Clinics.

Specific Indications and Specific Treatment of Typhoid.

By JOHN BENSON, M.D., COLFAX, WASH.

I wish here to give two cases taken from my casebook, whose histories are typical of many others. It is seldom such clear-cut indications for remedies are seen. But on that account they all the more indicate the line of treatment of a specific character.

The patients were both young men, twenty and twenty-two years of age, genuine farmer boys, strong, healthy and robust. Excellent family histories. Both had just put in a month to six weeks of most laborious work in the harvest field. Both were exposed to the same surroundings and conditions. For about a week they had been feeling weak and miserable, without knowing why, until fever appeared, when they went to their homes, and when seen they presented the following symptoms in common:

• Both in bed.
• Had fever eight or ten days.
• Face flushed.
• Heavy, sodden appearance.
• Complain of dull, heavy headache.
• Intelligence dulled.
• Answer questions slowly.
• Low muttering delirium at night.
• Tongue dry and coated.
• Sordes on lips and teeth.
• Bowels bloated, tense and tympanitic.
• Gurgling on pressure, especially in right iliac region.
• General tenderness over abdomen.
• A few rose-colored spots on abdomen.
• Urine scanty, high-colored, offensive.
• Stools, three or four a day, thin, watery and offensive.
• Morning Temperature, 101.5°F. To 102°F.
• Evening temperature, 103.5° to 104°F.

Upon the totality of these symptoms we can safely make a diagnosis of typhoid fever, and as safely prescribe for the same. But, shall we prescribe for the disease or shall we prescribe for the individual affected with the disease? While the main characteristics of typhoid are the same in all cases, yet the individuality of the person is often an important factor in the case and the same symptoms may have different manifestations in different persons. I have always made it a rule to study the personal idiosyncrasy of every patient, so here let us make a still closer examination of these cases and see, what further symptoms can be elicited by careful questioning and observation, to assist us further in our individual diagnosis and medication.

John Doe

• John Doe, aged twenty:
• Lies quietly in bed.
• Seems averse to moving.
• Irritable and cross when aroused.
• Wants to be let alone.
• Delirium, is always working at his last occupation.
• Face appears hot and puffy.
• Circumscribed red spot on right cheek.
• Tongue dry, pale, with whitish-yellow coat.
• Breath offensive.
• Pulse full and hard.
• Slight dry cough with stitching pains in right chest.
• Slight dulness on percussion over right posterior thoracic region.
• Few moist coarse rales in same region.
• Occasional stitching pains in abdomen.
• Stools about three a day, thin, biliouslooking, offensive.
• Complains of burning at anus.
• Urine scanty, brownish-yellow in color.

Richard Roe

• Richard Roe, aged twenty-two:
• Appears in a semi-comatose condition.
• Falls asleep while answering questions.
• Changes his position frequently.
• Complains of the bed being so hard.
• Delirium, cannot rest for he imagines his body to be broken into pieces, and he cannot get them together.
• Marked debility and prostration.
• Body slides down in bed.
• Face is a dusky, purplish red.
• Has a besotted appearance.
• Tongue dry, brown coat in center.
• Edges of tongue red and shiny.
• Breath very offensive.
• Pulse soft and compressible.
• Stools about four a day, thin, dark and horribly offensive.

Here, then, we have three distinct sets of symptoms. One set that is common to both patients, and that is characteristic of the disease; one set that is peculiarly those of John Doe alone, and another set especially symptomatic of Richard Roe. It would be wrong to treat those men with the same drugs, for although it is one and the same disease in both, yet each one has symptoms peculiarly his own, and no one else's; and although the history of the cases tells us they are in about the same stage of the disease, yet, otherwise, they are markedly different.

In John Doe, we find the system making a noble resistance to the disease. His strength and vitality are good. He is irritable and cross, and that is one of the best of signs, for irritability of temper always shows a reserve fund of strength to work on. Besides the typhoid symptoms, we find a slight bronchitis of the right side, as shown by slight cough and stitching pains, and involvement of the liver, as shown by the bilious stools and burning at anus. The pale tongue and whitish coat show that as yet the system has not become profoundly saturated by the septic invasion, and that under proper medication and with no new complications we might expect an uneventful recovery.

So for John Doe we will prescribe the sulphite of sodium, 10 to 20 grains in a glass of water, to render it pleasantly alkaline, and administer it ad libitum. In addition we will give one granule of bryonin, gr. 1/67 every hour until effect is noticed and then, less often. Also emetine, gr. 1/67, one granule every four hours, to loosen up the pulmonary secretions and relieve the congestion.

With Richard Roe we have to deal with an entirely different case. Here we find the system most profoundly overcome with the septic infection, as evinced in the marked prostration, the low delirium, the dark, purplish color of skin and mucous membranes, the weak heart, and the intense fetor of breath and sweat, urine and stools. It is putrescence itself. It shows that the blood and the tissues themselves are disintegrating under the septic influence. Hemorrhages, nasal and rectal, may be expected any moment, and if we are to save our patient we must prescribe promptly and rightly. What are the two great remedies for putrescence? Hydrochloric acid and baptisin. So to the drinking water of Richard Roe we will add a few drops of hydrochloric acid, just sufficient for a pleasant acid drink, and given freely. Also we will give a granule of baptisin, gr. 1/12 every hour until effect and then less often, also a granule of strychnine arsenate, gr. 1/134 every three hours, to support the flagging heart.

In the first case, the remedies relied upon were sodium sulphite and bryonin. In the second case, hydrochloric acid and baptisin with strychnine arsenate as an adjunct. Why? Why were these remedies given instead of any one of perhaps twenty other remedies that might have been prescribed with advantage ?

The sodium sulphite was given because wherever a pallid mucous membrane and a tongue coated with a whitish or yellowish white deposit be found, there is a call for alkalis in the system. Sodium sulphite supplied this demand and being also one of the best of antiseptics it corrects the decomposition going on in the digestive tract. If the same conditions existed without sepsis the sodium bicarbonate would be the proper alkali to use, or if there were extreme fetidity, as in diphtheria, typhoid and like diseases, potassium chlorate should be used.—Am. Jour. Clin. Med.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.