The Value of Antipyrine in Puerperal Fever. BT PAUL F. MUNDE, M. D. REPRINTED FROM 2Tt)e Neto ¥orft JWeUical Journal for October 9, 1886. Reprinted from the New York Medical Journal for October 9, 1886. THE VALUE OF ANTIPYRIUE IY PUERPERAL FEVER. By PAUL F. MUVDE, M. D. The remarks made by several prominent obstetricians at the first meeting of the German Gynaecological Society in Munich last June, while discussing the treatment of puer- peral fever, to the effect that they had abandoned the use of antipyrine in that disease, because they saw no particular or lasting benefit from it, induce me to carry out an inten- tion formed previous to that meeting to report my experience with that remedy in a number of cases of puerperal septi- caemia and peritonitis during the past two years. During this time I chanced to see quite a number of such cases in consultation, in nearly all of which I recommended the use of antipyrine to reduce the temperature, and the result was such as to lead me to look on this remedy as a great boon, far superior as an antipyretic to quinine, aconite, or even cold, which agents have hitherto been our main-stays in re- ducing temperature. It would seem almost useless to say that all I expect from antipyrine is its temporary antipyretic effect, and that a permanent or curative influence is not hoped for, did not the German obstetricians referred to make this want of permanency of the reduction of tempera- ture one of their reasons for discarding it. But I can not 2 THE VALUE OF ANTIPYRINE help thinking it a poor reason for not employing a remedy simply because its effect is less permanent than we might desire when we have no better substitute at hand. In a disease like puerperal septicaemia it seems to me that any remedy which affords even temporary relief should be eager- ly grasped, since often so little can be done in this fearful malady. While the measures recommended by the German ob- stetricians—the dull curette to remove decomposing remnants of placenta and coagula, intra-uterine irrigation, cold affu- sions, baths, and compresses, to reduce temperature, alcohol and nourishment to maintain strength—are also those em- ployed by us, it is well known that irrigations have but an early and limited value, and that the application of cold to a large part of the body, especially after confinement, is dangerous, and may be followed by shock and collapse, not to mention the inconvenience of such applications. For these reasons, the practical and convenient ice-water coil has been introduced, which certainly, as an antipyretic, does all that can be expected from a measure applied to so limit- ed an area of the body as the skin of the abdomen. But even from these lieat-reducing methods only a tempor rv result is obtained, and they require more or less frequent repetition. What more convenient, then, than the administration of antipyrine at times, at intervals, and in doses proportionate to the return and intensity of the fever l Of course, we know that the period of comparative apyrexia which soon follows the use of the remedy is but temporary, and that perhaps soon the temperature will rise to its former height, and the reme- dy require to be repeated, which alternative may occur again and again for many days. But, in the intervals of comfort and freedom from fever, the exhausted system has an oppor- tunity to recuperate by sleep and by the accumulation of IN PUERPERAL FEVER. 3 the vital force which has been consumed by the fever, and we thus gain time to aid the system in throwing off the poison and weathering the disease. Surely this is not theory or fallacy, but can be and often has been demon- strated at the bedside ! What I have said applies equally to any acute inflam- matory affection characterized by general rise of tempera- ture. But I do not know whether the administration of antipyrine during puerperal septicaemia or peritonitis has become so general as the use of the remedy in internal medicine. I, for my part, certainly feel that its careful, systematic, and persistent employment has had a large share in enabling a number of the patients with puerperal fever whom I have seen in consultation to survive the disease. In making this assertion I do not undervalue the ice-water coil, or the stimulants and nutrients which were crowded into the patients almost ad nauseam. The manner of administering antipyrine as to dose, repetition, and vehicle, is, I think, of prime importance, if we would secure a rapid, satisfactory, and safe effect. To give it in large doses, say 20 to 30 grains, repeated every hour or two until 60 or 90 grains have been given, is, I am sure, exceedingly hazardous. The objection has been made that the reduction of temperature may be too rapid and in- tense, falling even below 98°, and that collapse may occur. This is perfectly true, and I once saw the temperature fall from 104° to 96-5° F. in a hospital case of pelvic peritonitis, after two doses of 20 grains each, within three hours. In one consultation case last winter I could find nothing to account for the temperature of 102° but a comparatively small exudation in the left broad ligament, the size of which hardly seemed to account for the sharp collapse and small pulse of 120 beats. At a loss to comprehend the cause of the collapse, I continued my inquiries, with the re- 4 TIIE VALUE OF ANTIPYRINE suit of ascertaining that the attending physician, the tempera- ture having been 105°, had given 30 grains of antipyrine in one dose shortly before my arrival. Appropriate stimulation soon brought down the pulse and relieved the collapse. I have always followed the rule never to begin with a larger dose than 20 grains (if the patient is strong), and to follow it up with 10- or 5-grain doses every half-hour or hour until 20 grains more have been taken. Usually, and always if the patient’s strength is below par, I begin with but 10 grains, and give 5 grains every half-hour until 20 more have been taken, which will make 30 grains within a little over two hours. The pulse is carefully watched, and any sign of flagging means discontinuance of the antipyrine and the use of stimulants. This same quantity or less is ordered to be repeated as soon as the temperature (taken in the mouth, rectum, or vagina) rises above 102°. Seldom have I found it neces- sary to order this quantity of 30 grains in divided doses to be given more than twice in the twenty-four hours; gener- ally but once, usually toward evening. Once, however, for over two weeks, the patient’s constantly recurring rise of temperature required the daily consumption of from 60 to 90 grains, urtil, finally, the temperature remained down, and recovery took place. All the patients were under the care of trained nurses, who were carefully instructed to take the temperature and pulse at regular intervals, and administer the antipyrine in strict accordance with their instructions and the effect of each dose. As soon as the temperature fell below 101°, as a rule, the remedy was discontinued. In this manner I never saw the least sign of collapse or excessive reduction of tem- perature (in the case above referred to the house surgeon gave the antipyrine in my absence), and can report none but the happiest results from the drug. IN PUERPERAL FEVER. 5 It was given either in solution with syrup and water, five grains to the tablespoonful, or in gelatin capsules (my favorite form), or, if the stomach was irritable, by supposi- tories or enema, in both of which latter forms it acted ad- mirably. In some cases I found it necessary to give it hypodermically, which was readily feasible, as it is very soluble, one grain being dissolved in one minim of water. In addition to the antipyrinc, I always had the ice-water coil applied when the temperature rose, and removed when it fell. And I often gave five-grain doses of quinine every three to four hours if the stomach could bear it, merely for its tonic properties. But I feel convinced that the quinine had but a small, and the ice water only a moderate, share in the recovery of the patients. Out of the twenty-eight cases of puerperal septicaemia (nineteen) and puerperal peritonitis (nine) which I have seen in consultation during the past two years, since I have been using antipyrine systematically in this disease, only three proved fatal, one of which developed chronic encysted peritonitis, to which the patient succumbed five weeks after delivery. Surely this is not a large proportion, especially when we consider that a consultant is often not called until the case becomes very serious, perhaps actually hopeless, and when I state that one of these patients was actually moribund when I saw her. The third case I saw last April, and found absolutely in- tractable to remedies, each lull in the disease being speedily followed by a fresh accession of septic infection more violent than the preceding one. I do not deny that I always expect a more lasting effect from the antipyrine and other similar remedies in the cases where the local inflammation predominates than when no cause for the fever can be found by an examination of the pelvic organs. And yet it has seemed to me that in pre- 0 THE VALUE OF ANTIPYRINE IN PUERPERAL FEVER. cisely those pure cases of septic infection with no apparent source has the antipyretic effect of antipyrine been most grateful and satisfactory. I will not weary the reader by detailing cases which all present the same general features. Suffice it to state that the repeated daily use of antipyrine, once or oftener in the twenty-four hours if the rise of temperature called for it, continued for days and even as lorg as three weeks, has, with proper precautions as to indications, doses, and mode of administration, proved in my hands a most potent symp- tomatic remedy, free from danger, in puerperal septicaemia. REASONS WHY Physicians sbouid Subscribe - FOR- The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medi- cal men of this country. 4. 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