only points we seem to have come to, at least a partial if not universal agreement upon, are the symptoms, diagnosis and treatment, and fortunately these latter are the most important from the standpoint of the patient, the physician and the surgeon.

Those symptoms which point to the earliest diagnosis are usually a tachycardia, muscular tremors, a gastrointestinal disturbance and general nervousness. Excessive perspiration and often an occasional rise in temperature have been noted. The exopthalmos and the enlargement of the thyroid gland are later manifestations of this disease. Theo. Kocher claims never to have seen a true case of Graves's disease without an enlargement of the gland.

Chas. H. Mayo says: "In our work at St. Marys Hospital, we have operated on exopthalmic goiters which were hardly palpable and have been surprised at the increased size of the gland over the normal when exposed. After all it is a question of increased secretion, absorption and delivery by the lymphatics, not necessarily the retention and development of a tumor." While in the treatment of goiter the general, medicinal, dietetic, serum therapy and radiotheraphy measures have yeilded in some few selected cases brilliant, but usually temporary results; on the whole they have been very disappointing and the real and permanent cures have only resulted from surgical methods. Of course this does not apply to those physiological types of thyroid enlargement so often found in young women around puberty, but to the real new growths like tumors which show upon microscopic sections a very different histo-pathology than the normal gland slightly hypertrophied. These types usually yield to iodine and electricity, or even disappear spontaneously without any treatment after a time. With a perfected technique, due largely to the improvements in surgical progress and a more careful study of the thyroid gland, we are now able to operate with a greatly reduced mortality.

Albert Kocher says: "The operation of Billroth differed from that of Kocher in that Billroth removed the capsule with the thyroid gland, whereas Kocher peeled out the

thyroid gland from the capsule and left the capsule. This resulted in deminution of hemorrhage and in preventing injury to the parathyroid glands. In Vienna sixteen per cent of the cases operated upon had tetany, while in Berne only four in a thousand."

He further has said concerning the examination of the patient before operation: "Prior to operation a careful study should be made of the strength of the heart with special reference to determining whether the existing enlargement were of a compensatory or dilatational type. The blood pressure determined by the Riva-Rocci instrument was of very great importance. If it was low it was necessary to study the effect of exercise upon the patient. They should always be prepared most carefully for operation. A second thing studied was the degree of intoxication.

Another important point, and one most recently developed, was the examination of the blood. In his 58 cases there has been a marked increase of lymphocytis and a deminution of polymorphonuclears. The leucocyte count itself was normal, the increase of lymphocytes being in proportional to the degree of disease. Nothing was as yet known of the cause of this lymphocytosis. It was different from that which accompanied pus formation. It explained the danger of the very slightest infection in these cases." (Medical Review of Reviews).

Without entering into a detailed description of the many and varied operations employed in the removal of goiters, the writer will briefly describe a technique which has yielded good results in his own work, and which is a combination of many of the essential points suggested by the work of the Kochers, Mayo, Crile, Halstead, and others.

A long transverse collar incision is made across the neck, this incision cutting through the skin and platysma muscle down to and completely exposing the tumor covered laterally by the sternothyreoid, the sternomastoid and the omothyroid muscle. These muscles are usually retracted, or what is often better, divided near their upper attachments so as to allow a good exposure of the tumor and

enable the operator to ligate the larger vessels with less difficulty. The tumor is now freed by blunt dissection, the superior thyroid artery is double-clamped and cut between the forceps. This artery is rather deeply seated and is the key to the situation, being the largest blood supply to the gland. It should be ligated as with all the other vessels as close to the capsule as possible, to avoid cutting off the branches which supply the parathyroids lying in the posterior part of the capsule.

Halstead, Berkeley, Pool and others have demonstrated from elaborate dissections that the main blood supply to the parathyroids is from a separate branch or branches from the inferior thyroid artery. By ligating all vessels close to the capsule and as high up on the tumor as possible we avoid injury to the deep seated recurrent laryngeal

nerve.

The capsule is now opened and the lobe enucleated, carefully ligating the isthmus which constitutes the stump of the tumor. Cystic goiters usually enucleate with great ease and rarely need the ligation of a vessel. The exopthalmic type of goiter have a very vascular capsule and great care is needed to completely control the hemorrhage.

Any divided muscles are sutured together and drainage with a large rubber tube is made through a stab wound just above the sternum, several inches below the incision, which should be carefully closed.

In exopthalmic cases the drainage should be as free as if we were dealing with a septic wound. The usual after treatment as of other similar wounds is instituted and the incision should heal quite promptly.

REPORT OF LIBRARY COMMITTEE OF JEFFERSON COUNTY MEDICAL SOCIETY.

MR. PRESIDENT AND Fellow MEMBERS:-We wish to state in this preface that the object of this report is to review the movement from its inception to the present time, to explain its present status and to venture a forecast of its possibilities. In addition we hope through its liberal publication in the Medical Press to aid the popularization of the movement.

The committee was appointed during the presidency of Dr. Wm. Cheatham, more than two years ago, and consisted originally of Drs. Bullitt, Pfingst and Schachner. Dr. Bullitt, after much valuable work temporarily left the city. This occasioned the appointment of Dr. T. H. Baker.

The original purpose of the committee was to create a department of current medical literature in the Louisville Free Public Library. In this the committee was not successful, and those who are interested in this part of the history of the movement, we would refer to the Kentucky Medical Journal, April 1906, page 789, which records some of the reasons explaining our failure in securing a footing in the Public Library, as well as other features that occurred at this time. Following this failure the committee prepared to establish its own library. About this time another committee from this Society was endeavoring to establish a club or academy of medicine. Both committees being entirely friendly in their purposes, the library committee, in deference to the other committee, retired to wait the outcome of its labors. After the failure of the other committee, which entailed a loss of about a year's time to the library committee, we began the second step in the evolution of the movement, namely, the establishment of an independent medical library. As soon as the Atherton Building, in which the library is situated was completed, we were ready to receive books. The library is located room 515, and is open to the entire profession from 10 A. M. to 9 P. M., excepting the hours 12-1 and 6 to 7.

The first contribution was the David Wendall Yandall

Memorial Library, consisting of 1,000 volumes. This occurred about October 1, 1907.

About the middle of October the library was ready with the above number of volumes, and fifty current medical journals, Foreign and American.

To-day, about two months after the opening, the library has 1,965 bound volumes and 23 unbound volumes, making a total of 1,988 volumes, not including 76 duplicate volumes, and some incomplete volumes of journals, making over 2,000 volumes.

In addition, there are more than fifty different journals, the latter representing the best current literature.

From the foregoing, a partial evolution of the movement is plain, and it is also apparent that its development in the future must be in keeping with the existing external conditions upon which it is dependent, and which it is intended to serve.

Heretofore one had to rely upon his own library which at best was inadequate, and while the present library is still in its infancy, it is to-day sufficiently complete to aid any member in the preparation of a paper or the investigation of any problem, and with time this value increases.

It is needless to say that every one who possesses a private library, concedes through the possession of a library the value of a public medical library as a powerful supplement to his own collection.

Right here it is entirely in order for us to remind the medical profession of the fact that for years the legal profession has had its own library through its own efforts and one that has grown extremely valuable. The clergy have several libraries, one of which occupies entirely a good sized building, centrally located. Even the engineers have their club and library. But the medical profession, where changes are more rapid, radical, varied and important has, up to this time, been without any collection of books whatever. Here is food for thought and if the medical profession has been unconscious of this omission we can testify that the outside world has not. For in our efforts to establish ourselves in the Louisville Free Public