A system of practical medicine. By American authors. Vol. 1

by Unknown

FIG. 12.

Chart of typical range of temperature in typhoid fever, after Wunderlich.

Frequent observations of the temperature in typhoid fever not merely give most important information in a diagnostic and prognostic point of view, but also often furnish valuable indications for treatment. From a close study of a large number of cases, Wunderlich and other physicians have discovered that the pyrexia has certain characters which distinguish it from other fevers, and which, being present in a case in which the other symptoms are obscure or ill defined, will often enable us to recognize its true nature. The pyrexia may be divided into three periods, each having its own peculiarities. It is usually said that each period lasts about a week, but in severe cases the second and third periods extend over a longer time than this, and the occurrence of a complication or of any other disturbing influence will have its effect in producing either a prolongation of any one or more of these periods, and especially of the last two, or an unwonted elevation or fall of temperature. During the first period there is a progressive rise of temperature, but the rise is never so abrupt as in typhus or in many of the phlegmasiæ. As there are morning remissions, ranging from a degree to two degrees in extent, corresponding to the morning fall in the daily variations of temperature, the tracing upon the temperature chart will be a zigzag line, each evening temperature being from a degree and a half to two degrees higher than that of the preceding evening, while the same difference will be observed in the morning temperature. The temperature ought, therefore, never in an uncomplicated case to be much over 100° on the first evening or 102° on the second. A temperature of 104° at any time during the first or second day will consequently exclude typhoid fever from the diagnosis. From six to eight days are usually occupied before the maximum is reached. I have seen it attained as early as the fourth day in mild cases, and, on the other hand, not until much later in severe ones. It is usually 104° or 105°, but will of course vary with the gravity of the other symptoms. The temperature rarely rises higher than 106° at this period. On the other hand, I have known cases in which it never exceeded 103° during their whole course. It would therefore be wrong to exclude typhoid fever from the diagnosis, as Wunderlich does, if this temperature is not reached by the sixth, or at latest the eighth, day.

In the next period the temperature usually ceases to rise, but has a tendency to oscillate about the maximum temperature of the previous period as a fixed point, occasionally not quite reaching it, at other times rising a little above it. The morning remissions, too, become less decided. In other words, the fever now becomes continuous. This period, although usually lasting about a week, may extend over more than two weeks, even in the absence of complications, in cases which run a severe course, and when it is prolonged from this cause the temperature may again show a tendency to rise, and may even attain an elevation considerably above that of the preceding period. The prognosis in all such cases in which the temperature rises after the middle of the second week is grave. Temperatures of 108°, and even of 110.3°, have been noted at this time. Death invariably follows such high temperatures as these, but before death actually occurs a considerable fall of temperature very often takes place. Wunderlich has also called attention to the fact that it is not uncommon for a sudden and temporary remission of temperature to take place at this stage, varying from one degree to two degrees and a half, which may last from ten to twelve hours, and which usually has occurred in his experience from the sixteenth to the eighteenth day. Toward the close of the second period the morning remissions will be observed to be more decided, while the evening temperature remains about the same as before. The beginning of the third period is indicated by a diminution of the evening exacerbation, while the morning remissions become still more marked. The diminution is progressive, but slow, the temperature each evening falling short by from half a degree to a degree of the point it reached the preceding evening. The morning remissions, on the other hand, each day become greater, a fall of three and a half degrees being not uncommon. The lysis, therefore, occupies usually a longer time than was required by the pyrexia in reaching its maximum. Toward the close of this period the morning temperatures may be normal, as even subnormal, while an elevation of temperature may continue to take place in the evening. Occasionally, however, an abrupt defervescence takes place. The duration of this period will be very much prolonged if complications are present or if the intestinal ulcers are slow in healing. I have known it to last for more than three weeks. During convalescence the temperature is frequently subnormal even in the evening, but the slightest cause is often sufficient to produce a considerable though temporary elevation of temperature. I have known the temperature in one case to rise from 99° F. to 105.6° in a few hours in consequence of an indiscretion in diet, and in another from 100° to 104° from the suffering and excitement caused by a severe attack of toothache. Indiscretions in diet are a fruitful source of these recrudescences of fever. The fever of the third period has all the characters of an irritative fever, and is probably kept up by the irritation arising from the intestinal ulcers. On the other hand, that of the first two periods is due to the action of the specific poison upon the nervous system and the other tissues of the body, and corresponds exactly with the primary fever of the eruptive diseases.

FIG. 13.

Chart showing recrudescence of fever from indiscretion of diet.

The febrile movement, however, rarely follows a perfectly typical course, and I consequently find, in looking over the temperature sheets of a large number of cases, very few which bear, except during the first period, anything more than a general resemblance to the chart which Wunderlich has prepared as typical. A very slight cause will exercise, as has already been said, a disturbing influence upon the course of the fever, and serious complications or accidents will of course produce a still more marked effect. An intestinal hemorrhage, for example, will cause a rapid and decided fall of temperature. I have often known it to fall from 104° to the normal temperature, or even below it. This depression, unless the bleeding continues and the case ends fatally in the course of a few hours, is only temporary, the temperature rising within twenty-four hours to its former height, and sometimes even beyond it. A free epistaxis or a copious diarrhoea will in the same way cause a fall of the temperature, but it is rarely so marked as in the preceding case. The same effect is produced by the administration of large doses of quinia or by the application of cold water either in the form of the bath, the douche, or any other form, to the surface of the body. On the other hand, the occurrence of a complication will cause a rise of temperature, often considerably above the maximum of the first period.

FIG. 14.

Chart showing fall of temperature from intestinal hemorrhage in typhoid fever.