The Significance of Pyrexia in Surgical Cases. WITH SPECIAL REFERENCE TO THE TEMPERATURE CURVE BEFORE AND AFTER LAPAROTOMY. BY I. s. stone/m. d., WASHINGTON, D. C. REPRINTED FROM The American Gynecological Journal, Toledo, Ohio MARCH, 1893. The Significance of Pyrexia in Surgical Cases. WITH SPECIAL REFERENCE TO THE TEMPERATURE CURVE BEFORE AND AFTER LAPAROTOMY. BY I. S. STONE. M. D., WASHINGTON, D. C THE SIGNIFICANCE OF PYREXIA IN SURGICAL CASES.* With Special Reference to the Temperature Curve Before and After Laparotomy. I. S. STONE, M. D., WASHINGTON, D. C. The clinical thermometer maintains its unique position among the useful inventions given the medical profession, as an aid to accurate diagnosis and treatment. It can scarcely be said that any instrument of precision in our possession equals it in value. But its value to the physician is far greater than to the surgeon, and it is the purpose of this paper to show some of the reasons why this is true. It is well known to all, and for obvious reasons, that prior to the discovery of the circulation of the blood, very indifferent importance was attached to the pulse as indicative of the temperature of the body, or showing the degree of illness suffered by the patient. The temperature of the surface of the body was valued by Hippoc- rates and his followers, while they ignored the pulse altogether. We find that but little progress was made in thermometry until the latter half of the 18th century. Boerhaave and his pupil, Van Sweiten, thought the thermometer only measured surface heat. The latter was among the first, however, to declare that a rapid pulse was pathognomonic of fever. DeHaen, of Vienna, studied the temperature in health and disease, 1747-1759. In 1839, Gavarret confirmed the investigations of De Haen of nearly a century previous. In England, Brodie and Davy, in 1850, established thermometry upon a firm and scientific basis. Sidney Ringer, in 1866, also helped by his observations to thoroughly establish the use of the clinical thermometer. In France, Claude Bernard should be mentioned for his valuable contributions to this important litera- 1. Read before the District of Columbia Medical Society, November, 1892. 4 ture. We may, in concluding this historical inquiry, justly consider the years 1835 to 1870 the rennaisance of the clinical thermometer. For one, the writer can well remember when a clinical thermometer was a novelty. We were taught to rety upon its indications almost implicitly. A temperature of 105°-106° meant grave and immediate danger. Higher than this, the inevitable approach of death. On the other hand, so low a temperature as 96° was thought incompatible with life—i. e., death was already claiming the victim. An intermediate range, 100° to 103°, meant a safe and very easy course of disease, and happy was the practitioner who attended the fortunate patient. For one, the writer had a rude and sudden awakening from this idea, soon after engaging in practice. A young and previously healthy woman was thought to have colic. A messenger came to my office for an anodyne. I was called two days later and found obstruction of the bowels. The patient was seriously ill, and all efforts were unavailing. But the temperature was only 101°, the pulse 120, and I was confident that a movement of the bowels would cure the patient promptly. She had tenderness, and some distension, over the entire abdomen, but I was surprised to find general peritonitis at the autopsy, on the fourth day after her illness began. A gangrenous vermiform appendix had caused the peritonitis. Morphia had obscured some of the symptoms. The temperature had not reached a higher point than 102°. On another occasion I was called by a very excellent practitioner to see a case of septicaemia from placental remains following delivery at term. The temperature had reached 104° each afternoon for several days previous. A radical cleansing of the uterus caused a drop of the temperature to 96° the next morning. I was summoned in haste by the physician in person, who was greatly alarmed. I expected to find the patient in collapse, and on the way very anxiously reviewed in my mind the steps of the operation, fearing that I had punctured or rup- tured the uterus. But upon my arrival the patient was found perfectly calm, far more so than her medical attendants, for she did not suspect their fears. Her pulse was perfectly normal, and there was absolutely no trouble in her convalescence. If her physician had not taken her temperature he would not have suspected any trouble whatever. On another occasion, after an important laparotomy, one among my first cases, the nurse discovered a temperature of 102° an hour or two after operation, in a woman who had not previously had any rise in temperature. This patient had suffered for many years with chronic disease of tubes and ovaries. The operation was well done, a drainage tube inserted, and there was no reason to fear any peritonitis, had the thermometer not been used at all the day of operation. She made a perfectly satisfactory recovery and the temperature never again reached as much as 100°. The alarm was created by a temperature caused entirely by the nervous excitability of the patient. 5 These cases are cited merely to illustrate the fallacy of thermo- metrical indications alone, and unaided by other useful signs of disease. In the consideration of pyrexia attending surgery, within the peri- toneal cavity especially, we must remember with what an interesting membrane we have to deal. We well know the dread formerly experi- enced by surgeons who invaded its sacred precincts. We may now well consider it the surgeon’s best ally and friend.2 Inflammation of this “ lymph sac ” gives us very numerous, very serious, very various symptoms, and no one, nor any group of them (according to Mr. Lawson Tait), can be depended upon as furnishing reliable indications or symptoms. There may be an almost normal pulse and temperature. On the other hand, “ a temperature of 106° and a pulse of 150 or more may not indicate peritonitis,”3 even after a laparotomy, when we have reason to fear it. Again, a severe peritonitis may be present with a temperature below normal, and even the pulse, (usually more to be relied upon than the temperature) may not be greatly accelerated. Pyrexia alone cannot be considered an absolute indication of peri- tonitis, nor even sepsis after any surgical procedure. It is quite the custom for nurses, and indeed many physicians, to ply the thermometer during or immediately after a chill. Such information is absolutely unreliable and of no service whatever. A chill or rigor is an important manifestation of extending disease (if not merely due to nervous ex- citability) and an indication whose value and significance is not to be measured by the height of a column of mercury in a glass tube. What importance can then be attached to pyrexia by the surgeon ? If I have cast a doubt upon the usefulness of careful observations of the temperature of the body in disease, let me disclaim such intention, for it is my intention to urge a better understanding of their valwe. But let us consider, other and equally, if not more, important tests of our patient’s welfare, if recovering from any surgical operation, or even ill with any malady possibly requiring surgery for its relief. To the obstetrician, pyrexia is full of meaning. If there be rigors, with pain in the region of the uterus and quick pulse and temperature anywhere over 100° or 101°, the patient is fortunate who obtains relief when her uterus is carefully cleansed of all septic matter. In these cases the temperature is far more reliable before the disease extends beyond the uterus than after. I know of no more valuable surgical operation than that of curetting and irrigation of a septic uterus. If the pulse and temperature both promptly respond to treatment, the 2. I