CLINICAL ITEMS CONCERNING THE TREATMENT OF TYPHOID FEVER, GATHERED FROM THE MEDICAL WARDS OF THE MERCY HOSPITAL, DURING THE SIX MONTHS ENDING MARCH 31, 1887. BY N. S. DAVIS, M. D., CHICAGO, ILLINOIS, Professor of the Principles and Practice of Medicine and Clinical Medicine in the Chicago Medical College. Only about one-half of the wards and beds open for the reception of medical cases in the Mercy hospital are under the care of myself and Dr. N. S. Davis, Jr. During the six months ending March 31, 1887, thirty cases of typhoid fever were admitted and treated in our department, presenting the usual variations in severity and complications. Nearly all of these patients were from the poorer and working classes of the city population. But very few of them were admitted at the end of the prodromic stage or on first being compelled to take the bed; a larger number came during the last half of the first week of confinement; more than half of the whole number during the second week; while others were admitted during the third and fourth weeks of the progress of the disease. All of them presented more or less complete the usual symptoms characteristic of typhoid fever in its different stages of progress, which it would be superfluous to enumerate for our present purpose. About half of the cases proved mild, presenting only the usual bronchial dryness, moderate intestinal looseness and tympanites, and little or no delirium at any stage of their progress. Of the other half, several presented severe abdominal tympanites with frequent and copious stools and mental wandering, while as is usual in the colder months of the year, a large number were complicated with bronchitis and in some a limited extent of pneumonia. Our principal object at present, however, is to call attention to some items connected with the two following cases: Mr. A. B., aged about twenty-seven years, laborer, was admitted to the hospital six or seven days after he had taken to his bed. His face was flushed, countenance dull, mind drowsy, skin dry and hot, tongue and lips dry, pulse soft and 90 per minute, abdomen only slightly tympanitic with only two or three thin stools during twenty-four hours, chest resonant and no more than the ordinary bronchial dryness. Temperature under the tongue 39° centigrade (103° Fahrenheit). The man had been addicted to the use of alcoholic drinks, but otherwise apparently healthy until the present attack. Regarding the case as one of ordinary typhoid fever, we directed the whole cutaneous surface to be frequently sponged with cold water whenever the temperature was at 39° centigrade or above, and four cubic centimeters (one fluid drachm) of the following formula to be given every four hours: Mix. grms..... ziv. R. Carbolic acid (cryst)... .500 grms..... grs. viii. Elixir simplex............. 60. grms..... ziv. grms..... ii. grms..... ii. The chief nourishment was to be sweet milk and some beeftea or other meat broths. During the first six days after admission the most important changes in the symptoms were increased delirium, more frequent pulse, and respirations less full with steadily increasing dry râles in the chest and some dulness on percussion over the lateral and posterior part of the right side of the chest. The temperature had ranged from 38.5° centigrade to 40° centigrade for the morning and evening notings, notwithstanding the frequent sponge baths. During the first part of the third week of the fever the case presented a very grave aspect. The delirium and sleeplessness had become constant, the face deeply suffused with dark red flush; pulse 110, soft, systole of the heart short, respirations frequent and superficial, with dulness and but little expansion over the whole right side of the chest, apparently from hypostatic and oedematous infiltration of the pulmonary tissue. The temperature was 45.5° centigrade or 105° Fahrenheit at 1 P. M. The patient had been faithfully using the medicines and diet previously named with the addition of two grain doses of sulphate of quinine three or four times per day. But it was apparent that the function of the vaso-motor nerves as well as the inherent susceptibility of the tissues must be promptly sustained or the rapidly increasing pulmonary and cerebro-spinal engorgements would soon extinguish the life of the patient. He was accordingly wrapped in a cold wet sheet, and the same sprinkled with water until the temperature fell to 38.5° centigrade, the same to be followed by as frequent sponging as the temperature might indicate. At the same time he was ordered the following medicines and diet: R. Salicylate sodium.......... 30. grms...... Zi. Tinct. digitalis... i. Mix. Aqua mentha.......... 90. c. c......... Ziii. Gave four cubic centimeters or one teaspoonful every two hours, diluted with water, until the delirium began to abate and then lengthened the time to three hours. To lessen tympanites and restrain the intestinal evacuations he was to take one teaspoonful of the following emulsion three times a day: R. Ol. terebinth................ Rub together and add Mix. Aquæ........ 12. c. c......... ziii. 3. c. c......... mpxlv. 15. c. c......... ziv. āā..... 25. grms...... zvi. .130 c. c......... ziv. For nourishment, one or two tablespoonsful of thin wellboiled wheat flour and milk gruel every hour, and the same quantity of good coffee as properly prepared for ordinary drink, between the doses of the gruel. The treatment was faithfully carried into execution, and at my visit the next day, all the bad symptoms were moderately improved. The temperature was 1.5° centigrade lower; the face less red, delirium less active and had been interrupted by one or more brief turns of sleep; pulse and respirations less frequent, and some more expansion of the right side of the chest with inspiration, and more moist râles. The skin and the mouth were more moist. No change was to be made in the treatment, unless the temperature should fall to 38° centigrade, and the delirium cease, when the mixture of salicylate of sodium, ammonium, etc., should be given not oftener than four hours. The next day I found the patient free from delirium and inclined to sleep, breathing slower with still more expansion of the right chest, skin bathed in perspiration, face pale, extremities cool, temperature 37° centigrade, pulse 70 and weak, mouth and lips moist, abdomen but slightly tympanitic, and intestinal discharges semi-fluid and only two in the last twenty-four hours. The reduced temperature, entire absence of delirium, weak pulse and profuse sweating induced me to omit the further use of salicylate of sodium and ammonium mixture, and substitute in its place a mixture of carbonate of ammonium, tincture of belladonna and tincture of digitalis suspended in camphor water and simple syrup, given every four hours, with two grains of quinine between, and a diligent continuance of the same nourishment ordered yesterday. The emulsion of turpentine and tincture of opium to be given after each intestinal evacuation. Under these influences the sweating diminished, the pulse gained in force but not frequency, the delirium did not return, the pulmonary obstruction diminished day by day, and before the end of the fourth week of the patient's confinement, convalescence was fully established. Case II.-Was a young man, aged about twenty-three years, occupation clerk, slender form and nervous temperament. He was admitted into the hospital at the beginning of the second week of his confinement with all the symptoms of typical typhoid fever well developed. He was given the same treatment in all respects as was ordered for Case I, when first admitted. During the first five days after admission no unusual symptoms were noticed, except more headache and less disposition to sleep. At the end of that time a hard swelling was discovered behind the angle of the jaw in the right parotid region, the pulse increased in frequency, the mind began to wander, and the temperature rose to 40.5° centigrade (105° Fahrenheit) notwithstanding diligent use of cold sponge baths. Cloths wet in an infusion of aconite leaves and hydrochlorate of ammonia were applied over the parotid swelling, and in addition to the carbolic acid and iodine mixture, the patient was to have twenty grains of antipyrin, morning and evening. But during the next four days the parotid swelling continued to increase, pulse 110, temperature about 40° centigrade to 40.5° centigrade, face and neck deeply flushed and hot, and so excitedly delirious that the constant attention of a strong nurse was required to keep him in bed. The antipyrin was then discontinued, emolient poultices were applied to the swelling at the angle of the jaw, and the same prescription containing sali cylate of sodium, carbonate of ammonium, and digitalis ordered for Case I was given, every two hours, and frequent sponging of the whole surface continued. Milk was chiefly relied upon for nourishment. Within the first twelve hours after commencing the salicylate the patient began to be more quiet, and by the end of the third day his delirium had entirely ceased, his temperature had fallen to 38.5° centigrade or 101° Fahrenheit, pulse slower but feeble, some moist râles in the chest, and profuse general sweating. The salicylate mixture was discontinued and the subsequent internal treatment was the same as for Case I. The swelling in the parotid region, however, had undergone suppuration with some sloughing of the connective tissue. It was freely opened, drainage established, and treated antiseptically. Full convalescence from the general fever was not established until the end of the fourth week from the time the patient had taken to his bed; and his subsequent recovery of flesh and strength was slow. The two foregoing cases were the only ones treated during the six months under consideration, that were characterized by the supervention of unusual delirium, high temperature and sleeplessness, and consequently the only ones in which we prescribed the salicylate of sodium and ammonium. Two other severe cases, however, became complicated with hard and painful swelling of the parotid glands, commencing near the end of the second week of the fever. These were treated locally by rubbing into the surface of the swelling a little oleate of mercury and morphine twice a day, and they slowly disappeared without suppuration. Of the thirty cases of typhoid fever treated in my wards of the hospital during the six months, only one died; and he was admitted in the third week of the disease and died on the third day after his admission. No alcoholic liquors, either fermented or distilled, were used by any of these patients while in the hospital. STATIC ELECTRICITY IN MEDICINE. [CONTINUED FROM PAGE 261]. BY AMBROSE L. RANNEY, M. D., NEW YORK CITY. THE CHARGING OF A MACHINE. It is well to know what steps are necessary to start a static induction-machine, in case it loses its charge. I have seen a few instances where the owner of such an instrument has worked himself into a heat of passion as well as of body by fruitless |