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Fever by H. C. Wood, Jr., M. D.

1876

At present all branches of Science possess an intrinsic interest for every intelligent man, but such elementary knowledge as enables its possessor to understand the explanations of the medical attendant has a double value. Over and over again I have heard the remark when some bold successful treatment was being discussed, "But you would not have dared to do that in private practice." The days of medical mystification are not yet entirely passed, but year by year the profession is assuredly losing that peculiar virtue of office which it formerly possessed in so eminent a degree. The doctor is no longer a dignified personage with gold-headed cane and powdered wig, mounting the mansion steps with stately tread, but a busy man in various garb, hurrying from house to house, studying the multitudinous problems of disease, and applying the fruits of such study to the relief of individual cases. No longer able to awe his patients into obedience, he must rely upon his moral and intellectual powers in controlling them. To enable any one to understand the explanations of physicians, and to protect himself, by discovery, against the impudent assumptions of quacks, some knowledge of medical truths and of the drift of modern medical thought is necessary. Every successful physician, no matter how independent he may be by nature, is necessarily more or less cramped by the prejudices of patients—prejudices which often a little primary instruction would have done away with.

Of all the diseased processes fever is one of the most frequent and one of the most serious in their results. A discussion, therefore, of its nature, the method of its production and of its relief, will, it may be hoped, engage the attention of the general reader.

If the hand be laid upon the skin of a person in a high fever the attention is at once attracted by the great heat, and if the bulb of a thermometer be placed under the tongue or in the armpit of the patient the mercury may indicate a temperature of 107°, 108°, 109°, or even 110° Fahrenheit, instead of 98° to 99° Fahrenheit, the normal temperature of the human body. It is a common belief that the skin in fever is always dry as well as hot, but this is a mistake, as intense fever may coexist with a reeking perspiration. During the fever the pulse is greatly increased in frequency, the head aches and throbs, and if the attack be very severe restlessness, sudden startings, irregular muscular twitchings, or even violent epileptiform convulsions and stupor, delirium or coma, indicate the disturbance of the nervous system.

These various symptoms are simply results of the excess of caloric, which excites universal irritation, and, if prolonged, destroys the tissues. This fact I have verified by three series of experiments, by the first of which it was shown that the general application of external heat so as to raise the bodily temperature produces all the phenomena of fever; by the second, that the local application of heat to the brain and to the heart causes the nervous and circulatory disturbances so universally seen in fever; and by the third that the abstraction of heat in fever is followed by immediate subsidence of the other symptoms.

If a small animal, such as a dog, cat or rabbit, be placed in a chamber heated by means of the sun's rays falling upon a slanting glass roof or by some artificial method to a temperature of considerably over one hundred degrees, a very constant series of phenomena is developed. The breathing becomes hurried and the pulse greatly quickened, whilst the restless movements of the body indicate nervous distress. After a time, if the exposure be continued, the symptoms are intensified, and restlessness passes into the weakness of partial paralysis; then suddenly or gradually, with or without convulsions, stupor sets in, deepening into coma, and death from arrested respiration is the final result. If the temperature of the animal be tested from time to time during the exposure, it will be found to rise steadily, and the severity of the symptoms will be directly, and in any one species constantly, proportional to the intensity of the bodily heat.

The nervous system of man apparently resists the action of heat, but in reality it does not do so. Man, it is true, is the only animal that can thrive almost equally amidst arctic snows and in tropical jungles. This is not, however, because his nervous system lacks sensitiveness, but because he has the power of heating or cooling his body in such a manner that its temperature is comparatively unaffected by that of the surrounding air. Man might be well defined as the naked sweating animal. In the north he strips the bear and the fox of their coat to keep him warm; in the south his own skin acts as a refrigerator. The dog has a few sweat-glands about the mouth—man has two millions densely covering his body. In the horse exposed to heat the hair soon becomes wet and matted, interfering very greatly with evaporation; in man the bare skin offers an excellent surface, from which the perspiration passes off almost as fast as formed. Evaporation, conversion of a liquid into a vapor, means a steady conversion of sensible heat into what was formerly called latent heat, but what we now know to be repulsive force: the heat-energy of the body is lost in driving the particles of sweat asunder in the form of vapor.

It is possible, however, to have a temperature which even a Hindoo cannot resist. When a man is exposed to such a heat his bodily temperature rises, and as it rises the symptoms of fever develop precisely as they do in the lower animals—sometimes slowly, sometimes suddenly—with disturbances of the respiration, circulation and innervation precisely similar to those already noticed as occurring in the dog, the cat and the rabbit. Sunstroke, or thermic fever, is generally believed to be instantaneous in its onset, but the wide experience of the English in India has shown that whilst in some cases it is thus sudden in its development, in others it is a slow process, and probably in almost all cases close observation would have revealed the existence of premonitions.

External heat, by producing an internal rise of temperature, may thus cause all the phenomena of fever. Of these phenomena the most prominent is disturbance of the nervous system and of the circulation. In order to determine whether the heat itself directly causes the nervous disturbance, or whether it produces it indirectly by causing changes in the blood, I applied caloric directly to the brains of animals. This was done by fitting a hog's bladder like a bonnet over the head and allowing hot water to run through it. It was found that stupor, coma, convulsions, and finally death from arrest of the respiration, were produced, sometimes gradually, sometimes suddenly, precisely as in the case of exposure of the animal in a hot chamber. Moreover, on opening the skull and plunging a thermometer into the cerebrum immediately after death or the supervention of unconsciousness, it was found that these phenomena were developed at the same brain-temperature when the heat was locally applied as when the animal was exposed in the hot box. Thus, if any given species in the hot box became unconscious when the temperature reached 110° Fahrenheit, this species also became unconscious when the locally-heated brain attained a temperature of 110°; or if death occurred by arrest of the respiration in the hot box at 114°, so did it when the locally-heated brain reached that point.

Dr. Lauder Brunton of England has performed a series of experiments upon the circulation parallel to those just narrated. Anæsthetizing animals and exposing the heart, he has found that the action of that organ is accelerated and weakened by the local application of heat, precisely as occurs in fever.

In order to test the effect of the withdrawal of heat, I have taken a rabbit out of the hot chamber, in which it lay upon its side totally unconscious, and plunged it into a bucket of cold water. The temperature of the water rose rapidly, whilst that of the rabbit fell even more rapidly. As soon as the bodily heat approached its normal intensity consciousness returned, and in a few moments the animal, which had just before been at the point of death, was running about the grass.

Some months since I had an opportunity of repeating this experiment upon a human being.

In acute inflammatory rheumatism it sometimes happens that the swelling and pain of the joints suddenly disappear, and the patient becomes comatose or wildly delirious. It has been customary to explain these symptoms as the result of the rheumatism leaving the joints and attacking the brain. Evidently, this being the case, the proper thing to do was to irritate the joints so as to draw the rheumatism back to them. This method was formerly practiced, and the almost invariable result was death in a few hours.

In most if not all of these frightful cases of sudden accession of severe nervous symptoms in rheumatism the temperature will be found, on testing it, to be exceedingly high—108°, 109° or even 110° Fahrenheit. If the views advocated in this paper be correct, it is not the rheumatism, but the intense bodily heat, which causes the severe symptoms, and finally death. The joints lose their sensitiveness, not because the disease has left them, but because the heat so overpowers the brain that it has lost its power of perception: the patient's leg might be cut off without his feeling it. In such a case the proper treatment is to take away the heat by plunging the patient into a cold bath. But can there be anything more shocking to the universal belief and prejudices than to put a patient dying of acute rheumatism into an almost ice-cold bath?

Last spring there was in my ward in the Philadelphia Hospital a stout young Irishman who had passed through an acute attack of inflammatory rheumatism, and was suffering from a sharp relapse. Entering the ward one day, I saw at once that the man was unconscious, and turning to the resident physician asked, "What is the matter with James?" "Nothing," was the reply: "I saw him an hour and a half ago, and he was doing very well, except that the fever was very high." "He is dying now, at any rate," was my rejoinder. On going to the bedside the patient was found perfectly unconscious, the skin dry and intensely hot, the affected joints pale and devoid of sensibility, the breathing irregular and jerking, the pulse 170 and scarcely perceptible, every muscle relaxed as in death, every power of perception abolished. A thermometer placed in the armpit registered 108-4/5° Fahrenheit.

Believing that the symptoms were due simply to this excessive temperature, I ordered the man to be at once stripped and put in a full bath drawn from the cold-water spigot. The temperature of this bath was found to be 60° Fahrenheit. In one minute and a half after the patient had been placed in the tub he recovered consciousness sufficiently to put out his tongue when told to do so in a loud, commanding tone. In three minutes he began to struggle to get out and to complain of the cold. In six minutes and a half he had become quite rational. He was now taken out, only partially wiped, laid upon an India-rubber blanket and covered with a single sheet, the temperature of the room being between 65° and 70°. Three minutes after this the temperature in the armpit was 94°, in the mouth 105-3/5°; five minutes later the mouth-thermometer marked 103°, and the pain and tenderness had reappeared in the affected joints. It would be out of place here to give further details as to his treatment. It is enough to state that, although owing to a misunderstanding of my orders, the man was left in a cool room for twelve hours upon the gum blanket, wet and covered only with a sheet—or possibly because he was so left—he recovered without a relapse or any bad symptoms.

The first case in which the cold-water treatment was practiced in the Philadelphia Hospital was that of a woman suffering from a desperate relapse of typhoid fever. She was semi-comatose, with a pulse of 150 and a temperature of 107° Fahrenheit: death was seemingly inevitable and imminent. As the bath-tubs were not convenient, the order was given that the woman be laid upon an India-rubber cloth, and be wrapped simply in a sheet constantly wet with water at a temperature as near 32° as practicable. The nurses, aghast, refused at first to carry out the order, but the physician's power being despotic, obedience was enforced. About three pints of whisky were given in the twenty-four hours, besides drugs, the whole treatment being successful.

It has been shown that excessive bodily heat is capable of producing the various symptoms of fever, and that its withdrawal is followed by the immediate relief of these symptoms; and since excessive heat is always present in fever, it is a logical deduction that it is the cause of fever symptoms; or, in other words, that it is the essential part of fever.

It must be borne in mind, however, that the term fever is here used in an abstract sense, to express a general diseased process, a bodily condition. A fever is a very different thing from fever. We may have a fever, such as typhoid, without the existence of fever. In a fever, the fever—i.e., the elevation of temperature—is only part of the disease, and great judgment and experience are often required to decide how much of the general symptoms is caused by the fever, and how much by the disease which is the cause of the fever.

The importance of high temperature having been recognized, it becomes a matter of the gravest scientific and practical interest to determine the method in which it is produced.

There are only two systems which bind the body together—namely, the circulation and the nervous system. As fever is usually a universal phenomenon, occurring simultaneously in every part of the body, it must be produced either through the nervous system or by a poison in the blood acting simultaneously on every tissue. Every physician knows, however, that there are cases of fever in which there has been no introduction of a poison into the blood: hence it follows that at least sometimes fever must be produced by the nervous system.

This being so, the study of the influence of the nervous system upon animal heat is naturally the next step in our investigation. Before making this step it may be well to call to mind the fact that chemical processes are usually accompanied either by the giving out or the withdrawal of heat. Thus, the chemical actions which result when ice and salt are mixed cause a withdrawal of heat, and a "freezing mixture" is formed. When a candle is burnt, the oxidation of its constituents, a chemical process, evolves heat. Oxidation is the great source of artificial heat, and animal heat is chiefly generated by the same process; in other words, animal heat is always the product of the chemical movements of the body, and these movements are almost exclusively of the character of oxidation. In the animal tissues a lessened oxidation is equivalent to a lessened heat-production, and vise versâ.

If a large nerve be exposed in one of the lower animals, and a galvanic current be sent through it for half a minute or more, the temperature of the animal falls very decidedly; and if the irritation be repeated several times at intervals, the diminution of the animal heat may amount to several degrees. Galvanization of a nerve affects very powerfully the circulation, and it has been believed that this derangement was the cause of the lessened chemical movements. But the alteration of the circulation is immediate, and ceases almost at once when the current is broken, whereas the fall of temperature comes on only after several minutes, then progressively increases, and persists for many minutes—it may be hours. The two phenomena being thus differently developed, it is impossible that they should have the relation of cause and effect, and the fall of temperature must be traced to a direct influence of the nervous system upon the chemical processes of the body.

This lowering of temperature under the influence of a powerful irritation of a nerve-trunk or of its minute branches, which everywhere pervade the tissues and spread out in the skin, is common to all species of mammals. If a rabbit be merely tied down tightly upon a table, the fall is perceptible, and if it be severely wounded, the temperature diminishes very greatly. It has long been known that severe burns are followed by a very great depression of the animal heat. Redard, a French physician, made during the late siege of Paris a most interesting series of observations upon the influence of severe gunshot wounds. He found that, entirely independent of any hæmorrhage which might have occurred, the temperature fell enormously, and in direct proportion to the gravity of the wound; so that by the aid of the thermometer he was able to predict whether a fatal issue would or would not occur in the course of a few hours.

We have found that both in man and the lower animals the nervous system is able to check the chemical movements of the body, but before we can decide how it does so facts not yet noticed must be looked at.

If the spinal cord of an animal be cut just below the origin of the nerves of respiration, an immediate fall of temperature occurs, and, if the animal be left in a cool room, persists until death ensues. If, however, the victim be put in a warm place, after a time the temperature begins to rise, and finally a most intense fever is developed. Parallel phenomena follow division of the spinal cord in man. Indeed, Sir Benjamin Brodie was first led to experiment upon animals by observing in 1837 an excessive fever follow in a patient a wound of the spinal cord.

I have already explained, in a former number of this Magazine, the nature of the so-called vaso-motor nerves, which preside over the little circular muscles that run round and round in the coats of the blood-vessels. When they are excited, these muscles contract and the size of the arteries is diminished: when they are paralyzed, the arterial inner muscles relax and the vessels dilate. The vaso-motor nerves have their governing centre in that upper portion of the spinal cord which is within the skull, the so-called medulla oblongata. When the spinal cord is divided, the vessels are cut off from the influence of this vaso-motor centre, and at once dilate, profoundly affecting the blood-current by doing so.

The first fall of temperature which follows division of the cord is believed by most physiologists to be due to this dilatation of the vessels. Very probably the blood-stream, flowing sluggishly, does not give the normal amount of stimulus to the tissues, so that at first their chemical actions are lessened, and consequently less caloric than usual is generated in the body. Further, the blood moving slowly through the dilated vessels of the lungs and of the surface of the body, is cooled more completely than it should be; hence, unless the body is protected by being surrounded with warm air, no excessive accumulation of heat in it can occur, and therefore no fever can appear.

Assuming that this explanation of the primary lowering of the temperature after division of the cord be correct—and no better one has as yet been offered—what is the cause of the fever which afterward develops itself? As it occurs only when the animal is exposed to a somewhat elevated temperature, it has been thought by some to be due to the absorption of this external heat. This, however, is certainly not true, as is shown, to omit less decisive proofs, by the experiments of Naunyn and Quincke, who exposed animals for two days to a temperature of 90°, and at the end of that time, their bodily temperature not having risen, cut their spinal cords, after which intense fever was developed in a few hours without any change of atmosphere.

Section of the cord must therefore give rise to an increased chemical movement and heat-production in the body. As already stated, this section affects very greatly the circulation, but the fever is independent of such action. The upper end of the medulla oblongata is continuous with a nervous mass which joins the two brain hemispheres together, and hence is known as the pons or bridge. If, instead of cutting the spinal cord, we separate the medulla oblongata from the pons, an immediate rise of temperature occurs, and continues until death, whether the operation be performed in a cold or heated room.

Cutting the medulla at its junction with the pons causes, then, an immediate and direct elevation of temperature, without disturbance of the circulation. What can this mean? Evidently, only one thing—namely, that by the division of the medulla there has been separated from the general tissues of the body a repressive force—a something which normally controls their chemical activity and the production in them of animal heat.

The existence of nerves whose function is to repress action is no new discovery in physiology. Readers of Lippincott's Magazine may remember my description of the pneumogastrics or brake-nerves of the heart, whose duty it is to control the action of that viscus. Nerves which repress or inhibit action are spoken of in modern physiology as inhibitory. The experiments which have been adduced prove that there are nerves whose function it is to control the general vital chemical actions, and that the governing centre of these nerves is situated above the medulla oblongata. To this centre, whose exact location is unknown, the name of the inhibitory heat-centre has been given.

The way in which galvanization of a nerve, violent injuries and excessive pain depress the temperature, independently of any action upon the circulation, is now evident. An impulse simply passes up the irritated or wounded nerve, and excites this inhibitory heat-centre to increased action, and the temperature falls because the chemical movements of the body are repressed.

The method in which fever is produced also becomes very evident when once the existence of an inhibitory heat-centre has been established. Any poison having the power to depress, and finally paralyze, this centre must, if it find entrance to the blood, produce fever. If the poison, from its inherent properties, or from its being in very small quantity, only diminishes the activity of the inhibitory heat-centre, the controlling influence is not entirely removed from the chemical movements of the body, and only slight fever results; but if the poison actually paralyzes the inhibitory nerves, a very great rise of temperature must rapidly follow the complete removal of the brake-power.

As an illustration we may consider the intense rheumatic fever, or the so-called "cerebral rheumatism," such as affected the young Irishman whose case has been narrated in the present article. Without any apparent reason the poison of rheumatism habitually attacks one joint on one day, and another joint on another day, and with as little apparent reason it occasionally falls of a sudden upon the inhibitory heat-centre, and actually paralyzes it. In a few minutes intense fever is developed, and the bodily temperature rapidly approaches nearer and nearer that line on the other side of which is death.

In many cases of fever, however, there is no poison in the blood; thus, the local irritation of a boil or other inflammation may cause what is well termed "irritative fever." The way in which this is produced is by an indirect, and not a direct, action upon the inhibitory heat-centre.

The casualties of the late war proved but too abundantly that a man may be wounded in one part of the body and suffer from paralysis of voluntary motion in another part. Thus, a soldier struck in the neck fell unconscious, and on awaking was astonished to find his right arm powerless at his side. This is the so-called "reflex paralysis." Very commonly the irritation of a nerve will give rise to an impulse which will travel up the nerve to a motor-centre, and so excite it that it shall send in turn an impulse down a second nerve to a distant muscle, and a spasm result. Sometimes, however, the impulse which travels to the nerve-centre is of such a character that, instead of exciting it to action, it deprives it of the power of action. In the former instance reflex motion, in the latter reflex paralysis, results.

We have seen that galvanization of a nerve may excite the inhibitory centre to activity, and the peculiar persistent irritation of a local inflammation may deprive the same centre of its power of action: in the one instance a reflex inhibitory heat-centre spasm—i.e., lowering of temperature—is produced, and in the other a reflex inhibitory heat-centre paralysis—i.e., fever—results.

It would be going too far at present to assert that all fever is produced in the way spoken of. There are certain drugs which lower the temperature in the fever that follows division of the cord and consequent paralysis of the heat-centre, and which must therefore act either upon the blood, or universally upon the tissues so as to diminish their-chemical movements. It is most probable, although not yet absolutely proved, that there are other substances which act directly upon the blood and tissues in such a way as to increase their chemical activities, and thereby cause fever.

The practical considerations in regard to the treatment of disease which naturally flow from the recent investigations of fever are very important and very obvious. This is especially true since it has been shown in Germany that under the influence of a continuous high bodily temperature, not intense enough at any time to compromise life, all the muscular tissues of the body undergo a peculiar granular degeneration. Many a typhoid-fever patient has undoubtedly died from the heart-muscle having undergone this change, when, if by artificial cooling the temperature of the body had been kept down, the alteration of the heart-structure would have been prevented, and death averted. It is obvious, also, that the old plan of thwarting the intentions of Nature, and depriving the fever-patient of the free use of cooling drinks, was practically a baneful cruelty. As the body is burning up in fever, it is also evident that to deprive it of sustenance is to aid in the production of fatal exhaustion. The burning will go on, whether food is given or not, so long as the tissues can serve as fuel. Of course no more food should be taken than the patient can digest, but every grain of digested food is so much added to the resources of the system, which is engaged, it may be, in a close and doubtful conflict with disease.

If it were possible, of course the best treatment for fever would be that which lessened the production of heat. Fortunately, we have some drugs—notably, quinine and alcohol—which do exert a decided influence upon the vital chemical movements, but, unfortunately, their power is limited. As we are therefore often unable to control heat-production, the best we can do is to abstract the caloric from the body whenever it becomes so excessive as to threaten serious results. To do this, all that is necessary is to put the patient in a cold bath, or wrap him in a sheet wet with ice-cold water, or lay him upon an ice-mattress, or surround him with coils of tubing through which cold water runs, or use some similar efficacious device. I do not wish to be misunderstood. External cold is not to be lightly employed: it is a powerful two-edged weapon, capable of cutting both ways—a weapon as injurious and destructive in the hands of the ignorant and inexperienced as it is efficient in the hands of those to whom study and experience have taught its skillful use.

To illustrate what cold water may effect when employed by intelligent and skillful physicians, I may be permitted to cite a few hospital statistics from Germany and Switzerland, the only countries where the so-called antipyretic treatment of continued fever has been efficiently carried out on a large scale. From 1850 to 1861 there were treated without cold water, at the hospital at Kiel, 330 cases of typhoid fever, with 51 deaths—a mortality of about 15-1/2 per cent.; from 1863 to 1866, 160 cases were treated with cold baths, with 5 deaths—a mortality of only 3-1/10 per cent. In the hospital of Bâle, from 1843 to 1864, there were 1718 cases without antipyretic treatment, with 469 deaths—a mortality of about 27-1/2 per cent; from September, 1866, to 1873, 1121 cases were treated antipyretically, with 92 deaths—a mortality of a little over 8 per cent. Assuredly, we may claim that this water-treatment in typhoid fever is one of the greatest gains of modern medicine since the discovery of anæsthesia.

Some of my readers may here say to themselves, "Why, this is hydropathy!" Not so. It is the legitimate, not the illegitimate, use of cold water. It is the use of it as a single weapon, not as the only weapon of the armory. It is the employment of it in a single affection, not as a cure for all diseases.

Perhaps, in concluding this essay, I may be pardoned one word of counsel to my lay audience. Any physician who proclaims himself a follower of any special doctrine, be he a hydropath, an electropath, an allopath, a homoeopath, or any other path, should be viewed with suspicion. Water, cold, heat, electricity, drugs, are all agents capable of being used advantageously in the treatment of disease. Above all men, the physician ought to have that teachable spirit which is the offspring of true humility. Knowing the grave responsibilities which he assumes, living almost beneath the shadow of that past whose life-imperiling mistakes are so plainly visible in the light of the present, he, of all men, should be ever seeking for new knowledge, gathering with equal zest the seeds of healing in the waste as well as in the cultivated places, amongst the lowest and most ignorant of the populace, as well as in far-famed schools of medicine.

H.C. WOOD, JR., M.D.