The

Regarding the Holy Cross Hospital, Calgary, Dr. Kennedy writes as follows: "I visited and inspected this hospital on Tuesday, 31st March. Since my last visit the hospital has been enlarged by the addition of a wing, 35 ft. by 24 ft., four stories high, built of brick with stone basement, and giving additional accommodation in the shape of a general ward, and an isolated ward in the basement. Notwithstanding the increased accommodation, I found that the hospital had been taxed to its capacity during nearly the whole winter. It provides at present accommodation for 47 patients, distributed as follows: Male patients, private, semi-private and public wards, 24; women patients, II; isolated cases, 12. isolated wards have been used for infectious diseases, as scarlet fever, of which there has been rather an epidemic in Calgary during the past autumn and winter. As a consequence of the increased accommodation offered by the new wing, the old isolated wards at the top of the building, which were so objectionable, and which I reported against on a previous occasion, have been done away with, and, after being thoroughly cleansed and renovated, are now used as part of the general hospital. The new isolated wards, while still leaving something to be desired, are a great improvement upon the old and it is now possible to treat cases of an infectious nature there without entering the part of the building devoted to general purposes, and without any danger to other patients. I might point out, however, that it is not desirable that any infectious diseases, such as scarlet fever, measles, diphtheria, and so on, should be treated at any general hospital, and isolated wards should only be for the purpose of receiving infectious cases occurring in the hospital itself.

Of the 499 patients registered during 1902, 23 per cent. were free patients, 8 per cent. paid in part, and the remainder paid in full.

Edmonton, like Calgary, has two hospitals, the General and the Public. Each of these hospitals has been taxed to receive all the patients desiring admission. But at Strathcona, just across the river, the inhabitants were then contemplating building another hospital, to cost $10,000. Whilst finding some minor fault with the way the register was kept at the General Hospital, the inspector said that the wards as usual were clean and well kept, and that there were no complaints. The same praise was given to the Public Hospital.

We have not space for any further quotations from this interesting report, but sufficient have, we think, been given to show that a most praiseworthy effort has been made by the settlers in this new country to provide hospital accommodation for the growing population. "Quite likely," writes Dr. Kennedy, "this work has been augmented though the efforts of the Lady Minto Cottage Hospital Fund, and it is to be sincerely hoped that the controllers of this fund will see their way clear to still further enlarge the scope of their benefactions.

Clinical Department.

An Unusual Case of Mammary Cancer. H WARD CRUTCHER, M.D., of Chicago, in American Medicine.

ment. sore.

The patient, aged 60, is a woman of remarkable vigor of mind and body, and the mother of two healthy daughters. Fifteen years ago she first noticed a small lump in the upper and outer quadrant of the right breast. Her husband, a medical practitioner of large general experience, opposed all mechanical interference, and the condition was permitted to drift along with internal treatThe lump grew slowly, and in 1898, broke into an open Examination showed a deep cavity with angry edges and a mass of very dark tissue at the bottom. The entire gland appeared to be firmly attached to the chest wall. The husband asked me to scrape out the cavity as best I could, but gave positive orders that I was under no circumstances to attempt the removal of the mass. Indeed, such an attempt was foredoomed to failure. In June, 1899, I scraped out the cavity with a sharp spoon, applied the usual antiseptic dressings, and left the case to its fate. This surgical makeshift was followed by certain local applications, the nature of which I am unable to state. The cavity healed within a few months, and I heard nothing of the patient until December, 1904, when the reappearance of a small cavity. accompanied by violent pain, caused me to etherize the patient and remove with the knife about two ounces of the tissue that appeared to be most seriously at fault. Relief from pain was immediate, granulation was prompt, and the patient is now sojourning on the Pacific coast. She expresses herself as feeling perfectly well. It is worthy of note that at no time have the axillary glands been in the slightest degree involved, so far as thorough palpation could determine.

The specimen removed last December was submitted to Dr. W. A. Evans, who pronounced it scirrhus. Within a year this woman has lost a sister through mammary cancer, which ran a more typic course, ending life within three years. It was never treated surgically, but was looked after by soothsayers, mind readers, and a peculiar class of internists whose presence among us is a singular commentary upon the boasted enlightenment of the age in which we live.

The lesson to be drawn from the foregoing case is that palliative surgery is often practicable and helpful when ideal practice cannot for one reason or another be applied.

A Case of Cystic Goitre. NATHAN JACOBSON, M.D., Syracuse, N.Y., Professor of Clinical Surgery in the College of Medicine, Syracuse University Surgeon to St. Joseph's Hospital, in Buffalo Medical Journal.

I desire to occupy but a few minutes of your time in the presentation of the history of a case of cystic goitre :

The patient, a boy of 18, who was attending school, was brought to me on the 22nd of March, 1904, by his physician, Dr. Kaple, of Elbridge. His father came with him also. The boy had had measles and whooping cough, but otherwise had been free from the diseases of early life nor had he ever been seriously sick. When but eight years of age his neck began to enlarge in the median line and the growth had steadily increased in size since that time. During the past two years the increase had been greater than during the preceding eight; and in fact during the past six months it had been particularly rapid. He suffered no great distress in breathing except when his head was carried well backwards.

Examination showed the presence of a smooth tumor with an irregular surface which was elastic and in which fluctuation could be made out. The mass was placed largely to the right side of the median line. At its most prominent part the circumference of the neck was seventeen and one-half inches. With a hypodermic syringe introduced into the tumor some bloody fluid was withdrawn. The diagnosis of cystic goitre was made and radical operation advised.

An interesting point in the history of the case was the fact that the boy's father had a goitre, apparently of the adenomatous type. These were the only two instances in the family.

The patient did not consent to operation until April 26th,

On the preceding day he was admitted into St. Joseph's Hospital, Syracuse. There was an apparent increase in the tumor during the five weeks which had intervened. I was assisted in the operation by Dr. Coon and the hospital internes. A curvilinear incision was made beginning at the angle of the jaw on the right side and ending over the sternal notch. This was deepened through the superficial muscular structures overlaying the tumor. The sternomastoid was pushed back. The outer border of the sternohyoid was cut through. A number of greatly enlarged veins, some of them with a diameter of one-quarter of an inch, were doubly ligated and severed between the ligatures. All bleeding was controlled and the cysts were then shelled out separately with the handle of a knife or the finger. Most of them presented no difficulty in their enucleation. The deepest one was firmly attached to the right lobe of the thyroid gland and with it a part of the gland was removed. The right recurrent laryngeal nerve could be

readily recognised and injury to it was, therefore, easily avoided. About thirty vessels were ligatured. All of the cysts were removed intact with a single exception and this, though ruptured, was entirely enucleated. Three strips of folded gauze one-half inch in width were packed in the resulting cavity. The wound was closed with interrupted silkworm-gut sutures.

Throughout the operation the head was steadied by an assistant so as to secure it in a position in which respiration could be least disturbed. Chloroform was the anesthetic used. The patient bore the operation well.

In the subsequent history there was nothing particularly disturbing. Twenty-four hours after the operation the pulse, which had been below 100, rose to 120 and on the second day to 150. During this period there was an increase in the temperature to 102°. May 1, five days after operation, the temperature dropped to 99° and the pulse ranged from 90 to 100. He had some difficulty in swallowing and was unable to move his head from side to side. By the fifth day after the operation this also had cleared up and from this time on he had but little discomfort. There was from the very start a large amount of serous discharge which steadily decreased in quantity. On May 11th he was able to be up and on the 14th returned to his home, having been in the hospital nineteen days. The boy has remained in perfect health since his return home. I present to you the cysts which were removed. You will note that there are eight in number. They vary in circumference from two inches to seven and one-half inches and in diameter from three-fourths o an inch to two and one-half inches.

While it has been my privilege to operate upon a number of cases of cystic goitre, the one presented for your consideration contained the largest number of cysts I have ever removed from a neck.

It seems to me that the case has a number of interesting features associated with it. Diseases of the thyroid gland much more frequently affect women than men. To encounter, therefore, a family in which only the males are affected is certainly unusual. What to me seems quite as rare is the appearance of this disease so early in life, beginning as it did with our patient when he was but eight years of age. There is no doubt whatsoever that these are true cysts of the thyroid gland. In my experience also, single cysts of the thyroid are much more frequent than multiple ones. In our patient the mass, because of its size, did not move upwards and downwards with the act of deglutition. With the aid of a hypodermic syringe there was no difficulty in establishing the diagnosis.

There may be some difference as to the best method of treating a single cyst, especially where the walls thereof are calcareous and

fixed and where the enucleation of it would be very difficult and perhaps attended with great danger. Such a case might possibly do better with incision and drainage. But where enucleation is possible and especially where one has to deal with multiple tumors, nothing but complete enucleation is to be considered. With care as to hemorrhage and avoiding unnecessary traction so as not to produce kinking of the trachea, these operations are attended with. an exceedingly low mortality. Our patient, despite the size of the tumor, presented no special difficulty in the way of anesthesia. While there is a growing preference for local anesthesia in these cases, I have always obtained good results with chloroform as the anesthetic. The advantage of absolute quiet on the part of the patient, which can only be obtained with general anesthesia, is apparent. It is admitted that cocaine does not absolutely control the pain and it surely does not overcome the anxiety and nervousness of the patient. As to the safety of chloroform in operations for goitre, it is only necessary to remind you that Kocher has used it in 900 cases without a death. The febrile disturbance and tachycardia which were present after operation, are tered in practically all of the cases of goitre as a post-operative manifestation.

encoun

Some Unique Cases of Amblyopia. DR. T. W. Moore, Huntington, West Va., in The American Journal of Ophthalmology.

At the time I selected this subject, I did so to report three cases of transient amblyopia without fundus changes occurring in children between the ages of ten and eighteen, presenting no special features of nervous debility and without neurotic family histories.

Since that time Dr. L. Webster Fox has reported several cases of the same type under the title Anesthesia of the Retina," in a paper read before the ophthalmological section of the American Medical Association. His patients were all young girls, who were healthy and all were cured after a few applications of the constant electrical current.

Case 1 of my series came to me in March, 1903, complaining of having suddenly lost her vision, being unable to see either far or near, and having been compelled to give up her schoolwork on this account. I found a healthy, active, full-blooded girl, aged eleven years. Pupils reacted normally, vision in each eye = 10/200, accepting no lenses. Under atropine, vision remained the same, but with a .50 +.50 cyl. ax. 90° over each eye she read 20/80. Her field for white was contracted in all directions as it was for colors, the normal relationship being retained; a second examination at this time remained practically the same. The media and fundus were normal in both eyes.