After these first symptoms, which are common to all cases, the course varies; many run a rapidly fatal course, partly by local spreading, partly by the infection of the lymphatic glands and internal metastases, while other cases continue for a long time. The duration varies from six - months to twenty years. It has therefore been necessary to differentiate different forms and different stages of cancer of the breast.• Though the signs and limits of these different forms at different times of medical ob servation were deduced from very different symptoms, yet the principal types are so characteristic that the descriptions in different centuries agree very nearly. For this it is only necessary to bear always in mind that it is not a question of systematizing from purely logical principles, but only a grouping of products of nature, the varieties of which are unusually nu merous. While such a division of carcinoma of the breast into its different forms serves an important practical purpose, the inclusion of minute de tails themselves, taken from the symptomatology or histology, is only of practical value when it gives some information as regards the prognosis and course; at the same time, a purely scientific interest in such details is not injurious, and may be in itself entirely right. But I cannot think it of value to divide carcinoma into so many kinds, as, for example, Vel pean has done, though I admire the fine gift of observation which there expresses itself.
The surgeons of the middle ages differentiated three stages of malig nant neoplasms.
1. denoted originally only "hardening," and was ap plied to every kind of induration, whether due to a neoplasm or a chronic inflammatory process (these two were not as distinctly separated as now). The designation " scirrhus degeneration," formerly did not include malig nancy. It was in the beginning of the present century that it first be came more and more the custom to use the expression schirrhus for the harder, and "fungus medullaris " for softer neoplasms, while for the chronic inflammatory induration the designation " callous " came into use. Later, when the expression " carcinoma " was used for malignant growths generally, and by German writers especially (in France and land, cancer and squirrhe are most used for the designation of malignant tumors), the term scirrhus became more limited, and a number of authors have followed my example, and call only the retracting cicatricial forms scirrhus or " fibrous cancer." Others have used the term " fibrous can cer" for those forms also which figure in English literature as " infiltrated cancer." 2. Cancer ()emit us formerly denoted that form which had been perceptible as nodules, or as a tumor, and which had gradually become softer.
3. Cancer Apertus was applied to the broken-down cancerous ulcer ation.
In order to enable the reader to understand the different customary designations still used in different places, I will now give the most usual names together with those usually employed by me, choosing as types of the different schools in different countries, Schuh (Vienna school), Birkett (England), Gross (America), and Velpeau (France).
1. The partly softer, partly harder carcinoma nodules; histologically appearing mostly as acinous carcinoma (Billroth). Identical with it: Fungus medullaris, fibrous cancer with large nodules (Schuh). Carci noma medullare, encysted carcinoma, lobular carcinoma, attached to or involving only one lobe, tuberous form of cancer (Birkett). Encephaloid, tuberous form of cancer (Gross). Enc6phaloide, Squirrhe proprement slit on globnlenx (Velpeau). As already remarked, many forms designated as soft cancer belong also to the category of soft sarcoma and cysto-sarcoma.
2. Carcinomatous infiltration; histologically mostly appearing as tub ular carcinoma. Carcinoma simplex (Billroth). Generally soon invading the skin, partly as infiltration, partly in the form of multiple nodules. Fibrous cancer with small nodules, lenticular cancer (Schuh). Intra glandular carcinoma, infiltrating form of cancer (Birkett). Infiltrating form of cancer (Gross). Souirrh,e liqneux (densite et l'inextensibilite du bois), squirrhe en masse, en nappe, squirrhe dissimine on pustule:ix, squirrhe larded., keloides (Velpeau) 3. The atrophying, contracting cancer of the breast. Scirrhus, (Bill roth). Atrophic scirrhus (Gross). Squirrhe retractile ou atrophique (Velpeau.) 4. Colloid cancer. Squirrhe gelatinaux, alveolaire, cancer colloids (Velpeau). Gelatiniform carcinoma (Gross).
Anatomy of Cancer of the Breast.—The manifested form of all pro ducts of nature is dependent upon their finer structures, and this depends again upon the material and quality of its formation; so that different structures and different processes of development must lie at the founda tion of the above-mentioned different forms of carcinoma. These will soon be mentioned. Of course the chief interest in all forms lies in etiological factors, which unfortunately have thus far been hid from us almost entirely, but it also lies in the nature of its further development, of its course, concerning which a large number of observations has been col lected, which it is difficult to collate. The anatomical structure of all car cinomas of the breast offers common points of support, though it must not be forgotten that there are so many different varieties, that many cases cannot be understood as belonging together except by the most careful study, and especially by the study of their developmental history.