The combination of the heterologous parenchyma with cyst-formation, the groundwork of which is here, as elsewhere, the parent cyst and the alveolus, together imparting to the new texture the glandular aspect.

Just as the basis of the cyst in sarcoma is identical with that of the pure cyst, so, in like manner, do the types of both simple and compound cyst-formation here recur. In point of fact, therefore, the forms designated by Muller as varieties of cysto-sarcoma, offer a mere repetition of those types.

These varieties are:

1. Cysto-Sarcoma Simplex

The cysts imbedded in the parenchyma of the sarcoma, are on their inner surface smooth, or simply speckled with little, isolated, injected elevations of parenchymatous texture.

2. Cysto-Sarcoma Proliferum

In the same parenchyma are found numerous intra-cystic cysts, some flattened along, others attached by a pedicle to, the parietes of the parent-cyst. With A. Cooper, we have seen some of these secondary cysts as hollow appendices, or even free within the parent cyst. In like manner parenchymatous masses of a fibrous, or of an acino-glandular structure, grow as pedunculate offshoots into the cavity of the parent cyst. This offers a transition-link to the following variety.

3. Cysto-Sarcoma Phyllodes

A large clavate tumor, consisting of a firm mass, and presenting a fibrous torn surface. Within is one large cavity, or there are several cavities, unprovided with any cognizable proper membrane, into which firm, sarcomatous, red, vascularized, folia-ceous, or warty, tufted, broad-based, or pedunculate, bulb-shaped, sometimes cauliflower-like, or fringed and villous excrescences, germinate and grow. These consist of the same substance as in the former case, but are mostly less dense and more succulent, readily drawn out length-wise into fibres, or spread out to a membrane, showing that they exist in a folded and rolled-up condition. Along with them the cavity contains a viscid humor.

In this description of the cysts in sarcoma, we easily recognize the types of pure cyst-formation. Whatever interest, however, attaches to this repetition, its description is inconclusive as regards the real nature of the new growths. The main feature is still the heterologous parenchyma, which becomes the cysto-sarcoma without doffing its primitive character. This parenchyma is that of the gelatinous and albuminous sarcoma. A peculiarity, in point of form, consists in the membranous basement of sarcoma phyllodes, in its above-described exquisite form. Cysto-sarcomata, and the species phyllodes most particularly, often attain to a very considerable magnitude. They are frequent in the genital organs, of females more especially, in the mammary gland, in the ovary, less often in the testicles. In a word, they occur in all those organs specified as liable to the development of sarcoma, in its several species.

Appendix

[Since the publication of Rokitansky's treatise on cyst and on goitre, he has devoted much attention to the subject of cysto-sarcoma, the chronic mammary tumor of the late Sir A Cooper, the imperfect hyper-trophy of the mammary gland of Mr. John Birkett, the mammary glandular tumor of Mr. Paget. Rokitansky, in an essay, read before the Imperial Academy of Sciences, at Vienna, in Jan. 1853, on "The new growths of the mammary gland texture, and its relation to cysto-sarcoma," gives the details of several minute examinations of these tumors, the results of which are thus summed up: "In the one case are found imbedded within a small transparent, succulent tumor, acinus-like formations, consisting of a structureless membrane, and replete with nuclei. In the second case are found, in the texture of nodules, of which the tumor is composed, numerous delicate fissures bordered by a fringe, in which the matrix substance is, with the naked eye, seen to shoot inwards, in the form of almond- or bulb-like projections. There are also larger cavities present, into which stellate masses project. A magnifying power shows that these projections themselves begin to become lobulated at their terminal points. In other cases an extreme, lobulated, textural mass is thrown forward into a fibrous cyst; some of its lobes being again enveloped by a cyst. Upon the surface of others are found furrows, whose margins spring up into conical and bulbous excrescences, and, together with these, larger, open, cyst-like chinks. In the texture of those lobules are, moreover, channels and acinus formations, as also upon the cut surface, chinklets cognizable with the naked eye, which, under a magnifying power of 90 diameters, appear as considerable cavities branching out in all directions, whilst between their emissaries the neighboring texture shoots inwardly in the shape of conical and bulbous excrescences".

It results from this that -

1. The acinus-like cavity with its emissaries resides in a layer consisting partly of embryonic, partly of fibro-cellular tissue.

2. The cavity enlarging, coalesces with the matrix substance, which grows into its space in the shape of conical and bulbous excrescences, whilst these, at their free extremity, throw out lesser projections.

3. As these multiply, the number of the fissure-like emissaries increases.

4. They shoot out from all points around the dilating hollow growth, or from individual points, or from one point only, into the excavation. Where they are wanting, the dilatation of the cavity is uniformly that of a cyst with smooth parietes.

5. This dilatation is often very considerable, and the excrescences may also attain to a vast size.

6. In these excrescences, a secondary formation of acinus-like growths takes place, in which the events which occurred in the primary one are severally repeated. This occasions certain excrescences to appear encysted whilst others remain bare.

7. At the surface of the excrescences are observed furrows or open cyst-like clefts, into which excrescences intrude in like manner.

Dissenting from the view to which Mr. Paget inclines, namely, that these tumors originate as cysts, subsequently lose their cyst form, and continue to grow as solid masses, differing, moreover, with Mr. J. Birkett, who attributes them to a blastema effused into the areolar tissue of the mammary gland, Rokitansky contends that an acinus-like hollow growth which determines this tumor, and repeats one element of the mammary gland, becomes developed within a matrix of new-formed connective tissue, which primarily constitutes the tumor. And this tumor is by no means encysted, unless an adventitious fascia-like sheath of areolar tissue be called a cyst. A true cyst is only subsequently developed within it through the dilatation of the said gland-structure, the connective tissue layer being expended upon the construction of the fibrous cyst-wall. This, growing into the space of the cyst, and carrying before it the primitive structureless cyst-membrane, works out an encysted textural mass, an encysted tumor, in which the gland elements are reproduced.

The dendritic excrescences, therefore, which vegetate in the cyst of cysto-carcoma, are not, in Rokitansky's opinion, and, as he once held, outgrowths from the internal cyst-membrane, but intrusions into the cyst of its own cradle mass, or matrix, still invested with the primitive cyst-membrane and its epithelium.

Cysto-sarcoma simplex, in which the cradle mass does not intrude at all into the cavity of the cyst, is of the rarest occurrence.

C. proliferum is engendered by the development, within the terminal excrescence-bulbs, of the acinus-like cavities into filial cysts, and the ingrowing of the cradle mass is here repeated.

The cysto-sarcoma phyllodes of Johannes Muller, with its amply developed, warty, cauliflower- and foliated- or cock's-comb-like ingrowths, has nothing to mark it beyond the size and development of the excrescences. The cyst-membrane is here no longer demonstrable, having coalesced with the cradle mass of the cyst.

It has been stated that the dendritic intrusions into the cyst may occur at one point only of the cyst, at several points, or, lastly, at all points simultaneously. In the last case they converge, coalesce, and eventually fill the entire cyst, determining thus its aggregate, lobulated structure.

With two exceptions, the one mentioned by Johannes Muller, the other by Mr. Paget, of these tumors occurring in the breast of the male, Rokitansky knows them only as affecting the female breast, where they are generally seated at the inner and upper part of the mammary gland.

Their figure approximates to the spherical. Small tumors are commonly even and smooth, greater ones irregularly nodulated, knobbed, lobulated, at the same time tolerably resistant, elastic, often generally or partially presenting the feel of a cyst tense with fluid.

The skin often presents a livid aspect, and is traversed by dilated veins. It is sometimes found coherent with the tumor, but not degenerated. The mammary gland becomes displaced by large tumors, and wastes away.

These tumors have an enormous capacity of enlargement, growing, now slowly, now rapidly, often with lengthened periods of arrest. Occasionally they disappear spontaneously. In a few instances several small tumors are concurrently present.

They are usually painless; there are cases, however, in which the pain is excessive. These represent Cooper's irritable tumor of the breast, a fibrous tumor (a neuroma) for the most part associated with the present new growth.

The individuals affected are often unwedded, or childless females. The married and child-bearing are however not exempt.

The tumors are innocent, and, although often recurrent at the same spot after extirpation (Mr. Birkett relates a case of their reproduction five times in succession), not so beyond the range of the mammary gland. In many respects they are analogous to the fibrous tumor of the uterus, and to enchondroma.

In rare instances they undergo ulceration, which involves the superimposed cutaneous textures].