Malta Fever in Southwestern United States In summarizing an article on Malta fever, G. C Lake, passed assistant, United States Public Health Service Health Service states: 1. Malta fever has, in all probability, existed in Texas for at least 36 years and in Arizona for at least 14 years. Absolutely authentic cases have been known in Texas since 1911 and in Arizona since 1912. 2. Conditions favorable for the exist ence and spread of Malta fever are present in all the Southwestern States. 3. More than 30 authentic cases of Malta fever occurred in the recent outbreak at Phoenix, Arizona, concerning which the following can be stated: (a) These cases were typical clini cally and serologically; and in two cases B. melitensis was recovered. (b) Goat's milk is known to have been used in all but three of the (c) Tests made on the goats supply- 4. Goat's milk is being sold in a number of cities in the United States. From the evidence at hand the writer believes the following conclusions are warranted: 1. Malta fever is probably epidemic in certain sections of the southwestern part of the United States and in some parts of Mexico. 2. It is extremely difficult to recog nize Malta fever early in the course of an outbreak, from the clinical symptoms In coucluding an article on this subject, in South. Med. and Surg. (Oct., 1922), Dr. A. G. Brenizer states: (1) Cystic, fibro-cystic ovaries and ovarian cysts are not infrequently found in association with hyperthyroidism. (2) At puberty, menstruation, the menopause and during pregnancy, the thyroid works parallel with the corpus luteum. When the thyroid is enlarged, we assume that the corpus luteum is inadequate. (3) The pelvic conditions, whatever they may be, associated with hyperthyroidism are in the nature of a hypoovaria. The percentage of sterility in these cases is high. (4) Thyroidectomy will not cure a cystic ovary, but it may restore the generative function. We may assume this to be due to the reduction of thyroid toxemia. (5) The assumption that an endoerine balance is restored in hyperthyroidism by oophorectomy is not warranted. Conservative operations tending to establish efficient ovarian functions may favorably influence hyperthyroidism. (6) In myxedema there appears to be an increased activity of the ovaries, especially in the folliciles, except in so far as these glands are compressed by fat and mucin infiltration. The uterus, along with the other tissues, is infiltrated with fat and mucin. (7) The percentage of sterility in myxedematous and hypo-thyroid cases is fairly low. When their oxidation processes are increased by the administration of thyroxin, the generative organs may function normally. ministration or later, seems to be neces sary as the drug itself tends to increase peristalsis. The logical procedure would be to begin with the dose of 3 c. c. for the average patient, and, if the dosage seems too small, increase it. It would appear safe to give as much as 10 c. c. Caution. Care must be taken to see that the capsules are swallowed promptly. Should one open in the mouth or Carbon Tetrachloride for Removal of throat and some of the drug enter the trachea, serious results might follow. Hookworms The use of carbon tetrachloride for the removal of hookworms, with special reference to its toxicity for monkeys when given by stomach tube in repeated doses is the basis of an article by G. C. Lake, passed assistant surgeon, United States Public Health Service. He quotes from a paper by M. C. Hall in which he gives an account of experimental work in which he used carbon tetrachloride as an anthelmintic for dogs, and found it highly effective against hookworms. With a large series of dogs he was able to secure expulsion of all the hookworms following a dose by the stomach of about 0.3 gm. of the drug per kilogram of the dog's weight. The indicated dose of the drug for a man is the same as for the average-sized dog (10 kilos), viz, 3 c. c.; this is equivalent to 0.05 c. c. per kilogram for man. It was found that carbon tetrachloride was not only the most effective drug therapeutically that he had tried as an anthelmintic for hookworms but was also the least toxic of any of the active vermifuges tried. In man the drug should be given in hard gelatin capsules, the patient having fasted overnight, and should not be accompanied with castor oil. In fact no purgative, either at the time of ad Toxic Goiters Israel Bram, in the Therapeutic Gaz ette (Oct., 1922), finds that the greatest danger confronting the patient with toxic goiter is a failure on the part of the medical attendant carefully to discriminate between toxic adenoma and exophthalmic goiter. While there are many features in common in both these types of toxic goiter, there are so many points of differentiation to be noted that a knowledge of them should yield an accurate diagnosis in at least nineteen out of every twenty patients. The following is a brief tabulation of the essential differential points: Toxic Adenoma (Hyperthyroidism, Secondary Toxic Goiter, 'Basedowified' Goiter, etc.) 1. Patient is usually of middle age. 2. Goiter present years before onset of symptoms. 3. Goiter is essentially adenomatous, often nodular in nature, and usually large, non-pulsating, non-compressible, without thrill or bruit. 4. Exophthalmos and expression of chronie fright absent; eyes may present a mere brilliancy or stare. 5. Tachycardia not extreme; often materially influenced by sleep and digi talis. 6. Hypertension and myocardial degeneration common. 7. Tremor often absent; if present, is coarse and atypical. 8. Mental symptoms relatively mild. 9. Dermographia often absent; when present, is not intense. The surgeon in performing a thyroidectomy upon a patient with toxic adenoma obtains a brilliant result, but this is far from true in exophthalmic goiter. The former is essentially a local disease, yielding successfully to local attack by knife. The latter is es 10. Loss of weight comparatively sentially a generalized disease, and the slow. 11. Symptoms may be produced in a normal person by administration of thyroid extract or thyroxin. 12. Surgical interference with the thyroid eminently successful. Exophthalmic Goiter (Graves' Disease, Basedow's Disease, Hyperplastic Goiter) 1. Patient is a young adult. 2. Goiter often absent; if present, is of recent occurrence. 3. Goiter is essentially hyperplastic in nature, rarely large; usually a symmetrical thyroid fullness, often pulsating, is compressible, and presents thrill and bruit. 4. Exophthalmos and expression of chronic fright with characteristic eye signs usually present. 5. Tachycardia more pronounced; not materially influenced by sleep and digitalis. 6. Hypotension common; myocardial degeneration may occur late in the dis ease. 7. Tremor nearly always present and typical. 8. Mental symptoms relatively prominent, with occasional major psychoses. 9. Dermographia constant and usually intense. 10. Loss of weight comparatively rapid. 11. Syndrome not produced by administration of thyroid extract or thyroxin. 12. Surgical interference with the thyroid a questionable procedure. knife may as well attempt to remove the enlarged spleen as a cure of typhoid fever as to attack the enlarged thyroid in Graves' disease with cure in view. Anesthesia in Children In summarizing an article on anesthesia in children, in the Ill. Med. Jour. (Sept., 1922), F. E. Haines states: 1. Accidents and even death may result from the administration of any anesthetic agent even in the most skilled afterhands. Many slight untoward effects which do not cause much distress clinically, escape the knowledge of all except the careful observer who makes proper use of the laboratory. 2. Methods. The safest method of producing general anesthesia in children is by inhalation. Ether is given by the open drop method or intrapharyngeally. Nitrous oxide-oxygen is given with a higher percentage of oxygen usually than in adults and under slight positive pressure, with a proper amount of rebreathing. Infiltration is the only method advisable for local anesthesia. 3. The importance of a slow induction period with the child's mind calm. and his respiration regular cannot be overestimated. a. Children are extremely susceptible to suggestion. Their confidence must be gained and their fears and thoughts controlled. b. The deep inhalations resulting from fright lead to dangerous irritation of the respiratory tract with ether and cause an excessive concentration of any anesthetic agent to reach the heart suddenly. c. If a child is frightened or smothered with his first anesthetic, his remem brance of the ordeal may imperil his safety if an anesthetic becomes imperative at any subsequent time. 4. Chloroform should not be administered to children for the dangers of immediate depression and of delayed poisoning are too great. 5. Ethyl chloride is applicable for very short operations and for induction, but dangerous except in skilled hands. 6. Ether is perhaps the safest anesthetic if the anesthetist is only moderately expert. The untoward effects of a first class ether anesthetic are almost negliable. I prefer a preceding hypo of atropine. 7. Nitrous oxide-oxygen is the safest as to immediate and remote affects when administered by an expert. Gas with a little oxygen is preferable for induction as a routine. Gas-oxygen is indicated in all septic cases. 8. In children age is not a contraindication to the use of ether, nitrous oxide-oxygen, or local. 9. Since there is a much narrower margin between surgical anesthesia and the danger zone in children than in adults, it is advisable that a competent anesthetist administer the anesthetic. Radical Antrum Operations After a radical antrum operation, it is best to leave the case alone for the first few days at least, until the acute inflammation has subsided. One is forced to plug the cavity with gauze during the operation to obviate bleeding and the formation of clots, but on the second day this should be removed. Nothing is to be done until the third day; then gently douche with antiseptic astringents or saline solutions, douching through the nose with a bent antrum canula. Encourage the patient to sit up as soon as possible. Gentle douching has to be continued for a few weeks. In antrum operations, the patients should wash the mouth with an antiseptic solution. Lying on the back or the sound side is liable either to cause an inflammatory condition of the normal sinuses or to make the pus and muco-pus flow down the naso-pharynx into the throat and infect the trachea and bronchi, with respiratory troubles as sequellae. Andrew Wylie, M. D., Amer. Jour. of Surg. Medical Diathermy in Joint and Bone Lesions He Stimulated by results in the department of physico-therapy in base hospitals during the war, many orthopedists are now using diathermy in the treatment of lesions of bones and joints, writes Dr. E. C. Folkmar in The American Physician (August, 1922). states that diathermy is an agent that can be employed in the office of the general practitioner. The day is past when a surgeon can dismiss a case of fracture of the hip with a stiff knee following fixation, or when an internist can dismiss a case of articular rheumatism with a joint contracture without censure. The primary indicated treatment in joint lesions deduced from nature's process in the production of heat within the joint and the surrounding tissues. This can be accomplished only by the use of diathermy. Physiologically, diathermy in its therapeutic effects is identical with local heat. Nature always generates heat when she undertakes a task of restoration. Heat relaxes tonus. By relaxation of the muscular fibres of blood and lymph vessels, she dilates them. Blood and lymph from the surrounding tissues rush in and fill the dilated vessels. The chemical processes of metabolism. are quickened. Waste and toxic substanees are more rapidly eliminated. Heat softens the tissues and makes them sus ceptible to mechanical treatment, or to voluntary exercise. Heat relieves pain and tenderness by relieving the pressure from exudates. Diathermy in the treatment of acute joint lesions, especially those of trauma, is a means of reinforcing and speeding up of nature's restorative processes. In the treatment of chronic joint lesions diathermy is a means of stimulating nature to initiative restorative processes, and of abetting her in the continuation of these processes to a successful conclusion. In the treatment of joints, the diathermic treatment should be followed by deep massage of the tissues and exercise of the muscles. This may be accomplished by the static wave current, by the rhythmic faradic current, by the sinusoidal current, by mechanical vibration, by hand massage, and by passive and active exercise. Pellagra The method of treatment given by A. L. Nason in The American Physician (Sept., 1922) is as follows: Examine the feces for any kind of infection, and treat it, and feed the patient balanced diet. I try to leave out for a while, what he has been eating and try to give him a balanced ration of what he has not been eating and give him chlorine and iron and arsenic. You find the pellagra chlorin-free and hydrochloric acid is needed in digestion. I give it all the time in heroic doses, with an initial clean out, and also give plenty of iron. Under this treatment the diarrhea, ptyalism, sore mouth and skin rapidly disappear. One to two ounces of Epsom salts usually promptly stops the diarrhea. If patients have ascarus lumbricoides, santonine in heroic doses promptly cures the patient if repeated once in six days; as long as you see a worm, save the consequent anemia, which is promptly relieved by the iron and arsenic, if deficient in red blood corpuscles. If there is uncinariasis, the once-per-week dose of sixty to ninety grains of thymol, until the ova are no longer in the stools, will promptly cure that. If from amebiasis (I had one such), treat with emetine, and the accompanying anemia as before, and your patients get well promptly and remain well until infected again, which is rarely, but when it is strictly nutritional, you have the worst of it. 0 Quartz Light Therapy Dr. S. J. Rose became interested in the use of the Alpine and Kromayer mercury-quartz lamps after noting the results that were being obtained in the New York Skin and Cancer Hospital, in many local conditions, such as chronically enlarged and inflamed tonsils, Pyorrhea, certain skin conditions of the scalp and loss of hair, protatistitis, hemcrrhoids, etc., which serve to stimulate. him on to further investigations. Ile reports several interesting cases in the Ky. Med. Jour. (Aug., 1922) in which the use of the Alpin and Kromayer lamps has resulted successfully. states that it is very important for the operator to remember that blonds are more sensitive than brunettes, and that the colored patient can tolerate three to fives times more severe treatment than the white patient. He Plang has proven that the Alpin lamp will penetrate a body weighing 110 pounds in ten minutes, and that the Kromayer lamp will penetrate a hand in one-half minute. His conclusions are: 1. Infected wounds of all kinds yield readily. 2. Actinic rays produce local effects when desired. 3. Actinic rays produce systenhic effects, even at. a distance from the area rayed. 4. Actinic rays energize. 5. Actinic rays soothe. 6. Actinic rays produce a benign inflammation which is not destruc |