GENERAL MANAGEMENT OF THE FEBRILE STATE

GENERAL MANAGEMENT OF THE FEBRILE STATE
Although pyrexia, arising from interference with the function of the heat regulating centre, is usually a cardinal sign of an infection, in some of the most toxic cases the temperature may not rise above normal. Wasting, due to increased catabolism; dry hot skin, acceleration of the pulse and respiration; coated tongue, anorexia, vomiting and constipation or diarrhoea; headache, restlessness, insomnia and delirium; quantitative and qualitative changes in the urine; all these manifestations are a result of the reactions of the tissues of the host to the effects of the pathogen or its products.
In the general management of the febrile patient the essential needs are (a) rest; (b) efficient nursing ; (c) a suitable diet with adequate intake of water ; and {d) relief of symptoms.
Rest.—Confinement to bed is essential as long as the temperature remains elevated, and should be continued for a varying, but not prolonged, period in convalescence. Strict bed rest should never be regarded as an end in itself. When there is no obvious contraindication, early activity should be encouraged. The young patient is better to be up and properly dressed than to be continually in and out of bed without adequate clothing. In the elderly the real risks of a long period in bed far outweigh the potential risks of allowing a fair degree of freedom.
A single bed and firm mattress are preferable for nursing purposes. Careful bed-making contributes greatly to the patient's comfort. A length of plastic across the bed covered by a taut drawsheet will prevent extensive soiling and save linen. The bed should be made twice daily—oftener if the patient is perspiring profusely. An adequate supply of pillows will make for comfort. Bedclothes should be light and not tucked in tightly : a cage at the foot is often desirable. Quietness in the sickroom and its environment is essential; traffic in and out should be cut down to a minimum.
Ideally the sickroom should be bright and adequately ventilated and heated. Proximity to a bathroom, which should if possible be reserved for the patient's use, is advantageous. The temperature should be kept around 13° C. (55° F.) except in the case of infants or the aged, when it may be raised to between 15° to 18° C. (60° and 65° F.). Even when the room temperature is low the patient can be kept warm by hot-water bottles—and this is particularly appreci­ated by the elderly.
Nursing.—Practically all of the common infectious diseases, provided the illness is not unusually severe or complicated, are best treated at home. The mother will as a rule prove the best nurse. With modern therapy the period of heavy infectivity is comparatively short, so that the risk of spread of infection is slight. The mother should be given instructions in simple home nursing and, in particular, emphasis should be placed on the following points.
An overall should be worn when attending to the patient and should be hung conveniently near the door. A bowl of chloroxylenol or even plain water, with soap and towels, should also be adjacent to the door and the mother should be instructed to use this frequently for hand-washing. The practitioner should be careful to practise what he teaches. A simple temperature chart should be constructed ; the thermometer should be placed in the groin or the axilla and left in position for two minutes. All treatment ordered should be entered on the chart and precise instructions given regarding administration.The patient's skin should be kept clean by sponging with soap and warm water daily, especial care being paid to areas liable to soiling. These should be freely dusted with talcum powder. The body should be washed and dried limb by limb. The windows, of course, must be kept closed during the bathing process. The refreshing and soothing effect of a "blanket bath " of this nature is of inestimable value in any febrile condition. The seriously ill patient must have his position changed every two or three hours ; areas subject to pressure should be massaged with spirit and dried with talcum powder twice daily.
Food should be given at the usual meal times, but the individual patient's likes and dislikes must be noted. Any remaining scraps of food should be removed from the sickroom and burnt. Cold water, plain or with various flavourings, must be given freely. In young children the mouth should be gently cleansed after each meal by inserting the index finger enveloped in cotton-wool soaked in warm water or warm solution of bicarbonate of soda containing 2 g. (30 gr.) to 600 ml. In older children the teeth should be brushed and the mouth rinsed with warm water or mild antiseptic solution. The lips may be smeared with petroleum jelly.
Nasal discharge must be promptly removed preferably on paper handkerchiefs, and the nostrils gently cleaned with a cotton-wool swab soaked in' warm saline or bicarbonate solution. Older children should be encouraged to clear the nose by gentle blowing. Petroleum jelly applied to the nostrils and upper lips prevents crusting and excoriation.
The eyes may require regular cleansing, and saline swabbing is usually best. The very toxic or comatose patient often lies for long periods with the eyelids partially separated so that the cornea dries, and may become ulcerated. This can be prevented by instilling a drop of castor oil into the conjunctival sac.
All excreta should be removed from the sickroom and consigned to the closet as quickly as possible. Care must be taken to avoid contamination of water-closet seats. Specimens required for the physician's inspection should be placed in covered fly-proof receptacles. Bed-linen, towels, etc., which may have been soiled with excreta should be left soaking in weak lysol solution over­night before being thoroughly washed with soap and water. Swabs used for wiping away discharges from the mouth, nose, ears, eyes and other'organs must be burnt.
Flies must be excluded from the sickroom and, in summer, spraying with dicophane or some similar material is an important measure.
Diet.—The characteristic change in the metabolism of the fevered person is the greatly increased destruction of the nitrogen-containing tissues of the body. Instead of endeavouring to make good this loss by an increased nitrogen intake, it is a better policy to supply an abundance of " protein sparers " in the form of carbohydrates. Fevered patients strongly dislike fatty foods. On theoretical grounds a high caloric intake is indicated, but in practice, owing to loss of appetite and actual distaste for food, this is impossible to attain during the height of the fever.
When the febrile period does not exceed four or five days (and, it may be noted, this is now usual with specific therapy), the diet should be restricted to fluids and " feeding up " is to be deprecated. One and a half to three pints of milk daily usually form the basis of the diet. Not more than 150 to 180 ml. (5 to 6 fl. oz.) should be given at a feed. Glucose is a most valuable and easily assimilated food, which should be given freely in the form of sweetened lemon or orange juice drinks. From 150 to 300 g. (5 to 10 oz.) of glucose can readily be administered in the 24 hours. Jellies, clear soups, eggs and custards are useful additions to the diet, and varying flavouring agents can add spice to an otherwise monotonous round. Because of their low nutritive value, high content of extractives and relative cost, the various commercial beef-juice preparations have little to commend them.
The free intake of water favours the elimination of waste-products. Hence the patient should be encouraged to drink cold or hot water freely between feeds. Including glucose lemonade, the water intake should amount to at least 2 to 3 litres in the 24 hours. The best indication of an adequate fluid intake is the excretion of i -5 to 2 litres of urine daily. Alcohol should not be administered as a routine.
Relief of Symptoms.—Pyrexia.—A raised body temperature is in itself not harmful. The presence of fever is a natural reaction to infection and it should be assumed that the restoration of a normal temperature by means of antipyretic drugs is never desirable.
When the temperature exceeds 39-5° C. (103° F.), the skin of the whole body should be sponged with warm (37° C., 98° F.), tepid (27° C., 80° F.), or even cold water. Quite apart from any effect in reducing temperature, the application of tepid or cold water to the skin exerts an important reflex tonic effect on the nervous, respiratory and circulatory systems, and is very refreshing. This is particularly important at night, and a tepid sponge-down will often soothe a restless patient and be followed by a period of sound sleep.
Headache and Malaise.—A combination of 0-6 g. (10 gr.) of acetylsalicylic acid and 15 mg. (1/4 gr.) of codeine administered at intervals of six hours usually gives relief. Should headache persist, phenacetin, caffeine and phenazone, 0.2 g. (3 gr) of each dihydrocodeine (10-30 mg.), may be prescribed in place of the above ; the dose to be repeated every two hours for three or four doses. The severe headache which occurs in meningitis will require more potent drugs. When headache is severe, a quiet environment and the exclusion of bright light add to the comfort of the patient.
Imomnia and Delirium.—Restlessness and inability to sleep are characteristic symptoms in febrile cases and should always be taken seriously. Nursing technique should first be reviewed and everything done to make the patient comfortable. Where sleeplessness is due to worry or anxiety, some whisky diluted with hot water followed by i g. (15 gr.) of chloral hydrate is frequently successful. The relief of headache may cure the insomnia. If pain is keeping the patient awake, i ml. (15 min.) of tincture of opium may be added to the chloral mixture ; relief may only be obtained by the hypodermic injection of 10 to 15 mg. ( 1/6 to ¼ gr.) of morphine.
Paraldehyde, 8 ml., is another excellent and safe hypnotic; unfortunately it has a most unpleasant taste and odour. It may be administered by mouth well diluted with whisky or brandy and water, or by the rectum in double the oral dose. Cyclobarbitone, in a dose of 0.1 to 0.2 g. (1 ½ to 3 gr.), and butobarbitone, 0.1 g. (1 1/2 gr.), are valuable for their general sedative as well as their hypnotic effect and although the thoughtless use of tranquillizers is to be deprecated, promazine (50 mg.) and perphenazine (2, mg.) are valuable in the control of delirium especially in the elderly.
Mild confusion can usually be controlled by chloral and tincture of opium, but active delirium calls for the hypodermic injection of 15 mg. ( ¼ gr.) of mor­phine with, in cases of maniacal excitement, the addition of 0-6 mg. ( 1/100 gr.) of hyoscine hydrobromide ; the injection may be repeated after an interval of one hour Nausea and Vomiting.—Common initial symptoms in many febrile conditions, nausea and vomiting are seldom sufficiently severe or persistent to cause anxiety once specific therapy has been started. (The occurrence of vomiting can have great importance when the intention is to give specific treatment by mouth for, of course, much of the oral dose may be lost. Its presence should, therefore, always be elicited and the nurse attendant specifically instructed to report the matter.)
When vomiting is persistent arid severe, the electrolyte disturbance may require to be rectified by intravenous infusions. This demands the closest co-operation between biochemist and clinician and is in general beyond the scope of domiciliary practice .
Constipation.—Constipation is present during the course of many infectious fevers. It is seldom a matter of much importance though it may cause the patient great concern. During a severe illness it is usually better to empty the bowel by an enema than by the administration of purgatives.
In convalescence from a severe fever a patient may become excessively anxious about constipation. He should be reassured that his normal bowel habit will be regained. One of the anthracene purgatives may be given tempor­arily such as a teaspoonful of the elixir of cascara or two Senokot tablets at night.
Disinfection.—Although the aim of disinfectants is to destroy the micro-organisms released from the patient in his various discharges and excretions, it must be realized that as generally used they are not very effective. Many spores resist their action, viruses vary considerably in their susceptibility to them and the physical properties of the excretions themselves usually impair their lethal effect. Nevertheless, in the management of infectious diseases in the home, disinfectants have a limited place in reducing the contamination of objects surrounding the patient. As a rule the aim is to eliminate the vegetative forms of bacteria, and spores do not constitute a serious problem.
The most useful disinfectants are : Chloroxylenol (B.P.C.) a phenol-related substance which makes a pleasant disinfectant for hand-washing and damp-dusting and which is particularly effective against gram-positive but not against most gram-negative organisms; lysol and its allied preparations which are valuable general-purpose disinfectants for bed linen, etc., but which must not be brought into contact with the skin; hypochlorites which are useful in dealing with dishes and glassware, but to be effective must be mixed with a detergent; and chlorhexidine or hexachlorophane which have gained a wide popularity and are often contained in soaps, handcreams and dusting powders. They are specially effective against gram-positive organisms and, since Staph. aureus can be so dangerous in nurseries, they are of value in the care of the newborn. To be of greatest benefit they must be used repeatedly. The most important point to realize is that no disinfectant can be regarded as serving all purposes and that none is a sterilizing agent. Sunlight, fresh air and soap and water are equally important.
The Attendant.—The attendant must be instructed in the importance of observing some simple rules. The hands will become grossly contaminated by bed-manipulations, cleansing of discharges, etc., and the importance of washing the hands after any attention to the patient must be emphasized. An overall or gown must be put on as soon as the sickroom is entered and removed before leaving. The fact that the air and dust of the room is charged with infection should be explained to the attendant. Damp-dusting, wet-mopping of floor surrounds and the avoidance of " brush and pan" should be insisted on. Vacuum cleaners are an asset—but when they are used, it must be remembered that the contents of the bag are heavily infected and that it should therefore be emptied with as little disturbance of the dust as possible.
The attendant must in this way be " inoculated " with the concept that the patient is the centre of a series of concentric circles of infection : this is most dense at the inner circle, and the constant endeavour must be to prevent spread outwards. The air and dust of the room form the important means whereby the outer circles become contaminated, so that all steps to reduce dust and the care­less circulation of air which disturbs dust will tend to limit spread. These measures are not only of importance in preventing the infection of others; the patient himself, especially if nursed alongside other patients, may acquire. secondary complications from the implantation (particularly in the respiratory tract) of organisms acquired from infected dust.
The use of a mask by the attendant is as a rule undesirable. If the attendant has a cold and the patient is under the age of a year, a mask is worth while, for at this period of life a very ill infant may have its chances of recovery reduced by the acquisition of secondary infection. An effective paper mask is now available which can be destroyed after use. It should only be used once and should not be touched by the hands when being worn. The wearing of a mask is often thought to infer a special efficiency in preventing infection, but it is worth' emphasizing that among careless or untrained attendants the''mask may con­stitute more of a danger than a safeguard.
The Patient.—All discharges emanating from the patient must be assumed to be infective. Attention should be particularly directed to :
Coughing and sneezing should be guarded by the use of paper handkerchiefs. Sputum as well as nasal, aural or ocular discharges should be carefully collected in paper handkerchiefs and placed in paper bags to be burnt.
Vomitus should, if possible, be collected in a basin and immediately disposed of. The basin should be disinfected by wiping with weak lysol and washing in hot soapy water. If the linen is soiled, it should be steeped in disinfectant and ' then washed. Children who are ill often vomit unexpectedly, and the bed-linen may be saved by the use of towels, old sheets and pieces of plastic sheeting at the top of the bed or cot. Faeces and faeces-soiled bed linen must be promptly disinfected.
Strict asepsis is of course essential in attending to wounds. Steps should be taken to avoid soiling of pillows and bed linen with discharge, for as this dries it may be shaken off to form infected dust. All fluids removed for testing (blood, cerebrospinal fluid) must be handled carefully and sent to the laboratory as speedily as possible.Articles closely associated with the Patient.—The most important of these are the bedclothes, linen, towels, etc. All of them become heavily contaminated and, if the bed is made vigorously, organisms will be liberated into the air of the room. The enclosing of the blankets in linen sheets will tend to limit the amount of fluff disseminated when beds are made. The attendant should be instructed to avoid vigorous movements of bedclothes, mattresses, etc. Feeding utensils are best kept separately for the patient. After each meal the dishes should be washed and scalded by pouring a kettleful of boiling water over them. Toys and comic papers are a possible source of transfer of infection in children. Books and papers should be burnt, and most toys can be adequately disinfected with soap and water at the end of the illness.Final Domestic Cleansing.—A thorough domestic cleansing is all that is required for those infections which can be treated in the home. The process of laundering will effectively purify all bed linen, clothing, etc. Bulky articles such as mattresses and carpets can be exposed to fresh air, and the vacuum cleaner will be effective for cleaning. Sprays and gases have no place in the ritual except in the case of smallpox when the responsibility will rest with the Medical Officer of Health.