THE USES OF FEVER. THE DANGERS OF ANTIPYRETICS IN TYPHOID FEVER. BY J. H. MUSSER, M.D., OF PHILADELPHIA. FROM THE MEDICAL NEWS, April 23, 1892. [Reprinted from The Medical News, April 23, 1892.] THE USES OF FEVER. THE DANGERS OF ANTIPYRETICS IN TYPHOID FEVER.1 By J. H. MUSSER, M.D., OF PHILADELPHIA. Animal heat serves a physiologic purpose in the economy. When this degree of heat is beyond the limits of the norm its purposes are not physiologic. In health, normal heat is a stimulus essential to the carrying on of physiologic processes. Without it the nerve-centers controlling respiration, circu- lation, and other processes are dormant. No stretching of the imagination is necessary to con- ceive of such an impairment of the vital forces in consequence of which increased heat or fever is essential as a stimulus to enfeebled nerve-centers. The following observation impressed the writer with the use of fever as a vital stimulant: The patient, two years old, was ill of whooping- cough and its graver pulmonary complications- capillary bronchitis and atelectasis. Exhaustion was extreme, on account of her long illness of three months. Fever was marked. During the last week of her illness death was daily, then hourly expected. The hands and feet became cold, the face pale, the respirations excessively rapid and feeble (from 100 to 11 o), the pulse feeble and irregular and so rapid that 1 Read before the College of Physicians, February 3, 1892. 2 MUSSER, it scarcely could be counted ; a cold sweat bathed the brow, while stupor was present. These grave symp- toms were first observed in the mornings. The temperature ranged between ioo° and ioi° at this time. As the day advanced, the usual afternoon ex- acerbation of fever took place. With such degree of heat came evidences of renewed strength. The ex- tremities warmed, the color brightened, the respira- tions were less labored, the pulse became perceptibly stronger and fuller and more regular; intelligence was restored; though refused before, food was now taken with avidity, and even asked for, and notice taken of objects and events. Hope was restored, to fall again with each degree of decline of the ther- mometer. These paroxysms of heat-exacerbation and stimu- lation at first took place daily. On the last three days of the child's illness, as recorded by the ther- mometer, they took place every two or three hours. Indeed, during the period of lowered temperature, so depressed and feeble was the child that death was momentarily looked for. As the temperature rose -but not until it was above normal for some time- the grave symptoms disappeared. These hourly heat-paroxysms were closely watched, and to no other cause than the stimulus of heat could the re- vivals of strength and increased functional activity of the circulatory and respiratory apparatus be at- tributed. It was difficult to picture, and was cer- tainly a most striking exhibition of the play of heat- centers in the phenomena of life. Finally, the heat- centers did not respond to the unknown stimuli, after the stage of exhaustion they had undergone, the temperature did not rise, and gradually all func- tion ceased. I wished more particularly to place this observa- tion on record in order that we should bear in mind THE USES OF FEVER. 3 in these times, when so much is said about the use of antipyretics, the dangers of fever, and the necessity of reducing temperature, that at certain times high temperature may have a physiologic use in the economy. I am well aware that certain German and French writers have held that high temperature is a conservative process, particularly in septic con- ditions, through its effect upon the bacteria or the poisons generated by them. But, independently of this action, fever serves quite a physiologic use in the economy. This is the only observation that I wish to record in regard to the use of fever. The following remarks are addressed to prac- titioners who continue to use, and think they must use, antipyretic medicines, because the thermometer records high temperatures. I have never used such means to reduce temperature in typhoid fever, but I wish to particularly impress upon those who will use antifebrile drugs that it is at times essential they should withhold their hands. The present intem- perance in the use of antipyretics is due to laudation in the past of this class of drugs by eminent therapeutists. Now, in regard to the danger of the use of anti- pyretics in certain cases of typhoid fever. There are three periods in the course of typhoid fever when, without doubt, the use of antipyretics is dangerous, and these must be carefully considered : First, in the early or middle period of cases that come to us after removal from a distance. Sir Wil- liam Jenner was the first to lay great stress upon the danger of the removal of a patient suffering with typhoid fever. Anyone that observes cases in the 4 MUSSER, medical ward of a hospital will notice that the temperature for the first twenty-four hours after ad- mission is unusually high-that is, higher than one would expect at the period that the disease has reached. This rise of temperature is undoubtedly due to the exhaustion that has taken place on ac- count of the removal to the institution. I have seen this so often and made so many observations in connection with it that I hesitate to use any anti- pyretic during the first twenty-four hours after ad- mission. The records that I have bear out the cor- rectness of this course. Even if no antipyretic is given, the temperature usually falls to the proper point in twenty-four hours. Sometimes stimulants are required, and under their use the temperature falls. On the other hand, I have seen cases ad- mitted with a temperature of 105° or 105.50, in which an antipyretic was given with serious results. I am so sure of the inadvisability of administering an antipyretic under these circumstances that I direct that no antipyretic be given during the first twenty- four hours after admission, but that stimulants shall be administered. Again, there are certain cases in which peculiar idiosyncrasies exist, in which it is inadmissible to use antipyretics during the course of typhoid fever, no matter how high the temperature may be, if life is not threatened. I remember one such case among a number of others. We have all seen patients that were particularly susceptible to drugs, to the appli- cation of external cold, to any kind of stimulant, and to opiates or alcohol in any form. The case that I have in mind is that of a young woman who THE USES OF FEVER. 5 was in the private ward of the Presbyterian Hos- pital, with typhoid fever running a regular course, but with excessively high temperature. It was im- possible to administer any antipyretic. She was ex- traordinarily susceptible to quinine, one grain pro- ducing serious nervous symptoms. The use of alcohol caused increased headache and violent nervous symptoms. The external application of cold and the external use of alcohol or other re- frigerants produced shivering and great depression. Without my concurrence, five grains of antipyrin on one occasion were administered with such serious collapse that for five hours it required the efforts of three of the internes to restore the patient to her natural temperature, and, in fact, to save her life. It was the most extraordinary degree of depression that I have seen from a single administration of the drug. This is an example of a number of cases in which it is impossible to administer antipyretics, as a result of peculiarities of individual constitution. I think that physicians who are constantly calling attention to the use of antipyretics neglect to look for these peculiarities, which I think are present in many cases. I have now under observation an indi- vidual of highly nervous temperament, to whom I would not administer an antipyretic unless life was absolutely threatened. It is in the latter stages of typhoid fever that I think antipyretics are especially dangerous, and must be administered with the greatest care. Two classes of such cases are worthy of attention. There is one class in which the temperature persistently remains at the maximum, but there is abatement 6 MUSSER, of all of the other symptoms-lessening of the diar- rhea, cleaning of the tongue, diminution of the delirium, and even lowering of the pulse, with in- crease of strength. We feel that the typhoid pro- cess is ended, but the fever, nevertheless, continues high. I will illustrate this with brief reports of two cases : In the first case, in a lad ten years of age, whom I attended during the course of an attack of typhoid fever, from the fifteenth to the eighteenth day of the disease the temperature ranged between 104° and 105.50. The tongue had cleaned, the number of stools had lessened and these were gradually be- coming formed, and I felt that the pathologic process was at an end, and that if we waited a little while the fever would probably subside. There were no danger- ous symptoms except the high fever. At 10 o'clock on the evening of the eighteenth day the temperature was 105°; it then began to fall until, at 6 o'clock in the morning, it was just below 96° ; it required all the efforts of the father and the nurse to prevent what they thought to be a fatal collapse. The temperature remained below 96° for an hour, then began to rise, and by 9 o'clock in the evening it was 104°. It remained at about this point for two hours, and then gradually fell until in the morning it was 96.5°. It then rose again, to be followed by another fall, but not to such a low point. There is no way in which this fall in temperature could have been anticipated. If we had applied external cold or administered an internal antipyretic, I am quite sure that the collapse that occurred naturally would have been a fatal one. This sudden fall often occurs in typhoid fever in children, and it is one of the ways in which the fever subsides, the disease terminating by crisis. THE USES OF FEVER. 7 In the second case-that of a young man, seven- teen years of age, who was treated in the private wards of the University Hospital a year ago, and who had a prolonged and severe attack of typhoid fever, the temperature keeping high-without warning or cause a " nervous chill " occurred, followed by a fall in the temperature from 104.40 to 95.5°, the thermometer rising again to its former level. The temperature kept thus for five or six days, and then gradually fell. I know of no way in which the fall of temperature could have been anticipated. Before it occurred we were much tempted to use some active means to reduce the temperature, but, had this been done, it might have been serious for the patient. I recently treated with turpentine, in the Presby- terian Hospital, a case of typhoid fever in a man twenty six years of age, in whom the disease ran a perfectly normal course. While grave, the symptoms were not alarming, and the temperature ranged be- tween 103° and 104°. At one of my visits I found a falling temperature, which continued until the mer- cury registered 96.5°, being followed by a gradual rise, with a subsequent decline by lysis. This is another case in which no one could have antici- pated the fall of temperature, which, I am sure, was a part of the disease, and not due to any cause that would produce collapse. These three cases are examples that I have taken at random from an abundance of typhoid fever notes, in which the administration of an antipyretic in the latter stages of the disease would have been dangerous. Of course, there is still another class of cases in which it would be dangerous to administer an anti- pyretic, those, viz., to which Dr. DaCosta has par- 8 THE USES OF FEVER. ticularly called attention, in which the morbid process has terminated, but-on account of the exhaustion, or the long continuance in bed, or the limited diet-the temperature keeps up, or even begins to rise. Such a case was under my care last year. These have been spoken of as cases of bed- fever, and in such instances the administration of an antipyretic would not have the desired result. In these cases the fever is due to exhaustion, lack of food, and long continuance in bed. The use of stimulants, solid food, and getting the patient out of bed, bring back the temperature to the normal. The foregoing are the classes of cases to which I wished particularly to call attention in connection with the dangers of antipyretics in typhoid fever. The attention of the College is invited as much for criticism as for discussion, and, finally, in order to say that if physicians will give antipyretics in typhoid fever, it behooves them not to administer them in the cases or under the conditions related. The Medical News. Established in 1843. A WEEKL YMEDICAL NEWSPAPER. Subscription, $4.00 per Annum. The American Journal OF THE Medical Sciences. Established in 1820. A MONTHL YMEDICAL MAGAZINE. Subscription, $4.00 per Annum. COMMUTA TION RA TE, $7.50 PER ANNUM. LEA BROTHERS &> CO. PHILADELPHIA.