, 1910

Series, Vol. V.

Tubulo-dermoids:-These occur in the obsolete skin and mucous membrane lined canals previously mentioned, i. e., thyrolingual duct, post anal gut, infundibulum, and branchial clefts. Closure of both ends of the canal, without obliteration of the central portion forms the nucleus for the dermoid. In the lingual portion of the thyro-lingual duct the cyst forms a swelling which is rarely recognized at birth. As it increases it bulges the floor of the mouth and raises the tongue; one is reported which reached the size of a cocoanut. This was successfully removed. Cysts of the thyroid portion are prone to rupture and leave a median cervical fistula. between the hyoid bone and the top of the sternum. Cysts of the pituitary body and the pouch of Rathke occur; the latter forms a cyst which projects into the pharynx.

From the post anal gut and rectum we have three varieties of dermoids; the thyroid dermoid, which is of large size at birth and in structure resembles the thyroid gland; the post rectal dermoids, which are rarely apparent at birth, grow slowly and usually contain teeth and hair. The rectal dermoids which project into the rectum are pedunculated and contain long hairs which occasionally protrude from the anus, these develop late in life.

The internal portions of the branchial clefts are lined with mucous membrane, the external portions with skin. These cysts usually contain only mucus or sebaceous matter, occasionally one contains a tooth. Rupture of these cysts or imperfect closure of the clefts leave branchial fistulae. The location of the openings of these fistulae are as follows:

1. Normal external auditory meatus and Eustachian orifice.

2.

External opening close behind the angle of the jaw in front of the sternomastoid, or more rarely slightly behind the lobule of the pinna; the internal opening is in the recess of the tonsil.

3. Externally, anterior border of sternomastoid at the level of the thyro-hyoid space; internally, sinus pyriformis.

4. Externally, along anterior border of the sterno-mastoid within one and onehalf inches of the sterno-clavicular articulation.

These cysts and fistulae show a tendency to be bilateral and hereditary.

Treatment:-Some dermoid cysts cease their growth and shrivel up. Most increase slowly unless inflamed or the seat of carcinoma or sarcoma. When removed the removal of the wall should be complete or a sinus will persist indefinitely. 1132 Bergen St., Brooklyn, N. Y.

THE TREATMENT OF TYPHOID

FEVER.1

BY

CYRUS J. STRONG, M. D., Visiting Physician to Bellevue Hospital; Attending Physician to Willard Parker Hospital.

It is not the purpose of this paper to detail the history of typhoid fever nor to follow too closely its evolution, but to present some general considerations, omitting mention of symptoms or complications the treatment of which is universally conceded, and then tell you the results obtained from measures I have employed during the past three years in hospital and private practice to the exclusion of all others, claiming no originality for the scheme outlined but be

'Read before the West End Medical Society, May, 1910.

ing convinced that it contains elements of advantage not found in other plans of treatment. This presentation is offered in the hope of inducing a full discussion of the whole subject which must at times appeal to us all, whether physicians, surgeons or following special branches of our art. If this be accomplished, my paper will have fulfilled its purpose.

The first step toward scientific or rational treatment must necessarily be a thorough understanding of the etiology, pathology and natural history of the disease under discussion, hence prior to 1840, at about which date typhoid fever was finally differentiated from typhus, cerebro-spinal meningitis, malaria, etc., and its identity. and pathology conceded, treatment in any modern sense could scarcely be said to exist. The names of two Americans, Gerhard and Pennoch (1) with those of Stewart (2) and Louis (3) are prominent among those who first accepted and established the identity of typhoid. When in 1880, Eberth discovered the bacillus typhosus, the etiology rested at last upon a firm foundation and treatment could be expected to advance beyond the baldest empiricism. Of the measures in vogue prior to this date and advocated even later, it is enough to say that they proved conclusively the tenacity of human life and the violence which could be done to physiological activity, especially nutrition, without higher mortality than the statistics of this period show.

Diet: Diet constitutes so large a part of the treatment of typhoid and is the feature upon which I desire to lay such special stress, that I shall speak of the other factors first and briefly then give in detail the diet I wish to advocate.

Specific Treatment: I am unable to speak from personal experience regarding

the use of sera or prophylactic vaccines and shall therefore pass over this most interesting field, merely voicing the hope we all entertain that its final outcome may be results as brilliant as those obtained from the use of other antitoxins.

Stimulation: Beyond question one of the greatest advances has been the lessened amount of stimulation, especially alcoholic, administered as a routine. Those of us who were so unfortunate as to have had typhoid under the old regime will, I am sure, never forget the huge and frequently repeated doses of brandy or whiskey poured down our throats, especially if, as in my own case, all water was absolutely prohibited.

The following quotation from Nothnagel's Encyclopaedia of Medicine (4) perfectly represents the position then held: "In spite of all theoretic objections, alcoholic beverages are still indispensable to the practitioner in the treatment of typhoid fever, as well as in the treatment of acute febrile diseases in general. It would be superfluous at the present day (1902) to discuss former objections with regard to the influence of alcohol in increasing the fever. Von Ziemssen, Jurgensen and Liebermeister have permanently disposed of this prejudice. Although the theoretic explanation is difficult, practically the stimulating influence of alcohol upon the circulation and respiration is established beyond a doubt. I should be unwilling to treat typhoid patients at all in certain stages and conditions without alcoholics."

Since using the diet I shall mention, stimulation has been needed but rarely and in small doses to meet definite conditions Alcohol has been practically restricted to those in whom a long continued habit has created a seeming demand, its withdrawal having been followed by either increased

nervous disturbances or marked depression. Strychnine has been my choice in 1/30 gr. doses when plainly required.

Temperature: At some period in the course of practically every case of typhoid, the temperature demands careful treatment, both as indicating the severity of the toxic absorption, with its attendant disturbance of all functional activity, and also because of the consequent increased demands made upon nutrition and nervous resistance. Osler speaks of an afebrile type but admits he never saw such a case. I have seen one in which the maximum temperature was just over 100° F., which ran an otherwise typical course, with subnormal variations. Hydrotherapy in some form is the means now so universally employed to reduce the fever that it is needless here either to argue in its favor as a principle or describe in detail the various modifications adopted to meet individual requirements.

Just a few words I may be allowed in relating the results obtained from the exclusive use of cold rectal irrigations with the Kemp tube in two cases where all other means either failed or were impossible of application. The first time I resorted to this expedient was soon after finishing my interne service at Bellevue, when every private patient really ill caused me the greatest anxiety. This patient, a female aged 22, music teacher, was in a badly depreciated condition, markedly anaemic, with pronounced mitral regurgitation none too well compensated, of which she was perfectly aware and most apprehensive. After trying every form of bath with which I was familiar, all given by a most competent nurse under my personal supervision and all alike either failing utterly to reduce the high temperature and relieve the intense nervous excitement, or else produc

ing such prostration with cyanosis, irregular and intermittent pulse that on several occasions it was a question whether free stimulation would tide her over, a rectal irrigation was tried as a last resort. By regulating the temperature in the irrigator and making pressure on the outlet tube from the rectum, any variation of temperature and volume of fluid in the rectum could be maintained. After the second repetition the patient experienced the greatest relief and satisfaction and her final recovery was largely due to this expedient. Last summer I again resorted to this method under most trying circumstances. This case was the most des

perate I have ever seen; the surgical features were reported to this society by Dr. T. A. Smith last November. After unsatisfactory results from all forms of bathing, ice cold irrigations were employed, lasting at times from one to two hours. None but the happiest results ensued. The temperature was perfectly controlled, and nervous manifestations relieved to such an extent that the patient frequently slept after the first fifteen to twenty minutes. Further advantages may be claimed for these irrigations aside from the obvious flushing of the intestine and the absorption of water into the circulation; they may be safely employed under conditions which contra-indicate the full Brandt bath, cold packs, etc. Cardiac disease or profound functional disturbance, chlorosis, obesity, old age with its attendant arterio-sclerosis or even mild intestinal hemorrhage need not deter one from using carefully regulated irrigations with the Kemp tube. It has been my habit to use the ice coil for the abdomen in all cases showing a tendency to hyperpyrexia in the intervals of more active measures, and I am thoroughly convinced that it has a much more pronounced effect than is generally admitted.

Of antipyretic drugs, I have used none for several years except an occasional dose of aspirin in the cases of typhoid (four in all) treated at the Willard Parker Hospital complicating scarlet fever, or when after a long severe attack complete defervescence has been delayed by what for want of a better term I may call a habit, a few doses of quinine or aspirin have reduced the temperature to normal where it has remained.

Hemorrhage: Ice bags locally with calcium lactate in xx gr. doses every three hours and especial care regarding diet to prevent undue irritation or distension has been our rule. An occasional dose of codeine or even morphine if the patient is restless but never if in pain or presenting any areas of tenderness lest the evidences of perforation be masked. In future I shall try injections of serum, preferably normal horse serum, since it is easily obtained, as the first resource.

Perforation: Perforation demands immediate operation and the brilliant result obtained by Dr. T. A. Smith in the case just referred to proves the advisability of accepting the most desperate chance, since a fatal termination is the only alternative.

Intestinal Antiseptics: The use of intestinal antiseptics from salol to chlorine water with large doses of calomel was the routine procedure during my interneship in Bellevue Hospital, and the authority of its advocates made us rather hopeful until a sufficient number of cases had been under observation to warrant the conclusion that until the discovery of some intestinal antiseptic of greater potency or more specific activity, little could be accomplished.

We are all perfectly well aware of the necessity for the greatest care in the choice of rooms, beds, nurses, etc. for our typhoid

patients. The refinements of the modern sick room nowhere count for more and the physician who most successfully meets these requirements will have the best results. Nursing in its broadest meaning must necessarily frequently turn the scale in a disease whose normal duration is four weeks and for which we have no specific.

Diet: All that has been said thus far of treatment is of less importance than the selection of a proper diet. Three years' observation has convinced me that most of our severe cases may be rendered mild by this means and therefore in need of little treatment of any kind. Again quoting from Nothnagel: "Among actual articles of diet, the first place should be given to milk. Theoretically this appears undoubtedly to be the most rational form of nourishment for febrile patients, inasmuch as it represents the ideal combination of proteid, fats, carbohydrates and salts in a liquid form."

This statement represents fairly well the views held by all up to within a comparatively few years. The other articles advocated or permitted were all in addition to milk never regarded as perfect substitutes. I know of but two men who taught otherwise up to three years ago. Text books, systems of medicine, articles culled from current medical literature, even the reading of Dr. Coleman's admirable paper (5) before the American Medical Association brought forward no advocacy of a diet from which milk should be excluded, at the same time increasing its acceptability to the average patient. So impressive was my introduction to this method, that Ward 6 in Bellevue Hospital, as it was when I took up my service three years ago this month, always comes to my mind when typhoid fever is under discussion. From that day

to this no typhoid patient under my care in hospital or private practice has had a drop of milk.

In five consecutive beds were five typhoids ranging in age from adolescence to middle age, and in duration of the disease from early in the first week to convalescence. None had been given milk since admission to the ward. One patient gave the ordinary evidences of a mild attack in his general appearance. Among the others, not a coated tongue, distended abdomen, emaciated body, flushed face or temperature requiring a bath. Mentality was normal in all and several of these patients were complaining of being kept in bed, saying they evidently were not sick since they were being given no medicine. It was difficult to realize they were typhoids and the impression was equally lasting upon those of my friends who visited the ward. Any diet which could produce such results even once was surely worthy of careful trial and while I admit that at no time since has the above picture been perfectly reproduced yet I hope to induce others. to test this diet for themselves, and then follow, modify, or abandon as their results indicate.

Do not understand me to say I regard the last word said on diet-by no means, but I do most sincerely believe that a milk-free diet presents advantages over all others yet advocated.

The laboratory work was done by Dr. C. G. L. Wolff in determining the nitrogen balance and nutritive equilibrium in all our typhoids and was, so far as I know, the first time this had been systematically undertaken in determining typhoid diet. His thusiasm over the results from a purely theoretical standpoint fully equalled that of the clinician.

en

It was determined to force the diet up to the point of satisfying the nutritive requirements of the patient if this could be done without disturbing the digestive or assimilative functions.

Now let us take the nutritive standards in health as a basis for comparison. Atwater gives 2,700 calories per day for an adult of sedentary habit. Chittenden (6) proved that 3,000 per day was ample to maintain in healthy nutritive equilibrium men doing a considerable amount of muscular work, even when diet and labor were continued for several months. Lower figures have been given but these may be taken as fairly rep

resentative.

Now let us see how the diet for typhoid patients compares. How greatly the demands of continual high temperature and the increased katabolism to toxic absorption may affect the nutritive requirements, we do not know but an approximate answer seems to have been made. Coleman gives the following values for the different typhoid diets formerly in vogue. About 300 calories for the starvation diet, 1,400 for the milk diet so long a standard. The tendency toward a more liberal diet of greater variety has been growing ever since 1892 when Peabody published his results. Milk had long been declared to be the only safe and sane diet. I well remember the feeling among the internes at Bellevue when the new diet was proposed and the predictions of disaster freely made by those of the visiting staff who refused to adopt the suggested alterations. When it had been proved that a more liberal diet could be safely employed, the nutritive value was gradually raised, though in many of the proposed changes the proteid equivalent was too high, often producing profound gastro-intestinal dis