Febricula.

Synonyms.—Ephemeral Fever; Simple Continued Fever; Synochal Fever.

Definition.—A slight transient fever of doubtful etiology, unattended by any characteristic lesions, and terminating in recovery in from twenty-four hours to seven days.

"In malarial regions, periodic fevers are the rule; in non-malarial regions, in the majority of years, the disease is evanescent fever, or, as it has been lately described, febricula. Of this we have two varieties,—one which may be strictly termed evanescent, passing off by the third or fourth day; the other protracted, and which terminates from the sixth to the ninth day."

Etiology.—A number of conditions predispose and possibly cause febricula, among which may be mentioned colds, retained secretions, prolonged physical or mental effort, gastric disturbances from overeating, or from tainted foods or hurriedly eating while overheated, from exposure to the sun or excessive heat, and to inhalation of sewer-gas or other noxious odors.

Anders speaks of "undeveloped or abortive forms of the infectious diseases (typhoid, influenza, rheumatism)." Evanescent fevers frequently occur during epidemics of the above-mentioned diseases, and may be due to a modified infection.

Symptoms.—The disease begins abruptly. Commencing in the morning with a slight chill, the temperature rapidly ascends to 103°, but instead of falling through the night, as in other cases, it is 104° the next morning. Then there is a gradual decline through the day to 100°, a slight increase through the night and entire subsidence of febrile symptoms on the third day.

"Any one that has suffered from this evanescent fever will see that Fig. 15 is a correct index of his sensations. Commencing in seeming perfect health, there is a chill, with febrile symptoms increasing through the day; then follows a restless night, the person suffering from headache, pain in the loins, and a burning fever,—the broken sleep being attended with unpleasant dreams; the feeling of exhaustion in the morning; the gradual improvement during the day; the second uncomfortable night, but not near so bad as the first; breakfast on the third morning, followed by a pleasant feeling of relief and rapid convalescence."

Sometimes the fever takes a slightly different course as seen in the second diagram. The elevation of temperature the first day is about the same, but the patient passes a better night, and the morning temperature is below 102°; there is then a continued increase during the next day to 104°, and a bad night carries it up to 104.5° the next morning. During the third day the patient is very sick, and suffers more than in the grave forms of fever, the temperature continuing uniform. Then we notice a marked decline on the fourth day, and the low range of temperature from that until the entire subsidence of the disease.

"Synochal and Synochoid Types.—Sometimes, owing to a more intense character of the exciting cause or to greater depression of the system, the fever assumes a still more grave form, and is known as synochal or synochoid, according to the length and gravity of the fever.

"'In synochal fever there are but few premonitory symptoms, the onset being more or less sudden. The patient's attention is often first arrested by chilly sensations passing over the body, and a sense of dullness and languor. Sometimes the chill is well marked, in rare cases amounting to a rigor, but often the sensation of cold is but slight.

"This chilliness is rapidly followed by reaction; the skin becomes injected, dry, hot, and burning; the countenance flushed and animated; the pulse frequent, full, strong, and bounding, rarely hard and oppressed; respiration is frequent, the respired air hot, and the mouth and nostrils dry; the bowels are constipated, and the urine scanty and high-colored; the tongue white, its papillae elongated and erect. The patient experiences great thirst, and manifests increased sensibility, especially in regard to light and noise. There is frequently some headache, with sometimes vertigo, and the patient is watchful, restless, and uneasy. In children it may commence with a convulsion.

"As the disease progresses, these symptoms increase in severity; the secretions are still further arrested, the heat and dryness of. the skin increase, and the patient is more watchful and uneasy. All the symptoms are usually more exasperated in the evening and early part of the night. The fever continues to increase in intensity until about the fifth or sixth day, when there is a tendency to a crisis, and the disease is frequently arrested by the establishment of secretion. If it progress much beyond this period, we observe a manifest prostration, the symptoms being those of synochoid; and in the course of as many days more, marked evidence of disorganization of the blood and typhoid symptoms. We rarely, if ever, see the disease terminate fatally as a synochal fever, unless complicated with inflammation of some important organ.

The temperature in synochal fever has a pretty high range. Yet the wave-lines or difference between morning and evening temperature are well marked. The following table gives the variations of temperature in a fever terminating the fifteenth day:

"In a case developing typhoid symptoms in the third week, from improper treatment, we find the following range of temperature from the thirteenth day until death:"

The synochoid type is of longer duration and shows greater depravity of the blood; in fact, very closely resembles typhoid fever.

"The stage of incubation is generally of some days' duration, though when the cause is intense, it may be brief. The patient complains of languor, indisposition to exertion, loss of appetite, irregularity of bowels, dryness of skin, and more or less pain in head or back, and soreness of muscular tissue. These symptoms increasing, at last a tolerably well-marked chill comes on; the patient feels cold, especially at the extremities, and chilly sensations pass over the body. These are shortly alternated with flushes of heat, which become more and more marked, until febrile reaction is established.

"In rare cases, the cold stage is as well marked as in an intermittent, amounting to a rigor; in many, the patient hardly notices the cold stage, it is so slight.

"With the development of reaction, the skin becomes hot and dry, the urinary secretion scanty, high-colored, and does not deposit a sediment, and the bowels are constipated. The mouth is dry and the tongue coated with a slightly yellowish white coat, or, in some cases, a heavy yellowish coat on base, with a bad taste in the mouth and slight nausea; in others, the gastric mucous membrane being irritable, it is elongated, the tip and edges reddened, but coated white in the center; there is thirst, but not so intense as in the preceding form of fever. The pulse is frequent, full, sometimes hard, especially if there is irritation of the mucous membranes, or cerebro-spinal centers, but rarely bounding. In some cases there is nausea and even vomiting; but if so, the tongue will either be found heavily coated at base, with a disagreeable taste in the mouth, and sense of oppression in the epigastrium, or pointed, with reddened tip and edges, and tenderness on pressure over the stomach.

"The condition of the nervous system is variable; sometimes the patient is restless, uneasy, and watchful, the special senses being painfully acute, so that the patient can not bear a bright light, and is disturbed by the slightest noise; at others, he lies torpid, does not appear to appreciate his condition, is but slightly affected with what transpires around him, and lies quiet in one position. In either case there may be headache; in the first .it is acute, the face being flushed and eyes reddened, evidencing determination of blood; in the last it is generally dull, a disagreeable sensation of heaviness and oppression.

"The symptoms above named increase in intensity to the third or fourth day, after which the fever exhibits but little change, if uncomplicated, except the increasing debility, until after the seventh day; when, if it does not terminate by the establishment of secretion, either naturally or by the aid of medicine, we observe symptoms of deterioration of the blood and prostration making their appearance, and after a variable length of time a low typhoid condition ensues, and we have, in fact, to treat a fever of the next variety, less the disease of Peyer's glands.

"Temperature.—The range of temperature in this form of fever is not very different from that represented in the diagrams of typhoid fever. In the milder cases, the evening range is from 102.5° to 104°; the morning range from 100.5° to 102.5°. In the severer cases we find, during the first week, the high range of evening temperature, and long wave-line of synochal fever; and as it advances in the third week, the diminished wave-line, or high morning as well as evening temperature.

"We may thus readily determine the progress of the disease and the prospect of its speedy arrest. A low range of temperature, with long wave-lines, gives a favorable prognosis. Even though the fever is severe, the evening range of temperature being high, if there is the large wave-line (low morning temperature), our remedies will act kindly. It is in these cases in which we have a high morning temperature and, of course, short wave-line, that we fear difficulty."

Complications.—Febricula is often associated with sore throat, tonsillitis, irritation of the larynx, bronchial catarrh, and gastro-intestinal disease.

Synochal fever is apt to be associated with inflammatory diseases of the respiratory apparatus, determination and congestion of the brain, and gastric irritability.

Synochoid fever is frequently complicated with local diseases, most generally of an inflammatory character; yet, as the fever is fully developed before the local disease commences, the symptoms of the latter are often very obscure.

"With Predominant Affection of the Cerebro-Spinal Centers.—This forms the nervous fever of older writers, and is not an uncommon disease. The symptoms are all increased in intensity; the skin is intensely hot and pungent, especially of the head and face; the pulse is rapid, strong, and full; the breathing frequent and suspirous, and the eyes injected and suffused. There is great irritability and restlessness, with more or less intense headache, giddiness, intolerance to light and noise, and greatly increased general sensibility. Within three or four days, delirium makes its appearance, followed in a longer or shorter time by coma-vigil, coma and insensibility, and by subsultus tendinum.

"In some cases, the cerebral affection being intense, we find stupor making its appearance speedily, accompanied by a slow, oppressed, and intermittent pulse. If the affection of the nervous centers is acute, the disease may terminate fatally without much disorganization of the blood; but if not, the fever rapidly assumes a typhoid character.

"With Predominant Affection of the Respiratory Apparatus.—This is the most common complication of continued fever, though, generally, it exists in but a slight degree. The bronchial mucous membrane is frequently irritated, with slight implication of the lungs. This necessarily aggravates the fever, and induces farther complication by preventing proper oxygenation of the blood. The patient complains of slight oppression and difficulty of breathing, with accelerated respiration and slight cough. If bronchitis is fully developed, the difficulty of breathing is increased, and secretion is generally established early, and a mucous rhoncus is heard over the chest, upon auscultation. If much of the structure of the lung becomes diseased, the breathing is hurried, oppressed, and sometimes laborious, the sputum rounded and streaked with blood, and in a short time exhibits the characteristic rusty color of pneumonia. There are manifest symptoms of imperfect aeration of the blood, dark, dusky hue of the lips. and tongue, flushed appearance of face, oppressed circulation, and coldness of tlie extremities. With such complications, we notice that prostration is very rapid, and contamination of the fluids speedily ensues, with typhoid symptoms. Low delirium and coma are frequent attendants upon this condition.

"With Predominant Affection of the Gastro-Enteric Mucous Membranes.—In some cases we observe, at the commencement, marked symptoms of disorder of the stomach; the tongue is heavily coated, especially at its base, with a dirty-yellowish secretion; there is slight nausea; disgust for food, and oppression in the epigastrium; everything that is administered is taken by the patient with difficulty, and frequently ejected. This condition is not generally accompanied with as high febrile reaction as in the uncomplicated fever; but there is rapid prostration, and manifestation of typhoid symptoms. In this case there is increased secretion of mucus from the mucous membrane of the stomach, which, if allowed to remain, will undergo decomposition, and, being slowly absorbed, will generate decomposition of the blood. In other cases there is marked irritation of the stomach, manifested by redness of the tip and edges of the tongue, uneasiness in, and pain on pressure over, the epigastrium, with nausea and rejection of fluids and solids taken into the stomach. In this case, all the febrile symptoms are increased.

"The enteric affection does not generally manifest itself in the early stage of the 'disease. It commences with looseness of the bowels, two, three, or four evacuations in the twenty-four hours, with pain and soreness in the abdomen, especially on pressure. The tongue is moist and loaded with a dirty-white or grayish fur, which, as the fever advances, changes to brown, and sordes appear on the teeth and lips; in some cases, the edges and tip of the tongue are reddened. In this case, the fever rapidly assumes a typhoid character."

Diagnosis.—The diagnosis of febricula is not difficult if we remember its chief characteristics; namely, the sudden onset, high temperature, 104° or 105° within twenty-four hours, and great restlessness and undue complaint, notwithstanding the tongue is comparatively clean and moist, and the absence of hardness of pulse, although very rapid, and the early decline of all of the above seemingly grave symptoms, render the case quite plain.

In synochal fever, the continued reaction determines the type of the fever; the great excitation of the nervous system, with but little prostration, and the full, bounding pulse, distinguish it from synochoid or typhoid.

In synochoid, the history of a slow forming stage, the uniform temperature after the fourth or fifth day, and the tendency to septic conditions, determine the type of the fever. Where complications have arisen, the symptoms are usually sufficiently pronounced to determine the local lesion.

Prognosis.—The prognosis is favorable in all cases of febricula, and in the graver forms of synochoid, with careful treatment, the mortality will be very small.

Treatment.—The treatment for febricula is quite simple. To a half glass of water add five drops of aconite, if the pulse be small; or twenty drops of veratrum and ten drops of gelsemium, if the pulse be full and bounding; of this give a teaspoonful every hour. A seidlitz powder for the bowels, and cooling lotions for the head, will be about all the medicine required.

In the synochal form, sthenia is the most characteristic feature, and our medication will be directed to overcoming the force and frequency of the circulation, relieving the irritability of the nervous system, and establishing secretion from the skin, kidneys, and bowels.

The full, bounding pulse speaks of excessive heart power, while the Hushed face, bright eyes, and contracted pupils tell of nervous irritability. Here,—

Sig. A teaspoonful every one or two hours till the pulse loses its force and frequency, and the irritability of the nervous system is overcome.

Generally, as these remedies accomplish the purpose for which they are given, the secretions become established; if, however, this desired end is not accomplished, we commence the administration of remedies for the kidneys and bowels, continuing the sedative, however, as before. A dose of antibilious physic, followed by a diaphoretic powder, accomplishes the desired end. Should complications arise, we treat them according to the symptoms present.

The synochoid form is more of an asthenic type, and requires somewhat different medication. The patient is more passive, the temperature not so high, and the tendency is to typhoid symptoms with sepsis of the blood.

The treatment is along the same line as that of typhoid, and does not need a repetition at this time, other than to say we must keep the stomach in good condition, control the circulation, correct the wrongs of innervation, and overcome sepsis. The diet and nursing will be the same as for typhoid. (See treatment for typhoid.)

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.