CHAPTER I.
INTRODUCTION.
Definition of Fever: Causes: Physiology: Varieties: Lysis: Crisis: Recrudescence: Relapse: Normal and Abnormal Temperature: Symptoms,
Fever.—Synonym, Pyrexia. Fever, in the ordinary acceptance of the term, is understood to signify an abnormally high body temperature. In the present state of our knowledge, however, it must be considered as a group of symptoms caused by some derangement of the chemistry of the body which may be the result of a variety of causes. These causes may act from within, being generated in the body, or from without, having been introduced into the body. In either case they act by affecting the nervous system. For in- stance, fever may result from the failure of the body to throw off certain excrementitious products, as in cases of uremic poisoning ; from certain changes in the blood, as in cases of anemia; from exposure to ex- tremes of heat, as in sunstroke ; from various intestinal disturbances; from mental abnormalities, as in hys- teria. Most often, however, rises in temperature are due to the products of bacterial infection. The bac- teria, as they grow in the body, throw off certain poi-
2 I
2 FEVER NURSING.
sonous substances which are taken up by the circulating blood and affect the nervous mechanism which controls body heat.
It is believed that in the central nervous system a centre or centres exist which control the heat produc- tion and the heat radiation (the two factors which regulate the temperature) of the body. Fever, there- fore, is the result of the abnormal working of this nervous mechanism.
Heat production and heat radiation being responsible for the maintenance of a fairly constant body tem- perature, it follows that when variations from this tem- perature occur, they must be the result of abnormalities of these factors. Thus, fever may follow an increased heat production, a diminished heat radiation, or any other lack of proper ratio between the workings of these two functions. As a matter of fact, however, the most usual cause of fever is an increased pro- duction of body heat. Abnormalities of heat radia- tion are rare.
The word “ fever” is incorporated in the designa- tions of certain diseases of which, to the superficial observer at least, the chief manifestation is a rise in temperature. Of these diseases, which are sometimes spoken of as the essential fevers, typhoid fever may serve as an example. However, in these diseases, as in all others, the fever, that is, the high body tempera- ture, is merely a part of the clinical picture, or in other words only a symptom.
Fevers are spoken of as continued, intermittent or
INTRODUCTION. 3
remittent. A continued fever is one in which the temperature maintains a continued high level with only slight variations. Typhoid fever may be taken as an example of this type. An intermittent fever is one marked by periods when the temperature may fall to normal, or even below this point, but only to rise again. Of this type ordinary malarial fever may serve as an example. A remittent fever is one characterized by a temperature continuously above the normal, and which falls and rises but is without intermissions. Remittent malarial fever may be considered as an example of this class.
Again, fevers are classified as sthenic (dynamic) and asthenic (adynamic). A sthenic fever is one charac- terized by a hot, dry skin, thirst, full, strong, rapid, tense pulse, high temperature, and perhaps active de- lirium. An asthenic fever is one in which the skin is cold and clammy, the pulse feeble, and the nervous system depressed.
In rare cases what is called an inverse fever occurs. In this type the elevation is highest in the morning and lowest in the evening, the opposite of the usual rule.
The return of an elevated temperature to normal is known as the defervescence. This may take place by a gradual fall with intermissions during which there is a rise, but not to so high a point as that at which the fall began, and, as a rule, each successive rise is less than its predecessor; a defervescence of this character is called a defervescence by lysis. At the termina- tion of typhoid fever the temperature drops in this
4 FEVER NURSING.
manner. When a temperature falls to normal or be- low this point in the course of a few hours, the defer- vescence is spoken of as occurring by crisis. The usual defervescence in pneumonia is of this type.
After defervescence has taken place a rise of tem- perature lasting for only a short time sometimes hap- pens; this is spoken of as a recrudescence. Such a circumstance is usually due to some insignificant and often unaccountable cause. When the fever and the other symptoms of the original disease return, it is evi- dent that re-infection has taken place, and this mani- festation is known as a relapse. To guard against the possibility of such occurrences, and in order that they may be immediately detected, it is wise to take the temperature at least once in the day, preferably in the evening, for a number of days after it has become normal.
The temperature of convalescent persons is much more easily affected than that of those in health. Errors in diet, constipation, too much muscular exer- tion, or mental excitement are often followed by rises of temperature in such cases. A rise of three degrees or more may signify the onset of some complication or a relapse, and, consequently, should immediately be re- ported to the attending physician. Sudden falls in temperature are likely to indicate collapse. In apo- plexy and febrile diseases a considerable rise in tem- perature often takes place just before death, while in chronic wasting diseases the temperature may be sub- normal for a number of hours before the end finally
INTRODUCTION. 5
takes place. The temperature of infants and young children is much more easily influenced than that of adults, and consequently in them even slight constitu- tional disturbances may cause a fever of considerable height.
The temperature is nearly the same in all parts of the body ; which may be accounted for by the fact that all parts are supplied by the blood, one of the functions of which is the distribution of heat. The average tem- perature of the human body in health is 98.6° F. (37° C.), but any temperature from 97.5° F. (36.5° C.) to 99.5° F. (37.5° C.) is not considered abnormal, since body heat may be influenced by various factors even when disease is absent. The temperature of the body uninfluenced by disease may vary thus:
(a) With the time of day. It is usually highest from four to seven o’clock P. M. Its maximum is maintained for three or four hours, when a slow and gradual drop begins, lasting until from two to six o’clock A. M., at which time its minimum is reached ; consequently at this time vitality is at its lowest ebb. As the morning progresses a gradual rise takes place until the normal 98.6° F. (37° C.) is reached. In persons who sleep by day and work at night the tem- perature is lowest in the evening and highest in the early morning.
(b) With the performance of the body functions. There is usually a slight elevation after a full meal, due to the active performance of digestion, and also during muscular exercise; though if at this time there
6 FEVER NURSING.
is profuse perspiration, there is, as a rule, a decrease in the temperature.
(c) With the part of the body used in measuring the temperature. These variations are slight and of no importance. Rectal or vaginal temperature is slightly higher than that of the mouth or axilla. The sensation imparted to the hand by the feel of the body is no guide to the height of the body temperature, though at times fever may be suspected and later proven by the use of the thermometer.
(d) With the age of the individual. In the infant it is slightly higher than in the adult and in old age it is a trifle lower, as the following table shows:
Normal temperature in the infant.. 99.5°F. (37.5°C.) Normal temperature under 25 years. 99 °F. (37.2°C.) Normal temperature about 40 years. 98.8°F. (37.1°C.) Normal temperature in old age.... 98.6°F. (37 °C.)
(e) With the season of the year. The tempera- ture of the body is very slightly higher in summer than in winter.
A temperature above or below the limits previously indicated signifies the existence of some abnormality of the functions of the body, and often the degree of the severity of this departure from the normal is in direct ratio to the height of the fever. The tempera- ture may, however, descend as low as 77° F. (25° C.) or ascend as high as 108° F. (42.5° C.) without death resulting, but such extremes, when maintained for any considerable period of time, almost invariably termi- nate life. Extraordinary cases are on record of very
INTRODUCTION. 7
low and very high temperatures. After long exposure to severe cold a temperature of 75° F. (24° C.) has been noted, and yet the individual has recovered, and cases of sun-stroke have occurred in which the tem- perature has risen to 112° F. (44.5° C.) without caus- ing death.
In hospitals patients are sometimes found who will cause the column of mercury in the thermometer to tise to very unusual heights. This is accomplished by shaking the instrument or by rubbing its bulb upon the bed clothing. Such patients are usually maling- erers, and, if carefully watched, can be detected and prevented from practicing such deceptions.
In shock, after hemorrhage, in certain forms of nervous disease, during marked alcoholic intoxication, especially if the individual has been exposed to cold and damp weather, and in any other condition pro- ducing a considerable weakening of vitality and a con- sequent condition of collapse, a subnormal tempera- ture may exist.
The various ranges of body temperature may be classified thus:
Temperature of collapse. 95°- 97°F. (35 °-36.1°C.) Subnormal temperature.. 97°— 98°F. (36.1°-36.7°C.) Normal temperature... 98°— 90°F. (36.7°-37.2°C.) Temperature of “ fever-
ishness” .. Slight fever. Moderate feve: High fever...
Intense feve: Hyperpyrexia
99°-100°F, (37.2°-37.8°C.) 100°-10r°F. (37.8°-38.4°C.) « 102°~103°F. (38.9°-39.5°C.).
- 104°-105°F, (40 °~40.5°C.). 105°-106°F. (40.5°-41.1°C.) 106°F. (41.1°C.) and above.
8 FEVER NURSING.
An elevation in body temperature is, as a rule, ac- companied by certain symptoms referable to the vari- ous tissues and organs. Not all these symptoms show themselves in every case, they may not all be present in a selected case, but many of them are likely to be noticed in a patient who has any considerable rise in temperature. In certain diseases various of these symptoms may be particularly marked, and this fact often is of great aid in diagnosis. Instances in point are the conjunctivitis that usually accompanies measles and the sore throat that is a feature of the onset of scarlet fever. If the fever is caused by inflammation localized in any part of the body, there are usually manifestations which call the attention of both the patient and the observer to this part. For example, the pain in the chest, the cough, and the shortness of breath of pneumonia immediately suggest some inter- ference with the proper action of the lungs.
Febrile diseases in the adult are usually ushered in by a distinct chill, with marked shivering, pallor, blue- ness of the lips, chattering of the teeth, and inability to keep warm, no matter how thickly covered, or by chilly feelings of greater or less severity. In the child it is often a convulsion, which may vary in intensity from slight muscular tremors of face and extremities to distressing movements of the entire body, which indicates the onset of fever. Following the initial chill or convulsion the rise in temperature, accom- panied by other symptoms, appears.
INTRODUCTION. 9
Tue SYMPTOMS OF FEVER.
Symptoms Referable to the Skin.—The skin is as a rule hot and dry and the patient complains that there is “ fever” or that he “ feels feverish,” although it is quite possible for the temperature to rise to 102°—104° F. (38.9°-40° C.) without being noticed by the patient. At times, and more often in some diseases than in others, the skin may be damp with a cool perspiration. Various eruptions associated with the different erup- tive fevers may appear. These will be described later.
Tiny vesicles (water blisters) may show themselves, often in great numbers, upon various parts of the body; these need cause no alarm since they indicate nothing worthy of notice. Delicate skins often show a general rosy blush which pressure with the finger- tip causes to disappear, but which immediately reap- pears upon removal of the pressure. This phenomenon is probably due to an increased quantity of blood in the cutaneous capillaries. In the late stages of fevers the outer layers of the skin are likely to scale off. Especially is this a feature of the eruptive diseases. At times large pieces of epidermis may be peeled off, notably after typhoid fever, when the skin of the fingers or toes may come away almost intact, forming veritable “ moulds” of the parts.
Symptoms Referable to the Mucous Membranes. —The so-called “ fever sore” (herpes labialis) is likely to be present, especially in malaria and pneumonia. There is, even early in fevers, thirst and a tendency to dryness of the mouth and tongue. The latter may be
ro FEVER NURSING.
of brighter pink than normal or coated with a grayish or whitish fur, swollen, and often showing indenta- tions caused by the teeth. As the fever reaches its height the upper lip may be drawn back so as to show the teeth, and the tongue and lips become covered with a dirty, brown, foul, viscid deposit, consisting of food particles, cells from the lining of the mouth, mucus and bacteria, which is termed sordes. The lips may become fissured and the gums spongy and bleeding. At first the tongue may be coated only down its middle while its margin is redder than normal; as the disease progresses the tongue may tend to become dry at night while it remains moist by day. When the fever becomes very severe it may be difficult for the patient to extend the organ, and it becomes tremulous, brown, dry, crusted and cracked. Bleeding from the fissures readily takes place. As the patient recovers, the tongue gradually assumes its normal appearance, which pro- cess begins at the tip and extends progressively back- ward,
The pharynx is at first dry and may be the seat of a catarrhal inflammation ; the tonsils and fauces may be swollen or ulcerated. The characteristic appearances of the throat in scarlet fever, diphtheria, etc., will be described in the sections devoted to those diseases. The salivary glands may be swollen and tender. The mucous membranes of the nose and eyes are likely to be congested and their secretions may be increased. There may be nose-bleed, especially early in typhoid fever.
INTRODUCTION. Ir
Symptoms Referable to the Organs of Digestion. —The appetite is greatly diminished or entirely absent. The mere thought of food may be distasteful to the patient. At the onset of febrile disease nausea is com- mon and vomiting often follows. Gas in the intestines isa less common symptom. It usually causes little dis- comfort and may not be worthy of notice except in typhoid fever, in which disease it frequently occurs and is the result chiefly of a paralysis of the muscular coat of the bowel caused by the general infection, rather than that of the presence and growth of the bacteria in the intestine. Usually in fevers the bowels are constipated. Diarrhoea formerly was considered a marked feature of typhoid fever, but constipation is frequently present.
Symptoms Referable to the Circulatory System.— The usual pulse of febrile disease is one of increased force and frequency and of greater resistance. As a tule the increase in these qualities is proportionate to the height of the temperature, as the following table shows, though in certain patients the acceleration may not be marked even with high fever.
Temperature of 98°F. (36.7°C.) corresponds toa pulse of 60 Temperature of 99°F. (37.2°C.) corresponds toa pulse of 70 Temperature of 100°F. (37.8°C.) corresponds toa pulse of 80 Temperature of 101°F. (38.4°C.) corresponds toa pulse of 90 Temperature of 102°F. (38.9°C.) corresponds toa pulse of 100 Temperature of 103°F. (39.5°C.) corresponds toa pulse of 110 Temperature of 104°F. (40 °C.) corresponds toa pulse of 120 Temperature of 105°F. (40.5°C.) corresponds toa pulse of 130 Temperature of 106°F. (41.1°C.) corresponds toa pulse of 140
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In children the pulse is particularly susceptible to rise of temperature, rates of 150 to 190 per minute not being uncommon. In adults a rate of 110 to 130 is not infrequently observed, and it is often feeble; in extreme cases it may become so rapid and weak as to be uncountable and impart merely a sense of undu- lation to the finger—the so-called running pulse. A dicrotic pulse (one with a double beat), an intermit- tent pulse, or one irregular in force and frequency, is an indication of heart weakness. Any sudden in- crease in the rapidity or weakness of the pulse is likely to indicate the onset of some complication. Position, muscular action, and emotional excitement influence the strength and rapidity of the pulse to a considerable degree. Consequently in fevers the re- cumbent position should be insisted on, for conserva- tion of the heart’s strength may be a considerable factor in the preservation of the patient’s life if the disease prove a protracted one.
Symptoms Referable to the Respiratory System. In fever the number of respirations per minute may be slightly increased, and the depth of the breathing diminished, even when no lung involvement is associ- ated with the disease. There may be cough due to an accompanying bronchitis. When pulmonary involve- ment coexists, the respiration may be rapid, irregular and painful. In marked pulmonary disease the breath- ing may become very difficult or impossible when the patient is recumbent, and it may be necessary to allow him to sit up in bed with his back supported by a rest.
INTRODUCTION. 13
When cough exists it is often accompanied by expec- toration, the character of which will be described in the sections devoted to the febrile pulmonary diseases. Specimens of this should be retained for examination by the physician.
Symptoms Referable to the Urinary System.— The urine of a beginning fever is less in quality than in health, of higher specific gravity, of darker color, and occasionally turbid. It may cause a burning sensation on being passed, due to its increased acidity. As the disease progresses toward recovery the quantity in- creases and the urine becomes more nearly normal in other respects. In convalescence the quantity may be even greater than in health. Fever urine, on standing, often deposits a red or reddish-brown sediment, con- sisting usually of uric acid or urates, which are the products of the unusual tissue changes which take place during febrile conditions. In severe febrile disease albumin, casts and even blood may appear; these, however, do not of necessity indicate permanent impairment of the kidneys. Retention of urine is a rare concomitant of fever.
Symptoms Referable to the Nervous System.— The initial chill or convulsion of fever has been dis- cussed above (p.8). When a chill manifests itself in the course of a fever it is likely to signify a sudden alteration for the worse in the patient’s condition or the onset of a complication. Consequently such an event should be immediately reported to the attending physi- cian. The convulsion of beginning fever, as a rule, is
14 FEVER NURSING.
not the result of any change in the nervous system, but is caused by the poison of the disease. Convulsions developing later in febrile disease not involving the nervous system are rare, and may be due either to hysteria or to the presence in the system of substances which shou