ADVERTISEMENTS (MENTION THIS JOURNAL.) This serves to point out and accentuate the fact-already Colden's Liquid Beef Tonic acts specifically on the Sold by all druggists. THE CHARLES N. CRITTENTON CO., Sole Agents, Copyright 1905, The C. N. Crittenton Co. THE ANEMIAS OF CHILDHOOD. The anemias of early life are usually sequels of the acute diseases common to this period. The exanthemata are especially liable to be followed by a depreciation of blood quality, and a protracted convalescence often depends on this one condition alone. Moreover, the frequency with which physical stigmata or infirmities actually date from an attack of measles, scarlet fever, diphtheria or any of the other similar diseases of childhood, can often be properly laid at the door of insufficient or improper care during the very important stage of convalescence from the diseases. It should be recognized that the hematogenic function while exceedingly active in childhood, is yet very susceptible to all inhibitory influences, among which the toxins generated in the course of the acute diseases are most common. When a storm infection of measles, scarlet fever or any of these similar ailments is passed, there must follow a period of reconstruction. If the damage has been slight as a result of a light storm or an unusually strong structure, the reconstructive process places little demand on the resources of the individual. But if the storm has been unusually severe and the structure ill prepared to meet its fury, the rebuilding process is certain to be long and laborious. Deficiency in the quality of the blood is one of the greatest handicaps at this time, and the clinician should recognize this as one of the most important indications for therapectic assistance. The action of Pepto-Mangan (Gude) is always very marked in these cases, and it is interesting to note how rapidily children respond to its upbuilding influence. A marked increase in hemoglobin at once follows its use and the red cells multiply rapidly. With improvement in the blood constituents there is a corresponding increase in the whole bodily tone, and it only takes a few days to carry the average patient safely away from the dangers of a trying period. Pepto-Mangan (Gude) is therefore a very valuable tonic in childhood, and unlike so many of the ordinary hematinics it can be given, with impunity to the youngest infant. It has marked alterative properties, and in strumous or marasmic conditions it is especially valuable. It is absorbed rapidly, and is never rejected by even the weakest stomach. In early life its administration is best effected by giving it in milk, and the dose should range from ten drops to two teaspoonfuls, depending, of course, on the age of the patient. A USEFUL TONIC. The season is now on us in which we find many patients suffering from coughs and colds. In many of these cases the general system is below par, and in order to hasten recovery from the catarrhal conditions of the air passages a general tonic is indicated. Cod liver oil is a century old remedy for coughs, and where the stomach can handle it there exists no reason why it should not be employed, and in such cases the results are satisfactory. But in many of the sufferers digestion is enfeebled, the appetite is poor and cod liver oil is not well borne. Fortunately for patient and doctor modern pharmacology has provided a preparation of this valuable agent which contains "all of the oil except the grease," to which has been added the hypophosphites, with glycerin and agreeable aromatics. It is not only wonderfully efficatious but pleasant to the taste and readily handled by the weakest stomach. We allude to the well-known THE American Practitioner and News. "NEC TENUI PENNÂ.” 'Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downwright facts at present more than anything else." -RUSKIN. VOLUME XLII. NUMBER 2. FEBRUARY, 1908. Original Communications. THE SURGICAL TREATMENT OF GOITER.* BY JNO. R. WATHEN, A. B., M. D., Surgeon to St. Anthony's Hospital; Kentucky School of Medicine Hospital, and Louisville City Hospital. Go LOUISVILLE, KY. OITER, which has always been especially prevalent in Switzerland and certain other parts of Europe, is nevertheless present in this country in a larger proportion than the surgical statistics of the past would seem to indicate. Many of these cases have been either treated medicinally or a diagnosis has been overlooked, as there is no doubt that the condition has often not been recognized; the later statement is especially true of the earlier stages of the exopthalmic variety. The reason some few of our prominent surgeons have been able to report many cases is possibly the same as Bigelow, the authority on stone in the bladder, has said when he was asked how he happened to have so many cases of stone, replied that it was because he looked for them and others overlooked them. Chas. H. Mayo has written: "The general impression to be obtained from a review of the surgical literature of America would be that diseases of the thyroid gland are * Read before the Louisville Clinical Society, December 10, 1907. greatly on the increase. This is probably not the case, but the public has learned that operations on goiter are not as fatal as were supposed from the results obtained when operations were made as a last resort. The fact is that the mortality attending the operation (excluding cancer and advanced cases of exopthalmic goiter) compares very favorably with other major surgery; and, in the hands of those experienced, with much of the so-called minor surgery." Mayo's mortality for all the varieties of goiter which presented at their clinic during the past seventeen years, was a little over three per cent. Over one-third of their cases were for exopthalmic goiter with a mortality of nine deaths in 110 cases, and in the last sixty-four of this number only two deaths. Theo. Kocher reported at the German Surgical Congress (1906), the results of his last series of 1000 thyroidectomies with a mortality of only 0.7 per cent, and in three of the seven fatal cases the thyroid was the seat of malignant disease. In the exopthalmic variety he lost one case in fifty-two thyroidectomies in his last series. He has reported 175 operations for this variety. In a still later report Albert Kocher (paper at A. M. A., 1907), reported a total of 315 operations for Graves's disease with a mortality of three and one-half per cent, and in the last ninety-one operations for exopthalmic goiter had not had a single death. The cause of deaths has been analyized in 93 cases by Riverdin, with respiratory conditions causing 43 deaths, hemorrhage 19, infection 13, shock and nerve injury 9, cardiac failure 6, with only four due to tetany and myxedema. The diseases of the thyroid gland have usually been classified into hypertrophy, comprising the simple and the exopthalmic varieties; and tumors again divided into cysts, adenomata, carcinomata and carcomota. Some have made a further classification into functional derangements and inflammations, which later are rare. Bloodgood, after discussing the usual thyroid enlargements has written concerning the malignant variety: "Every asymetrical enlargement of the thyroid in in dividuals over thirty years of age should be subjected to immediate operative removal. Only by following this rule will surgeons eradicate malignant tumors before they have given inoperable metastases." He further says: "This knowledge of thyroid tumors should be widely circulated among the profession and the public. As compared with the breast, they are much more malignant." Recently a great deal has been written upon the function of the thyroid and other ductless glands, especially the physiology as relates to exopthalmic goiter or Graves disease where there is supposed to be a hypersecretion, but much more remains to be learned and our knowledge is mostly confinded to the theoretical. Nevertheless certain surgical facts have presented themselves and lead us to a more careful consideration of our technique in operating upon this gland. It is a well established fact that young adults, whose entire thyroid has been removed retrograde in intelligence and older individuals may develop myxedema. We further have noted that the complete removal, injury or cutting off of the blood supply to the parathyroids, when operating upon a goitre, frequently results in tetany, a condition characterized by painful tonic and symmetric spasm of the muscles of the extremities. The parathyroids are four small glands resembling the suprarevals, and are situated on either side posterior and attached to the capsule which covers the goiter. The two lower glands are in close relation to the inferior thyroid artery, and the upper close to the superior; therefore care should be exercised in ligating these vessels as not to injure the parathyroids or to entirely cut off their blood supply. Many years ago Graves and also Baselow described the disease which bears their names, or exopthalmic goiter, a condition now generally recognized as the result of hyperthyroidism. While exopthalmic goiter has been a disease long recognized, there exists at present much deversity of opinion as to the etiology, physiology and pathology, and the |