SIMPLE CONTINUED FEVER.
BY JAMES H. HUTCHINSON, M.D.
DEFINITION.—A continued, non-contagious fever, varying in duration from one to twelve days, and in temperate climates almost invariably ending in recovery. It may arise from any non-specific cause capable of producing a temporary derangement of one or more of the important functions of the body, is generally easily distinguished from the other continued fevers by the absence of the characteristic symptoms of these diseases, and presents in fatal cases no specific lesions.
SYNONYMS.—Synocha, vel Synochus Simplex, Febricula, Ephemera or Ephemeral Fever, Irritative Fever, Ardent Continued Fever, Sun Fever.
HISTORY.—Much difference of opinion continues to prevail, even at the present time, in regard to the existence of a simple continued fever, which, on the one hand, occurs independently of local inflammations or traumatic causes, and, on the other, is distinct from typhoid, typhus, and relapsing fevers; many observers contending that the condition to which this name is given is only a mild or modified form of one or other of the graver varieties of continued fever, from which the characteristic symptoms are absent. Prominently among modern writers, Dr. Tweedie1 has taken this view of the subject, for, after reviewing the arguments for and against the recognition of simple continued fever as a distinct disease, he asserts that there is not sufficient evidence to justify us in encumbering our nosology with a doubtful novelty. If, however, there is room for doubt as to its right to a place in the list of diseases, there is certainly no good reason for characterizing it as a novelty, since it has been referred to, according to Murchison,2 by many authors from the time of Hippocrates down to the present day, who not only separate it from the graver forms of fever, and give a very accurate description of its symptoms, but seem to have been perfectly familiar with the causes which give rise to it, and to have had very correct notions as to its proper management. Thus, Riverius3 was aware of the existence of two forms of simple fever—the ephemeral, which lasts, as its name implies, only a single day, and the Synochus Simplex, arising from the same causes, but in which the fever continues for from four to seven days. Strother4 and Ball5 also allude to this fever in terms that leave no doubt upon the mind but that they distinguished it clearly from other forms of continued fever. Among more recent writers who have made this distinction may be mentioned Lyons,6 Jenner,7 G. B. Wood,8 Flint,9 Murchison,10 and J. C. Wilson.11 Indeed, the weight of authority is decidedly on the side of those who claim for it a recognition as a distinct and separate disease.
1 Lectures on the Continued Fevers.
2 A Treatise on the Continued Fevers of Great Britain, London, 1873.
3 The Practice of Physick, being chiefly a Translation of the Works of Lazarus Riverius, London, 1678.
4 A Critical Essay on Fever, 1718.
5 A Treatise on Fevers, London, 1758.
6 A Treatise on Fever, London, 1861.
7 Medical Times, March 22, 1851.
8 A Treatise on the Practice of Medicine, Philadelphia, 1855.
9 A Treatise on the Principles and Practice of Medicine, Philadelphia, 1868.
10 Ibid.
11 A Treatise on the Continued Fevers, New York, 1881.
Unquestionably, many cases which have been classed under the head of simple continued fever, are really mild or abortive cases of typhoid or typhus fever, in which, in consequence of partial protection on the part of the patient, the characteristic symptoms of these diseases have not been developed. Such cases are seen in numbers during epidemics of these diseases. But, making due allowance for this source of error, there yet remain many cases which cannot be thus explained. Moreover, the disease occurs at times when no such epidemics exist. It may, therefore, be safely assumed that there is such a fever, and that, consequently, it must be accorded full recognition.
CAUSES.—Any non-specific cause which is capable of producing a profound derangement of one or more of the important functions of the body may give rise to simple continued fever. It may follow, therefore, upon excesses of the table, extreme mental or bodily fatigue, exposure to the direct rays of the sun, or to great heat or cold, or upon the suppression of a secretion. One of its most frequent causes is over-exertion in warm weather. James C. Wilson has called attention to its frequent occurrence as a consequence of the combined influence of the excitement, the physical exhaustion, and the exposure to the direct rays of the mid-day sun which are attendant upon surf-bathing. It is often due in young children to the irritation involved in the process of teething or to that caused by the presence of worms in the alimentary canal. Wood taught that it might also sometimes occur during the prevalence of contagious diseases as an effect of the epidemic influence in those who were partially protected by a previous attack of the disease, or from some other cause, but it is more probable that cases arising under these circumstances are either mild cases of the prevalent disease or else are attributable to fatigue from nursing or to over-anxiety. The disease is more common in the young than in the old, and in children than in adults—probably from the greater impressionability of the nervous systems of the latter.
The causes of the ardent continued fever of the tropics, which is usually recognized as a form of simple continued fever, do not differ materially, except in degree, from those of the simpler forms of the disease; but exposure to the direct rays of the sun would seem to be especially prone to give rise to the disease in those who are unaccustomed to the heat of a tropical climate. Robust young Europeans lately arrived in a warm country are, it is said, peculiarly liable to suffer from it.12 It is most common in those parts of India which do not experience much of the benefit of the monsoon rains, and whose hot season is not tempered by regular breezes from the sea. It is hence more frequently met with in inland districts in which the temperature is high, but in which malaria-generating conditions are absent.
12 Morehead, Clinical Researches on Diseases in India, London, 1856; also Twining, Clinical Illustrations of the More Important Diseases of Bengal, Calcutta, 1835.
SYMPTOMS AND COURSE.—Simple continued fever occurs in this country only as a sporadic disease, and almost invariably ends in recovery; in tropical climates, however, it may prevail epidemically, and sometimes presents symptoms of a very grave character. In its mildest form it not infrequently runs its course in a few hours, and is rarely prolonged much beyond twenty-four, and is hence called ephemera. It then usually begins somewhat abruptly with a chill, but in a few instances this is preceded by feelings of languor and weariness. Febrile reaction is soon established, and is generally well marked; the pulse is quick and full, the temperature rises rapidly, and the face is flushed. The tongue is coated with a whitish fur, the urine is scanty and high-colored, and the bowels are constipated. Other symptoms are excessive thirst, headache, restlessness, and sleeplessness, or, on the other hand, a tendency to somnolence. Vomiting is not common except in those cases which follow upon an error of diet, but there is generally some nausea and anorexia. Muscular pains are also occasionally present, and may give rise to a good deal of distress. The subsidence of these symptoms is often quite as abrupt as their onset, the crisis being frequently marked by a copious perspiration.
In other cases, however, the fever is more prolonged, and the symptoms, although not differing in kind, are apt to be more severe than those above detailed. The pulse is often full, hard, and bounding; the headache throbbing or darting in character; the tendency to somnolence increases, or gives place to delirium; and the pyrexia is more marked. Frequently an eruption of herpes is observed upon the lips and upon other parts of the face, from which circumstance the disease is sometimes called herpetic fever. Davasse13 also observed in a few cases pale bluish spots, not elevated above the surface and not disappearing under pressure, which are identical with the tâches bleuâtres sometimes seen in typhoid fever and other diseases, and therefore have no diagnostic value. In this form the duration of the disease may be from four to ten or twelve days. The defervescence is usually less rapid than the rise in temperature, and is generally accompanied by a free perspiration, diarrhoea, a copious deposit of urates in the urine, or less frequently by hemorrhage from the uterus or rectum,14 or from the nose, mouth, or urethra. This constitutes the synocha or inflammatory fever of the older writers. In children in whom there is no reason to suspect malarial poisoning the disease sometimes assumes a remittent form, and then constitutes a variety of the infantile remittent fever of authors—a name, however, which, it must be remembered, has been made to include a great many distinct diseases.15
13 Quoted by Murchison.
14 Murchison.
15 Lyons.
When the disease occurs in individuals who are broken down in health from any cause16—as, for instance, previous illness, deficient food, long-continued anxiety, or great fatigue—it not infrequently presents symptoms of an asthenic character. The febrile reaction is then less intense, and the pulse feebler and more frequent, than in the variety just described. The duration of the disease in this form is also generally longer. Murchison has proposed for it the name of simple asthenic fever.
16 Wood.
Under the name of ardent continued fever, Indian medical writers have described a variety of the disease which is frequently met with in tropical countries, and which is usually much more severe than the varieties already referred to. In addition to the symptoms presented by these, Morehead17 says that there is often intolerance of light and sound, contracted and subsequently dilated pupils, ringing noises in the ears, anxious respiration, pains in the limbs and loins, and a sense of oppression at the epigastrium. The bowels are sometimes confined; at others vitiated bilious discharges take place. The tongue is white, often with florid edges, and the urine scanty and high-colored. At the end of from forty-eight to sixty hours the febrile phenomena may subside, the skin become cold, and death take place from exhaustion and sudden collapse. In some cases the symptoms of cerebral disturbance are greater in degree, and in these coma may soon supervene upon delirium. Convulsions, epileptiform in character, with relaxation of the sphincters and suppression of urine, also frequently occur, and occasionally cerebral hemorrhage. In other cases the symptoms of gastritis are more prominent, or jaundice may appear and aggravate the disease.
17 Clinical Researches on Disease in India, London, 1856. See also "Croonian Lectures," by Sir Joseph Fayrer, Brit. Med. Jour., April 29, 1882.
Symptoms closely resembling those just described are occasionally met with in this country in patients who have been exposed for some time to the direct rays of the summer sun, but who have escaped a sunstroke. Indeed, a few writers have been so much impressed with the general resemblance which this latter condition bears to the fevers that they have insisted upon including it in this group, and have given it the name of thermic or heat fever. This view of the pathology of sunstroke has, however, never been generally accepted.
One of the most characteristic symptoms of the disease in all its forms is the rapid rise of temperature, which may in ephemera be as great as from four to seven degrees in the course of a few hours, and which may be followed in a few hours more by an equally abrupt defervescence. When the fever is more prolonged, although the temperature rises rapidly, it may not attain its greatest elevation for from forty to sixty hours after the onset of the symptoms, and its fall will be more gradual than in the preceding variety. Unfortunately, there are no reliable thermometric records of ardent continued fever. The urine is usually scanty and high-colored during the height of the fever, especially in the severer forms of the disease. Its specific gravity is high, and it contains a large amount of solids, especially of urea. With the fall of the temperature it rapidly increases in quantity, and is very apt to let fall a copious lateritious sediment on cooling. According to Parkes,18 who closely observed six cases with the view of determining this question, albuminuria does not occur at any stage of the disease. Convalescence is usually rapid, and is not liable to be interrupted by the occurrence of sequelæ.
18 The Composition of the Urine, by Edmund A. Parkes, M.D., London, 1860.
DIAGNOSIS.—The diagnosis in those cases of simple continued fever in which the connection between the disease and some one of the conditions which have been referred to above as capable of exciting it has been distinctly made out, presents little difficulty. It is otherwise, however, when this relationship is not apparent. Indeed, the symptoms of the disease so closely resemble those of an abortive or mild attack of typhoid or typhus fever, in which the characteristic eruption is wanting, that the physician may sometimes remain in doubt as to the nature of the disease he has been called upon to treat, even after the recovery of the patient. This difficulty will of course be especially likely to present itself during the epidemic prevalence of these diseases. Simple continued fever may, however, generally be distinguished from either of the latter by the much greater severity of its initial symptoms, and particularly by the rapid rise of temperature—a rise of from four to seven degrees in the course of a few hours—which does not take place in these fevers, but which, it must be remembered, may occur in erysipelas, measles, pneumonia, and some other diseases. The absence of a characteristic eruption, although it would not render it certain, would be in favor of the diagnosis of simple continued fever, as would also the absence of diarrhoea in cases in which there was difficulty in deciding between this disease and typhoid fever. On the other hand, Murchison regards the presence of an herpetic eruption on the lips as almost pathognomonic of simple continued fever; but in this country such an eruption is not an infrequent attendant upon fevers of malarial origin, and many observers attach great importance to it in the diagnosis of these diseases.
Simple continued fever is not likely to be mistaken for relapsing fever, except during epidemics of the latter disease. It may be discriminated from relapsing fever, the first paroxysm of which it closely resembles, by the absence of severe articular pains, of tenderness in the epigastric zone, of enlargement of the liver and spleen, and of jaundice. It may be mistaken for tubercular meningitis, especially in those cases in which the nervous symptoms are more than usually prominent, or in which a hereditary predisposition to tuberculosis exists; but its true nature may generally be recognized by its more abrupt commencement, and by the absence of the constant vomiting, screaming fits, strabismus, and paralysis so characteristic of the latter disease.
It is scarcely necessary to add that a local inflammation or a traumatic cause may give rise to symptoms simulating those of simple continued fever, and that the diagnosis of this disease must be uncertain until these conditions have been positively ascertained to be absent, or, if present, until they have been proved to be complications, and not the causes of the disease.
PROGNOSIS.—The prognosis of this disease, as it is met with in this country, is favorable. Indeed, when uncomplicated it may be said to end invariably in recovery, except in the aged and feeble, in whom, when it occurs during the great heat of the summer season, it is apt to assume the asthenic form, and to be accompanied by symptoms of a grave character. The ardent continued fever of the tropics, on the other hand, not infrequently terminates fatally, or may leave the sufferer from it a chronic invalid for life, which is frequently shortened by obscure cerebral or meningeal changes, which give rise to irritability, impaired memory, epilepsy, headache, mania, partial or complete paraplegia, or blindness.19
19 Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., Brit. Med. Jour., April 29, 1881, p. 607.
ANATOMICAL LESIONS.—Death so rarely occurs in this latitude from simple continued fever that the opportunities for making post-mortem examinations do not often occur. There are, however, a sufficient number of such examinations on record to show that the disease gives rise to no specific lesions. According to Murchison and Martin,20 inspection in fatal cases of ardent continued fever usually reveals the presence of great congestion of all the internal organs and of the sinuses of the brain and pia mater, of an increased amount of intracranial fluid, and occasionally of an effusion into the abdominal cavity, and more rarely into the thoracic cavity.
20 The Influence of Tropical Climates on European Constitutions, by James Ranald Martin, F.R.S., London, 1856.
TREATMENT.—In the milder forms of the disease little or no treatment is required—a fact which seems to have been recognized and acted upon long ago, since Strother remarks that the cure of it is so easy that physicians are seldom consulted about such patients. An emetic when the attack has been caused by excesses of the table, and there is reason to believe that there is undigested food in the stomach, a purgative when constipation exists, and cooling drinks, the effervescing draught or some other saline diaphoretic, are usually the only remedies that are called for. In cases in which the febrile action is more intense and prolonged, in addition to the use of these remedies an effort should be made to reduce the heat of the skin and the frequency of the pulse by sponging with cold water and by the administration of digitalis and aconite. The headache which is often a distressing symptom may usually be relieved by the application of evaporating lotions, and restlessness quieted by the bromides. Subsequently, quinia may be given with advantage. The patient should be restricted to liquid diet during the continuance of fever.
In the asthenic form quinia and the mineral acids, nutritious food, and very frequently alcoholic stimulants, must be given from the beginning. In the treatment of the ardent continued fever of the tropics the cold affusion or the cold bath, with quinia, would appear to be indicated, but Morehead and other Indian physicians advise the use of evacuants with copious and repeated venesections, cupping, and leeches, aided by tartar emetic, till all local determination and the chief urgent symptoms are removed; and Murchison expresses the belief, founded on his own observations, that life is often sacrificed by adopting less active measures.