resemblance to it is met with
sometimes in exanthematic or true typhus, and in catarrhal pneu-
monia.
§ 5. An anomalous course of temperature is not infrequent in
scarlatina.
The temperature, more particularly, sometimes remains rather
low. This does not exclude danger, and by no means guarantees a
favorable termination, wdiich is very often missed on account of dis-
orders which affect the temperature but slightly (diphtheria, croup,
nephritis {q. v.), cerebral irritation, and parotitis). Here and there
fresh elevations of temperature interrupt its descending course, de-
pending on varied causes, and lasting for varying periods. Some-
times they can be traced to complications, but not always. In any
case thev retard recoverv.
350 THE TEMPEllATURE IN SCARLATINA.
Tliere is also n peculiar typhoid course of the disease, iu which
not merely transient but persistent cerebral disorders, diarrha'a,
mcteorisin, and great enlargeuieut of the spleen^ are met with, and
the duration of the disease may be extended a fortnight or more
after the fading of the eruption. The fever thus remains more or
less high, sub-contiuuous or remittent iu form, yet in general it takes
a descending course.
§ 6. During convalescence the temperature remains normal so
long as it is undisturbed by complications or fresh diseases, or it
may be by a second eruption. Tlierefore the persistence of a normal
temperature is a pretty good guarantee for the absence of other dis-
orders; the occurrence of fresh rises of temperature, on the other
hand, may be regarded as a danger signal, and as a demand for a
more careful examination and very painstaking supervision of the
case. If any incipient disease provokes the fresh rise of temperature
in convalescence, it will be found that the previous attack of scarla-
tina has no particular influence upon it.
§ 7. In fatal cases the course of the temperature may be very
varied, and is chiefly affected by the time at which the tendency to
death sets in, and by the disorders which induce the fatal result.
If death happens during the eruptive stage the temperature may
reach very high degrees indeed, but it may also fall during the death
agony.
If the fatal termination sets in after the exanthem has passed its
maximum, and the temperature has begun to decline, the dying hour
is generally heralded in by previous irregularities of the course.
"Whether fresh elevations of temperature precede death, and to what
extent they do so, or w^hether, on the contrary, the temperature falls,
depends chiefly on the nature of the processes which bring about the
fatal result.
Cases also occur in which very suddenly, and v.'ithout obvious
motive, the temperature rises to enormous heights before death.
(In one of my cases it rose to 43*5° C. (iiO'3°F.).2
31// own frequently quoted paper, "Ueber den Normalverlauf
1 And Ijmpliatic glands. I Lave seen several eases of leucocytLsemia dating
from scarlatina, also valvular disease of the heart. — [Tkaxs.]
2 See note 2 to page 204. Also (as regards defervescence) the note to page
221. — [Traxs.]
THE TEMPERATURE IN RUBEOLA. 351
einiger typischen Krankheitsformen," may be consulted on the tem-
perature in scarlatina. Also Riibler's * Beobachtungen iiber Scliar-
lacli^ (Leipzig Thesis, 1861).
For the curves of scarlatina see lithographs, Table V.
VII. — EuBEOL^ [and Varicella; see page 341].
§ I. Rubeolse (Rubeola notha, Rotheln, or the so-called hybrid
between measles and scarlatina, sometimes called roseola also) , which
needs the experience derived from the observation of an extensive
epidemic to carry conviction as to its peculiar characters, docs not
necessarily entail any fever at all, or only a slight transient attack before
and during the eruption. The elevations of temperature are generally
sub-febrile, or at the worst moderately febrile. And although in
isolated cases more considerable elevations of temperature may be
met with, they depend, no doubt, either upon complications or on the
peculiar mobility of temperature which is characteristic of very young
children.
Refer to Thomas ('Jahrbuch der Kinderheilkunde/ N. F.
ii, 240).
[The English reader will also find a summary of what are sup-
posed to be the distinguishing characters of this disease in Dr.
Aitkin^s ' Science and Practice of Medicine,' vol. i, 345 (chiefly
from Dr. Eobert Patterson, who was one of the first to clearly distin-
guish this disease). — Teans.]
VIII. — Erysipelas.
§ I. Eacial erysipelas is pre-eminently a poly typical disease, and in
many cases it is quite atypical.
This probably depends upon the fact that undoubtedly the self-
same anatomical changes are brought about by very varied condi-
tions, and may thus vary greatly in their significance.
Purely local erysipelas, arising from the irritation of wounded
parts j the kind that is brought about by local predispositions ; the
erysipelas which is connected with gastric and intestinal disturb-
ances j protracted erratic or vagrant erysipelas ; the kind analogous to
an acute exanthem, especially the primary and spontaneous; and
that arising from pyemic infection ; the erysipelas of glanders ; the
352 THE TEMPEllATUllE IN ERYSIPELAS.
terminal erysipelas which is developed in cases of marasmus and
severe disease, and precedes death only one or at most a few days ;
all these different forms, I say, arc undoubtedly in great measure
radically dilfereut diseases, which have hardly anything else in com-
mon except the localised dermatitis, and the name of the disease.
It is easy to understand that the participation of the whole organism
anil the course of the temperature must needs differ widely in these
cases.
But at present it is not possible to associate special forms of
erysipelas, or special causes of it, with particular forms of fever
curves, or at least to do so with anything like precision or
accuracy.
Erysipelas in other parts of the body presents us with similar
varieties — but quite atypical courses are rather the rule than ex-
ceptions in these.
§ 2. The disease begins, in an overwhelming majority of cases
(excluding cases free from fever, with an atypical course) by an
intense and rapidly occurring rise of temperature, generally with a
strono; feelino; of chilliness.^ So far as can be determined from the
comparatively limited number of cases which afford an opportunity
of examination at this time, the temperature rises in a few hours to
a height of nearly 40° C. (104° F.) or even more. In most cases
the inflammation of the skin of the face can be seen on the following
morning, although, perhaps, it is not very evident yet, and liable to
be confounded with the heightened colour of feverishness.
Much more rarely, a more gradual rise of temperature is met with,
which takes from two to three days before any considerable degree of
fever heat is attained.
§ 3. The greatest number of variations is met with during the
fastighm. In just a few cases the curve of this consists of a single
slender peak (Akmespitze), lasting a very short while.
]\Iost frequently the high temperature persists in a continuous, or
sub-continuous fashion, but still rising, and with but sHght morning
falls, so long as the inflammation simultaneously develops and
extends itself. In this way the temperature in the evening hours is
very generally above 40° C. (104° F.), and may reach as much as
1 It is not very uncommon, even in adults, for convulsions of an epileptiform
character to usher in erysipelas. — [Tkans.]
THE TEMPERATURE IN ERYSIPELAS. 353
41° to 41-5° C. (105-8° — 1067° F.), or, altliougli seldom, 43° C.
(107 '6° 1\), whilst the morning remissions go a little below 40° C.
{104° F.), though but seldom below 39° C. {io2-2° P.)- Yet some-
times cases are also met with which show a more remittent, or even
intermittent, course in the fastigium, in which case the exacerbations
generally run very high.
The maxlfiium temperature does not generally occur at the end of
this fever course, but one or two days before. And then a trilling
moderation of the temperature succeeds (corresponding to a somewhat
less rapid further development of the inflammation), wdiich is, how-
ever, sometimes overlooked on account of a critical perturbation pre-
ceding defervescence. Sometimes a pseudo-crisis reaching to normal
temperatures, or very nearly so, occurs towards the end of the course,
whicli is succeeded by a transient and final rise of temperature to
heights of 40'^ C. (i04°r.) or even more.
§ 4. Defervescence succeeds this, and generally goes on with such
speed that in the course of twelve hours, or a single night, the tem-
perature falls to normal, or very nearly so. At other times, parti-
cularly when the previous temperatures have been very high, normal
temperatures are not reached in the first twelve hours, but the tempe-
rature rises once more in the evening, and first reaches normal during
the following night.
It is not very unusual for defervescence to be less rapid, and to
occur rather in a sort of remittent form, but always far more rapidly,
than in abdominal typhus. These cases are generally such as have
been marked by considerable daily fluctuations during the fastigium,
and in which dermal inflammation still progresses a little, even
during defervescence. This remittent sinking may sometimes ter-
minate in such cases with a final more rapid downfall, which com-
pletes the defervescence.
In the cases in which the eruption ends with defervescence this
freedom from fever holds its ground, and convalescence sets in with-
out any further disturbance.
§ 5. The cases in which the first well-marked fall of temperature
goes on to definite defervescence, or in which more particularly the
feverless condition maintains itself, are indeed pretty commonly met
with. Yet it not infrequently happens that after a brief interval (of
one to six days), whether the temperature has become perfectly
23
3."} I THE TEiMPEUATUllK IN A PECULIAR REMITTENT.
normal or not, a fresh and s////ihitjf rise of temperatnre occurs,
which either accompanies or hcrahls in a new extension of the iiilhim-
matiou of the skin. This sort of rehipse of the fever, which, however,
does not generally last so long as the first fasiigium, but nsually
only one or two days, may be repeated several times, and the
more the erysipelas assumes the erratic form the more immerous are
the rcj)ctitions. The fever does not cease till the erysipelas is
checked, and for the most part there is no check to the eruption as
long as fresh elevations of temperature are met with.
Yet one observes that the longer the affection lasts, and the more
it wanders, the less elevated do the rises of temperature gradually
become, and sometimes assume the form of only daily moderate even-
ing exacerbations.
§ 6. In cases with a fatal termination death generally seems to
occur with very high temperatures. At least it was so in the cases
observed by myself. Consult my oion publication, ' Ucber den
Normal verlauf typischer Krankheiten,^ p. 15; Blass (' Beobach-
tuugeu der Erysipelas,' Leipzig Thesis, 1863); Eidenhurg (" Ueber
Pracmortale und Postmortale Steigerungen der Eigenwiirme bei
Erysi])elas,^' an original pa})er in the ' Centralblatt' for 1866, p. 6^^);
Ponfick ('Deutsche Klinik,' ^867, 20 — 26).
For the fever-curves in erysipelas see lithographs. Table V.
IX. — Eemittent Fever with Phlyctenular Eruption
(Miliary Fever?)
§ I. Under this name I described in the 'Archiv der Heilkunde'
for 1864, vol. v, 57, and 1867, viii, 174, a form of disease which
appeared to me very peculiar, as well as previously undescribed,
and I gave details at the same time of seven cases of my own, and
one sent to me by Lad' of Geneva.
The disease is distinguished by an exanthem which is peculiar
both in its form, its situation, and its course; and by a number of
typhoid symptoms (especially affecting the nervous system and the
spleen, but not so much the intestines), by considerable disorders
of the respiratory organs, and finally by the course of the fever.
§ 2. There was no opportunity, in any of the cases, of observing
the course of the fever daring the first week. Its subsequent course
THE TEMPERATURE IN FEBRICULA. 355
was of great intensity, and unlike the type of any other exanthem.
It neither declined with the appearance of the exanthem, like vario-
loid, nor exhibited a fresh and injurious rise of temperature, like
smallpox ; nor did a rapid defervescence coincide with the maximum
of the exanthem, as in measles, nor was there the protracted defer-
vescence of scarlatina nor the irregularities of miliaria nor the
rapid or rather rapid downfall of spotted fever (true typhus), which
seems independent of the exanthem ; nor a swift downfall, with ten-
dencies to recrudescence, as in erysipelas.
It is a continuous remittent, with high degrees of temperature,
generally marked by evening exacerbations exceeding 40° C.
(104° F.), or even above 41° C. (105*8° P.), and with morning
remissions of one or two degrees (i"8° to 3*6° P.), for the first two
to eleven days of residence in hospital ; then on one occasion as early
as the eighth day, or else towards the end of the second or third
week, the temperature began to decrease by large daily fluctuations,
analogous to the period of improvement in abdominal typhus. From
eight to fourteen days it ran on pretty much in this fashion — that
from day to day the morning remissions became somewhat more
marked, and the evening exacerbations generally became a trifle less
from day to day, till the patient exhibited normal temperatures, first
in the morning, and a little later on in the evening also. Slight and
transient relapses interrupted convalescence in four of the cases.
Thus, the course of these cases was considerably protracted, and in
every one the exanthem lasted during the greater part of the fever,
l^or details of these cases see the accounts quoted above.
Eor the curves see lithographs, Table V.
X. — Febricula.
§ i. Under the name of febricula we may include two ditferent
courses of temperature.
In the first place, febrile movements, which last for a longer or
shorter time, but in which the temperature, even in the evening-
exacerbations, rises but very little above sub-febrile heights, or only
occasionally reaches greater elevations.
And, secondly, we must include under this name brief fevers
ending in recovery, which last only one, two, or at the most a few
days altogether — ejiltemera. In this form a sudden rise of tempe-
356 TllK TEMl'KKATURE IN rKBRICULA.
raturc accompanies the llrst feelings of indisposition, and the tempe-
rature in the course of a few liours rises as much as from i° to 3° C.
or more (= 3-6° to 5-4° F.) There may or may not be a rigor at
the same time. Sometimes the highest temperature is not reached in
an unbroken line, or within a few hours, but in the course of one or
one and a half day, and is interrupted for a short while by a moderate
fall on the morning following the beginning of the sickness (ephe-
mera protracta). The fastigium lusts only a few hours, or at the
furthest one day, but the height of its temperature may be more or
less considerable, sometimes even 40° C. (104° l'\) or more. A rapid
decrease of temperature immediately succeeds, which in twelve, twenty-
four, or thirty-six hours, has already regained the normal. During
this course of defervescence a slight interruption from a trifling ele-
vation of temperature in the evening hours is not unusual. Complete
restoration to a condition free from fever may also be somewhat
longer delayed, and from two to three days may be required in some
cases before normal temperatures are securely reached.
§ 2. Both these courses occur under a great variety of circum-
stances. The condition which follows wounds (of an operation, cS:c.)
generally involves a febricula, the course of which has been espe-
cially elucidated by Billroth {' Archiv fiir Klinische Chirur-
gie/ ii).
It is true, indeed, that a great number of lesions (sometimes by no
means inconsiderable in themselves) are not followed by any febrile
movement.
But in a great many cases, indeed in the majority of cases, a rise
of temperature is to be noted on the days succeeding any considerable
injury [traumatic or wou7id fever).
The fever which sets in most rapidly, that is, usually during
the first twenty-four hours after the injury, generally shows a
rapid rise of temperature, so that in the majority of cases the
maximum temperature is already reached on the first or second
day, or at all events between the third and sixth. The rise of
temperature is generally continuous ; it is only interrupted by
morning remissions when protracted. The acme is usually reached
on some evening during the attack ; it is quite the exception for it to
occur in the morning hours, and the time of day at which the injury
occurred has no influence upon this. The maximal height attained is
less than 40° C. (104° F.) in the great majority of cases, and very
THE TEMPERATURE IN FEBRICULA. 357
often less than 39° C. (i02"2°r.); it is quite exceptional for tlie
temperature to rise to 40*5° C. (104*9° ^■) °^" more.
When the maxima of the first two days are both alike, tolerably
high, it is more favorable for the patient than when the tempera-
ture at the beginning of the attack remains only moderately febrile
and later on rises all at once, in which latter case there may be
reason to suspect some accidental inflammation or pyremia.
There is no particular relation between the duration of the whole
attack and the particular height reached by the temperature. The
temperature keeps in the neighbourhood of the highest peak {i.e.
near to the maximum) only a few hours on one day, in the great
majority of cases. Sometimes very nearly the same peaks of eleva-
tion are reached in two evenings, which are separated by a morning
remission.
If the temperature remains long at any considerable height, or a
severe exacerbation is often repeated, we may suspect some compli-
cation, or internal inflammation, or that pyeemia is commencing.
Defervescence begins pretty commonly even on the first day of the
fever, more often on the second, and pretty often on the third or
fourth day, seldom so late as from the fifth to the seventh. It is
sometimes rapid, sometimes protracted. In the latter case there are
evening elevations of temperature. Both kinds appear to occur
about equally often. During defervescence the temperature never
sinks below normal.
The age and constitution, &c., of the patient appear to have no
influence upon the height of the temperature, or upon the course of
traumatic fever.
On the other hand, when the injury has been followed by con-
siderable haemorrhage, there almost immediately occurs either a
slight or, in some cases, a considerable fall of temperature. This
depression of temperature is only transient. The traumatic fever is
not warded off by it, but succeeds in the course of a very few hours,
and may be quite as severe as in cases where hardly any blood at all
was lost.
Once more, if a chronic condition of fever existed before the
injury or operation, the traumatic fever is usually acute, exceeds its
accustomed heights, lasts longer, and is exceedingly prone to further
complications. Patients, too, who, though free from fever, were
suffering from chronic disease, such as consumptive patients without
858 THK TEMPERATURE IN FEDRICULA.
hectic, those with Bright's disease, or with amyloid degeneration,
arc affected by traumatic fever in the same way.
All immoderate elevations of temperature in the wounded, or
after operations, for the most part announce the existence of further
complications, greatly increase the hazards of the lesion, and com-
monly nullify the success of operations.
§ 3. Pretty often, although perhaps not in the majority of cases,
the wounded are again attacked with fever after the fourth day —
secondary fever (Nachfieber of Billroth).
The intensity and duration of the traumatic fever do not affect
the genesis of the secondary fever, which may even develop itself
when there was no (primary) traumatic fever. On the other hand,
when the primary fever is protracted, it may be very difficult to dis-
tinguish it from this secondary fever. Sometimes no particular
origin can be assigned for the secondary attack ; in such cases it is
usuallv slight and transient.
In the majority of cases, however, the secondary fever has a
definite origin, and may even serve the useful purpose of drawing
attention, and making us search after the causes which disorder the
healing process. Retention of the secretions of the wound, progress
of inflammatory changes in the subcutaneous or intermuscular
cellular tissue, or retention of faeces or urine, or the development of
some fresh morbid process, or inflammation of internal organs, are
the principal determining causes of the fever which occurs later on.
Secondary fever may set in on any day from the second half of the
first week, or in any of the successive weeks, even up to the end of
the sixth week.
The Blighter cases occur almost imperceptiblyj and particularly
without rigors ; their duration is brief, one or two days, or a week
at the outside. The severer forms of secondary fever generally
begin with a rigor.
The course taken by the temperature in secondary fever is very
varied, because it is induced by such varying conditions, and
because, in fact, these varied fevers have little else in common except
the circumstances of their occurrence at a given time after the injurv.
They are the general constitutional expressions of very manifold
shght or severe disorders to which the subject of a lesion is ex-
posed for the first six weeks after the injury or operation. It is
imposgible, therefore, that they should follow any definite typo, and
THE TEMPERATURE IN FEBRICULA. 359
tlieir practical importance lies in the fact that they are amongst the
first signs which indicate that some injurious influence or other,
acting upon the increased disposition to morbid activity induced by
the lesion, has led to disturbance of the healing process.'^
§ 4. In cases of abnormal uterine action thermometry is in a
condition to decide (as Winchel has pointed out) the important
question between weak labour-pains and the so-called cramp-pains,
or colicky pains.
During insufficient labour-pains the elevation of temperature
proper to normal labour is wanting ; the temperature, as a rule, is
lower, and follows the fluctuations of health. In all cramping pains,
from whatever cause they originate, the temperature rises in propor-
tion to the duration of the anomalous pains. The elevation of tem-
perature in any case is, however, inconsiderable, and seldom exceeds
1° C. (i*8° P.), but it persists quite unaff'ected by the normal daily
fluctuations.
Immediately after the labour the temperature still remains high
after cramping pains, but if no inflammation has supervened it falls
within the next twelve hours.
§ 5. In childbed a temperature above 38'' C. (ico"4° ^O ^^7
not be a certain sign of a pathological process, but it is at least
suspicious, whilst a normal temperature in the lying-in woman by
no means ensures an undisturbed recovery.
Very many lying-in women show a slight rise of temperature in
the first twenty-four hours after labour, a species of mild traumatic
fever, without any indication of any local morbid process. The
temperature in these slight febrile movements does not exceed
38'5° C. (ioi'3° F.) The rise generally lasts only one day.
Some of these patients exhibit a more intense fever, sometimes
preceded by rigors. This more intense form usually begins on the
second or third, sometimes on the fourth, fifth, or sixth days, and
' The English reader will find a good resume (by Mr. Windsor) of Bilh-oth
on " Traumatic and Secondary Fever," in the New Sydenham Society's ' Year-
Book for 1862,' p. 183. lleference may also be made to the articles on "In-
flammation," by Mr. Simon and Mr. J. Croft, in Holmes's 'System of Surgery,'
vol. i, pp. 2 and 287, and to numerous cases in the reports of various hospitals;
also a paper on "Traumatic Fever" by Dr. Macdonald, 'Dublin Quarterly
Journal,' Aug., 1869, p. 31.
SfiO Till'. Tl'.MPKRATURK IN I-'EBIUCULA.
therefore coincides witli great distension of Hie 1)rcasts (so-called
milk-fever).
This fever may reach its culminating ])oint after only a few hours,
or not before from two to five days, and this often reaches 40° C.
(104° F.), then suddenly turns, if no unfavorable local complica-
tions exist, to defervescence, so that a normal temperature is reached
very quickly indeed after the beginning of the fall of temperature.
From this time the temperature either remains normal, or a
secondary fever sets in after from twelve to twenty-four hours or a
longer interval of apyrexia ; in this secondary fever the temperature
may even rise to 42'^ C. (io7'6° F.), and this again decreases after
from one to two days' duration, and passes into the normal con-
dition without further disturbance.
All deviations from such a course, either higher degrees or a
longer duration of rising temperatures, are signs of more severe
disease, which may be either a local inflammation or an essentially
constitutional affection.
§ 6. A great variety of circumstances may induce attacks of
ephemeral fever. They occur in weakly or sick people, and women
and children, often without any recognisable cause.
They set in sometimes along with very rapid growth, dentition,
exhaustion, and in menstruation.
Sometimes they indicate the beginning or the increase of some
more or less latent and protracted [morbid] process.
They form the prelude to transient disorders of tissues ; for ex-
ample, a very intense ephemera often precedes the eruption of a
herpes confined to the labial region.
A single attack not infrequently occurs during the incubation stage
of infectious diseases.
They sometimes occur during the very time that a morbid poison
is extending itself througli the body by means of the lymphatics^
although it may be followed by nothing more serious, or at the time
of an embolic obstruction. When the contagion has been insuffi-
cient, or the individual exposed to it but little predisposed, an
ephemera often represents the entire effect of the operation of a spe-
cific morbid poison.
Ephemerte may also occur, without any further results being
necessarily entailed, after other potent causes of disease (such as
severe chills, wettings through, or powerful emotions).^
' See note to page 155.
THE TEMTERATURE IN rY/E:\IIA. 3G1
XI. — Py/EMIA.
§ I. Pyremic fever, that is the fever vs-hich accompanies acute
multiple inflammations, very seldom originates as a primary or
spontaneous disease, but generally succeeds other processes, such as
severe lesions or the puerperal state; and, without doubt, has its
genesis in infection, and either develops itself out of a condition
entirely free from fever, or is preceded by a more or less con-
siderable fever originating from the processes wbich precede it. In
either case the commencement of pysemia is (as a rule) sharply
defined ; in the latter case, however, one sometimes remarks a
slight or sometimes more considerable fall of temj)erature, imme-
diately before the beginning of the pycemic symptoms ; whilst in
other cases there is a slight preparatory rise of temperature, and it
is possible, and, indeed, not improbable, that these alterations of
temperature constantly belong to the pyfemic attack, and are the
first effect of the infection.
The first elevation of temperature with which unmistakable
manifestations of the disease commence, which is generally accom-
panied also by a severe rigor, is generally very rapid, sometimes
completing itself even in a few hours, or half a day, generally in the
course of a day, seldom lasting more than one day and a half, or
more, and amounting usually to 2^° to 32° C. (=4^° to 6i-°r.)^ or
more, and only exceptionally less. During the rise the tempera-
ture almost always exceeds 40° C. (104° P.), generally, indeed, ex-
ceeds 41° C. (io5'8° P.), and commonly enough approaches to 42°
C. (107-6° P.).
To be more precise, this rise of temperature generally happens in
this wise — that in the first twelve to fifteen hours, for example, from
morning till near midnight, the temperature rises about 1° to i|° C.)
(i*8° to 2*7° P.), which (supposing any particular fever to have
preceded it) resembles the daily fluctuation affected by this, and yet
is somewhat different. This is followed, after midnight, by a more
rapid rise, and in the morning the temperature is found to be con-
siderably increased ; in cases where there has been fever of any kind
beforehand it is from 1^° to 2^° C. (27° to 4^° P.) higher than
during the daily maximum of the days which preceded.
Sometimes a further, although moderate, rise persists on the days
succeeding the night of fever. The rigor may occur at any point in
302 THE TEMPER ATURE IN PTyEMTA.
tlie apcciullng temperature, and ?oniotiincs may occur even twice
during tlie ascent.
In a minority of cases the rise of temperature during the first
j)aroxysm is essentially more rapid, especially where there has been
fever beforehand, so that in a very few hours the highest peak of
the tlrst paroxysm is reached.
§ 2. The first paroxysm of fever takes an acuminated form (akme-
artig). After the temperature has reached the highest peak or
maximum it begins immediately, just as rapidly, or perhaps more
rapidly than it rose, to fall again ; in a few hours, indeed, it sinks from
two to four degrees Centigrade (= 3"6° to 7*2° Pahr.), so that^ as a
rule, the temperature is lower after the first paroxysm of fever in
pyrcmia than it was before it^ even when a state of fever existed
before the pyremia set in. But after the first paroxysm the tempe-
rature seldom falls quite to normal, although, indeed, it comes very
close to it, but generally falls only as low as 38 — 38-5° C. (100-4'^
to 1 01 '3° F.) The low temperature which succeeds the first
attack of fever, does not, as a rule, last long, scarcely half a day ; in
most cases, as soon as the temperature has reached its minimal
depth, it begins to rise again immediately, and this fresh rise,
whether a vigor is associated with it or not, is generally just about
as rapid as the first; it does not, however, in general reach quite so
great a height.
The first accession of pysemic fever has many points of resem-
blance to the beginning of other acute diseases which are distin-
guished by a short pyrogenetic stage. But, on the one hand, the
temperature in pyeemia reaches a greater height in a shorter time
than it does in any other disease, and, on the other hand, the first
pysemic paroxysm may be distinguished from forms of continued
fever at all events, by the temperature quickly turning back and fall-
ing rapidly as soon as it has reached the acme.
The diagnosis from a paroxysm of intermittent fever or ague is
far more difficult. However, the rise of temperature in the first
access of pysemia is essentially more protracted than in a case of in-
termittent fever. And besides, after the paroxysm of pysemia the
downfall of temperature very seldom reaches the normal, but usually
turns again before 37*5'' C. (99*5° P.) has been passed, and often
long before, to begin a fresh ascent.
THE TEMPERATURE IN PYAEMIA. 3G3
§ 3. The following circumstances in the further progress of the
course deserve notice :
(i) A "brusque'^ rise of temperature to more or less considerable
heights, sometimes more, sometimes less, closely approximating to the
summit of the first paroxysm, and sometimes even overreaching it by a
few tenths of a degree. This is scarcely ever absent, and in the
great majority of cases repeats itself more or less frequently, with-
out any regular rhythm, sometimes twice or even three times in a
day.
(2) A sudden turning back again of the temperature, after reach-
ing the maximal point. Only very exceptionally it happens that the
temperature lingers a half-day or more in the neighbourhood of the
maximum; generally speaking, it goes rapidly downwards immediately
after the summit is reached.
(3) Eapid downfall of temperature after the manner of a rapid
defervescence, or even more rapid than this, not seldom reaching
even to normal or below it, in the later attacks, although even then
not infrequently pausing at 39® C. {io%'2° F.) or even above this.
(4) Only seldom do we meet with pauses of apyretic, or approxi-
mating normal temperatures of half or a whole day in length.
(5) Intercurrently and, as it were, thrust in between the parox-
ysms of fever, more particularly towards the fatal termination of the
disease, there are one or more days' fragments (Strecken) of a con-
tinuous or remittent course, with either an ascending or descending
direction, or it may be of irregular progression.
The well-known rigors, or shivering fits, which are more or less
frequently repeated, and generally coincide with the rapid rise of the
tem.perature, yet are often independent of this, and are som^etime?,
though rarely, absent altogether. The course of pyieinic fever ia
very well characterised by this behaviour, and is thus distinguished
from all other diseases. Amongst the manifold individual ditTerences
met with, diagnosis is much assisted [lit., finding the longitude is
furthered) by Heiibner's setting forth the following principal forms
assumed by the course of the disease :
{a) Cases in which the abrupt rises and downfalls of temperature
very quickly succeed one another.
{h) Cases with widely separated febrile paroxysms, and ajiyretic or
barely febrile intervals.
((?) Cases with continuous fever, and intercurrent sharp elevations
of temperature.
3G4 TIIK TEMTKRATURK IN PV.E.MIA.
Tlic duration of i)ymnic fever, as a rule, is about a week, seldom
less than tliree or four days, seldom more than a week and a half.
Death is not generally preceded by any thermoinetric indications
of a pro-agonistic stage, and sometimes it takes place with com-
])aratively low, or even normal, temperatures, sometimes with those
of medium height, and sometimes with high febrile temperatures.
This is especially the case in rapidly fatal puerperal fever with
hyper-pyretic temperatures.
§ 4. But the fact of deviations occurring in particular cases must
not be overlooked.
In patients already suffering from severe disease death may occur
even at the very beginning of the jjyrcmia, and thus the charac-
teristic features of the course may be lost.
In rare cases pyrcmia follows for a few days a continuous course,
without rigors, or only marked by a rigor at the beginning. This
course is sometimes met with in traumatic pya?mia, and still more
commonly in puerperal {qyqy, especially the form which kills quickly,
and does not go on to the formation of abscesses.
Just about as rarely, at the beginning of pya3mia, we meet with
a rise assuming a zigzag curve, or shaped like an easel, and ex-
tending over several days; or if there were a strong remittent fever
present before pyemia set in, there is a diminution of the remissions,
which later on is followed by an almost instantaneous and extreme
rise of temperature.
Many cases also, at least for a time, exhibit a certain amount of
rhythm in the return of the paroxysms.
Sometimes the disease is protracted, and the paroxysms may even
become less frequent and less severe for a time, but finally the case
terminates fatally notwithstanding.
Lastly, cases occur with a very protracted course, in which for a
long time occasional intense paroxysms of fever interrupt an apy-
retic or mildly febrile course, and sometimes have intervals of one
or two weeks between, and so occupy a correspondingly long time.
The febrile paroxysms may finally cease, and recovery take place, or
deatli follows, whilst the paroxysms become more frequent, as at the
conclusion of a short continued fever.
On the course of the fever of pyaemia consult Ileuhner, whose
work is based on the material of my own wards and those of the
TEMPERATURE IN CATARRHAL AFFECTIONS, ETC. 3G5
Surgical Clinic of Leipsic (1868, 'Arcliiv der Heilkuiide/ ix, p.
289).
Tor pycemic temperature curves see lithographs at end, Table A' I,
XII. — Catarehal Affections op Mucous Membranes.
§ I. As regards the course of their temperature, catarrhal affec-
tions of mucous membranes generally follow no particular type.
In many cases there is either no alteration of temperature,^ or it
only shows somewhat greater daily fluctuations than are met with
in health, so that in the evenings supra-normal, sub-febrile, or even
moderately febrile temperatures, are met with.
Sometimes an ephemeral elevation of temperature, which leads to
no further consequences, may be observed at the beginning of the
disease, and occasionally during its course.
Here and there quite anomalous rises of temperature occur, which
are generally connected with fresh malignancy or with accidental
increase of the catarrhal affection.
They more particularly happen to very delicate people, or such as
before being attacked by the catarrhal malady already suffered from
some chronic disorder.
Little children also often exhibit high temperatures during
catarrhal affections. When catarrh runs a chronic course there
occurs in many cases a fever which assumes the form of hectic,
especially when the chronic catarrh is marked for some time by
exacerbations.
In many catarrhal affections the occurrence of an elevated tem-
perature is a pretty safe sign of commencing comjjlications ; this is
particularly the case in liooplng- cough, in which, therefore, a con-
tinuous daily observation of temperature may be of great practical
importance.
This behaviour of the temperature is common to catarrh of the
pharynx, of the larynx, of the deeper organs of respiration (trachea
and bronchi), of the intestinal canal, of the urinary apparatus, and
of the female genitals. In all these cases fever is the sign of in-
tense irritation of the mucous membranes, rises and falls with this,
' This is ofLen tlie case as regards simple bronchitis and simple diarrhoea, as
I have over aud over again demonstrated to myself and others. — [Tkans.]
3GG TEMPERATUllIi IN CATARRHAL AF1-'ECTI0N8, ETC.
or depends on the surroundings, idiosyncrasies, injurious influences,
and complications of the case.
Tiic temperature may, however, display a more connected and
almost typical course — {o) in intense and particularly in epidemic
catarrhs of the respiratory mucous membrane, which arc then gene-
rally associated with intestinal catarrh and more or less strikinu'
nervous symptoms (influenza) ; {6) in severe gastric catarrh and
catarrhal afTections of the mucous membranes of the bowels, and
again more particularly during epidemics or in cases where these
attacks have been grossly neglected.
^ 2. It is only in severe cases of injltienza that any considerable
alteration of temperature is met with.
The beginning of the rise of temperature is, therefore, seldom
rapid. The temperature usually ascends in a similar course to that
of the initial period of abdominal typhus (see page 300), not, how-
ever, with the same regularity, nor is the time so regularly kept, but
sometimes more rapidly, at other times more slowly, it rises, but
not generally to the identical heights of typhoid fever.
During the fastigium the course is very similar to that of the above
disease, at least similar daily remissions and exacerbations are met
with. The latter may be as high as in ileo-typhus, but are not
generally quite so high.
Besides this, the fastigium is almost always of essentially shorter
duration than in abdominal typhus, and after a few days, under good
nursing, unless other disease supervene, the temperature shows a
tendency to fall. In general, too, the defervescence follows the same
remitting type (lysis) as in abdominal typhus, yet its decrease is
generally more sudden than in that, and its termination takes place
more punctually. On the other hand, it is not unusual, in influ-
enza, for the temperature, after it has almost reached the normal, to
linger for a certain time on a level somewhat above this, or at least
to show somewhat greater evening exacerbations than are consonant
with complete recovery.
The most important diagnostic question in connection with this
behaviour is whether in a given case we have to do with a severe in-
fluenza or a case of typhoid fever (abdominal typhus), a cjuestion
which is rendered still more difficult to decide by the fact that very
often there is a general correspondence between severe influenza and
ileo-typhus in numerous other respects (as regards the prostration,
TEMPERATURE IN CROUP, DIPHTHERIA, ETC. 367
cerebral and nervous symptoms, and bowel symptoms), and that
even when we find enlargement of the spleen it often remains doubt-
ful whether this may not have existed before the present illness ;
even the absence of the rose spots is not conclusive against the
existence of typhoid. If the temperature remains decidedly below
the ranges of abdominal typhus, the answer to this question is easy
in young adults^ and we must exclude typhoid fever.
But if the typhoid ranges are reached or exceeded, which occurs
pretty often, particularly in severe epidemics of influenza, the
differential diagnosis must often be deferred some days ; but with
moderately good nursing, if catarrhal pneumonia do not supervene,
one may be certain that the high temperature will begin to abate,
however severe the influenza, at an earlier date than in ileo-typhus.
In favorable cases the defervescence also will be completed more
quickly than in that. Even in unfavorable cases, where there is very
intense bronchitis, bronchiolitis (capillary bronchitis) and peribron-
chitis, and even in fatal cases, the temperature generally returns to a
level which is incompatible with typhoid fever, whilst at the same
time other severe symptoms persist and contrast with the moderated
temperature. As regards the course of the lung-infiltration which
supervenes, see Fnetimonia.
§ 3. The temperature in febrile gastro-intestinal catarrhs is pretty
nearly similar, and elevated temperature chiefly occurs in greatly
neglected cases, or with defective nursing, or in very delicate per-
sons. We may notice in them the same type of rising temperature,
the same remitting fastigium, and the same kind of zigzag defer-
vescence, and the same practical question arises whether or not we
have to deal with an ileo-typhus (or typhoid fever). The same
criteria are decisive as in influenza, and, indeed, with moderately
good nursing the temperature will be observed to begin to fall
in febrile intestinal catarrh more quickly than even in influenza.
XIII. — Ciioupous AND Diphtheritic Inflammations of the
Mucous Membranes.
In no other acute affections has the temperature so little signifi-
cance as it has in croupous and diphtheritic affections — pharyngeal
3G8 THE TEMPERATURE IN PNEUMONIA.
(lil)lithori;i, laryngeal croup, intestinal croup, dysentery, an,l dipli-
theritic and croupous puerperal endometritis.
One may indeed regard very high temperatures in all these atl'ec-
tions as adding very greatly to the danger.
But moderate or even normal temperatures do not give the slightest
guarantee for a favorable termination. The high temperatures may
even dechuc, whilst the disorder unhaltingly goes on to worse and
worse.
See Richardson on "The Temperature in Diphtheria '' (' IMedical
Ixecord,^ 1^67, ii, 219).
XIY. — Pneumonia.
§ I. The forms of disease which arc comprehended under the name
oi jnieumonia exhibit a very varied thermomctric course. In parti-
cular cases, even acute ones, the temperature is quite unaltered [?J,
in others only a slight febrile movement is induced. In the majority,
however, a more or less sharply defined fever course can be observed ;
but even this, at least to superficial observers, shows the widest
variations — continuous, remittent, relapsing, and intermittent forms
being met with.
Yet it is possible to bring together groups of cases which per-
fectly coincide as regards the course of their temperature, and in
which, therefore, there is as much a typical character as in any other
disease.
It is clear that the varied types met with do not depend (as in
abdominal typhus and variola) on a distinction between sim2)le and
complicated forms.
This manifold complexion of the course taken by the temperature,
which, as said before, must not be regarded as an anomalous
casualty, must rather be regarded as an indication that widely differ-
ing affections are designated by the common expression pneumonia.
And already anatomical investigations have begun to indicate a re-
cognition of this. The names croupous, Immorrhagic, serous, embolic,
purulent, and putrid or sejitic (jauchige) pneumonia, lolular pneu-
monia, &c., &c., represent varieties of such importance that they
must necessarily be regarded as different morbid processes. It must
also not be forgotten that forms of disease which may currently be
regarded as anatomically identical may yet diverge from one another
THE TEMPERATURE IN PNEUMONIA. 369
ill very essential points; and tliat besides the different anatomical
forms assumed by the results of the process, the varying aetiology
may produce differences which essentially differentiate complaints
which many persons comprehend under the same name.
The designation of any form of disease as pneumonia is about as
superficial a classification as that which comprehends all diseases of
the skin which run their course with inflammation under the name
of dermatitis. But the term is useful and necessary, because it is
very often impossible whilst the patient is living to make a more
accurate diagnosis, and to differentiate from one another the different
morbid processes ; and partly so, indeed, because the essential dis-
tinctions tliemselves are, as yet, not clearly mapped out.
Symptomatology has indeed, already discovered a number of data
which indicate different processes as taking place in the lungs in the
diseases classed as pneumonias. But it must be conceded that the
aids thus given to differential diagnosis are as yet exceedingly scanty.
Thermometry is able to considerably increase these diagnostic means.
Yet it must be acknowledged that many gaps yet remain to be filled
up, and it cannot be denied that with all the aid rendered by the
thermometer both our diagnosis and our prognosis of pneumonic
patients is exceedingly fragmentary.
§ 2. In the first place, the thermometer by itself alone cannot de-
cide as to the presence or absence of pneumonia. On the other
liand, when pneumonic affections have already been diagnosed, ther-
mometric observation is able to demonstrate differences which can be
recognised by no other means, and to facilitate the diagnosis of these
special forms ; —
To determine the degree of the affections and its danger ; —
To furnish a delicate standard (Maas-stab) of improvement or re-
lapses, and thus to test the effect of therapeutic measures ; —
To indicate the occurrence and persistence of complications ; —
To determine the completion of the processes ; —
To guarantee the certainty of convalescence and recovery ; —
Or to give warning of the continuance of unresolved and lurking
disorders, and of the supervention of sequels.
In other diseases also, where the access of pneumonia is especially to
be dreaded, thermometry is able to indicate, with great probability, the
earliest actual development of this complication (in measles, bronchial
catarrh, hooping-cough, pulmonary consumption, and pleurisy).
24
370 Tin: TE.MPKRATUiiE IN pm:i:monia.
It must therefore not be forgotten that thermometry in rehition
to ])neumonic ad'ections (in contradistinction to what occurs in abdo-
minal typlius, Sec.) has only the value of an accessory means of
diagnosis. The more decisive, or, if one may call them so, ruder
means of investigation, must give all the aid they can to diagnosis,
and make it in the rough, and then first we learn what important
practical questions, based on what has already been gained, can be
quickly answered by thermometry.
§ 3. Besides the cases of pneumonia which run their course with-
out any fever at all (always exceedingly rare cases), there are some
almost equally rare cases of pneumonic atfections, with almost
momentary and very moderate elevation of temperature (i. e. lasting
for only a few hours), cases in which even the lower limits of mode-
rate fever (38*5° C. = 101-3° P.) are scarcely reached, and that
generally on the first or second day of the illness, and the disease
almost immediately becomes devoid of fever.
Somewhat akin to these are two different sorts of somewhat more
pronounced pneumonic /I'^y/c?^/^. In one of them there occurs,
generally with symptoms of a rigor, and in an abrupt manner, a more
or less considerable elevation of temperature (even to above 41° C.
= 105*8° F.), which is immediately succeeded by a rapid defer-
vescence, so that by the second or third day the normal temperature
has again been attained (ephemera with pointed peak — ahneartige E.) .
In a second series of cases the rise of temperature is more tedious,
sometimes remittent. The highest point (lower than in the first
form, scarcely 40^ C. = 104° F.) is not reached before the third day
of the illness. The temperature then begins immediately to decline
(ephemera protracta).
All these cases of febricula go along with slight local processes,
and only occasionally become dangerous on account of their sur-
roundings. They correspond to moderate, rather (edematous infiltra-
tions, or such as continue very hmited ; the form of ephemera with
pointed peak especially occurs in embolic pneumonia ; the ephemera
protracta occurs in attacks in which little pneumonic deposits (foci)
occur in the course of catarrhal bronchitis. Pneumonic febricula
also occurs not infrequently in secondary pneumonias, also in mild
inflammations of the lung in young children, in very old or emaciated
and phthisical patients, and those with declining powers, and in these
cases the results may easily be very unfavorable. These two forms
THE TEMPERATURE IN PNEUMONIA. 371
of febricala at once represent rudimcutary types of the two chief
forms of pneumonic fever. If we imagine the sharp peak of the first
form of ephemera flattened out, the result is the continuous type,
with its sudden commencement and rapid end ; and if we imagine the
ephemera protracta extended, we get the remittent type, with its
gradual commencement and defervescence by lysis.
§ 4. The fever of pneumonia also shows another peculiarity when-
ever it is more fully developed, which is, indeed, met with in other
diseases, but not so often nor so constantly in any other malady as in
pneumonia — namely, the occurrence of isolated brusque elevations
and of intercurrent falls of temperature.
This hrusciue elevation (like an acutely peaked ephemera, such as,
for example, sometimes momentarily breaks the course of advancing
convalescence in abdominal typhus) very often occurs in pneumonia,
and not merely after decided advance has been made towards reco-
very, but very often immediately after defervescence, or even during
the same, and, so to speak, interru])tiug it ; and lastly, in the course
of the fever itself, in which case we get a very considerable but tran-
sient rise of temperature to heights of 41*5° C. (1067° P.) or more.
The ephemeral elevations of temperature met with during defer-
vescence, or subsequently, very usually amount to 39° C. (io2'2°l\),
and often even above 40° C. (104° F.), but very seldom approach
41° C. (105-8° P.) or exceed it.
§ 5. The intercurrent falls of temperature are in direct contrast to
these brusque elevations. They may occur in the course of almost
any form of pneumonia, so that the regular course of the tempe-
rature suffers a sudden interruption through a deep descent of the
temperature, which sharply contrasts with Ijoth its preceding and
subsequent course.
This intercurrent sinking occurs in the majority of pneumonic
cases, whether slight, severe, or, indeed, fatal. The downfall generally
occurs very rapidly, and may amount to from one and a half to
four or even five degrees Centigrade (= 27° to 7*2° or 9°rahr.),
and the temperature more or less nearly reaches normal ; indeed, it
very often reaches it, and sometimes falls even below this. If the
descent be comparatively trifling (1^° to 2° C. = 27° to '^•6° F.), it
only appears striking because it is thrust into an essentially con-
tinuous course, and, indeed, the most abrupt descents of temperature
do occur intercurrently in this very kind of course.
37.2 THE TEMrilRATLllE IN PNEUMONIA,
Tlie temperature, as a rule, remains only a very short time at this
low level, for generally it rises again almost immediately to its old
heights, or often falls a little short of these, but not very seldom rises
even a little higher. The whole episode generally occupies only
about half a day or, perhaps, even less. Yet sometimes this downfall
of temperature extends itself to a somewhat more protracted apyrexia.
This intercurrent decline of temperature may occur at any time in
the course of pneumonia, from the second day of the illness to the
last day of the defervescence, or even to the death-agony. For the
most part it is met with only once in the course, but sometimes
twice or thrice.
The significance of this intercurrent downfall of temperature is
affected by these varieties. Especially does it modify the course,
and may even give rise to a false prognosis. It is easy to under-
stand that such an event raises hopes that defervescence has already
begun. If defervescence very quickly follows this, it looks as if the
pneumonia had already completely developed itself. But the tem-
perature again rises, and so its downfall proves to be only a deceptive
pseu do- crisis, which momentarily interrupts the course, which after-
wards goes on as before. Yet it may so happen, that when the
temperature again rises it docs not regain its pristine heights, but
assumes a descending direction. Thus, the intercurrent downfall
divides the fastigium into two portions of different character, and
may even appear as the first beginning of a moderated course.
In more protracted pneumonias, such, namely, as last over a week,
a pseudo-crisis very often occurs on the seventh day, and after this
the course may go on with great severity and end fatally, or the
intercurrent downfall may inaugurate a more favorable conjunction
of circumstances. This intercurrent fall can be more safely re-
garded as the first beginning of moderation in the attack when it
occurs, as it often does, although this cannot be prognosticated, on
the day before the definite defervescence. Even then we may be in
doubt whether to reckon it as the actual commencement of the pro-
cess of shaking off the fever, in which case the fresh rise of tem-
perature must be considered as a break in the defervescence; or
whether we should reckon them both as a part of the fastigium.
If the downfall of temperature is several times repeated, we get a
transition to the remitting type.
If an abrupt sinking of temperature occurs regularly several times
M'ith great punctuality, the pneumonia becomes truly intermittent.
THE TEMPERATURE IN PNEUMONIA. 373
If the repeated succession of descending temperatures is less punc-
tual and orderly; the course resembles the abrupt fluctuations of the
If the low temperature persists for a longer time^ and the fresh
rise of temperature does not occur till after two or three days, we
get the relapsing form, and if the temperature does not fall quite to
normal the form with recrudescing fastigium.
The fall of temperature before the death-agony is equivalent to a
pro-agonistic stage.
The true reasons for these intercurrent falls of temperature are by
no means always easy to discover. In many cases the fall appears
manifestly to result from energetic therapeutic measures, which have,
however^ proved insufficient to destroy the disease. In other cases,
perhaps, very frequently it may depend on the local process having
terminated in the part first attacked, and beginning afresh in some
neighbouring place, or extending itself, in which it is very probable
that the second development of pneumonia is less perfect than the
first. But neither of these explanations will suit all cases, and the
unusual frequency of this behaviour of the temperature in pneu-
monia gives rise to the opinion that this is an especial peculiarity
of its course ; and hence we can understand that therapeutic
measures of no marvellous potency in themselves may easily
produce this phenomena of intercurrent falls in pneumonia,
which is a disease already so predisposed to such interrup-
tions.
It is of the highest practical importance to distinguish the pseudo-
critical downfall from definite defervescence, and from the moderation
of temperature which precedes the latter. It is, however, not always
practical. The earlier the downfall occurs, the more reason have we
to expect a fresh rise of temperature, although there are plenty of
cases in which the pneumonia actually and definitively terminates as
early as the second or third day. I'urther, the more unexpectedly
and, as it were, unpreparedly the downfall occurs, the less it har-
monises with the progress of the case in other respects, the closer it
follows some therapeutic proceeding, and the more rapidly the fall
itself takes place so much the more must it be taken for a pseudo-
crisis.
Besides, the preparatory rapid downfall which precedes deferves-
cence by only a single day cannot be distinguished from true defer-
vescence with anything like certainty in many cases, and we must
374 TITK THMPKUATURF. IN PNEUMONIA.
therefore expect a fresli rise of temperature on the followiiiir Clay
after every rnjiid f.ill.
§ 6, The coni'innous or SHbcontinnous type of pneumonia occurs
cliietly in primary croupous^ or lobnr pneumonia, and very often
also in secondary affections. The beginning of the disease is marked
by an abrupt rise of temperature, generally accompanied with a
rigor. The temperature in a few hours rises above 39° C. (io2'2°
F.) and still continues to rise, till it attains a height of about 40° C.
(104° F.), or in severe cases even 41° C. (105*8° F.) or more.
During this first appearance of fever there is very often no other
symptom which directs special attention to any disease of the
lungs. Occasionally only do we find cough, pain in the chest, and
dyspncca. It is very seldom that any auscultatory symptoms can be
found in the thorax. It is much more common to meet with head-
ache, or even delirium, sometimes vomiting, generally loss of appe-
tite, and the patient feels very unwell. Even on the second or third
day the thoracic, and especially the auscultatory symptoms, are often
wanting, and this may be the case even on the fourth day, whilst the
fever continues with great fierceness.
The course of such cases resembles that of an exanthem, and if
we are to make a distinction between attacks of "pneumonic fever "^
and cases with "febrile pneumonia," the cases with a continuous
course of temperature belong, in overwhelming proportions,, to the
first category.
The temperature for the first few days remains at a considerable
height, that is, generally from two to three and a half degrees above
the normal (= 3 6° to 4*66° F.), or in mild cases at 39*2° to
39-6° C. (io2'j6° to 103-28° F.), in severe ones above 40'^
(104° F.), but shows slight fluctuations of i° to 1° C. (= ^"-„° to
I "8° F,), sometimes by brief remissions occurring in the morning,
with quickly returning exacerbations, sometimes by a second rise
occurring about midnight, and sometimes by several exacerbations
occurring in a single day, or quite anomalous fluctuations of plus and
mmus temperatures.
This course practically lasts as long as the process set up in the
lungs progresses, which is seldom less than three days, seldom longer
' This awkward name is the desiguation given in Germany to what is gene-
rally called acute pneumonia in tliis country. — [Teaxs.]
THE TEMPERATURE IN PNEUAIONIA. 375
than seven. Intercurrent falls of temperature may break the regu-
larity of the course on any day. Sometimes also, though very rarely,
tlie daily maxima and the daily minima remain pretty stationary all
through the stage.
More commonly one observes the daily average getting higher and
In'gher, and the excursions or extent of the remissions becoming less
and less (ascending exacerbations), and thus the maximum tempera-
ture of the attack is not reached till a late period. But in the great
majority of cases the opposite happens. The maximum temperature
is met with on the second or third day (generally some time in the after-
noon), or on the day upon which observations are first taken, and from
henceforth the height of tlie temperature declines from day to day,
though, perhaps, only by a few tenths of a degree. Even in fatal
cases this moderation of temperature often occurs. Moreover, it is
conceivable that this customary and steady, although tedious, down-
fall of temperature from the very considerable heights observed at
the beginning of the attack is the result of medical treatment, or of
the careful nursing prescribed.
Even in cases which terminate fatally this descending direction is
commonly enough seen in the fastigium. Yet more or less accidental
irregularities are generally observed. Sometimes a morning remis-
sion is wanting, sometimes an unusually deep fall intervenes, or the
regular remission occurs at unaccustomed hours ; thus the exacerba-
tions are unusually high, at least in the earlier days, and when they
begin to moderate do so but partially. Sometimes before the
disease unmistakably tends to death there occurs a very marked
downfall. Death may occur with low temperature, but generally
the temperature begins to rise again just before death, at first very
slowly, and towards the end very suddenly. When death follows
vi'ith symptoms of suffocation the height of temperature finally
reached is by no means remarkable, generally less than 40*^ C.
(104° E.). But if severe nervous symptoms precede death then a
rapid final rise of temperature occurs to 41° C, (105*8° E.) or more,
and even to 43° C. (109-4° E.).
In favorable cases there is often a visible preparation for im-
provement. The descending direction taken by the temperature
]}ecomes quite clear after the occurrence of the maximum, wliich is
attained early, or after an intercurrent downfall of temperature, whilst
llie remissions become more striking and the exacerbations dimi-
nish in severitv. On the dav before the definitive defervescence a
370 TFIK TKMrRllATURr, IN PNKUMONIA.
psciulo-crisis ol'U'ii takes place, in uhicli the tcinporalnrc falls to
normal, wliicli is followed by a transient but considerable final rise
of temi)crature. On tlu' last or last but one day of the fastigiuni a
remarkable fall (amounting to h° to ^° = 9° to i\35° F., or if the
temperatures liave previously been very high as much as 1° C.
= i'i^° ¥.), or even more, is in contrast to the previous slow increase
of evening temperatures, or in cases not marked by this in contrast
to the continuous height of the fastigium. All these varieties in the
course may be regarded as preparatory moderations of temperature
preceding defervescence. On the other hand, it likewise happens,
often enough, that immediately before the process of defervescence
a considerable rise of temperature sets in [perturbatio critica),
whether there has been any preliminary reduction of temperature or
not. This generally lasts only one evening, or perhaj)s, though less
frequently, a whole morning, or even twenty-four hours. But in this
the temperature only exceeds the height of the previous maximum in
exceptional cases.
The defervescence, in the majority of cases, begins late in the even-
ing, though sometimes as early as the afternoon, or in others during
the night, comparatively seldom in the morning or noon-time, and
occurs most commonly between the fifth and seventh days, tolerably
often on the third or fourth, or on the eighth, more rarely on the
ninth or tenth, or at a later date ; and the opinion advocated by
Traubc, and others who have followed him, that the crisis occurs in
the majority of cases on the odd clays, is quite erroneous. Compare
Thomas on the doctrine of critical days in croupous pneumonia in
1865 ('Archiv der Heilkunde,^ vi^ 118).
Defervescence generally takes place rapidk, so that when the
previous temperatures have not been excessive the normal point is
very often reached in the course of one night, and, indeed, in most
cases this occurs within twenty-four to thirty-six hours, and on the
intervening evening the temperature usually continues to fall, but
less rapidly, or is sometimes broken by a considerable rise (evening
exacerbation) .
It is not very rare, especially when there has been very high fever,
for the defervescence to require forty-eight hours for its completion.
It pretty frequently happens that the temperature in falling over-
steps the normal, and collapse temperatures result. Other severe
symptoms of collapse may also be met with in the stage of defer-
vescence^ which appear very dangerous to the uninitiated, but which
THE TEMPERATURE IN PNEUMONIA. 377
may be considered as formiug an essential portion of tlie transition
to recovery.
In most cases of pneumonia the arrest of its extension and the
remission of its symptoms first begin during the defervescence^ or
after its completion. On the other hand, the nervous symptoms,
when such are present, generally last through the period of defer-
vescence in great and undiminished severity, or even occur at this
period for the first time, if they have previously been absent. The
course of the defervescence may be varied by the simultaneous pre-
sence of very severe bronchitis or acute pleurisy along with the
pneumonia, and also in cases where pneumonia attacks a patient
who was suffering from some other disease beforehand. In general,
when the normal temperature has once been fairly reached, the
further progress of convalescence is not marked by any more devia-
tions, but runs a regular course. Yet occasionally on the evening
of the second or third day after, there are slight elevations of tem-
perature, which, when repeated, justify us in assuming some com-
plication to exist, or that the local process in the lung is imperfectly
recovering. But during the early days of convalescence very
considerable, although transient, elevations of temperature may
occur without any unfavorable significance attaching to them.
Eelapses also occur pretty often, but such cases cannot be distin-
guished from relapsing pneumonia.
"When subnormal temperatures and other symptoms of collapse
have set in, the low temperature and a very extreme degree of col-
lapse may last for several days, marked by fluctuations, till at last
the temperature settles at normal.
§ 7. Many cases of pneumonia show the continuous type less
ferfecihj, since more or less deviations in the course of the tempera-
ture occur either in the beginning, middle, or end of the course,
which do not materially affect the most important feature of the
course, l^or example, its beginning may be less rapid and less
abrupt, and it may last for two days or more, till the temperature
has reached a high level.
Or the temperature in its course may remain at a lower level than
in well-developed pneumonias, or may approximate to a remit-
tent type by the fluctuations being very considerable, or to an
intermittent or relapsing type by great falls of temperature.
Or on the other hand, the course of the fastigium may be both
.'378 THE TKMPKllATUm; IN rNKUMONTA.
uimsually severe aiul unusually jirolongcd, which hajjjx'ns in dijiihle
pneumonias, or with acute pneumonia of the upper lobes, or Avhen
a whole lung is attacked with inllammation. In such cases the
t'astigium is generally prolonged into the second week, or even to its
end. JJut then it is by no means stationary, but towards the end of
the first week, or sometimes even earlier, there commences a stage
of fluctuations, an amphibolic stage, with alternations of improvement
and relapses. W e must not expect a rapid defervescence in such
cases.
In particular, the defervescence may be protracted and com-
plicated, may occur less ra])idly, and may exhibit slight subsequent
elevations of temperature.
Such deviations from the normal fashion of the continuous course
occur under very many different circumstances. On the one hand
they occur in children, on the other in very old people, and espe-
cially in sick persons, whose idiosyncrasies predispose to irregu-
larities of the fever course.
They occur in secondary croupous pneumonia, which, indeed,
sometimes follows an identical course with that of primary,
but in other cases exhibits more or less deviations from such a
course.
And occasionally such variations occur in all kinds of pneumonic
attacks, just as in other typical affections there are some epidemics
in which irregular cases greatly preponderate.
Accidental complications of the case, sometimes with actual sepa-
rate disease, sometimes only with isolated disturbances originating
in other organs (severe delirium, obstinate constipation, or retention
of urine, Src), may, indeed, easily induce more or less considerable
modifications in the course of the temperature, and this especially
occurs with previously existing emphysema of the lungs or coin-
cident acute pleurisy, the occurrence of bilious symptoms, of albu-
minuria during the course of the attack, and of severe diarrhoea or
vomiting. In those cases, too, in which the fever supervenes on an
already developed inflammation of the lung, which is most charac-
teristically shown by traumatic pneumonia, deviations from the pure
continuous type are almost constantly met with.
Deviations from the regular course of pneumonia are very often
brought about by the operation of energetic therapeutic measures,
or by some favorable event occurring, in which case they may be
advantageous to the patient.
THE TEMPERATURE IN PNEUMONIA . 379
The most deeiclecl ivfiitence on the course of the fever is hrought
about hy a sufficiently/ copious Lloodlettinj or a free spontaneous
hemorrhage {bleeding from the nose, the metises, ^c). The immediate
result of a considerable loss of blood is almost always a considerable
reduction of temperature ; but it depends on circumstances whether
this may shape itself as a definite defervescence, or be followed
by a fresh rise of temperature, and in the latter case a more or less
complete approximation of the course to the relapsing type may
occur. Emetics operate in a similar way to losses of blood ; digitalis
and veratria do so somewhat more slowly, whilst the influence of
other medicaments (potassic nitrate, aconite, &c.) on the type of the
temperature in pneumonia is either less striking or not so well
established.
On the other hand, injudicious therapeutic measures and other
accidental injurious influences may cause deviations from the type
of an injurious nature.
Lastly, in many cases of pneumonia, in which tlie course of the
fever exhibits certain irregularities, the true reason can sometimes be
only surmised (as, for example, that the infiltration approximates to
a hsemorrhagic form, or to cedema), and is generally not discoverable
at all.
§ 8. A remittent course of fever occurs in those pneumonias
which are developed after a longer or shorter course of bronchial
catarrh, in catarrhal pneumonias and the pneumonia of influenza;
but even in the latter case the pneumonia exhibits the remittent
type most clearly when its course begins to be complicated by severe
bronchitis. In the same way the pneumonia of measles aiul of
hooping-cough is often distinguished by a remittent fever; but
sometimes cases occur with a remitting type in which we are
unable to demonstrate any particular bronchitis either before or
during the whole course of the pneumonia.
Eemittent forms of pneumonic fever are common enough in
children and in very old people.
At many periods almost all cases of pneumonia exhibit a remittent
course.
Even although the pneumonia may be developed in a person pre-
viously free from fever, the beginning of the rise of temperature is
less rapid in the remittent type than in the continuous ; sometimes
it is even zis'zag in character, like the be2:innin2: of abdominal
380 Tin: tioitkratukk in pneumonia.
typhus ami inllucnzn, yet it is generally rather more sudden and
irregular than the lirst of them at all events.
If the luug-aHectiou is developed in a patient who was previously
feverish, although the course of the previous fever may have been
very moderate, as, for example, during a mild feverish bronchial
catarrh, the beginning of the proper pneumonic rise of temperature
is generally not clearly defined.
During the fastigiuni the course of the temperature exhibits more
or less considerable iluctuations, similar to the morning remissions
and evening exacerbations of ileo-typhus (typhoid fever). In cases
of moderate severity the exacerbations seldom reach the height of
the daily maxima in abdominal typhus, and therefore fall short of
the maxima which occur in the continuous course of pneumonia.
Ill, certain severe cases, however, they may equal or even exceed these,
and more than one severe case has occurred in which the afternoon
temperature amounted to 40° Cent. (104° Fahr.), or even a little
more. However, the course of the disease is seldom so regular as
in abdominal typhus — more often larger and smaller exacerbations,
and more or less considerable daily remissions, alternate with one
another.
On an average, the duration of remittent pneumonia exceeds that
of the continuous, without, however, extending to the same length
as abdominal typhus.
The termination of the fever only exceptionally happens by very
rapid defervescence ; it generally occurs in a protracted manner by the
morning remissions gradually becoming greater and the evening
exacerbations growing less, but always, however, more rapidly than
in ileo-typhus.
It is pretty common, too, for the fever to terminate at the close,
after the daily excursus has already become very considerable, by
a sudden, final descent from a still very considerable evening
exacerbation.
Imperfect convalescence is more commonly associated with the
remitting than the continuous course.
Transitional forms between the continuous and remitting course
are by no means rare, just as undoubtedly croupous and catarrhal
pneumonia are closely allied to each other.
The truly characteristic remittent catarrhal pneumonia only ex-
ceptionally occurs sporadically, but, on the contrary, chiefly during
the prevalence of a severe epidemic of influenza.
THE TEJIPERATURE JN PiNEUMONIA. 381
The diagnostic question, whether there is hronchitis or pneumo-
nia during a remittent course, cannot be settled entirely by ther-
mometry, but this must generally be done by taking into account
the acoustic symptoms. But pneumonia is highly probable when
the exacerbations exceed 40° Cent. (104° Tahr.) in height.
The differential diagnosis from abdominal typhus may present no
little difficulty, more particularly as infiltrations of the lung may
occur in this disease, and, on the other hand, the cerebral and abdo-
minal symptoms are very similar to those of typhoid, and even the
ppleen may become enlarged. And it is not always possible to make
a correct diagnosis when only a limited abstract of the course lies
before] us. But in favorably progressing pneumonias the diagnosis
is generally possible after observation for some four days or so. If
they are the first four days of the disease, the rise of temj^erature in
pneumonia will be found less regular than in abdominal typhus.
(See page 300.) If the days are at later periods, one generally observes
in favorable cases of pneumonia a constant diminution of the high
evening temperatures, and if the disease has already shown a decided
decrease it may be taken as true that this makes more rapid progress
than in ileo-typhus.
§ 9. A course with recrudescing fastigium not infrequently
occurs as a modification both of the continuous and remittent types,
and is remarked in those cases where, after the hepatization of one
part of the lung, either a second lobe or the other lung is attacked
{saccade 'A. progressing pneumonia) .
After the previous temperature has been pretty moderate, or the
course has already begun to moderate, there occurs all at once a rise
of temperature, which is shortly succeeded by either a continuous or
discontinuous course.
Unless death occurs, the convalescence generally resembles that of
the other cases, though it sometimes displays irregularities, and is
at least more protracted than in the simple continuous course.
§ 10. Sometimes the fever in pneumonia displays a relapsing
course. This may occur after a general or large local abstraction of
blood, and sometimes also without any external interference at all.
For the most part a rapid defervescence occurs unusually early,
perhaps on the second or third day, although sometimes later, ju^t
as in recovery from croupous pneumonia.
38.2 THE TKMl'EUATUllK IN PNEUMONIA.
Tlic temperature continues fully normal, or it may be sub-febrile,
for eighteen, twenty-four, and sometimes thirty-six hours or more,
and it seems as if recovery would follow, yet there is uo actual retro-
cessiou, generally speaking, in the local symptoms.
All at once the temperature rises again rapidly, although it does
not usually reach quite its former height, remains generally only a
few days at the fastigium, and then tends towards a definitive defer-
vescence, or the fever may thus renew itself a second or even a third
time.
By imperceptible gradations these relapsing cases are allied to
the one just described above (§ 9), in which there occur remissions
or pseudo-crises, with an extended apyrexia.
During the febrile relapse the local chaiiges either remain sta-
tionary, or they become intensified in certain spots (the duluess
becomes intensified, the bronchial breathing more perfect), or they
extend further.
Sometimes, although nut invariably, erratic pneumonias exhibit a
relapsing form; by erratic, I mean those pecuhar forms of the disease
in which (like erratic erysipelas or many cases of polyarticular rheu-
matism) the lung affection jumps from one spot to another, the
places first attacked heal again, whilst new spots are invaded, and so
infiltration and resolution succeed with extraordinary rapidity, as in-
dicated by auscultation and percussion.
§ II. The i?ifermiUen( course is closely allied to the relapsing, and
only differs by the fact that the apyrexise and the paroxysms alternate
in tolerably regular rhythm, and are more sharply defined, one from
the other, than is the case in the relapsing form. The fever
paroxysms themselves resemble the pneumonic ephemera with
acutely pointed peaks. The local anatomical symptoms may also
diminish during the apyrexia or interval. This form is only ob-
served in its most perfect development during epidemics of intermit-
tent fever.^ An intermittent type may also be observed in embolic
pneumonias with a tendency to repetition (self-repeating).
Intermittent pneumonias may lead to erroneous opinions in a two-
' This iulermitteut form of pueuinouia is occasionally found in maiuiiuus dis-
tricts in England, I have myself observed it in patients from Barking lload,
and I remember Dr. Tsicholas Parker, late Physician to the London Hospital,
pointing my attention to the same fact. — [Tkans.]
THE TEMPERATURE IN PNEUMONIA. 383
fold manner. The defervescence which occurs leads to the con-
clusion that the disease is at an end, and perhaps tliat some par-
ticular treatment has cut it short. And, on the other hand, after
repeated attacks and returns to apyrexia, we may easily fancy that
we have to do with an intermittent fever. However, in intermittent
pneumonia — at least so far as I have seen — the attacks become spon-
taneously weaker after two or three attacks, which seldom happens in
intermittent fever, unless specially treated.
Intermittent pneumonia may terminate either by no fresh rise of
temperature occurring after defervescence and the establishment of
convalescence, or by the intermittent character becoming obscured
after several repetitions, and later on the pneumonia terminates with
moderately high temperatures as a remittent form, which goes on to
convalescence by lysis. I have never seen it cud fatally.
§ 12. The course with abrupt, and hence for the most part imi)er-
fect fails of temperature and fresh irregular elevations, exhibits the
greatest resemblance to jj^aania, and is doubtless pysemia with a
preponderance of lung symptoms. Sometimes repeated embolic
processes in the lung with multiple centres (foci), sometimes septic
processes, display this course, wdiich, as a rule, ends in death. If the
individuals are emaciated, the rising temperatures alternate with
more or less intense collapse.
§ 13. Pneumonias vi\ih.2:irotracted course generally display nothing
remarkable at the commencement of the attack. They are either
continuous or discontinuous in their course during the first few days.
Eemissions occur later, if not beforehand. But instead of showing
a tendency to recovery, the fluctuations continue considerable. High
evening temperatures alternate with severe collapse. The daily
maximum generally occurs about noon. In the evening there is a
remission, which has a great tendency to collapse, and this is suc-
ceeded by a second, although slight, exacerbation about midnight.
Thus it may happen that, whilst the remissions continually increase in
depth, the exacerbations also increase, and thus the daily difference is
augmented.
But this tolerably regular course only lasts a few days; other modes
of temperature occur intercurrently, which again make way for the
great daily excursus. If the patient does not succumb, the case lasts
a long while, till the exacerbations diminish, and very often a course
SSI TllF- TEMPEllATURE IN PNEUMONIA.
which has ahnost advanced so far as to be free from fever, is again
inferrupted by fresh elevations of temperature for one or more days.
lu those cases in which only moderate evening exacerbations con-
tinue for along time, which may depend partly on imperfect recovery
from the pneumonia itself, and partly upon the existence of marked
comi)lications (pleurisy, or purulent bronchiectasis), the transition
towards a state free from fever, when it does occur, is always gradual
and almost unnoticeable.
§ 14. Terminal pneumonias (pneumonic des agonisants) do not
always necessitate an elevated temperature. And where this has pre-
viously existed it is by no means necessary that this should be
altered by the occurrence of infiltration of the lungs.
Yet, on the other hand, in cases of patients previously very ill,
whether the original disorder has been acute or chronic, the suj)er-
vention of pneumonia very frequently leads to the fatal termination,
and this is indicated by the temperature rising.
At first it only rises moderately, but may rise to very considerable
heights in the last few days, or even at an earher period. But it is
quite exceptional, no doubt, to find a high febrile temperature pro-
duced by such a terminal pneumonia, and when this is met with it is
pretty surely brought about by otlier circumstances, and not by the
pneumonia itself.
§ 15, Traule has communicated some remarkable facts on the
peculiar course of the temperature in pneumonia, in his paper on the
effects of digitalis (1850, 'Charite Annalen,' i, 622), and on crises
and critical days (1851 and 1852, ^Deutsche Klinik^). Consult,
further, wj/ oivn publications concerning pneumonia (in the 'Archiv
f. phys. Heilkunde,^ 1856, p. 17, and 1858, p. 27, and the 'Arclnv
der Heilkunde,' 1862, p. 13) ; Ziemssen. ('Pleuritis und Pneumonic
im Kindesalter,' 1862); Thomas (\\\ the 'Archiv der Heilkunde,'
1864, p. 30, and 1865, p. 118) ; Koclter ('Behandlung d. crouposen
Pneumonic mit Yeratrum,' 1866); ScJ/yditer ('Sitz-Ber d. Kais.
Acad.d. Wissensch.,' Juli, 1868); Kumann ('Prager Yjschr.,^ 1868,
iii, 72); Grmshaiv ('Dublin Quarterly Journal/ May, 1S69);
Maclagan ('Edinburgh Medical Journal,^ February, 1869, p.
684), &c.
For the curves of the fever-course in pneumonia see the diagrams
at the end, Table YI.
THE TEMPERATURE IN AMYGDALITIS. 385
XV. — Amygdalitis.
{Tonsillitis — Qmn sj/.)
§ I. Tonsillar angina is analogous in many respects to pneu-
monia, and its various modifications ; though, if we exclude diph-
theritic affections of the pharynx, the danger is never so great, and
therefore its course in every respect exhibits less severe types.
As in pneumonia, so also in tonsillitis, there are two distinct
species of fever, as regards their relation in point of time to the
local symptoms. Whilst in a number of cases the fever, and the
topical disorder are simultaneously developed, or the former only
succeeds the latter ; there are also not a few cases in which (as fre-
quently in croupous pneumonia also) an intense fever, resembhug
the prodromal fever of an exanthem, precedes the development of
the tonsillar angina by some twenty-four to thirty-six hours^ or
even two or three days.
The latter course occurs in catarrhal as well as in parenchymatous
tonsillitis : and is relatively more common in the first, although on
the other hand absolutely less frequently met with, since febrile
catarrhal anginas are not quite so numerous as those of the paren-
chymatous form.
No sharp boundary line can be drawn between the fever-type of
these two forms of tonsillitis, but certain symptoms occur more
frequently in one form than in the other.
§ 2. When fever sets in at the very beginning of the disease,
whether any phenomena of the disease can be observed localised in
the tonsils, or none can be seen so soon, there is almost always a
rapid development of febrile symptoms ; very often accompanied
with a rigor, and still more frequently with strong sensations of chil-
liness ; though it is not so very rare to find cases with an imme-
diate feeling of heat. In this respect there is no essential distinction
between the catarrhal and parenchymatous forms.
It is not possible to accurately state the form assumed by this
initial rise of temperature, since the cases which come under obser-
vation during this period are not sufficiently numerous. The
temperature generally reaches its maximum height during the first
few days of the disease, most commonly on the third day of the
25
386 THE TEMPERATURE IN AMYGDALITIS.
illness, though oftcu enough on the second or fourth. The maximal
heights arc on an average lower in the catarrhal, than in the paren-
chymatous form ; in the former they seldom exceed 40° C. (104°!'.),
whils^t in the parenchymatous form, though it may not be very
connuon, still there are many cases which reach a height of from
40° — 4075° C. (104° — J05'35° r.). In the great majority of cases
the maximum temperature in the parenchymatous form remains
between 39° and 40° C. (i02'2° to 104° F.), whilst in the catarrhal
it still remains under 39" C. (102-2° T.).
A descending direction can be generally noted in both forms,
after the maximum is reached, although the crisis may not occur
directly.
The course of the temperature in both forms is diseonthmous
during the fasiigium : but in the catarrhal form when the tempera-
tures are higher than those mentioned above, the fluctuations are
greater, and the remissions sometimes almost descend to normal;
whilst in cases of very high temperature, in the parenchymatous form,
the course is actually wont to approximate more to a continuous
type, at least in the first few days, or exhibits only an isolated peak
of elevation. But very marked remissions, on the other hand, are
more often seen in the parenchymatous form, when the temperature,
after reaching its maximum, begins to moderate.
A critical perturbation precedes the crisis in some casc-Sj although
it is rare.
§ 3. A rapid defervescence is by far the commonest form in both
kinds of amygdalitis, occurring in about two thirds of the cases of
the catarrhal form, and in about five sixths of the parencliymatous
cases.
In the great majority of cases the crisis begins betw^een the third
and fifth day, more rarely on the second, sixth, or seventh days, and
still more rarely at a later period. In catarrhal tonsillitis a post-
ponement of the crisis to the two last days of the week (of the,
illness) is relatively more common. On the other hand, the defer-
vescence, if it takes place at all rapidly, is sooner over in this form
(doubtless because the temperatures are less high than in the other
form), and generally takes place in one night, whilst in the paren-
chymatous form, though often enough completed in a night, it just
as often takes from twenty-four to thirty-six hours.
Sub-normal temperatures are sometimes met with after defer-
THE TEMPERATURE IN rAROTlTlS. 387
vescence in the parenchymatous form, but never occur at this stage
in catarrhal tonsilHtis. If, on the opposite, defervescence takes the
form, of Ijsis, which especially happens in cases with moderate tem-
peratures, slight elevations of temperature may be met with for
several days, and recovery is retarded.-^
Consult Thomas (1864, in the ' Archiv der Heilkunde,' v, 170)
and Treihmann ('liber Angina Tonsill/ Diss., 1H65), who both
made their observations on cases in my wards.
XYI. — Parotitis.
{Mum^s, and Inflammations of the Parotid Gland.)
Parotitis affords us an immense variety of varying carves of tem-
perature, and indeed we cannot expect that it should be otherwise,
when we consider under what various circumstances the inflammatory
affections of the salivary glands and their surroundings occur ; not
only as a primary epidemic affection {M?cmjjs) in w4iich the fever is
generally very slight ;" as a catarrhal affection ; as an inflammation
induced by contiguity ; as a complication of the most varied infec-
tious constitutional diseases ; as a metastatic form in pysemia ; as a
terminal disorder in severe febrile and wasting diseases, &c., &c.
Many of these forms, and particularly such as are accompanied
by fever, do not occur sufficiently often to render it possible to lay
down rules for the course of the temperature in particular cases,
especially as such cases are almost always complicated, and therefore
' In addition to the croupous and diphtheritic affections of the tonsils, which
properly belong to diphtheria and croup, I thiuli. the following forms of tonsillar
affections are frequently met with :
1. Catarrhal (as described above), most common in xantho-tubcrcular, or
epithelio-rheumatic patients, generally young persons or children of either sex
commonly affects both tonsils.
2. Gouty, attacking one tonsil usually.
3. Erysipelatous, attacking one or both tonsils, and tending to spread (most
common in middle-aged or old people).
4. Consecutive, following the exanthemata (scarlatina being of course
excluded from this classification).
5. Syphilitic, attacking both tonsils.
6. Tubercular, analogous to tubercular pneumonia.
7. Catamenial (see note, page 102) — [TraisS.]
- I have often seen a maximum of dO^ C. (104' P.), and sometimes a littlr
more, in the fastigium. — [Teans.]
388 THE TEMTERATURE IN PAROTITIS.
require a largely accumulated experience to enable us to eliniinate
the effects of the parotitis from those of the original disease.
It can, therefore, only be stated generally that in the various
forms of parotitis the temperature behaves itself as follows :
There is either no alteration of the previously normal or febrile
lcmi)crature (this ha])pcns pretty frequently); or there maybe a
moderate elevation of temperature ;
Ephemeral rises of temperature may occur, followed by either
sudden or protracted downfall ;
There may be several days' continued fever ;
Or remittent fever ;
Or the course of the fever may assume a pycemic form ;
Or final elevations of temperature to very high degrees ; —
Or collapse may occur.
XVIL— Meningitis.
§ I. Many attacks of meningitis occur, which either run their
course without any fever at all, or only display irregular elevations of
temperature, which are by no means characteristic. Such is the case
in chronic and partial forms of inflammation of the meninges.
Even the acute and more extensive forms of meningitis do not
correspond, one with the other, as regards the course of the tempera-
ture ; yet it is possible to lay down certain definite rules, which in-
deed are not very precise, nor are they invariable, but still serve
for the great majority of cases.
In this way there are three special modifications of meningitis,
which difi'er as regards the course of their temperature : —
{a) Acute sporadic inflammation of the pia mater of the convexity,
or upper surface of the brain.
{b) The granular (tuberculous) form, which has its seat more
especially at the base of the brain, in the fissure of Sylvius, and about
the cerebellum.
(c) The epidemic form generally attacking the base and the con-
vexity simultaneously, and extending itself even to the spinal cord
(epidemic cerebro-spinal meningitis).
As these various forms differ in their aetiology and their special
symptoms, so also they exhibit variety in the course of the
temperature.
THE TEMPERATURE IN MENINGITIS. 889
§ 2. The fever in acute meningitis of the convexity, according to
the cause of the disease, sometimes begins very rapidly, sometimes
more or less slowly.
So far as I can decide from not very numerous cases, the rise of
temperature very soon becomes very considerable, and maintains
itself at striking elevations (above 40° C. = 104° F.) in a conti-
nuous fashion ; and rises still higher in the death agony, so that death
usually occurs with hyperpyretic temperatures. The whole course
lasts only a few days.
§ 3. In granular basilar -meningitis (tubercular meningitis), the
commencement of the elevated temperature generally escapes obser-
vation, either because the insidious beginning of the disease has
excited no attention, or because the previously existing disorders
(tuberculosis of the glands, or of the lungs) have already caused the
temperature to be high.
Sometimes the course of the temperature continues very slightly
above normal, sometimes at moderate fever-heights with (usually)
a remittent type ; but it is not very unusual for it to reach the same
height as the fever of abdominal typhus, and then to display isolated
and striking falls of temperature, and sometimes pauses extending
over several days.
When the fatal termination approaches, after a longer or shorter
course, it is quite exceptional for the temperature to rise. In general
it sinks rather, if it has been febrile, if not quite to normal, yet far
below the previous degrees, whilst the pulse is rising all the tvhile.
During the death agony this sinking may continue, or just before
death there occurs a final more or less considerable rise of tempera-
ture ; the pulse, on the other hand, rapidly increases in frequency,
almost up to the very moment at which the heart ceases to beat.
§ 4. Epidemic cerehro- spinal meningitis is obviously a form of
disease, which in spite of the actual identity [of the anatomical lesions]
may present itself under apparently widely different symptoms.
Accordingly the temperature may pursue varied courses. As,
however, observations on temperature have only lately been made at
a few places in the last German epidemic, the materials are still
too scanty to enable one to represent the manifold varieties of the
fever course of this disease in an exhaustive manner.
From rather more than thirty cases observed by myself, it appears
390 THE TEMPERATURE IN MENINGITIS.
to me tliat three special varieties of the fever course can be particu-
larly distinguished.
(a) In some voy severe and rapidly fatal cases, the temperature
displays a similar course to that of meningitis of ihc convexity.
Though not invariably very high at the bcgiiuiing of the disease, it
reaches very striking heights in the briefest time, which persist con-
tinuously for some days, and rise just near death, and in the very
moment of death to quite unusual degrees (42° C. (io7"6° P.), and
more; and in one case 4375° C. (11075° ^0 ^" ^yi"g)^ ^^^ ™^y
even rise some tenths higher after death (three cjuartcrs of an hour
after death in the case just mentioned, it was 44* 1 6° C. = 1 1 1*48° V.).
There were also some fatal cases, in which the temperature for some
time was very moderate, and rose considerably all at once just near
the end of the disease.
{d) On the other hand, relatively mild cases, exhibit only a fever
of short duration, although there are sometimes considerable eleva-
tions of temperature (which contrast with the quiet pulse), and the
course is generally discontinuous. Recovery does not take place by
decided crisis, but generally happens rather with remittent defer-
vescence [lysis] : and the pulse then begins to quicken just as the
temperature has become normal, or nearly so. Here and there cases
occur, which after defervescing, and apparently almost recovering,
relapse all at once, with a rapid rise of temperature, and run a course
like the cases marked {a).
(c) In contrast to these brief courses of fever with either very
severe or slight character, we find cases which are more or less pro-
iracted, with a corresponding course as to the fever. The height of
the temperature in these may be very varied, and indeed exhibit
manifold changes in the very same case, though indeed this chiefly
depends upon the varied complications which supervene, in the shape
of bronchial, pulmonary and intestinal affections, and affections of
serous membranes.
Sometimes the fever has the same duration, and the exacerbations
of temperature the same height as those of typhoid fever, and its
curves when projected may greatly resemble the latter; but there is
not the regularity of abdominal typhus, and at the best the course is
only that of the amphibolic period of that disease, or hke that which
occurs in very irregular forms of it. Tluctuations of considerable
extent, apparent improvements, and fresh and sudden rises of tern-
THE TEMPERATURE IN PLEURISY, ETC. 391
perature are met with. Sometimes the course resembles the fever of
phthisical patients.
Defervescence may , occur rapidly^ but is^ however, for the most part
protracted [by lysis] .
With a fatal termination, we may get either a rising or falling'
temperature^ according to the kind of case, and the various imme-
diate causes of death. I have related at some length a very remark-
able case, in which both the course of the temperature and the other
symptoms rendered the diagnosis doubtful for a long time, whether
we had to do with abdominal typhus or cerebro- spinal meningitis,
in the ' Archiv der Heilkunde/ vi, 371.
Compare also my oivn publications (1864, ' Archiv der Heilkunde/
v_,4i7, and 1865, ibid., vi, 368), also Ziemssen and Hess (1865, in
the ' Deutschen Archiv f iir Klinisch Medicin,' i, 7 2 and 346) , and
Mannhopf (' liber Meningitis cerebro-spin. epidem.,' 1866).
See lithographs, Table YI.
See also ' New Sydenham Society's Biennial Retrospect of Medi-
cine for 1865-6 ' (pp. ^^)-^%, &c.), and articles in Hussell Ecynolds'
^ System of Medicine,' and Aitken's ' Theory and Practice of
Medicine,' and the " Supplemental Bibliography " at the end.
XVIII. — Pleurisy, Endocarditis, Pericarditis, and
Peritonitis.
Inflammations of the serous membranes of the chest and abdo-
men exhibit, in the great majority of cases, perfect absence of any
typical character.
They may run their course without any elevation of temperature,
for if they are occasionally found with high temperature, at another
time we find them quite free from fever.
If they are associated with any other febrile diseases, they very
often effect no change in the temperature course, or only cause it to
be irregular, without any characteristic form. They generally retard
the defervescence of the primary disease, making it protracted and
imperfect, and they have a share in the fresh elevations of tempera-
ture which occur at a later date.
They may, however, themselves induce the temperature to rise,
sometimes moderately, at other times to considerable heights.
■•■{02 TTIK TEMPRRATURE I\ Pl-EURISY, ETC.
Lastly, they may depress the temperature to sub-normal degrees,
or even collapse-temperatures.
Tn spite of the great number of temperature curves of such cases
which I possess, 1 have never been able to deduce more than a few
"■cneral propositions as to the significance of temperature in those
aU'ections, which I may formulate as follows :
(i) There is no course of the temperature in these affections
which can be regarded as denoting safety ; whatever the course of
the temperature, a fatal termination may ensue. No behaviour of
the temperature guarantees that the disease shall end in perfect
recovery.
(2) The most advantageous course, i. e., that which renders a
favorable termination most probable is —
"When the temperature all through is either not affected at all, or
when the temperature keeps within the bounds of sub-febrile tem-
peratures, or of slight febrile movement, or only very slightly
exceeds them, and especially when it does not fall to sub-normal
degrees (Fundamental Propositions, § 15), or when a moderate fever
with remittent character is present, and does not exceed a fortnight,
and then gradually subsides, without any other suspicious symptoms
supervening.
(3) Subnormal temperatures are especially common in peritonitis,
and are always highly suspicious. Death very often occurs with
temperatures below the normal, which may either result from a fall
shortly before death, or they may have lasted some time already, or
have alternated with normal and elevated temperatures.
(4) Temperatures of considerable fever height, and particularly
rising temperatures, are per se, however, no argument for an un-
favorable termination, although they certainly add another danger-
ous element to the case. If these high temperatures become
moderated, the danger is not entirely removed, but this is better at
all events than their persistence.
(5) It is not so much the actual height of the temperature, but
especially its remaining stationary (the absence of remissions) which
o-reatly increases the danger ; and still more a long continuance of
very high temperatures, and this is so even when the high evening
exacerbations alternate with considerable morning remissions. In
the first case the disease is very severe, in the second event a perfect
recovery is at least doubtful. The return to normal temperatures
after high ones, when it occurs in these aflfections (whether they are
THE TEMPERATURE IN PLEURISY, ETC. 393
inclepenclent, or only complications of other diseases), is often
delayed, and greatly hinders complete restoration to health, and
induces disturbances during convalescence, but does not prevent the
temperature finally finding its level.
(6) Very considerable and irregular fluctuations between very
high temperatures and very low ones, such as occur in pyaemia, are
especially common in endocarditis ; sometimes occur in inflammation
of the pericardium, and of the pleurae, and also in peritonitis : they
are always most highly dangerous, and render a fatal termination
very probable.
(7) Hyperpyretic temperatures are more especially met with in
many cases of peritonitis ; particularly in the puerperal form : and
lead us to suspect that besides the inflammation of the serous
membranes, another process (originating in infection) has been set
up : whilst those forms of peritonitis in child-bed which run their
course without much elevation of temperature are apparently to be
grouped with simply local affections. The former (those with very
high temperatures) are tolerably certain indications of a speedy
termination in death, which occurs in such cases with more or less
considerable degrees of temperature. A very interesting observation
of KussmauVs deserves to be mentioned here. It is contained in
the 'Deutsch. Archiv fiir klinisch. Med.' for 1868, iv, i. He
noticed in cases of foetid and purulent febrile pleurisies (empysema),
that after thoracentesis the temperature very quickly returned to
normal. I have observed a similar case myself, whilst in a case of
fibro-serous exudation (pleuritic effusion) the moderate fever which
was present was not materially affected by the tapping.
[Dr. Edwin Long Fox {' Medical Times and Gazette,' and ' St.
George's Hospital Keports') confirms the author as to the uncertainty
of the temperature as a sign of pericardial or endocardial affections
in acute rheumatism. Dr. Herhert Davies' cases show the same
thing. Dr. Habershon, Dr. Reginald Thompson, and Mr. J. F.
Good/iart {' Guy's Hosp. Reports,' N. S., vol. xv) all agree in the
same statement : that uncomplicated pleurisy, peritonitis, and other
serous inflammations seldom exhibit high temperatures (often not
above 100° F. = 377 C). My own observations entirely confirm
these, so that we seem to be very nearly warranted in assuming as
a law, that inflammations of serous membranes are generally
attended by only slight fever. Mr. Stephen Mackenzie (Resident
Medical Officer of the London Hospital) lately showed me a chart
391< TIIF. TEMPERATURE IN ACUTE RHEUMATISM.
of pleurisy, which exhibited no symptoms of pneumonia, but in
wliich the temperature throughout was high. There aj)peared to be
no other compHcation. Tso doubt, liowcver, many cases of pleurisy,
pericarditis, and peritonitis, are complicated by renal or other
visceral disorders, if not originated by them. — Tra7is.'\
XIX. — Acute Riieumatism.
§ I . If one roughly compares a few accidentally varying isolated
cases of acute polyarticular rheumatism, its fever appears to sliov.-
remarkable and extreme difl'erences in different cases. Perfect
absence of fever, or intense fever; its duration very brief, or
protracted; a continuous, or remittent course ; and the most sudden
elevations and intercurrent downfalls of temperature are all met
with under the same nominal diagnosis. However, when a great
number of cases of this disease are compared, it becomes apparent that
certain forms of temperature-course are more commonly met with
than others, so that one may describe them as definite, or loose and
indefinite types of polyarticular rheumatism : although it is not
always easy to determine the reason why a given case should belong
to one or the other group ; and although we may not be able to
determine the forces which cause the disease to pursue a definite
course, or whv a certain number of cases deviate from it.
It may also be remarked, that whereas this multiplicity of courses
makes a very motley mixture amongst a few hundreds of cases only,
yet that they are not found to multiply themselves infinitely. "When
we greatly increase the number of cases observed, we rather find
these difficulties clearing up, and get an idea that there may be a pos-
sibihty of reducing all of them to a few primitive forms.
§ 2. A very large number, indeed nearly half of the cases of
acute rheumatism, especially cases of slight or medium severity and
severe cases too for a time, display in the main a moderate amonnt of
fever ; during which the temperature gradually rises at the com-
mencement, and reaches its maximum height at the end of the first
week, or at the beginning of the second ; lingers for a few days only
(or sometimes only for a single evening) at or near this height with
no fluctuations, or only slight ones; and from this time forth, under
good nursing, sinks hy a protracted descent, generally with moderate
THE TEMPERATURE IN ACUTE RHEUMATISM. 395
morning remissions : whilst^ ho^rever^ pretty sensitive to external
influences^ it appears strikingly little affected by the occurrence of
inflammation of internal organs (unless they are of extreme severity).
There is also very often a disproportion between the temperature and
the frequency of the pulse, even when the heart itself is free from
disease. Nothing like weekly cycles is to be observed. With good
nursing (timely at hand) when the surroundings are also favorable,
freedom from fever, or comparative freedom is already obtained in the
course, or towards the end of the second week, or in severe cases
during the third week.^ These general characteristics of the course
must, however, be considered with more detail.
The course naturally divides itself into three divisions ; namely —
(i) The ascent of the temperature or pyrogenetic stage ;
(2) The Jieiglit of the fever, which sometimes rises to a solitary
peak, or acme, and sometimes constitutes a fastigium of several days'
duration ;
(3) Lastly, the period of descending temperature, which gradually
loses itself in defervescence.
{cl) The legmning of the fever seldom comes under observation
in polyarticular rheumatism, because the patients hardly ever come
under our notice till the course has lasted for several days. But their
statements allow" us very fairly to conclude, that the fever does not
commence in the sudden manner common in croupous pneumonia,
and in most cases of acute exanthematous affections, but takes a
more gradual development, which is sometimes more tedious than
that of abdominal typhus.
Cases do occur, however, in which patients show a temperature of
nearly 40° C. ( 1 04° T.) or even more, even as early as from the second
to the fourth day ; such cases are however exceptional. On the
other hand, it is common enough to find that in the very middle, or
^ That our treatment, if not our medication of acute rlieumatisra is improved,
is, I think, evident from this faet, which is also true of more than half our
English cases. It is not so long since that it used to be publicly taught that
at least six toeeks was required for rheumatic fever ; and a little further back,
six months was a rather common period. I myself believe that, with any treat-
ment at all, and good nursing, no genuine case of this affection extends any-
thing like so long as the latter date. Mistakes are of course easy between
gouty, pyajmic, syphilitic, and albuminuric rheum«^ozc? cases, and true rheu-
matism. As regards the absence of warning of serious complications, such as
pericarditis, endocarditis, and pleurisy, sec the note appended to the previous
section. — [Tbans.]
396 TIIK TKMPKHATL'RK IN ACUTK llli KUM ATIS.M.
even the end of the first week of the iUncss, the temiierature is still
very moderate, and begins to rise liigiier at a later period ; or when
the disease is well nursed, remains moderate.
(/>) Even the height of the fever is very often not eompletely
under our own observation. For it is very remarkaUe, as regards
the course of acute articular rheumatism, that in an overwhelming
majoritij of hospital cases, the tnaximum temperature is reached either
on the day of admission or almost directly after, and that it gene-
rally falls on the first evening after their removal to the hospital,
and that from this time either a gradual and steady decrease of tem-
])erature is observed, or at worst a descending direction becomes
decidedly manifest, after a fastigium of from two to four days'
stationary temperatures. This extremely common course appears to
indicate, either that the removal of rheumatic patients is extremely
injurious, and is able considerably to raise their temperature ; or that
good systematic nursing is able to very quickly alleviate the fever.^
AVe cannot admit the hypothesis that, by a happy accident, the
patients always come under treatment at the very moment the tempe-
rature has naturally and spontaneously attained its summit. For
this maximum height at the beginning, and the speedy completion of
the descent, occur just as commonly whether the patient is brought
into the hospital at an earher, or more advanced period of the disease ;
indeed it appears to me that the decrease of temperature takes place
the more quickly the earlier the reception into hospital occurs, and
accordingly the earlier good nursing enters into competition with the
rising temperature.
If the maximum height does not occur only at the first taking of
observations, but is observed after the occurrence of lower tem-
peratures, still, in spite of this, the maximum often presents only a
solitary peak, which often sharply contrasts with the lower tempe-
ratures before and beliind it. In such a case we cannot talk of a
proper fastigium stage, but only of a momentary elevation of tempe-
rature. Tliis maximal point, which occurs in the evening hours, is
generally by no means inconsiderable in height, usually indeed quite
40° C. (104° F.), and may often exceed the temperatures of the pre-
ceding and following evenings by at least i°C. (i-8°F.), and those of
the preceding and following mornings by even 2° C. (3*6° F.) or more.
This acme-point generally occurs between the fifth and ninth day of
the disease, but may occur even earlier (perhaps on the third day), or
' Will no one give us good cases from private practice ?
THE TEMPERATURE IN ACUTE RHEUMATISM. 397
at a later period in some cases. Very commonly, however, the
summit extends itself into an actual fastigium. But this in the
majority of cases is very brief in comparison to the whole duration of
the disease, and is still shorter when very high temperatures are
reached, though the case in itself may not be very severe. It lasts,
as a rule, only from two to three days. It is only in very exceptional
and in other respects severe cases, that temperatures of 40° C.
(104° r.) or more, are reached or exceeded on three successive days.
In a great number of cases of very perfectly developed articular
rheumatism, the daily maxima, even at the height of the disease,
remain between 38*6° and 39*5° C. (ioi'48° and 103*1° P.).
In such cases the fastigium lasts rather longer ; but even when it
lasts a week, it is almost always longer than the period which suc-
ceeds. The course of the temperature during the fastigium is
sometimes continuous, sometimes exacerbating, somethnes sub-
remittent, and sometimes shows remissions of no inconsiderable
amount.
[c) The descending period shows a varied type according to the
form assumed by the decrease, and the suddenness with which it
occurs.
In favorable cases, and particularly such as come early under
treatment, the downfall of temperature is proportionately quick and
then occurs generally in a zig-zag manner like a rapidly recovering
typhoid fever, and perhaps without any evening rise of temperature,
just as many cases of scalatina behave. The downfall then takes the
form of defervescence by lysis, which may perfect itself in from five
to six days.
It is exceptional to meet with a more rapid downfall, almost like
a crisis. More commonly the decrease is protracted, and sometimes
halting (stockend). After the first decrease of temperature a mode-
rate, and generally remitting fever, of tolerably stationary daily
average persists for several days, and it is only by looking at the
whole course that one can faintly recognise a descending direction.
Or there may be a daily decrease, but so trifling in amount, that from
ten to twenty days are required, before the temperature reaches
normal, w'hich happens, so to speak, almost imperceptibly.
After freedom from fever has been attained, and convalescence has
set in, the temperature is accustomed to fluctuate for a while, on a
plane which is a few tenths higher than that of a healthy person, or
of one who is convalescent from any really typical acute disease. So
398 THE TEMPERATURE IN ACUTE RHEUMATISM.
that the evening tem])eratures may occasionally show an approach to
even febrile degrees, and even higher transient elevations of tempe-
rature may occur here and there.
After all^ the fever in these cases of acute rheumatism, is only of
moderate, or at the most, medium severity/. Apart from its brief
acme it remains at heights which only exceptionally exceed the
bounds of moderate fever.
§ 3. There are, however, many, and varied exceptions to this
medium, and throughout favorable sort of course ; which, however,
when all comprehended together, scarcely reach the number of the
former kind.
Ahnormally mild cases are particularly common, or rather cases in
which the temperature is either very slightly or, perhaps, not at all
affected ; although the local condition is not always correspondingly
insignificant. Indeed, w'e cannot always tell why the fever should
remain so trifling, or perhaps be altogether absent, when the joint
affection is very severe ; and cardiac complications are by no means
excluded by the absence of fever. Cases with slight fever (not above
38'5° C. (ioi*3° F.), or with only sub-febrile temperatures, consti-
tute about one third of all the cases of acute rheumatism. All other
deviations from the course described, comprehending more or less
severe cases altogether, do not, at least in our country, amount to
more than one sixth of the cases.
§ 4. One of the commonest forms assumed is the //-o^/'ac/f^^ (Len-
tescirende) type. The duration of the disease in this is essentially
lengthened. The fever persists as late as the fourth or fifth week.
The daily differences are usually far more considerable, and thus the
temperature may fall to normal in the morning hours, whilst in the
evening the fever is more or less considerable, and indeed, generally
exceeds 40° C. (104° F.) Numerous abnormalities and changes of
type are met with, and the temperature only very gradually returns
to normal. Large daily fluctuations show themselves most strik-
ingly when the affection of the joints and articulations becomes fixed ;
and thus fluctuations of three degrees or more (== 5"4° F.) may
occur in one day.
Recrudescence of the fever, or apparently objectless intercurrent
elevations of temperature are by no means rare. Eight in the
THE TEMPERATURE IN ACUTE RHEUMATISxM. 399
middle of a moderate course of fever, or even after return to a sub-
febrile, or fever-free condition, there often occurs a more or less
considerable rise. of temperature (even a couple of degrees or so,
= y&^ F.) , wliich is sometimes quite ephemeral, sometimes com-
pensates itself after a day or two, or sometimes lasts rather longer.
This fresh rise is not always dependent on fresh increase of the joint
affection, nor yet on the occurrence of complications. It is especially
difficult to find an explanation for the cases of very brief inter-
current elevations of temperature, which only last one day or so : and
this short fever paroxysm, of which the patient is often quite uncon-
scious, has no influence at all upon the regular and proper termina-
tion of the case. More slowly developing, and longer lasting
elevations of temperature may be associated with a relapse in all the
symptoms.
Those cases may be classed as apparent recrudescence, in which
the temperature has been artificially depressed at the height of the
disease, by medicine (such as Digitalis and Aconite), and has risen
again when the influence of the medicine is exhausted, or when it is
left off.
§ 5. Complications, especially pericarditis and endocarditis, in
many cases have no effect at all on the course of the fever [see
notes to pp. 393 and 395]. They sometimes occur without ele-
vating the temperature even the tenth of a degree, or without at
all affecting its downward progress. In other cases, however, the
opposite is the case, and the course may be modified as follows :
{a) The course of the temperature during the fastigiam and during
recovery may, indeed, be unaffected, but during convalescence the
temperature remains in a somewhat higher plane than is commonly
the case with rheumatic convalescents, and sometimes in the further
course of convalescence rises somewhat higher still; this occurs
occasionally in pericarditis and in endocarditis, when this has pro-
duced valvular mischief. It is sometimes a considerable time before
the temperature descends from this elevated platform (Niveau).
{h) Associated with this, we find after actual recovery from the
acute disease a protracted sub-febrile or actually febrile condition :
sometimes in the temporary stage, paroxysms of fever, lasting several
days, may set in. These sometimes consist of aberrant secondary
fever, dependant pericarditis, made up of several isolated febrile ex-
peclilions of a week or more, which are only separated by a brief
100 THE TKMl'KKATURli IN ACUTK Hi I HUM ATI SM.
interval of sometimes only imi)erfect freedom from fever. With a
fresh development of aortic valvular iiisufliciency througli endocar-
ditis, very considerable elevations of temperature sometimes occur
late in the disease ; whilst mitral insufficiency appears to have far
less effect on the temperature.
(c) Sometimes, however, even during the fresh course, or relapse
of acute rheumatism, more or less considerable rise of tempera-
ture is brought about by complications. The supervention of pneu-
monia most certainly, although not invariably, raises the temperature,
yet without impressing on the course the characteristic type of
pneumonia.^ The remaining complications (pericarditis, endocar-
ditis, bronchitis, urticaria, miliaria, &c.), only exceptionally produce
this inflammatory rise of temperature, either when they are very
severe, or perhaps on account of individual predisposition, or per-
haps according to some special form of the complicating inflam-
mation.
§ 6. When the disease becomes fixed in a joint or a bone, the
articular rheumatism may hang about for a very long time, through
recrudescence of the process or through successive complications.
Such ohst'inate attacks are not very frequent amongst my hos-
pital patients. I think, however, that I am not wrong in saying
that they occur much more frequently in private practice. Obstinate
rheumatism with fixed or changing and successive localisations some-
times displays great intensity, but sometimes produces only very
slight symptoms, differences which are very clearly indicated in the
course of the temperature. On the other hand, severe incidents
occur now and then without corresponding elevations of tempe-
rature.
§ 7. Amongst the y^ifa^ aflPections which accompany acute rheu-
matism, or have rheumatoid symptoms, we may notice two essen-
tially different courses, in which there is a corresponding difference
in the course of the temperature.
[a) In the one class of cases death occurs from ^ fixed localisa-
tion, particularly from heart affections or their results, sometimes in
immediate sequence to the rheumatic affections of the joints, and
sometimes not till after their recovery. The course of the tempera-
* This is one of those little touches so true lo nature, as to sliow clearly that
the author draws from life, aud uot merely from his own imagiuation.— [Tuaxs.]
THE TEMPERATURE IN ACUTE RHEUMATISM. 401
ture during the rlieumatisui itself is not generally much altered^ but
it displays irregularities^ and if death occurs at an early date, the
characteristic descent is either wholly wanting or interrupted.
Death, which results in these cases, not from the actual disease
itself, but from the unfortunate course taken by some local manifes-
tation of it, or some comphcation, may be preceded by a very
marked fall of temperature.
{h) In other cases which are just as commonly included with acute
rheumatism, a malignant character sometimes reveals itself from the
very beginning, at other times during the further progress of the
disease, at first in symptoms which may easily be misinterpreted,
but further on shows itself more powerfully. The most commonly
observed symptoms of a pernicious nature are rigors, very intense
fever, various severe nervous symptoms, jaundice, haemorrhages,
diarrhcea, and enlargement of the spleen.
No one of these symptoms by itself is perfectly diagnostic, but
the combination of several of them characterises the case as a ma-
lignant one. The pains in the joints are more or less severe, and
generally extend to the muscles, over the head, chest, and abdomen.
Death generally occurs with very considerable and sometimes enor-
mous elevation of tenijoerature (to 43° C. or even 44° C. and
more = 109*4° Eahr. and iii"2°rahr. Cases by Qndncke ; and
II. Weher in London (' Transactions of the Clinical Society^), and
by myself (Wunderlich) .
These cases, which, perhaps, ought to be called rather rheumatoid
affections, though regarded as genuine articular rheumatism, dis-
play as far as my observations have yet extended, peculiar differ-
ences, in three distinct directions = a pycemic, an icteric, and a
nervous form. They rank along with spontaneous pyaemia, with
primary pernicious jaundice [acute yellow atrophy], and with those
rapid and pernicious nervous catastrophes which are devoid of an
anatomical basis ; and they are only to be distinguished from these
forms by the fact that the strongly pronounced articular pains, for
some time at least, simulate acute rheumatism. These differences
are, however, by no means strongly marked; and one might say
that the nervous form was the least perfectly developed, the icteric
form the most pronounced, and the pysemic form the most complete.
In the completest (pysemic) form, indications of the malignant
nature of the process may be very early recognised ; the fever is
very intense, whilst rigors, jaundice, and enlarged spleen are met
26
102 THE TEMPERATURE IN ACUTE RHEUMATISM.
with, and the only moderations of the course which occur arC;
transitive, deceptive, and imperfect.
Such deceptive remissions occur more especially in the proagnostic
period, whilst on the very day of death the temperature regularly
rises considerably.
The course of the temperature fashions itself thus when the
centres of suppuration are not too numerous, but a complexity of
grave disorders exists, corresponding to the jaundice.
In the cases which end fatally without multiple centres of sup-
])uration, and without jaundice, the disease at first runs its course
like a very severe articular rheumatism. A descending direction
may even have set in as regards the temperature, but suspicious
nervous symptoms show themselves simultaneously. These suddenly
arise with very rapid fresh increase of temperature, and in the
briefest time reach most extreme degrees, so that death occurs with
hyperpyretic temperatures, whilst no anatomical lesion in the brain
can be discovered in the corpse, or only very moderate degrees of
meningitis. Post-mortem elevations of temperature may be met with.
[See papers by Drs. Herbert Davies, Puller, Gull, Sutton, and
E.Long Fox, in the 'London Hospital Pieports,' 'Guy's Hospital
Reports,' and 'Medical Journals' for iSyo, passim. Dr. Wilson
Pox ('Lancet,' July and, 1870) gives two cases with pra:-
mortem temperatures of 110° and iio'8°, and Dr. E. B. Baxter has
kindly given me notes of a case of acute rheumatism under Dr.
DufBn's care, whose temperature in dying was 111° Pahr. (43*9° C).
Dr. Edwin Long Pox (in one of a series of valuable papers in the
'Medical Times and Gazette' for 1870) also says that death often
occurs when the temperature reaches 105°, but not invariably (the
latter statement I can confirm from notes of several cases) . He fur-
ther observes that high temperatures usually correspond with a high
pulse, but an evening temperature of 103° Pahr. may go with a pulse of
84° or 90°. The urine is generally acid with high temperature, but
it may be alkaline. There may be profuse sweating with temperature
of 1 03° and 1 044-° Pahr., and sudamina also." He thinks that blisters
do not diminisb the temperature ; but many of Dr. Herbert Davies'
cases lead to an opposite conclusion, especially those in which blisters
were applied after recrudescence. — Teans.]
[See the curves in Lithographs at the end, Table VII] .
THE TEMPERATURE IN OSTEO-MYELITIS. 103
XX. OSTEO-MYELITIS.
In acute osteo-myelitis, wliicli resembles typlius \iyplioid fever]
in many respects, and has, therefore, been called "bone-typhus,"
the course of the temperature only very imperfectly and, it would
appear, exceptionally, coincides with some typhoid attacks.
Of six cases which came under my own observation, five displayed
a brief and somewhat continuous course till the fatal termination ;
in three it lasted eight days, in one fourteen days, in the fifth case
the commencement was not accurately determined ; the whole
course even in this did not last over a fortnight. Pour of these
cases were observed in the last two to five days, and one was noted
only on the day of death. This case died with a temperature of
407° C. (io5'36°r.), and after death the temperature rose to 4i'i°
C. (= 105*98° E.) . In the remainder the bounds of pretty high fever
40-5" C. (=104*9° r.) ^®^^ never exceeded. The course of the tem-
])erature displayed irregular, but on the whole trifling fluctuations,
and only isolated deeper falls of temperature (to 38*4° and 38*6° C.
= ioi*a° to 101*48° r.). The contrast was always remarkable
between the temperature, which was never immoderate, and the
enormous frequency of the pulse (which in one case was 188 per
minute, twelve hours before death), and this contrast was only
absent in one case.
In contradistinction to these not very typhoid-like courses of
temperature, there was one case which came under observation on
the seventh day of the disease, in which the affection was pretty
soon limited to the left femur, and gradually improved at a
later date. During the whole of the second week this exhibited
the remittent course of abdominal typhus (up to the twelfth day a
daily maximum of 39*8° to 40° =^ -103*64° to 104°]?., and a daily
minimum of 38*6° to 39*2° = 101*48° to 102*56° F.; and from
the twelfth day assumed a descending direction with considerable
remissions), and, indeed, in such wise that even the brain-symptoms
and those of the intestines and spleen corresponded to a severe
attack of typhoid fever, and the diagnosis remamed in suspense
during the whole of that week. Further on, when the fever
moderated, the course assumed a hectic type.
404 THE TEMPERATURE IN HEPATITIS, ETC.
XXI. — PAREXCnYJIATOUS INFLAMMATION OF THE KiDNEYS.
Acute inflammation of the kidneys (acute Bright's disease) ex-
hibits very h'ttle regularity as regards the course of the temperature,
whicli is apparently dependent on the varied rapidity and intensity of
the attacks, and partly on the circumstances under which they are
developed.
The temperature is often only febrile, and perhaps only mode-
rately so ; in other cases it attains a height of 39*5° to 40° =i03'i°
to 104° F., or even more. In cases which recover there is a gradual
defervescence by lysis ; in fatal cases death may occur with either a
rising or falling temperature.
Chronic inflammations of the kidneys (chronic Bright's disease)
as a rule affects the temperature very little, and even in fatal cases
terminal elevations of temperature are exceptional.
[I have notes of several cases (some of which are still attending at
the London Hospital) in which, after acute desquamative nephritis
for the most part of scarlatinal origin, the temperature has re-
mained on an elevated plane, with occasional exacerbations, accom-
panied by other signs of renewed kidney mischief (such as alteration
in the quantity of urine, or in the amount of albumen, or occasional
hsematuria, and the occurrence of casts and epitheHum from time to
time) for from two to three years ; and in one case for four years.
The noon temperature in these cases has remained sub-febrile
(99*5° to ioo'4° F.), or slightly febrile (100-4° to 101-3° ^■)> ^ver
since, whenever noted (once or twice a week), although the other
symptoms of kidney mischief have been comparatively slight. —
Trans.]
XXII. — Hepatitis.
Acute parenchymatous inflammation of the liver exhibits varieties
which differ widely from one another as regards the course of the
temperature ; but these cases are too rare to allow one to deduce
any definite common principles from them.
In the form with malignant (pernicious) jaundice, whether from
phosphorus poisoning or not, the temperature is sometimes un-
aff'ected even till death, whilst sometimes it is moderately elevated,
THE TEMPERATURE IN HEPATITIS, ETC. 405
or begins to rise towards the end of the attack ; and sometimes
highly febrile, or even hyper-pyretic temperatures are met with.
The course of the temperature in ijelloio fever has been made known
to us through an interesting paper of SchmicUlein's in the
' Deutsches Arcliiv filr klinische Medicin/ IV, 50. According to him
the temperature is highest in the first few days of this disease, and
very often reaches a height of from 40° to 41° C. = 104° to i05"8° T.,
very frequently with slight evening exacerbations. From the fourth
to the fifth day the temperature steadily falls, and sinks down to
normal, or even below this. In cases which end fatally it rises
again towards the end some 2°C. = 3"6° P., or even more.
In suppurative inflammation of the liver, the temperature, with
the abscess of the liver, may follow the same course as in })y8emia,
or in chronic suppurations. Fmntzel (in the ' Berliner Wochen-
schrift,' 1869, p. 5) quotes Trauhe as saying, '^Repeated attacks of
severe rigors with great elevation of temperature are only observed
in two diseases of the liver — in blennorrhoea of the gall-ducts, and
in abscess of the liver.'' Further on (p. 13) he says: "With the
exception of abscesses of the liver originating in pyemia, endocar-
ditis, and pyle-phlebitis -^ all the other forms, directly they take on
an intermitting fever, and pursue their course accompanied by
attacks of rigors, constantly exhibit a perfectly regular course all
through ; that is, paroxysms of fever preceded by rigors, or febrile
exacerbations occur ; and it is a matter of indifference whether they
maintain the type of a simple quotidian, or of a duplex quotidian,
or that of a tertian; it is always just at or close to a definite period
of time, as in malarial disease ; whilst, on the other hand, those
fever-paroxysms and exacerbations induced by pycemia, endocarditis,
and pyle-phlebitis,^ which are preceded by a rigor, always exhibit an
irregular rhythm throughout, with very much shorter intervals,
occurring from three to four times in the twenty-four hours."
XXIII. — Lues (Constitutional Syphilis).
I. By the term I/ues I mean those numerous and complicated
affections which have hitherto been known by the name of secondary
and tertiary syphilis. [See Note to page 247.]
' " Pyle-phebitis or pylo-phlebitis (7ri;Xj/, the vena porta — phlebitis, inflamma-
tion of a vein). Term for inflammation of the vena porta." — 'Expository-
Lexicon,' Dr. R. G. Mayne.
•lOC; THE TEMPERATUHK TN S-JPIIILIS.
By this I avoidj on the one hand, tlie ambiguons expression
" syphiHs/' and, on the other hand, their doubtful relation to the
local chancre is not either assumed or denied.
The luetic (syphilitic) symptoms may certainly occur without any
fever, and there is, perhaps, no form of luetic manifestations which
may not develop itself, and run its course perfectly free from fever.
On the other hand, with certain symptoms of lues, fever is far
more common than is generally believed ; and this fever is somewhat
peculiar ; and indeed so characteristic that it is by no means difli-
cult to at least suspect the nature of the disease by a glance at the
course of the temperature. [See fig. 39 opposite.]
§ 2. In luetic (syphilitic) cases, elevated temperatures are most
commonly met with at the time when the first extensive hyper?emic
papular or pustular skin eruptions are developed.
The fever which accompanies the luetic (syphilitic) eruptions of
the early periods may be very severe, and the maximal temperatures
may reach nearly 41° C. (= io5"8 E.).
The course of the temperature is markedly remittent (pseudo-
intermittent), with a daily downfall which descends quite to normal,
or very nearly so. The alternation of these deep morning remissions
with the high evening exacerbations is tolerably regular, but in
spite of the rapid rise of the evening temperature rigors only accom-
pany it in exceptional cases. It is also equally exceptional for a
day quite free from fever to intervene between the days of fever, or
for the fever subsequently to display a tertian type, or for greater
and more moderate exacerbations to prevail alternately from day to
day. The duration of the fastigium is indefinite, sometimes it is
short, occupying a few days only, but it may last over a fortnight
[and even longer than this. — Trans.], The fever subsides by the
evening exacerbations gradually becoming less severe, in a manner
which corresponds pretty closely with the behaviour of the tempera-
ture in advanced periods of convalescence from abdominal typhus.
§ 3. In many of the acute internal luetic affections of the liver
and Israin, and also in those of the bones which occur from time to
time, we sometimes meet with an analogous though less regular
course of the temperature, which is marked by the alternation of
considerable morning remissions, with more or less severe evening
exacerbations. In that malignant form of lues which is marked by
THE TEMPERATURE IN SYPHILIS.
407
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•108 TIIK TKMPKRATURF, TN SYPHILIS.
rapidly fatal attacks, similar cousidcrablc rises of temperature are
met with (40° C. = 104° F., and even more) ; but the intervening
remissions are less, or if tliey occur, less regular ; sometimes they
are actually less in depth, and sometimes wholly absent. The fever
observes no order in its course. The remissions of temperature are
deceptive, and are by no means signs of a favorable termination.
On the course of the temperature in luetic (syphilitic) marasmus
see Marasmus.^
XXIV. — Glanders and Parcy.
I can only find one case of observations of temperature in glanders
in the human subject (Goldschmidt^s Giessen Thesis, 1866). This is
somewhat interesting. He remarks (from observations commenced
in the fourteenth day of the disease) that the fever displays a remit-
tent course, which is of moderate severity at its commencement,
from the nineteenth day of the disease it rose gradually, zig-zag
fashion, and reached highly febrile degrees ; from the twenty-fifth day
forward it never sank below 40° C. (104° T.), and in the last few
* The author's observations in the text, and those of Dr. T. E. Guntz, in
" Das syphilitische Fieber," Kiichennieister and Pross' Zeitschrift f. Medicin,
Chirurgie and Geburtshilfe. N. Folge iv, 1865, p. 192) (for a reference to
which I have to thank Br. Christian Bduviler), as well as the cases of syphilitic
rheumatism in Dr. Garrod's and his own practice reported by Dr. DufQh, at
p. 81 of the 2iid vol. of the ' Clinical Society's Transactions ;' and the "Report
of the Committee on Temperature in Syphilis," at page 170, in the 3rd vol. of
the ' Transactions ' of the same society, may be referred to along with the
diagrarii specially added to this English edition, as tending to prove that some
forms at least of constitutional syphilis, particularly those resembling rheu-
matism, are at least as typical as most fevers. I have to return special thanks
to Dr. E. B. Baxter for first directing my attention to this subject, and for
kindly lending me his own notes and charts of several cases, which have
enabled me to present an ideal chart (all the temperatures of which, however,
are real) compiled from his careful observations, which in one case at least
extended over more than two months. Besides showing the great fluctuations
of temperature met with in these cases, the figure shows the striking effect of
10 gr. doses of Iodide of Potassium, in reducing the temperature — an improve-
ment which coincided in some of the cases with a remarkable and striking gain
in weight (20 lb. in fourteen days in one case). See also " Lancereaux on
Syphilis," Xew Sydenham Society's Translations, by Dr. Whitley, vol. i,
p. 125. — [Thaxs.]
TEMPERATURE IN ACUTE MILIARY TUBERCULOSIS. 409
days (fifth week of the disease) it progressed in a pretty continuous
course (41 "3° to 41-6° C. = 1 06*34° to io6-88°F, being attained).
No observations w-erei taken during the last twenty-four hours. ^
XXV. — Acute Miliary Tuberculosis, &c.
Acute mihary tuberculosis produces considerable alteration of
temperature in the majority of cases, and this is in general so much
the more, the more copiously and extensively the tubercle deposits
are diff'ased, and the freer the person attacked was from other dis-
orders, before the formation of the miliary granulations.
When the miliary tubercles are scanty and localised, or in patients
who are already greatly under the influence of other serious afl'ections
(such as advanced pulmonary phthisis, pneumonia, or cerebral dis-
ease), miliary tuberculosis sometimes fails to affect the temperature
at all, or at least its influence is very slight. The course of the tempe-
rature in miliary tuberculosis assumes the following leading types : —
[a] A type resembling that of catarrh at its commencement, with
an intense hectic fever later on ;
{^j) One resembling the course of the temperature in abdominal
typhus ;
(c) A type resembling the course of intermittent fever.
These three different forms may succeed each other in one and the
same case. The first form is met with in cases whose course is
subacute.
The illness, at least as regards its temperature relations, perfectly
resembles, at its commencement, the course of a severe attack of
influenza, or one of catarrhal pneumonia. Only the obstinate per-
sistence of the fever excites suspicion. Gradually deep remissions,
which almost descend to normal, occur, and alternate with febrile
evening exacerbations of considerable height. Yet even by this
behaviour of the temperature it is not possible to distinguish acute
tuberculosis from an acute non-tuberculous phthisis ; and so it may
remain even up to the time of death ; unless meningeal tubercles are
developed, and the characteristic symptoms of basilar meningitis
display themselves.
1 A case, under the care of Mr. de Morgan, is reported in the 'British
Medical Journal' for April, 1870. The temperatures in this were not very
liigli, and death took place on the 20th day with a temperature of i04'4° F,
(= 40-2" C).
110 IHK TEMl'KRATUlli; IN ACUTE niTllISIS.
In tlic second form a diagnosis between that and typhoid fever is
often for a long while, and perhaps even up to the time of death,
impossible. However, the course of the temperature is more irregular
in acute tuberculosis than is ordinarily the case in abdominal ty])hus ;
the remissions are generally somewhat greater than in the latter
disease, and do not sink down to normal.
Those cases of acute tuberculosis which simulate typhoid fever
are generally those which are most rapidly fatal. Should life, how-
ever, be prolonged, which^ is exceptional, the fever later on assumes
another character, it may be either the hectic or the intermittent
type. Undoubtedly the intermittent fever type is the rarest form in
acute tuberculosis. The course of the temperature of each fever-
abscess (or local suppuration) may perfectly resemble that of an
intermittent fever, and repeat itself with the same regularity, sometimes,
indeed, with a tertian or duplicated quotidian rhythm. Yet the
occurrence of the attacks, especially in the afternoon, and the fact
that the heights reached by the temperature are somewhat less, or
become so in time, than those met with in intermittent fever ; whilst,
on the other hand, the temperature of the intermission (or apyrexia)
generally falls deeper below the normal than in that, may raise our
suspicions of the j^resence of acute tuberculosis. In the further
course of acute tuberculosis the intermittent type is generally lost,
and the succession of an invariably less severe remittent fever renders
the diagnosis certam, if that has not already been settled upon other
data.
[See notes at end of the next section.]
XXVI. — Acute Phthisis.
§ I. Acute phthisis may take its origm from a condition per-
fectly free from fever, upon which elevations of temperature supervene
in a zig-zag fashion, with remissions and exacerbations of increasing
severity ; less regularly and more tediously, however, than is usual in
abdominal typhus.
Or acute phthisis may closely follow the fever of an attack of
bronchitis, pneumonia, or some other acute affection ; in which case,
^ So that, as has been well said, " The incautious practitioner pooh-poohs
the attack at first as only a trifling cold, and in a week or two has to sign tlie
death certificate." — [Tra^s.]
THE TEMPERATURE IN ACUTE PHTHISIS. 411
when tlie phthisis sets in, somewhat lower daily remissions are met
with, but the height of the daily exacerbations may either remain the
same, or diminish somewhat, or even increase.
§ 3. In the further progress of the case, the course of the tempe-
rature generally shows pretty continuously, or at least for the most
part, a non-continuous type.
The daily differences, as a rule, are very considerable, they amount
to 3° or more (Centigrade = 5*4° Fahr.).
The daily maxima occur for the most part in the afternoon or
evening, but not very infrequently in the morning also, and approxi-
mate to or even exceed 40° C. (104° P.) Even heights of 41° C.
(io5"8° P.j or more are observed. Sometimes they occur twice in
one day, but only very exceptionally every two days. Sometimes
they are pretty nearly the same height for a series of days, sometimes
from day to day they show a pretty regular slight increase or decrease,
whilst sometimes there is a persistent alternation between higher and
lower exacerbations, and this alike whether the type be simple or
duplicated quotidian. The daily falls of temperature are abrupt, and
their minima may reach to normal or even sink beneath it. Even
profound collapse is not very rare. An alteration from day to day is
sometimes displayed in the amount of the remissions, though less
commonly than is the case with the height of the exacerbations.
There is sometimes an intervening period, thrust in as it were upon
the course, in which the remission becomes considerably less, and
the course of the temperature becomes sub-continuous, or even
somewhat ascending in its type, in which the exacerbation-peaks of
the earlier stages are sometimes reached by the temperature. Com-
plications (such as intercurrent attacks of pneumonia) may bring
about these modifications. Yet they may occur independently.
The fever is often interrupted also Ijy short {less often hy longer)
intervals of moderate fever, or of suh-fehrile or even of normal
temperatures.
On the other hand it is somewhat rare to meet with a persistent
sub -continuous course with considerable or moderate fever from the
very beginning to the fatal end.
§ 3. In the majority of cases the temperature falls from its pre-
vious height towards the approach of death, and the remissions
become less distinct. The daily differences become less, whilst the
ir? TTIK TEMPERATURE TN ACUTE PllTHTSlS.
daily average may either fall or rise. Death indeed may occur with
a tolerahly low temperature. Or the temperature which had pre-
viously fallen may rise afresh during the death-agony, and sometimes
to hyper-pyretic heights.
On the other hand, it is seldom that death occurs with per-
sistently rising temperature, in immediate sequence to the previous
fever.
Note.
[Dr. Sydney Einger has rendered such good service to thermo-
metry in England, especially by his book ' On the Temperatures of
the Body as a means of Diagnosis in Phthisis and Tuberculosis,^
1S65, that I feel loth to differ from him; but if I understand him
aright, that there is an elevation of temperature in all cases of tuber-
cular deposit, I am compelled to do so ; if that statement be intended
to apply at all times, after the deposit of tubercle has once taken
place ; and to express my conviction that Wunderlich is correct in
saying that there are intervals free from fever in some cases of
phthisis; and further, that in some cases miliary tuberculosis does
not affect the temperature at all. I believe these intervals may
sometimes extend over three or four weeks, and I certainly agree
with M. Henri Eoger when he says — " Si dans Fenfance, comme aux
periodes plus avancees de la vie, les tubercles donnent quelquefois
lieu a un accroisement de la chaleur animale, ce n^est point par eux-
memes, mais par leurs effects consecutifs, par I'irritation locale que
leur presence determine dans les tissus. Lorsque cette inflammation
n'existe point, ou qu'elle est devenue chronique, le therm ometre
raonte a peine audessus du niveau ordinaire." And again —
" M. Andral a constate pareillement chez les adultes que la tempe-
rature reste normale, dans la phthisie pulmonaire, tant que la fievre
ne s' allume point."' H. Roger — "De la temperature chez les
enfants,^' &c., Paris, 1844-5.
MM. Herard and V, Cornil assert confidently that, apart from
' " Although both in infancy and at more advanced periods of life tubercles
sometimes cause an increase of temperature, they do not do so on their own
account, but only by the effects which they produce, and by the local irritation
caused by their presence in the tissues. Wlien this inflammation is wanting,
or if it become chronic, the thermometer will scarcely rise above the average
degrees." And again, "M. Andral has similarly established for adults that
the temperature remains normal, even in pulmonary consumption, so long as
there is no fever."
THE TEMPERATURE IN ACUTE PHTHISIS. 413
complications, there is no fever in the stage of deposit {' De la
Phthisie Pulmonaire/ Paris, 1867, p. 200).
Dr. Pinlayson also objects to Dr. Einger's statement, that there is
a continued elevation of temperature in all cases of tuberculosis and
tubcrculisation, and that the thermometer will always detect it. He
thinks many of Dr. Ringer's temperatures are too low, which he
ascribes to the thermometer being retained only five minutes. His
own observations on children with tubercular disease (made in the
Manchester Clinical Hospital for Children) lead him to believe that
there are three principal types of tubercular disease, corresponding to
Sir W. Jenner's clinical classification of " the insidious, the active
febrile, and the adynamic." In this way he combines the views of
Jochmann (Berlin) and of Wunderhch. These three types may be
briefly expressed as follows:
Firsi type. — The morning temperatures are normal, or rather less
than normal, whilst the evening temperatures are more or less high.
E. g., a child has a temperature of 99'33° Pahr, (in the rectum) in
the morning, whilst the evening temperature = loi "53 or
ioi"8o° Pahr. This equals the insidious and often unexpectedly
fatal type.
Second type. — The morning and evening temperatures are hotk
high, whilst there are evening exacerbations. F. g'.: a child has a
morning temperature of ioo*i6° P. (rectum), whilst the evening
temperatures are from ioi*57° P. to 103*67° P. = the active
febrile type.
Third type. — The morning and evening temperatures are Iwtli
high, but there is a tendency to exacerbations at odd times. E. g. :
on one day the child has a morning temj^erature in the rectum of
103° P., and in evening one of 102*33 P. 0^ another day the
morning and evening temperatures may be 102*6° and 104° P. re-
spectively. This characterises the adynamic type.
Dr. Pinlayson lays most stress on the continued absence of that
evening fall in temperature which he considers as so characteristic of
healthy children. He contends that the daily range of temperature in
the healthy child is greater than in the adult, amounting to as much
as two or three degrees Pahrenheit, and that there is invariably a fall
of temperature in the evening, amounting to one, two, or three
degrees Pahrenheit ; the most striking fall usually occurring between
7 and 9 p.m., often before sleep comes on.
See 'On the Temperature of Children in Phthisis and Tuber-
HI
Tin; TliMPEUATURE IN ACUTE THTHISIS.
culosis/ by James Fiiilnysoii, M.D., p. 32, Dunn and Wriglil, (jllas-
ijow, and the 'Glasgow ]\redical Journal/ November, i(S69. Dr.
llillicr also admits that the morning and evening temperatures in
pliihisis may sometimes be normal, and even Dr. llinger admits
this. It is therefore rather the course of the temperature than its
height on a particular day Avliich must be cur guide. — Trans.]
[Dr. Finlayson's table of the variations of temperature in twenty-
four hours in. healthy children is here combined with Dr. Ogle's
tables of temperature in adults (male and female) referred to at
p. loj, and for convenience represented by a diagram. — Tuans.]
Fig. 40.
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THE TEMPERATURE IN TRICHINOSIS. 115
' XXVII.— Trichinosis.
Trichinosis cannot have a typical form of fever; for the participa-
tion of the system in general is essentially determined by the nu-
merical circumstance of the little foci of inflammation induced by
the parasite being more or less numerous. Notwithstanding this,
the course of the temperature in this disease is more than usually
interesting, because it affords us almost the only certain proof that
a considerable elevation of the general temperature of the body may
be brought about by purely local, although enormously multiphed
disturbances (inflammations), for a considerable time at least ; for
when the disease has lasted some time, and the deposits have reached
a later stage, it is quite true that further mischief is developed ;
which is shown by the implication of the brain, lungs, and kidneys,
and by the simultaneous disease of other organs in which there are
no trichinse. In such advanced cases it is clearly not possible
to determine how much of the fever which is present should be
ascribed to the topical inflammation of the muscles, and how much
to the cerebral disease, the pneumonia or nephritis, and such like.
Observations on patients sufl'ering from Trichinse show —
(i) In spite of tolerably extensive muscular symptoms, and,
doubtless, no inconsiderable localisation of Trichinae, there may be
perfect freedom from fever, or a sub- febrile condition, or at most a
very slight febrile movement.^
(3) In the same manner the fever is either absent or only slight,
M'lien the muscles are first attacked.
(3) When the symptoms grow increasingly severe in the further
course of the disease, the temperature may be very considerably
varied, and even 40° — 41° C. (= 104° — 105-8° Eahr.) may be
reached; only such high temperatures are interrupted by more or
less considerable remissions, generally reaching the normal point, or
1 In a mau admitted into the London Hospital, under Mr. Curling's care, and
who died almost immediately in consequence of having been run over in the street,
almost all the voluntary muscles were thickly studded with trichinte. Yet
Dr. Bathurst Dove, who made the post-mortem which discovered this fact,
found, on careful inquiries of his nearest relatives and friends, that he had
never complained of any of the usual symptoms, and considered himself as
almost a model of health.
-ilQ THE TEMPEKATLUE IN MALIGNANT DISEASES.
even descending beneatli it, so that there is then an almost daily
compensation or re-establishment of an equilibrium of temperature.
(4) Such high degrees of temi)crature do not persist long. Even
in fatal cases they are interrupted by the occurrence of either normal
or only sh'ghtly elevated temperatures for several days together.
(5) These circumstances combined, render the course of the tem-
perature in trichinosis somewhat characteristic, at least in those
cases where the temperature reaches high degrees. In such cases
there is little danger of confounding it with typhoid fever, and with
the fever of articular rheumatism; it is more likely to be con-
fused with acute tuberculosis, or with cases of internal suppuration
running a rapid course.
On the other hand, when the fever continues to be very mode-
rate and inconsiderable, all characteristic features are lost.
See the curves in lithograph at end, Plate Yll.
XXVIII. — Malarious Diseases.
Only the intermittent form of malarious infection is accurately
known as regards the course of the temperature. There is no op-
portunity in our country of making any observations on the remit-
tent forms.
We must distinguish in this kind of disease between the course
of the temperature in the several paroxysms and its course during
the entire duration of the disease.
§ I . The separate paroxysms are each characterised by a sudden
rise of temperature (generally with rigors and " cold shivers^^), to a
height of extreme fever, and an equally rapid return to the normal
or a little below it.
The temperature begins to rise before any other symptom of the
incipient attack announces itself.
The rise of temperature is, however, comparatively slow just at
first, that is, it may continue for a couple of hours without reaching
more than 38-5° or 39° C. (= 101-3° or 102-3° Fahr.). As soon
as the rigor occurs, which may begin at temperatures of varying
height, the rise becomes more rapid, and in the course of about an
hour has reached a height of 41° — 41-5° C. (105-8° to 106-7° Fahr.),
or only exceptionally a little higher. Meanwliile, the stage of dry
heat (hot stage) may have set in, and during tliis, the rise of teinpe.
THE TEMPERATURE IN MALARIAL DISEASES. 417
rjiture may still go on. This ascent to the summit or acynS of the
temperature of the paroxysm is generally quite steady and uninter-
rupted; at the furthest the temperature halts once or so, for a
few minutes at some given point; or occasionally there occurs a slight
fluctuation just close to the highest point [so that the summit is
slightly bifid] .
The maximum of the temperature is reached in the stage of dry
heat, though sometimes perhaps, after the appearance of partial
sweating. It only lasts for a few minutes.
When the sweating becomes general [moist stage], the tempera-
ture begins to fall again, only slowly for the first hour or half hour;
and sometimes it fluctuates a little ; then it begins to fall somewhat
more rapidly, without any fresh rise occurring : it does so, however,
in such a way that the temperature halts for a quarter or even half
an hour, and then falls about one or two tenths of a degree Cent.
(= one fifth to one third of a degree Tahr. nearly), then rests again,
then begins to fall again and so on (so as to resemble terraces) ;
M'hen this has continued some four hours or so, and the temperature
has fallen to somewhere about 40° C. (104° Fahr.), it sinks some-
what more rapidly; requiring, however, some ten or twelve hours or
more before it regains the normal point.
During the intermission or apyrexia which succeeds, the tempera-
ture is sometimes a little under the normal ; but if the apyrexia
lasts more than one day, there is a very slight evening exacerbation,
which scarcely exceeds the range of a normal daily fluctuation. Not
infrequently, especially after the use of febrifuges (quinine, &c.),
there occur paroxysms without any subjective symptoms, which only
announce themselves by the elevated temperature, and run their
course without a rigor and without any sweating or only very trifling-
perspiration. The maximal height in these attacks may equal, or
very nearly so, that of the perfect fever paroxysm ; the rise and fall
of temperature are, however, compressed within a briefer period than
is the case in paroxysms accompanied with a rigor.^
' As the two facts of the rise of temperature during the cold stage, and the
existence of paroxysms of fever (as shown by the thermometer) after the
apparent cure by antiperiodics — attacks which are scarcely known to the patient
himself — are still unknown to a large number of medical men, and even denied
by some, although recognised by dc Haeu (see Chapter II of this work), it is
jicrhaps not superfluous to remark that I have often verified this observation,
and have demonstrated the fact to others. Were it necessary I could easily
furnish corroborative cases from my note-book, — [Teans.1
27
418 THE TEMPERATURE IN MALARIAL DISEASES.
This bcliaviour of the tcmpcralurc in tlio ])aroxysin and the apy-
rcxia which succeeds it, is itself so characteristic of intermittent
fevers (agues, &c.), that it renders tlie diagnosis tolerably certain.
There are extremely few forms of disease in which there is so rapid
a rise of temperature from the normal level to a height of 41° or
41*5° C. (105-8° to 1067° Fahr.), immediately followed by an
equally rapid return to the normal temperature. Hardly any except
ephemera, the solitary relapse into fever during convalescence from
typhoid fever, the paroxysms of acute tuberculosis and those of
pyaemia, display a similar course ; and to distinguish between these
diseases it is in general sufficient to wait for a second paroxysm, and
at the same time to pay attention to the exact time of its occurrence.
However, even a single paroxysm is enough to enable us to dis-
tinguish intermittent fever from those affections for which it is
most Hkely to be mistaken when its symptoms are severe, such as
typhus, meningitis, and cholera. In these, which often resemble a
very intense and pernicious intermittent in all the other symptoms,
the course of the temperature is so perfectly diff'erent, that the use of
the thermometer makes our diagnosis absolutely certain.
§ 2. In relation to the manner in which the paroxysms of inter-
mittent fever succeed one another, it has long been known that this
may happen in various kinds of rhythm. It appears to me, after
making very numerous observations, that the most normal course, i. e.
that which is undisturbed by individual pecuharities, complications,
&:c., is that in which the paroxysms are repeated after about forty-
four to forty-six hours (tertiana anteponens).
Thermometry alone is often able to reveal the fact that the appa-
rently pure quotidian, tertian, or quartan rhythm is duplicated; and
that either stronger paroxysms alternate with weaker ones (in the
apparently quotidian rhythm) ; or that between the separate paroxysms
which are completely developed m all their symptoms, there are
attacks interposed which only announce themselves by the elevated
temperature.
In a similar manner complete recovery from intermittent fever
can only be guaranteed by the thermometer. Thermometric ob-
servation teaches us that the disease does not generally terminate
with a well-pronounced paroxysm, but that fresh attacks may
succeed which consist only in a rise of temperature (which is some-
times very great), and announce themselves in no other way but
THE TEMPERATURE IN CHOLERA. 419
which may again give place to perfectly developed paroxysms if the
treatment be too early discontinued. Besides Zmmermann and
Barensprung , special reference may be m.ade to Michael's paper in
the^Archiv filr physiol. Heilkunde' (for 1865), xv, 39, entitled^
" Specialbeobachtungen der Korpertemperatur im iutermittirenden
Fieber."
See the curves in the lithographs at the end. Plate VII.
XXIX. — The Temperature in Cholera.
§ I . Observations on temperature in cholera are attended with
some special difficulties, and in particular the results derived from
those taken in different regions of the body, require to be separately
estimated, since they do not run parallel courses.
Temperatures taken in the axilla cannot be trusted unles's taken
with great precautions. The mercury rises very tardily, and some-
times takes half an hour before it becomes stationary, particularly
in the cold stage. However carefully taken, these axillary tempera-
tures in the cold stage afford no correct standard of the general
temperature of the body (or temperature of the blood). However
they are valuable, because they represent the conditions of the sur-
face temperature (the heat of the skin). In the reaction stage,
the axillary temperatures are once more trustworthy standards for
the general temperature of the body.
The degree of surface warmth, or the extent rather to which the
skin is cooled, is indicated far more perfectly on exposed parts of
the body, and particularly in the hands and feet. But any accurate
measurement of temperature in these spots is almost impossible, and
the results obtained are, therefore, comparatively worthless.
During the algide stage temperatures taken in the mouth give
hardly any idea of the general temperature. They may, indeed, be
of some value, as giving indications as to the temperature of the
expired air ; though, indeed, these are comphcated, and little trust-
worthy.
Only observations taken in the rectum or vagina can serve as a
standard of the general temperature of the body. The former, how-
ever, are difficult to make at this period of the disease, and are easily
disturbed by the action of the bowels. Vaginal measurements are
by far the best, but cannot be had recourse to in some females ; or,
at least, caimot be repeated sufficiently often ; and may be affected
420 THE TEMPERATURE IN CHOLERA.
by the croupous (iliplitheritic) affections of tlie vagina which often
supervene iu these cases.
There is very often a considerable contrast between the results
obtained by readings taken in various parts; and sometimes this ver^
contrast may afford us valuable hints {lit. winks) for prognosis.
Thus a great difference between the axillary and rectal or vaginal
temperatures is decidedly unfavorable, and in the progress of re-
covery we often observe the temperature in the mouth to rise, while
the vaginal temperature falls.^ The behaviour of the temperature in
sporadic cases of cholera, when these are severe, does not essentially
differ from that of the epidemic form. Only the average differences of
temperature are rather less, unless the choleriform attack accompanies
some special affection, which necessitates considerable alteration of
temperature.^
§ 2. Even before the heginning of any other symptoms, a fall of
lemperatui'c may be observed m patients previously suffering from
fever, when they become infected with cholera (as Friedlmder has
shown from observations made in my wards) ; which although closely
connected with the still latent infection, yet demonstrates clearly,
that the decrease of temperature of the surface is in no way the
result of the evacuations alone ; [perhaps, however, it does result
from the increased flow into the intestinal canal, just as a fall of
temperature succeeds internal haemorrhages. — Teans.]
In the stage of evacuations (cholera flux), in slight eases which
do not become asphyxiated, both the axillary, vaginal, and rectal
temperatures are, as a rule, normal, or (particularly the vaginal
temperature) a httle raised. As soon as there is any indication
of asphyxia, the temperatures are always more divergent; the
vaginal temperature appears somewhat higher, and the axillary
temperature somewhat lower than normal. If the algide form is
developed, the temperature of internal parts in cases which recover,
is moderate, as a rule, although sometimes rather high (in a case of
Giiterfjock's it was 39*6° C. = 103*28° Fahr.), and it is exceptional
to find it normal or dimuiished,
^ See note to page 183.
2 Numerous cases in the medical journals, especially in 1806, when attention
was drawn to the subject by several physicians, show that all the appearances
of cholera may be perfectly simulated by many other affections — as perforating
ulcers, toxic influences, intestinal obstructions, hajmorrhages, &c. &c. —
TuA>-s.]
. THE TEMPERATURE IN CHOLERA. 421
In cases in -whicli deatli occurs in the asphyxiated stage, the tem-
peratures in the vagina and rectum sometimes reach still higher
degrees (40° C. = 104° Fahr.), or more, and in one case of Gilter-
hock's, even 42*4° 0. = 108-32° Fahr.). Any considerable rise of
temperature, or any considerable fall, indicates great danger, and
with either alteration quickened respiration.^ Cyanosis, asphyxia,
and suppression of urine, may be present.
Very profuse and violent alvine discharges are generally indicated
by a fall of temperature, though sometimes only accompanied or
preceded by a relative fall.
When the temperature rises, although the rise may be only rela-
tive, the alvine discharges cease, and if the temperature rise higher
there is a tendency to coma (sopor).
Both a rapid fall of considerable amount, and a rapid and con-
siderable rise of temperature are indications of approaching death.
On the contrary, the less the temperature fluctuates, the less it
varies from the normal, the more probability there is of recovery.
On the cutaneous surface, even in the axilla, the temperature during
the algide stage is, as a rule, diminished, sometimes, indeed, very
greatly so, yet not often below ^^° C. (95° Tahr.) . The axillary
temperatures generally show less striking fluctuations than the heat
of internal parts of the body. There is especial danger when the
surface temperature of the body remains persistently low, or after
being considerably lessened, rises rapidly, or sinks afresh after it had
begun to rise. On the other hand, it is a good sign when the low
temperatui'e slowly and steadily begins to rise with only slight fluctua-
tions, and thus the normal temjierature is not exceeded or only slightly.
The temperature under the tongue may be still more diminished.
In the stage of asphyxia, the temperature there seldom exceeds
31° C. (87-8° F.), and even in cases which recover may fall to about
26° C. (78*8° P.). If it falls below this, recovery would appear to
be impossible.
§ 3. In the post-choleraic stage (period of reaction) the tempera-
ture in favorable cases is normal or approximately normal. In this
stage, from its previously abnormal condition, it returns to tlie
normal acrain.
*&•■
' Quickened respiration is present in almost all cases of cholera, as it is in
nearly all fevers, probably from failure of muscular power, or to compensate
the pulse frequency. — [Trans.]
•l-^S THE TEMPRRATURK IN CnOLERA.
Yot moderately febrile rises of temperature arc by no means signs
of great danger; they are, however, suspicious, and denote complica-
tious of some sort.
!Morc considerable elevations of temperature are a sure sign of
complications, and of the supervention of various local afTections,
and give little prospect of recovery. Very high temperatures are
particularly induced by parotitis and erysipelas, and sometimes,
though less invariably, by pneumonia, which only exceptionally
pursues a typical course.
Patchy exanthems [roseola, &c.], do not invariably induce a rise
of temperature.
A normal or approximately normal course of temperature in the
post-choleraic stage is, however, by no means an absolute guarantee
of recovery.
When the reaction assumes an actually typhoid form, the tempe-
rature in many cases is normal, or only slightly elevated. It is true
these are in general favorable cases with but slight development and
inconsiderable local affections, yet even in these all danger is by no
means got rid of. However, the temperature may rise, and that
pretty considerably, even in the typhoid form, and the type is for the
most part remittent. These are cases which run a stormy course,
with severe local disorders, and if they do not suddenly end fatally,
they lead us to expect that the disease will be protracted. Paren-
chymatous nephritis occurs indifferently both in cases with moderate
and those with elevated temperatures.
The most unfavorable thing in the post-choleraic stage, is for a
previously normal or elevated temperature to suddenly sink below
normal. Even a considerable diminution of the peripheral heat
[surface-warmth] at this period, indicates considerable danger.
In many cases, the temperature of the body falls more or less
suddenly after death. Yet m some cases when the temperature has
previously been but slightly raised as well as more especially in those
with already high temperatures, the temperature actually rises for
some minutes, or about half an hour after death.
§ 4. The temperature in cholera has attracted attention for a long
while, and from the time of the first appearance of the disease in
Europe, thermometric observations have been published {Czermaky
Goppert, LockstdcU) . These earlier observations, however, were not
worth much. The observations made in the years 1848-52 by Ross,
TEMPERATURE IN INJURIES OF CORD, ETC. 423
Mair, Bernhardt and LeuluscJier, Roger, Boy ere. Briquet and Mignot,
Iluhbeuet, and Biirensprung, were more valuable. The most important
facts in a diagnostic and prognostic point of view were discovered in
the epidemic of 1866. Consult particularly Charcot (on the tempe-
rature of the rectum in cholera, ^Gazette Medicale/ 1866, 11).
2Io7iti (' Jahrb. d. Kinderheilk./ 1866, p. 109) and Guterloch
("die Temperaturverhaltnisse in der Cholera," 1867, in ' Virchow's
Archiv/ xxxviii, 30).
[Particular reference may also be made to the authorities quoted
in the notes to pp. 183 and 204. By an accidental omission
in the latter place, Mr. E. Nettleship's name does not appear as it
should amongst those who contributed largely to our knowledge of
the temperature in the cholera epidemic of 1866. Dr. Thudichum^s
arrangement of some of the observations made in the London Hos-
pital, appears in the 9th ' Report of the Medical Officers of the
Privy Council.^ Por some reason Dr. Thudichum has, however,
fixed the line of normal temperattire at 36'8° C. (98*24° P.), which
is a lower average temperature than that generally admitted as
normal. — TeaoS's.]
XXX. — Injuries op the cervical portion of the Spinal Cord.
B. Brodie (in 1837, in the ^ Medico-Chirurgical Transactions/
XX, 146), first made the remark, as an addendum to Chossat's expe-
riments, that he had observed a considerable rise of temperature in
several cases of injury to the spinal marrow; and published his cele-
brated case of laceration of the lower portion of the cervical cord,
in which death occurred after twenty-two hours, after the inspi-
rations had fallen to five or six in the minute, and the thermometer
applied between the thigh and the scrotum had marked 43*9° C.
(cii-02° Pahr.).
Since that time other observations have been made which confirm
the influence of injuries of the cervical portion of the spinal cord
in producing enormous elevations of temperatui'e, by Billroth
(^ LangenbecFs Archiv,' 1862, rise of temperature to 42*2° C.
(io7'96° Pahr.); Quincke (^Berliner klmische Wochenschrift,'
1869, No. 29. Two cases with temperature of 43'4°and 43"6°C.
= iiO"i2° and 110*48° Pahr.). IFeler in London ('Transact, of
the Clinical Society,' vol. i (1868), two cases, one with temperature
424- TEMPERATURE IN NEUROSES.
of 44^ C. — 11 ra*^ Falir. ; the other with a post-inorlcm tempera-
ture of 4^-f C. = 109-94^ Eahr.). Flsc/icr {' Centralblatt/ i86y,
J). 2-^9 ; a rise to 42*9° C. = 109*22° Ealir.).
On the otlier haud, the latter has observed two cases of injuries
of the cervical portion of the spinal cord with a diminution of tempe-
rature in one case to 34° C. ( = 93*2° Eahr.), in the rectum, in the
other to 30-2° C. ( = 86-36° Fahr.) in the axilla.
[See also JBbiz on alcohol in paralytic fever in the ' Practitioner/
July, 1870, and a paper on the temperature of shock in surgical
cases by W. W. AFagstafTe, F.E.C.S., ^St. Thomas's Hospital
Heports/ vol. i, new series, p. 466, where {inter alia), a case is
given of fracture and dislocation of sixth cervical vertebra, which
died after forty-eight hours, when temperatures of 92*3° Fahr. on
admission, and 8175° Fahr. (forty-five hours after injury) were
recorded. See also a paper by Dr. Frederic Churchill in the same
volume on shock and visceral lesions. Compare also remarks on
injuries of the nervous system at pages 145, &c. — Trans.]
XXXI. — Neuroses.
Uncomplicated neuroses, whether evincing their presence in
psychical, sensitive, or motorial functions, do not, as a rule, exhibit
any alteration of temperature at all, whether they are recently de-
veloped or long existing, or extremely chronic, or, at all events, the
alterations of temperature are very inconsiderable.
The following exceptions must be made :
{a) Sometimes intermittent neuroses are developed under ma-
larious influences, and in their attacks there may be an elevation of
temperature.
{b) The hysterical neuroses, in which elevations of temperature
even to excessive heights may occur, like every other possible symp-
tom, to all appearance without any motive at all.
(c) Those affections which we may designate as vaso-motor neu-
roses, which are by no means thoroughly understood as yet ! In
these cases also there may be alterations of temperature.
In psychical neuroses, indeed, there is generally no particular
alteration of temperature to be observed, unless it is produced by
intercurrent corporeal affections. Yet a rather subnormal tempe-
rature may be constantly observed in many insane persons (Geistcs-
TEMPERATURE IN NEUROSES. 425
krankeii), and iu others again moderate and apparently objectless
elevations of temperature are sometimes seen which for the most part
scarcely reach the' limits of fever. In cases of extreme inanition,
exposed to great external cold, the temperature of the insane may
also sink in a most extraordinary manner. See the remarkable case
by Lowenhardt already quoted on page 204. On the other hand,
West/phal has pubhshed observations (in * Griesinger's Archiv fi Ir
Psychiatric/ i, 337), according to which very considerable elevations
of temperature occurred in an intercurrent manner in paralytic
lunatics. However, they occurred along with epileptic and apoplectic
attacks; but Westphal implies that they had no relation to the muscu-
lar spasms or their intensity, and even when the muscular movements
were very shght they occurred, and sometimes when these were
altogether absent, and also that the epileptic attacks in themselves
caused no very special elevation of temperature. He believes just
as little in the dependence of the elevated temperature on the gene-
rally co-existent acute affections of the respiratory organs, since the
latter are by no means always present in the attacks with elevated
temperature. [The observations of Br. T. S. Clouston in the
' Journal of Mental Science,' ' Edinburgh Medical Journal,' and
elsewhere, of which there is a very good abstract in the New Syden-
ham Society's 'Year Book' for 1863, p. no, would seem to show
that tuberculosis is present in a large number of cases of insanity.]
It is also quite proper to note, as only apparent exceptions — where
there are latent processes going on in a case in which, at the same
time, only the neurosis is to be recognised, and deviations of tem-
perature result ; or where complications interrupt the quiet course of
a neurotic affection, and although by no means visible, constantly
affect the temperature. On the other hand, there is a very peculiar
symptom to which I first drew attention, although it has since been
confirmed by several observers {Billroth, Ley den, Ebmier, Ferber,
Erh, Quincke, and Monti) ; namely, that in the last stage of fatal
neuroses, and more particularly in Tetanus, although met with in very
many other disorders of the nerve-centres (of the brain), the tempe-
rature begins to rise, and rises in the briefest space of time to extra-
ordinary heights ; to heights, indeed, which are only exceptionally
reached in diseases which are of distinctly febrile origin (sometimes
to 43° C. (109-4° Fahr.), or even to above 44° C. (iii'2° Fahr.)
and in one case of tetanus to 4475° C. (iia"55° Fahr,), which is
usually succeeded by a still further post-mortem rise of temperature
'1-20 TFMPERATURE IN NEUROSKS.
amounting to a few tenths of a degree. Ilerr llofratli Unlcrhcrfjer,
Professor of Veterinary Surgery in Dorpat, has informed mc in a
letter, that he has observed temperatures of above 43° C. (107*6°
Falu".), in fatal cases of tetanus in horses.
These facts, taken in conjunction with the equally extraordinary
high temperatures which are observed in tissue changes of the brain
and upper ])art of the spinal cord, appear to show as has been ad-
duced already (pp. 150 and 195) that there are, apparently, mode-
rating centres or apparatus in the brain, the paralysis of which is
succeeded by a morbidly increased action of the processes which
produce warmth.
This observation is of practical importance, because it indicates
that any considerable elevation of temperature in patients suffering
from neuroses, when no particular reason can be assigned for the
fever which is developed, affords the worst possible prognosis.
Mt/ own piihlicatluns on this behaviour of the temperature may
be found in the 'Archiv der Ileilkunde' for 1861, ii, 547; 1862,
iii, 175; and 1864, v, 205; and those of Erb in the 'Deutsch.
Archiv fiir klinische Medicin,^ 1866, i, 175.
[In addition to the author's remarks on neuroses, I may just re-
mind the reader of the remarks made at pp. 106 — 145, &c., 195
and the note to p. 225. In studying the temperature in neuroses,
we have, of course, to eliminate the influence upon temperature of
the primary cause of the neurosis ; thus, for instance, in most of the
fatal cases of chorea, this symptom supervenes upon acute rheu-
matism or scarlet fever, whilst in most of the cases which recover
the setiology is obscure or utterly unknown. Of the latter class of
cases, Br. Finlayson states that in a girl aged 9:^ suffering from chorea,
the average of six observations of morning temperature was 99-01°
Tahr. (37*22° C.) in the rectum, whilst the average evening tempe-
rature of eleven observations was 103*21° Fahr. (39*56° C). In a
boy aged jo^ the average of eleven morning observations was
99*44° Fahr. (37*46° C.) ; and that of thirteen evening temperatures
was 98*93° Fahr. (37*18° C). //. Eager also states that in chorea
there is little or no alteration of temperature. Br. Long Fox ('Med.
Times and Gazette,' 1870), says the temperatures in chorea are
seldom over 99° Fahr., often less, or below normal. I myself have
often observed sub-normal temperatures (97° and 96° Fahr. = 36*1°
and -i^c^'^P C), in feeble children sufi'ering from the common forms
THE TEMPERATURE IN CHRONIC DISEASES. 427
of chorea ; whilst in two cases supervening on acute rheumatism, I
observed temperatures of 105° and 106° Eahr. for two or tliree
days preceding death (= 40*5° and 41-2° C).
In epileptic attacks also, the co-existence of tubercular or syphi-
litic disease must greatly affect the temperature. Eefer also to Blnz
on " Alcohol in Paralytic Fever/^ in the ' Practitioner' for July.
I am indebted to Mr. Semple for an account of a case of general
paralysis, in which the temperature was perfectly normal. — Tkans,]
XXXII. — Chronic Disorders of the Blood, of the Tissues, and
OF Secretions.
Yery many changes of essentially chronic course, affecting the
composition of the blood, and the formation of tissues and secretions,
may influence the course of the temperature. But the true relations
of the former to the latter are by no means exactly or entirely
determined. Sometimes the temperature is found normal all through
the course of the disease; whilst at other times there are more or less
considerable elevations of temperature, which very commonly belong
to intercurrent acute processes ; sometimes chronic fever of various
kinds is met with, or on the contrary, the temperature may be per-
sistently subnormal. Even when these chronic diseases end fatally,
their closing course may exhibit numerous differences.
JocJimann (in his ' Observations on the Temperature of the Body
in Chronic Febrile Diseases,^ published in 1H53) has published a
number of facts, especially taken from thermometric observations in
phthisical patients, and has determined several types of chronic fever.
It may be sufficient for our purpose to lay special stress upon the
following empirical discoveries relating to the course of the tem-
perature in chronic diseases affecting the blood, nutrition, and
secretion.
§ I. An abnormally low temperature is very commonly met with in
conditions of inanition, and such temperatures are more parti-
cularly met with durhig the last days of life in a great many
chi'onic conditions which are associated with marasmus, although
marasmus in itself by no means excludes the possibility of an elevated
temperature.
Inasmuch as inanition is so commonly both a sequel and a con-
comitant of very many chronic diseases, the course of the temperature
428 THE TEMPERATURE IN CHRONIC DISEASES.
may be modified by it in very many ways. Not only docs it very
frc([ucntly depress the temperature persistently^ and sometimes also
without any recognisable reason, depress it even to the extent of
collapse; but in conditions of inanition, any considerable or extreme
cooling of the body, deprivations of nourisliment, muscular exertions,
perspirations, vomiting, or diarrhcca, and losses of blood, have
generally a very unusual (ungleicli) effect in considerably lowering
the temperature, because the diminished production of heat in these
cases is no longer able to compensate and conceal the effect of the
loss of warmth. This is especially noticeable when the fatal end is
approaching. The decrease of temperature in emaciated children
just before death is very great, and is especially to be noted in
children who are subjects of luetic (syphilitic) marasmus whilst at the
breast.
In one sucb case, which was recently under my care, the tem-
perature began to be subnormal six days before death, and by a
gradual process of sinking it fell at last to 25° C. ( = 77*^ F.) as
measured in the rectum. In another case of common atrophia
infantum (marasmus) it was only 28'6° C. (83*48^ F.).
§ 2. According to the observations of //. Hoger, the temperature
(at least in the axilla) is extraordinarily diminished in congenital
induration of the areolar tissue (sclerema of new-born children) . He
says that the average of twenty-nine cases was only 31° C. (87*8°
P.), and in seven cases was less than 26° C. (78"8° F.).^ As regards
this behaviour, Bdrens})rung reminds us of the effects of experiments
artificially preventing the action of the skin [see page 143].
§ 3. It has been thought that thermometry might afford an aid
to diagnosis in distinguishing tubercular and non-tubercular phthisis
[see notes to p. 412], or, perhaps it is better to say, to enable us to
determine the presence or absence of tubercles in a phthisical patient,
even in life.
This hope is, for the most part at least, illusory. As the same
meaning is not always now-a-days attached to the word tubercles, it
may not be superfluous to express my meaning in the following
propositions :
{a) The existence of cheesy (caseous) deposits cannot in any way,
and still less in phthisical patients, be recognised by any thermometric
peculiarity.
' I have sliglitly altered tlie text in accordance wiili Roger's own statemcnf,
—[Trans.]
THE TEMPERA.TURE IN CHRONIC DISEASES. 429
[b) Thermometry only affords us data for detecting the develop-
ment of phthisis fj:om caseous pneumonia, when the observations
were commenced whilst the pneumonia was still recent, and when
they are continued throughout the period of transition. The
suspicions that the relics (Eeste) of the pneumonia are undergoing
casefaction may be justified by the persistence of high temperatures
at the end of the fastigium of a remittent type, and by considerable
elevations alternating with low temperatures.
((?) All the symptoms of hectic fever, whether they present them-
selves in the form of moderate febrile movements, or of a remittent,
subcontinuous, or fragmentary continuous fever, may, however, be
induced simply by chronic suppurative bronchitis, with progressive
dilatation of the bronchi, peribronchitis, chronic pneumonias,
repeated lobular and vesicular pneumonias without any casefaction,
and also without any development of granular tubercles. And
just in the same manner the fatal termination of non-tubercular
phthisis maybe heralded either by a fall or a rise of temperature; and
the latter may succeed in a zig-zag, continuous, or sharply-peaked
pattern.
{(l) The mere presence of sparse, or even tolerably numerous
tubercle-granules in the lungs, pleura, spleen, or liver, is absolutely
devoid of effect on the course of the temperature.
(e) It is only when extraordinarily numerous and closely studded
miliary tubercles are rapidly deposited, that we sometimes meet with
a modification of the course of the temperature in phthisical persons ;
which then approximates closely to the course it is accustomed to
take in what is (relatively) called primary miliary tuberculosis. The
same modification may, however, be brought about by complications
of other kinds (for example, protracted pneumonia) .
{/) However, very copious deposits of miliary tubercles in the
peritoneum, and especially the development of granular meningitis,
may affect the course of the fever in phthisical patients.
§ 4. It is a peculiarity of cancer cases that elevated temperatures
are comparatively rare, and that the temperature generally maintains
itself on a normal, or even subnormal plane, which, however, by no
means precludes the occurrence of high temperatures through inter-
current complications, or at the close of the disease. But fever tem-
peratures of long duration are at least rare in cancer patients.
{Br. Finlayson (loc. cit.) states that he made observations of tem-
perature in cancer of the uterus and ovary in a woman, aged forty-
130 THE TEMPERATURE IN CHRONIC DISEASES.
seven, and found in eight observations of morning temperature an
average of 9^-47° i\ (36-92° C.) in the vagina, and in seven observa-
tions of evening temperature (also in vagina) an average of 98*51°
1\ (36-95° C), which is decidedly sub-normal.
He also refers to observations by Da Costa on the same subject
in the 'American Journal of Medical Sciences/ vol. liii, p. 156,
Philadelphia, 1867.
I am indebted to Dr. E. B. Baxter for notes of the temperature
of a case of medullary cancer of the liver in a patient of Dr. Garrod's
in King's College Hospital, in which the temperatures on the six last
days of life ^ye^e as follows :
ist day, M., 99-5° F. ; £"., loo-o' F.
2nd ,, M., 99-5° F. ; E., 98-4° F.
3rd „ il/, 99-5^F.; Z, 99-5^ F.
4th „ M., 98-2^ F. ; E., 99-0^ F.
Sth „ M., 97-6^ F. ; E., 99-4^ F.
6tli „ 21., 98-9° F. ; E., Died.
The few observations I have myself made of carcinoma of the
hver, uterus, and breast, before marasmus had set in, only show very
slight elevations of temperature, or none at all; never above 101°
F. (38-4°), unless from some comphcation; whilst I have found
sub-normal temperatures with rapid pulse in several cases of
advanced cancer, with emaciation. See paragraph i of this section. —
Trans.]
§ 5. Chronic cases of heart disease generally exhibit considerable
elevations of temperature only when acute attacks supervene. In
congenital malformations of the heart connected with cyanosis, such
as stenosis of the pulmonary artery [which Dr. Peacock has shown to
be the most commoii cause of cyanosis], sub-normal temperatures are
by no means uncommon.
§ 6. In diabetes mellitus (glycosuria) it is quite exceptional to
find an abnormally high temperature, whilst it is by no means rare
to find it persistently sub-normal ; and even the formation of
abscesses, pneumonia or pulmonary consumption, very often fail to
elevate the temperature of diabetics. [See Dr. B. W. Porster's
Piemarks in the 'Journal of Anatomy and Physiology;' London,
1869, p. 377.]
THE TEMPERATURE IN CHRONIC DISEASES. 431
§ 7. Jaundice runs its course without elevation of temperature,
unless it is of a pernicious kind, and on this account any elevation
of temperature in tlie subjects of jaundice is always ominous. [The
author probably refers to the jaundice of intermittents, and that met
with in hepatic abscesses ; or perhaps the word pernicious takes in a
wider range, and refers also to the latter stages or complications of
cancerous tumours.]
§ 8. Dropsical patients very often have a low axillary temperature;
yet rises of temperature frequently occur in such cases. [Especially
if the dropsy be associated with nephritis.]
§ 9. "When alterations of temperature occur in chronic diseases,
they generally show great variety in their course, even in one and the
same case, in the course of time. Yet sometimes a pretty stationary
and even course of temperature may be met with, lasting for not
weeks only, but whole months ; indeed, I have observed a chronic
fever with a perfectly steady and even, though very peculiar, course,
extending over a whole year.
§ 10. The commonest behaviour of the temperature in chronic
diseases is for it to show great mobihty and susceptibility to ex-
ternal influence ; and for its daily fluctuations to be rather more
considerable, although somewhat disorderly, so that the exacerba-
tions very often begin at an earlier time in the day, and thus fre-
quently approximate to the ranges of slight febrile movements, or
actually reach them ; and very often, too, whilst the daily remission
is not quite normal (it is seldom too low, generally too high, fre-
quently alternating) ; the general temperature moves, so to speak,
upon a somewhat higher plane as regards the daily average, than it
does in the healthy condition ; and besides this, there are occasional
rises of considerable amount (not infrequently to over 40° C. =
104° Fahr.), lasting only for a few hours or a few days, and thrust-
ing themselves in after the manner of an ephemera. This course
of temperature may occur under the most varied conditions, and
contributes next to nothing to our accurate knowledge of the given
cases, only tending to show that the condition is not a normal
one.
§ II. Whilst the morning temperatures are normal or very nearly
133 THE tempi; II ATU UK IN CHRONIC DISEASES.
so, or, perhaps, even subnormal ; (he temperature in the evenini,'
liours may rise more or less considerably, even as much as some 4°
to 6° C. = 7*2° to io"8° Fahr., in which case it is common enough
to find collapse tem})eratures alternating with highly febrile eleva-
tions (a course resembling that of an intermittent.) This kind of
course may last for a long time with tolerable regularity, unless,
indeed, the extent of the daily excursion is too great, and the
breadth of the exacerbation too striknig. Sometimes two exacerba-
(ions may occur in one day, separated by a perfectly normal tempe-
rature, or one nearly normal, and one of these exacerbations may be
much more severe than the other (like a duplex quotidian.) Some-
times when there is only a single daily exacerbation, a stronger and
a weaker one alternate very regularly with each other from day to
day; less commonly, the exacerbation is altogether absent on the
alternate days (tertian rhythm) ; or still wider intervals may occur
(quartan and sextan rhythms.)
In the latter sprawling kind of return, the exacerbation in many
cases no longer keeps its appointed day with punctuality, but the
course imperceptibly merges into one with irregularly repeating
elevations of temperature of an ephemeral type.
Such a course of chronic fever, resembling that of an intermittent,
is tolerably common, but its determining causes and conditions
cannot be formulated. It occurs in chronic suppurations and phthi-
sical conditions, although not as tlie usual type of fever in these.
It occurs also in diseases of an obscure sort, in which we sometimes
find this course of fever lastuag for mouths, associated with some
enlargement (intumescence) of internal organs, and no other de-
monstrable morbid symptoms ; in such cases recovery may occur, or
before their fatal end such farther developments of disease occur,
with alterations of the fever type, that the relations of the inter-
mitting course of temperature to the original disease still remain
unexplained. It is, however, worthy of note, that quinine and in a
higher degree arsenic, have an indubitable influence upon the course
of the chronic fever. The attacks become less severe and sometimes
are even completely suppressed.
[Eeference may also be made to the report of Drs. Murchison,
Symes Thomson, and H. AYeber, to the Clinical Society, on the
" Value of Quinine in Pyrexia,^^ vol. iii of the Clinical Society's
' Transactions,' pp. 201 — 238, which besides including acute diseases
such as typhus, typhoid and scarlet fever, pneumonia, measles, ery-
THE TEMPERATURE IN CHRONIC DISEASES. 433
sipelas, and rheumatic fever, includes a number of cases of phthisis.
The reporters state thatthe effect of the quinine in these was generally
" to lower the temperature^ pulse, and respiration, to mitigate
the severity of the paroxysms, and often to postpone the attack
of the following day, and lessen its severity. The effect of the
quinine rarely lasted more than thirty- six hours ; it was sometimes
apparent in half an hour after the dose, but in other instances was
not observed for three or four hours, and was most marked when
given at the end of the attack." Other notices of quinine will be
found at pp. 139 and 325. — Trails.].
§ 12. Chronic fever very often assumes a remittent type, in which
the temperature during the remissions is usually only a little above
the limits of slight febrile movement, whilst during the exacerba-
tions it amounts to as much as 39'5° to 40° C. (103-1° to 104° F.),
or even more. The remissions usually occur early in the morning,
and the exacerbations in the afternoon and evening hours. Yet it
is not uncommon to find the highest temperatures at noon, or for
two exacerbations to occur, one at mid-day and the other usually
less severe at midnight. This course of temperature, however,
seldom lasts long, or persists with even tolerable steadiness. It soon
slides into some other type, either more dangerous or less severe.
Even in itself it appears to work very prejudicially and exhaustively.
It is found in chronic suppurations, phthisical affections, and large
fluid exudations, and is more particularly related to the rapid
progress, relapses, and complications of the essential process.
§ 13. Chronic fever may sometimes very closely resemble the
continuous type. The temperature in such a case is generally rather
high, or, indeed, very high. Such a fever, particularly when there
are very high temperatures, produces rapid consumption, and, there-
fore, burns too fiercely to last long. It therefore either speedily
moderates and merges into other types, or it quickly pulls the patient
down. It is met with in intercurrent relapses and complications,
and at the conclusion of fatally ending chronic diseases.
§ 14. Intercurrent relapse may occur in any form of chronic
fever, and a repetition of such an evil is far from rare. It is most
commonly seen when the state of the tem])erature has previously
been very high. After the collapse the temperature sometimes quickly
28
434 THE TEMPERATURE IN CHRONIC DISEASES.
rises again to the former level, or sometimes this occurs very slowly ;
sometimes also collapse may set in without the ])recetling tempera-
ture having been very high, and towards the fatal close of a chronic
disease it is very common to meet with repeated falls of temperature
below the normal.
§15. Those almost critical downfalls of temperature which some-
times occur after a remittent or continuous course of chronic fever
have many points of resemblance to collapse, especially w^hen the crisis
is immediately preceded by a considerable rise of temperature (Per-
turbatio critica). But the downfall does not happen so rapidly as in
collapse, and does not go down so low as in that, only reaching the
normal or a little below it. These defervescences are sometimes
really favorable, and in such cases sometimes show that the effect of a
comphcation has ceased. In the majority of cases they are, how-
ever, deceptive pseudo-crises, and after remaining normal for a few
days the temperature again rises rather slowly or suddenly.
§ 1 6. Very great irregularities are displayed by the course of the
temperature during the course of many chronic diseases; rude and
apparently objectless (unmotivirte) fluctuations occur ; and although
very considerable rise of temperature is always a symptom worthy
of attention, no hopes must be based upon the occurrence of lower
temperatures, partly because they are often transient, and partly
because the disease may go on to a fatal termination with the dimi-
nished temperature. The more abrupt the changes of temperature
the less are they to be trusted.
§ 17. Towards the fatal close of chronic diseases, and in the death
agony, the course of the temperature may be widely different in
different cases, which need not surprise us, since death may be
brought about in so many different ways in chronic diseases, and
very often with only slight connection with the essential process.^
^ As, for instance, death in cancer may happen (i) from haemorrhage; (2)
nervous exhaustion (as when pain has become unbearable) ; (3) starvation,
either immediate, from direct pressure on thoracic duet, or direct interference
with organs essential to digestion ; or mediate by the enormous growth of the
tumour diverting other supplies ; (4) by asphyxia, when it presses upon or
invades the air-passages ; (5) by septic and pysemie processes being induced ;
(6) by invading organs whose integrity is essential to life, as the lungs, for
example, or the nervous centres, and perhaps in other ways. — [Tkans.]
THE TEMPERATURE IN CHRONIC DISEASES. 435
As a general rule, the temperature in chronic diseases more often
I'alls than rises before death ; sometimes it falls only a little, and
rather in comparison with previous heights ; and in other cases very
considerably^ indeed, very often to extraordinarily low degrees, as
in marasmus, particularly the marasmus of children, that of the
insane, and luetic marasmus (syphilitic atrophy) as has been already
mentioned (p. 428).
§ 18. The opposite conditions or final elevations of temperature
do, however, occur. The temperature which had before been normal
or but slightly raised, begins to rise a short time before death,
and this increase of heat which begins slowly and moderately may
at a later period become more rapid and more considerable; in
from twelve to thirty hours a height of from 40° — 41° (104° to
1 05* 8° Fahr.) or more may be reached; terminal fever.
Sometimes a cause for this rise of temperature can be found in some
special circumstances afl'ecting the dyhig patient — a terminal ery-
sipelas, parotitis, meningitis, or pneumonia, but in very many cases
the real cause of these final elevations of temperature remains un-
discovered.
CHAPTER xiir.
ON THE INFLUENCE OF ALTERATIONS OF TEMPEllATUilE
UrON THE SYSTEM.
^ I. Every one must agree that any considerable change in tem-
perature must produce more or less effect upon the general system
and its separate component parts and their functions^ upon the
secretions and upon tlie nutrition of ])arenchymatous tissues. It
has long been acknowledged that both the presence and degree of
fever in a given case affect the subjective sensations of the patient
and the frequency of both the pulse and the respiration^ as well as
causing changes in the patient's urine and perspiration ; and, still
further, that consumption may be produced by fever.
As regards the physiological aspects of the question, it has been
demonstrated experimentally that alterations of temperature produce
remarkable effects upon the irritability of muscles and nerves. Consult
EcJckard [' Zeitschrift fiir rat. Medicin/ 1 8,50, x, 1 65) ; Calliburces
('Comptes rend.,' xlv, 1095, and xlvii, 638) ; /. Rosenthal (^ Allg.
med. Centralz.,' 1859, 761); Harless (' Zeitschrift fiir rat. Med./
i860, cviii, 122) ; SchelsJce (^ Ueber die Yeranderungen der Erreg-
barkeit durch die Wiirme,' 1 860) ; Afanasieff {' Reichert's Archiv,'
1865, 69T).
[See also, on kindred subjects, the following memoirs, &;c. : —
Chmonlevitch , J. {'' Sur I'influence de la chaleur sur le travail me-
canique du muscle de la granouillo," 'Revue Medicale,' 1867 (2),
p. 491); M. Andral (ibid.), 1869 (2), p. 716) ; J^Moutier ("Mem.
sur la theorJe mccanique de la chaleur," ('Ann. de Chimie, &c.,'
torn, xiv (4me serie), p. 247) ; Kirn (" Memoires sur la Thermody-
namique" (ibid., tom. x (4me ser.), p. 32, torn, xi, p. 5) \ Bertheloi
(several papers in ibid., tom. xviii, 5 — 196, entitled "Nouvelles
recherchcs du themochemie") ; M^l. A. and F. Uupre {^ive, memoirs,
" Sur la Thcorie mccanique de la chaleur/' ibid., tom. ii (4rac serie).
THE EFFECTS OF ALTERED TEMPERATURES. 437
p. 185, torn, iiij p. 76, torn, iv^ p. 436, torn, vi^ p. 374, torn, vii,
pp. ^2)^, 406, tom. xi, p. 194, torn, xiv, p. 64) ; T'icIiescJdcJdn
(" Zur Lehre vou cler tliierisclie Warme/'' ' Reicliert's Arcliiv/'
1866, p. 151) ; Schllfer, I)r. JtUius (Berliii)^ ('Ueber die Wiirmbil-
dung erstarrender Muskeln," ibid., 1868, p. 442); E. Cyon ('Der
Einfluss der Temperatur verauderungen auf Zabl u. s. w. der Herz-
schlage," ' Arbeiten aus d. pbys. Anstalt zii Leipzig, von J. 1866,
Leipzig, 1867, ])p. 77 — 137); Cavagncs (" Versucli viber die Tast-
empfindlichkeit/'' 'Ann. Univers./ cci, p. 268, Agosto, 1867,
quoted in 'Schmidt's Jalirbilclier/ 1868, Bd. 137, p. 157) ; and
Supplemental Bibliography at end. — Trans.]
E. Cyon's work is still more closely connected with clhncal expe-
riences, since it treats " on the influence of changes of temperature
on the number, duration, and strength of the beats of the heart"
(/ Bcrichte iiber die Verhandluugen der k. silchs Gesellschaft der
Wissenschaften,^ 1866, xviii, 358 ff.), for by means of an ingenious
apparatus he studied the effects of serum, at various temperatures,
circulating by means of glass tubes through the heart of a frog
separated from the body of the animal. The results of gradually
rising temperatures are of special interest, for they first produced a
slow increase in the number of the cardiac contractions, but when the
rise of temperature was carried further there was observed a sudden
decrease in the number of contractions, and they began to be irre-
gular, till finally they ceased altogether; and, besides, the extent
(Umfang) of the contractions of the heart was equally increased at
the beginning of the experiment, but always diminished again,
whilst the number of the beats increased for a greater length of
time, which seems to indicate that the heart is best able to deal with
the blood-stream at certain temperatures only. Cyon^s experi-
ments on sudden changes of temperature are, on the other hand, not
applicable to pathology, since the temperature never takes such
sudden plunges in actual disease.
Even in these experiments, however, it was noticed that all hearts
did not behave exactly alike under similar circumstances, for the
definite effects named occurred in some hearts with a rather low
temperature, and in others with a much higlier one.^ How mucli
more must these individual differences make themselves felt in patho-
logical cases ! Indeed, it is easily conceivable that the conditions
in diseased human beings are essentially far more involved and com-
* See also 'Biennial Retrospect' (New Sydenham Society) for 1867-8, p. 11.
438 THK EFFECTS OF ALTERED TEMPERATURES.
|)lira(c{l than in an cxpcrimcnl which strives to represent the pheno-
menon in its full and inicom])licated simplicity.
Thus, in morbid conditions, the varied operations and effects
must be studied within somewhat narrow ranges of temperature de-
grees, both as regards the varied influence of suddenly or slowly
occurring alterations of these, as well as of their longer or shorter
duration.
It must further be very important whether the altered tempera-
ture in a given case depends on a disorder of heat-production or from
altered giving off of heat, or how far it may depend on both these
combined. The idiosyncrasies of the patient must also concur in the
production of these effects, and peculiarities in his structure, which,
in any case, will probably differ quite as much as the individual dis-
positions of extirpated frogs' hearts do from one another. More espe-
cially must the co-operation of pathological changes in the organs of
the body and in the secretions — and particularly in many forms of dis-
ease, the co-operation of the original cause of the disease itself, and
in all, the combined influence of factors which cannot be estimated,
and of the most widelv difFerius; influences duriniir the course of the
disease — be reckoned up and eliminated, if we want to estimate the
influence of altered temperatures on the behaviour of the organism
and its several members, in all its simplicity and completeness
(Pteinheit) . Such results are out of our power.
If we only represent to ourselves in this manner the uncertainty
attending such a determination in special cases, we are led to doubt
even the possibility of an approximative determination of the influ-
ence of an abnormal temperature on the system or its members in
any particular case.
§ 2. Nevertheless, the attempts made by Liebermeistcr, are none
the less valuable on this account, to determine at any rate the effects
of febrile rise of temperature (' Deutsche? Archiv fiir klin. Medicin,' i,
298, ff.) . He has, very properly, greatly simplified the question by fol-
lowing out more particularly the effects of only highly febrile degrees
of temperature, and he appears to imagine that there is a sort of indi-
vidual sliding (wechselnde) scale of elevated temperature at which the
unfavorable influence begins in different diseases. He particularly be-
lieves in the malignity of many attacks of disease, certain wide-spread
processes destructive to tissues, many disorders in the functions of the
central organs of the nervous system, the occurrence of multiple
THE EFFECTS OF ALTERED TEMPERATURES, 439
lisemorrliages iu severe febrile diseases, and many of the shapes
assumed by local processes, to be properly assumed as the results of
high febrile temperatures ; and he has adduced a great many obser-
vations of his own, and quoted copiously from others, in support of
his views.
Unless I deceive myself, his views have met with nothing but
applause, and the recent and extending preference for the cold-water
treatment of febrile disease (which is certainly reasonable) is based
in great part on this exposition of the dangers of high degrees of
temperature, as, on the other hand, the favorable results of this
therapeutic method have afforded strong support to the opinion as
to the injurious effects of fever.
§ 3. But however we may be inclined to admit that alterations
of temperature may exert a considerable influence on the system and
its several parts, we cannot on this account exclude from view the
facts, which are not isolated, but accumulated, which teach us that
in general this effect is far from being clearly manifested. The con-
viction is forced on us that there must be regulators (Einrichtungen)
in the system which are able to paralyse and compensate more or
less completely the influence of an abnormal temperature, as well as
the influence of many other disturbing forces, up to a certain poin*
at least. In this point of view (as also in many others) no disease
is more instructive than relapsing fever, in which not only enormous,
but in nowise transient, extremes of temperature, which in any
other case would be infallibly fatal, are borne without much injury
or distress ; in which also not only the extremest and most sudden
changes of temperature leave scarcely a trace behind, but in which,
moreover, the very same individual during the insignificant and brief
intermediate rise of temperature in the apyretic stage exhibits severe
brain symptoms, and disordered sensations, &c., whilst, on the other
hand, in the severe paroxysm with abrupt rise of temperature
amounting to from 4° to 6° C. (7-2° to io-8° E.), and sudden falls
of temperature of some 5° to 7° C. (9° to I2"6° F.), the patient is
actually far less affected.
§ 4. The organs and parts of the body which may be influenced
in their functions, and in the degree of their nutrition, by alterations
of temperature, are, without doubt, very numerous ; or rather, there
seems to be no part of the body which is not sometimes affected in
this way.
410 THE EFFECTS OV ALTERED TEMPERATURES.
TIic follo\vin£» arc sonio of the commonest and most striking
results of tliis clfcct in cliHcrcnt parts, under dilfercnt circumstances :
(a) On the general nervoiis system ; although it must not be
forgotten how susceptible the nervous system is to manifold pro-
cesses and influences, and what the degree of its impressibility is
in different individuals. On this account the influence of the tem-
perature in special cases can least of all be conclusively demonstrated
by mere functional disorders of the brain or the nerves. This much
is certain, that the brain functions may continue in all their
integrity at any degree of temperature which is compatible with life,
at least so long as increased exertions are not demanded from them.
In hypcrpyretic temperatures, such as occur shortly before and in
the death agony, there is seldom wanting a certain strangeness
(Benommenhcit) and confusion of manner (Verwirrung) ; only in such
cases the original cause of the brain disorder must not be sought
for only in the temperature, but generally also in numerous and
extensive lesions of those organs. But once now and then restless-
ness, headache, sleeplessness, startling dreams, and sometimes even
delirium, may result from the height of the fever, but the cases are
rare in which these symptoms can be attributed solely to this
circumstance.
(b) On the movements of the heart. — Although quite independent
of any local cardiac disease, there are many other subordinate in-
fluences, and the contrast of the frequency, as well as their potency,
with the degree of temperature, is so common that it is met with at
some time or another in almost every case.
None the less must we admit that there are certain relations
between the behaviour of the pulse and the temperature. It is
particularly certain that with high febrile temperatures we no longer
meet with quiet and satisfactory contractions of the heart, but, quite
otherwise, that they generally not only become more frequent, but
insufficient, and generally irregular. However, it is by no means
certainly determined that the cardiac contractions are determined by
the temperature ; it is rather more common to find that the changes
in the pulse have slightly preceded the alterations of temperature,
and, as it were, announced the occurrence of the latter.
(c) In the fulness of the capillaries, for since their behaviour
reacts upon the giving off of warmth, and, therefore, has great
influence on the degree of temperature, their relations are at least
somewhat complicated.
THE ErFECTS OF ALTERED TEMPERATURES. 441
{(i) On the frequency of the respirations, of which^ however, the
same may be said as about the heart's contraction, with this super-
added, that in almost all severe diseases it is tolerably common for local
disorders to develop themselves in the organs of respiration, which
produces an effect upon the frequency of respiration.
(e) On the tongue. — Although the extremest degrees of dryness
are very often observed with normal temperatures, and without any
local affection of the cavity of the mouth. ^
(/) On the digestive faculti/. — Although through the frequency
with which gastric catarrh sets in in almost all diseases, the direct
influence of the temperature on digestion is by no means a simple
question.
{g) On the hitegritij of the functions of the muscles (functions
bceintriichtigung), which may, however, have many other causes
affecting it.
(//) On the secretions, especially that of urine ; although the
relations of this to the changes of temperature are far from being
accurately determined as yet.-
(?') On the composition of the blood, and especially in the diminu-
tion of its red corpuscles, which, however, may take place through
exudations and deprivation of nourishment.
i]c) In the tendency to extravasations and transudations, and to
the aggregation of deposits, which are, indeed, every one of them
possible effects of the most widely differing factors.
(/) On Q-kitm\v& parenchymatous processes of a destructive nature
(acute fatty degeneration), although, indeed, this too may occur
without any considerable alterations of temperature (as in poisoning
by phosphorus).
(w?) On the general nutrition of the hody ; on its arrest, on its
^ It is almost superfluous to remiud the reader that dryness of the tongue
may be produced («) by breathing througli tlie nioutli instead of the uose, as in
sleep, especially when the surrounding air is deficient in humidity ; {b) from
defective water supply, which often liappens in bad nursing ; indeed, I believe,
that if the patient be liberally supplied with drinks, extreme degrees (such as
sordes) of dryness of the tongue are seldom met with, {c) From the effect of
certain medicines, or tonic agents. (Opiates are often credited with this, yet,
in common with Graves and Trousseau, I have often seen the tongue grow
moister and cooler under their use.) id) From local affections of the mucous
membrane, and perhaps other causes. — [Tkaxs.].
- Although Professor Faikcs has ably led the way iu researches of this
nature.
442 TIIK El'FRCTS OF ALTERED TRMFER ATDl^ES.
(liniinution; although, indeed, consumption or wasting never appears
to be produced purely by fever, or by collapse ; and the share of the
otlier morbid processes of the disease in the diminished nutrition
can as little be calculated as the influence of the temperature
upon it,
§ 5. If one tests a very large number of separate observations it
becomes impossible to escape the following conclusions :
{a) AVhen the c/mnf/es of temperature are moderate, either in a
rising or falling direction, nothing can be detected in the system
which need necessarily be attributed to the abnormal temperature or
which may not often enough occur without any such alteration of
temperature.
let even in such cases it rather seems that the subjective feelings,
the general turgescence, and the aspect of the patient dependent
upon it, the faculty of digestion, the free and perfect co-ordination of
the functions of the brain and of the muscles, the quantity and
quality of the urine, and, perhaps, of other secretions also, are
simultaneously affected by the change of temperature. These effects
generally appear much more evident when the system at the same
time is called upon to make any considerable effort.
{b) When the temperature rises ahruptly from normal or almost
normal degrees to considerable heights, it is very common to meet
with striking nervous and other functional disorders ; yet in not a
few cases not the slightest symptom of these is observed, and the
patient and those around him have not the slightest suspicion of the
processes gomg on, which can only be recognised at such a time by
thermometric observation.
It is also remarkable that even in the cases when the abrupt rise
of temperature is accompanied with many and severe symptoms, it is
uncommonly rare to find delirium associated with them, whilst
headache, absence of mind, fainting, or even sopor, are by no means
rare.
(c) Iiven rather considerable elevations of temperature, when they
alternate vnth daily remissions of tolerable extent, may last for a
considerable time without being accompanied at the moment by any
particular phenomena, dependent (with any probability) simply upon
the anomaly of the temperature.
The functional disorders which display themselves at such a time
are, at least extremely ofteii, by no means parallel with the height of
THE EFFECTS OF ALTERED TEMPERATURES. 443
the exacerbations, and in such cases at least the perhaps immediate
effects of the change of temperature are dominated by the influence
of the primary cause of the ilhiess and the manifold changes in
various organs which are set up by the disease itself. This, however,
does not preclude even remitting febrile temperatures having their
share in impoverishing the blood, in the alteration of secretions,
and in diminished nutrition. These results appear, however, to be
far more dependent upon the duration than upon the intensity of the
remittent febrile course.
(d) In sii^b -continuous and continuous elevations of temperature of
considerable amount there are either so many other serious conditions
present that it would be inappropriate to attribute special functional
phenomena and consecutive disorders of tissues to the increased
temperature, or they are special obscure cases, which cannot Avell
be made use of as bases for general conclusions, or as illustrative
arguments.
In any case there is no particular morbid symptom which can be
shown to display anything approaching to a regular parallelism with
the degrees of temperature, or of which it can justly be said that it
must infallibly occur with certain degrees of temperature. But,
again, this by no means precludes the anomalies of temperature from
being followed either directly or mediately by certain subsequent
results.
{e) But it is tmdeniahle that there is a definite relation between
the temperature and the event of death, inasmuch as the continu-
ance of life is clearly incompatible with certain heights of tempera-
ture, although the reason is certainly unknown, and can scarcely be
that propounded by Weikart ('Archiv der Heilk.,' iv, J93), who
mentions that fibrine begins to be separated from the blood at
certain high degrees of temperatures. Even in this respect relapsing
fever has taught us that the limits of bearable temperature must be
extended furtlier than was at one time beHeved to be possible.
(,/) ^f'^l^' a fall of temperatare from high degrees to normal or
below it, we generally find remarkable anomalies of function, under
circumstances which prove by no rise unfavorable to the ])aticnt,
and it may be in the direct road to recovery. In exanthematous
typhus the delirium often lasts some days after the fever, and even in
abdominal typhus the greatest disturbance of the brain sometimes
coincides with the period when the temperature has decidedly taken
a descending direction. In pneumonias the severe functional dis-
I 1 1 Till", FFFECTS OF AI.TKRKD TEMFRRATURES.
orders of the brain, ns well as doliriuin, occur far more fn'(|ueiit]y
after the maximum of the temperature has been attained, when the
temperature is quickly falling, or has again become normal, rather
than at the height of the fever. And the same is true of any other
kind of disease.
But just as frequently very abrupt downfalls of temperature occur
in which neither the functions of the brain nor those of any other
organ appear to be disturbed in any way.
{g) 1)1 subnorraal temperatures there is, indeed, generally, an in-
lluence on the turgescence of the surface of the body [washerwoman's
hand of cholera], and, therefore, not to be overlooked in the aspect
of the face. Other parts of the body also may be disturbed in
their functions. But in any considerable downfall of temperature
the circumstances of the case are always so complicated and intri-
cate, that it appears impossible to attribute the symptoms sim])ly
to the decrease of tem])crature.
APPENDIX No. I.
Note to iwges 105 and 115, on the Ivfluence of Best and Work,
and the Influence of Atmosi)]ieric Pressure, on Temperature.
Lortet lias made very interesting observations on variations of the
temperature in conditions of rest^ and of muscular movement^ on
level ground and on high mountains, and has lately published them
in the'Comptes Rendus' (1869, p. 709, seance pour 20 Sept.).
The temperatures were taken under the tongue.
In Lyons (200 metres = 2i8| feet elevation), with an atmo-
spheric temperature of 227° C. (72*86° Pahr.), the temperature
during rest was 36*4° C. (97*52° Pahr.), whilst with bodily exercise
it was only 36*2° C. (97*16° Pahr.). On the other hand, Zortei
found in two ascents of Mount Blanc on the 17th and 26th of
August, 1869, the temperature affected as shown in the table on
page 446.
No doubt the diminished chemical processes resulting from the
rarefaction of the atmosphere were quite sufficient during bodily
rest to maintain a normal temperature. But as soon as exertions
were made, and the chemical forces had to resolve themselves into
motion, they no longer sufficed to produce the warmth which is
necessary for the maintenance of the normal temperature. Tlie
temperature suddenly sank several degrees, even as much as nearly
5° C. (9° Pahr.). But directly a few minutes' rest intervened the
chemical forces again produced warmth, and the temperature quickly
began to rise to normal again. On the summit of Mont Blanc,
however, it required half an hour's rest before the temperature re-
gained its normal height.
During digestion, on the other hand, this discrepancy between
rest and movement was no longer remarkable. In spite of con-
tinued exertion, the temperature remained between 36° and 37° C.
(96-8° and 98*6° Pahr.), and, indeed, reached as much as 37'3°C.
(99*14° Pahr.). However, the compensatory influence of nourish-
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APPENDIX. 447
ment was not lasting. An hour after the meal the cooHng of the
body by exercise recommenced.^
APPENDIX No. II.
Table of Thermometric Equivalents, according to the Celsiau {or
Centigrade^ Reaitmur^s, and Fahrenheit' s Scales.
[N.B. — Any numbers not included in the table can be easily con-
verted if once the principle of division of the scales be mastered.
The principle of the Centigrade or Celsian thermometer is to divide
the space between 32° of Pahr., or freezing-point, from which the
Centigrade starts, and 212° of Pahr., or boiling point, into 100°.
Therefore, every 180° Pahr. = 100° C, or every 1° C. = i-8° Pahr.
In Eeaumur's thermometer the same space is divided into 80°
only. Therefore, 1° C. = r8° Pahr., or 1-25° R. ; or 1° Pahr.,
= f,° C. or -;r°^- Therefore, the relation between the degrees of Pah-
renheit. Centigrade, and Reaumur, is explained by the numbers 9, 5, 4.
In converting from Pahrenheit into Centigrade or Reaumur we must
first subtract 32, and then reduce ; whilst in converting into Pahren-
heit from either Centigrade or Reaumur we must add 32 after the
multiplication and division are completed. The following arbitrary
rules may be found convenient :
(i) To convert Centigrade into Pahrenheit, multiply by 9, divide
* In the 'Lancet ' of Jan. ist, 1870, 1 find the following observations of Dr.
Marcet (see also ' Archives des Sciences physiques/ xxxvi, 247, and tlie ' Bib-
liotheque Universelle et Revue Suisse,' Nov. 15th, 1869), who gives an
account of some observations, made in an expedition to the Mont Blanc chain
of mountains, on the influence of altitude on temperature. His observa-
tions were made with a thermometer in the mouth, by means of a mirror
attached to the instrument. It will be seen that they substantially confirm
Lortet's researches.
1. The temperature of the human body in a state of repose is not less
elevated at the summits of high mountains than at the level of the sea.
2. During the act of ascent the temperature appears to diminish progres-
sively— the time from the last meal is one of the chief factors. As a general
rule, rapid mounting, with free cutaneous transpiration, produces the greatest
depression of temperature.
3. The temperature soon rises again when at rest, or by moderating the speed.
4. The cardiac oppression and general feeling of indisposition, &c., is accom-
panied at great altitudes by remarkable depressions of bodily temperature." —
[Tkans.]
418
APPENDIX.
by 5, add 32, or multiply by 18 and add 32. Example: 20"^ C.
= 20 X 1*8 + 32 = 68° Eahr.
(2) To convert Centigrade into llcaunmr, multiply by 4, divide
by 5, or multiply by o'8. Example : 20° C. x o-8 = 16° 11.
(3) To turn Ealirenheit into Centigrade, deduct 32, multiply by
5, and divide by 9. Example : 104° Eahr. — 32 x 5 -^ 9 ^ 40° C.
(4) To turn Ealirenlicit into lleaumur, deduct 32, divide by 9,
multiply by 4. Example : 104° Eabr. — 32 -^ 9 x 4 = 32° R.
(5) To turn Eeaumur into Eahrenlieit, multiply by 9, divide by 4,
and add 32.
(6) To turn Reaumur into Centigrade, multiply by 5, divide by 4.
The following figures will still further cxj)lain.
Fr
eezin
(T.
Boiling.
Fahrenheii
! . . 0
V-
77
122
212
B,eaumur
• •
•
m
•
0
•
•
20
•
•
40
•
•
80
Centigrade
0
ri
•
50
•
•
•
100
C.
R.
F.
C.
R.
F.
0
0
32
33
2G„
91,,
5
4
41
33„
26,48
91,58.
10
8
50
33,.,
26,s6
91,76
15
12
59
33,3
26,64
91,94
17,3
14
03,5
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26,72
92,12
20
16
68
33,3
26,3
92,3
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18
72.,
33,0
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92,48
25
20
77
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27.52
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26,08
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32„
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94,28
32,3
26,24
9I,C4
34,;
27.76
94,46
32,3
26,32
9i,zi
34,3
27,84
94,64
" THERMOMETRIC EQUIVALENTS.
449
c.
R.
r.
c.
R.
F.
3-i,o
27,92
94,8z
38,75
31
101,75
35
28-
95
38,8
3I'°4
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28,08
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31,12
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28,16
95,36
39
31,2
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28,.4
95,54
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28,32
95,72
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102,56
35,5
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95„
39,25
31,4
102,65
35,0
28,48
96,08
39,3
31,44
102,74
35„
28,56
96,26
39,75
31,5
102,875
35,s
28,64
96,44
39,4
31.52
102,92
00,9
28,72
96,62
39,5
31,6
103,1
36
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96,8
39,6
31,68
103,28
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28,88
96,98
39,;
3^,76
103,46
36„
28,96
97,16
39,75
31,s
103,55
36,15
29
97,25
39,3
31,84
103,64
36,3
29,04
■ 97,34
39,9
31,92
103,32
36„
29,12
97,52
40
32
104
30,5
29,2
97„
40,1
32,08
104,18
36,«
29,28
97'88
40,2
32,16
104,36
36,7
29,36
98,06
40,25
32,2
104,4s
36,75'
29,4
98,15
40,3
32,24
104,54
36,8
29,44
98,24
40,4
32,32
104,72
36,3
29,52
98,42
40,5
82„
104,9
37
29,6
98,6
40,6
32,48
105,08
37,1
29,68
98,78
40,625
32,5
105,125
37,2
29,76
98,96
40,-
32,56
105,26
37.»s
29,8
99>t>s
40,75
32,6
105,37
37,3
29,84
99>i4
40,3
32,64
105.44
37„
29,92
99,32
40,9
32,72
105,62
37,5
30
99,5
41
32,3
105,8
37,6
30,08
99,68
41,1
32,88
105,98
37„
30,16
99,86
41,125
32,9
106,025
37>75
30,2
99,95
41,2
32,96
106,16
37,8
30,H
100,04
41,25
33
106,25
37,0
30,11
100,22
41,3
33,04
106,34
38
30,4
100,4
41,4
33,12
106,52
38,1
30,48
100,58
41,5
33.
106,7
38,15
30,5
100,67
41,6
33,28
106,88
38,2
30,56
100,76
41,625
33,3
106,925
38,25
30,6
100,85
41,7
33,36
107;06
38,3
30,64
100,94
41,7s
33,4
107,15
38,4
30,72
101,12
41,3
33,+^
107,24
38,5
30,8
101,3
41,875
33,5
107.375
38,6
30,88
101,48
41,9
33,52
107,42
38„
30,96
I0Ij66
42
33,6
107,6
29
150
0
TEMrEllATUKE OF ANIMALS,
ETC,
c.
R.
F.
C.
R.
F.
42„
33,68
107,78
43)37$
34,7
110,075
4^.115
33,,
I07,8»s
43.,
34,7*
110,12
42,„
33.76
107,96
43,,
34,3
110,3
42,iJ
33,3
108,0s
43,0
34,88
110,48
i2,3
33,84
108,14
43>62$
34,9
IIO,s2S
42,37s
33,9
108,185
43,7
34,96
1 10,66
42„
33,9»
108,31
43>75
35
1X0,75
42.,
34
108,5
43,8
35.04
110,84
42,0
34.08
108,68
43,9
35,u
111,02
42,62s
34,1
108,715
44
35,2
111,2
42,;
34,16
108,86
44,1
35.28
111,38
42,7s
34,.,
108,9s
44,2
35,36
III,;6
42,3
34,24
109,04
44,3
35,44
111,74
42,87s
34,3
109,17s
44,375
35„
1 1 1.875
42,9
34,32
109,12
44,4
35,5*
111,9*
43
34„
109,,
44„
35.0
112,1
43„
34.48
109,58
44,0
35,68
1 12,2s
43."S
34,3
109,625
44,7
35,76
112,46
43,2
34,s6
109,76
44.3
35,84
112,64
43,iS
34,e
109,85
44,9
35,92
112,81
43,3
34,64
109,94
45
36
113
APPENDIX No. III.
The following notes came under my notice too late for insertion in
their proper places :
1. K. Th. Schmalz (in Schmidt's ' Jahrbiicher/ B. 137, p. 212
(1868) gives the following as the average temperature of several
domestic animals taken in the rectum, the vaginal temperatures being
about o-2° to 0-5° Reaumur, =ii"-oth° to 1*125° Palirenheit lower
than these :
BuUs = 31-3° R. = 102-41° F.
Cows = 31 '2" 11. = I02-20° F.
Calves = 31-4= 11. = 102-65° F.
Sheep = 32-2° R. = 104-45° ^^
Lambs = 32-5° R. = 105-12° F.
Horse and ass = 30-7° R. = ioi'o7° F.
Some of these differ rather considerably from those given at
page 85.
2. Lombard has found, by means of a very delicate thermo-electric
SUPPLEMENTAL BIBLIOGRAPHY. 451
apparatus registering ., ^\^^° C, that the temperature of the skin
over the radial artery at the wrist falls for a few seconds after
suspending respiration. [See p. io8.] Quoted in 'Medico-
Cliirurgical Review' for January, 1871, to which also I am indebted
for the following reference.
3. Drs. Brown-Sequard and Tholozan find that pinching a limb
raises the temperature of that limb, but lowers the temperature of its
fellow on the opposite side ; also, that pinching one leg often raises
the temperature of the arm of the same side, and lowers the tem-
perature of the other (opposite) arm, as well as of the opposite leg.
They consider all these to be phenomena of a reflex kind, and due
to vascular contraction or dilatation. {' Gazette Medicale de Paris/
1870, p. 142.) — [Trans.]
APPENDIX No. IV.
Supplemental Bibliography.
AllhuU, T. Cliforcl, two articles "On Medical Thermometry,"
including review of Wunderlich, ' Brit, and Por. Med-Chir. Eev.,'
1870, April, p. 429 ; July, p. 144.
Alcock, Assist.-Surgeon, " On Nervous Power in relation to Tem-
perature, and Eise after Death,'' 'Med. Times and Gaz.,' 1869,
vol. i, p. 206, vol. ii, 6ai.
'American Journal of Medical Sciences,' 1866, p. 241 ; 1867, p.
506, 525, 245; vol. ii, 539; 1868, I, 495, 557 ; 1869, 243,425,
521.
Andral, M., "On Temperature of Infants," * Med. Times and Gaz./
1870, vol. i, 526. 'Comptes Eendus/ t. 70, p. 825. 'Archiv.
Generales/ 1869, 2, 716.
Anfmn, M., " Thermometrie Medicale," 'Bulletin Gen. de
Therap./ 1869, iii, 50.
Barclay, A. W., " On High Temperatures in Acute Ehcumatism,"
'Lancet,' July 30th, 1870.
Baumler, C, "On Treatment of High Temperatures by external
Application of Cold/' 'Lancet/ August 6th, 1870 (ii, 181).
Bec(p(,erel, E., " On Thermo-electric Piles and Thermo-electrics/'
' Annales de Chimie et de la Physiologic/ 1866, tom. viii, ser. 4, 389.
452 SUPPLE3IENTAL BIBLIOGRAPHY.
^^^/^/Oj/y/zM," A peculiar case of Fever [higli temperature (i03'8"
F.) with slow pulse (60)]/' 'Edinburgh Med. Journal/ i.Syo.
Bergeron, 31., " llecherches sur la Piieumouie des Viellards,"
Paris, 1866.
Bertis,F. IF. C, " On Temperature/' 'Nederlands Archiv./ Bd. v,
p. 179. 'Brit, and For. Med.-Chir. Rev./ January, 1H71, p. 233.
Berthdot, M., " Des Carbures pyrogcncs/' ' Annales de Chimie,
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Binz, C, " Pharmak. Studien iiber Chinin/' ' Yirchow's Arcliiv/
1869, Bd. 46, Heft. I, p. 67, Heft. 2, p. 129.
Binz, " On Quinine and Alcohol in Paralytic Fever/' ' Prac-
titioner/ vol. iv, July, 1870, p. I.
Binz, C, " On Effects of Quinine and Alcohol/' * Viichow's
Archiv/ Bd. 51, Heft, i, p. 6, and Heft. 2, p. 153.
Bird, R., " Effects of Sulphurous Acid on Temperature/' ' Prac-
titioner/ vol. ii, p. 247.
BlaJce ''On Inequality of Temperature on two sides, &c./' 'Med.
Times and Gaz./ 1870, vol. i, p. 676.
Bhm, A., " Etude sur la Fievre traumatique primitive/' ' Arcliiv.
Generales,' 1869, tom. i, ser. 6, p. 414.
Bossc/ia, M., " On Air and Mercurial Thermometers," ' Comptes
Eendus/ 1869, tom. Ixix, pp. 875, 879, and 1185.
Braune, Wilhelm, "On Intermitteuts with several months' in-
tervals,-" 'Archiv. der Heilkunde/ 1870, Heft, i, p. 68.
Breuer, "On Senator's Paper/' 'Virchow's Archiv.,' 1869, Bd.
46, 3rd Heft., p. 391.
' British and Foreign Med.-Chir. Review / various papers in vol.
xxxviii, p. 93 (July, 1866), vol. xlv, pp. 260, 279, 168, July, 1870,
pp. 241-2-3, January, 1871, p. 233.
Browii-Sequard, and /. E. Lombard, " On effects of Irritation of
Sensory Nerves on Temperature," 'Archives de Physiologic,' 1868,
p. 688.
Buzzard, Thomas, "Effects of Aconite on Temperature and Pulse/'
'Practitioner,' vol. ii, p. 127.
Carter, Thomas, "On Thermometer as a Test of Death," ' Lancet/
1867, vol. ii, p. 544.
Charcot and Vzdpian " On Temperature," ' B. Sequard's Archives
de Physiologic' (1870), iii, 451.
Clark, Le Gros, " The Temperature in Diseases/' ' British Med.
Journal,' 1868, i, 451.
SUPPLEMENTAL BIBLIOGRAPHY. 453
Clouston, T. S., "On Bromide of Potassium in Epilepsy/^ ' Journal
of Mental Science/ October^ 1868, p. 305.
Coli7i, 31., " On Temperature of Venous and Arterial Blood,'^
'Archives Generales de Medecine/ torn, ii, Ser. 6, p. 45 (1865).
Compton, T. A. {and S. JFarter) "On Temperature in Acute
Diseases/' 'Dublin Quarterly Journal/ August, 1866, p. 60.
Da Costa, " Temperature of Body in Cancer and Tuberculosis "
(review);, 'Brit, and For. Med.-Chir. Eev./ vol. xxxix, April, 1867,
P- 5^5-
Davies, Br. Herlert, " On Temperature in Acute Rheumatism,
and Effect of Blisters/' ' Med. Times and Gazette,' 1870, vol. i, p.
47- _
Deville, H. Sainte Claire, "On variations of Temperature by
Mixture of Two Liquids/' 'Comptes Rendus,' 1870, tom. 70, p.
1377-
Ehrle, Carl, " On Registering Thermometers/' ' Deutsch. Archiv.,'
6d. vii, June, 1870, p. 345.
FalcJc, C. Ph., "Experiment. Studien, &c., der Temperatur
curven der Acuten Intoxicationen/' ' Virchow's Archiv.,' 1870, Bd.
49, Heft, iv, p. 458.
Fastre's "Spirit Thermometers," ' Schmidt's eTahrbiicher/ Bd. 139,
p. 144 (1868).
Faye, M., "On Zeuner's Traite de Thermo-dynamiquc," and
other papers, ' Comptes Rendus,' 1869, tom. Ixix, pp. loi, 858,
1057-
Fergus, Walter, " On Inequality of Thermometers," ' Med. Times
and Gazette,' 1870, vol. i, p. 696.
Fox, Cornelius B., " Remarks on Clinical Thermometers," ' Med.
Times and Gazette/ vol. ii, 1869, p. 459; 'Lancet/ 1870, vol. ii,
180; 'Brit. Med. Journal/ 1869, ii, 247.
Fox, E. Long [a series of valuable papers on Temperature, with
charts], ' Med, Times and Gazette/ 1870. "On relations of Phos-
phoric Acid to Temperature/' 'British Med. Journal/ 1867, vol. i,
p. 544. "Clinical Observations on Acute Tuberculosis," 'St.
George's Hosp. Reports,' vol. iv.
Frese, J. B., "On the Temperature after transfusion of
Healthy Blood/' 'Yirchow's Archiv.,' 1867, Bd. 40, Heft, ii, p.
302. _
Gihson, F. IF,, paper m ' Journal of Mental Science,' Jan.,
1868, p. 497.
454 SUPPLEMENTAL BIBLIOGRAPHY.
Gibson, F. JF., "On Temperature," 'Brit. Med. Journal,' 1866,
i, 249, 278.
Good/iart, J. F., " Thermometric Observations in Clinical
Medicine/' 'Guy's IIosp. Reports/ 1869 (3rd ser., xv, p. :^6^).
Greeii//02c, Dr., " On progressive fall of Temperature [to 84° in
axilla]/' 'Brit. Med. Journal/ 1870, i, 652.
Grimshaw, T. IF., " Observations of Temperature in Pneumonia/'
*Dub. Quarterly Journal/ May, 1869, p. '^'7^^. "On Temperature
in Typhus," 'Dub. Quarterly Journal/ May, 1867, p. 313.
''Thermometric Observations in Fever/' Dublin, 1866 (reprint from
'Med. Press and Circular).
Gmber"Oii Temperature in Pregnancy," 'Schmidt's Jahrbiicher/
1868, Bd. 139, pp. 197-8, 346.
Hamilton {Iloyal Artillery) "On Effects of Quinine" (from
'Indian Medical Gazette'), 'Lancet/ January 14th, 1871.
llankel, Ernst, " On a Thermo-electric Apparatus of s})irals of
iron and virgin silver wire," ' Archiv. der Hcilkunde,' 1868, ix, 4,
T> T
" Haiohsleij s Thermometers," 'Lancet,' 1870, vol. ii, 12.
Hayden and Cruise, Drs., "On Temperature in Cholera," 'Dub.
Quarterly Journal,' May, 1867, 396.
Hirsch, Br., " Ou development of Doctrine of Pever," ' Archiv.
der Heilkunde/ Heft iv, 1870, p. 400.
Uirz, M., " Chaleur dans les Maladies," ' Nouveau Dictionnaire de
Med. et Chirurg. Pratiques,' 1867.
Hollis, JF. Ainslie, " On value of Thermometer to Physicians/'
a very valuable paper, in ' St. Bartholomew's Hosp. Reports,' vol. ii
(1867), p. 285.
Roncath (of Kiew) " On Temperature/' in 'Wiener Acad.
Anz./ 1870, No. II; ' Centralblatt f. d. Med. Wissenschaften/
No. 35, 1870; 'Brit, and Eor. Med.-Chir. Rev./ Jan., 1871,
233-
Huppert, H., "TJeber die Ursache der postmortale Temperatur
steigerungen," 'Archiv. der Heilkunde/ viii, 6, p. 321, 1867; also
in 'Schmidt's Jahrbiicher/ 1868, Bd. 138, p. 79.
Jacohi, Professor, " On Antiphlogistics in Diseases of Children "
(lectures to New York Med. Journal Association), ' New York
Medical Record.'
Jacohson, Heinrich, " On normal and pathological Local Tempera-
tures/' ' Yirchow's Archiv.,' Bd. 51, Heft, ii, p. 275.
SUPPLEMENTAL BIBLIOGRAPHY. 455
Janim, M., " On Temperature in mixtui-es of Alcohol and Water/'
&c., 'Comples Eendus/ 1870, torn. Ixx, pp. 1237, 1309.
Jordan, Fiirn-eatix, "Temperatures in Shock/' 'Brit. Med.
Journal/ 1867, vol. i, p. 164.
Kettler, C, "On Frese's Paper on Transfusion/' 'Virchow's
Archiv,/ 1867, Bd. 41, Heft, iv, p. 542.
Lahhee, Leon, " On Effects of Veratrum Viride/' ' Gaz. de Paris/
44j 45; 'Schmidt's Jahrbiicher/ 1870, Bd. 145, 273.
'Lancet/ Oct. 23rd, 1870, p. 584; Oct. 29th, p. 624, "Effects
of Medicines on Temperature/' by E. J. Mavor.
Laschkewitsch " On causes of Depression of Temperature in Sup-
pression of Perspiration/' ' Reichert und Du Bois Raymond's Archiv.,
1868, p. 61.
Lerklie, M., " Effets varies des traumatismes du rachis/' ' Lyou
Medicale/ tom, v. No. 18, p. 598.
Le Roiix, F. P., " On Thermo-electric Currents/' ' Annales de
Chimie/ &c., tom. x, ser. iv, p. 201 (1867).
Leivizhj, P. (Kosan), "On Sulphate of Quinine/' 'A^irchow's
Archiv./ 1869, Bd. 47, Heft, iii, p. 352.
liebermeister, " On Antipyretic Effect of Quinine/' 'Deutsch.
Archiv. f. Klin. Med./ 1867, iii, 23-66.
Lombard, J. S. (Harvard, U. S.), " Influence of Respiration on
Temperature/' ' Brown-Sequard's Archives de Pbysiologie" (1869),
tom. ii, p. I.
Lombard, J. E., " New Thermo-electric Apparatus/' ' Archives de
Physiologic/ 1868, p. 498.
Maclagan, T. J. (Dundee), "Notes on Fall of Temperature in
Infants for a few days after birth/' ' Proceedings of Royal Society of
Edinburgh.'
McDonnell " On Temperature in Injuries of Spine/' ' Dublin
Quarterly Journal/ August, 1866, p. 28.
Mantegazza Paolo " On Pain in relation to Generation of Heat/'
' Gaz. Lombard/ Nos. 26-29, 1866.
Mendel, E., " D. Temperatur der Schiidelholde in normalen und
pathol. Zustiiude/' ' Virchow's Archiv./ Bd, 50, Heft, i, p. 12.
'Medical Times and Gazette/ 1866, i, pp. 177, 201, 311, 394,
418, 228, 31 J, 666, 659, 251, see E. Long Eox, &c.
Medvng, Dr., "A case of very High Temperature (108-5° F.)
with Preservation of Life," 'Archiv. der Heilkunde/ 1870, Heft.
V, p. 467.
456 SrrrLEMENTAL BIBLIOGRAPHY.
]\[oore, J. jr., " ]\Iean Temperature in relation to Disease, &c./'
'Dublin Quarterly Journal/ Nov., 1869, p. 107.
Muirhead, Claud, "On llelapsing Fever in Edinburgli in 1870/^
' Edinburgli Med. Journal/ 1870, July, p. i.
Murc/iison, Charles, " High Temperature in Acute Eheumatism/'
'Clinical Society's Trans./ vol. i, p. 32.
Nanmann, Osw., Dr., " Influence of Epispastics on Pulse and
Temperature/' 'Schmidt's Jahrbilcher/ 1867, Bd. 133, p. i^^fi.
Naun)/n, B. 8)' II. Quhicke, " Ueber den Eiuflusz dcs Central
Nerven-systems auf die Wiirmebildung im Organismus/' ' Eeichcrt
und Du Bois Reymond's Arcliiv./ pp. 174, 521, 1869.
Nauiujn, ^.[(Dorpat), " Beitrilge zur Fieber-lehre/' ' Reichert und
Du Bois Reymond's Archives/ 1870^ Heft, ii, p. 159.
Ohermeier, " Ueber das wiederkehren des Eiebers/' 'Virchow's
Archiv./ Bd. 47, 4tes Heft., 428.
Oehl, E. de Bienzi, and Trauhe, " On Temperature in Cancer and
Tuberculosis " (Review), ' Brit, and For. Med.-Chir. Review,' July,
1867, vol. xl, p. 249.
Oehl, "Die Beziehungen des Yagus zur T. der Bauchhohle,"
'Schmidt's Jahrbilcher,' Bd. 143, 1869, p. 280 [section of vagus;
temperature of abdomen] .
Onimus and Viry, " Relations de I'activite musculaire avec la
Temperature/' &:c., (review of), 'La Revue Medicale' (Paris), 1868,
tom. i, 607.
Farl-es, E. A., and Count WoUoioicz, " On Effects of Alcohol,"
'Proc. Royal Society/ vol. xviii. No. 120, p. 362, ' Lancet,' August
20th, 1870.
Peter, Dr., " Modifications de la Temperature/' ' Archives
Generales,' 1867, tom. i, ser. 6, p. 616.
Picic, Thomas P., " On Traumatic Fever," ' St. George's Hosp.
Reports,' vol. iii, p. 73.
Pochoy, 21., " Recherches experimentales sur les centres de Tem-
perature," Paris, 1870, V. 'Lyon Medicale/ Oct. 23, 1870,^0. 22,
tom. vi, p. 197.
Potain's Alcoholic Clinical Thermometer, notices of, 'La Revue
Medicale/ 1868, tom. i, p. 631 ; 'Med. Times and Gazette/ 1868,
vol. i, 338.
Prior, a E. (Bedford), " On Temperature, &c./' ' British Med.
Journal/ 1868, vol. i, p. 451.
Rattray, Alexander, " On Effects of Tropical Climates on Tempera-
SUPPLEMENTAL BIBLIOGRAPHY. 457
ture^ &c., of Body/' 'Proc. Eoyal Society/ vol. xviii, No. 122, p.
5^3-
Bedwood, T. H.^ " Temperature in Typhoid/-* 'Lancet/ t868, vol.
h PP; 497-528.
Ringer, Sijdney, and W. Richards " On EflFects of Alcohol on
Temperature/' 'Lancet/ vol. ii, 1866^ p. 208.
Richardson, B. W,, "Effects of Higli Temperature on Animal
Substances/' 'Medical Times and Gazette/ 1869^ vol. i^ pp. 29, ^2»
84.
Rohin, Rdouard, " Effects of Temperature on Growth of Horns,
Eeathers, &c./' 'Revue Medicale/ 1869, i, 139, 272.
Roch, St off -Surg., "On Heat Apoplexy/' 'Medical Press and
Circular/ 1868, vol. i, 519 [records a temperature of 113° F.].
Rosetti, F., " Sur Fusage des couples thermo-electriques dans la
mesure des temperatures/' ' Annales de Chimie^ &c./ tom. xiii, p.
68 (4 serie).
Rnge, Paid, " "Wirkung des Alkohols auf dem thierische Organ-
ismus/' 'Yirchow's Archiv./ 1870, Bd. 49, Heft, ii, pp. 252, 265.
Sanderson, J. Burdon, " High Temperatures in Acute Rheuma-
tism/' 'Clinical Society's Trans./ vol. i, p. 34.
ScJiiff, Moritz, and Levier, "Recherches sur I'echauffement des
nerfs, &c., ^ la suite des irritations sensorielles and sensitives/'
'Archiv. de Physiologic' (B. Sequard), 1869, ii, 157.
' Schmidt's Jahrbiicher ' (besides papers quoted elsewhere), Band
133, p. 241, Bd. 135, pp. 6, 237, 248, Bd. 136, pp. 90, 112, 116,
119, 217, 263, Band 137, pp. 213, 232, 248, 249. 250, Band 138,
pp. 77, 78, 95, 104, 129, 303, 334, Band 139, p. 94, Band 140,
pp. 139, 155, 167, 171, 210, Band 141, pp. 98, 100, 214, 250,
Band 143, pp. 134, 221, 225, 293, Band 146, pp. 13, 14, 16, 19,
23^ 93> 204, 205, 304.
Schroder (of Bonn), " Temperatur-beobachtungen im Wochen-
bette," ' Monatsschrift f. Geburtskunde,' xxvii, p. 108, February,
1866.
Senator, H., " Beitriige zur Lehre v. d. Eigenwiirrae u. d. Fieber,"
' Yirchow's Archiv./ 1869, Bd. 45, Heft, iii, p. 351. "Uebcr das
Verhalten der Korperwiirme bei Abkiihlung der Haut," ' Virchow's
Archiv./ Bd. 50, Heft, iii, p. 354.
(Smw?.?, ^., Inaugural Dissert., Bonn, 1870, "On Gases (CO2,
&c.) depressing Temperature," 'Brit, and For. Med.-Chir. Rev.,'
January, 1871, p. 233.
45S SUrrLEMENTAL BIBLTOGRAniY.
Smi/tii, If'., " On EIFects of iVlcoliol on TemperaturCj" ' Med. Times
and Gazette/ 1869, vol. ii, 744.
Sjmnff, A. F. (Luttich), ''On the Eelation of Sense of Toucli,
Temperature, and Pain/' 'Med. Press and Circular/ 1866, vol. i,
400.
Squire, IF. (papers " On Puerperal and Infantile Temperatures"
already quoted), "On Temperature Variations from Vaccination,"
'Lancet/ 1869, ibid., 1870, vol. i, 806.
Squareij, Charles, "Observations on the Temperature, Urea and
Chlorides in Typhus Pever/^ 'Trans. Med,-Cliir. Society/ 1867, and
'Lancet^ in 1866.
Stieler, Guido, " On Ten Patal Cases of Cold Water Treatment of
Typhus Pever," ' Zeitschrift f. Rat. Medicin ' (Henle and PfeuCTcr's),
xxvi Bd., 3 Reihe., p. 254.
Sutton, H. Gawen, " Cases of Acute Rheumatism," ' Guy's IIosp.
Reports,' 1866 (3rd series, xii), 509.
T/ieurkauf, J., "Ueber Typhus/' 'Virchow's Archiv.,' Bd. 41,
Heft, iv, 443 ; Bd. 43, Heft, i, p. ^^.
Thompson, R. ^.," On Temperatures in Typhus Epidemic, 1864-5,"
'St. George's Hosp. Reports,' vol. i, p. 47, "Temperature
Observations in Typhoid Pever/' ' St. George's Hosp. Reports/
vol. ii, p. 75. "On Rheumatic Pericarditis/' 'St. George's PIosp.
Reports/ vol. iv.
Traube and E. Lei/den " On the Temperature in Puerperal Pever/'
' Annalen der Charite/ Berhn, 1863.
Troost and Hatitefeuille, " Chaleur due a des actions chimiques,"
' Comptes Rendus,' 1869.
TsckeschicJdn, M., " Zur Lehre von d. thierisclie Wiirme/'
' Reichert und Du Bois Reymond's Archiv./ 1868, iv, 151.
Vallin, 31., " On Insolation," ' Archives Generales,' torn, i,
ser. 6, p. 113. Also a paper 'On Convulsions/ ibid., p. 129,
1868.
Veratrum viride, effects of, on Temperature. See ' Schmidt's
Jahrbiicher/ Bd. 139, p. 282; Bd. 140, p. 156; Bd. 143, pp. 11,
136, 139, V. Labbee.
Wa(/ner " On Temperature in Phthisis, &:c.," ' Schmidt's Jahr-
biicher," 1854, Bd, 81, pp. 117-120.
Warter, S., papers in 'Med. Times and Gazette,' 1866, vol. ii, pp.
416, 483. Also vol. ii (1866) ' St. Bartholomew's Hosp. Reports/
p. 65.
EXPLANATION OF PLATES. 459
Weber, Hermann, " Eemarks on Hcemoptysis/' ' Clinical Society's
Trans./ vol. ii, p. 143.
IFilliams, Dr.," On Temperatures in Insanity/' ' Med. Times and
Gazette/ 1867, ii, 324.
WiUsliire and 8(jidre "On Puerperal Temperatures/' 'British
Medical Journal/ 1867, vol. ii, p. 410.
JFolf and Schroder "On Temperature of Childbed" (Review),
' Brit, and For. Med.-Chir. Review/ vol. xsxviii, p. 280.
Wunderlicli and Hirz, review of, 'Med. Times and Gazette/
1869, vol. ii; p. 19.
APPENDIX No. \/.
Explanation of the LithogirqMc Plates.
The first plate affords a model for the registration of the frequency
of the pulse and respirations, and for the temperature.
The publishers keep such ready for use, at a cost of two silber-
groschen each=2-jd, or thirty for one thaler, ten silbergroschen =
35. rod., or 100 for 3} thalers=8^. ^d. nearly.^
On this, as in the remaining tables, the strong perpendicular line
indicates midnight, the finer perpendicular line mid-day. The space
between these vertical lines may be employed to note measurements
taken at different hours of day or night. For convenience, the
Celsian (Centigrade) and Reaumur's scale are placed side by side.
[Centigrade and Fahrenheit's are substituted in our copy.]
In order to facilitate the use of this chart, I have noted the
particulars of a case, which is interesting even in itself, on account of
its changing fortunes. It will be easily seen how such curves assist
1 Mr. Hawksley, surgical instrument maker, of 80, Blenheim Street, Bond
Street, W., keeps charts of large and small size (the latter bound for the pocket).
He has also made considerable improvements in clinical thermometers, particu-
larly in the graduation.
Messrs. Harvey and Keynolds also supply charts at a moderate cost;
and have lately made an improvement by introducing a chamber at the
upper end of the thermometer, by which the index can be recovered, if it
has been shaken down into the bulb, in accordance with a suggestion of the
late Professor Phillips.— [Tkans.]
460 EXPLANATION OF PLATES.
in rapidly gaining a correct idea of the whole disease. A few
remarks on the special occurrences of the case, and on the therapeutic
measures employed, suffice to show at one glance all that is worthy
of note in the case. After some details of a personal nature, the
beginning and common diagnosis of the disease, and the number of
the thermometer, the days of the month are appended in Arabic
numerals, the days of the disease in lloman figures. Besides this,
the principal therapeutic measures employed are recorded ; then
follows the temperature curve, with, on an average, six daily
observations, which is succeeded by curves of the pulse (taken
inoriiing and evening), and then the curve of the frequency of
respirations.
At the lower part of the chart there are the weights of the patient
at different periods [in kilogrammes — a kilogramme = 2'2046a 13
English pounds avoirdupoise, and the reduction has been made in
our copy], and some further remarks are also appended. It is very
easy to supplement and complete a table of this kind by adding, for
example, a diagram or curve of the size of the spleen, or of a
pleuritic exudation, and by noting down the chief and special
symptoms as they occur.
For a beginner it may, perhaps, be useful to mark the space
between 37"5 and '>^6'^ C. (99"5°and 97*7° F.) in some way; with a
red pencil, for instance, in order to denote the range of normal
temperatures.
The case which I have used to exemplify the mode of using the
table was one of extraordinarily severe and much complicated
abdominal typhus, with recrudescence in the middle of the fourth
week, in which the treatment was somewhat varied. The action of
the calomel given is recognised by a sudden fall of temperature, but
any lasting effect from the remedy could not be expected, because
the disease had already made considerable progress when it was
prescribed. When the temperature again rose, in spite of a good
deal of bronchitis a cold bath of 18° C. (64*4° F.) was given for
twenty minutes on the twelfth day, and douches of iced water were
applied at the same time, and repeated three times in the course of
twenty-four hours. The immediate effect of the baths on the tem-
perature may be seen in the dotted lines (temperature taken in the
rectum) ; after the first bath the temperature fell from 40° C.
(104° F.) to 39*5° C. (103-1° F.); after the second bath from 40.3° C.
(i04'5° ^0 to 39'5° C. (103*1° F.), and then sank spontaneously (see
EXPLANATION OF PLATES. 461
the continuous line) to 39-i°C. (102-38 P.) . After the third bath from
39-9° C. (103-9° .^O to 38-3° C. (ioi-i2°) ; after the fourth bath the
immediate effect was barely ^th of a degree (Fahr.) . Between the baths
the trunk was covered with ice-bags. But although all the symptoms
improved under this treatment, and the dry smoky tongue perfectly
cleaned, the appetite returned, the meteorism diminished, the spleen
decreased in size, and the brain symptoms in particular were essentially
improved ; although the bronchitis also became better, the patient
complained so bitterly of the torment of the cold baths that the next
baths employed were only lukewarm (25° — 32° C. = 77° — 89-6°
P.). The results, as the dotted lines show, were proportionately
small. Prom the fifteenth day the patient positively refused to take
the baths. Soon after they were discontinued the temperature rose
in spite of persistence in the application of cold compresses ; how-
ever, after the seventeenth day the disease appeared to take a
favorable turn. An increase of fever on the seventeenth day, which
the patient herself found very uncomfortable, determined her, partly
also because she observed the favorable effects of the baths in a
fellow patient, to take another bath, and the same on the next day.
The result was favorable; the remissions became more marked.
However, an exacerbation on the twenty-first day again made the
patient refuse the baths, and they were not persisted in, because the
symptoms on the whole appeared to take a favorable aspect. But
from the twenty-fifth day the exacerbations again became more severe,
and at the same time the remissions grew less from day to day. The
spleen now began to enlarge again ; at first, however, there were no
particular subjective feelings of discomfort, and the patient con-
tinued most decidedly to refuse to resume the baths, and still did so,
whilst all the symptoms of a fresh fastigium gradually developed
themselves : the head symptoms grew worse and worse, till persis-
tent delirium, a dry, fuliginous, and tremulous tongue, increasing
meteorism, the spleen growing bigger, fresh rose-spots, and extreme
prostration, set in. To these were added severe bronchitis, with
infiltration of the lower lobes of both lungs, great debility, and
frequency of cardiac contractions ; the urine became albuminous, and
there was painful thrombosis of both lower extremities, with severe
(Edematous swelling. It is true that the high fever temperature was
lowered on the thirty-fifth day by the use of digitalis, but the patient
became collapsed, and whilst the cheeks had a circumscribed fiusli of
redness, the rest of the surface was pale, the nose, ears, hands, and
462 EXPLANATION OF PLATES.
feet cold, the breathing irregular and shallow. She quite lost con-
sciousness, and only murmured incoherently, and exhibited automatic
movements of the facial muscles and of the hands. The second
sound of the heart grew indistinct, and was almost lost, and the
patient appeared to be in the death-agony. She was, however, then
plunged into the baths (at a warmth of 2%'^° C. = 72'5° F.). The
effect, which could scarcely have been hoped for, was overwhelming.
All the threatening symptoms vanished after only a few baths.
Not only was their influence on the temperature very considerable,
but the tongue very quickly cleaned, the spleen began to diminish,
consciousness was restored, sleep returned to her, she passed a large
quantity of urine free from albumen, the breathing became regular,
both the infiltration of the lungs and the bronchitis were amelio-
rated, the swelling of the legs subsided, and after only six days
convalescence set in, and no further baths were required.
The remaining tables give examples of the more important forms
of the course taken by the temperature in various diseases. They
are, however, all taken from actual (concrete) cases. The apices
of the curves between midnight and noon generally correspond to
the daily minimum, although generally but little regard has been had
to the exact hour of the forenoon on which this occurred. The
apices of the curves between noon and midnight correspond in the
same manner to the daily maximum.
It often seemed necessary to draw more perpendicular lines, to
accurately represent the intercurrent elevations of temperature
which sometimes occurred. However, they cannot well be misun-
derstood.
As regards other matters, the letter-press will, doubtless, afford
sufficient explanation of the several curves represented.
INDEX.
Abnormal temperatures always suspi-
cious, 2
Acme or fastigium (see also special dis-
eases), 9, 10
Acute rheumatism, 394
Age, effects of ou temperature, 97, 158,
209, 320, 414
Ague, see" Fever," intermittent, 16,416
Air, effects of cold, 96, 109
Aitken, Dr., on temperature, 42, 62
Alcoholic liquors, effects of, 117, 137,
424
Amphibolic period {see also " Fever"), 9,
11, 263, 315
Amygdalitis, 385
AndrciTs theories, &c., 30, 142
Anaemia, in typhoid, 321
Animals, immunity of some to poisons,
126
— , temperature of lower, 84 j see" Ap-
pendix "
Animal poisons, see "Putrid"
Approximatively typical diseases, 5
Arteries, ligatures of, 133
Atmospheric pressure, effects of varied,
115; see " Appendix"
Atropine, effects of, 138
Atypical diseases, 5
Auerhach's fever theory, 188
Average temperatures, see " Normal
temperature," &c., 1, 83, 230
Average height of temperature in spe-
cial diseases, 248
Axilla, best place for thermometer, 68
— normal temperature of, 1
— should be closed, 70
Axilla, temperature of right and left
not always same, 166
BaUly's memoir, 27
Bdrensprung and Trauhe, 37, 97
jBarnes, Hohert, 139, 155
BarraVs calculations, 88
Baths, cold, eff"ects of, 109, 112, 322
Baiimler, C, 42, 71, 135
Beclard, J., on muscular contraction,
44, 87
Becquerel and Breschet, 27, 93, 107,
143, 161
Beer and brandy lower temp., 117
Be'rard, P. E., 28
Berger's treatise, 28
Bergmann's researches, 34, 141
Berlinghieri Vacca, 25
Bernard, Claude, on nerves in relation
to heat, 43, 93, 131, 147, 185
Berthelot, 43
Bilious typhoid, 333
Billroth and Weber on traumatic fever,
&c., 41, 140, 162, 188
Biot, quotation from, 28
Blagden's experiments, 23
Bleeding, eff'ects of, 118, 134, 378-9
Blisters, eff'ects of (see also " Mustard ")
402
Blood, loss of, see " Haemorrhage "
— temperature of venous and arterial,
92
— composition of, 142, 441
Boerhaave on thermometer, 20
Bouillaud's observations, 28
Bright's disease, temperature in, 404
Brodie's, Sir B., views and cases, 25,
29, 145
Bronchitis, 365
Brown- Sequard and Tholozan, experi-
ments of, 44, 112, 114, 133, 145, and
Appendix
Budge and Waller's experiments, 147
Buntzen, 25
Calomel, eflfects of, 324
Calorimetry, 26, 67, 87, 190
Calorien (heat units), 87
Camphor, curare, coff'ee, and muskj
raise temperature, 139
464
INDEX.
Cancer, temperature in, 429, 431
Casella first maker of registering clini-
ciil thermometers, 62
Catamenia affect temperature, 102,
135
Catarrhal affections of mucous mem-
brane, 365
Causes of specific beat, 85
— of alterations of temperature, 120,
102
Cerebro-spinal meningitis, 222
Charts, thermometric, 78, see " Appen-
dix"
Cheesy deposits not recognised by ther-
mometer, 428
Childbed and labour, 102, 359
Children, tvphoid diagnosed with diffi-
culty in, 320
Children, temperature of, 96, 98, 413
Chloroform, 32, 137
Chloral-hydrate, 137
Cholera, temperature of, 94, 183, 313,
419
Chomel on temperature, 28
Chorea, 225, 426
Chossat's experiments and theories, 26,
31, 135
Chronic diseases, temperature in, 16
Chronic fever, 16, 431
Clark, Andrew, and Crisp, Edwards,
on tuberculosis, 143-4
Climate, effects of tropical, kc, 114;
116, 131
Clothes must be free of thermometer,
71
Cold, effects of, 128, see " Baths, ther-
mal, &c.," 322
' Coleman's dissertation, 25
Colin s experiments, 93
Collapse, temperature in, &c,, 4, 7, 179,
200, 207, 421
Collard de Martigny, 28
Compensation of temperature, 89
Constipation, effects of, 136
Convalescence, 224, 265, &c.
Constancy of temperature in health,
1
Course of temperature in febrile dis-
eases, 241, 249
Course, varied, in different fevers, 13
Crawford' s experiments, 24
Crisis, 9, 268
Cord, injuries to spinal, 29, 145, &c.,
205, 423
Croupous and diphtheritic affections,
367
Croupous pneumonia, 368, 374
Currie. James, in advance of his times,
24,25
Curves of temperature, 8, 78, 244, &c.,
see also Lithographs at end
Daily fluctuations of temperature, 8,
101, 226 (Chart of, 414)
— in disease, 255
Dalton opposes Brodie, 26
Damrosch ou temperatures, 101
Davies's, Dr. Herbert,, observations,
393, 402
Bari/, John, experiments of, 26, 30,
33, 99, 107, 108, 114, 116
Death, temperature at time of, 13, 283
Defervescence, 12, 223, 268, 308, 317,
330, 345
De Raen on thermometer, 22, 30
Delirium, 440, 443
Demarquay and Dumerril on ether and
chlorof(;rm, 32, 137
Depression of temperatures (see " Col-
lapse," &c.), 127
De Ruyter and Danders on tempera-
tures, 148
Deyeux, 27
Diabetes, 430
Diarrhffia, 365
Digitalis, effects of, 137, 325
Directions taken by the temperature,
259
Diseases obey fixed laws, 39
Dohson's experiments, 23
Donne on temperature, 28
Drinks, effects of various, 114, 117
Dropsy, 431
Druffs, effects of various, 137, &c., 264,
324, 379, 432, 407, 408
Dtdong and Despretz, 26
Earle, experiments of, 26, 152
Edioards' resume, 27, 28
Effects of altered temperatures, 436
Elevated temperatures, causes of, 127
Endocarditis, 391, 399
Ephemera, 14
Ephemeral fever, 209
Epicritical period {see " Fever," &.c.)
10,12
Epilepsy {see " Neuroses") 225, 352, 425
Erysipelas, 222, 351
Exercise (muscular), effects on tem-
perature, 105, 154
Fahrenheit invents thermometer, 21
Fastigium {see "Acme"), 9, 10, 247
Febricula {see " Ephemera") 355
Febrile temperature {see " Fever,"
" Smallpox," &c.), 7
Fajcal accumulations, 198
Fever, continued, 15 {see "Typhus,"
" Typhoid," &c.)
INDEX.
465
Fever, intermittent, 16, 223, 416
._ or pyrexia, 4 ; theory of, 184
peculiar remittent, 354
— relapsing, 16, 333
— remittent, 15
— terminal, 14, 435
— yellow, 405
ringers, temperature in, 70
Finlayson and Forster on temperature
of children, 98, 413, (cbart) 414
Fluctuations of temperature, 8, 80, «sc.
{see " Daily" also)
— in disease, 92
Food, effects of, 115
— see Appendix I
Fourcault and Flonrens, 34
Frese's experiments, 140
FricJce's experiments, 29
FrlecUander's observations on cholera,
313
FroUicJi, Anton, 27
Garrod, A. E., on minor fluctuations
of temperature, 40, 95
Gamrret on de Haen, 30
— thermo-electric pile, 66
Gentil on variations of temperature, Z7
Giers^s dissertation, 30, 31, 162
Glanders and farcy, 408
Grainville and Some, Sir F.> 27
Grimshaw, T. W., 42 ^ . ,
Groin, Levier takes thermometnc ob-
servations in, 69 i
Grilnewaldt and WincJcel on tempera- |
ture in labour, 103
Hemorrhages lower temperature and
then raise it, 118, 134, 313
Sale's communication, 26
EaUer-Marcard, 23
Sallmann on typhus, 31 , , , „
Hand, not reliable as a standard of
temperature, 60 , , , xu
Sarvey and Reynold's portable ther-
mometers, 63
Health, temperature in (see "Normal
temperature," &c.), 80, 82, &c.
Heat, effects of great, 130, 132, /OS
Heart, disease of, 430 (see « Endocar-
ditis," &c.)
Heart (of frog), effects of temperature
on, 437 - . I r
Heat equivalent to mecnanical force,
35, 36, &c. . . , „
Heat, specific, 83 {see also « Ammals,
" Temperature," &c.)
Heat-units, 36, 87
Seqewitsch on Currie, 25
Helmholtz demonstrates heat from mo-
tion, 34, 35, 87, 105
30
Hemiplegia, temperature of, 165
Hepatitis, 404
Herpes labialis often preceded by severe
fever, 360 .
Hio-h temperatures observed m lite, 4,
131, 132, 204, 208, 350, 401, 425
Hippocrates, opinion of, 19, 308
Sim (Colmar) on consumption of oxy-
gen, &c., 37, 43, 106
Hooping-cough, 222 .
Hospital wai-ds, use of thermometer in,
77
Suf eland on Cuvvie, 25, 21
Sunter, John, experiments of, 23, Ibl
SuteUnson, J., on injuries to nerves,
153
Hydrocele, temperature after operation
for, 161 . „ .
Hydrogen, more consumption ot in
fever, 188
Hyperemia, effects of, 133
Hyper-pyretic temperatures, 7
Hysterical neuroses, 166, 424
latro-mechanical theories, 19
Ice-bags, Sayspielou effects of, US
Idiosyncrasies affect temperature, lOU
and passion
Inanition, 135 . . •
Index, how to set the, of registering
thermometers, 63
Initial or pyrogenetic stage {see
" Fever," &c.), 9, 10
Inflammation raises temperature, Ibi
Influenza, 222, 336 _
Insanity, temperatures m, 171, -^01,
426
Interior of body, temperature of, 93
Iodide of potassium, effects of, on tem-
perature, 407-8
Irregularities of temperature, 25o
Irritants, effect of, 133
Jaundice, 225, 431 .
Joclmann on types of chronic fever,
427 . , ,
Joule (Manchester) on heat-equivalents,
36
Kidneys, diseases of, 404, 431 {see
« Cancer," " Tubercle," &c.)
Kilogrammeter, 36 „ i en oo"?
Kussmaul and Tenner, 44, 133, 150, ^J J
Labour (*ee "Childbed," "Exercise,"
&c.), 102
Lavoisier's theories, 24, 25, 34, 83
Law, domain of, in disease, 39, ol
Legallois, 26
IGG
INDEX.
Lepine ou hciiiiplegic teuiporatures,
165
Lei/den's experiments, 190
Lichtenfels ami FruJilich, 40, 45
Licbermeisier's researches, 44, 47, 71,
108, 112
Liebig's chemical theories of beat, 34,
93
Limits of human temperature in dis-
ease, 2
Liver, diseases of, 404, 431
Livingstone and Thomsen on effects of
race, &c., 99
Local variations of temperature, 3
Lombard's thermo-electric apparatus,
m, 95
Low temperatures {see "Sub-normal,"
" Collapse," &c.), 204
Lowenhardt's cases, 204
Lucas's dissertation, 27
Ludwig's speculations, 90
Lues, or syphilis, 405
Lysis, 271
Mackenzie, F. M., 183, 20d-, 287
Maqendie, F., 34
Malarial diseases, 16, 22, 382, 416
Malignant rheumatism, 401
Malingering, thermometer aids detec-
tion of, 53, 212
Marasmus, 428
Martin, Charles, 23
Marci/s thermograph, 66
Maximum temperatures, 204 {see
" Height in life ")
Mayer, J. R., ou correlation of forces,
35, 106
Mean temperature {see " Normal,"
" Health," " Average," &c.)
Measles, temperature, 221, 342
Meningitis, 222, 388
— cerebro-spinal, 389
Menstruation {see " Catamenia ")
Mental exertions raise temperature, 95,
108
Michaelis translates Currie, 25
Miliary tuberculosis, acute, 143, 409,
427
Milk fever, 105
Mobility of temperature a bad sign, 3
Montgomery, JE., observations by, QQ,
162
Morphia, effects of, 138
Mouth, inside of, temperature, 68, 72
Mumps, 387
Muscles {see " Exercise")
Mustard epithems, 133, 164
Nasse supports Brodie, 26
— F. and H., 29, 30
Nasse, F., 34
— 33
— JL, 43
Naunyn and Qttincke's experiments,
151
Nerves, effect of injuries to, 152
Nervous system, effects of, on temi)cra-
ture, 25, 27, 43, 145, &c., 225
Neuroses, 424 {see "Chorea," "Cord,"
" Nervous," &c.)
New-born, temperature of, 97
Normal types of disease, 291
— temperatures {see "Average," "Ax-
illa," &c.), 1, 7, 82
— temperature need not mean health,
2, 53
Nurse or friends may take temperatures,
74
Obcrnier on heat apoplexy, 131
Observations, mode, and precautious for
thermometric, 70
Ogle, IF., on diurnal variations, 45, 95,
99, 101, IIG, 414
Operations, fever after {see " Trau-
matic," and " Wounds"), 356
Osteo-myelitis, 403
Parotitis, a complex designation, 387
Paralysed parts, temperature of, 152,
164, &c.
Paroxysms of ague only recognisable by
thermometer, 417
Pericarditis, 391, 399
Peritonitis, 391
Perturbatio critica, 10, 11
Phlyctenular eruptive fever, 355
Phthisis, acute {see also " Tuberclu,"
" Miliarj-," &c.), 410
Fic/cels' dissertation, 23
Fiory, remarks on, 29
Pitschaft's essay, 27
Pleurisy, 222, 391
Pleural cavitj', temperature of, 94, 393
Pneumonia, 197, 222, 368
Post-mortem temperatures, 205,286
Pregnancy, effects of, 102 {see " Child-
bed")
Priestly and Scheele discover oxygen,
24
Private practice, thermometer in, 77
Pro-agonistic or pro-lethal tempera-
tures, 10, 13, 207, 277
Pseudo-crises, 253
Pulse, ratio to temperature of the, 213,
281, 347, 389
Pus {see " Putrid," &c.)
Putrid products, effects of, 140
Pyemia {see " Billroth;' " Weher,"
" Putrid," " Pus," &c.), 361
INDEX.
467
Pyrexia, 4, 177, 200 •
Pyro^enetic stage {see " Fever," &c.),
9, 10, 243
Quinsy, 385
Eace, station, and occupation, 99
Eange of temperature in disease, 2
Rectum, temperature of, 1, 69, 72, 163,
183
Relapsing fever, 333
Relation between certain temperature
and death, 443
Rciuval of patients, effects of, 155
Respirations and temperature, 214, and
Appendix
Retention of urine, &c., 136
Seuss's essay, 27
Rigors, temperature is increased in, 4,
i7, 172, 199
EilUet and Barthez on normal cases,
291
Minger, Sydney (and Stewart, A. F.), on
temperature in health, 41, 97
Ringer, S., 42, 118, 412
Rise of temperature in typhoid fever,
300
Roderer on animal heat, 23
Roger, Henri, important services of,
31, 98, 412, 426, 428
Rubeolse or Rotheln, 351
Sais.iy on hybernants, 25
Sanctorius the father of thermometry,
20
Scarlatina, 204, 221, 347
— resembles typhoid, 305
Schdfer on temperature of infants, 97
Schiff, M., on temperature, &c., 44,
149, 185
Schmitz, J. P., makes 300 observations,
33
Schroder on temperature in labour, 103
Secondary fever, 358
Senator, H., 190, 285
Sequelaj, 276
Sex, effect of, on temperature, 99 {see
"Childbed," &c.), 158, 210
Serous cavities, temperature of, 164
Simon, John, 42, 162
Single observations, value of, 6, 7, 202
Skin, checking action of, 143
Smallpox, 222, 335
Squire, Wm., observations by, 98, 105
Stages in febrile diseases, 9
Starvation, 135
Sub-febrile temperatures, 7
Sub-normal temperatures, 7, 18, 171,
199, 428, 421, 444
Sunstroke, 132, 208
Syphilis, constitutional, 405
Tea, effects of, 118
Temperature the expression of many
processes, 3
Temperatures, general significance of
certain, 7, 205
— effects of very high, 17
Tension, efiects of, 95
Terms used in medical thermometry
227
Tetanus, temperatures in, 204, 425
Therapeutics, thermometer as a con-
troller of, 59, 133, 135
Thermometers, mercurial, 61, &c.
— registering, 62
— thermo-electric, 66
— require testing, 63
— how to use, 72
— metastatic, 64
— where procured, 62 {see Appendix
also)
— characteristics of clinical, 61
Thermal influences, &c., 109, 131
Thermograph, Marey's, 66
Thierfelder on abdominal typhus, 39
Time of observation should be noted, 73
Thoracentesis, effects of, 393
Todd's ' Cyclopasdia,' 28
Tonsillitis, 385
Trauhe {see " Bdrensprung"), 186
Traumatic fever, 356
Trichinae, effects of, on temperature,
415
Tropical climates, Dr. Day's observa-
tions on, &c., 114, 116
Tscheschichin's observations, 47, 150,
190
Tubercular disease (^ee " Miliary,"
"Meningitis," &c.)
Tubercle does not raise temperature,
412, 427
Typhus fever, 327
Typhoid fever, diagnosis of, 306
— 221, 292
Typical diseases, 5
Units of heat, 36, 67
Urinary constituents, 102, 142, 155
Uterus, temperature of the, 102
Vagina, normal temperature of, 1
Vaginal temperatures, 69, 163, 183
Value of thermometer, 47, &c., 53
Van Swieten on thermometer, 21
Variation of temperature in disease,
1,7
Variations of temperature in health, 1
Varnishing skin, effects of, 143
Variola {see " Smallpox"), 337
ICS
1NI>KX.
VuriooUii, 341
Titlfiiiin on tulionulosis, IKt
J'ircJiow's llu'iiry oT lovers, 181
Vicenot's cxperiiucuts, 115
Wachsmuth's theory of fever, 188
li'alferdin's metastatic thenuomoters,
61
IValther's oxporlments, -15, 128, 131
NN'ariuth, priHluction of, 23, 3-1', 85
— givina: oil' of, 87
Warter^^J. S., 12
Water-treatment (see "Cold"), 97, 322
Webci; Jl., hypcrjjyrctic teinpeiiilures,
42, 101
W^ber, O., 140, 163, 1<J0
Wi.stiuqhauscu, dissertations of, 29
W'oumls, temperature of, IGl, &c.
Wnnderlich collects several million
observations, 38, 46
WundtrVich's assistants, 40
Yellow fever, 405
Zimmermann, Oeorge, industry of, 32,
33, 185
TABLE OF EREATA.
PAGE. LINE.
30, 9 from bottom, for " Auschaimg zu hingen" read "zur Auschauuiig zu
hringen."
31, 12, for " starch" read "starvation."
42, 8 from top, for " Lewick" read " LevicTc."
42, 18, for " Sidney " read " Sydney."
42, 20, for "Aitkin" read "Aitken-" the same mistake also occurs at
pp. 213 (note, line 1) and 351, line 15 from bottom.
94, 3 and 4 of note, transpose the symbols " Fahr." and " C."
126, 15 from top, for " trying " read " tying."
118, 1, for " Bonvier " read " Bouvier."
153, 13 from bottom for " ulna " read " ulnar."
161, (Chapter VII), the heading should be " Local Alterations of Tempera-
ture in Disease."
213, 7 from bottom, for " lAebermerster " read " Liebermeister."
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