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these as it may any other adjacent part.

When seated at or near the centre of the gland, it commonly draws down the nipple, which descends, as it were, into a round pit sunk below the general level of the breast. As it extends, also, the cancer structures deposited in the nipple make it hard, or very firm and elastic, inflexible, and comparatively immoveable."*

ease,

In most cases, scirrhus appears as a primary disthe lymphatic glands generally soon becoming affected as secondary disease; but what is very remarkable, the secondary disease is not in all cases the same as the primary, for scirrhus has been known to exist in the breast as the primary disease, whilst the glands became secondarily affected, not with scirrhous, but with medullary cancer. Scirrhus appears to increase by the gradual addition of new particles to the surface of the diseased tumour already existing. This form of disease, unlike medullary cancer, is but sparingly supplied with blood-vessels; indeed, some authors state that in scirrhous tumours no bloodvessels can be detected. However, these tumours, like all other parts, whether diseased or no, possess vessels for their nourishment and increase. Scirrhus, as a general rule, increases but slowly; but it increases

* Paget's Pathology, p. 308.

at various rates, and in the same cases at times more rapidly than at others. "I believe no average rate of increase can be assigned. Cases often occur, especially in lean, withered women, whose mammary glands share in the generally-pervading atrophy, in which two, three, or more years pass without any apparent increase in a cancer; and the progress even of ulcerated cancer is, in such cases, scarcely perceptible even in the lapse of years. On the other hand, cases are sometimes found of most rapid increase. I saw such a one last summer. A hard cancer grew in five months from the size of the tip of a finger to a mass five inches in diameter. This was in a woman thirty-two years old, in whom the disease began while she was suckling, and immediately before, even while suckling, she again became pregnant. Extensive and speedy sloughing followed this rapid growth, and she died in seven months from the first observation of the disease."*

Scirrhus in almost all cases, when left to itself, tends to ulceration, which takes place in one of two ways. Either ulceration begins upon the surface, and extends into the substance of the tumour, or else the change leading to ulceration takes place in its substance, and works its way to the surface. The

* Paget's Surgical Pathology, vol. ii. p. 331.

first form of ulceration is usually met with when the skin has become involved, which first cracks, or excoriates, over which a yellow scab is formed, which, when removed, is soon replaced; this goes on for a little, when a more decided form of ulcer appears, not now covered with a scab, but exuding large quantities of acrid watery fluid. The ulcerating surface now spreads rapidly, but seldom extends to any considerable depth; and, as the ulceration increases, so does the disease, involving more and more the adjacent parts. The second form of ulceration, however, is very different from this. A softening or decaying of the cancerous matter takes place in the interior of the mass. This mass, of a soft and yellowish colour, when thrown out, leaves a deep hole or cavity in the tumour, in some cases of an equal width throughout, in others with a small external opening, but enlarging as it proceeds inwards. The walls of these hollows or pits gradually become decomposed, and so enlarging the cavities, whilst the cancer itself rapidly increases in the adjoining parts. The discharge is abundant, of a thin, watery, and irritating character, never resembling true pus.

Epithelial Cancer. -Epithelial cancer generally in some portion of the skin or mucous

first

appears

membrane. It is this form that usually primarily attacks the tongue, the lip, the cheek, the anus, the labia, scrotum, os uteri, &c. &c. It is a form of disease seldom met with in the breast; it confines its ravages generally to the integuments and mucous membranes. Its extension is rapid, destroying in its progress adjoining parts, whether they be bone, fibrous tissue, or muscle. It most generally appears a little elevated above the surface, of a warty growth; sometimes, from the papillæ being the seat of disease, they appear like long warty pendulous bodies, growing from small, narrow bases. Again, they occur perfectly level with the integuments, but feel like deep-seated, hard, pealike masses. Again, they are found slightly elevated above the surface, and slightly sunk below the integuments. Epithelial cancers have a tendency to increase downwards, towards deep-seated parts, yet this is not always the case, for sometimes, like encephaloid cancer, they grow rapidly towards the surface, throwing out innumerable cauliflower excrescences. When this form of disease begins to grow, or increase, the neighbouring glands soon become secondarily affected. Epithelial cancer soon tends to ulceration. "The epithelial cancers in or near the integuments are so prone to ulceration that

the occasions of seeing them as mere growths are

comparatively rare.'

In cancers of this variety, ulceration generally takes place by an excoriation of the surface, covered with a scab formed from the matter that exudes from the cracks, underneath which the ulcer is formed, and gradually increases, extending in depth as well as in breadth, the cancer always increasing faster than the ulceration destroying it. Again, especially in that form of epithelial cancer which is imbedded below the integuments, we find that ulceration takes place much in the same manner that it does in scirrhus; but sometimes it throws out cauliflower growths not unlike the ulceration sometimes met with in medullary cancer.

Having very briefly noticed the three most frequent forms of cancer that are met with, I shall hastily glance at a few of the special symptoms of the disease.

Pain. Perhaps there is no symptom in this disease on which such undue stress has been laid as that of pain. Cancer has always been looked upon as a painful disease, yet in some cases we find that the disease exists for a long time without any pain, and from its absence the patient has looked upon the

* Paget's Pathology, vol. ii. p. 431.

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