Scirrhus has been again subdivided into genera by different authors, some in relation to their external appearances and situation, others in accordance with their internal structure. Dr. Benedict, Professor in the University of Breslau,* in giving the following arrangement has rather pursued the former plan :-1st. Cu taneous cancer. 2d. True scirrhus ; consist ing of-1. Modulated scirrhus; 2. Lard-like scirrhus; 3. Bladder scirrhus.
Muller, in his late work on cancer, which has been translated by Dr. West, describes the different kinds of carcinoma to which the breast, in common with other organs, is liable, not in reference to their seat whether cutaneous or glandular, but in accordance with their intimate structure; and to scirrlins, medullary sarcoma, carcinoma alveolare, and carcinoma melanodes of former authors, has added carcinoma reticu lare and fasciculatum. To these we shall return a little further on, dwelling previously on a form of cancer which is not very common but highly important in a practical point of view to the surgeon.
" Cutaneous cancer of the breast," says Dr. Benedict, p. 39, " deserves to be particularly noticed, because most surgeons frequently con found it with the common cancer, from which it, however, materially differs. It never springs in the substance of the organ, but always and solely in the surface of the skin, and most probably from fat and adipose glands of the same. Its form is similar to that of cancer in the face and eyelids, and arises in the same way. At first there is nothing but a little knot, wart, or hard little spot somewhere upon the skin of the breast. This place begins gradually to redden and then passes into a stage of ulcera tion. The swelling which has hard edges and a hard base spreads out, increasing both in depth and width so as to advance from the skin into the substance of the gland, not passing far, and only very gradually destroying the breast. The glands of the axilla are not attacked so early as in carcinoma of the gland itself, and the hectic fever which ultimately destroys the patient developes itself after a much longer period.
Mr. Travers (Med. Chir. Trans. vol. xvii.) also describes this cutaneous cancer in the fol lowing words : " There is a cancerous tubercle of the skin which appears upon the breast as in other parts, connected with a remarkable change in the texture of the skin. The affection of the skin is, I believe, primary. It consists of a brawning induration with extension of the areolw, a coarseness such as this texture pre sents when viewed through a magnifier, and which gives it a resemblance to pig's skin.
Isolated tubercles of various sizes appear at con siderable distances apart : the texture of the subjacent cellular membrane is enormously thickened and has a cartilaginous hardness; and breast when the skin undergoes this change upon that organ is early and immoveably fixed to the chest." I have drawings of two cases of the kind : one which occurred in the practice of Mr. Travers, at St. Thomas's Hospital, the other in the private practice of Mr. South ; the for mer I inspected in company with that gentle man. The post-mortem appearances were interesting from the immense crop of white hard tubercles which were found studding the pleura costalis.
Dr. Benedict considers that " the primary skin disease can be removed almost always with a favourable result if the operation is performed previous to enlargement of the neighbouring glands, disease of the parenchyma of the mam ma, or constitutional fever." The ordinary scirrhus of the mamma in its early stages usually presents itself to the sur geon as a hard tumour, situated in not on the glandular substance of the breast. At first it is comparatively moveable, but it cannot be moved independent of the structure which sur rounds it, and in the progress of development it soon contracts adhesions by means of root-like prolongations with the whole mamma. Its surface varies, not decidedly nodulated nor yet uniformly smooth ; not tender to the touch, though it may be the seat of sharp lancinating pains. As the tumour increases, its adhesions extending on all sides, the nipple becomes drawn in, and its most prominent surface as sumes a dusky hue. The constitution now begins to suffer, the glands in the walla enlarge, and at this period there is no difficulty in dis tinguishing the nature of the disease. In its early stage it might be confounded with a tumour which Mr. Travers in his paper just referred to has thus described : " There is a tumour met with in the breasts of young women, more like a shelled walnut in point of size and nodosity than any thing to which I can com pare it. It is of a stony hardness, and it is not reduced by regulated equal compression, mer cury, iodine, or blisters. It is an enlargement and partial cohesion of the lactiferous-tubes in a cluster, in one or more places, and which dis position in a less degree pervades the ducts throughout the organ." The absence of lanci nating pains, constitutional disturbance, and the peculiar countenance attendant on malig nant disease, assist the surgeon in his diagnosis. The earlier period of life at which it makes its appearance is also a circumstance worthy of attention.