The Treatment of Typhoid Fever. BY GEORGE DUFFIELD, M.D. REPRINTED FROM MEDICINE. GEO. S. DAVIS, Publisher. April, 1896. [REPRINTED FROM MEDICINE, APRIL, 1896.] THE TREATMENT OF TYPHOID FEVER. BY GEORGE DUFFIELD, M.D., Attending Physician at Harper Hospital, Clinical Professor of Medicine in the Detroit College of Medicine. At the beginning of my three months of service at Harper Hos- pital, in October, 1895, I resolved to try Dr. Woodbridge's method of treating typhoid fever, as it appeared reasonable in theory and had proved satisfactory in his hands. Before speaking of this treatment in detail, let me call attention to some of the pathological conditions with which we have to deal. In common with most pathologists, we regard the Eberth bacillus as the cause of typhoid fever. Uffelmann has investigated the resis- tance of typhoid bacilli by drying, and their transmission in the air. Various materials after sterilization were saturated with water containing typhoid bacilli. The experiments showed that these organisms resist drying, and retain their power of development, in earth twenty-one days, in white sand eighty-two days, in house and street sweepings thirty days, and on linen from sixty to seventy-two days. In a warm, moist atmosphere the duration was longer. Sarnelli, of Rome, has studied the relation between typhoid virus and human and experimental typhoid fever, which, he says, " is not primarily an intestinal infection." From a series of experi- ments on guinea-pigs he concludes that Eberth's bacillus, after penetrating the organism, produces a toxin which exerts its force upon the nervous centres, causing death in the lower animals; acting upon the mucous membrane of the intestine, it gives rise to the familiar ulceration in the solitary glands, all of the symptoms pre- senting a close analogy to those of typhoid in the human being. In experimental typhoid, Eberth's bacillus is not frequently found in the intestinal contents; this fact militates against the idea that the disease is an infectious process, localized in the intestine. The absence of Eberth's bacillus from the intestine of the animals thus inoculated is to be explained by two circumstances: first, that typhoid fever is an affection of the lymphatic system only; secondly, that, directly the poison begins to act on the intestinal walls, the colon bacteria become pathogenic and increase so enormously as to assimilate all other forms. The colon bacteria are supposed to con- stitute the first cause of secondary infections. The lesions of typhoid fever are generally divided into two groups - those characteristic of the disease, and the secondary changes in the tissue that result from the long-continued fever. 7777? TREATMENT OF TYPHOID FEVER 2 The characteristic post-mortem changes are seen in the lymphatic glands of the intestine, the mesentery, and the spleen. ' The altera- tions are divided into four stages: (i) stage of infiltration; (2) stage of necrosis; (3) stage of ulceration; (4) stage of cicatrization. These pathological conditions are undoubtedly caused by the action of the bacilli upon the structure of the intestine. The separate stages are not necessarily chronological in the order of their devel- opment, but one, two, or evtn all three stages may be present in one Peyer's patch, and other glands may be found illustrating two or more stages. The secondary infection of the mesenteric glands, especially near that portion of the bowel most affected, is undoubtedly caused by pathogenic bacterial absorption. Glands in other parts of the body are often enlarged and show on section bacterial infection. The blood is vitiated, the white blood-corpuscle is destroyed, and the whole body suffers from constitutional infection, due to the long-continued fever, absorption of toxins, and destruction of blood- corpuscles. In the Woodbridge treatment we have a well devised attempt to employ antiseptic methods which have yielded such brilliant results in surgery. We no longer hear of " laudable pus," but on the contrary it is now regarded as an avoidable evil. Intestinal antisepsis is the corner-stone of this treatment, and under Dr. Woodbridge's method it is pushed to an extreme limit. According to the Doctor, three formulas are employed. The first consists of: no. 1. Podophyllum resin 1-960 grain. Mercurous chloride, mild 1-16 grain. Guaiacol carbonate 1-16 grain. Menthol 1-16 grain. Eucalyptol q. s. and should be given every fifteen minutes during the first twenty- four hours, and oftener if necessary during the second twenty-four, until not less than five or six free evacuations of the bowels are secured during each of two consecutive days. On the third or fourth day of treatment the following tablet is to be given at intervals of one and two hours: no. 2. Podophyllum resin 1-960 grain. Mercurous chloride, mild 1-16 grain. Guaiacol carbonate 1-4 grain. Menthol 1-16 grain. Thymol 1-16 grain. Eucalyptol q. s. THE TREATMENT OF TYPHOID FEVER 3 This formula, and also formula No. i, should be given as freely as possible at first, then gradually reducing the size and frequency of the doses, the object being to so regulate them as to allow the movements of the bowels to become less and less frequent until the temperature has dropped to normal, when the movements will have been reduced to .one or two each day. Should symptoms of ptyalism (a wholly unnecessary complication) supervene, the tablets should be promptly discontinued for a day or two, and, if necessary, sodium or potassium chlorate given, returning as soon as possible to formulas Nos. i and 2. About the fourth or fifth day of treatment the soft elastic capsules should be commenced: no. 3. Guaiacol carbonate 3 grains. Thymol 1 grain. Menthol y2 grain. Eucalyptol 5 minims. one capsule to be given every three or four hours, alternating with the tablets. During all the course of treatment the patient must wash down each dose of medicine with large draughts of distilled or sterilized water, or, if indicated, some good laxative or diuretic mineral water. Note the physiological actions of the medicines used by Dr. Woodbridge: Podophyllum is a slow cathartic and in minute doses a laxa- 'tive which acts upon the liver and intestinal glands, increasing secretion. Neuberger concludes, after a series of experiments, that it acts simply as an irritant, exciting catharsis in its elimination by the intestinal glands. The physiological action of calomel is well known. It affects principally the excretory glands in the lower part of the small intes- tine and the upper part of the colon. It is supposed that calomel is changed by the action of the hydrochloric acid of the stomach into the corrosive chloride, when it acts as an hepatic stimulant and cholagogue. Calomel acts also as a stimulant to the kidneys, and is useful in increasing the diuretic action of such drugs as squill and digitalis. It has an antiseptic action in the intestines, retarding decomposition, which power it retains in the presence of fecal matter, which accounts for the beneficial action of this drug in intestinal diseases due to micro-organisms. It is claimed (Lang- lois) that calomel limits the absorptive activity of the intestinal wall. In guaiacol carbonate we have an excellent antiseptic. Wood- 4 THE TREATMENT OF TYPHOID FEVER tar creosote is chiefly composed of guaiacol, creosol, menthol-creosol, and phloral, the guaiacol being present in the proportion of 60 to 90 per cent. Guaiacol is colorless, sparingly soluble in water, freely soluble in ether and alcohol, and is more agreeable to the taste and better borne than creosote. It has a special sedative action upon the nerves of the stomach, allays irritability and nausea, and checks fer- mentation in stomach and intestine. It is useful in diarrhea depen- dent upon bacterial fermentative processes in the intestines, and its action as an antipyretic is more rapid than that of sulphate of qui- nine (Robilliard). It is a powerful antipyretic (Friedenwald and Haylen) when locally applied, and is readily absorbed by the skin. It should be mixed with equal parts of glycerin and pure olive oil and painted on the skin over an area not to exceed 20 square inches; this to be covered with an impermeable dressing. Menthol, a crystalline solid, with a sharp and pungent taste, has decided germicidal properties and is recommended as an intes- tinal antiseptic, though it is more frequently used as a topical remedy. Eucalyptol excites the flow of saliva, produces a sense of warmth in the stomach, and acts as a carminative and antiseptic. The gastric and intestinal juices are increased by it; it is well borne by the stomach, and is decomposed in the intestine into hydrochloric acid. The excretion of urea is augmented and the action of the heart increased by eucalyptol, which is also an efficient antiseptic, minute quantities preventing putrefaction, though not checking the action of the digestive ferments. Shoemaker, in his latest work on materia medica and therapeutics, says ' ' Eucalyptol exerts a decided antiseptic action upon the bowel; it is appropriate in the treatment of diseases involving the intestine, such as enteritis, typhoid fever, the green diarrhea of children, etc." Thymol is a valuable antiseptic. It is less powerful than car- bolic acid, but is less poisonous and much less irritating. It is a powerful disinfectant and at the same time lowers arterial tension, lessens reflex action, and reduces temperature. The first action of these remedies is to cause a flow of bile into the intestine, which emulsifies neutral fats, promotes osmosis, excites contraction of the muscular coats of the intestine, and prevents putrefactive decomposition of the intestinal contents (Eanglois). The stools of typhoid fever are fetid, ammoniacal, and alkaline in reaction, usually liquid, of a yellow-ochre color, often pultaceous, frothy, and so light as to float upon water, exhibiting bacterial fer- 77/7: TREATMENT OF TYPHOID FEVER 5 mentation (Pepper and Murchison). Bartlett compares them to new cider, others to pea-soup in color and consistency. It is to be regretted that the stools of the cases that we will later describe were not examined for the Eberth bacillus, but the clinical phenomena were sufficiently marked to justify a diagnosis, which was based upon the following symptoms: All the cases but three were sick from one to three weeks before entering the hos- pital; tympanites, with pain and gurgling in right iliac fossa; furred and coated tongue, with musty and semi-cadaveric odor from mouth -the edges and tip of tongue were usually red in the beginning, while later that organ cleared off and became red, glazed, dry, or fissured, or it became dry with the formation of brownish crusts, the gums and teeth showing sordes; diarrhea usually developed at the end of the first week, varying from a light yellow-ochre, and extremely offensive, to a dark bloody or even blackish appearance; enlargement of the spleen, with tenderness on pressure. Most of these symptoms were noted on the first examination in nearly all the cases; rose spots over lower part of thorax and chest were present in all but one case and were looked upon as the final proof of the typhoid state. In the care of the cases of typhoid fever during 1893, the anti- pyretics acetanilid and phenacetin were given when the temperature rose to 102.50 or 103°. Salol was also given for its carbolic-acid anti-fermentative effect in the intestinal tube. The former anti- pyretics, even in small doses, produced great depression of the heart, and the longer they were continued the more susceptible were the patients to the depressant action, with a consequent lessen- ing of the antipyretic effect! Plunge baths were given an effectual trial, but they did not produce the brilliant results claimed by Brand. It is so laborious a method that it seemed impracticable, tiring out the nurses and attendants, to say nothing of the exhaustion of the patients. We have had better results from sponging when the temperature has been 103° or over. Sponging with alcohol and water has been used with the Woodbridge method, and has proved successful, relieving patients without causing the chills or cyanosis that so frequently followed the plunge bath. The first series of charts, numbered 14, 16, and 18, chronicle the fever curve in cases that were treated by bathing and anti- pyretics with the one aim uppermost to reduce the temperature. The average duration of fever in these cases was 61 days, as against i3t7t days by the Woodbridge method. 6 THE TREA TMENT OF TYPHOID FE VER By reference to chart No. 14 it will be observed that the fever persisted for ninety days. It was a severe continued fever. On the twenty-second day the morning temperature touched normal, only to rise by evening to 103.6°. Seven days thereafter it fell again, and on the thirtieth day Went one degree below normal, but TTYS' TREATMENT OF TYPHOID FEVER 7 soon rose again, and continued above normal with irregular rise and fall for many days before reaching and remaining at the normal point. Plunge baths; salol and acetanilid (three grains of each) internally was the chief medication, five or six such doses in each 8 77/7' TREATMENT OF TYPHOID FEVER twenty-four hours. Rarely was the temperature reduced more than one or one and a half degrees after the bath, and it soon rose again. The pulse was weak and compressible, ranging between 116 and 136. Stimulants were given every two or three hours during the course of the disease. Forty-five plunge baths were given - or whenever the temperature reached 102.50 the patients were im- mersed in water of about 90°, which was rapidly cooled to 65°. In case 16 the morning temperature did not reach normal until the thirty-fourth day (see chart on preceding page). Twelve days after the chart closes, the temperature remained between ioo° and ioi°-or forty-seven days of continued fever and a total hospital detention of over sixty days. Case 18 was twenty-three days in hospital before temperature reached normal, then a marked relapse occurred and twenty-one days more of fever followed before normal temperature was again reached. Plates Nos. 14, 16 and 18 show the long curves of typhoid fever when antipyretics and the Brand methods were used to reduce the temperature. Compare these plates with those that follow, showing the abortive treatment of typhoid by the Woodbridge method. I will now call your attention to a series of thirteen cases that were under my care from October 1 to December 31, 1895, in which the Woodbridge method was used exclusively. In all the cases it proved satisfactory, shortening the disease and lowering tempera- ture. In all cases when the temperature reached 103° a sponge bath was ordered, as it gave relief and quieted restless patients. These were rarely required after the fourth or fifth day, because of the rapid reduction of the fever. These thirteen cases are reported very briefly, as they were all treated similarly. The cases are given as they appeared in the hos- pital. They are not selected, but are all the cases that came under my care while I was on duty. Continuance Continuance Continuance Case No. of Fever. Case No. of Fever. Case No. of Fever. I 17 days 6 12 days IT 16 days 2 5 days 7 14 days 12 18 days 3 23 days 8 15 days 13 12 days 4 7 days 9 15 days - 5 13 days IO 8 days 176 days It will thus be seen that the average duration of treatment was 13A days. THE TREATMENT OF TYPHOID FEVER 9 As a fair example of the whole, charts Nos. 2, 4, 10 and 13 are submitted herewith. Case No. 2 (see chart) showed a very decided and rapid fall after being under treatment for two days. Temperature was sub- normal for three days, after which it remained normal. Patient had been sick three or four days before entering the hospital. No. 3 had been recently confined, and it was thought the puer- peral state might have affected the fever, which was very high during the first week. It was a bad case from the start, and proved the good effect of the treatmemt that was being tried-for after the first week the temperature fell and remained below 103°, only touching that point twice during the week and once during the fol- lowing week. She was very delirious in the first week, and it was thought she might die-in fact, we felt that with any other treat- ment she certainly would have died-but she made a good recovery and was discharged well. Her temperature, Oct. 3, at 8 a.m., was 103°; at 4 p.m., 104.40; at midnight, 104°. Oct. 4-8 A.M., 104°; 12 noon, 104.20; 4 p.m., 105.20; midnight, 104.40. Oct. 5 - 8 A.M., 103°; midnight, 104.20. Oct. 6-2 A.M., 104°; 4 a.m., 103.6°; 12 noon, 104.20; 4 p.m., 105.8°; 8 p.m. and 12 midnight, 105°. Oct. 7-4 a.m., 105°; 12 noon, 104°; 4 p.m., 105°; 8 p.m., 10 THE TREATMENT OF TYPHOID FEVER 105.40. Five plunge baths, thirteen sponge baths, and three cold packs were given during the week. No. 4 was seen early, and the clinical symptoms were plain. The medicines acted promptly and with gratifying results, the sub- normal temperature lasting one week, with the evening temperature rising to normal. This peculiarity is especially to be noted. No. 5 was another "aborted case"-after the fourth day the temperature was normal, and it did not rise again above ioo°. This case was practically well in five days, though the evening tem- perature rose one-half a degree above normal for six days more, with morning temperature normal. No. 6 showed the evening temperature on the fourth day fall- ing instead of rising, and by the thirteenth day remaining normal. No. 7 entered the hospital in a collapsed condition, having been sick about seven days. On the fifth day of treatment the tempera- ture fell, remaining below ioi° for two days, and then falling to normal in the morning and ioo° in the evening for five or six days, when it remained at normal and convalescence progressed rapidly. No. 8 showed marked hebetude from the beginning, and had to be roused for every dose of medicine and for food; the temperature never rose above 102°. He made a good recovery, the temperature THE TREATMENT OF TYPHOID FEVER 11 reaching normal in fifteen days. He had several hemorrhages during the fever and several successive crops of rose spots. No. 9 suffered a relapse after having been up for a week, the primary attack having lasted three weeks. The former attack had not been treated by the Woodbridge method. The temperature did not show a marked decline until the seventh day; it would probably have remained normal on the ninth or tenth day, but the gums had become soft and painful-due to too much mercury. No. io.-This case was seen in the beginning. Patient had been feeling miserably for several days, but was not sick enough to go to bed. The diagnosis having been early established, the Wood- bridge method was pushed to see if the case could be aborted. There was a good deal of tenderness over iliac fossa, with gurgling and tympanites. The afternoon temperature kept falling from half a degree to a full degree each day after the patient had been thor- oughly medicated. On the eighth day the temperature was normal, appetite returned, tongue cleared, and abdominal symptoms disap- peared. The rose spots persisted for seven or ten days after the disappearance of the fever. The gums were slightly ' ' touched ' ' because of old specific disease. No. ii.-On the eighth day the temperature fell from 102.6° to ioo°, with a degree more for evening elevation. This case was the only one that showed no rose spots. The spleen was enlarged and 12 THE TREATMENT OF TYPHOID FEVER tender. She had indigestion after taking the medicines, but made a good recovery in sixteen days. No. 12 showed marked elevation and fall; on the eleventh day the temperature was much reduced, and on the eighteenth day was normal, where it remained. No. 13 was a typical case. On the sixth day there was a marked fall in temperature, which would probably have remained normal had the patient not suffered from ptyalism. Notwithstand- ing the salivation, the typhoid symptoms improved steadily, and he made a rapid recovery. In conclusion I wish to say that in my hands this treatment has worked most satisfactorily, shortening, aborting and greatly modifying the severe cases of typhoid fever. There is no tendency to relapse, no unfavorable complications arise, and the bad effect of prolonged stimulation is done away with. I found the plan a most successful one, and heartily commend it to my fellow practitioners. Note.-I have used in the cases above reported the formulas as prepared by Parke, Davis & Co., in harmony with Dr. Wood- bridge's instructions. Prescriptions Nos. 1 and 2 are tablets, and No. 3 is issued as a soft elastic capsule. These are easy to admin- ister, accurate, and reliable.1 1 Since this paper was written, Messrs. Parke, Davis & Co. have added to their list two formulas intended for children under ten years of age. These formulas are a slight modi- fication of the three originally prepared by Dr. Woodbridge. "Medicine" appearance of. the first number of the second volume of Medicine, X the monthly medical journal edited by Harold N. Mayer, M. D., of Chi- cago, and published by George S. Davis of Detroit, prompts the just comment that no medical journal that we have seen at all approaches it in newness and beauty of typography or, in general, in the quality of the printer's and publisher's work. In contrast with the host of so-called medical journals, printed poorly upon inferior paper, it is a keen pleasure to pick up a number of Medicine and realize what an important part the mere mechanical work put upon a journal plays. It must not be concluded, however, that charm of appearance is the only good quality of Medicine. It is well edited and its pages are clean and free from any objectionable feature. It deserves a place among the very foremost of American medical journals and we' sincerely wish it a full measure of success. The general quality of medical journals of this coun- trv is so low that the success of all the better ones is to be devoutly wished for.by a'll physicians who feel a pride in American medicine. Editorial in February Cleveland Journal of Medicine. MEDICINE A Monthly Journal of Medicine and Surgery. HAROLD N. MOYER, M. D., EDITOR. JUNE, 1895.'W* CONTENTS. ORIGINAL ARTICLES. ■SUMS CONSIDERATIONS CONCERNING THE LOCATION AND DETECTION OF MISSILES. 11T . Roawu-L Fa.h. A.M.. M.D . ,a# THE SURGICAL ANO MEDICAL TREATMENT OF CHOLELITHIASIS. Bv Joiw B. Mum. AM. M.O .......~ - " RELATION OF INFECTION TO THE NERVOUS SYSTEM. B« Hakold N. Mo««. M D iw THF. TREATMENT OF EFILEFSY. BY T. F. Stanton. M.D< BOOK REVIEWS. A Sntix or LloAt M«M> INN. By Alim McLane Himllon. M D. .nd tawRliec Codkln. Es« IM Atlas oi> Mnnsciiuciinn Gnhinnn vno LU Fasmvnnlauhb. Von Dr. Edward Fuuu •« Moths on Naw Boon* - 1 5 PROGRESS OF MEDICAL SCIENCE. MEDICINE. Comparative Antiseptic Action of Phenyl-Substt- tart, .1 ol ai'mwhoi.uio.7in7oi'Acide SURGERY. ou Saline Digestion '®' New Method olloduci.f Gwwral Nefco*!. ...w.... .«7 U» .1 M.ee«y lo A.-,om«.l, aS. Indications tor Operation in Vertebral Carle* tt« OBSTETRICS AND GYNECOLOGY. The Operative Treatment of Buboes-s »6* A New Haemostatic•.- The Parietal Incision In Abdominal «urgcry i«t Mechanism of Death In Cocaine Intoxication,«6Q Freund's New Operation for Vaginal Prolapse ika Sarcoma Complicating a Recent Fracture A Cate of Chrome Inversion ol the Uterus Success Spina Bifida»*» fully Treated with Elastic Pressure 18J "Button" w. Absorbable Plate#Wandering DermoMTumor.... iba , The Prophylactic Treatment of Blennorrhea Neo- PATHOLOGY. , natorum• »••• 'Sa Acute Yellow Atrophy of the Liver, with Special An Abnormality in a Placenta~ ie>« R.,.,.«. to th. .r. NEUROLOGY ANO FMCHIATRV. THERAPEUTICS. d1>.i.u«i.» .«». spm. .1 T«b.re«i« Dr,'nT"IS by Mean, of Wood-V.n.gar V* Anx.ety Neurosis Thyroid Gland in Treatment ol Goitre «77 OPHTHALMOLOGY. Hepatic Symptoms Resulting from the Use of Fluid Extract Male-Fem as a Vermifuge'. iyS Parenchymatous Keratitis and Tubercular Disease The Dangers of Thyroid Feeding t79 Sodium Salicylate In Exophthalmic Goitre179 FORENSIC HEDICINL. Atropine In the Treatment ol Gastric Hypersecre- M... 180 Responsibility ol Physicians.-lit COPYRIGHT 1893. GEO. S. DAVIS, Publisher, DETROIT, MICH. Entered at the Post-office at Detroit. Mich., as second-class matter.