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method is by far the most accurate. In Gundo- rectum. This applies chiefly to children kept bin's clinic the rectal method is strictly forbidden in incubators. It is explained by the fact that because he considers that the danger of breaking
the surface of the body under these conditions the thermometer is great. Others object because
is warmer than the internal temperature because
of the artificial heat. Wunderlich noted that in of the ease of carrying infection and the difficulty of sterilizing the thermometer. It has been
the vagina and in the feces-free rectum the
readings were 0.20-0.7° higher than those of the recommended to introduce the thermometer into
axilla. These observations were at various times the rectum so that the end entirely disappears,
corroborated. One observer used a perfectly i. e., about three centimeters, holding it there
accurate bulb thermometer, and the axilla was for five minutes. A reading is made and the
tightly closed down upon the bulb. By allowing themometer is pushed in two centimeters deeper.
it to remain one or two minutes after it had The difference between these two readings is more
reached its highest point (eight to ten minutes) marked when the body temperature is low than
he found a variation from the rectal temperature when the child suffers from fever. In newly born of 0.9° to 1.4° though in weaklings it was only infants it is well to introduce the thermometer
0.4o. The difference in these temperatures into the rectum to a uniform depth of three to
would probably be more marked in fever. It is five centimeters. If it be introduced further
obvious, however, that the rectal temperature is the thermometer shows a proportionately higher the more accurate of the two and is the method temperature. With a good standard fever ther
most frequently employed by clinicians of experimometer the temperature can be obtained at
Filatoff suggests a method of taking the five centimeters in one minute. It appears that
axillary temperature which is unique. He claims a number of factors must be considered in judg- for it the advantage that it is more rapid. He ing the accuracy of rectal thermometry. Some
uses a chemical, not a self-registering, thermomof the factors which influence the accuracy of eter and by rubbing or closely applying the thumb the readings are the age of the patient, sex,
and forefinger to the bulb he raises it to 104°. condition of bodily nutrition, relaxation of the
He quickly introduces it into the axilla. In a anal sphincter, and presence of feces in the minute or two it has fallen and records the rectum. When taken with an accurate, though axillary temperature. He maintains that the not a self-registering, chemical thermometer, the
reading obtained by this method is 0.20-0.4° less rectal temperature obtained at seven to fourteen than the rectal reading. centimeters was found to be 0.20-1.3°higher than
The heat regulating mechanism of newly born a reading made at two to six centimeters. This
infants is incompletely developed and unstable. is not only true of patients with fever but also
Marked temperature variations occur even in those without fever and in normal health. Whero health. The temperature curve shows greater the bowel is filled with feces, the deep and more daily variations in younger infants than in older superficial temperatures are more nearly equal. children and adults. Transitory elevations of These facts were determined in children of dif
temperature frequently occur which seem to deferent ages, and it was found that the same pend upon bodily movements, taking of food, variations occurred in the six-day-old child as
and the external temperature. Similarly, sudden in the seven-month or eighteen-month-old child. sinking of temperature may depend upon sudden It was thought possible that if the thermometer chilling, cool baths or insufficient clothing. It were allowed to lie in the superficial parts of seems certain proof that a baby is delicate and the rectum for a longer time, it might show a undeveloped when its temperature is low or conhigher temperature, but the difference between
siderably under normal. Babies who are receivthe superficial and deep temperatures was con- ing insufficient food as well as those receiving instant no matter how long the thermometer sufficient fluids show a loss in temperature. It remained in this superficial position.
may be noted that a baby may show a temperature The axillary temperature, of course, is lower immediately after nursing which is several tenths than that of the rectum or vagina. Occasionally higher than the interval between feedings. On one observes in premature infants that the the other hand, infections may be present which axillary temperature is higher than that of the produce no elevation in temperature and, indeed,
may be characterized by a subnormal temperature. bath leads to a loss of about one degree. This
Naturally very little is known of the fetus in loss in bodily heat is characteristic of the first utero. Still, some facts have been developed few days of life. After the minimum is reached which throw light on heat production in the (on the first or second day) the temperature fetus. Any knowledge that might be obtained .
gradually rises more slowly, however, than the about the temperature of the fetus in utero will initial decline. After the second day the temthrow light on tissue metabolism in the unborn perature begins to approach normal, but it reinfant. In experimental animals the tempera- quires eight or ten days before the heat regulating ture of the fetus falls and rises with that of the function is of the same constant kind as in mother. In the human, increased rapidity of the older children. In more delicate babies the rise fetal heart tones probably points to febrile reac- does not occur until the third day. tion in the mother. Clinical observations have The daily variations of the temperature in the taught that the fetus will die when the maternal first ten days of life have been made the object temperature reaches 107.6° and sometimes at of study by numerous observers. Forster, Som
, 104°. It is difficult for the fetus in utero to mers, Jürgensen, Wolff, and Gundobin state lose heat. Consequently it is to be expected that that the highest temperature occurs about noon its temperature will be higher than that of the and the minimum at various times during the maternal organism. It is scarcely conceivable night. On the contrary, Eross and Feiss found that the fetus in utero has a well-dercioped heat the maximum at night and the minimum at regulating mecbanism if it possesses one at all.
To further confuse the situation Jundell Since it is protected from outside changes it has decides that some children reach their high no demand made upon it by its environment. We point early in the morning and some in the late would be interested to know whether the fetus afternoon. To sum up the observations, Muhlitself has the power to produce heat. An oppor- mann concludes that it is not possible to establish tunity presents itself in breech presentations to any rule for twenty-four hour variations. He · obtain the rectal temperature of the infant and emphasizes the influence of frequent food taking, the vaginal temperature of the mother. It is crying, restlessness, motion, sleep, and the exalmost invariably found that the temperature of ternal factors such as the room temperature and the fetus is higher than that of the mother.
the infant's clothing. The new born mature infant shows a slightly Undoubtedly the most
the most marked variations higher temperature than that of the mother im
occur in delicate and premature babies. The mediately after its expulsion. It has been found
temperature changes are markedly exaggerated that there may be a difference of 0.30-0.5° be- in the premature infant. The temperature is tween the temperature of twins. It has also subnormal shortly after birth. It has been known been observed that well-developed infants have to fall to 86° or lower. We have long since a slightly higher temperature than feeble infants learned that in order to maintain the life of the directly after birth. These observations indicate premature infant it is necessary to guard against that the fetus in utero receives heat from the chilling and to supply external heat in the form mother but may be to some extent a producer of an incubator or a warm room. Further proof of heat itself.
of the instability of the heat regulating mechanThe mature baby's temperature immediately ism is furnished by the ease of the development after birth is usually 99.7°-100.6o. Shortly after of hyperthermia. If the room is warm the tembirth the temperature falls, particularly in the perature may rise to 100° or 102° or even higher. first hour, and in two or three hours is 2.70-3.6°F. This is particularly true, however, of somewhat lower than at birth. This is, then, the first
better developed children who are slightly older occasion when the heat regulating mechanism is than a week. During the first days of life infants called into play. The diminution in temperature do not usually react with hyperthermia. These depends upon the atmospheric conditions and the prematures who become infected frequently run protection of the baby by clothes and blankets. an afebrile course. There are other factors beThe less protected the baby or the cooler the sides the insufficient heat regulating mechanism room, the lower the temperature sinks. The first in the skin which may explain the tendency to low temperatures. The skin surface in prema- cranium and muscles of the neck, and hematures is relatively greater in proportion to the tomata. Recently it has been pointed out that volume of body than in older children. The autopsies on infants, particularly those extracted poorly developed subcutaneous fat enhances the with forceps, show small hemorrhagic foci in the heat liberation factor. Furthermore, prematures central nervous system, most frequently in the take only small amounts of food and so limit the cervical cord, medulla and pons. The series heat production. Under ordinary circumstances, referred to by. Devilliers considered for the most however, the temperature of the human body is part the mild lesions with a short, febrile course. not dependent upon the food intake. Gundobin Nevertheless, the facts are of interest and sustain considers that the temperature of the premature the opinion that a forceps operation is a potential is a criterion of its development. Incidentally,
Incidentally, traumatism to the fetus. This doctrine of aseptic it should be mentioned that Budin believes that fever is concurred in by Mendelsohn who thinks sclerema, which is due to the coagulation of the that the fever following fractures, hematomas, subcutaneous fat at low temperatures, is infre- and tissue contusions in children is due to the quent in modern times because the temperature absorption of assimilable body proteins. of the premature infant is carefully maintained. One of the phenomena peculiar to the first days
In the newly born, infections of the umbilicus of life is the so-called “inanition” fever of Holt or the umbilical vessels sometimes proceed with and Crandall, the "thirst” fever of Eric Muller, a normal or subnormal temperature. This may and the "desiccation” fever suggested by Von occur in well-developed and mature infants as Reuss. This is observed on the first to the fifth well as in the premature. Of 1,665 newly born day, lasting a few hours with remissions rarely infants which he studied, Smudzinski found 14 lasting five days. The temperature reaches who fell under this classification y of whom died 100°-102° though if long continued it may go and the remainder recovered.
to 103°. Cold packs reduce the temperature It has been suggested by Devilliers that a certain though it rises following removal. The child number of cases of fever in newly born infants may be quiet and drowsy, or it may be fretful and are due to obstetrical traumatism. He thinks cry a good deal. The appetite is poor, and the that the application of forceps, a rigid birth child nurses little even when the breasts contain canal compressing the head, prolonged labor as an abundance of milk. The loss in weight is occurs in brow, face, transverse, and breech posi- relatively marked, and usually the time of the tions, hemorrhage into the sternocleidomastoid fever and the loss in weight coincide although or cephalohematoma may be sufficient to produce the weight loss may be more marked after the a febrile reaction. Indeed, the hyperthermia may temperature has subsided. The stools may have be the principal symptom of the traumatism. The the hunger appearance. It is peculiar that wellinterpretation of these cases shows that the ob- developed strong children are usually attacked. stetrical traumatism has been relatively severe In the preaseptic period this transitory fever due to traction and prolonged period of expul- was thought to be an unlocalized sepsis and was sion. These cases occur most commonly in compared to that occurring in puerperal women. primipara. The fever is not protracted and Eross thought that the umbilical, gastro-intesrarely lasts longer than two days. In thirteen tinal, and pulmonary processes were complicaout of twenty-one cases it lasted one day; in five, tions of the original infection. There are many two days. It usually reaches 100° and rarely facts which oppose the theory of infection. The exceeds 102°. To make these observations accu- attack always occurs on the third to the fifth rately it is necessary to make frequent readings. day. Premature and weak children, who are There are numerous lesions following the use of predisposed to overheating, are not affected. the forceps the most serious of which are frac- Under identical conditions only a few children tures and meningeal hemorrhage. In such cases develop the fever. It is difficult to understand there are paralyses, focal symptoms, coma, and how an infection through the navel will disappear rigid protuberant fontanelles. The fever is pro- in a few days without reappearing. The theory longed and the condition is more grave than in has been advanced that there is a contest between the cases with contusions of the scalp, peri- the meconium and the milk flora occurring at
this time. Chossat noted that starving animals is capable of producing fever in the manner deattempted to maintain their temperature. In
scribed. Various observers have reported the cats and dogs before death the temperature shows occurrence of temperatures following hypodermic a marked increase. Shortly before death this or intravenous injections of salt solutions. These power is lost and the temperature rapidly sinks results have been called into question, and the until death ensues. L. F. Meyer and Rosenstein experiments have been repeated with sterile salt showed there is a distinct tendency towards a solutions without producing any temperature. sinking temperature after eight to ten days in Conclusions have been expressed that the teminfants who are starved. Experiments must be peratures following the hypodermic injection of carefully controlled because applying external salt solutions were not to be ascribed to the salt heat may elevate the otherwise low temperature. but to saprophytic impurities in the water used After long continued starvation the administra- in the solution which contained bacterial proteins tion of diluted milk tends to produce a fall in not destroyed in the ordinary cooking process. temperature. The temperature is kept low by The effect of external conditions have been salt-poor malt soup while butter and skimmed previously alluded to. Normal and previously milk tend to keep the temperature on a level. healthy children may suffer from heat stroke. Eric Muller states the greater the loss in weight, Very high temperatures may be produced by a the higher the temperature. He noted that complete breaking down of the heat regulating fifty-five per cent. of infants who lost from 500 center. Children who have suffered frequent to 720 grams had fever. There may be a specific insults from gastro-intestinal diseases during the toxic product, which is probably the result of summer are liable to acute exacerbations of aliprotein metabolism, retained by the body because mentary intoxication associated with high fever of imperfect elimination. This theory would and marked losses in weight. These are the place transitory fever in the group of autointoxi- patients who contribute to the marked increases cations where it probably belongs.
of infant morbidity and mortality in the hot seaFevers associated with digestive disorders of Rest and sleep. also exert their ininfancy have been variously explained. For the fluence on the temperature levels. In these most part the possible bacterial origin of the conditions there is an absence of the stimuli fevers has been difficult to reconcile with bac- acting on the nervous system tending to elevate teriological and pathological knowledge. Finkel- the temperature. It has been noted that the stein and his students have attempted to explain temperature of an animal rudely awakened may this fever phenomenon in a unique way. They rapidly rise. maintain that the salt content of whey whether It has frequently been shown that adults show administered as pure whey or milk damages the a slight rise in temperature after exercise, the intestinal mucosa. The carbohydrates, particu- rise varying with the violence of the procedure. larly the sugars, whether milk or malt sugar, Jürgensen showed that individuals sawing wood undergo abnormal fermentation, which results for four hours exhibited a rise in temperature of in the production of toxic products. The dam- two degrees. Penzoldt states that tuberculous aged intestinal wall no longer acts as a barrier individuals show a characteristic rise in temperabetween the intestinal lumen and the organs ture after exercise which was higher than that beyond which are concerned in intermediary found in normal individuals. The correctness metabolism. Consequently, the toxic products of his observations, however, has been doubted.. readily pass through the intestinal wall and exert Soldiers who have been subjected to a long march their deleterious influences producing that long frequently show a rise in rectal temperature train of symptoms which Finkelstein calls ali- which may be 100° or higher. After they have mentary intoxication, not the least important rested for thiry minutes the temperature tends symptom of which is high fever. Finkelstein's
to fall to normal or nearly so. This occurs in theory rests upon the fact that salt injected normal individuals although accentuated in the subcutaneously or taken by mouth is capable of tuberculous subject. It is likewise present in
. producing febrile reactions and that sugar in neurotics and those convalescing from acute inthe presence of whey salts in the intestinal tract
fection and tonsillar hypertrophy. This obser
vation also applies to older children. The fact few of these cases occur in the families of has already been referred to that the temperature physicians, former nurses, and in neurotic of young infants is influenced by bodily exercise, families where it was a common practice to resort restlessness and crying. In older children this
to the thermometer. fact comes out in a more striking manner. In one girl after thirty minutes' exercise, the tem- THE IMPORTANCE OF THE ANAEROBIC perature rose to 99.9°. After a half hour more
BACTERIA TO MAN.* it rose to 100.4°. After she rested thirty minutes
W. L. HOLMAN, M. D., the temperature fell. Such children show a .
PITTSBURGH, PA. concomitant increase in pulse rate and a moderate
(Continued from July issue, page 289) increase in the leucocyte count. Young children who undergo athletic training not infrequently
The most important anaerobes met with in show an increase in temperature. On the other
war wounds are-1. B. welchii (Welch 1892), hand, those who have weak muscles tend to show
known as B. aerogenes capsulatus in America some increase in temperature after long physical
and as B. perfringens in France This is the effort. It is not always necessary that the actual
anaerobe with which we are all most familiar. It exercises be carried out, but activities such as
is very widespread, extremely common in feces tossing in bed or dressing violently may produce
and is comparatively easy to cultivate. It is a moderate rise in temperature. One observer
a large Gram positive frequently diplobacillus, noticed that children who came to his dispensary
non-motile and capsulated. It gives large with nutritional disturbances or anemias pre
colonies in and on media under a variety of sented themselves with a temperature of 99o.
anaerobic conditions. On account of its strong After a rest it fell to a point 0.50-0.7° lower.
powers of fermentation it makes itself very eviIf they were sent out to jump or run up and
dent in mixed cultures in milk, meat and similar down stairs the temperature would again rise
media. Injected into the muscle of guinea pigs 0.50-0.7°. He observed that diseased conditions
it is pathogenic and produces a marked breaking seemed to exert no influence on this rise; weak
down of the muscle which is probably the result or strong, normal children or those infected with of the carbohydrate fermentation and possibly autuberculosis, the change was the same. He found tolytic ferments as suggested by Dernby's studies: that definitely neuropathic children responded
since B. welchii shows in the test tube only the more readily with an increased bodily tempera- most minimal attack on solid proteins such as ture after exercise than normal children. These meat. It spores readily in feces, not infrequently oscillations in temperature are so universal that in wounds, and with comparative difficulty in they should be considered normal manifestations artificial media. Acid production interferes with based upon a somewhat unstable heat regulating sporulation. It is found in the vast majority of mechanism in young children.
deep lacerated wounds and is the most frequent From personal observations I have been able
cause of gas gangrene. Its toxine has been disto follow many children through infancy and covered by Bull and Pritchett, Weinberg and childhood who thrive and seem to be in perfect others and an antitoxine prepared and used efhealth and constantly show a temperature of fectively, both experimentally and practically. 99°, 99.5° and even 100.5°. They have fre
2. Vibrion septique (Pasteur 1872) is much quently been a source of great anxiety to their
more difficult to isolate. It is a rather long, modparents, and in the first years of my practice erately stout, motile bacillus with usually subterI confess that I participated in their fears. I minal spores. Its colonies are very small, both finally came to the conclusion that a certain
surface and deep, so that it may remain in mixgroup of children show a temperature some- tures of other anærobes and not be recognized. It what higher than normal, and after every possible is very pathogenic when injected into the muscles pathological condition is excluded, such as ton- of animals and gives rise in man to a serious and sillitis, pyelitis, and indeed any acute or chronic often fatal form of gas gangrene. It is probably infection, I advise that the thermometer should the second most common cause of this condition. be rarely if ever used. Strange to say, not a
*Read before the Chicago Medical Society, March 12, 1919.