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The most malignant and intractable of tumours is the Carcinomatous. This term is applied to the disease in its occult state, whilst Cancer, a term pretty indiscriminately employed, may denote its condition after ulceration. The word scirrhus is often used synonymously with carcinoma; but the former has been, and still is, improperly employed to denote indurations and enlargements of structures in all situations, and has been altogether so much abused as to warrant its being erased from the nomenclature of diseases. Carcinoma seldom occurs before the age of thirty, and generally not till a later period of life; there are instances, however, of its appearance at a much earlier period. Very frequently it is not primary, but supervenes on adventitious formations originally of an innocuous character, and which might have long remained so. All tumours, though at first not of a hurtful tendency, are liable to assume malignant action, either from a constitutional cause, from external injury, or from latent disposition. When it occurs in newly-formed parts, the surrounding cellular substance is frequently condensed and thickened, so as to form a cyst round the tumour; and when it supervenes on chronic tumours, the cysts which enveloped these remain, for some time, as entire and distinct as formerly, though the character of their contents is remarkably changed. Afterwards the cyst may be contaminated with the same disposition as its contents, assume the same action, and be converted into a similar substance. When the disease is seated in the lymphatic glands, the cyst is at first distinct, and gradually disappears; whilst in this affection of the conglomerate glands a cyst is at no time perceptible, and the cancerous matter insinuates itself, and is lost, in the surrounding substance. The carcinomatous tumour is of great density, and communicates a peculiarly grating sensation and noise when cut. In its section there appears a central point, or nucleus, from which dense ligamentous bands of a white colour proceed towards the circumference, diverging in regular succession, as rays of light from a luminous body; or the larger bands subdivide into smaller ones, which follow a similar course with their parent trunk, or ramify regularly; or, from the first, follow an irregular and intricate course, uniting with and crossing one another, so as to present a retiform appearance. In general, the interposed substance is of a greyish colour, extremely dense, and generally homogeneous, though sometimes granular. Often the ligamentous bands are so numerous, and so intimately interwoven, as to leave little or no room for any intervening substance. Sometimes, and most frequently in the advanced state of the tumour, the greyish matter appears to have been broken down and removed, its situation being occupied by a glairy or turbid fluid, by a soft pulpy substance, or by blood; the parietes of such cysts are formed by the whitish bands, which sometimes appear to be much thickened, and coated with a membranous lining. The term gelatiniform cancer has been applied to that kind in which the reticulated texture is filled with glairy-looking fluid. Frequently, as has been already observed, the external cyst or covering becomes assimilated to the substance of the tumour, and the ligamentous bands then shoot forward into the surrounding tissues, more especially the cellular and adipose, establish a new footing for the disease, and thereby gradually enlarge the boundaries of the original tumour. All parts in its immediate neighbourhood become affected, and none withstand its morbid and destructive influence; bone, muscle, ligament, skin, and membrane, are successively or simultaneously involved; and even the bloodvessels and nerves. From what has been already said, it is almost superfluous to add that the tumour is most malignant, incessantly encroaching on the neighbouring parts, and imparting to them its own disposition; and this too frequently continues to exist after the removal of the primary source of the evil. The disease, in its commencement, occupies a minute and limited space, composed, it has been said, of enlarged and varicose capillaries, interspersed with the peculiar matter of cancer. It would even seem that these dilated aneurismal or varicose vessels, in morbid growths, are from the first gorged with what has been called heterologous matter. Judging from the imperfect account which has yet been given of them, it would appear, from the observations of Mr. Kiernan, that cancerous growths are entirely vascular in their early stages,—composed, in fact, of capillaries filled with cancerous matter, which shoot from the free surfaces of membranes in a flocculent or villous form, having no albuminous matrix, as has been commonly imagined in regard to adventitious growths generally; the progress of the cancerous tumour appearing to depend on the multiplication of the capillaries, their becoming remarkably varicose, tortuous, and dilated, the dilatation being accompanied by thinning, by more or less absorption of their coats, so as to allow of the escape partially of the accumulated matter from their cavities. Thus may be formed a tumour of unlimited extent. As the secerning vessels are excited to undue action in all cases where they have to form and supply preternatural growths, it is to be expected that they will in such cases become enlarged. Accordingly, the enlargement both of the smaller arteries and veins in tumours, generally, is a fact with which surgeons who have been in the habit of operating on such parts must be familiar. Farther, the enlargement of the capillaries in inflammation has been shown by the experiments of Hastings, and Thompson; and Mr. Gulliver, who informs me that he has seen pus in the capillaries of a suppurating surface, remarks, in regard to the observation of Professor Müller, as to the capillaries having only the diameter of a blood corpuscle, that these vessels become during suppuration sufficiently dilated to admit of rows of pus globules. Thus, during the formation of an ordinary product of inflammation, the capillary vessels are enlarged; and if excited to still further activity, and for a more protracted period, in the nutrition and formation of tumours, the minute vessels will become still more dilated, and filled with other materials than purulent matter. In a melanotic eye, which I lately examined with Mr. Dalrymple, there was a part in which the black matter seemed to be contained within the capillary vessels.

The cancerous tumour afterwards presents a stony hardness, is generally of a globular form, and irregular and unequal in its surface. At a still later period it gradually enlarges, in the way already mentioned, remains moveable for some time, but ultimately becomes fixed by the increased extent of its connections. By these circumstances it may, in general, be distinguished from the tumours which, from the first, occupy a wide space, and are firmly fixed by intimate connections with the surrounding parts. When the tumour has once been developed, its progress is slow and steady, being arrested, or made to recede, neither by the efforts of nature nor by the interference of art. Pain is generally complained of in the region of the tumour, and is of a lancinating kind, compared by the patient to the passing of sharp instruments through the part; occasionally, however, there is no pain in the new formation, and little inconvenience is caused by it. When the disease is left to itself ulceration occurs, frequently at an early period; but sometimes only after the tumour has been of long duration. The superimposed integuments appear stretched, change their natural colour, assume a dusky or livid hue, become attenuated, and ultimately give way; the breach of surface not being caused by tension and pressure, but by the parts having assumed an action similar to that of the tumour. The ulcerated point slowly enlarges, a thin ichorous fluid is discharged, the surrounding integuments are of a dusky red, and the margins of the ulcer are thickened, callous, everted. Whilst the destructive action proceeds in a lateral direction, it at the same time advances towards the more deeply-seated parts, the cavity becomes excavated, irregular, and ragged; and the parts seem to be destroyed partly by ulceration and partly by sloughing. The exposed surface seldom aims at reparation; and when it does, the granulations are greyish, hard, warty, and endowed with but little vitality; never investing the whole surface, but protruding from certain points, and presenting somewhat of a fungous character. The thin unhealthy discharge becomes profuse, and exhales a peculiarly fetid odour, highly offensive to the patient and attendants. By these means the ulcerated cavity may attain an enormous size, presenting a most disgusting and lamentable spectacle. If the patient bear up under the profuse discharge, the greater part of the original tumour may be destroyed by the ulceration, and some attempts may be made at cicatrisation; that is to say, the cavity may contract, and granulations be formed: but these are always unhealthy, and, in fact, carcinomatous, and often bleed profusely. New skin is seldom formed, the remaining parts resume their virulency, and the process of destruction again advances, surpassing the former both in extent and rapidity.

Along with these local symptoms and appearances, it can be readily understood that the constitution is, from the first, materially affected. The alimentary organs are deranged in function, the patient has a wan and sallow countenance, and is in general weak and much emaciated. After ulceration, the system is still more reduced by the discharge, the patient becomes hectic, and is often afflicted with diarrhœa; along with the other symptoms of extreme debility, the patient may become anasarcous, is affected with cough and dyspnœa, or by other symptoms indicating disease of some internal organ, and is ultimately carried off in a state of exhaustion.

The disease attacks various textures, but perhaps most frequently the mammary gland. The mamma generally diminishes in size from absorption of the fatty matter; the nipple is retracted, often to a great degree, and the surrounding integuments are of a purplish hue, and exude a sanious fluid; at length the nipple is completely destroyed by ulceration. In other instances the tumour is large, and there is a hard œdema of the integuments; the skin is thick, coarse, and of a dark red colour. The tumour soon adheres immoveably to the subjacent muscles and ribs, converting the contiguous portion of the former into a substance similar to itself. There may be other varieties in the appearances and symptoms of carcinoma; but the above are those which are most frequently observed, and are sufficient to denote the general character of this species of tumour, and to show its peculiar and inveterate malignancy.

Ulcers or swellings, at first simple, may assume a malignant action, either carcinomatous or of another kind; thus, in one instance, a simple ulcer, produced by a burn, assumed a foul and unhealthy aspect; and ultimately degenerated into a most malignant sore. Various malignant actions commence in glands of the conglobate or conglomerate kind, at first simply enlarged from irritation or injury. The female breast often becomes indurated from a blow, or from milk abscess, and remains for a series of years, half a lifetime perhaps, without any perceptible change in the enlargement and induration; but the tumour frequently is roused into activity at the critical time of life, and malignant action ultimately commences. The menstrual period ought to be particularly attended to in affections of the mamma more especially, but also in all tumours and ulcers; for both during and before it tumours become larger and more painful, the whole system appears to be excited, then relaxed, and all morbid actions seem to possess increased activity.

In this disease, as in soft cancer, as it has been called, (and they occasionally pass into each other,) the bloody masses, or sacs containing bloody fluid, are to be dreaded, and when they exist are to be considered as very unfavourable; for if, on the removal of a carcinomatous tumour, such appearances be found, the disease will certainly return; a new tumour, of even a worse character than the preceding, will be formed; a fungus will be protruded, and from this hemorrhage will occur.

The lymphatic glands, both above and below the tumour, generally enlarge early in the disease, become hard, and cut like cartilage, and with a grating noise. Frequently they become converted into a dense and fibrous substance, resembling carcinoma; sometimes they are softened and broken down at several points, and contain a purulent or bloody fluid. They enlarge, coalesce, and form irregular masses, which rise more and more above the surface; the superimposed integuments give way, and then occur those destructive ravages by ulceration and sloughing already described. The lymphatic vessels entering these tumours and emerging from them feel hard and wiry, as if thickened. The integuments in the neighbourhood of the tumours, and in the course of these absorbents, are of a blue colour, and the veins enlarged and tortuous; the limb below the enlargement swells and is œdematous. The absorbents often become affected months or even years after the removal of the original and exciting tumour; the immediate cause being taken away, yet the inherent disposition to malignant action is too often left, not to be eradicated. In fact, the disease generally returns, either in the original integuments, in the form of tubercles or buds, in the cicatrix, or in the glands; very frequently all are affected. It seems also to spring not unfrequently from fascia. Such enlargements of the glands have been said to arise, in the first instance, from irritation, and not from any participation in malignant action; and on this supposition, though in general extremely incorrect, cruel, bloody, and unnecessary operations have been performed.

Cancer seizes either the mucous or the cutaneous surface, with hardness and a warty excrescence; this ulcerates, and is surrounded by a hardened base. The process of destruction advances, and the ulcerated part presents the same appearances as those of a sore arising from a similar action in a deeply-seated carcinomatous tumour. The glands also enlarge, and assume the same aspect as if they had been the original seat of the disease. Some pathologists seem disposed to deny this, but apparently on no very sufficient grounds.