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whereupon the wine was left off, and a pint of strong beef-teasubstituted. On the 15th day he appeared much depressed,was still at times incoherent, and an ulcer formed over theinner’condyle of the humerus, apparently the result of pressure.He was then ordered half an ounce of wine every four hours,which he bore well.Twenty-second day.-Pus has burrowed up the arm along

the inner and back part; the patient seems weak; the pulse isfrequent and feeble, and the tongue white. A counter-openingwas made through the integuments, a tailed bandage appliedto the hand and fore-arm, and the wine increased to fourounces in the day.

Thirtieth day.-He has made favourable progress since thelast report; counter-openings have been made from time totime, and sinuses divided, which measures have served to puta stop to the burrowing of the purulent matter up the fore-arm. The sore is dressed with a dilute solution of sulphateof zinc, and has diminished in size. As he seemed ratherprostrate, he was ordered six ounces of wine in the day, and acouple of eggs, in addition to the beef-tea.

Forty-first day.-The patient is doing well. The edgesof the wound are cicatrizing; his appetite is excellent.

Forty-fourth day.-The ulcer is healing steadily; there isno great secretion of pus, and the hand is somewhat puffy; asmall disc of necrosed bone has separated from the internalcondyle of the humerus. Ordered five ounces of wine in theday, and half a pint of porter, with ordinary diet.Four months after admission the patient was discharged

from the hospital in good health, with all the sores healed,and able to move the fingers, but with the elbow-joint some-what stiff, in consequence of its having been kept for so longa time in the same position.A compound fracture implicating the carpal joints, with

extensive laceration of the integuments and tendons, is un-questionably a serious injury, and one in which the proprietyof amputation becomes a very nice question. Fortunately, inthe present instance, the hand was preserved-a result whichthe patient owed to his youth, to the soundness of his consti-tution, and partly, in all probability, as above suggested, tohis fatuous state, whereby he was exempted from all mentaldisquietude as to what had befallen him. In the treatment ofa case of this description, much discretion is needful in ad-ministering stimulants so as to apportion the quantity, andmaintaining power without over-exciting the naturally feeblesensorium of the patient. Too much stress cannot be laid onthe importance of giving free egress to pus whenever it accu-mulates after injuries of this kind, by the aid of counter-openings and the division of sinuses. The recovery is thusaccelerated, the undermining and spoiling of fascial and otherstructures prevented, and the contingent risk of danger frompurulent infection averted.A case having some analogy with the preceding, and which

was successfully treated by Mr. Holt, at the WestminsterHospital, will be found in a former " Mirror," (THE LANCET,vol. i. 1852, p. 45.)

MIDDLESEX HOSPITAL.Two Cases of Scirrhous Cancer of the Breast of twelve years’

standing; former ablation of the organ in the first case;

non-interference in the second.(Under the care of Mr. SHAW.)

THERE are now in the female cancer ward of this hospitaltwo cases of ulcerated scirrhus of the breast, which offer con-trasts and analogies of a very curious kind; we are confidentthat tht’se histories will prove highly interesting, and throwsome light on the difficult question of surgical interference incancer of the breast. Those who see many cases of scirrhusof the mamma are fully aware how seldom it is possible tomake the rules laid down in books available in actual cases.We are told to operate early, or abstain from using the

knife when the disease is of some standing, the skin adherent,and the lymphatic glands involved. But patients will presentthemselves with slightly adherent skin, the glands merelyirritated and enlarged by the disease, and the health, thoughthe tumour be of some standing, unimpaired. How is the

surgeon then to act? Another case will exhibit the scirrhusin an ulcerated state, the patient suffering much pain, andbeing worn out by the irritation. Can we refuse the suffererthe chance of : P- months or even years of comparative ease tAnd may we not t tki5 into consideration that recurrence ofthe aifection in some of the viscera leads to the fatal issue ina less harrowing and distressing manner? Other patients aremet with, who, according to rule, should be treated by pallid.-tives only; but the ulceration is so distressing and fcetid, the

poor creatures are so thoroughly shut out from the society oftheir fellow-beings, that we can hardly resist their earnestentreaties for a relief which they know to be but temporary.Examples might be multiplied to show that it is unfair to

condemn a snrgeon whose patient meets with a recurrence;and we must say that we are very much inclined to believethat a re-appearance of the disease is almost certain, and thatthe difference, after all, lies chiefly in the more or less timewhich elapses between the operation and the recurrence,either externally or internally, of the cancerous manifesta-tions. (These views apply principally to scirrhus of thebreast; for encephaloid cancer is so fearfully rapid, thatpatients generally apply at too late a period.)

It is, on the other hand, likewise true that the surgeonsometimes shows the soundness of his judgment by refrainingfrom an operation, as it is to be feared, in certain constitutions,that the activity excited in the part by the use of the knifemay cause the cancerous phenomena to succeed each otherwith more rapidity than would have occurred had no opera-tion been performed. But such cases may almost be lookedupon as exceptions; the re-appearance of the disease is usuallya slow process; but though slow, it is no less sure; for canceris, according to all probability, a blood disease, and, as such,will become developed again and again whenever an aptlocality" offers.The two cases which we desire to put upon record exem-

plify this proposition-viz., that the progress of scirrhouscancer in the breast may be equally slow both with and with-out an operation.CASE 1.—Ann T-, aged sixty-six years, was admitted

into the female cancer ward, Jan. 16, 1852, under the care ofMr. Shaw. The patient is married, and has had three children,who are all at present living; no sign of malignant disease hasever been noticed as regards her parents, and she has a sisterwho is enjoying good health.

It appears that, about twelve years before admission, andshortly after the catamenia had ceased, the woman’s rightbreast was struck with a basket, the same organ having shortlybefore experienced a slight injury of the same kind. A tumoursoon formed in that breast, which tumour in a short timeattained the size of a hen’s egg. The patient then sought re-lief in St. Bartholomew’s Hospital, where she was placed underMr. Lawrence’s care. It should be noticed that the womanhad a milk abscess in the left breast, at the birth of her lastchild, when she was forty-three years of age; this had left someinduration, which subsequently became entirely absorbed.She therefore hoped the right breast might get well in thesame way.

It was considered by Mr. Lawrence that the disease was ina sufficiently early stage to warrant an operation. This wasproposed to the patient, but she was unable to overcome hernervousness and timidity, and did not submit.She left St. Bartholomew’s Hospital soon afterwards, and

the tumour continued to grow very slowly for the followingnine years, without causing an intolerable amount of pain. Atthe expiration of that period, ulceration took place, and afterthat process had continued for two years and a half, the womanreturned to St. Bartholomew’s hospital. It was now found thatthe disease had involved the whole of the breast, the tumourhad assumed a high degree of induration, ulcers had formed inseveral parts, the axillary glands were enlarged, and it wasdeemed prudent not to attempt an operation. The patientsubsequently applied to this hospital, and was admitted asabove stated.On examination the skin was found drawn in by the indu-

rated mass in various places, this circumstance giving rise tosome deep furrows, running transversely; the ulcerating pro-cess was going forward on several points, the discharge beingvery copious, and the patient suffering a great deal of pain.It was evident that no operative means could be thought of in acase of such long standing; the treatment was therefore directedto tie relief of the pain, and to the keeping up of the generalhealth. The usual sedatives and tonics have succeeded to aremarkable degree in accomplishing this end, for the progressof the disease is extremely slow, and no signs of cachexia haveappeared. The patient has now been six months in the

hospital; her appetite is good, she sleeps tolerably well, and herpulse is 72, with moderate force and great regularity. In fact,it may be said that the disease has been kept in completeabeyance, and that the system has suffered very slightly fromthe existence of the cancerous diathesis, or from the manifes-tations of the disease in the breast.

This case might certainly go far to make us look upon theexpectant method as the most advisable in cancer of thebreast; but there is in the next bed a patient similarly

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affected, and with whom, though originally operated upon, thedisease has progressed at an equally slow pace, and wholesystem has also remained unaffected by the malady. Themain facts of this second case are these :

Sarah H——, aged fifty years, unmarried, was admittedJanuary 14th, 1851, under the care of Mr. Shaw. No signsof malignant disease have been known to exist in her family,and the patient’s health had always been pretty good, whenabout twelve years ago a scirrhous tumour began to developin the left breast. There was no discoloration of skin, thegrowth was small, but very hard, and only of a few months’standing. Mr. Coulson, who had been consulted on the case,removed the breast, and the wound cicatrized almost com-pletely. One spot, however, about the size of a pin’s head,did not close, and remained stationary for about a twelve-month ; it then assumed more activity, and began to ulcerate.Various points of the cicatrix were successively attacked bylow inflammation and slight ulceration, these changesstretching over no less than ten years, the disease remainingall this time almost stationary.The patient has now been eighteen months in this hospital,

and the ulceration has not assumed a more rapid character,no destructive process has been set up, and the general healthhas, to a certain extent, remained unaffected. The principalsymptom has been an extension of the induration towards thesternum and axilla, but the woman’s looks are far from beingcachectic; she sleeps pretty well, her appetite is satisfactory,and the pulse (72) is as regular and steady as in the firstcase.

In comparing these two cases, we find that the first patienthas been a mother, whilst the second has never been married;in the first, the disease appeared at fifty-four years, in thesecond, at thirty-eight; the first underwent no operation, thesecond had the breast taken off; and yet the progress in bothhas been somewhat similar. There is, however, a differencebetween the present state of the parts in these two patients,for the first, who did not submit to an operation, presents amuch more extensively ulcerated and indurated surface thanthe second; but both are equally unaffected with cachexia,and their systems seem to contend successfully with the evilinfluence both of the contaminated blood and of the localdisorder. It is clear that the operation in the second casedid not actually exasperate the disease, and that the presentstate of the patient is probably more favourable than if thescirrhous tumour had been allowed to soften, ulcerate, andbecome disintegrated, without the interference of the knife.Nor can it be said with certainty that the first patient wouldhave been made worse by an operation, though the diseasemight possibly have been rendered more active by operativemeasures. It remains, however, clear that cancer of thebreast, whether we interfere or not, will run a certain course,which is more or less rapid, according to the original consti-tution of the patient, and the means employed for maintainingthe due performance of the various functions of the economy.We would finally remark that the cancer ward of this

hospital offers very striking examples of the peculiar cachecticcountenance induced by scirrhus of the womb the leaden hueof these patients contrasts very strongly with the com-

paratively healthy look of those who suffer from cancer of thebreast. The system seems to sympathize earlier and moredeeply with the former than with the latter.

MEDICAL REFORM.

WE gave a short account, in the last LANCET, of the proceed-ings on the above important subject at the late AnniversaryMeeting of the Provincial Association. A more extended

report, extracted from our contemporary, the Provincial Medicaland Surgical Journal, is now inserted.

Dr. RoBERTSON said he had been called upon to move a reso-lution relating to the Medical Reform Bill. The subject hadbeen before the notice of the profession for a number of years, andthey had had frequent opportunities of discussing it. He mightobserve that Mr. George Hastings, (son of Sir Charles,) barrister,who had been concerned in the drawing up and preparation ofthe Bill about to be submitted to Parliament respecting it, wasin attendance to explain its leading provisions. The resolutionwas as follows :—

"That this Association consider that the Draught Bill for MedicalReform, which has been prepared by the Central Council, em-bodies the principles uniformly advocated by the Association,and that the Bill be referrad to a Committee, who are hereby

empowered to make such alterations and modifications in theBill as to them may appear expedient, and also to negotiate withthe Home Secretary, and with the Medical Corporations, with aview that such Bill, on the earliest opportunity, be presented toParliament, in order to its passing into a law."

Mr. PEPLOE CARTWRIGHT, in seconding the motion, said, itwas important that a Committee should set to work actively tocarry out the Draught Bill emanating from the Central Council; itwas the more necessarv as there was reason to fear that theapathy of the profession on this long-debated question was sogreat, that when all differences were nearly adjusted, the finaland crowning measure of the whole would be lost for want ofenergy. The Draught Bill (if not a perfect measure) had givenmuch more universal satisfaction to the profession at large thanany other measure submitted to it. It was unnecessary for him(Mr. Cartwright) to enter into details of the construction of theBill, as that would be much more ably done by a talentedbarrister, (Mr. George Hastings,) who would fully explain theprovisions of the Bill to the meeting. The construction of theBill was simple, not interfering with any strirtly professionoJ,corporations, and appointing such penalties only as were neces-sary to correct irregular practice. The Bill was based on theadoption of the two new Charters of the Colleges of Physiciansand Surgeons, which were framed in a liberal spirit, and thelatter of which has already come into operation, and tended muchto heat those disputes which had existed between the College ofSurgeons and their members. (Applause.) The governingbody (in the present Bill) was to be formed by one-third of itsmembers being appointed from the College of Physicians ; one-third from the College of Surgeons; and one-third independentlyselected from the bulk of general practitioners by the Secretaryof State; the Council would also receive weight and dignity fromthe addition of the Regius Professors of Oxford and Cambridge,and from the Presidents of the Colleges of Physicians and Sur-geons. It was his firm opinion, that a Council so selected fromthe élite of the profession would carefully watch over the inte-rests of the general practitioner, and would be found of muchgreater utility, more effective, and more agreeable to the pro-fession, than any third incorporation. (Applause.) Mr.Cartwright would here appeal to those gentlemen who -had favoured the proposed third incorporation ? As it wasnow clearly impossible to carry out the institution of a third in-corporation, he suggested that the appointment of such an inde-pendent Medical Council as the Bill provided for, would form aneutral ground on which the members of the Institute of GeneralPractitioners could unite with the promoters of this Bill, andprovide effectually for what they were all deeply interested in,the improvement of the status of that hard-working and deservingclass, the general practitioners of the country ; he hoped theappeal he now made would end in some of the Institute gentle-men being now appointed on the Committee. The advantage ofthis would be, that, if by mutual concessions an understandingcould be come to, they could approach the Colleges of Physi-cians and Surgeons as one body, united to obtain a Bill for thegeneral benefit of the profession ; it was already known that theCollege of Physicians approved of the measure ; he hoped theCollege of Surgeons would listen favourably to their require-ments ; and such unanimity on all sides would greatly enhancethe favourable opinion which the Home Secretary was disposedto entertain of the measure; in fact, it had been stated, that if itcould be presented to Mr. Walpole under such circumstances, itwould be adopted as a Government measure. He would urgethe Committee to push forward to such a consummation ; and inthe hope that ere long this long-agitated and most importantmeasure would be honourably and satisfactorily arranged bylegislative enactment, he would conclude by seconding the nomi-nation of the Committee proposed by Dr. Robertson, to carry outthe proposed Draught Bill of the Central Council. (Applause.)

l Mr. G. HASTINGS, (barrister,) then rose, and at considerablelength explained the steps he had taken in the preparation of

this measure, under the direction of the Committee of the Asso-ciation. He observed that it was at first desired to include within

. the scope of its provisions Scotland and Ireland, but from theL difficulties ascertained to exist, it had been deemed advisable toI confine its action to England and Wales, as reciprocity of prac-t tice could only be secured ’6y uniformity of education. It was, his belief that bad Sir George Grey remained in office, so im-F pressed was that gentleman with the importance of the subject, a; measure would have been passed by the late Government whichL would have proved acceptable to the profession generally; but the

change of administration ht:d prevented his doing so, and singu-I larly unfortunate was it that such change occurred only a day

.1 before Sir George Grey would have taken up the Bill. After, the formation of the present ministry, he (Mr. Hastings) had an- interview with Mr. Secretary Walpole, to whom (having the