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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. 




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ABNER WELLBORN CALHOUN 
MEDICAL LIBRARY 
1923 



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CLINICAL THERMOMETRY. 



E, SE GUIN, M.D M 

OF NEW YOKK. 



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 on 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 on 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. 



HISTORIC. 



After ages during which physic and true physicians suffered 
as much as mankind itself under the pressure of medical 
theurgism, 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 calor, reopened 
the Ilippocratic question : Be Colore in Morbo. 

After centuries of apparent neglect of temperature as a fac- 
tor m 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 
cluneal importance to temperature. But to De Haen, of Vienna 
belongs the honor of having introduced thermometry in the 
practice and m 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 
ahreilh -eit 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- 

TO ,?„ < L IIaen obs , erved the temperature of healthy people of 
of Xa~d 8 ' T ™. &e flret to ™» a '- k Wgh temperature 

aPphea^n-o/L^rt 1^ ^ ™ ^ ° f » is 
was aware of themoS^ S "T Wld P"*»«''«- D. 

of temperature in feZT.^i lT' " ^'"^ ^"^ion 
febrile rigor (fieber TZ) ■ of f, ° f te '"P era t"re duriug the 
tares ^JntenS^^^™ 4 ™? ? *"» t«n,pera- 
of the discrepancies between tlLTTf 7 b "" CUred ; «d 
patients aud in certain d ea Te S P h W »' some 

the subjective feeling of wanmh or eold as mTT 
and the objective temperature ai Z 7 ' C l Jf " ie »t, 
the changes of temperature as Z^L^T™' 7 ' he "rt 

^^^^^ rr,j r - 

* Born in Capo dlstria^rTlo^r^r^T^Tr^r: _^__con- 

Padua from 1600 to his death, in 1636 dlC1De * th ^W^7 f 



HISTORIC. 



3 



valescence. He 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 Haller 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 Academic, 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 leadership 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 Reports 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 has its temperature recorded ; ther- 
mometry pervades the whole of Carrie's practice ; nevertheless, 
it influenced very little the medical profession. So that for 
many years his 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. 

Vacea Berlinghieri, Bnntzen, Coleman {Dissertation on Sus- 
pended Respiration, 1791), and Saissy {RecJierches sur la Phy- 
sique des Animaux Hybernans, 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 Heat, and 
Fartlier 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 Hale and Legallois also deserve 
mention here. 

Chossat (These, Paris, 1820), Sur V Influence du Systeme 
Nerveux sur la Chaleur Animale, 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 Hufeland offered a prize for the demonstration of 
Currie's theory and method of treatment. The prize essays of 
Anton Frolieh and Beuss (published m Hufeland' s Journal, 
1822) contain many valuable contributions to pathological ther- 
mometry. Bailly wrote a Memoire sur V Alteration de la 
Chaleur Animale dans les Fievres Algides {Revue Medicate, 
1825, v. 384) ; and Edwards (1824), in De V Influence 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 Breschet 
published their researches on human temperature (in Annates 
des Sciences Naturelles, 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- 
tifs d la Construction oVune Echelle de Degres de la Chaleur 
Animate (in Me moires de la Societe 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 : De V Influence de la Circula- 
tion Generate et Pulmonare sur la Chaleur du Sang. P. H. 
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 tant de 
resultats obtenus par le seul secours d'un pen 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 concoit 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. Transact., vol. 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 V Experience) 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 Andral's 
Lectures on General Pathology, was the Dissertation of 
Gierce, On the Causes of Organic Heat in Inflamed Parts. 
Hollman 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 1838. 

Of the same date are the investigations of Henri Eoger (Be 
la Temperature chez les Evfants, a Vetat Physiologique et 
Pathologique published in Arch. Gen. 1844, and since in book- 
form, still highly valued. His thermometrical observations bear 
on the normal temperature of children at birth, during their 
first seven days, and later ; then in ephemeral, intermittent 
tvphoid 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, wbooping- 
cough, chorea, dropsies, rickets, and paralysis, besides thrush 
and sclerema of newly-born infants. Finally, Dr. Eoger 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. 

Demarquay,* 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 Eoger, 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. 

Zipmermann, a military surgeon, advocated the cause warmly 



* Lately deceased. — See Bibliography and Surgical Thermometry. 



HISTORIC. 



7 



and furnished a great number of valuable facts. The disserta- 
tion : De Colore in Morho, Bonn. 1849, of T. P. Sehmitz, 
will not be forgotten, nor the teachings of Nasse on the same 
subject. Let us supplement these brief notices by an acknow- 
ledgment of the value and abundance of the thermometric 
observations of John Davy, which successively appeared from 
1844 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 on 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 incidentally. 

About 1846, chemists and physiologists took up the question — 
Fourcault, Flourens, Magendie, Helmholtz ; Donders treated of 
The Tissue- Changes as a Source of Heat in Plants and Ani- 
mals : Liebisr 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. E. 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 no 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 



s 



HISTOKIC. 



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 Organumw&s too much for the medical public, 
who needed the authority of Helmholtz 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 hilogrammeter. 

Finally, Him, 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-production. 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 since 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 



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, Thierf elder, Uhle, Friedmann, Rotter, Ea- 
konz, Giesler, Wolff, Blass, Thomas, Siegel, Schenkel, Treib- 
mann, Friedlander, Ileinze, Heubner,^ Stecher, 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, Grimshaw, 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- 



to 



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 ; Yulpian at the Ecole 
Pratique ; Bert, Berthelot, Lorain, Potain, See, Jaccoud, Le- 
pine, Bourneville, Dupuy, Padouan, Onimus in hospitals and 
private practice ; Hirsh and Wurtz at the Ecole de Medecine ; 
Claude Bernard and Marey at the College de France ; Becquerel, 
Poger 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 Hippocratic, 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 Becquerel's, f undation of the norme 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 method 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 heat 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 doable 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 nobme. 

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 self — 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 Noeme. 
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. Lich- 
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.) 36.31° 

Medium of the day (24 hoars) 37.03° 

Labbee indicates two daily maxima irrespective of digestion or 
sleep, therefore tidal too, and thinks that the sum of the tern- 



!4 PHYSIOLOGICAL TEMPER ATUEE. 

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. How 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, cannot 
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. 

HI- — -Are there Abnormal Normes ? 

Displacements of the norme by idiosyncrasy, or in consequence 
of some accident or affection, are likely not .infrequent, though 
rarely noted. Thomas expresses the opinion that, as there are 
persons who naturally have a slow ^-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 Ko-er 
admits the reality of these displacements, either by idiosyncrasy 
or from accident, during the first septennat of life ' 

Wunderli.ch recorded quite a number of normal adult 
temperatures^^ 96.8° F. = 36° C.=l (one degree below zero 
ot the physiological scale), in other terms an abnormal norme • 
and he took the observation of a girl, ret . 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 ustion, 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 ; Eoger— taking 
care to operate on 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 Iioav 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 ; (b) 
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 two 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 Eepublic 
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 mtal-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 TEMPERATURES. 



19 



Before birth the infant temperature is a little higher than that 
of the mother's uterus or vagina — a difference which may 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 norme 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. = 1.26° 
— 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°— 37.9 3 , neglecting accidental motived 
ecarts. (See Appendix No. V.) 

The children of 3,000 grammes (6 pounds) and upwards are 



20 



INFANTILE TEMPERATURES. 



those who keep nearer the norme ; 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 firsteweek (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 
he considered as sickly pertxirbations. 

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 f rigerates ; 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 



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 will 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 No. 2 
not washed, nor fed for some hours ; rectal temperature 97.4° ; 
after suckling, 98°. Case No. 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 chillness, 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, 



23 



INFANTILE TEMPERATURES. 



but can only refer to the Part Second already referred to, and 
to Appendixes V. (a, b) and VII., on the 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.' 3 



4 



CHAPTER V. 

THERMAL INFLUENCES ON THE NORMS. 

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 VI.) 

Of Drinks. — The transient effect of a moderate and habitual 
use of ardent spirits and other drinks on the temperature of 
the healthy 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 
for 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 Physiologie, 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 lathing, in good ordinary conditions, equalizes the 
temperature, and comes next to food — with food, must we say ? 
as a factor of the norme with a weak circulation, fatigue or 



24 



INFLUENCES ON THE NORME. 



chill, the bath, like the food and drink, must be warm, and 
yet not so hot as to promote hyperpyrexia temperatures. 

The possibility of frigeration by cold water is more marked 
in those born before'their 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 
wi th therm o-therape uti cs. 

b. — 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 "VVunderlich : — 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 S° C.= 56.4° F., he obtained a mean 
body temperature of 36.625° C.=97.9° F. Eight days later, 



INFLUENCES ON THE NORME. 



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° C=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. — How 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 affects the respiratory functions, and through 
them the circulation and the calorification, but more in walking 
or working 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 
harometric 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 VIIL). 



20 



INFLUENCES ON THE NOEME. 



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 on with less 
danger the submarine and subterranean works of engineer- 
ing. 

In medicine the combined action of oxj-gen 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 on 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 NOEME. 



27 



Him, 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 THE 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 anthropo- 
phagist is contented with a few pounds of human flesh, but the 
civilized anthropophagist 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 on 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 
sior les epidemies et endemies aVanemie 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 anaemia, 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, Have we two 
orains? showing that the thinking brain — ordinarily the left- 
has a higher temperature than the 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 the 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 
atfect the body-temperature in the scheming classes, as does the 
loss or paucity of calories in working people. Here hyperaemise 
are the factors of frequent hyperpyrexias, 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 where, 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 NOEME. 



Morally, the keeping of the norme 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 the}- 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. 



CHAPTEE 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. 
Eemember the struggles of combustion in a boil ; or have you 
ever studied the temperature over and around a cold abscess 8 
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 poiuted 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- 
mometry 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. 
Thermometry 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. 



CHAPTER VII. 



PRINCIPLES 

BY WHICH TO JUDGE OF THE SIGNIFICANCE OF THE TEMPERA 
TUKE-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. = of the 
physiological scale (see Appendix L), 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° ¥.=±2.5° =53 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 n'orme (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 temper atxire 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 
88.5° C. = 101.3° F.j 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 'sharply 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, cere- 
brospinal 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 an 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 TEMPEKATUKE-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- 
temperatures. 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.j 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.= 
104.9° 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 TEMPERATUKE- 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 jpro- 
dromic, of which we know so little. 

The initial or jpyro genie 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 d&Uy 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 deferves- 



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 pro-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 : 

The procfcomic 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. % 

The next period, or fastigiurn, 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. Tjj 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- 
giurn. 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 fastigiurn 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 f astigium, 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 inarch of the 
defervescence may be by a continuous fall, which, however, 
when it lasts more thanj 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 epicritical 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. = 4° — 6° F., 
relapses and secondary affections show themselves in this 
period, whose illimited duration merges in true convalescence. 

In convcdescence, 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 hefore, it may continue to rise in death and after 
death. In the former case the cooling is rapid, in the latter it 



SIGNIFICANCE OF TEMPEKATURE-CHANGES. 



41 



is tedious, and corpses have bzen 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: fehricula 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 Kamsbotham, 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 contimied elevation of temperature usually 
begin suddenly, with rigors and shivering. During the fasti- 
ginm 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 (but 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 relapsing 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 apyrexiae 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. 

Iu the relapsing the paroxysm is less limited, the temperature 
more variable, the intermissions longer, the relapse 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, "fevre 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 
those 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, and 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 bet ween 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 diseases, 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. 
' Let us now inquire into the causes of abnormality of the 
body's heat. 



CHAPTER VIII. 



CAUSES OF ALTERED TEMPERATURE. 

Thermometry observations show how narrow are the limits 
between health anal 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. 



45 



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 experi- 
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 on 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. 

Tho* 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 on 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 
clown 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- 



4:6 



CAUSES OF ALTERED TEMPERATURE. 



tion and its sequels do, as in Walter's rabbits. On the other 
hand; the application of cold on 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 hyperaemia (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 (ventonses 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 on the 
sick, are complex. (See Chossat, Mem. de V Academic des 
Sciences, viii., p. 43S ; 1842. Schmidt, Lichtenfels, and Froh- 
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- 
menia 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 (Demarquay, 
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 pyaemia, 
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 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, 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 Experimental 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 cerebrospinal 
nervous system, in producing these, cannot well 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- 



1 



CAUSES OF ALTERED TEMPERATURE. 49 

pression of temperature in animals whose body-surface was 
covered with an impermeable coating. 

Budge (Oomptes Bendus, 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 Kuyter (De 
Aotione, 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 hypersemia 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) they 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. Schiff 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. 

The 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 hyperemia (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 Hebdom., 1867) gives the fol- 
lowing conclusions from his long observations on hemiplegic 
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. 



58 



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 
thermometric 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 when the cold increases. In very 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 hyperaemias, 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. Here 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, 36.11° ; 
same increase in the rectum, etc. 



Fig. 1. 




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 reaches 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, but 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. = 104: 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 finds its analogue in the shivering of nervous people in 
some forms of intoxication, etc. 



Rigors occur, also, with a falling temperature, or in the midst 
of an elevated one, or when it rises 2° to 3° C. 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 fieberfrost 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 



Fi£f. 2. 




I 




53 



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. 



50 



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-hook of Pathology, etc., Zimmerman, CI. Bernard, 
Schiff, Traube, Marey, Auerbach, Wachsmuth, Billroth, O. We- 
ber, Senator, etc., though one-sided, throw light on 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 



GO 



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 aetivit} 7 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 greater 
part T>fthe 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 riiay 
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 norms. 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 TEMPEEATUEE. 



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 very 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—.S6 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 W underlich 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° O. ==101.1" F., mildly febrile; any- 
thing above, decidedly febrile. Then to determine whether the 
fe ver 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 hyperpyretic. 

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 cliief 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, 
pyaemia, 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 ; they 
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, of ten 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° (1 = 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 
was 33.5° C. = 26.8° R — 92.3° 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 (]S T os. 
69 and 71 of the Gazette des H&pitatix, 1866), and Bergeron, 
Eecherches 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 ivhich 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 protracted alterations of temperature produce 
functional disturbances and even alterations of tissues; they 
lay the foundation of diseases of the circulatory, respiratory, 
secreting, and nutritive systems, and of the nervous functions 



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 rep>eat 
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 : — 



Fahr. 


Cent. 


Corr'g pnlse. 


Fahr. 


Cent. 


Corr'g pulse. 






60 


103 










70 


104 


40.0... 


120 






80 


105 


40.6... 








90 


106 


41. L 








100 





VALUE OF A SINGLE OBSERVATION. 



67 



According to Liebermeister : 

98.6 37 

100.4 38 88.1 

102.2 39 97.2 



104-0 40 105.3 

105.8 41 109.6 

107.6 42 121 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 grown 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- 



68 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 te7nperature 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 always do. 

Subnormal and collapse temperatures only occur in diarrhoea, 
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 on 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 OBSEKV ATTON . 



danger and possible complications of it. It is thus 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 ; contrarily, 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 OBSERVATION. 



71 



pleurisy, pericarditis, endocarditis, peritonitis, while a moderate 
or apyretic one does not insure a favorable prognosis. 

In presence of a g astro-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 patients ;, the 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 affections 
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 become fluctuations and perturbations ; the v 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 triple-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 
on the kind of disease, its intensity, the stage it has reached, 
the regularity, irregularity, or other peculiarities of its course, 
the improvements or relapses, the occurrence of complications 
or special events, the progress toward health, the fatal crisis. 
It may also depend on 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. 
/ 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 level, if it 
is high, medium, or low. Whilst the base line of the daily 
oscillations in health is 37° C.=98.6° F., on 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 mean 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°— 10° 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° (1 = 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 TEMPERATURE. 



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 intermission, 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^ 
mg 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 TEMPEEATUEE. 



77 



pneumonia, in the last stage of acute fatty degeneration, in 
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 septicemia, 
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 aommonest 
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 6 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 early minimum is considered an improvement, unless brought 
on 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 no 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, interrupted 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. 



FLUCTUATIONS OF TEMPERATURE. 



TO 



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 multiple-peaked 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. 



So 



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 I 
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 apart 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 FEBRILK 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. Pahr. Cent. Fahr. 




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 



8^3 COURSE OF FEBRILE TEMPER ATT RES. 

scarlatina, croup-like pneumonia, pyaemia, malarial and rolaps- 



Fig. 5. 




Fahr. 

104.9 Cent. 

40. 



39. 



Fig. 0. 



38.5 

38. 

37. 







I 


■ 

MS 


■ 


m 


■ 


H 


H 


W 


H 


m 



Fahr. 
104. 

103.1 

102.2 



37.5 



99.5 



99.5 



ing fever ; it is common in typhus, febricula, facial erysipelas, 
tonsillar angina, meningitis of the convexity. It never occurs 



Cent. 
40.5 

40. 

,39.5 
39. 

38.5 

38. 



Fig. 7. 



37. 



■1 


■ 

■ 


■ 
■ 


t 

i 




■■ 


1 


■ 




1 


■ 




m 


■ 



Fahr. 
104 » 

104. 

103.1 
102.2 

101.3 

100.4 

98.6 



iti typhoid fever, basilar meningitis, catarrhal affections,' nor. i 
acute polyarticular rheumatism. 



in 



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. 

39.6 

39. 

38.6 

38. 

37.6 



1 








/ 


■ 


i 


1 


1 


m 


I 

1 


■ 


■ 




1 


■ 


■ 




■ 


f) 


I 


1 


■ 




■ 


V 


1 




■ 


i 


1 


1 


■ 


■ 













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 
acme* 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 fever 
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.= 



Fig. 9. Fig. 10. 

Cent. Fahr. 




102.2°— 104.36° F. ; typhus, 39.2°— 40.5° = 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 TEMPERATURES. 



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° 0. = 101.8°— 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 fastigium 
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. 



Cent. 



41. 



40.5 



40. 



39.5 



38.5 



Fahr. 



105.8 



104.9 



Fig. 12. 




Cent. 
42. 



41.5 
41. 

40.5 

40. 

39.1 
39. 



■ 


>r 


■ 

H 




■ 




■ 


■ 


■ 


■ 


SH 





Fahr. 
107.6 

106.7 
105.8 

104.9 

104. 

103.1 

102.2 



The acuminated course of temperature during the fastigium 
occurs in the paroxysm of short intermittent, in ephemeral, and 
malarial fevers, pyamiia, erratic erysipelas, seldom in pneumo- 



86 



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 



■ 


■ 






m 




■ 


■ 


I 


I 


a 


■ 


■ 


■ 


■ 


■ 


■ 













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 



mm 


m 


■ 


■ 


u 






■ 




m 


■ 


\ 



Fshr. 



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. 



41.5 



41. 



40.5 



40. 



IB 


■ 


■ 


■I 






■ 


n 


I 


/ s 

/ x 

/ 


V 


4 


■ 


■ 


■ 


m 











Fahr. 



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. 10. 



Cent. 
40.5 

40. 

39.5 
39. 











1 


■ 


ii 


■ 


i 




11 


■ 


n 


m 


■ 


I 




■I 


■ 


m 


■ 


■ 




II 


■1 


■ 


m 






HI 



Fahr. 



104.9 



104. 



103.1 



102.2 



Id the great majority of diseases the course of temperature 
is non-cjntinuous during the fastigium. This is the rule in 



88 course or FEBRILE temperatures. 

typhoid fever, catarrhal affections, catarrhal and putrid 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 
f astigium of the disease (Fig. 16) ; whilst in severe cases they 
remain above that average (Fig. 17). 

Fig. 17. 

Cent. Fahr - 



41. 



4C.5 



40. 



■ 


■ 


■ 


■1 


■ 




I 




■ 


■ 


■ 


■ 


■ 


■ 


■ 


■B 



105.8 



104.9 



104. 



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 pysemia. 

The varieties in the non-continuous course of temperature 
during the f astigium 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.=, 



Cent 

41. 

40.5 
40. 

39.5 

39. 

38.5 



Fig. 18. 



mi 


■ 


■ 


1 


nn 


i 


■ 


I 


mil 
■Ml 


111 
111 


M 

K 




m 


1 


1 


1 














1 













Fahr. 

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 absohite 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 



Fig. 10. 



40. 



39.5 



39. 



38.5 



38. 



1 






n 




■ 


1 


1 


■ 








■ 






K 


r 


■ 


y 




m 


■ 


mm 


■ 


m 


■ 


mm 




1! s 




i 





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. 



Cent. 
40.5 

40. 

89.5 

39. 

38.5 

38. 







I 








Fahr. 
104.9 

104. 

103.1 

102.2 

101.3 

100.4 



The direction taken by the temperature when the course is 
non-eontinuous may likewise differ, the fastigium being either 
uniform, ascending, or descending, rather corresponding in this 



COURSE OF FEBRILE 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 may terminate it ; called in the good old language 
of physic, perturbatio critica. 



Cent. 



40.5 



40. 



39.5 



39. 



38.5 



Fig. 21. 



mm 


iml 


■ 


■ 


■ 


m 



Fahr. 



104.9 



104. 



103.1 



102.2 



101.3 



In small-pox the fastigium 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 
course 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 cerebrospinal meningitis ; and is marked by 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 amphy- 
boiic stage. A rise of temperature is induced in febrile patients 



COURSE OF FEBRILK TEMPERATURES. 



9H 



by mental excitement, bodily exertion, being kept too warm, 
errors of diet, persistent constipation, and the occurrence of cer- 
tain complications. & 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, febriculae, 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, epicritical period of recovery. 

The first 6tage 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.) 



94 



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 

Cent. 
40.5 

40. 
39.5 
39. 
38.5 
38.. 

may consist in a moderation or absence of the regular evening 
exacerbation ; or in a greater morning remission (with the oin 
di nary 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. 



05 



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. 




Fahr. 


Cent 


105.8 


40.5 


104.9 


40. 


104. 


39.5 


103.1 


Off . 


102.2 


38.5 


101.8 


38. 


100.4 


37.5 


99.5 


37. 


98.6 





Fig. 24. 




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° C.=.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. Fah r - 
40.5 

40. 

89.5 
39. 

88.5 
88. 
87.5 
37. 

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°— 10.8° 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 




COURSE OF FEBRIXiE TEMPERATURES. 



»7 



with evening exacerbations ; but, on the whole, either the daily 
maximum, or the daily average, is less from day to day ; this 
may last from three to seven days, even subject to interruptions. 
In this way evening exacerbations may continue high, and 

Pig. 26. 

Cent. Fahr. 




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 loiuj as febrile temperatures are met with in 
7 



98 



COUESE OF FEBEILE TEMPEEATUEES. 



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 



87. 













4. 

■ 


- 






■ 


i 


■ 


■ 






B 


■ 








1 


1 


1 


1 






■ 




■ 


■ 




■ 










■ 






■ 








1 


i 


i 





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 sequelae 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 new 
course is determined by the nature of the sequelae, not bv 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. 

105.8 



41.1 
40.5 
40. 
39.5 
39. 
38.5 

38. 

37.5 

37. 



p 


nun 


m 




■ 


■ 


■ 


■ 


nnn 


m 


■ 


■ 


■ 


■ 


■ 


■ 


Hi 


H 


H 


■ 




■ 




■ 




II 


n 


n 


1 


■ 


■ 


■ 


■ 




■ 




n 




■ 


■ 




■ 


■ 


■ 


u 


■ 


■ 


H 


1 11 


■ 






■ 


m 


■ 


■ 


mm 


■ 


1 


■ 


■ 


m 


■ 


■ 


■ 


H 


m 



104.9 



'04. 



03.1 



02.2 



01.3 



00.4 



99.5 



98. 



being simple, but thermometric observation throws a light on 
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, or 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. 



mm 


■ 


■ 


■ 


mm 


MM 




n 

■Ml 




■ 


mm 


mm 


MM 


H 

ammm 


i 


■ 


mm 


■1 


mm 


m 


MM 




■1 


11 


■ 


m 


m 








■ 




m 


MM 




■ 


■ 


i 


m 


mm 


II 




■ 


■ 


■ 


MM 




■ 


■ 




■ 


mm 





105.8 
104.9 

104. 
103.1 
102.2 
101.3 



38.5 

! 8! 

: — : 

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-agony (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. 



41 



40. 



39. 



38. 



37. 



BE 


II 


■ 


HI 


HI 


11 


■ 


IH 


■■11 ■ 

HI 


II ■ 

M 


■ 


■ 




In 


■ 




HI 


H 


in 




■l 


H 


la 


mm 


■ 


H 


■ 


Hi 


1 




n 


■ 




] 



Fahr. 



104.9 



104. 



103.1 



102.2 



101.3 



LOO. 4 



98.G 



Lastly, 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 



COUKSE OF FEBRILE TEMPERATURES. 



The pro-agonic stage may be short in this descending type ; 
twelve hours to two days for a decrease of 1° C.=1.8° F., or 



Fig. 31. 



Cent. 



40. 



39. 



38. 



37. 




H 




Fahr. 



104. 










I 



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. 



41. 



40. 



Fahr. 





mm 


mm 


mm 


mm 


mm 



105.8 



104.9 



104. 



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 iu 
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 eases (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 



Cen+. 



42. 



41. 



40. 



Fig- 33. pig. 34. 

Fahr. Cent. Fahr. 

105.8 



■ 

■ 


■ 

■ 


n 


■ 
m 


■ 


H 
■ 


m 


■ 


■ 


* 




■ 



107.6 




1 


1 


S 




106.7 


40. 






1 


■ 


105.8 




■ 


1 


1 


1 


104.9 


39. 


■ 


1 


1 




104. 




■ 


1 


1 


1 




38. 


■ 


1 


1 





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. 
Pysemic affections are of this type. (See Fig. 38.) 

In the death-ago7iy 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, 2. fall of tempera- 



Fig. 35. 



Cent. 



42. 



41. 



40. 



M 
m 


1 


■ 


■ 


r 


1 






1 






1 


1 








I 


1 


1 


1 


1 
















/ 

t 

/ 


1 













38. 



37. 




Fahr. 



107.6 



105.8 



104. 



102.2 



100.4 



98.6 



ture occurs in the death-agony, which, wheu 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 



Cent 



40. 



39 



33. 



37. 



Fig. 36. 


■■ 


■ 


HI 


■ 


■ 


■ 




■ 




n 


In 


H 



Fahr. 



104. 



102.2 



100.4 



3.6 



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. 



■ 




■ 


■ 






1 


7 


1 


1 




m 


■ 


■ 


■ 





104. 



102.2 



exhibited no elevation of temperature. This rise in the death- 
agony happens in malignant febrile affections whose infectious 



106 



COUESE OF FEBKILE TEMPERATURES. 



character is probable, typhus and typhoid fever, in fatal cases of 
yellow fever, scarlatina, variola, pyaemia, septicaemia, 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 
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 Yirchovv'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 scarcely seems so 
simple, though no other cause could be more effective than an 
enormous elevation of temperature. 

The moment of dexth is not indicated by any special altera- 
tion of temperature; a moderate, even low pro-agonic tempera- 
ture sinks most in the few last jnoments 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 on two causes : The occurre »ce 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. in., p. 454. Note by 
Dr. W. B. Woodman. See also Appendix VLll.,f) 



CHAPTER XIV. 



TEMPERATURE IN SPECIAL DISEASES. 

" A complete insight into the course of the temperature in 
disease can only be obtained by comparison of the curves of 
many separate cases. 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 stamp 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 absolute 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 Avill be of service to those interested in medical 
thermometry. 

" In this ?nethod 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 
Itilliet and Barthez, in their incomparable Treatise on the 
Diseases of Children. For them, the normal course of a dis- 
ease is stich 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 of 
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 
the 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. 



cions 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/dnenteritis, 

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 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 first 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 diminutions of the evening temperature are met with. 

Contrarily, 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 
presence of typhoid fever, morning and evening temperatures 
for three days in the beginning, four to six in the fastiginm, 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 no 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 fever is characterized by a fever which lasts for 
at least three weeks (excepting extraordinary cases and those 
of rapid death, seldom lasting less than a week). The maxi- 
mum temperature is seldom less than 39.6° 0. = 103.28° F. ; 
more commonly 40°— 41° C. = 104°— 105.8° F. ; when hyper- 
pyretic, rarely above 43.5° C.= 110.3° 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 
recovery. Its course may repeat itself irregularly in many of the 



H2 TEMPERATURE IN TYPHOID FEVER. 

severe cases, at critical periods, or by 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 snbcontm- 
uous and continuous 40° C. = 104°F. or a few tenths more or 
less: in the milder remittent about 39.5° C. = 103.1° 1.; in 
slight cases as low as 39.2" C.=102.56° F. ; at the commence- 
ment of and in the convalescence still lower, m 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 maxima are included between noon and 11 p.m. : 
commonly between 4 and 7 p.m. 

The extent of the emulations at the height of severe cases 
is very large ; 'the rise begins between 7 and 9 a.m. ; the curve 
is sino-le-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 0) ; 
the nio-ht-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., ottener 
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 ca^es, 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 tardy, 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 co arse. 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 molles) ; 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 TYPHOID FEVER. 




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 informatiou if they have no thermom- 
eter * the patient does not go to the hospital before his forces be- 
8 



114 TEMPERATURE IN TYPHOID FEVER. 

tray him ; and then his observation begins somewhat as the fol- 
lowing one. 

Fig. 40. 




Here the patient surrendered himself after two weeks of 
struggle. What struggle? 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 TYPHOID FEVER. 



115 



< course of the t} 7 phoid 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 days the temperature al- 
ways takes the ascending course, rising about 1° — 1^° C. = 1.8° 
— 2.7° F., from every morning till evening ; and falls from every 
evening till the next morning about .5° — .7° C. = .9 — 1.3° F., till 
on the third or fourth evening a temperature of 40°C. = 104° 
F. is reached, or a little exceeded. The formula 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 approximative^ 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 is alike ; if the temperature of the first two days rises 
to 40 o 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 later. 

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. 



TEMPERATURE IN TYPHOID 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 typhoidal 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 
4 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- 
brospinal meningitis, acute osteo-myelitis (which has the same 
fever course, but with local phenomena), acute tuberculosis, 
trichinosis (which has 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 1 
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 daily 
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 un lowered 
morning remissions ; this is fraught with irregularities and 
fresh elevations of temperature. 

The surest course towards convalescence is increased morn- 
ing remissions, sttcceeded 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 w T eek ; 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 due 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- 
lapses 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 dangerons 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 at least 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. 
= .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 



TEMPER AT LIRE 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, thus 
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° C. = 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., recovery is a rarity. Fiedler had two recoveries at 



122 



TEMPERATURE IN 



TYPHOID 



FEVEK. 



41.15° C, all the others and higher ending fatally. Wunderlich 
had a recovery at 42.2 u C.=33.7 o R=107.825°F. during a rigor. 
A repeated rise to a considerable height, say 41° C.= 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. Intercurrently 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 
gre&tfall 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 towards death, the jpro agonic stage 



TEMPERATURE IN TYPHOID FEVER. 



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 preparatory 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, 
onlv 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 (viroarpo^rj, 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 



unpeople 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 of tener 
than in younger people. The beginning is often mild, even in 
fatal cases. Death occurs with a high, but of tener with a mod- 
erate or low temperature. 

Anaemic 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 sub-continuous 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=3i. — 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. 



YEARS. CUBED. 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. : Spotted Fever, Exanthema tic, 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 typhoid al, 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. 




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 



TKMI'HRATUKE IN TYPHUS. 



and on 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 on 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.j lasts from one to three days, and 
slowly descends. On the twelfth day appears a preparatory 
remission occupying half a day or two mornings. A third and 
brief rise may succeed— -perturbatio critica — terminating in 
true defervescence; unless this last has 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 

412° 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° C.=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 typlms 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 typlms ; the brain symptoms may be equally severe in both ; 
liquid stools or profuse diarrhoea 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 TYPHUS. 




Fatal cases of typhus announce themselves from the begin- 
ning by the enormous height of the temperature, 41.2° C.= 



130 



TEMPERATURE IN RELAPSING. 



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. ; 
averao-e 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 Wunderlich, and confirmed by Griesinger. 

III. — Relapsing Fever. 
(Syn. : Typhus Recurrens, Famine Fever, Fievre a Rechute. 

Relapsing 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° 
(^ — 105.8° — 107.6° F. : two or three elevations in a day are 
rare. The 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° 0. = 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 evolution 1 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, oi- 
l's 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. = 3.6° — 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° F., 
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. 

TYPnUS BECTJRRFNP. 




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 Wunderlich, the second attack was followed by an 
amphibolic stage of fluctuations of a week ; he died at 41.4° t. 
=106.52° F. 



CHAPTER XV. 



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 these 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, h 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. 

Hennig, 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 L° R to the tenth day, 
the most notable feature being the local initial apvrexy caused 
by the penetration of the cow-poison. 

" 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 
relapsing type, to the variola vera, which attacks oftener the 
nn 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° = 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 
more 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. 



VARIOLA, 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. 




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 :i 
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 
{Charity 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. — Yaeicella. 
(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 Temp., p. 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 



IV. — Measles — Rubeola. 
(Syn. : Morbilli.) 

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 (Wunderlich). 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°— 103.64° 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° — 40* 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 snbfebrile 
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, are 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 regularly 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 ; evidently 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. y 

Fig. 46. 

MTT/D 8C ART/ ATTN A. 




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. 

■pROTRAOTTCD 8C ART/ ATTN A. 




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 exanthem has covered the whole body, 
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 exanthem ; 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. 



m 


C 


ws-a 


-it 


104- 


40 


102 ■ 2 


39 


700-4 


38 


9h ■ <: 


37 




mmnm 

fiW ■■■■■■■■■■ 



An anomalous course 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 



KOSEOLA. 



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, subcontinnous 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 SCARLATINA. 




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 noted 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 H. C. d'Aquin. 

Fig. 50. 

DENGUE. 




ERYSIPELAS. 



143 



Reynolds' System of Medi cine, 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 polytypical 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 exanthein, especially 
the primary and spontaneous ; that arising from pysemic infec- 
tion ; that of glanders; that which is developed in marasmus; 



Fig. 51. 

FACIAL ERYSIPELAS. 




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. The 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 fastigium 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 Rayer, 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. ( Clinique de VHdtel Dieu, T. 1, 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 our predecessors could 
surmise and conjecture upon 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 necessary to come to conclusions. 

I ha've instead given two cases recorded by myself mathe- 
matically, another by Mole representing graphically the altera- 
tions of functions after the manner of Lorain. (See Part II., 
Chap, ii., § ii., a.) 

Fig. 52. 

ERYSIPELAS (MOI.6). 



a 


c 


D 


CL 


u 


p; 


T(d) 


a 


D 






m 


1,600 




1,023 


JO 








■ 








m 


1,500 


6^ 


1.026 


25 


50 - 










■ 


■ 




1,400 


J2 


1.024 


SO 


45 






BB 


m 




H 


m 


1,300 


76 


1,022 


15 


4- ■ 


100 


J7° 












1200 


S 


1,02 




*3 5 


90. 


- C6° 




/\ 








1,1 JO 


4- 


1,0 lis 


5 


ao 


50 




/ 

/ 










k 


1, 000 


2 


J. 016 





2 .5 


70 












m 



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 



148 



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 primipara 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 norme 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 sej3tenary 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 no 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 No. 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. 

Fig. 53. 

EPHEMERAL FEVER. 



-j 05 M £T M EM E 

104 X 

103 dl.__V_^ 

102 1 \ 

101 / \ 

100 I zl \ 

99 \ 

98 M J I _A_ 



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 



FEBRICT7LA. 



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. 



OOTSTTrN'TTOrrH T'WVH'R. 




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 pycemia, 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 



FEBRICTJLA. 



In fever-temperatures what is the part of the excess of heat- 
production and of heat-retention % 

When are these excesses simultaneous or alterne ? 

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 fevres 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 au 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 



FEBEICULA. 



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 fibrillse has constricted 
the issues of heat and of moisture in order to economize the 
latter for the coming 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., 
h). 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 
wa y — 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 Winternitz in his Nature and Treat- 
ment of Fevers. Wunderlich is less explicit. 



CHAPTEK 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 Pappui, 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 well 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 jet if the wounded was drank 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 anaesthesias 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 chlorhydrate of morphine ; on the battle- 
field beware of sleep. 

Demarquay and Duineril, 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 
Eoeckel, 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 musUook 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 fasces (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 Fever. 

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. 

IY. — Pyaemia, 

Or Purulent Infection, distinguishes itself by different ther- 
mometry 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, Avith 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. 

Y. — 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. 

YI. — 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 ther- 
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 poussees would 
spread, and to establish the mathematical relations of priority 
and of intensity between the local and the general ustion. 

VII.— Tetanus. 

The complication of tetanus in the wounded does not elevate 
the temperature per 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., 
§ "iO 

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. But how can 
these delicate indications be detected without very sensitive and 
accurate instruments? 

(For other modifications of local temperature see Gaillot, 
Es^ay sur la Thermometrie Chirurgicale, and farther Chapter 
xx., § vi , e,f, g.) 



CHAPTER XVII. 



TEMPERATURES IN PUERPERISM. 

It was once the 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, pyaemia, 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 (rapprocher) 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 (Wunderlich). 



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 fetus— 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 
Winkel 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 aifects 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 hemorrhagics. " La perte normale du sang 
dans V accouchement 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 lochias 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 leniency, 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) 
in puerperal traumatism, but it will be by the latter entering 
the nosological frame as the mildest form of infectious puerper- 



INFECTIOUS PUERPERISM. 



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 Puekperism. (Syn. : Pyaemia.) 

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 
2i 3 — 3i° C.=4£°— 6£° 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. . 




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 PUEEFEKISM. 1(J3 

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 Compte rendu de V Associa- 
tion Frangaise jpour Vavancement des Sciences, 1873, p. 891.) 



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 supranormal, 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. — Croup 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. : Grippe.) 

In the former the temperature is commensurate to the depth 
of the inflammation. If the large bronchiae 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. 




Respi- 




Day of 


Date. 






Pulse. 


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 


Cough, harsh respiration, bowels relaxed. 


8 


" 26 


l6l'.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. 


ti 


" 28 


101.0 


102.3 


160 


60 


Secretion commencing. 


7 


" 29 


100.5 


101.0 


140 


60 


Large loose rales, dulness at left base. 


14 


Feb. 5 


99.2 








Expansion good, lungs healthy, some conso- 














nant rales 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 be 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 febriculai, 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 febriculae are accompanied 



168 



PNEUMONIA. 



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 pycemic 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' m 
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 subcontinuous 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 dyspnoaa. 
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 
of i° — 1° C.=£° — 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 MT. 83 (CHARCOT) 



DAYS\ '1 \ 2 -3 \ 4 \ 5 6 



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 JEST. 75 (CHARCOT). V 




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. 

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 bv 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 denned 
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, lapneumonie 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. Eoger 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. 

But 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 on 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 exudatior, 
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- 
. tagious 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. 

How 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 infections 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. 

VI. — 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 exanthem) 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° (1=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. 



177 



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 
8 y m ptoms, and course of temperature. 



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. 




Here 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 Part 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° £3.75° 0. 

=107.6°— 110.75° F., and once, three-quarters of an hour before 
death, to 44.16° C.=111.48° F. Kelatively 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 t,he 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 
epanchement 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 pyaimia, com- 
mon in & endocarditis,less frequent in inflammations of the peri- 
cardium, pleura, and peritoneum; those are always highly 
dangerous. Hyperpyretic temperatures are especially met m 
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 jpyrogenic 
stage; height of fever, a solitary peak or an acme of several 
days ; and a descending temperature, which loses itself in defer- 
vescence. The heginning seldom comes under observation ; we 



ACUTE RHEUMATISM. 181 

know by report its rise to be more tedious than that of typhoid 
iever, though there are exceptions of 40° C.=106° F. reached 
m 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° C.=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. 




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 KHEUMATI8M. 



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 pysemic, 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, pyaemic the most complete. Eigor, 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 Eoger, 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 



Figs. 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 cerebrale, so named in 1835 by 
my compatriot, Hervey de Chegoins. 

1. From Wilson Fox (see Appendix XIT., 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, 1 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, K. 32. During that night the patient 
took, by the mouth or by enemata, twenty ounces of brandy, 
milk, eggs, beef-tea. Kecovery (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. 





1. 


2. 


3. 


4. 


5. 


6. 


7. 


8. 






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. 

100° 
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 H&pitaux 
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 Koger 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 hone-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 
by 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. 



XIY. — Hepatitis. 

Acute parenchymatous inflammation of the liver exhibits 
varieties whose temperature differs widely ; but no 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. 

XY. — Yellow Fever. 

In yellow fever, according to Schmidtlein's Deutsches 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 (TOUATRR). 




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 FEVEE. 



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 w r ith 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 case3, 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, 15th, 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, L7th 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. 

(/.) 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 hypersemic 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. How 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. 

HI. — 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, Delow 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 Snmmerbrodt. 



9 I 10 \ 77 .12 j M 74 75 1C 77 78 19 \ 20 \ -27 I iZ 



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. T. 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- 



TKICHIN 08TS. 



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. 

MILART 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 ; Wunderlich 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 accroissement 
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 constate" 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." (Zegons 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 type. — 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° P., 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 e carts between 39° — 40°, ending at 37.5° C. Pulse 
118 to 180 beats, average 140. Inspirations 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 norme 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, — triple 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 the oscillations of temperature during twenty-four 



Fig. 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 : 

O" — 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. 

— The phthisis called galopante, whose final hyperpyrexia 
continues after death. 

But in ordinary cases the temperature is above the norme, 
as Sydney Kinger found it in its prodromes. It is not always 
equally 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 XXI. 



MALARIOUS DISEASES. 

1. Intermittent Fever. (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. Intermitt. 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, but 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 apyrexia 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. 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 MALARIA. 



203 



with cold sweat ; the pupil dilated, the look vacant, the lips 
without expression ; the tongue soft, smooth and pale ; the 



Fig/71. 

QUARTAN FEVEE. 




region of the stomach sensitive (Hertz in Ziemssen's Cyclo- 
paedia). Torti more expressively said (1712) : Tertia perniciosa 
hominem jugulat — symptoma ferox. 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, an}' more than of congestive 
remittent, by climatic exaggeration, is, according to the vivid 
expression of Tissot, because a disease is malignant when tt 
strikes as the dog who bites without barking. When the 



201 



THERMOMETKIC TEST OF FEVERS. 



second or third access is prevented, it was not the pernicious ; 
if not prevented it kills, leaving in either alternative no 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 Hippocratic 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 phlegmasia will become possible only when good, sen- 



THEKMIC 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. 



CHAPTER XXII. 



APYRETIC DISEASES. 

A coldness below nature, Frigor pr aster 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 
prater 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 f rigorigenic 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 (Stat 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 
apyrexise ; 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. 

Koger did this, and tried to force all diseases in the pigeon- k 
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 apyrexise. 

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. ' 

I" irst in this field, as in several others, Magendie announced 
m 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 by 
new discoveries. But several difficulties retarded the study of 
the temperature in cholera. One, that though cholera is a mor- 
bid entity, 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 fseees 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 



CHOLKRA. 



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 mouth; 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. Czermak 
did not witness a single cure where the temperature of the feet 
had been 24°. Wunderlich, 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 
a-lacial, and communicates an icy coldness. The body is so be- 



CHOLERA. 



211 



numbed by cold that 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 ap/yrogenic medication. (See second part.) 

Adult choleraics have rarely revived from 14° below the 
norme (Czermak says 13°) ; but no children from 4—5° Ph. = 
32.5° 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 the post-choleraic, or reaction period, the temperature re- 
turns from its abnormal condition to its norme 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 ara 
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 many 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 cf it. 

Nervous diseases are just now the theme of the most ardent 
studies. Since the pioneers, Magendie, Bayle, Le Gallois, Flou- 
rens, Brown-Sequard, Ol. Bernard, Virchow, Sliiff, have posed 
the generalities, the young school, Charcot, Yulpian, Bourne- 
ville, Lepine, Hitzig, Fritsch, E. Dnpuy, 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. — Tempekatuke in Affections of the Brain. 

Charcot and Bourneville, above all, have carefully investi- 
gated the temperature in cerebral hcemorrhage 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, apoj?lexie foudroyante, or multi- 



214 



CEREBRAL HAEMORRHAGE. 



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 Lupine). 



I 




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 



peratnre ; 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 f resh elf usion of blood. The pulse and res- 
piration vary so much in all these thermometric 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 brain 
presents the following contrast with cerebral hcemorrhage : 

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 haemorrhage. 

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 thermometric 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 hemorrhage ; 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 hemorrhage the temperature remains above 39°, and falls 
to the norme only from the effects of new effusions of blood. 
The ascending period of softening follows the stationary later 
and slower than the corresponding one in hemorrhage. The 
therminal temperatures of softening (barring the first excep- 
tion) are lower than those of cerebral hemorrhage. 

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 
Loewenhardt, 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 gravity 
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 1°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 could generate, and will soon die. 

c£— Temperature in Idiocy. — For obvious reasons too the 
same remark obtains for idiots ; the great majority of whom die 
early without hardly giving 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, K". 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. Yan Duyn, surgeon of this institution (see Appendix 
XYII.) with a Casella's thermometer — as good as a Fahrenheit 
can be. 

From the thirty-three cases observed by Yan 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, H. 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 or the axiom : where there 
is no disposable calor do not ask labor. 

We cannot form a judgment so precise in regard to the cre- 
tins. We have only six observations (see appendix XY1L, 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 cretin 's pneumonia (it is 
their common fate), it resembles in young subjects the kind 
Charcot since discovered at the Salpetriere, and named la pneu- 
monie des VieiUards. (See Chap. XV II I., § 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 the Spine. 

In diseases and lesions of the spinal cord no 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, Tschechichin, 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- 
d need 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 systema- 
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 French 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 ehroaic 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 
study 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 43.9 3 twenty -f oar hours after the acci- 



220 



INJURY TO THE SPINAL COED. 



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; Freriehs 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 Farcfuharson 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 rise. 

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 noparalfsis 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 114°. 



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 (sometimes per 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 norme). 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 
epilepsy 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 on the temperature of epilepsy till the next 
paragraph. 

IV. — Temperature in Central Neuroses. 

From the experiments of Claude Bernard, Brown-Sequard, 
Skiff, 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 on the brain. But this idea will be clearer twenty 
years hence. 

a.— The shock (Syn. : ictus) is a collapse of the central ner 
vous power, caused by accidental, surgical, or spontaneous 
lesions (whose vastness bears no 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 chaleur or coup de soleil. It was called maladie 



TEMPERATURE IN SUN-STROXE. 



223 



n^t rale, 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 their 
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 apyrexy. 

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 on dogs, buccal and 
pulmonary secretions were abundant and frothy. Respiration 
from 40, 50 at first, reaching 160. Temperature (its norme 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 no 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 r 
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 Hessian 
soldiers fell from the effects of the extraordinary heat and of 
their heavy clothing ; and many more fell on 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 Banlmer, 42.9° C. = 109.22° F. ; by Dowler, 
45° C. = 113° R, 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 Keports, 1872-3 : — 

(1.) Dr. Atzenbach's case : Entered comatose ; temperature, 
110J° 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 lOlf ; 
of jmlse 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 deperditiou 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 city 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 why 
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. 73. 

INTESTINAL OCCLUSION. 




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 k>west_plrysiological tempera- 
tures A . 6 .8, and descending to 1, 1.5, 2, 3, without reaction, 
but those produced by hot enemas, etc. Concurrently the 
15 



226 



TEMPERATURE IN CONVULSIVE AFFECTIONS. 



fades 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. 



V. — 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 Bourne ville. 

Temperature is the better criterion of epilepsy at large, and 
of its modalities. But of what use, since men already en- 
trusted with Universities teach that St. John cures the haut- 
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 epilepticus, the temperature progres- 
sively increases from the first 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. 

(d.) 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. 

HYSTERO-EPILEPSY. 



Jam. 19 \ 30 \ 21 \ r 2% Z3 A4 25 26 



J8 



(3 7 i« 



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 EXT AST. 



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, no rest ; 
yet, by expiration, she exhales carbonic acid and water, which 
do not come from her own substance, since she loses no 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 get, doit 
faire bien plaisir. However, this spectacle may be prevented, 
or stopped, by Mgr. the Bishop of Tournay, in virtue of his 
power of Mappel over extases, etc. 

The temperature of Louise Lateau was taken but once, and 
found 37.3° C. The Academy of Medicine of Bruxelle made 
a mild report, from which it appears that Belgian physicians 
walk 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 vade in pace : 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 (Sniff), 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 once 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 color 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— Albuminury, like polynry 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 tctaniform convulsions of neo- 
nati (one to sixteen days old), to reduce at once their calori- 
city 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., 
a, 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 fails 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°. 

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 sotnewhat warmer, and the sur- 
rounding angry circle (in which 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! 
Kemarks on the effects of 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 • 
mg 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 SalpStriere 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 air 
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 double cause of error. 

Therefore, in a local (or 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 APYEEXY. 



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.— h. 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.— And, finally, the tem- 
perature may affect the march of an endless lysis, ending never- 
theless in a collapse or collapses. 



Infantile Apyeexy. 

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 T= one centigrade degree below the norme. 

But it is decidedly a disease, and it imperils life, when it 
causes the body-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.) Frigeeation of the jSTew-Born. 

It may have begun in utero, being caused by certain condi- 
tions of the mother, sickness of the fcetus, 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 frigeiation, 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 Paris. 
There the death-rate of the first year was ninety per cent., 
showing how nearly synonymous decalorification is to devitaliz- 



TEMPERATURE IN SCLEREMA. 



237 



at ion. 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 warmth-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 IV., 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 Roger. 



(c.) Sclerema, 

Or, algid oedema neo-natorum. 

In sclerema the child is like transformed into a cold-blooded 
animal : {a) temperature low, (b) circulation slow, (c) respira- 
tion imperfect, (d) mobility neutralized, (e) cellular tissue in- 
dured. Most of these disorders, at least their ensemble, are 



238 



FATAL FRIGER ATION. 



pathognomonic, but which of them 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 
Vcedeme" etc. 

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 ; 
(c') 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. 



Parrot 



f progression ) 
descendante f 



intermittent . 



f progressive. . 
ascendant. . . 

| progressive . . 
^ descendant. . 



::} 



1 


2 


3 


4 


5 


6 


31.8 


28.8 


26.4 


24.8 


Death 


Death 


30.8 
32.4 


26.3 
u 


25.7 
it 


Death 
26.8 


u 

29.5 


(the last) 


33. 


33. 


34.5 


Cured 


it 




33. 
32.5 


29.5 


22. 
28.25 


(the last) 
26.5 


n 
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 lias 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 
oedematous, 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 cal- 
oriciti 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, bnt 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, cireu- 



240 



CONCLUSIONS OF TEMPERATURE. 



lation and respiration, and presented, in health, deviations 
which would later be considered as grave, sickly ecarts. 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 m^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 iiervonfl 
svstem 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, placoi'ds, 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 



CALORIPIC 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 aud 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 color 
(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 f rigorification 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 aud 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 
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 synthase. 



I 



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 Sauctorius. 

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 Syriac Wars, but it was possible 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 w r as actually fast declining. Erasistrates, the illustri- 
ous professor and friend of the royal family, tried to recognize 
his disease by its physical symptoms, manipulated and in- 
spected his body in all sorts of ways, and looked through its 
parts y 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-^Ae glow of heat be percejytible 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 off — 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 fever- 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 his 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 only 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 iiniuence of the ner- 
vous system on the distribution of warmth, the disengagement 
of heat by muscular contractibility, 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, Avenbnrgger, 
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 to rest 
their heads under the tree sprung from their imagination ; no 
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 w<>uld be more difficult yet to realize what 
it will he 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, sesthesiometers, sphygmo- 
graphs, thermographs, myographs, thermoscopes, and spectro- 
scopes—instruments of Positive Diagnosis. But we 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 THE 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. 



j 



CHAPTEE II. 



INSTRUMENTS OF THERMOMETRY. 

Hippocrates did not consult the 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 



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 or 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. — Hand-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 visit, 
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 his- 



* 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-THERMOMETRY. 



255 



torj 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 on the temperature 
arid 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. 

h. — Manual of Hand-Thermometey. 

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 TIIEKMOMETEKS. 



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 wish, 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 De Haen. They must have been, 
like those of Currie, Davy, Donnd, Demarquay, mere weather- 
thermometers. They must have been pretty scarce, since 
Koger 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 
1 17 



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 on 
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 thermo- 
pathology, 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 o£ 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- 



FIEST 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-temperature 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 why medical thermometry 
has been and would remain a sort of arcanum anions: 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 observations, upon the method of 
recording observations, and extend to new and important 
objects of general interest. But before coming to this, let us 
only see how the question stood a few years ago. 

b. — Variety and Sameness of the First Improvements in 
Th ermometers . 

"We have previously remarked that physiologists and ph} T si- 
cists, aware of the shortcomings of the weather-thermometer to 
measure animal heat (la chaleur animate, la chaleur hwnaine), 
had made several trials to improve them. These first essays 
bore on 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 



200 



SELF-KEGISTEKING TI 1 ERMOMETERS. 



substances obeying thermal 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. 
Alveroiiat 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 cheap- 
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 coining 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 shilHngs 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-thermometers 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- 
tnres, 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 thft 
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 Kew 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 he graduated before their 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 Hoboken, 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. — How 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 ail 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- 
o-raved upon it % France had embodied the thermic scale in 
iier 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 on 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 calor. (b). 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 astronomv 
physics, chemistry, surgery ; why not in medicine ? ... if for 
the followers of Laplace, why not for those of Sanctorius ? 

I said long ago: " Pien n'est plus pratique que la recherche 
d'une bonne theorie." Nothing is so practical as the searching 
for a soand theory. In 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 pyrometric instru- 
ments. Then let the physiological scale and instruments, and 
the mathematical records of thermometry, answer for them- 
selves and be judged by their asuvres. Their practical use 
will make good their theory. 



III. — The 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. 



265 



IV. — Schema of Human Temperature. 



Degrees 



of fever 
(above the^ 
axis). 



7 Only two alleged recoveries. 

6 Generally death. 

5 Often fatal. 

4 High fever. 

3 Considerable fever. 

2 Moderate fever. 

1.5 Slight fever. 



Axis of healthy j ^ 
undulations. ( 

(J 
\ 1 

Degrees of depres- J ^ 
s i o n (below " 
the axis). 



Norme, or standard of health. 



Sub-normal. 
Depression. 
2 Collapse. 

3- 4 Algid collapse. 

4- 5 No known recovery (except 

cholera and sclerema). 



in 



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 C. 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 they 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 

V. — 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.«0°, the Walferdin 77°. 
The physiological 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 norme, reaches higher than the 
bed-post. 



PHILOSOPHY OF THE HUMAN NOKME. 



267 



VI. — Philosophical Valle of the Nobme. 



. 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 modifi^ti 0118 of the caloricity of our race and of our globe ; 

series of physiological monuments unequalled by any other 
discovery for its importance upon the Natural History of 
j} a n and Earth. 



268 



THERMOGENESIS. 



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 onr 
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. 

Cuvier 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 THEEMOMETEB. 2C9 



gradual changes of organic and inorganic (so-called) tempera- 
tures the modifications towards which tend our planet, its flora 
and fauna, ourselves included. 

Such results, far from being a diversion of human ther- 
mometry from its proper course, would be accounted its chief 
honor 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 fluctua- 
tions of the meanest individual ailments. 



YII. — Application or the Physiological Theemometee. 

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 p ut 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, and 
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 w T hich 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 apousse'e 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- oVelection 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 conn 1 -, 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 Thp:rmometers. 

In the New York Medical Record, of January, 1867 (quoted 
by Wnnderlich), I urged the necessity of inventing a thermo- 
meter for the surfaces, as we had for the cavities, and ventured 



272 



StJRFAGE-THERMOMETKRS. 



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 Jinds : 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 ine 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 SURFACE-THERMOMETER. 



273 



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 1 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 on the 
sick, the other on the well side ; on 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 
fatigue 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, ere. 

\Vunderlich has shown how extensive is the application of 
the cavity-thermometer to the diagnosis, prognosis, and thera- 
18 



274: 



APPLICATIONS OF THE SURFACE-THERMOMETER. 



peusis of general diseases. It wiy. 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. 

(b.) Applications. — In local diseases of children, idiots, in- 
sane persons, and of other patients who 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 has shown a higher temperature on one side than on the 
other (Brown-Sequard, E. C. Seguin). 

In 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. In articular rheu- 
matism, sciatica, facial neuralgias, etc., it will show elevations 
and depressions of local temperature which may throw a new 
light on the origin of neuroses. 

In 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. 

In 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 TN SURGERY, ETC. 



275 



the surface thermometers, as I have known dermatologists do 
to their complete satisfaction. 

In the formative stage of deep-sealed 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 ease, 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 THEEMOSCOPE. 

that we needed an instrument which could show the body-heat 
m the act of escaping (radiation) under the most delicate con- 
ditions. This idea became in the beginning; of 1875 



IX. — The Clinical Theemoscope, 

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 Kumford and 
Leslie constructed their differential thermometer. 



Fig. 77. 

THEBMOSCOPE — HALF SIZE. 




The clinical therm oscope 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 two or three inohes 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 THERMOSCOPE. 



277 



makes itself isothermal to the ambient temperature, and the 
tliermoscope is ready. 

Simpler yet: Over-heat the bulb, 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. 

But in summer the air in the bulb, becoming isothermal to 
the 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 (lieu cP 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 on 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. 

h. 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 



278 



THE THERMOSCOPE 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 thermoscopy 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 progressively 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 Thennometers, 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 of a 
thermometer, whose graduated stem projects outside. It is 



280 



THE CALOEIMETEK. 



applied to almost all the surfaces, and the heat 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 Hi. 



CONDITIONS OP 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. — Thekmometeicians. 

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, 
caii be made a useful assistant to the medical therm ometrician. 

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 Hojntal des 
Enfants, rue de Sevres, the finest staff ever gathered : Becquerel, 



282 



FAMILY CLINICAL ASSISTANTS. 



Roger, Contour, Jules Seguin, Rilliet, Barthez, and he 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 on 
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 hand- 
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 oontinue 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 oE his times— he sinks as much as raises his 
hospital confrere, whose fa*ne 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- 



WKONGLY 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 on 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 powers ruling these matters. It was Escu- 
lapins, Apollo, Chyron, Lucine, etc., till these worthies being 
unable through discredit— see Oribasus' letter to Julianas— to 
pay expenses at Delphi, Epiclaurus, 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 no 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 deli very t 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 iar 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 ivomen, thoroughly educated in all 
other matters, out left ignorant in this ? Seeing everything 
around them 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- 
cularly in the art of taking and recording the temperature of 
their children. 

e. Bow 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 noeme. 
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 JS~ew 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 true 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 
workingmen, 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 hospitaliers 
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- 
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, K 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 TIIE CLINTO 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 
I 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 
seems: 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 on 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 the 
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,— *no true physician is too great, none too small, to 



THERMOGRAPHY. 289 

keep himself aloof. We must not forget, inoreoyer, that the 
Daily Medical Kecord 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 



290 



GRAPHIC OF VITAL SIGNS. 



GRAPHIC RECORD OP VITAL SIGNS. 

DATE, NAME, DISEASE, 



DAYS OP 


DISEASE. 




110° 




109° 




T08^ 


la 
•J 


107° 


■4 

o 


106° 


CQ 
H 

3 


105° 


» 


104° 


H 
OS 


103° 




102° 




~ior°~ 


p 
H 
-1 


100° 



99° 



97 o , 



95 c 



MS ME M E | M E | M E M 



50 
l5~ 
"40" 

35 
"30" 

25 
~W 





150 




B 


140 




E- 

e 


130 






120 




— 

H 
B. 


110 




m 
«l 


100 




H 

« 
a 


90 




GO 
& 


80 




Pu 


70 






60 


— V s — i i i — ~ i i i i i i 1 f~ — i — 



me|me|me mk me|me mb|me 



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 Mote, 
and as can be seen by the following beautiful type of : 



Fig. 78. 

rOZBPJRKAIi HEMORRHAGE (LORAIN'S). J 




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. 



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 Mote, 
and as can be seen by the following beautiful type of : 

Fig. 78. 

PUERPERAL 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. 



293 



KEYS TO GRAPHICS. 



1 Fig. 79. 



mold's key of signs.] 




Fig. 80. 

LORAIN'S KEY OP SIGNS. 




Pulses. 

Temperature in vagina or reotum. 
[ 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. 



ADVANTAGES OP THE GRAPHICS. 



293 



Fig. 81. 

SEQUIN'S KEY OF SIGNS. 




Temperature in the axilla, T. 

" in the rectum, same 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). 
HI 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. 

^ 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 tram of a graphic is above 



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 out 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 mathematic 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 lavjs 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 curve-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 only 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 the 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. = 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, 
(/) 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 CALORE corporis humani {In Ratio medendi, T. II., 
cap. 10). " 

n 



MATHEMATIC COMPUTATIONS. 



Skeleton Table 
On which the uninitiated can write records of signs till the physician comes. 



Aoe. 



£>ats of Disease. 

Time of Observation. 

*■ , 1 
§ Fever 

2 Zero Health . . y 

Pi 

§ Depression I 



Daily average. 



Daily difference. 
Pulse , . . 



Respiration. 



I. 

M~>— E 



II. 
M-*-E 



III. 
M-*-E 



IV. 
M-*-E 



V. 
M-*-E 



VI. 



VII. 
M-^-E 



No. 



Total up. 



I 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 present point of completeness : 

This chart being tilled for a "week— a 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 6f 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 and*' the 
respiration, and the sum of all the daily figures m septenaries. 
To these features may be added the sphygmographie, 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. careful practitioner, 
to the scholar, and to all who look beyond the mere routine of 
our profession toward its philosophy. It. is the provision made 
for the record of the critical days an4 prises. 



TABLE OF COMPUTATIONS OF VITAL SIGNS. 



f i 



CO S. 

S3. S' ^ 

^ 2; X 



Local 
temp. '. 
taken on 



gag 



^ 2. 



Central temp, 
taken in 



O t) O t2j ^ 

P S= CD o ® 

P C 13 h ^ 

^ 3 3 2 



1? 

a, 



i3- g >B 2. 



1- B 



p p 

ca, ty 22. 

s o° 

tr 1 ~ 



Pfi p 



go gj; 



pi 

•■S . <J5 - a 




CHAPTEE IV. 



DOCTRINE OF THE CRISES. 



That is a small place offered to a very old, and once muefi 
revered host of ours, the Doctrine of the Crises; yet it is a 
krger 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 Theujrgism. 

When medicine was blended with theology, and therapeutics 
with theurgy, God was one, matter two, their union three the 
universe twelve, ite 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, m virtue of numerical and biological laws: hence 
their crises and critical days could be foreseen, and were 
foretold (prognosis). 

Hippocrates believed m both, but-as far as is known-wrote 
on the subject only practically, not theoretically. Contrary 
Galen, who admitted the crises, but rejected the critical dlvs 
wrote the theory of the latter, though under prote IT to the 
gods whom he was in the habit of using as small change 

After that period, the old dogma fared still worse bein* 
made subserv,ent to the practices of necromancy, mvstic! m 



COS HOSPITAL KECOEDS. 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 ? 
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 



HIPPOCKATIC DOCTRINE. 



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 antiquit}'. 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. 

§ H. — 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 
•fiose of elimination and reparation in disease. 

This latter and double elaboration, iever,febris, ends by an 
even resolution, \vo-19, or by a sort of revolution, icpi<T<i, at cer- 
tain days called for this reason critical, decretory, or judicia- 
ry- . -, 

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 ot 
an approaching crisis. . ■ 

The intercalary days, the third, the sixth, the ninth the 
sixteenth, etc., give issue to imperfect, or irregular, or fatal 

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, 

Se Feve ) rs come to a crisis on the same day, as' to number, on 



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 these diseases it is difficult to as- 
certain d 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 these diseases it is difficult to as- 
certain d priori in what spaee^of tirne ,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. 

Kelapses 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 
tyP e ; 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 make 333 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 the,_seventh 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 h&rdly 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 temperatnre is indispensable 
to learn the laws presiding over the evolution of certain dis- 
eases, and the deviation from 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. 

Not only must we know the" laws derived from this principle 
of unity of life ; but in our application of these laws to special 
6ases errors are unavoidable when the initial period has nofc 
been uuikr observation^*!*^ still more easily when no inforxatf* 



THE BEIGN OF LAW IN DISEASE. 



305 



fcion 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 Ephemera are included fevers which last 
only a few days ; the length of the fever does not affect its height 
nor its issue. Diseases which begin with a strong pyrogenie 
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- 
Hons. 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 f astigium, 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, foux days, de- 
scribing zigzags, composed of diurnal elevations of 1° — 1.5° 
C and nightly falls almost to normal, and reaching 40° C. the 
20 



MEDICAL SETTENAKEEB. 



fourth day. This jeourse is almost pathognomonic of the ty- 
phoid fever. 

In the second half of the first week the morning tempera- 
tare is lower by C. at the same time that the maximum 
is reached, 40.8° C. 

The end of the first half of the fastiginm 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 io 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 on 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 t8 DISEASE. 



307 



In severe or neglected cases the continuous ascent and ex- 
acerbation continue through the first week at 40.2°— 41.6° 0., 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 ttye 
theogony and geogony cf 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 subjec. 
between them. Previously to Wunderlich, Aymen {Disserta- 
tion sur 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 ; m 
the dark ages it was a symbol ; for us it must become a law; 
instead of remaining the ignis fatuus which lights our faces 
with its sardonic glare. 



r 



* 



CHAPTER V. 

MATHEMATICS OF DISEASE. 

Man 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 the, destructive 
power of new mathematical combinations. 

About this discrepancy of words, and in view of others on 
onr whole subject, it is good to remark tnat in judging of pasfc 
doctrines^we must not let ourselves be deceive^ 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 fifteeni^ sixteenth and 
seventeenth centuries. 

In Greece, whose doctrines we have npw in. view v every thing 
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, number* we deified, particularly 
after the mathematical masteries e£ the echookof Corinthe 
Syracuse, Bergam, Alexandria. Bat in plain thinking, de- 
nuded from the amiable theolatry o£ 'oid time*, we read 
through the doctrine of the ruling power of numbers, that of 
the. harmonies of the world-the visible face of law Z nature 
~^what can be seen of God. wnure 

From the bulk and course of the celestial bodies to th£» 
^oyemente, of the rotatory,., infusoria and filifomu bacteria ; 



MATHEMATICAL RELATIONS OF THE FUNCTIONS. 



309 



from the normal f rigeration 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,TIerophyles, 
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 iight at 
each other. 



§ I. Mathematical Kelations 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 tor 
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, tihese views on the subject 
of correlation of all the symptoms i " 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 thermometricians ; 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 ik& sick, and how 
many days a disease will continue, or in how many it will 
cease, must understaja4 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 the acuteness 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 An dral, founded their famed 
diagnosis upon the even exercise of all their 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 Hippocratic 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. — Delations of Central to Surface Temperatures, etc. 
— The alteratipns, (by disease) of the mathematical relation* 



RELATIONS OF TEMPERATURE TO PULSE, ETC. 311 

t>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 <;ould 
supply. (For the generalities of this almost new branch of the 
subject, see Part L, 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 VII.) 
Having seen that an elevation of temperature in a part may be 
communicated to the all body, or leave it at its norme, 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 foetal 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.) 

(b) 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. 
""(c) In healthy adults, the three functions are quite harmonious, 



312 



SAME RELATIONS AT DIFFEKENT AGES. 



though there are exceptions : — a pulse at 30, 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. T, P. 75, I admonished him 
from some perturbation, and he acknowledged having had some 
business excitement a few hours before. Jnst 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 r61e, the temperatnre becoming low, and 
the pulse quickening in proportion to the 'e'panchement 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- 
dition 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). 

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 TEMPERATURE TO URINE, 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 dB, 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 married 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, fyey 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 temperatwes 
which have been recently studied (see Bibliography). 



314 RELATIONS OF TEMPERATURE TO UREA, ETC. 

(a) It was found that in the period of effervescence, to the in- 
crease of heat corresponds a diminution of the urine in pneu- 

Fig. 82. 

RELATIONS OF TEMPERATURE TO UREA, CHLORURES, ETC. (/WWl 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 1 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- 
ure 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 thermograph ically 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 — Eelations of Temperature and Body-weight.— From 
the beginning of medical thermometry, the fluctuations of the 
body-weio-ht 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 m 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 ot 
bodv-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 OF BOOT-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. S3. 

PROPORTIONS OP 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 
pule. Let us read both. 

The broad rule is : (a) In fevers the body-weight decreases in 
the same ratio as the temperature increases. 

The special rules are ; {b) In typhoid fever the body-weight 
increases during the prodromic ascension of temperature / an 



RELATIONS OF TBS SAME TO BODY-GROWTH. 811 

increase which represents the retained urine, faces, and sweat 
and the great quantity of liquids absorbed during this char- 
acteristically thirsty period. 

Jo) The body-weight rapidly decreases from the fourth to the 
nfth day, though urine remains scanty, aud 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 (pe'riode d'e'tat) th&- 
weight remains stationary $ 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 tempera^ 
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. 

(g) In pneumonia the body-weight falls during the all period 
of ustion. (effervescence, and fastigium) ; and more in the defer- 
vescence, owing to the abundant flux of urine which heralds 
this period, 

(h) In variola, the a>diema> coincides with an increase of 
weight, which subsides when the pustules are drying up, and 
when diarrhoea sets in. 

(i) In the exanthematous fevers of children, like scarlatina ^ 
a latent anasarca or intestinal dropsy is rendered evident by 
the increased weight of the patient. 

— Parallelism op 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 inioxmations. of, inestimable value for rearing: 



318 



FAIRY COURSE OF FUNCTIONS IN YOUTH. 



children. The concordance of these signs gives security ; then- 
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, spirometry, 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 have their mathematics • 
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. 



CHAPTER VI. 



THERMO-THERAPEUTICS. 

Ce ne sont pas les remedes qui nous ont manque" , ce sont les 
moyens mathematigues oVen doser le besoin et V action. 

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 no 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. 

Therrno-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. — Thejoio-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 oi decomposition, are re 
presented in the urine by their haematine. 

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. 
(I^ihamel and Dutillet) ; by a woman, called the Salamander, 
who could keep her body above and across a fire during the 
time neJ^essary 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. (Currie), and not often from a 
protracted one to 41.5° C. (Wunderlich). 

(b) 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 niay 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. 

(o) Next in order cornea 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 
©r stand-still takes place, (f) 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; 



THERMO-THERAPY. 



321 



§ II. — Thermo-Theeapy 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 ' ill 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 they 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. Lot 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 IIyperpykexy. 

{a) In general Kyperpyrexy 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 



APYEETIC MEDICATION. 



323 



cause cerebrospinal meningitis, progressive atrophy, paralysis, 
insanity, and leaves on the organs its indelible marks, sclerosis, 
etc. Horizontal rest is the anti-pyrogenic by excellence. 

(b) In local hyperpyrexy : 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. 

0) 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. 

(<?) 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 on 
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 on her own. Even latterly it has found 



324 



H.EMOSPASIA. 



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 Yierordt 
and Marey, which surpass the sphygmometers of Jules Herisson 
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 
sphygmography 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) Hsemospasia, 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 plus- and minus with 
mathematic precision. 

When either of these effects of haemospasia 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 — 1 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 



HJEMOSPASIA. 



325 



has 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 anaesthesia to syncope. 
Such is the gradual physio-pathology of hamiospasia. 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 issapplicable 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-therapeutics, 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 the body. 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 APYEETIC. 



327 



peasants of the old Isivernois, 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 so, 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 
o-ain of 3° could come only from the human heat-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° where- 
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 &° 
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 



DOSAGE OF EXTERNAL TEMPERATURES. 

baths, from W. H. Thomson and F. H. Rankin, in the Nem 
York Medical Record, Oct. 23, 1875. 

Pig. 84. 



EFFECTS OF EXTERNAL OX INTERNAL TEMPER AT Ult S3. 




(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 
Immediately after the bath.. 

One hour after 

Two hours and a half after . 
Three hours after , 

This simplification must not deter earnest students from re- 
peating and perfecting, if possible, the experiments of Lieber 
ineister; but, practically, hydro-thermo-therapy is difficult 



39.6 
38.4 
39.1 
39.4 
39.6 



SUM OF CLINICAL EXPERIENCE. 



320 



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 
very 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 isotherm ization 
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 frigorific 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 isothennized — by the external. Far from being a 



POWER 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 them 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 accommodation. 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 phvsical 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. 

(<?) 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 
deoree 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 ot 
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 wave 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 13° 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 physiological 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 pyrexiae, 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. 

(h) 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, or 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 TEMPER ATUR fc. 

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 degrees of the fall have a meaning— not the same at 
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 mathe- 
matic progression. 

6. A sudden fall in pyretic affections indicates a crisis. 

(. 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 isj)er se a cause of death. 



§ IT- — The Bath. 

Though I resolved to restrict my remarks on the application 
of water to its bathing form, the bath itself is not a tiling 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 generally well ar- 



RULES FOR BATHING IN TYPHOID 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, Liehermeister points out its uses and imperfections. 
He says, passim, Vol. L, 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 on the tissues which brings on their necro- 
biosis, whence paralysis of the heart, etc. In the antipyretic 
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 affusions, ice, etc.) ; on the whole, those will 
be found preferable which 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 he 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 he con- 
tinued till the body-temperature has proved to he normal at 
least from three to six evenings without interruption. 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 M etc. Certainly 
the typhoid patient must be bathed, but he must not be moved ; 
then how to bathe and to not move him ? . . . . 



333 



THE BATH WITHOUT BATH-TUB. 



Moreover, this ordinary mode of taking baths had other in- 
conveniences which Liebermeister 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 bv 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 Quartier 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 



MATHIA8 MAYOR'S BATHING-DEES 8. 



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. 

(b) Now it seems to me that this forgotten bain 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 medical 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 



PRO RATA OF CURES BY LOW TEMPERATURE. 



or cooler. It most happily fulfils the desiderata of continued 
mmfngoration; I consider it impossible to read the therrao, 
gr-aphy of the treatment of severe hyperpyrexia* (see Appendix 
AlII.) without being convinced that as soon as they will have 
the means of doing so, physicians will give the preference to 
continued mild frigoration 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- 
tour hours, constitute quite a rapid thermic balangoire. (Same 
remarks upon the fluctuations noted, page 224.) 

Such appears to te, prima facie, the advantages of the adap- 
of medt^nt t0 ^ therapeutics of the Positive school 

(c) 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 ; and yet who met with so little of reward That, 
u he had cared a fig for a tombstone, he would have caused to 
be written upon his, « Woe to him who comes too soon » 

lY Gad f , Wh ° feelS r6Stive Under the development of 
deas and their deductions, let us condense in facts and figures 
the most recent — s u *«» 



§ IY—Results of the Treatment ,qf Hyperpyrexia by 
Low Temperatures. 



Namea 



Carrie (1804). 

Jacquez (1839). 

Brand. 

Jurgensen. 

Liebermeister. 

Zieruissen. 

Lindwnrm. 

Bamberg. 

Winternitz. 



Localities. 



Liverpool. 
Lure (France)i 
Stettin. 
Kiel. 
Basel. 
Erlangen. 
Munich. 
Vienna. 
Vienna. 



Typhoid fever. 
Typhoid fever. 
Pernicious fever 
Typhus. 
Typhus. 
Typhus. 
Typhoid fever. 
Typhoid fever. 
Fevers. 



Number 
of Cases. 



Number 
of Deaths. 



229 

SIS 
170 
60 
478 

120 

40 



4 
12 


8 



Percentage 
of Cures. 



2 per cent. 



4 

6.6 
6.6 



From a great many observations CI. Bernard estahli«W n, 
proportions of mortality to twenty-three pe oeT^ Z * 
treatments, and of nine per cent by the water EL*^ 



TREATMENT BY BATH DESCRIBED IN HOMES. 



339 



Now we could^expatiate on the use 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° 
Y. = 30°— 40° C.)is so well known, that Homer describes its 
use to restore thfc. circulation x>f the teguments in old people 
(Odyss. XXIV.). It is not the ancients who did not know ; it 
is we who have forgotten. 



CHAPTER IX. 



PTHBTIO MEDICATION. 

A pyretic 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 



PTBETIO MEDICATIOH. 



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 ynperial 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 f rigoration ; 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 
m 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° K, 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 hum, 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, 

L° Tn f netrate deeper and dee P er > tato 

and farther, till the desired impression is obtained When the 

operation need be protracted, one hammer is at work and an- 
other m the kettle ; the linen is watched and changed as of ten 
as it becomes humid. An assistant takes the genefal and local 
temperature, Besides its use in ultimate an d g so el 1 L 
stances, the pyrogenic hammer will be used with advantage ^ 
I trust my personal experience, when heat is wanted genfral ly 
or locally; for old people in periodical collapsesfwithout 
reserved heat to support the reaction; for children coded by 



TRANSFUSION. — MESOTHERAPY. 



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 turn favored and neglected. The substances thus 
introduced in the liquid form were oftener Warming 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 to 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 orjcure 
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 
o-rape. 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 matters are few, and the writings are 
scattered on rare pages (See Appendix XX., Leurtet, and Bibli- 
ography, Paul Bert, Quetelet, Bertillou). Meanwhile Mother- 
Earth remains before us like the Afcundance of P. P. Rubens, 
in the Medicis Collection, covered with .raammge, from which, 
in our ignorance, we suckle either milk or poison. 

(A) 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 o&er forms of physiological and psychological activity. I 
would say nothing of its general and surgical applications ; 
but the necessity^ 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 
ita power of restoring communications, by running its currents 
through 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 is not always 
«o ; and between necessary failures to he palliated, and success 



MATHEMATICAL TEST OF REMEDIES. 345 

claimed where little or nothing was accomplished, -who will 
judge ? . . . Sorry sight, described by Cyori in his preiace of 
Prineipes d? Electrotherwpie, Paris, 1873, to prevent which the 
shortest means is by submitting the operations of thia new 
treatment to the sure test of mathematical thermography. To 
this effect one can use the following: 



346 



PYEOGENIC ACTION OF TREATMENT. 



(i) Table of Pyrometric, Dynamometric, and other Obser- 
vations DURING THE USE OF REMEDIES. 



18.... MONTH. 



NAME. 



V 
£ 



Day of application. . . 

Pulse* Before 

" .After. 

Breathing-. B 

«• A 

Right band B 

a 

Left band B 

" A 

Right axilla B 

Left axilla B 

" A 

f Right hand t B 

" A 

Left hand B 

A 

Right foot*.. B 

A 

Left foot B 

" A 

' Right cheek§ B 

" A 

Left cheek B 

" A 

Right arm B 

A 

Left arm. B 

" A 

Mensuration of 

Urine, ep. gravity. . . 
" oz. per 24 hour 



SEX. 



REMARKS. 



I SS^^S^S^^^^"^^ taken oaeel^I " 

vi to*"" - ° n a 6WiDg * V6rtiCa] Aboard, alternately pressed.by the rigb* Md 

§ Or other points of observation.^ 



mm 



^CHAPTER X. , 

^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- 
matism, 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 "Wnnderlich — 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 IN -DIAGNOSIS, 

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. 7 But,' far from 
this' impious impossibility, thermometry will find' out even fshe 
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 up of normal tem- 
perature, that is to say, life ; and the suppressing of the 
sources of pathological temperatures — 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 wilH 
not be to feel the pulse,, but to apply the thermometer; he wilfe 
not proceed to percussion or auscultation before having collect- 
ed in his naresthe emanations always indicative, if not of the- 
disease, at least of the degree of saturation by the morbid' fer- 
ments ; as does and processes Behier at the Hotel Dieu of Paris*. 

Then, when the other medical senses will have made their/ 
survey, sphygmometry may be the first operation next to> 
sphygmbgraphy, around which will stand, as the case 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 wrested^ 
the leadership from Germany, and the recent progress aceomr 
plished in the chemical laboratory, bring to thermometry tiie- 
means of branching in two directions. 



PHYSICAL AND POSITIVE DIAGNOSIS. 



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 updn 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,— lor 
a part, at least, of its investigationsy—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 modm 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, 
m traces A 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 results 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 and 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 and symptoms as they are, and the positive ones as they 
vrill 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, e^fcc.-, 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 prognosis 
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. nxr , 

When 43' C. is reached, death was unavoidable (Wunder- 
lich) previously to the strict antipyretic treatment (W- Fox, Da. 

C A a fatal issue generally follows a series of temperatures from 
40° to 41° C. (Hirtz). 

A fatal issue generally follows several temperatures ot 

41.9° C. (Hirtz). ' • .. . n 

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, but more particu- 
larly as specimens of what any one of us can condense from his 
private experience : 

(5.) Prognostication from the Length of the Periods 

in ustions. 

Signs. Significances. 

^ ( Effervescence.. 2 to 3 hours ) ^ accegs o£ intermittent, ephemeral 

•S. ] Fastigium ... .4 to 8 > fe febricula. 

(| ( Defervescence. 2 to 4 " ) 

( Effervescence. .2 to 8 " 1 Acute inflammatory disease ; pneumo- 

-2 \ Fastigium 4 to 8 " [ nia, angina, pleurisy, typhus, scar- 

©> ( Defervescence. 1 to 3 " J latina, rubeola, etc. 

^ ( Initium 3 to 5 days 1 

o -| Fastigium 2 to 3 septenaries >• Typhoid fever. 

55 ( Defervescence. 3 to 5 days ) 

•d ( Initium 3 to 5 " ) 

j§ \ Fastigium 2 to 4 septenaries >■ Rheumatism and anomalous fevers.' ] 

& ( 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 tq 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. 

(g\) — Prognostications by Thermometry during the Incuba- 
tion of Diseases. 

JVo|rjBoetication must be supported by prenotions / an$ no 
prenotions, or warnings of danger come earlier than those 
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 Experimental). 
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 ofvinfeetions (Temperature Variations, etc.) " The 

study of all what pertains to the ingress of disease may be said 
to commence " . . . , etc. (Tke period of infection' in epidemic 
diseases, London, 1871). 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- 
in^ 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 WHERE 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 short, 
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 jpullulation, or proliferation, in which new germs per- 
vade the organism, which will try to throw them off 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 plantsf 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 orily 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 theiHmpalpable'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 
Has been well observed, it was thermometries ly characterized 
by 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 i& 



THERMOMETRY 05* 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 must be. sequestered one way, and the 
exposed ones another. 

Dr. Squire remarks on this subject: "The old quarantine 
of forty days, or six weeks' isolatii in, 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 
tuberculization s and consumptions. 

(d.) — Th&RMOM£TBY DETECTING INCIPIENT PHTHISIS AND OTHER 

Incipiences. 

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 omf attention 
in 1866 to this superiority of the positive over the physical 
method of diagnosis, as permitting to establish ^prognosis of 
phthisis before it is incurable. According to the/talented, pro- 
fessor of the London University Medical College, arid notwith- 
standing quibbling objections, thermometry gives a prenotim 
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 ; 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 
qf the continuance, the amount, and the cessation of tuberculi- 
zation. 

It i6 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, beef and veal broth, or jelly, 
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.) — Thebmometey 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 fa'ije, 
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 with 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), sphygmography, plessimetry, spirome- 
try, sesthesiometry, etc. Then let any one be sick without help } 
or simulate sickness, or deny his identity ; his livret of vital 
signs — stud-book — or its copy from where it was issued or last 



358 THERMOMETRY DETECTING DISSIMULATED DISEASES. 

registered would tell of what disorder be 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 ideas we rapidly drift. 



CHAPTER XI. 



FROM MORBID TO HUMAN THERMOMETRY. 

Laplace said : " Si Von consider e avec attention la s4rie des 
objets de meme nature^ on apergoit en eux et dans leurs change- 
merits des rapports qui se manifestent de plus en plus d mesure 
qui la serie se prolonge, et qui en attendant et se generalisant 
sans cesse cand uisent enfin au principe dont Us derivent." This 
description of the ascension of au idea in the human mind, from 
its incipience in a point of fact to its crystallization in the form 
of law, or principium, 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. — Theemometeio Lessons. 
(a) feom oeleans. 

" 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 QV8T* 
study. 



3<50 THBEMOMETEIC LESSOR FROM CHI8ELHURST. 



In 1873, his cousin, a Duke of Montpensier, died of theeanw 
disease, brought on by the same cause, in the seminary of the 
Sishop of Orleans. 

The men in charge of these religious and learned haunts pre- 
tend to know all the particulars about the hyperpyretic 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 6ame 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) FROM CHISELH UEST. 

" 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 sphygmographic 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 millimetrie 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. 



THERMOMETEIO LESSON FROM SANDEINOHAJiL 361 

Bossuet would have invited an auditorium with his grandilo- 
quent: Erudimini regea ! .... 

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. 

(c) FROM 8ANDEINGHAM. 

" 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 Men 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 Dr3. Jenner, Gull, and 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 preclndedjthe possibility of publish- 
in^ 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 
ungcientifLo character of these bulletins, but is far from find- 



362 THEBMOMETJKIC .LESSON FBOM SANDRINGHAM. 

iog 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 vim 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 plivsicians 
have, m no small degree, lowered, or at least preventeoithe 
legitimate rise of the standard of physic in public estimation. 

On the contrary, let us for an instant suppose that these emi- 
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 
fagures and summed up every septenary. They could also 
have been accompanied by a few commentaries, such as escape 
from the hps of a medical man looking ac the table of vital 
sigm appended to the bed of an ordinary subject of typhoid 

Supposing that these popular and progressive views had 
prevailed m the judgment of the physicians in charge at 
Sandrmgham, 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 Peyers glands-we mean the narration, by telegrams of 



THJESMOMETRIO LE880N FROM SANDRINGrJiAM. 



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 tb.e thermometer ; 
neversuch 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 sphygmograph. 
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, See, 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 bis 
a-oodness ! 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 d 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 van predict the rise 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. We 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 «Bf?eree 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 <>f the parties on the other; for, in 
a wife, a young man will find rejuvenation — like Antseus each- 
time he touched the ground— or his 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 Kicean 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 FOB 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. Iu 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 thein. Men educated as they 
now are to be blown up without the sixteenth part of a second 
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 
for a set-off, most of their concerns would soon break down 
under 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 THEEMOMETEK IN LIFE-INSURANCE.; 



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-live, after an attack of apoplexy followed by 
slight paraplegia, had his 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 live thousand dollars. 
Moral No. 2. — In the former case, the sphygmographic 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- 



S68 



TSESMQtolSTRT IN SOBOOLg. 



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 he 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 the physical signs or the symptoms. 
By means of the thermometer we can diagndse 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 
«sthesiometry ? . . . 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 on 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 j 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 saying 
that in this 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- 
tions, the harmony of his motor and sensory apparatus on both 



THERMOMETRY IN SCHOOLS. 



369 



sides, 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- irpon the f urtn6i* development of the 
children. 

To me the subject is so' impressive that I hardly dare to touch 
it ; still I must go oh, knowing the while that I cannot expect 
to do it justice ih ; 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, I 
liave not given to that question the prominence it deserves. 

During the years children go through their school education, 
"they have to grow too ; so willetb 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 come out of it bent or crippled, never to* 
rise again in beauty and capacity. But what of those who, 
meanwhile, have to pass through tlfe ordeal of stupendous 
studies or stupid im mobilities ? (See the 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 

- degenereseence oi organs, and the exaggeration or decline of 
functions in children under training, I will suggest: the daily- 
elevation of general temperature during the latest hours of 
study ; and the following* irregularities in the distribution of 

j local temperature— as peY s^face-thermometer. Extremities 
. cold and body too hot. GTeneral coldness", with either dry heat 
in the palm of the hand'j or a Cold and abundant moisture of 
the whole hand. TbS-same general coldness with parched and 
peeling lips, and inordinate thirst ; or localized heats signalized 
by 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 venom arbo- 
reacence. The hand-thermometer and the sight admonish o£ 

- these dangerous anomalies ; the fever and smiace-thermopietor 

24 



T»-n Huparanou or tne CQm 



5H KRMOAI ETRY IN SCHOOLS. 



mea&ur* them, the thermoscope too; and also the pyrogenic 
action of the elements, 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, so^ of fchem will undergo remarkable 
changes, of which note, tiie. fallowing :— 

They feel all the uneasiness attending growth, and yet they 
do not grow ; but symptoms which cannot be synthetized under 
the name of a particu&y. 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 hag 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 them spddenly dry up pithless amidst 
its sappy fellows, can form aa idea of this degenerescenoe of 
special organs by localised deficiency of nutrition. 

This form of localized arrest of nutrition, French decroitl 
(Trousseau), popularly degras, is always, unilateral, a characters 
which permits, us to detect it early, by the comparative use, .om 
both sides, of the instruments of positive diagnosis : of the suiv- 
face-thermometer, which will detect a coolness of half a degree 
and upward on the suspected side, long before any other sign, 
of the affection can be otherwise descried ; o£ accurate mea- 
surements which will spy the. difference of size.of the limbss- 
©f electricity and aesthesiometry, delicate tests of tactile sen- 
sibility; of the dynamometer which gives mathematical, evi- 
dences of difference of contractility located in. % hands .and! 
arms ; and of the dynamometric swing, excellent test of. tifett 
of the lower limbs. 

The gravest affections of tke nervous systems, central ana; 
peripheric, visit the young student in proportion^ it seems t+i 



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 m«£t 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 ceases 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) — nray be referred to an in- 
sufficiency of the vital properties of the blood, and its causes 
synthetized in deficiency <rf nutrition — of whatever origin of 
eourse. 

IV. — 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 lym$>h, 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 
COngǤti?e (^ft 3 * 111 ) disposes to a separation of theoom 



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 sphyginograph 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-m easure 
and lead circle ; and the dynamometer will mark a weaker con 



PRINCIPLES OF ECONOMY OF 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 thennoinetry. 

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 make foe the CHIL- 
DREN, NOT THE CHILDREN FOE THE CURRICULUM. 



374 



THE THERMOMETER IN EVEKY 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. 

T.— 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-temperatur& 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. 



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 ae 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 hand 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 with 
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 
Bnrvey 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 
ontside temperature is any way excessive or versatile. 

With older children the explorations should be 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. 



ipai ly directed towards the weak or affected parts in the 

delleate or the convalescent. 

During 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 nstion. 

Here ends her 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 as 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 $iat of an "apyretic affection by a fall of 
more than l°,,of which she must carefully ; note the degrees 
and fractions at stated times, the first $art 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 feave 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 iias a right to know all t&at she can understand (I 
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 
more, seeing a sudden rise or falj of temperature when we am 



ALL WOMEN INSTRUCTED m THERMOMETRY. 877 



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. e 

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, teachers, 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-Book 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- 



376 



FAMILY HEALTH RECORD. 



tions 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 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 hi& 
mind to co-ordinate his individual experience to that of his 
medical brethren. If he gives nothing, he receives the same ' r 
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. 



r m v a lent Die- 
eases. 


No. 


Duration. 


Cures. 


Death. 


tufatment and 

Remarks. 


Min. 


Max. 


Aver. 


\ 

















(5.) — 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 days and weeks: the latter 



TTNtFOBMfffl? 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- 
rific 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 w&o w&nt 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 hm to husband their vitality expressed by 
their eaTorieity, 

The- value of thew^tfon^etry in the hands of mothers to pre- 
dict diseases' or relapsesy to help the physician in the manage- 
rmM of the sicky and^ to protect herself against the assailing^ 
soggestions-ol the ignoifawt or of the designing, who hover around 
a, sick-bed', like ravens- aoove a corpse. 

Ther necessity for" p%"sic, not only to be - one of the physical 
sciences-, but tk> ; show iteelf such, by the scientific concordance 
of its -fflecordisy whic& permit any physician to read, criticise, 
eompare> eveni to* continue any observation, or group of obser- 
vations- pertaining;: tfo'^le' practice of a confrere, or to the phi- 
losophy of his art?,, as- db' physicists and mathematicians. 

These' suggestions^, once brought together by simple apposi- 
tion,, must aireadjy appear what they really were — the inten- 
tional parts of an; intended plan : the segments of an intellectual 
cycle; - 

The segments -are 'the' means I have suggested, and the new 
onesr which' will' soon be' offered by other observers to enforce 
their cohesion. 

The cycle is the ensemble of the means of substituting posi- 
tivism < for 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- 
withstanding;^ wonders^ because its data are not always posi- 
tive, and' it 13, SO far, too exclusively engaged in analytical in- 
vestigations^ ; i* 1 ifr tlfetherniometer, 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 
crsrriculums. 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 aesthetic, social, and working qualities of the race. 
Here therjmometry, 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 
this 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 v ami <U^vv«rie». 



WHAT THERMOMETRY WILL DO FOB MANKIND. v 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 kwa and means by which our race will attain 
and maintain the highest degree of health, proficiency, and hap- 
piness, inherent to the preservation of the physiological temper- 
ature : mens s%na in <x>rpore sano. 



VIII, — Gonc&usiojn. 

Looking back to the preceding pages, I see the proportion® 
of the responsibility I have incurred, yet do not propose to take 
advantage of the attenuating circumstances ; whatever could; 
be the verdict, I plead 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 to v be true I have worked to make it real. 
Though I began long ago, I never dud more for the lionor of 
the art, whose practice honored me, than since I came into my 
sixties. I have developed several points of this philosophy of 
medicine two 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 j. but with ai no less firm confidence in 
the strength of the cause. I have given it all that the young, 
offers for the possession of his ideals and the old for the realiza- 
tion of his idea. 



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 lbbked for in vital 
problems. 2d. The keeping of thermometry accounts in 
graphics, which nCed the hand of an artist, and must be recon- 
verted in figures to be serviceable in practice. These causes 
excluded clinical thermometry from mariy hospitals, from almost 
all private practice, from the nursery, the 4 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 phj'sician ; enfranchises mothers from the imposition of the 
bonzes ; reconstitutes the atttiqne 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 eannot perish, but after having accomplished their evolu- 
tion. In this persuasion my last wor$ ifc ; — Thermometry begat 
thermography, and thermography is- pregnant with medical 
jnaihem&tism. 




APPENDIXES. 



3 



T 

T 

T 
T 



APPENDIX L 



table of equivalents op the celsian (centigrade), 
Reaumur's, Fahrenheit's, and physiological 
theemometees. 

To convert Centigrade into Fahrenheit, multiply by 9, divide by 5, and add 32 ; or, 
mtdtiply 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. 
Example :— 104° F. -32 x 5 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. 


Reaumur. 


Celsius 
(Centi- 
grade). 


Physio- 
logical. 


Fahrenheit. 


Reaumur. 


Celsius 
(Centi- 
grade). 


Physio- 
logical. 


32 








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 


IT 


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 


4.4 


75.2 


19.2 


24 


13 


90.86 


26.16 


32.7 


4. 3 


77 


20 


25 


12 


91.04 


26.24 


32.8 


4.2 


79.8 


20.6 


26 


IT 


91.22 


26.32 


32.9 


4.1 


81.5 


22 


27.5 


9.5 


91.40 


26.4 


33 


4 



388 



APPENDIXES. 



Fahrenheit. 


>R6aumur. 


Celsius 
(Centi- 
grade). 


Physio- 
logical. ! 


Fahrenheit, j 


Reaumur. 


Celsius 
(Centi- 
grade). 


Physio- 
logical. 


1.58 


| 

26.48 


33.1 


3.9 


98.24 


29.44 


36.8 


.3 


91.76 


26.56 


33.2 


3.8 


98.42 


29.52 


36.9 


.1 


91.94 


26.64 


33.3 


.8.7 


98.60 


29.60 


37 





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 


99.32 


29.92 


37.4 


.4 


93.02 


27.12 


33.9 


8.1 


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 


2.8 


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 


84.4 


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 


2.2 


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 




100.94 


30.64 


38.3 


1.8 


95.18 


28.8 


35.1 


1.9 


101.12 


30.72 


I 38.4, 


1.4 


95.36 


28.16 


35.2 


r.8 


101.30 


30.80 


38.5 


1.5 


95.54 


28.24 


35.3 


1.7 


101.48 


80.88 


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 


1.3 


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 


:f 


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 

1 


39.8 


2.8 



APPENDIXES, 



389 



Fahrenheit. 


Reaumur. 


Celsius 
(Centi- 
grade). 


Physio- 
logical. 


Fahrenheit. 


Keanmur. 


Celsius 
(Centi- 
grade). : 


Ph Bio- 
logical. 


"fl AO OO 


31.92 


39.9 


2.9 


108.725 


34.1 


42.625 


5.625 


104 


32 


40 


3 


108.86 


34.16 


42.7 


5'. 7 


10418 


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 


109.175 


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 


105.98 


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 


6.629 


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 


0. ID 


106,34 


33.04 


41.3 


4.3 


110.84 


35.04 


4<5.o 


ft S 
0.0 


106 52 


33.12 


41.4' 


4.4 


111.02 


35.12 


43.9 


o.y 


106.70 


33.20 


41.5 


4.5 


111.20 


35.20 


44 


i 


106:88 


33.28 


41.6 


4.6 


111.38 


35.28 


44.1 




106.925- 


33.32 


41.625 


4.625 


111.56 


35.36 


AA O 

44. a 


7 2- 


107.06 


33.36 


41.7 


4.7 


111.74 


35.44 


aTq 
44. 6 


7 3 


107.15 


33.40 


41.75 


4.75 


111.875 


35.5 


44.0(0 


7.375 


107.2* 


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 


AA K 
44.0 


7.5 


107.42 


33.53 


41.9 


4.9 


112.28 


35.68 


AA A 

44.0 


7.6 


107.60 


33.60 


42 


6 


112.46 


35.76 


aa >y 
44. ( 


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 


42.3* 


5.2 


113 


36 


45 


8 


108.05 


33.80 


42.25 


5.25 


114.8 


36.8 


46 


9 


108.14 


33.84 


42.3 


5.3 


116.6 


37.6 


47 


10 


108.185 


33.90 


42.375 


5.375 


118.4 


38.4 


48 


11 


108.32 


1 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 

r 


42.6 


5.6 











390 APPENDIXES. 



APPENDIX II 

NOTE ON THE HEAT 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 

glasses 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 hisnorme without endangering his life. 
This is said for teachers as well as for physicians. The temperature of man oscillates 

.between 36.50° and 37.5> ; a/eragss 37°. A sudden change of 5°, or a steady loss of 
.5° are equally incompatible with life. 

a.— Tables of Temperature of Btrds 

Petrel 

Parrot ,- 

Goose 

Jackdaw 

Screech-owl 

Heron 

Sparrow 

Yellow Hammer , 

Tiercelet 

Pigeon • 

Cock ... 

Turkey-cock . » ■. 

Moor-hen 

Guinea Fowl 

Common Fowl ■ 

Thrush 

Common Duck 

Crow 

Raven 



° Cent. 
.40.30-40.80 

41.10 

41.70 

42.10 

41.47 

41. 

.41.67-42.10 

42.88 

41.47 

.41.80-43.30 
.39.44-40. 

42.70 

.42.00-42.50 

43.90 

.39.44-43.90 

42.80 

.42.50-43.90 

41.17 

42.91 



6.— The Temperature of Mammifers. 

° 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 , 35.50-59.70 

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 35.62-37.80 

Sea-cow 38.89-40. 



-Excess of Temperature of Reptiles over that of their Surrounding 
Atmosphere. 

Cent. 

Viper , 5.06 

Toad 0.50-2.80 

Prog 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 Pishes over that of their Surrounding 

Atmosphere. 

Cent. 

Pike 3.88 

Carp 0.36-3. 

Eel 0.93 

Tench 0.50-0.71 

Shark 130 

Trout , 0.55-1.10 

Ablet 055 

Perch 052 



—Excess of Temperature of Articulata and Anneeides over that of 
their Surrounding Atmosphere. 

Cent. 

Beetles 0.25-0.70 

Glow-worm ••• ■ 

Ground-worm x - 1L ~^ 6y 

Silk-worm • 

Larvse of Sphinx 

S° c S nella :::::o.3i-o'.94 

Gryllus moms 

Scarabaeus Vernalis nlZn an 

, O.oo-U.oo 

Leech 

—Excess of Temperature in Lower Animals over that of their Sur- 
rounding Atmosphere. 

Cent. 
.... 0.60 

Crustacea 

Cephalopoda • • > * 



392 



APPENDIXES. 



° Cbnt. 

Molluscs 046 

Echinoderma ®* *^ 

27 

Meduses v- *" 

Polyps °- 81 



APPENDIX III. 



DIURNAL OSCILLATIONS. 

-Dr. Ogle's observations were made in the St. George Hospital, by day in 
SSmmer, by night in winter, and lasted many months. The average daily variation 
C 1 ',° F. The minimum, a winter's morning, at 5.30 A.M., was 36.1 C.= 
! , and the maximum 38.25° C. =100.6° P., in a Turkish bath. (Temperature 

Is a under the tongue.) Means of monthly results : 



Time of the day. 




sflfc-11 a.m. before breakfast 

11 A..M.— 2 I'.M..- 

:> —5 P.M. ; lunch at 3 p.m 

f>.S0 r.:.i. —'.:-('• p.m. ; dinner at 7 p.m 

?.i:.-10i'.M 

■ j .,—12.36 p.m 

12.30 A.M. — 1 a.m; bed at 1 A. m 

A.M.— 5 AM ... 

">.;)0 a.m.— 6.30 a.m 

8 A.M. — 9 A.M 



97.73" 


98° 


98.2° 


98-56 


98. i 6° 


98.57 


98.63° 


98.6° 


9o* 


98.45° 


97.96° 


98" 


97.9° 


No observa- 


97.. r ;° 


tion taken of 


97.2° 


females during 


97.66° 


the night. 



(ft,)— Alveranga extended similar observations to two hundred and eighty persons, 
•Whose ages varied from nine to sixty-five years, and who took their meals at eight, 

.me, and seven o'clock: 



Hours of Observation. 



Temperatures. 



Minima. 



Media. 



o'clock A.M. 



<> 

10 

11 

2 

4 

8 



37.5° 
37.6° 
37.8° 
37.9° 
37.9° 
37.9° 
37.9° 
37.9° 



36.0° 
36.3° 
38.8° 
36.6 2 
3fi.6 c 
36.7= 
S6.6 3 
36.6° 



36.81° 
37.04° 
37.32° 
37.35° 
37.36° 
37.42° 
37.42° 
37.36° 



APPENDIXES. 



393 



(c ) Barensprung 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 ani 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. 



I 

n.... 
in... 

IV... 

v.... 

VI... 

vn.. 

VIII. 
IX... 

x. .. 

xi. .. 

xii. . 
xin. 

XIV. 



days. 



Ses. 



Male. 
Female. 
Male: 



Female. 



Male. 
Female. 
Male. 



I Temperature 
Constitution. (under the Pulse. 
I Axilla). 



Strong. 
Sickly. 
Feeble. 

Strong. 
Feeble. 
Medium. 
Strong. 

(C 

Feeble. 
Strong. 



Respi- 
ration. 



37 


7° 


132 


48 


37 


3° 


112 


38 


37 


5° 


108 


24 


87 


8° 


120 


48 


38 


0° 


120 


28 


36 


8° 


132 


30 


38 


1° 


120 


36 


87 


4° 


132 


36 


87 


5° 


120 


33 


87 


&° 


134 


38 


38 


0° 


132 




37 


9° 


132 




37 


6° 




42 


37 


8° 


132 



APPENDIXES, 



APPENDIX V. 

(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 m ) — eoger's table of comparative temperature of mother 

AND CHILD AT BIRTH. 



Age. 


Number of 
Respirations. 


Number of 
Pupations. 


Axillary Temperature 
of the Infant. 


Axillary Temperature 
of the Mother.* 




50 




37.75° 


36.75° 


34 


'iib 


36.75°. 


36.25° ' 


3 to 4 minutes 


39 


105 


3f>° 


37° 


5. to 30 minutes 


68 


120 


37° 


37° 




36 


132 


36° 


37° 




60 


96 


35.50° 


37° 




60 

28 


96 


35.50° 


37° 




130 


35.50° 


36° 




22 


65 


35.25° 


37? 



This table gives the following — 

Maxima. Minima. Average!. 

Of temperature 38.1° 36.8° 37.45° 

Of pulse 134 108 117ft 

Of respiration 48 24 36ft- 

(6.)— 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° 


113 


38 


37.5° 


108 


24 


37.4° 


132 


36 


37.8° 


120 


48 


37.5° 


120 


33 


38° 


120 


28 


37.9° 


134 


38 


36.8° 


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 

1 


36 > 


Average. 37.61 


126 


36; 



* 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 thi» 
juncture wonld be the vagina, and correspondingly, that of the babj, the rectnm. 



APPENDIXES. 395 

/ 

(c.) — Pretty close contest, since — 

The temperature average for boys was. 37.7° 

" 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 ©f the 
superiority of either sex. 



APPENDIX VI. 

— barensprung's table of temperature op the 
different ages. 



At birth 37.08» 

A few hours after 36.95° 

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 " 37ll ° 

" 41 to 50 " 36 94° 

« 61 to 70 " 3 ?.09° 

At 80. •• 3716 ° 

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.,f 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 


Jruny. 


bleeping. 


36° C. 


70 


36 


1 


cc 




36.25° 


104 


64 


3 


Girl. 


it 


it 


36.25° 


80 


24 


4 




(t 




36.25° 


88 


28 


3 


It 


11 


4t 


36.50° 


140 


40 


6 


U 


t< 


ii 


36.75° 


120 


44v 


1 


u 


t i 


ii 


36 . 75° 


120 


48 


2 


uoy. 


it 


it 


36.75° 


84 


86 








37° 


80 


36 


1 


ti 


ti 


II - 


37° 


100 


44 


2 


cc 


ii 


11. 


37° 


120 


46 


2 


GirL 




Ci 


37° 


84' 


44 


3 


Boy. 


it 


II 


37° 


112 


32 


4 


Girl. 




II 


37° 


104 


34 


4. 


U 






37° 


120 


40 


5 




n 


II 


37° 


84 


32 


5 


Boy. 


Strong. 


II 


37°' 


96 


36 


5 


Pretty strong. 


II 


37° 


112 


42 


7 


Strong. 


II 


37° 


128 


50 


3 


Girl. 




II 


37° 


84 


42 


t:= 


u 




(( ' 


37° 


120 


36 








II 


37° 


120 


38 


! 




ii 


II 


37.25° 


92 


32 




3oy. 


Very strong. 




37.25° 


76 


40 




Girl. 


it 


II 


37.25° 


112 


32 




Boy. 


it 


II 


37.»5° 


116 


37 






11 


37.25° 


80 


40 


5 


Giil. 


ti 




37.50° 


76 


24 


t 


3oy. 


Pretty strong. 


II 


37.50° 


112 


32 






Strong . 


II 


38° 


112 


38 


4 


' it 


II 


38° 


108 


32 
36 




Girl. 


ii 


c« 


38° 


84 







Pretty strong. 


11 


39° 


124 


44 



Thus on 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 e carts of temperature in infants than- in adults. 



APPENDIXES. 



397 



APPENDIX VII 



(«.) ROGER'S TABLE OF COMPARISON OF USTION, CIRCULATION, 

AND RESPIRATION OF TWENTY-FIVE CHILDREN FROM 
FIVE MONTHS TO FOURTEEN YEARS. 



Age. 


irstion. 


Pulsa- 
tion. 


Respira- 
tion. , 


Age. 


Ustion. 


Pulsa- 
tion. 


Respira- 
tion. 


4 Months 


37° C. 


120 


36 




37. C. 


80 


24 


4 " 


37.35° 


112 


32 


8 " 


37.75° 


84 


28 


5 " 


37 25° 


100 


30 


10 " 


37.75° 


80 


20 


fi " 


36. "i 5°. 


120 


44 


11 " .., 


37.25° 


88 


26 


6 " 


37° 


120 


38 


12 " 


37° 


70 


28 


6 " 


37° 


80 


24 


12 " 


37° 


82 


28 


9 " 


^6.75° 


120 


36 


12 " 


37.25° 


74 


34 


9 " 


37.25° 


116 


12 


12 " 


37.25° 


70 


34 


2 Years 


37.25° 


80 


32 


13 " 


37.50° 


88 


32 


3 u 


37° 

37.50° 
37.75° 
36.75° 


116 

80 
96 
64 


36 
24 
34 
22 


13 " 


37.50° 
37.25° 
37.2j° 


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. 



(b.) — tFORSter's (in New Syd. Soc. Year Book, 1862) tempera- 
ture-variations WITHIN THE FIRST TWO DAYS AFTER BIRTH. 



Hours after Birth. 



Average Temperature 
(Reaumur). 



Minimum Temperature 
(Reaumur). 



1- 2... 

2— 6.. 
6—10. 
10—15 
15—20 
20—25 
25—30 
30—36 
36—42 
42—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 hours 
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. 

(e.) — TEMPERATURE OF THE FIRST NINE DAYS, FROM THE SAME 

AUTHOR. 



Maxima (K.). 



1-1)* 

2^-3 

3- 3^ 
33^-4 

4- 4^ 
4J^-5 

5^-6 
6-6Ji 
6^-7 

7^-8 
8— 8K. 



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. 


1 

| Abdomen. 


Mouth. 


In the Arm 
fold. 


In the Shut 
Hand. 


Between the 
closed Feet. 


| In the 
Groin. 


At the 
Scrotum. 


37.75° 


37.50° 


36.75° 


36.50° 


33.50° 


31.50° 










35° 




1 30.50° 














37.'25° 
35° 










87.50° 




37 .'75° 


35.50° 


34. 75° 


29°" 




37°' 






36.50° 














37° 










37'.25° 






36.50° 


34 .'50° 








. . . '. 




36.80° 
















36.25° 
















35 3 




35°" 












36.25° 










37° ' 


37^" 


37.*25° 


35° 


31 .'56° 


31.50° 


36° 


35.75° 






33° 












37.'25° 


35.75° 


36 .'75° 




31°" 







APPENDIXES. 



399 



(b.) — TEMPERATURE OF SIX OTHER CHILDREN OE THE SAME AGE! 

Axillary Temperature. Rectal Temperature. 

38.2° 38.2° 

31.8° 37.2° 

37.6° 37.8° 

370 37.4° 

38° 38.4° 

37 4° 37.8° 



(('.) — J. davy's local temperatures. 





Foot. 


Hand. 


Under the Tongue 


Urine. 




21.4° 
36.2° 


27.2° 
35.8° 


36.7° 
37.7° 


37.8° 
38.3° 



(^.)— 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. 



Head 

Thorax 

Epigastrium . . . 
Hypogastrium . 
Fold of arm... 

Thigh. 

Groin 

Foot (under) . . 



Local Temperatures. 



Maxima. Minima. Media. General Average 



37.2° 


35.1° 


36.4° 


34.6° 


37.9° 


32.0° 


36.0° 


32.0° 


37.6° 


34.0° 


36.8° 


33.5° 


37.5° 


34.5° 


36.8° 


34.0° 


37.6° 


35.5° 


37.0° 


34.0° 


37.5° 


35.0° 


36. 6P 


34.6° 


37.7° 


34.5° 




84.5° 


35.4° 


31.0° 


34.4° 


31.0° 



36.05° ) 
35.74° j 
35.60° i 
34.55° \ 
86.01° ) 
35.21° \ 
36.43° ) 
35.30° \ 
36.33° I 
36.16° \ 
35.86° ) 
■ •35.75° S 
35.98° ) 
35.92° j 
33.52° i 
32.70° i 



35.92° 
35.20° 
35.66° 
35.94° 
36.26° 
35.81° 
35.95° 
33.20° 



400 



APPENDIXES. 



^ alvarenga's 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 FINGEK. 



4th.... 

5th.-..: 

6th.... 
7th... 
8th... 



Observation 9 to 10 a.m. 



'•gs 



Axilla 

Sick part 

Opposite side 

Axilla 

Sick part. . . . 
Opposite side 

Axilla 

Sick part 

Opposite side 

Axilla 

Sick part .... 
Opposite side 

Axilla 

Sick part. . . . 
Opposite side 



38.9° 
37.5° 
35.5° 
37.6° 
36.4° 
34.8° 
36.8° 
35.3° 
34.1° 
36.0° 
33 
32 

36.2° 
33.5' 
33.8 



U i 
5° V 
5°f 



68 
60 
44 
60 
68 



24 
20 
16 
16 
16 



Observation 3 to 4 p.m. 



(38.5° 
^36.7° 
{35.2° 
(37.4° 
■^36.4° 
35.6° 



68 



24 
IS 



(/.)— ALVARENGA'S COMPARATIVE TABLE OF LOCAL AND CENTRAL 
TEMPERATURES, IN LIGHT ORCHITIS OF THE RIGHT 
SIDE, MT. TWENTY-FOUR. 



a a 

P. o 

<s a 



•|"S 

Hi 



4th 
5th 
6th 



( Axil 1 a 

•{Sick test'cle.\.. 
( Healthy testicle. 

( Axilla 

1 Sick testicle 

( Healthy testicle. 

AxiUa 

< 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° 



60 
62 
60 



16 
16 
16 



Observation 4 P.M. 



37.1° 

36.7° 

36.4° 

37.0° 

36.6° 

36.4° 

37.0° 

36.4° y 

36.2° ) 



62 



62 



60 



16 
16 
16 



APPENDIXES/ 



401 



ty.) — TABLE r 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 TEE ABDOMEN. 
gg~ {From Dr. Taylor's Principles and Practice of Medical Jurisprudence, p. 6.) 









First period 2 


Second 


period^Third period elFourth 


period 








to 3 


hours 


4 to € 


hours 


to 8 


hours 


12 hours af- 








after 


death. 


after death. 


after .death. 


ter death. 








76 


49 


29 


35 

/ ... 








F. 


c. 


F. 


c. 


,| 


c. 




c. 


Maximum temperature 


of 


the 


92° 


34.4° 


86° 


30° 

to 


80° 


26.6° 


79° 


26.1° 


Minimum temperature 


of 


the 


60° 


15.5° 


62° 


16.6° 


60° 


15.5° 




13. 3° 


Average temperature 


of 


the 


77° 


25° 


74° 


23.3° 


70° 


21.1* 


67* 


19>° 



APPENDIX IX 



(a.)— SQUIRE'S THERMOMETRY OF THE PKE-ERUPTIVE AND CONTA- 
GIOUS STAGE OF MEASLES. 
f«._A girl, ret.' 5, exposed to infection, March 30, shows abnormal temperatures 
before any other signs. 



Days before Ill- 
ness. 


April. 


Pulse. 


Respira- 
tion. 


Temperature, 
Axilla, at noon. 


4 


3 


110 


26 


98.6° 


3 
2 


4 
5 


120 
120 


82 
30 


99.4° 
100.7° 


1 


1st of illness. 


6 
7 
8 


104 
100 
110 


30 

26 
26 


99.0° 
97.3° 
99.2° 


2 

3 


9 
10 


130 
130 


30 
40 


100.3° 
100.5° 


4 


11 






102.0° 


5 


12 









Remarks. 



skin. 



OIU" "^"'i o— 

Respiration weak, a wheeze on 

forced inspiration, 
nl, but not in bed. 
Respiration clear, spots of 

measles visible. 
Rash, purulent secretion from 

the conjunctiva. 
Rash fully out, eyes better. 



26 



402 



APPENDIXES. 



night' T. 103.6- full rash on the 25th, oroupy cough and tracheal ofle, P. 104 , 
next day temperature only 98.7°. 

c -Pre-eruptive and contagious stage of mumps (parotitis). A boy, st 13, ex- 
posed to infection of mumps at school by the end of September. 



Days before 
Illness. 


&.t Home, 
Oct. 


Pulse. 


Respi- 
ration. 


Temperature. 
Morn. Even'g. 




lto5 








Days of 
illness . . 


6 




• 




1 

2 


7 


100 


24 


101.2° 103. C 


i 


8 


110 


27 


102.4° 102.4 


4 


9 


84 


26 


100.2° 


5 


10 


68 


24 


98.4° 


15 


20 









I Remarks. 
Headache, uneasiness, fatigue. 



One side of throat tender, and neck 

Left^arotid and right sub-maxillary 
;land enlarged, bowels open, urine 
rree, delirious at night. 
Pace swelled, eyes red, vomiting, 

better at night. 
Swelling of parotid less hard, no 

No^welling of parotids, a little of 

left submaxillary gland. 
Quite well, had felt weak till now, 

no metastasis, no relapse. 



(5.)— PERIOD OF INCUBATION OF INFECTIOUS DISEASE. 



Diseases. 



Vaccine 



Variola •■• 

" inoculated . 
Varicella 



Stage of Latency 
and Innocuity. 



Stage of In- 
vasion i nd 
Infection. 



Scarlatina 



Roseola. 
Measles 



u inoculated. 

Parotitis 

Whooping-cough . . 
Influenza 



Typhoid fever 
Typhus. 



Days 4 — 5 

12-14 
.. 3-4 
.. 10—12 



3—7 



10—14 
12-14 

7 " 
14—21 
4 " 
4—8 

10-12 

12 .. 



Days 



4-5 



Remarks. 



Infectious when the vesicle is 

formed and by its lymph. 
Infectious when tha papuies appear 

f Exceptionally a few hours only, 
or a wee!t 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 



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 
3—4 



2—5 



2— 15 

3— 5 



3—30 
40—120 

3-8 [ 



Stage of In 
vasion and 
Infection. 



At once. 



Incubation sometimes shorter or 
longer. 

Infection illimited and uncertain 
infection. 

Infection rarely 8 to 10 days. Spe- 
cific smell prodromic. 

u A few days' incubation " is the 
answer of the cholera commission 
sitting (1865) 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 (inoocuity and incu- 
bation), and the period of infection (proliferation and propagation) . 

(c.) — MEAN TEMPERATURE IN SOME DISEASES OF CHILDREN. 



Disease. 



Authori- 
ties. 



Minima. 



Maxima. 



Media. 



Remarks. 



Bronchitis, simple. . . 
** complicated 



Pneumonia 

Pleurisy 

Peritonitis 

Dysentery 

Enteritis 

Pericarditis 

Thrush .... , 

Meningeal tubercles. 

Meningitis 

Scarlatina 

u 

Measles 

Mumps 

Tooth-rash — Zoster. 

Varicella 

Small-pox 



Squire. 

Roger. 
Moreau. 

Roger. 
Moreau. 



Squire. 
Roger. 
Moreau. 



103° F 



99° 
98.7° 
99. 2 a 
98.7° 
105.5° 



95° 
198° 
100° 



101 c 
98. 



',.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° 
108° 



And above- aa 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. 



102 J 



102.2° 

101.75° 

102.2 



404 



APPENDIXES. 



(d)— SOGER'S AVERAGE TEMPERATURE OP CHILDREN IN ACUTE 
AFFECTIONS OF THE DIGESTIVE ORGANS. 



Peritonitis.. 
Dysentery . . 
Stomatitis . . 
Enteritis . . . 
Thrush 



39.55" C. 
88.16" " 
38.08° «• 
37.96° " 
37.85°, »« 



= 103.19° F. 
= 100.70° " 
= 100.50° " 
= 100.30°" 
= 100.13° « 



APPENDIXES. 



40$ 



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Q S 



a I 



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•Unix's 9T t? ^ 



I 

fc. PS. 



406 APPENDIXES. 



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s { s 


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2 H 

p § 

b O 




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ft 
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-9 2 
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Appendixes. 



40* 



X 
X 

H-l 

p 

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02 
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Ah 
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02 
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02 

to 
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408 



APPENDIXES. 



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-eftix!? otto UdXV* 



APPENDIXES. 



409 



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02 
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4#0 APPENDIXES. 



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APPENDIXES- 411 

APPENDIX XII. 

PUERPERAL TEMPERATURES. 

(«.) DUKINGr THE mOfltde OF MILK. 



Decimal Measures. 



G .., aet.127. 


Pulse. 


Temper. 


Urine. 


Gravity. 


Urea. 


Chlore. 


April 21.. 
" 22.. 
" -23.. 

11 24.. 
" 25.. 

" 26.. 


7 a.m., successful delivery.. 

Breast full ; child begins to 
suck ; no chill ; hot skin ; 

Breasts not so tense ; eats 
And following days, plenty 


82 
68 

64 
58 

56 


37.5° 
37.6° 

37.6° 
37.5° 

37.4° 


800 gr. 

1230 " 
830 " 

900 " 


l6*20 

10.23 
10.22 

10.20 


18." 

34.44 
25.32 

22. 

20-23 


4.53 

10.13 
5.13 

5.60 

5-600 


46.) quenquand's temperature, ETC., -IN TRAUMATIC pueepeeal 

FEVER. 


H , set.~— . 


Decimal Measures. 


Pulse. 


Temper. 


Quantity 
Urine. 


Sp. 
Gravity. 


Urea. 


Chlore. 


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. 

Eata well ; sleeps well. 

Same condition. 


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 41 
1650 u 


1018 
carmine- 
red. 

1010 
light- 
red. 

1013 
light- 
yellow. 

1018 
orange- 
yellow. 

1020 
orange- 
yellow. 

1021 

1017 
orange. 


21 

29.50 

19.55 

17.22 

19 

22 
38 


8 

10 

4.98 
2 

1.'89 

1.50 
5.62 



412 APPENDIXES. 

LIGHT INFANTILE PTJERPERISM OF INFANT (dire). 



E Mother, set. 27, being well. 



Temperature. 



Feb. 26.. 
" 27. . 



» 28.. 
March 1 . . 

" 2.. 

" 3.. 

«« 4.. 

" 5.. 

11 6. 



11 p.m., natural delivery .•••« 

I morning. 

«■> ••• ( evening . 

j morning. 

No diarrhoea ■ 1 ] evening.. 

Do not suckle; complains; pale; vomits; j morning, 
distended abdomen ( evening. . 

Suckle a little; green diarrhoea; bili- ( mom i n g . 
ous ; vomiting ; somnolence ; swollen < even i D g. , 

abdomen ' 

j morning 

Diarrhoea continues. -j eV ening. . 

, . . ('morning. 
Tries to suckle ; pale in the evening -j evening.. 

, . . mm , , , i morning. 

Improved facies ; suckles better j evening. . 

Suckles well; pale yet. discharged- at 



36.8° 

37° 

37.8° 

37.6° 

37.9° 

38.2° 

38.8° ) 
38.9° j 

35.5° ) 
35.9° ) 
37.8° ) 
37.9° f 
37.5°/ 
37.7° f 
37.8° ■ 



(d.) IN INFANTILE PUEKPERISM OF INFANT (death). 



P...., Male. Mother, aet. 23. Has had pelvi-peritonitis. Cured. 


Temperature. 


Weight. 


April 13.. 

" 14.. 
" 15.. 

" 16.. 

" 17.. 

" 18.. 


. ^ \ morning. 
Passes meconium ; does not seem to sufler j evenm g . 

\ morning. 

Cries all night; some diarrhoea; swol- i morning . 

len abdomen ; loss of flesh sensible. . . ( evening. . 
Vomited ; abdomen tense, traversed ( morning . 

Abdomen tense; sensible; vomit green: ) morn i n g. 
refuses food ; mouth dry ; features al- V eve nin^. . 

Bilious vomit; green stools; emacia- \ morning. 
Death in the night. 


37.6? | 

37.6° 

37.4° 

37.5° 

38.8° 

38.8° 

39. 

38.2° 

39.1° 
38.5° 

39.5° 
40.0° 


I 

; 

1 

f 


3770 
367Q 
3570 
3470 

3370 

3270 



{g^j INFANTILE PUERPERISM COMPLICATED WITH MENINGITIS 

(death) . 



Afterbirth; is well; nurses 

Temperature 36.7° C 

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, 

Increase of weight, 
Loss " 

II it « 

Stationary, 
Loss of weight, 
Stationary, 

Loss of weight, 



80 
120 

50 
180 

20 

'io 



90 

85 



gram. 



APPENDIXES. 



APPENDIX XIII. 

(a.) — "WILSON FOX'S TABLES OP TEMPKRATUKEfr SHOWING THE 
EFFECTS OF THE TREATMENT BY COLD. 

MRS. BROPBT 



Date. 



Hour. , 



June 5. 9th day 

of disease. 
June 6. 



10. 14th day 
of disease. 



June U. 
15th day. 



Temp. 



Pulee. 



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. 

8.20 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. 



Besp. 



Eemarks. 



102.9 


88 


SO 


101.2 






100. 


88 


28 


99.66 


80 


32 


-100.9 


92 


28 


100.6 






100.7 


88 


42 


99.2 


84 


36 


101.5 


88 


30 


* 






105.0 


. . . 




106.3 






1C6.7 






105.6 






106.4 


i22 


'44 


106:2 


113 


44 


106.6 


104 


42 


106:2 


168 


•40 


106.2 


j!2 


40 


106.4 


112 


38 
40 


106.9 


120 


107.1 


118 


42 


107.3 


116 


40 


107.6 


112 


36 


107.8 


120 


34 


108.4 


122 


32 


109.2 


136 


36 


109.1 






110.0 






109.4 






108.4 






107.5 


120 




106.2 


140 




104.0 






103.6 






101.5 






100.6 






99.5 






99.5 






97-4 


130 




97.4 






98.0 






98.2 




*42 


98.3 


130 


98.3 







Ax. 
Ax. 
As. 
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. 
Vag. 
Vag. 



* Not ex. 102°. 

Quin. 3j. 
Quia. 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. 63°. 
Patient can speak. 
Rigidity of lips and of 

muscles of neck. 

Pulse imperceptible ; 
warmth to feet and 
spine. 



414 



.APPENDIXES. 



Date. 



Beopht— cant. 
June 11 — cont. 



June 12. 
16th day. 
26 hours. 



June 13.1 
1 17th day. 
50 hours. 
3d day. 



June 14. 
, 18th day. 

76 hours. 

4th day. 



Hour. 



12.45 a.m. 
12.55. a. m. 

1.15 am. 

1.40 a.m. 

2.15 a.m. 

2.55 a.m. 

4.0 a.m. 

5.0 a.m. 

6.30 a.m. 

7.15 a.m. 

7.35 a.m. 

7.40 a.m. 

7.45 a m. 

7.50 a.m. 

8.0 a.m. 

8.7 a.m. 

8.15 a.m. 

8.30 am. 

8.40 a.m. 

8.50 a.m. 

9.10 a.m. 

9.40 a.m. 
10.0 a.m. 
10.45 a.m. 
12.15 p.m. 

1.45 p.m. 

3.0 p.m. 
12.15 a.m. 

I. a.m. 
4.0 a.m. 
7.30 a.m. 
9.40 a.m. 

10.30 a.m. 
3.10 pm. 
8.50 p.m 
9.20 p.m. 
9.45 p.m. 
9.55 p.m. 

II . 45 p.m. 
12.40 a.m 
12.55 a.m. 

1.25 a.m 
4.40 a.m 
5.10 a.m 
5.40 a.m 
8.15 a.m, 
8.50 a.m. 
9.50 a.m. 
12.0 noon 
12.48 p.m. 
2.53 p.m. 
3.55 p.m. 
4.45 p.m. 
6.15 p.m. 
10.0 p.m. 
2.0 a.m. 
3.0 a.m. 
a.m. 
a.m. 



0.0 

8.0 

8.30 am 

9.20 a.m 
10.0 a.m 
10.25 a.m 



Temp. 



99.4 
99.2 
101.1 
101.4 
102.4 
102.9 
103.4 
103.8 
104.5 

105.0 
104.6 
103.9 
102.0 
101.7 
100.8 

99.4 
( 99.9 > 
j 99.8 ) 

99.4 

99.9 
100.0 
100.4 
100.7 
100.9 
100.7 
101.2 
100.8 
101.0 
100.2 

99.8 
100.7 
101.3 
102.1 
102.2 

101.6 
101.8 
101.0 
100.5 
101.6 
101-6 
102.4 
101.5 
100.9 
101.2 
101.9 
102.5 
102.6 
101.4 
101.7 
101.8 
102.2 
101.9 
101.4 
101.0 
101.6 
101.8 

101.8 
102.1 
102.1 



Pulse. 



120 
188 



116 
10b 



Eesp. 



as 



108 
84 



120 



100 



104 



25 



30 



30 



26 



32 



Remarks, 



Ax. 

Ax. 
Vag. 

Ax. 

Ax. 

Ax. 

Ax. 
Rec. 

Vag. 
Vag. 
Vag. 
Vag. 



Mouth 
I Rec. 
1 Mou. 
Mouth 
Mbuth 
Mouth 
Mouth 
Mouth 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Mouth 

Ax. 
Mouth 
Mouth 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 

Ax. 
Mouth 

Ax. 

Ax. 

Ax. 

Mouth 
Ax. 
Ax. 



Asleep. 



Bath, 64°. 

Taken from bath, 66° 



Rigor; warm bottles. 
Rigor. 



Hot bottles removed. 
Perspiring freely. 



Cardiac dulness at 3d 

cartilage. 
Pains in knees. 



Ice-bag to spine, 3 
hours. 

Ice-bag removed. 



Ice-bag applied 3 hours. 

Ice-bag removed. 

Rales in both lungs. 
Ice-bag, 18 hours. 



Ice-bag removed. 

Ice-bag, 1\4 hour . 
Ice-bag removed. 



APPENDIXES. 



Date. 



BkoPHT — cont. 
June 14 — cont. 



June 15. 
19th day. 
104 hours. 
5th day. 



June 16. 

20th day. 

6th day. 
June 17. 21st day. 

7th day. 
June 1H. 22d day. 

8th day. 
June 19. 23d day. 

9th day. 
July 1. 35th day. 

18th day. 



11.25 a.m. 
2.50 p.-m. 
3.40 p.m. 
4.30 p.m. 
6.0 p.m. 
ll.O.ga.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.:-S5 p.m. 
8.45 a.m. 
9.0 p.m. 
11.0 a.m. 
10.0 p.m. 
M. 
E. 



Temp. 



101.5 
101.3 
102.1 
101.7 
162.2 
102. s 
103.2 
102.6 
102.0 
101.8 
1C2.4 
101.4 
101.7 
.100.5 
101.8 
102.3 
ICS. 7 
101.9 
102. 7 
101.8 
1(2.4 
100.0 
99.8 
99.8 
98.4 
99.1 
99. 8 
98.2 
98.4 
100.0 
98.5 



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-hag removed ; not 
again applied. 

9 a.m. Dulness, right 
base, disappeared ; 
still rales in lungs. 



17th. Sibilant rales in 
lungs. 

22. Rales disappeared 
from lungs. 



J)_WIL60N 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 Batb. 
15m- 
lOm- 
SOm. 


fall 


Q..6 
L0 
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 
Fall. 


Temp. 


Temp. 


Amount 
of reduc- 
tion. 


Time. 


Average 
reduction 
per min- 
ute de- 
grees. 


Remarks. 


10m. 


rise 


0.5 


104-5 


















to 


















105 










Bath 64°, rose to 60°. 


5m. 


fall 


0.4 












10m. 


>t 


0.7 


103-9 


1.1 




L5m. 


0.07 




After Bath. 


u 
















7m. 


>( 


1.9 














8m. 


(I 


0.3 














15m. 




0.9 












* Mouth 


10m. 


u 


1.4* 


99-4 


4.5 




40m. 


0.11 



(C.)—\V. H. DRAPER'S TABLE SHOWING (1) THE EFFECT OF THE BATH 
ON THE TEMPERATURE, (2) THE PROMPT REACTION FOLLOW- 
mfl SHORT BATH, (3) THE EFFECT OF THE BATH 

IN RELIEVING THE HEAD-SYMPTOMS. 
Admitted 20th Maroh, 1875. No. 2. — D. Forest, adult male. 



Day. 



Hour. 



9.00 A.M. 
3.45 P. M. 
5.30 " 

fi.OO " 

8.00 " 

8.30 " 

9.00 " 

10.30 " 

12.45 " 

2.00 A.M. 

2.10 " 
4.15 " 

4.45 " 
11.30 " 
11.45 " 

3.10 p.m. 



8.00 " 
8.15 " 
12.00 " 
12.10 " 
2.30 P.M. 



Temperature. 



103° P. 

104° 

104.5° 

100.2" 

107.3' 

99.3 a 
105.5° 

99° 
102.5° 
105.7° 

99.5° 
106.2° 

100° 
105° 

loo; 

9'™ 

Nk 

H^100.7° 

105° 
101.5° 
105° 
101.2° 
103.2° 



Clinical Remarks. 



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- 
6ultus 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. 



These case» of W. Fox and W. H. Draper would read more easily, and present their conclusions 
much more forcibly, if they were divided into septenaries, and written in the flgnri'S of the physio- 
logical scale of thermometry employed in Appendices X. and XI. The latest records of the treat- 
ment of hyperpyrexia by cold are from W. H. Thomson of the Eellevue Hospital, i f this city, in 
the New York Medical Record (Nov.), and from Sydney Ringor of the Universitr Hospital. Lou 
don, in the Bxitioh I.'edical Journal (Oct.). 



; 



( 



Date Due 














































































































































• 




Library Bureau Cat. no. 1137 " 



r 



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