Muller describes scirrhus, or carcinoma, sim plex (syn. carcinoma fibrosum) as "irregular in form,* not lobulated, hard and resisting the knife, and presenting, when divided, a greyish appearance which has but very little similarity to cartilage. Whitish bands are not invariably present. Scirrhus of the mammary gland oc casionally shews, here and there, whitish fila ments, some of which are hollow, and contain a colourless, whitish or yellowish matter. Pro bably this appearance of white filaments is the result of thickening of the walls of the lacti ferous tubes and lymphatics, and this idea is confirmed by the absence of these filaments from scirrhus of non-glandular parts. The mass of scirrhus is composed of two substances, the one fibrous, and the other grey and granu lar." The fibrous substratum is composed of a very irregular net-work of firm bundles of fibres. The grey consists of microscopic, formative globules, but slightly adherent to each other ; they are transparent hollow cellules, from 0.0048 to 0.00166 or 0.00130 of an English inch in diameter, some of them exhibiting a distinct nucleus. They have no connection with the fibrous structure." Carcinoma reticulare, Miller says,* " occurs more frequently than carcinoma simplex. On making a section of it, it may be immediately distinguished from the latter by the white reti culated figures intersecting the grey mass, which are perfectly evident to the naked eye. It ac quires a large size more readily than carcinoma simplex, and is further distinguished from its tendency to assume a lobulated form. It some times approaches the consistence of scirrhus, at other times it is softer and more nearly re sembles fungus medullaris." Though its con sistence varies, its structure always remains the same, and with the exception of cancer alveo laris, no form of carcinoma can be so readily distinguished.
Carcinoma alveolare, though usually found in the stomach, occasionally attacks the breast, and a very good specimen of it is deposited in the museum of St. Thomas's Hospital. This dis ease, like the former one, consists of innumera ble white fibres and lamina crossing each other in all directions, and having their interspaces occupied by cells which vary in size from that of a grain of sand to that of a large pea. For the history of the development of this and other forms of cancer see PRODUCTS, AIoRnsu.
Soft cancer, fungus hiematodes, and medullary carcinoma, are oneand the same disease. It forms a soft elastic swelling, giving something of the sensation to the fingers of deep-seated fluid, increases rapidly, and is seldom confined to any single organ in the body. It occurs earlier in life than scirrhus, and is more decidedly a con stitutional disease. " The tumour with which alone this is liable to' be confounded," says Mr. Travers, "is the hydatid breast, as it is called, and there is sufficient resemblance in the rounded outline, the elastic resistance, the ab sence of glandular affection, the distressing in conveniences of size, weight, and distension, the turgid veins and livid discoloration of the surface, to create some hesitation. But in the medullary disease it seldom happens that the health is not affected, whereas in the hydatid breast it is undisturbed ; the figure of the me dullary tumour is less uniform, being marked by dark tuberous elevations and immovably fixed to the side by the prolongations of the diseased growth in one or more parts of its cir cumference ; whereas the hydatid tumour, not withstanding its oftentimes enormous bulk, is globular and remains perfectly detached and pendulous. The main distinction is that the mammary gland is not, in my experience at least, the seat of the medullary or fungoid dis ease as it is of the hydatid.
" In proportion as the malignant fungus is recent and of small dimensions, is the diffi culty of diagnosis from the hydatid cyst, for the fungus, as I have before said, ordinarily commences on the interior of a cyst containing a fluid, from the vascular lining of which it hangs like a fringe, and it is common to find more than one, often several contiguous cysts, in the early stage of the disease. As the fungi grow, the cysts burst and are blended in the same mass. From this account it will appear that there is sufficient analogy between the hydatid and fungoid disease in its incipient state to require more aids to diagnosis than those derived from manual examination. We sometimes meet with puzzling analogies in these diseases." " The relation of medullary sarcoma," says Muller, " to scirrhus or carcinoma simplex is displayed by the fact that after amputation of a scirrhous breast, real fungoid tumours may oc cur in other parts, as many observations of Zaup taft, Cruveilhier, and others abundantly shew. This affinity is further illustrated by microscopic examination, which shews that many structures comprehended under the generic term of fungus medullaris differ greatly from each other, and have nothing in common but the softness of their texture." Muller therefore employs the term fungus medullaris " as a collective name for different forms or stages of developement of soft cancer, which undergo imperceptible transitions into each other." The following are
the varieties for a knowledge of the minutiae of which we must refer our readers to the original.
" I. Carcinoma medullare, abounding in roundish formative globules which make up the greater part of the medullary mass, though intersected by a delicate fibrous net-work.
" 2. Carcinoma medullare, with an exceed ingly soft cerebriform base composed of pale elliptical bodies without caudate appendages.
" 3. Carcinoma medullare, with caudate or spindle-shaped corpuscules.
" Carcinoma fasciculalum (syn. hyacinum.) —Among the structures commonly included under the name fungus medullaris, are some altogether fibrous in their texture, and which correspond with other forms of that disease only in the softness of their tissue. The fibrous structure of these growths is immedi ately evident on breaking or dividing them ; when torn they do not crumble, but are readily rent in the direction of the fibres. If ex amined under a microscope they display nei ther the cellular globules of other varieties of carcinoma, nor the caudate corpuscules which give a fibrous appearance to some forms of fun gus medullaris." Mr. Travers, in the paper previously referred to, says that " certain anomalous morbid changes, as large fungous excrescences and deep cavernous fetid ulcers, are now and then the sequelw of tumours in the female breast which are in a loose and slovenly classification termed cancerous. They are not so ; but they are almost as incapable of being conducted to a curative termination as if they were; their progress can scarcely be said to affect the health, being remarkable for its slowness and freedom from pain." lie also describes an excoriation of the integument around the nipple gradually extending over the breast, accompanied by an ichorous exudation which remains in the same incurable state many years, and ultimately throws up a broad toad-stool fungus exquisitely irritable and much disposed to bleed. It affects neither the glands nor health." Melanosis or black cancer has been met with in the breast, but we believe never as a primary disease, the breast having been attacked sub sequently to other tissues. Breschet, in his treatise on this disease, gives a representation of it in this organ. There is a preparation of it in the museum of Bartholomew's Hospital. It is considered by Muller as "merely a variety of cancerous degeneration, and terminates in the same way as other forms of carcinoma." " Microscopic examination," says Muller, " detects two forms of melanotic structure. In both instances the basis of the structure is formed of a fibrous network, the stroma of me lanosis, within the meshes of which the mela noid matter is deposited. This matter is gene rally composed of cells, filled with yellowish or blackish green granules. These cells are and always continue to be free, never becoming coherent. Their forms are very various. Many, indeed most, are round, oval, or irregular ; some are elongated ; a few actually caudate, terminating at one or both extremities in a point or in a fibril. Still more rarely the cells present several points. They are real pigment cells." This author discovered in one of the larger cells a nucleus with its nucleolus, in dependently of the pigment granules. We cannot conclude this article more satisfactorily than by quoting from the same accurate ob server, Mr. Travers, of whose observations we have already so fully availed ourselves.
" No description can comprehend all the varieties of tumour to which this organ is liable, nor does any share of experience enable the nicest observation to suggest an infallible clue to their nature. We have sometimes only manipulation to depend upon, which is an art imperfectly cultivated by scientific surgeons. Cases now and then arise about which the most accurate observers are liable to error. True it is this does not frequently happen in the distinction between innocent and malignant growths. The several species of innocent tu mours already enumerated may all be distin guished from scirrhus with comparatively little difficulty ; but if any doubt exists we must consider the age, habits, and circumstances of the patient. For example, we should ascertain if marks of scrofula are present; if the uterine functions are regular and healthy; if the tu mour can be referred to violence in the com mencement, which from the exposed situation of the organ is far from uncommon ; if more than one lump exists in the same breast; if both breasts are infected ; if painful, the cha racter of the pain ; if any absorbent glands are altered in the neighbourhood and how. How many cases of breast tumour are in the recol lection of experienced surgeons which have been dispersed by some one or other of the remedies in ordinary use, local or constitu tional; and how many that have resisted all and remained stationary for years, the patient's mind having been tranquillized by the assur ance of their innocency. Doubtless on. the other hand a fatal result has sometimes ad ministered a silent but painfully intelligible reproof to the over-confidence of the surgeon." (Samuel Sally.)