Treating typhus

December 20, 1818: William A. Graham and his schoolmates were in the throes of the Christmas season—like many young men during this time, they may have been shooting off firecrackers and publicly carousing when Mr. Hickenbottom, a fellow medical student at the University of Pennsylvania, fell ill. Hickenbottom, from a well-to-do family in Virginia, lived in Graham’s boarding house. Graham and his friends called in the best doctor they knew: their professor, Dr. Nathaniel Chapman. Chapman took the case and Graham proceeded to chronicle how Chapman used a plethora of oils, barks, roots, balms, opiates, cathartics, and emetics in an attempt to cure Hickenbottom. This case study gives us insight into how early nineteenth century physicians treated typhus.

On December 20th, Dr. Chapman went to visit the patient in his boarding home(1). Chapman asked the patient a few questions about his overall wellbeing, and prescribed mild treatments to induce perspiration such as lemonade and sweet spirits of nitre. He also bled 12 ounces from Hickenbottom. The next day, Graham was forced to go looking for the good doctor, as Chapman had, perhaps accidentally, forgotten his morning appointment with the patient. Graham found Dr. Chapman dining and immediately brought him to see Hickenbottom. A few days later, Chapman drew another ten ounces of blood, bringing the total to at least 22 ounces of blood drawn. At this point, five days after the first entry, the case was definitively labeled as typhus. The next day, Chapman told Hickenbottom to take a wine glassful of wine whey, which is whey made from milk coagulated by the use of wine, along with a breakfast of oysters and sago, which is starch from a palm stem. Oysters were also rich in starch and are described in Chapman’s 1822 book, Elements of Therapeutics and Materia Medica. Both sago and oysters provided immeasurable dietary benefits for sick patients, and Chapman says that they are useful for aiding in digestion and calming the stomach (2).

As Hickenbottom got progressively worse, Dr. Chapman began to get more varied in his prescription. It also seems as though Chapman did not mind conferring with other doctors. As a matter of fact, it almost appears as though they are in the same practice. Although Chapman is the lead doctor, the other physicians from the medical school help him out. For example, a few days after Christmas, Chapman brought in noted physician Dr. Philip Syng Physick for a consultation, and a couple days after that, Dr. Chapman, feeling unwell, called on Dr. Dewees, midwifery professor at the university, to attend the patient. Dr. Dewees made no changes to the prescription. By December 30, Doctor Chapman believed his medicine was working.

Around this time, Graham himself got sick with Cynanche Tonsilaris, probably an inflammation of the tonsils, and his diary stopped for six days. By January 15, Mr. Hickenbottom had gotten worse, yet there was still hope for his recovery. However, despite Chapman’s best efforts, on January 22, 1819, Mr. Hickenbottom died. There is a brief part of the manuscript that talks about his burial, and we can only imagine what it must have been like for Graham: already far from home, and now having to bury a classmate, roommate, and friend.

Despite the melancholic nature of this incident, it does provide a valuable example for how an early nineteenth century physician would have treated typhus, and it also enables us to compare and contrast Chapman’s recommendations from his book and his lectures with a real typhus case that he treated. He prescribed some remedies in Hickenbottom’s case that were not found in his book or his lectures, such as lemonade, essential oil, magnesia, volatile Alkali, Sanguinaria, Portence, Cretacious Julep, and Chalk Mixture. Perhaps they are secondary cures or very uncommonly used or maybe he treated Hickenbottom with different medicines because he had not yet realized that the disease was typhus. Whatever the case may be, most astonishing is the sheer volume of remedies that Dr. Chapman prescribed. We don’t know what affect this may have had on the patient, but we do know that the disease lasts around two weeks and 10-60% of patients without treatment will die. It is actually unclear whether or not Chapman’s treatments would have increased or decreased the Hickenbottom’s survival.

Chapman’s limited view of typhus was probably heavily influenced by his mentor, Dr. Benjamin Rush. Dr. Rush was a staunch advocate of “aggressive bleeding”, and the practice of ‘heroic’ medicine, meaning bleeding and purgatives in heavy, frequent doses (3). Chapman encouraged venesection in both his lectures and his book, but he is careful to say that it is appropriate only in the beginning stages of typhus. We can see from his treatment of Hickenbottom that he drew twelve ounces of blood on the first day, ten ounces on the second day, and applied leeches on the seventh day. It is clear that he felt bleeding was important, but as he said, only in the formative stages. Chapman wrote in his book that purgatives, heavy laxatives, were also important during most phases of typhus, and these sentiments were echoed in his lectures. He also made extensive use of cathartics, which induce vomiting, like calomel, volatile Alkali, and Senna throughout the case. The middle junctures of the disease should have been combated with Serpentaria and wine. Chapman acknowledged this in his book, lectures, and in practice as he used roots and wine whey to treat Hickenbottom. Chapman advised opium for the final stages of typhus, where the patient was likely to be delirious. In the case, he used laudanum and regular wine to ease the patient’s feverish delirium. According to Graham, Chapman’s lectures also advocated the use of “cordial and diffusible stimulants such as volatile Alkali,” as well as the use of wine whey, Myrrh, Castor, and Peruvian bark (4). Another stimulant he suggests is brandy infused with cayenne pepper (4). Interestingly, he supported switching up prescriptions when treating patients in order to keep the body guessing, saying it was “necessary to alternate the stimulants in this disease, for the system accustomed to their impression they at length loose [sic] their effect” (4).

For the most part, Chapman’s remedies were largely consistent, although, because of the reserved nature of Graham’s reaction, it is difficult to ascertain whether or not Graham agreed with his professor’s prescriptions. Nowhere does the manuscript record an instance where Graham explicitly agrees or disagrees with Dr. Chapman. He straightforwardly reported what happened without imparting any of his own judgment. When practicing on his own only two years later, Graham recounts a “cold plague” that swept through the country in 1820 (4). Graham treated the fever with bleeding, opium, cathartics, sudorifics, stimulants, wine whey, volatile Alkali, red pepper tea, and cold compresses. Chapman used all of these, so the similarities between Graham and Chapman’s treatments of typhus suggest that Graham may have agreed with Dr. Chapman’s treatment of Hickenbottom (5).

By: Benjamin Phillip Brams, V

References

  1. Chapman, N. Elements of Therapeutics and Materia Medica. Vol. II; Philadelphia, 1822.
  2. PubMed Health Medical Encyclopedia. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002339/. (Accessed May 11, 2012)
  3. Discovering Lewis and Clark. Medicine of Benjamin Rush. Accessed May 9, 2012.
  4. William Alexander Graham, “A Narrative [1827] of Graham’s Journeys, Medical Training and Career 1816-1819 in Lexington, Va., Abingdon, Va., and Philadelphia,” pp. 84-124, Washington and Lee University Library, Special Collections.
  5. The student was apparently Shannon Higginbotham, whose obituary appeared in the Lynchburg Press on February 11, 1819

Doctor Chapman’s treatment of Mr. Hickinbottom

Day Symptoms Treatment Prescribed
1 Foul tongue, dry and tight skin 12 oz. blood drawn, sweet spirits of nitre, lemonade
2 Fever, headache, foul tongue Calomel, oil of cinnamon, magnesia
3 10 oz. blood drawn
4 Soft, frequent pulse Laudanum
5 Quick, weak pulse
6 TYPHUS DIAGNOSIS Wine whey
7 Delirium, foul tongue, fetid bowels, weak pulse, restlessness Wine whey, oysters and sago, laudanum, volatile Alkali, Senna
8 Frequent pulse, delirium, Dr. Physick attends Calomel, wine whey, leeches
9 Volatile Alkali, wine whey, Senna
10 No restlessness, stronger pulse, Dr. Dewees attends Volatile Alkali, wine whey, calomel
11 Fetid bowels, stronger pulse Senna, Serpentaria, volatile Alkali
12 Sanguinaria, wine whey, Portence
13 Calomel, Senna
14 Oleum Terebinthinae
15 Sago, calomel
16 Calomel, jalap
No record for days 17-25 – Graham also ill
26 Sinking pulse, delirium
27 Soft pulse, cold extremities
28 Soft, full pulse Chalk Mixture, Cretacious Julep, volatile Alkali, wine
 29 DEAD

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