CHAPTER XII THE INFECTIOUS FEVERS (Part 1)

CHAPTER XII THE INFECTIOUS FEVERS CHARACTERISTICS OF FEVER Stages. — The febrile stages are invasion, fastigium, and defervescence. Invasion is the gradual rise until it reaches its maximum. Fastigium is the stage in which the temperature shows a tendency to reach again and again its highest point, although there may be marked variations. Defervescence is the gradual fall to normal. Terminations. — Crisis is a fall of temperature from its height to normal or subnormal within twenty-four hours. Lysis is a gradual fall to normal taking several days or a week. Hyperpyrexia is temperature above 1060 F. Febrile Remissions. — All temperatures of fever show a diurnal remission, usually of one degree. The maximum is at 6 p. M. and the minimum at 6 a. m. Types of Fever. — Continued Fever. — The diurnal vari- ation is slight, from i° F. to 1.50 F. Remittent. — The diurnal variation is marked and the minimum temperature remains above the normal. Intermittent. — The diurnal variation is marked and the minimum temperature is normal or subnormal. Hectic. — Due to pus. High, irregular fever, with wide fluctuations, accompanied by sweats, chills, and pallor. 230 DISEASES OF CHILD REX FOR NURSES Pulse and Fever Ratio. — There are about ten extra beats of the pulse for every degree of fever. Simple continued fever without any definite cause is called jebrieula. F. t ,-./ / ■.,' L f vt. 1 A- I M / ■ VI / •v; ICt 105 104 103 101 101 /OO 99 .98 Fig. 70.— Represents a continued fever. It is observed mostly in erysipelas, acute tuberculosis, lobar pneumonia, and typhoid fever (Kerr). The period of incubation is the period elapsing between the entrance of the poison and the development of the symptoms of the disease. It varies considerably, being F E A <1. £ M f i\ A £. A ■1. S M i '. M E. M. f. M. 10b /OS 101 A 103 A A A / \ 102 l\ A / \ /\ / ^ 101 1 / \ / \ / \ It i 00 \r \ r V I 99 98 Fig. 71. — Represents the remittent type. This is suggestive of one form of malaria, of tuberculosis (not acute), and suppuration (Kerr). influenced by the susceptibility of the patient and the virulence of the infection. For the following diseases the average period is: Typhoid fever — two to three weeks. THE INFECTIOUS FEVERS 231 Measles — two weeks. Rotheln (German measles) — ten to twelve days. Scarlatina — a few hours to a week. Smallpox — one to two weeks. F E M E M £■ M E M F. M. £ M. £ M. £ M 106 105 M /03 I \ \ | /oz / 101 / l \ \ 100 / 99 / 98 J L s~ J Fig. 72. — Represents intermittent fever. The left hand half showing the quotidian type, while the right hand half shows the tertian type. It is significant of malaria (Kerr). Erysipelas — three to seven days. Diphtheria — two to ten days. Varicella — ten to fifteen days. F f- M F M / M £ M £ M f M £ M I M 106 105 — /04 K 103 A A A A 101 \ / > /\ 1 lot 1 \ \i ' \l \ 100 1 V V V \ 9V 1 9,9 Fig. 73. — Represents a hectic and suppurative fever type, which is generally accompanied with sweating (Kerr). Tetanus — a few days to two weeks. Mumps — two to three weeks. The date when rashes appear in various diseases is as follows: 232 DISEASES OF CHILDREN FOR NURSES Typhoid fever — seventh to ninth day. Smallpox — third or fourth day. Measles — third or fourth day. Scarlatina — first or second day. Rotheln— first or second day. Varicella — first day. Protection from future attacks conferred by various diseases is as follows: Typhoid fever — relapses are common; second attack are sometimes seen. Measles — second attacks rare. What are supposed to be second attacks are usually rotheln. Rotheln — second attacks rare. Smallpox — second attacks occasionally occur. Mumps — second attacks rare. The following diseases do not confer immunity. Erysipelas, diphtheria, malaria, influenza, and croupous pneumonia. An injections disease means one due to a specific micro- organism. A contagions disease is one which can be communicated by actual contact, either through the person or by infected clothing. A complication is a condition occurring in the course of a disease. A sequel appears after the attack. CEREBROSPINAL FEVER This disease is also called spotted fever and epidemic cerebrospinal meningitis. It is a specific infectious disease characterized by inflammation of the cerebrospinal men- inges (the membranes covering the brain and spinal cord) THE INFECTIOUS FEVERS 233 and usually occurs in the winter and spring. The young are more susceptible than the old. The disease is now supposed to be contagious, although the method of trans- mission is still unknown. It is caused by a diplococcus. Symptoms. — Common Form. — The disease generally begins abruptly with a chill followed by vomiting and excruciating pain in the head, back, and limbs. The muscles of the head, neck, and back become rigid and contracted so that the head is bent backward and the back is straightened. In severe cases the body may be arched in a state of opisthotonos. The mind is soon K^A i^^ ^Kr & ^^^^ ,--' '>?PMP: ^ \ ^B^ S\ '•>~~_ — j-^iZ5- ."•'-'■'■> Fig. 74. — Cerebrospinal meningitis: Tache cerebrale shown on left thigh (Ruhrah). affected, delirium is rarely absent, and in severe cases it is followed by stupor and coma. Pressure of the exudate upon the cranial and upon the spinal nerves may produce either paralysis or hyper- sensitiveness, according to the nerves involved. The cranial nerves are usually paralyzed and the spinal nerves irritated. When the finger is drawn over the skin a red line develops; this is called the tdche cerebrale (see Fig. 74). The temperature is irregular and indefinite in duration; ordinarily it ranges between 1010 F. to 103° F. In some 234 DISEASES OF CHILD REX FOR NURSES cases it is almost normal, while in others it is very high. Tlie pulse is rapid and full, the bowels constipated, and there may be polyuria. The eruption is neither constant nor peculiar. In many cases a blotchy, purpuric rash appears over the entire body. Herpes facialis (fever blisters) are also fre- quently observed. In other cases urticaria or a roseolar or erythematous rash appears. The duration ranges from a few hours to several weeks. Convalescence is very protracted in favorable cases. Fortunately the children usually die, for if they do recover they are nearly always partially paralyzed and have some mental defect. The disease is isolated in most cities under the Board of Health rules. Lately the study of a series of cases occurring in Philadelphia has led the health authorities to consider the disease as contagious, and stricter rules in regard to isolation have been enforced. The diplococcus probably gains access to the cerebral meninges through the nose and along the blood-vessels' running from that organ to the brain. Nursing. — In nursing the disease follow the same routine described under contagious cases (see page 273). Take every antiseptic precaution and spray the nose and throat frequently with some germicide. MALARIAL FEVER This is a specific noncontagious disease caused by the hematozoa of Laveran. It is characterized by splenic enlargement, by fever with periodic intermissions or re- missions, and by a tendency to extreme anemia. Etiology. — Malaria is prevalent in very warm climates THE INFECTIOUS FEVERS 235 and in the summer season. A moist atmosphere, low, badly drained soil, and decaying vegetable matter are conditions which favor the development of the malarial poison. Special Predisposing Causes.— Residents in the lowlands are more liable to become infected than those who dwell on the hills, and visitors to malarial districts are more susceptible than permanent residents. One attack seems to predispose to others. During the night and in the early morning the air is thoroughly impregnated with the 00Bffl OefSP Fig. 75. — Some of the principal forms assumed by the Plasmodium of tertian fever in the course of its cycle of development (after Thayer and Hewetson). miasm and exposure at such times is very apt to be fol- lowed by infection. The exciting cause is the hematozoa of Laveran and the common mode of infection is by the bite of a mosquito which has previously sucked the blood of a malarial patient. All ages, from the newly born to the aged, are subject to malaria. Manifestations. — Malaria may manifest itself as intermittent fever, remittent fever, or chronic malarial cachexia. 236 DISEASES OF CHILD REX FOR NURSES Pathology. — The Hcmatozoa. — A small, colorless ame- boid body enters the red blood-corpuscles, increases in size, and becomes pigmented from the coloring-matter of the corpuscles. When the red blood -corpuscle is destroyed the granules of pigment collect in the center of the organ- ism, which finally divides into a number of small hyaline bodies, each of which begins a new cycle of existence. The chills or paroxysms occur at the time these small bodies are thrown into the blood current after the blood- cells are destroyed, and are due to the production of a poison. The parasite of tertian intermittent fever requires forty-eight hours to complete its cycle of existence; there- fore, when a single group of these parasites exist in the blood a paroxysm occurs every other day. If, however, two groups co-exist and sporulate (the term given to the time when the organisms are thrown into the blood-cur- rent) on alternate days, a paroxysm occurs daily (quotidian intermittent fever). The parasite of the quartan intermittent fever requires seventy-two hours in which to develop and undergo sporulation; hence, a single group of these organisms in the blood excites a chill on every fourth day. When two groups co-exist a chill occurs on two successive days and is followed by daily intermission. When three groups co-exist a chill occurs every day and there is quotidian intermittent fever again. The life-history of the parasite of remittent fever within the body is not definitely known. Its cycle of existence occupies from twenty-four to forty- eight hours. In advanced malaria the blood shows a diminished number of red blood-corpuscles and a large quantity of THE INFECTIOUS FEVERS 237 free pigment. The spleen is greatly swollen and deeply pigmented. All the organs, including the brain, are discolored by this free pigment. Intermittent Malarial Fever. — Symptoms. — The char- acteristic features of this form of malaria are the intermit- tent type of fever, the enlargement of the spleen, the hematozoa in the blood, and the occurrence at regular intervals of the paroxysms divided into three stages — the chill, the fever, and the sweat. leinfi- M. £. z M £. M.E ■9- M-E s M-E, 6 M.£. 8 M.£ 9 M.E /o M.E // M-E /Z M.E. 108 107 10b 105 | lO'f 1 103 A 1 loz 101 ' 100 99 I A / A A n / s A I ' _ J xv j\ /~ '7 Fig. 76. — Tertian type of malarial fever. Male child of six years. Quinin begun at X (Kerr). Cold Stage. — There is malaise, headache, and great chilliness. The features are pinched, the lips are blue, and the surface of the body is cold and covered with "goose flesh." The rectal temperature is high — 1040 F. to 105 ° F. Vomiting may occur. The chill lasts from a few minutes to an hour or two. Hot Stage. — The surface temperature gradually rises, the skin becomes hot, the face flushed, the eyes injected, and the pulse rapid and full. The temperature in the axilla may reach 1060 F. to 107 ° F. The child complains 238 DISEASES OF CHILD A' EX FOR NURSES of severe pain in the head, back, and limbs, and of thirst. The urine is scanty and dark colored. This stage usually lasts from one to five hours. Sweating Stage. — The fever gradually subsides, the pain grows less, free perspiration follows, and the child falls asleep from which he awakens feeling fairly well. Varieties. — When the disease occurs every day it 13 termed quotidian intermittent fever; every other day, tertian intermittent; every fourth dry, quartan intermittent fever. Prognosis. — Always favorable. Even when no treat- ment is instituted the paroxysms gradually subside. Chronic malarial cachexia may develop. Remittent Malarial Fever or Estivo-autumnal Fever. — In temperate zones remittent fever is observed chiefly in the autumn. It is uncommon in children who live outside of malarial districts. Symptoms. — There is malaise with moderate chilliness followed by a continuous fever which daily remits. The maximum temperature ranges from 1030 F. to 1060 F., and while this lasts the skin is hot, the face flushed, the eyes injected, the pulse full and strong, the urine scanty, and the patient complains of pain in the head, back, and limbs. Definite paroxysms may or may not be present. Delirium is sometimes noted, vomiting often occurs, and jaundice may appear from the destruction of the red blood- corpuscles and the liberation of their pigment. The spleen is enlarged and the hematozoa are found in the blood. Prognosis. — Favorable. The average duration is from one to three weeks. Chronic malarial cachexia is characterized by anemia, a sallow appearance to the skin, and splenic enlargement. THE INFECTIOUS FEVERS 239 Etiology. — It may result from repeated acute attacks of the disease or it may develop as a primary condition from slow infection. Symptoms. — The child is thin and pale, the complexion h of a dirty yellow or muddy hue, fever is often absent or if present, it is slight and irregular. The spleen is con- siderably enlarged. There is great weakness from the attending anemia. Headache and neuralgia are common symptoms. Hematuria is sometimes observed. Prognosis. — Guarded. With the spleen very large and extreme anemia the patients rarely recover. Malarial infection seems to predispose to certain cases of dys- entery, pneumonia, and amyloid degeneration of the viscera. Treatment. — As malarial fever is usually contracted by exposure to the night and early morning air, and by means of infection through mosquito bites, people living in malarial districts should not allow children to expose themselves at such hours and should protect them from the mosquitos. Quinin is a specific remedy, killing the hematozoa. The dose is from 5 gr. to 10 gr. a day in divided doses (4 years), and in ordinary cases in older chil- dren is from 15 gr. to 20 gr. a day in divided doses. The drug is given so that the last dose is taken two hours before the expected chill. The cold stage is treated with hot-water bottles and blankets, and the hot stage by sponging. SYPHILIS Syphilis is a communicable disease and may be acquired or hereditary. Syphilis is acquired usually from the mother of the child or from syphilitic wet-nurses. It follows the same >40 DISEASES OF CHILDREN FOR NURSES course as syphilis in the adult and is divided into three stages. The first is characterized by a chancre, the second by a rash, and the third by a bone lesion and ulcerations. It is contagious only in the first or second stage. Hereditary syphilis is more common. When born the child at times has large blebs on the skin surfaces and scars develop around the lips called rhagadcs. Fir,. 77. Herediti rv syphilis: radiating fissures of the lips (after A. Fruhinsholz). Symptoms. — The Bones. — Epiphysitis, an inflammation of the ends of the bones, is present. Later in the disease chronic osteoperiostitis and syphilitic dactylitis are seen. The liver and the spleen are enlarged. The Respiratory Tract. — Pneumonia is common. Ulcers of the larynx are sometimes observed. THE IXFECTIOUS FEVERS 24 1 Digestive Tract. — A chronic catarrh of the pharynx is present, causing "snuffles." The Organs of Special Senses. — Otitis media and interstitial keratitis are common. Nervous Symptoms. — Often absent, but there may be impairment of mentality. The children are weak and sickly and usually die young. If three months pass after a child is born from syphilitic parents without the appearance of any characteristic symptoms, the child will in all probability escape. Hutchinson^ Teeth. — If a child suffering from heredi- tary syphilis lives, the second or permanent teeth are characteristic (see Fig. 4). The teeth most frequently affected are the upper central incisors. They have a dull, opaque color and have a roughly rounded and stunted appearance. The cutting edge of the tooth is narrower than its neck. Over the tips of these stunted and conic teeth the enamel is irregular and forms a semilunar notch. Treatment. — The treatment of both hereditary and acquired syphilis consists in giving mercury. This, in infants, is given in the form of ointments. Great care must be taken by the nurse to avoid contamination in handling syphilis in the first and second stages. TETANUS OR LOCKJAW An acute infectious disease excited by the tetanus bacillus and characterized by painful tonic spasms of the voluntary muscles. The bacillus gains an entrance to the system through some wound. Lacerated and punctured wounds, burns, 16 242 DISEASES OF CHILDREN FOR NURSES and frost-bites arc most likely to become infected. Stables seem to be the breeding ground for the bacillus. Symptoms.— The disease begins with rigidity in the muscles of the neck and lower jaw, by degrees the mus- cles of the back, abdomen, and extremities are similarly involved. The face has a peculiar expression, the brow is wrinkled, the corners of the mouth are drawn up (the sardonic grin) and the jaws are tightly closed (trismus). The body may become arched