Crisis

CRISIS (from Greek krisis — decision, outcome), one of the forms of the third period of fever (stadium decrements), characterized by a rapid fall in temperature and a sharp turn in the course of the disease itself. The fall in temperature occurs within a period of 4–5 hours to 2 days, from high feverish figures to normal and subnormal values, in contrast to the gradual fall called lysis. The cause of a crisis should be recognized as the rapid elimination of irritants that caused the disturbance of the body's heat regulation. Such an irritant is most often some infectious agent — pathogenic microorganisms, more precisely — the products of their vital activity or decomposition (toxins). However, a similar effect can be caused by the entry into the circulation of various so-called pyrogenic or febrigenous substances, which are products of the decomposition of cellular elements of a living organism. Depending on the number of irritants and the speed of elimination of each of them in different diseases, a whole series of forms of fall of fever temperature can be observed. Among these are forms in which critical fall of temperature is the rule (typhoid fever, malaria, lobar pneumonia, erysipelas, etc.). In the first two diseases, the duration of the fall of temperature sometimes of 5–6–7° is measured by 5–8 hours (curve I). In lobar pneumonia and erysipelas, along with such a rapid fall of temperature, a lowering of it to normal is often observed over a longer period, as if in two stages; the sharp drop of the temperature curve is delayed, not reaching the normal level, sometimes giving a larger or smaller jump upward, in order to fall to normal during the second day (curve II). Typhus fever is usually included among the diseases that end critically. However, during the last pandemic it could be confirmed that even uncomplicated forms of typhus fever often end with a stepwise decrease in temperature over 3 and even more days (curve III). Such a duration of the period of fall of temperature brings the crisis closer to lysis (prolonged crisis or shortened lysis, crisisolysis) and vividly illustrates the conventionality of the qualitative opposition of phenomena that differ in essence quantitatively. It should be noted that critical fall of temperature is, as a rule, characteristic of those infectious diseases that develop equally quickly, with a sudden high rise in temperature and chills. This rule, however, is not without exceptions: for example, scarlet fever, measles. Often directly or shortly before the temperature crisis, a maximum rise in temperature (perturbatio praecritica) or a deep notch of the curve downward (the so-called false crisis, pseudocrisis) is observed. The term pseudocrisis emphasizes that the concept of crisis is not exhausted by a rapid and significant fall in temperature. The difference between deep remissions, repeated 'critical' falls in temperature (for example, in pyemia, sepsis, etc.) and a crisis lies in the fact that they are transient, quickly alternating with new rises in temperature, and are not associated with the complete elimination of the cause of the febrile state of the organism. A crisis is present when the rapid fall in temperature depends on the completion of the cycle of a given disease (for example, lobar pneumonia) or a certain period of it (for example, in typhoid fever). With normal and complete completion of the crisis, the symptom complex caused by fever — increased pulse, increased and deepened breathing, excitement or clouding of consciousness, dry skin, decrease in the amount of urine and qualitative changes in it, reflecting the characteristic change in metabolism during fever — changes; usually even before the temperature falls, sweat appears, reaching profuse sweating, in full accordance with the subsequent rapid fall in temperature. The pulse slows down, bradycardia is even sometimes observed; breathing comes to normal. If consciousness was clouded, it clears, excitement and insomnia are replaced by deep sleep, from which waking up, the patient, despite sometimes sharply expressed general weakness, states the feeling of relief and recovery experienced by him. Various painful sensations (neuralgias, muscle and joint pains, aches) that are so frequent during a febrile state also disappear, diuresis increases, urine lightens, specific gravity falls. The lag in the regression of the above-mentioned symptoms of the febrile state compared with the sharp fall in temperature finds its explanation in the fact that not all of them depend directly on the cause that caused the disturbance of heat regulation. The sudden sharp change in the tone of the nervous and cardiovascular systems associated with a crisis can cause collapse states (see). Clinical assessment of collapse and crisis is quite different. Collapse, having a common sign with crisis in rapid fall of temperature, differs sharply from crisis by increasing pulse, decreasing it to thread-like, frequent shallow breathing, pallor, cyanosis, clouding of consciousness, nausea, vomiting; instead of the so-called hot reactive sweat, a cold, asphyctic sweat appears. Furthermore, the immediate cause of collapse is insufficiency of the cardiovascular system, while a crisis is a relatively appropriate moment marking the completion of the immunobiological cycle called an infectious disease. To eliminate the disturbances of heat regulation and metabolism underlying the febrile process, the organism can either free itself from the main source of irritation that caused these disturbances, or neutralize it; this position remains in force regardless of the way in which the irritation of the corresponding systems and centers is achieved — by direct intoxication of them or reflexly. The possibility of critical resolution of the febrile process following the freeing of the organism from the pathogenic agent is often proved by the abortive action of opening a purulent focus causing fever. A vivid example of a crisis of the same order is the abortive therapeutic action of salvarsan in typhoid fever. The natural development of a crisis can be a consequence not only of the destruction of the pathogenic agent, but also of its neutralization (temporary or final) or the formation of corresponding immunity by the organism. - Critical resolution of a number of infectious forms is not always associated with the prior death of all microorganisms causing the given disease. If the crisis in the last attack of typhoid fever usually coincides with the death of all spirochetes; then the repetition of attacks testifies to the preservation of the living virus in the patient's organism despite the critical end of previous attacks. Periodic repetition of crises during paroxysmal febrile diseases is conditioned by a change in the relations between the causative agent and the organism depending on the new stage of development of the infection. A vivid example of the dependence of crisis on the cycle of development of infection, periodically passing into a stage at which the presence of the causative agent in the organism does not cause fever, is malaria. - Crisis in such infectious diseases as lobar pneumonia, erysipelas, etc., is explained by a change in the immunobiological state of the organism, and not by the destruction of the causative agent. The form of resolution of the febrile process caused by infection cannot remain without influence on the character and number of infectious foci; that is why crises must end such infections in which the simultaneous elimination of the main irritation causing the febrile state of the organism is possible. Hence it is understandable the critical end of the so-called blood infections (malaria, recurrens) and such strictly defined forms as lobar pneumonia and erysipelas. Wandering forms of pneumonia and erysipelas do not resolve critically. - The crisis phenomenon from a clinical side is often very desirable — can take on large proportions and cause, as already said, a reaction directly threatening the life of the patient. It is the duty of the clinician to support the patient's organism at this time and take measures to prevent possible complications. During the waiting for a crisis, antipyretics should by no means be prescribed; if cardiac activity is weakened, camphor under the skin, strophanthin, digalen, caffeine orally. With the first signs of sweat — remove ice from the head of the feverish person, cover warmly, quickly and carefully changing the sweat-soaked linen. A hot water bottle to the feet. Abundant warm drinking. In case of threat of collapse — caffeine, strychnine, adrenaline into muscles, subcutaneous saline infusions; stimulants — hot coffee, wine (especially for alcoholics!). With increasing weakness of the heart — strophanthin, digalen into the vein. In collapse — adrenaline into the vein or into the heart cavity, oxygen, artificial respiration (see Collapse). Lit.-see lit. to the article Fever. G. Ivashentsov.