of carcinoma as it affects other tissues, as bone or muscle, undergo certain modifications, and these will be now described, together with those "accidental" conditions of carcinoma to which have been assigned special names, as colloid, villous, osteoid, melanotic, &c. One need hardly enter with any detail into the consideration of the naked-eye characters and clinical features of ordinary breast cancer. To the hospital surgeon the clinical characters of scirrhus are but too well known. The careworn woman who applies with a "lump in the breast," and who displays on uncovering her wasted form the shrivelled, hard gland, with sunken nipple and puckered skin, and who then complains of "kernels in the armpit," and of failure of health and strength, is too familiar an object to need description here, and the many varieties of appearances occasionally met with are amply set forth in such classical works as that of Sir James Paget on 'Surgical Pathology.'

CHAPTER IV.

CARCINOMA (continued).—Microscopic Appearances modified by Tissue affected, as Muscle, Bone, &c.-Villous Cancer-Hæmatoid Cancer, or Fungus Hæmatodes-Melanotic Carcinoma-Colloid-Myxoma.

BEFORE entering upon the brief consideration of the varieties of carcinoma to which have been assigned special names, some notice should be given to the modifications caused by the locality or tissue affected by the growth. It has been already said that the secondary growths met with in the liver or lungs are, as a rule, more richly cellular than the primary tumour; but, excepting that the stroma is less obvious, there is very little other difference discernible, either in the form or size of the cells, or in their arrangement. Sometimes, when the development of these secondary tumours is exceedingly rapid, an unusual preponderance of the small cells before described may be met with. I have seen, for instance, a very rapidly growing carcinoma recurrent near the scar of an amputated breast, in which the cells were so uniform in shape and so small in size that it would have been very difficult to name the growth at all without the aid afforded by the examination of the primary tumour. In the outlying pea-like nodules which occasionally occur in the pectoral muscles beneath a scirrhous breast, and which afford such beautiful opportunities for the study of the infiltrating characters of carcinoma, it often happens that the bulk of the tiny mass is made up of these small "indifferent cells," with merely a trace of the alveolar fibrous stroma so characteristic in mature carcinoma.

Carcinoma affects bone either in the form of distinct

tumours or as an infiltration of the bone with cancer elements, so as to affect its consistence rather than the shape of the bone. In such cases of bone-softening in connexion with cancer elsewhere as I have had the opportunity of examining, I have seldom been able to detect any cancerous elements, but occasionally one meets with instances of considerable deformity of the flat and long bones occurring as either primary or secondary carcinoma.1 In such cases there is an abundant milky juice to be scraped from the section of the softened bone, and in this juice are just such cell-forms as are commonly met with in the juice of a scirrhous tumour. Very thin sections of bone so diseased show groups of such cells enclosed in spaces corresponding to the Haversian spaces of the original bone; but, besides this, the osseous lamellæ are occasionally found to be divested of calcareous matter, and to form a fibrous stroma very like that of ordinary carcinoma, the lacunæ being swollen into groups of new cells in some parts, as though these cells resulted from the proliferation of the original lacunal cell. In other cases of primary carcinoma of bone a structure precisely resembling ordinary scirrhus is met with, the fibrous stroma being replaced more or less largely by interlacing spicules of new bone (see Plate I, fig. 2). To follow up in detail the modified appearances of carcinoma as they are altered by the tissue affected, however, would lead us beyond the scope of these sketches. With the brief suggestion that the statement of Virchow, as to the absence of any visible intercellular material being an essential condition of true carcinoma, is probably not to be received without exception, since one occasionally meets with instances of undoubted scirrhus of the breast in some parts of which a certain amount of granular material separates the cells, we may pass on to the notice of those named varieties of cancer whose distinguishing characteristics are caused by degenerative processes or other accidental conditions.

Villous Carcinoma has been described, but is, I fancy, an

1 For a remarkable case of this kind see 'Path. Trans.,' vol. xix, p. 356.

extremely rare variety. Malignant villous tumours are almost invariably associated with epithelioma rather than with carcinoma, and are met with on such mucous surfaces as are normally villous-the villi, owing to the disturbed nutrition of the part, becoming greatly hypertrophied. Certainly many tumours which are called villous cancers are simply due to a more or less active overgrowth of the healthy villi of the part, which may give rise in the bladder or rectum to large masses of velvety substance, forming beautiful objects when floated out in water, but having no trace of malignancy about them, either in their anatomical structure or clinical history.

At the same time it must be mentioned that villous tumours of the bladder and elsewhere have been described by Prof. A. Luecke and others, in which groups of carcinoma cells were imbedded in the fibrous matrix of the papillæ ; and such growths would be quite rightly named villous carci

noma.

Hæmatoid Carcinoma or Fungus Hæmatodes may be dismissed with a very few words. Very soft and rapidly growing tumours, whether carcinomatous or sarcomatous in type, are supplied with very delicate capillary networks, and these fine vessels, when separated by careful washing from the cell-elements of the growth, are seen to be variously dilated, the vessel wall yielding in the direction of least support. This is particularly the case where fatty degeneration advances as rapidly as the cell-proliferation, and it is specially in such instances that, the vessels bursting, large quantities of blood are poured out, and by their subsequent changes diversify with such rich colours the cut surfaces of these growths. It is obvious that this accidental hæmorrhage is an insufficient ground for according a special name to tumours exhibiting it, for precisely the same thing happens in a greater or less degree with every soft new growth.

But I will take this opportunity of directing attention to those growths occasionally met with, in which the blood so poured out plays so important a part amongst the various

characters of the tumour that the elements of the new growth are in danger of being overlooked. I have twice seen tumours of this kind, each time in the ham or lower part of the thigh, and both times with similar symptoms. A swelling had been present for some weeks or months, and latterly had rapidly increased. It presented all the signs of a cystic growth or large abscess, but on making an exploratory incision a stream of pure blood flowed forth, and the surgeon thought that he had opened an aneurism. On pressing upon the artery in the groin and enlarging the opening, a large sac of blood was discovered, with clot-layers enclosing it, and in one case the surgeon was with difficulty induced to believe in the true nature of the disease, and amputate the limb. In both cases, however, a comparatively insignificant basis of spindle-cell sarcoma was found infiltrating the muscular tissue, and it was from the new vessels of this growth that the blood had evidently been poured; and in one of these cases death occurred after three or four years from sarcomatous growths disseminated through the viscera.

Melanotic Carcinoma.-This form of disease is exceedingly rare. The great majority of cases of "black cancer" are really instances of sarcoma, and will be referred to with the other sarcomata. When a true carcinoma is melanotic, the black tint is due to a certain proportion of the cells containing granules of pigment; but almost all the dark nodules in carcinomatous growths which have come under my own observation have derived their colour from the changes resulting in blood extravasated into the part, and could not be strictly classed with melanotic growths at all.

Colloid Carcinoma.-This very interesting variety is probably much less common than is usually affirmed, for most English surgeons have unquestionably been in the habit of placing in this class those purer forms of mucous tumour or myxoma which bear to the naked eye a close resemblance to jelly, in the clear flickering masses sometimes met with. The true colloid also owes its characters