The product of this breaking down is a clear yellowish substance like masses of tubercle in the large-nodular, soft (acinous) carcinomas. There are cases in which this breaking down occurs very rapidly, and with ex udation, so that the cavities eventually break externally, like a cold abscess; the contents are then evacuated, the edges of the healed nodule are turned outwards so that a crater-like ulcer is formed; then an agaric like growth, as is so characteristic of these forms of carcinoma (Fig. 51). Though the secretion of such ulcers partly consists of true pus, yet there is seldom a formation of a really acute or chronic abscess in mammary carcinoma; it is much more frequent in infiltrated epithelial carcinomas of the lymphatic glands of the neck.
In the infiltrated (tubular) mammary cancer the process, as a is different. As, in this case, much more connective tissue is reserved with the contained vessels, because the cell-collection is less largely concen trated in separate foci and nodules, the cell-degeneration is much slower. The still existing veins take off a part of the detritus with the blood, and only a small part remains behind, around which the infiltrated connective tissue contracts, and thus an interstitial cicatrix is formed. This process again corresponds to the similar processes in chronic inflammations, with the restriction that the tissue which has become infiltrated does not return exactly to its former state, but retains the character of a firm (callous, scirrhous) cicatricial tissue. The externally noticeable results of this process are very striking. The retraction acts on the skin, nipple and pectoralis major muscle; all these parts may be drawn in, i.e., drawn into the retracting centre, and even the remaining parts of the mamma may thus suffer considerable dislocation. Now since such a carcinoma, under going partial retraction, consists in fact in part only of cicatricial fibrous tissue, this has probably led to the designation of these cases as " fibrous cancer," even though such carcinomas may still be very numerous in other parts and so remain.
There are cases, especially in elderly women, in which the carcinoma tous infiltration breaks down, for reasons unknown to us (perhaps on ac count of deficient vascularity) so soon after their beginning, that the cicatricial retraction appears to follow immediately upon it. We find in such carcinomas, which I designate as scirrhus xar' eZoxiiw, in most places only a hard tissue, grating under the knife, which plainly consists only of connective tissue and an unusual amount of elastic fibres (Fig. 52).
These are the cases which it is often difficult to differentiate from chronic interstitial mastitis (cirrhosis mammme. Wernher). Only by close examination of the fatty yellowish red boundary portions do we find the usually small tubular cancer bodies.
From these considerations it does not appear to be impossible for a can cer to completely cicatrize and heal spontaneously. I have never seen this, nor, so far as I know, have there been any observations of the kind by others. The most striking example of shriveling of a carcinoma which I have seen is the following: A woman, about 40 years old, came to my clinic with an infiltrated carcinoma as large as an apple in the left breast; she refused an operation. A year afterward she came back on account of paralysis of the lower extremities, caused (as was shown later at the autopsy) by carcinoma of the vertebral column and spinal cord. Of the former tumor of the breast, indeed of the whole of the left breast, noth ing remained, excepting a flat, indurated cicatrix, partially excoriated superficially, and in which no new infiltration occurred up to the time of death, which occurred shortly. Unfortunately, in my brief notes, it is not noted whether the lymphatic glands were infected. However simple these processes, after the above exposition, may seem in the typical cases, it was very difficult to find and understand them. In fact, we must have a tolerably large amount of mammary cancer material at our disposal, and must use it industriously, if we would convince ourselves of all these things, and obtain typical pictures of the separate forms, which differ so widely from one another. By far the greatest difficulty is in correctly comprehending the relation of the epithelial growths to the small-celled connective tissue infiltration in all cases. Here there are still many points to be cleared up by further researches. The relation to each other of two such powerful factors in carcinoma is not at all wholly clear for all cases.
For example, at one time we see, especially in the acinous forms, that the connective-tissue infiltration at first appears to be absent, and then again, though not often, at another time the small-cell infiltration is prom inent at the beginning, and the epithelial growth is so far surpassed that one is scarcely inclined to consider it an important factor.