within it contain younger cysts in their interior, which are attached to their walls by pedicles. An instance of this is afforded by the case of Mrs. King, described by Sir A. Cooper. This form of morbid growth is a repetition of the cystis prolifera, but imbedded in a sarcomatous mass, which constitutes the chief part of the tumor; and it may, therefore, be termed with propriety cystosarcoma proliferum. The pedunculated offsets from the cysts are hollow, and Sir A. Cooper saw some of them loose in the interior of the older cysts. It would likewise appear from an observation of Sir A. Cooper that the young cysts contain cholesteatomatous matter, for he found their interior composed of several laminæ, easily separable from each other, and presenting a glistening appearance.

The pedunculated bodies may, however, be sarcomatous.

"The third form, cytosarcoma phyllodes, differs greatly from the other two. The tumor forms a large firm mass, with a more or less uneven surface. The fibrous substance which constitutes the greater part of it is of a greyish white colour, extremely hard, and as firm as fibro-cartilage. Large portions of the tumor are made up entirely of this mass, but in some parts are cavities or clefts not lined with a distinct membrane. These cavities contain but little fluid; for either their parictes, which are hard like fibro-cartilage, and finely polished, lie in close apposition with each other, or a number of firm, irregular laminæ sprout from the mass, and form the walls of the fissures; or excrescences of a foliated or wartlike form sprout from the bottom of the cavities and fill up their interior. These excrescences are perfectly smooth on their surface, and never contain cysts or cells. Ths lamina lie very irregularly, and project into the cavities and fissures like the folds of the psalterium in the interior of the third stomach of ruminant animals. In one instance the author saw these lamina here and there regularly notched or crenated like a cock's comb. Sometimes the laminæ are but small, and the warty excrescences from the cysts very large, while in other instances both are greatly developed. Occasionally these warty excrescences are broad, sessile, and much indented; others have a more slender base, and somewhat resemble cauliflower condylomata. They are always formed of the same firm apparently fibro-cartilaginous matter as the non-hydatid portions of the tumor. The preceding description has been made from a cystosarcoma phyllodes of the female breast, weighing 2 pounds, which was extirpated by M. v. Gracfe, and is now preserved in the museum at Berlin, and is numbered 8906 in the catalogue.

On a microscopic examination of the firm mass, it is seen to have an indistinctly fibrous structure, but to contain neither cells nor cartilage corpuscules. It is very difficult to distinguish the fibrous texture of the mass; and this circumstance as well as the difference in the results of chemical analysis, suffice to distinguish the solid mass of cystosarcoma phyllodes from the tumor fibrosus s. desmoides. When boiled for twenty hours it yields no gelatine, and consequently consists of an albuminous substance; but the author never met with any other albuminous body of so great firmness. Whatever may be dissolved by long boiling is precipitated by corrosive sublimate, acetate of lead, tannin, and alcohol, but neither by acetic acid nor by alum. Once the author saw a large mass of cholesteatoma contained free within the cyst of a cystosarcoma phyllodes, which had been successfully extirpated by M. v. Brunn, of Coethen, and which was preserved in Meckel's museum at Halle. Tumors of this kind attain an enormous size; hitherto the author has seen them only in the female breast, nor are they even there of frequent occurrence. They are decidedly innocent, occur earlier than it is usual for cancer of the mamma to develop itself, and sometimes they appear even in youth; they have but little tendency to grow to the skin or to the subjacent muscles, and are not attended with retrac

tion of the nipple. They are not disposed to soften internally, but continue to grow slowly until they have attained an enormous size, when they at length burst, and a very ill-looking suppurating fungus forms upon their surface. Even in this state, however, the operation has been performed with a successful result." 174.

These tumors have been described under the names of steatoma mammæ, carcinoma mammæ hydatides, carcinoma phyllodes, &c. and M. Müller appends some historical notices of the affection.

He adds a short section on the curability of the disease by operation. M. Müller remarks:-There are many and sufficient observations on record, all of which concur in representing cystosarcoma as curable by extirpation, and as having nothing in common with cancer, notwithstanding the extraordinary appearance which its warty excrescences or its lamina exhibit. The case described by Chelius was cured by the operation. The same result followed the operation in the case from which the specimen in St. Bartholomew's Hospital was obtained; and amputation cured all the cases of hydatid tumors of the breast described by Sir A. Cooper. Swelling of the axillary glands is not a common occurrence, and, when it is met with, is the consequence of simple irritation, and subsides after the operation. The extraordinary forms which cystosarcoma phyllodes assumes, at once suggest the notion of its cancerous nature; and yet the disease is perfectly innocent, and as far removed from carcinoma as are those non-suppurating cauliflower condylomata of the penis, and of the female genitals, which have so often been mistaken for cancerous structures. The author has been fortunate enough to learn the history of a case which came under his own observation; and, likewise, of two others, the preparations from which are contained in the anatomical museum at Halle. In all of these the operation was completely successful. M. Müller adds:

"

Although it is a well established fact that these forms of cystosarcoma are innocent, yet it must not be imagined that the appearance of cysts in a parenchymatous tumor necessarily excludes carcinoma, or a malignant nature. Indeed, just as cysts may be developed in every part of the organism, so it is quite possible that they may be formed in a carcinomatous structure. Among the many cases of innocent hydated tumors of the breast, Sir A. Cooper mentions one which was malignant, namely, a combination of cancer and hydatids. Moreover, the occurrence of carcinoma alveolare in the breast, although rare, has been observed by the author, and may lead to mistakes. In a carcinoma reticulare, the author saw part of the tumor presenting the ordinary structure of carcinoma alveolare, and containing cells filled with jelly. These cells might very easily. have been mistaken for ordinary hydatids.

Carcinoma of the breast never attains that enormous size which cystosarcoma of the female breast sometimes reaches, before it passes into the open state. In Chelius' case the tumor had existed for ten years before the operation was performed, and a cystosarcoma proliferum had lasted for fourteen years before it was extirpated by Sir A. Cooper. The development of the tumor at a period of life when cancer mammæ is infrequent, its tardy progress, the enormous size which it attains without causing pain or producing, at the most, only very slight discomfort, and the fluctuation more or less distinct at the part where some cyst is situated, are points which, even before an operation, may lead to a tolerably certain diagnosis of these growths.

Enchondroma and cystosarcoma are the only forms of benignant tumor of the mammary gland which have hitherto come under our notice. The female breast

is liable to innocent tumors of other kinds, which will hereafter claim our attention; as the albuminous and gelatinous sarcoma, and the fibrous tumor which in the breast, as well as in the uterus, is susceptible of transformation into bone." 182.

This completes our account of the part before us. We have given it in full and in detail, as we were anxious to place before our readers the opinions and observations of so accurate a pathologist as well as physiologist, on so difficult a subject. We shall return to it when the next part appears, and in the mean time we will remark that the work should be in the possession of every physician and surgeon who affects to practise with dignity and an expectation of success.

II. The length to which we have gone in pursuing the investigations of M. Müller into the nature and properties of carcinoma, must prevent us from entering so fully on the examination of the article "Cancer," in the Cyclopædia of Practical Surgery, as its merits could justify, and we should otherwise have done. The author, Mr. Spencer Wells, has bestowed on it great pains, and no less discrimination; and we think it offers a very favourable sample not only of his labours, but of the Cyclopædia itself.

We cannot pass it by with merely a barren encomium. There are many parts of it from which we may extract particulars necessary to complete the view of which M. Müller's work has offered us so large a portion. Over these parts we shall run, and if our notice of them is unconnected it is for the reason we have stated.

Nosological Position of Cancer.

Mr. Wells insists on the propriety of employing cancer or carcinoma as the generic term, scirrhus and encephaloid formation being only species. To these he adds, in accordance with the researches of Laennec, Otto, Cruveilhier, and Müller, "colloid" growths.

"The union of these morbid structures into a distinct class is not a mere nosological artifice: it is manifest that the formations, to which we propose to apply the generic term cancer, possess characters entitling them to be grouped together and separated from all others to which the frame is exposed. They agree anatomically, for they are all composed of a containing and a contained part forming a combination without its counterpart in the natural structures; they agree chemically, for they are all distinguished by the vast predominance of albumen in their composition: they agree physiologically, for they all possess in themselves the power of growth and of extension by continuity of tissue, that is, of assimulating to their proper substance the most heterogeneous materials an inherent tendency to destruction and the power of local reproduction; they agree pathologically, for they all tend to affect simultaneously or consecutively various organs in the body, and produce that depraved state of the constitution known as the cancerous cachexia. Their title to be united is quite as strong in respect of practical medicine and surgery, as in respect of scientific pathology, a consideration of the very highest importance. As respects the name to be given to the genus, cancer or carcinoma is clearly the best; to limit these terms to one particular tissue, when others possess the very properties on account of which they were originally employed, is a palpable contradiction."

Family.

To this no rational objection can be urged. It is the expression of the present advanced state of opinion. The following table seems to us a very good and useful one. It will assist the pathological student, and relieve him of the embarrassment which an over loaded nomenclature has given rise to. As Mr. Wells remarks, it will be seen from this table that cancer is synonymous anatomice with adventitious heterologous tissue. The fact of its being a tissue, that is, of its possessing structure, separates it unequivocally as a morbid product from others belonging to the same class, for example, pus and tubercle. The heterologous material of all carcinomatous formations is organizable, susceptible of vascular development, and hence of undergoing all the changes of increase and decay consequent on such susceptibility.

Class.

Order.

Genus.

Species.

Varieties,

Synonyms of the Species.

vel Fungoid disease.

Nephroid. Idem.
Napiform. Idem.
Carcinoma fasciculatum
hyalinum. Mueller.
Fungus Hæmatodes. Hey.
Hæmatode Cancer. Auct. Gall.

A. Cooper, Hodgkin.

Medullary fungus. Maunoir, Chelius.
Acute fungous tumor. C. Bell.
Medullary cancer. Travers.
Cephaloma. Hooper, Carswell.
Carcinoma medullare. Mueller.
Soft cancer. Auct. Var.

Pancreatic sarcoma? Aber- Carcinomatous sarcoma. Abernethy.

nethy. Napiform, Chondroid,

Carcinoma scirrhosum. Young.
Scirrhous cancer.

Travers.

Scirrhoma. Carswell.

Carcinoma simplex vel fibrosum. Mueller
Stone cancer. Auct. Var.

Areolar gelatiniform cancer. Cruveit-
hier.

Carcinoma alveolare. Mueller.
Gum cancer. Hodgkin.

The heterologous character of carcinoma distinguishes it too from the analogous adventitious growths, as fatty, fibrous, and cartilaginous tumors. Mr. Wells, however, uses the terms analogous and heterologous in reference to external, not to microscopical characters.

Mr. Wells divides his article into two parts; devoting the first to the subject of cancer in general, in the second describing the disease as it occurs in those tissues and organs in which it is likely to come under the notice of the practical surgeon.

We pass by the anatomy of encephaloid disease, scirrhus, and colloid, and stop at their physiology.

In treating of the Physiology of cancer, Mr. Wells judiciously passes over, or very lightly alludes to, many of the ridiculous theories promulgated at various times. He examines more particularly the hypotheses of Hodgkin, Cruveilhier, Carswell, and Müller.

On that of Dr. Hodgkin we need not speak, as it has been sufficiently examined and objected to. Our readers, perhaps, are less familiar with the opinions of Cruveil hier, and we shall therefore notice them.

"M. Cruveilhier's doctrine embraces two essentially distinct propositions. First, he regards all heterologous formations, as the exclusive result of a successive deposition of morbid products in the cellular element of organs;' he believes that this cellular element is alone affected; that the proper tissue of organs is in itself incapable of undergoing any organic lesion, cxcept hypertrophy and atrophy; that at first rendered hypertrophous by the state of irritation existing in the neighbouring cellular membrane, these proper tissues subsequently become atrophous, and finally disappear in consequence of the pressure they undergo from the diseased formation.' But this unalterableness of composition of the organic tissues is the least important part of the doctrine; for, secondly, it results from his researches that the formation of cancer, like all nutritive phenomena, physiological and morbid, takes place in the venous capillary system; that from it the morbid products are poured into the cellular membrane, either by exhalation or through lacerated openings.' This latter proposition, as it affects cancer, is evidently only a part of his more general theory, according to which the various phenomena of nutrition, secretion, and inflammation, are accomplished, not as has heretofore been believed in the arterial, but in the venous capillaries."

Mr. Wells remarks that, much as M. Cruveilhier insists upon the doctrine that carcinoma occurs primitively and invariably in the seat he has assigned to it, yet the only fact that he advances in support of it is the occurrence of carcinomatous matter in the veins.

From the full account which we gave, at the time of their publication, of Dr. Carswell's Fasciculi of Morbid Anatomy, our readers may perhaps remember his opinion-that, carcinoma originates in three positions-in the molecular structure of organs as a product of nutrition; on free serous surfaces, as a result of secretion; and in the blood. It is in the latter, indeed, that Dr. Carswell places the real site of cancer, and the hypothesis is one of the most important description. Mr. Wells, therefore, collects what is known upon the subject.

The earliest careful observations, he says, respecting the presence of cancerous matter in the vascular system appear to have been by M. Velpeau. In 1824 this inquirer read an essay to the Academy of Medicine, containing two cases related with much precision. In one of these an encephaloid mass appeared in the vena cava communicating with similar structure in the kidney; and an enormous coagulum extending from the iliac veins through the cava inferior to the right auricle, presented from place to place the characters of encephaloid matter of varying firmness. The coagula in the heart had apparently formed after death, yet in one of them, placed between the walls of the ventricle and the tricuspid valve, was contained “some substance of purulent or encephaloid aspect, like that contained in the kidney." In 1829 M. Andral announced his having discovered carcinomatous matter in

H