Can Typhoid Fever be Aborted ? Third paper read before the Mahoning County, Ohio, Medical Society, Maren 12,1894, with the Records of the Reported Cases Continued to Date of Recovery; also of three other Members of the Family who were attacked after the Reading of this Paper. BY J. E. WOODBRIDGE, M.D. YOUNGSTOWN, OHIO. REPRINTED FROM THE A M ERICA N MEDIC A L APRIL Ik, 189^. CHICAGO; PRINTED AT THE OFFICE OF THE JOURNAL OF THE ASSOCIATION. 1894. CAN TYPHOID FEVER BE ABORTED? As a preface to my paper, I wish to acknowledge my indebtedness to the President of this Society, to our last ex-President, to the ex-President of the Ohio State Medical Society present, to Dr. Thomas, Dr. Barnes, Dr. Dickson and all others who have con- firmed my diagnoses, watched the results of treat- ment, or in any way have aided me in my work; and to thank them for their very complimentary remarks in the discussion of my previous papers. Having my work characterized as the greatest discovery of the age by one member, my name associated with that of Jenner by another, and another give expression to his pride that a member of this Society had done what I have; would be exceedingly gratifying to me at any time, but especially just now when I am pro- mulgating ideas which must arouse the indignation of every great medical professor in the world, because they, if true, convict him of teaching errors that have not only cost hundreds of thousands of lives, but have discouraged all investigation in this most im- portant field, and must incur the bitter hostility of a large class of physicians who not daring to adopt my treatment, or failing to secure the results I claim, will lay all the blame to my method, rather than up- on their application of it. I wish, too, to thank the editor of the Journal of the American Medical Association, for so promptly defending me from the spiteful attacks of the editors of two or three medi- cal journals. I wish too, to say to the members of this Society that I fully appreciate their courtesy in giving up most of their last meeting to my second paper on the 2 same subject. And when they by a unanimous vote gave me the floor again this evening, I could not help wishing that my work were enough advanced to en- able me to make my third paper something more than a mere effort to inaugurate a new era in the diagnosis, prognosis and treatment of typhoid fever, the subject which for more than twenty years has lain nearest my heart, and to which all the best years of my life have been devoted. To the strictly scien- tific part of my work I need not even call your atten- tion. Most of it has been better done by abler work- ers, and some of it is in too chaotic a state to be even alluded to amongst scientific men, since we know so little of the cause of typhoid fever that we can not say positively that anyone germ invariably produces it. And so little of the real action of the remedies exhibited that we are unable to say whether eucalyp- tol and guaiacol, or creosote, or calomel, or any one agent is essential, or how of why a cure has invaria- bly followed their exhibition. The importance of the subject to you, to all Amer- ican and Canadian physicians, and indeed to practi- tioners of medicine all over the world, wherever typhoid fever prevails, can not be overestimated, be- cause of its terrible mortality.-(The death rate in Pittsburg in 1892 was 23 per cent.); because of the broken constitutions of the more than 100,000 who recover from the disease in the United States annu- ally ; because the king upon his throne, the states- man wielding the destinies of the greatest nation, the merchant with his princely wealth, and the most brilliant physician, with all their resources, and all their power can not escape it, and because, last but not least, aside from the method of treatment I have given you, there is no known means of aborting the disease or of saving the life of every case. That I can do this, the charts shown you at the last meeting of this Society (a few of which have been published), and which represent only cases that I have treated since the 25th day of June, 1893, and 3 of the cases I have treated since that time only such as presented absolutely pathognomonic symptoms of typhoid fever, in nearly every one of which the diag- nosis was confirmed by from one to five of the ablest diagnosticians in the country, are unquestionably conclusive evidence. At least you must accept them as such, until you can produce an instance where I have had a case which had been sick less than eight days when I was called, and lost by death, or failed to abort, or to so modify the disease as to cause it to run an exceedingly mild course (unless complicated by preexisting or co-existing disease). A bold assertion after reading Osler's statement, ("The Principles and Practice of Medicine," 1892, page 33): "The profession was long in learning that typhoid fever is not a disease to be treated by medi- cinesalso on page 531, he says : "We are still with- out an agent which can counteract the gradual influ- ence of the poisons which develop in the course of acute febrile diseases, such as typhoid fever, pneu- monia and diphtheria." And yet twelve years before this book was pub- lished (in 1880)atan unusually largely attended meet- ing of this Society, I condemned all of the published methods of treatment of typhoid fever; gave in detail my treatment and foreshadowed in some measure the important results I expected to follow its adoption, by telling the essayist of the evening that if he would abandon his own, and all known methods of treat- ment, and pursue the course I had indicated he would have better results, but «he, while expressing his respect for me as a careful practitioner condemned my theories and the remedies I proposed, as did every other member who joined in the discussion. In 1882 I addressed the Society on the subject of intestinal hemorrhage in typhoid fever, saying that it would be unknown if the disease were properly treated, and that it would be a safe rule to send to State's prison any physician who ever had such a case, presupposing that he was called in due sea- 4 son, admitting such a law might occasionally do* injustice, but claiming that its general effect would be beneficent. Some of you will remember Case No. 55-A. Name, T. M. Diagnosis confirmed by Drs. McCurdy, Dickson and Robert Gibson. This patient not seen again until March 3. that on Nov. 13, 1884, in the discussion of a paper by Dr. Thomas on the use of the term, "typho-malarial fever," I condemned its misapplication to cases of 5 true typhoid fever with no malarial taint, and took occasion to say at the same time that the term, "ma- larial fever," was misapplied when used to designate a fever that runs three or four weeks without inter- mission or distinct remissions, and ends in death Case No. 55-B. Name, T. M. March 2. from intestinal hemorrhage or exhaustion. That again in 1890 I spoke in condemnation of the use of the coal tar derivatives in the treatment of the disease, saying that I believed that a very large 6 percentage of the deaths from heart-failure were due to their exhibition, and that in 1891 I again spoke to the Society on the subject, saying that I believed Case No. 60. Diagnosis, Typhoid fever. Name, Mrs. A. McF. Diag- nosis confirmed by Drs. McCurdy and Dickson. Complicated with Inflammation of both lungs and hemorrhage from the right lung. typhoid fever could be aborted. Thus the fact that I have regarded typhoid fever as a curable disease 7 Case No. 62. Name, Miss A. M. Diagnosis confirmed by Drs. McCurdy and Dickson. 8 has been no secret since 1880; and that when called before the sixth or eighth day of sickness I invariably give a prognosis of ten or twelve days sickness, or if longer, so mildly sick as to cause no uneasiness-no danger-is also well known; and the medical pro- fession abroad will understand that if I had failed in a single instance to make my prognosis good, both the people and the profession here would have held me responsible years ago. During all these years I had made every possible effort to prove the correctness of my theories, so that when I appeared before my Society, claiming the abil- ity to do what all of the great teachers have taught and believe is impossible, I might have the means, not alone of proving my assertions, but also of defining the principles governing the proper treatment of the disease. But my claims were too absurd for belief, even by the most credulous, and although the author- ities in some hospitals would permit me to see their pa- tients or make dissections, it was long an utter impos- sibility for me to secure an opportunity to treat even a few patients in a public way, under the observation of a skilled diagnostician, notwithstanding the fact that my applications were supported by the highest credentials. I met with so many discouragements that lack of money alone prevented me from opening a hospital for typhoid fever in which to demonstrate to the world how to abort the disease, and a few thousand dollars placed at my disposal in 1880 would long ago have resulted in the saving of many thousands of lives annually, as well as the great amelioration of those other thousands who languish weeks in a burn- ing fever, then suffer the horrible pangs of hunger (I have felt them), and finally as mere shadows of their former selves emerge from their sick-room and creep about more dead than alive, often for months, when they might just as well have sat up and eaten beefsteak or bread and butter after the sixth or sev- enth dav of treatment. 9 A few years since when Dr. McCurdy was President of the Ohio State Medical Society, and by virtue of his office was the highest representative of .the pro- fession of the State, we had several interviews on the subject of publishing my claim that typhoid fever could be aborted, and the method of treatment that seemed best calculated to produce this result, and we both felt that without more conclusive evidence than I could then adduce of my ability to abort the dis- ease that no possible good would result from such publication: and although he has done me the honor to pronounce my method of treating typhoid fever a wonderful discovery, yet he expressed the belief that such premature publication would greatly imperil my professional career. I believe the Doctor still thinks, and I am sure the opinion is correct, that it would have been better to have waited a few years longer, before making any public announcement on the sub- ject, because my cases are yet too few to carry con- viction to the mind of every member of the profes- sion that it is possible to abort typhoid fever, and twelve years of active private practice, without a death, is not long enough to convince every one that death is a wholly unnecessary consequence of the disease. Had I -waited until I could have reported the cases of twenty years, without a death from ty- phoid fever, and a proportionately increased number of aborted cases; waited, too, until I had completed my investigations so far as to enable me to state with exactness the laws upon which the scientific treat- ment of typhoid fever depend, instead of detailing the treatment which I gave individual cases, and giving formulae which, while acting admirably, may and probably do, contain ingredients which add little, if any to their efficiency, enough of thinking men in the profession would then have accepted my theories to aid me in convincing the unthinking, and the treat- ment of typhoid fever would have been revolu- tionized. Now what will the result be? We must wait and see. How long ? Who can tell ? The 10 lessons of the past must be unlearned before the les- sons of the future can be understood. All of the great teachers of the past and the present have so iterated' and reiterated the statement that typhoid fever can not be aborted, that it will take long to unlearn that one lesson, especially while the very best and latest text-books, and all of the leading medical professors of the world are teaching the contrary: and until this lesson has been learned it is useless to expect physicians to succeed with the abortive treatment of typhoid fever, for only to the most careful watching and the most skilful use of the remedies at our disposal will this treatment yield its happiest results. How can he succeed in such a work who firmly believes in the impossibility of suc- cess, or how can he be expected to give due energy to a work in which he has no faith? Another lesson which will be difficult to unlearn and which is taught by the great teachers with as much unanimity as the other, is, not to treat symp- toms. Beginning at any given day early in the dis- ease, one should treat a patient with a temperature of 105 or 106 degrees exactly as one would were the temperature 101 or 102 degrees. The physician who says that the important object to be attained is to bring the temperature down, is like the man who would attempt to resuscitate a drowning man with- out first taking him out of the water, and the end would probably be the same in either instance. It is not the symptom which kills the patient, and one patient with a temperature of 105 degrees may be on the high road to recovery, while another with a tem- perature of 101 degrees or even lower may be rapidly approaching the grave. Watch the temperature, the pulse and all other symptoms as matters of scientific interest, and as showing the results of treatment given hours or even days before, but not as giving any indication for treatment in the future. This rule applies only in cases which have been properly treated prior to the eighth day of sickness. Last month, I 11 gave in detail the treatment of three typical cases of typhoid fever. Two were treated regardless of symp- toms, and one which I did not see until the sixteenth day of his illness, and for that reason, was treated almost entirely by the symptoms. All recovered, but while one was not allowed any solid food for ten days after his temperature was normal, the others ate solid food all of the time. Two were never sponged at all; the other thoroughly. The one was notallowed even to rise to stool; the others sat up and walked about and one of them went out of doors during his ill- ness. The detailed treatment of these individual cases was given because to them I gave nearly, if not quite, every remedy that I regard as essential to the abortive treatment of the disease, in all of its various stages, and because I wished to make more careful observa- tions before attempting to publish a thesis on the treatment of typhoid fever. In future, as my inves- tigations result in improved methods, I shall give the profession further details, and I hope to be able to go much more fully into this part of my subject in a paper which I propose to read at the San Francisco meeting. Admitting that typhoid fever can be aborted, it be- comes a matter of prime importance to decide how to abort every case and save every life. This will be impossible as long as the people buy and use patent medicines, take domestic remedies or for any reason neglect to send for a physician in season, and they will never realize the importance of sending for a physician in due time so long as he fails to make a diagnosis and institute proper treatment promptly when called. Typhoid fever is man's most insidious enemy; having a long period of incubation its early diag- nosis becomes a matter of the greatest importance, and should invariably be made the first time the pa- tient is seen, with sufficient accuracy to warrant the institution of proper treatment. I readily concede the impossibility of always making a correct or pos- 12 itive diagnosis at the first visit, but every case in which the temperature is ever so slightly elevated and the pulse ever so little accelerated, in which no contra-indications can be discovered should be prescribed for as a case of typhoid fever, thus giving the patient the benefit of every possible doubt, since Case No. 68. Diagnosis, Typhoid fever. Name, Miss M. McF. Diag- nosis confirmed by Dr. Dickson. I know of no disease or condition which under this rule would be unfavorably influenced; on the con- trary the diseases in which this course would be ideal treatment are too many to be even mentioned in one short paper. In diphtheria, in measles, in variola, in malarial fever, in pneumonia, in influenza 13 and all catarrhal troubles you have given your pa- tient the best possible initial treatment. You will remember that I was assigned the duty of present- ing a paper on "La Grippe" at our annual banquet, after its visitation in 1889, and that I then said that Case No. 65. Diagnosis, Typhoid fever. Name, F. McF. Diagnosis confirmed by Dr. C. C. Booth. I accredited the fact that I had had no deaths from la grippe or any of its sequelae to the treatment I had invariably pursued. I might have added that although I made no mistake in diagnosis, I regarded for purposes of treatment, every case of la grippe as a 14 case of typhoid fever, except that I usually gave the remedies in larger doses. Thus, while la grippe and typhoid fever differ so widely that I do not think any careful physician would be likely to make a mistake in diagnosis, they are best treated in almost identically the same way, at least, in their earlier stages, and the same is true of all of the ma- larial fevers and of the so-called " typho-malarial fever," if there be such a thing. During my long and intimate association with my uncle, Dr. Timothy Dwight Woodbridge, whose well- stored mind and brilliant intellect enriched by the observations of more than fifty years of active prac- tice, made him not only a pleasant companion but always a wise guide in all matters relating to our profession, he often said that there was no malarial fever in this locality which would ever cause death, even if left without medical treatment, and yet our Health Officer's report for last year (1893) shows twelve deaths from malarial fever and only nine deaths from typhoid fever. If Dr. Woodbridge, Sr., were right, and my experience certainly sustains his opinions, then there are three horns, and three only, to the dilemma of the physicians who made these re- ports. Every one of these cases was a mistake of diagnosis, a false report, or the medicine and not the disease killed those twelve patients. In this conclu- sion I am ably sustained by Dr. Eliot, of New Haven, who says: "When typhoid fever really exists but is not cor- rectly diagnosticated it is, in this vicinity most fre- quently called malarial fever, and at a later stage, typho-malarial fever. This mistake generally de- pends upon a mixture of ignorance and carelessness. I do not care to maintain at the present time that typho-malarial fever never occurs. I presume that every one is aware, however, that this term should be limited to cases of disease which are due to the simultaneous action of the typhoid and of the ma- larial poisons. I am thoroughly convinced that 15 most cases of so-called typho-malarial fever are in reality cases of typhoid fever. If a malarial element is present in some of them it is possible to remove it promptly by appropriate treatment. With regard to Case No. 66. Name, Mrs, H. McF. cases of so-called malarial fever it should be re- membered that most fevers which are caused by ma- larial poison are of a distinctly intermittent or remittent type. If, therefore, a case of continuous 16 fever occurs which is uninfluenced by adequate doses of the ordinarily used anti-periodics, there is good reason for challenging the diagnostic accuracy of any one who pronounces such a case malarial fever. In most cases of this kind the disease is enteric fever. The vital statistics of our city and State show a number of deaths as due to malarial and typho-malarial fever which is almost equal to the mortality reported from typhoid fever. There is little doubt that the majority of these cases reported represent mistakes in diagnosis, where enteric fever has been overlooked and called by another name." The above quotation is perfectly applicable to this locality, except that our statistics are worse than those of New Haven, and would have been even worse than they are had not some diagnoses of malarial fever been corrected to typhoid fever by consulting physicians before death, sometimes even in the third or fourth week, corrections that came too late to benefit the patient. There can be no doubt if these reports could be analyzed and autopsies made, there would be found a large number of deaths due to typhoid fever which have been reported under other names. Osler, than whom there is perhaps no better authority, says, in "Principles and Practice," page 30, that "cases coming on with severe headache, photophobia, delirium, twitching of the muscles and retraction of the head are almost invariably regarded as cerebro-spinal meningitis ;" that he has thrice per- formed autopsies on cases of this kind in which no suspicion of typhoid fever had been present, and adds : "Cerebro-spinal meningitis is, however, a rare disease, typhoid fever a very common one, and the onset with severe nervous symptoms is by no means infrequent. Fully one-half of the cases of so-called brain fever belong to this category." Some of you may object to my method of making a diagnosis; may say that I reach conclusions from insufficient data. But you are reminded that this is a diagnosis for treatment only, and to be verified 17 or corrected by future observations and at the earli- est possible moment, and that it can be justified only on the premise that the physician's most important duty is to cure his patient rather than strive for the unattainable absolute accuracy of diagnosis. I am aware that you can approach very close to an abso- lutely exact diagnosis in typhoid fever if you await the development of all the characteristic symptoms of the disease, but you will purchase your exact diag- nosis at far too high a price, and it will come too late to benefit your patient. It is strange, too, what a varied value different members of the profession place upon the symptoms ordinarily supposed to be pathognomonic of typhoid fever. One will pin his faith to rose spots, another to tenderness in the right iliac-fossse, another attaches much importance to tympanites and dullness over the spleen ; while one old physician who actually believes he is something of an authority, says he never saw a case of typhoid fever in which there was not diarrhea with little black specks through it. He is on a par with those who fail to make a correct diagnosis until their wits are awakened by the appearance of rose spots or the supervention of an intestinal hemorrhage. Their diagnoses may be exact, indeed, but so far as any benefit to be derived from treatment is concerned they might almost as well have been made in the dead house. A diagnosis of typhoid fever based on such slight evidence as two symptoms only, and those com- mon to many other pathologic conditions might and probably would occasionally require future correc- tion, but could never result in harm to the patient, because the remedies administered in the doses ad- vised could do no possible harm in any condition which could be mistaken for typhoid fever; and while the best possible treatment for any stage of this disease would be almost equally beneficial in the early stages of any acute fever, and a very large majority of these, including mild cases of typhoid fever, or typhoid fever taken very early, would be 18 cured long before a positive diagnosis would ordi- narily be made in typhoid fever, or indeed before the development of pathognomonic symptoms would render such diagnosis possible. If you await the ap- pearance of these, you will rarely succeed in abort- ing^the fever; and unless you are an exceedingly ex- pert diagnostician you will sacrifice a very large per- centage of this class of patients. I hand you the completed chart of Angus McFee, No. 51, which was shown up to date at our last meet- ing, and in whose case a fatal end was so confidently predicted by a member who had examined him in the afternoon. You will please observe the rapid fall of temperature after each application of large doses of the eucalyptol-guaiacol mixture to the abdo- men. He had two or three small hemorrhages of the bowels. (Dr. McCurdy, who saw Mr. McFee with me immediately after I was first called, during the dis- cussion of this paper said that he considered this the worst case of typhoid fever he had ever seen.) I was called to-day to see his wife, Mrs. Angus McFee, Chart 60, who undoubtedly has typhoid fever. If so hers will be an exceedingly interesting case, since it will be complicated from the beginning, she having had extensive pelvic trouble since the birth of her child. On the night of she was called up and stood on a cold oil cloth, contracting a severe cold to which she accredited her violent headache and backache, cough and the agonizing pains in the region of the right nipple, and for this reason did not send for me until to-day. Dr. Dickson and Dr. McCurdy confirmed this diag- nosis. The abdominal symptoms yielded promptly to treatment, but the trouble of the lungs grew rapidly worse and culminated in a profuse hemorrhage of the right lung. The temperature to-day, March 29, as you will see, is in the morning 97.8 degrees, and this evening 99.6 degrees; cough still troublesome, but otherwise she is quite well, has eaten a little beef- 19 steak yesterday and to-day, and her diet is left unre- stricted hereafter. A brother, sister, and sister-in-law who aided in nursing A. McFee have each had an attack of typhoid fever since Mrs. McFee was taken sick, and all are well. See Charts No. 63, No. 65 and No. 66. One of the charts published in my last paper as complete is reproduced. T. Murdock (Chart No. 55), whose temperature and pulse were normal, who sat up and ate beefsteak on the tenth day, who took no medicine after the thir- teenth day of treatment, and whose temperature and pulse were still normal to the eighteenth day, after which he was not seen until March 3, which was the twenty-seventh day. He was therefore, with the ex- ception that he did not regain his strength, apparently entirely well for fifteen days; ate such food as he wished, walked out of doors and up stairs every night to bed until March 3, when I was recalled and found morning temperature 102.6 degrees; afternoon tem- perature 104.8 degrees, with pulse 112 to 116; although there were no rose spots, much abdominal tenderness, nor tympanites, it was unquestionably a relapse of true typhoid fever, from which he recovered more slowly than from the first attack; his temperature first touching normal on the fourteenth day of treat- ment. Of cases that I have seen early in the disease this is the first relapse I have ever had. His sister, Miss A. M., No. 62, residing in the same house, consulted me March 12, 1894. She presented fairly well-marked symptoms of typhoid fever, except that the tenderness and pain in the right iliac fossae seemed to justify a graver disease. She had been attended during last summer for what her physician diagnosed as inflammation of the bowels. The de- velopment of well-marked swelling in the painful and tender right iliac fossae prompted me to call in consultation two eminent abdominal surgeons, Dr. McCurdy and Dr. Dickson, who both expressed the opinion that she had typhoid fever complicated with 20 grave pelvic trouble. She recovered in fourteen days. (See clinical chart.) If in these preliminary papers I have convinced you that it is possible to cure typhoid fever; that in the future a death from the disease will be prima facie evidence of culpable ignorance or criminal carelessness, either on the part of the patient, his friends or his medical attendant; that the long weeks of burning fever followed by a shattered constitution and sometimes clouded intellect, need no longer be feared; if I have impressed upon your minds the im- portance of making an early diagnosis and promptly acting upon it; have shown you the danger of mis- taking typhoid for malarial fever or any of the milder diseases, and have clearly indicated that the scientific treatment of typhoid fever in its earliest stages is also the best possible initial treatment for any disease for which it is likely to be mistaken, then your time and mine, and the space these pages will occupy in the Journal, could hardly have been put to better use.