– Obscure fevers in small children (G. Tucker) ,

This title of “Obscure Fevers in Small Children,” is misleading, for it is not the fever that is obscure; in fact, fever is the most prominent and often the only symptom that proclaims the child sick. A better title would be “Fevers Due to Obscure Causes in Children.” Please to note that we say children, for we do not wish to consider for the time the infant, but rather the child after the period of first dentition, say two and a half years onward to ten years, possibly to puberty, which is, strictly speaking, the child period.
 Formative periods of life are easily disturbed, and the function of a developing organ is very easily deranged, hence it follows that the physiology of a child subjects it easily to morbid conditions, and fever is one of the most frequent of symptoms to proclaim the child out of the normal state.
 In sickness waste is greater than repair, and there can be no development during this time: therefore, it follows that when a child is sick, even if only slightly ill for a short time, if such sickness is frequently repeated, it becomes a serious menace to its future welfare. The office of the physician with children is not alone to cure, but to prevent sickness, and to cure in children is often far easier than to prevent a return of sickness. These may be trite truisms, but whoever has to deal with children’s diseases cannot in a single instance lose sight of them.
 The sick child in whom fever is the most prominent symptom presents a number of problems. The physician is expected to cure, that is why he is called, hence the prescription for the eradication of the fever is foremost. It has been said to know a disease is half of the cure. Here is a fever, the results of some cause, what is the cause? To push one’s investigation till the cause be found, as a rule, embraces the solution of all the problems, viz., the prescription for the eradication of the fever, the diagnosis, prognosis and the prevention of a recurrence.
 Perhaps a few moments spent in the examination of such fever case will be the quickest and most practical way to get at this subject. To properly take this case cultivated powers of observation are required. Every sense must be called into play and trained to observe accurately and with the finest discrimination. Semeiology is an important adjunct, and will stand the physician in good stead in this examination.
 What was the outset of this particular case of fever? Was it preceded by symptoms, vomiting, malaise, coryza, etc.? If there were no symptom apparent before the development of the fever, and frequently there are not, we are quite safe in eliminating all contagious diseases, as fever is seldom if ever the earliest symptom in the prodroma of scarlet fever, diphtheria, measles, etc. Even in acute polio-myelitis, where fever is early manifested, vomiting is the rule before a rise in temperature. It is not enough to ask the mother or attendant if there were symptoms preceding the fever, but more often is it necessary to enumerate symptom after symptom, for often vomiting, constipation, lack of appetite, etc., will wholly escape the attendant’s thought unless attention is called to it again. A child will have a slight coryza for several days, and the mother will not mention it, thinking it of no significance. Again, we should never fail to ask the child how it was taken sick. We all know how hard it is to get subjective symptoms from the child, but often a very young one will give a reply that proves the keynote to the whole situation. Never fail to question the child directly no matter how young. If the fever has been preceded by vomiting or other symptoms, then it follows we must carefully go over the prodroma of each particular contagious disease before eliminating it from this special case. While the physician has been doing this he has also taken the objective symptoms. The position and evidence of the child’s distress and the condition of the skin. He notes the different zones of the face indicating disturbances in the brain, chest or abdomen. While these zones in the child may not be as indicative as in the infant, they are not to be ignored. He has inspected the abdomen and perhaps the chest. The temperature has been taken, also the pulse and respiration. He gets a picture of the general make-up of the child, whether it is well developed, healthy and vigorous or undersized, puny and strumous. Farther than this, he has noted the physical status of the parents and the probable inheritance the child receives from them. He has figured on the home environments and the influence they may have on the present condition. Not satisfied, he goes into the former history of the child, the diseases it has had, its tendencies when sick, etc.
 In this manner he eliminates the contagious diseases, acute bronchitis, pneumonia, acute meningitis, both cerebral and spinal, and the usual inflammatory diseases of childhood. None of these cover this case. Long before he is through with this examination he may have decided the remedy for the cure of the fever, but not the cause of it. That there is a cause for every fever is axiomatic. Where shall we investigate farther? We answer, the organs concerned in the nutrition of the child. If you are ever at a loss to account for any disturbance in a child’s system turn to the organs concerned in its nutrition. Why? Because nutrition comprises the large proportion of the sum total of the child’s existence. When the infant at the end of first dentition merges into childhood, no great transition of function takes place till puberty is reached. Its life is largely one of eating and growing, and the growth appears largely an increase in kind rather than a metamorphosis. If there is proper nutrition there is little to menace health in a child save the contagious diseases.
 One child will take on size and strength, is scarcely ever sick, escapes the contagious diseases, or else has them in a very light form, while the next child is frequently sick, undersized, puny and feeble. What makes the difference? Nine times out of ten it is found in the nutrition of the child. This is the reason why we turn first to nutrition and the organs involved when we find a fever with obscure cause. The foremost factor that disturbs the child’s equilibrium of health is the auto-infection that comes from its intestines. It has been scientifically demonstrated that the intestines are the habitat of many micro-organisms and their products of fermentation and putrefaction are the cause of many diseases that formerly were attributed to colds, hot weather, etc. It is the auto-infection of these micro-organisms that are the source of the many unclassified fevers in children. Again, the source of infection is from the impacted intestine, for the average child does not clear the intestine, notwithstanding the daily stool. The excess of proteids, sweets and starches, with a lack of fat in a child’s food, causes more waste products than are eliminated, and is a constant menace to its health. Again, lumbricoids are a source of ptomaine poisoning. It is not long since a French physician reported twenty lumbricoids obtained from a case in the children’s hospital in Paris. You know the practice of our grandmothers, in the so-called worm fever, was to give a big dose of castor oil, and why? Some one observed, and the same can be observed to-day, that when a child had “worm fever,” if diarrhoea occurred, the fever abated quicker than if it were constipated. It was this observation that led me to flush the intestine in every case that I felt was due to auto-infection, the results led me to the practice of flushing with a saline solution, the bowels of every sick child. It cannot harm any case, and the quicker curing of my cases since I began this routine practice has been most gratifying. If one protests this is not in accord with Hahnemann’s teaching, I also protest that they are not familiar with his Organon, for if there is one thing that Hahnemann makes plain it is that the Similia will cure the effects of a sewer gas poisoning quickly, pleasantly and safely, but it is beyond its province to flush the sewer and remove the cause of the poisoning. Hahnemann puts great emphasis on recognizing “What is curable in the disease and what is curative in the remedy before applying the one to the other.” Many of the auto-infectious fevers have been classified as enteric or typhoid fever associated with the particular bacillus, enterocolitis, gastritis, etc. Many of the auto-infectious fevers do not pass on to true inflammation of tissues. Two characteristics mark these fevers before the stage of true inflammation occurs. First, the lack of a prodroma stage; second, the irregularity of the fever. A child will be put to bed apparently well, awaken with fever during the night or in the morning. There is practically no fever curve or regularity in the remissions or intermissions. There will be fever a few hours, remission, then again it appears without cause or regularity. You remember this was characteristic of the “worm fever” of our grandmothers, a fever of auto-infection. Auto-infectious fevers attack all children. A strong, sturdy child will have an attack from ingestion of improper food or constipation. Such children need only to be fed properly and attention given to their habits, and they will escape for years. What is meant by proper food? Hours could be spent in such a discussion and it would be of benefit. One illustration: A sturdy boy had fever attacks, the food and habits seemed correct, but Presto! when I found the number of doughnuts in his diet and stopped them, his fever attacks stopped also. In a little girl the exciting cause was bananas. These were vigorous children. The individual child must be studied. One’s meat is another’s poison. With the greatest care in diet and habits another child is always having attacks, and these are the strumous children. By strumous I mean all children of syphilitic, tuberculous and scrofulous diathesis. The tissues of a strumous child are delectable ground for all bacteria and their products. Their tissues invite micro-organisms as the richest soil for development. These children are the first to contract contagious diseases and have them the most severely.
 These children are the victims of auto-infection and malnutrition. Constitutional treatment must be vigorous to prevent recurrence of sickness. Another source of auto-infection is outside of the intestines, and is found in the decayed teeth of children. These also are found most often in the strumous child. Fever due to infection from this source often ends in a true adenitis. The source is apparent, but the removal of the teeth contracts the arch and is the source of deformity in second dentition. In one case where the dentist absolutely refused to remove the decayed teeth, after cleansing the teeth from food particles, a wash of hydrozone was used after each meal. Then a daily wash of Plantago major at night eradicated our fever attacks and improved the child’s health.
 There are two conditions that may be confounded with an auto-infectious fever of intestinal origin: First, the fever that comes to a chronic case of capillary bronchitis. This cause will not be found unless the lungs are carefully examined. Down at the base of the lung (and I wish to emphasize base) a small area of rales will be found. From slight exposure the child develops fever. There may be no cough or only a slight one later. I have seen a few such cases, usually in the children of tuberculous parents. The little daughter of a tuberculous mother caused me no little anxiety by frequent fever attacks, until I found the condition of the lung. When cured, the fever returned no more. The other cause is the beginning or rather the forerunner of tubercular meningitis. These fever attacks soon develop vomiting. In the vomiting of meningitis the abdomen is apt to be retracted rather than bloated or pot-bellied. History and diathesis will aid the diagnosis. Again, I believe a child may develop fever from exhaustion, perhaps it would be more correct to say nerve excitement. I recall the case of a vigorous boy of ten years, who arose at 4 A. M. to watch Ringling’s Circus unload. He scarcely stopped to eat until after the evening performance; afraid he would miss seeing something, you know; slept well so far as known, awakened the next morning with high fever, which expended itself in twenty-four hours without further symptoms. Another case was that of a little girl, who skipped the rope until she fell exhausted, followed in a few hours by a fever. What are these cases but fever due to exhaustion?
 When the fevers of auto-infection are attended by true inflammatory and other complications it takes the finest of discrimination to differentiate. One cannot know too much of etiology in dealing with children’s diseases. There is no pleasure in completing a cure without eradicating the cause and preventing the recurrence. Dietetics, every phase of nutrition, habit, heredity and environment as well as the indicated remedy will enter into the solving of the problem.
 The children of to-day will be the men and women of the next generation. To give them sound bodies is the obligation of physicians. The character of the future depends upon their sound minds in sound bodies.
 Dr. O K. Richardson, Minneapolis, Minn.: I hardly know what to say in discussing this paper. It is a very excellent paper and seems to cover the ground very completely. I do not think there is any one here who will not agree with the essayist that the intestinal canal should be cleared out before we try to find the indicated homoeopathic remedy. I think we are all Hahnemannians enough to do that first of all. She speaks of curing the disease without eradicating the cause. I hardly think that would be possible, as before the case would be cured the cause would have to be eradicated, and when we talk about a “cure” I hardly know what we mean. It is easy to say we have cured obscure fever in children, but you cannot cure the trouble so it won’t return if the cause remains. If the cause is a loaded bowel, and you unload it, and the child gets well, I do not think you can claim a cure. Certainly you cannot give any promise of immunity to future attacks along that line. In children who are subject to those feverish attacks. I think it requires the constant care of the parents and physician to keep them well, and the office of the physician in those cases is to so direct the line of treatment that the attacks will not recur.
 Dr. J. P. Cobb, Chicago, Ill.: I was very much impressed with this paper. There is one more thing I would like to see go on record, and that is, that one cause of fever in children, which is comparatively rare, is lack of elimination. There are times when the fever is not due alone to absorption, not due to pneumonia, bronchitis or some infectious disease, but because they are not eliminating the poisons they ought to. If you are in the habit of examining the urine in these cases, you will every little while run across an obscure fever, that you can clear up after this examination.
 Dr. Simmonson, New York, N. Y.: I am very much interested in this subject of obscure fevers in children. Down in New York, in the baby ward of our hospital of which I have had charge for a number of years, we get a great number, comparatively speaking, of these cases. We have babies brought in any time of the day or night. We do not know their histories, and there is no possible way of getting the symptoms. We can get nothing, except that the children have been running a temperature. The diagnosis in these cases has, to my mind, proven exceedingly interesting, and I have mapped out a sort of scheme which I follow in the majority of these cases. The first thing is to watch the temperature, and make a thorough physical examination. That physical examination may disclose some acute inflammatory process in the lung, in the pleura, or in some other part of the body, a peritonitis, or an endocarditis, or a pericarditis, a pleuritis, etc. Now if it does not disclose any of these, there are two or three diseases we think of first. Very frequently you will find in children a pneumonia which will show very few local signs. If we can rule that out the next thing we do is to examine the urine. Take these cases of intestinal auto-infection, and you can always strike it through the urine. This is sometimes a big help in clearing up the diagnosis. If we can rule out intestinal auto-intoxication, the next thing to do is to take up this scheme. Ruling out the inflammatory processes we have four diseases that we think of – four common ordinary conditions – malaria, tuberculosis, typhoid and pus. Typhoid fever is very much more common than is usually supposed. We examine the urine, and then make a blood examination. Ordinarily in typhoid fever you get a leukopenia; in malaria you get a leukopenia; in tuberculosis you have no effect on white corpuscles at all; in pus you get a leukocytosis. That rules out one or two troubles right away. If we get leukopenia with temperature we have either malaria or typhoid. If we have leukopenia and a high temperature we almost invariably have typhoid. If we have a leuocytosis, it is either tuberculosis or pus. If we have a leukocytosis we begin to search for the location of pus, and in many instances we find this pus. There is no localized inflammatory process, but it is surprising how many of these cases will show a suppurating pyelitis. I have seen cases time after time in which, before the pus showed, we would get colon bacillus in the urine of a child with suppurating pyclitis. The point I want to make in this discussion, however, is the plea that where it is possible for an early laboratory diagnosis, you will be able to make a diagnosis long before it is possible to make a bedside diagnosis.
 Dr. Waters. Boston, Mass.: There is one point I would like to mention, and that is, that in children with typhoid I frequently get a leukocytosis of 10,000 to 15,000. Of course, the differential diagnosis may be a point, if we get an increase of leukocytosis, but my experience has been that in children we not infrequently get a mild leukocytosis of 15,000 early; but with adults my experience has been that we do not get a leukopenia, although that frequently appears later. It has also been my experience that tuberculosis may give a leukycytosis, may give a leukopenia, or may give a normal blood count. While these things are very important I do not think we should rest a diagnosis upon them.
 Dr. Simmonson. New York: I did not mean to say that tuberculosis would show anything in the blood whatever. I have seen many cases with normal count. As far as the distinction between leukemia and leukocytes in children is concerned, you must remember that what would be a leukocytosis in an adult would hardly be an average in a child. Then, again, we do not get these children early enough in typhoid to see what the blood count would show. Now if we do find a leukocytosis of 12,000 or 15,000 we would hardly think that amounted to anything. Then, again, in that case, if you have a typhoid fever with a leukocytosis, you have an enormous preponderance of lymphocytes. I would make a distinction there. You would hardly speak of an amount of 12,000 or 15,000 in young children as a leukocytosis.
 Dr. Rebecca R. George, Indianapolis, Ind.: I believe that all of us in private practice experience this fact, that we get hold of certain families where children are constantly having these sudden attacks of fever, and we find almost invariably that they are due to absorption from the intestines, and in my experience, at least, I do not feel that I have cured my patient until I convinced the parents that they must look after the diet of their little ones. I have in mind a family in which there are two or three children, and it has become almost a chronic joke in the neighborhood that the doctor’s automobile is at their house once or twice a week. It is not because the father and mother are not intelligent; they are highly cultivated people. They are great lovers of candy, however. They love it and their children love it, and, therefore, they think their children must have it. They would rather pay doctor bills, and see their children suffer, than deny those children their candy. Of course, we must convince them that they must not have candy every day, but they do not feel that candy once a week will hurt them. They usually have two or three pounds on Sunday, and divide it among the members of the family. We must educate the parents before we can cut short the sudden attacks of fever in children found in our practice. 

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