In every way the most malignant heterologous growth, described by Burns as spongioid inflammation; by Hey, and afterwards by Wardrop, as fungus haematodes; by Abernethy as medullary sarcoma; by Monro as fish-testicle-like (soft roe-like) turn or; by Laennec as encephaloide; by Maunoir as fongue medullaire. All these appellations serve well to designate the external characters of this new growth; that of fungus haematodes being, however, applicable to a combination of this malignant growth with redundant vascularity. (See New Growth of Bloodvessels).

If, for the sake of unity and clearness, we select for our principal delineation, medullary carcinoma in its most marked form, and with all the attributes of the most malignant cancer, we must preface the description by admitting that in the instance of no other cancer are more variations from this cardinal character cognizable.

In this, its exquisite form, medullary carcinoma certainly does offer a striking resemblance with the brain-medulla of younger individuals, or with the testicle of fishes; namely, a soft, semi-fluid, when present in large quantity, fluctuating, white, or under certain conditions, reddishwhite or gray, yellowish-white, red or russet, or even in various degrees blackened, heterologous mass.

As an independent tumor, its cut surface exhibits either a perfectly homogeneous or else a variously cancellated, lobulated, more or less distinctly fibrous structure. When pressed or scraped, the cut-surface also yields a perfectly homogeneous substance out of a parenchyma which mingles with water to a uniform mass. Or, again, the entire mass separates into a looser medullary constituent, and into another more consistent, which furnishes a sort of stroma for the former, and appears as a more or less fibrous or villo-membranous framework. The relative quantity of both varies considerably.

These relations are subject to great variations, determined for the most part, by the degree of consistency of the heterologous growth as cognizable with the naked eye. There are some growths of this kind which recede so far from the medullary character, as hardly at all to tally with the description above given of medullary carcinoma. Still, the occasional blending or interlacing of such deviating structures with exquisite medullary carcinoma, in one and the same organ, the embryonic condition of their elements, their rapid growth, and their voluminous character, seem to justify their mention in this place.

Thus there are, on the one side, medullary carcinomata of almost cream-like fluidity, or which, infiltrated into the textures, into the medullary system of the bones, or into the sheaths of organs after the destruction of their parenchyma, - for example, the neurilemma of the pituitary gland, the capsule of the spleen, etc, - resemble a milky juice. No stroma enters into their composition. On the other side, there are congenerous growths - heterologous masses, very commonly regarded as medullary carcinoma in a crude state, that is, in a primitive stage of the true medullary encephaloid - which, in point of consistency, do not yield to the fibroids, to fibro-cartilage. Amongst these denser masses there is one particularly remarkable - namely, an often very voluminous, in appearance, and also in reality, unevenly-lobulated, homogeneous, whitish, or yellowish-white, heterologous mass, which offers a striking analogy with the virgin mammary gland, especially in point of firmness and of elasticity. It is probably to this that Abernethy applied the term mammary sarcoma. Others present the aspect of a glandular structure; for example, of the texture of the salivary glands, or of the cortical substance of the kidney.

Lastly, the vast difference in bloodvessel-formation, referable to the structure of medullary carcinoma, is perceptible even to the naked eye. In no other parenchyma does it appear so frequently in redundance as in medullary carcinoma. Conformably herewith none is so susceptible of hyperemia, of tumefaction, and of rapid growth; in none do hemorrhage (apoplexy) and inflammation so readily occur - processes, upon which the anomalous coloration of genuine white medullary carcinoma obviously depends.

The differences, however, discoverable with the naked eye in carcinoma, are slight compared with those revealed in the elementary texture of medullary carcinoma, with the aid of a magnifying power.

They are divisible into those recognized by the naked eye as components of medullary matter, and into those which, at the same time, present an intercellular substance, - a stroma.

With reference to the former, there are medullary carcinomata.

(a.) Consisting of granulated cells with a more or less distinct nucleus, and resembling pus-globules.

(b.) Consisting of smaller and greater, granulated, round, or angular, protuberant cells, more or less resembling the cells of tessellated epithelium, the hepatic cells, the ganglion globules, and provided with one or several nuclei.

(c.) Consisting of spindle-shaped and caudate, nucleated cells, fibre-cells, amongst which are many others, both spherical and oval.

(d.) Consisting of elliptical corpuscles, of 1/100 to 1/50 of a millimetre in circumference, and furnished with one or two nucleoli. They have the significance of a (heteroplastic) transcendent development of cell nuclei.

(e.) Consisting of spherical or oval corpuscles corresponding in size and tendency with the cell-nucleus if) Consisting of elementary granules down to the finest molecule-mass, with scanty nucleus formations in progress of development.

(g.) A further element concurrent with those specified at b, are pouchlike formations (see Metamorphosis of Blastema), and chiefly the parent-cell, which often constitutes a prominent element in medullary cancers. It forms here again the groundwork for the alveolar textural type of medullary cancer.

These elements occur predominantly, it may be, in the one or the other form, but intermingled with others. Viewed with the naked eye, the elementary composition of a texture is, even to the well initiated, a matter rather of conjecture than of any certainty. The consistency and density of a texture may vary infinitely, being dependent upon the character of the intercellular substance. It is only where there is the appearance of fibrillation that we may perhaps infer a composition of spindle-shaped or caudate cells.

Differences More Important

Differences More Important affect the character of the intercellular substance, and of a stroma in which the elements adverted to lie imbedded. This stroma is developed either out of those elements themselves, which, according to the laws of the cell theory, form into a fibrous skeleton work; or else it springs immediately out of a consolidated, amorphous, intercellular substance. Both together occasion, in medullary carcinoma, a special structure manifest to the naked eye, in the shape of a variously disposed fibrillation and lobulation, etc, the character of which so greatly modifies the consistency of the heterologous growth.

In this regard, we have the following forms, some more or less cognizable with the naked eye.

(a.) A medullary carcinoma, with an amorphous fluid, or semi-fluid, intercellular substance. The aforesaid elements vegetate in a thin or a thickish medullary juice. It is represented in the very lax, milky or cream-like encephaloid cancer.

(b.) A medullary carcinoma, with a solidified, amorphous, or else striated, indefinitely fibrous, intercellular substance, interspersed with roundish and fibro-elongated nuclei.

(c.) Medullary carcinoma, with a stroma consisting of fibre-cells (spindle-shaped, caudate) arising out of the development of the elements of the medullary substance itself, with consumption of the intercellular substance, and condensation of the heterologous growth.

(d.) Medullary cancer with a delicate hyaline, structureless, or else an opaque, striated, membranous stroma, studded with elementary granules and nucleus formations, or fibrillated like areolar tissue; which stroma, at the same time, forms the groundwork for the vascularization of the alien growth. Its interspaces are filled with a loose, fluid medullary matter, and it is easily thrown into relief if the tumor be scraped, pressed, or simply steeped in water. In villous cancer this stroma appears developed into a main constituent.

(e.) Medullary carcinoma with a more or less developed fibrous stroma, whose fibre-elements, upspringing from a solidified blastema, now resemble fibro-cellular tissue, now organic muscle-fibre. It represents either a scaffold-work or a stellate structure, the gaps being filled up with embryonic elements. Even with the naked eye it is discernible as denser striae, disposed as aforesaid, and remarkable for their whiteness and their tendon-like lustre. This stroma has frequently the significance of fibrous cancer blended with medullary. It is, however, often enough an innocent fibroid growth, which may very possibly become the seat of so-called ossification (bony concretion). Hence the extraordinary phenomenon of medullary cancer becoming traversed by a concrete skeleton-work, in the midst even of soft parts.

This seems the proper place to take into consideration another combination with a benign new growth in the shape of a stroma, namely, that with normal bone-texture.

A normal bone-texture occurs very frequently in medullary cancer affecting bones, as a thorny or stellate skeleton or stroma. This is, however, generally limited to the base of the alien growth. Greater interest attaches to a medullary carcinoma, possessing throughout a firm bony stroma, which, as a finely cancellated diploe, receives into its cancelli the soft parenchyma of the medullary cancer, to which it bears a relation similar to that of bone to its normal medulla. This growth certainly affects bones and their vicinity, although not exclusively. It is what Johannes Muller termed malignant osteoid. The bony texture entering so largely into its composition, is a very remarkable phenomenon, but its nature is simply that of a benign stroma for the reception of a cancerous, soft parenchyma.

An important part is assigned, in medullary carcinoma, to the parent-cell, and to the alveolar textural type resulting from it. We have often examined medullary carcinomata which mainly consisted of parent-cells. One consisted entirely of parent-cells, and being in the progress of fatty conversion, it presented a very peculiar aspect. Numerous liver cancers were found to consist of a fish-roe-like accumulation of yellow, poppy-grain-sized granules - parent-cells, replete with fat-containing filial cells - loosely connected together by a liquid, lardo-glutinous, yellowish-brown, intercellular substance.

Both forms of the alveolar texture occur in medullary cancer, the true alveolus, and also the aciniform, excavated body. Both, more especially, however, the latter, determine the likeness of many medullary cancers with gland-textures. Both may coexist independently of each other, or the second vegetate as an endogenous growth within the alveolus. Medullary carcinoma occurs no less frequently as cysto-carcinoma.

Upon the dura mater, heterologous formations are not unfrequent, which, closely resembling granular cortical substance of the kidney, consist of spherical or roundish rolls of caudate cells, imbedded in a layer composed of the same elements. They are gorged with a white medullary juice, are for the most part considerably vascular, and of a turgid, soft consistence.