Donated to his Father's Memori
George Alberts Hayunga, Born in Williamsburg Town¬
ship, Ontario, Canada, Jan 13, 1839, educated in public
schools in Canada; M. A. Hobart College, 1861; M. D.
New York University, 1863; Assistant Surgeon U. S.
Navy until 1866. Practiced medicine in New York City
until his departure from this life, March 6, 1907.
ene
ladae
u-an^e/tca/ S$u/^eian ^Aulcd
(Qs1/ memo-ltce-lf
-/ftben ■/&
rffieiman <ffiayunyaj
' /> J/7- c~zZ
fef
■lefztz/t-o-ri'
mit
THE
ABNER WELLBORN CALHOUN
MEDICAL LIBRARY
1923
/
St
CLASS-
34, s<Sf2-
ttive cilt-ec/
ebelt/ed
z r/fu-lcsi.
3 hi
BOOK_
PRESENTED BY
o
I 11 PC U f\ Q
- 1
«
* ■
1
CLINICAL THERMOMETRY.
y by
E. SE6UIN, M.D.S
OF NEW YORK.
PART FIRST.
HUMAN TEMPERATURE.
CHAPTER I.
HISTORIC.
In the earliest ages of medicine the significance of tempera¬
ture as a symptom in maladies was fully recognized. The
Greek and Latin names for fever signify elevation of tempera¬
ture.
By Hippocrates, heat was deemed the chief diagnostic sign
of acute diseases; around it were grouped all the symptoms,
and upon it, as 011 a pivot, hinged the remarkable, and not yet
equalled, unity of observation of the schoof of Cos.
Little by little, however, the pulse, being studied under the
Ptolemies, took the prominent place in diagnosis. Put soon the
savage and bigoted interruption of the courses of anatomy and
of experimental physiology in Alexandria—the same which
threatens us to-day—having left unconnected the streaks of
light thrown upon the mechanism of the vascular system,
medical observation was unable to seize and trace the law of
circulation, even with the finger of a Galen 011 the pulse-beat;
and having lost, after Erasistrates, the Hippocratic tradition of
prognosis by temperatures, having no other guide than credulity
to authority, darkness began and spread with the swiftness of
a tropical night.
1
2
historic.
After ages during which physic and true physicians suffere
as much as mankind itself under the pressure of medica
tlieurgism, the revival of anatomy rendering again possible the
demonstration of the circulatory system, served to restore to
diagnosis its Galenic unity around sphygmometry. Soon ex¬
perimental physiology went further, and finding at the founda¬
tion of all the phenomena of life the radical calok, reopened
the Ilippocratic question: De Colore in Morbo.
After centuries of apparent neglect of temperature as a fac¬
tor in disease, Sanctorius * applied a thermometer of his own
invention to the determination of human temperature. Sanc¬
torius pleaded the concordant importance of the determination
in disease of temperature and body-weight (to measure which
he also invented a weighing-chair). After him Boerhaave
and Van Swieten were the first known to have attached a
clinical importance to temperature. But to De Haen, of Vienna,
belongs the honor of having introduced thermometry in the
practice and in the teaching of medicine.
Experience had led De Haen to leave the thermometer in
situ seven and a half minutes, and to add one or two degrees
Fahrenheit to the registered temperature. However imperfect
this method, it afforded him valuable data, which have been
confirmed—even rediscovered since. His thermometrical labors
are dispersed through the fifteen volumes of his Ratio Me-
dencli.
De Ilaen observed the temperature of healthy people of
various ages, and was the first to remark the high temperature
of the aged. In various parts of his work are proofs of his
application of thermometry to diagnosis and prognosis. He
was aware of the morning remission and evening exacerbation
of temperature in fevers ; of the rise of temperature during the
febrile rigor (fieber frost) ; of the persistence of fever tempera¬
tures after intermittent fevers have apparently been cured ; and
of the discrepancies between pulse and temperature in some
patientb and in certain diseases ; he knew the contrast between
the subjective feeling of warmth or cold as felt by the patient
and the objective temperature as per thermometry • he us 1
the changes of temperature as therapeutical means; and r
garded the return to normal temperature as a proof of con
* Born in Capo d'Istria in 1561, teacher of Medicine in
Padua from 1600 to his death, in 1636.
HISTORIC.
3
valescence. lie advocated his own theories on animal heat with
considerable perseverance and ardor.
In spite of his great fame, the discoveries of de Haen were
neglected, and medical thermometry was once more abandoned
after his death.
In England Ch. Martin published the first accurate obser¬
vations on temperature in healthy men and animals, De
Animalium Colore, 1740. The followers of Iialler experi¬
mented in various directions upon human temperature, and
Blagden discovered the notable fact that an ambient tempera¬
ture of 212° Fahr. cannot sensibly modify the vital temperature
of a healthy man.
John Hunter began (1775-78) to publish his experiments on
temperature in the Philosophical Transactions / and was the
first to remark the local elevation of temperature in inflamma¬
tion, after an operation for hydrocele.
Shortly after, the celebrated work Sur la Chaleur {Mem.
de V Academie, 1780) was published in France by Lavoisier, the
discoverer of oxygen. In collaboration with Laplace—himself
second to none—he investigated the causes of animal heat, and
attributed it to the chemical combinations of oxygen with hy¬
drogen and carbon in respiration. He says: "The animal
machine has three regulators: respiration, which consumes
hydrogen and carbon and produces heat; transpiration, which,
according to the necessities of the case, lowers the temperature
and cools the body ; and digestion, which restores to the blood
what it has lost." He places the seat of warmth-production
(combustion) in the lungs. These discoveries and doctrines
gave to human thermometry a broader impulse than the one
we have witnessed these thirty years, under the lead'ership of
pathologists. Everybody then wanted to add something to
organic thermonomy, as conceived by the father of modern
chemistry.
Crawford {De Colore Animalium, 1779-86) sought the
source of heat in the chemical processes in the lungs, and tried
to explain the pathological changes of temperature and the
local temperature of inflamed parts.
James Currie published in 1797 Medical Heports on the
Effect of Water, Cold and Warm, as a Remedy in Fever and
other Diseases. For the first time since De Haen, the obser¬
vation of temperature was by him made available for medical
4
HISTORIC.
purposes, and especially as a means of controlling therapeutic
experiments. Each case lias its temperature recorded; ther¬
mometry pervades the whole of Currie's practice ; nevertheless,
it influenced very little the medical profession. So that for
many years liis Medical Reports stood alone, like the Giant's
Causeway, a melancholy monument of what a single man can
conceive, and the many cannot comprehend.
No less astonishing, but farther related to therapeutics, was
the discovery of Ben. Thomson (Comte Rumford), of the iden¬
tity of movement and caloric—a principle which comprised
within itself the later discoveries of Meyer and Joule, and fruit¬
ful in physiological and medical applications.
Yacca Berlinghieri, Buntzen, Coleman (Dissertation on Sus¬
pended Respiration, 1791), and Saissy (Recherches sur la Phy¬
sique des Animaux Ilybernans, 1808), added some interesting
facts. Sir B. Brodie published, in 1811, Some Physiological
Researches respecting the Influence of the Brain on the Action
of the Heart, and on the Generation of Animal Ileat, and
Farther Experiments on the same subject, in Philosophical
Transactions, 1812, p. 378. Dalton and John Davy opposed
his views on the source of animal heat; Nasse and Earle sup¬
ported them. The labors of Ilale and Legallois also deserve
mention here.
Chossat (These, Paris, 1820), Sur VInfluence du Systeme
Nerveux sur la Chaleur Animate, supported by a great num¬
ber of experiments the opinion that "the source of animal
heat was to be sought in the sympathetic nerve." In the course
of the discussion which followed this important paper, Dulong
and Despretz (1822-23) decided in favor of Lavoisier's theory.
At the same time Gentil observed the variations of temperature
according to age, sex, temperament, etc.; and Thomson the pro¬
duction of heat in an inflamed part (in Meckel's Archives, v. 405).
In 1821 Ilufeland offered a prize for the demonstration of
Currie's theory and method of treatment. The prize essays of
Anton Frolich and Beuss (published in Ilufeland?s Journal,
1822) contain many valuable contributions to pathological ther¬
mometry. Bailly wrote a Memoire sur VAlteration de la
Chaleur Animate dans les Fievres Algides {Revue Medicate,
1825, v. 384); and Edwards (1824), in De VInfluence des
Agents Physiques sur la Vie, gave a resume of all that was
then known about temperature.
HISTORIC.
5
These thirty years gave few methodical and comprehensive
results of temperature in health or in disease.
But a new era opened in 1835, when Becquerel and Bresehet
published their researches on human temperature (in Annates
des Sciences JVaturelles, Zoologie, torn, iii., iv., et ix.). Although
they regarded pathological conditions but slightly, they tested
the variations of temperature in different parts of the bodies of
men and animals by means of extraordinary sensitive thermo¬
electric apparatus. They found the temperature of inflamed
parts higher than that of the healthy ones; and established the
mean healthy temperature of man at 37° Centigrade = 98.6°
Fahr. This was the corner-stone of the new edifice, Medical
Thermometry.
Another production of great merit, but with no pathological
bearing, was the Zoo-physiological treatise of Berger, determin¬
ing the temperature in various species of animals, Fails Rela-
ti/'s a la Construction (Tune Echelle de Degres de la Chaleur
Animate (in Memoires de la iSociete de Geneve, torn, v., part
2, torn, vii., part 1). Edwards furnished a comprehensive arti¬
cle in Todd's Cyclopedia, vol. ii., p. 648, 1836-39. Collard de
Martigny published in 1836 : l)e VInfluence de la Circula¬
tion Generate et Pulmonare sur la Chaleur du Sang. P. PI.
Berard wrote the' physiological, and Chomel the pathological
part, of the article " Warmth," in the Medical Dictionary
32 vols.). Bouilland and Donne used thermometry in their
practice. Piorry had a thermometer added to his stethoscope,
urged the necessity of even measuring the temperature of the
skin, and strengthened the claim of the thermometer by repeat¬
ing this prophetic utterance of Biot: " Lorsqu'on voit taut de
resultats obtenus par le seul secours d'un peu de mercure
enferme 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 coiKjoit que rien de ce qui peut agrandir et perfectionner
les sens de l'homme ne doit etre pris en legere consideration."
In 1837 Sir B. Brodie made known his experiments " On the
Elevation of the Temperature after the Division of the Spinal
Cord, etc." {Med. Chir. Transactvol. xx., p. 118). Wisting-
hausen, Fricke of Hamburg, and Friedrich Nasse furnished val¬
uable contributions, at the same time (1839) that Gavarret con¬
firmed (in the Journal VExperience) several of the almost for¬
gotten discoveries of De Haen.
6
HISTORIC.
About 1840 thermometry took a new start when Andral, the
then leader of progress, applied it like Currie, not only to indi¬
vidual cases, but to " map out the courses of temperature, and
to find out their laws." Still more valuable than Andrei's
Lectures on General Pathology, was the Dissertation of
Giei^e, On the Causes of Organic Ileat in Inflamed Parts.
Roll man made many observations On the Variations of Tem¬
perature in the Healthy, under various conditions and circum¬
stances ; and Chossat completed his Experimental Researches
on Inanition in 1S38.
Of the same date are the investigations of Henri Roger (De
la Temperature chez les Enfants, a Vetat Physiologique et
Pathologique published in Arch. Gen. 1844, and since in book-
form, still highly valued. His tliermometrical observations bear
on the normal temperature of children at birth, during their
first seven days, and later; then in ephemeral, intermittent
typhoid fevers, small-pox, scarlatina, measles, erysipelas, rheu¬
matism, pericarditis, cardiac hypertrophy, stomatitis, enteritis,
dysentery, meningitis, encephalitis, laryngitis, bronchitis, pleu¬
risy, and pneumonia; and further in tuberculosis, whooping-
cough, chorea, dropsies, rickets, and paralysis, besides thrush
and sclerema of newly-born infants. Finally, Dr. Roger sums
up, in a practical manner, the result of these observations in
diagnosis and prognosis. Such a wealth of thermometric facts
had never been accumulated before; and though many of the
observations are incomplete, and the generalizations lack the
vigor of the Prussian school, one must not forget that they were
without precedent, that ten years later it was easy to improve
upon them, and that as they are, they cannot be dismissed with a
compliment from a manual of thermometry.
Deinarquay,* first in surgery like Roger in medicine, publish¬
ed in the Archives Generates, 1848, his experiments on the influ¬
ence of pain, loss of blood, ligature, toxic agents, etc., on the
temperature of animals ; and, conjointly with Dumeril, Experi¬
ments on the Lowering of Temperature by Ether and Chloro¬
form, and like Roger, in this latter respect, he has no reason to
be thankful for the acknowledgment of his early and great
services to surgical thermometry by his confreres.
Zipmermaim, a military surgeon, advocated the cause warmly
* Lately deceased.—See Bibliography and Surgical Thermometry.
HISTORIC.
7
and furnished a great number of valuable facts. Tlie disserta¬
tion : De Colore in Morho, Bonn. 1849, of T. P. Schmitz,
will not be forgotten, nor the teachings of Nasse 011 the same
subject. Let us supplement these brief notices by an acknow¬
ledgment of tlie value and abundance of the thermometric
observations of John Davy, which successively appeared from
184-4 to 1863. He gave special attention to " The Temperature
of Healthy Persons" as a basis for other observations ; the tem¬
perature in advanced age; influence of the external tempera¬
tures 011 animal heat; diurnal fluctuations ; influence of seasons,
of active and passive exercise, of concentrated attention, of
increased alimentation, of sea-sickness, etc., on temperature;
with comparisons of the same in tropical and northern climates;
and many subjects of lesser importance treated incidentall}\
About 1846, chemists and physiologists took up the question—
Foureault, Floureus, Magendie, Ilelmholtz; Donders treated of
The Tissue-Changes as a Source of Heat in Plants and Ani¬
mals ; Liebig referred the ultimate source of heat to chemical
processes, and especially to slow combustion, and thus extended
and fortified the doctrine of Lavoisier.
After this, it was only necessary for physicists to complete
the idea of temperature, and its applications to physiology and
pathology would follow as a matter of course. More or less
directly, three or four men did it;—but, be it remembered, long
after B. Thomson (Comte Rumford).—First, J. R. Mayer, of
Heilbronn, declared (1842-45) the essential unity of the so-
called imponderables, by which the chemical processes which
appear,—as, light from the sun, disengagement of heat?, mechani¬
cal motion, electric affinities, etc.,—are converted into a single
force or power. This doctrine of the " unity and correlation of
forces " was a perfectly new idea: Ex nihilo nil fit, nil fit ut
nihilum. The effect equals the cause ; the operation of force is
again force in its turn. In truth, there is but one real force
which runs through an eternally changing round in dead as in
living Nature. There, as here, there is 110 progress, unless the
force changes its form. Heat is a force, it becomes changed
into motion. Chemical difference is a force, the changing of
chemical difference into heat results from combustion. In all
chemical and physical changes the given power always main¬
tains a constant magnitude. The sole cause of animal heat is a
chemical process, a kind of oxidation. The chemical force
8 HISTORIC.
which is contained in the food ingested and in the oxygen in¬
haled, is the source of two manifestations of power, viz., motion
and warmth; and the sum of the physical power of any animal
is equivalent to that of the simultaneously produced chemical
processes. Mayer made application of this theory to some
pathological, and to many physiological phenomena.
This Novum Organum was too much for the medical public,
who needed the authority of Hehnholtz to pay it any attention.
To Joule, of Manchester, belongs the honor of having experi¬
mentally demonstrated the absolute and unchangeable relation
between heat and mechanical power; and of having shown
that a given quantity of power produced a determinate quantity
of heat; conversely, that the quantity of heat which would
raise a given quantity of water one degree, would (if otherwise
applied) perform exactly an equivalent amount of mechanical
work. In other words, the heat capable of increasing the tem¬
perature of one gramme of water by 1° C. is equivalent to a
force represented by' the fall of 423.55 grammes through the
space of one metre. This is consequently the effect of a unit
of heat or calorie, called the hilogr ammeter.
Finally, Hirn, of Colmar, showed, with mathematical posi-
tiveness, that, whilst at work, the production of heat never cor¬
responded to the oxygen consumed ; much of it being changed
into work: instead of the missing heat, so much work was
done. This can give but a faint idea of the influence exercised
by Dr. Mayer's theories of warmth-prcduction. Physiologists
and pathologists received from them a lasting impulse, since
henceforth the temperature of the body became like all other,
a force convertible, i.e., manageable and subject to laws.
In consequence, Barensprung and Traube, in 1850, began
the new and henceforth endless series of pathologists who
mainly founded diagnosis, prognosis, and, to a certain extent,
therapeusis upon thermometric observation. Soon Traube
discovered that the thermometer was the key to the derelict
doctrine of the (irises; for which he was soundly abused by
some of those who now support it.
Ever smce October, 1851, Wunderlich, induced by Traube's
printed labors and spoken recommendations, introduced the
use of the thermometer in his clinic. The number of cases
thus studied amounted to nearly 25,000, and the number of
single observations to some millions. When the number of the
O
HISTORIC.
9
latter reached 100,000, they appeared to him capable of serving
as a basis for the determination of this most decisive question
of pathology : Do certain diseases in their progress obey fixed
laws or rules, and can this be determined and displayed by the
course of the temperature ? The affirmative answer was first
afforded by the thermometric observation of typhoid fever, dur¬
ing the occurrence of a short epidemic of typhus.
This discovery was due, not only to a great mental effort, but
to an uncommon power of discipline over other men of ability,
his faithful assistants, Thierfelder, IThle, Friedmann, Rotter, ISTa-
konz, Giesler, Wolff, Blass, Thomas, Siegel, Schenkel, Treib-
mann, Friedlander, Ileinze, Ileubner, Steelier, Hankel, and
zealous above all, his own son,—who died at the task in the
hospital of Leipsic, in July, 1873. One week before I met the
bereaved hero of medical thermometry,—I say hero, because,
though the French, Roger, Jaccoud, etc., entered the field
earlier, the Prussians won it.. So stand the two nations in the
contest; France established the norme, without which medical
thermometry had no physiological basis, and Prussia discovered
the first laws of pathological temperature. What a man alone
can, the French did ; what discipline carries, the Prussians con¬
quered.
In the meanwhile, other nations had worked hard for the
prize : in England, Aitken, the inventor of the self-registering
thermometer ; Ogle, J. Simon, Grimsbaw, Woodman, the able
translator of the New Sydenham Society edition of Wunder-
lich ; the three Foxes, E. Long, Wilson, and Tilbury; Finlayson,
who observed the temperature of tuberculosis in children;
Sydney Ringer, who espied it in incipient phthisis of the adult;
William Squire, who proved that in several respects private
practice is a better field than hospitals for the cultivation of
thermometry, etc.
In Italy, Maurice Schiff and Paolo Mantagazza gave the im¬
pulse ; in Portugal, Alvarenga ; in Brazil, Torres Homem ; in
Russia, Zorn.
This Republic may claim besides Rumford, J. S. Lombard,
inventor of the most sensitive thermometer; L. D. Bulkley,
who wrote a prize essay on thermometry ; Dacquin, Benet-Dow-
ler, Faget, J. Jones, Touatre, authors of valuable monographs
on the temperature of diseases prevalent in the Southern States,
yellow fever, dengue; and a host of excellent practical ther-
10
historic.
mometricians, whose observations have given such high tone to
the American medical press.
But to-day, already, the defeated of yesterday present again
a strong array—too many for my narrow roll-call: Charcot,
with, his brilliant staff of the Salpetriere ; Vulpian at the Ecole
Pratique; Bert, Berthelot, Lorain, Potain, See, Jaccoud, Le-
pine, Bourneville, Dupuy, lladouan, Onimus in hospitals and
private practice ; Ilirsh and Wurtz at the Ecole de Medeeine;
Claude Bernard and Marey at the College de France ; Becquerel,
Roger and Gavarret, old guards who neither surrender nor die ;
Brown-Sequard, present wherever discovery is needed.
In the impossibility of doing justice to all, 1 refer for omis¬
sions to the Bibliography, and resume this imperfect outline
of the History of Medical Thermometry in its most salient
phases.
The first, or Ilippocratic, in which physicians had no other
guides than their sense of touch, and the sensations of their pa¬
tients.
The second, or Sanctorius', opened with the invention of the
thermometer.
The third, or De Haen's, practical application of thermometry
in the clinic.
The fourth, or Bec^uerel's, fundation of the nokme base of the
numeration in mathematical diagnosis.
The fifth, or Wunderlich's, first demonstration of some laws
of ustion in diseases.
The sixth, in which uniformized thermometry will be the
centre of a positive vnethod of observation, applicable not only
to physic, but to insurance, labor, training, education ; and the
most rapid and direct improvement of our race. " If mankind
can be improved, it will be through the progress of physic,''
says Descartes, the prince of the metaphysicians.
CHAPTER II.
PHYSIOLOGICAL TEMPERATURE.
Heat is the first and last manifestation of life we are made
aware of, with our actual means of perception. Absolute
privation of lieat would be death; where there is heat there is
life, patent or latent.
Inorganic bodies receive their sensible temperature from
their surroundings when at rest, and chemical or other combi¬
nations develop in them sensible temperatures, which are their
ratio vivendi / whose exhaustion shall be in turn their ratio
moriendi (of desaggregation). But organized bodies have a
sensible temperature of their own, with apparels to feed and
distribute it, and others to regulate its safe-keeping and
escape.
Our physiological temperature, color, is produced by the
conflict of oxygen with combustible substances: this conflict is
the operation of the function we call ustion (urere, bruler, to
burn).
The cause of human ustion must be sought in the chemical
combinations which take place—not in one organ—but in the
whole organism, and by which the formation of carbonic acid
and water, urea, etc., is accompanied—like all labor or friction
—by a degagement of heat or calories.
The forces which are changed into heat in the body are the
chemical affinities of its own substance, and of the material
introduced into it from without. Of these substances the
most important, by far, is the blood, which, on account of its
capacity for taking up oxygen, is the main agent of heat-pro¬
duction ; and on account of its circulation almost equalizes the
temperature of all the parts of the body.
Part of this force-calor is employed for self-preservation,
12
physiological temperature.
part is converted into productive activity, the rest is. given off
in a double operation of keep and escape (a) by the circulatory
system, which—not unlike a hot-water calorifer—carries all
over the body an almost uniform temperature ; (b) by the skin,
a large condensing apparatus, through which the excess of heat
is converted into sweat, or escapes by radiation. Claude Ber¬
nard places the power of regulating the functions participant
to ustion in the sympathetic. From the compensating action
of this great harmonizer results the normal temperature of
every living body, its norme.
Every animal has its norme of temperature, which has been
established for those nearer us (Appendix II.). Although sub¬
ject to the law of diffusion of heat, their specific color resists
the permeating action of the ambient temperatures—be they
higher or lower than the inward ones—with a tenacity which
characterizes living organism. Even in the lowest forms of
life, the inward temperature—this irrecusable assertion of the
identity of the ^elf—exceeds the ambient temperature by some
tenths of a degree, at least. Flattering things have been said
on the superiority of man over animals by Dogberry; but, at
least, we can attribute to ourselves the greatest power of keep¬
ing our norme against the action of external temperatures,
without making the ant shake its antennae, and the bee curl
its mandibles.
Birds have a higher temperature than mammals, and reptiles
a lower one; man occupies the median place among the mam¬
mals which these latter occupy between birds and reptiles ; he
is the centre of the thermic scale.
I.—The Human Norme.
Ascertained by Becquerel and Brechet to be—
37° Centigrade scale.
29.6° Reaumur.
98.6° Fahrenheit.
77° Walferdin's tetracentigrade.
0° of the physiological scale.
(See Appendix I., Table of Equivalents^)
This norme must be the basis of all our judgments as to the
significance of temperatures in disease, growth, labor, etc., and
physiological temperature.
13
the guide of our determinations in regards to the preservation
and recovery of health.
For human temperature varies from this type. Besides its
unhealthy variations, perturbations proper, resulting from ex¬
cesses or sickness, there are ecarts from the norme, like those
of the pendulum from its axis; and there are even displace¬
ments of the axis (norme) by age, climate, occupation, acci¬
dent, etc., without sickness: anomalies, as normal for a few as the
norme for mankind.
Let us explain the idea by its very application, and first to
II.—The Diurnal Oscillations.
Temperature varies a little, oscillates, even in healthy per¬
sons, accordingto the time of the day, by .5° C. = .9° F. Lieh-
tenfels and Frohlich state the time of the lowest from 10 p.m.
to 1 a.m., and from 6 to 8 a.m. ; the highest from 4 to 5 p.m.
According to Damrosch the temperature rises from 7 to 10 a.m.
about .5° C. = .9° F.; falls till 1 p.m. about .1°—.2° C. = .2°—.4°
F. From thence till 5 p.m. it rises .2°—.3° C. = 4°—.6° F. ; and
then falls again till 7 p.m. by about .3°—.5° C. = .6°—.9° F.
Occasionally the afternoon fall is absent, the 7 to 10 a.m. ele¬
vation and the 5 to 7 p.m. fall are the most constant. (See
Appendix III. a.—Ogle; b.—Alvarenga; c.—Barensprung.)
Ogle states an ecart of 1.5° F., Alvarenga excursi from
.49° above the norme to .71° below it, total difference 1.20° C.,
average temperature 36.9° C. Finlayson, of Glasgow, found a
daily excursus of 2° C. as the daily average of 283 observations
taken on 18 children. Barensprung (same Appendix, c) notes
the excursus above the norme .49°, below .69° C.; total 1.18°.
Like Alvarenga he notes the influence of the meals besides that
of the hours. In the following table the same observer shows the
tidal movement of daily oscillations:
Maximum of the evening (4 to 6 o'cl.) 37.49°
Maximum of the morning (9 to 11 o'cl.) 37.26°
Minimum of the evening (8 to 10 o'cl.) 37.05°
Minimum of the morning (5 to 7 o'cl.) 30.31°
Medium of the day (24 hours) 37.03°
Labbee indicates two daily maxima irrespective of digestion or
sleep, therefore tidal too, and thinks that the sum of the tem-
14
physiological temperature.
peratures of 10 a.m. and 10 p.m. divided by 2 represents quite
correctly the average of the day.
Paul Bert comprises the diurnal oscillations of the temper¬
ature of healthy adults in one degree C. and finds the mean
daily at 10 a.m. ; others place it nearer to 12 a.m.
These discrepancies are attributable to several causes: to the
object in view when the observations were taken ; to the subjects
on which they were taken; in or out of hospital conditions;
on chronic or acute patients, etc. All these uncertainties show
that, of the human norme, we know the central axis; we know
that it has an oscillatory diurnal movement, but we are not agreed
as to the extent, times and rhythms of this movement; moreover,
we hardly suspect that seasons, atmospheric and sidereal condi¬
tions, may have an action on human temperature. IIow much
more to be learned.
In the concrete and in the practice, we must know the norme
of all our patients, and make people aware of the importance
of knowing their own norme of ustion, of circulation and respi¬
ration.- The meanest cur lost in the street can answer his name,
and the most learned man, if accidentally taken sick, canfiot
tell a casual practitioner the habits of his vital functions, whose
figures must be the basis of an urgent, and sometimes solemn,
diagnosis. Therefore let us know more, theoretically and prac¬
tically, about the norme, the range and rhythm of its oscillations,
and next of its abnormalities.
III.—Are there Abnormal Normes ?
Displacements of the norme by idiosyncrasy, or in consequence
of some accident or affection, are likely not unfrequent, though
rarely noted. Thomas expresses the opinion that, as there are
persons who naturally have a slow pulse—others may have for
their individual norme a low temperature.
We have seen children born with a sub-norme, some of whom
keep it as long as we were enabled to follow them. Eo^er
admits the reality of these displacements, either by idiosyncrasy
or from accident, during the first septennat of life.
Wunderlich recorded quite a number of normal adult
temperatures at 96.8° V. = 36° C. = l (one degree below zero
of the physiological scale), in other terms an abnormal norme •
and he took the observation of a girl, jet. 18, who was said to
PHYSIOLOGICAL TEMPERATURE.
15
have been cold from infancy, whose temperature in scarlatina
never rose above 38.3°, and since remained at 36.1° C. while he
had the opportunity of continuing his observation. Neverthe¬
less he concludes that idiosyncrasies show their peculiarity
in temperature as in anything physiological, but that observa
tions are too few to draw conclusions.
Let us conclude, on the contrary, that it is a reciprocal duty
for physicians to take all the normes they can ; and for every
man and family to keep their norme (of ustjon, circulation,
and respiration) as the criterium by which all possible anoma¬
lies of health may be foreseen, judged, and eventually cured.
The key to the aberrations of combustion is the physiological
temperature.
CHAPTER III.
WOMEN'S TEMPERATURE.
We have no more certainty about the comparative degree of
women's temperature.
According to the table of Ogle, just quoted, it would be .5°
F. higher than men's; about the same according to the calcu¬
lations of Wunderlich. But Davy found the temperature of
male adults .7° F. superior to that of women; Roger—taking
care to operate 011 healthy children—found the temperature of
boys superior by .5° C., at the same time that the pulse of girls
was more frequent by 7 beats (Roger, confirmed by Trous¬
seau). The tables of Mignot, though bearing also on other
points, sustain the latter opinion (see'Appendix No. IV.). Ac¬
cording to Andral and Gavarret, women produce less color
than men, because they are more accessible to causes of cooling,
and exhale less carbonic acid through the lungs, etc. Such
contradictions among authorities show how much of the work
remains to be done.
The temperature of women in relation to their monthly
functions, during gestation, delivery, lactation, will be consid¬
ered with that of the puerperal state.
CHAPTER IV.
INFANTILE TEMPERATURES.
Age, more successfully studied than sex, has been shown
to displace the norme, and though these displacements rarely
exceed one degree (Paul Bert), their figures, ordinarily mere
fractions, are important, since from them must be calcu¬
lated : (a) the march of constitutional affections in infancy ; (5)
the modes and degrees of alteration of temperature in disease;
(c) the restoration of the norme at its starting-point, defer¬
vescence and convalescence. These variations by age are:
At birth 37.08° In youth and virility... 37.39°
A few hours after 36.95° In old age 37.04°
In infancy 37.30° In senility 37.17°
(See Appendix No. VI.)
The temperature of the foetus, prematurely born, is lower in
proportion to the advance of its birth (Edwards, Nonat).
Meigs and Pepper (in Diseases of Children) sum up the obser¬
vations of Finlayson in this concise manner: " The daily range
of temperature is greater in healthy children than that recorded
in healthy adults, amounting to twro degrees F.
" There is invariably a fall of temperature in the evening,
amounting to one, two, or three degrees.
" This fall may take place before sleep begins.
" The greatest fall is usually between 7 and 9 p.m. (at least
under the conditions of life in hospital).
" The minimum temperature is usually observed at or before
2 a.m.
" Between 2 and 4 a.m. the temperature usually begins to rise,
such rise being independent of food being taken.
" The fluctuations between breakfast and tea time are usually
trifling in amount.
" There seems to be no very definite relationship between the
2
18
INFANTILE TEMPERATURES.
frequency of the pulse and respiration and the amount of tem¬
perature ; the two former functions being subject to many
disturbing influences."
Infantile temperature is, from the beginning, subject to so
many causes of versatility that few robust men could stand it.
Then its changes of type about the seventh day, an inward dan¬
ger added to the external casualties which make its study dra¬
matic from thence, at least till the seventh year. But above
this artistic impression, the humane one suffices to raise our
interest to the pitch of devotion.
Let us give a comparatively large place to the " tempera¬
ture of the first years," if only for the immense loss of life and
of the subsequent loss of power mankind sustains by want of
knowledge of what the temperature of the young ones ought
to be, a knowledge which it is the sacred duty of a physician to
possess and to impart to those who trust him in the sanitary
management of their families.
We do not know how many children die in this Republic
from deleterious temperatures; but, without a string of evidence
at hand, we can say: in London 45.5 per 1000 children die in
the first month, mostly by want of proper care of their tem¬
perature. In France, at large, the first year's loss is 204.2 per
1000, in some departments 308 to 369 per 1000; and from one
to five years the average is 34.65 per 1000 (from Bertillon's
Demography). This successor to Quetelet remarks that, by
taking better care of the children of the twenty departments
whose mortality is presently the largest, it would be easily re¬
duced, not to the minimum, but to the medium mortality of the
other departments, and that this little care would save annu¬
ally 14,000 children—just the number of the annual births in
Alsace and Lorraine ; so that, if the physicians of these localities
were willing to impart a sound knowledge of thermometry to
those who have the charge of breeding children, in twenty years
France would be as powerful again as she was before the sev¬
erance of these provinces. Here, not so many children die from
absolute want as in Europe, but from uncontrollable neglect,
which is the chief source of loss of vital-calor in infancy.
At birth infantile temperature invites comparison with that of
the mother, and some of the best observers recorded it. (See
Appendix V., a.)
The " foetus in utero " is about .5° C. hotter than the uterus.
INFANTILE TEMPER A TUKES.
19
-Before birth the infant temperature is a little higher than that
of the mother's uterus or vagina—a difference which ma}' be
accounted for, either by the hypothesis that the muscular efforts
of the child to disengage itself raises its temperature, as all labors
do; or by the other one, that the unborn being has already its own
proper source of heat, and its own means of regulating its tem¬
perature. Against the first hypothesis may be noted that if
muscular contraction develops heat in the child, it cannot fail
to develop heat in the mother likewise, or in a superior degree,
since she too works ; but which of the two works harder for lib¬
eration ? . . . .
In favor of the second thermogenic theory may be argued that
the egg—and the child in the membrane is yet an egg in the
shell—is, towards the end of the incubation, hotter than the hen ;
so much so, that when she is intelligent, she eventually leaves it
to cool a while. Moreover, J. Hunter found under the hen the
temperature of the fecundated egg 37.2°, and that of the sterile
one 36° ; this 1.2° C. testifying that the germ, not the mother, is
the focus of heat of the new life.
In children prematurely born, avortons, the temperature is
lower than the norrne in proportion to the shortness of their
foetal existence. 32° C. have been found by Edwards and Nonat.
'Not so low is that of the child born after the natural term, but
inferior to the norme by several degrees, owing likely to the
want of proper nourishment during this forced internation.
At the timely birth of a healthy child, his temperature will
be found sensibly higher than after a few hours of exposure to
our atmosphere, always more severe than the watery sphere of
the amnion; change by which it readily loses .7°—.8°C.=:1.260
—1.44° F., and, if not well provided for, a good deal more.
Nothing is more instructive for the management of infants
than the knowledge of these first fluctuations of their tempera¬
ture. When yet adherent to the cord, be it the effect of fever,
pressure, work (as we suggested), or of inward power of heat-
production, their temperature attains 37.8° —38.2°, and event¬
ually 39.5°—40° C. But in half an hour to one day it falls even
to 35.5°—34.2° C. Generally, after five hours reaction slowly
commences, bringing the body to its first norme, 37.5°, through
oscillations from 37.2°—37.93, neglecting accidental motived
ecarts. (See Appendix No. Y.)
The children of 3,000 grammes (6 pounds) and upwards are
20
INFANTILE TEMPERATURES.
those who keep nearer the nor me; if lighter, the consequent
frigeration comes nearer algidity, with less power of reaction.
If this double loss of body-weight and of temperature per¬
severe, they die. This lands us in the middle of an important
problem, the double movement of body-heat and body-weight
in the new-born. In the first twenty-four hours he may lose
30 to 120 gram. (1—4 oz.); if 160 gram, he is ill. The initial
weight comes back the third day, whence the ascension is pro¬
gressive, with a temperature below 38°.
There is the Schema of this movement:
1st day. . .loss 60 gram. (2 oz.) 5th day.. .augment 70 grams.
2d " ... " 60 " 6th "... " 60 "
3d " ...augment 60 gram. 7th " ... " 60 "
4th " ... " 60 "
The nearer these figures, the healthier the child. If mother
or nurse cannot render a clear account of their charge, by com¬
paring the temperature and the body-weight you can supply
their malice or stupidity, and save many children. See Part
II., Chapter V., § c.
After these stormy events of the firstcweek (see Appendix No.
V., a) the puerile norme 37.2°—-37.5° is established, and the dan¬
ger of revolutionary temperatures lessened till the seventh year
(see Appendix No. VII.), but not suppressed.
One of the difficulties in observing the temperature of babies
is its want of regularity. Their life is spent in eating and
sleeping without regard to day or night. It is only after the
fourth or fifth month that a slight morning and evening oscil¬
lation begins to be noticeable. In their first weeks, and even
months, they are extremely impressible to the causes of fluctu¬
ation of temperature, which later in life have little action. To
this especial sensitiveness are attributable in apparent health-
fluctuations of .5°—2.6° C.=.9°—3.6° F., which in adults would
be considered as sicMy perturbations.
Even crying will cause a raise of temperature in children.
Sleep or no sleep acts on the same function. A light one cools,
a protracted one frigerates; the want of it increases the heat;
its long privation brings on algidity. "Wakefulness in the even¬
ing considerably lowers, and sleep harmonizes their temperature;
but protracted, it lowers the three great vital functions. A
I
INFANTILE TEMPERATURES. 21
healthy child awake had temperature (rect.) 99° F., pulse 150,
respiration 50 ; during a deep sleep at noon he had temperature
98.4°, pulse 120, respiration 30.
Babies cool quicker and more by night than adults ; they die
sooner, too, in algidity from starvation. But without going to
extremes, " a depression of temperature in infancy is of more
immediate practical significance than the slighter eleva¬
tions, since it points at once to the want of a better nutri¬
tion " (W. Squire, in Infantile Temperatures, etc., London,
1869).
Thus what apparently surrounds the baby with danger proves
to be the means of saving him, if those in charge only under¬
stand the thermometric signs.
We know food to be the main source of heat, and an equality
of temperature to depend principally from a regular supply of
wholesome food. Therefore we "svill look towards bad feeding
whenever we meet with apyretic temperatures in the young.
Two hours when awake, and three when asleep, must elapse
after a full meal to influence the temperature of a healthy child.
This effect is not so sensible on one uniformly well fed, as
on another insufficiently fed and improperly cared for; there¬
fore a sudden elevation of temperature indicates the evil, as
per cases reported by Dr. Squire (op. cit.). When a child has
suffered from weakness or want, a direct increase of the bodily
temperature follows the administration of food. " Case ISTo. 2
not washed, nor fed for some hours ; rectal temperature 97.4° ;
after suckling, 98°. Case lso. 3 not suckled for three weeks,
thrush, danger of inanition; temperature in recto 96°— 95° ;
after two days of breast-milk 97° ; third day 98.8°, an increase
of a whole degree in twenty-four hours, besides other signs of
returning health."
In well children, food or warm drink will sooner heat the
surface than increase the central temperature. Cold bathing
acts the same. When the circulation is feeble, and there is fatigue
and dullness, warm food and bath rise both, internal and exter¬
nal temperatures : almost two degrees may be gained by this
double method of applying heat. We have not here in view any
medical treatment, simply the uniform preservation of the
norme.
On this point, as on several others, we feel that we cannot do
full justice to the subject of infantile temperature in health,
22
INFANTILE TEMPEKATUKES.
but can only refer to the Part Second already referred to, and
to Appendixes Y. (a, b) and YII., on tlie very important rela¬
tions of temperatures to pulse and respiration. But we will
sum up our interest—the interest that every physician cer¬
tainly feels in this subject—by the memento of Ilufeland:
" Remember!.. .. two-thirds of the sick are children." Adding:
" Deviation from the norme of temperature is often the only
warning of their danger."
CHAPTER Y.
THERMAL INFLUENCES ON THE NORME.
a.— Of Food.—Nutritious materials introduced into the
body, though chief means of warmth-production, hardly affect
the temperature, because the excess of heat produced is disposed
of. The breakfast raises the temperature more than the lunch,
and the evening dinner causes simply a delay in the fall, which
otherwise takes place at this time of the day. Generally the
effect of a meal on temperature is slight, unless the individual
is unwell or the food unhealthy. (See Appendix YI.)
Of Drinlcs.—The transient effect of a moderate and habitual
use of ardent spirits and other drinks on the temperature of
the healthjt are thus resumed. Two pints or so (a mass) of beer
lower the temperature of .5° C. = .9° F. in fifteen minutes. Wine
and brandy lower the temperature too. In full doses brandy
lowers the fever heat by fully two degrees, and gives the pulse
fulness and frequency. Warm alcoholic drinks elevate the
temperature ; also coffee and tea ; carbonic acid drinks lower it
fur a short time.
The effects of drinking cold water (Lichtenfels and Froh-
lich) was to lower the temperature ; and that of immersing one
hand in very cold water was to lower its temperature 8°—18°
C. = 14° —34° F. in a few minutes; did not alter the general
temperature, but lowered that of the other hand as soon as
the immersed hand became painfully affected by the cold
(Brown-Sequard and Tolozan, Journal de Physiologic, i. 497).
But as the action of food, alcohol, wines, water, etc., extends
farther than the mere preservation of the norme—to its restor¬
ation, for instance—we will put off further remarks till we
speak of them as therapeutic agents.
Cold bathing, in good ordinary conditions, equalizes the
temperature, and comes next to food—with food, must Ave say ?
as a factor of the norme with a weak circulation, fatigue or
24
INFLUENCES ON THE NOEME.
chill, the bath, like the food and drink, must be warm, and
yet not so hot as to promote hyperpyretic temperatures.
The possibility of frige ration by cold water is more marked
in those born before'tlieir term, and next in those born after their
term. Then old people frigerate easier than adults, though
when well their actual temperature does not differ from that
of adults, because if they produce less heat, they lose less too,
from diminished perspiration, pulmonary exhalation, etc.
The thermal influences are modified by the nature of the
agents, air, water, etc., which bring heat or cold in contact with
us. They are also modified by their duration. Thus the im¬
mediate effect of cold is to abstract blood and to cool, as that of
a higher temperature is to heat and prevent cooling. But every
diminution or elevation of temperature which occurs through
short thermal agencies is transient, and followed by a reaction ;
so a high temperature of the body commonly follows a cold
bath, and after a warm bath the body feels cooler.
But how can these often delicate influences be appreciated,
particularly in children ? By the thermometer, which, instead of
standing at the window " pour voir si le printemps s'avance,"
must be applied to the child by the mother, to detect any
threatening temperature, and indicate its cause. But to say
more on this subject, as on the preceding one, would interfere
with thermo-therapentics.
1).—Latitudes.—The most comprehensive word for location,
climate, seasons, etc., acts on the body's temperature in several
ways. By sudden exposure it causes fluctuations, soon followed
by reaction ; by extreme transitions it raises the temperature in
a more marked and permanent degree ; yet by continuing in
the same latitude it produces accoutumance, which may con¬
firm or displace the former norme (besides producing other
effects on the constitution). These apparent contradictions are
rendered sensible by the examples of climatic actions on the
body-temperature chosen by Wunderlich :—The "transition
from a hot to a cold climate " (John Davy) lowered the temper¬
ature .88° C. = 1.58° F., whilst the transition from France (tem¬
perate) to Mauritius (hot) gave to Brown-Sequard the following
results on eight healthy persons, between the age of seventeen and
fifty-five. With the thermometer under the tongue, the atmos¬
pheric temperature at 8°'C. = 56.4° F., he obtained a mean
body temperature of 36.625° C. = 97.9° F. Eight days later,
INFLUENCES ON THE NOEME.
25
with the temperature of the air at 25° C. = 77° F., a mean body
temperature of 37.428° C. = 99.4° F., and nine days later, under
the equator, with an atmospheric temperature of 29.5° C. = 85.1°
F., a mean body temperature of 37.9° C. = 100.21° F. But six
weeks later on the voyage, in 37.4° latitude, with the external
air at 16° C. = 60.8° F., the mean body temperature had sunk to
37.25° C. = 99.04° F. (Journal de Physiologie, ii. 551). Living¬
stone (Travels in South Africa, p. 509) found the temperature
of the natives 1.8° 0=2 F. less than his own; and Thomson
that of the Faroe Islanders somewhat higher than our norme,
37.2° C. = 98.96° F. under the tongue.
Davy and Brown-Sequard had noted temperatures in transitu.
Livingstone compared the transient effect of the high climate
of Africa on himself with its permanent effect on the indige¬
nous ; instead of which Thomson compares the temperature
of the Faroe Islanders—not to his own, which was likely displac¬
ed by the transition—but to the accepted norme of Europeans.
When the premises differ, the conclusions cannot agree. How¬
ever, the action of climate on man is so limited that it affects his
temperature only one-tenth of a degree from winter to summer,
and not much above one degree from the equator to the polar
regions.
c.—IIow much more altitude acts upon our body-tempera¬
ture ; not by tenths of a degree during long journeys, but by
many degrees during a single ascension of a few hours.
It primarily affeo,ts the respiratory functions, and through
them the circulation and the calorification, but more in walking
or workino; than at rest. During transient ascensions the
temperature fluctuates when descending below the norme.
During a protracted sojourn on the uplands, the norme may
become displaced ; in which case the pendulum of the oscilla¬
tions continues its diurnal movement around this new centre,
with or without other constitutional changes following the
" accoutumance." En somme the compression of air increases
our temperature, its rarefaction lowers it with mathematical
precision.
Three forms of experience have concurred in throwing new
lights on this subject: Paul Bert's " On the influence which
barometric pressure-changes exercise on the phenomena of
life ; " the aerial ascensions of Sivel, Glaisher, and others, and
the terrestrial ascensions of Leurtet, etc. (see Appendix VIII.).
20
INFLUENCES ON THE NORME.
These experiments concur in the demonstration of facts actu¬
ally available in physics and in homoculture.
The inhalation of oxygen in definite proportions, tested by
Bert, permits to undertake the exploration of the highest points
of our globe, hitherto inaccessible, and to push 011 with less
danger the submarine and subterranean works of engineer-
illg'
In medicine the combined action of oxygen and altitude
upon human temperature in many ill conditions, but particu¬
larly in lung troubles, is so precise that we now can prescribe
with more confidence the sojourn in or the passage through
certain altitudes, to mathematically lower or raise pathological
temperatures, than a physic for purging.
By showing where birds begin to be asphyxiated, Bert taught
us where the consumptive can breathe and live.
As for education, by introducing in it more of the action of
altitudes, longitudes, oxygen, insolation, mathematically dosed,
we may expect to raise homoculture as high in positivism as
horticulture. We already know, for instance, that from Vera
Cruz to Mexico the graduated altitudes and climates are like
so many step-mothers and fathers to the vegetable produces
of the whole world; but we hardly yet suspect that 011 each of
these terraces the most beautiful and esculent crops of human¬
ity could be raised, which die under the atmospheric pressures
of New York, Paris, London, in the poisoned air of upas-like
crowds ; this is the object of the oldest and newest science,
mesotherapy. (See Part II., Chap. VI., § c.)
d.—The influence of muscular activity upon the body-tem¬
perature has been ascertained by Becquerel and Brechet, who
found that when a muscle contracts, its temperature rises at
first half a degree, soon one degree and more. The heat thus
generated appears greater when the available force produced
is not employed ; and smaller in proportion as some part of it
has been converted into labor. These thermometric results
are thus explained: Setting aside the normal heat (37° C.) gen¬
erated and spent for the mere purpose of feeding life, the sur¬
plus generated by muscular contraction is found, partly in a
transient elevation of temperature, whose quantity will soon be
exhaled through the skin, lungs, etc., and partly in the mechan¬
ical results of labor; the sum of both being the equivalent or
the results of the chemical action evolved from the muscles.
INFLUENCES ON THE NORME.
27
Hirn, while at rest, produced 155 heat-units, Calories, and
whilst working at a treadmill, 251; and yet his temperature
was not higher; because at rest the heat is not liberated, whilst
at work, though produced in greater abundance, it passes off by
more rapid breathing, quicker circulation, sweating, etc., besides
the part converted through movement in labors by its factor
activity; so that, though more heat-units are produced, more
are evolved, and the final difference of temperature during rest
and during labor is trifling. (Excesses reserved.) This is what
interests mostly the dynamist and economist, from their point of
view, the quantity of work exactable from a man or a people.
Physicians are interested in the same problem from a differ¬
ent point of view—that of the durability and reproduction of
the self-contracting machine, man.
Restricting our duty in this matter as much as possible, we
feel an immediate interest in the variations of temperature—
even transitory, but frequently recurring—which have their
motor origin in muscular contraction, and their secondary cause
in either imperfect aeration and nutrition, or in an excess of
expense of calories. Without this knowledge, we would ignore
if nature has yet—or has no more—resources available to con¬
cur with us in the restoration of the norme.
In this investigation we find these variations of temperature
resulting from muscular contraction of two kinds—though pos¬
sibly differing only in degrees—but let us say kinds, in consid¬
eration of the difference in hind of their results. The first kind
of variations are those which can be considered as simple
exaggerations of the normal oscillations. Their characters are :
mathematically, their diurnal ecarts are greater than those of
repose, but they return to the norme; and physiologically, far
from being accompanied by exhaustion and suffering, they make
rest and work alternately more enjoyable.
The other fluctuations of temperature, produces of excess of
muscular contraction (or of mental sur-activity as well) are
recognizable, mathematically, sometimes by larger, always by
more lasting ecarts, and are followed by (slight at first, and
finally permanent) displacements of the norme. * Their physio¬
logical test is the absence of rest and re-invigoration after using
sleep, food, bath, and other usual restorative processes.
At this stage of deperdition of caloric man falls a prey to any
cause of enfeeblement and extinction ; excessive conversion of
28
INFLUENCES ON TIIE NOKME.
calories in labor will exhaust, not only him, but his race. Gav-
arret demonstrates that if the working-man spend more heat
that his heating apparatus, wholesome food, pure air, etc., can
furnish, sooner or later his central temperature will descend
below the norme, and he will be left without reaction against
any new cause of drainage of calories.
Therefore, whoever appropriates to himself the equivalent in
produces of this sacred 37° C., the norme upon which every one,
without exception, ought to live, eats up in fractional equiva¬
lents the thermal substance—calories—of his fellow women and
men. With this difference, however, that the direct anthrdpo-
phagist is contented with a few pounds of human flesh, but the
civilized antliropophagist consumes day and night thousands of
calories which are others' life. I would not have insisted on
this fact if "Wunderlich had not said: "No well observed facts
tend to establish a difference of temperature between the rich
and the poor, nor 011 account of difference of occupation." But,
besides Gavarret, Roger has shown that scleremic children owe
their algidity to the conditions of excessive work, privations
and sufferings of their parents; and Manouvriez, in his Rapport
sur les epiclemies et endemies d'anemie des mineurs d?Anzin
de 1803 d 1875, has shown to what fearful degenerescences are
condemned those-who work above their strength, away from
the heat and light of the sun, to enrich, with the red corpuscles
of their own blood, the blood of the gamblers in stock, etc.
Not only the overworked man has his own norme displaced
—higher or lower according as the strain affects his expense
of calories or his calorigenic capacity—but the diseases of his
family will all bear the stamp of apyrexy and anjeinia, sclerema,
thrush, croup, cholera infantum, etc. Later, the heir to the
rich (if spared the virus of vice) will have a more even tem¬
perature from the centre to the periphery, from youth to old
age, whilst the new crops of working humanity will be shorter
lived, shorter sized, deformed like the canuts of Lyons, and
show in their discolored skin the inheritance of a low peri¬
pheric circulation and temperature.
e.—The influence of intellectual activity and mental labor
upon temperature does not seem to differ in kind, in mechanism,
and in degrees from that of muscular activity. Brain-work in¬
creases the produces of oxidation (urea, etc.), and therefore
oxidation itself; so say chemical analyses. It also elevates the
INFLUENCES ON THE NORME.
29
central and cephalic temperatures, as shown by general and
localized thermometry.
This conclusion results from the experiments of John Davy,
showing also that brain-work is attended with a higher rise of
temperature under the tropics than in northern latitudes; and
from those of J. S. Lombard, proving that anything which ex¬
cites attention causes a slight rise (like .1° C.), and true brain-
work a much higher one.
Moreover, Brown-Sequard was enabled by an extensive use
of surface-thermometers to support, with figures, the theory
affirmed under the questioning form in his celebrated paper
read in 1873 before the Smithsonian Institute, Ilave we two
brains? showing that the thinking brain—ordinarily the left-
lias a higher temperature than thg right one; just as the right
hand is more active, and less subject to paralysis, having a more
even temperature than the left lazy one.
Here again we must be prepared to discriminate \he fluctu¬
ations which are only oscillations of temperature, tempora¬
rily exaggerated by a legitimate and well-supported activity,
from those which have lost their rhythm, and their centre of
gravity, under the double pressure of sur-excitement and exhaus¬
tion. The former make the scholars, and produce valuable ideas
and chef-d'ceuvres; the other develop in children granular menin¬
gitis of the base, produce in adults several intellectual incapaci¬
ties, and if persevered in, national or class degenerescences.
f.—Moral Strain.—After all, as the great keeper of the
norme of the body-temperature, and of its healthy oscillations,
is an equally balanced action of the sympathetic over all the
functions, it was to be expected that the causes of perturbation
of this sensitive apparel, like the tension caused by incessant
apprehensions, or the stunning shock of unexpected issues, would
affect the body-temperature in the scheming classes, as does the
loss or paucity of calories in working people. Here hyperaBmise
are the factors of frequent hyperpyrexia, over which the sym¬
pathetic loses, by suddenness or repetition, its regulating power.
General, spinal, and cephalic anaemia and apyrexy follow,
which paralyze, or sent the schemer and the wife who par¬
takes of his emotions wTliere, happily, the maniac does not
recognize the demented. A large percentage of their children
are born with soft bones or soft brains, bound for rachitism,
idiocy, epilepsy, hemicrany, etc.
30
INFLUENCES ON THE NORME.
Morally, the keeping of the norrae is the reward of an honest,
independent, useful life, during which the fluctuations of tem¬
perature in health are but slight; if they rise quickly they go
down as quickly; a great increase of warmth is accompanied
by a larger loss; a small production of heat is balanced by a
slight deperdition. Herein is the mystery of organism: in
health, calorification and decalorification compensate each other
with a wonderful regularity ; accidental disturbances are im¬
mediately brought back to the rule; disease will present the
opposite phenomena of strong, lasting perturbations from the
norme.
Thus we have brought human temperature from its norme
to its abnormalities, whose study follows.
CHAPTER VI.
PATHOLOGICAL TEMPERATURES.
All abnormal temperatures denote a disease, but all dis¬
eases do not show an abnormal temperature.
Is it because only in certain diseases the temperature (color)
becomes involved ? Not likely ; sooner because our means of
calorimetry are so imperfect that many forms of thermal aber¬
rations escape their sensitiveness. Simple pyrexy and apyrexy
are easily noted, but not so those perturbations of temperature
which consist in a conflict for the central and peripheric repar¬
tition of caloric, or between its local means of keep or escape.
Remember the struggles of combustion in a boil; or have you
ever studied the temperature over and around a cold abscess ?
To perceive the more delicate or hidden of these ustions, our
instruments are completely inadequate, or, like the thermoscope,
hardly yet invented. (See Part II., Chap. II., § VIII.)
Other diseases, whose temperature is little known, are those
in which, without being positively or permanently abnormal, it
is discordant with the other vital functions. These discordances
are the object of some further remarks, but have never been
thoroughly explored. They cover a large pathological ground,
which, with the other ones just pointed out, form a vast terra
incognita. (See Part II., Chap. V., § 1.)
For this and many other urgent reasons, a knowledge of the
course of temperature in disease is indispensable to medical
practitioners.
Because : all the phenomena of the sick are deserving of
study. The temperature may be determined with a nicety
which is common to few other phenomena. The temperature
can neither be feigned nor falsified. We may conclude the
presence of some disturbance in the economy from the
mere fact of altered temperature. Certain degrees indicate
32
PATHOLOGICAL TEMPERATURES.
that there is fever. The height of the temperature often
decides both the degree and the danger of the attack. Ther-
mometric observation may aid in the discovery of the laws
regulating the course of certain diseases. When once the
normal course of certain diseases has been determined, ther¬
mometry is able to simplify and confirm the diagnosis.
Thermometric investigations indicate rapidly and surely any
deviation from the regular course of a disease. The behavior
of the temperature during the progress of the disease discovers
either relapses or ameliorations before they could be otherwise
recognized. In this way thermometry is able to regulate
therapeutics. It puts us on our guard against any injurious
influence that may affect the patients in the course of their
illness. It serves to indicate the transition from one stage of
the disease into another, and particularly the commencement
of convalescence and its complete establishment. It reveals
complications, and how far recovery is from being complete. It
generally reveals the imminence of a fatal termination. It
announces the impossibility of the continuance of life. It
furnishes certain proofs of the reality of death, when this is
otherwise uncertain.
The application of thermometry to surgery answers already
its most pressing questions. At what temperatures operations
are possible or would be fatal ? When do accidents threaten
under natural or dressing occlusions ? How to use, and when not,
the anaesthetics, single or combined ? The answers have been
peremptory; proving to the surgeon that, with him, the ther¬
mometer must take precedence of the knife: temperature has
become the beacon of surgery.
Lastly, one may say" that there is no physiology possible with¬
out thermometry.
But this knowledge of temperature must not be kept an
arcanum among the profession, since it is wanted wherever,
the physician not being present, it is interesting to know
that heat is evolved faster than it can be generated, or vice
versa.
Laities begin to understand that their temperature is their
physiological soul. For them, inquiries about body-tempera¬
ture in all matters of work, enterprise, education, have lost their
strangeness ; mothers, nurses, teachers, leaders of men, begin to
feel that what they exact in the form of handy-work, exercise,
PATHOLOGICAL TEMPERATURES.
33
attention, memory, judgment, determination, is body-heat,
exhaustible by an imprudent husbanding.
So that three orders of facts render it necessary to study the
body-temperature: medical, surgical, and social facts. But
keeping ourselves, for the present, in the limits of physic, we
say that three facts render it necessary for the physician to take
a thorough knowledge of the body-temperature: its invaria¬
bility in healthy persons, its mobility in the delicate and during
exertions, its perturbations in the sick, over-worked and ill-
fed.
3
CHAPTER VII.
PRINCIPLES
by which to judge of the significance of the tempera
ture-changes.
A normal temperature does not necessarily indicate health,
but all those whose temperature varies on slight causes may be
considered as easy preys to disease or to decay; and those
whose temperature exceeds or falls short of the normal range
are actually on the way towards, in, or out of sickness.
The axillary temperature of 98.6° F. = 37° C. = 0 of the
physiological scale (see Appendix I.), is considered the central
thermic point of health, the axis of thermometric calculations.
The ordinary range of pathological temperatures is between
95° F.=35° C.=2 Ph. and 108.5° F.=42.5°=jU> Ph., and
very seldom falls below 33° C. or rises to 43° C.
However, Henri Roger discovered in children falls to 22° C.,
and Wunderlich in tetanus a terminal 45° C. Barring these
and other more recently discovered rarities, the ordinary patho¬
logical ecarts from the norme (0 Ph. = 37° C. = 98.5° F.) cover
2 below and 5.5 above the norme ; altogether a range of 7.5° C.
of the physiological and centigrade scales.
Such are the usual proportions of the stage on which the
drama of our life is played in, and out.
Deviations from the normal course of temperature never occur
without causes or fixed laws; that is the foundation of Pa¬
thological Thermometry. We sometimes fail to discover these
laws, because in disease, more than in health, the temperature
of the body is the result of mutually antagonistic factors.
Influences which in no way disturb the temperature of the
healthy, derange that of the sick, even if they hardly affect his
sickness. Mobility of temperature under the action of external
influences is, therefore, a sign of some diseased condition of the
SIGNIFICANCE OF TEMPERATURE-CHANGES.
35
body. It is so that the discovery of abnormal temperatures
in men previously healthy becomes a means of discovering or
confirming the existence of a latent disease.
Alterations of temperatures may be confined to special re¬
gions, whilst the rest of the body remains almost normal; they
seldom exceed 1° C. = 1.8—2° F. ; but are accompanied by
other obvious phenomena sometimes more useful for the diag¬
nosis than the local abnormality of temperature.
Since Wunderlich wrote this, the use of the surface-ther¬
mometers has modified these conclusions, by demonstrating
larger differences between local temperatures, and between the
central and the peripheric.
The use of the thermoscope will render these differences
more sensible, and lead to the creation of a localized ther¬
mometry.
The general temperature is the expression of several pro¬
cesses, some tending to the production of heat, others to its
exhalation. However varied is the combination of these pro¬
cesses, their thermal result, or the specific heat of the body,
remains the same in health ; and its variations in disease,
though not absolutely trustworthy, are yet the safest standard
by which to estimate the condition of the whole body. Varia¬
tions of temperature coincide with other functional and struc¬
tural disturbances not so easy to measure, and often appear
long before other morbid alterations can be recognized.
The heat of the whole body may be normal, increased or
diminished, whilst that of separate regions is different. A
normal temperature in sickness is only a relative sign, which
may exclude certain forms of disease, but cannot by itself
found a sure diagnosis. A fall of temperature below the nor¬
mal range occurs temporarily, favorable or not. An unequal
distribution of animal heat is unfavorable. Abnormal devia¬
tions furnish the best elements of diagnosis and prognosis.
Certain abnormal temperatures are generally associated with
a type of ill-health. A rapid increase in the heat of the body,
and decrease of the heat of the extremities, is associated with
cold shivers, rigors, fever-frost. A protracted temperature of
38.5° C. = 101.3° F., or more, is usually accompanied with heat,
lassitude, thirst, headache, frequency of pulse; if persisting
with diminution of body-weight, pyrexia, fever, fever-heat.
Any considerable diminution of warmth in the extremities,
36
SIGNIFICANCE OF TEMPERATURE-CHANGES.
with very high or very low central temperature, is expressed
by a small pulse, sunken features, weakness, nausea, cold
sweating, collapse.
The amount of temperature-changes, their relation to one
another, and their subsequent alterations, are commonly deter¬
mined by the course of the disease; so that the more typical
the disease, the more typical is the alteration of temperature.
In opposition to these types are the atypical diseases in which
the temperature, too, is irregular. Between them stand the
affections, whose types and temperatures are not'sharj^ly de¬
fined.
The typical diseases, which hardly deviate from their type,
are illustrated by typhoid fever, typhus; and apparently by
relapsing fever, small-pox, measles, scarlatina, lobar pneumonia,
and recent malarious fevers.
The approximately typical diseases, which exhibit great
regularity in certain stages, and none in others, are exemplified
by febricula, pyaemia, septicaemia, varicella, rubeola, facial
erysipelas, acute catarrhal inflammation, tonsillitis, acute rheu¬
matism, basilar meningitis, meningitis of the convexity, eere-
bro-spinal meningitis, parotitis (mumps), pleurisy, acute tuber¬
culosis, fatal neuroses in their last stage, and trichinosis.
Another group is formed by those diseases which generally
run their course without fever, but which display a regular
type whenever fever supervenes. To this group belong cholera,
acute phosphorus-poisoning, acute fatty degeneration, and
syphilis. Even diseases designated as atypical exceptionally
show ati approximation to some type, as diphtheria, dysentery,
pericarditis, peritonitis, acute and chronic suppurations (ab¬
scesses), and phthisis.
A temperature is monotypic or uniform, as a rule; but in
special cases it becomes pleotypic, or multiform. Thermometry
finds out these variations, which have enabled us to differenti¬
ate various types in the same disease. Thus, small-pox, typhoid
fever, scarlatina, pneumonia, and malarious fever may assume
the pleotypism that thermometry alone can demonstrate.
Any disease, however fixed may be its type, may exhibit de¬
viations from it (irregularities). These irregularities are circum¬
scribed and determinate; thermometry alone can assign their
extent and their form, and predict the time when the irregular
course will reassume the typical form.
significance of temperature-changes.
37
A single observation of an abnormal temperature (however
great or small may be the deviation from the norme). is not by
itself conclusive as to the kind of disease present. All we
learn from it is this: That the patient is really ill. When
there is considerable elevation of temperature, we know there
is fever. With extremes of temperatures, we know there is
great danger.
This is the abstract significance of a single observation.
Temperatures much below 36° C. = 96.8° F., are collapse-
temjperatures. Below 33.5° C. = 92.13° F., deep, fatal algide
collapse; 33.5°—35° C. = 92.3°—95° F., algide collapse with
great danger, still with possibility of recovery; 35°—36° C. =
95°—96.8° F., moderate collapse, in itself without danger.
Normal or almost normal temperature: 36°—36.5° C.=
96.8°—97.7° F., sub-normal temperatures; 36.6°—37.4° C.—
97.88° — 99.12° F., really normal temperatures; 37° C.=
98.6° F., the Norme; 37.5°—38° C. = 99.5°—100.4° F., sub-
febrile temperatures.
Febrile temperatures: 38°—38.4° C. = 100.4°—101,12° F.,
slight febrile action; 38.5°—39° C. = 101.3°—102.2° F., in
the morning, rising to 39.5° C. = 103.1° F., in the evening,
moderate fever; 39.5° C. = 103.1° F., in the morning, and
above 40° C. = 104° F., in the evening, considerable fever;
39.5° C. = 103.1° F., in the morning, and above 40.5° C.=
104.93 F., in the evening, high fever.
Hyperpyretic temperatures: 42° C. = 107.6° F., and above,
indicates a fatal termination, except in relapsing fever and other
rare conditions.
A single observation of temperature (corroborated by other
symptoms) may sometimes - lead to a diagnosis or exclude
another, or determine the severity or the innocuity of an
attack.
There are variations of temperature in the course of twenty-
four hours in health; so in disease, only greater. These varia¬
tions, in febrile diseases, are subject to rules dependent on the
kind, severity, and stage; upon them depends improvement or
crises. If the daily temperature of a patient deviates from its
pathological type, the cause of it must be looked for in circum¬
stances, complications with diseases of another or no type, sud¬
den relapse, constipation, diarrhoea, sudden emptying of a dis¬
tended bladder, spontaneous or therapeutic loss of blood, pro-
38
SIGNIFICANCE OF TEMPERATURE-CHANGES.
fuse perspirations, moving, fatigue, mental excitement, wakeful¬
ness, error of diet, thermal influences, or the operation of
medicines and other therapeutic agencies.
The daily fluctuations may be either simply ascending or
descending. They almost always describe a course composed of
one or more elevations of temperature; daily exacerbations,
and intercurrent falls of temperature; daily remissions. The
number of degrees (extent of the ecart or excursus) between the
daily maximum and minimum is the daily difference or range.
When the difference is trifling the temperature is called contin¬
uous ; when considerable, remitting. The mean or medium
between the maximum and minimum is the average daily tem¬
perature ; and its height shows the intensity of the fever.
Typical forms of diseases have during their intensity a deter¬
minate average temperature, and seldom sink below or rise
above their minima and maxima, unless shortly before
death.
Continued thermometric observations during a disease mark¬
ed by high temperature afford the best materials for diagnosis
and prognosis. They show us what is conformable to law or
normal in the course of a disease, and often form a correct ex¬
ample of a kind of disease (type). They mark distinctly the
stages of a disease, even their mode of transition • they afford
the best means of judging the severity of a case, its ameliorations,
exacerbations, irregularities, relapses, restoration to health, im¬
perfect recovery, and tendency to a fatal termination, besides
controlling the entire treatment.
In the course of febrile diseases we may distinguish the fol¬
lowing stages or periods in the range of temperature.
Periods preceding the termination of a disease. The pro-
dromic, of which we know so little.
The initial orpyrogenic stage, longer or shorter, is considered
closed by the development of a localized process, or when the
lowest daily average characteristic of the disease is reached.
The acme or fastigium, during which the fever maintains its
characteristic daily temperature. The amphibolic stage (per¬
turbation in some severe diseases), whose temperature is irreg¬
ular.
Periods in case of recovery :
The crisis, perturbatio critica, is the first stage of decrement.
The period of return to normal temperatures : stage of cleferves-
SIGNIFICANCE OF TEMPERATURE-CHANGES.
39
cence or cooling. The epicritical and convalescent period, in
which the temperature is normal or a little above or below.
Periods of the fatal termination :
The jpr o-agonic period, preceding the death struggle, whose
temperatures are varied, but more or less characteristic. The
agony, or death-struggle. The act of dying, and the post-mor¬
tem changes of temperature. (These last stages may be so
brief and contracted as to escape observation.)
Reviewing these periods separately :
Thq prodromic periods, hardly yet studied, must be found out.
The initial period has often a characteristic type, but com¬
monly escapes observation ; it is varied by the morbid local pro¬
cesses which may accompany the fever. The patients previous¬
ly ill and feverish, the type of the stage preceding the new attack
is very vague. The intensity of the symptoms (temperature,
etc.) in this period can found a diagnosis only when exceptionally
severe. t
The next period, or fastigium, affords characteristic data for
a correct diagnosis in three ways: from the height of the tem¬
perature, from its successive alterations, from the duration of
this stage. By the elevation of temperature, its continuance at
abnormal heights, and its deviations from the normal type, we
learn the intensity and degree of danger of a disease. On the
other hand, when the elevation of temperature is moderate, the
duration of the maxima short, and the remissions early, we
judge that the disease is of a mild type. Irregularities in the
course of the temperature, even when they indicate an abate¬
ment of fever, are favorable only in special cases. A rise of
temperature towards the end of this stage generally betokens
some complication.
The amphibolic stage is generally present in severe and in
fatal cases. It is more plainly recognized after a regular fasti-
gium. Its complications are ushered in by'noticeable eleva¬
tions of temperature. As long as it lasts, days or weeks, we
must be guarded in our prognosis. In it, a single very high or
very low temperature is less significant than a steady one: a
steady abnormal height threatens with relapse; moderately
elevated, it renders convalescence probable.
At the conclusion of either the fastigium or the amphibolic
period there is commonly a final rise of temperature, associated
with other critical symptoms, perturbatio critica, of which
40
SIGNIFICANCE OF TEMPERATURE-CHANGES.
the character, very uncertain, can be judged by the further
course.
The stage of decrement, or period of preparatory moderation,
is wanting in many cases of recovery. The first failure of the
temperature to reach its previous elevation, either at the even¬
ing exacerbation, or in the morning remission, is the character¬
istic of this stage : it may fall in a single sudden descent as low
as 36.5° C. = 97.7° F., once or oftener, with or without col¬
lapse.
The period of defervescence or cooling may directly follow
the fastigium, or be separated from it by an amphibolic period,
a perturbatio critica, and a decrement stage. It is a return
to the norme, and has two different types, taking place in from
twelve to thirty-six hours by a rapid crisis / or gradually, the
process of occupying several days, by lysis. The march of the
defervescence may be by a continuous fall, which, however,
when it lasts more tliai^ twelve hours, is less marked in the
afternoon; or by a remittent fall, which is interrupted by
evening exacerbations ; collapse may supervene and protract
the recovery.
A rapid and regular defervescence is followed by a clearly
defined ejpicritical period, in which the temperature returns to
normal through increased mobility and a sort of fickleness.
Isolated and apparently causeless rises of 2°—3° C. = 4r°—6° F.,
relapses and secondary affections show themselves in this
period, whose illimited duration merges in true convalescence.
In convalescence, or recovery, the disease having left no se¬
quelae, the temperature is much the same as in health; if it is
not, or ceases to be so, sudden elevations indicate fresh compli¬
cations ; continuous elevations, a residuum of the original dis¬
ease. Protracted subnormal have to be watched.
In cases which terminate fatally, some signs of the approach¬
ing end appear in the fastigium or in the succeeding periods,
among others a great irregularity of the temperature.
During the agony or death-struggle, the temperature alters
but little, remains where it was, sinks considerably, or rises
enormously, according to the previous generation and evolution
of heat.
At the moment of death the temperature may fall, but if it
was rising before, it may continue to rise in death and after
death. In the former case the cooling is rapid, in the latter it
SIGNIFICANCE OF TEMPERATUKE-CHANGES.
41
is tedious, and corpses have bsen warmer than healthy men
twelve hours after the cessation of life.
In reviewing the coarse of febrile disease, we find that its
duration and succession constitute five principal groups.
Fevers running a short course: febricula ephemera and ter¬
minal fevers.
Fevers which exhibit slight daily'differences of temperature
during their acme, and defervesce rapidly by crisis: continuous
fever.
Acute fevers with a remittent course or character, whose mid¬
dle periods are marked by considerable daily differences be¬
tween the evening exacerbations and morning remissions, and
whose defervescence is also remitting and by lysis. (Extreme
and deadly cases reserved.)
The intermitting and relapsing types of fevers.
Chronic and protracted febrile affections, extending over
several weeks or months; type remittent, intermittent, contin¬
uous, or interrupted by considerable intervals free from fever.
In f ebriculse the temperature may rise, with or without rigors,
to 40°—40.5° C. = 104°—104.9° F., seldom exceeding it; fall
in a short unbroken line ; last from a half-day to three. It is
seen in traumatic fever, brief child-bed, the ephemera or weed
of Harnsbotliam, during the convalescence of slight catarrhs,
etc. ; the paroxysm of intermittent fever assumes this type.
Another type of it rises little and slowly, and either returns to
the normal temperature in one or two days, or gradually rises
again to 40° C. = 104° F., its culmination, then rapidly defer-
vescing ; it happens in the same diseases as the former, but in
intermittent.
Fevers which terminate a disease, terminal fevers, resemble
the preceding, though widely different in their significance.
In the period of apyretic diseases which precede death, or in
' the death-struggle itself, there is a rapid elevation of tempera¬
ture at the point of culmination; or after a slight fall, during
the last moments, death ensues: this form is found at the con¬
clusion of fatal neuroses, and in many cases of poisoning where
the temperature may rise above that during life.
Fevers with a continued elevation of temperature usually
begin suddenly, with rigors and shivering. During the fasti-
o-ivnn the average temperature fluctuates, according to severity,
between 39°—40° C. = 102.2—104° F., seldom more or less.
42
SIGNIFICANCE OF TEMPERATURE-CHANGES.
The difference between the daily minima and maxima is .5°—
1° C. = .9°—1.8° F., rarely more. Defervescence is tolerably
rapid. This group is represented (bnt not always) in simple
lobar pneumonia, in the eruptive fever of small-pox, in scarla¬
tina (whose defervescence is less rapid), in cynanche tonsillaris,
in meningitis of the convexity, in typhus (where the fever lasts
longer), in the beginning of facial erysipelas, and frequently in
intense fevers, which, at first remittent, pass to the continuous
type with an increase of the temperature.
In fevers with a remittent course, the initial period may be
short, or protracted. The average daily temperature varies from
38.5°—40.5° C. = 101.3°—104.9° F., or more, because slight and
severe diseases affect this type. It may last several weeks, defer-
vescing by lysis. Typhoid fever is the best representative of
this group, in which enter the catarrhal affections, influenza,
catarrhal pneumonia, febrile rheumatic affections, measles, the
commencement of basilar meningitis, acute tuberculosis, acute
phthisis, and trichinosis.
In intermittent and relajpsing types, during the intervals of
the paroxysms there are normal temperatures. For the inter¬
mittent the paroxysms are always short, seldom extending to a
whole day ; the temperature is higher than in any other disease
of similar intensity, with similar absence of danger; 41°—41.5°
C.=105.8°—106.7° are common and passed by several tenths.
The apyrexise are also short, from a few hours to three days;
paroxysms and intermissions alternate with more or less regu¬
larity ; that is the feature, hence the name of that fever.
In the relapsing the paroxysm is less limited, the temperature
more variable, the intermissions longer, the relap>se or character¬
istic repetition happens once only or twice, and more rarely a
succession of times.
Malarial fever (ague) is the best example of the intermittent
type, whilst relapsing fever, " fev re d rechute" of the French, is
the best representative of the recurrent form. But many diseases
approximate, with more or less regularity, one or the other of
these types, especially pyaemia, erysipelas, true small-pox, many
cases of true pneumonia, and not unfrequently acute tubercu¬
losis, basilar meningitis, and acute phthisis.
Chronic diseases, aud those marked by hectic. are of long
duration, and their fever may persist for years, Their course,
seldom irregular, approaches some definite type, and may change
SIGNIFICANCE OF TEMPERATURE-CHANGES.
43
it for another in time. Their type is usually remittent, with
one or two daily exacerbations, some slight, some severe ; so
that the temperature reaches once or twice its maximum and
falls as many times to the normal or below it. There may .be
a tertian or other rhythm, characterized by intervals of days
left between the exacerbations. When complications come, or
death approaches, the remitting type often changes into a con¬
tinuous one, as in chronic inflammations of the lungs, chronic
ulcerations of the bowels, etc.
An elevated temperature (be its cause what it may) has by
itself an influence on the functions of the body, on the nutrition
of the tissues, and upon secretions. When it is only slightly
raised we cannot appreciate its action on the system ; but when
it is, and remains considerable, the most evident effect is a
diminution of the weight of the body; besides, the pulse and
respiration are accelerated, the brain exhibits functional disturb¬
ances, the secretions of the skin and the elimination of urea
increase, and there is a tendency to local congestions, fatty
degenerations, or even destruction of tissues. Yet these disor¬
ders do not elicit any proportion with that of the loss of caloric ;
and though the continuance of life is incompatible with certain
elevations of temperature, we know not why, unless heat is life
itself.
Very sudden alterations of temperature may influence the
functions; rapid rises, especially when the warmth of the
trunk considerably exceeds that of the extremities, are com¬
monly associated with rigors / with rapid falls, succeeding pre¬
vious height, then appear dyspnoea, delirium, signs of collapse,
etc.
Diseases which, instead of elevated temperatures, have abnor¬
mally low ones, never conform to rules as regards their pyro-
genic course; inanition, sclerema, cancer, chronic intoxication,
some mental d iseases, etc.
Exceedingly low temperatures are, however, frequent (but
intercurrent) in : the remissions of intermittent fever, in conse¬
quence of loss of blood or of powerful evacuations, in exces¬
sive defervescence, and sometimes in the death-struggle.
Abnormally low temperatures may disturb the functions, and
lower yet render the continuance of life impossible.
7 Let us now inquire into the causes of abnormality of the
body's heat.
CHAPTER VIII.
CAUSES OF ALTERED TEMPERATURE.
Theemometric observations show how narrow are the limits
between health and disease, and how imperceptibly one passes
into the other. Just so with the causes which determine the
alterations of temperature.
There are some influences which are nearly certain to produce
morbid changes of temperatures ; but one and the same influ¬
ence may induce very different, even opposite effects. The com¬
mon basis of the operations of these influences does not depend
so much on the increase or loss of heat, as on the imperfection
of its regulating power. This regulating power, or equilibrium-
factor, compensates the actions of the functions on which de¬
pends the temperature. Increased production of heat, or dim¬
inished loss of it, or increased giving off of warmth, or dimin¬
ished warmth-production, may act separately or together, in the
entire body, or in some part of it, to destroy the balance of tem¬
perature, or to simply hinder the action of the regulating power.
So, too, in sickness there is a plus and minus production and
evolution of heat, fresh sources of caloric unknown to the
healthy body, and besides there are new ways of getting rid of
heat. Among the new sources of heat-production are more
rapid destruction of the tissues by chemical process, the for¬
mation of abnormal products of the metamorphosis of the
tissues, and possibly the development of some fermentative ele¬
ment, as a new source of heat, as in zymotic diseases. Of the
modes of obstructing heat we mention, copious losses of fluids
and deposits of almost devitalized masses by exudation. For
even when the normal equilibrium is disturbed in disease, a sort
of abnormal one may be detected instead, ruling the apparent
anarchy. This increased heat quickens the movements of the
heart, which propels more blood to the surface, where it is
cooled. The same cause increases the need of breathing, by
CAUSES OF ALTERED TEMPERATURE.
4 5
which cool air is introduced in greater quantity, and by it the
temperature lowered, etc.
The primitive causes of altered temperature in disease are
the external influences, circumstances, or surroundings, the con¬
stitution of the individual, and the processes going on in the or¬
ganism itself. We are yet powerless to measure the action of
each of these causes on account of their intricacy ; but we are
already prepared to measure their sum total. The factors of
abnormal heat escape mensuration, their quotient is within our
reach by means of experiments, or by the artificial production
of morbid phenomena. However, the results of these experu
ments are highly interesting, but not always to be trusted, be¬
cause they are made on animals, whose range of normal tem¬
perature is larger than man's ; the rabbits, for instance. But
even were the experiments conducted 011 healthy men, we must
not forget that the results may not be the same in pathological
conditions, and indeed may differ from one disease to another.
It requires great attention and much thermometrical experi¬
ence to separate the effects of accidental circumstances upon the
temperature of the sick, from the effects of the progress of the
sickness itself, either in one of its periods, or towards its favor¬
able or fatal termination.
Thz depressors of temperature abstract heat from the body,
or increase the loss of heat, or hinder, or limitate the access of
warm blood to the parts under observation; and it is not easy to
find which, or how many, and .in what proportion these agents
are at work.
The experiences 011 elevated temperatures are more numerous
than on the depressed. Any elevation above the norme origin¬
ates either from an over-production, or from a diminished loss
of warmth, or from both combined; but in elevated tempera¬
tures the respective shares of these conditions is not easier to
determine than in diminished temperature.
Extreme degrees of external cold are the most certain means
of abstracting warmth from the body ; it may go so far as to
render death inevitable. The greatest depression arrived at in
rabbits before causing death was 9° C. = 48.2° F. Those cooled
down to 18° or 20° C. = 64.4° or 68° F. could not regain their
own temperature by being brought into a warmer medium, but
were restored by artificial respiration.
There is no proof that cold brings on diseases; but congela-
46
CAUSES OF ALTERED TEMPERATURE.
tion and its sequels do, as in Walter's rabbits. On the other
hand, the application of cold 011 febrile temperatures has proved
it one of the chief antipyretic and antiphlogistic remedies,
especially in typhus and exanthematic diseases. Cold drinks
and injections cool transiently; cold compresses and applica¬
tions, ice-bags and sitz-baths, act more durably, but little be¬
yond their locality; wet sheets, full baths, and douches cool
more generally and permanently. The benefits accruing from
cold applications in fever do not depend simply upon the sub¬
traction of an overplus of heat; the question is more compli¬
cated, and much is to be learned yet.
External temperatures above blood-heat, when long contin¬
ued, have a morbid influence, and cause that of the body to
rise. This latter fact is taken advantage of to restore a
body temperature sunken below the norme by warm applica¬
tions.
External irritants rather lower the temperature, mustard
does not elevate it, pains depress it (Mantegazza).
Considerable hypergemia (artificially produced) elevates the
temperature. The temperature of the head rises in animals
hung by their hind legs (Brown-Sequard). The ligature of an
artery, throwing more blood to a collateral part, increases its
temperature; conversely, narrowing or compressing a vessel
lessens the temperature of the parts where it ramifies.
Therapeutics turn to advantage this action of heat and cold
to increase or diminish the quantity of blood, as by local and
general blood-letting, position, compression, ligatures, large
cuppings (ventouses Junot), topical cold, heat, astringents, etc.
The temperature is at first lowered by copious haemorrhage
from the lungs, stomach, intestines, uterus, and general blood¬
letting ; but reaction soon follows, as remarked by Lorain,
Baunder, and others. Even the menstruation of the sick, often
preceded by a rise, is followed by a fall of temperature ; during
it variations are more marked, and the disease is often judged
by that crisis.
Deprivation of food lowers the temperature, a fact taken
advantage of in therapeutics; but its effects, especially 011 the
sick, are complex. (See Chossat, Mem. cle VAcademie des
Sciences, viii., p. 43S ; 1842. Schmidt, Lichtenfels, and Froli-
lich.)
The introduction of nutritious substances, which does not
CAUSES OF ALTERED TEMPERATURE.
47
affect the temperature of the healthy, elevates that of the sick
or convalescent 2° C. = 3.6° F. for a few clays.
Constipation, retention of urine, and suppression of the cata-
rnenia raise the temperature; very relaxed motions lower it,
particularly when induced by purgatives. Vomiting depresses
it more yet, even to the point of collapse.
The lowering of the temperature by alcohol is with the sick
the same as with the healthy, only more marked. Poisonous
doses of it depress considerably ; cases have recovered in the
London Hospital, after a fall to 32.2° C. = 90° F. The ingestion
of alcohol diminishes or retards the tissue-changes. Though
usually followed by a reaction, the effect of alcohol in fever is
to lower the temperature. Habitual soakers have, as a rule, a
lower temperature than the average patients, and fall more
easily into collapse, though a high temperature is often met
with at the termination of fatal cases of delirium tremens.
Other more or less poisonous substances depress the tempera¬
ture—ether, chloroform, chloral-hydrate, opium, hydrocyanic
acid, hyosciamus, digitalis, belladonna, tobacco, euphorbium,
camphor, acetic, oxalic, sulphuric, nitric, and hydrochloric
acids ; the mineral acids altogether, and saline purgatives also.
The raising of the temperature is one of the effects of the
toxic incorporation (in health or disease) of many substances, as
coffee, musk, curare; it follows, too, the subcutaneous intro¬
duction of certain animal substances, like pus, or the blood of
other animals suffering from fever of any kind (Deniarquay,
Billroth). This depends not on the fibrin, since beating and
filtering do not change the result; nor on the pus-corpuscles,
but upon the serum of the fluids, which keep this toxic prop¬
erty even when boiled and filtered. The maximum of temper¬
ature thus incited is obtained in two or three hours, the return
to the normal in three to six (Freze); and E. Bergmann, who
made other observations of the same kind, says that subcuta¬
neous injections of large quantities of water, or smaller of irri¬
tative substances, produce very similar alterations of tempera¬
ture to those noted by Freze.
The specific morbid processes, like septicaemia and pya?mia,
resemble the pyrogenic action of animal substances introduced
into the system; but most of them are imperfectly understood.
Andral states that when the blood contains more than T/0-¥ of
fibrin the temperature rises in a corresponding ratio; thus
48
CAUSES OF ALTERED TEMPERATURE.
pneumonia, being noted for its great increase of fibrin, presents
the highest temperature of all the phlegmasia, from 39°C.=
102.2° F. to 41.2° C. = 106.16° F. But in acute pleurisy there
is less fibrin, and the maximum temperature averages 39.5° C.
= 103.1° F. Though he does not consider an excess of fibrin
as the only cause of abnormal rise of temperature; for in
pyrexia (where there is no such excess), the temperature is as
high or higher than in phlegmasia. Thus 42.4° C. = 108.32°
F. has been reached in typhoid, 42° C.=107.6° F. in the onset
of small-pox, in the hot stage of ague, in glanders, etc.; indeed,
the highest degrees appear in diseases where there is the least
fibrin in the blood. The number of red globules does not much
affect it. The escape of albumen in the urine may lower it,
but facts are wanted. The amount of urea in urine is a good
test of fever; 10 to 15 per 1,000 are considered normal by
Andral, who found in 53 patients whose temperature was
normal, TVVo average of urea; in 45, with non-febrile dis¬
eases, from 4 to 12 per 1,000; but in 23 cases of intermit¬
tent fever the urea ranged 13 to 32 per 1,000 (W. B. Wood¬
man)
The influence of the nervous system upon temperature has
been the object of extensive researches, the most important to
be summed up here.
In his Exjyerimental Researches (page 9, Phila., 1853), Brown-
Sequard expressed the opinion that the increased warmth fol¬
lowing the section of the cervical sympathetic ought to be
attributed only to a paralytic dilatation of the cephalic blood¬
vessels, and to the consequent larger amount of blood flowing
in the parts. On the increase of animal heat after injuries of
the nervous system his conclusions are: An injury to the
nervous system may cause either an increased or a diminished
temperature in the parts which are paralyzed by it. It appears
that the respective shares of the sympathetic and cerebro-spinal
nervous system, in producing these, cannot wrell be determined.
The degree of temperature of paralyzed parts depends on the
quantity of blood which they contain, and this quantity varies
with the condition of the arteries and capillaries of the parts.
It is a matter of fact, hitherto unexplained, that the arteries
and capillaries of paralyzed parts may be either dilated, normal,
or contracted.
Becquerel and Brechet found out in 1841 a remarkable de-
CAUSES OF ALTERED TEMPERATURE. 49
pression of temperature in animals whose body-surface was
covered with an impermeable coating.
Budge (Comjptes Rendus, xxxvi. 377) has shown that this
elevation of temperature is not produced by the division of the
sympathetic, but that injuries of the parts of the spinal marrow
which lay between the seventh cervical and the first and second
dorsal have the same effect on the temperature of the head.
Waller (in p. 378) attributes the rise simply to the paralysis of
the circular fibres of the smaller arteries, and to the hyperemia
thus induced, caused by the section of nerve. De JRuyter (De
Actione, art. Belladonna*,) explains this phenomena by a larger
accession of blood in the parts.
Schiff observed that difference of the temperature of the two
sides of the head (taken at the ear) may amount to 12°-16° C.;
that this difference then, was proportionate to the difference in
the quantity of blood in the parts; and that when (as exception¬
ally occurs) the section of the cervical sympathetic has no effect
on the vessels of the ear, there is also no elevation of tempera¬
ture ; seeking to prove that the increased fulness of the vessels
depends upon paralysis of the blood-vessels; and that the
larger the quantity of blood, the higher is the temperature. He
holds that, in complete spinal paralysis of a part, the tempera¬
ture of this part must be elevated; but that in incomplete
(paralysis of motion only), the temperature must be diminished ;
conclusions which have since been partially confirmed by patho¬
logical facts.
Later, Schiff excited fever by injections of pus into the
pleura, or into the vascular system after dividing the left cer¬
vical sympathetic, or resecting the nerves of one extremity. As
soon as the fever set in, the parts unaffected by the section rose
in temperature, whilst those affected with vaso-motor paralysis
(though previously warmer) rose slowly or not at all; and
finally the former remained warmer than the latter: hence he
concluded that the hyperemia induced by nerve-section and by
fever are of a different nature, the latter being the more active
of the two.
Kussmaul and Tenner strengthened the doctrine which attrib¬
utes the thermal phenomena to the amount of blood, by con¬
stantly reducing the increased warmth of the ear on which the
sympathetic was divided, below that of the other ear, and even
lower than its own temperature, before the section, as soon as
4
50
CAUSES OF ALTERED TEMPERATURE.
(in addition to ligaturing or compressing the carotid on the
same side) thej also ligatured the two subclavians at their
origin, to prevent collateral circulation.
Brown-Sequard then discovered that complete division of
one lateral half of the spinal cord in the dorsal region was fol¬
lowed by a rise of temperature in the hinder extremity of the
corresponding side, and by a fall of temperature in the opposite
limb. Scliiff confirmed this, but attributed the fall to an acci¬
dental injury made to the other half of the cord.
Tscheschichin, after complete section of the cord in a variety
of parts, always observed a suppression of the active operations
of the vessels and a sinking of the general temperature, in ad¬
dition to the loss of voluntary movements (1866). But when
he divided the medulla oblongata in a rabbit, near to its junc¬
tion with the pons, the temperature began to rise, the pulse and
respiration greatly quickened. After half an hour the tempe¬
rature was 39.4°—40.1° C. = 102.92°—104.18° F.; after an hour,
41.2° C. = 106.16° F.; after one hour and a half, 42.2° C.=
107.96° F.; after two hours, 42.6° C. = 108.68° F. More
rapid breathing and convulsions set in; death half an hour
later.
The pathological conditions analogous to the results of the
former experiments are—the local alteration of temperature in
neuralgias; observations of temperature in paralyzed parts;
observations of variation of temperature in those forms of dis¬
ease which are considered as vaso-motor neuroses; the effect of
mental exertion or excitement in elevating the temperature,
and of sleep in lowering it in fever; the great elevation of tem¬
perature in acute inflammation of the brain; the more enor¬
mous elevation in injuries destructive of the spinal cord ; the
very disproportionate rise of temperature at the end of tetanus
and other fatal neuroses.
These facts favor the theory that a large share in the regu¬
lation of heat belongs, at least in complex cases, to the nervous
system. The influence of certain nerve-tracks on the activity
of the heart and on the circulation is indubitable ; many of the
pathological phenomena of warmth depend on the action of the
vaso-motor nerves; the most remarkable alterations of tempe¬
rature occur with profound disturbances of the nervous system,
without corresponding anomalies of the circulation ; and the
integrity of certain parts of the nervous central apparatus is
CAUSES OF ALTERED TEMPERATURE.
51
more necessary for the regulation of animal heat, than that of
any other part of the body.
Muscular exertions, as we said, cause a notable rise of tem¬
perature in cases where there is any previously existing morbid
condition, however slight. On this account we are quite justi¬
fied in feeling anxiety about the health of any one whose tem¬
perature exceeds the norme after only moderate exercise, how¬
ever cheerful and apparently well he may seem in other re¬
spects.
During convalescence, temperature rises one or more degrees
Cent. The first sitting up does the same ; and the removal of
a sick person so much more, that the first observation of tem¬
perature after the admission of a patient to a hospital, or after
a journey, is not trustworthy.
This large enumeration of the influences which affect the
temperature is not exhaustive. Many have been omitted as
due to complications, others to phenomena known to exist, but
not yet scientifically demonstrated, such as a process of fermen¬
tation of the blood, or chemical changes affecting the produc¬
tion of warmth, etc. The individual circumstances and sur¬
roundings, idiosyncrasies, etc., have also been left out.
A word about age to close :—
In children the temperature in disease is extremely mobile
and sensitive, its extremes greater. Women resemble children
in this respect; their temperature springs up or down without
apparent causes, especially if they are hysterical; this mobility
is found also among nervous men; those more advanced in
years present more steady temperature with less susceptibility
to impressions ; old people present a temperature .5° C. = .9° F.
less than younger persons. But this finding is so often attend¬
ed by the effects of accessory diseases and of infirmities on the
same function, that the safer way is to assert no rule till we
know more about it.
Finally, the repetition of certain influences augments the sen¬
sibility of the temperature in some persons or cases, and weakens
or blunts it in others.
CHAPTER IX.
LOCAL ALTERATIONS OF TEMPERATURE IN DISEASES.
Tiif. sickly variations of temperature are general or local.
This antithesis is not absolute, but relative; since any consider¬
able local alteration of temperature can hardly fail to be pro¬
pagated to the rest of the body in certain proportion, through
the circulation. On the other hand, a general rise of tempera¬
ture is never so uniform as not to leave some parts cooler than
others. But the two alterations are, nevertheless, distinct, and
demand a separate attention.
In health, different parts have different temperatures ; in
disease, these differences are more marked.
Local elevations of temperature have been observed in inflam¬
mations, first by John Hunter, since by Brechet. John Simon
found (Holmes' ' System of Surgery, art. Inflammation,' vol. i.,
p. 43), and O. Weber verified, that the arterial blood supplied
to an inflamed limb is less warm than the focus of the inflamma¬
tion itself; 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 limb. And that the
venous blood returning from an inflamed limb is warmer than
the corresponding current on the opposite side of the body.
There is no trustworthy observation of a rise of temperature
through simple hypersemia (Billroth) ; there is an appearance
of rise in exanthemata (Barensprung); in neuralgia and local
cramps the skin of the affected parts is somewhat hotter. As
regards paralysis, Folet (in Gazette Hebdom1867) gives the fol¬
lowing conclusions from his long observations on hemiplegia
patients :
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 alike, and a di-
LOCAL ALTERATIONS OF TEMPERATURE.
53
minished temperature on the diseased side is hardly ever
noticed. The rise of temperature varies between .3° and .9°
C.. = 54°—1.62° F.; but seldom exceeds 1° C. = 1.8° F.
The presence or absence of contractures has no influence on the
tliermometric results. The thermometric difference may be
greatly augmented by various causes. But the original cause
of hemiplegia lias no effect upon the result. Recovery from
the paralysis tends to equalize the temperature again: if the
paralysis continue, the height of the temperature varies greatly,
and in one case may return to the normal in a few months; in
others it may continue unequal for years together. Undoubt¬
edly paralytic atrophy necessitates depression of temperature.
In an old hemiplegia, when the affected side exhibits a high
temperature, and the other side becomes paralyzed at a later
date, either the two sides become equalized in temperature, or
the side last paralyzed now becomes considerably hotter. The
general temperature of hemiplegic patients is not usually above
the normal, but exhibits an average height of 37° C. = 98.6 F.,
except in the last hours of life, when it generally rises.
The results of Lepine's observations on hemiplegia show
smaller fluctuations of temperature than in health, either up¬
ward or downward, under external thermal influences. In re¬
cent hemiplegia, the paralyzed limb exposed to cold loses more
heat at first, less wThen the cold increases. In verj' old cases
the paralyzed limb appears colder than the other, but remains
relatively warmer. When exposed to heat again, it becomes
less warm than the second one, exhibiting less sensibility to
both heat and cold.
A girl, aged 18, presented during almost a year the following
symptoms :—An increased temperature all over one-half of the
body, connected apparently with spinal hysteria; higher tem¬
perature on the skin than in the vagina by .2°—.5° C.; and in
the right axilla and groin more than in the left by 1.5° C.=
2.7° F. There were at times right-sided hj^peraemias, urticoid
eruptions, local sweatings, and various troubles in the internal
organs.
Fig. 1 gives the traces of the movements of her temperature
on both sides during three weeks. ITere was evidently an affec¬
tion of the vaso-motor nervous system, which acted on one side
more than on the other.
In the same region, the deeper the observation, the higher
54:
LOCAL ALTERATIONS OF TEMPERATURE.
the temperature. In the urethra J. Hunter found it one inch
deep 33.33°; two inches, 33.89°; at the level of the bulb, 30.11°;
same increase in the rectum, etc.
Fig. 1.
miiiigiaiiiiii
IMS!
HI|iS||ii«SS!!!
iliiiiiSRIIlim
iKsani
SlllllliSiligfll
SllllllliiiiSHI
HIIIIIISIEs
IHIIIMiSiii!!;
■I llliaiEiSI
BHIIIHilPiia
illlllltisisllll
Illlllligiiiiai
llllllSIIRilllll
EllllllSiUIIIII
a«—isiamm
SiSSiillillUI II
Local temperatures in general and surface temperatures in
particular differ much; a difference which may be accounted
for, not only by regional susceptibility to frigeration from out¬
side influences, but by the cooling of the blood as it readies the
extremities (see Appendix IX.). Thus, the nearer the heart,
the hotter the region. Yet the arterial blood is hotter than the
LOCAL ALTERATIONS OF TEMPERATURE. 55
venous in the limbs, and the venous hotter than the arterial in
the viscera, according to CI. Bernard, who found it warmer in
the hepatic veins than in the hepatic arteries, and .6° higher
when coming from the liver than when running through the
aorta.
Pathological temperatures may be circumscribed to a part of
the body, or to a single organ, or locality in it; or they may com¬
municate their hyperpyrexy in variable degrees to the general
temperature by propagation, or by the general circulation.
The proofs of higher local temperatures abound : In two cases
of stomatitis, Roger found 37.75° and 38° in the mouth, with
37.5° in the axilla. In phlebitis of the right femoral, the ther¬
mometer marked 38.5°; on the other side only 36.5°; in the
inflamed tissues which encircle gangrene 1°—>2° more than on its
central surface (Alvarenga and others).
The most striking examples of peripheric frigeration with
central hyperpyrexy are met with in intermittent and cholera.
But local anomalies of local temperature are too many and
varied even for enumeration, and we pass to the alterations of
general temperature which are the most frequent and important
phenomena met with in clinical thermometry.
CHAPTER X.
TYPICAL ALTERATIONS OF GENERAL TEMPERATURE.
In many diseased conditions the anomalies of temperature
consist solely in its increased mobility. This extreme mobility
is met with, not only in definite diseases, hut also where we can
recognize but slight disturbance of the general health—chronic,
limited, or transitory.
We often meet with cases in which the temperature of a
patient remains a little above the normal, either persistently or
in the form of nightly rise. In addition, there may be the increased
mobility above mentioned, besides isolated and apparently cause¬
less elevations of temperature. This is seen in obscure disturb¬
ances, in incipient phthisis (S. Ringer), in convalescence (especi¬
ally from articular rheumatism), and in the decline of diseases.
We meet more rarely with the descending type of temperature,
in which the thermometer remains below the norme, or shows
only rare intercurrent elevations. This form is seen in inanition,
marasmus, cancer, diabetes, extreme anaemia, rarely in phthisis;
in mental depression, lypemania, chronic and declining diseases.
The affections whose alterations of temperature assume a
definite and characteristic type come next in order. Their types
are: the rigors, chills (fieberfrost), cold stage of fever, fever-
heats, hot stage of fever, pyrexia, collapse. These alterations of
temperature are not the sole characteristics of these pathological
processes, but simply those which we will study here.
During the rigor the temperature of the body is about 40°
C. = 104r° F., even more ; but the extremities are cold, bluish, or
pale, and affected by automatic movements, accompanied with
thirst, watery urine, etc. The rigor occurs at the beginning of
the fever, or is an incident of it; but generally the excess of
temperature precedes the rigor (see Fig. 2), at first in the body,
TYPICAL ALTERATIONS OF TEMPERATURE. 57
and subsequently reaches the extremities. This is the typical
cold stage, from which there are deviations and attenuations, and
which tinds its analogue in the shivering of nervous people in
some forms of intoxication, etc.
Fi£. 2.
ae c\>
^ *
im- 40
103-1 39*5
102 2 3 (J
l01-3\38-5
M-4-\3 8
995 3J-J
9$6 3 J
mmmm
wmmm
riBHB
■■■BBSSp™
IIKMI
iimraun
hSRHSBSSS
■«i»9IH ■■■
mi
Rigors occur, also, with a falling temperature, or in the midst
of an elevated one, or when it rises 2° to 3° 0. rapidly from a
very low point, say 35° C. = 95° F. This and the absence of rigor
in many instances of elevated or falling temperature, shows that
we must look for the cause of the Jieberfrost in the suddenness
of the difference of temperature between the periphery and the
viscera, or the extremities and the trunk.
Pyrexia (Fieberhitze, or fever-heat) may follow rigor, or may
start from a normal point, as in the ephemeral fevers of con¬
valescents. Discomfort, thirst, and other subjective feelings,
may be absent; but oftener they are present, and with them are
found alterations of the pulse, of the urinary secretions, of the
breathing, etc. Indeed, there is no necessary parallelism between
the height of the temperature and the kind and degree of the
other phenomena ; and though this may lead to the theoretical
belief that temperature is a deceptive guide, practically the
reverse is empirically true.
During pyrexia some parts may be warmer than others; and
5S TYPICAL ALTERATIONS OF TEMPERATURE.
by this we mean not only the body, but the head, or ears, or
palms of the hands, etc.; the height of temperature may vary
greatly, or become excessive. Perspiration abates this, some¬
times below the normal point. A tremendous increase of heat
often precedes death.
Collapse occurs by itself in the middle of pyrexia, in the
sequel of fevers, rarely during rigors, which it somewhat resem¬
bles. Not a disease itself, unexplainable by pathological
anatomy, it is the shortest and last act of the drama of life.
When slight, it does not modify the appearance of the patient;
growing worse, it substitutes for free circulation and breathing
a cold perspiration, and annihilates the signs of vitality ; it
occurs after loss of blood, perforation of serous membranes, or
chronic diseases ; is most severe and protracted in Asiatic
cholera. In chronic diseases collapse may be transient, prolonged,
or repeated.
Cases of collapse with a falling temperature in the trunk are
those most commonly met with in febrile diseases, and they
require to be watched with the most painstaking care. The
previously more or less high temperature sinks to the normal
and often considerably below 35°—37° C.=95°—98.6° F. The
fall is usually sudden, in a few hours or less. The descent may
amount in half a day to 6°—8° C. = 10.8°—14.4° F., or more.
Cases of collapse may last a few hours only, or several days,
through rises and falls, and the patient dies in it.
The collapse in which the temperature of the trunk falls
occurs during the stage of defervescence, mostly in pneumonia,
also in acute exanthems, etc. ; then the condition may look criti¬
cal and yet be quite devoid of danger; during the remission of
fevers, oftener the typhoid ; in the transition stage from inter¬
mittent fever to an apyretic condition, especially in pernicious
malarial fevers and in pyaemia; during rigors in pernicious
malarial fevers, in other severe diseases, and in very delicate
and susceptible individuals; in incidental perturbations caused
by blood-letting, vomiting copious evacuations, extreme nausea,
pains, exudations, perforation of pleura or peritoneum, and the
formation of coagula in the heart; in many kinds of intoxi¬
cation and in the cold stage of cholera; in the pro-agonic period,
and in the death-agony.
Cases of collapse with elevated temperature of the trunk are
scarcely to be met with except in severe forms of fevers ; and it
TYPICAL ALTERATIONS OF TEMPERATURE.
59
appears as if a very elevated temperature directly predisposes
to such collapse.
Comparison between these three forms of constitutional dis¬
turbance—fever-frost, fever-heat, and collapse—shows that the
temperature may be above the norme in all; always high in
pyrexia, highest in febrile rigors, generally above normal in col¬
lapse. No distinction, therefore, can be drawn between these
forms from the mere height of the temperature. Normal and
subnormal temperatures often occur in collapse, but exceptionally
in case of incomplete rigors. The extremities are always cold
in collapse, generally in rigors. A rapid rise at the trunk, with
cold extremities, is associated with rigors; a rapid fall at the
trunk accompanies collapse. The recurrence of warmth in a
particular part, when that of the trunk remains high, is peculiar
to collapse.
We are met by insuperable difficulties when we try to ex¬
plain theoretically the true meaning of all these varieties of
temperature. Previous attempts at explanation had in view the
theory of fevers, and ignored the condition of collapse itself.
But even as regards attempts to explain fever, temperature
alone does not do it, complex organic phenomena cannot be
solved by one simple formula. Those of Virchow, in his
Hand-book of Pathology, etc., Zimmerman, CI. Bernard,
Schiff, Traube, Marey, Auerbach, Wachsmuth, Billroth, O. We¬
ber, Senator, etc., though one-sided, throw light 011 the subject
but fail to explain, ' On what does the abnormal temperature
depend f Fever remains, after all has been said, a complex
assemblage of varied phenomena, of which one of the most
important is the alteration of temperature, though all the others
cannot be explained by it.
Of all the symptoms, the course of the temperature must be
studied first. Its principal alterations are : A general rise of
temperature (all over the body), an increase of temperature in
the greater part of the body, a general diminution of tempera¬
ture all over the body.
An increase of temperature all over the body (an ordinary
phenomenon at the beginning of a fever) is determined by a de¬
ficient abstraction of warmth, itself attributable to a variety of
causes ; from a pathological focus of warmth-production, the
ustion is communicated to the entire body through the circula¬
tion ; an abnormal activity in the modes of production of heat
60
TYPICAL ALTERATIONS OF TEMPERATURE.
may cause a general elevation of temperature, if the means of
giving it off are not adequate. A general elevation of temper¬
ature may also occur through pathological chemical processes,
as an increased combustion of hydrogen in fevers, or a sudden
diffused organic decomposition producing caloric, or an over¬
production of heat by extreme muscular contractions towards a
fatal termination, or new combinations of elements putrescent
or fermentable, not demonstrated yet, but probable, such as
could be produced by the transfusion of fever-blood, or of the
ferments advocated by the zymotic theory. Alterations in the
degree of activity of the vaso-motor nerves can, if extensive
and persistent, influence the temperature in several ways. Ele¬
vation of temperature may occur in consequence of a morbidly
increased action of the spinal centres. At times the above
causes combine or succeed each other so as to render difficult a
judgment upon their respective influence.
And lastly, the same temperature may indicate a very differ¬
ent quantity of over-production of heat, according as the amount
given off is diminished, normal, or increased. Here are present
opposite constitutional disturbances, since, in long-continued
high temperatures, urea may be in excess, and the body lose a
great deal of weight; or the latter may waste but little, and
furnish few products of tissue-change.
An elevated temperature which extends over the greaten"
part T>f the body, whilst that of other parts is lowered, may
arise from an unequal distribution of the heat produced in the
body, or from an unequal cooling through the surfaces, in con¬
trast to the continual increase of internal production of warmth ;
oftener from unequal fulness of the blood-vessels. But it may
come from a variety of causes : a patient in rigor and another
in collapse feel very differently, notwithstanding the fact that
the contrast between the temperature of the trunk and that of
the extremities is identical in both.
A lowering of the temperature all over the body can only be
induced by diminished warmth-production, increased loss of
heat, or both these conditions together. It may occur after pre¬
vious normal, low, or high temperature. In the latter case the
fall may not be so low as 98.6° F., and yet have the same im¬
port as if it had fallen under the norme. It is difficult to as¬
sign the respective share of diminished production or of in¬
creased loss of warmth, in a fall of temperature ; it is easier to
TYPICAL ALTERATIONS OF TEMPERATURE.
61
detect its causes either by its mode of progression, or from the
action upon it of some remedies.
The remaining phenomena of rigor, pyrexia, and collapse
may be attributed to the altered temperature itself, but react
upon the temperature in their turn ; for instance, an increased
temperature affects the movements of the heart and respiratory
organs, but an altered rhythm and force of the heart, and
changes in the respiration, affect the temperature: this shows
the interdependence of organic operations, whose combinations
would defy human reason, were it not that disease itself has its
laws, which we can discover by laborious observation, though
we cannot yet codify them.
Thus a rigor is a complex commencement of a series of phe¬
nomena, rarely a process complete in itself. It is most sure to
come when the temperature of the trunk rises so rapidly that
the extremities are left in the cold behind. But this condition
is not inseparable from a rigor, nor a rigor from it; since rigor
may be absent, in febrient persons not very impressible, or after
the use of quinine, though it will not prevent the hot stage, etc.
In A ery sensitive people a slight contrast of temperature will
bring it, even in health.
Pyrexia is an effort of the warmth-producing and warmth
exhaling powers to restore their equilibrium. It is preceded by
rigor when strong, and without rigor when gradually brought
about. ^
Collapse may occur as a primary phenomenon, or an episode
in a short pyrexia, or at the close of a fatal disease. The pri¬
mary depends on some nervous trouble, and is accompanied
with great loss of heat and profuse perspiration. The episodic
may be due to special influences, or to circumstances of the dis¬
ease, by which are caused great and uncompensated loss of heat,
particularly at the periphery. The pro-lethal may be due to
similar causes besides an absolute deficiency in the production
of heat. Collapse, during the transition from disease to health,
occurs when from the height of an elevated temperature a rapid
fall sets in. The favorable issue of this crisis at the end of a
sickness is due to the restoration of the power of producing a
normal instead of a morbid warmth.
CHAPTER XI.
DIAGNOSTIC VALUE OF A SINGLE THERMOMETRY OBSERVA¬
TION.
A single observation of temperature is always an imperfect
and unsatisfactory standard ; it may have been taken at an im¬
portant or insignificant or deceitful moment. However, a de¬
tached observation is worth taking, because it may decide if a
person is healthy or ill, or feigning a disease ; it gives an idea of
the severity and urgency of a sudden disorder supervening on
another ; it assists in diagnosing one kind of disease and exclud¬
ing others. Corroborated by other symptoms and circum¬
stances, it may be the basis of diagnosis and prognosis ; the di¬
vergence of a single temperature from the general course may
be valuable ; each observation of a series must be considered in
some respects as a single one ; the conclusions derived from a
single observation are valuable in proportion to its thoroughness ;
greater accuracy in recording the temperature is needed to ren¬
der valuable a single observation than a series, where a difference
of .2° C = .36 F. is of no consequence, or at least will not affect
the practical value of the conclusions.
With few exceptions the range of human temperatures (healthy
and sickly) is 8° C. = 15° F. Its minimum, more difficult to as¬
certain than the upper degrees beginning with 35° C. = 95° F.,
rarely descends to 33° C. = 9.14° F. Surface temperature in
cholera has indeed been observed as low as 26°C.=78.8° F.;
but how much higher in the vagina or rectum? Roger observed
32°—22° C. in sclerema.
The highest maxima recorded in the first edition of this book
were by Currie in scarlatina, 45° C., and by Wunderlich in teta¬
nus, 44.75° C. —112.55° F.; now we must record from the Lancet,
50° C. = 122° F. in spinal affection. After death the temperature
may rise higher, as it did in the case of Wunderlich, where fifty-
five minutes after death it mounted to 45.375° C. = 113.075° F.
VALUE OF A SINGLE OBSERVATION.
63
But even temperatures of 42.5°—43.5° C. = 108.5°=110.3° F. are
exceptional. The high temperatures met in even fatal diseases
do not commonly exceed 41.5° C.= 106.7° F. Narrow as seems
to be this range, its included degrees are full of meaning for
those who know how to draw conclusions from them.
Axillary temperature less than 38° C.— 30.4°R = 100.4° F.
proves actual absence of fever (apyretic). The nearer to that
point, the closer and oftener we must look ; since, thence to fever
there is no line of demarcation, circumstances will often decide ;
as when the highest temperature arises in the morning before
the stimulation of food or exertion, etc., fever is more probable.
All temperatures which exceed 38° C.-—100.4° F. are suspi¬
cious, probably febrile; 38.4° C. = 101.1p F., mildly febrile; any¬
thing above, decidedly febrile. Then to determine whether the
fever is moderate, considerable, or extreme, we must consider
the time of the day at which the temperature was taken; the
same temperatures being important or insignificant as they
occur at the usual time of rise and fall, or otherwise.
Some temperatures exceed considerably those common in
high fevers. They occur in circumstances where there is no
corresponding development of fever. Either the other usual
symptoms of fever are wanting, or they are not developed in a
corresponding degree to the extraordinary rise of the temper¬
ature ; hence the latter is called hyperjpyretic.
When the temperature exceeds 41° C.= 105.8° F., we may
suspect the case not to be one of simple fever ; if it rises higher,
say above 41.5° C. = 106.7° F., this suspicion becomes almost a
certainty. The circumstances producing such high temperatures
are varied. They occur in some specific forms, doubtless in¬
fectious, as malarious or intermittent, where temperature may
rise more than once to 4L°C. = 105.8° F., or in relapsing fever
above 42° C. = 107.6° F., without being fatal. In diseases of a
favorable type, terminating in recovery, 41° C. = 105.8° F. is
more exceptional, of shorter duration, and sometimes precedes
the crisis. There are diseases whose chief character is malig¬
nancy. Some are specific and infectious, others are suspected
of it, in which high temperatures are met with. The question
remains an open one whether the excess of temperature causes
the malignancy or the reverse? Typhus, scarlatina, measles,
pyemia, parenchymatous hepatitis, malignant pneumonia, puer¬
peral fever, meningitis of the convexity, and fatal rheumatic
64 VALUE OF A SINGLE OBSERVATION.
affections, present these sudden elevations of temperature ; tliey
last but a few days, but at 41.5° C. = 106.7° F. the prospect of re¬
covery is small; at 41.75° C. = 107.15° F. death is almost certain.
During the last hours of life temperature sometimes rises
enormously, often by a sudden spring to 41°—42.50°—44° C.=
105.8°—108.5°—111.2° F. It is so in tetanus, epilepsy, and hys¬
teria, near a fatal termination, in inflammations of the brain
and medulla spinalis, injuries to the upper part of the medulla,
and in other cases where there had been no previous evidence
of the nervous centres being implicated.
Collapse temperatures are not identical with collapse; for
they may happen without it, and collapse may happen with an
elevated temperature of the trunk.
The absolute height of a given temperature, without its ante¬
cedents, can mislead in diagnosis and prognosis. Thus isolated
the highest only portends danger, with this limitation : higher
temperatures are borne in typhus and typhoid fever than in
pneumonia, in scarlet fever than in measles, in relapsing fever
than in any other; there 42° C. = 107.6° F. being almost free
from peril. The highest temperature in a case of recovery
was 43.6° C.= 112.5° F., the case of sunstroke reported from
Bellevue Hospital by Dr. Atzembach ; 43.3° C. = 110° F., the
case of rheumatism of Wilson Fox. 43.3° C. = 109.94° F. was
noted by Mader of Vienna, in a soldier suffering from irregular
intermittent, repeated haemorrhages, deafness, etc.; transfusion
saved him; one case of sunstroke at 42.8° C. = 109.4° F., and
two of relapsing fever at 42.2° C. = 107.96° F. recovered ; since
came in February last the case of 50° C. = 122° F. recorded in
Chapter XX., § 11.
It is not easier to assign the limits of the temperature down¬
ward. The lowest among the cases of recovery of Wunderlich
wTas 33.5° C. = 26.8° R.=:92.30 F., pulse 62 (collapse of defer¬
vescence in enteric fever). Roger does not record any cure of
children below 32.5° C. = 90.5° F. (axillary temperature), and
24° C. in the mouth (an uncertain locality in cholera). In all
less extreme degrees of temperature attention must be paid to
idiosyncrasy.
In children the significance of temperature is in the main
identified with that of adults; but their changes are more sud¬
den and extensive ; consisting in more sudden plunges, earlier
rises, and a somewhat higher temperature throughout. They
VALUE OF A SINGLE OBSERVATION.
65
are affected more and quicker by incidental influences ; so that
a high febrile temperature in a child, unless from malarious
origin, has not the same import as in adults, where it would
almost warrant a fatal prognosis; but it must be watched more
closely, since it ends sooner, either way, in twelve or twenty-
four hours. Ephemeral fevers are very characteristic of child¬
hood ; therefore we must not draw conclusions from the first or
a single observation. We find their temperatures high in cases
where those of adults are almost normal, particularly in con¬
valescence, after muscular exertions, etc.
On the other hand, old people, everything but age being-
equal, show in sickness a fall from .5°—1° C. = .9—1.80° F.
under the average, even below the minimum of younger people;
this fall commences sometimes rather early, since between
forty and fifty the majority of men begin to exhibit this senile
character: so constant is it that in a given disease it will aid in
determining the age of a patient. On the other hand, this
physiological age of the temperature may lead to mistakes, for
which see Charcot, De VEtat Febrile chez les Vieillards (Nos.
69 and 71 of the Gazette des Hdjpitaux, 1866), and Bergeron,
Rechei'ches sur la Pneumonie des Vieillards.
Many women, and delicate, effeminate men, exhibit a similar
course of temperature to that of children; let us judge them
by the same standard.
The time of the day at which temperature is taken has a di¬
agnostic value. In the period of digestion it rises more in the
sick than in healthy people ; this and other incidental influences
must be taken into account, particularly in a solitary observa¬
tion. Therefore, before drawing conclusions from a single
thermometric reading we must notice the circumstances and the
other symptoms, and consider whether they agree or contrast
with the temperature, and see how many-sided are those symp¬
toms and their relations. The temperature itself may be altered
by an accessory disease of some organ, which itself modifies the
other symptoms ; or the altered temperature, and other symp¬
toms, may result from a definite primary cause, infection, in¬
toxication, or external morbific agencies, etc.
High and pi'otracted alterations of temperature produce
functional disturbances and even alterations of tissues; they
lay the foundation of diseases of the circulatory, respiratory,
secretin0-, and nutritive systems, and of the nervous functions
& 5
66 VALUE OF A SINGLE OBSERVATION.
generally. However, there is no exact parallelism between the
high or low temperature and the gravity of the accompanying
special symptoms; and we know empirically that, in particu¬
lar, the gravest nervous symptoms do not coincide with the
actual height, but oftener with the most versatile changes of
the temperature.
If the temperature harmonizes with the other symptoms and
the diagnosis deduced from them, it is an additional, and often
decisive confirmation of the latter. But if the temperature
contrasts with the other symptoms, we must rely more on tem¬
perature ; but if it is less marked than they, we ought to repeat
our thermometric observation, and make inquiries as to the
type or stage of the disease which may cause the discrepancy.
Then the discrepancy itself will be explained, either by the
slight type of the disease, or by its advanced stage, or by some
marked development, or by the initiation of collapse, etc.
If the heat is normal or slightly abnormal, and the subjective
symptoms strongly expressed, we have reason to suspect stimu¬
lation or exaggeration, and to hunt it down ; but if the expres¬
sion of subjective feelings is very indifferent, and the tempera¬
ture high, we have reason to suspect and to search for a severe
.and extensive disease, as typhus, etc. Otherwise, at the very
moment of a favorable crisis, miserable feelings may concur
with normal or subnormal temperatures: a form of deferves¬
cence verging on collapse, not to be overlooked.
Relations of ustion to circulation, respiration, etc. There
is often a contrast between the temperature and the frequency
of the pulse • though, as a rule, slight febrile heat coincides
with a pulse of 80°—90°; moderate fever with 90°—108°; con¬
siderable fever with 108°—120°; extreme heat with 120° and
upward per minute.
According to Aitken, in Science and Practice of Medicine,
an increase of one degree F. above 98° corresponds with an in¬
crease of ten beats of the pulse per minute, as below:—
t
Fahr.
Cent.
Corr'g pulse.
Fahr.
Cent.
Corr'g pulse.
98
36.6...
60
103
39.5...
99
70
104
^0.0...
120
100
37.8. ..
80
105
40.6...
130
101
. 38.4...
90
106
102
100
VALUE OF A SINGLE OBSERVATION.
According to Liebermeister:—
67
98.6
100.4
102.2
37
38
39
78.6 1104.0
88.1 105.8
97.2 107.6....
....40
. ...41
....42
.105.3
.109.6
.121.7
Otherwise their relation stands thus :—the pulse follows the
temperature when there is improvement, and precedes it in ex¬
acerbations.
In children and nervous persons this relation is altered by the
greater frequency of their pulse.
A pulse rather slow in proportion to the temperature is
favorable as indicating a tranquil nervous system. A low
pulse with high temperature invites us to look for some spinal
cause, or pressure on the brain, depressing action of drugs, etc.
Contrarily, a low temperature and frequent pulse points to
local complications in the thorax or pelvis. Not forgetting,
however, that moving accelerates the pulse of patients ; alto¬
gether the frequency of the pulse is a bad gauge of the amount
of fever.
The number of respirations per minute does not correspond
so closely to the temperature as the frequency of the pulse. In
collapse, there is often (not always) a frequency of respiration ;
and in slight fever of childhood also; in moderate fever the
respirations amount to 20 or so per minute ; in children to 40 or
50. In considerable or extreme degrees of fever they are higher
yet, 60 in many cases; movement, also, increases their fre¬
quency. In other cases a quickened respiration indicates local
causes.
Between the temperature and cerebral symptoms there is
sometimes a concordance, sometimes a contrast. The brain
symptoms accompanying fever are slight in gi'own people, and
deep or serious in children and old persons. In adults delirium
occurs with very high degrees of fever; if it is observed when
the temperature is low, we must attribute it to a local affection.
When the temperature is in the process of falling (as in collapse
or defervescence), fierce delirium and maniacal outbreaks may
appear, either of little import or similar to those preceding the
death agony. The distinction must be made upon other grounds
than the temperature and delirium.
Significance of the result of a single thermometric observa¬
tion in a person considered healthy. In the healthy the fluctu-
6S
VALUE OF A SINGLE OBSERVATION.
ations are very trifling ; yet, during menstruation, lying-in,
suckling, dentition, rapid growth, bodily fatigue, mental depres¬
sion, etc., temperature is often increased. Its maintenance near
the normal point in these conditions is a capital guaranty of the
capacity of endurance of the organism. A subnormal temper¬
ature in apparently healthy people is suspicious ; the commonest
deviation, a subfebrile temperature, indicates at least a morbid
susceptibility. In children, particularly the youngest, this is
caused by external influences, as excessive movement; in adults,
particularly in the robust, it indicates some latent mischief, and
invites an examination of the lungs, heart, etc., and a reapplica-
tion of the thermometer, and a vigilant supervision of the vital
signs.
Significance of a single observation of temperature in cases
of apparently slight indisposition. In such cases, thermometry
offers a rapid and striking method of acquiring information.
When the temperature is found normal, the slight character of
the illness is confirmed (yet it is well to repeat the observation
a few hours afterwards). Even subnormal or subfebrile tem¬
peratures do not denote a serious malady, provided the obser¬
vation is not taken at the beginning of a disorder. But inside
of the fever-limits, vigilance is necessary, though in children,
women, consumptives, etc., this excess of temperature may prove
transitory. But a very high temperature must always prepare
our minds for serious developments. Send the patient to bed
and let him be watchfully nursed.
A diagnosis is seldom possible at the very commencement of
an acute febrile disease. Proceeding by exclusion, a normal
temperature, or a moderate fever, excludes true pneumonia,
small-pox, scarlatina, typhoid fever; a high fever at the onset
precludes typhoid fever, influenza (grippe), articular rheuma¬
tism ; but, with the concurrence of other symptoms, opens the
area of probabilities to exanthemata, acute tonsillitis, pneumo¬
nia, pleurisy, intermittent and ephemeral fevers, pyaemia, men¬
ingitis of the convexity of the brain, typhus, etc.
The diagnosis of an acute disease is still very doubtful dur¬
ing the first half of the first week, unless thermometry can assist
in making it at the first observation, which it cannot alwavs do.
Subnormal and collapse temperatures only occur in diarrlicea,
cholera, haemorrhages, perforations, toxic gastritis, etc.
In the early days, a normal evening temperature suggests the
VALUE OF A SINGLE OBSERVATION.
69
idea of intermittent fevers. But if the morning temperature
is also found normal (unless some special circumstance keeps
it low), we may almost conclude that there is no disease. How¬
ever, catarrhal affections, measles, pleurisy, acute tuberculosis,
granular meningitis, and acute rheumatism may be present with
a normal morning temperature; whilst subfebrile or slightly
elevated febrile movements have about the same significance.
A high febrile temperature the first or second day, particularly
in the morning, precludes the idea of typhoid fever, or proves
that it began longer ago than indicated by the other symp¬
toms.
To conclude: a single observation indicating a high degree
of fever, scarcely allows us to form a conclusion as to the kind
of morbid process which is going oil for the first few days;
but if we are able to exclude the possibility of an intermit¬
tent fever we may with great probability expect a severe
illness.
Even in the second half of the first week of a febrile illness,
the diagnosis may remain very uncertain in the prodromal fever
of exanthemata, typhus, typhoid, and relapsing fevers, tardy
pneumonia, etc., in which a solitary reading of temperature con¬
veys but scanty information. But if this isolated reading shows
an evening temperature normal, subfebrile, or hardly high (with¬
out depressing influences), there is no exanthematic nor typhus
fever; if a high fever, we may exclude tubercular meningitis ;
if hyper-pyretic temperature, we are warned of masked inter¬
mittent and other malignant or infectious diseases ; thermome¬
try must be persevered in before forming hasty conclusions from
its first application.
"When an exanthematic eruption appears, with yet doubtful
characters, if the temperature (previously high) becomes low,
it is the small-pox; if normal, it is the varioloid ; if it falls (but
from a previously small height), it is a syphilitic exanthem ; if
it does not abate after the apparition of the eruption, it will
prove to be the measles, scarlatina, or typhus.
During the further course of an acute febrile disease, when
its diagnosis is uncertain, or appears so, the temperature con¬
tinues to afford the most important information, and the obser¬
vations must be continued. Yet, even then a single observation
may be of great value: it may remove a doubt, decide on the
severity of the disease, indicate its modifications, as well as the
70 VALUE OF A SINGLE OBSEBVATICXN.
danger and possible complications of it. It is tlms that we can
hardly admit the presence of typhoid fever when at any time,
between the third and tenth day, the temperature is not some¬
what febrile, and considerably so in the evening; that a low
temperature, contrasting strongly with the high previous ones,
raises the suspicion of internal haemorrhage before any blood
has appeared; and that, even later in the third week, typhoid
fever is doubtful if the evening temperature (accidents except¬
ed) is less than 39° C. —102.2° F., etc. But a high morning
temperature of 40° C.= 104° F., or an evening one of 41° C.=
105.8° F., are signs of great severity; and a normal tem¬
perature in the morning at a later period, is no proof that
the fever is over, if it still continues to rise in the even-
ing.
When the temperature remains febrile after the eruption
begins to fade in measlis, and little later in scarlatina, it threat¬
ens complications ; in small-pox the same symptom precedes
the suppurative fever or complications.
In (true) lobar pneumonia a single normal or subfebrile tem¬
perature is no proof that the process is over. All high febrile
temperatures in pneumonia are severe symptoms ; more so after
the sixth day ; though a striking rise of temperature sometimes
precedes the favorable crisis. In spite of other alarming symp¬
toms, a normal or subfebrile temperature at a later period
promises recovery.
In facial erysipelas, a febrile temperature announces further
extension of complications.
In influenza and bronchitis high fever, in the morning or
late in the disease, indicates extension to the finer bronchi, su¬
pervention of pneumonia, or masked deposits of gray or miliary
tubercle. In whooping-cough, complications are to be expected
from high fever in the second period.
In acute articular rheumatism a single observation is use¬
less, unless it shows a very high temperature, which is dan¬
gerous.
A high temperature in meningitis points out the seat at the
convexity or summit of the brain; contrarilv, a weak apyretic
temperature indicates granular meningitis of the base; but
temperature may reach almost to any height in cerebrospinal
meningitis.
A high temperature, at any time, indicates great danger in
VALUE OF A SINGLE OBSEKVATION.
71
pleurisy, pericarditis, endocarditis, peritonitis, while a moderate
or apyretic one does not insure a favorable prognosis.
In presence of a gastro-intestinal catarrh, if the patient has
been in good condition and not exposed, a single observation
showing a high temperature, excites a suspicion of typhoid
fever; yet a second observation of high temperature is neces¬
sary to make it certain.
The diagnosis of intermittent fever is doubtful if the temper¬
ature, at the conclusion of the cold stage, or at the commence¬
ment of the hot, does not reach 41° C. = 105.8° F., or if it ex¬
ceeds 41.8°C = 107.24° F., or if it is not normal in the inter¬
missions. Although the paroxysms may have ceased with the
other symptoms, as long as the temperature remains febrile, the
intermittent is not cured.
During defervescence, isolated observations afford no satis¬
factory results, although a low evening temperature would be
proof of the cessation of fever. When fever is about to leave,
after a severe illness, the temperature rises and falls some¬
times alarmingly in. weak, sensitive patientsthe closer to
the crisis,, the less dangerous are these collapses of deferves¬
cence.
After the termination of the disease, and in true convales¬
cence, the temperature is normal, or transitory collapse-temper¬
atures may occur. The latter may be caused by internal haem¬
orrhage or perforation of the bowels. Otherwise simple sub¬
normal temperature indicates, if not danger, unsettled conva¬
lescence and deficiency of nutrition. The more mobile the
temperature, the more unsettled the convalescence.
Febrile temperature in convalescence may be caused by
error of diet in regard to quantity, strong meat or drink, exer¬
tion, and leaving the bed too soon, constipation, external influ¬
ences, complications or extensions of the primary affection, or a
new one.
A single temperature taken during a great change in a fever,
may decide the tendency to a fatal termination. In a disease
without febrile character, if the thermometer discovers an
elevated temperature, it is noteworthy. In nervous afections
hyperpyrexy may indicate supervening disorders or fatal ter¬
mination.
In jaundice a high temperature is suspicious. In diseases
accompanied with vomiting, diarrhoea, and particularly col-
72
VALUE OF A SINGLE OBSERVATION.
lapse, a febrile temperature of the trunk indicates the com¬
mencement of reaction. If such temperature persists it may
indicate exacerbation or complication.
In chronic diseases with persistent fever a single observation
cannot detect anything; the observation must be continuous;
but it can detect collapse-temperatures, which are more signi¬
ficant here than in acute cases.
73
CHAPTER XII.
DAILY FLUCTUATIONS OF TEMPERATURE IN DISEASE.
In disease, the height of the temperature varies more or less
in the course of one day ; observations representing it as sta¬
tionary are to be disregarded. The daily oscillations of health
have beeome fluctuations and perturbations; they range from
1°—1.5° C. = 1.8°—2.7° F., even 5°—6° C. = 9°—10.8° F., or
more.
When the temperature is high and the daily variations slight,
the disease will be severe and lasting. The daily fluctuations
in different diseases, and in different patients from the same
disease, assume different forms, yet agree in some points regu¬
lated by certain laws. These fluctuations written in figures
may be operated upon as all other arithmetical quantities, and
so give mathematical results ; or drawn diagrammatically take
the form of waves composed of crests and furrows. Each daily
fluctuation is found to be a curve, composed of several second¬
ary ones. To understand a daily fluctuation several observa¬
tions are necessary, two to four during the exacerbations and
remissions, or more, or even continuous, to follow the thermal
law of the case.
The average of all the temperatures taken in a day, or add¬
ing the minimum to the maximum and dividing by two, form
the mean daily temperature. The daily difference, or ecart,
is the extent of the excursus between the maximum and mini¬
mum temperatures of the day. The elevations above the mean
daily temperature are exacerbations, the depressions below it,
remissions. The highest point of exacerbation just before a
fall is the acme. The exacerbation which falls suddenly is said
to be pointed or acute, the one which lingers at the acme before
sinking is broad-topped ; this may show a sinuous outline called
double or triplQ-peaked exacerbation; the highest is the max-
74
FLUCTUATIONS OF TEMPERATURE.
imum of the exacerbation. The maximum of several exacer¬
bations may not correspond with the maximum of the day.
The lowest point in a remission is its depth or nadir. If there
are several, the lowest corresponds with the day's minimum.
The time occupied by the rising of the temperature above its
daily mean, and its coming again to it, is the extent of the ex¬
acerbation ; the same movement downward is the extent of the
remission. The moment the temperature rises from the nadir,
it has begun its daily ascension, moderate, tedious, interrupted,
extreme, or sudden. The daily descent begins from the last
point of the exacerbation, even if it is not the highest, gradual,
interrupted, slow, or rapid: there are, in a day, as many exac¬
erbations \as remissions.
The form assumed by the daily fluctuations depends upon
the elements which constitute the morbid process, and chiefly
011 the kind of disease, its intensity, the stage it has reached,
the regularity, irregularity, or other peculiarities of its course,
the improvements 01* relapses, the occurrence of complications
or special events, the progress toward health, the fatal crisis.
It may also depend 011 the idiosyncrasy of the patient, intersti¬
tial or external influences, therapeutic agencies. Thus the
daily fluctuations exhibit very complex phenomena ; notwith¬
standing, they furnish valuable indications.
I A single day's fluctuation may suffice to determine the
degree of severity of a disease, and the stage of some of
them ; but we must compare the variations and repetitions of
these fluctuations during a certain number of days in order to
form a safe diagnosis and prognosis, to decide as to ameliora¬
tions and relapses, to the operation of accidental causes, and to
the action of therapeutic agents.
Among the conclusions to be drawn from the average tem¬
perature of a single day, is the important one of the levels if it
is high, medium, or low. Whilst the base line of the daily
oscillations in health is 37° C. = 98.6° F., 0 011 the physiological
scale, it is seldom so low, ordinarily more elevated in disease;
the level is below the norme in cholera, the sinking stage of
some diseases, some collapses, and transitorily in defervescence.
The daily 7nean temperature furnishes at once indications
as to the degree of fever present. In moderate fever the mean
daily temperature does not exceed 39° C. =102.2° F. In
somewhat high fever 39°—±0° C. = 102.2°—104° F., this in-
& /
FLUCTUATIONS OF TEMPERATURE.
75
eludes remittent types with a mean of 39°—39.5° C. = 102.2—
103.1°, and continuous fevers with a mean of 39.5°—40° C.=
103.1°—104° F. It shows high fever above 40° C. = 104° F.;
many diagnostic and prognostic conclusions depend upon this.
Highly febrile daily means, above 40° C. = 104° F., are met
with in pernicious (malarial) fevers, typhus and typhoid in
their fastigium, in relapsing fever, in severe pneumonia, which
may recover; but in other diseases this average makes death
imminent.
A considerably febrile daily mean (39°—40° C. = 102.2°—
104° F.), met with in well-developed pyrexia and in the fasti¬
gium of inflammations, deserves consideration, particularly in
catarrhs, acute polyarticular rheumatism, cerebro-spinal menin¬
gitis, neuroses, post-choleraic stage, trichinosis, diphtheria,
dysentery, pleurisy, pericarditis, peritonitis, and all affections
suspected to be tubercular or phthisical.
A moderately febrile mean (39° C. = 102.2° F.) has a varied
significance, as it occurs in continued or remittent febrile
diseases, in their rudimentary state, in their beginning, or in
their favorable crisis; but chiefly in cases in which in a single
day the temperature sinks from high to normal or subnormal,
after an uncompensated fall as in collapse, etc., in inflamma¬
tion of the serous membranes, and in death-agony, when
brought on by pressure on the brain, inanition, etc. When the
daily mean is much affected by circumstances or medication,
we must be cautious about conclusions.
The daily difference, or extent of the excursus between the
minimum and maximum of the day, may vary greatly; and
even when it embraces the same number of degrees in a high,
and in a low mean daily, its signification changes entirely. In
a daily mean of 37° C. = 98.6° F., a daily excursus of 1° C.=
1.8° F. is of no importance; but one of 1.5° C. = 2.7° F. is sus¬
picious. With a daily mean of 37.5° C. = 95.5° F., a daily
excursus of 1° C. = 1.8° F. indicates a certain disorder; and
1.5° C. = 2.7° F. indicates a disease, if not always a febrile one.
The daily difference grows in importance as the daily mean
temperature becomes higher. The latter being 38.5° C.=
101.3° F., a daily difference of less than .5° C.=.9° F. indicates
a continuous fever ; and less than 1° C. = 1.8° F. a subcontinu-
ous ; and a greater daily difference with a daily minimum of
39.5 C. = 99.5 F. indicates a remittent type. But when the
76
FLUCTUATIONS OF TEMPEKATUKE.
daily minimum remains high, an exacerbation of about 1° C.=
1.8° F. shows a high degree of fever with no sign yet of favor¬
able termination ; it is denominated exacerbating daily fluctua¬
tion.
If the daily minimum reaches the normal temperature,
there is a true intermissidn, though we class the case as re¬
mittent, not intermittent; and if it reaches the subnormal, we
class it as intermittent, though through great exacerbations the
daily difference may be 6° C. = 10.8° F. But intermissions
are considered real only when all the symptoms of fever abate,
and on their return assume the paroxysmal form ; they are
founded, not upon a single day's observation, but on the
observations of the whole course of the disease. (See next
chapter.)
The occurrence of remissions at the height of an illness,
indicates improvement, transition towards convalescence; its
continuance, with an increase in the amount of daily difference,
confirms the progress of convalescence; the opposite signs
indicate relapse or complication. When, in acute diseases, the
difference becomes greater, by the fall of the daily minima,
convalescence is progressing; but when the difference is
greater (forming more acuminated peaks), with rising daily
mean temperature, the patient is getting worse. When the
difference is augmented, through the temperature becoming
subnormal in remissions, it is either favorable, indifferent,
or dangerous. When the remissions are unduly protracted
(the patient seeming convalescent in all other respects), it
shows that the disease has yet a hold upon him. Decreasing
differences with decreasing daily means is favorable ; decreas¬
ing difference with increasing mean temperature is dangerous ;
whilst decreasing difference with stationary means is of doubt¬
ful significance. But the differences may remain the same,
in spite of the progress or diminution of the disease, because
the exacerbations rise to a height corresponding to the fall of
the remissions (stationary difference with increasing means) ;
or by the exacerbations decreasing in proportion to the increas¬
ing depth of the remissions (stationary difference with decreas¬
ing means).
The daily difference is usually slight in very severe typhoid
fever, in typhus, in the prodromes of small-pox, in the height
of scarlatina, in the majority of lobar (true) or croup-like
fluctuations of temperature.
77
pneumonia, in the last stage of acute fatty degeneration, m
facial erysipelas, in meningitis of the convexity of the brain,
and in the last stage of fatally ending neurosis.
On the other hand, the daily differences are generally con¬
siderable in moderate or medium typhoid fever, in the first days
of a severe attack, and again in its convalescence ; sometimes
in the convalescence of true typhus, in the convalescence of
small-pox and its allies, measles and all catarrhal affections, acute
polyarticular rheumatism, basilar meningitis, acute tuberculosis,
pleurisy, pericarditis, acute and chronic suppurations, pyaemia,
the various forms of phthisis, and trichinosis.
Daily differences, which alternate between normal or sub¬
normal, and considerable or high febrile temperatures, occur in
the advanced stage of recovering typhoid, sometimes in the sup¬
purative stage of small-pox and its allies, at the end of lobar
pneumonia, in all malarial diseases, in pyaemia and septicaemia,
acute tuberculosis, and chronic forms of fever. Such a change
may also occur in the course of a single day's fluctuation, through
some special occurrence, Like haemorrhages, etc. Daily differ¬
ences between moderately high and normal or subnormal tem¬
peratures, are frequent in fevers of moderate severity and pro¬
tracted defervescence.
In the majority of cases there is in a day (24 hours) only one
exacerbation with one, two, or three peaks, and one remission
with one minimal descent. This is the simplest and commonest
form ; but in complicated intermittent the entire fluctuation com¬
prising paroxysm and intermission lasts 48 hours (the tertian type).
Generally the remission begins between the late evening and
early morning, and the daily maximum begins late in the morn¬
ing or in the afternoon. The morning remission generally
reaches its lowest point from 6 to 9 a.m., and the daily maxi¬
mum its highest from 3 to 0 p.m., but both extend several hours
more. Such is the common course, yet we meet with cases in
which, without altering the result, the exacerbations occur in
the morning and the remissions in the evening.
In collapse, also, we meet with extraordinary low minimums
in the evening.
The time at which the daily maximum and minimum occur
may have a meaning. The eaily (noon) maximum is a sign
that the disease is severe and at its height; whilst a late maxi¬
mum indicates that the disease was trifling or has moderated.
78
fluctuations of temperature.
An earl}7 minimum is considered an improvement, unless brought
011 by collapse.
Far more important than the moment at which the maximum
or minimum is reached, is the moment when the daily rise of
temperature begins (ascent), and the other moment when the
temperature begins to fall (daily descent). The more punctu¬
ally (supposing 110 external disturbance) the ascent begins every
day, the more intense is the disease, and remote the cure. It is
a bad sign when the morning rise begins before 9 a.m. ; and
worse if it begins earlier from day to day. A postponement of
the ascent shortens the exacerbation and is favorable, even if the
daily maximum is not diminished thereby ; contrarily, the later
the exacerbation declines, the more severe the disease.
The suddenness of the rise and fall may offer indications, in
connection with extreme daily differences. The first rise of a
few tenths of temperature occupy some hours, then it becomes
very rapid in the middle, and ends as it began, very slowly.
An unusually rapid rise occurs in the early stage of acute
diseases. Before a favorable crisis, a protracted rise of temper-
ture, the last of its kind, often precedes defervescence : this
ascent is sometimes broken by a short descent. A very rapid
fall of temperature may precede convalescence, or mark collapse.
A very slow fall threatens imperfect or absent remission for the
morrow. Defervescence may be inferred when the morning
fall, intemipted in the afternoon, resumes its descent in the
evening. In somewhat severe fevers, the temperature lingers
less in the low than in the high temperatures ; it is therefore a
favorable sign when the peaks are quickly attained and sud¬
denly deserted.
The duration of the variations of temperature above the daily
average is the latitude of exacerbations, and the corresponding
movement below the-daily average is the latitude of remission.
If the former be longer than the latter, the case is judged
severe; the more so at a late period of the disease. When
recovery comes, equality is more marked between the two lati¬
tudes. In advanced convalescence the curves of the remissions
become broader, those of the exacerbations more pointed. Ex¬
acerbations of great extent have double or multiple summits ;
in the double-peaked one, the highest is that of the evening.
They begin at noon, not in the morning. These many-crested
fluctuations are unfavorable.
F
FLUCTUATIONS OF TEMPERATURE. 79
In many forms of disease presenting complexity, two or more
exacerbations succeed one another in the course of twenty-four
hours—duplex and triplex exacerbations—and are closely re¬
lated to the mxdtijple-jpeaked ones, just described. Their mean¬
ing varies according to the degree of daily difference, the type
of the fever, in proportion to the height (or lowness) of the
daily mean temperature, to the tendency to a rise or fall of
temperature, or to actual defervescence. But in fevers con¬
tinuously high, the daily waves furnish little if any informa¬
tion.
In the pro-agonic stage the fluctuations are wavy; let us not
be deceived by them.
80
CHAPTER XIII.
THE COURSE OF TEMPERATURE IN FEBRILE DISEASES.
In febrile diseases, the temperature exhibits rules which are
common, and differences which furnish the data to distinguish
their forms and varieties.
The temperature may remain continuously above the norme,
till it has reached its maximum, or only descend below it from
some accidental circumstance, whence it speedily regains its
normal height, as in continued fever. Or the elevations of tem¬
perature are interrupted once, or several times, as in intermittent
and relapsing fevers. In such cases, each interval of time,
separated by the apyrexia, may be regarded as a fever in itself.
Sometimes the fever is like & part of the disease, at other times
accessory or corollary to it: a great difference, since the course
of the disease is affected by the type in the former, by the cir¬
cumstances in the latter. The diseases in which the fever is
essential are principally those with a well-marked type / those
in which the fever is occasional, are mainly atypical.
The course pursued by the temperature in a given affection
may be determined by the nature of the disease: the more typi¬
cal the form, the stronger its influence on the course of the
temperature; this influence is not the only one, but the greatest;
by the intensity of the disease : even in typical forms this mod¬
ifies the course of the temperature; individual circumstances
in children heighten the temperature, in aged persons lower it;
hysterical temperament, etc., modifies it. It is changed by ac¬
cidental influences, which operate in proportion to their potency,
but more on atypical than on typical forms; by complications,
which supervening in a disease, modify the course of its temper¬
ature, sometimes obliterate the original type of it, sometimes
introduce instead their own.
C0UR8E OF FEBRILE TEMPERATURES.
81
The course of temperature in febrile diseases may be divided
into a number of periods or stages, which vary much,.in their
significance ; they are sometimes strongly marked, at other times
very indistinct.
The pyrogenic stage, or initial period, assumes various forms,
depending mainly on the fever preceding the local affection, or
succeeding it, or running its course independently.
There are forms of disease with a short pyrogenic stage, in
which the temperature rises suddenly in one line, or almost so,
to its characteristic height in a few hours, a day, or one day and
a half. (See Figs. 3 and 4.)
Fig. 3.
Fig. 4.
Cent.
Fahr.
Cent.
40.6
■
■
B
■B
■
104.9
40.
H
1
104.
40.5
■
J
1
H
103.1
40.
■■
39.
II
102.2
39.5
■
■■
38.5
II
101.3
39.
11
38.
II
100.4
38.5
II
1
37.5
1
1
09.5
1 .
i OS
! 00
1
Wt
37.5
Fahr.
102.2
101.3
100.4
99.5
In these cases the forearms, hands, legs, feet, and face even,
are cold, whilst the warmth of the trunk has risen considerably ;
there is chilliness, shivering, chattering of the teeth, till the ex¬
tremities have approximated to the elevated temperature of the
trunk. Attacks of illness, which begin with a short pyrogenic
stage, have but short paroxysms of fever, with a sharp elevation
of temperature, and a continuous course ending in less than a
week by a rapid fall of temperature, or death.
This kind of initial stage is the rule in variolous affections,
6
82 COURSE OF FFBRTLK TEMPERATURES.
scarlatina, croup-like pneumonia, pyaemia, malarial and rolaps-
1 Fig. 5. Fig. (I.
Cent. Fahr.
ing fever; it is common in typhus, febricula, facial erysipelas,
tonsillar angina, meningitis of the convexity. It never occurs
Fig. 7.
Cent. Fahr.
in typhoid fever, basilar meningitis, catarrhal affections, nor.in
acute polyarticular rheumatism.
COURSE OF FEBRFLE TEMPERATURES.
83
There are other forms of disease with protracted pyrogenic
stage, in which the temperature begins to ascend in the evening;
the next morning it moderates, and rises more the following
evening (Fig. 5). It may thus happen that the normal temper¬
ature is again reached in the morning of the second day (Fig.
6), or even that the initial stage is interrupted by a still longer
interval of apyrexia (Fig. 7).
In this type the initial stage lasts several days, seldom more
than a week. The height of the temperature indicates the seve¬
rity of the disease, and suffices to establish the diagnosis of ty¬
phoid fever, other symptoms concording. Otherwise this pro¬
tracted stage is initial to other affections—measles, catarrhal
pneumonia*, etc. (a class already enumerated).
There is also the insidious initial stage, which does not con¬
form to rules, and whose type can only be approximated, as in
Fig. 8. It initiates acute rheumatism, pleurisy, lues, phthisis,
and numerous atypical affections.
Fig. 8.
Cent.
40.
39.5
39.
38.5
38.
37.5
1
i - if
■
■
I
m
■
■
■
I
m
■
I
in
IBS
«a
mm
A
■
■
■
■ ■■ ■
Fa^r.
104.
103.1
102.2
101.3
100.4
99.5
The fastigium is the period in which the fever is most fully
developed. At this stage the temperature experiences great vari¬
ations from the many influences which affect the fever. The
acmd is the summit of the fastigium.
The variations of the height of the temperature in the fast¬
igium are relative to the height of the maximum temperature, or
84
COURSE OF FEBRILE TEMPERATURES.
highest point reached in a given case, which depends partly on
the kind of disease, partly on its severity ; but is not absolutely
reliable in diagnosis, because it is sometimes brought to an un¬
usual degree by collateral or accidental circumstances. The
lower range of the maxima is also not absolutely reliable, be¬
cause its observation may have not been taken at the opportune
time; yet, for example, one can pronounce against the existence
of intermittent fever after a careful observation, showing that
the temperature never reached the lower range of maximum
of this disease; or we may exclude typhus and typhoid feve^
if a temperature of 39.5° C.= 103.1° F. has never been met
with.
But the variations in the height of the daily means, or aver¬
age daily temperature, are far more important per se, though
they, too, are influenced by the severity of the disease, circum¬
stances, etc. The height of the daily means is somewhat as
follows in the fastigium of:—Typhoid fever, 39°—40.2° C.=
Pig. 9. Fig. 10.
Cent. Fahr.
102.2°—104.36° F.; typhus, 39.2°—40.5° C. = 102.56°—104.9° F. ;
eruptive fevers, small-pox, etc., 39°—40° C. = 102.2°—104° F.;
measles somewhat lower, on account of the extent of the morn¬
ing remissions; regular scarlatina, 40° C. = 104° F. ; croup like
COURSE OF FEBRILE TEMPER ATURE8.
35
pneumonia, 39.2°—40° C. = 102.56°—104° F. ; meningitis of the
convexity, 40° C. = 104° F. or more ; articular rheumatism, with¬
out complication, 38.5°—39.5° C. = 101.3°—103.1° F.; acute in¬
fluenza, 38.5°—39.2° C. = 101.3°—102.56° F.; facial erysipelas,
39.5°—40° C. = 103.1°—104° F. ; parenchymatous tonsillitis,
about 39.5° C.= 103.1° F.
When this stage is short, the average height of the fastigiw.n
may be easily modified by circumstances, as one accidental re¬
mission or exacerbation, in which case we must disregard the
mean obtained from them, in determining the intensity of the
disease.
The most valuable data for diagnosis and prognosis are ob¬
tained from the general course of the temperature during the
fastigium. Its form on a chart is acuminated (pyramidal),
reaching rapidly to a point from which it rapidly falls, or
where it ends fatally; or continuous, persistent at a certain
height, with or without slight fluctuations ; or interrupted, brok¬
en by considerable fluctuations in a single day, or by strong
differences in several.
Fig. 11.
Fig. 12.
Cent.
Fahr.
Cent.
Fahr.
107.6
103.1
105.8
104.9
106.7
104.
102.2
The acuminated course of temperature during the fastigium
occurs in the paroxysm of short intermittent, in ephemeral, and
malarial fevers, pyaemia, erratic erysipelas, seldom in pneumo-
S6
COURSE OF FEBRILE TEMPERATURES.
nia; in fever accompanying herpetic eruptions and tuberculosis,
and in terminal fevers generally. The fastigium may thus ex¬
hibit a single pointed summit (Fig. 9), a broad-topped maximum
(Fig. 10), or several peaks (Fig. 11).
Lasting only a few hours, and rarely more than a day, the
pyramidal fastigium either ends in death, as per Fig. 12, or
falls quickly after reaching the acme ; two or more such attacks
follow, as in malarial intermittent pneumonia, etc.; in these
abrupt fevers a relapse is frequent.
A continuous course is not always even, but may be undu¬
lated by slight fluctuations of .5° C. = .9° F., or a little more
(see Fig. 13). It occurs in the fastigium of severe acute dis-
Fig. 18.
Cent,
40.5
40.
39.5
■
■
■
a
mm
■
m
■
■
a
■
■
u
■
■
■
MB
■1
BHHi
■
■H
Fahr.
104.9
104.
103.1
eases; in severe complications, and in very mild miscellaneous
cases. The diseases which seem to have a predilection for this
kind of fastigium are typhus, scarlatina, croup-like (true) pneu-
Fig. 14.
Cent.
40.
39.5
Fahr.
104.
103.1
monia, the prodromal stages of variola and its allies, erysipe'as
before it spreads, meningitis of the convexity, severe general
febrile affections showing microscopic lesions, or having a
OOURSE OF FEBRILE TEMPERATURES.
87
short initial stage of rigors. When diseases, which usually ex¬
hibit the remittent or non-continuous course, assume this con¬
tinuous fastigium, it is an unfavorable symptom.
Here, the height of the average temperature is important;
its continuous course is either ascending (Fig. 15), a bad sign ;
descending, a good sign (Fig. 14); or persistent on the same
level, neutral. Usually the first part is more severe, the second
milder. These parts are often divided by a fall of tempera-
Fig. 15.
Cent. Fahr.
41.5
41.
40.5
40.
1
■
■
■I
■
A
H
1
/ X
/ N
/
/
v'
■
1
§
■
■
■
H
106.7
105.8
104.0
104.
ture, a pseudo-crisis. This continuous course of temperature
during the fastigium very seldom lasts more than a week, but
it may be repeated in a moderate or remittent form.
Fig. 1G.
Cent.
40.5
40.
39.5
39.
102.2
In the great majority of diseases the course of temperature
is non-cjntinuous during the fastigium. This is the rule in
88
COURSE OF FEBRILE TEMPERATURE8.
typhoid fever, catarrhal affections, catarrhal and pntrid pneu¬
monia, measles, osteo-myelitis, meningitis, pyaemia, lues, etc.
The fluctuations between evening exacerbations and morning
remissions, may be considerable, therefore varying much the
daily maxima. In cases of moderate severity the morning
remissions fall more or less below the average height of the
fastigium of the disease (Fig. 16); whilst in severe cases they
remain above that average (Fig. 17).
Fig. 17.
Cent. Fahr.
The extent or excursus of the fluctuations between the morn¬
ing and evening temperature may range from .8° to 3° or 4°
Cent. = 1.35°—5.4°—7.2° F. (See Fig. 18.) The alternations
between exacerbations and remissions may be repeated regu¬
larly for days and even weeks, almost identically; but in the
non-continuous course the daily temperature may show more
irregularities ; as remissions and exacerbations occurring earlier
or later, longer or shorter on a given day; non-concordance
between the depth of the remissions and the height of the exa¬
cerbations ; intercurrent retrograde movements, isolated and
powerful falls, or elevations of temperature, symptoms rarely
favorable; occasional intercurrent elevations of temperature
due to some unfavorable development or complication; and
more rarely present in inter-current collapse.
Often these irregularities combine by two or more, and a
type once broken by them is seldom resumed; they are fre¬
quent in pyaemia.
The varieties in the non-continuous course of temperature
during the fastigium result mostly from the nature and sever¬
ity of the disease, and sometimes from complications. Typhoid
COURSE OF FEBRILE TEMPERATURES.
89
fever is the most typical of all the diseases with non-continuous
fastigium. The minimum of its exacerbations is 39.5° C.=
Fig. 18.
Cent. Fahr.
41.
40.5
40.
39.5
39.
38.5
■MUW
105.8
104.9
104.
103.1
102.2
101.3
103.1° F. The limits of its daily excursions does not exceed
1.5° C. = 2.7° F. Its course is regular (when uncomplicated).
Its fastigium is never less than eight, nor more than seventeen
days; even circumstances do not easily affect its temperature,
still less its duration.
The absolute height of the maxima of exacerbation is con¬
siderable in the non-continuous part of recurrent or suppurating
fever, variola, catarrhal pneumonia, etc. (as supra). On the
other hand, it depends more upon the severity of the individual
case in the opposite series, polyarticular rheumatism, pleurisy,
etc.
The daily difference or width of excursus of the fluctuations
depends on the form and severity of the disease. Sometimes
the excursus is as extensive as in intermittent, sometimes as
limited as in continuous fever. The latter are often severe ;
the former with high exacerbations, may lead us to suspect
malignancy, pyaemic or septic infection, embolism, secondary
deposits, etc., though some cases may recover without confirm¬
ing or invalidating the suspicion, nor revealing the cause of
such an extreme course of the temperature.
90
OOORSE OF FEBRILE TEMPERATURES.
With the disposition of non-continuous fever to irregularities,
any special event in the course of the disease, such as the action
Cent.
40.5
40.
39.5
39.
38.5
38.
Fig. 19.
tmm
■■
■■■
A
/v
7\ /
mmm
an
n
ram
■■■
Fahr.
104.9
104.
103.1
102.2
101.3
100.4
of calomel, digitalis, cold water, etc., may produce sudden
plunges, elevations, or collapse.
Fig. 20.
The direction taken by the terwperature when the course is
non-continuous may likewise differ, the fastigium being either
uniform,, ascending, or descending, rather corresponding in this
COURSE OF FEBRILK TEMPERATURES.
91
respect to the dangeronsness of the disease. The ascending di¬
rection may consist in an increase in the height of the daily
average of temperature (Fig. 19); or in the remitting type ap
proximating to a continuous or exacerbating one (Fig. 20).
The descending fastigium is recognized by a contrary march,
which usually effects a gradual, rarely a sudden fall, preceded
by brief irregularities.
The fastigium may be broken in two periods of a whole or
half week. If an ascending direction is succeeded by a uni¬
form course, and then a descent, it warrants a favorable prog¬
nosis ; but if a uniform march assumes an ascending direction,
the case is bad.
The duration of the fastigium is longer in the non-continuous
type than in the continuous ; shorter (if not suddenly fatal),
it indicates less severity ; longer, more. The prodromal stage
of measles, in favorable cases, has a particularly short fasti¬
gium. In influenza, bronchitis, cynanche tonsillaris., parotitis,
catarrhal pneumonia, wandering erysipelas, suppurating fever
of small-pox, peritonitis, reactive fever from cholera, the fasti¬
gium cannot last more than five or six days without danger ; in
typhoid fever, eight to seventeen.
The fastigium lasts longer in polyarticular rheumatism, pleu¬
risy, trichinosis, suppuration, cerebro-spinal meningitis, and
lues, even when cure ensues. In basilar meningitis the length
of the fastigium has no significance in regard to the issue; in
septicaemia, pyaemia, and acute tuberculosis it rather has a
favorable one. In phthisis and other chronic affections, the
fever may persist for months, even for years, without much
affecting the issue.
In most diseases the fastigium is simple; but it may be re¬
peated more than once in the following affections: the relapses
of typhoid fever, relapsing fever, small-pox, irregular exan-
thems, pneumonia (relapsing forms), pyaemia, and septicaemia
(with apparent improvements intervening), facial (relapsing)
erysipelas, polyarticular rheumatism (complicated), basilar and
cerebro-spinal meningitis, pleurisy, and phthisis. When the
fastigium repeats itself, continuous, remittent, and paroxysmal
types may follow each other; the more continuously elevated
becomes the fastigium, the more unpromising the case.
The close of the fastigium is sometimes clearly defined,
sometimes indistinctly, merging into the following stages, or a
92
COURSE OF FEBRILE TEMPERATURES.
brief rise ma}' terminate it; called in the good old language
of physic, perturbatio critica.
Cent.
40.5
40.
39.5
39.
38.5
Fig. 21.
■
■
■
1
m
■
H
■
u
■
■
\
■
■
■
■
■
■
■
\
\
■
■
■
■
\
Fahr.
104.9
104.
103.1
102.2
101.3
In small-pox the fastigiuin ends as soon as the eruption be¬
comes shotty; 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, between the
third and ninth day ; in typhus, towards the end of the second
week or the middle of the third ; in mild typhoid fever, in the
com-se of the second week, and in severe cases in the course of
the third or fourth ; in influenza it lasts a few days; in paren¬
chymatous tonsillar angina, three to seven days; in other dis¬
eases the termination is more or less uncertain.
Most of the diseases have completed their evolution at the
end of the fastigium by death or convalescence; others con¬
tinue, after it, in a state of indecision—an amphibolic stage.
This stage is most strikingly severe in typhoid fever ; occurring
also in lingering pneumonia, typhus, polyarticular rheumatism,
epidemic cerebro spinal meningitis ; and is marked bv great
irregularities of temperature, which, however, seldom reach the
maximal height of the fastigium. It may last more than a
week, and lingers longest in grave typhoid cases. Intermittent
collapse is often met in this period.
Certain influences may modify the fastigium or the amphv-
bolic stage. A rise of temperature is induced in febrile patients
COURSE OF FEBRILK TEMl'ERATCRE8.
93
by mental excitement, bodily exertion, being kept too warm,
errors of diet, persistent constipation, and the occurrence of cer¬
tain complications. A diminution of temperature is brought,
on at this stage by haemorrhages, copious stools, vomitings, or
perspirations ; also by imperfect respiration, paralysis of the
heart, pressure on the brain, and starvation. Occasionally by a
deep sleep, external application of cold, blood-letting ; and the
administration of medicines already recognized as antipyretic,
calomel, antimony, lead, digitalis, veratrine, quinine, acids, and
cooling salts: though the individual susceptibility to these agents
differs greatly.
The course of temperature during convalescence differs as
much as the modes of recovery. In one disease, the morbid
process being exhausted, recovery takes place by a simple re¬
action ; it is the course in typhus, varioloid, measles, lobar and
uncomplicated pneumonia, febriculse, relapsing fever, facial
erysipelas, fever of the cholera reactions without parenchymatous
degeneration of the kidneys. But in convalescence of other
forms there is such alterations of texture, such organic destruc¬
tion of old tissues, and so many new products standing in new
organic relations, that in the midst of these conflicting elements
convalescence becomes almost a secondary disease. So it acts
in typhoid (enteric) fever, scarlatina, true small-pox, polyartic¬
ular rheumatism, all forms of meningitis, trichinosis, pleurisy,
pericarditis, dysentery, etc. Complications, in the first class,
may lead to the same difficult convalescence. In both classes
the course of the temperature corresponds to these various re¬
lations, and judges the chances of recovery. In cases of labori¬
ous convalescence considerable elevations of temperature inter¬
vene in the midst of the healing process; this harmonizes with the
fact that the greatest danger of patients often meets them in the
period of recovery. On the other hand, where there is no great
obstacle to recovery, the fever-heat passes away with the disease.
During convalescence the temperature passes through three
periods: of decided, still insufficient decrease, the stadium de¬
crement; of cessation of fever, named by Wunderlich and known
as defervescence ; and the terminal, epicriticdl period of recovery.
The first stage cannot be observed in all cases ; when present,
it succeeds the fastigium or the amphibolic period ; then comes
a slight fall, at once followed by unmistakable defervescence.
(See Fig. 22.)
04
COURSE OF FEBRILE TEMPERATURES.
This process may be gone through so imperceptibly that it is
difficult to mark the commencement of defervescence. It may
amount to .5° or 1° C. even to 3° C. = .9°—1.8°—5.4° F. ; it
Fig. 22.
Cent. Fahr.
may consist in a moderation or absence of the regular evening
exacerbation ; or in a greater morning remission (with the or¬
dinary exacerbation); or the morning remission is more, the
evening exacerbation less marked, making the daily difference
the same, though the average temperature of the day appear
lower; or it may consist in a pseudo-crisis followed by a slight
rise of temperature: so that the average temperature may be
lower, and yet a slow fever persists for almost a week, till it is
replaced by the true defervescence. This course is distinguished
from the amphibolic stage by the absence of aggravations, by the
normality of the rise of the evening temperature, and the regu¬
larity of the morning remissions.
This stadium decrementi may be met with in all sorts of
diseases; defervescence may succeed it rapidly or lingeringly ;
therapeutics may hasten it. Otherwise, its length varies with
the kind of disease; it is longest in typhoid fever and the sup¬
purating stage of variola, shorter in petechial typhus and scar¬
latina, shorter still in measles and lobar pneumonia. In atypi¬
cal diseases its length is variable. Such moderations of tem¬
perature are deceptive in pyaemia and the amphibolic stage
of many diseases.
COURSE OF FEBRILE TEMPERATURES.
95
The period of defervescence proper is that which affords the
safer indications as to anomalies and impediments to recovery.
Defervescence may be complete in four, twelve, twenty-four, at
most thirty-six hours, during which we witness a fall of 2° 5°
C. = 3.6°—9° F. and more, descending to normal or below it.
Fig. 23.
Fig. 24.
37.5
Fahr.
105.8
104.9
104.
103.1
102.2
101.8
100.4
99-5
98.6
The fever may terminate in that short time; yet its end
must not be assumed till we see whether the next exacerbation
rises to the height of the previous day ; if it does not, the defer¬
vescence is confirmed. It may also happen that the tempera¬
ture rises a little on the second evening, but not considerably.
(See Fig. 25.)
There may be no defervescence in the morning, only a mod¬
erate depression, even a heightening of temperature, followed
by defervescence in the afternoon or evening, which instead of
exacerbation marks a slight fall of .1°—.3° G.=.2°—.5° F. or a
little more, which will serve as the basis to calculate upon the
defervescence of the next evening. (See Fig. 26.)
96
COURSE OF FEBRILE TEMPERATURES.
The temperature often falls below the normal to 36° C.=
96.8° F., or even lower, especially when hastened by depressing
remedies, and yet defervescence is assured only when the tem¬
perature of the next evening remains normal. After such
rapid falls, collapse may follow, creating disturbance in the
patient and anxiety around him. Thermometry enables us to
Fig. 25.
Cent.
40.5
40.
39.5
39.
88.5
sa
87.5
37.
HI
IB
■1
m
■HI
■
■A
m
1
■1
M
I
V
m
■
Bi
IB
H
Fahr.
104.9
104.
103.1
102.2
101.3
100.4
99.5
98.6
judge of the position. The critical condition may last several
hours or days, accompanied with delirium and other symptoms;
yet, if the temperature continues normal or subnormal every¬
thing is safe, but from the effects of extraneous events, like per¬
foration. Relapsing fever presents the type of these rapid
defervescences of 5°—6° C. = 9°—30.8° F.; such excursus hap¬
pens at the close of the first attack, or of the relapse.
An opposite mode of defervescence takes place more slowly
on an extended line or lysis. Temperature continuous, falling
tediously, less from morning to evening than from evening to
morning, almost stationary; its decline occupies several days
or a week (Fig. 27); so it is in scarlatina and typhus, sometimes
in pneumonia, seldom in typhoid fever, etc. Or the lysis may
affect a remittent type, in which morning remissions alternate
COUKSE OF FEBRrLE TEMPERATURES.
97
with evening exacerbations ; but, on the whole, either the daily
maximum, or the daily average, is less from day to day; tin's
may last from three to seven days, even subject to interruptions.
In this way evening exacerbations may continue high, and
Fig. 26.
Fahr.
104.9
101.3
100.4
Cent.
40.5
40.
39.5
39.
88.5
38.
37.5
37.
morning remissions become more marked, till the exacerbations
decrease too. (Fig. 28.) Or, the daily differences remaining
the same, morning and evening temperature become lower
(Fig. 29); or the evening exacerbations gradually approximate
the morning remission. (Fig. 30.) These various forms may
succeed one another slowly or abruptly. Remitting deferves¬
cence characterizes typhoid fever, is met with in catarrhal dis¬
eases, trichinosis, peritonitis, pericarditis, and lasts about four
days. Collapse frequently occurs in severe remitting defer¬
vescence, in consequence of the fall of the morning temperature
being considerably below the norme during several days.
In the epicritical period, especially in convalescence, the tem¬
perature is normal in the morning and evening, showing only
the daily fluctuations; a guaranty that the healing process will
follow. But as long as febrile temperatures are met with in
98
COURSE OF FEBRILE TEMPERATURES.
the evening, convalescence is not perfect, and if in the morn¬
ing, they are yet less promising. However, in several cases
Fig. 27.
Cent.
40.5
40.
39.5
39.
38.5
38.
37.5
37.
II
,
W0;
||J|
IB
1
IB
■
I
il
H
■
I
■
''ZMzy
n
■
m
'
V • ■
'
IS#
.
,
SH
n
's/-
-
EH
|jgf|
■
'
il
|
'■ ' ■
\l
-
Hfpf
va
w$
m
11
f§§
5
s> ■
;.###
■ yy-y-y
m
K
lip
1
'' ; ;' v' :
--1 tyf-
Hi
'-'yy^y
Zyyyyy-.
—^
'
Fahr.
104.9
104.
103.1
102.2
101.3
100.4
99.5
98.6
and diseases, convalescence is arrived at through these febrile
elevations, which may be caused by an indulgence in animal
food, early walking, etc.
The beginning of an acute affection (whether relapse or com¬
plication) during convalescence is always attended with a rise
of temperature after the type of the new affection.
If an illness, instead of ending in cure or death, is followed
by sequelae, the healing process is retarded or interrupted, and
exhibits many deviations from the norme. This passage from
the primitive disease to its sequels may occur during the am¬
phibolic stage, the decrement, or the defervescence; then the
lysis is proved to be only apparent by a fresh elevation of tem¬
perature and the absence of farther progress, and the liew
course is determined by the nature of the sequelae, not by that
of the primary disease.
COURSE OF FEBRILE TEMPERATURES.
99
A fatal termination is preceded by symptoms long or short,
threatening or promising. The pro-agonic period is far from
Fig. 28.
Cent. Fahr.
being simple, bnt thermometric observation throws a light 011
its habits and duration. By the light of temperature we see
this stage assume various forms. The ascending, whose com¬
mencement may be uncertain, if its character is uniform with
that of the original disease, 01* if an amphibolic stage has pre¬
ceded; but are sharply defined if the primary disease has
entered into the period of convalescence, even in that of re¬
covery, or when the pathological temperature has been reduced
by therapeutics. It is also well marked when the previous
course was continuous, and especially when the pro-agonic
period begins with a rapid rise in the course of a disease pre¬
viously apyretic. In this ascending course the rise affects the
form of a zigzag, slightly declining in the morning, rising
higher at every evening exacerbation; thus the average height
increases with the daily maxima (Fig. 32).
In this way temperature may continue to rise regularly
100
COURSE OF FEBRILE TEMPERATURES.
through the pro-agonic period, or it may succeed to an irregu¬
lar course, or follow the fluctuations of the amphibolic stage ;
Fig. 29.
Cent Fahr.
41.
40.5
40.
39.5
39.
38.5
38.
37.5
37-
■I
■
■
■
■
■
1
w
n
n
■
■
■
■
■
BH
■
■
■
■
■
1
■
u
m
■
■
■
■
u
u
■
■
■
1
■
u
m
m
■
■
■
m
■
■
a
n
■
m
■
■
■
■
■
■
■
■
■
■
■
■
H
B
105.8
104.9
104.
103.1
102.2
101.3
100.4
99.5
98.6
or begins to rise after a moderate or not truly febrile condi¬
tion ; or after some apparently favorable event; or after con¬
valescence has made considerable progress; or it may set in
after a fall of temperature to normal or below it, after a decep¬
tive remission, or a short collapse.
In contradistinction to this steady rise of temperature, rapid
and extreme heights may be reached in the pro-agonic period,
succeeding to a high, moderate, or low previous temperature.
In the first and most common case the previous temperature
had reached 40°—41° C. = 104°-^105.8° F. or more, when a
further rise of one to two per cent., = 1.8°—3.6° F. sets in.
In this condition the pro-agonic stage is short, and impercep¬
tibly merges in the death-agoiiy (Fig. 33).
In the second case the final rise is often very considerable
when compared with the preceding fall ; yet the absolute
COURSE OF FEBRILE TEMPERATURES.
101
height is not altogether remarkable per se. In these eases, too,
the pro-agonic period merges at once into the final agony (Fig.
Fig. 30.
Cent- Fahr.
Lastty, in the third category, to which belong the hyper-
pyretic rises of temperature of fatal neuroses and of diseases of
the brain free from fever, we may consider the whole period
in which the temperature is rising as the pro-agonic stage. It
begins slow, becomes rapid, and attains enormous heights (Fig..
35).
Far more common than the ascending form of the pro agonic
stage, is that with decrease of temperature, the descending
type. And it is much more important to watch this form,
inasmuch as a superficial and partial consideration of the tem¬
perature only, might lead us to consider its decrease as a sign
of amendment. " 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 of temperature, the frequency of the
pulse increases in the most striking manner
102
COTTKSE OF FEBRILE TEMPERATURES.
The pro-agonic stage ma}7 be short in this descending type ;
twelve hours to two days for a decrease of 1° C.=1.8° F., or
Cent.
40.
39.
38.
37.
Fig. 31.
■
■1
M
■
■1
m
■
■1
»■
■1
■9
■1
■■
M
mi
■■
Fahr.
104.
103.1
102.2
101.3
100.4
99.5
till the normal is reached. After this pro-lethal moderation of
temperature there is a sudden rise in the death-agony itself.
(Fig. 36).
Fig. 32.
Cent.
Fahr.
In other cases the remissions are periodical, whilst interrupted
by fresh exacerbations ; there is irregularity by plunges, not the
zigzag descent of lysis. This form occurs in the early compli¬
cations of almost any disease, nervous affections, bad nursing,
and dosing. At other times the rise and fall of temperature in
the pro-agonic stage is tolerably regular, beginning with a fall
COURSE OF FEBRILE TEMPERATURES.
103
of half a day to two days and a half; rising again, even higher
than its starting-point, ending in an exceptional rise or a fall.
But in some cases (most difficult to prognose) the temperature
pursues a descending course, whilst all the other severe symp¬
toms continue; the patient dies whilst the temperature sinks
Fig. 33.
Fig. 34.
Cenf.
42
41.
40.
Fahr. Cent.
41.
ma
+
107.6
1 ,
n
10G.7
40.
i
1
105.8
u
i
l
■
104.9
39.
u
i
l
104.
m
i
l
■
38.
u
n
Fahr.
105.8
104.
102.2
100.4
deeper or undergoes fatal perturbations, in which death takes
place (Fig. 37); such is the course in basilar meningitis, typhus
and typhoid fevers, especially in scarlatina, rarely in pneu¬
monia ; indeed, some cases seem as if fated.
In rare cases the temperature is not modified in the pro-
agonic period, where an unfavorable prognosis must be founded
on other data, as a continuous quickening of the pulse inde¬
pendent of a stationary temperature. Lastly, the pro-agonic
stage may be marked by extraordinary fluctuations of tempe¬
rature repeating themselves several times in a day; there are
deep falls and high elevations, in either of which death comes.
Pyaemic affections are of this type. (See Fig. 38.)
In the deatli-agony the course of temperature is very
varied.
It may keep the daily fluctuations without peculiarity, rather
high if death occurs in the exacerbation, and moderate if in
the remission. In patients from fever the temperature rises .5°
104 COURSE OF FEBRILE TEMPERATURES.
to 1° F. during the agony. If the fatal rise is moderate, there
is a recession of a few tenths in the last hours, subject to two
exceptions. In not a few cases, whether the previous tempera¬
tures have been febrile, normal, or subnormal, a fall of temper a-
Fig. 35.
Cent. Fahr.
ture occurs in the death-agony, which, when the preceding tem¬
peratures have been above normal, may be rapid and considera¬
ble ; the patient dies in collapse. This happens in many con¬
sumptive diseases, inanition, haemorrhages, cholera-flux, perfora¬
tion of the intestines, etc.
COURSE OF FEBRILE TEMPERATURES. 105
On the other hand, an extraordinary rise of temperature
Fig. 36.
Cent Fahr.
40.
39
33.
37.
■
P
H
104.
102.2
100.4
98.6
occurs in the death-agony itself in patients who have shown a
high febrile warmth, and in those, as well, whose illness has
Fig. 37.
Cent.
40.
Fahr.
39.
H
■
■
■
■
■
i
■
■
m
H
■
■
■■
104.
102.2
exhibited no elevation of temperature. This rise in the death-
agony happens in malignant febrile affections whose infectious
106
COURSE OF FEBRILE TEMPERATURES.
character is probable, typhus and typhoid fever, in fatal cases of
yellow fever, scarlatina, variola, pyaemia, septicemia, and sun¬
stroke, and less commonly in pneumonia, measles, endocarditis,
fatty degeneration, malignant peritonitis, erysipelas and rheu¬
matism, osteo-myelitis and acute miliary tuberculosis. In these
cases severe cerebral disturbance exists, but the main cause of
the excessive disengagement of heat seems to be an extensive
o o
chemical process of a zymotic nature.
Fig. 38.
Cent. Fahr.
Moreover, 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., meningitis of the convexity, softening of the brain, and
the so-called central neuroses, tetanus, epilepsy, hysteria, etc., in
which the temperature begins to rise for the first time in the
last days of life, and very rapidly reaches enormous heights.
In these cases, is the fatal rise an effect or the cause of the
death-agony and termination ? Senator, in Yirehow's Archiv,
COURSE OF FEBRILE TEMPERATURES.
107
xiv. 412, thinks the latter is true, agony and death occurring
because (from some cause or other) the temperature rises to a
height incompatible with life. The matter scarce])7 seems so
simple, though no other cause could be more effective than an
enormous elevation of temperature.
The moment of death is not indicated by any special altera¬
tion of temperature ; a moderate, even low pro-agonic tempera¬
ture sinks most in the few last .moments of life. When the
temperature is high during agony, it often reaches at death-time
a height it never attained before ; or it simply falls to minimal
diminution from the previous height.
After death, in the majority of cases, the temperature begins
to fall. The decrease is more sudden when the patient dies
with a low than with a high temperature. The rapidity of cool¬
ing, at first slow, increases as it goes on.
In many cases a small rise, seldom amounting to more than a
few tenths of a degree, may be observed after death, and con¬
tinues from a few minutes to an hour ; then a short pause
ensues, followed by a tedious sinking of temperature, which after
a time becomes more rapid. This post-mortem rise occurs some¬
times in cholera, and in cases terminating in hyperpyretic tem¬
peratures, either when the rise continued to the moment of death
or left room for a short pro-lethal decrease. This phenomenon
is based 011 two causes : The occurre ice of death puts an end to
the process of cooling by inspiration of cold air and by per¬
spiration ; and new sources of warmth are opened by changes in
the substance of the muscles and post-mortem decomposition,
two sources foreign to the living body, sufficient to more than
compensate for the loss of heat from those of its sources extinct
with life.
In cerebro-spinal meningitis, temperatures of 104°—111° F.
have been observed just after death. Simon observed 104°—
113° after death from variola. Assistant-Surgeon F. M. Mac¬
kenzie observed 106.2° F. in the rectum after death from
cholera. (London Hospital Reports, vol. iii., p. 454. Note by
Dr. W. B. Woodman. See also Appendix VIII.,/!)
CHAPTER XIV.
TEMPERATURE IN SPECIAL DISEASES.
" A complete insight into the course of the temperature in
disease can onlj- be obtained by comparison of the curves of
many separate eases. It is only thus that the mind awakens to
the conviction of their harmony, and gains the faculty of find¬
ing itself at home in the manifold modifications and deviations
of the temperature of the sick.
" The rules deduced from the comparison of separate cases,
though derived from one's own large experience, are never com¬
plete, and, like empirical abstractions, fail to bear the stamjp of
inevitability: fresh experience may modify or overthrow them.
" To deduce the rules from quantitative materials would lead
to delusive results. The true characteristics are not to be
sought in the absolnte height of the temperature of a given
day, but in the orderly succession of the temperature in the
whole course of the disease, or during a definite portion of it;
in the rise to a certain height, and fall to a certain depth, at
regular, occasional, or fortuitous times. A more statistical
estimation of the curves obliterates the peculiarities of the
course of the temperature, and a more numerical treatment of
the mass of cases can only give a trustworthy answer to certain
limited questions."
Wunderlich advises to look less to the numbers and more
to the form of the wave-system. " Their comparison enables
us to construct a sort of model-curve or standard measure
of single cases. I am aware that the general rules, of which
the wave-system is, so to speak, the image, can never attain
to the concrete actualities of a particular case; but I have
so constant proof—in the copious stores of material at my
command—of the correctness of the principle these rules are
founded upon, that I hope they do not caricature or contradict
TEMPERATURE IN TYPHOID FEVER.
109
nature, but will be of service to those interested in medical
thermometry.
" In this method of representation, the types of diseases, and
their principal varieties, are the only details to be admitted.
In this course there is danger, I know, of considering mere
abstractions as special forms of disease; of comprehending
under the same name things which differ, and rudely separating
others closely related ; but there is no great danger that these
abstractions will be misunderstood by those who use thein as
standard categories.
"The typical course of the temperature in many forms of dis¬
ease is no mere speculation, but an acknowledgment of unde¬
niable facts. It is only doubtful or optional how many diseases
should be included in such a classification.
"Once the typical theory admitted, we are confronted with
the idea that there are such things as normal diseases. The dis¬
tinction (between normal and abnormal) was first introduced by
Iiilliet and Barthes, in their incomparable Treatise on the
Diseases of Children. For them, the normal course of a dis¬
ease is such as represents the uncomplicated results of a specific
primary cause in a previously healthy individual. Above all
other phenomena, the course of the temperature permits us to
distinguish what is normal and characteristic in the course oj
diseases, from what is abnormal in individual cases. The fact
that the abnormal cases may practically outnumber the normal
ones, will not invalidate the value of the type for any mind
familiar with the proportions of exceptions to law in other
physical sciences. It is only necessary to remember that in
different forms of disease the limits of the normal are some¬
times boldly, sometimes faintly defined, and at other times
merge obscurely into others; and that, though we recognize
tlie principle, we cannot force all forms of diseases to conform
to a given type."
(We will continue to treat of the temperature in special
diseases in the order adopted by Wunderlich. Not in ignorance
that there are better ones built from the stand-point of aetiology,
nor that we are unmindful of the classification offered by Roger
of the maladies: 1. With increased temperature; 2. With
stationary temperature; 3. With diminished temperature. This
is certainly a step towards the clinical thermometry of the
future; but the would-be stationary land-mark includes pre-
110
temperature in special diseases.
cious patches already surveyed by thermography, and many
more, which must be better known before they are assigned
their place in a methodical plan. This subject of ours, Human
Temperature, is many-sided enough of itself, without mixing it
up with the problems of a new nosology.)
I.—Typhoid Fever. (Syn. Enteric Fever, Dot/iinenteritis,
Abdominal Typhus.)
Typhoid fever pursues its course with unmistakable regular¬
ity, and next to the relapsing and intermittent, affords the best
proof of the theory of types. However the course of particular
cases may dissemble, yet it is impossible not to recognize,
amidst their differences, the marvellous regularity of its course,
the foundation of its type. And more : in this pre-eminently
typical disease there is not a single rule which is not subject to
exceptions; deviations may occur in any segment of its course,
but they are neither so numerous, nor so important, as to oblit¬
erate the type.
But there are cases whose diagnosis remains doubtful, till re¬
covery or death takes place, between typhoid fever and acute
tuberculosis, basilar meningitis, epidemic cerebro-spinal menin¬
gitis, typhus, pyaemia, etc., and also localized diseases, like
myocarditis, endocarditis, with ulceration of the valves, abscess
of the liver, etc., all of which closely simulate the march of
typhoid fever. Still more difficult is it to be sure whether the
typhoid affection has not supervened upon some other. Ther¬
mometry cannot always solve these doubts; but it can decide
some otherwise obscure points of diagnosis, such as certifying
that the apparently typhoid is another affection, or that the
typhoid really complicates the other affection; and it gives us
the means and power of answering questions relative to the dis¬
ease, and u standard for judging of the propriety of the answers.
To gain the full practical value of thermometry in typhoid
fever, attention must be paid to the following points: A single
observation,per se, is never sufficient; made at a certain time,
however, it may contraindicate the typhoidal character. It de¬
monstrates its improbability or impossibility when it shows a
temperature of 40° C. = 104° F. the lirst day or the second morn¬
ing ; when between the fourth and sixth day the temperature in
a child or adult under middle age never reaches 39.5° C.=
TEMPERATURE IN TYPHOID FEVER.
Ill
103.1° F., and indeed if it has failed to do so two or three times ;
when as early as the second half of the first week considerable or
progressive dim inntions of the evening temperature are met with.
Oontrarily, thermometric observations alone raise the suspicion
or support the conjecture that typhoid fever is latent: in slight
cases, when the course of the temperature does not depend on a
local affection, the object of the complaint of a parent; in the
first week or first four days of the disease, when the disease at¬
tacks one previously ill or convalescent. To decide upon the
pr esence of typhoid fever, morning and evening temperatures
for three days in the beginning, four to six in the fastigium, or
as much in the convalescence, are necessary.
The temperature indicates the severity of the disease about
the middle of the second week, rarely earlier. A single observa¬
tion does not do it, a whole day's observation gives it; but two or
three days are still better. It indicates, best of all signs, the
irregularities in the course; the complications that 110 other
means can detect; a relapse after the patient has begun to re¬
cover; warns of the tendency towards death ; regulates the po¬
tency of therapeutic operations ; shows the tendency to convales¬
cence with great defiuiteness, etc.; besides the most important
fact that a large thermometric experience in typhoid fever has
rendered possible the knowledge of its course and the certainty
of its diagnosis and prognosis, which were absolutely impossible
with the previous means of observation.
The typhoid fecer is characterized by a fever which lasts for
at least three weehs (excepting extraordinary cases and those
of rapid death, seldom lasting less than a week). The maxi¬
mum temperature is seldom less than 39.6° C. = 103.28° F.;
more commonly 40°—41° C. = 104°—105.8° F. ; when hyper-
pyretic, rarely above 43.5° C.= L10.3° F. Fatal above 41.5° C.
= 106.7° F.
The daily course is according to the intensity and the period
of the disease. Either continuous with highly febrile elevations
in very severe cases ; or subcontinuous or continuous without
great intercurrent elevations at any time in severe cases. It is
remittent at the beginning of all cases moderately severe or
slight; often at the height of the severe cases, and always at
the beginning of convalescence. Altogether, the type of the
typhoid fever is remittent (with sharp curves) during the period of
recoverv. Its course may repeat itself irregularly in many of the
112
temperature in typiioid fever.
severe cases, at critical periods, or bv the operation of circum¬
stances.
Accordingly the daily average on which the daily fluctuations
are based, varies a good deal; in the continuous form with ex¬
acerbations it is 40.5° C. = 104.9° F. or more ; in the subcontin-
uous and continuous 40° C. = 104°F. or a few tenths more or
less; in the milder remittent about 39.5° C. = 103.1° F.; in
slight cases as low as 39.2" C. = 102.56° F.; at the commence¬
ment of and in the convalescence still lower, in the former with
sharp curves, 38°—38.5° C. = 100.4°—101.3° F.
When the fluctuations are irregular, the daily average is un¬
certain, and affords no indications.
The daily mixima are included between noon and 11 p.m. :
commonly between 4 and 7 p.m.
The extent of the exacerbations at the height of severe cases
is very large; the rise begins between 7 and 9 a.m. ; the curve
is single-peaked with a broad summit (rarely two, three, four-
peaked). From the third week on, the latter peaks prevail, and
the single ones are more acute in the convalescence, thus nar¬
rowing the extent of the exacerbation.
• The rise of the multiple peaks occur : the first between 9 a.m.
and 4 p.m. ; the second between 2 and 8 p.m. (often at 6);
the night-rise is between 1 and 5 a.m. sometimes double, first at
11 p.m., second as above. The second of a double-peaked sum¬
mit is the higher in the period of increase. The lowest point
of the remission occurs between midnight and 10 a.m., oftener
at 6, 8, and 9 a.m. ; it is not very low, is very acute, lasts only a
few minutes in recent and in severe cases, but increases in
breadth with the progress of convalescence.
The rise of temperature is either gradual or sudden, a seg¬
ment of it may be tardv, the remainder rapid. The daily de¬
scent is slow, effecting the form of an easel, rapid only when
there are irregularities.
Typhoid fever has two principal types which agree at their
beginning and end, but not in their middle coarse. This distinc¬
tion is justified also by anatomical differences. One lasts but
three weeks, and presents only slight infiltrations of the plexus
of intestinal glands (plaques inolles); the other lasts from four
to six, sometimes nine or ten weeks, and presents extensive and
successive deposits. In the former, the cure takes place easily
by restorative, retrograde metamorphosis ; the latter, on the con-
TEMPERATURE IN TYPHOID FEVER.
113
trary, needs a complicated process of elimination, to dislodge
the deposits. Ulcers follow this dislodgment, whose healing is
protracted. This complicated process of restoration affords
numerous opportunities for ulcerous extensions, intercurrent
febrile attacks, complications, and accidents.
There are cases corresponding almost to these typical descrip¬
tions, but the majority occupy a middle ground, approaching
nearer one or the other type anatomically as well as pathologi¬
cally. Exceptionally, the difference between the two types is
marked from the beginning. The duration of the two varies in
different places, and in the same place at different times. The
mortality depends chiefly upon the preponderance in numbers
of one or the other type: all conclusions as to the results of
therapeutics must be subordinate to these rules.
Fig. 39.
MILD TYPICAL TYPIIOID FEVER.
HE glass sataHHMBriWiWiiw.iBnnnHSjBUMHiaaBHHHinBVHfflEiBU
SBHIBWMMUBUaMBMI'MllMMBBgBMM—BM—nil
iBBBBTflUBBBBBBnBBHBItJBI'IBVlBlVIBBrrBnBBBBBBHiraaBB
ieiBHBSHHHIIBUHniBMUaMllllWIIOBaaWHHaBNHiaaHB
|BBra:WlBBBBBBBBBBaBBflBBBUBBBlTiB14BB,i1BnaraBHBBfl
RHBaViBBnaBBBBBBBBBaaBBBBBBI'IBaBlMIBIiiaaBBBBaj
iHBBBBBaBBSBBBflflBBBBBBBBBBUBflfll'iBBIianB^BflBn
BIZVJB£:l:-£tvmf?<g3H!g]aBBBBBBBBiaBBBBBBBBBBB'aBiri&£aBBlBB
irflUBBBffigBBBBBaHBBBaBBBBBBBBBBBBBMHUIBnBBBB
^BBBBBMBBBBBBBBIBBBHBBBBBBBBBBBIIIBIIIBIW
'MaBBBBBBBBBflflflBBBHBBBHBBBBBBflBBI'iBllflllBSWfll
SBnBBBBBnSHBBBBBBBHBBBBilBBBBflBBBUBI'iBI'iBWBBH
IBBIiaHHBHHBBHBBBHBBBBflBBBBBBBBflBBBUBIIBIIflkVfl
iMHBBBBBBBBBBBBBBBBBBBBBBBHBBBBBBHBBBBHIBHai
|BBWBIBrailfimmBBBWnim«BBBBBBBWIBI1BBBBBMBBBII!ai———
An effervescence of seven days, afastigiumof seven days, and
a defervescence of seven days ; the antique trilogy. But sim¬
ple as it looks, how difficult it is to make it out. Mere chance
gave the opportunity to study the temperatures of the first
days. That admirable and terrible progression pathognomonic
of enteritis, Who is present to trace it from the first day, to
mark its progression from morning to night till it reaches the
characteristic evenness of the fastigium? If the physician is not
called almost before the disease is felt like a malaise, the
family has no means of information if they have no thermom¬
eter • the patient does not go to the hospital before his forces be-
/
114 TEMPERATURE IN TYPHOID FEVER.
tray him ; and then his observation begins somewhat as the fol¬
lowing one.
Fig-. 40.
IBBBHBB*9aBBBaBBi|
IBBBBaBBBBBBBB
IBBBBBBBBBBBBB
woBansnaa
■bbbbbhmIR
■MBBBiaatfi
saiuBHiam
BBBS9IBIBBBIBIII
[abmohi u bb aa aa bb aa aa isa bb hi
B—BBBBaBBBBBBBBBBBBBBBBHI
■MMMHaHIBBaBBaBBI
IBBBBBBBBHBia
■bbbbbijbbbib
,«BHBBBBBBBflBBBBBS>i«BailB!
[aian bigs Bra aa aa bb an b * an aai a
BBjli'BnBV9r:1BMBnBlkaffVl'll>ial
Era B't'aa aa bibm bib nana ibbb
BIBB Bit IB HMM
■bb bb iiB aaaaiaBi
■bbbbbbbbbbub——
Here the patient surrendered himself after two weeks of
struggle. "What struggle 1 In the absence of record of the
untold fourteen days, we may surmise that he had passed
through the ordinary crescendo, with remissions of the first
week of effervescence; and seeing the great ecarts of the 15th
and 16th day, we must suppose that they are the continuity-
waves of a very stormy second week. Thence the temperature
settled for almost two septenaries, with less than a degree of
ecart between 39.5° and 40.5°. So far up from the norme!
Yet note the sudden collapse of exhaustion the 24th day, as if
nature had given up supplying ustion at such rate; but the
impulse up was irresistible, combustion went on till death came
in the middle of an all-devouring hyperpyrexy of 42.6° C.
After the consideration of the types comes that of the indi¬
vidual circumstances, irregularities, and deviations from the
normal course of the fever, whose influence is almost null on
the first type, but great during the second.
A relapse entering, just when the fever of the first attack
leaves the patient, presents the most typical course of typhoid
fever. The regular course of typhoid fever is met with in
healthy persons, set. 18 to 20, other circumstances being favor¬
able. On the other hand, in children (the younger the worse),
in people above 35 or 40, or sick of some other disease, in puer¬
peral and scarlatina cases, and particularly in endo- and peri¬
carditis, pleurisy, phthisis, hysteria, and parenchymatous ne¬
phritis, the typhoidal type is more obliterated.
TEMPERATURE IN TTPIIOID FEVER. 115
The course of the typhoid fever is rendered irregular by
simultaneous epidemics, by being very slight, or very severe,
or extremely short, by injurious influences before or at the
beginning of the attack, defects of nursing, mistakes in the
treatment, undue muscular exertions, severe haemorrhages,
perforations of the bowels, complications of overwhelming
severity.
On the other hand, a skilful treatment will often favorably
modify the type.
At the approach of death the characters of the normal course
disappear.
Yet, through these deviations and irregularities some indica¬
tions of the reign of law are perceptible. In both regular and
irregular cases, the typhoid fevers may be divided into two
well-marked periods, which are distinguished by the thermom¬
eter with great certainty. The first corresponds to the deposi¬
tion and infiltration (in the intestinal glands); the second to
its elimination, and to the restoration and repair of the dis¬
eased parts. Both stages are marked by points at which an
alteration of the fever occurs, not sensible to anatomic, but to
thermometric investigation.
It is noteworthy that in the majority of cases which run a
regular course, the duration of the separate periods corresponds
in time with the division into weeks and half-weeks. The al¬
terations in the course, and the transitions from one stage to
another, occur at the beginning or end of a week, or in the very
middle. This type is most decidedly shown in the brief and
mild forms, and in the third or fourth week of the more severe
ones (in the relapses).
Setting aside a period of incubation whose symptoms—dis¬
orders of the bowels, headache, febricula, and rigor—escape the
observation, the initial stage of abdominal typhus runs its course
with great regularity, whatever complexion the case may after¬
wards assume. During three or four da}7s the temperature al¬
ways takes the ascending course, rising about 1°—1£° C. = 1.8°
—2.7° F., from everv morning till evening ; and falls from every
evening till the next morning about .5°—.7° C. = .9—1.3° F., tiil
on the third or fourth evening a temperature of 40° C. = 104°
F. is reached, or a little exceeded. The formula of this ascent
is nearly as follows :—
116
TEMPERATURE IN TYPHOID FEVER.
First day, morning, 37° C. =98.6° F. ; evening, 38.5° C. =101.8° F.
Second day, morning, 37.9° C. =100.21° F. ; evening, 39.2° C. =102.56° F.
Third day, morning, 38.7° C. =101.66° F.; evening, 39.8° C. =103.64° F.
Fourth day, morning, 39.2° C. =102.56° F. ; evening, 40.3° C. =104.54° F.
The initial stage of typhoid fever very closely approximates
this type; very seldom does any other disease show a similar
pyrogenic course, which is of itself a decisive test for diagno¬
sis. In other words, if the temperature of the second, third
and fourth evenings is only approximatively normal; if the
temperature of the first three evenings, or of two of them, is of
the same height; if the temperature of two out of the first three
mornings isalike ; if the temperature of the first two days rises
to 40° C.=104° F. or more ; if the temperature retrogrades only
once on any of the first four mornings and evenings; in every
one of these cases we may or must exclude typhoid fever from
our diagnosis; and contrarily, said diagnosis is the more certain
as the course of the temperature of the first four days comes
nearer to the above formula.
Meanwhile^ exceptions must not be overlooked. The rise
may be .completed in two days, or protracted five; both fore¬
boding a severe course, the latter a delay in the favorable turn
(crisis or lysis) till the middle of the third week ; the tempera¬
ture may return to normal the second morning, and be succeeded
by a greater rise the second evening; the rise of the first and
second day being less, that of the third and fourth will be much
more ; the height reached the third and fourth day is not always
40° C. = 104° F., but may be a few tenths less, or more by a
whole degree. 41° (1 = 105.8° F.; when the typhoid fever is sec¬
ondary to another disease its initial is obscure, often unrecogniz¬
able.
This first period decides nothing as to subsequent mildness
or severity, and in the majority of cases escapes observation
because medical advice is sought for ordinarily iater.
In the second half of the first week and the first half of the
second, the course of the temperature is quite uniform, but can¬
not help the diagnosis. At this time the maximal height, 40°
—41.5° C. = 104°—106.7° F., is reached rarely more than once
between noon and evening of the fourth or fifth day ; mean¬
time the morning temperature is .5°—1.5° C. = .9°—2.7° F. lower
than the evening's; one remission may be accidentally even
lower.
TEMPEKATURE IN TYPIIOID FEVER. 117
During the second half of the first week the daily maxima
remain close to the maximum; the first half of the second
week, though agreeing in the main with the former, shows a
trifle lighter exacerbations when the cases will turn favorably,
and the remissions become somewhat deeper; so that the fas-
tigium divides itself into two segments, the first with more
severe exacerbations and less average remissions, the second
with more moderate exacerbations and more considerable re¬
missions.
The first stage of the fastigium ends the seventh or eighth
day (really from the sixth to the tenth). During it, one tempo¬
rary diminution of temperature may occur, once in a morning
and once in an evening, generally before the tenth day. This
period may be mild or severe ; nothing can be predicted from
it with certainty.
Cases will occur with an unusually mild course of four to
eleven days, with evening temperature at 39.6°—39.8° C. =
103.28°—103.64° F., possibly with intercurrent moderations;
and morning remissions as low as 1.5°—2° C. = 2.7°—3.6° F.;
or the course appears to be cut short.
Early convalescences may be due to the mildness of the af¬
fection, to a judicious treatment, even to an opportune laxative ;
other cases occupy the normal time (three weeks), though all
the symptoms are mild ; and in others the fever recurs in con¬
sequence of new deposits, and runs new periods. We regard
this as the probable course of the disease, though in the early
recoveries, in the absence of post-mortems, the typhoid al char¬
acter remains doubtful; and in regard to the protracted recov¬
eries, we are not certain that the course of the typhoid fevei
must have a fixed duration, or cannot occur without certain
symptoms reckoned as pathognomonic. But we can say that,
in our time and our country, it is rare for a case of well-char¬
acterized typhoid fever to last less than two weeks and a half
(unless by the agency of therapeutics); and even for a mild
case to show a decided defervescence before the twenty-first
day.
Meanwhile, it is quite possible that under these denomina¬
tions, abdominal typhus, enteric, or typhoid fever, etc., may be
included two essentially different diseases, though both located
in the glandular apparatus of the bowels : one, a general dis¬
ease the product of infection, the other a local enteritis in
118
TEMPERATURE IN TYPHOID FEVER.
which the follicular apparatus alone is affected. What happens
in scarlatina supports this hypothesis, in cholera also, where the
epidemic induced by contagion is perfectly simulated by the
simple cholera morbus. This obscure condition thermometry
cannot clear up, but it adds the strongest light to the evidences
of etiology, of circumstances, and of the remaining symptoms.
For instance, if the temperature several evenings reaches the
range of typhoid fever, without particular reason or bad nurs¬
ing, the presumption is that it is typhoid. Even if the tempe¬
rature is like it for a septenary, or only a little below, all other
symptoms conformable, set. above 30, or an anaemic child, the
presumption is still for typhoid fever.
However characteristic may be the fastigium, its information
is no sure guide to those who have not had the opportunity of
studying the initial period ; and typhoid fever may then be mis¬
taken for pneumonia, and vice versa, especially where hepatiza¬
tion takes place slowly ; for acute exanthems, typhus by the tem¬
perature in the fastigium (though ordinarily higher in this), cere-
bro-spinal meningitis, acute osteo-myelitis (which has the same
fever course, but with local phenomena), acute tuberculosis,
trichinosis (which lias the same course of temperature), abscess
of the liver and pyaemia (similar symptoms), intestinal catarrh
(which has a lower range of temperature if the nursing is
proper), influenza, under the same conditions as the catarrh.
Although thermometry does not always, but often, succeed
in mastering these difficulties of the fastigium period, it per¬
mits us to exclude typhoid fever from the diagnosis in young
adults when the evening temperature keeps under 39.6° C.~
103.28° F., and in all cases when, during the severity of other
symptoms, the temperature sinks to normal. It confirms a
typhoid prognosis in illness of moderate severity during the
fastigium, when previously healthy persons of youthful or
middle age, after being ill five days or a week, ' exhibit even¬
ing temperatures of 39.7°—40.5° C. = 103.46°—104.9° F., or a
little higher, alternating with morning temperatures lower by
.7°—1.5° C. = 135°—207° F.' (grave complications or gross
neglect excepted).
If the fastigium mark 41° C. = 105.8° F. or more, or if there is
no remission, it is owing either to the severity of the case, to the
want of proper care, to manifold mistakes, or to complications
(rare at this period). Though extravagant temperatures are
TEMPERATURE IN TYPHOID FEVER.
119
rather against than in favor of typhoid fever, thermometric
observations conducted for a few days may decide the affirm¬
ative.
In the middle of the second week, between the ninth and
twelfth days, slight and severe cases show a well-defined dif¬
ference.
In slight cases the fastigium is shortened, with or without a
brief perturbation ; the favorable crisis (on the tenth or twelfth
day) shows the first decided morning remission ; the second
may be less marked, but those following increase at the same
time that the exacerbations decrease in severity; the dailv
ascent begins later, the corresponding fall begins earlier ; a
decidedly descending direction is taken by the temperature,
and the twenty-first day, if not sooner, the decrease of evening
exacerbations shows the convalescence established.
When the conversion of the short daily curves of the fasti¬
gium into the slanting ones of convalescence happens during
the second week, it is a sign of the mildness of the case, but no
pledge against unforeseen dangers ; it promises only that their
sequel, less severe, may be averted by vigilance.
Less trustworthy is a considerable and early decrease of the
evening exacerbations, so that they approximate the unlowered
morning remissions; this is fraught with irregularities and
fresh elevations of temperature.
The surest course towards convalescence is increased morn¬
ing remissions, succeeded by milder evening exacerbations, so
that in six to ten days the temperature approaches to normal,
through a descending zigzag progression. The difference be¬
tween morning and evening temperatures may thus remain the
same, or increase by the greater fall of the remissions; but the
daily differences become less through the steady fall of exacer¬
bations, till at the end of the third week normal temperature
and convalescence meet.
This regular course leaves no doubt as to the diagnosis. Ca¬
tarrhal pneumonia and influenza recover similarly but quicker,
without fever during the third week; cerebro-spinal meningitis
and trichinosis, with high temperature and in remittent form,
are more protracted and more commonly interrupted; and
other affections whose recovering affects this remitting form,
have not so high a fastigium.
Other varieties of defervescence (than the remittent) are less
120
TEMPERATURE IN TYPHOID FEVER.
common during the third week. Apparent deviations from
these types are dne to erroneous chronologic statements.
With this course of temperature complications are rare, unless
induced by epidemic, constitutions. On the contrary, recru¬
descences and relapses are frequent, particularly in mild forms.
Recrudescences are initiated by a rise of the temperature or by
an interruption in the descending course, rendering remissions
imperfect and hastening exacerbations. On the contrary, re-
lajpses begin after the fever has left the patient, even during
convalescence; they have a regular, and generally favorable
course of twenty-one days, as said before.
A severe course of disease is predicted by persistent morning
temperatures above 39.5° C. = 103.1° F., and evening ones above
40.5° C. = 104.9° F.; by the punctuality of the daily exacerba¬
tions, and by their prolongation beyond midnight, whilst the
daily differences are slight, rendering the course subcontinuous;
and when the minimum daily exceeds 39.6° C.=: 103.28° F.
(lowest limit of typhus exacerbations); or when the tempera¬
ture does not moderate sooner than the twelfth day.
All irregularities in the second week are suspicious, particu¬
larly no increase of the remissions, with almost standstill ex¬
acerbations, even if the morning temperatures are higher than
the evening. 40° C. = 104° F. in the morning, and 41° C.=
105.8° F. in the evening, during the second week, with a ten¬
dency to a rise, is a sign of a severe course; and worst of all
are apparently purposeless fluctuations, among which are sud¬
den decreases of temperature foreign to the course of typhoid
fever.
In severe cases a complicated course is particularly expected.
The least dangerous is that in which (everything else being
moderate) the evening exacerbation stands over 40° C. = 101°
F., and once above 41° C. = 105.8° F., with morning remis¬
sions of atleast 1° to 1.5° C. = 1.8°—2.7° F.: the course going on
till, or to the end of the third week, prior to any improvement.
Sometimes the moderation comes in this way: the high tem¬
peratures of the second week do not recur, falling about .5° C.
Iff.9° F., with high fever and inconsiderable remissions; con¬
siderable remissions may be postponed to the fourth week, even
in pretty favorable cases. Or the temperature may remain as
high as in the second week or rise higher, during the third and
fourth. The remissions are less than in the initial period, the
temperature in typhoid fever.
121
exacerbations higher, even exorbitant; the former at 39.5°—
40°, even 40.5° C. = 103.1°—104°—104.9° F., the latter to 41°—
42° C. = 105.8°—107.6° F., the mean daily being 40° C. = 104°F.;
the remission lasts one or two hours, and the exacerbation, thns
extended, begins at 8 or 9 a.m., continues till midnight or even
later, commonly describing two or more peaks.
Or, one irregularity may bring on another, resulting from
the severity of the case, bad surroundings, idiosyncrasies, epi¬
demic prevalences of an inflammatory character, like pneumo¬
nia. Asiatic cholera supervening, depresses even thirty-six
hours before its collapse, and twenty-four before its character¬
istic diarrhoea commences: apyrexia being here a premonitory
symptom. Intercurrent hemorrhages, too, depress the temper¬
ature even below normal, but it soon rises again. The momen¬
tary elevation of temperature in the former cases, and the mo¬
mentary fall in the latter, are not the sole effects of the compli¬
cations ; they, also, destroy the typhoidal type, and prove in¬
jurious even after they have been happily overcome.
Extraordinarily, considerable falls of temperature occur with¬
out known cause, without collapse, but with weakness of the
cardiac contractions, enormous frequency of the pulse, delirium,
automatic muscular movements, coma or extreme prostration,
resembling the fall of temperature of the pro-agonic period.
These falls presenting great danger, yet not always fatal, we
call " pro-letho^" or " pro-agoniform."
Unless death succeeds, all severe cases have this in common:
the fastigium and the whole course are protracted ; at tolerably
well-fixed days a moderation, at others an elevation of temper¬
ature happens. The remissions seem to prefer the last days or
the middle one of a week; the rises come immediately before
those days or at the beginning of a fresh week. The common¬
est event is a striking rise of at least .5° C. = .9° F. or more,
about the twenty-fifth day, happening in the middle of a well-
settled remission.
At this stage the diagnosis is seldom doubtful, unless tuber¬
culosis or cerebro-spinal meningitis be suspected (if the latter
is epidemic, for instance). Altogether, every case so protracted
and complicated is threatening. A height of 41.2° 0. = 106.16°
F. leaves little hope but through a tedious protraction ; at 41.4°
C. = 106.52° F. we see one cure out of three; at 41.5° C.=
107.15° F.j recovery is a rarity. Fiedler had two recoveries at
122
TEMPEKATUKE IN TYPHOID FEVER.
41.15° C., all the others and higher ending; fatally. Wunderlich
had a recovery at 42.2°C.=33.7°K.=107.825°F. during a rigor.
A repeated rise to a considerable height, say 41° 0. = 105.8° F.,
increases the danger considerably. Yet these are better borne
if the morning or intercurrent temperature is low, high tem¬
peratures with remissions being less dangerous than an almost
continuous height. If the morning temperature exceeds 41° C,
=105.8° F., death is almost certain. If the temperature is
higher in the third than in the second week, let us take notice.
All gross irregularities afford a bad prognosis or threaten
further complications.
Severe cases rarely terminate by favorable crisis oftener
an amphibolic stage intervenes. This stage may intrude in
cases previously slight; in aged persons, after previous ill-health,
in recrudescence or relapse, after an irregular early stage, in
patients exposed to injurious influences, having made great
muscular exertions, etc. It commences in the third, sometimes
in the fourth week, ordinarily preceded by an extensive remis¬
sion, even by collapse, and exhibiting its apparently purposeless
improvements and lapses. Its evening temperature is high, less
so, however, than that of the fastigium; if not at one particular
day, at least on the average. Intereurrently there are remissions,
extensive but not steady, since favorable symptoms are followed
by relapses ; the falling of the temperature may degenerate into
collapse, followed through great apparent danger by striking
rises of temperature. Sometimes exacerbations of a stationary
height alternate with deep remissions to or below the normal
point, followed by collapse.
Although defervescence may establish itself through these ab¬
normal alternations of a week or so. it is more common to see
other abnormalities succeed these, viz., deep fall of temperature,
or even collapse at the time appointed for exacerbation ; trans¬
fer of exacerbations to the time of the remissions, and vice versa,
with no apparent cause,object,or danger; complications which
raise the temperature and mask the remissions ; and sudden
great fall of temperature with haemorrhage or perforation after
a recrudescence of the course and a renewal of the symptoms.
Rigors also set in with great rise of temperature, indicating
pyaemia or septicaemia. This stage (amphibolic) lasts from
three days to almost two weeks.
If the disease is tending towaids death, the jpro-agonic stage
TEMPERATURE IN TYPHOID FEVEK.
123
often commences with deceptive and irregular depressions of
temperature, quite discordant with the remaining symptoms.
In other cases the temperature rises steadily, particularly in the
morning, to 41° C. = 105.8° F., followed by sudden elevations
up to 42.5°—43" C. = 108.5°—109.4° F., or above. Or a sud¬
den deep fall is accompanied with extreme collapse.
The death-agony is not always preceded by a distinct pre¬
agonic stage ; death may be as sudden as unexpected. In the
death-agony and in the actual moment of death the temperature
may be very low, highly febrile, or even hyperpyretic. If the
temperature rises in the death-agony, it is with an increased
rapidity at the approach of death, amounting to 1.5° C. = 2.7°
F. in a single hour. Death generally happens between 42°—
43° C. = 107.6°—109.4° F. Post-mortem elevations are met
with, but last only a few minutes.
When severe cases tends towards recovery, this often occurs
after a critical perturbation, lasting from a few hours to a few
days. Oftener, a moderation of temperature prepares the ill-
defined commencements of recovery. This jprejparaton^y mod¬
eration shows itself either in a single remission, somewhat
deeper than others, or in a slighter exacerbation, or in a tem¬
perature slightly descending for several days; the type remain¬
ing subcontinuous, with a daily mean of about 40° C. = 104° F.;
lasting a whole week before any improvement appears. The
amendment is generally announced by a great fall of tempera¬
ture during remission time, even somewhat lower than will be
that of the next day.
The beginning of decided improvement, in cases of moderate
severity, often occurs about the middle of the third week, in
severe cases at its end, in the middle of the fourth, or even later.
Defervescence occurs after the remittent type, as in lenient cases,
only it may last longer. It may be so excessive as to cause
more than one collapse, or it may induce a stand-still, even a
slight relapse. Sometimes its even course is broken by single-
moderate or colossal fluctuations, by a solitary large rise, or by
several such, between which the temperature of the morning
is found normal: or it is interrupted by a subcontinuous eleva¬
tion of temperature lasting several days. Actual relapses are
often witnessed during the defervescence.
Sometimes instead of showing a clear tendency toward death
or recovery, the amphibolic stage elongates itself in a lentescio
124
TEMPERATURE IN TYPHOID FEVER.
process (from lentesco, cleave, etc.), due to continuous ulceration
of the bowels, or suppurative bronchitis, or tardy local affections,
or to marasmus. The course of the fever, then, is chronic, with
evening exacerbations and morning remissions which may reach
the normal: duration illimited.
Complete recovery is admitted on the testimony of the tem¬
perature showing absence of fevers in at least two successive
evenings; the thermometer is the final judge of recovery.
However, during convalescence the temperature often falls
somewhat lower, say 36°—36.5° C. = 96.8°—97.7° F. in the
morning, and under 37° C. = 98.6° F. in the evening—a good
rather than a bad omen. But very often this period of recovery
is complicated. The least significant disturbance consists in a
brief, though quite considerable elevation of temperature,
caused by the first indulgence of animal or other food, or by
some moral impression.
In grave, more than in slight cases of typhoid fever, febrile
movements of one to three days will interfere with the march of
recovery (simply retarding it). Thermometry tests these, and
besides, the action of epidemics in protracting the disease. Fre¬
quently true relapses, or repetitions of the typhoid process, oc¬
cur during convalescence, and can be recognized only by the
temperature of the first few days (no other symptom being then
pathognomonic). These relapses are to be dreaded if elevations
of temperature above the norme occur eight days or more after
the beginning of convalescence ; though with timely care they
are not dangerous, and offer the most perfect example of a
simple, favorable, and quickly recovering typhoid process.
Various hypo strophes (vTroarpocpr], return, relapse) may occur
here, that a fresh rise of temperature only can expose. On this
account let us continue upon the convalescents the thermomet-
ric observations begun upon them when sick.
In childhood, particularly in the youngest subjects, the course
of typhoidal temperature is somewhat irregular. The com¬
monest of these irregularities is its extreme mildness; yet the
temperature rises in the first days to a higher average than in
adults; it passes more quickly into the remitting period, and
defervescence is less protracted ; but complications often occur,
clearly indicated by the temperature. These irregularities of
temperature render the diagnosis of typhoid fever very difficult
in children.
TEMPERATURE IN TYPHOID FEVER.
125
Injpeople over forty the temperature is lower than in younger
adults, reaching in the exacerbations of the fastigium only 39°
—39.5°=102.2°—103.1° F.; 40° C. = 104° F. exceptionally, and
in the morning it falls below 39° C. = 102.2° F. The course,
also, is more irregular. The fastigium seldom lasts over the
second week ; an amphibolic stage or complications protract
the recovery; collapse often occurs; the temperature falls be¬
low normal during their convalescence, and in recovery oftener
than in younger people. The beginning is often mild, even in
fatal cases. Death occurs with a high, but oftener with a mod¬
erate or low temperature.
Ancemic people recover comparatively early, but are rather
subject to complications, to haemorrhages (not severe), to affec¬
tions of the brain, lungs, parotid glands, and to bed-sores, more
dangerous in them than in other people.
Previously existing diseases, which persist through a typhoid
fever, render its course irregular, more severe, and obliterate
its type, even to the death hour. Pregnancy and the puerperal
state have this effect, but not by any means in all cases.
As to the effects of treatment on temperature:
The cold-water treatment, so-called, consisting in cold baths,
douches, ice-bags, compresses, wet sheets, etc , is the most
powerful. After each application it leaves a depression of
about 1°—3° C. = 1.8°—5.4° F. and more ; six hours or so a feb¬
rile reaction follows, which rarely attains to the previous height;
otherwise the kind, the extent, the duration of the application
diversify exceedingly the results. Greater and more lasting
are these results in complete baths and quickly repeated cold
packs, especially for children ; when the fever is mild, with a
remittent course, the application is to be made at the time of
the natural remission. Less, or no effect, is obtained from
shorter applications of cold to grown-up people in earlier
stages, in severe cases, in a subcontinuous or complicated
course, during the ascending height or exacerbation. By the
application of cold the_type of the course is altered, remissions
obscured, exacerbations dislocated/ the course itself is rarely
shortened, rather prolonged, but rendered milder. Also, when
the type is subcontinuous it passes to the remittent, though
anomalous at first, and further progress follows the remission.
Other good effects are obtained from the cold-water treatment
foreign to this subject. But as to its results, it diminishes con-
126
TEMPERATURE IN TYPHUS.
siderably the mortality, and has brought up cases considered
desperate.
The early use of calomel (30 centigrammes=6 grains), and
not so surely of some other laxatives, influence the course by
producing remission. This is followed by a rise, not commonly
to the former height; after which defervescence, apparently
hastened, follows in a remittent fashion. Their recovery takes
place earlier than in cases left to themselves, however mild.
The early use of calomel delays the rise to the maximum
height ; if the maxima attain 40.5° C. = 104.9° F., it has done
no good ; and the later it is exhibited, the less beneficial.
Digitalis (2 to 4 grammes = 3 ss.— 3 i., or more) in divided
doses, for several days in the second and third week, imme¬
diately moderates the temperature in a great number of cases,
producing in the exacerbation a fall of at least 2° C. = 3.6° F.,
which does not last more than a day. Then the temperature
rises again, not so high as before in favorable cases, but remains
stationary at a moderate height, with a much depressed pulse,
whilst defervescence takes place as usual. Then the pulse re¬
covers from its artificial retardation, and convalescence has
meanwhile advanced.
Quinine (1.2—1.8 grammes = Si.— 3 ss.), divided in three
doses, a few hours apart, powerfully lowers the typhoid tem¬
perature ; more moderate doses may do it, but are not reliable.
There is no other form of disease in which so numerous in¬
vestigations and facts have been accumulated as in typhoid
fever; but none has an importance equal to this.
Liebermeister gives the following figures as the results of
his own experience in the treatment of typhoid fever:
BY VARIOUS METHODS.
YEAR8. CURED. DIED. RATIO OF MORTALITY.
1845-53 444 159 30.4
1854-'59 643 172 26.7
1860-'64 631 162 25.7
INCOMPLETE APYRETIC TREATMENT.
1865-'66 982 169. 16.2
REGULAR APYRETIC TREATMENT.
From Sept., 1866, all 1867, 339 33
1868 181 11
9.7
6.1
temperature in typhus.
127
II.—Typhus.
(Syn. : Sjpotted Fever, Exanthematic, Petechial or True
Typhus.)
As far as known by accurate but not numerous observations,
the fever in typhus has a definite, typical character, most
readily recognized in mild and medium cases. It differs from
the typhoidal, with which, however, it has some analogies.' It
is shorter than the typhoid, and longer than all the rest of acute
diseases which run a typical course. Its initial stage, its fasti-
gium (with two periods), and its defervescence, are each .char¬
acteristic. Observation of the course of temperature through
one of those periods permits a diagnosis of great probability,
and through any two of them of great certainty ; it even gives
the means of distinguishing the mild, moderate, and severe
cases. Only in the latter alone is diagnosis sometimes almost
impossible. Irregularities in the course, with or without com¬
plications, have not been yet characterized, owing to the small
number of the observations.
Fig. 41.
mild typhus.
Fall1
101- 6\ 42
■■■■hnamrabansaaimibbianbmmi
■ibmhnnhhibkaamiflnaghmirmaan
ebbrabmbrbbbbbbbbhbbbbdbshh
bbiva.wawibbbnbbbbbbbmbbhi
rmmuamimnibbbbibhhbn
mbubub obii^bubbbbbbbbiiabb
hbbbbble*li»?r« bbbibbbbbib«hh
■jbbbrl'fbibubbbrbbbbbibmb
kbbbbbbbbbbibbbbbbhbhi
!SSSS
Baaa
bmm
bbbi
ksaxab »k»
isbskbbbbbi
wmiibhbb
bbbbhmbb
mbbbbbb
bbhbbbbh
bbhbbbmb
Sbmui bit!
hubbbwiill
bsbbbb
■bbbbblvbbb
blvbbbbbbbbn
mitjaibbbbbnan
bubilbbbbbib
BHBBiil'ilBBiBBSaB
■bht'ib'bbiabhbi
■iuarjnbm
ibbkvlhbbebh
ibbubbbbb
In the beginning (particularly with rigor), the temperature
rises more suddenly than in typhoid fever, reaching 40°—-
40.5° C. = 104°—104.9° F. in the first evening; on the next
morning it recedes between the norme, 39.5° and 40° C. = 98.6°
103.1°—104° F.; again on the second evening it is up to, or
above 40.5° C. = 104.9° F.; on the third to 41.5° C. —106.7° F.;
128
TEMPERATURE IN TYPHUS.
and oil the fourth rarely under 41° C.=105.8° F., often above,
even in cases which recover. At this period, neither ther¬
mometry nor the other symptoms are able to found a positive
diagnosis. Particularly it cannot differentiate typhus from
relapsing fever; but it can from typhoid, by its more sudden
rise. Etiology (proof of infection) is yet, at this stage, the
only foundation of typhus diagnosis.
In moderate cases, and such as take a favorable course, the
temperature has reached its summit 011 the fourth day. Thence
to the three days which close the first week, occurs the turning-
point marked by a very trifling decrease of temperature. On
the seventh or eighth day a greater remission succeeds, fol¬
lowed in its turn by a rise of a few days in the second week,
which, in favorable cases, do not attain the maximum of the
first. This happens seldom later than the ninth day, amounts
to .2°—2° C. = .4°—3.6° F., lasts from one to three days, and
slowly descends. O11 the twelfth day appears a preparatory
remission occupying half a day or two mornings. A third and
brief rise may succeed—-jperturbatio critica—terminating in
true defervescence/ unless this last lias followed the first
diminution of temperature of the second week, cutting short
all intervening transitions.
. In these slight cases the diagnosis remains uncertain during
the fastigium, and is confirmed only by etiology. Thermome¬
try offers a probability of typhus when it shows temperatures
uniformly ascending in the second half of the first week, and
not much less in the first days of the second ; probabilities
strengthened by the manifestation of cerebral symptoms, and
by the unimportance of all other phenomena, which cannot
of themselves found a diagnosis, but help to confirm it. How¬
ever, thermometry used from the very beginning to the middle
of the second week is able to give a valuable diagnosis. The
only mistake possible would be in the rare cases when relaps¬
ing fever extends into the second week.
In severe and neglected cases of typhus the continuous ascent
of the exacerbations continues through the first week, attaining
41.2°—41.6° C. = 106.16°—106.88° F., or more ; the remission of
the seventh day is absent, the high fever persists through part
or the whole of the second week ; morning temperature at
40° G. = 104° F., evening's 1° C. = 1.8° F. more; the remission
of the twelfth day is also absent or hardly perceptible; the ■
TEMPERATURE IN TYPHUS.
129
cases which will recover show a slight declination towards the
end of the second week ; yet high temperatures rule the morn¬
ings and evenings of the third week.
In these severe cases the diagnosis during the fastigium is
more difficult than in the mild ones, especially the distinction
from typhoid fever; for severe cases of typhis and of typhoid
are more alike in the fastigium than mild ones. However,
the daily maxima are higher in typhus, the tendency to remis¬
sion is less; these are mere quantitative differences. But
against this, rose spots may be copious in typhoid and scanty
in typhis; the brain symptoms may be equally severe in both ;
liquid stools or profuse diarrhcea may be present in both :
therefore let us understand the necessity of being careful in
making a diagnosis.
The stage of defervescence is usually very characteristic in
typhus. It is generally preceded by a short critical perturba¬
tion, a rise of a few tenths to 2° C. = 3.6° F. or more above the
preceding evening, greater in comparison to the morning; and
it follows either in a precipitous or progressive descent.
Where the critical perturbation is absent, the defervescence is
very gradual. It generally appears between the thirteenth and
the seventeenth day, seldom earlier. Postponed terminations
are rare or doubtful. The defervescence of typhus falls some¬
times in a single night from 40° C. = 104° F. or higher, to
normal ; quicker than in typhoid fever; but never so low as
in relapsing fever: characters which, in connection with the
preceding course, serve to distinguish the typhus from other
diseases.
Fig. 42.
FATAL TYPIIUS.
Fatal cases of typhus announce themselves from the begin¬
ning by the enormous height of the temperature, 41.2° C.=
9
130
temperature in relatsing.
106.16° F., and even more. There is no remission at the end
of the first week ; death may occur in the second, or the case
enters the third after some remission about the fourteenth day,
which is soon compensated. Yet, even in fatal cases the tem¬
peratures of the third week are not so high as in the former, at
least till the death-agony ; the danger during that week being
indicated, not by the height, but by the continuance of the
fever. Just before death, and in the death-agony, the tem¬
perature rises constantly from 1.25°—3.6° C. = 2.2°—6.48° F.;
average 1.8° C. = 3.24° F. During the agony I observed
40°—41°—42°, and once 43° C. = 104°—105.8°—107.6°—
109.4° F. The course of the fever in typhus was first demon¬
strated by Wunderlicli, and confirmed by Griesinger.
III.—Relapsing Fever.
(Syn.: Typhus Recurrens, Famine Fever, Fievre a Rechute.
Pelapsing fever shows itself in two forms, the recurrent or
relapsing and the bilious typhoid of Griesinger. The course of
the relapsing fever is typical; two, three, seldom four attacks
run a continuous course of several days with a remarkable
height of temperature, interrupted by intervals of several days
free from fever. The bilious form, far rarer and less studied,
runs a course quite similar. Yet, both in fatal and in recover¬
ing cases the second attack is often wanting, and the following
apyrexia too; thus the peculiarities of the type are lost.
The disease generally begins with rigor and a rapid rise of
temperature to 40°—41° C. = 104°—105.8° F. ; course continu¬
ous, interrupted by solitary peaks of exacerbation, of 41°—42°
C. —105.8°—107.6° F. : two or three elevations in a dav are
rare. Tliv fever-paroxysm lasts from three days to thirteen, and
average from five to seven. A descending direction is first
perceived at the end of the paroxysm, or if this is protracted, a
few days before the critical period. This period is one of great
and lasting fall, remissions as low as 38° C. = 100.4° F. ; the
ensuing exacerbation slighter.
The height of the temperature immediately before the crisis
is commonly 39.8°—40.5° C.-= 103.64°—104.9° F.; and the
downfall now occurs with extreme rapidity (accompanied by
TEMPERATURE IN RELAPSING.
131
perspiration or not) from 3°—6° C. = 4.4°—10.8° F. in an un¬
broken line in twelve hours.
According to Zorn, in the bilious form the fever is not so
high, from 39°—40.5° C. = 102.2°—104.9° F.; many cases prove
fatal at the first attack ; the fall is rapid too, turning sometimes
the fever into bilious typhoid. This evolntioii follows fresh
rigors, and is followed by copious perspiration ; others have a
protracted defervescence.
A period of apyrexia, free from fever, follows the deferves¬
cence ; it lasts from four days to two and a half weeks ; normal
temperatures, with healthy daily fluctuations, are rare at this
period ; more common are undulated elevations.
After reaching its lowest point of defervescence, the temper¬
ature rises again from subnormal to normal, or higher: an
ephemeral movement followed by a return to normal. Some¬
times a fresh elevation may occupy the next day, and such fluc¬
tuations may occupy several days, or at others be entirely ab¬
sent, or take place within normal limits. Thus the apyrexia is
divided into two almost equal parts, the first dangerous, often
mortal in the bilious form.
The second attack, or relapse proper, is oftener met with in
the remittent form. Its beginning is quite sudden, rising in an
abrupt line, in a few hours, at most in twenty-four, to 40°—41°
C. = 104°—105.8° F. ; but still almost always remaining under
the maximum of the second fever period. This second period
is of three or four days, versatile in temperature which ascends'
or continuously, or interruptedly through deep depressions, or
is marked by pointed paroxysms. The peaks thus formed
(rarely more than one in a day) grow higher and higher, and
the last represents the maximum of the second fever period,
which is rather higher than that of the first attack, 41°—42.2°
C. = 104.8°—107.6° F. : hardly any other disease rises so high
in cases which recover.
The intercurrent remissions are all inconsiderable but one
(first or last), lower than the others by 1°—3° C. = 3.G°—5.4° F.
In the intermittent form the remissions last longer, and the par¬
oxysms rise higher than in ordinary malarial (fever and ague).
Defervescence succeeds, with or without perspiration, by a rapid
and unbroken fall of half a day to 4°—7° C. = 7.2°—12.6° IH.,
even below the normal: isolated fluctuations are sometimes met
at the end of^this fall.
132
TEMPERATURE IN RELAPSING.
Relapsing fever generally terminates with this second defer¬
vescence, whose fall is greater than that of any other disease.
Death may occur, even after the cessation of the fever ; a third
or even a fourth attack (second and third relapses) may appear,
but are less acute, less exacerbated, less fatal.
Fig. 43.
TYPHUS RECURRFNP.
Thermometry does not yet throw any light on the fatal ter¬
minations which occur either in the fiercest paroxysm, in ex¬
treme collapse, or in other conditions. In the only fatal case
observed by Wnnderlich, the second attack was followed by an
amphibolic stage of fluctuations of a week ; he died at 41.4° C.
= 106.52° F.
CHAPTER XY.
ERUPTIVE FEVERS.
These fevers are treated of as eruptive, though others are
accompanied by eruptions, and called infantile, though adults
are not exempt from them. They may succeed each other, or
appear two at once on the same subject, or their eruptions be
so mixed that temperature remains their best or only criterion.
Unfortunately these temperatures, even their average maxima,
have not been yet irrevocably settled; we give those we have
in Appendix IX., c.
These diseases have another character in common, but not to
an equal degree, nor of the same length; it is their incubation.
This incubation has been proven for several of the^e diseases,
as well as for others, to be composed of two periods: one of
latency,in which the contagium sinks into the system; and that
of invasion, in which it begins to come out from the body in¬
fected (likely by proliferation). Moreover, the latent period
is proved to be innocuous, the invading infectious. (See Ap¬
pendix IX., A, a, b and c; and B.)
How important, then, it would be to have this distinction
extended to the incubation period of all the diseases communi¬
cable by a contagium, so that it would become possible to limit
to very narrow circles these most murderous diseases, produce
of infection (excepting the next in order).
I.—Vaccina.
Ilennig, of Vienna, notes in the first days after vaccination
an elevation of 0.2° Reaumur. On the spot of insertion a fall
of 0.5° R. during about twenty-four hours ; then a gradual rise,
which amounts, at the end of the fourth day, to 1° R., by com¬
parison with the healthy arm. Then begins the fever of gen-
134
varioloid.
eral infection, which goes up from .5° to 1° R. to the tenth day,
the most, notable feature being the local initial apyrexy caused
by the penetration of the cow-poison. 1
Squires, following its effects farther, finds that it leaves a
tendency to low temperatures for some time afterwards, partic¬
ularly during subsequent eruptions, such as the vaccineous
roseola.
II.—Variola, Varioloid.
The fever in variolous diseases exhibits two distinct types,
corresponding to the forms of small-pox: a brief continuous,
to varioloid, occurring chiefly in vaccinated persons; and a
relajpsing type, to the variola vera, which attacks oftener the
un vaccinated.
The initial fever has nothing typical. On the contrary, that
of the eruption-period, taken in combination with the outbreak
of the exanthem (even before this has any character), gives a
perfect diagnosis. The initial temperature does not distinguish
variola from varioloid, and affords no aid to predict the severity
of a case; but its course after the eruption is full of import.
That initial period is common to both types. On the first or
second day its temperature is seldom below 40° C. = 104° F.,
reached in an unbroken line, with rigor and shivering, or more
slowly in the second evening, after a morning'retrocession. In
patients previously ill (phthisis, etc.), this rise may be lower
and slower. The temperature may have attained its maximum
the second day, or continue to increase till the fourth, with
slight morning remissions. When the maximum of this initial
stage is reached (41° C. = 105.8° F.), a fall of one day begins
immediately. At this time the first traces of eruption in the
form of spots may be noticed. This stage of two to five days
is one of uncertainty; every day that passes without lung symp¬
toms, renders pneumonia improbable; but if the fifth day
passes without traces of eruption, small-pox is not likely.
Soon after the formation of the papules, the temperature falls
7nore or less rapidly, from the second to the sixth day ; if that
downfall lasts one day it is continuous, if two or three it is in¬
terrupted by evening exacerbations. In this downward course
the temperature soon reaches the normal point, and remains
there, unless modified by complications.
VAKI0LA, VARIOLOID.
135
The eruption of varioloid, when abundant, may be initiated
by a slight febrile movement, but its most trusty character is a
Fig. 44.
VARIOLOID.
WsaMMMMMBMMBMMWM—
■■=bbbbbbbbbbhhbbbbbbbbbbbb5H
gGHSarjfilBBBBBUBBBBBflBBBBBBUM
■=u»im
ffZjasaaBkVBBBBBBBBBBBBBBBBHBHBtHH
g
■=IHHMUUUIPHHIUUIIIII
nfflsBBBBABBBBBBBBBHBMB
HttiBBaukHBUHriamiun
■siviinimRmniiiiHiHMH
i^=>9nnMiiHHrs«annsBiiHHHBaH
■-■HIHUIIIlllMilllBIl
HiiiiiikiiMnHsanmHHiHii
i£a=aHannapv«B»iiiBaaiaainnBni
BBaSSBBBBBtfriBHUBHHHaBakBBflBBBB
iRisaaiBnanaBflBBaaBBBHinm
UtttfSflBBBBBUBRBBBBBBBBBliBBBBi
■fl=BBBBflHBHMHBBBHBBBlSnkBUBRHBI
BBgaaaaaaBaaaaaaaiaiaKiwaiBBwa
BMSBBBBIBBBBHBBBBSBBBHflaVBIBHB
SSBBBBBBBBBBBBBflBBBBBBQBBBBB
B33=9BBBBBBBBRBBIHraBBBHflBBnnEIHB
H=BBBBfll IBBBBBBBBBBBBBHBBB
BMsBBBBBBBBBBBBBBBBBBBBBBBBHB
MiaaBBBBBBBBBBBBBMBBBBMW
fall of temperature. This fall distinguishes small-pox from
measles, typhus, etc., and if it soon reaches normal, it charac¬
terizes also the varioloid from the variola vera.
Fig. 45.
FATAL VARIOLA.
In the variola vera (true small-pox) the falling temperature
does not quite reach normal, but remains sub-febrile, or deci-
136
VARICELLA.
dedly febrile ; or reaches normal, if at all, through tedious lysis.
Then, with the congestion of the skin renewed in the suppura¬
tive stage, the temperature rises again. This suppurative fever
is of indefinite duration, varied like the incidents of the dis¬
ease, and its temperature is commensurate with its severity : a
moderate variola hardly reaches 39° C. = 102.2° F.; irregular
fluctuations up to 40° C. = 104° F. are dangerous} in fatal cases
above 42° C. = 107.6° F. maybe reached at death; though a
patient may die with a moderate temperature. In non-fatal
cases the secondary fever lasts about a week ; in favorable ones
it defervesces gradually by lysis, or during the scabbing and
desiccation time fever may continue even longer. Simon
(iCharity Annalen, 13 Bd., 5) found after death 43.75° and
44.5° C. = 110.75° and 112.1° F.; and Roger, maximum 41°,
minimum 37.50°, medium 38.75° C. Media of the first day 41°,
of the third day 37.66°, of the fourth 38.25°, of the fifth 39°, of
the sixth 38.75°, of the seventh 40.75°, of the eighth 3S°, of the
ninth 39.25° C., confirming "Wunderlich's two prominent rules
—a high start, and a recrudescence from the fifth day up.
III.—V AKICELLA.
(Syn.: Chicken-pox.)
Varicella is inoculable with the contents of its own vesicles,
which never produce variola, and the inoculation of variola, or,
vaccination, does not prevent chicken-pox. However, the highest
authorities cannot always agree in discriminating varicella from
variola vera (Squire's Infant Temjp.,\). 25). Its incubation lasts
eight days. In about half the cases a prodromal period is man¬
ifested by a rise of temperature and a quickening of the pulse;
later, morning remissions and evening exacerbations, restless¬
ness, loss of appetite, redness of the mucous membrane of the
mouth and fauces. It may be very slight, or quite severe, its
temperature being proportionate to the extent of the eruption.
The illness precedes the eruption only by a few hours. In
well-developed cases the temperature rises 38°—40°; high stage,
two to five days; maximum of temperature attained in the
first, oftener in the second half of the fastigium ; morning re¬
missions more marked after than before the maximum; defer¬
vescence complete in half a day.
measles.
137
IY.—Measles—Rubeola.
(Syn.: Morbitti.)
4
To Squire and Thomas we owe the thermometrical demon¬
stration—in measles at first—of a stage of incubation which
cannot be recognized by any other means (Wunderlicli). Squire
traced the contagion of measles prior to the appearance of the
eruption in several subjects, and demonstrated it thermometri-
cally. (See Appendix IX, a, b, B and C.)
In measles the fever precedes the exanthem, and accompanies
it to its fullest development. Its typical character is pretty
strongly marked. But as measles is subject to many irregular¬
ities from beginning to end, so is the course of its temperature ;
and since it is the disease of children and young people, whose
temperature is the most sensible to accidental influences, it con¬
stantly exhibits strong variations from the type met in previ¬
ously healthy individuals.
At a time in which the infection has been taken (the incuba¬
tion stage) but in which no means of observation can recognize
it except thermometry, Thomas notices the presence of a short
preliminary fever-course (ephemera protracta), whose maxima
are 38.8°—39.8° C. = 102.84°—103.61° F., followed by a pause of
several days.
The 'ensemble' of symptoms of the measles commences with
its initial fever, which is complete in twelve to twenty-four
hours, and whose rapid rise, 39.1°—10* C. = 102.38°—104° F.,is
attained in the evening; 38.1°—39° C. = 100.5°—102.2° F., be¬
ing exceptional. Yet it is exceptional, too, for this first rise to
attain the maximum of the whole course of the measles. How
ever, the degree then attained is an index of the future eleva¬
tions, which are wont to exceed the initial by .8°—1° C.=1.5°
—1.8° F., or a trifle more. The initial rise is habitually fol¬
lowed by a downfall the next night, so that in the morning the
temperature is normal, and seldom exceeds 38° C. = 100.4° F.,
except in very anomalous cases ; this depression may last a few
hours, till night or till the next morning. The rise and fall of
temperature are so rapid in this stage, that it looks like inter¬
mittent, but for the lowness ; or it may be confounded with an
ephemeral fever, but for the appearance of the ocular and pul¬
monary symptoms.
138
scarlatina.
The true eruptive fever begins with a fresh rise of tempera¬
ture, which will have but temporary remissions till the exanthem
is fully developed. In most cases the eruptive fever is divided
into two sections, a moderately febrile stage and a fastigium or
acme.
The moderately febrile stage averages thirty-six to thirty-
eight hours, made up of one or two exacerbations of 38°—39°
C. = 100.4°—102.2° F., not quite to the level of the initial fever:
if two exacerbations, the second is the higher, the intervening
remissions are not so deep as those of the initial stage, yet one
of them may reach normal.
The fastigium commences early in the day, or late, leaving
behind all previous height; if early, the evening temperature
is higher, the next morning presents a slight remission, and the
next evening the maximum. If the acme begins in the evening,
the next morning the remission is slight or null.
In normal cases the maximum of the acme is contemporane¬
ous with the fulness of the exanthem ; in others it may precede
it by the effect of some complication. The fastigium lasts
from one and a half to two and a half days, and the eruptive
fever is completed in from three to four and a half days; a
course that complications may prolong.
Decided defervescence begins, according to rule, in the night,
and ordinarily runs a rapid course, reaching the norme on the
second morning, though one or two slight evening subfebrile
heights may undulate the descent. Defervescence may also be
protracted by bronchitis and other complications; when a case
began irregularly its defervescence may do the same; and be¬
sides, trifling causes elevate the temperature of children. But
sometimes a recrudescence of the fever is caused by an after-
stroke or recoil of the exanthem; this may raise the temperature
almost to the former maximum, but very transiently.
Complications alter the typical course of measles-temperature
somewhat to their own type. Since fatal terminations, in cases
of measles, arc due to complications, the last temperatures are
subordinate to these complications, not to the measles.
V.—scarlatina. (Syn.: Scarlet Fever.)
Scarlatina conforms far less closely and regularlv to its type
than the previous diseases to theirs; yet there is an apparent
SCARLATINA.
139
conformity of temperature in the cases which differ widely in
other respects; evidentlj' the pyretic deviations appear as ex¬
ceptions to a rule. ( See Appendix X., Mathematic course of
scarlatina.)
Cases of abnormally mild scarlet fever are tolerably common ;
so trifling their symptoms that they receive no medical care,
and fatal sequelae often ensue. But the course of the fever is
often quite characteristic when the scarlatinous infection devel
ops only a rudimentary disease, or even only an angina without
any eruption.
Fig. 46.
MTTjD scarlatina.
SrSSSSh3S5SSSS8
iKsssaai:
■■ 11 m■■mm■■■■■■■■
■aiwnnnHiiu
■■■B tan ■■■■■■■■■■
BpmuVnunS|Ba
huimwiimniSn
■■■■■filWW—M
!■*■■■ rofi ■■■■■■ ■■
naaiHBMHifaNmn
■nunuiiiamj
(■■■■■aaanmBUHng
|iiBb>BBWMW
In all cases of tolerably severe scarlatina the first symptom
(with or without others concomitant) is a rapid temperature,
steady rising, with shiver, to 39.5°—40° C. = 103.1°—104° F.
Fig. 47.
protracted scarlatina.
BDE90DDS00B0BBB0BB000EB0I
■■(■■^^■■■■■■■■■■■■■fl ■■■■!■■ ■!!■■■■■■ ■■■■■■■■
■■■■■■■■■■■
■■■■■■■■■■■
■HBinKll
■lUlVM
■ ViBWlB annHHH TiK I
■k'lHMHLimBnWBI'MI
■■■unvii'iiiim
mail
■lliHIII
■ til
■■■■■■■■■■■■■■■■■■■■■■■I'HtiBHiiTiavnaBH
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tarn
■■■■■■■■■■■ ■■■■■■■■■■wBiBi
The exanthem follows this rise or appears the next morning
(second day); if it delays, the temperature continues to rise,
140
SCARLATINA.
with slight morning remissions, beyond the considerable height
reached at first, till the exanthein has covered the whole bod}',
and even till the parts first attacked grow pale. The duration
of this invasion-stage is from half a day to four. The height
thus reached is from 40°—41° C. = 104°—105.8° F. As a rule
the height is parallel to the intensity of the exanthein ; though,
exceptionally, the eruption may be slight with a"high tempera¬
ture, and, more rarely, the eruption copious with a moderate
fever. The high ruling course of scarlatina distinguishes it
from the other exanthematous affections, typhoid fever, etc.
Defervescence is not always alike. After a moderate exacer¬
bation it may exceptionally fall and reach normal in half a
day ; but in most of the cases it requires three to eight days for
its completion From day to day the temperature gets lower
and slopes like an ease (Fig. 46), or through trifling remissions,
falls by night, keeping up, or almost so, by day, till it reaches
the norme. Seldom does this remitting defervescence liken
itself to that of typhoid fever. The defervescence of scarlet
fever may, like others, be delayed by complications (Fig. 47). A
subnormal temperature may set in before the normal is assured,
or a collapse. This form of defervescence is quite typical of
scarlatina—at least not often met with in other diseases, except
occasionally in typhus and catarrhal pneumonia.
Fig. 48.
FATAL SCARLATINA.
■■■■nnaiai
■WiCiBSBI
——I— —
711
■■mMiinnHi
■BHIiMDIBIH
■■■■»■■■■■■■
■IRIBIieiRII
■■■9 BRBMBBI
Bbbhihhhbh
■■■BI an ■■■em
■ ■■SIMHHIBMflm
An anomalous coarse is not infrequent in scarlatina. The
temperature may remain rather low—this does not exclude
danger; or its descent may be interrupted by fresh exacerba¬
tions—this may be traced to some complications, but not always,
and retards the recovery. There is also a peculiar typhoidal
roseola.
141
condition, with persistent cerebral disorders, diarrhoea, meteor-
ism, and enlargement of the spleen, during which (a fortnight
or more after the fading of the eruption) the fever remains
high, subcontinuous or remittent in form, yet generally takes a
descending course.
During convalescence the temperature remains normal, unless
affected by complications, fresh diseases, or a second eruption;
therefore the persistence of normal temperature is a guaranty,
contrarily a fresh rise is a signal of danger.
Fig. 49.
FATAL SCATCLATrNA.
In fatal cases the temperature is very varied, and ruled by
the contemporary circumstances. If death happens during the
eruptive stage, the temperature may range high, yet fall at the
death-agony; if after the height of the eruption, either fresh
elevations or fall of temperature precede death. Cases occur
where the temperature rises enormously and suddenly before
death; in one of Wunderlich's cases it reached 43.5° C.=
110.3° F.
VI.- -Roseola.
Roseola (an hybrid between measles and scarlatina, which
needs the experience of an extensive epidemic to distinguish
its peculiar characters) generally, but not necessarily, shows a
subfebrile or moderately febrile temperature during the erup¬
tion ; higher temperatures depend upon complications, or the
youth of the subject.
142
dengue.
VII.—Dengue.
(Syn.: Dandy Fever, Break-bone, etc.)
Apparently a purely eruptive, epidemic disease of the warm
climates. By its eruption often mixed with other epidemics
due to summer heat; looks like measles or scarlatina by its erup¬
tion, by its pains and swelling of the joints like rheumatism ;
by its glandular symptoms like typhus ; by its mode of invasion
like yellow fever, by its initial chill like intermittent, and by
its periods like remittent.
Thermometry takes it out from that hybrid status, and sets it
up as a malarial entity which has its own thermonomv, viz.:
invasion too sudden to be not;ed previously to its acme. Two
paroxysms separated by a short remission, and lasting from five
full days to seven short. Remission the second, third or fourth
day, remaining a few tenths above the norme. Exacerbation
whose media average 39.5° the fourth or fifth day. Variation
in the length of the stages which compensate each other, and
keep the all pyrexia in the limits of time aforesaid. The pulse
in dengue, unlike in yellow fever, remains concordant with
the temperature.
There is its thermography by IT. C. d'Aquin.
Fig. 50.
DENGUE.
We can only refer to the excellent monograph of Aitken in
erysipelas.
143
Reynolds' System of Medicine, which contains no thermometric
observations, and will follow the condensed report of D'Aquin
on the epidemic of 1873; though we dissent from both as to
the character of dengue, which must govern its classification.
They consider it as a purely eruptive epidemic; we think it
will before long find its place where L. P. Brockett marked it,—
as a malarial disease, with intermittent, remittent and hay fever,
influenza, true pneumonia, etc., a group which will grow larger
as our knowledge of aetiology will enlarge; in the meanwhile
leaving to others the reformation of Nosology.
VIII.—Erysipelas.
Facial erysipelas is pre-eminently a polvtypical disease, and in
many cases atypical. This may be due to the fact that the
same anatomical changes which bear that name are brought on
by varied conditions, and may have varied significances; the
erysipelas arising from the local irritation of wounded parts;
that brought about by local predispositions ; that connected
with gastric and intestinal disturbances; the protracted, erratic,
or vagrant; the kind analogous to an acute exanthem, especially
the primary and spontaneous; that arising from pysemic infec¬
tion ; that of glanders; that which is developed in marasmus;
Fig. 51.
tmotat, kryrtpf,t,as.
that preceding death, have hardly anything in common but the
local dermatitis and the name. The temperature differs widely
in these cases. Erysipelas of other parts than the face is quite
as atypical ; we will find it among the surgical temperatures.
144
ERYSIPELAS.
Excluding the cases free from fever, erysipelas begins with
chilliness, by a rise of temperature to 40° C. = 104° F., ordinarily
reached in a few hours, rarely in a few days ; after which the
inflammation of the skin is noticeable. Tha fastigium is of the
most varied character—from a single slender peak of short dura¬
tion, to (oftener) high temperatures; continuous or subcontinu-
ous, still rising with slight morning falls or to above 40° C.=
104° F., till the cutaneous process has fairly developed. There
are exceptional elevations of 42° C. —107.6° F., and openly re¬
mittent and intermittent fastigiums.
The maximum occurs one or two days before the end of this
fever. A trifling moderation succeeds, and a critical perturba¬
tion precedes the defervescence. This reaches the norme in
twelve hours, unless an evening rise interferes, and puts it off
to twenty-four. The cases in which defervescence assumes
the remittent form (more rapid, however, than in typhoid
fever) are those whose fastigiwm has been subject to consider¬
able daily fluctuations, and whose dermal inflammation is still
progressing. When the eruption ends with defervescence, con¬
valescence follows undisturbed.
After a few days afresh and striking rise of temperature may
herald or accompany a new extension of the inflammation of the
skin; this relapse lasts but a few days, and may be repeated
several times: as long as there is eruption there is elevation of
temperature.
In fatal termination death is accompanied with high temper¬
atures; it was so in the cases observed by Wunderlich.
But we have not yet touched the question, what are the re¬
lations of local to central temperature in erysipelas? From
the definition of the disease by the masters may be judged the
discrepancies of their opinions in this respect.
Erysipelas is, for Sydenham, a fever, an ebullition of the
blood (our own effervescence); for Cullen, an inflammatory
fever; for Raver, an exanthematous inflammation; for Vel-
peau, a superficial inflammation of the skin; for Hosack, a
pure inflammatory disease of the skin ; for Watson, an eruption
preceded by fever; for Niemeyer,an erysipelatous dermatitis',
for Reynolds, an acute specific disease, characterized by a
fever of a low type, and a peculiar inflammation of the skin;
Trousseau, more circumspect yet, enumerated what it is not, but
omitted to tell what it is. (Clinigue de VHdtel Dieu, T. l,p. 164.)
ERYSIPELAS.
145
To conciliate the dermatous theory contracted by Niemeyer,
with the daring generalization of Sydenham, will demand a
great deal of labor. Happily, where onr predecessors conld
snrmise and conjecture npon the results of their sensorial
observation, we are enabled to calculate the mathematical data
furnished by our instruments of positive diagnosis; at guess¬
ing, genii could be misled; at reckoning, ordinary men may
attain to wonderful accuracies. We have often comparatively
taken the central and local temperatures, but were not allowed
that frequency of observation necessar}r to come to conclusions.
I ha've instead given two cases recorded by myself mathe¬
maticallyanother by Mole representing graphically the altera¬
tions of functions after the manner of Lorain. (See Part II.,
Chap, ii., § ii., a.)
Fig. 52.
ERYSIPELAS (MOLtf).
My cases are mathematically represented in Appendix XL,
and commented below:
The first case was of a ripe woman of greater physical ex¬
pansion than strength, and subject to previous attacks. In her,
the general fever was never as high in proportion as the local,
though it preceded it; its daily differences being as small as
one-tenth of a degree, never above one degree, averaging 0.72.
In keeping with this remarkable moderation and uniformity of
the general temperature, the pulse never rose above 112, nor
fell below 72. Alone, the respiration, by it? initial frequency,
10
146 ERYSIPELAS.
averaging 23 during the effervescence, created an apprehen¬
sion of pneumonia—then prevalent—but soon settled at 16^ in
the defervescence. Quite in keeping with the higher height
of local temperature was the formation and oozing out of
purulent matter under the right eye, which left a persistent,
thick scab. The defervescence, moderate as the effervescence
had been, closed the seventh day at 2, apparently cut short by
bilious critical evacuations, which suddenly brought the tem¬
perature to zero-norme, and the patient into convalescence with
a ravenous appetite.
The second case—that of a priinipara not yet completely
recovered—was beset with more perils, still it ran its course of
three septenaries with a regularity which gives it the appear¬
ance of one of these beautiful types created by the synthetic
art of Wunderlich out of thousands of homologous cases;
therefore, let us mark the mathematics of its evolution.
In the first septenary the effervescence is protracted to the
fifth day ; in the second, to the third; in the third and last it
is subdued in forty hours.
In the first septenary the average of general temperature is
3.5 ; in the second, 2.42 ; in the third, 12.
In the first septenary the difference between the daily maxima
and minima averages 2.35; in the second, 1.7 ; in the third, 1.2.
In the first septenary the local temperature averages 4.5 ; in
the second, 2 ; in the third, 1.
The pulse, in keeping with the pyretic symptoms, averages in
the first septenary 107; in the second, 90 ; in the third, 73 beats.
The respiration remained so near the norine that it seemed
useless to record it.
The convalescence, which is yet in progress (28th of April),
caused a rise of the temperature of 0.5 to 1.5, and a cor¬
responding acceleration of the pulse.
As for the main question : In what relations of precedence,
causation, duration, and reaction stand the general and local
temperatures in the two cases herein reported . . . %
In the first case, the fever preceded the phlegmasia by fully
twenty-four hours, and overlapped it by thirty-six. In the
second case, the initial fever reached at once its maximum, 7 ;
and the local phlegmasia hers, 8 the second, and third day 8.5.
In the second septenary the fever reached its maximum, 6.6, the
first day, and the phlegmasia hers, 5 the second. But in the
remittent fever.
147
third septenary the fever's heat rose only the second and third
day ; whilst that of the phlegmasia rose steadily from the first
to the third day, after which it 110 more rose above zero.
These are mathematical facts which I have verified in
several subsequent cases.
What can be deduced from them ?
I will venture to surmise that—
1. If erysipelas did not show itself typical in its daily un¬
dulations, it proved to be endowed with septenary fluctuations
which have the appearance of a type.
2. No less distinct than this septenary cycle was its division
in two periods; one of effervescence and the other of defer¬
vescence ; though, in the subsequent attacks, as the elements
of ustion wore away, the days of combustion became less, and
those of cooling more numerous.
3. One may also surmise, from the march of the local
symptoms at the end of the second and at the beginning of the
third septenary (see Case ISTo. 2), that a complete resolution of
local temperature, even to zero=health for several days, is no
guaranty against a relapse; guaranty to be sooner looked for
in the state of the general temperature, and particularly in
the differences between the daily minima and maxima (see
these differences in both cases).
This, to be sure, is a small contribution to the study of the
relations of the general to the local temperature in erysipelas ;
but the thermoscope, more sensitive than thermometers, will
help us to prosecute this inquiry.
IX.—Remittent Fever with Phlyctenular Eruption.
Syn.: Miliary Fever.
This disease is distinguished by an exanthem peculiar in form,
situation, and course ; by some typhoidal symptoms, by diseases
of the respiratory organs, and by the course of the fever. A
case observed was a continuous remittent, with evening tem¬
peratures above 40°—41° C. = 104°—105.8° F., and morning
remissions of 1°—2° C. = 1.8°—3.6° F. (no temperature taken
the first week). From eight to fourteen days the temperature
decreased by large fluctuations, as in typhoid fever; from day
to day the remissions became more marked, the exacerbations
148
febricula.
less, till normal temperature appeared first in the morning ; but
this course may be considerably protracted by relapses.
As described here after Wunderlich from a single observation
it seems an hybrid, equally distant from the justly dreaded bil¬
ious remittent of America, and from the benign miliary fever
of England and France.
X.—Febricula.
There are two courses of temperature known as febricula.
One, longer or shorter, whose evening exacerbations rise very
little above subfebrile, and only occasionally higher.' The second
kind includes brief fevers {ephemera) ending in recovery, in
which the first symptoms of indisposition are accompanied by a
rise of temperature of 2°—3° C. = 3.6°—5.4° F., with or without
rigor. The fastigium is of a few hours, or at most a day; as
high sometimes as 40° C. = 104° F., followed by a rapid fall, and
restoration is sometimes protracted several days.
Pig. 53.
EPHEMERAL FEVER.
Ephemeral fevers occur in weakly or sick people, and
women and children, without assignable cause; with rapid
growth, dentition, exhaustion, or menstruation ; they indicate
the beginning or increase of some morbid process; are prelude
to transient disorders of tissues, like the eruption of herpes on
the lips; during the incubation of some infectious diseases ;
simultaneously with the spread through the body of a morbid
FEBRICTJLA.
149
poison through the lymphatics, or with the formation of an em¬
bolic obstruction, or as a sort of reaction against severe chills, a
complete drenching, powerful emotions, etc.
Fig. 54.
OONTrVUOTTH FKVRH.
Wounds (from an operation, etc.) involve febricula, and the
puerperal state too—of which in the next two chapters. (Here
Wunderlich only treats of traumatic fever and pyaemia, to
which we add the other surgical -and puerperal temperatures.)
With continuous fever we enter one of the most complex prob¬
lems of pathology—one which has been skirted in presence of the
zymotic and eruptive fevers, but must be faced here, and before
we reach the surgical, puerperal and malarial.
150
febricula.
In fever-temperatures what is the part of the excess of heat-
production and of heat-retention?
When are these excesses simultaneous oralterne?
What are the relations of the peripheric to the central
temperature ?
What Pathology and Therapeutics can conclude from the
answers ?
These questions, though distinct in many points, encroach on
each other in several respects ; so likely will the answers.
Also, though the latter may not be very satisfactory, they will
aim at furnishing the means and methods to find out better ones.
Two laws of anthropo-statics are broken in fevers: one, the
balance of the production and consumption of CALORIES ;
the other, the equal distribution of caloric.
It may be premised at large that in febricula, intermittent,
and fievres d'acces in general, the retention of heat, if not
the sole, is the primordial and likely the main factor; and
that in continuous fevers an over-production of heat, if not the
sole factor, is the most constant and manifest till the end—either
by restoration of the balance, or by bankruptcy. But how can
these positions be verified when hypothetic, or determined when
vague ? If thermometry can do this it will be a great way ahead
of the nosographies.
Thermometry has already ascertained that the consumption
—consequently the production—of heat of a healthy man (of 54
kilograms) is hourly of 96 units of caloric, or calories. In
sickness his temperature will rise above the norme by 1° C. for
every 44.82 calories added to the normal 96. Finding this
1° C. (or more) above the norme, how can we find its origin,
which is the pyrogenic origin of the disease? That is the
problem.
It may relate to time : the temperature being first cold, then
warm, and vice versa / or warming and cooling, according to
certain progressions. In these cases let us make as many op¬
portune observations as the succession of temperatures warrants.
It may relate to place: being above the norme at the centre,
and below at the periphery, and vice versa / or too high or too
low at both. In either case the observation is more complex.
In taking the temperature in reference to its localization, we
must start from the principles already enunciated, and devel¬
oped in Part II., Ch. n., §§ vii., viii., and ix.: take the central
FEBKICULA.
151
temperature in reference to the physiological norme—unless
the patient has a known individual norme, for which see p. 14 ;
and the peripheric temperatures by comparison with a healthy
person who has remained in the same ambient temperature, at
several points of the surface, and particularly on those points
known as, or suspected of being the seat of especial retention
or radiation of caloric.
Supposing we find the peripheric low and the central high,
the sympathetic through its vaso-Tnotor fibril]as has constricted
the issues of heat and of moisture in order to economize the
latter for the coining emergency, the next pyretic stage. Then
what is our duty ? To prescribe the retarders of ustion, and to
prepare a moderate reaction through the skin.
But supposing no chills, almost no remissions, the central and
peripheric temperatures equally exalted, we first see that the
sympathetic has equally lost control of the production and of the
radiation of calor ; we count the losses, so many degrees, each one
representing every hour a waste of 44.82 calories, and we pre¬
scribe accordingly, v. z., so much of x... to supply the lost calories
during x... time, and so much of x.... to retard both inward com¬
bustion and peripheric radiation, etc. Our therapeutics is a
counterpart of the thermometric operations.
I must not omit, because I cannot explain, certain anomalies
of ustion : some excessive, without or with hardly any appar¬
ent cause ; others perfectly normal in the middle of the great¬
est functional or organic disorders (see Part II., Ch. xi., § ix.,
b). The former may be referred to certain nervous status, of
which we know nothing except their compatibility with ex¬
treme temperatures both ways. The latter—unless it is a tem¬
perature in transit from above below the norme, or the other
way—belong to the class called by Roger neutral (Part II.,
Ch. xix.), which my experience taught me to class as compound
temperatures, i.e., temperatures in which several elements of
high and low figures concur to simulate the point of health.
These will be the matter of the next most interesting obser¬
vations.
Febricula offers the less complicated, therefore the most
favorable opportunities for studying these questions of anthropo-
dynamism. So judged Wmternitz in his Nature and Treat¬
ment of Fevers. Wunderlich is less explicit.
CHAPTER XVI.
SURGICAL TEMPERATURES.
A knowledge of the body's temperature cannot be more
useful in surgery than in physic^ but its want is more sensible
on account of the suddenness of many of its casualties. How¬
ever, surgery does not show as large thermometric record as
physic—not because it was not begun early, since Demarquay
made valuable and conclusive observations as early (1835) as
Donne, Bouillaud, Andral; but partly because the great field
of surgical temperature, the battle-field, was rarely opened
then, and mainly because the relations of local to central tem¬
perature, so important in surgery, can only be guessed at, or
grossly appreciated, without special instruments.
During the American civil war (1861-65), thermometry was
not practised enough to leave its traces in the otherwise so
remarkable reports of the Surgeon-General of the U.S.A.; but
during the Franco-German war (1870) it was applied on both
sides, and gave interesting results, though much limited, we
believe, by the want of special instruments.
The following propositions, and faits a Vajpjpui, may event¬
ually remain as the surgical trophies of this bloody contest.
A persistent pain keeps up the temperature above the norme.
A lesion of some extent—from any other cause than a fire¬
arm—even when it cures by first intention, is accompanied by
an elevation of the general temperature.
Then, as wrell as after operations of secondary importance,
Billroth found, a long time after Demarquay, a rise of 1°—1.5°
C., which subsided to the norme the second or third day, when
there was no accident nor complications. In case of compli¬
cated fracture without suppuration, the temperature continues
higher a few days longer.
But if traumatism is caused by a conical bullet, or a frag¬
ment of shell, the temperature will be lower with marked stu-
SURGICAL TEMPERATURES. 153
por, and lower yet if the wounded was drunk at the time, or
previously an inebriate, or above forty years.
Demarquay and Rodard observed 50 cases of lesions of the
limbs, mainly of the lower ones (like multiple fractures with
attrition of the soft parts by various projectiles), in which the
temperature ranged from 37° to 34.2° C.; the lowest being
caused by fragments of shell, the highest by bullets. None of
them survived whose temperature was below 35.5° C., and even
higher, if reaction did not take place in the five hours follow¬
ing the casualty.
From this somewhat large experience Rodard deduces that:
(1) wounded whose temperature is below 35.5° C., must not be
operated on, since they will certainly die; (2) wounded who
will not, inside of four hours, give signs of a reaction commen¬
surate to their traumatic fall of temperature, must be considered
as seriously affected.
Poncet professes the same doctrines, and acted accordingly
during the siege of Strasburg. Moreover, he gives the most
precise rules in regard to the use of anaesthetics in operating on
the wounded of this category (by projectiles). A great many
of them are under the influence of alcohol, deep in stupor, and
have lost much blood; cumulative causes of lowering (abaisse-
ment) of their temperature, and therefore cumulative reasons,
too, for the surgeon to not produce these long anaesthesiae which
lower the temperature, and lead the wounded from sleep to
death. Therefore, do not use with them chloroform, above all
do not add to it the chlorhijdrate of morphine ; on the battle¬
field beware of sleep.
Demarquay and Dumeril, during experiments on the in¬
fluence of pain, loss of blood, ligature, and anaesthetics, had
discovered, in 1847-48, the propriety of ether and chloroform
to lower the temperature. So that the surgeons of the war of
1870, French or German, and later experimentalists, like
Boeckel, could only give more practical precision to the appli¬
cation of this principle to surgery. They did it somewhat in the
terms above given, to which may be added: (a) Chloral lowers
the temperature like ether and chloroform, (b) Other factors
may enter into the apyretic action of anaesthetics, as the quan¬
tity of lost blood, previous fasting, etc. (c) A short anaesthesia
produces an apyrexy of only a few tenths of a degree, (d) A
longer one more in this proportion: (d') when the ball of the
154
surgical temperatures.
eye becomes insensible, 1°—2° C. of apyrexy; (d") when the
anaesthesia lasts half an hour, one mast look for a fall of 2°—
3° C.
In the wounds of the abdomen, if the peritoneum remain in¬
tact—even where the rectum and bladder have been hurt—the
temperature does not deviate from its previously ascribed course
in ordinary surgical cases ; but if it is lacerated, depressions of
temperature ensue. Here the figures on the thermometric scale
are pathognomonic: if above the norme, they indicate that the
sac is indemn ; if below, that it is torn. In the former case
surgery must follow its course ; in the latter, examinations and
operations are more than useless.
In extensive burns, which are among the casualties of war, the
temperature falls frequently to 35°, 34°, and even 33° C., the
lower in proportion to the area of the denuded surface, and to its
proximity to the abdomen and thorax. Ex.: X , set. 23.
Several contusions and burns of the chest and face; soon 35°;
two days after, 34.6°death some hours later at 34.3° C.
Similar lowering serves as a test of differentiation between
strangulated hernia and impaction of faeces (engouement). It is
also present in uraemia, due to urinary infiltration.
We have seen that after a wound, and subsequent operation,
if there is no suppuration, the temperature will, in three days,
come down to the norme. But this is not the most frequent
occurrence. Oftener, before cicatrization begins, the wound
undergoes more or less suppuration, which is fatal after an am¬
putation, or the ablation of a tumor. This suppurative process
is heralded by a fever.
I.—Traumatic Fever.
Will be the more considerable as the wounded parts were pre¬
viously more healthy, particularly after the ablation of a limb.
Its thermometric course needs to be well known, since it is too
often the precursor of septicaemia and pyaemia, or purulent in¬
fection.
Seldom one day, oftener two or three, rarely five after the
operation, anorexia is noted; the skin is hot, but one would look
in vain for these chills which make the teeth chatter. The
thermometer rises in two days to 39.5°—40° C. ; keeps for two
or three days at this height, with slight diurnal oscillations, and
surgical temperatures.
155
comes back to the norme in as many days, by lysis. Therefore
the traumatic fever is a typical one, having its effervescence in
two or three days, its acme at about 40° C. with morning remis¬
sions, and its gradual defervescence, each of these three periods
occupying the same time. When the maxima of the first two
days are alike it is a better sign than when that of the second
is higher. The length and the height of the fever have no con¬
nection. If the height remain considerable, a new diagnosis
is necessary. The defervescence is expected inside of the third
day. Age and constitution influence the course of traumatic
fever.
On the other hand, an injury with considerable hemorrhage
is followed by a proportionate fall of temperature, but reaction
soon follows. If a chronic fever, consumption, Bright's. dis¬
ease, etc., existed before the injury or operation, the traumatic
fever is more acute. Frequently the wounded experience on
the fourth day a secondary fever, whose temperature is varied,
being mostly the expression of constitutional habitus. These
febriculse are atypical.
II.—Septicemia.
A morbid produce of city hospitals (hospitalism) which never
enters an open country house, shows more threatening signs :
inflammation is intense, and purulent oedema surrounds the
wounds ; tongue dry and parched, somnolence, no coma, rarely
chills; the temperature rapidly rising, without or with feeble
morning remissions, proceed by ascending oscillations till it
reaches 40°—41° in adults, 39°—40° C. in old people. From
this fastigium, which is attained in about five days, starts pro-
agonic elevations, or hyponormal falls.
III.— Suppurative Feyer.
Takes place during the long suppurations necessary to eliminate
sphacelated parts, particularly in diffused phlegmons and after
amputations. This is a quotidian rhythmic fever, with well-
marked morning remissions, and with exacerbations about noon ;
the stronger as the wound is more extensive. But its fastigia do
not take place at irregular hours, no more than those of septi¬
caemia, unlike those of pyaemia. Moreover, the falling of the
156
surgical temperatures.
temperature toward, and to the norme, precedes the fall of the
eschars and the formation of healthy tissues ; also warrants
against septicaemia and pyaemia: its regularity makes its
security.
IV.—Pyjsmia,
Or Purulent Infection, distinguishes itself by different ther-
mometric modalities. Irregularity may be called its type, since
observations taken at regular hours, as well as every hour, will
show variations whose evident disorder is characteristic, and
even warns of its invasion. Then the daily maxima are
met with in the morning or evening, or at any hour of the night,
oftener in the morning, with vesperal remissions. The temper¬
ature rapidly attains 4L°, even nears 42°, with chill and shake,
and as swiftly falls below 37° under the action of diaphoresis;
then settles at 38°—39° between these exacerbations ; and lastly,
the tenth day, or sooner, the oscillations become more frequent,
their figures present large ecarts, to disappear only two days
before death, when remissions cease altogether, and the index
attains 42° C.
V.—Hectic Fever,
Presence of Resorption in suppurative osteitis, Pott's disease,
etc., particularly in their last stage, is characterized by a course
entirely different from the preceding suppurative fevers. In the
hectic, the thermometer never rises above 39°,, in the morning,
and falls to 37°, or below, in the afternoon. During the deval-
escence the figures stand in the same diurnal relation, but lower.
VI.—Traumatic Erysipelas.
Quite often the cicatrization of a wound is interrupted by a
specific well-known redness, and a continuous rise of temper¬
ature to 40° C., without the immediate remission which at this
stage takes place in pyaemia. This is the period of effervescence
of traumatic erysipelas; which is followed by a fastigium of
two to four days, and by a rapid defervescence to 37°, or below.
When there are poussees, each is accompanied by a sudden tlier-
mometric ascension, and a fall the morrow after. This pyretic
movement distinguishes traumatic erysipelas from pyaemia.
surgical temperatures.
157
I am not aware of the publication of any observations worth
recording upon local temperature in surgical erysipelas ; yet
they would be precious to give a warning, at least twelve hours
in advance, of the direction in which the jpoussees would
spread, and to establish the mathematical relations of priority
and of intensity between the local and the general nstion.
VII.—Tetanus.
The complication of tetanus in the wounded does not elevate
the temperature jper se ; only in virtue of the muscular con¬
tractions. But in the proagonic periods, when asphyxia is pro¬
duced by a paralysis of the diaphragm, then are seen those rises
to 43°—44°—45° C., noted by Jaccond and Wunderlich, and
sometimes followed by post-mortem elevations of several tenths
of a degree. (See temperature in central neurosis, Chap, xxiii.,
§ i"-)
Some Organic Causes of Local Modifications of Tempera¬
ture.
a. In fatty degenerescence of the heart the central tempera¬
ture fell 1° C. or more.
b. In arterial aneurism the temperature is higher than in the
indeinn corresponding part. In artero-venous aneurism it is
higher too, notwithstanding the impression of cold received by
the patient. In compression, the temperature, at first higher,
becomes notably lower. Ligatures produce the same variations.
c. In embolism, the temperature is normal upon the seat of
the emboly, higher above, and lower below. One can readily
Understand the value of such topographic indications for the
diagnose of recent local affections of this class. Bnt how can
these delicate indications be detected without very sensitive and
accurate instruments?
(For other modifications of local temperature see Gaillot,
Ess-ay sur la Thermometrie Chirurgicale, and farther Chapter
xx., § vi, £,/, g.)
CHAPTER XVII.
TEMPERATURES IN PUERPERISM.
It was once tlie custom in Burgundy to count to a boy an
active campaign as two years of military service; and to a
woman a successive pregnancy, parturition and nursing as two
campaigns, or four years' active duty in the service of the Res
Publica. This reckoning was not only just, and this assimila¬
tion dictated by a high sense of honor; but both seem, from
our standpoint, calculated to impress the physician with the
best appreciation of the female emergencies.
For women have their medical and surgical casualties very
much like warriors: wounds, contusions, lacerations of tissues,
hemorrhages, infections, pysemia, septicaemia, erysipelas, shock
almost identical. And mothers, besides, pine away after, and
from wasting their norme in over-nursing, anxieties, sleepless¬
ness, mounting unrelieved guards over a cradle, etc. Every¬
thing counted in, their casualties are fully two to one to the
soldier's.
Sufficient reasons to bring together (rajpprocher) the surgical
and puerperal temperatures.
I.—Temperatures Prior to Delivery.
It is very well to say that pregnancy, its prodromes and its
ordinary sequels are no sickness ; but they are, at best, accom¬
panied by so much uneasiness and suffering, and soon followed
by so many accidents and dangers, that, let it be a physiological
condition, and let us consider its most notable pathological
effects on temperature.
The influence of menstruation is felt by a slight raise before,
and a fall of temperature after (W. Squire), but insensible
during the flow in health, and sensible in dysmenorrhea and
other functional disturbances (TVunderlich).
puerperal temperatures.
159
The influence of pregnancy affects the general temperature
only after the sixth month (W. Squire;; is purely local; the
gravid uterus warmer than the vagina—independent of the
warmth of the foetus—by .25° C. = .4° F.; warmer than the
axilla .3° C. = .5° F. Schroder found the excess of temperature
of the uterus over that of the axilla, noticed in pregnancy, to
increase in labor.
Before the labor pains no rise of temperature. During the
pains a rise of .2° C.—.2.5° C., which falls back between the
pains; otherwise the elevation of temperature proportionate to
the intensity and quickness of the pains. The lowest tempera¬
ture in those delivered at 11 a.m. In the first twelve hours
Winlcel found a moderate rise, and in the second twelve a cor¬
responding fall. The average minimum of the normal lying-in
period is estimated by Grunewaldt at 37° C. = 98.6° F., and the
maximum often exceeds 38° C. = 100° F. A normal tempera¬
ture after birth is no guaranty against subsequent puerperal
mischief (Schroder).
II.—Temperatures toward the montee of Milk.
The temperature which has risen during the severe exertions
of labor, 100-101°, remains there to the termination of the de¬
livery, when it commences to decline, and is found the second
day in the vagina 98.5° F., in the axilla 98.3° F. The fifth
day : vaginal temperature 100.7° F., axillary temperature 100.3°
F. (showing how little the tenderness of the neighboring full
breasts affects the axilla). The ninth day: vaginal temperature
98.3° F., axillary temperature 98.2°.
In a case of abortion at two months, the temperature was
found, the ninth day, vaginal 98.4° F., axillary 98° F.
The loss of blood, during and after labor, is not followed by
the grave depressions of temperature which accompany and
often reveal other liemorrhagics. " La jperte normale du sang
dans Vaccouchement ne fait pas baisser la chaleur" (Quin-
quaud). Notwithstanding the assertion of this author, disturb¬
ances of temperature in the lying-in state generally accompany
the formation of milk. Once the milk formed, the temperature
falls rapidly fully one degree, then slowly. But if milk is scanty,
and the lochise correspondingly excessive, temperature remains,
160
puerperal fevers.
as a warning, proportionately high. Some authors (Quin-
quaud, Depaul) altogether deny this milk fever, and refer all
the high temperatures of this period to the healing process of
the lacerated os uteri. Without overlooking this cause of
traumatic fever, we believe with Caseaux and Squire (and with
our own medical senses) in the filvre de lait, because the con¬
current applications of the fever and surface thermometers,
and particularly of the thermoscope, demonstrate the presence
in the bosom pregnant with milk of an hyperpyrexia as capable
of propagation through the general circulation, as that of a
boil. (Appendix XII., a.)
III.—Traumatic Puerperal Fever.
Consequently to uterine lacerations, contusions of the small
basin, and other lesions, puerperal traumatic fever sets in, of
which the physician is admonished about the third day by the
change in the countenance of his patient. Yesterday attentive
and hopeful, to-day sunken in her couch, she shows a rise of
temperature of 1°—2° C.; and supposing that there will be no
complication, her case will run a course somewhat like that
shown in Appendix XII., b.
The temperature in this fever consists in a rapid rise the
second or third day to 39°—40.2° C.. rarely preceded by chills,
accompanied by pulse 110—113. This acme does not last, but
comes down by a lysis of a week. In hospitals, Quinquaud
counts 100 cases of it out of 180 women; likely by taking in
the milk-fever cases, whose identity he denies. But, as we said,
the milk-fever is explainable by a specific, cause, the congestion
of the mammae to prepare a new and energetic function; the
which once established, the fever ends—not sooner, nor later.
On the other hand, there is no evidence that the traumatic
puerperal fever is distinct from the gravest forms of puerperal
infection, but in degree by its lenie ncy, same march, shorter;
same rise, though lower; same slow resolution, yet rarely com¬
plicated. If the identity of one of these forms of pathologic
entities ought to disappear, it will not be by the immergence
of the milk-fever (which has its own movement of temperature)
\npuerperal traumatism, but it will be by the latter entering
the nosological frame as the mildest form of infectiouspuerper-
infectious puekperism.
161
ism; a position identical to the one we have seen occupied in
surgical diseases by traumatic fever in regard to septicaemia and
cognate camp and hospital infections.
IV.—Infectious Puerpekism. (Syn.: Pycemia.)
The fever which accompanies acute severe lesions or the
puerperal state, has its genesis in infection, and its commence¬
ment is sharply defined. It commences with a severe rigor, by
an elevation of temperature often brought in a few hours to
21°—3|-° C.=4£°—6|-0 F., and exceeding 40°—41° almost 42°
C. = 104°—105.8°—107.6 F. This first paroxysm takes an accu-
minated form.
Fig. 55.
PUERPERAL PYAEMIA. .
::s:s:s:sss3
Lbs
!■!■■■ ■§■■■■ ■■■
iiiHimaiia
iiiinumiiiii
■ ■IHMN !■■■■! Ill
■ ■■iii1 ii
■■■■itiiwiwaiii
UW'iii»if Willi
After the temperature has reached its highest peak it begins
to fall fully as rapidly as it rose, sinking from 2°—4° C. = 3.6°—
7.2° F. in a few hours, descending lower than it was before the
paroxysm. As soon as it has reached its minimum depth, it
begins to rise again; a brusque rise, more or less approximat¬
ing the summit of the first paroxysm, is scarcely ever absent,
subject to rhythmic repetitions, two or three in a day. Then fol¬
lows a downfall of temperature after the manner of a rapid de¬
fervescence, coming down to normal, or pausing at 39° C.=
102.2° F. These pauses rarely last a whole day. Intercurrently,
and more so towards a fatal termination, appear segments of a
continuous or remittent course.
11
162
INFECTIOUS PUERPERISM.
The duration of pyaemic fever is a week or so. In it death
does not affect any particular temperature.
But deviations occur. Death may occur at the beginning of
pyaemia in patients suffering from other diseases. The course
may be continuous, particularly in traumatic pyaemia, or assume
a zigzag shape, or affect a certain rhythm, or be protracted, and
through successive improvements lead to death or to unexpected
recovery.
It poisons the child (Appendix XII., d, e) as well as the
mother (Appendix XII., c); is sometimes lenient, sometimes
implacable. The gravest forms are those complicated (in order
of frequency) by peritonitis, erysipelas, phlegmon, phlebitis,
meningitis, purulent infection, gangrene, etc.
In the maternity of Munich, in 1861, of 80 women 41 died ;
of 33 children of dead mothers, 20 died ; of 47 children of cured
mothers, 12 died. Some physicians refer this infection of the
infant to the epidemic constitution or locality; some, like Heck-
er, to the mother, already infected, previously to the delivery;
and give as proof that of 51 infected children 24 died the two
first days (5 still-born, 5 the first and 14 the second day);
whereas the mortality diminished after the second day.
However, it has not been rare with Wunderlich to see the
infectious puerperism begin with the mother after the flow of
milk is established, and with the child after it has taken the
breast a few days.
The complications come later, insinuating themselves obscure¬
ly, so to speak, into the general infection, without affecting its
pyretic ascendency with their peculiarities. If thepuerperism
be lenient, its temperature, after reaching an acute acme at
about 39.5°, begins an uninterrupted defervescence by slow lysis#;
weigh equally slow to recover. In fatal cases there is no acme
proper, but a steady ascension towards proagonic temperatures,
with very small morning remissions if any, and several daily
chills at irregular hours.
On this question our first word will be the last. Though the
puerperal state of the mother and the nativity in the child
are no sickness per se, they both predispose to the reception of
the germs of puerperism in all its forms and degrees; and
the incipience of puerperism may be foretold, and its march
studied by two methods: in the mother by comparing the
temperature, the pulse, and respiration, and the daily composi-
INFECTIOUS PUEEPEEISM.
163
tion of the urinary secretions; and in the child by a steady
comparison of the temperature and body-weight. To eradicate
puerperism, the hospitals and houses in which it has shown
itself twice must be burned. (See Comjpte rendu de VAssocia¬
tion Franqaise jpour Vavancement des Sciences, 1873, p. 801.)
CHAPTER XVII.
CATARRHAL AFFECTIONS OF MUCOUS MEMBRANES.
The temperature of catarrhal affections of mucous mem¬
branes has no particular type. There may be no alteration of
temperature, as it may be supranorinal, subfebrile, or moder¬
ately febrile; if anomalous elevations occur, they are attribu¬
table to some malignancy, as whooping-cough, where it is safe
to take daily observations. Little children, young and delicate
people, already subject to catarrhal affections, present epheme¬
ral extra-elevations which, protracted, end in hectic fever.
The temperature may assume an almost typical form in epi¬
demic catarrh of the respiratory mucous membrane, when
associated with gastric and intestinal catarrh, or with the nerv¬
ous symptoms of influenza. Indeed, it is in the latter only that
any considerable alteration of temperature is met with. It
begins its ascent similarly to typhoid fever, though not quite
so regularly. The same comparison holds good during the
fastigium, which, however, is shorter; and during the defer¬
vescence of a remitting type (lysis), running its course more
rapidly, closing it more punctually. On the other hand,
in influenza the temperature may, after almost reaching the
normal point, linger somewhat above it with greater evening
exacerbations than is consonant with complete recovery. In
presence of these pyretic symptoms the question arises: Is
this a severe influenza or a case of typhoid fever ? The ap¬
proximate identity of the other symptoms in both diseases aug¬
ments the uncertainty. In young adults, a range of tempera¬
ture lower than in typhoid fever excludes it; otherwise the
diagnosis must be deferred. In febrile gastro-intestinal ca¬
tarrhs the course of the temperature is quite similar to that of
influenza, but falls more quickly with good nursing.
catarrhal affections.
165
I.—Ckoup and Diphtheria.
These affections are better differentiated in books than in
nature; for in an epidemic we may find in the same local con¬
ditions, even under the same roof, amygdalitis, catarrh, croup,
and diphtheria (besides bronchitis, pneumonia, broncho-pneu¬
monia, and pleuro-pneumonia).
Diphtheria is the culminating term of croupal affections. It
is local before being general. At least, its poison, either para¬
sitic or chemical (A. Jacobi), enters the blood by the limited
local surfaces of the fauces, but soon enters with respiration
the pulmonary alveoli, whose immense surface is the chemical
laboratory either of vital oxygenation, or of deadly toxication of
the blood. By this latter process the whole body is soon poi¬
soned as in septicaemia, unless supported and disinfected.
Wunderlich says of these affections: "In no other has the
temperature so little significance as in croupous and diphthe¬
ritic affections: pharyngeal diphtheria, laryngeal croup, intes¬
tinal croup, dysentery, and diphtheritic and croupous puerpe¬
ral endometritis. One may, however, regard very high tempe¬
ratures in all these affections as adding greatly to the danger,
though moderate or even normal temperatures do not give
the slightest guarantee of a favorable termination. The high
temperatures may even decline when the disorder unhaltingly
goes on to worse and worse" (W. B. Woodman).
Roger, as usual, avoids theorizing, and gives eleven observa¬
tions from simple angina to true croup, complicated by whoop¬
ing-cough, broncho-pneumonia, diphtheric exudation of the
wound after tracheotomy, etc. These complicated cases are
interesting, but sooner blind than enlighten the question of
temperature. To study the latter, all complicated cases ought
to be set aside, and those proving to run an unmitigated course
must be compared during the period of latency, during that
of localization, and during that of general toxication ; then,
with the figures so found, we may expect to arrive at the ele¬
ments of these compound temperatures which have defied the
first calculations of our predecessors.
166
catarrhal affections.
II.—Bronchitis, Influenza. (Syn.: Grijvpe.)
In the former the temperature is commensurate to the depth
of the inflammation. If the large broncliiae are alone affected,
the temperature does not pass 38°, averages 37.50°. If capil¬
lary, it goes higher: 38.31° (Roger), 38.50° (Andral); maximum,
39° C. If the mercury continue to rise to 40°—41°, pneumonia
may be looked for; if it remains about 38°, no complication to
be feared. But the pulse and respiration were more disturbed
than the temperature: thus in three children, two, four, and
fourteen months old, T. 37.5°, P. 132, R. 64.
In grippe, or epidemic bronchitis, the mercury rises higher,
maintains itself high four or five days, particularly in infants,
40°—40.6°, with an excursus of .8° from morning to night; so
that it would look like pneumonia or typhoid fever, if the con¬
current local signs of pneumonia were not absent, and if the
movement of the temperature was not retrogressive, instead of
having a typhoidal progression. As in all epidemics, the grippe
borrows its innocuous or fatal temperatures from the prevalent
constitution, besides those of its complications.
The complication with pneumonia is frequent, and formida¬
ble during epidemics in infants.—Obs. of Squire on Tempera¬
ture Variations, etc., p. 31. An infant three and a half months
old, infected by his elder brother in the nursery, was noticed
to sneeze January 23, and studied from the incipience :
Rectal Temperature.
Day of
Date.
Pulse.
Respi¬
Remarks.
illness.
ration.
Morn.
Even.
>
1
Jan. 23
98.8
120
40
Temp. below the norme of this child.
2
" 24
101.4
135
50
Congh, harsh respiration, bowels relaxed.
8
" 25
101.7
130
60
Kept awake by incessant cough, high pitched
rhonchi at scapula.
4
" 26
102.6
160
70
Dulness at the base and diminished expan¬
sion.
5
" 27
102.4
103.0
180
Crepitation.
6
" 28
101.0
102.3
160
60
Secretion commencing.
7
" 29
100.5
101.0
140
60
Large loose riUes, dulness at left base.
14
Feb. 5
9!). 2
Expansion good, lungs healthy, some conso¬
nant rilles in large bronchi.
pneumonia.
167
II.—Pneumonia.
The diseases comprehended under the name of pneumonia
have a manifold thermometric course, which, instead of being
an anomaly, must he regarded as an indication of the wide dif¬
ferences existing in the diseases comprised under that common
appellation, (and recognized after anatomical observations
under the sub-names of " croupy, hemorrhagic, serous, embolic,
purulent, putrid or septic, lobar, lobular,") and of others whose
anatomical characters seem identical, but whose other charac¬
ters and etiology differ.
The term pneumonia is about as broad and unspecific as der¬
matitis ; yet it is useful, because, while the patient is living, it
is often impossible to differentiate from one another the differ¬
ent morbid processes which it covers with its generality, and
which have not yet been clearly mapped out.
Thermometry, itself and alone, cannot decide as to the
presence or absence of pneumonia, but it may demonstrate dif¬
ferences in the special forms which can be recognized by no
other means; it can determine the degree of the affection and
its danger; furnish a delicate standard of improvement, re¬
lapse, and effects of the medication; indicate the occurrence
and persistence of complications; determine the completion of
the processes; guarantee the certainty of convalescence and
recovery; give warning of the continuance of disorders, or of
the supervention of sequelae; and indicate the intervention of
pneumonia as a complication in measles, bronchial catarrh,
whooping-cough, pulmonary consumption, and pleurisy. There¬
fore thermometry has only an accessory value in pneumonic
affections, instead of a direct value as in typhoid fever, etc.
There are exceedingly rare cases of pneumonia running its
course without any fever; and others, quite as rare, with a
very moderate and almost momentary elevation of temperature,
hardly 38.5° C. = 101.3° F., for a few hours in the first or second
day.
Somewhat akin to these are two pneumonic febriculce, one
with rigor, abrupt, rising above 41° C. = 105.8° F., immediately
succeeded by a rapid defervescence (ephemera with pointed
peak). In the second, the highest point, 40° C. = 104° F., is
reached the third day only; the temperature declining at once
(ephemera protracta). All these febriculge are accompanied
168
TNEUMONIA.
with local processes, and are rendered dangerous only by their
surroundings. They correspond to slight cedematous infiltra¬
tions, secondary pneumonias, mild inflammation of the lungs in
young children, and phthisis in old and emaciated persons, etc.
These forms may be considered as rudimentary copies of the
two types of pneumonic fever: imagine the sharp peak of the
first form of ephemera flattened out, it represents the con¬
tinuous type with its sudden commencement and rapid end;
imagine the ephemera protracta extended, we have the remit¬
tent type, with its gradual commencement and defervescence
by lysis.
The fever of pneumonia shows brusque elevations and inter¬
current falls of temperature. The brusque elevations in the
course of the fever reach 41.5° C. = 106.7° F.; when interrupt¬
ing defervescence, 40° C. = 104° F. The intercurrent falls
occur in almost any form of pneumonia, whether slight, severe,
or fatal, ranging from 1^°—4.5° C. = 2.7°—7.2°, even 9° F.,
reaching the normal temperature, or below it, very rapidly, to
rise again speedily.
The intercurrent decline of temperature happens in severe
or slight cases, from the second day to the last of the deferves¬
cence, even to the death-agony; it may repeat itself more than
once. This intervening downfall divides the fastigium into
two periods, it may be regarded as a moderation in the attack;
if several times repeated it may be a transition to the remit¬
ting type,' but if it occurs abruptly and with regularity,
pneumonia becomes truly intermittent; if less punctual it
looks like the pyoemic type; if the low temperature persist
and fresh elevations occur only after two or three days, we have
the relapsing form. The fall of temperature before the death-
agony is equivalent to a pro-agonic stage.
As for the causes of these falls of temperature, they seem to
result from therapeutic measures, sufficient to perturbate, not
to destroy the disease; or from local processes, terminating in
one part, beginning afresh in another. It is not always possible,
though it would be of the highest importance, to distinguish a
pseudo-downfall from a genuine defervescence. The earlier
the fall, or the less expected, the more must we look at it with
apprehension as representing a pseudo-crisis.
The continuous and subcontwiuous types occur chiefly in
acute primary (croupy) pneumonia, more rarely in secondary;
PNEUMONIA.
169
beginning with rigor and an abrupt rise from 39°—41° C.=
102.2°—105.8° F. or more. There is often no other symptom,
and only occasionally cough, pain in the chest, and dyspnoea.
Auscultatory symptoms are rarer till the fourth day than head¬
ache, delirium, vomiting, loss of appetite and general depres¬
sion, with strong fever. Meanwhile the temperature is 39.2°
(mild)—40° C. (severe) = 102.56°—104° F., with brief remissions
°f 4°—1° G. = —1.8° F.,and quickly returning exacerbations,
often more than one of the latter in a day. This course lasts,
as the pathological process in the lungs, from three to seven
days, with variable or steady daily maxima and minima. Of-
tener the daily average grows higher till the afternoon of the
third day, and thence declines a few tenths from day to day,
even in fatal cases: this steady fall may be attributed to the
medication or nursing. This downward tendency may be ob¬
served even in the fastigium.
Fig. 56.
CATARRHAL PNEUMONIA, WOMAN -<ET. 83 (CHARCOT)
Death may occur in low temperature; or in a pro-agonic
rise, when accompanied with suffocation, to 40° C. = 104° F.;
with nervous symptoms to 41°—43° C. = 105.8°—109.4° F.
In favorable cases the descending direction becomes visible
as soon as after the occurrence of the maximum, which is
170 PNEUMONIA.
attained early; or after a downfall of temperature whilst the
remissions become more striking and the exacerbations di¬
minished.
Fig. 57.
OBAR PNEUMONIA, WOMAN JET. 75 (CHARCOT).\
On the last day but one of the fastigium a pseudo-crisis
often takes place; great fall, followed by a considerable rise,
precedes the defervescence. This generally begins in the
evening, from the fourth to the tenth day or later, marches
rapidly (in twenty-four to forty-eight hours) to its completion.
The nervous symptoms may last through this period, severe
bronchitis or acute pleurisy may hinder it; relapses also will
occur; and finally, subnormal temperatures or collapse may
set in till, through fluctuations, the normal condition is con¬
firmed.
Many cases of pneumonia do not conform so perfectly to
the continuous type. For example, the beginning may be less
rapid and abrupt, lasting two days more till the temperature
reaches its high level; or the temperature may remain lower
than in well-developed pneumonias, or approximate the remit¬
tent type by great fluctuations, or the intermittent, or the
relapsing by great falls; or the acme may be unusually
severe and protracted into the second week, as in double pneu¬
monia, or in the acute pneumonia of the upper lobes, or when
PNEUMONIA.
171
a whole lung is attacked ; in which cases the acme is prolonged
and its latter part is marked by fluctuations and amphibolism ;
then defervescence will be protracted and complicated with
slight elevations of temperature. Accidental influences, idio¬
syncrasies, youth, old age, previous diseases, and complications,
cause pneumonia to deviate from its regular course. Injudicious
treatment is also a cause of deviation.
But the most decided influence on the course of the fever
is brought about by a sufficiently copious bloodletting or a
spontaneous hemorrhage. Emetics, digitalis, veratria accom¬
plish the same, somewhat more slowly, and nitrate of potash,
aconite, etc., not so surely; but it depends on circumstances
whether this sedative action will initiate defervescence, or in¬
duce a febrile reaction. Another cause of perturbation, not
demonstrable, only surmised, is an infiltration approximating to
a hemorrhagic form or oedema.
A remittent course may occur in pneumonias almost at
any period, developed from protracted bronchial catarrh, influ¬
enza, measles, etc., and is common enough in children and old
people.
Its fastigium somewhat resembles that of typhoid fever, but
seldom reaches its maxima or follows its regularity.
On an average, the duration of the remittent pneumonia
exceeds that of the continuous / it rarely terminates by rapid
defervescence, but is sooner effected by the morning remissions
becoming greater, and the evening exacerbations growing less,
in less time, however, than in typhoid fever. Remitting is
more subject than continuous pneumonia to imperfect conva¬
lescence. Transitions between these two types are by no means
rare. Whether there is bronchitis or pneumonia during a re¬
mittent course is judged by the acoustic symptoms; but pneu¬
monia is highly probable with exacerbations at 40° C.=
104° F.
The differential diagnosis from typhoid fever is rendered
more difficult if infiltrations of the lungs intervene; besides,
cerebral, abdominal, and spleen symptoms are similar to the
typhoidal; but in favorably progressing pneumonia the diffi¬
culty is less, and is overcome by about four days of thermo-
metric observation.
A recrudescing fastigium occurs in the continuous as in the
remittent type, when the hepatization of one part is followed
172 PNEUMONIA.
by the invasion of another. Unless death occurs, the convales¬
cence of the remittent type differs from that of the continuous
only by some irregularities and delay.
Sometimes the fever in pneumonia displays a relapsing
course: much bleeding has caused it. These relapsing cases
are allied to those marked by pseudo-crises with great apyrexia.
Sometimes erratic 'pneumonia exhibits a relapsing form (erratic
in relation to the rapid invasion and resolution indicated by
means of physical diagnosis).
The intermittent course is closely allied to the relapsing,
but has a more regular rhythm and more sharply defined
apyrexia and paroxysms. This form is perfect during epi¬
demics of intermittent, and is observable in embolic pneu¬
monias.
The intermittence of pneumonias may cause two mistakes:
one, to take first defervescence for the end of the disease; the
other leads to the belief that the periodic symptoms are
those of intermittent fever. However, the attacks of inter¬
mittent pneumonia become themselves soon weaker, and may
terminate by simple absence of rise after defervescence, and
by the establishment of convalescence. Wunderlich has never
seen it end fatally.
The abrupt course, with its imperfect falls and fresh irreg¬
ular elevations, resembles pyaemia, and is doubtless pyaemia due
to the lungs' disorders, be they embolic or septic processes with
multiple foci, whose course ends in death.
Pneumonias with protracted course display no particular
character at the commencement of the attack ; they are either
continuous or discontinuous; but later, remissions occur, and
instead of showing a tendency to recovery, the fluctuations
aggravate and alternate with repeated collapses. Generally the
•daily maximum occurs at noon, the remission in the evenings,
with a great tendency to collapse and an exacerbation about
midnight. But this tolerably regular course only lasts a few
days. If the patient does not succumb, the transition toward
a state free from fever is long, gradual, and almost imper¬
ceptible.
Terminal pneumonia, la pneumonie des agonisants, does not
necessitate an elevated temperature; which is brought on by
accessory causes, not by the pneumonia itself.
(Let us compare this dogmatic form of judgment of "Wunder-
PNEUMONIA.
173
lich to the French manner of viewing and handling the same
subject. The contrast is too great not to be instructive.)
In pneumonia the invasion of heat precedes the chill for
more than one hour ; even before it is felt. Half an hour be¬
fore the chill the skin begins to feel hotter. When the chill
commences, an antagonism begins between the surface and the
central temperatures, which may be figured on a graphic by two
parting curves—one representing the central ustion reaches 39°,
the other representing the chilled surface brought down even
to 29° C. in half an hour. As the chill subsides the two curves
come nearer again; this corresponds to a short improvement.
But as the internal heat has not come down, the skin soon be¬
comes dry and hot; the thermometer rises every hour, showing
an increase of both external and internal combustion.
Then only pneumonia begins to give out its other signs and
symptoms to our means of physical diagnosis, auscultation,
percussion, etc.
The march of lobar pneumonia varies hardly from one case
to another. That of the lobular varies in each case, because
each partial inflammation gives rise to a new exacerbation.
Therefore lobar pneumonia is a type, and lobular pneumonia is
atypical.
The extent, the location, the form and the gravity of the
pneumonia do not appear to affect its temperature; it soon
reaches 40°, and then its maxima, 41°—42.5°.
Children attain their acme in about forty-eight hours; it is
rather as high as that of adults and of old people; but in infants
it does not reach so high. Roger notes also that one of the
cheeks is often more red, more warm too, than the other; though
this excess of coloration does not always correspond to the
affected side. The same observation has been made in phthisis.
It lasts four or five days; the fever is continuous, with morning
remissions and evening exacerbations, followed by a sudden
defervescence to or below the norme.
The casualties from pneumonia do not appear—among chil¬
dren at least—to be in proportion to the elevation of the tem¬
perature ; since out of eight deaths four happened when 40° had
not been reached, and most of the cures after 40° had been
passed.
J3ut in old age pneumonia (mainly the lobar) needs be watched
by the light of thermometry. "Women, at the Salpetriere, will
174
stomatitis.
cat as usual, walk, make their bed, and suddenly recline 011 it,
and expire; their temperature, if taken, could have given a
warning; autopsy discovers a vast suppuration of pulmonary
parenchyma. (See Fig. .56 and Senile Temperatures, Chap.
XXI., § 1).
The relations of ustion, circulation, and respiration are re¬
markably concordant in pneumonia; excessive and protracted
combustion being accompanied by concordantly frequent pulse-
beats and breathings. In adults, 40° of pyrexy corresponds to
an average of 110 beats. In children these relations are exag¬
gerated 40° to 140°. The parallelism of ustion and respiration
is almost constant, but not so mathematic; thus 40.25° may be
found with 96 breathings, and 41° with 84 and 62 breathings in
infants. Such a concordance of exalted functions is found in
no other disease; in this it is expressed by the following aver¬
age taken from forty-seven observations: T. 39.97°, P. 133, R.
52 (Roger).
This concordance is the test of differentiation of pneumonia
from several diseases:—
From bronchitis, whose temperature, 38°, is in disaccord with
the frequency of the respiration and the rapidity of the pulse.
From pleurisy, whose temperature does not reach so high,
40°, 41° in two days, the other signs being about alike.
From typhoid fever, in which the measured steps of temper¬
ature during the first mornings and evenings are typical, and
in which the relations of the three great vital signs are remark¬
ably discordant: T. 40°—41°; P. 65—95, rarely above 100, R.
almost normal, sooner feeble, unless it is exalted and hurried
by the interference of pneumonia.
IV.—Stomatitis. (Syn.: Thrush, Muguet.)
In stomatitis the central temperature is inferior to the local
often by .5° C.; and averages in the axilla 37.8°, in the mouth
38°, with concordance between T. 37.8°, P. 108, R. 40.
In thrush the central temperature of seven children (Roger's
observations), not proportionate to the extent of the exudation,
averaged 37.85°, when it was not brought lower by the compli¬
cation of sclerema, diarrhoea, or inanition. These compound
temperatures are sometimes difficult to read aright. Squire,
parotitis.
175
reporting mainly from city practice, found some higher tem¬
peratures, and points out as a means of cure the removal of such
articles of diet as the child cannot digest, and the advantage of
neutralizing the acid state of the mouth.
V.—Parotitis. (Syn.: Mumps.)
The mumps that children catch at school, but not exclusively
affecting them, have an incubation from two to three weeks,
known to have extended two months, and proved to be con¬
tagions before their own apparition (W. Squire, Appendix IX.,
c). This kind appears to be a simple inflammation of the
parotid glands, rarely extending to Others. The fever, ordi¬
narily at night, precedes their appearance ; after which the rise
of temperature, though generally moderate, is of the continu¬
ous type, with hardly any exacerbation, oftener with sweating,
ascending from 2°—3° C., when the gland attains its maximum
size. Then the gland does not shrink, but softens while the
temperature comes down, by the same continuous process to
the norme—the all movement being included in a septenary,
provided no complication (like the earache) or accident occurs.
IIow different are the mumps, sequelae of infectious fevers—
and first how more sparingly contagious, but how much more
fatal ? They • may appear at the beginning of grave fevers,
being symptomatic; or at the end, being critic. Hippocrates
judged them fatal when not suppurating; it is likely under
the same apprehension that Baglivi would have them brought
to that stage with the red-hot iron.
Their temperature—but is it not sooner that of the original
disease ?—has been very unsatisfactorily reported. I cannot
give a better account of it than others, though I have treated a
case, sequel to an epidemic of typhus from Beaufort, S. C.,
during the American civil war.
But when it came to me, it had already attained its fastigium,
which ran almost two weeks at 2—3 in the evening, with hardly
any remission in the morning. I witnessed, however, the most
interesting period—a defervescence of three weeks cut up by
fresh rises of .5 to 1, and corresponding to the metastasis of the
mumps, to the left mammary glands, then to the right, and
finally to the left testicle. Convalescence began at the end
176
whooping cough.
of the seventh week, but the incapacity of mental labor and
physical exertion continued fully nine months.
Moral depression, over-work, under-feeding, crowding, create
or add to the proximate causes of infectious parotitis. In the
siege of Paris many died of it; in a healthy village near by,
out of 1,500 inhabitants, forty were struck with typhoid fever?
. ... (it is said, but likely typhus), out of which twenty had the
mumps, and all died. No record was left of their temperature.
YI.—Amygdalitis. (Syn.: Tonsillitis, Quinsy.)
In tonsillitis, as in pneumonia, the fever and the local disor- ♦
der are simultaneous; but in not a few cases the fever (resem¬
bling the prodromal fever of an exantliem) precedes by one or
more days the development of the tonsillar angina.
At the beginning, fever is accompanied with rigor or
strong sensation of chilliness. The initial temperature has not
been sufficiently observed ; it reaches its maximum commonly on
the third day ; in the parenchymatous form between 39°—40° C,
=102.2°—104° F.; in the catarrhal under 39° C. = 102.2° F. The
course of the temperature in both forms is discontinuous during
the fastigium. A critical perturbation may precede the crisis
which happens between the third and the fifth day. A rapid
defervescence is by far the commonest form in both kinds of
amygdalitis; but if defervescence takes the form of lysis, low
and high temperature may alternate for several days, and
recovery be retarded.
VII.—Whooping Cough.
The incubation-period is pyrexical, often hyperpyrexical.
It lasts a week or so, during which the temperature gives better
warnings of the illness than the cough, whose character remains
uncertain. This prodromic temperature is higher, and lasts
longer, than that of the influenza ; is often so high, before the
cough is established, that it is a sufficient warning of the
presence of a zymotic cause. As soon as the cough begins,
after a week's incubation, the infection commences, at the same
time that the temperature declines, to end in lysis, if not
heightened by numerous complications.
meningitis.
ITT
VIII.—Herpes Zoster (Syn.: Shingles), and other eruptions
of the face and body, mainly in children.
An elevation of temperature generally accompanies erup¬
tions. Herpes zoster, one of them, may be taken as the pyretic
type of those which affect children. It may be preceded by a
chill, occurs during the process of teething, in the course of
influenza, or under verminous diathesis.
The rise of the temperature coincides with the first appear¬
ance of the eruption, and reaches its maximum the third day.
When the dermatose has attained its vesicular form, the tem¬
perature attains 101° F., and comes down to the norme as the
vesicles begin to dry, though the integuments may remain red
and hot—according to the testimony of the touch ; but no men¬
tion is made of the control of this objective sensation having
been verified by surface-thermometry, thermoscopy, or other
means of positive diagnosis.
The pulse is quicker, but the breathing remains unaffected
by the height of the temperature.
IX.—Meningitis.
Attacks of meningitis run their course without any fever, or
with irregular elevations of temperature which are not charac¬
teristic ; such is the case in chronic and partial (local) inflam¬
mation.
In children the range of temperature is almost as broad as
that of life itself, 35°—42.5°.
In the acute and more extensive (regional) forms, it is pos¬
sible to lay down certain rules, not absolute, but adaptable, in
the great majority of cases, to the three great modifications of
meningitis: Acute, sporadic inflammation of the pia-mater of
the convexity, or upper surface of the brain; granular (tuber¬
culous) form, which has its seat more especially at the base of
the brain, in the fissure of Sylvius, and about the cerebellum;
the epidemic form, generally attacking both base and convexity,
and extending even to the spinal cord (epidemic cerebro-spinal
meningitis). These forms differ in their etiology, special
symptoms, and course of temperature.
1
178 CEREBROSPINAL MENINGITIS.
In acute meningitis of the convexity the fever sets in rapidly
or slowly, according to the cause; the elevation reaches and
remains above 40° C. = 104° F., and grows higher in the death-
agony; it becomes hyperpyretic at death, which comes in a few
days.
In granular basilar meningitis (tubercular meningitis), the
commencement of the morbid temperature escapes observation
by being insensible, or immersed in that of previous disorders.
Usually the course runs up as in typhoid fever, then displays
isolated falls, even pauses of several days. When the fatal
termination approaches the temperature rarely rises, generally
falls, whilst the pulse is rising all the while, to the very moment
at which the heart ceases to beat.
Figs. 58, 59.
ACUTE CEREBROSPINAL MENINGITIS.
I-ah <
H
101• 6
42
105-6
41
104.■ 0
40
102-2
• 39
WO- /!■
■■■■■■■■am
■■■■■■■(■■■
■Mill
llltll
■rat'ii
■Mill
wnwin
hcihui
Ilere ranks the combination of the two forms which we call
the scholar's meningitis. It overtakes the college student
whose head reclines on a desk ten or twelve hours a day,
whose brain is kept in a constant state of orgasm, which calls
more blood to the meninges than they can circulate without
congestion at first, soon followed by serous deposits soon organ¬
ized. These organisms pressing on the brain cause stupor, then
collapse, soon ending in coma or fits; unless in few cases the
victim of this gross ignorance tediously recovers, living behind
all his virtualities. (See Fart II., Lessons from Orleans.)
Epidemic cerebrospinal meningitis, the tetanoid fever of Ro-
denstein, with identity of anatomical lesions, may present widely
different symptoms, and varied courses of temperature, from
meningitis proper. But the materials at command are too scanty
to formulate the latter. From the observation of about thirty
pleurisy, peritonitis, etc.
179
cases Wunderlich distinguishes three special fever-courses. In
severe, rapidly fatal cases it is similar to the affection of the con¬
vexity, it persists, continually rising till death at 42°—43.75° C.
= 107.6°—110.75° F., and once, three-quarters of an hour before
death, to 44.16° C.=: 111.48° F. Relatively mild cases have short
fever with considerable elevation in contrast with a quiet pulse.
The course is discontinuous, recovery does not take place by crisis
but by lysis; as the temperature approaches the norme the
pulse begins to quicken. Once in a while after defervescence, in
the midst of apparent recovery, a relapse sets in, the tempera¬
ture rises rapidly toward the end just described. Other cases
are more protracted; the height of their temperature shows
manifold changes, depending upon bronchial, pulmonary, in¬
testinal, or serous complications. The curves greatly resemble
those of typhoid fever, less their regularity, more like it in its
amphibolic period ; or resemble the fever of phthisis. Defer¬
vescence, rarely rapid, takes place by lysis. The rise or fall
of the final temperature depends on the immediate cause of
death.
X.—Pleurisy, Endocarditis, Pericarditis and Peritonitis.
In simple pleurisy the temperature is less than in pleuro¬
pneumonia, and in the latter less than in pneumonia, in the
proportion of 40°—40.25°—41°, and even above. In pleurisy
thermometry gives the most precise indications in regard to the
intervening processes of empyema. Its formation is accompa¬
nied by an elevation, its resorption by a decline, and each new
zpanchement by a fresh rise of the temperature. But if the
initial course has been very high, and continues after the first
septenary at the height of 40°—41°, not only there is epanche-
ment, but it is no more serous—it has become purulent.
The majority of inflammations of the serous membranes pre¬
sent, according to Wunderlich, no typical character, and may
run their course with or without elevation of temperature.
Associated with another disease, they retard its defervescence,
and otherwise cause irregularities in its pyretic course.
In the temperature-curves of serous inflammations which
"Wunderlich has compared, he was unable to discover more sig-
v nificance than the following: There is no course of temperature
180
acute rheumatism.
which can be considered as denoting safety. The course is
;probably favorable when the temperature remains normal or a
little above (not below) with a moderate remittent type, lasts
but a fortnight, and then gradually subsides, without leaving
behind any suspicious symptoms. Subnormal temperatures
are especially common in peritonitis, and always suspicious;
death may follow them closely. High and rising temperatures
do not add,per se, arguments for an unfavorable termination,
although adding another dangerous element to the case. It is
not so much the actual height, as its constancy, which must be
feared; as are also great and irregular fluctuations between
very high and very low temperatures similar to pyajmia, com¬
mon in endocarditis, less frequent in inflammations of the peri¬
cardium, pleura, and peritoneum; those are always highly
dangerous. Iiyperpyretic temperatures are especially met in
peritonitis (puerperal form); they lead us to suspect an infec¬
tious origin, and indicate a speedy death with a high tempera¬
ture. The forms of peritonitis in child-bed, which run their
course without much elevation of temperature, are apparently
to be grouped among local affections.
XI.—Acute Rheumatism.
The comparison of a few cases of rheumatism shows extreme
discrepancies. Fever absent, moderate, intense, brief, pro¬
tracted, continuous, remittent, etc. But the comparison of a
great number of cases shows that these discrepancies may be
reduced to certain groups and primary forms. And first,
nearly half of the cases of acute rheumatism display a moder¬
ate amount of fever, which rises gradually, lingers a few days
at its maximum, and descends with moderate remissions in two
to three weeks; and though sensitive to external influences, is
little affected by the occurrence of other inflammations. There
is a discrepancy between the temperature and the pulse; no
weekly cycles are observable.
The course is divisible into an ascending or pyrogenic
stage; height of fever, a solitary jpeak or an acme of several
days; and a descending temperature, which loses itself in defer¬
vescence. The beginning seldom comes under observation ; we
ACUTE RHEUMATISM.
181
know by report its rise to be more tedious than that of typhoid
fever, though there are exceptions of 40° C. = 106° F. reached
in two to four days; but in good ordinary conditions the tem¬
perature is still very moderate at the end of the first week.
Even the height of the fever escapes clinical observation. In
the majority of hospital cases the maximum, is reached the
day of admission or directly after; the temperature beginning
to decrease the same evening, rarely later. This course indi¬
cates either that the removal of rheumatic patients is injurious,
or that good nursing soon alleviates the symptoms. Also, it
appears that the earlier the reception into the hospital the
quicker the fall of temperature.
However, the maximum often presents a solitary peak, is
quite 40° C. = 104° F., exceeding the previous temperature by
1°—2° C. = 1.8°—3.6° F., or more, and occurs in the evening
between the fifth and ninth day. The summit may extend into
an actual fastigium, brief in comparison to the duration of the
disease, shorter in proportion to the height of the temperature,
the latter under 40° C. = 104° F. The fastigium is longer '
than the succeeding period. Its course is either continuous,
exacerbating, subremittent, or considerably remittent.
The course of the descending period depends on its form
and suddenness. In favorable cases it is quick, and assumes
the form of zigzag, a defervescent lysis of five to six days. A
more rapid downfall, like a crisis, is exceptional. During the
convalescence the temperature fluctuates on a plane of a few
tenths higher than in healthy persons, so that the evening rise
is almost febrile. Altogether the fever of acute rheumatism is
only moderate and of medium severity.
But there are many exceptions to this medium and favor¬
able course. Abnormally mild cases are particularly com¬
mon. We cannot tell why the fever is so slight or absent, when
the joint-affection is so severe, or even cardiac complications
present. The other severe deviations do not amount altogether
to one-sixth of the cases. Among them the commonest is the
protracted. Numerous abnormalities protract it four or five
weeks ; the temperature may be normal in the morning, and
even exceed 40° C. = 104° F., in the evening. In a single day
large fluctuations, as 3° 0.3=5.4° F. or more, show themselves
when the affection of the joints becomes fixed.
Recrudescence of fever, or apparently objectless intercur-
182 POLYARTICULAR RHEUMATISM.
rent elevations of temperature of 2° C. = 3.6° F., come right in
the middle of a moderate course of fever, ephemeral or lasting,
without evident connection. More slowly developing and pro¬
tracted elevations may be associated with a relapse. The cases
artificially depressed by digitalis, aconite, etc., and rising again
when the medicine is left off or its therapeutic action exhausted,
may be classed as apparent recrudescences.
Complications, especially pericarditis and endocarditis, have
no effect on the course of the fever, or modify it as follows:
In pericarditis and endocarditis, when they have produced
valvular mischief, the temperature may remain unaffected dur¬
ing the fastigium, but becomes higher in the convalescence than
usual, and it takes considerable time to come down to its norme.
With fresh development of aortic valvular deficiency great ele¬
vations of temperature arise late in the disease; not so in mitral
insufficiency. Other elevations are due to complications; pneu¬
monia, for one.
Fig. 60.
POLYARTICULAR RHEUMATISM.
IP1DBHHBDDDDDBDDC9E3DI3BQ
lunxi'VivinKKuxuiim
»!■■■■■■
««*■■?!■■■■■■■■■■■■■■
U ■■■■■■ ■■■■■■
■■■■■■■■■■■■■NisnnniB
■■IIUM
B ■■■■ 55 ■■■■■■■■■■■■■■■■■■■■■■■■ ii^ ■■■■
When articular rheumatism becomes fixed in a joint or bone,
it may hang about a long while through recrudescence and com¬
plications, and displace itself with or without fresh disturbance
of temperature. Such obstinate cases have occurred to Wunder-
lich more frequently in private than in hospital practice.
Among the fatal affections which accompany acute rheuma¬
tism, or have rheumatoid symptoms, one class is fixed localiza¬
tion. Death, in these cases, does not result from the rheumatism
itself, but from the unfortunate course taken by some local mani¬
festation or accessory to it. Another class included with acute
rheumatism presents a malignant character revealed from the
beginning or during the further progress of the affection. The
FATAL RHEUMATISM.
183
most common symptoms are rigor, intense fever, severe nervous
symptoms, jaundice, haemorrhage, diarrhoea, enlargement of the
spleen. Death generally occurs with considerable, sometimes
enormous, elevations of temperature, 43°—44° C. = 109.4°—111.2°
F., and more. These rheumatoid cases run in three different
directions, the pvsemic, the icteric, and the nervous, corre¬
sponding to pyaemia, pernicious jaundice (acute yellow atrophy),
and pernicious nervous catastrophes, devoid of anatomical basis.
The nervous form is the less developed, the icteric the most
pronounced, pysemic the most complete. Rigor, jaundice, en¬
larged spleen are met with intense fever, moderated by decep¬
tive remissions.
In the cases which end fatally, without multiple centres of
suppuration or jaundice, the disease runs its course like a verv
severe articular rheumatism. A descending direction may even
have set in, but suspicious nervous symptoms appear. With
them the temperature reaches the most extreme degrees in the
briefest time, so that death occurs with hyperpyretic temper¬
atures ; whilst no anatomical lesion of the brain can be dis¬
covered, only a very moderate degree of meningitis: post-mor¬
tem elevations of temperature may be met with.
Acute rheumatism is rather a disease of the adult. Infants
and old people have it rarely, and less pyretic. Even in adults
its degrees are seldom as high as those of typhoid fever or pneu¬
monia; owing likely, infers Roger, to the facility and abun¬
dance of the perspiration. But when its temperature rises from
103°, 104°, to 107°, 108°, 109°, a fatal termination was expected
Fig's. 61, 62.
FATAL RHEUMATISM.
within a few hours, when Wunderlich wrote his book. The
cases reported by Quincke of 110.2°, and by Weber, of London,
of 111.2°, did not recover.
184
cerebral rheumatism.
Since, thermotherapeutics has conquered to human life a few
degrees, as shown by the following cases of rheumatism, the
first one being of rhumatisme cerebrate, so named in 1835 by
my compatriot, Hervey de Chegoins.
1. From Wilson Fox (see Appendix XII., A, B). A female,
B , set. 49. After two weeks of low temperatures in
acute rheumatism of the lower joints the thermometer rose
the fourteenth evening, at 9.55, to 109.1°. Put in the bath
unconscious, cyanotic, pulse imperceptible, breathing by irregu¬
lar gaspings; rectal temperature, ]10°. Lumps of ice on the
chest and abdomen; at 10.10 p.m. fall to 109.1°; at 10.15
to 108.4° (bath averaging 66° F.); at 10.20, 107.5°; at 10.25,
106.2°; pulse 140 ; consciousness returned. Brandy. At 10.35,
103.6°; 103° when taken out of the bath; at 10.55, 100.6°;
at 11.5, 99.5°; at 11.25, 97.4°; unconscious; brandy, hot bot¬
tles, and bags. Midnight, T. 98.2°, P. 130, R. 43°; at 1 o'clock
a.m., T. 99.4°, P. 118, R. 32. During that night the patient
took, by the mouth or by enemata, twenty ounces of brandy,
milk, eggs, beef-tea. Recovery (through fluctuations from 98°
—102°) at the end of the third septenary.
2. From Da Costa (American Journal of Medical Science,
January, 1875). Apyretic treatment of a woman, previously
healthy, took cold, articular rheumatism.
Days
1.
2.
3.
4.
5.
6.
7.
8.
Temperature ,
Pulse
Respiration....
105.5°
120
40
110°
120
25
103.5°
98
32
103.5°
92
36
Mor.
100°
88
40
Eve.
106°
88
40
Mor.
105°
86
40
Eve.
104°
86
40
Mor.
103°
72
40
Eve.
loo"
76
36
Convalescent at the end of the septenary. Da Costa remarks
that in his other cases (ten) of cerebral rheumatism, some died
who had attained but comparatively low temperatures—one of
them only 101°; that in the cases complicated by pericarditis
and endocarditis the fluctuations of temperature were smaller
than in the uncomplicated ones.
3. Drs. W. H. Draper and H. P. Maynard had in the Roose¬
velt Hospital a case which rose to 107^° F.=41.8° C., and cured ;
remarkable for the prompt subsidence of the pyrexia in the
bath, its reaction when out'of it, and the subsidence in it of
inflammation of the kidneys.
185
delirium and subsultus. Yet this case would not have likely
been published but for its great similarity with Dr. Wilson
Fox's (see Appendix XII., C.); for in New York the treatment
of acute rheumatism by water is so well accepted, that extra¬
ordinary recoveries alone are recorded. In Paris silence comes
from another motive. The Societe Medicale des Hojpitaux
had its attention called to three recoveries from acute or cerebral
rheumatism at 40°, 41°, 42° C. by the apyrctic treatment. The
discussion went on, without reference to the much more remark¬
able cases of Wilson Fox and Da Costa, when Dr. D
objected to the communication as "dangerous, inasmuch as
inexperienced physicians could take advantage of it to do
mischief with this doubtful mode of treatment." {Gas. des
Hopitaux, 16 Mars, 1875). Is that the France in which Trous¬
seau and Boger endorsed Currie when Wunderlich was a boy ?
XII.—Osteo-Myelitis.
In acute osteo-myelitis, which resembles typhoid fever in many
respects, and has, therefore, been called bone-typhus, the course
of temperature coincides accidentally with some typhoid attacks.
Wunderlich reports six cases, of which five displayed a continu¬
ous course till the fatal termination. In three it lasted eight
days, in one fourteen, the whole not a fortnight. One case died
with a temperature of 40.7° C.= 105.26° F., which rose after
death to 41.1° C. = 105.98° F. The fluctuations had been irreg¬
ular, but trifling; the contrast striking between a comparatively
moderate temperature and the enormous frequency of the pulse.
XIII.—Parenchymatous Inflammation of the Kidneys.
Acute inflammation of the kidneys (Bright's disease) has very
little regularity of temperature. Its course seems dependent on
the rapidity, intensity, and circumstances of the attack. Its
temperature is rather moderate, sometimes 39.5°—40° C. = 103.1°
—104° F. In cases which recover the gradual defervescence is
bv lysis ; in fatal cases death occurs in a rise or in a fall of tem¬
perature. Chronic inflammations of the kidneys affect the tem¬
perature very little, and even in fatal cases terminal elevations
of temperature are exceptional.
186 yellow fever.
XIV.—Hepatitis.
Acute parenchymatous inflammation of the liver exhibits
varieties whose temperature differs widely ; but 110 common
principle can be deduced from the paucity of the observed cases.
In the form with malignant pernicious jaundice, either from
phosphorus poisoning or not, the temperature is sometimes un¬
affected, even unto death. In suppurative inflammation, with
abscess of the liver, the temperature may follow the same course
as in pyaemia and in chronic suppuration ; repeated rigors, with
great elevation of temperature, are observed in blennorrhea of
the gall-ducts and in abscess of the liver.
XV.—Yellow Fever.
In yellow fever, according to Schmidtlein's Deutsche$ Ar-
chiv.fur Klinische Medicin, iv. 50, the temperature is highest
in the first few days, 40°— 41° C. = 104°—105.8° F., with slight
evening exacerbations ; from the fourth to the fifth day the
Fig. 63.
YELLOW FEVER (TOUATRE).
temperature steadily falls down to normal, or even below; in
fatal cases it rises again towards the end 2° C. = 3.6° F., or
more. (Wunderlich.)
YELLOW FEYEE.
187
We are expected to know more about yellow fever in the
United States.
Yellow fever has a short incubation of two to five days, rarely
eight or more. It is important, from the start, to observe the
pulse as well as the temperature, because their concordance at
this stage is pathognomic, and serves to distinguish yellow fever
from dengue, etc.
There is but one paroxysm, that of invasion. The tempera¬
ture attains its acme the first, second or third day, with a fasti-
gium ranging—according to the severity of the disease—from
38.9° to 43.4° C. It falls the third or fifth day, not quite to the
norme, exceptionally lower; otherwise it rises again to 40° in
fatal cases, accompanied with haemorrhage,black-vomit, jaundice,
and suppression of urines. Also, not unfrequent abscesses, mala¬
rial and other complications modify the late stage of this course.
When the initial temperature has reached 40.3°, there is im¬
minent danger ; at 43.4° treatment is useless.
Now for the pulse. It had begun quite in keeping with the
debuts of the effervescence, but soon slacks behind the tempera¬
ture and lingers in the 50, 40, 30, even 25 beats, accompanied
with an easy and fated like countenance. That rhythm known
as a solemn pulse bespeaks of some abdominal complication,
and when the patient recovers, it continues to beat its solemn
measure throughout the convalesence.
In other cases, the pulse rises from 72 in the morning to
120 in the afternoon, or from 112 (morn.) to 159 (even.); or de¬
scends from 108 (morn.) to 54 (afternoon), in discordance with
the movement of the temperature, but in accordance with some
sub-phenomena.
During the epidemic of yellow fever in British Guiana in
1852, Dr. Blair noticed strange irregularities in the tempera¬
ture of the body-surfaces: sometimes the forehead was the
hottest, at other times the cheek ; uncovered parts would cool
subito: but he could give no figures, having no surface-ther¬
mometer. With the fever-thermometer the axillary tempera¬
ture reached 41.7° C.
In Appendix XIII., A and B, will be found a synopsis of
the course of temperature and pulse in forty-eight cases of
yellow fever, by Dr. Joseph Jones, of New Orleans, and another
one of a single case, by Haenish, from Ziemsserfs Cyclopaedia.
Dr. Jones' report is a very important document, from which we
188
YELLOW FEVER.
condense the following figures: The synopsis shows twenty-
three deaths against twenty-five convalescences.
Days of convalescence : the 1st, 2d, 11th, 12th, 13th, none;
the 3d, 6th, 14th, one; the 4th, 8th, 9th, 10th, two; the 5th,
five ; the 7th, seven.
Days of death : the 1st, 2d, 12th, 13th, 15tli, 16th, none ; the
8th, 9th, 10th, 15th, 17th, one; the 3d, 4th, 11th, two; the
5th, three ; the 6th, 7th, four.
From these figures we read the inferences:
(a.) That from the absence of convalescence or death during
the first and second days, yellow fever is not as sudden a
striker, as sometimes are cholera and scarlatina.
(b.) That the 11th, 12th, 13th days having no convalescence,
and the 12th, 13th, 14th, 16th, no death, the second half of the
second week is not critical.
(c.) That the 3d, 6th, and 14th (a multiple of 7), each with
one convalescence, shows an earlier issue by lysis than the 8th,
9th, 10th, 15th, 17th days, without one death by catalysis.
(d.) That the 4th, 8th, 9th, 10th, with two convalescences,
stand almost even with the 3d, 4th, 11th, which have two
deaths.
(<?.) That the chances of recovery or death the fifth day are
even, 3—3.
(f) That the seventh day with seven convalescences, and
the 6th and 7th days with four deaths each, shows that in yel¬
low fever one-third of the crises takes place in the limits of the
Hippocratic septenary—a fact worth remembering, when the
antique question of the critical days will be considered from
the newest standpoint of mathematical thermometry.
Dr. Stone, of Woodville (La.), has noted a cadaveric smell
as prodromic of yellow fever. Its confirmation could suggest
some ingenious prophylaxis. Let it be ascertained.
CHAPTEK XIX.
ANIMAL POISONS.
(Syn.: Zoonoses of Jaccoud.)
I.—Lues. (Syn.: Constitutional Syphilis.)
Syphilitic symptoms may develop themselves without fever,
but with certain of them fever is far more common than is gen-
Fig. 64.
190 EQUINIA.
erally believed. This fever is so characteristic, that it is sus¬
pected by a single glance at the course of temperature as seen
in Fig. 64-.
In syphilitic cases elevated temperatures are most common
at the time of the first extensive hypergemic papular or pustu¬
lar eruptions; the fever may be very severe with maxima at
41° C. = 105.8° F.; its course is markedly remittent, with a
daily downfall quite to normal. The alternation of deep morn¬
ing remissions and high evening exacerbations is tolerably reg¬
ular; the duration of the fastigium is quite indefinite; the
fever subsides by the exacerbations becoming less severe in the
manner of the convalescence of typhoid fever.
In the acute syphilitic affections of the liver, brain, and
bones, temperatures almost similar to the preceding are met.
In the malignant form, so soon fatal, 40° C. = 104° F. are met,
with or without remissions, which are deceptive ; the fever has
no regular course nor order. (See Marasmus.)
II.—Hydrophobia. (Syn.: Rabies.)
Inoculable from animal, or from man, to man; incubation
lasting from a few hours to fourteen months, average forty
days. Its admirable description by Bouley, well translated in
English by Leotard, does not contain records of temperature.
Brouardel, Landousy, Goffroy, Peter (of Paris), have observed
great elevations of temperature in the last period. IIow much
more valuable would be the thermography of the period of in¬
cubation, giving warnings equally precious to the infected one
and to his circle of friends.
III.—Equinia. (Syn.: Glanders and Farcy.)
In the only case known by Wunderlich where temperature
was taken (at first the fourteenth day of the disease), it was
of moderate severity, rose from the nineteenth day in zigzag;
and never sank, from the twenty-fifth day forward, below 40° C-
= 104° F.; and in the last few days (fifth week) of the disease
41.3°—41.6°. C. = 106.34°—106.88° F. being obtained. No ob¬
servation of the last twenty-four hours.
Mr. de Morgan reports, in the British Medical Journal,
EQUINIA.
191
April, 1870, a case whose temperature was not very high, but
rose at death, the twentieth day, to 40.2° C. = 104.4° F. Jac-
coud is more explicit.
Fig. 65.
EQUINIA.
Diagram of acute glanders', by Summerbrodt.
Equinia is transmitted from animal to man by contact of the
skin bare of its epidermis, or by close cohabitation ; the inocu¬
lation is rapid, one to four days; the infection slow, three or four
weeks; men catch it more readily than women (Saussier's ex¬
periments), besides being more exposed. By inoculation, the
pus of glanders may produce farcy, and vice versa. The pro-
dromic temperatures (and other symptoms), not unlike those of
trichinosis, are those of purulent infection interspersed with
chills, rigors, etc. In the stage of eruption and invasion, the
temperature rises to 40°—41° with morning and evening ecarts
of one to two degrees ; no outbreaks, but a steady march by
broad undulations (see diagram) towards the fated issue; all the
way the pulse at 110—130, and the respiration, laborious at
40—44 remain, harmonious with the temperature. A specific
odor emanates from the body, death comes in coma about the
third week, though some are cut down in three days, and few
linger more than fifty.
192 trichinosis.
IV.—Trichinosis.
Trichina spiralis, found on the dead, are mere objects of
reference or curiosity, and cannot be searched on the living
without a strong presumption of their presence. The symp¬
toms—fever, diarrhoea, muscular pains, etc.—are so unspecific,
and even variable, that we must look for other signs. Ther¬
mometry affords some already, though more are wanted to es¬
tablish the law. (What we give is from the old New York
Hospital Reports.)
Trichinosis was first diagnosed and microscopically demon¬
strated on the living, by Dr. E. C. Seguin in 1867 (Case No. 13),
just before the introduction of the clinical thermometer in that
institution.
Soon after came a case hardly suspected before the post¬
mortem proof of its nature was given, in 1868 (Case No. 217.)
The third case was early recognized by living tissue being,
as in Case No. I., brought under the microscope, and it recov¬
ered :
Fig. 66.—From the N. Y. Hosp. Reports, Vol. 48.
TRICHINOSIS.
This diagram gives the first clue to a trichinic temperature
evolution. A fever much like the continuous, with well-
marked and rather even morning remissions near the norme,
and evening exacerbations even to 40°, 41°. This period, last¬
ing one, two or more weeks, walled up by a perturbatio critica
of about forty-eight hours in the fatal case, during which is
broken the previous concordance of ustion circulation and res-
TRICHINOSIS.
193
piration. Then from this perturbatio issues, either a chaotic
rise similar to the one which ends the typhus, or a sloping
resolution in which concur the three great vital functions.
Meanwhile, quinine may have supported the strength, but
not affected the pyretic diurnal evolution, as it would have
done in an idiopathic fever.
13
CHAPTER XX.
PULMONARY CONSUMPTION. •
Recent researches tend to reconstitute the former unity of
pulmonary consumption, and thermometry will help considera¬
bly this work of reconstruction.
I.—Acute Miliary Tuberculosis, etc.
Acute miliary tuberculosis produces alterations of tempera¬
ture generally proportionate to the abundance of the tubercular
deposits. When the miliary tubercles are scanty and localized,
or the patient is under the influence of previous diathesis, as
advanced phthisis, cerebral disease, etc., his temperature is
slightly affected, if at all, by the tuberculosis.
Fig. 67.
MILARY TUBERCULOSIS.
The course of temperature in miliary tuberculosis shapes it¬
self like that of an incipient catarrh ending in hectic, fever ; of
typhoid fever, or of intermittent fever ; and these forms may
succeed each other in a single case. The first is met in sub-
acute phthisis.
195
acute cases. As regards temperature, it commences like in
severe influenza ; only the persistence of the fever excites sus¬
picion. Gradually deep remissions, almost to a normal tempera¬
ture, alternate with high evening exacerbations, rendering acute
tuberculosis undistinguishable from non-tuberculous phthisis,
even up to death; unless meningeal tubercles are developed,
and the characteristic symptoms of basilar meningitis are mani¬
fest. In the second form, the temperature is more irregular
and the remissions greater than in typhoid fever, from which
the diagnosis is often impossible to the time of death. These
cases are most rapidly fatal; should they ,escape, the fever
assumes the hectic or the intermittent type, rarely the latter.
In it, the course of the temperature of each fever-abscess (or
local suppuration) may perfectly resemble that of an intermit¬
tent fever, even to a tertian or duplicated quotidian rhythm;
yet, the afternoon attack, the lower height of temperature, and
the deeper apyrexia (below normal), point to acute tuberculosis.
Jn the further course the intermittent type is succeeded by a
milder remittent which clears up any remaining uncertainty, j
II.—Acute Phthisis.
Acute phthisis may originate in a condition perfectly free
from fever, upon which elevations of temperature supervene
in zigzag with remissions and exacerbations of increasing
severity. It may closely follow the fever of bronchitis, pneu¬
monia, etc., a protracted intermittent, confinement in dark and
damp places, exhaustion or defective nutrition, etc.
In the progress of the disease the course of the temperature
is non-continuous, except in phthisis galopante. The daily
differences are as high or higher than 3° C.=5.4° F.; the daily
maxima (sometimes two) approximate to, or exceed 40°—41° C.
— 104°—105.8° F. The daily falls are abrupt, their maxima de¬
scending to the normal point, or below. Even profound collapse
is not rare. An alternation from day to day is sometimes dis¬
played in the remissions, more so in the exacerbations. Inter-
currently the remissions become less and the course becomes
subcontinuous in an ascending type: complications, like pneu¬
monia, may bring other modifications.
The fever is often interrupted, also, by short (less often by
196 ACUTE PHTHISIS.
longer) intervals of moderate fever, or of subfebrile, or even
of normal temperature. It is rare to meet with a persistent
subcontinuous course with considerable or moderate fever from
the very beginning to the fatal end; but it is a common occur¬
rence at the approach of death, for the temperature falls from
its previous height, and the remissions become less distinct;
unless (rarely) the temperature, which had previously fallen,
rises afresh during the death-agony, even to hyperpyretic heights.
Sydney Ringer, On the Temperature of the Body as a Means
of Diagnosis in Phthisis and Tuberculosis (1865), asserts that
there is an elevation of temperature in all cases of tubercular de¬
posit; Wunderlicli says that there are intervals free from fever
in some cases of phthisis; and that in some cases miliary tuber¬
culosis does not affect the temperature at all. Henri Roger
says, " Si dans l'enfance, comme aux periodes plus avancees de
la vie, les tubercules donnent quelquefois lieu a un accroisseinent
de chaleur animale, ce n'est point par eux-memes, mais par leurs
effets consecutifs, par l'irritation locale que leur presence de¬
termine dans les tissus. Lorsque cette inflammation n'existe
pas, ou est devenue chronique, le thermometre monte a peine
au dessus du niveau ordinaire. Andral a constat^ pareillement
chez les adultes que la temperature reste normale dans la
phthisie pulmonaire tant que la fievre ne s'allume point" (De
la Temperature chez les Enfants, Paris, 1844). Herard and
V. Cornil assert that, without complications, there is no fever
in the stage of deposit (De la Phthisie Pulmonaire, 1867)
These discrepancies among high authorities are more appa¬
rent than real. Roger's cases (p. 368, etc.) contradict his theory
by showing rises of temperatures followed by apyretic ten¬
dencies towards the terminus. Andral's words, " the tempera¬
ture remains normal as long as fever does not set in," are not
worth commenting. The " there is no fever in the stage of
deposit," leaves off the other stages. For Charcot, acute tuber¬
culization is frequent, but latent in the aged. Phthisis is slow
and insidious in the viellards; and again, " in the absence of
local symptoms, the thermometer alone can detect pulmonary
consumption in old people." (Legons sur les maladies des viel¬
lards, Chap. II.)
Finlayson adopts the three types of Sir W. Jenner; the in¬
sidious, the active febrile, and the adynamic phthisis.
First tyjpe.—Morning temperatures normal, or under; even-
ACUTE PHTHISIS.
197
ing's more or less high. Ex.:—A child has a temperature of
99.32° F. in the morning, and in the evening 101.53°—101.80°
(in rectum). This equals the " insidious," and often "unex¬
pectedly fatal type."
Second type.—The morning and evening temperatures are
both high, whilst there are evening exacerbations. Ex. :—A
child has a morning temperature of 100.16° F., and an evening's
of 101.57°—103.67° F., the "active febrile type."
Third type.—The morning and evening temperatures are
both high, but there is a tendency to exacerbations at odd
times. Ex.:—On one day the child has a morning temperature
of 102° F., and in the evening of 102.33° F. On another day
the morning and evening temperature may be respectively
102.6° and 104° F.; this characterizes the "adynamic type."
Practically all the cases can be grouped about the two fol¬
lowing types:
(a). Acute pulmonary consumption, which runs its course in
a few septenaries. In it the three vital signs are parallel.
Temperature 38°—40.5°. Most of the time small morning and
evening ecarts between 39°—40°, ending at 37.5° C. Pulse
118 to 180 beats, average 140. Respirations 36 to 60, average
50. Fever continuous.
(b). Slow pulmonary consumption. After the latent initial
period, of which Sidney Ringer has conquered the diagnosis
by thermometry, this affection proceeds, like its congener, the
acute meningitis of the convexity, by poussees not yet very well
observed. During the remissions, the temperature comes back
to the norrne or a little below; during the exacerbations, the
magnitude of the ecarts is in proportion to the magnitude of
the pathological injury to the tissues. But towards the end the
remissions become less distinct, till the fever becomes almost
continuous at a point, 39.5°—40.5°, dependent on the intensity
and duration of the previous ustion, nutrition, etc.
On the whole, the march of pulmonary consumption is
ascending—with or without remissions—till the last septenary,
when it falls, barring rare exceptions; the breathing growing
shorter and quicker, and the pulse rising in inverse ratio to the
temperature, till it reaches unaccountable strokes,—ti-iple effect
of asphyxia and inanition.
It is rather the course than the height of the temperature
which must be consulted in phthisis. To study that effect is sub-
198
SLOW CONSUMPTION".
joined the Fig. 68, from Dr. Woodman, which combines Finlay-
son's table of theoscillations of temperature during twenty-four
Fig1. 68.
hours in healthy children with Dr. Ogle's tables of tempera¬
tures in male and female adults.
From another point of view phthisis appears in two extreme
forms:
d-—The slow and silent consumption (once considered non-
tubercular), whose temperature may descend below the norme,
even to 34° (Weber), for three isolated or concurrent causes,
the failing of the thermogenic apparatus, the impairment of the
SLOW CONSUMPTION.
199
digestive and assimilative functions, and the exhaustion from
diarrhoea.
b.—The phthisis called galopante, whose final hyperpyrexia
continues after death.
But in ordinary cases the temperature is above the norme,
as Sydney Ringer found it in its prodromes. It is not always
equalty so : its lowering will be found to correspond to certain
periods in the evolution of the tuberculosis; higher during
tuberculization, lower during or after large expectorations and
vomits, lower still after hsemophthisis.
Another pyretic sign is the progressive increase of the ecart
of the evening from the morning temperature (2°—3° C.); but
when the end is near, the ecart diminishes by the rise of the
morning ustion to the height of the evening's. Slow consump¬
tion not uncommonly ends in apyrexia.
CHAPTER XXL
MALARIOUS DISEASES.
I. Intermittent Fevek. (Syn.: Ague, Chills and Fever,
Paludal Fever.)
\
Intermittent fever is, more than any other disease, character¬
ized by rapid temperature changes from hot to cold, and by
temperature inequalities from the centre to the periphery ; the
latter exceeded only in cholera.
Another peculiarity of the intermittent fever is the many
forms it assumes: some affecting only its periodicity (that is,
among the intermittent proper); others taking a bilious, a pul¬
monary, a cephalic or any other localized nervous types; others
again enveloping themselves in such disguises as to deserve the
appellation of masked or larved, or endowed with such mobil¬
ity or swiftness that they cannot be called otherwise than er¬
ratic : all, however, recognizable at one sign—the periodicity of
its extreme temperatures.
Senac is-probably the first who remarked that in the shiver¬
ing cold stage of the intermittent, a thermometer introduced
into the mouth did not mark any fall of temperature. (De Re-
condita febrium. Interinitt. Natura.) Gavaret mathemati¬
cally demonstrated in 1839 the increase of body-heat when the
febricant shivers with cold, and its precedence of some hours
before the chill, by which signs the therapeutist is warned in
time to administer the antidote. Baerensprung and Michael
have found the same elevation of central temperature before
and during the fieber-frost, btut several years after Gavaret, and
figure it as: .5°—1° C., one or two hours before the chill,
rapidly increasing during it by several degrees ; and when
perspiration begins, falling by a kind of defervescence called
en terrace.
Thermometrically, we distinguish in intermittent fevers the
QUOTIDIAN FEVER.
201
course of an isolated paroxysm, and the series of these
paroxysms which constitute a whole morbid entity.
The separate paroxysms are each characterized 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 below it. The rise is the first symptom. It may
continue slow for a few hours, up to 38.5°—39° C.=101.3°—
102.2° F. With the rigor it starts up in one hour to 41°—
41.5° C.=105.8°—106.7° F. Meanwhile, the stage of dry heat
(hot stage) may have set in, and the rise go on to the acme of
the paroxysm, forming a summit-pointed or slightly bifid.
The maximum, is reached in the stage of dry heat, or when
partial sweating appears; it only lasts a few minutes. With
the sweating (moist stage), the temperature descends slowly for
the first hour or so, then fluctuates, then falls decidedly without
any fresh rise. However steady may be this fall, it is accom¬
plished by an alternation of horizontal progressions and partial
descents, some at the rate of one-tenth, some at that of one-
half of a degree per hour, whose downward lines form ter¬
races, which in four hours bring the temperature back to
40° C. = 104° F. Then it sinks somewhat more rapidly, requir¬
ing, however, ten or twelve hours more to regain the normal
point, 37° C.=98.6° F.
During the ajpyrexia the temperature may fall below normal;
but if it lasts more than a day, there is a slight evening exacer¬
bation. Not infrequently the use of quinine suppresses the
subjective symptoms, but leaves the elevation of temperature
almost equal to that of a complete paroxysm. Then rise and
fall are compressed into less time than when there is rigor.
This behavior of the temperature in the paroxysm is so charac¬
teristic of intermittent fever (ague, etc.), that it renders its
diagnosis tolerably certain. There are very few diseases in
which it rises so rapidly from the norme to 41°—41.5°=
105.8°—106.7° F., and returns there with equal fleetness. The
study of the temperatures of a single paroxysm is therefore
sufficient to differentiate intermittent from typhus, meningitis
and cholera, at least.
The paroxysms of intermittent fever succeed one another and
have several rhythms, whence their nosologic entity.
The simplest of all is the quotidian, whose paroxysms return
every twenty-four hours.
202 TERTIAN FEVER.
In the variety called double quotidian there is two daily
paroxysms.
Fig. 69. Fig- 70.
QUOTIDIAN FEVER. TERTIAN FEVER.
The tertian, whose paroxysm returns the third day, therefore
every other day.
The quartan, whose paroxysm returns every fourth day—
that is, after two days of apyrexy.
Thermometry alone is often able to reveal the fact that the
apparently simple quotidian, tertian and quartan are dupli¬
cated ; that is, have a stronger paroxysm followed by a weaker
one.
Among the larved, let us mention the algid intermittent,
which runs its course without pyrexia. Like all of them, its
masks cannot cover its periodicity, and falls under the action
of true antiperiodics.
The bilious remittent, whose paroxysms are less distinct,
the fever more continuous.
It begins by a moderate initial chill followed by a hot stage,
after which the algidity begins; temperature in the mouth
86°—88°, in the axilla 84° F.; the body becoming cold like
marble. In the meanwhile there is a subjective feeling of
burning and thirst; the flabby skin is pale or livid, covered
malignant ma labia.
203
with cold sweat; the pupil dilated, the look vacant, the lips
without expression; the tongue soft, smooth and pale; the
Fig/, 71.
QUARTAN FEVEB.
region of the stomach sensitive (Hertz in Ziemssen's Cyclo¬
paedia). Torti more expressively said (1712): Tertiaperniciosa
hominem jugulat—symptoma for ox. In its worse forms it
is essentially a produce of the Tropics, transferred by ships
from Aspinwall, Mobile, etc., to our Northern hospitals. Its
records on board are blank, and it is only after the first septe¬
nary that the symptoms are tabulated, when death permits.
II.—Malignant Malarial.
A high temperature develops the malignancy. The acci¬
dents are without relation to the kind of disease, epidemic con¬
stitution, idiosyncrasy (Trousseau). Why we cannot furnish
diagrams of malignant intermittent, any more than of congestive
remittent, by climatic exaggeration, is, according to the vivid
expression of Tissot, because a disease is malignant when %t
strikes as the dog who bites without barking. When the
204 THERMOMETRIC TEST OF FEVERS.
second or third access is prevented, it was not the pernicious;
if not prevented it kills, leaving in either alternative 110 time
for thermometric observations. It flourishes on the banks of
low rivers like the Maumee River, or on the affluents of the
Yonne, near Clamecy, France, where hemp is deposited to rot
and bleach; as well as on the affluents of the lakes of Cen¬
tral Africa, where Gordon (of the Stanley expedition) recently
died in a cold stage of one hour. Less rapidly murderous
was the combination of malarial with typhic elements, which,
under the name of Chickahominy fever, mowed the besieging
army before Richmond in our civil war twelve years ago. It
is unfortunate that no thermometric records were then kept by
the medical staff of the United States.
But there is a tendency to view the fevers more connectedly.
After much acuteness spent in distinguishing these fevers,
we treat them as if they were but one with several'degrees:
a practice likely more sound than the theory.
Complete recovery from all malarial fevers can only be testi¬
fied by thermometry. We know that intermittent may be
broken by quinine, etc.; but is not cured, and will reappear
with a provoking cause, or without—some say in periods corre¬
sponding to the Ilippocratic septenaries. For my own part, the
cases whose recovery assumed the permanency of a law, were
those in which the use of quinine was continued every seventh
day, starting from the last of the fever, for a length of time
commensurate to its previous duration. Old cases have to
be quininized every spring and fall, or sent to parts several
thousand feet above the place where they got zymotized. In¬
deed, there is no disease—cholera and sun-stroke possibly ex¬
cepted—in which thermometry can render such services as in
intermittent. Yet it has not given in it all its natural results,
because we have followed only one set of observations—the course
, of the central temperatures; when the other one—the course of
the peripheric temperatures—ought to have been as thoroughly
recorded. Where surface-temperatures were taken it was
with a fever thermometer, in or on the hand, under the foot
or between the toes, on some point of the convexity of the fore¬
head, or in a fold of relaxed skin ; fanciful operations, capable
of discrediting thermometry at large.
The thermal history of intermittent fever and of most of
the local phlegmasiae will become possible only when good, sen-
THERMIC PHILOSOPHY OF FEVERS.
205
sitive surface-thermometers will be applied to the periphery,
and correct fever-thermometers to some accepted cavity. From
these comparative operations will be announced, and may be
prevented, or at least attenuated, these fearful inequalities of
surface and central temperatures, hyperustions here, and frige-
rations there, between which life is like a wrecking vessel in
a dancing sea.
In intermittent we had already two fine specimens of
apyrexy—the incidental and the localized frigeration.
But let us survey this field from a higher ground:
After all, the philosophy of fevers is adequate to their ther¬
mography. Their phlegmasy is more or less violent according
to climate; their prodromic chill is sensible or not; their
pyrexy may reach farther and remain longer above the norme,
or the reverse ; the progressions may be ascending, descending
or alternate ; the paroxysm may be matutinal or vesperal, di¬
urnal or postponed several days; it is nevertheless the same
enemy under different masks. A dam is formed to create
a water-power in a valley; it will cause hundreds to be struck
with the autumnal and spring fever, and to be engraved on
thousands the features of malarial cachexy. The pond of
Lindre (Dept. of the Meurthe, France) was fifty years ago
managed in rotation: the first year, filled with water, it grew
fish in, and intermittent out; the second year the crop was
fished from the low water, and the typhoid fever was rife
at the margin; the third year .the surface was allowed to dry
and remain fallow, then carbuncles were as thick as blackber¬
ries ; and every third year the same crops were grown as by
the hand of idiots. But latterly, the pond being kept full, for
industrial purposes, intermittents ruled in all their modalities,
from the ephemeral to the malignant, with such authority that
they generally baffled the efforts of fourteen physicians and
four druggists; the criminal who did this got rich.
The paludeal element is more poisonous as it advances south,
as digitalis grown in the fissures of rock at a southern exposure is
many times stronger than that of our gardens, as the sprouts of
conium, eaten like asparagus in Sweden, would kill in France
or in this Republic.
Those who deny the miasmatic nature of fever may try
to go out early and breathe it before the action of the sun has
raised the heavy layer of moisture which keeps the lethal prin-
206
PROPHYLAXY OF FEVERS.
ciple on a level with the organs of inhalation. Those who
believe in it must surround their properties and residences
with thick curtains of American cedar, or Australian eucalyp¬
tus, and ornament their yards, or even their modest windows,
with hops, hemp, or sunflowers, not likely the only vegetables
which enjoy swallowing the effluvia deadening for us, fattening
for them.
CHAPTEE XXII.
APYRETIC DISEASES.
A coldness below nature, Frigor propter naturam, is at the
foundation of all apyretic diseases, or conditions.
To better understand how our body becomes apyretic, let us
repeat that human temperature has several factors: the produc¬
tion of heat by the modification of the blood and tissues, and
by respiratory oxidations. The loss of heat by contact, rayon-
nement, evaporation, expiration, labor. The equilibration of
its production, exhalation and repartition on the divers parts of
the body by the circulatory apparels, whose movements are
under the immediate order of the nervous system.
Hyperpyretic temperatures have been studied conformably
to this theory of human color, caloricity, and been traced to their
factors: an excess of production, too great a deperdition, an
inequal repartition, and a failure of the moderating functions.
Now devolves upon us the converse task of tracing, when¬
ever we find traces of them, the connections of the apyretic
forms of distemper with the factors of low temperature, Frigor
prceter naturam, in the human body, viz.: diminished produc¬
tion, increased deperdition, irregular distribution of heat, or a
stunning of the great sympathetic, which stops its harmonizing
action.
A survey of the cold field of the body-temperature shows
that besides being either central, peripheric or local, apyrexy
may be congenial, or brought on by frigorigenic causes ; may be
the expression of a single or of compound circumstances ; may
stand alone or between pyrexiae, may be in ascending or in
descending progression; may be a misstep of the deferves¬
cence, or a status {etat d'etre), which may or will henceforth
constitute a healthy abnormal norme.
In other words, regarding its duration, it may be ephemeral,
periodic, continuous, ascending, descending, modifiable, or irre-
208 temperature in cholera.
trievable. It causes, in order of intensity, cooling, frigidity,
algidity and congelation.
From this survey it appears: first, that though apyretic
diseases are nominally few, apyretic conditions are many and
frequent; and second, that not a few of the latter have already
attracted our attention, as either antithetic to, or intercalated
with some of the pyretic conditions before studied : carried by
the current-force of their common subject. Thus have we
observed apyretic temperatures as the lower terms of extreme
fluctuations, or as the mathematical rendering of the exhaustion
of combustible materials after exaggerated ustions. Then,
when treating of surgical temperatures, we had to confront the
high and the low, in order to render their respective or com¬
mon causation more striking, and the theory and practice of
their treatment more forcible. Since, in the fevers of mala¬
rious origin, we have just met with true, though intermittent
apyrexias; and lastly, when soon treating of the temperatures
of nervous affections, we will meet with extreme ones both
ways of the scale; and we do not intend to sacrifice the advan¬
tages of closely comparing them to the systematic pleasure of
separating them in yet imperfect categories.
Roger did this, and tried to force all diseases in the pigeon¬
holes of pyrexy and apyrexy; but as many refused to enter, he
set them apart under the head of stationary. That will do as
an indication towards the future, and to mark the terra incog¬
nita of our present thermography ; but we had better keep
yet for a while close by Nature, which has thrown the most
extreme temperatures in the same, or in apparently similar
morbid conditions (in lesions of the spine, for instance), in order
likely to let us compare, and find out the why ? . . . How¬
ever, where the law of apyrexy is distinctly traceable, as in
certain diseases of the aged, and in certain conditions of the
new-born, we will be most happy to follow Charcot and Roger
in their appreciation of senile and infantile apyrexiae.
I.—Temperature in Cholera.
Cholera incubation lasts from a few hours to four days, and
the premonitory diarrhoea a few days only (Vienna Conference,
1874).
CHOLERA.
209
The temperature presents the same signs in sporadic as in
epidemic cholera, only less marked.
First in this field, as in several others, Magendie announced
in his Lessons of 1832, at the College de France, the fall of
temperature in cholera, and called the students' attention to
the discrepancy between the surface and central temperatures.
This early observation ought to have been soon followed bv
new discoveries. But several difficulties retarded the study of
the temperature in cholera. One, that though cholera is a mor¬
bid eutity, it is also a trilogy, whose phases are not only dis¬
tinct, but different. A choleric may die in the stage of active
cooling, in that of passive algidity, and in the pyretic reaction,
which can even continue its ascendancy after death. Till the
temperatures of these phases is studied distinctly and com¬
paratively, we may be able to say with Magendie in the
most general terms, and barring exceptions, that cholera is an
apyretic disease; but in observing individual cases our judg¬
ment will stumble against unexpected and unexplainable
pyrexiae in the middle of a ruling algidity.
This difficulty is aggravated by another. In cholera, the
points of selection most favorable to ordinary thermometric
observations become obliterated, and partly or temporarily
useless or even deceitful. The parched axilla emits hardly any
radiated heat, and is not much hotter than any other point of
the open surface (though anointing with A A glycerine and
water may restore part of its heat-radiating property). The
mouth is moist, but clammy cold, notoriously below the central
temperature ; the rectum and vagina remain the most trusty
representatives of the central temperature, unless the thermo¬
meter becomes embedded in fseces one way, and in diphtheritic
exudations the other.
It is Lorain who first insisted upon taking the temperature
of cholerics in recto. He gave (1850) among the results of his
observations on seventy-four cases: minima, one at 34°, two at
35°, ten at 36° (rectal). In forty-seven cases the index re¬
mained at the norme, in twenty-seven it rose to 38°, in fifteen to
39°, and once at 40° C.
However, the axillary temperature becomes valuable per se
in the period of pyretic reaction, and by comparison with the
vaginal and rectal. A great difference between these three
temperatures is unfavorable; but a rise in the temperature of
14
210
CHOLERA.
the mouth, with a fall in that of the vagina or rectum, promises
well.
In sporadic as in epidemic cholera, the difference between
the central and peripheric temperature is often extreme, as 36°,
37° in the rectum; 33°, 34° in the month; and 21°—24° on the
hand. Yet the central algidity is neither constant nor con¬
siderable in cholera as in the sclerema, where children are not
unlike to cold-blooded animals. The algidity increases from
cholera infantum to the sporadic and epidemic. The prognosis
is grave, with a fall of 4°—5° in the mouth, and from 2°—3° in
the axilla, but mortal with the same in the rectum. Czennak
did not witness a single cure where the temperature of the feet
had been 24°. Wnnderlich, too, noticed the diagnostic value
of the low temperature of the feet and hands ; but how can it
be mathematically measured without surface-thermometers,
thermoscopes, etc.? It is difficult to conceive of the successive
performance of these delicate operations with the fever-ther¬
mometer, so ill adapted to surfaces, so tedious in its indications.
But the difficulty increases when the question is to take these
temperatures during the successive phases of cholera which
have almost nothing in common but their contiguity, as we will
presently see.
In the cholerine form, after the first painless watery stools
and vomit, the temperature becomes lower: though the causes
of this lowering are not all from the evacuations; since it has
been noted to precede them in patients under observation for
other diseases before any other symptom appears, and thus to
be prodromic of the advent of cholera.
In the stage of evacuations of slight cases, which do not be¬
come asphyxiated, the axillary, vaginal and rectal temperatures
remain in their normal relations, or the vaginal a little raised.
With indications of asphyxia, these temperatures begin to
diverge—vaginal higher, and axillary somewhat lower than
normal. When flaky substances (albuminoid) pass, cramps
come, and algidity sets in. In the algide form that will
recover, the temperature of internal parts is moderate, rarely
exceeding 39.6° C. = 103.28° F., and seldom normal or below.
In the algide stage there is little purging, alterations of the
fibrin of the blood, arrest of secretions and of aeration of the
blood, mortal coldness, coma. Later yet the blood becomes
glacial, and communicates an icy coldness. The body is so be-
CHOLERA.
211
numbed by cold tliat it is rendered insensible to the contact
with boiling water. Choleraic, algidity is felt colder by the
physician than it is shown by the thermometer, on account of
the accompanying cold sweat. The central fall is ordinarily
4°—5°, rarely 9°—10° F. The extremities are coldest, then the
face, the mouth, the tongue, the periphery of the body at large;
the axilla (which is no test for the central, nor for the peripheric
temperatures), the rectal highest of all. Such vivid descriptions
abound; but no figures given in support of the relations of the
various peripheric temperatures to the central, nor of their
modifications by a jr>y oogenic medication. (See second part.)
Adult choleraics have rarely revived from 14° below the
norine (Czermak says 13°); but no children from 4—5° Ph. =
82.5° C.= 90° F.
In death by asphyxia the vaginal and rectal temperatures
reach higher, 40°, even 42.4° C. =104°—108.32° F. Profuse
and violent alvine discharges are indicated by a fall. When
the temperature rises (even only relatively to the other symp¬
toms), it announces the cessation of the alvine discharges. A
rapid and considerable fall and a rapid and considerable rise of
temperature are warnings of death ; on the contrary, the less
the temperature fluctuates the more probability of recovery.
During the algide stage, the temperature of the skin falls in¬
deed very low, 35°C. = 95° F. The axillary fluctuates less
than the internal. Rapid changes of surface temperature are
threatening. A low temperature slowly and steadily rising,
with only slight fluctuations which hardly exceed the normal,
is of good omen. Lowest of all may be the temperature under
the tongue ; in asphyxia it seldom exceeds 31° C. = 87.8° F.;
even cases at 26° C. = 78.8° F. have recovered ; none below.
In tliepost-choleraic, or reaction period, the temperature re¬
turns from its abnormal condition to its norine again, yet mod¬
erately febrile elevations are not dangerous, but must awake
the attention; higher elevations of temperature are sure signs
of complications and local affections, which narrow the pros¬
pect of recovery. Very high temperatures are induced by
parotitis, erysipelas, and more rarely by atypical pneumonia.
Roseola and other exanthems do not always induce a rise of
temperature. A normal or quasi-normal temperature in the
post-choleraic stage is no guaranty of recovery; but 42° is con¬
sidered mortal.
212
CHOLERA.
In a typhoidal reaction the, temperature may be normal or a
little higher, or rise above, and take a remittent course; these
are stormy cases; if they do not end by death at once, they arj
much protracted. Parenchymatous nephritis is one of the
sequels in both forms of reaction.
The most unfavorable omen in the post-choleraic period is
when a normal or elevated temperature suddenly sinks below
normal. A considerable loss of surface-warmth indicates great
danger.
Magendie, Briquet, Mignot have often noted a rapid ascen¬
sion of temperature as death sets in.
In man}* cases the temperature of the body begins to fall
just after death; in others (especially with those previously
high), it rises for some minutes or half an hour after death.
CHAPTER XXIII.
TEMPERATURE IN DISEASES OF THE NERVOUS SYSTEM.
This is a subject more vast than our knowledge of it.
Nervous diseases are just now the theme of the most ardent
studies. Since the pioneers, Magendie, Bayle, Le Gallois, Flou-
rens, Brown-Sequard, 01. Bernard, Virchow, Sliiff, have posed
the generalities, the young school, Charcot, Vulpian, Bourne-
ville, Lepine, Hitzig, Fritsch, E. Dupuy, Ferriere, II. Jackson,
B. Sanderson, etc., are throwing the bases of localization and
of temperature in nervous affections. Need I say that the work
is hardly begun, and that I can report it only as far as I am in¬
formed.
I.—Temperature in Affections of the Brain.
Charcot and Bourneville, above all, have carefully investi¬
gated the temperature in cerebral haemorrhage and softening,
and have reached valuable conclusions. (See Appendix XV.)
a.— Cerebral haemorrhage has a definite course of temperature,
whose very modifications indicate the gravity of the disease.
In cases of average severity, from the stroke to seven hours
later the temperature falls even to 35.8° ; then follows a
second period, in which the temperature reascends to the
norme or a trifle beyond it, and remains about that figure for
several days, when if recovery is to take place, the absolute
norme is reached : this is the stationary period.
In similar common cases which are to terminate fatally,
there occurs, after one, two, or four days, a raise of tempera¬
ture which goes on increasing until death, when the mercury
may have reached 40°, 41°, even 42°.
In extremely severe cases, ayojplexie foudroyante, or multi-
214
CEREBRAL HEMORRHAGE.
pie haemorrhages succeeding each other in rapid succession,
there is no other thermic condition but the initial fall, uninter¬
rupted from the moment of the seizure till death.
In cases of great severity short of that just referred to, the
initial depression is present, but instead of a succeeding station¬
ary period, we have a rise of temperature continuing until
death.
Fig. 72.
cerebral haemorrhage (from Leprae).
In other words, in cases in which a fatal issue is certain in a
few hours or days, the stationary period is wanting, the initial
depression is followed by abnormally great heat; in cases
which will prove very quickly fatal, there is only a rise of tern-
SOFTENING OF THE BRAIN.
215
perature; in cases in which recovery is to take place, we have
initial depression, stationary period, and return to the norme ;
in cases in which, after initial depression and stationary period,
there occurs a rise of temperature, death is quite certain.
During the periods of stationary and rising temperature, that
is, the first few hours or days, a new depression below the
norme indicates a fresh effusion of blood. The pulse and res¬
piration vary so much in all these tliermometric periods, that
they are wholly unreliable guides to prognosis. A few minutes
after death, the rectal temperature may reach a point a few
tenths of a degree above that noted just before the fatal issue ;
and the fall of temperature afterward is slow, the mercury
standing in some cases at 40° for as long as an hour, in one
instance the loss of heat amounted to only .7° in three hours ;
in another, to .4° in one hour.
b.—The course of temperature in softening of the brairi
presents the following contrast with cerebral haemorrhage:
In cases of acute cerebral softening, it is very seldom that
any initial depression is observed. When present, it is of
much smaller amount than in cases of haemorrhage—for ex¬
ample, 37°, 37.2^, 37.8°—while the mercury goes below the
norme in cerebral hajmorrhage.
When the softening involves a whole lobe or a large part of
a lobe, and is to terminate fatally in from one to three days,
the temperature rises until death. In cases of extreme sever¬
ity with softening of the corpus striatum, as well as of the con¬
volutions, the tliermometric course almost exactly resembles that
observed in cerebral haemorrhage.
In cases of softening involving smaller brain lesions, and
terminating fatally in from five to fifteen days, Bourneville
discovered remarkable, and as he thinks diagnostic oscillations
of temperature: variations of from 1°—2° in each day, until
near the end, when a further rise reaches 39°—40.8°—42° at
death. (In some cases the rectal temperature was quite nor¬
mal at some hour of the day.)
In cases of softening which get well, a gradual rise takes
place from the period of attack to the third or fourth day, the
mercury reaching 39.4°—39.8°, and then a fall to the normal
occurs, complete by the fourth or sixth day. At the close of
this period the central heat would be a little below the norme
for a day or two.
216
temperature in insanity.
To resume, except in extraordinary cases, the initial lower¬
ing of temperature is missing, o* less characterized in soften¬
ing than in haemorrhage; temperature remaining at 37°—
37.8° in the two hours following the attack. The stationary
period, which follows, is marked in softening by a standstill,
or by irregular morning or evening remissions; whilst in cere¬
bral hcemorrliige the temperature remains above 39°, and falls
to the norme only from the effects of new effusions »f blood.
The ascending period of softening follows the stationary later
and slower than the corresponding one in haemorrhage. The
therm,inal temperatures of softening (barring the first excep¬
tion) are lower than those of cerebral haemorrhage.
c.—Temperature in Insanity.—For obvious reasons there is
no typical temperature in insanity. For less acceptable rea¬
sons the subject has not been elucidated as it deserves.
Temperature is higher in the insane than in the sane. It is
highest in phthisical mania, very high too in general paralysis,
particularly when it runs a short course, and towards the end;
and is gradually falling in the following order: in acute mania,
epileptic insanity, melancholia, mania, mild dementia, and
complete dementia—the latter being the only form in which
the average temperature falls below the human norme,—yet
the evening temperature of every form 'of insanity (even of
complete dementia) is higher than the evening norme. (See
Appendix XVI.)
The difference between the morning and evening tempera¬
tures is due, at first, to the evening rise. The proportion of this
evening rise may serve to foretell the ratio of mortality. In
general this death-rate has its acme in general paralysis. When
phthisical insanity is acute the temperature runs high, when
latent it almost evades thermometric investigation.
The lowest temperatures found in chronic insanity by
Loevvenhardt, were : in one case 25°—31.4°, and in another,
23.7°—21°, during the last five days. They were not melan¬
cholic, but violent, throwing off their clothing by a low external
temperature ; had ideas of grandeur without general paralysis.
The greatest individual differences of temperature in the
same form of insanity were met with in general paralysis, in
epileptic insanity, and in acute mania; as much as 8.7° C. in
the former.
The temperatures taken by Langdon (see Appendix XVI.)
temperature in idiocy.
217
confirm in the main those of Clouston, accepted by Maudsley
(see Bibliography). They show that everything being equal in
each species of insanity, the temperature falls and the pulse
relents in proportion to the length of the affection, The young
resident physician of the Hudson River Asylum pointed out to
me the general fact that in recent paresis the pulse and tem¬
perature are low ; and the special fact that, if it is compli¬
cated of delusions and excitement—irrespective of the gravitv
of the paretic symptoms—the circulation and ustion are much
higher. Accordingly, I ^ counted in his first case of recent
paresis with illusions, agitation, etc., the average temperature
99.125° F., and the average pulse 89.2 ; and in his second quiet
case, average T. 98.15°, and average P. 67; making for the
first an elevation of almost l°F.,and of 22 beats to the minute.
Thus excitement increases 1°—2° the temperature of the in¬
sane ; so eventually (not always) does inanition, exposure, general
paralysis, in which case the hyperpyrexy follows a preagonic
ascension. In the great majority the progression of ustion is a
descending one. As the insane grows older the colder he be¬
comes, particularly in the morning—a warning that he has
spent more caloric than he coidd generate, and will soon die.
d.—Temperature in Idiocy.—For obvious reasons too the
same remark obtains for idiots j the great majority of whom die
early without hardly gi ving a warning of their illness—apparent¬
ly from one disease or another, oftener from latent pneumonia,
but really from exhaustion of caloric and paralysis of caloricity.
In 1860, I took the temperature of almost all the idiots of
the New York State Asylum, at Syracuse, N. Y.; but the in¬
strument to be procured then and there was imperfect, and I
substitute for my figures those obtained recently by my friend
Dr. Van Duyn, surgeon of this institution (see Appendix
XVII.) with a Casella's thermometer—as good as a Fahrenheit
can be.
From the thirty-three cases observed by Van Duyn it appears
that the mean temperature of the idiot is found in the morn¬
ing, the maximum at mid-day, the minimum in the evening ;
the pulse and breathing showing the same fluctuations, but not
always in the same cases. There are exceptions, however, of
which a close examination of each subject could only give the
key ; but operating on figures, instead of on subjects, the fre¬
quency of these thermic indications is remarkable, considering,
218
TEMPERATURE IN IDIOCY.
moreover, that a State asylum, as the one managed by my
friend, II. B. Wilbur, is opened to a great variety of helpless
children, under the generic appellation of idiots.
What is the meaning of these figures on the training of idiots ?
We can as well answer this question here, since we will likely
find no opportunity to recur to it. These figures signify that
the exercises of attention, comparison, minute imitation, must
principally (not exclusively) occupy the morning session ; the
training of activity, group imitation and articulation the middle
session; and the evening to be given to games, plays, sweet
songs before going to bed ; in virtue of the axiom : where there
is no disposable color do not ask labor.
We cannot form a judgment so precise in regard to the cre¬
tins. We have only six observations ^see appendix XVII., c);
besides, the subjects of three soon died, leaving in doubt if the
record of their vital signs represented strictly the status of cre¬
tinism, or its combination with the signs of the incipient dis¬
ease. All three died of pneumonia, accompanied by general
infiltration of the mucous (and serous?) membranes, whose
signs are negative breathing, pulse, and temperature (not
apyretic) with a gradual (no remittent) sinking of all the
synergies. I called this long ago the cretirtspneumonia (it is
their common fate), it resembles in young subjects the kind
Charcot since discovered at the Salpetriere, and named la yneu-
monie des Vieillards. (See Chap. XVIII., § III.) Dr. Wil¬
bur knows more than me now about it.
But to read these figures, as well as to take new and more
valuable ones, it is necessary to not search in insanity and
idiocy for what is not more in them, and to remember that the
conditions so called are never primary, sometimes even not
secondary, but tertiary ones. Thus insanity was creeping in,
felt or not, fought against or concealed, in the forms of hype-
rexise, wakefulness, palpitations, headache, etc., for years, even
during several generations, before it burst unruly; and idiocy
has been a drama in utero, or at the breast, long before the
alterations of organs and functions were synthesied in leaky
temperatures ill-supplied by an imperfect calorification.
infantile paralysis.
219
II.—Temperature in Affections of tiie Spine.
In diseases and lesions of the spinal cord 110 systematic ob¬
servations of temperature have been carried to conclusions. If
we could assimilate the results of diseases of the medulla in
man to those obtained by CI. Bernard, Tschechicliin, Pochoy
and a few others, after systematic sections or crushings of the
medulla in animals, we would say that injuries of the medulla
below the dorsal enlargement cause only temporary falls of
temperature, followed by rises, whose march and possible
heights are yet undetermined ; and that the same lesions pro¬
duced above that point are followed by a steady and progres¬
sive cooling, till death ensues. (See Appendix XVIII.) But on
man himself we have only isolated or accidental observations
of temperature in affections of the chorda, and we will give them
ad referendum,, without pretence to completeness or systetna-
tization.
a.—The medulla spinalis is considered the organ whence
originates infantile paralysis. (Charcot, Geoffroy, Cornil,
E. C. Seguin.) In its acute form this paralysis is rarely seen
in adults. Temperature and pulse high, fever continuous at 39°,
40°, or more; movements difficult, soon impossible on the af¬
fected side, then crippleness and atrophy That is the acute
form. Or the paralysis creeps on insidiously; fatigue, aching,
etc.,too often disregarded; then progressive denutrition of the
affected parts, called degras by the Freneh peasantry. Heine
observed in his cases of infantile paralysis a difference of .5°—
1.5°, between the healthy and palsied limbs. Brown-Sequard
has shown, and daily experience proves, that the contrary ob¬
tains in the prodromic and incipient stages of paralysis; and
that the hyperpyrexy of the soon-to-be paralyzed side or part
is pathognomonic. The rule is a higher temperature at the be¬
ginning, and a lower one in the chromic stag 3 of paralysis.
Though Roger and Brechet differ considerably in their con¬
clusions, this is the better elucidated part of the subject.
The first experiments of Chossat (1820), and the first obser¬
vation of Sir Benjamin Brodie (1835), opened the way to the
studv of the temperature in cases of injury to the spinal cord.
This latter was a case of crushing of the lowest part of the cer¬
vical medulla, sh »wing 43.9D twenty-four hours after the acci-
220 INJURY TO TIIE SPINAL CORD.
dent. Billroth since found 42.2°, fifty hours after a fracture of
the spine; Quincke, 43.4°, and 43.6° C. = 110.12°, and 110.48°
F., in two cases; Weber (of London), 44° C. = 112.2° F. in
two cases; Simon, 44° the third day after a fracture of the
twelfth dorsal vertebra ; Frerichs 43.8° nineteen hours after
the fracture of the fifth and sixth cervical vertebrae ; Fisher
met with 42.9° once, against two cases of fall of temperature
to 34° C. — 93.2° F. in recto, and 30.2° C. = 86.36° F. in the
axilla. More recently Farquharson reported before the Clin¬
ical Society of London a case of dislocation of the first dorsal
vertebra, and injury of the cord with temperature at 82° F.;
and Hutchinson had a case of injury to the cervical spine,
with paraplegia, which survived five days, with a temperature
never above 94.5° F. (But Churchill had the same lesion with
110° at death; see Lancet, 29th May, 1875.) Brown-Sequard
found a rise in all the cases he collected, and maintains, how¬
ever, that if in lieu of being hurt, the spine is only irritated,
the temperature must fall instead of i*ise.
These discrepancies show that the question is yet unsettled ;
we want more facts, and there is one which will extend but
not solve the difficulty: the most extraordinary rise of tempe¬
rature occurred in a case communicated in February last to the
London Medical Society, by Dr. Teale, of Scarborough : Sept.
4, 1874, a lady thrown from her horse had the fifth and sixth
rib fractured, and some obscure injury to the spine. Soon
the bones united, the spine only remaining tender.
As there was no paralysis of sensation or motion, the cord it¬
self was not supposed to be primarily affected ; only a pressure
on it of the inflamed spinal ligaments and intervertebral sub¬
stances : nothing like a definite diagnosis.
At the end of the first month the temperature was 101° F. ;
at the end of the second (October) 105° ; with respiration un¬
altered, pulse 100, 105° ; the sixth day of November a rise
to 110°; the eight day, 118°; the thirteenth, according to
the Lancet, 122°; the fourteenth, according to the Medical
Times and Gazette, 125°. This figure, being the highest
the thermometer could register, was reached five times more
from date to December 1st, alternating with fluctuations to
114°.
During the first half of this last-named month 110° was
reached, and during the second half 114Q.
temperature in peripheric neuroses.
221
For seven weeks the temperature never fell below 108°, •
rarely below 110.°
Early in January (fifth month), it fell to 104°, and about
the tenth to 98.6°.
Pulse never above 120 ; respiration quite feeble, but never
much embarrassed ; catameniae suppressed, urine scanty, liquid
food taken (sometimesper ani). The fourth month the spinal
sensibility began to diminish, and the general health to im¬
prove ; cured the sixth.
(The observations taken in the axilla, between the thighs,
and in the rectum, differed from each other only a few tenths
of a degree. Seven instruments were used at various times,
four of which were afterward verified at Kew and found accu¬
rate. They had been inspected by two or three competent
witnesses before and after each application, and the results in¬
stantly registered.)
Even reducing the maximum temperature (125°) given by
the Medical Times, to that of the Lancet (122°), this case and
cure changes entirely a written page of the natural history of
man. We must be on the watch for more cases.
III.—Temperature in Affections of the Peripheric
Nerves.
Few of these affections are anatomically demonstrable; yet
their peripheric nature cannot be denied where thermometry
asserts their localization. A girl, set. twenty, being very hot
after a violent exercise, put one of her hands to cool on a
marble tablet. Instant semi-insensibility and semi-paralysis
ensued, with a notable—but not mathematically measured—dif¬
ference of temperature between the two hands. No improve¬
ment for ten years, and likely none since.
In two cases of otitis with intense pains, I have seen falls
of temperature lasting several weeks, and marking .5°—1.6°
(below the nor me). But was the apyrexy caused by the neural¬
gia proper, or by the pain consequent to it?
Another form of peripheric nervous affection is the peri¬
pheric or spinal epilepsy, contradistinguished from cerebral
epileps}7 by Brown-Sequard. But we have not been able to
procure the thermography of a single case, and will defer what
222 temperature in central neuroses.
we have to say 011 the temperature of epilepsy till the next
paragraph.
IY.—Temperature in Ckntral Neuroses.
From the experiments of Claude Bernard, Brown-Sequard,
Shiff, etc., we are prepared to see the most excessive rise or
fall of temperature follow sections, crushes, injuries of, or com¬
pressions and impressions on the centres of sympathy, and of
regulation of the great vital functions. And precisely because
much remains to be learned, we know that the tendency of
the physiologists and pathologists is to restore to the great sym¬
pathetic many of the ruling attributes which have been heaped
like a crown 011 the brain. But this idea will be clearer twenty
years hence.
a.—The &\hocl& (Syn.: ictus) is a collapse of the central ner
vous power, caused by accidental, surgical, or spontaneous
lesions (whose vastness bears 110 relation to the severity of the
shock); by a moral impression, by arrest of the heart's action,
and by simple concussion (without lesion) at the epigastrium,
maxillary angle, scrotum, etc. It is the more imminent since
the wounds, contusions, and concussions are nearer the abdom¬
inal plexus. It has been observed in the most varied cir¬
cumstances—shell-wounds, ovariotomy, opening of a whitlow,
strangulated hernia (vide below, § d), as well as in the opera¬
tions for its reduction. Brown-Sequard produced shock by
simple compression of an intestinal fold. Its invariable effect
is to lower the temperature, and eventually to paralyze the pyro-
genic functions through the stunning of the great sympathetic.
In 1858, CI. Bernard had already demonstrated the lowering of
the temperature by the section of the pneumogastric. From
this date, every experiment in that direction shows the shock to
be a nervous affection, and confirms the position assigned in
human thermogenesis to the great sympathetic.
b.—Insolation (Syn.: Sunstroke, Heat Apoplexy, Maladie
Astrale, etc.).—This stroke, popularly attributed to the light of
the sun, is more frequent in a heated and moist atmosphere,
compressed under low clouds; that is why the French call it
either coup de cltaleur or coup de soleil. It was called maladie
TEMPERATURE IN SUN-STROKE.
223
astral*, because of suspected sidereal dispositions, some making-
it frequent, some rare.
If excessive insolation kills outright, (isolation decomposes
slower, but sure. Its effects have been particularly verified in
localities which, once agricole, are now absorbed by manufac¬
turing interests. There, where 60 years ago more little children
died from want of clothing and comfort, to-day more adults
die, particularly men of twenty to thirty ; and one-third of the
whole population is affected with tuberculosis. Why ? Shut
up from the action of the sun all day, they have a minimum of
red corpuscles, and no provision of combustible to satisfy the
eventual exigencies of combustion of a fever; so that then-
diseases are all of a low type, they have no reaction, and when
they die of a pyrexia it looks as if it was from apyrexv.
If the heat-stroke can be prevented in man, who is uncon¬
scious of its imminence, it is by his own or his friends' knowl¬
edge of its prodromes. As studied by Vallin 011 dogs, buccal and
pulmonary secretions were abundant and frothy. Respiration
from 40, 50 at first, reaching 160. Temperature (its norrne is
according to kind, 37.4°—39.6°) reaches 43.5°. Later the res¬
piration relents even to 60, but suspirious; intelligence and
sensibility preserved ; temperature, 43.5°—44°. Lastly con¬
vulsions, coma, death at 44.4° C. Immediately 110 galvanic
response of the muscles or nerves ; prompt rigidity and putri¬
dity; blood black in the arteries as in the veins ; almost no
trace of oxygen in the former (CI. Bernard).
Watson curiously and justly enough compares the effects of
heat-struck to those of cold-struck, and cerebral congestion by
cold to apoplexy by heat. Same appearance in the cadaver,
same anatomical lesions, paralysis of the centres of innervation,
rapid decomposition (only retarded by the action of the exter¬
nal cold continuing after death); and more, same moral causes
inducing the stroke, as described in Larrey's Memoires of the
Retreat of Moscow, 1812. Discouragement, fatigue, privation,
and above all the pressure of tight garments impervious to the
cutaneous evaporation, add to the casualties.
In this time of centennial reminiscence we must be excused
if we bring one to the point. At the battle of Monmouth,
June 28, 1778, without receiving a wound, fifty-nine llessian
soldiers fell from the effects of the extraordinary heat and of
their heavy clothing; and many more fell 011 the side of the
224
SUMMER-COMPLAINT.
Americans. (Surgeon Slioepff's report, in Boston Med. and
Surg. Journal, June, 1875.)
In pre-thermometric times, Andral had signalized the prompt
putrefaction of the bodies stricken by the sun. Now, thermom¬
etry teaches that in this apoplexy the heat attains to degrees
where the decomposition of the blood is sufficient to cause
death. Have been observed, 41.60°, 42.88°, 43°, 43.4°, 43.77°,
even 45° C. ; by Baulmer, 42.9° C. = 109.22° F.; by Dowler,
45° C. = 113° ¥., etc.
Wunderlich had seen no cure when 42.125° had been passed.
Lewig cured a case which had attained 42.8°. It was re¬
served to American physicians to go beyond that by the use of
the mathematical apyretic medication.
From the Bellevue Hospital Reports, 1872-3 :—
(1.) Dr. Atzenbach's case : Entered comatose ; temperature,
110-2° F. = 43.35° O. = 6.35° above the norme, which fell to
104f° in two hours, under the application of the wet sheet
kept cool by sprinkling; during which the pulse and respira¬
tion rose first, then fell (figures not given). Chest cupped du¬
ring half an hour on account of cyanosis ; pack renewed during
another half hour; temperature 102° ; total fall in 3.30 hours,
8£° F. = 4.65° C.; cold sponging again, digitalis, more fall,
recovery.
(2.) Dr. Perry's case : Comatose, puffing respiration, tracheal
rales ; temperature, 106^° ; stripped, laid on india-rubber cover;
body alternately rubbed with ice, or with a sponge wetted with
ice-water; then water poured from a pitcher from a heigh t of
three or more feet, adding the impression of the shock to that
of the cold. In fifteen minutes fall of temperature to lOlf0 ;
of pulse from 160° to 120° ; cure.
Fanning increases the evaporating and cooling powers of
water. Hot water too hastens the cutaneous evaporation, and
so diminishes central hyperpyrexia. By such treatment as these,
a fall of 5°—6° F.= 2.5°—3.5° C., may be obtained in one hour
and a half, in cases of sunstroke, whose acme is rarely above
105°—106°, and the proportion of recovery greatly increased.
c.—Summer-complaint. A softening of the nervous system
by a super-heated atmosphere weakening all the functions, and
expressed mainly by diarrhoea, torpor, head-cries, and occasional
fits, ending in convulsions, oftener in coma. Curable under the
trees, along a cool stream.
INTESTINAL OCCLUSION.
225
Its temperature is tempered by its symptoms. Its high fever-
degrees are repeatedly put down by the apyretic effect of evac¬
uations. tenesm, and deperdition of forces. The proportions
of the latter regulate the downward course of the pyrexy, which
soon becomes an apyrexy. Through that double movement we
have two guides—the increased frequency of the pulse, and the
diminishing body weight. Therein is the mathematics of the
death of those who are born only to be called angels.
We know that more than half the mortality of the citv of
New York strikes children under five years, and that in the
last weeks of July, just ending, we have lost 815 and 955 chil¬
dren: that is attributed to improper nourishment; but whv
would not the food kill as many all the year round? Because
the principal factor in these murders is the brick-oven habita¬
tion provided for the working classes, by M. Phalaris, Esq., and
landlord. But if guinea-pigs were exposed to the same mur¬
derous temperature for the sake of demonstrating its fatal ef¬
fects on children, the wife of said Esq. and landlord would
faint away. Such cruelty to animals !
Fig. 78.
INTESTINAL OCCLUSION.
i!MI
ibkM
d.—Intestinal occlusion. An apyretic affection of a descend¬
ing continuous type. Its symptoms are progressively pains,
constipation, meteorism, vomiting of alimentary, sero-bilious or
fecaloid matters; the aggravation is continuous, or composed
of successive occlusions, and reopening of the bowels, leading
both to death, unless relief is afforded. The scheme of its apyrexy
runs as follows: beginning in the lowest physiological tempera-
tures A .6 J4, and descending to 1, 1.5, 2, 3, without reaction,
but those produced by hot enemas, etc. Concurrently the
15
226 temper a.ture in convulsive affection8.
facies becomes altered, the teguments cyanosed,the pulse feeble,
the perspiration viscous, the voice soundless, the respiration short,
leading to asphyxia. Electricity often re-establishes the function,
apparently as a pyretic treatment. Is it by the shock which
starts anew the peristaltic action, by the conversion of electri¬
city in caloric, by the generation of heat during passive move¬
ment, or by a larger afflux of blood, singly or concurrently ?
e.— Tetanos. In tetanos the temperature increases progres¬
sively, if not continuously, till death, which happens at 41°, 42°,
even 44.75° (Wunderlich). This ascension takes place, not by
morning or evening exacerbations, but in concordance with ir¬
regular convulsive access, in which the disengagement of heat,
by muscular contraction, must not be overlooked; rest, if obtain¬
able by anaesthesia, would be a cure for that almost incurable
affection.
Y.—Temperature in Convulsive Affections.
When the nature of convulsions is left obscure by the other
symptoms, it is indicated by their temperature, which suffices
to assign, at least, their generic character. Thus, when the
muscular contractions are accompanied by an elevation of
temperature, the convulsion is tonic, as in tetanus and epilep¬
sy ; but when the muscular contraction is entirely spent (con¬
verted) in movement, the blood not being overheated, the tem¬
perature remains about the norme, or falls below, as it happens
in chorea, where there is a free liberation of heat by muscular
contraction ; and in paralysis agitans, where 37.2°, 37.6° have
been found with two hundred double oscillations per minute.
These, and the following differences in the temperature of con¬
vulsive affections, have been established mainly by Charcot and
Bouchard, and admirably expressed by Bourneville.
Temperature is the better criterion of epilejpsy at large, and
of its modalities. But of what use, since men already en¬
trusted with Universities teach that St. John cures the h/int-
mal, and St. Gilles the jpetit-mal.
(a.) During and between isolated accesses, it is subject to
fluctuations. T. S. Clouston first spoke of a fall of tempera¬
ture preceding the fit; Charcot, Gibson, A. Voisin, Bourne¬
ville, have noted a rise during, and a fall between the accesses
THESE TEMPERATURES COMPARED.
227
(which those who simulate epilepsy cannot well imitate without
being betrayed by the unnatnralness of their muscular exer¬
tions).
(b.) During the status ejpilepticus, the temperature progres¬
sively increases from the lirst fit; does not fall so low as after
a single one, and attains in a few hours, 40°—41°.
(c.) The epileptic fits of general paralysis are always followed
by a greatly increased temperature, which lasts for several
days.
id.) The epileptiform fits of hysteria develop an extraordi¬
nary low (sub-febrile) temperature, compared to other forms:
as per example : During three months of violent and almost in¬
cessant convulsions, in which the status epilepticus rose to the
highest degree of intensity, the degrees of caloric evolved at¬
tained but once 38.5° and habitually oscillated between 37.4°
and 37.8°.
(e.) But when higher temperatures supervene and death
ensues, it is the effect of asphyxia. (See Wunderlich, in Arch,
der Heilkunde, 1864.)
Fig. 74.
HY8TERO -EPILEPSY.
Let us sum up the preceding remarks:
In cerebral haemorrhage, the temperature falls at first; in
true apoplexy it rises from the stroke (Charcot, Westphal).
In epilepsy the thermometer often attains 40°; in an hystero-
epileptic attack, rarely 38° C.
In puerperal eclampsy it attains 40° ; in convulsive uremia
it falls, sometimes, to 28° C.
d.—The temperature of Eclampsy will be considered alto¬
gether with those of uremia.
228
temperature in extasy.
e.—Extasy.
Extase is a nervous disease of the most humiliating epochs,
just now spreading again. It is difficult to discriminate in the
extatic what is the legitimate produce of hypnotism, compres¬
sion and imposition on a feeble subject, from his share of com¬
plicity in the imposture. For the complicity does not negative
the neurosis, and the epi-phenomena of both become intricate.
Thermometry could have thrown some light on extasy, but the
managers of extatics do not want light. Wunderlich proposed
to take the observation of the last case, but was not permitted.
Here it is.
Louise Lateau, of Bois d'Haine, Belgique, enters daily in
extasis, and is marked with the stigmata of crucifixion. Since
four years she has taken no food, no drink, no sleep, 110 rest;
yet, by expiration, she exhales carbonic acid and water, which
do not come from her own substance, since she loses 110 weight.
Besides, her monthly periods are regular, and every Friday
blood ooses out from her stigmata, during cataleptic seizures
and rigidity, in honor of the crucifixion of Jesus, d qui go, doit
faire bienplaisir. However, this spectacle may be prevented,
or stopped, by Mgr. the Bishop of Tournay, in virtue of his
power of Iiappel over extases, etc.
The temperature of Louise Lateau was taken but once, and
found 37.3° C. The Academy of Medicine of Brnxelle made
a mild report, from which it appears that Belgian physicians
wralk the sacred grounds of Bois d'Haine as if they had in
their boots the scorpions which tread at their heels.
As for the end of the extatic ? One of them, La Sallette,
after having been the means of raising millions, became un¬
profitable, and was thrown in the cesspool of the Salpetriere;
aud on her being singled out, was transferred to some more
silent vadeinjpace: away with the girl, up with the miracles
she heralded. Nevertheless, extasy is a nervous disease, which
can be made scarce by educating our children out of the pale
of the mystics.
in disorders of the blood.
229
§ VI.—Temperature in Disorders of the Blood and
Secretions.
We can hardly say that we leave the map of the nervous af¬
fections when searching the temperatures in disorders of the
blood / for these disorders were first traced to lesions of the
mesocephale and fourth ventricle (CI. Bernard), since to other
regions of the encephalon and of the medulla (Shiff), later
to simple commotion of the nervous centres (Jaccoud), to
moral impressions on the sympathetic (Brown-Sequard, CI.
Bernard, etc.).
a.— Glycosuria (Syn.: Diabetis), of whatever origin, when
confirmed and uncomplicated, is always below the norme, from
1° to 5° F. ; though in the early stage of glycogenesis, with in¬
creased appetite, the temperature may have remained about nor¬
mal, only ouce in a while depressed (Vogel). The evening
figures are generally higher by .1°—.8° F. than the morning
ones ; the reverse obtains in the closing period.
Though the lowering of the body-heat is due to the loss of
sugar, thermal measurement does not show it every day propor¬
tionate to this daily loss; the downward movement of the ustion
is more uniform, the glycorrhea more variable. The lowering
of the temperature in diabetes is attributed to the incapacity of
the liver to chemically work the main fuel of the body; so
that sugar is expelled without having been converted by oxida¬
tion, and human calor is diminished by that much.
b.—Polyuria. There is a relation, but not a constant one, be¬
tween the temperature and the quantity of urine, the former
falling as the latter increases; the latter being somewhat in¬
fluenced by the quantity, sometimes excessive, of the water
drunk, at other times by the nervous condition (urines cri¬
tiques). However, through all these irregularities, the quantity
of water passed does not exceed the quantity ingurgitated
(Vogel). Warm drinks depress less the temperature than cold
ones.
c.—Albuminnry, like polyury and glycosury, tending tow¬
ard consumption, soon assumes the courses of temperature
characteristic of that termination.
d. — Uremia, of whatever origin, has a low temperature, which
230
TEMPERATURE IN UREMIA.
after a fluctuating or downward course ends with the life, as
low, sometimes, as 28°—33° C. True poisoning by an excess of
carbonate of ammonia (Billroth).
This is true of uremia in encephalopathy of the neo-nati, in
scarlatina and in Bright's disease, but not as a complication
in puerperal eclampsy. The upward tendencies of the latter
counteract the downward one of uremia, the result being a
compound temperature in which the strongest element—gen¬
erally the eclamptic—predominates.
For instance, in a case of forceps delivery, ending the follow¬
ing day in death, the phenomena of eclampsy priming those of
uremia, the temperature starts at 39.4° with the first attack ; is
to-morrow early, 41.8°, at 9 a.m., dying, 42.9°, rising soon to 43°,
43.1° post-mortem. But when uremia is intermittent, the tem¬
perature too is intermittent, only in an inverse ratio, and pass¬
ing several times from the neighborhood of 37° to lower degrees,
till 33° is reached as a finale. And again, when uremia is de¬
creasing, the pathological temperature, mainly controlled by
eclampsy, rises, and ceases with it, going up with the first at¬
tack to 39°—40.2°, and coming down to 37.8°—37.5°, convales¬
cent point of these combined affections. These thermometric
data are surer tests of prognostication than the pulse, the respi¬
ration, or the indications of the urine, which, though albumi¬
nous, may contain no albumen when just tested.
Chronic uremia may descend to 34.4° (Hirsh); Sidney Ringer
has seen it 92° F. before death.
Infantile uremia was observed by Parrot to cause a fall in
one day from 37.2° to 35.6°; in seven days, from 37.2° to 34.5°;
from 32.4° to 29.6°; and the tetaniform convulsions of neo-
nati (one to sixteen days old), to reduce at once their calori-
citv to 34.2°, 33.4°, 32.1°.
Temperature is the test by excellence of this class of affec¬
tions. In purely uremic convulsions there is a progressive fall
of temperature. In cerebral hemorrhage the initial fall is soon
followed by a rise. Uremic eclampsy begins by a fall; puer¬
peral eclampsy commences by a rise, which goes increasing,
etc.
In some neuroses of the hysterical order, polyury is accom¬
panied by a great diminution of urea and fall of temperature;
conversely the excretion of urea may become abundant at the
time urine becomes scanty and the temperature rises. In eclamp-
TEMPERATURE IN GANGRENE.
231
sy, tetanus, strychnisme, the temperature rises and urea dimin¬
ishes.
In phlegmasise, the diminution of the temperature and of
uiea with an increased liberation of chlorures, is the best sign
of convalescence; of which see illustrations in Appendix XII.,
«, b.
e.—The cancerous cachexy does not of itself affect much the
temperature. This is demonstrated by the cases (Roger, Da
Costa) on which the parts affected have no office in the acts of
nutrition ; for instance, in the cancers of the face, the mammae,
the uterus, etc., where even a slight rise may be noted a few
days before death. But when the cancer is situated in the or¬
gans whose office is connected with nutrition and calorification,
from the mouth to the lower bowels, the temperature falls in
proportion to the denutrition.
Therefore, the modalities of ustion alone are no test of the
cancer, but in comparison with those of the circulation they are.
Thus, next to ustion usually oscillating between 37° and 38.4°,
and rarely closing as low as 35.8°, let us bring pulse-beats of
130—160, and see the meaning of this discrepancy, viz.: the
cancer, almost foreign to ustion, is pre-eminently a disease of
the blood.
f—Scorbut, when it affects previously healthy people, does
not lower, rather raises the temperatures. But in already debili¬
tated people, as those who had suffered the long privations of
the siege of Paris, in 1870, this may descend to about 36°.
g.— Gangrene is a local obliteration of the circulation brought
on successively by syncope of the parts (almost invariably the
parts the more exposed to radiation), local asphyxia, stasis of ve
nous blood, exclusion of oxygenated blood, peripheric exten¬
sion of the obliteration. This march is the ratio of its temper¬
ature. In its application, a gangrenous foot has a temperature
lower than a healthy one, as 22°—33°, 34° C., in the same atmos¬
phere. In the gangrene of the lungs of the insane, the temper¬
ature is sub-normal; of other people it is above the norme, some¬
times 40°. Topographically, the centre of a gangrenous sore is
the coldest part.; its periphery is somewhat warmer, and the sur¬
rounding angry circle (in wThich the blood-vessels begin to im¬
bibe the cachexia) is decidedly above the norme. (See Appen¬
dix XIX., for gangrene of the mouth of infants.)
232
temperature in old age.
Senile Temperatures.
If senility is no disease, it invites many, and withstands not
a few. In old age, ills creep insidiously, and their symptoms
are not expressed with the frank exaggeration of youth, nor the
precision of virility. This led Charcot to the creation and nom¬
ination of Senile Pathology, which virtually created the study
of Senile Temperatures.
No part of our art can give a better idea of law in thermom¬
etry than the course of senile temperature, as traced by him,
and developed by his eleves, Bourneville, Lepine, Goffroy, etc.
Remarks on the effects qf old age on the temperature of several
diseases may have been here previously scattered ; a few pages
above this, when treating of insanity, cerebral haemorrhages and
apoplexy, it may have been noted that we were already thread¬
ing the grounds of senile temperatures ; and now I am conscious
that I will not bring on this focus all what can illuminate it;
but space admonishes to be brief.
In old people, says Marey, the heart is stronger than ever.
But the temperature is not higher. Ustion—though supported
by the ultime effort of a brave circulation—will not be equal
to the eventual demand of a phlegmasia for more fuel for com¬
bustion ; greedy of its resources, old tissues will not let out
those degrees of heat which in youth proclaim and entertain
abnormal combustions; old organisms have no such abun¬
dance of fuel to waste. They may, exceptionally—like in some
forms of pneumonia—spend all their combustible in a rapid,
progressive explosion ; but in the majority of cases, after giving
a feeble, though long or short indication of danger, the tem¬
perature collapses with the other symptoms.
The persistency of high temperatures, without well-deline¬
ated diurnal oscillations, constitute an important feature of
lobular pneumonia, particularly in the aged. The ecart from
morning to night is .5° C. in lobular, and 1°—1.5° in catarrhal
pneumonia. These signs are the more important in view of
the difficulties which beset the auscultation of old patients. By
it alone Charcot and his staff were enabled to pose the diagnos¬
tic of pulmonary inflammation at the Salpetri^re long before
the ear could detect a stethoscopic sound of pneumonia. They
IN DISEASES OF OLD AGE.
233
put. down this movement as follows : The initial chill, almost
like in adults, or rising slowly, as in broncho-pneumonia, where
the acme is lower than in the lobar. An improvement suc¬
ceeds, but does not last; the same evening or the next morrow
heat ascends to 40°, 41°, where it remains five or six days with
poor chances ; otherwise it has descended slowly to 39°, with a
more favorable prospect.
However, serious lesions are often represented by light symp¬
toms, or no symptoms at all, except an unsuspected tempera¬
ture. (See Pneumonia, p. 169, fig. 56, and p. 170, fig. 57.)
At other times the temperature expresses more the depression
of vitality, or a complication of pericarditis, etc., than the
pyrexy of pneumonia.
And let us close by this other discovery of Charcot, the al-
gide pneumonia of the aged. This ordinarily fatal lesion
is represented in the old inmates of his hospital by signs—the
algidity, for instance—entirely opposite to those which judge
the same cases in adults.
Tuberculization is frequent, but generally latent in old peo¬
ple. Phthisis is remarkably sly and insidious, may remain
latent during its whole course, and be revealed only by the au¬
topsy, if the alternations of temperature corresponding to fever
or depression have not been mapped out.
Here, like in many other points, we have the indications of a
man of genius, but nothing done with them, everything to do.
To extend this survey to many more diseases would not
modify the general conclusions arrived at in senile tempera¬
tures.
In old people, the central temperature must be consulted
more than the peripheric, and not so much in the axilla, which
is too parched, as in the rectum, which answers better in
average cases. Such is the advice of Barensprung, Moleschott,
Charcot; the latter having found that the difference of .2°—.3°
C. in adults, between the axillary and rectal T. rises in old peo¬
ple to .7°—.8°C. He gives the case of a woman, set. 103, axil¬
lary T. 37.25°; rectal, 38°, etc.
Still, let us make a broad reservation before summing up
the rules ; it concerns local diseases.
In the aged, as the different organs have got used to lead
quite an independent life, not only local diseases become more
frequent, but the general temperature is not, as in youth, so
234
temperature in chronic diseases.
easily, nor so completely involved in the thermic conditions of
local phlegmasia; a doable cause of error.
Therefore, in a local (01* in a one-organ) disease of the aged,
the fever-thermometer has often nothing to report; the surface-
thermometer, too, separated from the seat of morbid processes
by a dry skin, etc., may remain unmoved; hence, recourse
must be had to the thermoscope, whose subtilty will denounce
unheard-of, yet diagnostic differences.
Senile central temperatures may be noted as high—or higher
(Barensprung)—than adults; yet they cannot so long stand
the wear of illness.
They may reach above the patient's norme, but the highest
the shortest.
Any upward progression soon ending in death ; any down¬
ward progression difficult to break; reaction null, imperfect or
partial.
In senile temperatures daily fluctuations are stiff of motion,
with a narrow excursus.
Their effervescence has no neat ascendancy.
Their acme no neat peak.
Their defervescence is too often a mask for collapse.
Their convalescence a slow process of local or general frige-
ration.
Their figures start from the norme, but their progression is
downward.
Senile temperatures mean or portend apyrexy.
Senile diseases are, or become easily apyretic.
Generalities which must not only guide the diagnosis, but
serve as principles of treatment.
a.—Temperature in Chronic Diseases.
Though young persons may be affected with chronic diseases,
the latter appear almost the privilege of the old. I say privilege,
since some of them seem to confer a brevet of longevity, which
the sufferer from it enjoys the more as it appears to the looker-
on the more insufferable. The temperature of chronic diseases,
though subject to much diversity, not only in each disease, but
in each of the acknowledged periods of life-long maladies, may,
however, be brought to a sort of thermic classification : a. The
infantile al'yrexy.
235
temperature of the morning and evening are not far from the
norme, but the evening farther up; at noon it is either higher
or lower than the morning's.—b. The morning temperature is
normal or lower than the norme ; the evening always higher or
lower than the morning's. In this class are found those which
constantly keep under the norme.—c. The temperature con¬
stantly above the norme ; the evening's sometimes, at others the
noon's temperature is the highest.—d. And, finally, the tem¬
perature may affect the march of an endless lysis, ending never¬
theless in a collapse or collapses.
Infantile Apyrexy.
As life is in death, and death in life, so none looks so much
like a dying man as a coming man, and the last gape like the
first breath.
The child born with the signs of atavism brings with him the
marks, even the stigmata of his ancestors' impressions. First,
he continues the operation of breathing where they left it, at
the expiration, by an inspiration ; and the disease resulting
mainly from this break, apyrexy by asphyxia, is the last of the
old and the first of the young. Thus, at the two extremities of
our present individuality the problem of human temperature is
concentrated in the two alternate and rhythmic therms of expi¬
ration and inspiration, the diseases of the oldest and of the
youngest resolving themselves in apyrexy by asphyxia.
The first diseases of the new-born—the last of which we shall
speak—are mainly apyretic, i.e., caused by algidity; and the
varied movements of their temperature are the forms of the
struggle for more heat.
Many children bring their own death in their own bosom with
deadly central temperatures; others bring only—or mainly—
exceptional peripheric dispositions to cooling ; when others,
born in the most excellent thermal conditions, are chilled down
by the cold touch of neglect, or by want, to the level of the
cold-blooded animals. In the first hours and days either of
these conditions brings on diseases which—under whatever
name—are apyrexy ; and these children die chilled, being cold
like death when yet alive.
Their frigeration may have commenced in the uterus, or
236 infantile algidity.
under the first smarting impression of our atmosphere, or, later,
from several or complex causes. Unless in the extreme cases,
it is not at first a disease, only a relative incapacity of keeping
warm, or of generating warmth, easily remediable by hygienic
measures as long as the body's temperature has not fallen more
than l=one centigrade degree below the norme.
But it is decidedly a disease, and it imperils life, when it
causes the bodv-temperature to fall 2 (two degrees below the
norme). In this particular our children do not differ from the
young mammifers severed from their parents. However, care
and food generally bring up the temperature of the new-born
to its norme in twenty-four hours, simply because food is the
main source of heat, and the natural buoyancy of life raises and
keeps it up to that degree. But as soon as the temperature of
a baby falls 3, 4, or 5 (three, four, or five degrees below the
norme), he is in mortal danger, though he may live with a good
deal less warmth ; but how few survive will be seen. (Re¬
vert also to p. 17.)
(a.) Frigeration of tiie New-Born.
It may have begun in utero, being caused by certain condi¬
tions of the mother, sickness of the foetus, etc. ; or by a prema¬
ture birth or a .postponed one. Later it is induced by want,
neglect, dirtiness, exposure, beside the rude impression made
by the change from the watery sphere of the amnion to our
sharp atmosphere ; and as for the abandoned children, by the
want of contact with the warm body of a mother. If a reac¬
tion (to be thermometrically watched) do not take place soon,
decalorification continues the work of initial frigeration, and
the consequence will be a true apyretic disease.
(b.) Infantile Algidity,
In which the temperature may fall to 34°—35.6°, averaging
34.75° C., where Brechet found it on the foundlings of lJaris.
There the death-rate of the first year was ninety per cent.,
showing how nearly synonymous decalorification is to devitaliz-
temperature in sclerema.
237
ation. In humane circumstances, however, the chances are
much better.
When we see that the temperature of a baby is below the
norme, without waiting to study the terms of a progression
which may prove ascendant—but if descendant should be mor¬
tal—we must at once settle the question of the character of the
apyrexy by the very means which can best both correct and
test it. Did the frigidity initiate from the inner child or from
outward circumstances? Is the fall of the temperature due to
a deficiency in the production of caloric? or to an excess of its
escape ? In other words, what is at fault ?—the warmth-produc¬
ing, the warnith-retenting, or the warmth-harmonizing pro¬
cesses ? Happily food and thermometry altogether are able to
solve these questions, and to mathematically manage the cure.
Thus, thermometry, finding a flaccid and weak infant with
36° C. =1 Ph.; good food being given, followed by a good
sleep, he will in two or three hours awake with a normal
temperature. His case was one of incipient frigeration of
external origin. But if the thermometer descends to 2 (two
below the norme, = 35° C.), it indicates dereliction of duty in
the nursing, or a semi-starvation by inferior food. The con¬
sequent apyrexy will have acquired the inner force of a con¬
stitutional habit; a single meal will not have the power of rais¬
ing the temperature, but a series of good meals and judicious
bathing will in a few days. In the first case it was frigeration,
in the second algidity. (See W. Squire, Infantile Tempera¬
ture in Health and Disease, and our Chapter I\r., pages 17 and
18 on the causes of infantile algidity of 1 to 2 degrees (below
the norme).)
But this is not the last stage, nor the worst form of infantile
apyrexia. We find them in Hoger.
(c.) Sclerema,
Or, algid oedema neo-natonim.
In sclerema the child is like transformed into a cold-blooded
animal: {a) temperature low, (b) circulation slow, (<?) respira¬
tion imperfect, (d) mobility neutralized, (e) cellular tissue in¬
dulged. Most of these disorders, at least their ensemble, are
238
FATAL FRIGERATION.
pathognomonic, but which of tlieni precede and act as a cause
to the others ?
The experiments of Chossat on animals, of Squire, Roger,
Parrot, Mignot, on infants, give the precedence to the anom¬
alies of temperature; the latter says: " Valgidite precede
Vcedemeetc.
But setting aside authorities, let us see the reasons why
sclerema is essentially one of our subject-matters. Because (a')
the lowering of the temperature is the first symptom noticed,
and always present; (b') the pulse generally slow (70—60), often
insensible at the radiale, appears sometimes little or not affected ;
(g') the respiration, ordinarily fallen to 20,16,14, remains some¬
times in the neighborhood of the new-born's norme, 39 ; (^') the
impairing of the motility is not always noticeable ; (e') and the
induration of the cellular tissue, always an eminent symptom,
never precedes, always follows, the fall of the temperature.
Another and experimental proof of the causation of sclerema
by apyrexy, and of the secondary character of the other symp¬
toms, is that the means which we rationally use to raise the tem¬
perature, improve the other symptoms consecutively and pro¬
portionately to their pyretic action.
Sclerema is therefore a primary algidity, aggravated by
progressive frigeration. Hence its fatal tendency, thermo-
metrically written in a progression, and rarely in an intermit-
tence ; as per examples :
Days.
l
! 2
s
4
5
6
Parrot -
' progression )
descendante J '''
intermittent... j
31.8
30.8
32.4
28.8
26.3
4k
26.4
25.7
24.8
Death
26.8
Death
U
29.5
Death
(the last)
Roger -
' progressive.)
ascendant f
progressive
descendant
33.
33.
32.5
33.
29.5
U
34.5
22.
28.25
Cured
(the last)
26.5
It
<(
24.
For a full view of this downward movement, see Appendix
XIX., b. If we compare these temperatures with the average
at birth (37.8° C.,=.8 Ph.) of the same author, one is struck with
conclusions of temperature. . 239
the fatality and rapidity of the descent, and the incapacity, not
only of medicines, but even of intercurrent inflammations, to
bring the temperature to the normal point: the body cools in
virtue of a negative force, vis negativa. If we compare this
with the apyrexy of inanition, their march differs entirely. By
the privation of food the temperature falls .3° C. every day ;
but the last day hundred times more. And why ? Because the
subject of starvation feeds himself with his own substance by
autophagism, and thus keeps up his ustion as near the norme as
he can. But when his inward reserve of combustible has been
combured, then the tissues themselves cool like ashes : a pheno¬
menon named by Trousseau, which we must always have present
in our mind when reckoning temperatures in protracted dis¬
eases. (For the local algidity in gangrene of the mouth, see,
without commentary, the same Appendix XIX., a.)
Roger saw very well that sclerosis was an improper name for
that essentially apyretic condition ; but instead of calling it by its
name algidity, and qualifying it by its most apparent symptom
cedematous, he named it oedema, and qualified it algide : sooner
the result of timidity than of error; since, with force and sym¬
pathy, and disregarding his own nomenclature, he directs all his
treatment against the algidity. In presence of his loss of twenty-
seven out of twenty-nine young patients, he reverts to the phy¬
siological experiments of Chossat, who—more successful with
animals than we are with infants—recovered three out of his
six cases of refroidissement by starvation; and concludes that
algide oedema must be treated {a) in warmer milieux, (b) by
warmth-producing food, according to Chossat's axiom: La cai-
oricitd perdue se retrouve par la digestion.
Conclusion of Temperature.
This survey of the temperature of man in its normal condi¬
tions and in its abnormal peripeties has been long, possibly
tedious, but surely instructive for those who read it in the
spirit in which it was written.
We have seen human temperature in infancy difficult to
settle to its norme, because either ill-supplied by a nascent
calorigenation, or wasted by ill-regulated deperditions, it was
often incapable of keeping pace with its sister-functions, circu-
240
CONCLUSIONS OF TEMPERATURE.
lation and respiration, and presented, in health, deviations
which would later be considered as grave, sickly e carts. We
have seen children dying mainly from generating too little, or
from wasting too much of caloric.
In youth, disordered temperatures warn of peril, either
sudden or progressive, according to their succession, and to
their relations to the anomalies of other functions. In man¬
hood, a normal caloricity presents the surest guarantees of
longevity and of success under proper management; it is the
highest expression of life prior to its conversion in measurable
work, and in imponderable forces, thoughts and ideas. Its
fluctuations indicate uncertainties and danger.
In old age the temperature is supported about the norme
by two senile processes: the effort of the circulation, which,
as it grows weaker at the centres, appears stronger at the peri¬
phery, because it sends forth all the available blood in order to
keep up the body-warmth; at the same time that the hornified
skin—not unlike the purse of a mi^er—has acquired a reten-
tiveness which almost forbids radiation and perspiration.
By this double husbanding process, le vieillard keeps a suf¬
ficient caloricity, till the demand of some accidental phleg¬
masia is met by the absolute impossibility of more heat-supply.
Previous wastes and squanderings have broken the balance, and
the body is soon cooled down to the level of ambient matter.
Thus old people present pretty near the same circulation and
combustion as adults ; but potentially what a difference ! Let
almost any morbid condition supervene, and you will see—
after Charcot—that the pulse, instead of expressing the moda¬
lity of the circulation which belongs to the present disease, con¬
tinues to beat hard but empty-like; and that the temperature,
instead of taking to the rhythm which pertains to the intrent
disease, remains as unmoved in the neighborhood of the norme
—the more normal in appearance, the more critical in reality—
and soon resolves itself by simple devalescence, without fluctua¬
tions or struggles, into lethal apyrexy.
Now, at the end of our topographic survey of temperature,
whence originates human color f . . .
As on trees every year's growth leaves its foot-print in the
pith, the lignum, the liber, and the cortex, so in the nervous
system the progress of evolution, through ages in our minds,
and through the various forms of life under our eyes, is marked :
SYMPATHETIC REGULATION OF CALORIC.
241
(a) by the development from the single cell expressing its sym¬
pathies through radiating fibrillse, to the circular plexus of gan¬
glia—little brains of Hartley and Winslow—communicating the
same order of feelings with electric swiftness ; (b) by the addi¬
tion of a double rectilinear chain of closer ganglia, propulsor of
onward movement and generation ; (c) by the crowning efflores¬
cence of the convolutions and other special organs of sensation,
memory, comparison, and rational determinations.
Such is the trinary origin of the unique human nervous
system. So complex is the interdependence of these parts
anatomically and physiologically, that when we look for the
attributes of each in the functions, we are able to give up
the problem ; and if we consider the claim to superiority of
the apparels of the great functions—assimilation, sanguinifi-
cation, circulation, respiration, etc.—we find them equally
necessary to man, and, like people who, having no self-con¬
trol, elect a master—to say the head is king. But if we
inquire into the primordiality of one of the three forms of our
nervous system, we arrive by induction at conclusions, which
have already been prepared by the most searching analysis.
Considering first the biologic evolution of the nervous organ¬
ism, we see, as if it were through eternity, the physiological
color developing from the automatic ganglia, cause and effect,
cell-life.
Then the immense impetus and universal fecundation swarm¬
ing from the almost acephal gigantic spine, which spawned all
over the world ichthyosauri, saurians, placoids, etc.
Ancl laterly, in the cerebral period, the reign of intellect,
during which mental activity changes the face of the world,
mens agitat molem—with the drawbacks due to excess: (a)
rapid exhaustion of the surface of our planet by the misman¬
agement of its reserves of caloric and other vital resources;
and (b) for individuals, paralysis, idiocy, insanity, cancerous
and cerebriform outgrowths, and the various forms of con¬
sumptions resulting from inordinate combustions.
From this standpoint the great sympathetic appears to initi¬
ate caloricity—which really it distributes by an action called
reflex from the now prevalent theory of its procedure, but to
which the qualification of sympathetic would be much more
appropriate, considering the nature of its impulse.
This has not been overlooked by the masters. Currie, as
16
242
CALORIE 10 AND FRIGORIFIC OPERATIONS.
great in theory as in therapeutics, insisted on the influence of
feelings on temperature. Larrey, Percy and Dupuytren relied
on this influence in their field practice, as we all implicitly do
at the bedside. CI. Bernard, Schiff and Brown-Seqnard demon¬
strated the same in the laboratory by causing tears, saliva, and
other secretions to flow or to dry, blood to afflue or to retire,
central heat to rise or fall, local radiation to burst forth, or
clammy cold to set on a predesignated spot at a single touch,
pressure or severance of some part of the sympathetic—phe¬
nomena of which the encephalon is as innocent as of the act
of digestion. Likewise, moral—that is sympathetic—determina¬
tions, stand reciprocally as cause and effect in their relations
to temperature: fright lowers it; distrust keeps it down; joy,
ire, hope, love, rise or equalize it; even confidence and forti¬
tude will keep the norme up against the assaults of malaria
and epidemics; and conversely, as long as it has heat, the lone
cell is capable of determinations as strong as the Kaiser's.
In other terms: between health and disease there is no
difference in kind, but in degrees—only disharmony ; no new
products, only exaggeration of produces. Physiology cannot
yet explain everything, but what it has explained is in conform¬
ity with this principle. There is not two kinds of calor
(French, chaleur), one morbid, the other healthy; nor one physic,
and the other physiologic—any more than a physical and an ani¬
mal electricity, both being capable of condensation by the
same process.
There is no special calorigenic organ : as all the tissues and
organs are self-feeders, all produce color; calorification is
a universal property ; but the regulation of this property is
intrusted to an apparel, the sympathetic. There are vaso¬
motor dilator nerves, there are constrictor nerves ; the dilators
are calorific, the constrictor frigorific. Independently of this
action of the great sympathetic through the vaso-motors, it has
two other direct ones: its excitation (by sensations, etc.) is
frigorific; its section, paralysis or suspended action, during
fever for instance, is calorific ; conversely in cholera the exag¬
gerated frigorification of the great sympathetic brings algidity ;
at death (when this action ceases) the temperature rises, some¬
times enormously.
The great sympathetic is the centre of frigeration and of
sensibility; pain {dolor) raises at first, soon and permanently
HEAT IS THE SYNTHESIS.
243
lowers it. Moral excitations are phenomena of sensibility cen¬
tralized in the sympathetic. Fear acts like pain; wrath, shame,,
act on the pnpilla, the blood-vessels and the heart. The reaction
of the moral on the physic is a simple physiological phenomenon ;
a psychical pain {dolor) acts on the bodily economy as would the
painful, mechanical excitation of a nerve ; both have for agent
the great sympathetic, and carry with them perturbations of
nutrition, organic lesions, and the most varied diseases.
Having followed human temperature from its norme to its
most eccentric modalities, and seen that at all ages, and in all
7 O 1
circumstances, it appears as the primordial element around
which are grouped the principal functions, as circulation, res¬
piration, nutrition, the sensory and mental operations, we have
come to consider color as identical with life. And we con¬
clude that, in disease as well as in health, during the individ¬
ual existence, or in the transit from a definite form to the
milieu universal, and in the resumption of definite forms
again, color is the ultime perceptible phenomenon between " to
be and not to be."
For the physician, the keeping of the body's norme is equiv¬
alent to keeping alive. For the psycho-physiologist heat is-the
synthesis.
La chaleur c'est la synthese.
PART SECOND.
HUMAN THERMOMETRY.
PART SECOND.
HUMAN THERMOMETRY.
CHAPTER I.
Thermometry is the analysis of human temperature; one of
the three instruments—chemical, thermal, and spectral analy¬
sis—which actually revolutionize not only physic, but physics.
It is born of the conjunction of thoughts of many generations,
whose brain deposited the muck in which the idea of Hippo¬
crates was fecundated by the invention of Sanctorius.
Thermometry is an art, adjunct to the medical, which has its
instruments and their manual, and is almost a science, having
its vocabulary, and its methods of taking, recording and read¬
ing observations, and, like all arts and sciences, is susceptible
of growth or of decay, according to our neglect or cultivation :
if we do not improve it, it will deteriorate. This is no theoreti¬
cal assertion, but the expression of an historical fact. When the
monks of Upper Egypt invaded Alexandria, knife in hand, kill¬
ing savants to reach science, in order to give the undisputed
practice of medicine to their brothers therapeutes who cured—
as to-day at Lourdes, at Notre Dame des Victoires, etc.—by the
saints, the relics and the amulets, there was an art of physical
diagnosis comprising bodily mensuration, inspection, palpation,
percussion, concussion, succussion, etc., and at the summit of
this art a complete system of local and central thermometry.
The records of that art soon perished, after the art itself—not
248
THERMOMETRY BURIED IN HISTORY.
by the hand of Omar, but much earlier, in the wars which
the spiritualists waged against physical sciences (see Sprengel's
History of Medicine, I., II., III.). A single monument remained
of the existence of the physical diagnosis and thermometry of
the ancients, so touching, romantic and sovereign, that it was im¬
possible to deface it from the memory of men. It was therefore
most infamously travestied. Impossible to suppress the world-
famed narrative of the love affair of Antiochus with the second
wife of his father, as discovered by Erasistrates, and told by
Appian Alexandrin in his tSyriac Wars, but it was jx>ssible to
distort it so that its medical bearing would become incompre¬
hensible.
" Antiochus, son of Seleucus, King of Pontus, having become
madly enamored of the beautiful Queen Stratonice, wished to
die and was actually fast declining. Erasistrates, the illustri¬
ous professor and friend of the royal family, tried to recognize
liis disease by its physical symptoms, manipulated and in¬
spected his body in all sorts of ways, and looked through its
parts / but failing to see any trace or indication of illness, or
of corporeal infirmity, judged that it was not a disease of the
body, but of the mind. Having next ascertained that the
youth would not tell the truth, Erasistrates determined to find
it out, sat by him, and watched for hours. Antiochus did not
move, nor changed expression, nor gave out any other sign
of emotion, remaining dull and absent-minded for any one,
but for the queen. No sooner had he seen her stately form
moving in, than he changed altogether in color ; his body would
rise from prostration, and the glow of heat be perceptible all
over it. But as soon as Stratonice had left, he would fall again
in his cold prostration and indifference. (Here comes the
never equalled artifice of language, by which the physiologist
persuaded the king-botanist—founder of the zoological gardens
of Pergamos—to relinquish the beauty to the youth. But this
is beside our subject. What belongs here is the fallacy which
represented in history and in art Erasistrates diagnosing the
condition of Antiochus by the pulse. If the pulse could do
that, of what use palpation, succussion, mensuration, manual
thermometry, anatomy, experimental physiology ? . . . Even cir¬
culation was cut oft—as nonsensical—at the wrist. And like¬
wise to-day numbers of people would shorten thermometry to
its clinical functions, while others would even narrow its use
THERMOMETRY REVIVED. 249
to the measurement of pyrexiae with a/m^-thermometer; and
how few begin to consider it as a measure of vitality in all the
circumstances of life, as a biometer.
The mind of Wunderlich, not limited by his hospital wards,
embraced in liis admirable Manual this idea of a thermometry
larger than the purely clinical. He said in his preface:
Theoretical questions as to human temperature and kindred
subjects must not be overlooked, and well deserve to be ex¬
plored.
a.—This anticipated protest against shrunken apathy set him
on a different level from the practical men who excommuni¬
cate ideas without thinking what would the world be, even in
the most common affairs of life, without the ideas of onlv the
last year. Wunderlich knew that nothing is nearer the status
of fact than a germinating idea, even than the facts of to-day
themselves. For no sooner is a fact a fact, than an idea has
already crept on to alter it and create its substitute; so that
there is really and substantially more practicality and posi¬
tivism in the idea of to-day, which will be the fact of to¬
morrow, than in the fact of to-day, which to-morrow will be
dross.
b.—Happily, that wish of this most practical physician shall
not remain unfulfilled. Thermometry is the question of the
present hour; towards it all foreseeing eyes are turned. It is
irrevocably wedded to medicine by its force of prognosis and
diagnosis. By the mathematics of its data, and the positivism
of its method of observation, it has already discovered the nor¬
mal point of human health, some laws of general pathology,
and not a few of special therapeutics. Beyond this it has
identified physiology with the other physical sciences, by ren¬
dering mathematically demonstrable the influence of the ner¬
vous system on the distribution of warmth, the disengagement
of heat by muscular contractibilitv, and the convertibility of
human heat into physical and intellectual activity.
This and more has been done in a few years, by a few men,
with instruments made for another kind of work. But who
knows what medical—human, must I say ?—thermometry could
do, when the simplicity of its procedure, the adaptability of
its instruments, the number of its devotees will permit its ap¬
plication, not only to the treatment, but to the prevention of dis¬
ease, and especially to the supervision of the training of youth.
250
ITS POSITION IN DIAGNOSIS.
Then we shall begin to understand that, for physicians, ther¬
mometry is not only knowledge, but social power.
c.—It is only very recently that thermometry has become
the generally acknowledged means of diagnosis we know it to
be. De Ilaen could condole with his townsman, Avenburgger,
upon the indifference or malignancy* of their confreres in
regard to scientific improvement. Yet the discoveries of these
never too much to be honored men stand to-day for nine-tenths
of diagnosis, in lieu of the old methods founded on conjecture
and authority. To-day Percussion and Auscultation occupy
the highest place in Physical Diagnosis, just as Thermometry
soon will in Positive Diagnosis: though few men live forest
their heads under the tree sprung from their imagination ; 110
seeds grow so surely as those of the mind.
d.—Thirty years ago Physical Diagnosis had no name ; now
its teaching tills volumes. To-day the name of Positive Diag¬
nosis is almost unknown, yet soon it will grow out of the parent
stock, by a process of gemmation (budding), natural or artificial,
into organic life, a process becoming frequent in science. It
would be difficult to conceive what the practice of medicine
would be to-day without Auscultation, Percussion, Thermom¬
etry, and the host of other means of physical and positive
investigation ; but it would be more difficult yet to realize what
it will be after thirty years of close adherence to the laws of
observation, of education of the medical senses, of training in
the manoeuvres of the instruments which give more delicacy
and extension to the operations of our senses—the stetho¬
scope, ophthalmoscope, endoscope, etc.—instruments of physical
diagnosis—and in the handling of those which perceive and
report mathematically the phenomena which our senses cannot
reach—microscopes, thermometers, ajsthesiometers, sphygmo-
graphs, thermographs, myographs, thermoscopes, and spectro¬
scopes—instruments of Positive Diagnosis. But wTe can already
affirm that then physicians will be nearer physicists and farther
from metaphysicians than they now are, and that physic will
have completely reclaimed its place among the Natural Sci¬
ences.
The world has a critical eye upon the medical profession for
that.
* See Avenburgger on Percussion, etc., in Prcefacio.
ITS PLACE IN TIIE STUDY OF MAN. 251
Of all recent improvements none will be so potent to give
medicine a place among the Positive Sciences as its adoption
of Thermometry.
e.—But several moves are necessary to attain this object. The
hand must be educated to take a larger part in diagnosis. The
thermometers must be adapted by their scale and shape to
human temperatures and forms. The temperature must assume
in diagnosis the paramount and central place too long occupied
by the pulse. The method of registering temperature as the
centre of the other symptoms must be agreed upon, and its
records readable by all as easily as the news in the daily press.
Thermometry must occupy its place in the family, school,
insurance office, workshop, prison, army, navy, as it does in
hospitals; and in philosophy and social science it must, accord¬
ing to the far-reaching expression of Wunderlich, " Explore the
theoretical regions of human temperature."
The author cannot expect to accomplish all this; but where
he stops others will advance.
CHAPTER II.
INSTRUMENTS OF THERMOMETRY.
IIippockates did not consult thq pulse, but measured the fever
by the heat, which he studied by palpation all over the body;
even by localized thermometry, since he said: " Le mede-
cin examinera, si un des cotes est plus chaud que l'autre."
(Littre Translation, T. II., p. 133). So thermometry did not
begin with Sanctorius' instrument, nor can it be limited by
ours, whose mathematical precision must not make us distrust
and dismiss the Hand, reporter of heat, and of other accessory
qualities of the living tissues besides; rather should this inven¬
tion stimulate our ambition to perfect our natural thermometer,
so that it could in some respects complete, in others control, the
results obtained with automatic instruments.
I.—Education of the Medical Senses.
The time is not far distant when the instructors of youth,
instead of considering the perspicuity of the medical senses
as a personal attribute, will educate them as normal faculties,
which must be brought in physicians to the highest point of
efficiency; whose object, far from being the elevation of a few
favorites of transient fame, will be the education of a sufficient
number of efficient and reliable practitioners. Then—that is
to say, soon—will be organized courses of training of the Ear,
to hear and listen ; of the Eye, to see, look, discriminate, or
scrutinize, to embrace totalities or to concentrate on details,
etc.; of the Smell, to detect odors, smells, effluvia—of which
there are too many in hospitals—and to classify them as the
most subtle yet sure elements of prognosis ; of the Tact, to enter
into communication, by every nervous fibrilla peeping behind
the pores, with the tangible properties of tissues, superficial and
t
the hand-thermometer. 253
subjacent, to warn the mind against hasty judgments, to correct
erroneous impressions of the other senses, and, above all, to
measure life itself by its first and last expression, the evolution
of caloric.
I have claimed before the American Medical Association for
the medical students the right to this training. Not by the
trial of pluck and knuckle on the chest of the pleuritic 01* con¬
sumptive to begin with, but by a systematic course of exer¬
cises on non-living bodies calculated to gradually elevate the
perceptive functions to the rank of intellectual capacities.
And I now urge—to narrow this vast subject to the point at
issue—the necessity of the training of the sense of tact, concen¬
trated in the hand, to its highest pitch of delicacy, in view of
its application to human thermometry.
a.—ii and-thermometer.
The hand is a thermometer that rich or poor, educated or
ignorant, we cannot help carrying with us anywhere. It gives
—besides an idea of the temperature rendered more and more
accurate by education—a knowledge of the concomitant pro¬
perties of the parts under exploration, as tension, dryness, etc.
It does, not give a mathematical account of the temperature; but
by simple apposition, by slight, deep, or profound and metho¬
dical pressures, it can make us appreciate more difference in
the pyrogenic conditions of the cutaneous, infra-cutaneous, and
deeper regions, than any other mode of exploration, even more
than the simultaneous application of the fever and surface
thermometers. Moreover, the hand is the instrument of a sense
—the tact—which improves by use, rarely loses its virtue by
accident, and in many circumstances can be, and is substituted
for the other senses in observation: for the sight, so early and
easily impaired by use, by excesses, even by hereditary ten¬
dencies ; and for the audition, so often incapacitated for clinical
purposes by accidents or by diseases like scarlet, typhoid, and
other fevers; and not so soon, but as surely, by age. The
necessity of this substitution of one sense for another is parti¬
cularly felt by the young physicians who have contracted one
of these contagious or epidemic diseases which blunt the powers
of perception of the ear, eye, smell, taste, singly or collectively.
254
TRAINING OF THE PHYSICIAN^ HAND.
These confreres, more numerous than is supposed, and intellec¬
tually above the average, would have to quit the profession if
they could not substitute the perceptions of the tact for those
of the other senses in diagnosis. 1
Therefore, to urge the necessity of the medical training of
the hand, is equivalent to advocating the addition of several
instruments to ours, particularly of a thermometer of which
nothing but paralysis can deprive us.
As the eye of a physician must read more easily countenances
than books, so his hand must feel with the sensitiveness to con¬
tact of an aerometer.
In the exercise of this feeling the hand has to perform at
least four operations*—the approach, the touch, the tact, and
the pressure; distinctions which must be maintained, or ex¬
tended farther in some of the training exercises, and laid aside
in others.
The physiological exercises of the hand naturally bear upon
the properties it will have to discriminate when called to act as
a thermometer: heat, moisture, surface, configuration, dimen¬
sions, tension, elasticity, etc. Most of these exercises must be
performed by the hand unaided by the other senses, some¬
times like playful games,f at others by concentrated efforts of
attention.
For instance of what is not done, and what can be accom¬
plished in this form of training of the hand: great pains are
taken by professors to teach anatomy viva voce, and by students
to listen and read about it. Others teach anatomy de visu,
showing the pieces they vainly try to describe by words. But
how much more effective would be their teaching if it was done
with less words, but de visu and de tactu altogether, and de
tactu separately. The form of a bone cannot enter the mind
through the ear, is even imperfectly delineated on the convolu¬
tions of the brain through the retina, unless color is added to
form ; whereas, through the poly-surfaces of the tactile papillae,
its form is like molden in the sensorium, where it will rest, not
like an image, but a cast.
Why, then, not teach that part of anatomy, and natural liis-
* See Transactions of the Am. Med. Assoc., 1873, vol. 24, page 187, etc.
f See Manual of Thermometry for Mothers, Nurses, etc., pages 6 and
following.
MANUAL OF HAND-THEKMOMETKY.
255
t°ry at large, through the sense of touch, which would soon
become for all physicians what it is for the privileged few—the
tactus eruditus, companion and interpreter to the mens eru-
ditus.
By these and similar exercises bearing 011 the temperature
and other properties, the hand of the physician—but why not
that of all educated beings ?—would conquer the capacity
which constitutes the superiority of many insects over man—
the capacity of feeling, natural in the antennae, potential in
the hand.
This organ, so prepared, would be more than equal to the
exigencies of thermometry, whose technicalities would soon be
mastered.
b.—Manual of IIand-Tiiermometry.
The hand being in working order; that is to say, its feeling
capacities well developed through a smooth and sensitive sur¬
face ; its cleanliness unimpeachable, not only from actual
impurities, but even from suspicions arising from contact with
previous patients ; its temperature made isothermal, or equiva¬
lent to that of the surroundings, which is easily tested by shak¬
ing hand, or any other means of comparing temperature with
those present—then the manoeuvres of the hand-thermometer
are conducted in the following progression :
The flat of one or more fingers, or of the whole hand—
according to the size and configuration of the surface to be
explored—remains hovering a while above and near, to per¬
ceive the heat exhaled therefrom; then enters upon a slight
contact with this surface to receive the impression of its most
superficial temperature ; then by a firmer pressure receives the
full impression of the skin's temperature ; then by gradually
deeper pressures acquires the impressions of deeper and deeper
seated combustions. Every one of these pressures should be
made separately, after the impression of the'former has dis¬
tinctly-reached the mind through the inquiring hand. Then
the hand is gradually and slowly removed, in order to appreci¬
ate these different modifications of temperature in inverse pro¬
gression, or rather in retrogression.
But this manoeuvre would give imperfect results, if only ap¬
plied according to this general indication; whereas its results
256 clinical thermometers.
could be made faultless by the previous teachings of the ana¬
tomical sense of the parts to be explored, and moreover by the
anticipation of the pathological anomalies to be encountered.
If we Mash, for instance, to watch over the temperature of
the head of a child—in which operation, by the by, the hand
offers several advantages over any instrument—a kind of
spherical application of the hands to its surface would teach
very little ; an adaptation of them to the parts, taking into
account their topographical anomalies, would discover more;
and an intentional—I would sooner say interrogative—pressure
over some parts suspected of being in an abnormal state: the
parietal sutures during dentition; the superior fontanelle in
the first and second summer, or as long as it is bulging by
day, depressed by night, and pulsatile part of the time ; at the
temples during the committing of lessons to memory or their
recitation ; and at the base of the head, when there is a tuber¬
culous diathesis: these manoeuvres—now committed to the
pulp of the finger, then trusted to the palm of the hand as to
an impervious retainer of escaping caloric—would transmit
thermal impressions, whose mode of escape, continuity, and
localization should be incontestable, and whose meanings could
not be challenged.
Without looking for other illustrations, this will suffice to
support the affirmation that the hand, to become a meter of heat,
must, like the organs of the other senses, have received its
physiological education. Still, however perfect may be the
result of this sensory training, as there is no possible mathemat¬
ical scale to measure our feelings upon, the hand is not ex¬
pected to work as a graduated, but as a differential thermome¬
ter ; nor to take the place of the former, but to call for its
timely assistance: positive records of temperature being the
exclusive work of mathematical instruments.
II.—Clinical Thermometers.
Nothing is known of the first instruments of Sanctorius,
Boerhaave, Van Swieten and DeHaen. They must have been,
like those of Currie, Davy, Donnd, Demarquay, mere weather-
thermometers. They must have been pretty scarce, since
Roger rather prides himself upon having secured the one of
false principles.
257
-Donne for his observations on the temperature of children, pub¬
lished in 1844.
Becquerel, Gavaret, Helmholtz, and other physiologists used
thermo-electric apparatus inapplicable for several reasons to
ordinary practice. Bouillaud and Piorry were the first who
tried, to my knowledge, to construct theirs in view of taking
both central and peripheric temperatures. 1 have seen the one
of Bouillaud—a clumsy thing, of which he is proud, and justly
too, since it is the unique relique of the first idea that physi¬
cians must have their own instruments. But this failure of
the form was nothing compared to the error of the ideal looked
for in their construction. For the worse form improves by
successive adaptations, that is unavoidable; but once starting
from wrong premises, the more you go, the farther you are
from your objective.
a.—The False Principles.
Medical thermometry began with false notions; the worst
ones being that a single thermometer can do the whole clinical
work, and that any scale will do.
The first of these errors has prevented the methematical
study of the anomalies of ustion in fevers, cholera and the
other diseases characterized by large discrepancies between
the central and the peripheric temperatures. The want of
good surface-thermometers has certainly kept us backward in
that matter at least thirty years.
The second error has allowed to grow side by side several
scales, whose comparison obscures the subjects it pretends to
enlighten, and demands a time which we cannot afford. Phy¬
sicians do not alone suffer from this public nuisance. During
the forty years Humboldt was busy tracing his isothermal line
around the earth, he complained of nothing but the useless
labor inflicted on him by the dry task of establishing the con¬
cordance of the various thermometric scales. Berzelius suf¬
fered as much from the same anarchy in his undertaking to
establish a uniform scale of temperature in the vast domains of
chemistry ; and Arago rose—how many times ! . . . from his
seat of Secretaire Perpetuel de l'Academie des Sciences—to
protest against that Tower of Babel, more potent in its tiny glass
258
CONFLICTING SCALES.
tube to cause the confusion of languages than likely was the
huge pile on the plain of Shinar.
But all in vain. Glovers, shoemakers, gas-fitters, have agreed
to common standard measures upon which their work may be
duplicated, mended, adjusted all over the world ; manufactur¬
ers of pyroligneous acid and others have displaced the zero of
the centigrade scale to suit the requirements of their industry;
astronomers and seafaring people want a meridian unique
and a common nautical almanac, in order to save labor, and
thereby those errors of computation which cost many lives 011
the ocean. Indeed, savants, chemists, manufactures, mechan¬
ics, seamen, all strive to establish a standard measure of their
work ; all but physicians, who agree only to continue to dis¬
agree.
Under these unfavorable circumstances, a small number of
physicians, with borrowed tools and an indomitable persever¬
ance, began (1835- 55) to extract the elements, principles, and
laws of human temperature from the chaos of figures juxta¬
posed as equivalents from Fahrenheit, Reaumur, and Centi¬
grade.
As on a battle-field, many lives have been spent since five
and thirty years in taking temperatures, reducing one scale
into another, writing figures, drawing curves and diagrams,
summing up the products of the most intricate traces into gen¬
eral laws of thermo-physiology, and special laws of tliermo-
patliology, which will pass, like so many victories, to posterity
under the name of General Wunderlich and others, who
evolved the truth from the million of observations of the
thousand nameless observers.
This was good to begin with, in the heroic times of thermome¬
try. But since this mode of diagnosis has become popular, we
shall have to simplify and multiply its instruments and methods
of recording observations, to lower it to the vulgar heroism—
heroism yet, after all—of the daily laborers in physic, who are
willing to use the new method of diagnosis, provided it is made
as expeditious as it already is effective. Let us, therefore, ad¬
mire the monuments of the Titanic period of thermometry, like
the Treatise of Wunderlich On the Temperature in Disease,
etc.; but entertain no illusion as to the fate of medical ther¬
mometry itself. Thus presented with its unavoidable escort of
millions of facts, and with diagrams whose curves could com-
first improvements. 259
pete with the waves of the ocean; and moreover represented
by instruments which have no concordance among themselves,
no near relation to human temperature, and no adaptability to
the various parts of the surface of the body, whose temperature
is so often the thing looked for (as in intermittent fever, for
instance, where men like Wunderlich are reduced to guess
about the difference of surface-temperatnre of the trunk and
of the extremities), the present mode of taking and recording
clinical thermometry makes upon the mind of a practitioner,
first, an impression of awe, second, one of disappointment,
which too often is the last one.
Such being the principal causes wh}T medical thermometry
has been and would remain a sort of arcanum among the
hospital chiefs of service, who can command the labor of a
large and intelligent staff, instead of extending the benefits
accruing from its immense diagnostic and prognostic values to
the whole profession, thence to the sufferers at large ; I, for
one, conceived that it would be of great honor to my profession,
and of great benefit to my race, to render medical thermome¬
try so easy that its use could become general, and could be
extended to the solution of social and economical problems
far more important than those of individual disease and re¬
covery.
The simplifications—which I proposed for the first time eight
years ago and are accepted as fast as old routine permits—■
bear upon the instruments of observalions, upon the method of
recording observations, and extend to new and important
objects of general interest. But before coming to this, let us
onlv see how the question stood a few years ago.
b.—Variety and Sameness of the First Improvements in
T h ermometers.
We have previously remarked that physiologists and physi¬
cists, aware of the shortcomings of the weather-thermometer to
measure animal heat (la chaleur animate, la chaleur humaine),
had made several trials to improve them. These first essays
bore 011 the form and material of the instrument, but did not
correspond to its various destinations.
Of the material, we have only one Word to say. Only two
260
SELF-KEGISTEKLNG TE ERMOMETERS.
substances obeying tliennal changes were thought of—alcohol
and mercury.
Alcoholic thermometers were early made by Fastre for CI.
Bernard, and worked very well in the physiological laboratory
as well as at the clinic. The same skilful engineer made
(with alcohol) the tetracentigrade instrument of Walferdin
—a thermometer having a 400° range, and a capacity for divi¬
sion of fiftieths of a degree—which deserves a re-consideration.
Alvero-nat Bro. made for Potain an excellent alcoholic therinom-
eter, which is called by the latter's name; and others were
manufactured in Germany and England by men of lesser
reputation.
Yet they did not take. For two reasons: first, a moderate
movement breaks the continuity of the column of alcohol in
the tube, and therefore displaces its top level. It is true that by
applying a match to the bulb, as Fastre showed me, the alcohol
after striking the top of the tube comes down in an uninter-
rupting column, with its unique level at the right place. This
mode of correction, though very simple, failed to render to the
alcoholic thermometer the popularity it deserves for its cheaj3-
ness and easy reading of fractions. The other cause of the
neglect of alcohol was the invention of the index—a philoso¬
phical improvement realizable only with mercury.
Before coming to this, let us intercurrently say that though
the Germans did not invent (in the medical sense) any thermo¬
meter, they contrived some way of inserting a printed scale
between two glass-tubes ; which made them so cheap, that for a
few shillings the poorest practitioner could work with instru¬
ments concordant with those of the Traube, Thierfelder, etc.;
an immense advantage where a concordance in the results of
observation is the main desideratum (Leyster's, of Leipzig, ther¬
mometers).
By this time England had hit a more scientific improvement.
Aitken had suggested to L. Casella the formation of an index
which would reach the maxima of temperature, and remain
there when the bulk of the mercury goes down ; that is the
idea of a self-registering thermometer, whose realization per¬
mits the physician to read temperatures which he cannot wit¬
ness, and to read those he witnesses at a safe distance from the
body and bed, focuses of contagium.
However much we admire the index of the self-registering
OFFICIAL CONTROL OF ACCURACY.
261
thermometer, we must not blind ourself to a defect which does
not alter its habitual use, but absolutely impairs its usefulness
in cases of exceptional apyrexy. In these rare cases—but the
more interesting; to study for their rarity—the self-registering
instrument absolutely refuses to let go down the index as low as
the temperature may go itself, in cholera, or in the apyrexia of
the new-born, for instance. Besides, the short proportions of
our pocket-tliermometers do not permit to run their scale so
low, neither so high as go some rare unexplainable hyper¬
pyrexia. For this material reason, and for the moral one that
once in a while we must keep secret certain dangerous tempera¬
tures, 1 think every physician must possess a Walferdin's ther¬
mometer (alcoholic), which could be set to work in a range of
five degrees at any point of its immense scale of 400°, and will
mark accurately the 10th and even 50th of degrees known from
the physician alone who has prepared the instrument.
Another improvement came as a corrective to a material
defect in the construction of the index. This defect was the
too great ease with which the index came down in the reservoir
and lost itself in the bulk of the mercury—thereby ruining the
instrument—gave rise to the devices of strangling or twisting,
once or twice, the neck of the tube at its exit from the bulb, so
that it would be hardly possible for the index to find its way to
perdition in the mercurial mass below. For another material
improvement, the degrees were engraved on the glass, and other
finishing touches were given, which made the English thermo¬
meter popular where money is no object.
To the credit of England is also due the initiative of asking
the control of the savants of Ivew for the best of her clinical
thermometers. This guaranty was first demanded from the
royal observatory, and offered to the medical public by L.
Casella, if I am well informed; and other houses offer
now the same surety, which promises well, but is yet sub
judice.
Such a resort to authority by a nation to whom commercial
freedom is a religion, bespeaks of the grave difficulties encoun¬
tered in freeing from inaccuracy the best (yes, relatively the
best) thermometers in the world.
As England issues several thousands of them, and we—who
did not import fifty a year in 1867—need now more than three
thousand a year for home use alone, these defects, these im-
262
causes of inaccuracy.
perfections and their correction, are matters of money and of
science, and must b.e looked in the face.
c.—Inaccuracies of Thermometers.
We let alone the defects resulting from a greedy manufac¬
ture, which are sure to bring their desert. The imperfections
of honestly and skilfully made mercurial thermometers may be
summed in one, i.e., the change of relations (rapports) which
intervenes between the glass and its contents. This is partly
due to the shrinking of the glass, and partly modified by the
settling of the mercury under barometric pressure. It is a
slow double process, during which the level of the metal fluc¬
tuates with a strong upward tendency. If thermometers are
marked prior to, or during this movement, the level of the
mercury does not remain in concordance with the figures of the
hastily engraved scale. Errors are soon discovered, of .5°, 1°,
2°C., which mislead the more, since they are themselves subject
to variations. These variations consist, on the main, in a rising
of the level of the mercury, sensible during the first six months,
mathematically measurable for at least two years.
This being physically and unavoidably the case, it is evident
that no scale must be affixed to an unfixed level; in other words,
thermometers must not be graduated before tlieir elements have
harmonized. It takes two years at least to settle these ele¬
ments of clinical computation ; by what process can it be done?
We have not here a royal institution of universally acknowl¬
edged authority; and even if the Smithsonian Institute, the
Technological School of Iloboken, the Colleges of Columbia,
Harvard, or Yale, were offered this verification, it is doubtful if
they have the means and the men necessary to effect such a vast
control.
d.—IIow to make Thermometers correct.
But considering that the difficulty resides, not so much in the
skill of the instrument-maker, as in the time allotted to the ele¬
ments to settle, it seems possible to obtain the latter guaranty
without restricting the freedom of workmanship. There are
many ways of doing it, and if I must suggest one, I would say:
Let manufacturers set up their thermometers (with number
CONFLICTING SCALES. 263
and trade-mark) in boxes of 100 or 1,000, packed in light sand,
and have them examined and sealed by some professor of a
reputed college or hospital. After two years the boxes would
be officially opened, and the scales engraved on each instrument;
then let go the competition, and success to the best.
Moreover, as there is a silent bargain in almost everything,
the manufacturer could be expected to take advantage of the
reputation of those who would control his instruments, and the
medical institutions would receive the thermometers they need
for hospital and dispensary service at cost. But any other plan
will do which could secure the permanent concordance of the
scale with the level of the mercury, and would be agreed upon
by the physicians of this country.
So far we have considered only the mechanical improve¬
ments, and seen that they were directed on the objective of an
instrument unique for all the purposes of human thermometry ;
in this race England has shown herself far ahead of all other
nations. But how happened it that this unique instrument
remained multiple only by the incoherence of the scales en¬
graved upon it ? France had embodied the thermic scale in
her centesimal system, ten other nations had assented to the
change ; Austria and Russia—all but for the example of Eng¬
land—would have long ago embalmed Reaumur in a god-like
inactivity; but the Great Stubborn for good or evil continued
to use and to spread abroad her senseless Fahrenheit. Thanks
to the English physicians, we see what our fathers ought to
have buried—a clinical thermometer unique instead of many,
and several discordant scales of thermometry instead of a
unique one, whose unity should be founded on the thermic
conditions of man. But the physicians of several countries
have more than one finger in that bad pie.
This anarchy has not even the merit of being prompted by
national prejudices; since the English-speaking nations uphold
the scale of the German Fahrenheit, the Southern Germans,
Russians, and Swedes that of the French academician Reaumur,
and the French have only generalized the centesimal system of
the Swede Celsius. In spite, and even because of this absurd
position, we claim for human thermometry a human scale of
temperature—we want a scale unique, and a multiplicity of
metres.
264
THE HUMAN SCALE.
e.—Starting-point.
This proposition we support 011 two grounds: (a) The unity
of scale.—After inventing the lactometer for the milk at the
breast, the saccharometer for the sugar, the acetometer for
vinegar, the alcohometer for spirits, the urinometer for the
renal secretions, etc., etc., physicians must comprehend that
human temperature, having its norme and its deviations, is
worth having its own scale, measurer of its color. (5). Multi¬
plicity of metres.—Sciences progress in proportion to the num¬
ber, precision, and directness of operation of the instrument used
to supplement the senses, and to supply the mind with data
unattainable by the senses alone. This is true in astronomy
physics, chemistry, surgery; why not in medicine ? ... if for
the followers of Laplace, why not for those of Sanctorius ?
I said long ago: " liien n'est plus pratique que la recherche
d'une bonne theorie." Nothing is so practical as the searching
for a soand theory. I11 consequence of such a research we
come to the conclusion that medical thermometry must be *
founded upon the bi-basic idea of a scale human and unique,
and represented by an unlimited number of pyrometrie instru¬
ments. Then let the physiological scale and instruments, and
the mathematical records of thermometry, answer for them¬
selves and be judged by their muvres. Their practical use
will make good their theory.
III.—Tiie Normal Scale.
The scale of human temperature has for its pivot or axis
the point of normal ustion in man, or health point, from which
radiate up the degrees of fever, and down those of depression.
The former, but once as high as 122° F. = 50° C. = 13 of
the Physiological scale, the latter as low as 71.6° F.=22° C.
15 Ph. But for the ordinary practice the range of this Physio¬
logical scale may be advantageously limited to this
schema of the human scale.
2G5
IV.—Schema of Human Temperature.
Degrees of fever
7 Only tAvo alleged recoveries.
6 Generally death.
5 Often fatal.
(above the^ 4 High fever.
axis).
3 Considerable fever.
2 Moderate fever.
1.5 Slight fever.
Axis of healthy ( _ ,
undulations, j 0 or standard of teatth.
f .5 Sub-normal.
~ ll Depression.
Degrees of depres-j § C(l]1
si on (belowi ^ T . , . f n1
tlie axis). ! tt A1S,d collaPse'
i 4-5 No known recovery (except in
^ cholera and sclerema).
If this scale is truly human ; if its central figure is the
axis of the undulations of the vital tide and of the fluctuations
of the living storms, what prevents us from writing it on our
thermometer as the rule of clinical thermography ?
But men do not change their standard measures without
weighty reasons. Very well. Our reasons against the old
conflicting systems of thermometry are as follows :
First, we cannot be said to subvert any medical thermometry,
since there are several, all disagreeing, and none established by
common consent. Second, their scales, different as they are,
resemble each other in having nothing particularly human.
Third, the zero F. interests metals, and the zero 0. salads; but
when we reach either of these zeros, of what help can they be to
us? The struggle for existence takes place at many remote de¬
grees from either ; we reject them because thev are not human.
Our reasons for the adaptation to the clinical thermometer
of the physiological scale are, that the interest in its figures is
equivalent to an interest in our own health ; that its scale is
our biometer ; that, any deviation from its zero gives us a warn¬
ing with a reason; and that the figures of this scale are sus¬
ceptible of mathematical operations giving positive results, by
\
266 the physiological thermometer.
which we can calculate our own vitality, and the mathematical
sum of strength we are able to spend in working or in suffering,
or in enjoying (jouissance), as surely as we can keep our bank-
account : that is not all; but such are some of the reasons which
justify the creation of
Y.—The Physiological Thermometer.
Fig. 75.
It differs from the others only by the starting-point of its
graduation, which is zero where the centigrade marks 37°,
the Fahrenheit 98.6°, the Reaumur 29.(i0°, the Walferdin 77°.
The physiological 0 is placed in the centre of the drama, whose
acts are health, sickness, and death. Who could see that and
understand not ? . . . .
The degrees of the physiological thermometer could have
been borrowed from any previous scale ; but the centigrade
division was chosen because the conversion from centigrade to
physiologic is made by the simple mental addition and sub¬
traction of 37, without the trouble caused by the cumbrance
of fractions ; and moreover, because all the quantities having
a common divisor in the French metric system, the gravity of
urine, the quantity of salts, etc., the traces of the sphygmo-
graph, myograph, spyrograph, etc., the figures or curves of
the temperature, etc., are comparable and computable together
in all proportions by a single operation ; and moreover, be¬
cause thermometry can be, by it, expressed in the positive lan¬
guage of mathematics.
Before following up the application of mathematical ther¬
mometry to the various"departments of physic, let us not hide
to view the philosophical fact, that the principle on which its
calculations are founded, the riorme, reaches higher than the
bed-post.
philosophy of the human nokme.
2G7
VI.—Philosophical Value of the Isobme.
It can hardly be suspected now; but let it become the central
figure of our calculations in relation to the physiological soul
of individuals, of nations, of the whole race, and we will soon
realize by what ties our caloric binds us to the universe.
But, it may be objected, the norme in which we put so much
reliance for the sick, and from which we hope so much for the
provision of the future of our race, may prove erroneous %
That is true in two ways : either Becquerel, Helmholtz, F.
Davy, Gavaret, P. Bert, whom we trusted did err, and their
calculations in regard to the mean temperature of man, and
their conclusions, would be quashed—as were those of the Ju¬
lian calendar—or the thermal conditions of the race, now
rightly established, would in the future undergo some altera¬
tions which would displace our mean temperature lower or
higher than the present norme. If such possible alteration,
ever so insensible in its march, would happen, the discrepancy
between nature and the actual standard measure would soon
be detected, and the new norme acknowledged as the standard
measure of the next age. A series of such modifications of
human temperature in the course of ages—be they progressively
or alternately lower or higher than the present norme—would
be simply inconvenient in quoting data from the former
normes, as it is inconvenient to adjust our chronology with those
of the ancients, or with the present Russian era; but, on the
other hand, these series of changes would soon lay open for us
the demonstration of the relation of pyretic revolutions with
the entrance and exit of the so-called diseases in man, beast or
vegetable; while sooner or later they would have revealed
the hidden terms of the cosmic problems which have defied
the successive philosophies and mythologies. Considered at a
proper distance, these successive normes of human tempera¬
ture would stand like the pylones of Egyptian hydrometry,
instead of impediment to progress, as landmarks of the grad¬
ual inodificat'ons the caloricity of our race and of our globe ;
series of physiological monuments unequalled by any other
discovery f°r its importance upon the Natural History of
Man and EaHh•
268
THEEMOGENESIS.
This is not hypothesis, but a truth which only needs more de¬
monstration. Climates vary, not only under sidereal conditions,
and according to the movements of the earth on its axis —
double influence which cause each hemisphere to be in its turn
warmer every 10,500 years—but also in consequence of our man¬
agement of its surface. Under these climatic and other vicissi-
tudes, the flora has changed several times; palms, arborescent
ferns, and gigantic laurels have made room and soft beddings
for the meek but esculent vegetables we partake of with our
brute companions. Being given a perpendicular section of the
earth, representing a change of axis of rotation like the one
which produced Noah's deluge, these previous strata of our
planet appear like the figures of an endless and everlasting
thermometer, upon which we read the temperatures of past
ages. The extinct fauna is no less eloquent: by the presence
in the strata of certain fossils we can tell the succession of
torrid and glacial periods. Man himself, though he is such a
complex and perishable combination of parts, has left in his
fossil, or simply preserved skeleton, or in the debris of his habits
and surroundings, the records of his status previously to several
of the last diluvia.
Cuvler acknowledges that parts of the earth once inhabited
are covered with water, and other parts once oceanic are terres¬
trial, and our abode. We keep the tradition of the last deluge,
and the earth bears the traces of fourteen of them (Lehon). As
long as the present movement of the precession of the equinoxes
will last, our hemisphere will be warmer by 336 hours of heat
yearly than the Austral, where ice and water accumulate in the
same ratio (Adhemar). But when the inverse movement will
take place the glaciers will extend in our hemisphere, and
already they do (Agassiz); the seas will slowly invade our low
grounds ; and when the boreal field of ice, 1,500 miles in dia¬
meter, softened by more heat, and left unsupported by the ocean,
breaks, the fifteenth diluvium will have us. Will it seize us
unaware? Can thermometry help astronomy, not to prevent
such an event, at least our being carried away by it in the
ignorance of cattle ?
Having thus been enabled to see the prehistoric man and
world, and an illimited foreboding in the distance, how easy it
is now for us, by watching and registering the rate of earthly
and human ustion and frigeration, to deduce from the next
•Application of the physiological thermometer. 2C9
gradual changes of organic and inorganic (so-called) tempera¬
tures the modifications towards which tend our planet, its liora
and fauna, ourselves included.
Such results, far from being a diversion of human ther¬
mometry from its proper course, would be accounted its chief
hoy or and crowning, as connecting the study of the present
man in health and disease with his remotest links in the past
and in the future.
It is not the smallest reward of the worker to see that his
labor—as humble as it can be—is in constant communication
with the current of the cotemporary generalizations; to feel
this connection is the purest volupty ; and to alternately apply
the idea born or engrafted unto one's self to the solution of the
lowest or highest problems, makes one comprehend that he is
akin to the two extremes of the infinite.
With this elasticity of mind we find it equally easy to apply
thermometry to the course of human destiny and to the fiuctna¬
tions of the meanest individual ailments.
YII.—Application of the Physiological Thermometer.
After having selected the instrument, let us inquire where
and how to apply it.
a.—The lieu Selection is quite important, as the central
temperature—the only one in view here—is not equally distri¬
buted all over the body, and does not equally radiate from all its
parts, in all circumstances. Its highest point is in the right heart,
or sooner in the vena cava, in its passage from the liver to the
heart. As those parts are inaccessible in the living man, we
take the temperature nearer the surface, in natural or artificial
cavities, as little inferior as possible to the absolutely central—
for instance in the axilla, mouth, rectum, vagina, bladder;
some put the instrument in the folds of the neck, arm, or groin ;
and others in the shut-hand, between the toes, etc. These selec¬
tions are not all justifiable. What of the morals of those who
will not put or keep a thermometer in the axilla?
Moliere points and names them somewhere. Yet its frequent
introduction in the rectum or vagina of young children may
blunt a feeling which ought to be respected. On the other
hand, the axilla is easily cooled by throwing the arms out; an
270
MANUAL OF THE THERMOMETER.
involuntary movement in some paroxysms of the adults, ancl
in simple uneasiness of children; whilst in the aged the
parchedness of the skin all over necessitates the application of
the thermometer in points of contact with the mucous mem¬
brane. When this mucous membrane is the rectale, the dif¬
ference with the axilla is hardly of a half degree C., as could
be seen by a chart of Sutil, drawn purposely to settle this dif¬
ference, and which gives besides two good warnings. (See
page 149.)
Let us note two irregularities in the parallelism of the course
of the rectal and axillary temperatures, and point to their
cause. In the tenth day the rectal temperature is lower than
the axillary, which is accounted for by a cold enema injected
fifteen minutes before taking the observation; the other is an
elevation of both axillary and rectal temperature the twelfth
day—accompanied with apoussee of the pulse—in consequence
of the visit of some relatives; an occurrence too frequent to be
overlooked. Almost the same remark obtains when we place
the thermometer in the mouth, besides the chances of its being
•cooled by the introduction of air through the lips, oftener from
the nostrils. Consequently one may keep his mind at rest on
this point, on which too much of fuss has been made. Except
in particular circumstances, and for special purposes, let us
select the axilla, on the authority of and in conformity to the
practice of Becquerel, Gavaret, Roger, Bourneville, Will.
Squire, See, etc. This question of the lieu (Selection once
settled, we will explain the manoeuvre of the thermometer as it
ought to take place at the axilla; and we will give it in the
terse language used in 1866 by Dr. E. C. Seguin, in the first
account of the application of a thermometer in the New York
Hospital.
b. Manual of the thermometer.—" The bulb is to be inserted
in the axilla, previously dried, if moist from perspiration, just
beneath the fold of the pectoralis major muscle, not too deeply,
the forearm of that side carried across the chest, and the elbow
secured by an assistant, or by the patient's other hand. It is
left in situ, carefully isolated from all clothing, and in perfect
contact with the skin, for eight or ten minutes, being looked at
three or four times, the last two determining whether the
column of mercury has ceased to rise; the degree (and fractions)
>s then read off and registered on a blank diagram.
the surface thermometer.
271
"While waiting, the physician has time to counf. and record
the pulse and respiration, and even to proceed with many other
points of investigation. If the time be precious, the bulb may
previously be heated, about to the expected heat, and then
inserted, when three or live minutes will be' enough for a cor¬
rect estimate."
In the wards of large hospitals, method alone can shorten
this labor. To each patient the same instrument; all applied
before the visit by assistants, nurses, etc., correcting their posi¬
tion, and noting the results, which the doctor soon controls
himself; if he sees any difference, more time is given to repair
the error.
When taking observations we note carefully the number of
the instrument, the hour, the day, the month, and the disease;
avoid taking it just after a copious stool, a vomiting, a haemor¬
rhage, a meal, or an abundance of heating or cooling drink, or
during profuse perspiration. It is not always necessary to note
the temperature of the surrounding air, unless excessive; the
same of barometric pressure.
Generally it is enough to take the temperature twice a day,
from 7 to 9 a.m., time of the lowest temperature; and from 4
to 6 p.m., time of the highest, unless these daily remissions and
exacerbations are displaced.
The observation is repeated oftener in important cases, in
very acute diseases, in cases of doubtful diagnosis, and of devia¬
tions from the normal type ; in fact, whenever anything special
is noticed in the patient or occurs to affect him. Eventually
these repeated observations are suitable frOm 3 to 4, 7 to 8, and
8 to 10 a.m., 12 to 1, 3 to 4, 6 to 7, and 10 to 11 p.m. In a rapid
crisis, as in intermittent, hourly, half-hourly, or continuous,
observations can alone show the progress of the case. This
demands an immense amount of labor. By whom and by
what means shall it be done ? We will see, after completing
the description of the instruments used in thermometry.
VIII.—Surface Thermometers.
In the New York Medical Record, of January, 1867 (quoted
by Wunderlich), I urged the necessity of inventing a thermo¬
meter for the surfaces, as we had for the cavities, and ventured
272
SURFACE-THERMOMETERS.
to predict that it would come out under the pressure of what I
knew, and wrote as a law in these italicised expressions: What
mankind need, man finds : we needed a surface-thermometer.
Fig. 76.
But the question was not then so clear as it now is. The first
searchers, like Bouillaud, sought for some modification of the
thermometer by which the same could be used in cavities and
on surfaces; moreover, expecting to be able to submit to the
same standard-measurement the temperature of the cavities
which has a norme, and that of the surfaces which is only rela¬
tive, and in a great measure dependent on the ambient, and can
be figured only by comparison. Discouragement and derelic¬
tion of search were the result.
Since, when I almost pleaded the necessity of this invention
before the New York Library and Journal Association, in a
paper read Dec. 16, 1870, it was fortunate for me to be unaware
of the discouraging opinion against the possibility of contriving
a surface-thermometer already expressed by Wunderlich. If I
had then known it, I should probably have given up the
attempt, thus ignorance was bliss; though it is not safe to trust
it, it served me in this case. Not terrified by a great man's
opinion athwart my path, I saw that the instrument must be
exclusively to the purpose, have nothing common, but the scale,
with the cavity-thermometer, and be constructed with a view of
acting on surfaces whose temperature depends on a large range
of atmospheric and physiologic or pathologic combinations,
almost contingencies, most of them below the norme of central
temperatures.
In the absence of a norme, I established one by comparison :
from one side to another; from a well part to a similar or
analogous part suspected to be sick; from a part in health to
the same in a doubtful or unhealthy state, as the temporal
regions, for instance (of which it is so important to keep the
mean temperature as a point of comparison in children under
training); from a part before, during, and after its exertions, by
fixing two or more surface thermometers on the parts under ob¬
servation.
MANUAL OF THE STTRF ACE-THERMOMETER.
The comparison takes place either by transferring the sur¬
face-thermometer from one place to another, or (better) by
using always two or more surface-thermometers at a time. The
temperature of the well side is accepted as physiologic, or the
relative norme ; that of the sick side as pathologic : the differ¬
ence between the two is the excursus of the local fever-temper¬
ature. This is the principle of judgment in localized ther¬
mometry.
The executive conditions of success of this new instrument
were, a great sensitiveness to caloric; a plan easy to set and
maintain on any surface of the body ; and moreover, perfectly
equal divisions of its register. I think these conditions have
been obtained.
(a.) Modus operandi of the surface-thermometers. Have at
least two of them, self-registering or not, but perfectly alike.
If their correctness becomes altered by usage or accident, make
the compensation in your mind or change them.
When you want to take an observation, warm them equally
about three degrees below their zero. Apply them perpen¬
dicularly, by simple apposition—pressure being reserved to
test the upheaving of pulsatile tumors—to the surfaces selected,
in this wise: upon a bi-lateral region, one instrument 011 the
sick, the other 011 the well side; 011 a mono-organic region,
one instrument over the suspected organ and the other over
another viscera of quite similar temperature ; for instance, one
over the womb, the other on the epigastrium. Leave them
three minutes in situ and read, then two minutes more, to
make sure that you have attained the pathological difference
between two points, whose physiological temperature (health)
is alike. It is often necessary to apply, at the same time, the
ordinary thermometer in the axilla, to see the amount of fever-
temperature communicated to the system by the local process,
or the reverse influences. For continuous observations, a belt
with numerous holes of the diameter of the stem of the instru¬
ments can maintain the latter any length of time, and expe¬
riences may go on for hours or days without preoccupation or
fatio-ue for the patient or the observer, wherever it is of interest
to follow the differences and the variations of temperature,
apparently caused by disease, medication, overwork, study, etc.
"VVunderlich has shown how extensive is the application of
the cavity-tliermometer to the diagnosis, prognosis, and t'liera-
27-i applications of the surface-thermometer.
peusis of general diseases. It wilj not be here out of place to
indicate some of the cases in which the surface-thermometer
has been or will be as valuable a bearer of positive informa¬
tion.
(I?.) Applications.—In local diseases of children, idiots, in¬
sane persons, and of other patients m*1io cannot indicate the
seat of their affection, the surface-thermometer may point it
out.
In a great many feigned or dissimulated local diseases it will
detect the fraud.
In the obscure beginnings of hemiplegia and paraplegia, it
shows a larger evolution of heat on the threatened parts than
on the sound ones, and in confirmed paralysis the reverse ob¬
tains, the temperature of the affected parts being shown lower
than that of those remaining sound.
In certain affections of the brain, not otherwise appreciable,
it lias shown a higher temperature 011 one side than 011 the
other (Brown-Sequard, E. C. Seguin).
I11 acute metritis and peritonitis its findings have already
been a good guide to the treatment, and have proved concord¬
ant with the periods of danger and recovery. It may be
equally sensitive to the local evolution of pathological heat in
pneumonia, pleurisy, typhoid fever, etc., as in the slower affec¬
tions, chronic meningitis, pulmonary phthisis, tabes mesente-
rica, chronic metritis and ovaritis, etc., etc. I11 articular rheu¬
matism, sciatica, facial neuralgias, etc., it will show elevations
and depressions of local temperature which may throw a new
light 011 the origin of neuroses.
I11 intermittent fever it will establish the most pathognomo¬
nic sign, viz. : the exact difference of temperature in the trunk
and at the several extremities during the cold and the hot
stages.
I11 erysipelas it warns of the approaching invasion of the
skin, shows the side on which it will spread, its receding or
transference, and keeps a mathematical account of the rela¬
tions of the local with the general fever.
With or without modification in the shape of the bulb, it
will mark the changeable differences of temperature between
a sick and a well eye, and may warn of the approach of the so-
called sympathetic ophthalmia and of other accidents. Other
specialists, besides oculists, may find it to their advantage to use
THE SURFACE-THERMOMETER IN SEKGERY, ETC.
275
the surface thermometers, as I have known dermatologists do
to their complete satisfaction.
In the formative stage of deep-seated abscesses, their centre
will often betray itself by a higher temperature. In chronic
and cold abscesses it will not be so, and may be the reverse.
In deep-seated surgical lesions, the new instrument will
often reveal the very centre of disorganization, or the extent of
effusions, of which even a skilful hand may remain in doubt;
when, according to the energetic expression of John Hilton,
"a surgeon finds himself between two alternatives,plunge in
the knife, or wait till the abscess comes nearer to the surface,
but the patient may die in the meanwhile." Then the surface
thermometer will rise higher at the centre of an active tumor
than in ambient tissues, and less at the centre of a passive or
cold tumor than at its periphery, and will fluctuate, like the
sphygmometer of Jules Herrisson, over an aneurismal tumor if
the base of the bulb of the instrument is delicately flexible.
The surface-thermometer is precious to follow the rise and
fall of temperature in regions lately submited to grave opera¬
tions, and in the vicinity of those hidden from view by an im¬
movable apparatus. Here is the place for the remark that
the mode of observation instituted by this (and the following)
instrument is kind, and never presents the grave dangers to be
feared from deep palpations, percussion, succussion, and other
savant manipulations, too often accused of being repeated more
for the advantage of the students than for that of the patient.
In any case, the surface-thermometer will have also over the hand
—even the hand gifted with the tactus eruditus—the advan¬
tage of being readily brought to a mean, known, and unpreju¬
diced temperature. The surface-thermometer is already em¬
ployed by eminent physicians, surgeons, physiologists, chem¬
ists, etc., and is no more omitted in the classical treatises of
diagnosis.
However, in the course of practice and of experimentations,
I became convinced that the surface-thermometer and the
physiological-thermometer, though excellent metres of human
ustion, did not show plainly enough the small temperature-
changes, and failed to demonstrate the rate of velocity of the
escape of the body-heat. This rate or ratio of radiation, being
as important a factor in disease as the quantity of com¬
bustion at a given time measurable with thermometers, I felt
276
the clinical tiieemoscope.
that we needed an instrument which could show the body-heat
in the act of escaping (radiation) under the most delicate con¬
ditions. This idea became in the beginning; of 1875
o o
IX.—The Clinical Ti-ieemoscope,
An instrument of diagnosis in physic and surgery, a moni¬
tor in the nursery, a test in the physiological laboratory, also
a necrometer in the dead-chamber.
This little instrument is a simple application to medical
diagnosis of the principle of physics on which Rumford and
Leslie constructed their differential thermometer.
Fig. 77.
THERMOSCOPE—HALF SIZE.
B
The clinical thermoscope is a glass tube T, a quarter of a
line bore, seven inches long, closed at one end by a bulb, B,
nine lines in diameter, and open at the other end, mouth-like,
M, by a delicate enlargement of the rod. In this state it con¬
tains nothing but air. (Several other forms have been tried,
more fitting to the surfaces of the body; but none favors the
movement of dilatation of air like the spheroid.)
a. Manoeuvre.—To make the thermoscope ready for clinical
use, its bulb is heated over a lamp or fire, sooner in a bowl of
hot water, and when the air contained in the bulb is .dilated
a few degrees above the ambient temperature, the open end is
quickly plunged in—an inch deep—and quickly withdrawn
from another bowl of cold water. The drop or two, which
will have then entered the mouth, is seen to run up the tube.
If it stops near the bulb, it will be the index of the thermo¬
scope. If it stops sooner, say twTo or three inolies from the
mouth, or if it runs into the bulb, the latter was too cold or too
hot; we have to jerk away that drop of water and recommence •
three or four trials to obtain a good water-index take hardly
a minute.
In this condition, the air contained behind the water-index
APPLICATIONS OF THE THEKMOSCOPE.
277
makes itself isothermal to the ambient temperature, and the
tliermoscope is ready.
Simpler yet: Over-heat the bnlb, let the water run in it.
When you want an index, invert the instrument, apply your
hand on top; some water will descend in the tube and form an
index ; then quick, tit your scale to it, look at your watch, all
is ready.
Bat in summer the air in the bulb, becoming isothermal to
tlie ambient, is not dilated by contact with human color, the
three being almost alike. Then, previously to using the tlier¬
moscope, plunge its bulb in water at 60 or so, and after a short
time proceed as above directed.
It is applied—I do not say introduced—like the cavity-ther¬
mometer'—anywhere an anomaly of calorioity is known or sus¬
pected. Its habitual place {lAeu (T election) is not, however, the
axilla ; it is the shut-hand.
In ten to fifteen seconds the index has attained the maxi¬
mum height, or fall, of any significance.
To read it, we mark the starting-point of the index, the ter¬
minus of its course, and the time (in second) to reach it.
To take more mathematical observations, a mobile scale is
attached to the stem, and made to slide, in order to put its
lowest figure 011 a level with the head of the water-index; so
that a tliermoscope is always correct—that is more than can be
said of most of our clinical thermometers.
But with or without a scale, it gives, by contact, indications,
{a) at the start of the volume of heat escaping by radiation,
(b) at the end of its course, of the portee or reach of its velocity ;
whilst, without contact, by gently blowing on the bulb, it
shows the degree of combustion which takes place in the lungs,
and other phenomena of ustion which I have no place to
explain.
b. Applications.—Without a scale a mother can tell at what
hour the index rose quicker and higher, or quicker only, and
not so high, etc. Without a scale, too, a physician who well
knows his case, and is short of time, can, in less than ten
seconds, decide upon the dynamic conditions of the next twelve
or twenty-four hours dependent on the waste of caloricity by
radiation—that is to say, of life itself in many cases—and pre¬
scribe accordingly.
The tliermoscope may often be called to decide about the
^78
THE THEEMOSCOPE IN DIAGNOSIS.
precise seat of an affection indicated only by general, reflex, and
regional symptoms. For a few days a business man felt dispir¬
ited, good for nothing; no hunger,, no thirst, no true sleep;
complains of cephalalgy, nausea, hypogastric pains. The fifth
day he remains in bed, has several shivers; seen in the evening,
appearance prostrate, pulse 85, temperature one centigrade
degree above the norme. The family was whispering fears of
typhoid fever; but this rise only to 100.4° F. could hardly be
found the second evening of the abdominal typhus, but the
fifth! . . . Manual examination discovered nothing; the ther-
moscope revealed no difference of radiation between the right
and left iliac regions, but proved a decided rise (half an inch)
on the right of and above the pubis. This indication was
trusted ; warm fomentations in situ of a decoction of digitalis
leaves and elder blossoms, warm drinks, and five grains Dover
powder, brought on an abundant diuresis and a profound sleep,
followed by an early start for business. What an opening for
medication, if the thermometer had not told what the disease
was not, and if a delicate tliermoscopy had not limited the sick
organ in the painful region.
Besides this daily use, the thermoscope criticises and com¬
ments some of the rare enigmatic findings of the clinical ther¬
mometer. Called near a man fallen from a three-story hatch¬
way, I found a compound fracture of one leg, and a fracture of
the skull; rather insensible to pain, full connaissance, jactita¬
tion with a speck of erotism, pulse confuse, temperature, 98.5°
F.; in other terms, at the point of perfect health. Was it
derision or delusion ? Neither; it was a compound temperature
whose component elements escaped the fever thermometer.
I tried the thermoscope; put in the hand, it rose; in the
axilla, it rose more ; below the sternum, it rose less; in the inner
angle of the eye, it fell rapidly. The thermoscope had dis¬
covered the point where extravasated blood was coagulating—
at the base. Thus became comprehensible that sardonic 98.5°
F. = perfect health, in a dying man, as a compound tempera¬
ture whose composition could be schematically approximated by
these figures: 100.3° F. of general pyrexia, balanced by 96.7°F.
of hemorrhagic apyrexia, leaves 98.5° F. This thermoscopic
analysis saved the man further painful manipulations, and he
died, as predicted, inside of three hours.
If we pass from the sick-chamber to the death-slab, the ther-
the thermoscope is a necrometer.
279
moscope will prove to be yet the only necrometer founded
upon the radiation of vital temperature, notwithstanding the
joke practised on the Paris Academy of Medicine, to which my
physiological thermometer was presented as a necrometer, after
displacing the zero from the point of health to a fanciful point
of death.
To test the microscopic power of my new instrument, I
repaired to the Bellevue Hospital of this city. By the courtesy
of Dr. E. Janeway, I was shown, in the dead-house, about noon,
the body of a young woman brought in at 9 a.m. The thermo-
scope being applied below the sternum, its index did not move
from the position it had taken in the ambient temperature of a
very cold January day; but put in the axilla, it slowly and
steadily rose about 6 centimetres = 2 inches. A thermometer
inserted instead, and kept in the same axilla fully ten minutes,
did not perceptibly move.
So the thermoscope, in contact with the living, shows the
activity of their, caloricity; and, in contact with the dead, it
ceases to indicate heat only when and where organic combustion
becomes progressive^ extinct.
As thousands are and have been buried alive, the invention
of a true necrometer excites a deep interest, intensified, if
possible, since cremation is mooted. For some have knocked
at their coffin and re-entered the world. But of what use would
it be to knock for help inside of the furnace % The proof of
death is wanted now more than ever, and, if I am not mistaken,
the thermoscope will give it.
I present this simple and costless instrument to my confreres,
as I did give, seven years ago, the Surface and the Physio¬
logical Theririometers, begging them to try it in the spirit of
candor which made Biot say: "We must not shun the hum¬
blest contrivances, when they can improve or supplement our
medical senses."
c. Calorimeter.—An evidence that man thinks not alone, but
in synchronism with his fellow-men, is the fact that when I was
making my thermoscope—which I called first, from its main
function, a radiometer—Winternitz was contriving in Vienna
his calorimeter, whose object was, like mine, to have an instru¬
ment with which to measure the cutaneous radiation of heat
His is a double, square wooden box, containing the bulb o.f a
thermometer, whose graduated stem projects outside. It is
2S0
THE CALORIMETER.
applied to almost all the surfaces, and the lieat radiated and
enclosed therein is indicated on the scale.
But this invention of Winternitz, no more than mine, nor
those of other searchers unknown though prospecting on the
same track, do not blind me to the fact that clinical thermom¬
etry, and other parts of the medical clinic, are yet quite defi¬
cient in instruments of observation. We can smile at the last
generation, arming itself to diagnose fever with bladders of
Japanese variety, and pincers and saws whose teeth rivalled
those of the ophidians and the placoids; in their turn, our
children will laugh at our penury of instruments of medical
observation, and wonder how we could have done our duty
without a physician's (not a surgeon's) pocket-case replete with
the instruments of physical and positive diagnosis, etc.
CHAPTER III.
CONDITIONS OF SUCCESS IN THERMOMETRY.
But the best instruments have a value only subordinate to
the capacity of those who handle them, and to the force of
cohesion of the method which binds their data in a conceps.
In other words, the workman is more important than the tool,
and the method more than the man. We will proceed in this
natural order.
•
I.—Thermometricians.
If one or two observations are needed daily, the physician
must take them; and if he has no time he must not undertake
the case. If more are needed, he must have taught his
assistants to do it, and be able to criticise the results. For his
role is not only to take observations, but to superintend, control,
and rightly interpret them. Happily, as astronomic observa¬
tions are often better recorded by honest, attentive assistants,
than by astronomers, so a medical student, a nurse, a relative,
can be made a useful assistant to the medical thermometrician.
a.—Hospital Assistants.
There is no part of the work of a physician for which he
needs so much help as for the thermometry and thermography
of his cases; but he must create his helpers. He will have
them in the hospital if he inspires his pupils and his nurses
with the proper spirit, and bind them in the unity of object
which must be the aim of the chief, for, without an ideal,
patients may be well treated, but physic is ill-treated. S ,
by no means a small practitioner, had once in the Hojpital des
Enfants, rue de Sevres, the finest staff ever gathered: Becquerel,
282
family clinical assistants.
Roger, Contour, Jules Seguin, Rilliet, Barthez, and lie pro¬
duced nothing; but Wunderlich made a much more ordinary-
staff the instrument of numberless calculations, from which he
deduced laws. The strength of the staff depending so much 011
the hand which handles it, I will not insist upon the individual
capacities desirable in hospital assistants, only refer to what I
have said in a preceding chapter on the training of the liand-
thermometer, and in 1872, before the American Medical Asso¬
ciation, on the necessity of educating the medical senses (see
Transactions, etc., vol. xxiv., p. 187, etc.). What I have said
in these, and in other preceding circumstances, is applicable
also to the assistants which the physician must form himself, if
he wants them in his families.
b.—Family Assistants.
It is when called in a family for a sick child that the physi¬
cian feels the more the want of clinical assistants. If he has
not taught the mother the skilled duties of nursing, and partic¬
ularly the art of taking and recording the temperature from
the first moment of illness, the life of the child is as much in
jeopardy as his own reputation, and the woman not educated
to assist him counteracts his management by the clandestine
practices of thaumaturgy, quackery, etc., etc.: in Ephesus, Diana
neglected turns Hecate. But when she has been taught the
signs of disease, and particularly those furnished by thermom¬
etry, she has always taken the first abnormal temperature, and
when the physician calls, she shows him a series from whose
progression he can tell—if not at once what the disease is—
what it will not be, and how she must continue the observa¬
tion in his absence: thus an understanding is arrived at, at
once. But this understanding is rather a wish than a fact ?
The fact is, the absence of record of temperature ab initio
has been the principal obstacle to the progress of thermometry,
in the hospitals where the cases are admitted after several
days of sickness, and in the families where none is taught to
do his duty.
Since hospital clinicians cannot get at these much needed
initial temperatures, who will ? We must have them ; who can
give them ? . . . Let us see.
The family physician, too, seeing very few of his patients at
FAMILY PHYSICIAN UNAIDED.
283
the very beginning of their"disease, is unable to take their first
temperature : and, having everything to do himself, can sel¬
dom take it, later in the treatment, more than once or twice a
day, and almost never at the critical hours, when its variations
may be expected, and when they acquire the significance of
premonitions.
But why is the family physician alone ; and does he pretend
to do everything himself, everywhere he goes? Cannot he
find some help ? How seldom is devotion, wanted and not
found, particularly at the bed-side ! If the family physician
had looked around, would he not have seen the overworked
mother or nurse, who would be but too happy to learn how to
help him, by doing intelligently what she always did instinct¬
ively before ?
The family physician who complains of being unable to take
his share in the progressive labors of his time by want of a
clinical assistant, is simply the one who deprives of the knowl¬
edge necessary to accomplish that function the best of all the
assistants, the mother. But whatever could be the cause of
this grievous injustice, it first brings its bitter fruits upon him¬
self, who, unable to thoroughly record the results of his pri¬
vate experience, is incapable of producing these monographs
wrought to perfection now only by the Messoniers of the medi¬
cal art. Deprived of the means of doing this—his share in the
medical labors of his times—he sinks as much as raises his
hospital confrere, whose faVne grows from his own labor,
swelled to an untold extent by the,observations of his clinical
assistants ; and soon the worthy but lonely man will distrust
his own experience (of which he has no authentic records), and
submit to opinions, written or oracular, often less valuable than
his own.
As for the woman, she is not confined to the drudgeries of
the sick-room without feeling our want of appreciation of her
worth in this, her special field of labor ; and what knowledge
her legitimate teacher, the practitioner of physic, does not care
to impart to her, she receives distorted from the quack, the
supernaturalist, and the theologaster.
And now let us see the results of our neglect of educating
woman in the parts of our art which she can understand, in
which she can help us fully as much as we can help her, and
particularly in the application of the thermometer to the dis-
284:
"WRONGLY EDUCATED WOMEN.
crimination of illness from health, to the determination of the
stages, or critical periods of sickness, and to the perception of
the impressions produced 011 human temperatures by any given
medication. Here are some of them.
I would sooner pass by the teachings of the medical charla¬
tans with the simple remark, that it is our own silence which
beckoned them to speak in our stead.
c. Deceived Women.—Though woman never received her
due technical education in medicine, hygiene, and nursing at
large, yet in all times she heard muttered some mysterious words
about religious powTers ruling these matters. It was Escu-
lapius, Apollo, Cliyron, Lucine, etc., till these worthies being
unable through disci-edit—see Oribasus' letter to Julianas—to
pay expenses at Delphi, Epidaurus, Ephesus, etc., they were
superseded by other supernatural powers. So that when the
modern woman has some friends in pain or distress, she raises
her supplicating hand towards Olympus 110 more, but to the
worthies who received their diplomas from the Vatican.
For herself, as soon as the modern uneducated woman begins
to feel the first quickening of her child, equally ignorant,
alarmed, and delighted, but knowing that social conventionali¬
ties do not permit her to reveal the blessed secret, she feels too
that she must appeal to somebody who knows, and who could
not betray her trust. It is then, among the complex anxieties
of the mind and of the womb, or, later, during the superhuman
efforts at delivery, that she devotes her expected baby to the
Virgin Mary, or to some minor saint, to preserve it from ill or
malefice, or to endow it with health, talent, beauty, etc. Later,
to cure her infant, she would burn candles at some altar; and
to save him from the danger of an epidemic, she would have
expensive masses expressly officiated : whilst against the event¬
uality of general, hereditary, or chronic affections, she had,
from the first, hung to his neck an amulet on which the ana¬
gram of a gang of conspirators has been printed, instead of the
image of Hercules. So much for progress. Anyhow, that is
all these women have been stealthily taught, know, believe, and
practise to manage diseases and to prevent constitutional
affections from invading their families. For this, who is to
blame—the Bonze who played doctor, or the doctor who did
nothing ?
d. Wrongly Educated Women.—What is, on the other hand,
thermometry taught to mothers. 285
the mental position of the women, thoroughly educated in all
other matters, but left ignorant in this ? Seeing everything
around, tliem submitted to certain laws of physic, mathematics,
chemistry, etc., they wonder how it happens that they alone, in
their profession of breeders of men, are left without rule or
precept to abide by, and no possibility of acting in an emer¬
gency with any likelihood of obtaining an accurate result ?
They know that everything is made, cut, ornamented, or fitted
according to certain rules of mechanics or geometry, as soon as
men find out that it will save them time and give more satis¬
factory products; and, reflecting upon their own present status
in the field of labor, upon the incommensurable value of the
products of their loins and vigils, and upon the ignorance in
which they are left of the scientific and positive part of their
function, women cannot suppress their terror or disgust at
being obliged to raise our children without having been taught
how to do it. And I have no doubt that this is one of the
reasons, and not the least, why too many of these women
escape maternity, even at the risk of their own shame and
death, sooner than to undertake what they know nothing about.
No crime brings more surely its own punishment, dishonor,
crippleness, and that peculiar sadness which imprints itself
like a judgment on the once loveliest features. Who would
say that women alone deserve reprobation for this, and that
those are exempt of blame who could have taught them their
duty and have not ?
For myself I do believe, and I labor to make others believe
that it is our duty to teach women—at least those who trust us
as medical advisers—in the parts of our practical knowledge
which they can understand, and need so much; and most parti-
cularlv in the art of taking and recording the temperature of
their children.
e. How to teach thermometry to mothers, and to others hav¬
ing charge of children.—This teaching of family thermometry
is more easy than it seems; for it is not dogmatic, but occa¬
sional. Circumstances will call for the use of the instrument,'
and its use introduces our explanations; so each need of the
thermometer is turned into a lesson of thermometry. For in¬
stance, we take advantage of the high temperature of the new¬
born, to compare infantile temperatures to the virile norme.
Later we have occasions to compare said norme to the deviations
286
thermometry dispels superstition.
from it which characterize dentition, overgrowth, ill-feeding,
eruptive fevers, excessive studies, etc. But let us always start
from the norme, and constantly repair to this New World of
which Becquerel was the Columbus. Let the mother compre¬
hend it as the pivot of health, whence radiates consuming fever
and algid collapse, and she will be equal to any emergencies.
This once well understood, let us not be hasty, but bide our
time. Circumstances and the eagerness of the mother will draft
the sequel of the curriculum of her thermometric studies, and
she will soon have learned of it more than we have taught. We
want a clinical assistant; here she is. She wants to know her
motherly duties in the hours of peril: here is family thermometry.
• In my estimation, this part of human thermometry, which
belongs mostly to women, is like a ripe fruit, ready for assimila¬
tion by the minds which need it. It will emancipate women
from prejudices and from superstitious practices for which the
animals of the fields and of the main would despise our kind, if
they knew. ... It will place the physician nearer to the other
students of physical sciences, and be a great and good step
towards the triumph of positivism over supernaturalism.
If any one could think that I am a lone enthusiast on the
subject of family thermometry and its annexes,- let me quote
the opinion of M. Littre, to which I have already alluded: " I
am entirely of your opinion in regard to the services which
human thermometry must render in the families, in the schools,
and in society at large. Your indications are excellent, and we
must not cease to preach them till they have penetrated through¬
out the public mind." (Correspondence, 13th Sept., 1872.)
In this respect I am inclined to think that few of us do our
duty. We dogmatically prescribe or order, and do not educate
our nurses and mothers to appreciate how true to nature the
practice of the present day has become ; and how attractive and
dramatic it is to follow the parallelism of nature and art evo¬
lutions, even for those who do not command them.
It is so easy to interest these people in their hard and often
repulsive labors; they would be delighted if they could see, in
an improved temperature, the result of their steady nursing,
and soon they would, by their effectiveness, number, experience
and enthusiasm, drive away from the sick-chambers the bats of
charlatanism, and we should have in them no mean helps and
allies against the base theurgism now rampart. This reform
DAILY MEDICAL RECORDS.
287
implies the abandonment of the traditional forms of doctoral
authority. A trne physician loses nothing by speaking like a
man to his fellow women and men: honoring his subordinates
in function, he encourages them, and honors himself: of all
workingrnen, he must remember that, if there is ranks during
labor, there is none in humanity.
Gifted with this moral sense—which does not exclude a will—
the physician is sure to find true assistants when he wants them.
f Daily medical records.—With their assistance the physi¬
cian must begin at the base, and the base of all thermic opera¬
tions is the daily record thereof. It is said that hosjpitaliers
keep these records; but how incomplete, if we judge by the
quotations from Hospital Reports met with in books and
periodicals. If Roger's staff had been impressed by and
imposed that basic duty, his otherwise precious observations
would not have brought him more criticisms than compliments ;
and himself would likely have discovered these pathological
laws which he only pre-scented. One thing it is to accumulate
materials, another to melt them by a fulgent flash of thought in
a new idea. The word Patience is Genius ought to be written :
patience prepares the materials for genius. Few can accom¬
plish this double operation, usually completed when the toils
of the many are resumed in one man's brain. That is, at least,
the process by which a physician deduces his prognostications
in each case from the daily records of his hospital and family
assistants, and is thereby enabled, after a long practice, to
formulate one of those simple sentences, strong with the
strength of numbers, which once in a while dazzle as an unex-
O J
pected truth.
That is what I had in view when I issued successively six
editions of my Prescription and Clinic Record (W. Wood & Co.,
publishers, N. Y.). There must be some good in it, since it
was counterfeited in Philadelphia and in Cincinnati, without
acknowledgment. Oh! for human feeble-mindedness, which
expects a book-lifter to call himself a thief. If that Clinical
Record had no value in it, it would not have been stolen.
Seriously, whatever be its imperfections, it has already ren¬
dered services in the office to the physician, and at the bed-side
to the mother. In its simplest form it contains only these few
blanks : date, name, age, disease, to fill but once; and pulse, respi¬
ration, and temperatures, daily, or several times a day. When
288
OBJECTS OF THE CLINIC RECORDS.
the attendant is intelligent, more questions are made in regard
to several functions, morbid, or morbidly affected ; and another
series, which the physician alone can answer, in regard to the
analysis of secretions, etc. Indeed, the daily record of functions,
be it in register-form for hospital, or of pocket-book size for
visiting or home, is the basis of the natural history of diseases;
observations written without it may advantageously be read like
pathological romances.
Thus the object of a daily record is twofold: (a) To the
mother, or person having charge of sick or young people, it
shows the movement of the vital functions, with the progression
, towards better or worse. It enables them to give the physician
a mathematical instead of a guessing account. It gives the
nurse her legitimate share of the work, and of the honor due to
success as well. It identifies the nurse with the physician, by
giving them both a common aim, which do not allow the former
to get astray. (b) It keeps the physician well-informed, like
seeino- what he could not have looked at. It shows him at a
glance what he has done, what to do, and how does every one
of his patients. It serves to record the phenomena 011 the spot,
and the details of the treatment en suite, in order to keep their
parallel series in view. It substitutes more and more positivism
for conjecture in diagnosis and prognosis. It helps to treat
complex or protracted cases with scientific unity of plan. It
enables a physician to continue with perfect knowledge tlie
treatment of the case of a confrere absent or sick, and vice versa.
It furnishes the elements of comparison of the medical consti¬
tutions. It lays the foundations of reliable statistics, and of
true monographs, offsprings of thermography.
I do not say that my Prescription and Clinic Record fulfils
all these indications—though I feel somewhat paternal about it.
I acknowledge its imperfections, which can be corrected, after
perusal, by the criticism of the profession at large; but, what¬
ever form may be adopted, we are under the necessity of con¬
certing some plan of recording our cases in a readable and
comparable form, in order to find out the law—if there is a law
—of the symptoms, periods, duration, recovery, or death, after
the manner taught by Hippocrates, Sydenham, Andral, Wun-
derlich, etc. Of this work—demanded by the wants of that
positivism which rules all the human and scientific affairs of
our time—110 true physician is too great, none too small, to
V
thermography- 289
keep himself aloof. We must not forget, moreover, that the
Daily Medical Record is the cradle of
§ II.—Thermography.
It has for object to describe the course of human tempera¬
ture in a durable and comprehensible form, the plans of re¬
cording which are yet as unsettled as the choice of thermometers.
If the thermograph of Marey had become popular, we
should use the word thermography in the same sense as sphyg-
mography, myography, dynamography, etc., meaning an auto¬
matic representation of organic operations obtained from self-
registering instruments. With it we would have been enabled
to take continuous observations of temperature; without it we
can observe the evolution of heat only at stated times, and our
thermography consists in figuring or spotting these uncon¬
nected temperatures, which we later connect in various ways.
These records may be reduced to two systems, one by lines, the
other by figures, giving a graphic and a mathematic thermogra¬
phy. (Of the varieties of both we will say as little as possible.)
In the graphic system we connect the points truly observed
and spotted with traces, called curves, likely because they are
rectilinear, which cannot represent the true movement of the
temperature, but fill up the gaps between the hours of observa¬
tion ; so that, in a graphic, the isolated points are true, the
connecting lines are fictitious : this noted, let us proceed.
These curves represent the relations among themselves of
the successively noted temperatures, but they do not give any
clue as to their degrees, which have to be read from the scale
of a weather-thermometer appended at a side of the chart.
a.—Of simple graphic of temperature,- the diagrams of the
various intermittent fevers (pages 202, 203) are good specimens.
When the graphic is intended to also represent the movements
of the pulse and respiration, two other scales are added to the
one of temperature, and the movements of the three great vital
functions are figured by traces, either colored if made by hand,
or in chromos, or simply black in ordinary print. In the latter,
which is the more customary and the less expensive, the three
traces (of temperature, pulse and respiration) may be run
alone, each on separate and superposed plans, like those found
in the New York Hospital Reports:
19
respirations per minute.
PULSE-BEATS PER MINDTE.
TEMPERATURE. (FAHRENHEIT'S scale.)
days of
disease.
GRAPHIC RECORD OF VITAL SIGNS.
DATE, NAME, DISEASE,
Ox
to
o
to
co
O
Oi
m
o
tn
Oi
O
Oi
o
-J
o
cc
o
C£>
C
1 100 I
1 110
1 120 1
1 130 1
1 140 1
Oi
o
CO
OT
o
CO
CTi
o
CD
o
-
98°
99° i
1 oOOI
o
o
LO
o
O
CO
o
H—'
o
o
H-1
O
O'
o
i—1
o
o
1—i
o
o
o
00
0
i—'
O
CD
o
1—I
1—1
O
0
#
■
—
s
2
2
2
2
2
2
2
2
2
tc
2
2
2
W
2
REMARKS.
COMPOUND GRAPHICS.
291
Or the graphic may represent the three great functions on the
same plan by distinct conventional colors or signs. Th s led to
the idea of representing also on the same plan the results of anom¬
alies of other functions, as the dechets, or the increase of body
weight, growth, secretions, excretions ; each anomaly is thus al¬
lotted its symbol, which runs according to a special scale, as we
have given it in the diagram of a case of erysipelas by Mol^,
and as can be seen by the following beautiful type of:
Fig. 78.
rUZBPXBAl* HEMORRHAGE (LORAIN'S).
It must be acknowledged, however, that not only these signs
are arbitrary and limitedly accepted, but that the same author
has altered his own in the course of his publications. The
only chance to see these symbols accepted by the profession,
particularly for clinic and class demonstrations, is to bring
them to a uniformity which will insure a consensus. In this
hope we will give three of the keys, out of which a valuable
one could easily be devised and agreed upon.
o '. .
rnoif >
■
. )
SL. j .*) lii.jjrmdo-*
... .. v. .
■ : '
-, - v '' -;v
U . ML«... --- v
.
" V ' r^rr r*)n ocl Is.-
COMPOUND GRAPHICS.
291
Or the graphic may represent the three great functions on the
same plan by distinct conventional colors or signs. Ths led to
the idea of representing also on the same plan the results of anom¬
alies of other functions, as the dechets, or the increase of body
weight, growth, secretions, excretions ; each anomaly is thus al¬
lotted its symbol, which runs according to a special scale, as we
have given it in the diagram of a case of erysipelas by Mold,
and as can be seen by the following beautiful type of:
Fig. 78.
PUERPERAL HEMORRHAGE (LQRAOt'S).
HH1
mmm
i i: W
si
1
v.i ' ' ' ■
.M ■ mmm
.•*<* ,
v ? rs - ty ■
r_ && *25S3CS£!2£&S
It must be acknowledged, however, that not only these signs
are arbitrary and limitedly accepted, but that the same author
has altered his own in the course of his publications. The
only chance to see these symbols accepted by the profession,
particularly for clinic and class demonstrations, is to bring
them to a uniformity which will insure a consensus. In this
hope we will give three of the keys, out of which a valuable
one could easily be devised and agreed upon.
292
KEYS TO GRAPHICS.
1 Fig. 79.
MOLD'S KEY OP SIGNS.5
Pulse.
Temperature.
Quantity of urine,31111
Density of urine. 31
Coloring matter of urine.
Chlore of urine.
Urea of urine.
Points of change in the direction of traces.
Crossings of traces. :
'" ""P,
■.
Fig. 80.
LORAIN'S KET OF SIGNS.
Pulses.
Temperature in vagina or reotnm.
Temperature in the mouth.
Temperature in the axilla
Temperature in the hand.
Chlores.
Quantity of urine.
Curving point of a trace.
Crossing points of a trace
xxx x xxxy XX X.X<•<XX. / A KXX>:y.
ADVANTAGES OP THE GRAPHICS* 293
Fig. 81. ,
SEQUIN'S KEY OP SIGNa
Temperature in the axilla, T.
" in the rectum, Bame symbol with T. R.
" in the vagina, same symbol with T. V.
" in the hand with T. H„ mouth T. M..
etc.
Pulse beat.
Breathing.
Weight.
Quantity of urine, Q.
Density of urine, D.
Coloring matter, C. M.
Urea, U.
Defecations (number).
Vomiting (number),
x food, / drink, \ sweating.
Crossing points of the traces.
c.—These graphic charts show at a glance the drift of the fluc¬
tuations of temperature. They are particularly adapted to class
demonstration; they illustrate well the prominent points of a
febrile course; and when a generalization has attained the
maturity of a law, such graphic renders its acceptance by a
class almost an acclamation.
We must not forget that traced at home, by a skilful and.
loving hand, from infancy to childhood, from youth to virility,
such a chart reads like the canto of actual life.
On the other hand, a graphic speaks more to the eye than to
the mind, the latter having to translate the lines in figures, in
order to have them available for judgment.
d.—The graphic gives the movement, but not the mathematics
of a case ; unless its curves—after having been traced from the
original figures—would be translated into these figures again.
Then cui bono ? . . . These successive operations take time,
money, skill. Indeed, the single traee of a graphic is above
294
DEFECTS OF THE GRAPHIC.
the hand and patience-capacity of many clinical assistants,
who moreover keenly feel the waste in drawing of their time
needed otherwise. Besides, the cost of engraving these draw¬
ings do not allow the publication of one ont of a valuable hun¬
dred, and we must thank our publishers, MM. Wood & Co.,
for their costly liberality in this respect. Lastly, the graphics
are yet all graduated with the scale of one of the weather-
thermometers, not amenable to mathematie operations; since
the starting-point of their numeration is likely more foreign
to the temperature of man than to that of the moon.
Whence we conclude that if the graphic charts have helped
the demonstration of thermic laws in disease, they have kept
scarce the elements from which new lavis can be extracted, and
they have (worse yet) retarded the mathematic-reading of
individual cases which prepares the advent of positivism in
physic.
Trying to judge of mathematical thermometry with the same
impartiality, we would say: The mathematical tables of tem¬
perature were the first historical records of it, have been and
are yet the most used, and the easier written and read; besides
that they remain the ratio of the cwrve-charts.
Their great drawback is to have been dressed without uni¬
formity of plan, and on scales which preclude the possibility of
extracting their mathematics. These defects strike any one who
tries to read and compare the observations, otherwise so valuable,
of John Davy, Roger, Mignot, those of Wilson Fox and W. H.
Draper, the very latest (in Appendix XIII., c). But the adop¬
tion of the physiological scale to record physiological phenomena
seems to be ouly a question of time—the time necessary for an
idea as clear as brook-water to percolate through skulls—and
will have for unavoidable corollary the adoption of a uniform
plan of mathematical record of temperature, and of the other
signs of disease, worth recording. This plan has not yet been
applied in hospitals, but is perceptibly a favorite mode of taking
Observations among young physicians, and has received weighty
scientific adhesions. It is carried with the physiological ther¬
mometer, on mathematical charts in which tho, figures represent
the exact quantities of radiated color and are treated like all
other mathematical quantities.
e.—This mathematical treatment of pathological quantities
consists in submitting them to all the operations by which their
DE SUPPUTANDO CALORE. 295
ratio—relations and progressions—can be extracted. The plan
is as follows: Starting from the normes of temperature, pulse,
and respiration—if we have been allowed to take them—if not
from the norme proper 98.6° F. = 37° C. = 0 Ph., we write the
temperature on the chart once, generally twice, oftener in
severe cases, in the order in which it was taken.
These figures, which separately had only their own signifi¬
cance, acquire another by their progression, and several others
by their relations: (a) among themselves, (b) with the time of
the day, (c) with the time of the medical week, (d) with the
period of the disease, (e) with the complications of said disease,
(f) with the medication, food, excretions, etc., and (g) with the
circumstances—antecedents and prognosticable consequents—
of the patient himself; so that the writing of a mathematical chart
is simple enough for anybody, but its reading is an art which
has to be learned: family and hospital assistants must learn it.
These charts cannot be dispensed with by those who want to
study, in computable figures and fractions, the movement of
temperature, not only in the course of diseases, but during the
period of incubation of infections and contagions, or in the low
and slow forms of chronic affections, or in old age ; nor can they
be neglected by the intelligent mother, who does not trust her
children to latinists and theologians, without herself controlling
the constitutional effects of growth, education, training, moral
pressure, etc., on her thermographic charts, of which these
savants ignore even the name. Lastly, these charts are the only
ones which realize the idea and the ideal of De Haen: De
supputando caloke corpokis humani (In Ratio medendi, T. II.,
296
MATHEMATIC COMPUTATIONS.
Skeleton Table
On which the uninitiated can write records of signs till the physician comet.
Age.
Days of Disease.
Time of Observation.
«• » ]
g Fever
8 Zero Health .. J-
P.
S Depression |
Daily average...
Daily difference.
Pulse
I.
M—<—E
Respiration.
II.
M—E
III.
H—'—E
iv.
M-^-E
V.
M—'—E
VI.
M—-—E
VII.
M—>—E
No.
Total up.
(_ Tot. down
Average of
temperat.
Average of
differences.
Average of
pulse.
Average of
breathing.
As clinical assistants become familiar with thermography the
table may be brought to its prejsent point of completeness:
This chart being tilled for a week-ra week of disease, Or sep¬
tenary, commencing at the first moment of illness, irrespective
of the astronomic day—every new septenary is recorded on
another chart, which will be numbered Septenary No. 2) and
every new septenary comes en sy>ite without repetition of the
headings, name, normes, etc. (These charts can be- had of
several dimensions.) Thus, the plan of these mathematic tables
embraces the temperature, central and local, the pulse anchthe
respiration, and the sum of all the daily figures in septenaries.
To these features may be added the sphygmographic, spyro-
graphic, or other positive traces demanded by- each case, and in
almost all the cases, the clinical chart of the concomitant symp¬
toms. (See Appendix XXII.)
Apart from the extreme simplicity of the writing and reading
of these mathematic tables, there is a novel feature (very old,
I mean) which recommends them to the earefuj practitioner,
to the scholar, and to all who look beyond the mere routine of
oiir^profession toward its philosophy. It ia the provision made
for the record of the critical days an4 prises.
fe¬
es
MATHEMATICAL RECORD CP USTIOtf, CIRCULATION, AND RESPIRATION,
TAKEN WITH THE PHYSIOLOGICAL THERMOMETER.
NO. OF INSTRUMENT, NAME,
AGE,
SEX,
MALADY,
No. OF SEPTENARY,
Date,
Day of sickness,
Barometry,
External thermometry,
Time of observation,
f Fever
| Norme, 98.6° F.=37° C.=0.
■{ Depression
| Daily average
Daily excursus
S|«
t-l-5 d
rSick point....
: -J Healthy point.
L Difference.
Normal pulse
Pulse, daily excursus
Norm, respiration
Respirat. daily excursus.
. sickly.
. sickly.
M E
M E
Maximum day...
Minimum day....
Difference
Sum of morning.
Sum of evening..
Sums of the week.
of fevers.
♦
of normes ...... .
of depressions.
of averages.
of excursus .
at sick point,
at healthy point,
of difference.
of sickly pulse...
of pulse excursus...
of Isickly respiration.
of reBp. excursus
!■»>■. i ,-r-s— —
CHAPTER IV.
DOCTRINE OF THE CRISES.
That is a small place offered to a very old, and once mucfi
revered host of ours, the Doctrine of the Crises / yet it is a
larger one than modern hospitality proffers to it. We will give,
besides a commanding position on the mathematical charts, a
few pages to the exposition of its almost divine pretensions. In
return for which liberality—show-word for usury—I expect we
may obtain, after a few years of diligent researches, the unveil¬
ing of strange coincidences, in the results once obtained by
medical theurgism, and those now arrived at by medical ther¬
mometry.
§ I.—Medical Theukgism.
When medicine was blended with theology, and therapeutics
with theurgy, God was one, matter two, their union three, the
universe twelve, its square root four, the perfect number,—
whose union with three forms seven, which is endowed with
particular virtues. Since Plato and Paul some of these figures
have been somewhat altered. But then and correspondingly,
Nature was medicative as well as creative. Diseases had, like
all things, their proper lives and periods mathematically pre
ordained, in virtue of numerical and biological laws; hence
their crises and critical days could be foreseen, and were
foretold (prognosis).
Hippocrates believed in both, but—as far as is known—wrote
on the subject only practically, not theoretically. Contrarily
Galen, who admitted the crises, but rejected the critical days,
wrote the theory of the latter, though under protest to the
gods, whom he was in the habit of using as small change.
After that period, the old dogma fared still worse, being
made subservient to the practices of necromancy, mysticism,
cos' HOSPITAL RECORDS.
299
amulet and saint-cure, etc. To make short a long story, nowa¬
days many physicians—possibly not always the highest—are
indifferent to the crises and sceptical as to the critical days;
which is quite natural, having no means of verification com¬
mensurate with the magnitude of the problem. But dereliction
is no reason; how many discoveries of Hippocrates—I call by
his name him and his times—have lately been retrouvees f
Laryngotomy, auscultation, urinoscopy, etc.; it is now time that
his dogma of the crises should too be finally tested by the stand¬
ard of modern analysis.
Like all discoveries, this was the product of the copulation of
several ideas : the Pythagorean computations, the data furnished
by the highest education of the medical senses, particularly of
the tactus eruditus (including the hand-thermometer), and the
generalization of the hospital records of a school which the
pretended father of medicine declares already very old in his
time. Indeed, in the temple, school, and hospital of Cos, at
least fifteen generations of Asclepiades had preceded him,
practised upon all sorts of diseases, temperaments, and nation¬
alities, and registered all their cases, likely above one million ;
materials fully equal in number and importance to those accu¬
mulated by our indefatigable thermometricians.
This was the treasure in which Hippocrates found the ele¬
ments of his doctrine; not only on crises, but on revulsion
and on sympathies, out of which, by the by, it took two gener¬
ations of powerful Darwins to hatch the doctrine of Natural
Selections.
We can form an idea of the clinical notes of the ancient
hospitals by those of Hippocrates. His style is his assuredly ;
since his apocrypha are recognized by the absence of this style;
but his form is so much like a cast, that the description of his
own cases seems prisoned in the routine frame of the Cos'
Hospital Record.
We cannot so well form an idea of their classification / but
they must have laid in some nosologic or other order, without
which it would have been impossible to search for and extract
the elements of comparison from such a dense mass of facts,
and to deduce from their ensemble generalities like the Gni-
dian Sentences, the Aphorisms of the Master, and even the
weaker precepts of Salerno.
Altogether the monuments demonstrate that, in private and
300
etippocratic doctrink.
in public practice, records were kept and made use of, not only
for the advantage of the patients, and for the advancement of
medical knowledge, but for the incubation of powerful gener¬
alizations and pathologic laws.
It is in these conditions—which it was important to establish
—that Hippocrates (and his school) asserted the dogma of the
influence of numbers on the crises and cure, and referred to it
as to a law, whose eventualities, happy or fatal, could be calcu¬
lated and predicted. He presented it as a law known before
him, and which he confidently used as his surest criterium.
That it was his criterium is proven by the eagerness with
which he seizes upon any opportunity of founding upon it his
diagnosis and prognosis, of testing by it his treatment, and of
introducing it in almost all his books as the fundamental prin¬
ciple of his teachings ; his synthetic doctrine.
In the history of medicine there is only one thing like it: it
is the industry with which Wunderlich (and his helpers of
every country—I name him as the embodiment of thermome¬
try)—has evolved pathological laws out of the innumerable
and intricate data furnished by the thermometer.
But what is more surprising in this similitude than the simil¬
itude itself, is the quasi-identity of their results. Wunderlich,
starting from mathematical computations repeated and veri¬
fied upon a magnitude only equalled, if at all, by the chief of
the Coan School, arrived at conclusions which find their ana¬
logues in those deduced from the Pythagorean theories of
numbers applied to the clinical treasures of antiquity. This
coincidence, foreseen by Traube, hinted at by Dr. Woodman,
will cause such surprise, and is so momentous for the progress
of our art, that I will try to give it all the prominence it de¬
serves, and avoiding where I can, to give the facts in my own
language, I will let both Hippocrates and Wunderlich echo
each other's doctrines and clinical experience, at two thousand
three hundred years' distance.
§ II.—Hippockatic Doctrine and Experience of the Crises
and Critical Days.
The living body is a circle without beginning or end; an
harmonious whole, whose parts are in mutual dependence,
whose acts in mutual solidarity.
THEORY OF THE CRISES.
301
This law presides to the phenomena of health, as well as to
tliose of elimination and reparation in disease.
This latter and double elaboration, fever,febris, ends by an
even resolution, or by a sort of revolution, /cpta?, at cer¬
tain days called for this reason critical, decretory, or j udieia-
tory.
He—who is desirous to predict with certainty the recovery
or death, and how many days a disease will continue, or in how
many it will cease—must understand the whole doctrine of the
signs and how to compare their relative importance. Since
the foregoing signs are true in Lybia, and in Delos, and in
Scythia, you do not require the name of any disease which has
not been particularized here ; for you may know by the same
signs all those which terminate within the periods laid down
above (Third Book of Prognosis).
And what are these periods f
The crisis is an effort of nature to produce a change (benefi¬
cial or not), and which heralds the-end of a disease.
The days are divided into critical, indicator, and intercalary,
and non-decretory.
The critical, decretory, or judiciary days are comprised be¬
tween the fourth and eightieth; namely, the fourth, the
seventh, the fourteenth, the twentieth, the twenty-seventh, the
thirty-fourth, the fortieth, the sixtieth, and the eightieth.
Between each of these periods of seven or twenty days the
crisis may take place, or sooner be indicated the next fourth day,
thus: the fourth; the eleventh, which is the fourth after the
seventh; the seventeenth, which is the fourth after the four¬
teenth, etc.; these are indicators^ in other words, give signs of
an approaching crisis.
The intercalary days, the third, the sixth, the ninth, the
sixteenth, etc., give issue to imperfect, or irregular, or fatal
crises.
The non-decretory days, the second, the eighth, the tenth, the
twelfth, the thirteenth, the fifteenth, etc., were not expected to
give issue to crises.
To ascertain these periods it is necessary to observe from
the first day, and to remark the changes of every fourth day ;
and thus may the probable termination be predicted (Progn^
Sect. 3).
Fevers come to a crisis on the same day, as to number, on
302
CRITICAL DAYS.
which men recover or die. For the mildest class of fevers, and
those originating with the most favorable symptoms, cease on the
fourth day or earlier; and the most malignant, and those setting
in with the most dangerous symptoms, prove fatal on th$ fourth
day or earlier. Those who labor under the tetanus die. in four
days; if they survive this period they recover. Thus end the
first class of fever.
(If in a continued fever the patient suffers most on the
fourth and fifth days, and the crisis does not take place on
the seventh, the case is usually fatal. Other ardent fevers
(without remissions) terminate the seventh or fourteenth day).
The second class of fevers is protracted to the seventh day,
the third to the fourteenth, the fifth to the seventeenth, the
sixth to the twentieth. Thus these periods, from the most
acute disease, ascend by four up to twenty. But none of these
can be calculated by whole days, for neither the years nor the
months can be numbered by whole days.
After this in the same manner, in diseases in the same char¬
acter. and according to the same progression, the first period
is of thirty-four days, the second of forty, the third of sixty.
In the commencement of these periods it is very difficult to
determine those which will come to a crisis after a long inter¬
val ; for these beginnings are very similar, but one should-pay
attention from • the first day, and observe further at the first
additional tetrad or quaternary, and then one cannot miss see¬
ing how the disease will terminate.
Those which will come to a crisis in the shortest space of
time are the easiest to be judged of, for the difference of them
is greatest from the commencement.
In the same manner are the crises of puerperal diseases to
be ascertained, by calculating from the labor.
In the commencement of these diseases it is difficult to as¬
certain a, priori in what space of time they will come to a cri¬
sis, for they commence very much in the same manner. But
it is necessary to observe carefully from the first day, and to
remark the changes every'fourth day ; and thus may the prob¬
able termination be ascertained.
The course of the quartans observes the same order.
The tertian fever terminates generally in seven periods.
Acute diseases generally come to a crisis in fourteen days.
It is. easier to foreknow the crises of diseases which are to
..
■
■
■
302
CKITICAL DAYS.
which men recover or die. For the mildest class of fevers, and
those originating with the most favorable symptoms, cease on the
fourth day or earlier; and the most malignant, and those setting
in with the most dangerous symptoms, prove fatal on the fourth
day or earlier. Those who labor under the tetanus die in four
days ; if they survive this period they recover. Thus end the
first class of fever.
(If in a continued fever the patient suffers most on the
fourth and. fifth days, and the crisis does not take place on
the seventh, the case is usually fatal. Other ardent fevers
(without remissions) terminate the seventh or fourteenth day).
The second class of fevers is protracted to the seventh day,
the third to the fourteenth, the fifth to the seventeenth, the
sixth to the twentieth. Thus these periods, from the most
acute disease, ascend by four up to twenty. But none of these
can be calculated by whole days, for neither the years nor the
months can be numbered by whole days.
After this in the same manner, in diseases in the same char¬
acter. and according to the same progression, the first period
is of thirty-four days, the second of forty, the third of sixty.
In the commencement of these periods it is very difficult to
determine those which will come to a crisis after a long inter¬
val ; for these beginnings are very similar, but one should pay
attention from the, first day, and observe further at the first
additional tetrad or quaternary, and then one cannot miss see¬
ing how the disease will terminate.
Those which will come to a crisis in the shortest space of
time are the easiest to be judged of, for the difference of them
is greatest from the commencement.
In the same manner are the crises of puerperal diseases to
be ascertained, by calculating from the labor.
In the commencement of 't^ese diseases it is difficult to as¬
certain d priori in what space^of tijne .they will come to a cri¬
sis, for they commence very much in the same manner. But
it is necessary to observe carefully from the first day, and to
remark the changes every fourth day ; and thus may the prob¬
able termination be ascertained.
The course of the quartans observes the same order.
The tertian fever terminates generally in seven periods.
Acute diseases generally come to a crisis in fourteen days.
It is easier to foreknow the crises of diseases which are to
APPLICATION OF THIS DOCTRINE.
303
terminate in a short time, because, from the beginning, they
differ very much.
The prognosis of diseases that are verging to a crisis is to
be deduced from their duration and the manner of their acces¬
sions.
When fever ceases without evident signs of the disease being
resolved, and on days which are not critical, you may expect a
relapse.
Those in whom the pain in the head commences on the first
day, suffer greatly on the fourth and fifth, and die on the
seventh.
For the most part, however, the pain commences on the third
day, is much distressing on the fifth, and death occurs on the
ninth or eleventh day; but if the pain begins on the fifth
day, and " the other symptoms come in correspondent order,"
the disease will terminate the fourteenth day.
Young persons die of this disease (acute meningitis and
otitis) on the seventh day, or rather earlier.
Relapses in diseases are most fatal to very young persons.
These rules hold good both in men, women, and children,
and apply particularly to fevers of a tertian and continuous
type ; by these you may predict death or recovery.
If the Father of Medicine needed any sponsors, hundreds
could be found among the highest authorities of recent times,
but two will suffice. Sydenham says : " However true it may
be that intermittent fevers may last six months, particularly
under bad management, if you calculate rightly you will find
that fourteen days of twenty-four hours each mate 336 hours;
whilst, by allowing five hours and a half for each paroxysm of
a quartan, you find in one full attack fourteen days or 336
hours." And Andral observes that " of ninety-three cases of
pneumonia, twenty-three died on theseventh day, thirteen on
the eleventh, eleven on the fourteenth, and nine on the
twentieth. The recoveries on the critical days averaged four¬
teen, and in non-critical days hardly exceeded three."
304
wunderlich's doctrine.
§ III.—Wunderlich's Doctrine and Experience of Crises
and Critical Days.
The healthy temperature of the human body, disregarding
diurnal oscillations and the slight variations caused by circum¬
stances or moral impressions, is 98.6°F. = 37° C. (=0 on the
physiological thermometer).
All temperatures which decidedly exceed or fall short of
that norme are unhealthy, and signs of a diseased condition.
The typical course of temperature in many forms of disease
is an undeniable fact, upon which is founded the idea that
there are such things as normal diseases.
Certain diseases in their progress obey certain laws, or rules,
which can be determined by thermometric measurement of the
course of their temperature: these are the laws of pathological
thermometry.
When thermometry thus discovers a new law of disease it
reveals a new world in the domain of natural laws.
Disease has its laws, but we cannot yet codify them.
A knowledge of the course of temperature is indispensable
to learn the laws presiding over the evolution of certain dis¬
eases, and the deviation front these laws; to discover the ten¬
dencies to relapse or better, to regulate the therapeutic, to
ascertain the convalescence, or to reveal complications, the
imminence of peril, the impossibility of the continuance of
life, the proof of the reality of death.
And what are these laws ? -»■
Temperature is the regulator of life.
Thermometry is the art of measuring the deperdition of
life.
In physiological temperature the heat is generated and given
off in such proportions as to keep the body at zero-health.
In pathological temperatures the equilibrium-health is broken
by over or under-production or emission of heat, in a propor¬
tion written up or down the norme on the physiological ther¬
mometer.
JSTot only must we know the laws derived from this principle
of unity of life ; but in our application of these laws to special
cases errors are unavoidable when the initial period has not}
keen uiukir observatiou^wa&atiil more easily when no
THE BEIGN OF LAW IN DISEASE.
tion as to the commencement of the attack can be obtained;
and we are thus left in ignorance as to the time the disease has
already lasted. Thus all our computations become uncertain.
And more, before drawing conclusions from a single thermo-
metric reading we must see the other symptoms, and consider
if they agree or contrast with the temperature.
Under the name of EjpKemera are included fevers which last
only a few days; the length of the fever does not affeet its height
nor its issue. Diseases which begin with a strong pyrogenic
stage have a short paroxysm, with a sharp elevation of temper¬
ature and a continuous course, ending in less than a week in
defervescence or death.
Children exhibit more sudden and extensive changes of tem¬
perature than adults—more sudden plunges and earlier eleva¬
tions. A temperature of 38° C. may not be a sure sign of
disease, but invites renewed applications of the thermome¬
ter.
In childbed a temperature of 38° C. is suspicious ; the later
the fever the stronger its course, sometimes reaching 42° C. and
lasting to the fourth day
In traumatic fever the defervescence is expected the third
day. The duration of pysemic fever is a week, unless protracted
by series of zigzag deviations.
The reign of law in diseases is manifested in typhoid fever,
'even through its irregularities.
The fevers may be divided into more or less clearly defined
periods or stages: the pyrogenetic, the acme or fastigium, the
decrement, proceeding or not by a perturbatio critica (lysis or
catalysis) the defervescence and convalescence;, or, on the con¬
trary, the pro-agonic period-
It is noteworthy that in the majority of cases which run a
regular course, the duration of the separate periods corre¬
sponds in time with the division into weeks and half weeks.
The alterations in the course, and the transitions from one stage
to another, occur at the beginning or end of a week, or in the
very middle. This type is most decidedly shown in the brief
and mild forms, and in the third and fourth weeks of the more
severe ones.
Periods in typhoid fever: the initial stage, four days, de¬
scribing zigzags, composed of diurnal elevations of 1°—1.5°
C and nightly falls almost to normal, and reaching 40° 0. the
20
306
MEDICAL SEPTENAKIES.
fourth day. This course is almost pathognomonic of the ty¬
phoid fever.
In the second half of the first week the morning tempera-
tare is lower by .5°^1.50 C. at the same time that the maximum
is reached, 40.8° C.
The end of the first half of the fastigium most commonly
falls on the seventh or eighth day.
The first half of the second week agrees in the main with
the preceding period, but is marked, in cases whose course
runs favorably, by less severe exacerbations. In very many
severe cases there occurs, at tolerably well fixed days of the
disease, either a transitory moderation, or a particular eleva¬
tion of temperature. All irregularities in the second week are
suspicious.
The remission seems j prefer the last day of the week or
the middle of a week; the elevations come immediately before
those days, or at the beginning of a fresh week.
The rise of temperature towards the end of the fastigium
(seventh to fourteenth day) generally betokens complications.
We often observe a striking rise of temperature about the
twenty-fifth day.
The beginning of decided improvement in cases of moderate
severity is expected in the middle of the third week.
The regular course of typhoid fever is about twenty-one
days; each relapse indicates fresh exudations and infiltrations
of the intestinal glands; each better, elimination and repara¬
tion. This typical course of three weeks is not so well ex¬
hibited 011 the first attack as on the following ones. It is note¬
worthy that, in the majority of cases of typhoid fever which
run a regular course, the duration of the separate periods cor¬
responds in time with the division in weeks and half weeks.
Periods in typhus:—In moderate cases the temperature has
reached its summit the fourth day, and about the sixth day is
the turning-point, announced by a trifling decrease of tempera¬
ture, followed by a greater remission the seventh.
Truly there is another rise about the eleventh, but it does not
reach the previous maximum.,-and lasts only one to three days,
after which the twelfth is marked by a preparatory remission.
A third, but generally favorable rise, like a perturbatio critica,
occurs, terminating in final defervescence. These simple .cases
terminate in two weeks.
TRADITION OF LAW IN DISEASE.
307
In severe or neglected cases the continuous ascent and ex¬
acerbation continue through the first week at 40.2°—41.6° C., or
more. The remission of the seventh day is absent, and the
high fever persists through the whole of the second week. The
remission of the twelfth day is wanting or postponed to the
beginning of the third week, etc.
But this comparison must be cut short, to limit it to its strict
bearings on thermometry, whereas it interests all the important
points of physic which cannot be introduced here. However, I
have transcribed just enough of it to show that we are con¬
fronted with the double-headed fact that:
On the one hand, the first records of our art founded on the
theogony and geogony of numbers applied to a persevering
observation of the signs of health and disease; and on the
other hand, the latest records taken and arranged by our most
accurate men, with instruments whose precision is unimpeach¬
able, of physiological and pathological temperature, and of
other vital signs as well, have both developed the identical
conclusion that: The most important diseases (if not all) run a
definite course, in distinct periods, and in so many dats,
whose virtue resides in their numeral order, reckoning
from the first of the disease.—So said Wunderlich after
Hippocrates.
I do not mean to say that none was heard on this subject
between them. Previously to Wunderlich, Aymen (Disserta¬
tion sicr les climats et les crises, Dijon, 1751) admitted that
" the crises take place in the same manner, at the same days,
as in the time of Hippocrates." Landre Beauvais said (in his
Semeiotique, 1830), " The morbid phenomena may vary; but
as for the crises, during a practice of more than twenty years,
I have constantly observed their apparition at the very time
announced by Hippocrates." Traube transplanted the doc¬
trine from Paris to Berlin in 1840.
That doctrine of the crises was for the ancients a dogma; in
the dark ages it was a symbol; for us it must become a lawy
instead of remaining the ignis fatuus which lights our faces
with its sardonic glare.
9
CHAPTER V.
MATHEMATICS OP DISEASE.
"Ma-nt learns, but forgets too. This doctrine of the numbers,
which appears to us an isolated monument whose key is lost,
was one of the links of a cyclopedic chain of evidences on
which rested the purest knowledge of antiquity. In that doc¬
trine, of which the theory of the crisis appears in the dis¬
tance like an Hippocratic segmentation—though Hippocrates
acknowledges its antiquity—the power of numbers binds and
pervades the whole. Ideals result from the conjunction of
numbers (in our to-day's parlance " from certain combination
of ideas ") into life-forms, or realities, which in their turn dis¬
integrate (we say by oxidation), they said by th,e. destructive
power of new mathematical combinations.
About this discrepancy of words, and in view of others on
our whole subject, it is good to remark that in judging o£ past
doctrines we must not let ourselves be deceived by the forms
of language of the ancients, nor by that of the Renaissance, nor
even by our own: a deception which caused the burial, as rub¬
bish, of some of the pearls of the* sixteenth and
seventeenth centuries.
In Greece, whose doctrines we have now in, viewv everything
in nature was animated—a brook, a, temple, a. well, a national¬
ity, an art, a discovery, etc. By the same operation of the
polytheistic turn of mind, numbers -were deified, particularly
after the mathematical, masteries ©£ the 6chool& of Ccxrinfche,
Syracuse, Bergam, Alexandria. But ia plain thinking, de¬
nuded from the amiable theolai;ry o£ old times, we read,
through the doctrine of the ruling power of numbers, that of
the harmonies of the world—the visible face of leuw i/ti tULturc
—what can be seen of God.
From the bulk and course of the celestial bodies to the
movement*? of the rotatory^ infusoria and filiform^, bacteria;
mathematical relations of the functions. 309
from the normal frigeration of a planet to the norme and, ano¬
malies of our own combustion, the Whole obey the law of
harmony of numbers. Democritus knew the music of the
spheres; Laplace, the mathematics of the heavens; Lavoisier,
Priestley, Berzelius, the creative power of numbers in chemis¬
try : we calculate, and to a certain extent regulate, the biologic
properties of human color. Our language may differ from the
Greek, but for us as for Hippocrates, Pythagoras, Herophyles,
and Erasistrates, a disease is a disorder of the mathematics of
life, mostly by abnormal oxidation of its atomic constituents.
Those who have followed the development by moderniza¬
tion of the Hippocratic idea, will be prepared to rise from the
comprehension of the laws of the body's ustion to that of the
more general law of Calor in Nature; and reciprocally, to
descend from the ideal of Eternal Ustion, genitor of life and
death, to the mathematics of our own temperature in health
and disease—physics and physic reverberating their light at
each other.
§ I.—Mathematical Relations of the Functions Alterable
by Disease.
By the progress of positivism and the force of its method, the
other disorders of the mathematics of life—other than hyper-
pyrexy and aprexy—come one after another to be gauged by
the same mathematism; the sphygmograph and other inscrib¬
ing instruments, and chemical, microscopic, and spectral analy¬
sis bring around the figures of thermography their concordant
figures, by which is completed the halo of positive observation.
One must have noticed that the observations of temperature
have been carried with such enthusiasm, that they have left in
their progress—distanced behind—the other modes of observa¬
tion (except possibly microscopy); and have thus compara¬
tively and temporarily lowered the standard value of the other
signs and symptoms of disease.
This exclusivism was quite natural during the crusade for
the propagation of thermometry, which like all new religions
was not preached by half. But now that its success is assured,
it is wise to see to its legitimate spread, and to define the place
it must occupy, not instead of, but among the other means of
310 relations of central to surface temperatures.
diagnosis. Assuming its normal position, thermometry will
gain in associated strength what it may have to lose in solitary
grandeur.
Having only a small space, and wishing to speak with au¬
thority, I will borrow the words of the most concise of medical
writers, to convey, with due force, these views on the subject
of correlation of all the symptoms" It is a bad symptom
when the head, hands, and feet are cold, when the belly and
sides are hot. But it is a very good symptom when the whole
body is equally hot." This aphorism ranks Hippocrates among
the tliermometricians; but far from being an ^exclusive one,
he instantly adds: "He who is desirous of being able to pre¬
dict with certainty the recovery or death of tl^e sick, and how
many days a disease will continue, or in how many it will
cease, must understand the whole doctrine of the signs, so. as
to be able to judge of all the symptoms, and to compare their
relative importance according to the rules. . . (Prognostics,
p. 3). So we were forewarned against this natural tendency
to exclusivism, of which Bordeu furnished an example which
can well serve as a lesson. After writing his four volumes on
the Pulse, he would go through the Charity Hospital without
looking at his patients, only feeling their pulse and prescrib¬
ing : astonishing the crowd of students by tlbe acufceness of his
diagnosis. Malicious, chronicles do not say that he likewise
refused to look at his quasi-royal patient, the Duchess de
Pompadour; but grave history attests that his successors in
the celebrated clinic, Laennec and Andr&J, founded their famed
diagnosis upon the even exercise of all tlieir exalted medical
senses.
After all, the practical point of this is contained in these
few words of Hippocrates: We must understand the whole
doctrine of the signs. The doctrine may be improved; the
number of the signs may be increased, it must not be dimin¬
ished, under the penalty which overtook our predecessors for
their neglect of Ilippocratic urinoscopy, etc. The signs fur¬
nished by thermometry are indubitably invaluable; but they
cannot take the place of all the others, no more than any of the
others can take theirs. Therefore let us not only study all the
signs of disease, but constantly keep their relations in sight.
A.—Illations of Central to Surface Temperatures, etc.
—The alterations., (by disease) of the mathematical relation#
relations of TEMPERATURE TO PULSE, ETC. 311
©f functions are nowhere more marked than between the cen¬
tral and the peripheric temperatures, and between symmetrical
parts revealing an asymmetric ustion. I have just of the latter
a case in point:—Right ankle, tan-copper colored by syphilis,
T. 34° C.; left ankle indemn 29° 0., as per surface thermometer;
subsequent observations differed in figures owing to our au¬
tumnal variations, but remained in the same relation to each
other, till treatment (which would be here out of place) restored
the equilibrium. Be it noted, also, that all the while the
patient complained of the coldness of the all right limb, whose
ankle radiated more heat than his calorigenic function <jould
supply. (For the generalities of this almost new branch of the
subject, see Part I., Ch. IX.)
B.—Relations of the Temperature to the Pulse and
Breathing.—Theoretically, when one of the three vital functions
is disordered, the others follow suite. Practically we can hardly
say that such is the rule, since there are so many exceptions which
become rules in their place. (See Appendices VI. and YII.)
Having seen that an elevation of temperature in a part may be
communicated to fcbe all body, or leave it at its nonne, or cause
it to fall below, we are quite prepared to see an abnormal tem¬
perature either cause, or not, an abnormal circulation or res¬
piration—neutral, concurrent to, or antithetic to its own course.
These remarks obtain in health, and more yet in diseases,
where the three functions may be related, but not always
subordinated; and where their relations and reactions change,
according to the sort of disease, to its actual period; to its past
and expected duration, etc. . -
(a) At birth the regularity of the fcetal pulse-, yielding to the
influence of new stimuli, is greatly accelerated the while tem¬
perature undergoes frigeration, and when a few days later
the temperature rises, the pulse becomes slower. Then disease
is mostly expressed by accelerations of the breathing which
have no necessary concordance with the two other vital func¬
tions. (See Appendix VI., tables a, b, c, d, e.)
(3) In'adolescents, particularly scholars, a break of the equili¬
brium of the three functions by increased frequency of the
pulse warns of the dangers of too rapid a growth, or of bad
habits; and an elevation of temperature of .5 in the morning,
1-2 in the evening, points towards meningitis or phthisis.
'(e) In healthy adults, the three functions are quite harmonious,
312
SAME RELATIONS AT DIFFERENT AGES.
though there are exceptions :—a pulse at SO, 40 (25 have been
counted) with respiration and ustion normal; those and others
are idiosyncrasies precious to base a diagnosis. In old age the
pulse takes the precedence on the two other functions, either
by the quickness or hardness of its strokes.
(d) The mathematics of these relations in the aged is in¬
finitely precious, since it permits to foresee dangers ahead. I
have just seen a client (set. 60, not actually sick) whose normes
are T. .2, P. 64; and finding T. I, P. 75, I admonished him
from some perturbation, and he acknowledged having had some
business excitement a few hours before. Just as the concord¬
ance of the three functions is a guaranty of health, so the dis¬
ruption of their -equilibrium gives a warning of danger. In
the present case—be it noted by the by—the very relations of
the senile normes T. .2 to P. 64 indicate a condition which
cannot stand much pressure.
(e) During disease the restoration of the concordance of the
three functions affords more security than the .absolute return
to its norme of only one of them. Moreover, the very mode of
the anomaly of their relations is often sufficient to form the
diagnosis of a disease otherwise obscure. Thus the concord¬
ance of the exaggeration of the three functions is almost
pathognomonic of pneumonia; a moderation of the ustion with
rapid pulse and respiration warns of bronchitis; a low and
rising temperature with active pulse and breathing signalize
the first four days of typhoid fever, whilst later the tempera¬
ture is high and the pulse comparatively slow. But let an
hemorrhage supervene, you are instantly apprised of it by the
chief actors' changing role, the temperature becoming low, and
the pulse quickening in proportion to the tyanchement of
blood, etc. A clinical lecture on peritonitis, recently delivered
at the Bellevue Hospital of this city, by Prof. Loomis, of the
New York University Medical College, illustrates the low con-
edition of the temperature as compared to the pulse and respi¬
ration in affections of the serous membranes. Here, the tem¬
perature speaks by its silence, and the contrast of the two other
vital signs points to the often obscure diagnosis (see Biblio¬
graphy).
(f ) If it was possible to generalize the varied relations of these
three functions in disease we would say: During the efferves¬
cence the elevation of the temperature is synchronic with the
RELATIONS OF TEMPEBATUBE TO UBINE, ETC. 313
increased frequency of the pulse ; the fastigium is marked by
the (relatively) greatest concordance of the three functions; the
perturbatio critica, pseudo-crisis and pseudo-defervescence are
the periods of the greatest discrepancies ; the defervescence is
marked' by rapidity of the pulse next to sub-febrile temper¬
atures; and convalescence by an almost feverish ustion, the
pulse becoming slower and stronger, the breathing deeper and
less frequent.
Contrarily, in the issues towards dissolution, the great func¬
tions—which, from this point of view, may be called co-ordi¬
nate—become dissociated. Pulse uncountably rapid, or slow¬
ing with ominous stops, in contrast with temperature growing
from sub-febrile to algide, if the disease has lasted ; if not, ris¬
ing as from a pyre to consume all the reserve caloric in the last
moments, and with breathing generally hurried till the final
gapes, which are few and wide apart.
The mathematics of these dissociations of the co-ordinate
functions constitute, after all, the sorcery of prognosis, which
must guide Us, not only in disease, but in the critical passages of
existence, in infancy and adolescence, during the crises of
puberty, of tit© extra-labors necessary to conquer a social rank,
of new m&rried life; indeed, whenever a doubt hangs over the
sanitary influence of our doings.
C.—Relations of the Temperature to the Urines, and
their Constituents.—From the time the ancients conceived a
priori, and admitted in principle the depuration of the blood
by the excretory apparels, they became fascinated by urino-
scopy, attached a great importance to the signs furnished by
urine, and connected its successive characters with the periods
of maladies. Considering that they had not our chemical re-
actives, microscopes, etc., one is astonished at the happiness of
some of their hypotheses, particularly in regard to the urines
critiques (those which almost invariably characterize the passage
from the fastigium to the defervescence). We do not, of course,
see so much as they did in urine; but we try to see correctly.
The special diseases represented by the excess or the priva¬
tion of certain elements of the urine, those caused by the re¬
tention of urea (uremia) and by the loss of albumen (alburn^
nuria), will find their place later. Here we will only notice the
relations of urine and its components to febrile temperatures
which have been recently studied (see Bibliography).
314 RELATIONS OF TEMPERATURE TO UREA, ETO.
{a) It was found that in the jperiod of effervescence, to the in¬
crease of heat corresponds a diminution of the urine in pneu-
Fig. 82.
RELATIONS OF TEMPERATURE TO UREA, CHLORURES, ETO. (from BEAU).
monia and rheumatism, not in typhoid fever. Generally the
reaction is acid, the coloration deepened by the presence of
destroyed red globules of the blood; the sediments abundant
by excess of uric acid, paucity of water, constant augment of
RELATIONS OF TEMPERATURE TO BODY-WEIGHT. 315
organic and extractive matters! all causes of increased density.
At the same time the albumen may be slight, frequent and
favorable ; but the urea, often excessive, always variable, some¬
times absent, has no parallelism with the temperature, of which
it is no test. Surer tests of pyrexia would be the augment of
the extractive matters, and the almost disappearance of chlor-
nre of sodium from the urine.
(b) In the period of defervescence, with the decrease of the
temperature increased quantity of urine, lighter density, paler
coloration, less or no sediment. Keaction often alkaline, con¬
stant diminution of organic matters, ordinary diminution of
urea, considerable diminution of extractive matter. Consider¬
able augment of inorganic matter, and particularly of chlorure
of sodium. The urine of the convalescent offers the same
characteristics, only more marked.
These relations of urine and its constituents to temperature
can be comprehended only when thermographically written in
figures or in curves. The schema of the relations of tempera¬
ture, chlorures, urea, and quantity of urine in erysipelas, is
almost typical of the mathematical relations which can be
traced in any inflammation of short duration.
Similar observations, bearing on the relations of febrile tem¬
perature, pulse, and respiration with the sweating, saliva, and
sebaceous secretions, have not come to me ; though we are ad¬
vertised by our senses that almost every disease, and likely
every period in a disease, leaves its specific imprint, trace,
color, odor, or effluvia, perceptible by our medical senses and
comparable to and confirmatory of their thermography.
D.—Relations of Temperature and Body-weight.—From
the beginning of medical thermometry, the fluctuations of the
body-weight have been considered as corollary, and shown to
be valuable as a commentary to the fluctuations of tempera¬
ture. Yet, from the weighing-chair of Sanctorius, or from our
weighing-beds, few observations have been made available.
Let us except those of L. Thaon, On the Weight in Diseases of
Children (in Archives de Physiologie, 1872, p. 674), from
which we condense the following propositions: As ustion in¬
creases, the waste by combustion is represented by a loss of
body-weight in the proportion of, say, grains of ashes for pounds
of burned fuel, grains of urea for pounds of oxidized human-
tissue.
316 PROPORTIONS OP BODT-WEIGHT TO TEMPERATURE
But when the combustion of tissues has been brought to its
ultimate point of endurance, the balance is reversed, and the
effect of further emaciation is to reduce the temperature, even
-as low as 34° 0.; that is the period of consumption.
Fig. €3.
PROPORTIONS OF BODY-WEIGHT TO TEMPERATURE.
Whence theoretically, and generally in fact, fever, ferveo, is
marked by a deperdition of weight commensurate to the de¬
gree of the ustion. But practically it is sometimes otherwise,
these discrepancies giving as precious indications as the broad
rule. Let us read both.
The broad rule is: (a) Infevers the body-weight decreases in
the same ratio as the temperature increases.
The special rales are: (3) In typhoid fever the body-weight
increases during the prodromic ascension of temperature ; an
relations of the 8amis to body-gbowth. 31f
increase which represents the retained urine, feces, and sweaty
and the great quantity of liquids absorbed daring this char¬
acteristically thirsty period.
(c) The body-weight rapidly decreases from, the fourth to the
■fifth day, though urine remains scanty, and perspiration is null,
or limited to a spot, or at best to a region, because thirst is
gone, appetite has not yet come, and diarrhoea has begun its.
draining course..
(d) During an ordinary fastigium {pdriode d'dtat) th&
weight remains stationary i during a protracted one it grad¬
ually subsides after* the first septenary. In the first case, the
evenness of weight is maintained by the tendency of nature to
equipoise its resources and expenditures; in the second^ the loss
of substance is due to the irretrievable deficiency of nutrition,
which calls for autophagism.
{e) In the defervescence of typhoid fever, when the temperav
ture has come down, and the patient begins to eat, the body-
weight continues yet to fall. This fall indicates a continuation
of the loss of substance, measurable from the kidneys, latent
from the lungs, skin, and other emunctories, and permits to
computate the necessary elements of repair.
(/') Even in convalescence the weight is yet slow to come up
when fever-heat is down. But as soon as the patient can re¬
main in the standing and walking postures, his weight increases
abruptly, and then steadily, unless imprudent feeding, or a
relapse,, retards its tendency towards the previous healthy
standard.
icj) In pneumonia the body-weight falls during the all period
of ustion- (effervesceuce<and fastigium); avd more in the defer¬
vescence, owin^ to the abundant flux of urine which heralds
this period.
(h) In variola, the oedema* coincides with an increase of
weight, which subsides when the pustules are drying up, and
when diarrhoea sets in.
(i) In the exanthernatous fevers of children, like scarlqtinay
a latent anasarca or intestinal dropsy is rendered evident by
the increased weight of the patient.
E,—Parallelism of Temperature, Body-weight and Body-
height in Children.—Since Spallanzani, this has been studied
and tabulated again by Lorain and Quinquand. This parallel¬
ism. contains informations. o£ Inestimable value for rearing
318
FAIRY COURSE OF FUNCTIONS IN YOUTH.
children. The concordance of these signs gives security; their
discordance affords opportune warnings somewhat in this wise:
(a) In children with a normal temperature the body-weight and
the body-height grow abreast, (b) though during the spring the
height grows more, and in autumn the weight; (c) the parallel¬
ism reappearing in the meanwhile, unless deviated by some
perturbation always written on the temperature. These event¬
ful perturbations are indicated on the thermometer (d) either
by a depression (sooner in the evening) which prepares for a
stop of growth at first, of bulk too, if protracted, (e) or by
pyrexia, in which the bulk will melt like tallow in the fire;
( f) at the same time that the height has to be watched, since it
may attain enormous proportions, or shrink under deviations,
the while temperature increases, with more rapid pulse and
respiration.
To see these curves, or the figures which they represent, is like
following with our mind the fairy preservation of children
through the perils of the growth-period.
Such charts of the simultaneous or contrasting development
of the organs and functions in childhood, as I have seen at Dr.
Lorain's, are almost unique j whereas each family ought to have
them spread in the inner chamber: Homeric descriptions of
the fights of mothers against the child-ravishing demon, Hyper¬
pyrexia. (Between the writing and the correction of this, the
good and great professor of the History of Medicine died ; leav¬
ing his worthy wife to alone continue the drawing of the charts
of the physiological development of their beloved children.)
I wish I could say more on the relations of thermometry to
sphygmometry, spyrometry, etc., and thereby show more of
the concordance and discordance of the functions in disease;
but that more can be obtained only by substituting the unity of
means of observation to verbatim reports or olla podrida ther¬
mographies.
However, with the imperfect means at our disposal, we were
enabled to make sure that diseases "haue thetr irrtathjeyrtaijtcs '
and now, by improving our instruments and methods of obser¬
vation, we must soon be able to prove that therapeutics too
has its mathematics. This truth, lurking in the medical mind
since the beginning of our art, has fostered the origins of
therino-therapeutics.
CHAPTEK VI.
THERMO-THERAPEUTICS,
Ce ne sont jpas les remedes qui nous ont manqui, ce sont lea
moyens mathematiques d'en doser le besoin et Vaction.
Unfortunately, thermo-therapy partook in all times of the
fate of clinical thermometry: the want of instruments of preci¬
sion to measure both, ruined both. Without means of dosing it,
it fell in the hands of sharpers, then into oblivion ; and 110 sooner
resorted to again by the force of its virtue, it was blessed again
in the name of Diana, or of Notre Dame de Paray le Monial,
and sold for a panacea, in France, or in Indiana, Missouri, etc.
But let it be known that the physiological virtues of water, etc.,
reside in properties measurable by chemical or thermic analysis,
and our thermo-pharmacopceia will have nothing to envy in that
of the ancients, and will surpass it in point of precision.
Therino-pathology demands thermo-therapy, which finds its
means of action in thermo-pharmacopceia. Those are the three
terms included under the head of this chapter, Thermo-thera-
peutics.
I.—Thermo-Pathology.
The oldest distinction of diseases in pyretic and apyretic is
also the newest, and, though imperfectly elaborated, suits us
here.
{a) Hyperpyrexia is not only a very dangerous element in
disease: it is the danger itself. It consumes, therefore can last
only as long as combustible material remains ; that is a question
of mathematics. Also the substance of the muscles, myosine,
is altered at 42—43, and coagulates at 44.45° C. (Liebermeister,
Vallin). The blood coagulates at 43 (Veikart); its albumen
THERMO-PATBOLOGY.
too, and its red corpuscles, in a state of decomposition^ are re
presented in the urine by their hsematine.
Though true, this proposition is subject to exceptions, result¬
ing from vital resistances to the laws of organic chemistry—re¬
sistances which differ greatly in individuals* This power of
living chemistry is well illustrated by the peasant girls who
remained ten minutes in an oven heated to 14Q° C.=316° F.
(Dnhamel and Dutillet); by a woman, called the Salamander,
who could keep her body above and across a fire during the
time necessary to cook in front a roast of veal or mutton, and
who seemed to enjoy it; etc., etc.
At 5° 0. above their norme animals do not recover (Magen-
die, CI. Bernard, Obernier) ; man helped by man's skill does.
But here, more than anywhere else, the danger of the degree is
aggravated by that of the duration. So men may recover from
a short exposure to 44.45° C. (Carrie), and not often from a
protracted one to 41.5° C. (Wunderlich).
(ib) Apyrexy is not only a dangerous symptom in a number
of diseases, often it is the disease itself. It initiates grave
fevers; great and rapid falls are warnings of imminent death ;
death irt&y come from algidity alone ; though generally man
can stand more degrees below than above, it depends a good
deal on the rapidity of the operation, which is unfavorable, and
<of its shortness which diminishes the peril.
(a) Next in order comes the danger of extreme differences
between the central and the peripheric temperature, which
calls for, and finds ready the varied resources of thermo-ther-
apy. But more delicate to manage and modify by treatment
are (d) the excessive diurnal or tidal hearts, (e) the high and
low distances from the norme at which the diurnal movement
or stand-still takes place, (J) the advance or retard of the ex¬
acerbations or of the remissions, and the comparative and
changeable length of both.
(g\ Then according to the period of the pyrogenesis the
same degree, -or the same series of degrees, will require differ¬
ent, even opposite treatments;
th eemo-th era py.
321
§ II.—Thermo-Therapy and its Pharmacopeia.
The mind may sometimes indulge in classifications which
the logic of language cannot sustain. I find it to be the case
with thermo-therapy and thermo-pharmacopeia, which it would
cost a deal of repetitions to treat separately, then together.
The anomalies of body-temperature just synthetized have to be
met with their antidotes ; in broad terms, hyperpyrexy to be
encountered by coolings, and apyrexy by warmings. And going
deeper in the principles, we would say that the medication
must be antidotal, not only of the ruling anomaly of ustion, but
of its most intimate cause, which is either'?'^ distribution,
waste, or non-production of color.
Happily our means of action on disordered temperatures are
not all as recent as the study of temperature itself. When a
new light dawns upon an old art—as the light of thermometry
on therapeutics—a surprise is felt at finding that the ancients
acted precisely as if the}' knew what we are proud of having
discovered. This concurrence is due to the solidarity and so¬
lidity of traditional and recent observations; be they made
from the standpoint of the circulation or of the ustion, they
concur to the same end—the restoration of the functional
normes. Therefore—and so much the better for it—most of
the means of antipyretic medication have been tested by ages
of empirical success, under the name of antiphlogistics, for in¬
stance, before they could be demonstrated apyretic by the
mathematical method. Let us survey them first.
21
CHAPTER VII.
APYRETIC MEDICATION.
The elevation of temperature being the synthetic character
of fevers, the direct object of an antipyretic treatment is to
oppose this rise. So when we witness hyperpyretic tempera¬
tures the first idea—which takes possession of our mind like a
duty—is to put it down. The second is to inquire how; a
query which brings in its train a higher one: what is the source
of the hyperpyrexia? . . . For if it originates in an over-pro¬
duction of heat, we must employ the means which can dimin¬
ish or suspend the supply; if in excessive oxidations, those
which retard the metamorphosis of tissues ; if in retention of
calories, the means of opening to them the ways of radiation
and of various secretions; if in an ill-distribution of heat
between the centre and the periphery, the means of restoring
the equilibrium. And though the same thermic exaggerations
have to be met by very different means, according to the cir¬
cumstances and time of their production ; and the same means
may be used against pyrexy as well as against apyrexy; how¬
ever the anti-pyretic medication is a therapeutic entity, whose
recognition as such gives the efficacy of cohesion to its other¬
wise scattered means.
§ I.—Means Opposed to IIyperpyrexy.
(a) In general hyperpyrexy the horizontal position puts a stop
to activity, and does away with its sequelae, combustion, pro¬
portionate loss of calories, and dechets (organic detritus). It
relaxes the muscles and the skin, the latter becoming more
open to perspiration. It equalizes the central and peripheric
circulation, harmonizes the rhythm of the breathing, and scat¬
ters the congestions of the nervous centres, which functionally
APYKETIC MEDICATION.
323
cause eerebro-spinal meningitis, progressive atrophy, paralysis,
insanity, and leaves 011 the organs its indelible marks, sclerosis,
etc. Horizontal rest is the anti-pyrogenic by excellence.
(b) In local hyjperpyrexy ; If located in the viscera, the body
must be kept high, the limbs low, even hanging and loaded with
an afflux of blood. If located in the extremities, these must
be kept high and cooled, the body low and warm ; same treat¬
ments for the head.
(c) An appropriate ambient temperature, the purity and
equality of a wholesome atmosphere.
(d) Next comes the diet, apyretic by denutrition, and indi¬
cated at first by the natural horror of the febricant for animal
or solid food, later by appetences whose indications are often
precious. Under this head comes also the liquids to be in¬
gested or injected. Their qualities depend on many condi¬
tions; their quantity must be to a great extent regulated by
the quantities of moisture exhaled by the radiated heat (as per
thermoscope), with the various secretions and excretions.
(e) The modificators of nutrition, by relenting the exchange
of tissues and the consequent oxidation, and by diminishing
the losses of carbonic acid and urea. These agents of direct
or indirect retardation of nutrition are many and powerful;
among them is the large class of alterative remedies, gradually
brought from fractional to the high doses of contra-stimulism ;
certain preparations of mercury, arsenic, antimony, tea, coffee,
alcohol, which in large and repeated doses not only retard the
oxidations, and thereby lower the temperature, but diminish
the frequency of the cardiac and respiratory movements.
(f) The cardiac moderators, digitalis, quinine, conium, aco¬
nite, veratrine, delphine, etc., are powerful though indirect
anti-pyretics, mainly retarding the denutrition ; so do the salts
of potassium. Adding to this some metal and metallic combi¬
nations, several acids, as the carbonic, the acetic, oxygen, ether,
chloroform, chloral in various combinations, we have indicated
the principal remedies known to cause frigeration—by direct
or reflex action, it does not matter here—but whose action 011
the body temperature is not yet represented in figures. And
that is the next progress demanded of positive therapeusis.
(g) Bleeding is now rarely resorted to; it may justly be
dreaded, but cannot be expunged from our list of remedies,
since Nature keeps it 011 her own. Even latterly it has found
324
H^EMOSI'ASIA.
advocates, who try to make it reconquer, as an antipyretic, the
position it once occupied as an antiphlogistic. They failed, of
course; but even this failure was a triumph, for it caused the
invention of the sphygmograph, cardiograph, etc., by Vierordt
and Marey, which surpass the sphygmometers of Jules Ilerisson
and Blundell, as much as Lorain's little book on the pulse sur¬
passes the four volumes of Bordeu. But, after all, this superi¬
ority is the men's, not the doctrine's superiority ; they—the men
—succeeded in raising the ostracism pronounced against bleed¬
ing, but not to restore it to the presidency of therapeutics.
Thanks to their efforts, the part played in the Natural History
of man by phlebotomy will remain above contest; and when
the lancet will be called into requisition—thermometry and
sphygmograpliy accounting for the loss of every drop of blood—
its action on the temperature shall be supported by such a force
of apyretic evidences, and its direct bearing on the circulation
demonstrated by such sphygmographic testimonies, that it will
no more excite raillery, but admiration.
(h) Ilsemospasia, instead of drawing the blood out, draws it
in the parts where it is wanted, or from the parts where it is
judged noxious. It is a method of displacement of the liquids
of the body substituted to their drainage. Dr. Junod invented
it about 1830, as a substitute for phlebotomy, then spilling much
blood; it is now mainly a precious adjuvant to the medication
by temperatures, which it modifies in jplus and minus with
mathematic precision.
When either of these effects of hsemospasia is desired, one
of the ventouses Junod is applied to the part where an afflux
of blood is wanted. It is at first filled with warm water, then
emptied (the water being set apart in a measured vessel), and
the vacuum is made. If the ventouse is partly of glass (which
is desirable) one can see how far and how fast the integuments,
deprived of the support of atmospheric pressure, become tur-
gescent (red, swollen). The local heat increases, and the oppo¬
site parts of the body become correspondingly paler and cooler.
The proportion of these and other alterations are measurable:
the limb has grown in vacuo 6—10 centimetres larger at the
calf than it was; the apparatus, filled again with the water,
cannot contain it all: the quantity thus remaining being equal
to the quantity of the liquids drawn from the rest of the body
into that part kept in rarefied air; the axillary temperature
HJ5M0SPASIA. 325
lias come from 37° C. down to 36°—35°, even 34°; the pulse from
80 to 60, 50, even 40, and filifoim ; then insensible, even at the
temple; the respiration from 18 to 14,feeble and gaping; the
dulness of sensation has gone from anjesthesia to syncope.
Such is the gradual physio-pathology of hsemospasia. But no
sooner does the air re-enter the apparel, and the limb is raised,
than all the functions are resumed; even the swelling has dis¬
appeared the third day.
As far as the blood is a factor of temperatures by its ele¬
ments and its velocity, hsemospasia offers the most varied
modes of pyretic and apyretic treatments. It is .applicable to
more pathological circumstances than can be named here : to
congestions, inflammations, hypersecretions, neuroses, and
especially to incipient infantile paralysis, degenerescences, al¬
gidity and reaction period of cholera; after contusions of the
viscera and organs of special senses, in wounds, fractures, la¬
cerations, shock, after operations, etc. Ilsemospasia is em¬
ployed, not only alone, but with adjuvants and as an adjuvant;
like the other parts of thermo-therapeutics, it is not one of the
pathies : it is one of the agents of positive medication. As
creating artificial milieux, it could have been treated of as a
part of meso-tlierapeutics, farther classed in the pyrogenic
materia medica.
CHAPTER VIII.
WATER THE APYRETIO BY EXCELLENCE.
Though water is the best cooler of pyrexia, yet we must be
prepared to find it too a warmer of apyrexia ; and moreover, to
see its effects so varied, often so contrasting, that during its
operations we have to sound the pyrogenic ground with the
thermometer, as the mariner does uneven sea-bottoms with the
lead.
We cannot stop to describe, only to mention,the principal
forms of bath—or better, the principal means of using water as
a carrier of temperatures to thebody. Locally we note : sham¬
pooing the head; sponging the chest, or other parts ; local af¬
fusions and irrigations; ablutions or immersions of hands, etc.,
in alternately cold and hot water, the hot hammer; water-liga¬
tures at the neck, wrist, ankle, etc., to modify the circulation
at its passage ; local applications of ice-bags and of I oiling
water; sitz or half baths. Generalized application: vapor and
hot-air bath, ordinary bath in a tub, in a river, or the sea.
Stagnant or current bath in Mayor's apparatus; all sponge-
bath, wet-sheet and wet-pack, wet frictions, affusions, douches,
and showers ; dashes, and horizontal, lateral, and other sprays,
etc.
Three of these modes of applying water will arrest us a
moment: the rubbing with cold-sheet (50°—60° F.), which at
first lowers the temperature, and soon favors the appearance
of tardy eruptions in children, etc. ; the constant irrigation,
varied in its means, of which two—a barrel or bucket full
of water, on a higher level than the bed, has a string (coming
out from the bottom) whose other end is coiled over an in¬
flamed part, where it spreads a uniform stream of regularly
cool or warm water. I have seen my father (1825-1830) him¬
self set up these appliances in surgical and typhoid cases for
water as an apyretic. 327
peasants of the old Nivernois, who were not much more to be
trusted to keep parts evenly cool, or warm, than the average of
our urbane population. The other means of keeping the body
not only equally warm or cool, but mathematically sq, being a
sort of bath, will be included under the following heads :
§ I-—Water as a Carrier of Temperature to the Body.
(a) Currie put young, healthy men, with 37° C. buccal tem¬
perature, in a bath at 6° C. In two minutes their temperature
fell to 32°—31°, and four minutes later rose to 34°—35°. This
gain of 3° could come only from the human lieat-producing
apparatus being urged to fill up the gap between the deadly 31°
and the healthy 37°. But after this partially successful effort
of nature the ambient frigidity overpowered the central heating
power, and the body-heat fell again, in the next twenty-five
minutes, to 29°. The subject being taken from this frigorific
milieu (marking them 4.5°) and put in another marking 42°, it
took him twenty minutes to recover his norme—the 37° vvhere-
from he had started.
Neglecting the losses of caloric of both body and bath, we
see: (a) 6° of milieu subtracting 6° of body warmth in two
minutes. (b) The organism reacting by an over-production of
calories regains 3° in four minutes (without reckoning about
as much imparted to the bath). (c) But after this effort the
organism, overpowered by the milieu, and exhausted of its
means of heat-production, loses again about 3° in thirty-five
minutes, falling to 29°. (d) Then in danger, he is transferred
to another bath at 42°—that is to say, 5° above the human norme
—where it takes twenty minutes to make him recover the 8°
which separate him from his health starting-point, 37° C.
(b) Liebermeister and Leyden have obtained more exact re¬
sults (see Bibliography), but very few physicians can have as
complicated instruments as theirs; and as any one in posses¬
sion of a thermometer, and with the disposition of a bathing
apparatus, can apply the simple treatment of Currie with a
sufficient degree of precision, I will give of it an example, and
an average result. I take the example from the most recent
publication of a case of typhoid fever treated by ice-water
328
DOSAGE OF EXTERNAL TEMPERATURES.
baths, from W. H. Thomson and F. II. Rankin, in tlic New
York Medical Record, Oct. 23, 1875.
\
Fig. 84.
EFFECTS OF EXTERNA.!, OX INTERNAL T3MPERATU11S3.
(On this chart the plain lines mark the mean morning and
afternoon degrees, and the dotted lines show the effects of
the baths. The figures at the top of the dotted lines indicate
the temperature of the bath; the figures on the straight line
indicate in minutes the duration of each bath, and the lowest
figures indicate how many minutes after the removal from the
bath to the bed the temperature continued to fall. The bath
being at the freezing point, the first effort of nature to over¬
come its impression elevated the temperature for a few minutes,
as seen by the rise of the dotted over the plain lines, but soon
subdued it; as seen by their subsequent descent.)
(c) Here is an average estimate of the action of cold bath and
of the ensuing reaction, by Glenard of Lyon :
Temperature before the bath 39.6
Immediately after the bath 38.4
One hour after 39.1
Two hours and a half after 39.4
Three hours after 39.6
This simplification must not deter earnest students from re¬
peating and perfecting, if possible, the experiments of Lieber-
meister; but, practically, hydro-thermo-therapy is difficult
SUM OF CLINICAL EXPERIENCE.
329
enough of itself, without rendering its approaches impassable
to the mass of the practitioners by an array of mathematical
and mechanical sphynxes, not unlike those which guarded the
avenues of the temple of Isis (where physic was kept a mys¬
tery). To be plain, and understood by all, we will draw from
the experiments of Currie, of others, and from our own, conclu¬
sions and warnings which are chiefly clinical.
(d) The temperature of the watery milieux (bath, etc.) acts
upon that of the human body in proportion to the number of
degrees which separate the two, and of the time of its appli¬
cation.
The stronger the external action, the quicker the internal
reaction ensues.
When the external action has overpowered the internal reac¬
tion, two things will happen :
The first: After the body has been taken out from the
milieu, it continues for some time to be acted by its tempera¬
ture as if it were yet in it.
And the second : If the body has remained in the milieu
after the temperature of the reaction was subdued, it is left
powerless against the temperature of the milieu; a new reaction
becomes impossible. A continuance, then, of the action of the
bath-temperature calls for a watchful thermometry.
Extreme temperatures are heroic remedies, that may kill or
cure; baths are their most ordinary carriers.
With extreme and short temperatures, beware of the reaction.
When the reaction commences, watch over its progression
with your thermometer, and be ready with the most effective
antipyretics.
To an extremely hct bath, nature opposes the cooling process
of sweating of the alcarazas (cooling water-bottle). Against a
verv cold impression it generates a large surplus of heat, which
makes it appear for a few moments as if an ice-cold bath really
warms the body. But soon comes a reaction—which is really
the action. .
With extreme temperatures, protracted beyond the organic
reaction, beware of the continuation of their effect, even after
the body has been withdrawn from the bath.
After the reaction-temperatures have vanished, beware of
the passivity of the body if further exposed to extreme tem¬
peratures.
330
ACTION AND REACTION,
Therefore, what is the most to be dreaded in the treatment
by temperatures is not their first action, but their reaction, and
later the incapacity of reaction.
Conversely, moderate temperatures may kill by not effecting
the cure which high ones would.
Otherwise, the nearer the temperature of the bath is from
that of the body, the slower will be the work of isothermization
between the two.
And the slower this work, the longer it may be continued
without danger of excess or reaction.
But if the external temperature is moderate, and the organic
active, the latter will act on the former, and the former will be
powerless to subdue the latter: here a large difference would
do what time cannot.
Besides, in the treatment of sickly temperatures by water-
temperatures, opposite means may produce similar results, and
the same means may produce different results:
Warm water and vapor are pyrogenic, yet by inducing suda-
tion they indirectly lower the temperature; so frequent spong¬
ing with warm water will cool.
Cold water, ice, and frigoritic mixtures, etc., are antipyretics;
yet by contracting the apparels of sudation and of radiation
they prevent the peripheric evolution of calories, and by this
negative processus they increase the central temperature.
These apparently contradictory results render temperature
one of the most difficult remedies to dispense of all the materia
medica. But once mathematically handled it is effective and
exact in its effects.
Other difficulties, which I can but mention, arise from the
dosage of local or general, uniform, contrasting, decreasing or
increasing water-temperatures, and from the selection of its
means of administration, as douches, vapor, lotions, baths of all
kinds.
But the most difficult term of the problem of treating internal
by external temperatures symbolized in water, is, not the
knowledge of the changing virtues of the remedy, but that of
the ever-changing (in disease) status of the inner caloricity.
This is in order the second, in importance the first, element of
thermo-therapeutics.
The live body, no matter how sick, has its own temperature
affected—not isothermized—by the external. Far from being a
TOWER OF ACCOMMODATION OF MAN TO HEAT OR COLD. 331
passive receiver of temperatures, as is the dead body, it pro¬
duces its own calories, and distributes tliem unto itself in virtue
of physiological laws, or imparts them to its milieux, in accord¬
ance to physical combinations.
This self-supplying and heat-distributing aptitude renders
the body capable of living in temperatures sometimes higher,
habitually lower than its own, and of resisting higher or lower
milieux without becoming isothermal to them. We are thereby
induced to consider physiological temperatures separately from,
and superior in the scale of life and power, to mere physical
heat, in proportion as organisms are superior to simple mole¬
cular aggregates.
This superiority is prominently expressed by the power of
regulating the relations of the body's caloric with the external
heat, the capacity of accow.modation. Not meaning to say
that alone in the human system the calorigen functions possess
this power of accommodation, since it was first assigned to
vision, and applies just as well to the functions of the brain,
stomach, bladder, etc. But having no room for theories we
say : the law of accommodation of inward to outward tempera¬
tures, and its monstrous derogations in sickness, makes it a duty
for the physician to give the prominence to the study of the inter¬
nal anomalies of accommodation over the fixed rules of action
of purely physical temperatures.
This transfers our point of view from the objective to the
subjective, and elevates the question of the treatment of diseases
by temperatures to one of vital dynamics.
(e) In presence of the sick we must have constantly in mind
his actual and ever-changing power of accommodation of inter¬
nal to external temperatures: we ought to have studied what
degree of calor-accommodation he had in health; how increased
or diminished it has been since the sickness began; how much
of the caloric has been wasted, retained, ill-distributed, etc.,
during the struggles for accommodation, and what remains of it
for active service in the next conflict of the external with the
internal temperatures,—in order to bring the latter to the phys¬
iological point.
In this struggle, let us remember, water is but a vehicle of
temperature : its application is not hydro-therapy, but a part of
thermo-therapeutics; its success depends less upon the degrees
332 DOSAGE OF TEMPERATURE DURING EFFERVESCENCE.
of heat applied, than upon the masterly knowledge the physician
possesses of the range of accommodation left to the body.
What is that range? We will try to answer this question
in its generality, though keeping in mind that each case can
alone give daily its own answers.
(/) When a person begins to show signs of sickness, either by
high continuous temperatures, or by progressively higher ones
with morning and evening remissions, his power of accommo¬
dation, not yet exhausted, rather exalted, will stand the treat¬
ment by temperatures in various ways, and even in excessive
degrees. If he is of average strength, with no local determi¬
nation of the blood, and had not been previously healing, he
will be favorably affected by sharp and short temperatures, as
30° C. below his own, repeated as often as reaction indicates.
If equally strong and of full habit, a temperature of 25° from
his own will be borne better, longer, with less danger during
reaction, than a more extreme one. If he has periodic head¬
ache, or occasional palpitations, an application of temperatures
distant only 15°—20° from his own would be better borne yet,
and as effective, supposing it to be continued longer.
But descending to the continuous applications of moderate
cold—after a reaction, or in the absence of it—when the tem¬
perature of the patient has been actually reduced the half of the
lowering presently desired, he must be taken out from the cooling
milieu, because the other half of the frigeration is expected to
follow en suite, as a wrave follows another in rhythmic oscilla¬
tions. Thus, if a febricant at 3° Ph. = 40° C. = 104° F. is put
in a bath at 15° C. = 59° F., as soon as he reaches 1.5° Ph. he
must be taken out from the bath, and put to bed, with the ex¬
pectation that his temperature will continue to fall almost as
much as it has in the bath ; that is, to the ph}Tsiological zero.
This is quite a safe doing at such and at less distance from
the norme. But supposing the pathological temperature to be
decidedly higher, it would be dangerous to try to bring it thus,
almost at a swoop, to the norme, as exemplified in the treat¬
ment of sunstroke, page 224. Thus, for safety sake, instead of
starting from extreme temperatures, say 5° C.=41° F. applied
a long while, at the risk of weakening beyond recovery the
power of accommodation, we ought to undertake to lower it in
successive antipyretic operations; each one subtracting .5° or
1° C. or so, and followed by bed-rest and food-support, during
EOSAGE OF TEMPERATURE DURING DEFERVESCENCE. 333
which as much more may be effected by simple continuity:
the distance between the frigeraut operations being shortened
if reaction threatens, the thermometer always being the judge.
As for the great majority of incipient pyrexite, they may be
subdued by external temperatures nearer to the internal than is
generally thought and practised—no more distant, let us say,
than 10°—15° C. from the pathological, but on condition that
they will not be withheld till they have produced their second¬
ary action—past the reaction.
(g) When a pyretic disease has run its ascending course, its
effervescence up to, and into its fastigium, or jperiode d'etat,
it takes its principal characteristics from what remains to the
patient of his power of accommodation ; and from the manner
we husband, utilize, neglect, or strain that remnant during the
fastigium, depend the issues (then obscure, soon clearly read¬
able in the figures) of the defervescence.
ill) Defervescence, though treated of by authors as a unit,
presents to the thermometrician two phases rendered particu¬
larly distinct by their differences of accommodation. The first,
in which the capacity of this function—though variable on ac¬
count of the great diversity of the pyretic antecedents—is
characterized by its dulness or passivity. The second—a fore¬
runner of convalescence—marked by its prompt and delicate
response to moderate thermic impressions: a distinction which
must regulate the choice of the temperatures to be employed
during the decisive fluctuations of effervescence.
Therefore, as long as the accommodation is inactive, or sim¬
ply apparently inert (first phase), the temperatures employed
to arouse this function have to be pretty sharp, yet quite short;
but as soon as accommodation becomes more active (second
phase), till it reaches a high pitch of sensitiveness, the water
or other external means, employed to rise, 01* to subdue the
inward temperature must come nearer to this latter, till it
seems to act more by its sameness than by its contrast; and,
sometimes also, more by tonic adjuvants than by its own pyro-
genic capacity.
(i) This explains also why in convalescence water is used,
more for its stimulating effects than for its pyretic properties.
Without entering into other details of application, it is easy to
conceive, and to take advantage of, the preponderance of the
mobile degrees of accommodation over the fixed properties of
334
thermonomy of the fall of temperature.
outward temperatures, especially during the reconstructive
efforts of nature to restore life by harmonizing warmth.
j.—Thermonomy of the Fall of Temperature.
1. The danger of a fall in temperature is in proportion, first
to its suddenness, second to its degree.
2. A sudden fall of temperature in a febrile affection warns
of an evolution, or of a revolution.
3. The decrees of the fall have a meaning-—not the same at
o ~
the beginning, in the middle, and at the end of a disease.
4. The circumstances attending the fall give its commen¬
tary ; but its form expresses more particularly the nature and
period of the morbid process to which it belongs.
5. A sudden fall indicates a tendency whose meanings
depend first from its starting-point, and second from its matlie-
matic progression.
6. A sudden fall in pyretic affections indicates a crisis.
7. A sudden fall in apyretic affections threatens collapse.
8. Any fall of several degrees is to be dreaded.
9. A progressive fall is favorable towards the norme, and
dangerous below it.
10. Sudden falls in a chronic affection, or from a steady
norme, command immediate rest, ready restoration and vigi¬
lant observation.
11. A great fall must not be provoked all at once (without
successive rest and restoration), even to bring down the most
excessive hyperpyrexias.
12. Any fall of temperature, ether natural or provoked,
calls for a supply of restorative means ready at hand, since
algidity is jper se a cause of death.
/
§ II.—The Bath.
Though I resolved to restrict my remarks on the application
of water to its bathing form, the bath itself is not a thing so
simple, so well defined, so easily brought and kept to the"de¬
sired temperatures, not even so easy to obtain when and where
needed, and—I may hazard to say—not so generallv well ar-
RULES FOR BATHING IN TYPIIOID FEVER.
335
ranged, that it does not lend several weak sides to criticism, and
therefore that it could not be improved, at least for medical
purposes? In his article on Typhoid Fever of the Ziemssen's
Cyclopedia, Liebermeister points ont its uses and imperfections.
He says, passim. Vol. I., pp. 205—230:
{a) " By far the greatest number of those who succumb to
typhoid fever die from the direct or indirect effects of fever-
heat : the true danger consists in the deleterious influence of a
high temperature oil the tissues which brings on their necro¬
biosis, whence paralysis of the heart, etc. In the antipvretic
treatment is included that by cold water. It is immaterial in
what way the abstraction of heat is accomplished. The means
are not always the most effective which seem most energetic
(referring to cold affnsions, ice, etc.); on the whole, those will
be found preferable jvhich achieve the desired effect with the
least inconvenience to the patient. For adults the bath must be
68° F. ; if feeble, 75°. As the majority of the patients find
the cold bath decidedly disagreeable, Ziemssen immerses in 95°,
gradually reducing to 72°. Warmer for children. Nothing
essential can be accomplished by one bath or a few. They do
not reach the innermost temperature, or their action, too short,
is followed by a reaction. Four to eight, sometimes twenty
baths daily, and from forty to sixty in the aggregate, are
needed. They must be given night and day, as often as the
recurring high temperature demands it."
But here comes the counter indication: to not move the
patient, and yet at the same time to bring him so often to and
from the bath. The most important for a typhoid-fever
patient, from the beginning of the attack, is complete bodily
(and mental) rest. In severe cases, of those laid abed before
the end of the fourth day, only five per cent, died; of those
between the fourth and the eleventh, thirteen per cent.; and
later, twenty-eight per cent.—the laying posture to be con-
tinued till the body-temperature has proved to be normal at
least from three to six evenings without interruptio7i. When
moved at all. the patient must be lifted in the horizontal pos¬
tures. Such are the dictates of Liebermeister; but how can
we accommodate them to his prescription of bathing day and
night the patient who must not be moved, etc., etc. Certainly
the typhoid patient must be bathed, but he must not be moved ;
then how to bathe and to not move him 1 ... .
333
the bath without bath-tub.
Moreover, this ordinary mode of taking baths had other in¬
conveniences which Liebenneister did not stoop to detail, but
which had been noticed long before he expressed his views. We
will recall (a) the difficulty of keeping the whole mass of water
at the same temperature, and of making it warmer or cooler
with any desirable precision ; (b) the danger of the spread of
diseases by the effluvise which water, particularly when warmed,
communicates to the atmosphere ; (c) the impossibility for feeble
patients to long remain in the positions imposed by the form of
the bath-tub, and particularly to stand the continued pressure
of several pounds of water over their chest.
(b) These inconveniences of the ordinary forms of bathing
never appeared to me so glaring as when I saw the bath recom¬
mended in the remarkable book of Wilson Fox, and the same
mode of bathing used to apply temperatures as remedies in
several hospitals of Europe, even in the pavilions of Wunder-
lich. Then I felt encouraged to not throw away a suggestion
which the lecture of the treatment of hyperpyrexia by Wilson
Fox inspired to me, and which I published March 6th, 1872, in
the New York Medical Record, under the name of its original
inventor. It is the more necessary now to reproduce this idea
in its entirety that no better one has been since devised, and
that the medical papers are adorned with mutilations of it.
There it is, shortened.
§ III.—The Bath without a Bath-Tub.
To facilitate the application of water, Dr. W. Fox insists
upon the introduction in the wards of hospitals of movable
bath-tubs, in which the patient could go, or be immersed, as
near as possible from his own bed. This happy suggestion
recalls to mind a mode of bathing which ought not to have
been forgotten.
(a) Les bains sans baignoire, was the title of a little pam¬
phlet handed to me, in the summer of 1835 or 1836, by a gaunt
and weather-beaten Swiss physician during my introductory
visit to him in a meagre lodging of the Qxiartier Latin. He
was wrapped in one of those broad blue cloaks in which the
Old Guard are represented falling at Waterloo. Under this
historical garment he was taking his bain sans baignoire in a
MATHIAS MAYOR's BATHING-DEES8.
337
double habit of flannel and waterproof. He never took any
other, enjoying them especially when going on horseback to
visit his clients, several miles away « and the three hundred
and odd patients of his hospital used the same bathing apparel
for many years and liked it very much: indeed, there was not
a single bath-tub in the hospital of Lausanne.
For mine host was he of whom it has been said: " There
are two systems of surgical deligation—the one handed to us
under the name of Hippocrates, the other Mayor's." He had
come down to Paris to have one of his free fights upon his pro¬
posed improvements at the Academy of Medicine: this was
Mathias Mayor's yearly recreation.
(ib) Now it seems to me that this forgotten lain sans
baignoire would be just the thing which, with slight modifica¬
tions, would render easy in hospitals, and popular among the
middle classes, the treatment of hyperpyrexia by wxdical tem¬
peratures, not only in public institutions, boarding-schools,
naval, military, industrial, and scientific expeditions, etc., but
in the homes of the many who have no bathing facilities. The
apparel would consist of a covered reservoir of a few gallons,
having inserted in one of its sides a rib of glass, showing the
level of the liquid, and an ordinary thermometer to regulate-
the temperature of the latter. Hence, one pipe or more would
let down the water into the bathing-dress.
This dress—which entirely enrobes the patient, even, if need
be, his head and some parts of his face—is double, of thick flan*-
nel against the skin, and of vulcanized cloth outside. It is also
open in the centre, like a pouch, to permit the insertion of the
clinical thermometer in one of the natural cavities, at various
points to admit the water from the reservoir, and at the feet
and other declive parts to give it an issue into a covered
receiver below.
This bathing-dress could be made as stout or as light as desir¬
able ; it could be so adjusted as to hardly hold two quarts of
water, pure or medicated; mathematically warm or cold as per
thermometer ; stagnant around the body or streaming along it.
It could be worn for hours, or days, in bed by the paralytic and
rheumatic patients, or in the room, even in the open air, by those
who need at the same time bathing and exercise. It is equally
adapted to the five principal forms of whole-bath—the short,,
the protracted, the mild, the extreme, the progressively warmer
338 pro rata of cures by low temperature.
or cooler. It most happily fulfils the desiderata of continued
mild frigoration• I consider it impossible to read the thermo¬
graphy of the treatment of severe hyperpyrexias (see Appendix
XIII.) without being convinced that as soon as they will have
the means of doing so, physicians will give the preference to
continued mild frig oration in the bathing dress to the short
and extreme ones in bath-tubs, so soon and so often followed by
reaction. Twenty baths in a day (Liebermeister) followed by
twenty reactions, forty revolutions of temperature in twenty-
four hours, constitute quite a rapid thermic balangoire. (Same
remarks u^on the fluctuations noted, page 224.)
Sueh appears to be, prima facie, the advantages of the adap¬
tation of Mayor's bath to the therapeutics of the positive school
of medicine.
(<?) It seems that it would be doing an act of justice if we
were to give to this bathing apparel the name of Mathias Mayor,
who was never equalled for ingenuity in the mechanical depart¬
ment of surgery; aud yet who met with so little of reward that,
if he had cared a fig for a tombstone, he would have caused to
be written upon his, " Woe to him who comes too soon."
For the reader who feels restive under the development of
ideas and their deductions, let us condense in facts and figures
the most recent—
§ IY.—Results of the Treatment of Hyperpyrexia by
Low Temperatures.
Names.
Localities,
Diseases.
Number
of Cases.
Number
of Deaths.
Percentage
of Cures.
Carrie (1804).
Liverpool. ;
Typhoid fever.
229
4
2 per cent.
Jacquez (1839).
Lure (Prance):
Typhoid fever.
313
12
4 "
Brand.
Stettin.
Pernicious fever.
170
0
u
Jurgensen.
Kiel.
Typhus.
60
0
li
Liebermeister.
Basel.
Typhus.
478
8
2 "
Ziemssen.
Erlangen.
Typhus.
7 "
Lindwurm.
Munich.
Typhoid fever.
120
4 "
Bamberg.
Vienna.
Typhoid fever.
6.6 "
Winternitz.
Vienna.
Fevers.
40
0
6.6 "
From a great many observations CI. Bernard establishes the
proportions of mortality to twenty-three per cent, by varied
treatments, and of nine per cent, by the water treatment.
TREATMENT BY BATH DESCBIBED IN HOMEB. 339
Now we could expatiate 011 the nee of water as a conveyer of
high temperatures to the body as we have on its frigorific prop¬
erties. But the same modes of propagation rule both ways, and
the revival of the peripheric circulation by hot bath (86°—104°
F. = 30°—40° C.) is so well known, that Homer describes its
use to restore the, circulation of the teguments in old people
(Odyss. XXIV.). It is not the ancients who did not know; it
is we who have forgotten.
CHAPTER IX.
PYRETIC MEDICATION.
A pybetio treatment consists either in the means of adding
heat to that of the body, of inciting the inward generation of
heat, of preventing its excessive escape, or of equalizing it all
over the body and limbs. The means to these ends are many;
we will see a few.
(a) Like water, alcohol and its congener, wine—which I
have hardly room to name—act as a double-edged sword in
thermo-therapeutics. In certain pathological conditions it
supports, in others it depresses the temperature. This double
property was divined by my Burgundy ancestors, who would
urge the acceptance of their national beverage by saying in
winter to friends and visitors: " Take a glass of wine: it will
warm you;" and in summer," Take it: it will cool you." Truth
from the heart, confirmed by science, but not yet reduced to a
system. In toxic doses it depresses, in small it raises the tem¬
perature ; in therapeutic doses it sooner prevents the deperdi-
tion of heat. It does not act on the sick as on the healthy, nor
in all diseases alike. In the absence of absolute rules as to
quantities and their effects, we have to watch these effects by
the light of thermometry to decide on the doses.
(5) Food is as much a part of the pyretic medication as fasting
is of the antipyretic. But how much easier it is to refuse satis¬
faction to the demand of nature for it, and count the results on
the thermometer and sphygmograph, than to measure the dif¬
ference of ustion produced by different kinds of food. In this
last selection we are guided by a good many prejudices and a
little positive knowledge. However, the little we know is pre¬
cious ; and I am persuaded that if all those who die of starva¬
tion in sickness (not by privation of food, but by want of the
proper food as a heater) could rise, no medical student would
PYRETIC MEDICATIOBf.
341
afterward receive his diploma without having passed a solid
examination on the art of feeding and of keeping warmth by
food.
(c) Spices, aromates, odors, rank between food and medicine,
being allied to both. Introduced into Europe by the savant
companions of Alexander, early sought for by the golden youth
of Rome, incorporated in the ijnperial theriaca, they retained
a costly supremacy in the polypharmacy of the middle ages.
Now we laugh at their pretended virtues, and have almost for¬
gotten their real ones. However, being the products of high
temperatures, they must have sunny qualities. For instance,
medicines act quicker and more thoroughly with diffusible aro-
matics than without, whenever the sympathetic needs to be
aroused, like in cholera. I would not affirm that so many
Roman emperors were murdered because their theriaca pre¬
vented them from timely enjoying a natural rest, but I have
seen lives apparently protracted by the use of aromatic prepara¬
tions ; there are more rays of a beneficent sun than we can
count in a little clove, but we can measure the heat it imparts
to our bodies; thermometry is called here, too, as a judge.
As for the odors and perfumes already dispensed as drugs,
there is a whole pharmacopoeia, from neroli to Valeriana, from
tolu to assa. Their properties are called nervine, but beyond
that vague-qualification, and the other, more ambitious, of being
aphrodisiac, some act on the temperature by lowering it, as do
jessamine, otto of roses, musk (which is hardly inferior to qui¬
nine on that score), in virtue of the law discovered by Brown-
Sequard, that a nervous excitement causes frigoration; others
keep up or increase the heat. The relations of odors to calor
are intimate; their reciprocal convertibility is demonstrated in
some cases, beyond which we have yet everything to learn.
The action of the body's emanations due to an occasional
development of caloric would open a new chapter. Sufferers
from melancholy have been revived by it, and others have
been -like paralyzed, as it happened to King Henry III. of
France, by the immediate contact with a piece of the garment
of Mary, Princess of Cleves.
(d) Vestment, considered as a means of warming or cooling
the body, belongs to this part of our subject; nevertheless, we
will give its place to other pyrogenic agents, apparently more
important, certainly not of such general and constant utility;
342
MATHIAS MAYOR'S HAMMER.
for the same reason, likely, that people are moved to awe by
the presence of a coarse surgeon who can sever a limb in one
minute, and before the physician who spent his life trans¬
forming sore-nosed and sore-eyed children, neck-laced with
scrofulous beads, into faultless brides, they feel.... rien du
tout.
(e) I called the attention, first, on the pyrogenic properties of
the hot hammer, or Marteau-Mayor, from the name of its
almost forgotten inventor. It has no connection with the red or
white hot cautery, the moxa. nor anything that burns ; it only
warms. This energetic and expeditious means of accumulating
heat is indicated when the circulation is impeded, or just
stopped, in embolism, certain forms of apoplexy, defervescences
with collapse, central algidity, sclerema, cholera, and wherever
(except in internal haemorrhages) the quickness and feebleness
of the pulse is associated to a fast-falling temperature. Even
in agony it is known to accumulate heat enough to permit the
departing to remain a little longer, in order to perform a last
duty; indeed, it is to that effect, and with that result, that,
Mayor first applied the hammer in medicine.
Modus operandi.—It must be clean, if not new; kept in
boiling water long enough to come to its degrees, 100° C. =
212° F., of which it will soon lose a few by exposure. It is
generally applied at the pit of the stomach. The place must
be dried from moisture, and covered with a piece of muslin,
linen, or paper, perfectly dry too ; for any humidity included
between the body and the hammer would vaporize at a higher
temperature than the latter, and burn, instead of heating.
With these precautions the hammer is softly applied till the
superficial layers of tissues have become isothermal with it.
Then, and not sooner, the hammer is pressed more and more,
in order to make the heat penetrate deeper and deeper, farther
and farther, till the desired impression is obtained. When the
operation need be protracted, one hammer is at work and an¬
other in the kettle; the linen is watched and changed as often
as it becomes humid. An assistant takes the general and local
temperatures. Besides its use in ultimate and solemn circum¬
stances, the pyrogenic hammer will be used with advantage, if
I trust my personal experience, when heat is wanted generally
or locally; for old people in periodical collapses, without
reserved heat to support the reaction; for children cooled by
TRANSFUSION. MESOTHEBAPT.
343
rapid growth, at the end of a protracted winter; when food
has been scant; to facilitate digestion; to arouse the sympa¬
thetic in melancholy, in some forms of hysteria,, in secondary
and tertiary syphilis, etc.
(f) Transfusion, or injection of some liquid in the veins,
after its first applications in 1660 by Denny, of Paris, has
been in tarn favored and neglected. The substances thus
introduced in the liquid form were oftener wanning than cool¬
ing : we will mention only solutions of chlorure of sodium,
warm milk, warm water, defibrinated or quick blood from
another's vein ; and quote:—Magendie, in 1840, injected water
in the veins of an hydrophobe, who immediately rose from his
bed, went to the fountain, drank, and lived eight days longer
-^-through peripeties of better and worse. Lorain, in 1865, in¬
jected 400 grammes of water at 37° C. in the vein of the forearm
of a choleric; cyanosed; temp, in mouth 26.8° C., which imme¬
diately rose to 30° and on the morrow to 35.9°. The pulse be¬
gan to be felt, cyanosis disappearing; hiccough ceased the third
day, diuresis was restored the fourth; cure (from St. Antoine's
Hospital Reports). There is more recent records of success
from various quarters, but published without reference to
the first temperature found, and t© those obtained by the trans¬
fusion.
(g) What we said in Part 1, Chap. V., dispenses us from
entering into long details about Mesotherapy (prophilaxy oijcure
by the milieux). Insects build or burrow North or South,
high or low for their winter or summer residences; and birds
migrate according to mesologic laws, besides selecting the
winds to sail with, their camping shelters, etc. In this wintry
season my black angora lounges where the sun shone several
months ago. Man, when a brute yet, descends from the north¬
ern plateaux to bask on the hills golden or purpled by the
grape. The Cossack feels that he must soon wash his tallowed
beard in the warm waters of the Bosphorus, and his fleet horse,
given the spur that way, neighs at the prospect. The pale
men found the red men at their Saratoga water-cure, but our
artificial wants have obliterated owr natural besoins. What the
wild goose seeks unerringly, we must ask from science. Un¬
fortunately the earth has been more prospected for gold than
for health; though mesotherapy has always been considered
the great achievement of our art. It employs to cure, and
344
MEDICAL ELECTRICITY.
better, to breed finer men, the physiological effects of longi¬
tudes, latitudes, altitudes ; of expositions in relation to the sun,
the winds, the rain-fall, the fogs, the direction of the surface
and subterranean streams, the stagnation of others, the effects
of pollens, of living or decaying vegetation. We know that
climates good for invalids may be deadly for infants; that
where a baby will prosper till fifteen months old, his chances
of death are increased tenfold from thence to four years ; that
a milieu favorable to laziness is fatal to activity, or vice versa'
that exposures which kill one, invigorate the other; that a re¬
gion where incipient consumption cures, hasten the fatality of
the more advanced; that where an adolescent will develop,
another will pine away; that finally, in these decisive questions,
the thermometer and the hygrometer must take the place of
our anaesthesied natural propensities. But how far are we
from mastering those problems ? On one hand, men travel
far more for wealth than for health ; on the other, those com
patent to advise in such rraattevs are few, and the writings are
scattered on rare pages (See Appendix XX., Leurtet, and Bibli¬
ography, Paul Bert, Quetelet, Bertillon). Meanwhile Mother-
Earth remains before us like the Abundance of P. P. Rubens,
in the Medicis Collection, covered with .mammae, from which,
in our ignorance, we suckle either milk or poison.
(h) I can only give a few lines to the pyrogenic properties
of electricity. Let us only remark that some of the mysteries
which surround its application to our art are explainable by
Mayer's, Jouley's and Helmholtz's theory of the identity or
convertibility of the forces. As others convert this force into
light, movement, and an infinite variety of laboring powers,
the physician introduces it into the human system as a spark;
whence it comes out converted into contractility, sensibility,
and other forms of physiological and psychological activity. I
would say nothing of its general and surgical applications;
but the necessity <of using thermometry as a local application is
obvious. When the sap of life abandons a part or limb which
is proven by a lowering of the temperature—electricity shows
its power of restoring communications, by running its currents
tlUQUgh the forsaken ducts. Then the cold part is warmed
the inert limb is moved and fed again; a new life is infused
with the spark into the lifeless organism. But it iB not always
«o; and between necessary failures to be palliated, and success
MATHEMATICAL TEST OF REMEDIES.
345
claimed where little or nothing was accomplished, who will
judge ? . . . Sorry sight, described by Cyon in his preface of
Princiyes d?Electrotherapie, Paris, 1873, to prevent which the
shortest means is by submitting the operations of this new
treatment to the sure test of mathematical thermography- To
this effect one can use the following:
346
PYROGENIC ACTION OF TREATMENT.
(i) Table of Pyrometric, Dynamometric, and other Obser¬
vations during the use of remedies.
18....MONTH.
NAME.
AGE.
SEX.
Day of application...
Pulse* Before
u .After.
Breathing B
" A
Right band B
" A
Left hand B
" A
Bight axilla B
" .......A
Left axilla B
" A
f Bight hand + B
" A
Left hand B
" A
Right footlf.. ..,. B
A
Left foot B
A
f Bight cheek§ B
A
Left cheek B
A
Right arm B
A
Left arm B
" A
Mensuration of
Urine, pp. gravity...
" oz. per 24 hour'
REMARKS.
* Also the Sphygmography of the right and left radial artery, taken once or often
t Measured on the Dynamometer.
left %3T* °n a 8Wlng fronting a vertica] spring-board, alternately pressed.by the right and
§ Or other points of observation.^
ct'crjscs
..yato
PTCHAPTBR X. j
'[medical] mathematism.
This table—specimen of others—can give an idea of the
philosophical part an omnipresent thermography can act be¬
tween pathological temperatures and thermo-therapy. It
will, besides, become the test by which will rise or fall that
pretender to the succession of medical scepticism, theurgism,
thaumaturgism, and empiricism, medical positivism or mathe-
mobtism, or whatever may be its name when success will have
given it one. No other instrument of positive observation will
have so large a share in this revolution as the thermometer,
and the mathematical treatment of its findings, thermography.
To therapeutics, thermometry opens a new era more promis¬
ing than the one opened by the discovery of America. To the
latter we owe the acquisition of the Peruvian bark and bal¬
sam, of the Mexican ipecac and jalap, of the mandrake and
curare, etc.—valuable specifics added to the list of the empiri¬
cal arcanes : for arcanes they are in their action. But to ther¬
mometry we owe the mathematical regulation of the powers of
two medicines, heat and cold, the productor of warmth and the
retarder of combustion, whose action on normal and abnormal
temperatures becomes as positive as Can be any operation of
statics, hydraulics, or chemistry. With thermometry, heat and
cold, antithetic terms, or poles of the force-temperature, are con¬
vertible into movement, activity, thoughts, feelings, and all the
manifestations of life. In showing us how to use them mathe¬
matically, thermometry has truly discovered-—according to the
vivid expression of "Wunderlich—anew world, the one dreamed
of by De Haen and Currie, the law of-the action of external
upon human temperature. But this therapeutic application of
the two antipodic terms of caloric to the treatment of diseases
is only the initial impulse of an immense revolution, whose
348 POSITION OP THERMOMETRY JN JIJAGNOSIS.
subsequences, hidden to the view of the far-seeing Currie, are
hardly traceable in our horizon ; I mean the calorific and frig-
orific action of all our medicines, vegetables and their alka¬
loids, metals, metalloid bodies and gases. This entirely-new
field of observation and of therapeutic action would vanish like
a mirage if thermometry could be suppressed.,.. But, far front
this impious impossibility, thermometry will find'out even the
positivism hidden in empiricism, by demonstrating* the law of
concordance of the apparently most discording treatments;
and it will reconcile schools which were- divided, only because
they did not know that their diverging means converged to the
same action and object, viz.: the keeping lip of normal tem¬
perature, that is to say, life; and the suppressing of the
sources of pathological temperatures1—that is death, in propria
persona.
§ I.—Position of Thermometry in Diagnosis..
Though and because the first part of this book is consecrated!
to the exclusive demonstration of diagnosis by thermometry,,
now that the demonstration is beyond cavil, it becomes neces¬
sary to reconstitute diagnosis on its old solid materials, after-
having only substituted thermometry to sphygmometry for its
corner and central stone.
Henceforth, at the bed-side, the first act of the physician willi
not be to feel the pulse, but to apply the thermometer; he willi
not proceed to percussion or auscultation before having collect¬
ed in his nares the emanations always indicative, if not of the'
disease, at least of the degree of saturation by the morbid fer¬
ments ; as does and professes Behier at the Hotel Dieu of Paris..
Then, when the other medical semes will have made their
survey, sphygmometry may be the first operation next to-
sphygmbgraphy, around which will stand, as the ease may
demand, the cardiograph, the myograph, or other of the regis¬
tering instruments (instruments inscripteurs) which exercise
the ingenuity of many earnest students in the laboratory of the ■
College de France. This activity, of which Marey has wj-estedi
the leadership from Germany, and the recent progress- aceomt
plished in the chemical laboratory, bring to thermometry the
means of branching in two directions.
physical and positive diagn0si8.
349
By the comparative study of the concordance and discord¬
ance of the three great vital signs, and by the concurrent
use of the thermometer with the sphygmograph, the myo¬
graph, the microscope, the sesthesiometer, the dynamometer,
and other instruments and methods of positive diagnosis, we
will soon be able to settle, like mathematical affairs, all ques¬
tions relating not only to disease, but to vitality, longevity, and
adaptability to the various climates, altitudes, longitudes, train¬
ing, studies, sports, indulgences, labors, individual and social
fitness.
Moreover, the range of its diagnostic powers has been and
will yet be greatly extended by the combination of its action
with that of the instruments and methods of physical diag¬
nosis. This combination of the surface and the fever ther¬
mometers and thermoscope with the stethoscope, laryngoscope,
specula, plessimeter, etc., will bring into focus many facts
which, scattered, had no possible diagnostic connection. I can¬
not diverge from my central objective point to dwell up6n the
consequences of this alliance of thermometry with physical
diagnosis, but I can spare a few paragraphs to indicate some
of the operations which the thermometer can accomplish at the
head of, and in collaboration with, the instruments and methods
of positive diagnosis.
II.—Physical and Positive Diagnosis.
But first, as I have originated this division of the instruments
of diagnosis into physical and positive, I may be allowed to
support this proposition by considerations which will, in my
judgment, altogether enlarge and specify the functions of the
thermometer itself.
The instruments of physical diagnosis, stethoscope, ophthal¬
moscope, specula, etc., are always, like spectacles, accessory to
our senses, to which they give a farther reach and a finer ac¬
curacy.
The instruments of positive diagnosis, the microscope,—for
a part, at least, of its investigations,—thermometers, dynamom¬
eter, etc., are substitutes to our senses, and give automatic re¬
sults which cannot be influenced by the personal modalities of
the senses or of the mind.
350
INSTRUMENTS OF BOTH METHODS.
Practically, the results obtained with "the instruments, and
methods of physical diagnosis are the? expression of individual
sensory impressions rendered in the individual's own language
—impressions and language which necessarily vary from man
to man, and cannot be finally adjudicated by a more stable
authority From this modus operandi arise all the doubt and
controversies consequent upon auscultation and percussion;
what is perceived through the stethoscope can be controverted.
Practically, the result obtained by the instruments and meth¬
ods of positive diagnosis are given out by the instrument itself,
in traces,'^figures or diagrams which the imagination of the
observer cannot alter, nor his power of rhetoric enlarge or
color 'deliberate lying excepted). Their arithmetical or geo¬
metrical vesults will always come out identical, when taken in
identical conditions ; and though taken by several observers and
with different instruments of positive diagnosis, they will sus¬
tain among themselves a concordance that bespeaks truthful¬
ness, and which, moreover, could always be controlled from
whatever distance. What all the instruments of positive diag¬
nosis indicate are unchallengeable indications, which it remains
only to read aud interpret correctly; what the thermometer
says no man can contradict.
From this it appears that the instruments of physical diag¬
nosis may corroborate but not invalidate the testimony of the
instruments of positive diagnosis ; but that the latter can re¬
affirm or negative the findings of the former, and even can
testify of pathologic symptoms on which the other remained
yet (as is often the case in consumption) silent or doubtful.
Another practical difference between these instruments is
that those simply physical are more fitted to give an account of
signs aud symptoms as they are, and tl^e positive ones as they
villi be, also. Thus auscultation, speculation, etc., afford an
idea of the present state, but unless frequently repeated fur¬
nish uncertain and disputable clues to the progression and
durability of affections; whereas the operations of the ther¬
mometer, sesthesiometer, ejtc., need hardly be repeated twice
in ordinary cases, to permit the prediction of distant issues.
Therefore the former are decidedly best—but not exclusively
adapted to the diagnosis of actual diseases, and the latter more
pointedly to the pre-diagnosis (in a certain sense a prognosib
at longer range than usual) of the deficiencies and wastings of
prognostication by thermometry.
351
vital forces which threaten longevity) not so suddenly, but more
surely than disease itself.
Here thermometry and its allies in positivism almost cease
to be medical; become human, social, commercial, and the
most direct agents of progressive morality. I cannot, of course,
follow thermometry through all these new fields of observa¬
tion, even at the speed of the previous suggestions; and must
content myself with the delineation of a few of its most im¬
portant new features, commencing by those which directly
interest the healing art.
§ III.—Prognostication by Thermometry.
No part of our art is so interesting as prognosis. For Hip¬
pocrates, the best physician is the one who prognoses best; and
none made such powerful prognostications as his, which became
our fundamental aphorisms. Such is the origin of our store of
sapience, to which the antiquity, including the school of Salern,
added little ; the Renaissance, including Sydenham, a few sen¬
tences ; and which thermometry has already enriched by some
prognosticant aphorisms.
a.—Prognostications in Disease.
The Master had said: " The signs of improvement must not
appear too soon."
A true crisis (our defervescence) must come after the two
first periods (the effervescence and the fastigium) ; if sooner, it
is a cause of complications, the period of augment not being
well exhausted.
What remains of the disease after the crisis causes the reci-
dive or relapse ?
Critical phenomena without true crisis predict a difficult or
fatal issue, etc. The moderns have not been able to negative
any one of these magistral sentences, but have more or less
reaffirmed them with the help of thermometry. Wunderlich
did it in many circumstances :
Everything else being equal, the danger is commensurate to
the distance of the mean temperature from the norme.
A series of temperatures at 42° C. prognosticate death.
352 prognostications from the period of ustion.
A series from 40° to 41° C. prognosticate nine deaths out of
twenty cases.
When 43° C. is reached, death was unavoidable (Wunder-
lich) previously to the strict antipyretic treatment (W. Fox, Da.
Costa).
A fatal issue generally follows a series of temperatures from
40° to 41° C. (Hirtz).
A fatal issue generally follows several temperatures of
41.9° C. (Hirtz). * *
When the heat rapidly increases in the effervescence, it will
decline according to the same ratio in the defervescence
(Hirtz).
When the fever-heat develops slowly, it prognosticates a slow
decrement of a protracted disease.
When the temperature affects a continuous type, let us be¬
ware of a grave affection.
In typhoid fever, if no remission appear in the latter part of
the first septenary, the prognostication is grave (Thierfelder).
A great excursus between the morning remission and the
evening exacerbation offers a favorable prognostic (A. Beau).
In forming a prognosis about children, we must always
remember the extreme mobility and exaggeration of their mor¬
bid ustion (Roger), and the reverse about old people (Charcot).
Here is from Hirsh a tabulated series of prognostications,
which we reproduce for their intrinsic value, bujt more particu¬
larly as specimens of what any one of us can condense from his
private experience:
(b.)—Prognostication from the Length of the Periods
in Ustions.
Signs.
p f Effervescence..2 to 3 hours
"3< -| Fastigiurn ... .4 to 8 "
£3 ( Defervescence. 2 to 4 "
*44 ( Effervescence. .2 to 3 "
| ■< Fastigiurn ... .4 to 8 "
<y ( Defervescence. 1 to 3 "
Significances.
An access of intermittent, ephemeral
fever, febricula.
Acute inflammatory disease ; pneumo¬
nia, angina, pleurisy, typhus, scar¬
latina, rubeola, etc.
£ ( Initium 3 to 5 days }
_o -j Fastigiurn ... .2 to 3 septenaries >- Typhoid fever.
52 ( Defervescence.3 to 5 days )
•a f Initium 3 to 5 " }
■] Fastigiurn 2 to 4 septenaries [• Rheumatism and anomalous fevers.; J
jv ( Defervescence.3 to 7 days )
PROGNOSTICATIONS DURING THE INCUBATION. 353
These types can combine by borrowing one period from one
another.
The march of one stade indicates another as follows:
A rapid or short effervescence indicates a fastigium and a
defervescence equally short, like in intermittent.
An initial period of twenty-four hours prepares for a fasti¬
gium of a few days, with transient delirium in some inflamma¬
tory fever, like a typhus.
The slow and gradual invasion belongs to typhoid fever.
The same computations applied to the second or third stade
could afford quite as good an insight into the previous ones,
which the physician had no opportunity of observing.
(c.)—Prognostications by Thermometry during thr Incuba¬
tion of Diseases.
Prognostication must be supported by pvenotions ; and no
prenotions, or warnings of danger come earlier than thbge
given by thermometry. This new power was demanded, that
is to say, predicted by Claude Bernard: " Physic would have
made an immense progress if it was rendered capable of fore¬
seeing in health the morbid dispositions, and thus warning of
impending danger" (Principes de Pathologie Kxperhnentale).
Nearer to practical medicine, W. Squire judged that " the
investigation on the temperature-changes, preceding the dis¬
eases of infancy, may increase the certainty of our diagnosis,
and give us the power of identifying at the outset those dis¬
eases most requiring early recognition, and of preventing the
spread of'infections{Temperature Variations, etc.) " The
study of all what pertaina to the ingress of disease may be said
to commence " ..., etc. (The period of infection' in epidemic
diseases, London, i871). To the same sagacious observer is
due part of our knowledge applicable to prognostication dur¬
ing the period of incubation, and to the possibility of restrict¬
ing infection in the narrowest limits, particularly among chil¬
dren.
The diseases which have a short incubation—scarlet-fever,
diphtheria, plague, cholera, yellow-fever, diarrhoea, influenza,
dengue, erysipelas; and those which have a longer incubation:
small-pox, vaccina, measles, rubeola, mumps, varicella, typhoid
fever and typhus; also those which partake of both characters,
23
354 THE PERIOD OF INFECTION COMMENCES.
whooping-cough and relapsing fever—all these infectious and
other communicable diseases, though different in other respects,
agree in these: that their mode of incubation, long or 6hort,
has shown, as far as our studies go, two successive and well-
differentiated periods:
A first one of latency, or of insertion of the virus—the poi¬
soning proper—in which the germ is sunk in the system ; and
that of pullulation, or proliferation, in which new germs per¬
vade the organism, which will try to throw them oft' by all its
possible issues, or to combure them by excessive ustions ; either
of which alternate efforts of nature we call the disease.
But this fruitful issue is often replaced by a fruitless one
that is, by an abortive fecundation of the virulent germ. Either
the poison lacked the conditions of vivacity, or the system was
unpropitious to its germination, and—almost or quite harmless
—it is expulsed during a pseudo-crisis. So terminate the im¬
mense majority of cholera poisonings in diarrhoea or cholerine,
of scarlatina and measles in roseola, of diphtheria in more or
less benign tonsillitis, of variola in varioloid or varicella, etc.
The seeds of diseases, like the seeds of plants?-would destroy
every other form of life—ours the first—if they were not them¬
selves as perishable as any.
However, not concerned here with this conservative process,
we are oiily trying to find out the effects, upon human calori-
city, of the initial periods of insertion of these seeds, which,
either being more viable, or having fallen in more favorable
ground, will not only reproduce the pathological conditions
they are heir to, but will spread far away their impalpable pol¬
len-like germs. In this line of inquiry, thermometry has shown
in a large majority of cases—yet not with such unanimity as to
proclaim it a law—that during the process of infection the first
period is innocuous, the'second poisonous, and why ?.... Be¬
cause in the first period—that of insertion—the movement of
the virus carries it from the periphery to the centres, not from
the periphery to the surrounding tissues ; is entirely centripetal,
therefore does not possess the power of contagion ; where it
lias been well observed, it was thermoraetrically characterized
bjr a lowering of the temperature. And, conversely, in the
second period, that of pullulation, the movement of the virus
becomes centrifugal and communicable to the surroundings,
even before it> has made its appearance at the periphery; it is-
thermometry op incipient phthisis.
355
always accompanied by a rise of temperature, whose initium
and movement, once well established for each infectious dis¬
ease, will constitute its thermic prototype. Then will be known
the precise commencement and the duration of this period, in
which the infected mast be. sequestered one way, and the
exposed ones another.
Dr. Squire remarks on this snbject: "The old quarantine
of forty days, or six weeks' isolation, allowed to prevent those
who have suffered from an infectious illness to carry it to
others, singularly approximates the conclusions of experience."
It may not be always found sufficient, as in severe cases of
scarlet-fever, or may be excessive in other ailments; yet, as a
general measure of security, allowing three weeks for the incu¬
bation and the course of the disease, and three more for the
convalescence, the infected party must remain isolated about
forty days. For those who have only incurred the possibility
of infection, a much more restricted isolation is sufficient, from
three days to three weeks. (See Appendix IX., a, b, c.)
But prognostication by thermometry does not stop at the pre¬
diction and prevention of infectious diseases. It equally detects,
and can stop the inroads of dialytio tendencies, particularly
those due to a discordance between oxidation and nutrition, and
represented by the processi of incipient, or recurrent, or hasty
tuberculizations and consumptions.
(d.)—Thermometry detecting incipient Phthisis and other
Ingipiences.
During tuberculization all the signs expected from the keen¬
est recourse to physical diagnosis may be silent, whereas ther¬
mometry will give out the positive evidences of the consump¬
tive processes of ustion. Sydney Ringer called outf attention
in I860 to this superiority of the positive over the physical
method of diagnosis, as permitting to establish the prognosis of
phthisis before it is incurable. According to the/talented, pro¬
fessor of the London University Medical College, and notwith¬
standing quibbling objections, thermometry gives a pr'enotion
of the impending danger in time to avoid it. In the three
recognized forms of phthisis, the catarrhal, tuberculous and
fibrous, the diurnal movement is this: temperature higher in
356 thermometry detecting other incipiences.
the evening than in the morning, irrespective of intercurrent
fatigue or excitement 5 and later higher in bed early than up
at noon, and worse again at dusk. And the course of the dis¬
ease is marked generally more than once by a, long-run move¬
ment of elevation during the formation of deposits ; by a period
quite normal when the morbid products cease to be formed;
and another, even subnormal, when the elimination of these '
products leaves the subject exhausted—three periods which
constitute the rotation movement of consumption. Ordinarily,
the initial period of pyrexia is not missing, but missed by want
of timely observation ; and yet Sydney Ringer noted it twenty
times out of twenty-four cases : whence he concludes that these
thermometric observations afford a delicate and valuable test
of the continuance, the amount, and the cessation of tuberculi¬
zation.
It is readily understood that phthisis is but on« of the con¬
stitutional degenerescences by consumption which may be
reined up, enrayees, by the timely disclosures of pathological
ustions by thermometry. I have room only for an illustra¬
tion :
May B , Hudson Street, set. 7, growing fast, fond of read¬
ing, takes suddenly to her mother's lap as a baby ; feels well
nowhere else. Pulse frequent, harsh, almost rheumatic; no
pains, no chills. Axill. T. .5° C., increasing in the afternoon to
1.5° at home, to 2° coming from school. Feet cold, hands
warm; no transient flush on the cheek or ear; no cough;
pupil dilated; slight headache; insuperable bodily languor.
Undressed she presented three lateral curvatures, the largest
deviating from the axis almost two inches. Allowed to lay on
her back, and to exercise moderately every alternate hour;
Liebright chair, fresh eggs, beet and veal broth, or jetty,
every hour, besides the family fare; insolation and rest on the
hot rocks of the Park. Two months later temperature almost
even from morning to night (.1°—.2° C.); back almost straight;
the child cheerful and active again. Had the temperature said
nothing, there would have been no physical examination, and
she would have grown distorted.
thermometry detecting simulated diseases. 357
(e.)—Thermometry detecting Simulated and Dissimulated
Diseases.
It takes a life's experience and exceptional opportunities to
form an idea of the large part these exceptions play in physic,
and of the difficulties encountered in detecting them, or in
dealing with them. Some are ignored by the patient himself
or his relatives, who attribute the incapacities resulting from
the unknown cause to laziness, ill-will, etc. Some are the
result of epileptic seizures known to nobody. More are dis¬
simulated, to be kept in responsible or lucrative stations, to be
admitted to the privileges of insurance, mutual associations,
etc. But how many more feign a disease in order to be re¬
lieved from duty, to escape danger, confinement, hard fai;e,
hard work, to regain freedom, to enlist sympathies, to exercise
a moral pressure, to create a stir, to act sickness as a fine art, for
lucre, or for the sole pleasure of deceit, or of being petted,
pitied, etc. In this order of simulation there are constantly
some people making it their business to live without food;
cataleptics and epileptics at their own hours—not at yours ;
febricants, vomitants, rheumatisants, egrotants of some sort, in
colleges, shops, prisons, asylums, navies, armies. Old Turcoes
from Algeria can beat any doctor vvitli the description of their
last attack of tertian fever, but not impose on the thermometer
a rise of 3° C. at the next access. Once 60,000 men out of
120,000 on the sick-list were playing possum in hospitals, actu¬
ally paralyzing the American army, because thermometry was
not applied to give them the lie, and send them to the front.
In this country more than anywhere else will be felt the
want of starting our diagnostic and prognostic operations from
their only irrecusable base—the individual norme of the great
vital functions. In Europe every traveller or ouvrier must
have his passport, or livret, bearing his signalement, or signs of
individuality ; but how much more useful signalement would
be a livret describing everybody by the signs of his thermome¬
try (general and local), sphyginography, plessimetry, spyrome-
try, sestliesiometry, etc. Then let any one be sick without help,
or simulate sickness, or deny his identity; his livret of vital
signs—stud-book—or ita copy from where it was issued or last
358 THERMOMETRY DETECTING DISSIMULATED DISEASES.
registered would tell of what disorder lie is affected—roguery
or sickness.
This physiological passport ought to be held in honor as the
book of nobility in an age of equality: a good physiological
record showing more blood than does a crooked heraldry. In
this order of ideaa we rapidly drift.
CHAPTER XL
FROM MORBID TO HUMAN THERMOMETRY.
Laplace said : " Si Von considere avec attention la s4rie des
objets de meme nature, on apergoit en eux et dans leurs change-
ments des rapports qui se manifestent de plus en plusdmesure
qui la aerie se prolonge, et qui en ts etendunt et se generalisant
sans cesse conduisent enjin au principe dont Us derivent." This
description of the ascension of an idea in the human mind, from
its incipience in a point of fact to its crystallization in the form
of law, orpvincipium, seems to have been given to justify the
transition of our idea from morbid to human thermometry. In¬
deed, being true for one, it is true for all generalizations. There¬
fore, as we are conscious of this leading power, let us be carried
where all ideas come from, and go, to their synthesis.
We have seen the utility of thermometry for the sick,
and for those exposed to contagion or infection, or threatened
with some form of hereditary or constitutional degeneracy. Let
us now consider its usefulness for those interested in the issues
of disease, be they a family, a social circle, an industrial group,
or a whole nation. Before entering the generalities of the sub¬
ject, let us report its three last historic illustrations, which bear
respectively on: 1st The power of thermometric indications to
warn of a fatal issue; 2d. The positivism of the signs given out
by thermometry; 3d. The authenticity of thermography in
historic contingencies.
I.—Thermometry Lessons.
(a) from orleans.
u Thermometry warning of fatal issues."
In 1872, a young Duke of Guise died in a religious semi¬
nary of Switzerland, from acute meningitis, induced by over-
study.
360
TH^BMOMETBIC LESSON FKOM CHI6ELHUR8T.
In 1873, his cousin, a Duke of Montpensier, died of the same
disease, brought on by the same cause, in the seminary of the
8ishop of Orleans.
The men in charge of these religious and learned haunts pre¬
tend to know all the particulars about the hyperpyretie tempera¬
tures of one of the next worlds, but do not seem to care about the
deadly combustions resulting for their charge from over-work,
juvenile exhaustions, etc. Therefore, having neglected the
warning of increasing ecarts between the morning and evening
temperatures of their pupils, they fervently prayed for a miracle,
saying: Les miracles sont la voix de Dieu.
That is bad enough for the little dukes, but how much worse
for peoples; since these men who sent those grandsons of Louis
Philippe to heaven—not an unfit place for princes, though—are
the same who claim the right of educating all the children,
and who invade the school in all countries'! In France, to¬
day, education is at the mercy of this same Bishop of Orleans,
M. Dupanloup, who, by his ignorance of the indications of
thermometry in education, and particularly of its warnings
during the growth-period, wilfully caused the death of his
charge, Fernando, Duke de Montpensier.
(b) FKOM CHISELH URST.
" Importance of electro-thermography."
When Napoleon lay low at Chiselhurst, a wire from his bed
to his doctor's desk could have sent thither his thermometry in
figures, even in curves, the sphygmographio traces of his heart
and wrist, besides the other signs of sudden collapse, and in
five minutes have returned prescriptions which could have
supported life according to rules in such emergencies; instead
of which, the physicians in charge used the steam as mean of
communication, and when coming to the rescue found him dead.
I do not wet my handkerchief for that; I merely say: by con¬
necting our self-registering instruments to the telegraph, and
placing at the other end a paper imbued with millimetric water-
lines, we can reproduce from one continent to another the
curves of temperature, the movements of a muscle, the flap of
the wing of an insect; and when the dying insect is an emperor
his last temperatures are good thermometric lessons, to which.
THERMOMETRY LESSON FROM BANDRINOHAM. 361
Bossnet would have invited an auditorium with his grandilo¬
quent : Erudimini reges / ... .
If I am well-informed, the treatment of Senator Sumner by
Brown-Seqnard was, for years, conducted through the telegraph.
Thus all the progress of art, of mechanism, and of science, must
advance hand in hand, as they are represented by noble figures
around the chariot of Apollo.
((?) FROM SANDRINGH AM.
" Authenticity of thermography in historic eventualities."
"When a person of high station becomes sick, so many inter¬
ests stir about his couch, and bruit interested accounts of the
illness, that one of the first wants, from the first hour, is an
authentic record of the case.
Never was this want more felt than during the typhoid fever
of the Prince of Wales. Yet we simply heard that the Prince
was better, worse, recovering, sinking, rallying, convalescing,
relapsing, and finally out of danger. For many weeks this was
all the news given to an attentive world. The prognosis was
as wavering, and seemingly as uncertain as it might have been
half a century ago, before thermometry or sphygmography was
dreamt of. Naturally, these bulletins, very much resembling
those issued from Metz, when France had the misfortune of not
losing Louis XV., alias le bien aimd, were soon distrusted, and
accused of exaggeration, even of falsehood; and openly said to
be calculated in view of manufacturing loyalism, even for the
vile object of fostering gambling combinations.
That men like Dn. Jenner, Gull, aud Lowe, whose scientific
reputation is so high, could have exposed themselves, and the
medical profession as a body, to .such impossible imputations,
shows that there was a serious misconception of their duties not
to their royal patients, but to the science of medicine, and that,
at a time when they had the whole civilized world for an
audience.
It seems that the cause of their mistake was the idea that
the Majesty of the subject precluded^the possibility of publish-
inc the true clinical record of his sickness, as if the disease
should behave differently in a prince than in a simple hospital
patient This courtly idea offers the only extenuation for the
unscientific character of these bulletins, but is far from find-
362 theemometkic .lesson from sandringham.
ing its justification even in courtly habits and traditions. For
these traditions and habits have always been, in case of sickness
of a queen, king, or crown-prince, to issue bulletins, as com
plete as the science of the time could afford, and to keep the
royal patient constantly in view of some of the high officers of
state.
And why that publicity of sickness and death; why cannot a
king agonize quietly; why must peoples prey upon his decom¬
posing form by minute reports and by de visit proxies ? Evi¬
dently because a prince—whatever may otherwise be his indi¬
vidual worth—is a cipher, whose social value is borrowed from
the millions standing by him—millions who have never been
denied the right to know what becomes of the zero.
Therefore we do not hesitate to affirm that, if the physicians
of the Prince of Wales in issuing their bulletins have literally
conformed themselves to courtly traditions, in avoiding or
neglecting to stamp these bulletins with the seal of modern
positivism, they have left the door of their council chamber
open to untrue but deserved suspicions ; they have neglected a
solemn occasion of impressing the people with the precision of
the methods of observation which have been substituted for
guessing at the bedside ; and thereby these eminent physicians
have, in no small degree, lowered, or at least preventecj^the
legitimate rise of the standard of physic in public estimation.
On the contrary, let us for an instant suppose that these ejjii-
nent men, improving the opportunity actually offered to them by
the traditions of all the courts of Europe, would have clothed
their bulletins in the scientific form adopted by the medical
institutions of London, Paris, Vienna, Berlin, New York;
these daily or hourly reports would have been written in a few
figures and summed up every septenary. They could also
have been accompanied by a few commentaries, such as escape
from the lips (if a medical man looking ac the table of vital
signs appended to the bed of an ordinary subject of typhoid
fever.
Supposing that these popular and progressive views had
prevailed in the judgment of the physicians in charge at
Sandringham, the world would have assisted at a novel and
dramatic spectacle. We do not mean the spectacle of the
pitiable youth slowly eaten up, then let go by the ulceration of
his Peyer's glands—wo mean the narration, by telegrams, of
THJERMOMETRIO LESSON FROM SAJNDKINti-HAM.
363
the phases of an almost typical case of complicated typhoid
fever. Never before would nations have listened to such a tale,
mainly told in advance, like a prophecy, by t\ie thermometer ;
never such interest would have been attached to predictions of
better or worse, foreshadowed on the stem of the instrument,
and to the degrees of vitality infused in the patient by tonics
or food, and written in the pulse-wave of the sphvgmograph.
Such a medical problem would never before have been solved
to a larger or more interested audience : no better opportunity
could have been found to prove to the civilized world how
much of a science medicine has come to be. . *
If this mode of bulletins had been adopted—and we firmly
believe that Aitken, Sydney Ringer, Wunderlich, S6e, or Jac
coud would have carried it out—what an impulse would that
lesson on positive diagnosis have given to the profession; how
higher would physic have instantly ranked in the estima¬
tion of the public ; and, to speak but once like a courtier,
what a chance the prince would not have lost of being as use¬
ful and celebrated for his sickness as his father was for his
goodness! These are some of the lessons we had, and had not,
from Sandringham.
[ CHAPTER XII.
L—SOCIAL PROGNOSTICATIONS.
Let us take a larger view of our subject. By the comparative
study of the concordance and discordance of the three great
vital signs, and by the concurrent use of the thermometer, with
the sphygmograph, the myograph, the microscope, the sesthesi-
ometer, the dynamometer, and other instruments and methods
of positive diagnosis, we have already (Part II., Chapter V.,
§ 1) been enabled to establish several of the mathematical rela¬
tions of the great functions during their alteration in plus and
minus by disease. Now the rationale of the same elements
will soon enable us to settle, like mathematical affairs, all ques¬
tions relating not only to disease, but to vitality, longevity, and
adaptability to the various climates, altitudes, longitudes, train¬
ing, studies, sports, indulgences, labors, individual and social
fitness.
I will first remark that thermometry and its adjuncts are of
paramount importance in all the interests resting upon the con¬
tingencies of life or death. In all important questions men
want to know the future; in a state of expectation anything is
better than nothing. On the banks of the Cephyse, Niger,
Orinoco, Winnipeg, as in the by-streets of London, Paris, New
York, the sac a medecine, the cards, the sibyl, the gypsy, the
turning tables, the bones of St. James, Ste. Rosamonde's tooth,
etc., are asked, What next ? The educated classes, knowing the'
trumpery, silence their curiosity or satisfy it in secret, half
laughing, half credulous. And it is a pity ! Since astronomy
succeeded astrology, and chemistry alchemy, as sure as positive
diagnosis is slowly but surely taking the place of conjecture
and imposture.
It is a pity for which we are responsible. We ought to edu¬
cate our public to understand the individual, commercial, and
SOCIAL PROGNOSTICATIONS BY THERMOMETRY. 365
social value of the predictions founded upon the signs of health
and vitality given out by the physical, chemical, microscopic,
and thermometric methods of diagnosis. Their knowledge
makes us the exponents of the laws of temperature, physio¬
logical dynamics, and affinities; from the observance or derelic¬
tion of which we can predict the ri^e or fall of conceited self, of
ignorant families, of blind nations. That is our main function
in society, besides that one to which we like to confine ourselves,
of Sextons of Catalysis. Let us remember: the excellence
of the physician is in the prognosis. (Hip. Progn. 1.)
To speak pointedly, I mean to say that our main function is
to advise, not only the sick, but those who, being well or appar¬
ently well, may become exposed, or protract their exposure to
loss of life, or to incapacities, infirmities and failures worse
than death by lysis, through the crevices open in their vitality
by the straining of the exigencies of modern life.
In this part of our profession we claim the whole world for
our client. "VVe have the instruments and methods, we must
also hatfe the skill to prognosticate in all matters of life and
death which are not accidental, but depend on series; to pre¬
dict for instance, therefore to prescribe the kind and £ea;ree of
education and of the various trainings children can stand ; the
climate and the climatic changes required for their growth and
maturation to a healthy virility. In the choice of a life-part¬
ner a discrepancy on the tenets of a credo were once all-im¬
portant; now the question of physiological harmonies takes the
precedence. In this solemn dilemma the physician can test the
power of absorption of one of the parties on the other; for, in
a wife, a young man will find rejuvenation—like Antaeus each
time he touched the ground—or bis vitality will be pumped out
as by pneumatic suction. For young women, discrepancies of
a somewhat different character are still more murderous, whose
tests are not the articles of the Nicean creed.
Before young people wed themselves to the world by the
choice of a profession, our meters must have measured their
capacity for outdoor or sedentary occupations, erect or stoop¬
ing postures, standing or moving-about trade, cerebral or spinal
work, etc. Before they plant themselves, and likely their race
in a locality, they must be informed about the kind of air,
water, soil, vegetation, food, necessary for their prosperity and
happiness; since the terrestrial paradise we all look for is not
366
THE THERMOMETER FOR LIFE-INSURANCE.
at a pre-fixed longitude and latitude on earth, but where posi¬
tive observation teaches ns that we can keep at the permanent
zero of the physiological thermometer. In these matters phy¬
sicians must be teachers too.
Indeed, I do not consider them exempt from blame who keep
the knowledge of the social value of these positive tests of
vitality to themselves until they are urged, in the name of the
sick or the dying, to communicate them. Men educated as they
now are to be blown up without the sixteenth part of a 6econd
warning, must be, methinks, prepared to see without flinching
the advance of the signs of their own devitalization, with two
compensations—one that the chances of postponing the crisis
are offered by him who prognosticating best can prescribe best
(Hip. Progn. 2); and the other, of quietly settling the interests
of those dear to them, in view of the eventuality of the foretold
departure,
But life and death are no more the simple individual phe¬
nomena they used to be in mankind, as among the rabbits.
The most insignificant unit of the genus (woman or man) can¬
not disappear without breaking social or financial connections.
In this respect the thermometer holds in its tiny stem the fate
of mighty interests ; let us only consider how fare without it,
and how would fare with it, those interests having their origin
in life-insurance policies.
II.—The Thermometer for Life Insurance.
The financial guaranties presently offered by the life-insur¬
ance companies are considered as very insecure. I know noth¬
ing of the accusations published against their officers; but I
know that if these smart men were not looking somewhere else
ZD
for a set-off, most of their concerns would soon break down
nnder the mismanagement of their medical (diagnostic) depart¬
ment : there is the flaw in the life-insurance companies. They
have remained profoundly or willingly ignorant of the re¬
sources offered them by the recent improvements in vital diag¬
nosis ; in the midst of the progress of all trades and industries,
few of them have improved the medical guaranties devised for
their own security half a century ago; meanwhile the appli¬
cants for policies have became more and more crafty in the art
of insuring death instead of life.
THE THERMOMETER IN LIFE-INSURANCE. 367
It is very seldom that a man actually sick asks for the benefit
of a policy of insurance (for which physical diagnosis would
instantly detect his unworthiness); it is, on the contrary, of
common occurrence that, as soon as a man feels, or his relatives
suspect, that his vital powers are imperceptibly but steadily
declining, he becomes an applicant for a policy; the larger,
because they know he will not live long enough to pay several
annuities. On these cases physical diagnosis throws very little
light indeed, whilst the instruments of positive diagnosis would
denounce the fraud with unanswerable evidences.
Two cases which recently came under my observation illus¬
trate the respective situations of the insurer and insured.
A man of sixty-five, after an attack of apoplexy followed by
slight paraplegia, had iiis life insured and died within a year.
Another, not over forty, but completely exhausted and worn
out, came to me boasting that a company had insured his life,
notwithstanding that I had told him that I would not give two
cents for it; within six months he had a pneumonia that he had
not the vitality to carry to the seventh day. Moral No. 1.—
The wives of each respectively pocketed five thousand dollars.
Moral No. 2.—In the former case, the sphyginographic traces
would have been blunted by senile calcification, and otherwise
distorted by the irregularity of the waves of the circulation.
In the latter case, thermometry would have shown evening ele¬
vations of temperature of more than two degrees; both patho¬
logical signs forbidding or invalidating any contract of insur¬
ance. In this unequal contest, the managers of the life-
insurance companies are said to resort to unfair means, instead
of borrowing their protective weapons from science, which
always comes to the rescue of those who diligently ash for its
assistance.
The officers of these companies know from long experience,
that their great losses do not result from mortality caused by
acute diseases, casualties largely provided for; but that they
are imposed by comparatively sudden demises due to chronic
conditions not diagnosed by their physicians, and not provided
for in their calculations. Knowing this, they should soon have
learned that the means of physical diagnosis employed by their
agents were more appropriate to ascertain actual diseases than
to measure the vitality and longevity. A step more in the
same line of inquiry would have taught them that the instru-
368
thermometry in sohooifi.
ments and methods of positive diagnosis, the thermometer, and
-the study of temperature in particular, offered them the surest
guaranties against the dishonesty of their customers.
Who of these smart men would not instantly have introduced
thermometry among the means of examining the applicants for
a policy, if lie had read what Sydney Ringer said in his Tem¬
perature as a Means of Diagnosis :—" The temperature may
be taken as a measure of the amount of tuberculosis and tu¬
berculization, and any fluctuations in it indicate corresponding
fluctuations in the severity of the disease. The temperature is
a more accurate indication of the amount of tuberculosis and
tuberculization than either th.& physical signs or the tnfmptoms.
By means of the thermometer we can diagnose tuberculosis
and tuberculization long before the physical signs and symp¬
toms are sufficient to justify such diagnosis." And what is
more pathognomonic of paralysis, for instance, than a progres¬
sive difference in the contractility or tactile sensibility of both
sides, as mathematically demonstrated by dynamometry and
aesthesiometry ? . . « yet who enters these positive signs in the
calculation of probabilities of life insurance?
Soon the signs given by the method and instruments of
positive diagnosis will certainly increase in number, accuracy,
value, and importance; but even as they now are, they offer to
the life-insurance companies—without excluding other methods
of observation—the surest means of fighting successfully the
ever-living demon of cheat, and of fairly and successfully
managing their own business 011 a cheaper and more remunera¬
tive basis.
But dear as money may be, there are things dearer yet, upon
which thermometry and positive diagnosis will be brought to
exercise a leading control; among these I name Education.
III.—Thermometry in Schools.
I hope the next progress in education will be such that,
before twenty years my veracity will be impugned for skying
that in thia present month of October, 1875, out of three mil¬
lions of children entering the schools of our country, not one
will be examined in regard to the state of his great vital func¬
tion^ the harmony of his motor and sensory apparatus on both
THERMOMETRY IN SCHOOL8. 369
^ides, the effects of muscular exercise and of mental efforts
upon his circulation, respiration, and local and general tempera¬
ture ; and no individual record taken of these, to ascertain the
effects of the curriculum- ujpon the further development of the
children.
To me the subject is so'impressive that I hardly dare to touch
it; still I must go on, knowing the while that I cannot expect
to do it justice i!ri these few brief paragraphs. Even in my
Meport to the American Government on the questions of edu¬
cation as represented at the exhibition of Vienna of 1873, 1
Jhave not given to that question the prominence it deserves.
During the years children go through their school education,
they have to grow too ; so willetli Nature. One of the effects
of this transitory function of growth is' to throw a great dis-
turbance upon the ordinary functions; the more since, by a con¬
stant interstitial accretion of neoplasm and new cells, every part
changes its actual, and all parts their relative positions in each
organ as well as in the whole body. Some children die in this
body-quake, and more com6 out of it bent or crippled, never tor
rise again in beauty and capacity. But what of those who,
meanwhile, have to pass through the ordeal of stupendous
studies or stupid immobilizes? (See th'e lesson from Orleans,
page 360.) They are superintended and taught by doctors in
all the faculties, but they have not yet seen the one whose duty
it is to be the keeper of the ledger of their vital resources.
Out of the cyclopaedia of symptoms which warn against the"
* degenerescence of organs, and the exaggeration or decline of
functions in children under training, X will suggest: the daily
elevation of general temperature during the latest hours of
study ; and the following* irregularities in the distribution of
local temperature—as p£K ^fade-thermometer. Extremities
k cold and body too hot. General coldness", With either dry heat
in the palm of the hand'j or a Cold and abundant moisture of
the whole hand. The-same general coldness with parched and
peeling lips, and inordinate thirst; or localized heats signalized
foy a flush on one cheek, oftener on one ear, not always on the
; same side-; or an over or unequal temperature on the two tem¬
poral regions, marked by a deeper blueness of their venous arbo-
j-escence. The hand-thermometer and the sight admonish of
- these dangerous anomalies, the fever and surface-thermometer
" 24
~J a separation or tne-com
THERMOMETRY IN SCHOOLS.
measure them, the thermoscope too; and also the pyrogenic
action of the element^ which enter into the school life.
The body development of the youth is accomplished by os¬
cillations, zoological seasons corresponding, if not in times, in
operations at least, with those which regulate the development
of vegetables.' In one of the, springs of these physiological
years of children, sos&e of fell em will undergo remarkable
changes, of which note. the. flowing:—
They feel all the u^ea&iness attending growth, and yet they
do not grow; but symptoms which cannot be synthetized under
the name of a particu&f- sickness lurk about their frame—mark
their anorexy and dirt-gray skin. If this state is not closely
watched by thermometry, and treated by revolutionary changes
of climate, training, food, etc., a secondary fever supervenes,
which carries off the child ; or receding, leaves bare to view a
constitutional affection: this process of degenerescence of a sys¬
tem affects particularly the nervous^ lymphatic, and osseous-
In another case the child looks above his fellows in ampli¬
tude, freshness, and rich curves j he is amiable though irri¬
table, kind, and studious, but h^3 oftener become tired,, than
can be accounted for. The danger is of a degenerescence of
apparatus—of the locomotion, for instance. Whoever has
followed with wonder the hasty spring growth of an elder's
sprouts, and seen one of theip suddenly dry up pithless amidst
its sappy fellows, can form aa idea of this degenerescence of'
special organs by localized deficiency of nutrition.
This form of localized arrest of nutrition, French de droit I
(Trousseau), popularly degras, is always unilateral, a character/-
which permits us to detect it early, by the comparative use, .om
both sides, of the instruments of positive, diagnosis : of the surf-
face-thermometer, which will detect a coolness of half a degreec
and upward on the suspected side, long before-&ny other-sig^n
of the affection can be otherwise descried; o£ accurate mea¬
surements which will spy thc^'difference of size.of the limbss:
of electricity and sesthesiometry, delicate tests of tactile sen¬
sibility; of the dynamometer which gives mathematical, emi-
dences of difference of contractility located in tl^p hands aad
arms; and of the dynamometric swing, excellent test of t\kit
of the lower limbs.
The gravest affections of the nervous systems, central asocd'
peripheric, visit the young student in proportion, it seems.
HUSBANDING THE VITAL FORCES.
371
the severity of his training; and are almost unknown among
the young vagabonds and street boys. I intentionally choose
these two extremes to show what nutrition is, and what non-
nutrition can produce. The college children are better fed
than the abandoned children; yet they receive legs nutriment
from their food because they spend, in mental and other exer¬
cises, more of the pabulum vitas than their food—supposing it
the best—could afford. To show that this bunkruptcy of nutri¬
tion, by inordinate expense of the pabulum, is the cause to
which we mast refer the majority of the nervous affections I
have in view, and their reactions on the rest of the economy, I
refer again to one too frequent and too fatal among young
scholars—m eningitis.
It is in its various forms as complex as the etiology of these
forms. However, from the baby who ceasee to be nourished,
though he is fed, the moment his nurse becomes pregnant, from
the child overpowered by heat, and the student by his studies;
that the subject be not nourished enough, or spend too much
pabulum, the multiform affection—under the symptomatic
name of cerebral fever (Trousseau)—may be referred to an in¬
sufficiency of the vital properties of the blood, and its causes
synthetized in deficiency of nutrition—of whatever origin of
course.
IY.—Husbanding . the Vital Forces.
For there are more ways than one to starvation. When
we spend more than we can assimilate of forces expressed by
caloricity, as in the previous example of the school and vagrant
boys; when the blood is not well oxygenated, nor rich in red
corpuscles; whenever it does not penetrate all the-tissues, by
circulation and endosmosis; whenever its serum lags behind in
its primary form, or in that of lymjDh, pus, effused fluids, sur¬
rounding or not miliary and tuberculous deposits, there is defi¬
ciency of nutrition.
And as there is a general and a, local circulation, there are
local as well as general starvations, caused by the devitalized
elements of the blood remaining behind in certain localities,
If it is cruor, it produces gangrene, dry-rot, etc.; if it is serum,
it produces dropsies, tubercular affections, etc. A continuous
congestive iftofce (orgafim) disposes to a separation of the corn
HUSBANDING THE VITAL FORCES.
ponents of the blood, and to their transformation into secondary
products, as much as a prolonged scantiness (anaemia); hence
the unrelenting attention exacted from young students makes
their meninges the particular seat of vascular congestion, which
cannot fail, sooner or later, to end in thickenings and protean
formations, which devote the school-laureate to vulgar incapa¬
city, imbecility, or death.
The teacher must know that all the operations exacted from
a child—actions, perceptions, emotions, imaginations, thoughts,
and volitions—are the direct, reflex, or converted products of
sensory and cephalic movements, manifestations of a force.
This neurine force is fed and spent, never lost, but converted
into labor or wasted in shocks and frictions. In regard to this
neurine force, those who assume the charge of the youth will
have twofold duties: one to direct its usage through the mus¬
cles, senses, and mind, so that they could produce the most
valuable labor with the least friction or shock ; the other to
keep a constant equilibrium between the forces incoming and
those going out. But this duty includes a third, more impor¬
tant than both: it consists in husbanding the nervous and cor¬
relating forces, so that the children will have enough, not only
to spend in labor, in growth, and in necessary repairs of their
organism, but always enough in store to spare for an emergency,
like extra work, exposure, disease, surgical accidents, etc. This
investment, managed by the true manager of a school, is the
real insurance of life and of future capacity ; without it, the
existence or the welfare of children are never secure.
Therefore, not content with having ascertained their condi¬
tion at the beginning of each course, we must continue to re¬
cord their vital signs and the working of their functions periodi¬
cally for all of them, and more frequently for those whose con¬
dition is suspicious. The general thermometer will detect fluc¬
tuations (more than diurnal oscillations) in a child too much
confined ; the local thermometer will descry a line of fever-
heat at the base of the forehead in another who overtaxes his
memory ; the sphygmograph will trace the jerked pulse of one
who has been running or boating to excess, or an intermittent
one for more secret reasons; the spirometer will show a loss
of inspiration which corresponds with a loss of circumference,
or with a lateral depression in the chest, as per tape-measure
and lead circle; and the dynamometer will mark a weaker con
principles of economy 01" the forces. 373
tractility otherwise suspected by the circular measurement of
the arm and from the loss of body-weight, etc., in the young
one's crouching for hours upon books.
This positive knowledge of the organic and functional con¬
dition of each child once acquired and steadily kept up, like a
commercial account, let the programme of instruction, or even
the plan of general training be what they may—dictated for
some years yet, but not forever, I hope, by pride and love of
the useless—the man in charge of children must in any circum¬
stances manage them upon this physiological basis:
Every animal is a producer of heat, and correspondingly a
consumer, too.
He must produce enough of it to live, to grow, to repair its
constituent elements, and to move towards its ends, whether
man, child, bird, or buffalo (Appendix II.).
The degree of normal production of temperature is the mea¬
sure of the physiological capacity for action, alias latent force.
The first duty of the teacher is to see that there is no useless
consumption of this latent force by friction, shocks, etc., as
may be ascertained by thermometry.
The second is to supply this force by sufficient food, exercise,
aeration, and insolation.
The third is to consume this power in preparing the child
for the most useful and congenial modes of activity.
To work—at school or in the fields—the child consumes the
organic materials of his blood.
This ustion is the sine qua non condition of labor.
The thermometers are the ' meters' of this local or general
ustion, and therefore the index of the capacity of each child
for labor.
I most respectfully call the attention of the otherwise so
learned and capable superintendents of schools and seminaries
towards these principles, the bases of the physiological condi¬
tions in which the children must be kept during the entire
time, and at the different periods of their tuition and growth.
This must be the object of the earliest reform. The man
who understands best the pyrogenic conditions during labor
must be the teacher, not only of the pupils, but of the teachers;
and will cause to be written in each school-room—but in words
invisible for the young: the curriculum is made for the chil¬
dren, not the children for the curriculum.
374:
the thermometer in every family.
I began this exposition of the application of thermometry and
of the instruments and methods of positive diagnosis to the
general management of education reluctantly, knowing that I
would close it without having room or courage enough to say a
tithe of what has so deeply and painfully impressed my own
mind and conscience.
I enter more hopefully upon the exposition of the next point,
upon which positive diagnosis will be called to exercise a lead¬
ing control—the use of the thermometer in the management of
children by their mothers.
v.—The Thermometer in every Family.
I hardly need say to a mother that the question of tempera¬
ture takes the precedence over all others in the rearing and
breeding of her offspring. She knows that from the first
moment, coming out from its liquid atmosphere and its soft
surroundings, itself warmer than either, the new-born infant
feels our air like a chilly combination of needles and vinegar,
in which it loses at once several degrees of temperature—
enough to give the ague or kill grown people. This knowledge
by sympathy explains how, yet in pains, her first inquiry is if
the baby is warm. That is it. That is and will be the main
question. Is it warm ? ... Is it too warm ? ... Is it warm
enough? ... Is it equally warm? . . . That is it. She
knows more with her feelings than we do with our books. I
have only to show her how to make use of her heart-knowl¬
edge.
If the body-temperature is the first thing to be considered,,
the instruments to take it are the second, and the method of
appreciating it in health and disease is the third.
To nobody is the thermometric power of the hand so indis¬
pensable as to a mother. Happily the hand of woman is gen¬
erally better educated to feel than that of man; a great
superiority, indeed, which compensates for many assumed ones
on'the other side.
In nursing children, this capacity of the hand to feel—allied
to the other delicacies of contact and prehension of which a
feeling hand only is capable—is so indispensable, that I cannot
understand how those who do not possess these tactile and pre-
THE THERMOMETRY OF MOTHERS. $75
hensive delicacies of the hand dare to touch a new-born infant,,
for fear to break it.
Not that this delicacy of the hand is acquired by our present
systems of education: I have seen refined women handle a
child with their elaborately softened and bedecked hands as
pinchingly as the spider does a fly with her forceps; and rustic
women carry it in their clumsy hands as softly as Bouguereau's
mothers and sisters.
However, since there is an art in everything, and all baby-
nurses are not mothers, I will refer to the directions for the
use of the hand-thermometer given on page 255.
If asked when the band of a mother ought to be used as a
thermometer, I answer, without hesitation, always. But not
always in the same manner.
With a healthy child the ■caressing hand is involuntarily
inquisitive of any possible abnormal temperature; while, with
a puny or convalescent one it is the inquiring hand which is
caressing. But in sickness the anxiety of the mind is commu¬
nicated to the hand, which spends more nervous skill in inves¬
tigating the temperature than in petting, so that, out of the
millions of modes of contacts of the hand of a mother witli'
her child,I have dared to draw tactile categories corresponding
to the intensity of purpose of the application of that hand as a
thermometer—the necessity of the demonstration was my
excuse.
By the same rule, the urgency of using the hand-thermome
try begets its frequency as well as its topographic action,
"With healthy infants it has to be resorted to in the morning
before nine, in the afternoon after outside exposure, at bed-time,
and one hour or more later, without disturbing the sleep ; the
enrvey comprises the head, neck, chest, epigastrium, iliac
region, extremities, more carefully the epigastrium the first
year, the head (parietal and great fontanella regions) during
the teething, the iliac fauces when solid food begins to be
greedily and almost toothlessly ingested; the chest when the
outside temperature is any way excessive or versatile.
With older children the explorations should te gone through
whenever reckless activity, thirst of knowing, indulgence in
food or drink, and circumstances to be espied as they occur,
give rise to anxiety for any of the important apparatus of the
life of relation or nutrition, whereas the investigations will be
,376
HOW MOTHERS EXPLORE TEMPERATURES.
particularly directed towards the weak or affected parts in the
delicate or the convalescent.
Daring these more frequent than daily explorations, the
hand of the mother has acquired a delicacy of perception
which would be desirable in that of physicians, and by which
she is made aware of any true, general, or local disturbance of
temperature. With the hand alone her knowledge cannot ex¬
tend farther, .$he is made sure that there is a disturbance /
but it is only -with her two medical thermometers that she can,
in five minutes, gauge the extent and intensity of the abnor¬
mal ustion.
Here ends he.r part as a pre-diagnostician.
[I must say to her incidentally, that with young children
much contention is avoided by introducing the fever thermom¬
eter in the axilla from behind.]
As soon ps she has recognized the presence of a pyretic
affection by a sudden rise of 2°-3°, or a steady one from l°-2°
with fluctuations, or (that of an apyretic affection by a fall of
more than 1°, of which she must carefully snote the degrees
and fractions at stated times, the first part of her work is
ended; she has to transfer her responsibility to the physician
she knows most competent to bear it; here her independent
action ceases, and my direct advice to her also.
Every physician is alive to the importance of good nursing.
No pains, I -fcave repeated after competent authorities, must
be spared to form competent nurses. But when the mother is
also the nurse, we owe more to her, who works with us for
love, than to strangers, who work under us as a trade. It is my
opinion she ihas a right to know all th,at she can understand (X
purposely restrict this remark to thermometry) on the man¬
oeuvre and use of the surface and fever thermometers; and their
application to the present case; on the recording and signifi¬
cance of their reading; on the relations of human temperature
with health, disease, and therapeutics; and on the general
philosophy of thermometry, as far as her mind can go.
This is not all. Make her love, study, and trust the little
magician who, like the little finger in the fairy tale, tells things
that nobody can know otherwise. With it she will give us a
trusty account of the condition of her patient. During our
absence, her hand will be our hand, her eye our eye; and
jnpre, seeing a sudden rise or fall of temperature when we ar»
all women instructed in thermometry- 377
away, she foresees the peril that thermometry predicts several
hours in advance, as the barometer does the storm; her mind
becomes our mind, she hastens our return, giving us a chance
to ward off a deadly exacerbation or collapse; truly herself
saving the life of the patient and eventually our own reputa¬
tion.
Therefore let us educate women in the arts secondary to ours,
and particularly in the handling, recording, and intelligent
reading of the operations of the medical thermometers. And
when the hours of family trials and of heavy professional respon¬
sibilities come, when zymotic or contagious diseases invade the
home circle, we have by our side the faithful woman. Neigh¬
bors, quacks, and mediums proffer in vain their nostrums; she
stands by her thermometer, knowing that a calm and correct
record of a day's fever brings more hopes and is a better foun¬
dation for a cure than a dishevelled therapeusis. (More details
can be found in the little Manual of thermometry for mothers,
nurses, teachers, etc.)
Less solemn, but not less useful, is the prophylactic home-
use of the medical thermometers. I can only give one instance
of it: when parents are preparing for an absence, the husband
looks at his weather-thermometer to provide extra coverings
against the rigors of external temperature, and the mother looks
to her medical thermometers to make sure that she does not
leave behind, ignored, a bodily temperature foreboding sick¬
ness to one of the children in the next twenty or forty hours.
VI.—Family Health Records.
But mothers, teaehers, and physicians as well, need a stand¬
ard-measure upon which to proportion their action on the
young, the sick, the invalid. That standard-measure which we
have not and must have, will be found in a Stud-Bouk or
Health Record from infancy. This would be broader in its
scope than the Prescription and Clinic Record, previously de¬
scribed, which could conveniently be included in it; if it was
not better to leave the Health Record under the charge of the
mother, among the private papers of a family, and the Pre¬
scription and Clinic Record in the pocket of the physician.
The Health Record would begin, if possible, by the condi-
378
FAMILY HEALTH RECORD.
fcions of gestation, birth, nursing, teething, with inter-current
illnesses. Note the time at which the muscular and sensory
functions have begun to obey the will and to be co-ordinated ; at
which the mind passed from the simple perceptive to the du¬
plex reflective state. This done once for all, and as a basis,
the record would register every year, better every season, the
general growth and weight, the length and breadth of the prin¬
cipal parts, head, chest, etc. It would be particularly devoted
to the keeping of the vital signs as aforesaid; of the progress
of muscular contractility; of general and special sensibility
as given by physical tests and by positive mensurations, and
most particularly to the concordance and discordance of the
signs furnished by the circulation, the respiration, and the
temperature. Let us observe, in reference to the latter, that if
it be true that the general temperature in health varies but a
few tenths, it is not indifferent to know how these variations,
ever so small, are brought on; for, if by powerful emotional or
circumstantial causes,' this shows a constitution eventually
capable of reaction against catalytic agencies; but, if by slight
causes, we must be prepared to find the subject in ulterior
sicknesses, without much power of resistance to the morbid
process, or reaction towards recovery; in this latter case, a
trifling loss of a few tenths of a degree of heat is portentous.
Another order of pyrogenic facts, whose data in health, if
properly recorded, insure the ulterior formation of sound med¬
ical and educational diagnosis, is that given by the surface-
thermometers. The data thus furnished refer to the average
heat of regions like the head, chest, palm of the hands, and
comparatively of the feet, of the epigastrium, etc., in the
various seasons and under the action of food, exercises, stu¬
dies, sports, etc.; data of local thermometry which are to be
industriously compared with those of general thermometry,
of the pulse strokes, sphygmographic waves, spirometric indi¬
cations, etc.
Another order of pyrogenic facts of great practical value is
the one resulting from the application of the thermoscope to
the demonstration of the quantity of radiated heat, and of the
velocity of this radiation.
By the concurrent reading and interpretation of these facts,
carefully prepared and registered by the mother, teacher, or
family physician, the latter cannot fail to foresee a long way
co-ordination of plan.
off, in any or several functional disturbances, the coming or¬
ganic accident, and to stamp it out.
Who of us has not been seized by a feeling like that of giv¬
ing up at the sight of patients, mostly children, whose enigmat¬
ical symptoms cannot be illumined, neither by the unconscious
patient nor by the ignorant family? Then twelve lines of
records of vital signs, each depicting one year of life, would
clear up the dark past, and light up the prognosis and treat¬
ment; and thereby, also, how many diseases could be pre¬
vented. Families would not be slow to perceive what a saving
of time, money, suffering, and lives this Record of Health
could afford, and would soon beg their physician to begin his
practice with them where it really begins, at the taking of all
the details of the physiological diagnosis as a standard-meas¬
ure of the gravity of ulterior pathological symptoms.
§ VII.—Co-ordination of the Plan.
(a.) of the labors osf the practitioner.
What a practising physician wants after—but no less than
—an ab initio family record is a record of the present medical
constitution and medical doings in his surrounding. The
county, state, and general medical societies are well organized
to form such timely records.; only they do not, for the simple
reason that none bring to their meetings the elements of the
needed information.
Reports on general questions are rarely made; the last we
had, at the New York Medical Library Association, from Dr.
Marie Putnam-J acobi, on The Progress of therapeutics during
last year, was deservedly appreciated; but what the isolated
practitioner needs—if not more—oftener than generalities, are
these summings-up of the medical actualities which force his>
mind to co-ordinate his individual experience to that of his
medical brethren. If he gives nothing, he receives the same ^
conversely, the mites of each form the loaf of all.
A summary somewhat in the shape of the following one
ought to be given by every physician to the secretary of his
medical society; and the collection of these monthly reports,
would reverberate the light of experience when and where it is.
most needed.
380 MONTHLY NOSOGRAPHIC SUMMARY OF PREVALENT DISEASES.
NOSOGRAPHICAL SUMMARY.
Pbsvalknt DIS¬
eases.
No.
Duration.
Cures.
Death.
Treatment and
Remarks.
11 in.
Max.
Aver.
\
1
(b.)—CO-ORDINATION OF THE MEANS OF UNIFORM OBSERVATION.
A word more to bind together these apparently isolated sug¬
gestions.
The creation of a thermometric scale starting from the
physiological temperature of man, zero-health, up to mark
fever, exacerbation, etc., down to mark depression, collapse,
etc.
The invention (1) of a surface-thermometer to measure by com¬
parison local pyrexias, as the fever-thermometer measures gen¬
eral temperatures, and particularly susceptible to demonstrate
the differences of temperature of the temporal region caused by
mental work, concussions, bursts of passion, etc.; (2) of the
thermoscope to measure the loss of body-heat by the velocity
of its radiation.
The arrangement of a Prescription and Clinic Record, to
register the data of thermometry, and of other important methods
of diagnosis in the shortest possible time, and whose simplicity
and uniformity of plan permit any physician to compare his
clinical notes with each other, and with those of his confreres,
upon any given subject.
The formation of new tables of temperature and of other
vital signs, which require no drawing skill; on which can be
grouped all the clinical matters by dajs and weeks: the latter
tflsrtFOItMIflf OF MEANS OF OBSERVATION.
381
arrangement by septenaries, offering the much needed oppor¬
tunity of definitively testing the old doctrine of the Crises and
Critical Days.
The new era open to therapeutics by the power of the ther¬
mometer of mathematically measuring the calorific and frigo-
rifie action of medicines.
The method of using, thermometry and other means of posi¬
tive diagnosis to predict the extent of capacities for labors of
various kinds, the degree of vitality, and the chances of lon¬
gevity of people who want to enter any active career, and to
give or receive guaranties dependent upon their capacity or
longevity.
The transfer of the* management and training of children
to those who know how to husband their vitality expressed by
their ealorieity.
The value of thermometry in the hands of mothers to pre¬
dict diseases or relbpsefiy to help the physician in the manage¬
ment of the sicky ami to protect herself against the assailing"
suggestions- o£the'ignorant or of the designing, who hover around
a sick-bed like ravens aJjove a corpse.
The necessity for' p&ysic, not only to be one of the physical
sciences-, but to- show ifeelf such, by the scientific concordance
of its- Record's,- which* permit any physician to read, criticise,
compare,, evens t©» continue any observation, or group of obser¬
vations pertaining: to the' practice of' a confrere, or to the phi¬
losophy of his artvasdW'physicists and mathematicians.
These suggest ion sr once brought together by simple apposi¬
tion,- must already appear what they really were—the inten¬
tional parts of aniiitended plan: the segments of an intellectual
cycle.
The segments are the means I have suggested, and the new
ones-which will'soon' be'offered by other observers to enforce
their cohesion.
The cycle is the ensemble of the means of substituting posi¬
tivism fbr conjecture, authority and credulity in the manage¬
ment of health,-disease, education, human solidarity, and social
progression.
The key to 'this cycle could not have been the microscope, not-
with3tanding;its-wonders; because its data are not always posi¬
tive,.md: it is, so 'Pdi-y ixto exclusively engaged in analytical in-
vesfetions, in is thi thermometer, which has shown an equal
382
THE CYCLE OF POSITIVE OBSERVATION.
adaptability to the industry of analysis in individual observation,
and to the genius of synthesis in the formation of important
entities by the creation of several laws of diseases, but from
which much more is expected.
Thermometry will find new laws of disease, new relations of
temperature to the various modes of vitality, new standards of
observation, and new means of communicating them among
physicians. It will extirpate quackery, whose ways cannot
stand the light of positive observation, particularly if we give
it a scientific and readable unity among ourselves, and if we
communicate its rationale to our clients. It will protect legiti¬
mate interests founded on vitality, whose claims can be authen¬
ticated by means of the instruments of positive diagnosis; it
will, in particular, rule the question of Life Insurance.
By keeping a correct record of the phenomena of life in each
child, thermometry will take the lead in the management of
youth, and particularly in that of general education, assuming
as the basis of all the modes and phases of the training, the in¬
dications of the temperature and of the other vital signs, instead
of the arbitrary pretensions of literary, scientific, or religious
curriculums. The application to practical education of the
tests offered by thermometry, and by the other means of positive
diagnosis, will keep constantly the balance of vitality in favor
of the students, thereby improving their beauty and capacity,
and soon the jestlietic, social, and working qualities of the race.
Here thermometry, as I promised it would, without ceasing to
be medical, becomes human / the thermometer opens the way
to the most positive application of physiology to the solution
of the problems of education ; and the prophecy of Descartes
will be fulfilled : if it is possible to improve mankind, 'physic
will give us the means thereof.
At this point I cannot say a word more. Not in vain will
thi6 great Seer have traced our future. He gave us the object¬
ive, we acquired the means of attaining it. To organize these
means in a working unity is to organize victory over fatal de-
generescence.
We owe our art to co-ordinate the means by which physic
will take its rank among the natural sciences.
We owe our profession the use of uniform instruments, scales,
methods of observation, and common modes of communicating
among ourselves ideas, observations,^!!*! «U#cvY«rieg.
WHAT THERMOMETRY WILL DO FOR MANKIND. y 383
We owe each individual a statement of his status in regards
to heredity, health, moral and physiological dynamics : a stud-
book not refused to a horse, often granted to a pig.
"We owe a clear exposition of our principles, most particularly
to mothers, too long left, by our pride or levity, ignorant of
the naturalness of diseases, which have their laws; and credu¬
lous to the supernaturalist, who assumes towards them the
-atheistic power of infringing the natural laws in matters of
cure or death.
We owe to society all what we know of our art, since it is no
more an arcanum but an heirdom, the property of all who can
understand it, and help us in its application.
We owe to the progress of our species to study, and to apply
in our limits, the laws and means by which our race will attain
and maintain the highest degree of health, proficiency, and hap¬
piness, inherent to the preservation of fch© physiological temper¬
ature : mens sckna in Gorpore sano.
VIII.—CetNC&USKJtN.
Looking back fco the preceding pages, I see the proportions
of the responsibility I have incurred, yet do not propose to take
advantage of the attenuating circumstances; whatever could
be the verdict, I j>lead guilty. At the end of a patient expo¬
sition of what thermometry has done in the last thirty years,,
by its highest interpreters, I have attempted to foreshadow what
it will accomplish in the next twenty.
What I believe tovbe true I have worked to make it reaL
Though I began long ago, I never diid more for the honor of
the art, whose practice honored me, than since I came into my
sixties. I have developed several points of this philosophy of
medicine twTo year# in succession before the British Medical
Association and the French Association for the Advancement
of Sciences, and oftener before the New York State and the:
American Medical Association ; and I did it each time—without
regard to personal inconvenience—with a decided opinion of
my individual deficiencies but with a no less firm confidence in,
the strength of the cause. I have given it all that the young
offers for the possession of his ideal, and the old for the realiza¬
tion of his idea.
384
Go^chvm&tf.
Human thermometry, though of recent origin, is already
much more directly useful to man than the climatic. The two
principal obstacles to its propagation were: 1st. The diversity
of its instruments, whose various centres (zeros) are away from
the scale of the living; far from the figures lobked for in vital
problems. 2d. The keeping of thermometry accounts in
graphics, which need the hand of an artist, and must be recon¬
verted in figures to be serviceable in practice. These causes
excluded clinical thermometry from maiiy hospitals, from almost
all private practice, from the nursery, th£ school, etc.
The physiological' thermometer, having its zero at the health
point, can be understood by all; and the mathematical thermo¬
graphy being written in plain'figures, can be read as easily.
Thus rendered human, thermometry protects the life of
children and invalids, as well as of the sick; guides and justifies
the physician ; enfraribhises mothers from the imposition of the
bonzes; reconstitutes the antique unity of diagnosis around the
phenomena of ustion ; and connects the laWs of animal heat—
as far as they are discovered—with the known laws of the
universe.
That is the idea to which I gave my last years. (See Appen¬
dix XXII.)
I spent my youth in demonstrating that idiots can be im¬
proved, and that—from the comparative study of their infirmi¬
ties with the means of making them perceive, think, etc.—there
would result a Physiological Method, of Education, by which
mankind could be improved. Having lived long enough to
witness the initial success of this first idea, I confidently expect
—though I may not see—the proximate success of the second :
ideas cannot perish, but after having accomplished their evolu
tion. In this persuasion my last word' is:—Thermometry begat
thermography, and thermography is pregnant with medical
snathematism
APPENDIX I.
table of equivalents of the celsian (centigrade),
Reaumur's, Fahrenheit's, and physiological
thermometers.
To convert Centigrade into Fahrenheit, multiply by 9, divide by 5, and add 32 ; or,
multiply by 1.8 and add 32.
Example 20° x 1.8 + 32 = 68° F.
To convert Centigrade into Reaumur, multiply by 4, and divide by 5 ; or, multiply
by 0.8
Example 20° C. x 0.8 = 16° R.
To turn Fahrenheit into Centigrade, deduct 32, multiply by 5, and divide by 9.
Example104° F. -32 x 5-s-9 = 40° C.
To turn Fahrenheit into Reaumur, deduct 32, divide by 9, and multiply by 4.
Example :—104° F. — 32 ■+■ 9 x 4 = 32 R.
To turn Reaumur into Fahrenheit, multiply by 9, divide by 4, and add 32.
To turn Reaumur into Centigrade, multiply by 5, and divide by 4.
To convert Fahrenheit or Reaumur into the Physiological Scale, or vice versa,,
reduce them to Centigrade. From Centigrade to Physiological the difference of
37° can always be made cursorily in the mind without formal operation.
Fahrenheit.
B,6aumur.
Celsius
(Centi¬
grade).
Physio¬
logical.
Fahrenheit.
Rearamur.
Celsius
(Centi¬
grade).
Physio¬
logical.
32
0
0
37
83.4
22.4
28
9
41
4
5
32
85.2
23.2
29
8
50
8
10
27
86
24
30
7
59
12
15
22
86.9
24.4
30.5
6.5
63.5
14
17.5
19.5
87.8
24.8
31
6
68
16
20
17
88.7
25.2
31.5
5.5
69.8
16.8
21
16
89.6
25.6
32
5
72 5
18
22.5
14.5
90.5
26
32.5
4.5
73.4
18.4
23
14
90.68
26.08
32.6
£.4
75.2
19.2
24
13
90.86
26.16
32.7
4.3
77
20
25
12
91.04
26.24
33.8
4.2
79.8
20.6
26
rr
91.22
2032
32.9
4.1
81.5
22
27.5
9.5
91.40
26.1
33
4
388
APPENDIXES.
Fahrenheit.
H6aumur.
■
Celsius
(Centi¬
grade).
Physio¬
logical.
Fahrenheit.
Reaumur.
Celsius
(Centi¬
grade).
Physio¬
logical.
■ 1.58
26.48
33.1
3.9
98.24
29.44
36.8
$
91.76
26.56
33.2
3.8
98.42
29.52
36.9
.1
91.94
26.64
33.3
3.7
98.60
29.60
37
0
92.12
26.72
83.4
3.6
98.78
29.68
37.1
.1
92.30
26.80
33.5
3.5
98.96
29.76
37.2
.2
92.48
26.88
33.6
3.4
99.05
29.80
37.25
.25
92.66
26.96
33.7
3.3
99.14
29.84
" 37.3
.3
92.84
27.4
33.8
3.2 1
99.32
29.92
37.4
.4
93.02
27.12
33.9
3.1
99.50
30
37.5
.5
93.20
27.20
34
99.68
30.08
37.6
.6
93.38
27.28
34.1
2.9
99.86
30.16
37.7
.7
93.56
27.36
34.2
5.8
99.95
30.20
37.75
.75
93.74
27.44
34.3
2.7
100.4
30.24
37.8
.8
93.92
27.52
34.4
2.6
100.22
30.32
37.9
.9
94.10
27.60
34.5
2.5
100.40
30.40
38
1
94.28
27.68
34.6
2.4
100.58
30.48
38.1
1.1
94.46
27.76
34.7
2.3
100.67
30.52
38.15
1.15
94.64
27.84
34.8
5.2
100.76
30.56
38.2
1.20
94.82
27.92
34.9
2.1
100.85
30.60
38.25
1.25
95
28
35
5
100.94
30.64
38.3
1.8
95.18
28.8
35.1
1.9
101.12
30.72
38.4
1.4
95.36
28.16
35.2
1.8
101.30
30.80
38.5
1.5
95.54
28.24
35.3
1.7
101.48
30.88
38.6
1.6
95.72
28.32
35.4
1.6
101.66
30.96
38.7
1.7
95.90
28.40
35.5
1.5
101.75
31
38.75
1.75
96.08
28.48
35.6
1.4
101.84
31.4
38.8
1.8
96.26
28.56
35.7
r.3
102.02
31.12
38.9
1.9
96.44
28.64
35.8
1.2
102.20
31.20
39
2
96.62
28.72
35.9
1.1
102.38
31.28
39.1
2.1
96.80
28.80
36
1
102.56
31.36
39.2
2.2
96.98
28.88
36.1
.9
102.65
31.40
39.25
2.25
97.16
28.96
36.2
.8
102.74
31.44
39.3
2.3
97.25
29
36.25
.75
102.875
31.48
39.35
2.35
97.34
29.4
36.3
-.7
102.92
31.52
39.4
2.4
97.52
29.12
36.4
.6
103.10
31.60
39.5
2.5
97.70
29.20
36.5
.5
103.28
31.68
39.6
2.6
97.88
29.28
36.6
.4
103.46
31.76
39.7
2.7
98.06
29.36
36.7
.3"
103.55
31.80
39.75
2.75
98.15
29.40
36.75
.25
103.64
31.84
39.8
2.8
APPENDIXES.
389
Fahrenheit.
Reaumur.
Celsius
(Centi¬
grade).
Physio¬
logical.
Fahrenheit.
B6aumur.
Celsius
(Centi¬
grade).
Physio¬
logical.
103.82
31.92
39.9
2.9
| 108.725
34.1
42.625
5.625
104
32
40
3
1 108.86
34.16
42.7
5.7
104.18
32.08
40.1
3.1
; 108.95
34.20
42.75
5.75
104.36
32.16
40.2
3.2
109.04
34.24
42.8
5.8
104.45
■ 32.20
40.25
3.25
L09.175
34.3
42.875
5.875
104.54
32.24
40.3
3.3
109.22
34.32
42.9
5.9
104.72
32.32
40.4
3.4
109.40
34.4
43
6
104.90
32.40
40.5
3.5
109.58
34.48
43.1
6.1
105.108
32.48
40 6
3.6
109.625
34,5
43.125
6.125
105.125
32.52
40.625
3.625
109.76
34.56
43.2
6.2
105.26
32.56
40.7
3.7
109.85
34.6
43.25
6.25
105.37
32.60
40.75
3.75
109.94
34.64
43.3
6.3
105.44
32.64
40.8
3.8
110.075
34.7
43.375
6.375
105.62
32.72
40.9
3.9
110.12
34.72
43.4
6.4
105.80
32.80
41
4
110.30
34.8
43.5
6.5
i05.98
32.88
41.1
4.1
110.4S
34; 88
43.6
6.6
106.025
32.92
41.125
4.125
110.525
34.9
43.625
6.625
106.16
32.96
41.2
4.2
110.66
34.96
43.7
6.7
106.25
33
41.25
4.25
110.75
35
43.75
6.75
106.34
33.04
41.3
4.3
110.84
35.04
43.8
6.8
106 52
33.12
41.4'
4.4
111.02
35.12
43.9
6.9
106.70
33.20
41.5
4.5
111.20
35.20
44
7
106:88
33.28
41.6
4.6
111.38
35.28
44.1
7.1.
1(D6.925-
33.32
41.625
4.625
111.56
35.30
44.2
7.2
107; 06
33.36
41.7
4.7
111.74
35.44
413
7.3
107.15
33.40
41.75
4.75
111.875
35.5
44.375
7.375
107.24'
33.44
41.8
4.8
111.92-
35.52
44.4
7.4
107.375"'
33.50
41.825
4.825
112.1
35.6
44.5
7.5
107.42
33.53
41.9
4.9
112.28
35.68
44.6
7.6
107.60
33.60
42
5
112.46
35.76
44.7
7.7
107.78
33.68
42.1
5.1
112.64
35.84:
44.8
7.8
107.825
33.70
42.125
5.125
112.82
35.92
44.9
7.9
107.96
33.76
42. a-
5.2
113
36
45
8
108.05
33.80
42.25
5.25
114.8
36.8
46
9
108.14
33.84
43.3
5.3
116.6
37.6
47
10
108.185
33.90
42.375
5.375
118.4
38.4
48
11
108.32
33.92
42.4
5.4
120.2
39.2
49
12
108.05
34
42.5
5.5
122
40
50
13
108.68
34.08
42.6
5.6
390
APPENDIXES.
APPENDIX II.
NOTE ON THE IIEAT PRODUCED BY ANIMALS, AND THEIR RESIST¬
ANCE TO ATMOSPHERIC DIFFERENCES OF TEMPERATURE.
We have seen the foetus warmer than its mother. All animals have, like man,
their normal temperature, capable of resisting the action of external heat or cold.
Here are subjoined, from Gavarret, Valentin, etc., tables of temperature of different
, classes and species of animals, showing that their degree of resistance to cold is very
much in proportion to the perfection of their organization. This reminds us that the
vital laws have not been made for man separately from animals. The law of resist¬
ance of animals to their ambient atmosphere applies to man mainly in this, that he
too cannot evolve more heat than is shown by his norme without endangering his life.
This is said for teachers as well as for physicians. The temperature of man oscillates
between 36.50° and 37.50° ; a/eragas 37°. A sudden change of 5°, or a steady loss of
.5° are equally incompatible with life.
a.—Tables of Temperature of Birds.
° Cent.
Petrel 40.30-40.80
Parrot .. 41.10
Goose 41.70
Jackdaw 42.10
Screech-owl 41.47
Heron 41.
Sparrow . 41.67-42.10
Yellow Hammer ...... 42.88
Tiercelet 41.47
Pigeon 41.80-43.30
Cock ...39.44-40.
Turkey-cock 42.70
Moor-hen 42.00-42.50
Guinea Fowl 43.90
Common Fowl .39.44-43.90
Thrush 42.80
Common Duck 42.50-43.90
Crow 41.17
Raven 42.91
5.—The Temperature of Mammifers.
0 Cent.
French Horse 36.80
Arabian Horse 37.50
Common Rat 38.80
Common Hare 37.80
Tiger 37.20
Common Cat 38.30-38.90
Squirrel 38.80
Panther 38.90
Dog 37.40-39.60
Elk (female) 39.40
Monkey , „,,, 35.50-39.70
Sheep * 37.30-40.50
APPENDIXES.
391
° Cent.
ichneumon 39.40
She-goat 40.
He-goat (castrated) ,... 39.50
She-ass 37.98
He-ass 37.95
Jackal 38.50
Ox.
37.50
Capibara 35.76-39.
Rabbit 37.50-40.
Porpoise 35.62-37.6
Sea-cow 38.89-40.
-Excess of Temperature of Reptiles oyer that of their Surrounding
Atmosphere.
° Cent.
Viper 5.06
Toad 0.50-2.80
Frog ....0.04-4.44
Iguan , 1.22
Boa 2.50
Lizard 0.75-1.25
Adder 1.35-3.90
Turtle 1.22-3.90
-Excess of Temperature of Fishes oyer that of their Surrounding
Atmosphere.
° Cent.
Pike 3.88
Carp 0.36-3.
Eel 0.93
Tench 0.50-0.71
Shark 1.30
Trout 0.55-1.10
Ablet 0.55
Perch 0.52
-Excess of Temperature of Articulata and Annelides over that of
their Surrounding Atmosphere.
° Cent.
Beetles 0.25-0.70
Glow-worm 0.50
Gr o und-worm 1.11-1.39
Silk-worm 1.
Larvae of Sphinx 1.66
Coccinella 0.44
Gryllus 0.31-0.94
Scarabseus Vernalis 0.12-0.18
Leech 0.56-0.85
-Excess of Temperature in Lower Animals over that of their Sub-
rounding Atmosphere.
° Cent.
Crustacea 0.60
Cephalopoda (0:57
39 2 appendixes.
° Cent.
Molluscs 0.46
Echinoderms 0.40
Meduses 0.27
Polyps 0.21
APPENDIX III.
DIURNAL OSCILLATIONS.
(•/.)—Dr. Ogle's observations were made in the St. George Hospital, by day in
inner, by night in winter, and lasted many months. The average daily variation
v, a,a C.=l>,° P. The minimum, a winter's morning, at 5.30 a.m., was 36.1 C.=
0' • , and the maximum 38.25° C. =100.6° P., in a Turkish bath. (Temperature
fc.tkcn under the tongue.) Means of monthly results:
Time of the day.
Female.
<)—') 1 a.m. before breakfast
31 .< .m.—2 p.m..
o —5 p.m. ; l '.nch at 3 p.m
p.m.—7.30 p.m. ; dinner at 7 p.m
y p . m„—10 x'.m
12 m.—12.30 p.m
12.-0 a.m.—1 a.m ; bed at 1 A.M
a.m.—5 .'..m
&30 a.m. —0.30 a.m
8 a.m.—9 a.m
73°
2°
: 6°
63°
»
90°
9°
-o
2°
66°
9856
98.57
98.6°
98.45°
98°
No observa¬
tion taken of
females during
the night.
(&.)—Alveranga extended similar observations to two hundred and eighty persons,
•Whose ages varied from fliue to sixty-five years, and who took their meals at eight,
uric, and seven o'clock:
Hours of Observation.
Temperatures.
Maxima
Minima.
Media.
General
Average.
5 o'clock A.M
■9 " "
10 u " ..j.....
11 " "
2 " P.M
4 " " I
8 " "
37.5°
37.6°
37.8^
37.9°
37.9°
37.9°
37.9 5
37.9°
36.0°
36.3°
38.8°
36.6
3(1.6°
36.7°
36.6 D
36.6°
36.81°
37.04°
37.32°
37.35°
37.36°
37.42°
37.42°
37.36°
37.27°
APPENDIXES.
39 B
(c.) Biirensprung gives the results of his observation of temperatures (a) at stated
hours, (b) and after meals ; a compound cause for oscillation
Morning, before breakfast, between 5 and 7 o'clock 36.69°
Morning, after breakfast, between 7 and 9 o'clock 37.19°
Before noon, between 9 and 11 o'clock 37.26°
Before dinner, between 1 and 2 o'clock 36.84°
After dinner, between 2 and 4 o'clock •. 37.16°
Afternoon, between 4 and 6 o'clock 37.49°
Early evening, between 6 and 8 o'clock 37.44°
After supper, between 8 and 10 o'clock ' 37.03°
Before going to bed, between 10 and 12 p.m 37.35°
Being abed, between 12 and 2 a.m 36.65°
In bed, between 2 and 4 a.m 36.31°
Difference between extreme minima and maxima 1.18°
Comparing among themselves these figures, we remark that the heat-producing
power of food is less in the two first hours than in the two following ones, and that
cooling begins from four to six hours after meals. Compare also these figures with
those of Dr. W. Squire, who found the heat to begin sooner, and to attain quicker
much higher figures in infants than in adults (see Temperature in Infancy).
APPENDIX IV.
MIGNOT^S TABLE OF PROPORTION OF TEMPERATURE, PULSE,
AND RESPIRATION IN FOURTEEN CHILDREN FROM
THREE TO SEVEN DAYS OLD.
( The temperature of the room was 15°—16°.)
Number of Cases.
Age.
Sex.
I
n...
hi..
IV...
v...,
VI...
vn..
VIII.
IX...
x...
xi...
xii..
XlH.
XIV.
5 days.
4 "
5 "
4 "
5 "
4 "
4 "
7 "
3 "
5 11
5 "
3 "
4 "
5
Male.
Female.
Male;
Female.
Male.
Female.
Male.
j Temperature
Constitution. (under the Pulse.
' Axilla).
Strong.
Sickly.
Feeble.
Strong.
Feeble.
Medium.
Strong.
tl
Feeble.
Strong.
37.7°
37.3°
37.5°
37.8°
38.0°
36.8°
38.1°
37.4°
37.5°
37.93
38.0°
37.9°
87.6°
37.8°
132
112
108
120
120
132
120
132
120
134
132
132
132
Respi¬
ration
48
38
24
48
28
30
36
36
33
38
42
APPENDIXES,
APPENDIX Y.
(The reasons why we will give more tabulated temperatures from Roger than from
any other are contained in this appreciation of W. Squire, of London : " These figures
have been unintentionally verified in the course of inquiries made independently and
in ignorance of the good work there extant.")
(a.)—Roger's table of comparative temperature of mother
and child at birth.
Age.
Number of
Respirations.
Number of
Pulsations.
Axillary Temperature
of the Infant.
Axillary Temperature
of the Mother. *
1 minute
50
37.75°
36.75°
U
34
110
36.75°.
36.25° '
3 to 4 minutes
39
105
36°
37°
5 to 30 minutes
68
120
37°
37°
" "
36
132
36°
37°
" "
60
96
35.50°
37°
u "
60
96
35.50°
37°
" "
28
130
35.50°
36°
22
65
35.25°
37?
This table gives the following—
Maxima.
Of temperature 38.1°
Of pulse 134
Of respiration 48
Minima. Averagei.
36.8° 37.45°
108 117-,^
36-/i
24
(b.)—What can be inferred from the comparison of the temperature, pulse, and res¬
piration of the two sexes.
Boys.
Girls.
Temperature.
Pulse.
Breath.
Temperature.
Pulse.
Breath
37.7°
132
48
37.3°
112
38
37.5°
108
24
37.4°
132
36
37.8°
120
4S
37.5°
120
33
38°
120
28
37.9°
134
38
:;6.y°
132
30
-38°
132
38.1°
120
36
37.6°
—
37.9°
132
—
—
37.8°
132
42
—
Total... 301.6
996
256
Total... 225.5°
630
145
Average. 37.7
122
36)
Average. 37.6f
126
361
* We wonld suggest that the mother having just had the worse opportunities for keeping her
axilla well shut up and warm (as a natural cavity), the best place to take her temperature at thin
juncture would be the vagina, and correspondingly, that of the babj, the rectum.
appendixes. 395
(c.)—Pretty close contest, since—
The temperature average for boys was 37.7°
u " girls was 37.6°
" total for boys was 301.6°
" " girls was 307.7°
The pulse average for boys was 122
" " girls was 126
" total for boys was 996
" " girls was 1,008
The respiration average for boys was 36f
" " girls was 36|
" total £or boys was 292.5 •
" girls was 290
So that the total temperature of the eight boys is above that of the same number
of girls by .9° (less than a degree).
The total of pulse of the girls over the boys is but 12 beats.
And the total of respiration of the boys is more frequent than that of the girls by
2.5 breathings.
This small piece of statistics is not likely to solve the pending problem of th«
superiority of either sex.
APPENDIX VI.
(a.)—barensprung's table of temperature of the
different ages.
At birth 37.08°
A few hours after o6.95°
During the first ten days 37.55°
To puberty 37.63°
From 15 to 20 years 37.39°
" 21 to 30 " 37 08°
" 31 to 40 " 37.11°
" 41 to 50 " 36 94°
" 61 to 70 " 37-09°
At 80
This table shows the average temperature of infancy 37.30°; of youth and virility,
37.39° ; of old age, 37.04° ; of senility, 37.17° C.,£ a
396
APPENDIXES.
(b.)—ROGER'S TABLE OF TEMPERATURE, PULSE, AND
RESPIRATION OF THIRTY-THREE CHILDREN
FROM ONE TO SEVEN DATS OLD.
Days.
Sex.
Constitution.
Status.
Ustion.
Pulsation.
Respiration,
3
Boy.
Puny.
Sleeping.
u
36° C.
70
36
1
44
36.25°
104
64
3
Girl.
U
It
36.25°
80
24
4
u
((
u
36.25°
88
28
3
It
tt
u
36.50°
140
40
6
u
ct
((
36.75°
120
44 v
1
cc
tc
((
36.75°
120
48
2
Boy.
t<
It
36.75°
84
86
1
It
37°
80
36
1
it
u
37°
100
44
2
it
it
It
37°
120
46
2
GirL
tc
II
37°
84
44
3
Boy.
ii
tt
37°
112
32
4
Girl.
It
37°
104
34
4
CI
ti
37°
120
40
5
(I
tc
It
37°
84
32
5
it
Strong.
II
37°
96
36
Boy.
Pretty strong.
It
37°
112
42
7
Strong.
tl
37°
128
50
3
Girl.
ii
tt
37°
84
42
4
it
44
II
37°
120
36
6
C
i i
II
37°
120
38
2
'.t.
44
II
37.25°
92
32
2
3oy.
Very strong.
II
37.25°
76
40
4
Girl.
It
37.25°
112
32
7
i i
II
37.^5°
116
37
]
Boy.
44
It
37.25°
80
40
5
Girl.
tt
37.50°
76
24
6
Boy.
Pretty strong.
It
37.50°
112
32
2
Strong,
It
38°
112
38
4
tt
38°
108
32
5
Girl
ii
tt
38°
84
36
Pretty strong.
II
39°
124
44
Thus ori thirty-three apparently healthy children the maximum temperature has
been 39° C., the minimum 36°, and the medium 37.08; showing how much larger,
without danger, are the ecarts of temperature in infants than in adults.
APPENDIXES.
APPENDIX VII
(<z.)—Roger's table of comparison of ustion, circulation,
and respiration of twenty-five children from
five months to fourteen years.
Age.
Ustion.
Pulsa¬
tion.
Respira¬
tion.
Age.
Ustion.
Pulsa¬
tion.
Respira¬
tion.
4 Months
37° C.
120
36
6 Years
37. C.
80
24
4 "
37.25°
112
32
8 "
37.75°
84
28
5 "
37 25°
100
30
10 "
37.75°
80
20
f> "
36.15°.
120
44
11 "
37.25°
88
26
6 "
3?°
120
38
12 "
37°
70
28
6 "
37°
80
24
12 "
37°
82
28
9 "
26.75°
120
36
12 "
37.25°
74
34
9 "
37.25°
116
32
12 "
37.2.";°
70
34
2 Years
37.25°
80
32
13 "
37 51°
88
32
S LL
37°
37.50°
37.75°
36.75°
116
80
96
64
36
24
34
22
13 "
37.50°
37.25°
37.2.>°
70
80
68
30
30
26
4 "
13 "
4 "
14 "
5 "
Thus on twenty-five children, from their first to their fourteenth year, the maxi¬
mum temperature was 37.75°, the minimum 36.75°, the medium of the thirteen
youngest under seven years was 37.11, of the twelve above six years old 37.31°, and
of the whole 37.21° C. At this age, therefore, the excursus does not present any more
a larger ecart from the norme (1° C.) than in adults, as announced by Paul Bert, and
life becomes safer. h
(b.)—-forster's (in New Sycl. Soc. Year Book, 1862) tempera¬
ture-variations within the first two days after birth.
Hours after Birth.
Average Temperature
(Keaumur).
Minimum Temperature
(Reaumur).
4 2. .
2—6..
6—10.
10—15
15—20
30—25
25—30
30—36
36—43
43-48
28.97°
28.2°
29.12°
28.1°
29.49°
28.7°
29.53°
29.0°
29.31°
29.8°
30.04°
29.7°
29 9°
29.7°
30.07°
29.7°
30.04°
29.4°
29.86°
29.3°
398
APPENDIXES.
The average time of the highest temperature was from thirty to thirty-six hour*
after birth, at which it was 30.07° R. =37.6° C. = .6° Ph. = 99.67° F.; the maximum
30.40° R.= 38° C.-1° Ph. = 100.4° P. ; the minimum 29.7° R. = 37.12° = .12° Ph. =
98.80° P. This elevation is independent of the food taken or not. A subsequent
elevation always occurs, followed by two tide-like falls.
(C.)—TEMPERATURE OF THE FIRST NINE DAYS, FROM THE SAME
AUTHOR.
Days.
1-1M
1X-2
2-2^
2^-3
3-3^
3^-4
4-4^
4^—5
5-5^
5^2—6
6-6^
7-7%
7%-8
8-SM
8^-9
Maxima (R.).
30.4°
30.5°
30.4°
30.3°
30.3°
30.2°
30.4°
30.3°
30.4°
30.5°
30.6°
30.3°
30.4°
30.4°
30.0°
29.9°
Minima (R.).
29.7°
29.3°
29.3°
29.2°
29.3°
29.0°
29.2°
29.2°
29.2°
29.3°
29.4°
29.1°
29.3°
29.0°
29.4°
29.6°
Media (R.).
30.01°
29.93°
29.87°
29.74°
29.76°
29.68°
29.68°
29.72°
29.82°
29.81°
29.83°
29.75°
29.82°
29.72°
29.70°
29.75°
APPENDIX VIII.
(a.)—Roger's local temperatures of fifteen children from
eight to thirteen years old.
Axilla.
Abdomen.
Mouth.
In the Arm-
fold.
In the Shut
Hand.
Between the
closed Feet.
In the
Gruin.
At the
Scrotum.
37.75°
37.50°
37 ".25°
37° "
37.50°
37°"
37.25°
36.75°
35°
37 .'75°
37 .'25°
33°
35.75°
36.50°
37.25°
35°
35.50°
36.50°
37°
36.50°
36.80°
36.25°
353
36.25°
35°
36.75°
33.50°
30.50°
34.75°
34 ."50°
si .'50°
31.50°
29°"
35°"
31.56°
31°''
36°
35 "75°
J
APPENDIXES.
399
(b.) TEMPERATURE OF SIX OTHER CHILDREN OF THE SAME AGE I
Axillary Temperature.
38.2°
31.8°
37.6°
37°
38°
37.4°
Rectal Temperature.
38.2°
37.2°
37.8°
37.4°
38.4°
37.8°
(C.) J. DAVY'S LOCAL TEMPERATURES.
Foot.
Hand.
Under the Tongue
Urine.
Before marching
21.4°
36.2°
27.2°
35.8°
36.7°
37.7°
37.8°
38.3°
(d.)—LOCAL TEMPERATURES TAKEN BY DR. ALVARENGA ON TWO
HUNDRED AND EIGHTY PATIENTS WITH THE FEVER THER¬
MOMETER, ONCE COVERED WITH COTTON, THE
OTHER TIME UNCOVERED.
Parts.
Head
Thorax
Epigastrium..
Hypogastrium
Fold of arm...
Thigh
Groin
Foot (under)..
Local Temperatures.
Maxima.
Minima.
Media.
General Average
( 37.2°
1 36.4°
i 37.9°
| 36.0°
t 37.6°
1 36.8°
( 37.5°
1 36.8°
t 37.6°
•1 37.0°
('37.5°
i 36k6p
( 37.7°
1 37.6°
I 35.4°
\ 34.4°
35.1°
34.6o
32.0°
32.0°
34.0°
33.5°
34.5°
34.0°
35.5°
34.0°
35.0°
34.6°
34.5°
84.5°
31.0°
31.0°
36.05° \
35.74° f
35.60° i
34.55° f
36.01° 1
35.21° \
36.43° )
35.30° j
36.33° 1
36.16° j
35.86° )
• •35.75° i
35.98° I
35.92° \
33.52° i
32.70° i
35.92°
35.20°
35.66°
35.94°
36.26°
35.81°
35.95°
33.20°
400
APPENDIXES.
{e.) alvarenga5s comparative table of local and central
temperatures, with pulse and respiration, in lym¬
phangitis following the bite of a rat on the
first articulation of A finger.
•Observation 9 to 10 a.m.
Observation 3 to 4 p.m.
4th...
5th....
6th...
7th...
8th...
Axilla
38.9°
Sick part
37.5°
Opposite side.
35.5°
Axilla
37.6°
Sick part
36.4°
Opposite side.
34.8°
Axilla
36.8°
Sick part
35.2°
Opposite side.
34.1°
Axilla
36.0°
Sick part
33.5°
Opposite side.
32.5°
Axilla
36.2°
Sick part
33.5°
Opposite side.
33.8°
63
60
44
60
24
20
16
16
16
37.4°
36.4°
35.6°
68
64
24
IS
(f.) alvarenga's comparative table of local and central
temperatures, in light orchitis of the right
side, ALT. twenty-four.
4th
5th
6th
P* O
< a
V 52
rr &
-Sh
( Axil'a
•< Sick test'cle
( Healthy testicle.
i Axilla
■< Sick testicle
j Healthy testicle.
( Axilla
< Sick testicle
( Healthy testicle.
Observation 9 to 10 a.m.
37.1°
36.7°
36.4°
37.0°
36.6°
36.4°
37.0°
36.4°
36.4°
APPENDIXES.
401
(<?•)—TABLE ' OF TEMPERATURE TAKEN IN THE DEAD-HOUSE OF
GUY'S HOSPITAL, PROBABLY AFTER THE BODIES HAD BEEN
WASHED, BY PLACING THE BALL OF THE THER¬
MOMETER ON THE ABDOMEN.
; ] (From Dr. Taylor's Principles and Practice of Medical Jurisprudence, p. 6.)
No. [of^observations
Maximum temperature of the
L. body
Minimum temperature of the
k.body
Average temperature of the
body
First period 2
to 3 hours
after death.
76
F.
92°
60°
77°
C.
34.4®
15.5°
25°
Second period
4 to 6 hours
after deatU.
Third period 6
to 8 hours
after 4eatU.
49
F.
86°
62°
74°
C.
30"
sy
16.6®
23.3'
Fourth period
12 hours af¬
ter death.
£9
F.
80°
60*
70®
c:
26.6°
15.5°
21.1°
35
F.
79°
66°
67°
C.
26.1°
13.3°
19 .ft0
APPENDIX IX
{a.) SQUIRE'S THERMOMETRY OF THE PRE-ERUPTIVE AND CONTA¬
GIOUS STAGE OF MEASLES.
{Tga. A girl, set.' 5, exposed to infection, March 30, shows abnormal temperatures
before any other signs.
Days before Ill¬
ness.
4
5
2
1
0
1st of illness.
2
3
4
5
April.
9
10
11
12
110
120
120
104
100
110
130
130
Respira¬
tion.
Temperature,
Axilla, at noon.
26
32
30
30
26
26
30
40
98.6°
99.4°
100.7°
99.0°
97.3°
99.2°
100.3°
100.5°
102.0°
Remarks.
Slight cough and coryza.
Eyes red, tonsils full.
Doubtful mottling of parts of
skin.
Face mottled.
Skin clear, sl'ght cough.
Respiration weak, a wheeze on
forced inspiration.
Ill, bi.t not in bed.
Respiration clear, spots of
measles visible.
Rash, purulent secretion from
the conjunctiva.
Rash fully out, eyes better.
26
402
APPENDIXES.
b.—Measles infectious before the eruption; a child on » visit leaves Feb. 13th with
symptoms of illness, but no signs of measles till the 15th. A girl, cct. 10, had slept
with this child from the 9th to the 13th, and remained at home, unexposed, after her
visitor had left. She seemed ill on the 20th; had chorea on the 23d, with epistaxis
in the evening, temperature 101.4°; rash of measles on the 24th, croupy cough at
night, T. 103.6°; full rash on the 25th, croupy cough and tracheal sifle, T. 104° ;
next day temperature only 98.7°.
c.—Pre-eruptive and contagious stage of mumps (parotitis). A boy, Eet. 13, ex¬
posed to infection of mumps at school by the end of September.
Days before
Illness.
At Home,
0;t.
1 to5
Pulse.
Respi¬
ration.
Temperature.
Morn. Even'g.
Remarks.
Headache, uneasiness, fatigue.
Days of
illness..
1
2
o
4
5
15
6
7
8
9
10
20
•
One side of throat tender, and neck
stiff.
Left parotid and right sub-maxillary
gland enlarged, bowels open, urine
free, delirious at night.
Face swelled, eyes red, vomiting,
better at night.
Swelling of parotid less hard, no
pain.
No swelling of parotids, a little of
left submaxillary gland.
Quite well, had felt weak till now,
no metastasis, no relapse.
100
110
84
68
24
27
26
21
101.2° 103.0°
102.4° 102.4°
100.2°
98.4°
(b.)—PERIOD OF INCUBATION OF INFECTIOUS DISEASE.
Diseases.
Vaccine
Variola
" inoculated.
Varicella
Scarlatina
U
Roseola
Measles
11 inoculated
Parotitis
Whooping-cough.
Influenza
Typhoid fever
Typhus.
Stage of Latency
and Innocuity.
Days 4—5
12—14
3-4
10—12
3—7
10—14
12-14
7 "
14—21
4 "
4—8
10-12
12 ..
Stage of In¬
vasion • nd
Infection.
Days
Infectious when the vesicle is
formed and by its lymph.
Infectious when the papules appear
Exceptionally a few hours only,
or a wee'e of innojuity. Much
less contagious in the first days
of the eruption than in those
of desquamation.
Initial depression of temperature
less than in scarlatina.
Catarrhal stage highly infectious.
Infejt.ous shorter when catarrhal,
longer when herpetic.
Infectious from a single night ex¬
posure for a long time.
Infectious rarely more or less than
the 12th day.
APPENDIXES.
403
Diseases.
Remittent fever
Intermittent fever...
Dengue
Relapsing fever
Yellow fever
Plague
Cholera
Snake-bite
Glanders—Farcy.
Rabies
Diphtheria and
Epidemic pneumonia
Stage of Latency
and Innocuity.
Days 14—21
12 "
3—4
2—5
2-15
3—5
" 3—30
41 40—120
44 " I
" 3-8
Stage of In
vaaion and
Infection.
At once.
t< tt
Remarks.
Incubation sometimes shorter or
longer.
Infection illimited and uncertain
infection.
Infection rarely 8 to 10 days. Spe¬
cific smell prodromic.
A few days' incubation" is the
answer of the cholera commission
sitting (18f>5) in Constantinople.
With chilliness.
According if inoculated or conta¬
gious.
Examples of latency of above "a
year.
Infection likely extends farther
than has been observed.
There is a great deal more to learn about the periods of latency (innocuity and incu¬
bation), and the period of infection (proliferation and propagation).
(G.)—MEAN TEMPERATURE IN SOME DISEA8E8 OP CHILDREN.
Disease.
Authori¬
ties.
Minima.
Maxima. I Media.
Remarks.
Bronchitis, simple...
" complicated
Pneumonia
Pleurisy
Peritonitis
Dysentery
Enteritis
Pericarditis....
Thrush
Meningeal tubercles.
Meningitis
Scarlatina
4 C
Measles
Mumps
Tooth-rash — Zoster.
Varicella
Small-pox
Squire.
Roger.
Moreau.
Roger.
Moreau.
Squire.
Roger.
Moreau.
103° F,
99°
98.7°
99.2'
98.7°
105.5°
95°
198°
100°
101°
98.7°
93.7°
100° F*
105.8°
104°
105°
101.2°
102"
103.5°
102°
102°
108.5°
104.5°
102.9°
103.3°
99.95°
102.2°
103°
103°
102.2°
106°
102.2°
101.75°
101.5°F.
103°
100.7°
99.5°
101.5°
100°
100°
1C2°
102J
102.2°
101.75°
102.2°
And above as high as the
temperature of the com¬
plication.
In two cases with rheuma¬
tism, and one after scar¬
let fever.
Convulsions with or before
the eruption.
404
APPENDIXES.
(d.)—eogee's average temperature op children in acute
affections of the digestive organs.
Peritonitis
Dysentery
Stomatitis.
Enteritis.
39.55® c.
38.16° "
38.08° 41
37.96° «
37.86°, «•
= 103.19° F,
= 100.70° "
= 100.50°"
- 100.30° "
= 100.13° «
APPENDIX X.
MATHEMATICAL CHART OF USTION, CIRCULATION, AND RESPIRATION.
(filled by a mother.)
Name, Grace G Age, 10. Sex, Fem. Disease, Scarlatina.
Nor me of Temperature, .2.
Of Pulse, 84.
,©,f Respiration, 26.
1872. Month, December.
Days of Disease.
Hours of Observation.
li
4) C3
Q-i ©
a|
153
® o
s-y
Fever 1
Zero Health V 0
Depression J
Daily average
Daily difference
16
I.
m — e
1.6 2.2
Pulse
Respiration.
17
n.
m s-*— e
1.7 2.1
18
in.
m e
2.4 2.4
19
IV.
m —e
2.8 2.9
130 140
30 36
1.9
.4
127 135
32 40
2.4
0
135 120
38 40
20
V.
—— e
3.25 3.8
2.85
.1
72 100
36 40
2.5 2.81.5 2.5
3.52
,55
132 136
36 36
21
VI.
22
VII.
2.65
.3
120 116
32 34
2
1
104 104
32 35
Septenary No. 1.
j Maximum day, the 5th,
1 Minimum day, the 7th. .
( Total of morn. temp...
j Total of even. temp.,..
f Total up
j Zeros
I, Total down
Average of temp.
Id. of difference....
Id. of pulse
Id. of breathing.
3.8
1.5
15.75 :
18.7 :
84,45
17.22
2.95 :
1672
497
7 = 2.2
7 = 2.7
7 = 2.46
7= .42
14 = 120
14 = 36.5
MATHEMATICAL CHART OF USTION, CIRCULATION, AND RESPIRATION.—(Continued.)
Name, Grace G.
Age, 10. Sex, Fem. Disease, Scarlatina.
Norme of Temperature, .2.
Of Pulse, 84.
Of Respiration, 26.
1872. Month, December.
Days of Disease.
Hours of Observation.
2 j
Fever
S'B
O) eg
1
Zero Health
Depression
If
Daily average....
$ -3
Daily difference
Pulse
Respiration
23
VHI.
m — e
1.9 2.2
1.55
.3
24
IX.
m —>—•
1.25 1.5
1.37
.25
86 106 102 104
30 36' 34 32
25
X.
100
28
26
XI.
m —e
.5 1.4
.95
.9
28
27
XII.
m
.1 2.6
1.8
1.6
102
31
28
XIII.
m —'— e
100
27
29
XIY.
m e
100
28
Septenary No. 2.
Maximum day, the 12th.
Minimum day, the loth..
Total ot morn. temp.. ..
Total of even, temp
Total up
Zeros
Total down
Average of temp.
Id. of difference..
Id. of pulse
Id. of breathing.
2.6
.1
6.35 :
9.35 :
15.35
7.17
3.45
992
247
*** The other signs and symptoms, as well as the treatment—which happily was of the simplest nursery kind—have been omitted, to not
obstruct the mathematical course of the case,;
APPENDIX XI.
MATHEMATICAL RECORD OF TWO CASES OF ERYSIPELAS.
No. 1.
Name, S.
Age, 45. Sex, F. Disease, Erysipelas.
u
p
g.3
<1) -+3
ft a
0) <13
Pr3
$1
1872. Februaey.
Days of Di^pase.
' Fever 1
Zero Health !■ o
Depression j
Daily average,...
„ Daily difference
23
I.
m —— :
3.2 4
(above)
Local temp. (!),.,.•< V
( below )
3.6
24
H.
— e
4.2
25
in.
m —e
4 5
4.1
.2
6.5
Pulse <100 106104 112
Respiration , 28 22
4.5
108 118
20
26
IV.
m
5 4
4.5
6.3
27
V.
m e
3.2 3.1
28
VI.
m e
3 4
3.15
4.2
96 89
22
80 82
17
29
VH.
m e
3 2
3.5
2.5
80 100
16
77 72
16
One Septenary.
( Maximum days, the 3d and
\ 4th
( Minimum day, the 7th..
f Total up.
Total down...
Total of temp...
Id. of difference.
Id. of local temp
Id. of pulse
Id. breathings in
51.7 :14 = 3.7
u <(
<t ti
25.85 : 7 = 3.7
5.1 : 7= .72
4.9
94.5
23
16#
.1
£
MATHEMATICAL RECORD OF TWO CASES OF ERYSIPELAS.— {Continued.)
No. 2. Name, E Age, 24. Sex, F. Disease, Erysipelas.
r].
P
i: ©
N
s
i: g
1872. March.
[ Days of Disease.
Fever 1
Zero Health lo
Depression J
Daily average.
Daily difference.
[.iical temp.
f above "1
I
(.below j
Vise.
23
I.
24
H.
m e m e
7 4 3.5 5.5
5.5
123 125
25
in.
m •—e
3 6
4.5
8.5
26
IV.
m — e
3 5.7
27
V.
m —• i
2.5 5.C
4.35
2.7
113 115 98 120
4.05
3.1
4.8
104 115102 123
28
VI.
m e
.7
.35
.7
29
vn
m —e
1.4 2.3
1.85
.9
108 80
Septenary No. 1.
j Maximum day, the 1st
( Minimum day, the 6th
("Total up....
One zero
Total down.
Average of temp.
Id. of difference.
Id. of local temp.
80 88
Id. of pulse.
.7 and 0
49.3 114 = 3.5
23.6 : 7 = 3.34
16.4 : 7 = 2.35
31.3 : 7= 4.5
1501 :14 = 107
MATHEMATICAL RECORD OF TWO CASES OF ERYSIPELAS.—(Continued.)
No. 2. Name, E Age, 24. Sex, F. Disease, Erysipelas.
§ =«
"8 3
<d
1872. March—April .
Days of Disease.
' Fever ")
Zero Health j^O
Depression J
Daily average.
13
™ Daily difference
f above "j
Local temp.. J- 0
I. below J
Pulse
30
vin.
m e
3.2 6,6
31
IX.
m e
5.8 6
4.9
3.4
1
X.
m -•*— e
2
XI.
m e
5.9
2.3 6.22.2
.2
3.5
98 120
106 116
4.25
3.9
4.5
-0-
1.1
2.2
104 96 92 64
I
3
XII.
m —*-•- e
.2
4
XIII.
m —— e
.3 1.2
.7
.25
70 82
.75
.9
0-
82 84
5
XIV.
m — e
.35
.7
-0-
Septenary No. 2.
Maximum day, the 10th...
Minimum days, the 12th
and 14th
f Total up.
•J Two zero.
L Total down.
Average of temp.'.
Id. of difference.
Id. of lopal temp.
Id. of pulse
6.2
.7
34 :14 = 2.42
1.4 : 14 = .1
15.4 : 7 = 2.2
12.2 : 7 = 1.7
14 : 7 = 2
1264 :14 = 90
MATHEMATICAL RECORD OF TWO CASES OF ERYSIPELAS.—(Continued,)
Wo. 2. Name, E Age, 24. Sex, F. Disease, Erysipelas.
1S72. April.
Days of Disease.
" Fever
Zero Health j-0
Depression J
II
h
1
8
a
a>
a
. Daily difference
{above "j
10
below J
Pulse
Daily average.
6
XV.
m —'— e
.45
78 88
7
XVI
m —'— e
3.8 5
4.4
1.3
3.5
xvn.
m —— e
5 1.7
>
3.35
3.3
4.3
—
* s'
9
XVIII.
m e
Septenary No. 3.
10
XTX
M ~*->E
.5
21
.4
98 96
92'
.75
1.5
11
XX
m e
.5
12
XXI
.5
65 82 66 82
M •
.6 .4
.5
68 82
Maximum days, the 16th
and 17th
Minimum days, the 15th
and 19th
Total up
Two zero...
Total down.
Average of temp.
Id. of difference.
Id. of local temp.
Id. of pulse.
.9,
ib.5
.8, .6
: 14 = 1.8
3.3 :14 = .23
5.65: 7= .8
8.9 : 7 = 1.8
7.3 : 7 = 1
1025 :14 = 73
APPENDIXES.
411
APPENDIX XII.
PUERPERAL TEMPERATURES.
(a.)—during the montee of milk.
G , set. *27.
April 21.
u 22.
" 23.
24.
25.
26.
7 a.m., successful delivery..
Bosom flabby
Breast full; child begins to
suck ; no chill; hot skin ;
cephalalgy
All well
Breasts not so tense ; eats
well
And following days, plenty
of milk
82
68
64
58
56
Decimal Measures.
Pulse. Temper. Urine. Gravity. Urea. Chlore,
37.5°
37.6"
37.6°
37.5°
37.4"
800 gr.
1230 "
830 "
900
10.20
10.23
10.22
10.20
18.
4.53
34.4410.13
25.32
22.
20-23
5.13
5.60
5-600
{p.) QUINQUAND's TEMPERATURE, ETC., IN TRAUMATIC PUERPERAL
fever.
April 18..
*' 19..
" 20..
21..
" 22..
» 23..
24..
25..
No hemorrhage; child liv¬
ing.
Uterine colics; no tender¬
ness on pressure ; vulva
lacerated ; small lips tu¬
mefied.
Great pain in the right hy-
pochondrium; 6 dry cup¬
pings ; reliefs ; vulva
swollen; no induration.
No pain; good sleep ; milk
well up.
Vulva yet tumefied ; uterus
contracting normally ;
pression insensible.
Bats well; sleeps well.
Same condition.
Decimal Measures.
Pulse. Temper. Gra^'ty Urea- CMore
84
92
108
104
96
84
80
76
37.7°
38.9"
39.9°
39.3°
.38.5°
38.4®
38.3"
38.2°
1600 gr.
2120 "
900 "
700 "
900 "
1200
1650
1018
carmine-
red
21
1010 29.50
light
red
1013
light-
yellow.
1018
orange-
yellow.
1020
orange-
yellow.
1021
1017
<mmge.
19.55
17.22
19
22
38
10
4.98
2
1/89
1.50
5.62
412
APPENDIXES.
(C.)—LIGHT INFANTILE PUERPERISM OF INFANT {cure).
R Mother, set. 27, being well.
Feb. 26.
" 27.
" 28.
March 1.
" 2.
" 3.
11 p.m., natural delivery
( morning.
* | evening .
Nod»rtImi jssft;
Do not suckle; complains; pale; vomits; ) morning.
distended abdomen ( evening..
Suckle a little; green diarrhoea ; bili- ( rnnrT)^T)0.
ous ; vomiting; somnolence; swollen-< °'
abdomen (evening..
Diarrhoea continues j ^^ing^
Tries to suckle; pale in the evening j herring'*
Improved facies; suckles better j "
e ' ( evening..
Suckles well; pale yet discharged-at
Temperature. Weigh!..
36.8°
37°
37.8°
37.6°
37.9°
38.2°
38.8° )
38.9° f
35.5° )
35.9" f
37.8° i
37.9° f
37.5 "I
37.7°f
37.8°
2900
2900
2800
2740
2700
2675
2750
2710
2710
2715
(d.) IN INFANTILE PUERPERISM OF INFANT {death).
P , Male. Mother, set. 23. Has had. pelvi-peritonitis. Cured.
April 13.,
" 14.
" 15.,
" 16.,
" 17..
" 18.,
Passes meconium ; does not seem to suffer
Little sucking -j
Cries all night; some diarrhoea; swol- j
len abdomen; loss of flesh sensible... |
Vomited; abdomen tense, traversed i
with blue veins; some diarrhoea 1
Abdomen tense; sensible; vomit green;
refuses food; mouth dry ; features al¬
tered ; scrotum tumefied, etc
Bilious vomit; green stools; emacia¬
tion ; hippocratic facies
Death in the night.
morning.
evening .
morning,
evening.,
morning,
evening.,
morning,
evening..
morning,
evening..
morning.
evening..
Temperature.
37.6?
37.6°
37.4°
37.5°
38.8°
38.8°
39.
38.2°
39.1°
38.5°
39.5°
40.0°
Weight..
3770
3670
3570
3470
3370
3270
{e.)—INFANTILE PUERPERISM COMPLICATED WITH MENINGITIS
{death).
1st day.
2d "
3d "
4th "
5th "
6th "
7th "
8th "
9th "
10th "
After birth ; is well; nurses
Temperature 36.7° C
U U
U u
Sucks well to this day
Intermittent and convergent strabism
Temperature rises ; thrash
No more suckling; local and general con
vulsions alternately
Temperature 41.1° C,, morning and even
ing; intense convulsions ; death
Autopsy: purulent meningitis.
Loss of weight,
80 gram.
120 "
Increase of weight, 50
Loss
U 11 11
Stationary,
Loss of weight,
Stationary,
Loss of weight,
(( U 11
180
20
'io
90
85
APPENDIXES.
41,3
APPENDIX XIII.
(a.)—WILSON FOX'S TABLES OF TEMPEEATUEEy SHOWING THE
EFFECTS OF THE TREATMENT BY COLD.
MRS. BROPHT
Date.
June 5. 9th day
of disease.
June 6.
" 10. 14th day
of disease.
June 11-
15th day.
Hour.
8.0 p.m.
11.0 a.m.
10.0 p.m.
10.0 a.m.
11.0 p.m.
12.0 noon
9.0 p.m.
11.0 a.m.
9.0 p.m.
9.0 a.m.
3.0 p.m.
4.0 p.m.
4.30 p.m.
5.30 p.m.
6.0 p.m.
6.25 p.m.
6.45 p.m.
7.5 p.m.
7.20 p.m.
7.35 p.m.
7.50 p.m.
8.5 p.m.
8.30 p.m.
8.40 p.m.
8.55 p.m.
9.15 p.m.
9.30 p.m.
9.50 p.m.
9.55 p.m.
10.10 p.m.
10.15 p.m.
10.20 p.m.
10.25 p.m.
10.30 p.m.
10.35 p.m.
10.50 p.m.
10.55 p.m.
11.5 p.m.
11.10 p.m.
11.25 p.m.
11.40 p.m.
11.55 p.m.
12.2 a.m.
12.20 a.m.
12.35 a.m.
Temp.
Pulse.
102.9
101.2
100.
99.66
-100.9
100.6
100.7
99.2
101.2
*
105.0
106.3
1C5.7
105.6
106.4
106.2
106.6
10612
106.2
106.4
106.9
107.1
107.3
107.6
107.8
108.4
109.2
109.1
110.0
109.4
108.4
107.5
106.2
104.0
103.6
101.5
100.6
99.5
99.5
97-4
97.4
98.0
98.2
98.3
98.3
Resp.
84
122
113
104
168
112
112
120
118
116
112
120
122
136
120
140
130
130
44
44
42
40
40
38
40
42
40
36
34
32
36
42
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Rec.
Vag.
Vag.
Vag.
Vag.
Vag.
Remarks.
* Not ex. 102°.
Quin. 3 j.
Quin. 3j.
Quin. 3j.
Quin. 3j.
Quin. 3j.
Quin. 3j. Vomited.
Unconscious.
Bath 96°.
Iced water poured over
patient.
Spinal icebag.
Paitly conscious.
Taken from bath at
temp. 633.
Patient can speak.
Rigidity of lips and of
muscles of neck.
Pulse imperceptible;
warmth to feet and
spine.
414 APPENDIXES.
Date.
Hour.
Temp.
Pulse.
Resp.
Remarks,
Beophy—cord.
12.45 a.m.
120
Vag.
June 11—cont.
12.55 a.m.
98.9
/
1.15 am.
1.40 a.m.
2.15 a.m.
99.4
99.2
1-01.1
188
*32
Vag.
Ax.
Ax.
Asleep.
2.55 a.m.
101.4
iies
'40
Vag.
4.0 a.m.
102.4
10b
36
Ax.
5.0 a.m.
102.9
Ax.
6.30 a.m.
103.4
Ax.
7.15 a.m.
103.8
Ax.
7.35 a.m.
104.5
Ree.
7.40 a.m.
Bath, 64°.
7.45 a m.
105.0
,,,
Vag.
7.50 a.m.
104.6
Vag.
Vag.
8.0 a.m.
103.9
Taken from bath, 66°.
8.7 a.m.
102.0
• » .
Vag.
Vag.
8.15 a.m.
101.7
8.30 a.m.
100.8
....
Vag.
Rigor; warm bottles.
8.40 a.m.
99.4
ios
Mouth
Rigor.
8.50 a.m.
( 99.9 }
\ 99.8 )
84
25
j Rec.
1 Mou.
9.10 a.m.
99.4
Mouth
9.40 a.m.
99.9
Mouth
10.0 a.m.
100.0
Mouth
10.45 a.m.
100.4
* • •
Mouth
Hot bottles removed.
12.15 p.m.
100.7
Mouth
1.45 p.m.
100.9
• .
Ax.
3.0 p.m.
100.7
96
*30
Ax.
Perspiring freely.
June 12.
12.15 a.m.
101.2
Ax.
16th day.
1.0 a.m.
10O.8
Ax.
26 hours.
4.0 a.m.
7.30 a.m.
101.0
100.2
Ax.
Ax.
9.40 a.m.
99.8
Ax.
Cardiac dulness at 3d
10.30 a.m.
100.7
• • .
Ax.
cartilage.
3.10 pm.
101.3
120
Ax.
Pains in knees.
8.50 p.m.
102.1
Ax.
9.20 p.m.
102.2
Ax.
9.45 p.m.
Ice-bag to spine, 3
9.55 p.m.
101.6
Mouth
hours.
11.45 p.m.
101.8
Ax.
June 13.1
12.40 a.m.
101.0
Mouth,
Ice-bag removed.
17th day.
12.55 a.m.
100.5
ioo
'30
Mouth
50 hours.
1.25 a.m.
101.6
Ax.
3d day.
4.40 a.m.
101-6
Ax.
5.10 a.m.
102.4
Ax.
Ice-bag applied 3 hours.
5.40 a.m.
101.5
Ax.
8.15 a.m.
100.9
Ax.
Ice-bag removed.
8.50 a.m.
101.2
ioi
'26
Ax.
9.50 a.m.
101.9
Ax.
Rales in both lungs
12.0 noon
102.5
Ax.
Ice-bag, 18 hours
12.48 p.m.
102.6
Ax.
2.53 p.m.
101.4
Ax.
3.55 p.m.
101.7
Ax.
4.45 p.m.
101.8
Ax.
6.15 p.m.
102.2
Ax.
10.0 p.m.
101.9
'96
*32
Ax.
June 14.
2.0 a.m.
101.4
Mouth
18th day.
3.0 a.m.
101.0
Ax.
76 hours.
6.0 a.m.
101.6
Ax.
Ice-bag removed
4th day.
8.0 a.m.
101.8
Ax.
8.30 a.m.
Ice-bag, l^hour.
9.20 a.m.
101.8
...
» • •
Mouth
Ico-bag removed.
LO.O a.m.
102.1
. . «
Ax.
L0.25 a.m.
102.1
Ax.
APPENDIXES.
415
Date.
Broptiy—cont.
June 14—cont.
June 15.
10th day.
104 hours.
5th day.
June 16.
20th day.
6th day.
June 17. 21st day.
7th day.
June 1^. 22d day.
8th day.
June 19. 23d day.
9th day.
July 1. 35th day.
18th day.
Hour.
11.25 a.m.
2.50 p.m.
3.40 p.m.
4.30 p.m.
6.0 p.m.
11.0 jp.m.
2.30 a.m.
3.0 a.m.
4.0 a.m.
5.0 a.m.
7.0 a.m
8.45 a.m.
9.40 a.m.
10.30 a.m.
12.15 p.m.
1.15 p.m.
3.15 p.m.
7.15 p.m.
8.30 p.m.
11.30 p.m.
12.30 a.m.
4.0 p.m.
11.30 p.m.
2;0 a.m.
10.35 p.m.
8.45 a.m.
9.0 p.m.
11.0 a.m.
10.0 p.m.
M.
E.
Temp.
01.5
01.3
02.1
01.7
00.2
02.H
03.2
02.6
02.0
01.8
02.4
01.4
01.7
00.5
ca.8
02.3
C2.7
01.9
C2.7
01.8
(2.4
00.0
99.8
99.8
98.4
99.1
99.2
98.2
98.4
100.0
98.5
Pulse. Resp.
96
24
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
Ax.
8 p. m. Rales in lungs.
Some dulness, right base
Ice-bag applied 6
hours.
Ice-bag removed; not
again applied.
9 a.m. Dulness, right
base, disappeared;
stJl rales in lungs.
17th. Sibilant rales in
lungs.
22. Rales disappeared
from lungs.
(&.)—WILSON FOX'S TABLE SHOWING THE EFFECT OF THE BATHS
IN THE REDUCTION OF TEMPERATURE.
BROPHY.
First Bath.
Time in Bath.
Rise
or
Fall.
Temp.
Temp.
Amount
of reduc¬
tion.
Time.
Average
reduction
per min¬
ute.
Remarks.
15m.*
5m.
5m.
5m.
5m.
5m-
After Bath.
15m.
10m.
20 m.
fall
it
it
tl
tt
u
it
it
ft
ft
0.6
L.O
0.9
1.3
2.2
0.4
2.1
2.0
2.1
110°
103.6
97.4
6.4
6;2
40m.
45m.
0.16
0.13
* Iced water.
416
APPENDIXES.
Second Bath.
Time after
Immersion.
Rise
or
Fall.
Temp.
Temp.
Amount
of reduc¬
tion.
Time.
Average
reduction
per min¬
ute de¬
grees.
Remarks.
10m.
rise
0.5
104-5
to
105
5m.
fall
0.4
Bath 64°, rose to 66°
10m.
0.7
103-9
1.1
15m.
0.07
After Bath.
U
1m.
u
1.9
8m.
41
0.3
15m.
U
0.9
10m.
u
1.4*
99-4
4.5
40m.
0.11
* Month.
(<C.)—W. H. DRAPER'S TABLE SHOWING (1) TIIE EFFECT OF THE BATH
ON TIIE TEMPERATURE, (2) THE PROMPT REACTION FOLLOW¬
ING- SHORT BATH, (3) THE EFFECT OF THE JJATH
IN RELIEVING THE HEAD-SYMPTOMS.
Admitted 20th Maroh, 1875. No. 2.—D. Forest, adiilt male.
Day.
Hour.
Temperature.
Clinical Remarks.
1
3
5
5
5
5
5
5
5
5
5
6
9.00 A.M.
3.45 P.m.
5.30 "
6.00 "
8.00 "
8.30 "
9.00 "
10.30 "
12.45 "
2.00 A.M.
103° F.
104°
104.5°
100.2°
107.3J
99.3°
105.5°
99°
102.5°
105.7°
99.5°
106.2°
The cold pack was used on the fifth day of disease
without effect on the temperature. Two hours
later the fir&t bath was given, reducing the temp,
from 107.3° to 99.3°. Each subsequent bath, as
will be seen from the table, reduced the temp, in
the same marked manner. The delirium and sub-
sultus which accompanied the high temp, subsided
in every instance after the bath. The temp, of
the baths was from 70° to 80° Fahr. when the
patient was immersed, and was lowered after im¬
mersion to 55° or 60°. The duration of the baths,
was from 5 to 11 minutes.
6
6
2.10 "
4.15 "
100°
105°
6
6
6
6
6
4.45 "
11.30 11
11.45 "
3.10 P.M.
3.30 "
100ii
1C5MM
9
10'.
|^100.7°
6
6
6
6
7
8.00 "
8.15 "
12.00 "
12.10 "
2.30 P.M.
105°
101.5°
105°
101.2°
103.2°
These cases of W. Fox and W. H. Draper would read more easily, and present their conclusion
much more forcibly, if they were divided into septenaries, and written in the fignrns of the physio¬
logical scale of thermometry employed in Appendices X. ami XI. The laic^t records of the treat
ment of hyperpyrexia by cold are from W. H. Thomson of the Bellevue Hospital. > l this city, in
the New York Medical Record (Nov.), and from Sydney Ringer of the Universit Hospital Lou
don, in the British Kedicai Journal (Oct.).
-
'
'
.
Date Due
Library Bureau Cat. no. 1137
f
'
'
'
' . ' ' ■ • • i
^ -
: V.
»
■
■
-