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Tubulo-dermoids:—These occur in the 2. External opening close behind the obsolete skin and mucous membrane lined angle of the jaw in front of the sternocanals previously mentioned, i. e., thyro- mastoid, or more rarely slightly behind lingual duct, post anal gut, infundibulum, the lobule of the pinna; the internal openand branchial clefts. Closure of both ends ing is in the recess of the tonsil. of the canal, without obliteration of the 3. Externally, anterior border of sternocentral portion forms the nucleus for the mastoid at the level of the thyro-hyoid dermoid. In the lingual portion of the space; internally, sinus pyriformis. thyro-lingual duct the cyst forms a swell- 4. Externally, along anterior border of ing which is rarely recognized at birth. the sterno-mastoid within one and oneAs it increases it bulges the floor of the half inches of the sterno-clavicular articumouth and raises the tongue; one is re- lation. ported which reached the size of a cocoa- These cysts and fistulae show a tendency nut. This was successfully removed. to be bilateral and hereditary. Cysts of the thyroid portion are prone to Treatment:—Some dermoid cysts cease rupture and leave a median cervical fistula their growth and shrivel up. Most inbetween the hyoid bone and the top of the crease slowly unless inflamed or the seat sternum. Cysts of the pituitary body and of carcinoma or sarcoma. When removed the pouch of Rathke occur; the latter forms the removal of the wall should be complete a cyst which projects into the pharynx. or a sinus will persist indefinitely.

From the post anal gut and rectum we 1132 Bergen St., Brooklyn, N. Y. ! have three varieties of dermoids; the thyroid dermoid, which is of large size at birth and in structure resembles the thy

THE TREATMENT OF TYPHOID roid gland; the post rectal dermoids, which

FEVER.1 are rarely apparent at birth, grow slowly and usually contain teeth and hair. The

CYRUS J. STRONG, M. D., rectal dermoids which project into the rec- Visiting Physician to Bellevue Hospital; Attum are pedunculated and contain long tending Physician to Willard Parker hairs which occasionally protrude from the

Hospital. anus, these develop late in life.

It is not the purpose of this paper to deThe internal portions of the branchial tail the history of typhoid fever nor to clefts are lined with mucous membrane, follow too closely its evolution, but to prethe external portions with skin. These sent some general considerations, omitting cysts usually contain only mucus or se- mention of symptoms or complications the baceous matter, occasionally one contains treatment of which is universally conceded, a tooth. Rupture of these cysts or im- and then tell you the results obtained from perfect closure of the clefts leave branchial measures I have employed during the past fistulae. The location of the openings of three years in hospital and private practice these fistulae are as follows:

to the exclusion of all others, claiming no 1. Normal external auditory meatus originality for the scheme outlined but beand Eustachian orifice.

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

BY

ing convinced that it contains elements of the use of sera or prophylactic vaccines advantage not found in other plans of treat- and shall therefore

pass over this ment. This presentation is offered in the most interesting field, merely voicing the hope of inducing a full discussion of the hope we all entertain that its final outcome whole subject which must at times appeal may be results as brilliant as those obtained to us all, whether physicians, surgeons or from the use of other antitoxins. following special branches of our art. If Stimulation: Beyond question one of the this be accomplished, my paper will have ful- greatest advances has been the lessened filled its purpose.

amount of stimulation, especially alcoholic, The first step toward scientific or rational administered as a routine. Those of us who treatment must necessarily be a thorough were so unfortunate as to have had typhoid understanding of the etiology, pathology under the old regime will, I am sure, neve and natural history of the disease under forget the huge and frequently repeated discussion, hence prior to 1840, at about doses of brandy or whiskey poured down which date typhoid fever was finally dif- our throats, especially if, as in my own case, ferentiated from typhus, cerebro-spinal all water was absolutely prohibited. meningitis, malaria, etc., and its identity The following quotation from Nothnagel's and pathology conceded, treatment in any Encyclopaedia of Medicine (4) perfectly modern sense could scarcely be said to exist. represents the position then held: "In spite The names of two Americans, Gerhard and of all theoretic objections, alcoholic beverPennoch (1) with those of Stewart (2) and ages are still indispensable to the practitioner Louis (3) are prominent among those who in the treatment of typhoid fever, as well as first accepted and established the identity of in the treatment of acute febrile diseases typhoid. When in 1880, Eberth discovered in general. It would be superfluous at the the bacillus typhosus, the etiology rested at present day (1902) to discuss former objeclast upon a firm foundation and treatment tions with regard to the influence of alcohol could be expected to advance beyond the in increasing the fever. Von Ziemssen, baldest empiricism. Of the measures in Jurgensen and Liebermeister have permavogue prior to this date and advocated even nently disposed of this prejudice. Although later, it is enough to say that they proved the theoretic explanation is difficult, pracconclusively the tenacity of human life and tically the stimulating influence of alcohol the violence which could be done to phys- upon the circulation and respiration is estabiological activity, especially nutrition, with- lished beyond a doubt. I should be unout higher mortality than the statistics willing to treat typhoid patients at all in of this period show.

certain stages and conditions without alDiet: Diet constitutes so large a part of coholics." the treatment of typhoid and is the feature Since using the diet I shall mention, upon which I desire to lay such special stimulation has been needed but rarely and stress, that I shall speak of the other factors in small doses to meet definite conditions first and briefly then give in detail the diet I Alcohol has been practically restricted to wish to advocate.

those in whom a long continued habit has Specific Treatment: I am unable to created a seeming demand, its withdrawal speak from personal experience regarding having been followed by either increased

nervous disturbances or marked depression. ing such prostration with cyanosis, irregular Strychnine has been my choice in 1/30 gr. and intermittent pulse that on several occadoses when plainly required.

sions it was a question whether free stimulaTemperature: At some period in the tion would tide her over, a rectal irrigation course of practically every case of typhoid, was tried as a last resort. By regulating the temperature demands careful treatment, the temperature in the irrigator and making both as indicating the severity of the toxic pressure on the outlet tube from the rectum, absorption, with its attendant disturbance any variation of temperature and volume of of all functional activity, and also because of Huid in the rectum could be maintained. the consequent increased demands made After the second repetition the patient exupon nutrition and nervous resistance. perienced the greatest relief and satisfaction Osler speaks of an afebrile type but admits

and her final recovery was largely due to he never saw such a case. I have seen one

this expedient. Last summer I again rein which the maximum temperature was

sorted to this method under most trying cirjust over 100° F., which ran an otherwise

cumstances. This case was the most des

perate I have ever seen; the surgical features typical course, with subnormal variations. Hydrotherapy in some form is the means

were reported to this society by Dr. T. A.

Smith last November. After unsatisfacnow so universally employed to reduce the fever that it is needless here either to argue

tory results from all forms of bathing, ice in its favor as a principle or describe in de

cold irrigations were employed, lasting at

times from one to two hours. None but tail the various modifications adopted to

the happiest results ensued. The temperameet individual requirements.

ture was perfectly controlled, and nervous Just a few words I may be allowed in re

manifestations relieved to such an extent lating the results obtained from the exclu

that the patient frequently slept after the sive use of cold rectal irrigations with the

first fifteen to twenty minutes. Further adKemp tube in two cases where all other

vantages may be claimed for these irrigameans either failed or were impossible of

tions aside from the obvious flushing of the application. The first time I resorted to

intestine and the absorption of water into this expedient was soon after finishing my

the circulation; they may be safely employed interne service at Bellevue, when every under conditions which contra-indicate the private patient really ill caused me the great- full Brandt bath, cold packs, etc. Cardiac est anxiety. This patient, a female aged disease or profound functional disturbance. 22, music teacher, was in a badly depreciated chlorosis, obesity, old age with its attendant condition, markedly anaemic, with pro- arterio-sclerosis or even mild intestinal nounced mitral regurgitation none too well hemorrhage need not deter one from using compensated, of which she was perfectly carefully regulated irrigations with the aware and most apprehensive. After trying Kemp tube. It has been my habit to use every form of bath with which I was the ice coil for the abdomen in all cases familiar, all given by a most com- showing a tendency to hyperpyrexia in the petent nurse under my personal super- intervals of more active measures, and I am vision and all alike either failing utterly to thoroughly convinced that it has a much reduce the high temperature and relieve the more pronounced effect than is generally intense nervous excitement, or else produc- admitted.

Of antipyretic drugs, I have used none patients. The refinements of the modern for several years except an occasional dose sick room nowhere count for more and the of aspirin in the cases of typhoid (four in physician who most successfully meets all) treated at the Willard Parker Hospital these requirements will have the best recomplicating scarlet fever, or when after a sults. Nursing in its broadest meaning long severe attack complete defervescence must necessarily frequently turn the scale in has been delayed by what for want of a a disease whose normal duration is four better term I may call a habit, a few doses weeks and for which we have no specific. of quinine or aspirin have reduced the tem- Diet: All that has been said thus far of perature to normal where it has remained. treatment is of less importance than the

Hemorrhage: Ice bags locally with cal- selection of a proper diet. Three years' cium lactate in xx gr. doses every three observation has convinced me that most of hours and especial care regarding diet to our severe cases may be rendered mild by prevent undue irritation or distension has this means and therefore in need of little been our rule. An occasional dose of treatment of any kind. Again quoting from codeine or even morphine if the patient is Nothnagel : "Among actual articles of diet, restless but never if in pain or presenting the first place should be given to milk. any areas of tenderness lest the evidences of Theoretically this appears undoubtedly to perforation be masked. In future I shall be the most rational form of nourishment try injections of serum, preferably normal for febrile patients, inasmuch as it reprehorse serum, since it is easily obtained, as sents the ideal combination of proteid, fats, the first resource.

carbohydrates and salts in a liquid form." Perforation: Perforation demands im- This statement represents fairly well the mediate operation and the brilliant result views held by all up to within a comparaobtained by Dr. T. A. Smith in the case just tively few years. The other articles adreferred to proves the advisability of accept- vocated or permitted were all in addition to ing the most desperate chance, since a fatal milk never regarded as perfect substitutes. termination is the only alternative.

I know of but two men who taught otherIntestinal Antiseptics: The use of intes- wise up to three years ago. Text books, tinal antiseptics from salol to chlorine water systems of medicine, articles culled from with large doses of calomel was the routine current medical literature, even the reading procedure during my interneship in Bellevue of Dr. Coleman's admirable paper (5) Hospital, and the authority of its advocates before the American Medical Association made us rather hopeful until a sufficient brought forward no advocacy of a diet from number of cases had been under observation which milk should be excluded, at the same to warrant the conclusion that until the dis- time increasing its acceptability to the avercovery of some intestinal antiseptic of age patient. So impressive was my introgreater potency or more specific activity, duction to this method, that Ward 6 in little could be accomplished.

Bellevue Hospital, as it was when I took We are all perfectly well aware of the up my service three years ago this month, necessity for the greatest care in the choice always comes to my mind when typhoid of rooms, beds, nurses, etc. for our typhoid fever is under discussion. From that day to this no typhoid patient under my care It was determined to force the diet up to in hospital or private practice has had a the point of satisfying the nutritive requiredrop of milk.

ments of the patient if this could be done In five consecutive beds were five ty- without disturbing the digestive or assimilaphoids ranging in age from adolescence to tive functions. middle age, and in duration of the disease Now let us take the nutritive standards from early in the first week to convalescence. in health as a basis for comparison. Atwater None had been given milk since admission gives 2,700 calories per day for an adult of to the ward. One patient gave the ordinary sedentary habit. Chittenden (6) proved evidences of a mild attack in his general that 3,000 per day was ample to maintain appearance. Among the others, not a coated in healthy nutritive equilibrium men doing tongue, distended abdomen, emaciated body, a considerable amount of muscular work, flushed face or temperature requiring a bath.

even when diet and labor were continued for Mentality was normal in all and several of several months. Lower figures have been these patients were complaining of being given but these may be taken as fairly repkept in bed, saying they evidently were not

resentative. sick since they were being given no medi

Now let us see how the diet for typhoid cine. It was difficult to realize they were patients compares. How greatly the detyphoids and the impression was equally

mands of continual high temperature and lasting upon those of my friends who visited the increased katabolism to toxic absorption the ward. Any diet which could produce may affect the nutritive requirements, we such results even once was surely worthy

do not know but an approximate answer of careful trial and while I admit that at no seems to have been made. Coleman gives time since has the above picture been per

the following values for the different typhoid fectly reproduced yet I hope to induce others diets formerly in vogue. About 300 calories to test this diet for themselves, and then for the starvation diet, 1,400 for the milk follow, modify, or abandon as their results diet so long a standard. The tendency indicate.

toward a more liberal diet of greater variety Do not understand me to say I regard the has been growing ever since 1892 when last word said on diet—by no means, but I Peabody published his results. Milk had do most sincerely believe that a milk-free long been declared to be the only safe and diet presents advantages over all others yet sane diet. I well remember the feeling advocated.

among the internes at Bellevue when the The laboratory work was done by Dr. new diet was proposed and the predictions of C. G. L. Wolff in determining the nitrogen disaster freely made by those of the visiting balance and nutritive equilibrium in all our

staff who refused to adopt the suggested typhoids and was, so far as I know, the first alterations. When it had been proved that time this had been systematically undertaken a more liberal diet could be safely employed, in determining typhoid diet.

His en

the nutritive value was gradually raised, thusiasm over the results from a purely though in many of the proposed changes theoretical standpoint fully equalled that of the proteid equivalent was too high, often the clinician.

producing profound gastro-intestinal dis

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