Dr.Ajith Kumar D.S MD(Hom)
Department of Physiology
Govt. Homeopathic Medical College. Calicut. Kerala
Body temperature is controlled by the hypothalamus. Neurons in both the preoptic anterior hypothalamus and the posterior hypothalamus receive two kinds of signals: one from peripheral nerves that reflect warmth/cold receptors and the other from the temperature of the blood bathing the region. These two types of signals are integrated by the thermoregulatory center of the hypothalamus to maintain normal temperature. In a neutral environment, the metabolic rate of humans consistently produces more heat than is necessary to maintain the core body temperature at 37°C. Therefore, the hypothalamus controls temperature by mechanisms of heat loss.
A normal body temperature is ordinarily maintained, despite environmental variations, because the hypothalamic thermoregulatory center balances the excess heat production derived from metabolic activity in muscle and the liver with heat dissipation from the skin and lungs. According to recent studies of healthy individuals 18 to 40 years of age, the mean oral temperature is 36.8° ± 0.4°C (98.2° ± 0.7°F), with low levels at 6 A.M. and higher levels at 4 to 6 P.M. The maximum normal oral temperature is 37.2°C (98.9°F) at 6 A.M. and 37.7°C (99.9°F) at 4 P.M.; these values define the 99th percentile for healthy individuals. The normal daily temperature variation is typically 0.5°C (0.9°F). Rectal temperatures are generally 0.4°C (0.7°F) higher than oral readings. The lower oral readings are probably attributable to mouth breathing, which is a particularly important factor in patients with respiratory infections and rapid breathing. Lower esophageal temperatures closely reflect core temperature.
In women who menstruate, the A.M. temperature is generally lower in the 2 weeks before ovulation; it then rises by about 0.6°C (1°F) with ovulation and remains at that level until menses occur. Seasonal variation in body temperature has been described but may reflect a metabolic change and is not common. Body temperature is elevated in the postprandial state, but this elevation does not represent fever. Pregnancy and endocrinologic dysfunction also affect body temperature. The daily temperature variation appears to be fixed in early childhood; in contrast, elderly individuals can exhibit a reduced ability to develop fever, with only a modest fever even in severe infections.
The individual first notices vasoconstriction in the hands and feet. Shunting of blood away from the periphery to the internal organs essentially decreases heat loss from the skin, and the person feels cold. For most fevers, body temperature increases by 1 to 2°C. Shivering, which increases heat production from the muscles, may begin at this time; however, shivering is not required if heat conservation mechanisms raise blood temperature sufficiently. Heat production from the liver also increases. In humans, behavioral instincts(e.g., putting on more clothing or bedding) lead to a reduction of exposed surfaces, which helps raise body temperature.
The processes of heat conservation (vasoconstriction) and heat production (shivering and increased metabolic activity) continue until the temperature of the blood bathing the hypothalamic neurons matches the new thermostat setting. Once that point is reached, the hypothalamus maintains the temperature at the febrile level by the same mechanisms of heat balance that are operative in the afebrile state. When the hypothalamic set point is again reset downward (due to either a reduction in the concentration of pyrogens or the use of antipyretics), the processes of heat loss through vasodilation and sweating are initiated. Behavioral changes triggered at this time include the removal of insulating clothing or bedding. Loss of heat by sweating and vasodilation continues until the blood temperature at the hypothalamic level matches the lower setting.
In some rare cases, the hypothalamic set point is elevated as a result of local trauma, hemorrhage, tumor, or intrinsic hypothalamic malfunction. The term hypothalamic fever is sometimes used to describe elevated temperature caused by abnormal hypothalamic function. However, most patients with hypothalamic damage have subnormal, not supranormal, body temperatures. These patients do not respond properly to mild environmental temperature changes. For example, when exposed to only mildly cold conditions, their core temperature falls quickly rather than over the normal period of a few hours. In the very few patients in whom elevated core temperature is suspected to be due to hypothalamic damage, diagnosis depends on the demonstration of other abnormalities in hypothalamic function, such as the production of hypothalamic releasing factors, abnormal response to cold, and absence of circadian temperature and hormonal rhythms.
It is important to distinguish between fever and hyperthermia since hyperthermia can be rapidly fatal. However, there is no rapid way to make this distinction. Hyperthermia is often diagnosed on the basis of the events immediately preceding the elevation of core temperature¾ e.g., heat exposure or treatment with drugs that interfere with thermoregulation. However, in addition to the clinical history of the patient, the physical aspects of some forms of hyperthermia may alert the clinician. For example, in patients with heat stroke syndromes and in those taking drugs that block sweating, the skin is hot but dry. Moreover, antipyretics do not reduce the elevated temperature in hyperthermia, whereas in fever¾and even in hyperpyrexia¾adequate doses of either aspirin or acetaminophen usually result in some decrease in body temperature.
The term pyrogen is used to describe any substance that causes fever. Exogenous pyrogens are derived from outside the patient; most are microbial products, microbial toxins, or whole microorganisms. The classic example of an exogenous pyrogen is the lipopolysaccharide endotoxin produced by all gram-negative bacteria. Endotoxins are potent not only as pyrogens but also as inducers of various pathologic changes in gram-negative infections. Another group of potent bacterial pyrogens is produced by gram-positive organisms and includes the enterotoxins of Staphylococcus aureus and the group A and B streptococcal toxins, also called superantigens. One staphylococcal toxin of clinical importance is the toxic shock syndrome toxin associated with isolates of S. aureus from patients with toxic shock syndrome. Endotoxin is a highly pyrogenic molecule in humans:
Approach to the Patient
It is in the diagnosis of a febrile illness that the science and art of medicine come together. In no other clinical situation is a meticulous history more important. Painstaking attention must be paid to the chronology of symptoms in relation to the use of prescription drugs (including drugs or herbs taken without a physician’s supervision) or treatments such as surgical or dental procedures. The exact nature of any prosthetic materials and/or implanted devices should be ascertained. A careful occupational history should include exposures to animals; toxic fumes; potential infectious agents; possible antigens; or other febrile or infected individuals in the home, workplace, or school. A history of the geographic areas in which the patient has lived and a travel history should include locations during military service.
Information on unusual hobbies, dietary proclivities (such as raw or poorly cooked meat, raw fish, and unpasteurized milk or cheeses), and household pets should be elicited, as should that on sexual orientation and practices, including precautions taken or omitted. Attention should be directed to the use of tobacco, marijuana, intravenous drugs, or alcohol; trauma; animal bites; tick or other insect bites; and prior transfusions, immunizations, drug allergies, or hypersensitivities. A careful family history should include information on family members with tuberculosis, other febrile or infectious diseases, arthritis or collagen vascular disease, or unusual familial symptomatology such as deafness, urticaria, fevers and polyserositis, bone pain, or anemia.
A meticulous physical examination should be repeated on a regular basis. All the vital signs are relevant. The temperature may be taken orally or rectally, but the site used should be consistent. Axillary temperatures are notoriously unreliable. Particular attention should be paid to daily (or sometimes more frequent) physical examination, which should continue until the diagnosis is certain and the anticipated response has been achieved.
Special attention should be paid to the skin, lymph nodes, eyes, nail beds, cardiovascular system, chest, abdomen, musculoskeletal system, and nervous system. Rectal examination is imperative. The penis, prostate, scrotum, and testes should be examined carefully and the foreskin, if present, retracted. Pelvic examination must be part of every complete physical examination of a woman, with a search for such causes of fever as pelvic inflammatory disease and tubo-ovarian abscess.
Laboratory Tests :
Few signs and symptoms in medicine have as many diagnostic possibilities as fever. If the history, epidemiologic situation, or physical examination suggests more than a simple viral illness or streptococcal pharyngitis, then laboratory testing is indicated. The tempo and complexity of the workup will depend on the pace of the illness, diagnostic considerations, and the immune status of the host. If findings are focal or if the history, epidemiologic setting, or physical examination suggests certain diagnoses, the laboratory examination can be focused. If fever is undifferentiated, the diagnostic nets must be cast farther, and certain guidelines are indicated, as follows.
CLINICAL PATHOLOGY :
The workup should include a complete blood count; a differential count should be performed manually or with an instrument sensitive to the identification of eosinophils, juvenile or band forms, toxic granulations, and Dohle bodies, the last three of which are suggestive of bacterial infection.
Neutropenia may be present with some viral infections, particularly parvovirus B19 infection; drug reactions; systemic lupus erythematosus; typhoid; brucellosis; and infiltrative diseases of the bone marrow, including lymphoma, leukemia, tuberculosis, and histoplasmosis.
Lymphocytosis may occur with typhoid, brucellosis, tuberculosis, and viral disease. Atypical lymphocytes are documented in many viral diseases, including infection with Epstein-Barr virus, cytomegalovirus, or HIV; dengue; rubella; varicella; measles; and viral hepatitis. This abnormality also occurs in serum sickness and toxoplasmosis. Monocytosis is a feature of typhoid, tuberculosis, brucellosis, and lymphoma. Eosinophilia may be associated with hypersensitivity drug reactions, Hodgkin’s disease, adrenal insufficiency, and certain metazoan infections. If the febrile illness appears to be severe or is prolonged, the smear should be examined carefully for malarial pathogens (where appropriate) as well as for classic morphologic features, and the erythrocyte sedimentation rate should be determined.
Urinalysis, with examination of urinary sediment, is indicated.
It is axiomatic that any abnormal fluid accumulation (pleural, peritoneal, joint), even if previously sampled, merits reexamination in the presence of undiagnosed fever.
Joint fluids should be examined for bacteria as well as crystals.
Bone marrow biopsy (not simple aspiration) for histopathologic studies (as well as culture) is indicated when marrow infiltration by pathogens or tumor cells is possible.
Stool should be inspected for occult blood; an inspection for fecal leukocytes, ova, or parasites also may be indicated.
1. Electrolyte, glucose, blood urea nitrogen, and creatinine levels should be measured.
2. Liver function tests are usually indicated if efforts to identify the cause of fever do not point to the involvement of another organ. Additional assessments (e.g., measurement of creatinine phosphokinase or amylase) can be added as the workup progresses.
Smears and cultures of specimens from the throat, urethra, anus, cervix, and vagina should be assessed when there are no localizing findings or when findings suggest the involvement of the pelvis or the gastrointestinal tract. If respiratory tract infection is suspected, sputum evaluation (Gram’s staining, staining for acid-fast bacilli, culture) is indicated. Cultures of blood, abnormal fluid collections, and urine are indicated when fever is thought to reflect more than uncomplicated viral illness. Cerebrospinal fluid should be examined and cultured if meningismus, severe headache, or a change in mental status is noted.
A chest x-ray is usually part of the evaluation for any significant febrile illness.
Outcome of Diagnostic Efforts : In most cases of fever, either the patient recovers spontaneously or the history, physical examination, and initial screening laboratory studies lead to a diagnosis. When fever continues for 2 to 3 weeks, during which time repeat physical examinations and laboratory tests are unrevealing, the patient is provisionally diagnosed as having fever of unknown origin.
Some febrile diseases have characteristic patterns. With relapsing fevers, febrile episodes are separated by intervals of normal temperature; when paroxysms occur on the first and third days, the fever is called tertian. Plasmodium vivax causes tertian fevers. Quartan fevers are associated with paroxysms on the first and fourth days and are seen with P. malariae. Other relapsing fevers are related to Borrelia infections and rat-bite fever, which are both associated with days of fever followed by a several-day afebrile period and then a relapse of days of fever. Pel-Ebstein fever, with fevers lasting 3 to 10 days followed by afebrile periods of 3 to 10 days, is classic for Hodgkin’s disease and other lymphomas. Another characteristic fever is that of cyclic neutropenia, in which fevers occur every 21 days and accompany the neutropenia. There is no periodicity of fever in patients with familial Mediterranean fever.
- Fever: Skin dry and hot; face red, or pale and red alternately; intense nervous restlessness, tossing about in agony; becomes intolerable towards evening and on going to sleep.
- Complaints caused by exposure to dry cold air, dry north or west winds, or exposure to draughts of cold air while in a perspiration; bad effects of checked perspiration.
- Great fear and anxiety of mind, with great nervous excitability; Restless, anxious, does everything in great haste; must change position often; everything startles him.
- Tongue coated white.
- Intense thirst. Thirst for cold water. Bitter taste of everything except water.
- Evening and night, pains are insupportable; in a warm room; when rising from bed; lying on affected side.
- In the open air
- Aconite should never be given simply to control the fever, never alternated with other drugs for that purpose. If it be a case requiring Aconite no other drug is needed;
- Clinically, its therapeutic application has been confined largely to the treatment fever with respiratory diseases, Rattling of mucus with little expectoration has been a guiding symptom.
- Tongue coated, pasty, thick, white, with reddened papillae and red edges; red in streaks; very red, dry in the middle;
- Thirst for cold water, little and often, and desire for apples, fruits, and acids.
- There is much Drowsiness, debility and sweat characteristic of the drug.
- Great sleepiness or irresistible inclination to sleep, with nearly all complaints.
- Aggravation; in evening; from lying down at night; from warmth; in damp cold weather; from all sour things and milk.
- Amelioration; from sitting erect; from eructation and expectoration.
- Fever; Afternoon chill, with thirst; worse on motion and heat. External heat, with smothering feeling. Sweat slight, with sleepiness. Perspiration breaks out and dries up frequently.
- Sleeps after the fever paroxysm. After perspiration, nettle rash, also with shuddering.
- Tongue fiery red, swollen, sore, and raw, with vesicles.
- Aggravation; heat in any form; touch; pressure; late in afternoon; after sleeping; in closed and heated rooms. Right side.
- Amelioration; In open air, uncovering, and cold bathing.
- For the fever resulting from mechanical injuries;
- Sore, lame, bruised feeling all through the body as if beaten; traumatic affections of muscles.
- Mechanical injuries, especially with stupor from concussion;
- Everything on which he lies seems too hard; complains constantly of it and keeps moving from place to place in search of a soft spot.
- Heat of upper part of body; coldness of lower. The face or head and face alone is hot, the body cool.
- In typhoid; Unconsciousness; when spoken to answers correctly, but unconsciousness and delirium at once return.
- Aggravation; least touch; motion; rest; wine; damp cold.
- Amelioration; lying down, or with head low.
- Fever: High temperature. Periodicity marked with adynamia. Septic fevers. Intermittent. paroxysms incomplete, with marked exhaustion. Cold sweats. Typhoid, not too early; often after Rhus. Complete exhaustion. Delirium; worse after midnight. Great restlessness. Great heat about 3 a.m.
- Great Prostration, with rapid sinking of the vital forces;
- The greater the suffering the greater the anguish, restlessness and fear of death. Mentally restless, but physically too weak to move; cannot rest in any place; changing places continually; wants to be moved from one bed to another, and lies now here, now there.
- Great thirst; drinks much, but little at a time.
- Aggravation; After midnight [1 to 2 A. M. or P. M. ]; from cold, cold drinks or food; when lying on affected side or with the head low.
- Amelioration ; from heat; from head elevated; warm drinks.
- Baptisia has gained its greatest reputation as a remedy in typhoid fever, to the symptoms of which its pathogenesis strikingly corresponds.
- Fever; Chill, with rheumatic pains and soreness all over body. Heat all over, with occasional chills. Chill about 11 a.m. Adynamic fevers. Typhus fever. Shipboard fever.
- All exhalations and discharges foetid, especially in typhoid or other acute diseases; breath, stool, urine, perspiration, ulcers, etc.
- Stupor; falls asleep while being spoken to or in the midst of his answer.
- Tongue: at first coated white with red papillae; dry and yellow-brown in centre; later dry, cracked, ulcerated.
- Face flushed, dusky, dark-red, with a stupid, besotted drunken expression.
- In whatever position the patient lies, the parts rested upon feel sore and bruised.
- Aggravation; humid heat; fog; indoors.
- Fever: A high feverish state with comparative absence of toxaemia. Burning, pungent, steaming, heat. Feet icy cold. Superficial blood-vessels, distended. Perspiration dry only on head.
- No thirst with fever.
- Belladonna always is associated with hot, red skin, flushed face, glaring eyes, throbbing carotids, excited mental state, hyperaesthesia of all senses, delirium, restless sleep, convulsive movements, dryness of mouth and throat with aversion to water.
- Worse; touch, jar, noise, draught, after noon, lying down.
- Better; semi-erect.
- Fever; Pulse full, hard, tense, and quick. Chill with external coldness, dry cough, stitches. Internal heat. Sour sweat after slight exertion. Easy, profuse perspiration. Rheumatic and typhoid marked by gastro-hepatic complications.
- Complaints: when warm weather sets in, after cold days; from cold drinks or ice in hot weather; after taking cold or getting hot in summer; from chilling when overheated;
- Lips parched, dry, cracked. dryness of mouth, tongue, and throat, with excessive thirst. Tongue coated yellowish, dark brown; heavily white in gastric derangement. Bitter taste.
- Aggravation; warmth, any motion, morning, eating, hot weather, exertion, touch. Cannot sit up; gets faint and sick.
- Amelioration ; lying on painful side, pressure, rest, cold things.
- Fever; Chill daily at 3 p.m. Painful swelling of various veins during a chill. Shivering even in a warm room.
- Periodicity is extremely well marked, the attacks returning at the same hour each day.
- Great sensitiveness of the dorsal vertebrae
- Fever; Intermittent fever; paroxysm anticipates from two to three hours each attack; returns every seven or fourteen days; never at night; sweats profusely all over on being covered, or during sleep. All stages well marked. Chill generally in forenoon, commencing in breast; thirst before chill, and little and often. Debilitating night-sweats. Free perspiration caused by every little exertion, especially on single parts.
- One hand icy cold, the other warm
- Pains are < by slightest touch, but > by hard pressure.
- Aggravation; Slightest touch. Draught of air; every other day; loss of vital fluids; at night; After eating; bending over.
- Amelioration ; bending double; hard pressure; open air; warmth.
- In the early stages of febrile conditions, it stands midway between sthenic activity of Aconite and Bell, and the asthenic sluggishness and torpidity of GELS.
- The remedy for first stage of all febrile disturbances and inflammations before exudation sets in ; especially for catarrhal affections of the respiratory tract.
- Causation; Checked perspiration on a warm summer’s day. Mechanical injuries.
- Aggravation; at night and 4 to 6 a.m.; touch, jar, motion, right side.
- Amelioration ; cold applications.
- Fever; Wants to be held, because he shakes so. Pulse slow, full, soft, compressible. Chilliness up and down back. Heat and sweat stages, long and exhausting. Dumb-ague, with much muscular soreness, great prostration, and violent headache.
- Chill, without thirst, along spine; wave-like, extending upward from sacrum to occiput.
- Bad effects from fright, fear, exciting news and sudden emotions.
- Complete relaxation and prostration of whole muscular system, with entire motor paralysis.
- Aggravation; damp weather, fog, before a thunderstorm, emotion, or excitement, Bad news, tobacco-smoking, when thinking of his ailments; at 10 a.m.
- Amelioration ; bending forward, by profuse urination, open air, continued motion, stimulants.
- Fever; Chilly in open air or from slightest draught. Dry heat at night. Profuse sweat; sour, sticky, offensive.
- In diseases where suppuration seems inevitable, Hepar may open the abscess and hasten the cure.
- Oversensitive, physically and mentally;
- Extremely sensitive to cold air, imagines he can feel the air if a door is opened in the next room; must be wrapped up to the face even in hot weather; takes cold from slightest exposure to fresh air.
- Aggravation; Lying on painful side; cold air; uncovering; eating or drinking cold things; touching affected parts; abuse of mercury.
- Amelioration; in damp weather, from wrapping head up, from warmth, after eating.
- Fever; Shivering, even in a warm room. Flushes of heat all over body. Marked fever, restlessness, red cheeks, apathetic. Profuse sweat.
- Right-sided pneumonia with high temperature. Pneumonia. Hepatization spreads rapidly with persistent high temperature; absence of pain in spite of great involvement, worse warmth; craves cool air.
- Iod. individual is exceedingly thin, dark complexioned, with enlarged lymphatic glands, has voracious appetite but gets thin.
- Hungry with much thirst. Better after eating.
- Aggravation; when quiet, in warm room, right side.
- Amelioration; walking about, in open air.
- Intermittent fever: in beginning of irregular cases; with nausea, or from gastric disturbance; after abuse of, or suppression from quinine. Intermittent dyspepsia, every other day at same hour; fever, with persistent nausea.
- Oversensitive to heat and cold.
- Adapted to cases where the gastric symptoms predominate.
- Tongue clean or slightly coated.
- In all diseases with constant and continual nausea. Nausea; with profuse saliva; vomiting of white, glairy mucus in large quantities, without relief; sleepy afterwards;
- Aggravation; periodically; from veal, moist warm wind, lying down.
- Fever; Chilly in back; feet icy cold; hot flushes and hot perspiration. Paroxysm returns after acids. Intermittent fever every spring. Internal sensation of heat, with cold feet.
- Typhoid, typhus; stupor or muttering delirium, sunken countenance, falling of lower jaw; tongue dry, black, trembles, is protruded with difficulty or catches on the teeth when protruding; conjunctiva yellow or orange color; perspiration cold, stains yellow, bloody.
- Better adapted to thin and emaciated than to fleshy persons; to those who have been changed, both mentally and physically, by their illness.
- Left side principally affected; diseases begin on the left and go to the right side.
- Intolerance of tight bands about neck or waist.
- Wants to be fanned, but slowly and at a distance.
- Aggravation; after sleep. Sleeps into aggravation; ailments that come on during sleep; left side, in the spring, warm bath, pressure or constriction, hot drinks. Closing eyes.
- Amelioration; appearance of discharges, warm applications.
- Fever; Chill between 3 and 4 p.m., followed by sweat. Icy coldness. Feels as if lying on ice. One chill is followed by another. Neglected pneumonia, with great dyspnoea, flying of alae nasae and presence of mucous rales.
- Chilliness in the afternoon from 4 to 8, with sensation as of numbness in hands and feet.
- For persons intellectually keen, but physically weak; upper part of body emaciated, lower part semi-dropsical; predisposed to lung and hepatic affections.
- Ailments from fright, anger, mortification, or vexation with reserved displeasure.
- Intolerant of cold drinks; Craves everything warm.
- Aggravation; right side, from right to left, from above downward, 4 to 8 p.m.; from heat or warm room, hot air, bed. Warm applications, except throat and stomach which are better from warm drinks.
- Amelioration; By motion, after midnight, from warm food and drink, on getting cold, from being uncovered.
- Fever; Generally gastric or bilious, with profuse nightly perspiration; debility, slow and lingering. Heat and shuddering alternately. Yellow perspiration. Profuse perspiration without relief. creeping chilliness; worse in the evening and into night. Alternate flashes of heat in single parts.
- Great weakness and trembling from least exertion. Breath and body smell foul.
- Tongue: large, flabby, shows imprint of teeth, mapped tongue.
- Intense thirst although the tongue looks moist and the saliva is profuse.
- Aggravation; at night, wet, damp weather, lying on right side, perspiring; warm room and warm bed.
- Fever; Chill between 9 and 11 a.m. Heat; violent thirst, increases with fever. Fever-blisters. Coldness of the body, and continued chilliness very marked. Hydraemia in chronic malarial states with weakness, constipation, loss of appetite, etc. Sweats on every exertion. old chronic, badly treated cases, especially after suppression by quinine; headache, with unconsciousness during chill and heat; sweat >. pains.
- Tongue: mapped, with red insular patches; like ringworm on sides.
- Craving for salt; great aversion to bread.
- Great emaciation; losing flesh while living well. Great liability to take cold.
- Aggravation; noise, music, warm room, lying down; about 10 a.m., at seashore, mental exertion, consolation, Heat, talking.
- Amelioration; open air, cold bathing, going without regular meals, lying on right side; pressure against back, tight clothing.
- Fever; Cold stage predominates. Paroxysms anticipate in morning. Excessive rigor, with blueness of finger-nails. Aching in limbs and back, and gastric symptoms. Chilly, must be covered in every stage of fever. Perspiration sour; only one side of body. Chilliness on being uncovered, yet he does not allow being covered. Dry heat of the body.
- Oversensitive: to external impressions; to noise, odors, light or music; trifling ailments are unbearable; every harmless word offends
- Bad effects of: coffee, tobacco, alcoholic stimulants; highly spiced or seasoned food; over-eating; long-continued mental over-exertion; sedentary habits; loss of sleep; aromatic or patent medicine; sitting on cold stones, especially in warm weather.
- Aggravation; morning, mental exertion, after eating, touch, spices, stimulants, narcotics, dry weather, cold.
- Amelioration; from a nap, if allowed to finish it; in evening, while at rest, in damp, wet weather, strong pressure.
- Fever; Chilly every evening. Cold knees at night. Adynamic with lack of thirst, but unnatural hunger. Hectic, with small, quick pulse; viscid night- sweats. Stupid delirium. Profuse perspiration.
- Thirst for very cold water.
- Tongue Dry, smooth, red or white, not thickly coated.
- Oversensitiveness of all the senses to external impressions, light, noise, odors, touch.
- Burning: intense heat running up the back; of every organ or tissue of the body
- Aggravation; touch; physical or mental exertion; twilight; warm food or drink; change of weather, from getting wet in hot weather; evening; lying on left or painful side; during a thunder-storm; ascending stairs.
- Amelioration; in dark, lying on right side, cold food; cold; open air; washing with cold water; sleep.
- Fever; Adynamic; restless, trembling. Typhoid; tongue dry and brown; sordes; bowels loose; great restlessness. Intermittent; chill, with dry cough and restlessness. During heat, urticaria. Hydroa. Chilly, as if cold water were poured over him, followed by heat and inclination to stretch the limbs.
- Ailments: from spraining or straining a single part, muscle or tendon; overlifting, particularly damp ground; too much summer bathing in lake or river.
- Great restlessness, anxiety, apprehension; cannot remain in bed, must change position often to obtain relief from pain.
- Corners of mouth ulcerated, fever blisters around mouth and on chin.
- Tongue: dry, sore, red, cracked; triangular red tip; takes imprint of teeth.
- Great thirst, with dry tongue, mouth and throat.
- Aggravation; during sleep, cold, wet rainy weather and after rain; at night, during rest, drenching, when lying on back or right side.
- Amelioration; warm, dry weather, motion; walking,change of position, rubbing, warm applications, from stretching out limbs.
- Fever; Chilliness; very sensitive to cold air. Creeping, shivering over the whole body. Cold extremities, even in a warm room. Sweat at night; worse towards morning. Suffering parts feel cold.
- Great weariness and debility; wants to lie down.
- Ailments. caused by suppressed foot-sweat; exposing the head or back to any slight draft of air; bad effects of vaccination, especially abscesses and convulsions;
- Has a wonderful control over the suppurative process – soft tissue, periosteum or bone – maturing abscesses when desired or reducing excessive suppuration.
- Takes cold from exposure to feet. Sweat of hands, toes, feet and axillae; offensive.
- Aggravation; new moon, in morning, from washing, during menses, uncovering, lying down, damp, lying on left side, cold.
- Amelioration; warmth, wrapping up head, summer; in wet or humid weather.
- Fever; Frequent flashes of heat. violent ebullitions of heat throughout entire body. Dry skin and great thirst. Night sweat, on nape and occiput. Perspiration of single parts. Disgusting sweats. Remittent type.
- When carefully- selected remedies fail to act, especially in acute diseases; it frequently arouses the reactionary powers of the organism.
- Sensation of burning: on vertex; and smarting in eyes; in face, without redness; of vesicles in mouth;
- Constant heat on vertex; cold feet in daytime with burning soles at night, wants to find a cool place for them.
- Aggravation; at rest, when standing, warmth in bed, washing, bathing, in morning, 11 a.m., night, from alcoholic stimulants, periodically.
- Amelioration; dry, warm weather, lying on right side, from drawing up affected limbs.