Skip to main content

Full text of "On the temperature in diseases: a manual of medical thermometry"

See other formats


L-~. 

O: 

=  00 

■2.= 

^co 

^CD 

O 

1 

^CO 

u.  ^^= 

^CO 

0-~" 

^m^mm  ^^" 

>^= 

^■^/"~^ 

<^J) 

en 

IX^= 

SS^Sf 

UJ^^ 

■^^  ■^_ 

> 

2=^ 

— CD 

^ 

— >- 

^_''~ 

CO 

Handle  with 

EXTREME  CAR 

This  volume  is  damaged  or  brittl 
and  CANNOT  be  repaired! 


.  photocopy  only  if  necessary 

return  to  staff 

do  not  put  in  bookdrop 


Lyi  \^     ' 


^? 


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 


— 

— 

^. 

___^ 

--• 

f. 

^ 

-- 

— ; 

^ 

— 

-- 

^1 

!a 

s      ^ 

-^K 
^ 

k 

< 

> 

*c 

i» 

*iL 

-^ 

a 

_    - 

_            — 

2_ 

-= 

L^. 

- 

""      "~— 

^^ 

rd- 

— 

^ 

> 

< 

1 

<P 

> 

5^ 

— 

< 

«  — 

•< 

V 

^7 

— 

««3 

- 

I 

\ 

^^--^1 

— 

~^ 

T:; 

• 

t 

^ 

±! 

" 

•<t!!r 

"^ 

a.--' — 

» 

*^' 

r-^ 

:»• 

>T5 

■ 

• 

"5: 

1 

\ 

r 

<>i 

\ 

vt 

f 

=0 

^ , 

, 

\ 

(>x 

r 

— 

- I 

" 

y 

1 

>             <N!              •;p                <t                  Vrj              ^                    I^ 

^" 

■^ 

c^ 

^ 

>v 

>.-s 

t^ 

V^ 

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. 


Fah': 

Cent 

4' 

15 

Jii> 

4^ 

•i 

/J 

30 

4<^ 

6 

15 

^e 

mi 

m-2 

101-2 

9.r5 
gs-e 

40 

38-5 

38 
3J 

■ 

p 

n 

w 

1 

V 

i 

f 

.t 

■> 

^ 

\^ 

f 

•vi 

^ 

i' 

1 

-A 

\\ 

/ 

A 

/  \ 

^ 

f 

N 

;  t 

^ 

\- 

— 

— 

y 

i 

i- 

— 

— 

— 

— 

— 

— 

— 

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 


o 


1 

l~^__^ 

-^ 

>• 

.^ 

'   ' 

— 

•< 

-- 

:::><• 

«<: 

— 

« 

•• 

— 

•=: 

-— 

.--    '^^1 » 

6>=r 

^, 

» 

Kl 

yr.f. 

;5. 

^^.cZ 

« 

>:^— 

^ 

p* 

« 

_^ 

c=c:dl 

--^ 

e 

— 

"^ 



^ 

=a 

^5 

«= 





— 

i 

(-'•y 
-^ 

-^^r 



___. 

^*^ 

-S 

St= 

— ^::r: 

=>•< 

t^ 

Ota 

-- 

•fcC 

--— 

:^ 

=* 

--S 

©=: 

— - 

--^ 

p* 

^8 

*< 

---^ 

:^:« 

— 

-S 

ox 

- — 

— 

11^^^^^^ 

9=^ 

^^^^^m. 

- — - 

^^^r:!=< 

' 

'^5 

< 

— 

=* 

^S 

^-^ 

1 

'^^ 

^ 

^^ 

"S 

1 

— 

-1 

!___ — - 

1 

"5 

c 

^     2    i      s    1      gj'  g      ^    §    ^     c 

•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. 

^^ 

— 

1 

fA 

> 

^^^ 

"^^^ 

¥ 

> 

^^ 

1 

PI 

OS 

^/ 

\ 

N 

1 

cxc 

^ 

c^ 

1          ^ 

\ 

Co 

1 

-«r 

1       1 

0 

1 

,-'— 

H — 1 

f\ 

1 

Sf 

^ 

^^\■ 

t-i 

\ 

^    \ 

c?*^ 

N 

Cj    \ 

.t- 

^ 

'^  \ 

'^l^ 

<\ 

\ 

< 

'^ 

\ 

X 

\  X 

-^ 

::5 

\ 

1    N 

\    X 

Co 

— tzb^ 

- 

>! 

'       ^ 

^ 

1-= 

^H! 

\ 



t^ 

"^<^^ 

-y 

t) 

^-- 

-^ 

} 

»o 

1 

^ 

\ 

/\ 



— 

1 

1 

N 

-^ 

1 

N^ 

/ 

r 

"S  U 

-  <M 

V^ 

/ 

> 

^  ^ 

1 

1 

^  4 

^   1 

f^ 

1 

a.     ev    Ci    00    Vs     <i-    fl     CO    00     V 

0  -.-    c,  5J  00  -o 

6 

0                *^               to                 ^^               to 

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- 


r  >>      r      o 

o 

o 

o 

o 

o 

o 

"2   r 

,1      ■+ 

■rf 

vo 

M 

-I- 

o 

■^ 

•t 

2  ti 

^    o 

r^ 

o 

1- 

_C\ 

o 

HI 

CI 

o:3 

;f      \n 

r^i 

ro 

''l 

H4 

b 

b 

C\ 

"^      CN 

0\ 

C\ 

CN 

C\ 

CV 

C\ 

X 

5^- 

II 

II 

II 

II 

II 

II 

II 

II 

c^ 

O 

o 

0 

ri 

o 

o 

o 

c 

CO 

C4 

■«i* 

CO 

« 

CO 

CO 

E  * 

rj« 

•^ 

CO 

CO 

C5 

« 

iH 

^     1^^  eo 

CO 

CO 

CO 

CO 

CO 

CO 

CO 

!»>      r 

o 

0 

o 

o 

o 

o 

2-. 

N 

■3 

l!    O 

•+ 

•«J- 

M 

vo 

vo 

vo 

00 

O 

■=  ^ 

CO 

p 

!"> 

l-H 

p 

N 

00 

•< 

u-    - 

Ui  00 

t^ 

r^ 

1^ 

r- 

00 

vb 

i^ 

a 

f'  m 

Cv 

0\ 

e* 

C^ 

C\ 

C\ 

Ov 

CN 

M 

=  "- 

II 

II 

II 

II 

li 

II 

II 

11 

K 

£  "^ 

o 

."> 

.'-, 

ri 

o 

ri 

n 

P 

•i.   o 

CO 

CO 

•«d< 

(N 

l>- 

t' 

CO 

5  is 

,^   t- 

CD 

CO 

CO 

CD 

CD 

«b 

CO 

^ 

H       L^   CO 

CO 

CO 

CO 

CO 

CO 

CO 

CO 

o 

o 

o 

o 

o 

o_^ 

o 

PI 

00 

cc 

o 

00 

•+ 

00 

»-< 

f 

p 

fO 

-t 

•^ 

oo 

^    1^  -* 

VD 

vb 

1~-. 

Vt\ 

b 

'■+ 

io 

1 

g  .       ^-^ 

lO 

o 

lO 

Cl 

n 

CI 

CI 

i'1    1" 

II 

II 

II 

II 

11 

11 

11 

o 

o 

Cy 

f^ 

o 

o 

o 

^ 

CO 

T-t 

ura 

•* 

C4 

■«*< 

CO 

CO 

-it* 

yM 

cb 

"^ 

CO 

i-( 

1-1 

T-t 

+ 

+ 

+ 

+ 

I 

1 

1 

I 

o 

o 

o 

o 

o___ 

o 

'5    . 

^     tT 

VC- 

't 

"t 

OD 

■* 

vo 

o 

2  tb 

•=  r' 

w 

vp 

C\ 

yj 

p 

_cv 

vo 

t-.S 

;S    r- 

vb 

*•^• 

k-H 

hH 

IH 

CV 

CV 

o  ^ 

C\ 

CN 

CN 

o 

C\ 

c\ 

00 

oo 

=  5- 

II 

II 

II 

II 

II 

II 

II 

II 

£5 

0 

o 

c 

o 

o 

o 

o 

CJ  ■  — 

-S   CO 

I' 

00 

CO 

T-t 

00 

<M 

o 

s  s 

-^   CO 

lb 

■^ 

CO 

CO 

C^ 

(>l 

«J4 

H 

^       ^-^  CO 

CO 

CO 

CO 

03 

CO 

CO 

CO 

>»      ^ 

o 

o 

o 

o 

o 

-= 

t:  o 

p« 

OD 

o 

o 

S 

c» 

^ 

u 

—  ti 

•3    '^ 

TO 

00 

r^ 

t^ 

CO 

yi 

CO 

< 

iS    r- 

r- 

i-- 

p~ 

r^ 

1-- 

t^ 

r^ 

CJ    OJ 

Cs 

C\ 

C\ 

Cn 

C\ 

CV 

o\ 

CV 

l£-^ 

II 

II 

II 

II 

II 

II 

II 

II 

s 

g;2 

o 

o 

o 

0 

o 

o 

o.. 

o 

Ch 

■£  "O 

«* 

CO 

»o 

»o 

eo 

'^I* 

CO 

H 

33 

^      CO 

CO 

CO 

(d 

CO 

CD 

CD 

is> 

■3 

H 

CO 

CO 

CO 

eo 

eo 

CO 

CO 

o 

o 

o 

o 

o 

o 

q^ 

p_ 

o 

^ 

>:  00 

vo 

Tj- 

vo 

vo 

«* 

vo 

e« 

«»i 

f    •" 

11 

N 

r- 

7i- 

r* 

■* 

vo 

Q 

ph    o 

*M 

■fO 

lo 

w 

r~ 

CO 

i-O 

I  ._• 

to 

lO 

l-O 

lO 

CO 

»-( 

M 

n 

-S-S' 

II 

11 

II 

II 

II 

II 

II 

II 

2^ 

*    O 

o 

o 

o 

o 

r^ 

o 

o  . 

=  1-1 

(M 

CO 

<M 

CO 

d 

CO 

1-1 

,So 

1^ 

1-H 

CO 

T-1 

O 

do 

o 

1-) 

OS 

^  + 

+ 

+ 

+ 

1 

1 

1 

1 

•i       >.     00 

o 

lO 

o 

vo 

o 

CO 

o 

'io-'S        "f 

^ 

lO 

T 

CO 

2s 

r- 

vo 

"5 .5  -js        M 

vo 

r- 

M 

CO 

CO 

C\ 

M 

iS          to         w 

>^ 

H4 

M 

CO 

•t 

t 

lO 

i 

;§  II 

II 

II 

II 

II 

II 

II 

II 

1 

^    »    o 

O 

m 

<x> 

O 

OJ 

CD 

o 

■3)^g     lO 

o 

o 

^ 

lO 

CO 

O 

1-t 

»-=^    o 

lO 

CO 

o 

o 

cs 

»o 

00 

s  a   ,-H 

1-H 

1—1 

(M 

CO 

CO 

-!}< 

"^ 

' 

Q^ 

1          • 

1      • 

•         • 

r^*— V 
1 

3    O 

3  o 

9 

"3 

'5 

o 

n3 

n    ■ 

5   • 

J3 

"=J 

«! 

■s 

o 

,     g 

^ 

^^ 

uJ 

o 

'5'H 

o     • 

'O    ^ 

m    2 
u   s 

o     . 

5 

t  3 

si 

2  J 

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 

33„ 

26,72 

92,12 

20 

16 

68 

33,3 

26,3 

92,3 

22„ 

18 

72., 

33,0 

26,88 

92,48 

25 

20 

77 

33,; 

26,96 

92,66 

27,, 

22 

81,5 

33,3 

27,04 

92,84 

30 

24 

86 

00,, J 

27.12 

93,oi 

-0,, 

24„ 

S6„ 

34 

27,2 

93,2 

31 

21,s 

87,8 

34,. 

27,28 

93,J8 

:3l,5 

25,2 

88.7 

34,2 

27,56 

93,s6 

32 

25,0 

89,G 

34,3 

27,44 

93.74 

32,3 

26 

90,5 

34m 

27.52 

93-9^ 

32,0 

26,08 

90,68 

34,5 

27,0 

94„ 

32„ 

26,16 

90,86 

34,0 

27,68 

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 

102,84 

35,1 

28,08 

95,'8 

38, y 

31,12 

102,02 

35,. 

28,16 

95,36 

39 

31,2 

102,2 

35,; 

28,.4 

95,54 

39,1 

31,28 

I02,}8 

35,4 

28,32 

95,72 

oJ,2 

31,36 

102,56 

35,5 

28„ 

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 

28,8 

96,8 

39,6 

31,68 

103,28 

36,1 

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, 
&c./  torn,  xii,  ser.  4,  p.  94,  kc.  (1867). 

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." 


\^ 


s 


PKIKTED   BY   J.   E.   ADIAED,    BAETUOLOMEW   CLOSE. 


PLEASE  DO  NOT  REMOVE 
CARDS  OR  SLIPS  FROM  THIS  POCKET 

UNIVERSITY  OF  TORONTO  LIBRARY 


HicMfcJ