says: It is sufficiently curious to see the anatomicopathologists the most expert, such as MM. Cruveilhier, Lebert, Broca, lay hold of the doctrine of the independence of cancer-a doctrine I have maintained throughout my whole life-and defend it in an absolute manner or sense, at the moment when, on my part, I begin to doubt its exactness.'

Of our own countrymen who have directed their attention to this subject, it will not be disputed that Mr. Paget combines a very considerable surgical experience, with a profound knowledge of histological pathology. It will be found, in his admirable 'Lectures on Surgical Pathology,' that although he greatly favours the opinion, that what are called innocent tumours scarcely ever become malignant, he, with rare impartiality, acknowledges that the same methods of degeneration, and of disposal of liquefied materials, which are observed in tubercle and aplastic lymph, may be noticed in other products for instance, in cancerous and other growths with ill-developed structures,' p. 830. Although given to illustrate another principle, he relates a remarkable case, which shows the intimate relationship between cancer and tubercle. He removed the breast of a woman, twenty-five years old, including a large mass of well-marked scirrhous cancer of three months' duration. She could assign no cause for the disease. It reappeared in the cicatrix six months after the operation. Tubercles formed and ulceration ensued. Twelve months after this second appearance, the ulcer began to heal, and in the next six months a nearly complete cicatrix was formed. But during and after the healing of the cancerous ulcer she lost strength, became much thinner,

and at length died nearly two years after the operation, and six months after the cancer had so nearly healed.

The post-mortem examination is the point to which I would direct attention. In the examination after death I found in the situation of the scar of the operation a low nodular mass of the very hardest and densest cancer, extending through the substance of the scar and the pectoral muscle, and nearly all covered by thin scarlike tissue. In the axilla was one hard cancerous gland, and in the liver were many masses of cancer as dense and hard as that on the chest. In all these parts the cancer structures appeared to be condensed and contracted to their extreme limit. The lungs contained no cancer, but were full of groups of grey succulent tubercles and greyish tuberculous infiltration in every part except their apices, where were numerous small irregular tuberculous cavities. The other organs appeared healthy.'

I quote this case as an addition to my own experience, which I shall have to substantiate by a recital of cases to be brought forward in a different part of this work. Mr. Paget believes that he has seen at least one instance in which active tuberculous disease of the lungs was arrested immediately before the appearance of a scirrhous cancer in the breast; and we find, in so many of those who die with cancer, the remnants of tuberculous disease from which they have suffered in earlier life, that we may believe that the from the one has been in some manner conrecovery nected with the supervention of the other.' Thus far Mr. Paget does not intimate any opinion as to the possible conversion of cancer into tubercle, or the reverse,

C

which the facts he has mentioned strongly suggest; but in his able summary of the facts and opinions he has collected upon the affinities of tuberculous disease (p. 830), he says:

'The chief grounds for regarding tubercle and cancer as diseases of the same order are the following:

1. Tubercles sometimes appear as distinct tissues, like tumours in the brain, and in other instances of socalled encysted tubercle, and the dissimilarity between these and tumours, in that they neither grow by inherent power nor are vascular, is only because their elementary structures abort and very early become degenerate; it is only the same dissimilarity as exists between a degenerate and a growing mass of cancer.

2. The general characters of malignant tumours as deduced from cancer are also observed in tuberculous diseases; namely, the elementary tuberculous structures are heterologous; they are usually infiltrated, and at length exclude and occupy the place of the natural textures; they have a peculiar tendency to induce ulceration after softening; the walls of the ulcer are commonly occupied by tuberculous deposits like those which preceded it, and while thus occupied, have no disposition to heal; the tuberculous deposits apparently multiply in all the same numbers as the cancerous do; and whether in their extension or in their multiplication, there is scarcely an organ or tissue which they may not affect, though, like cancers, the primary tuberculous diseases have their "seats of election," and different seats at different periods of life.

3.

The tuberculous diathesis, the constitutional state which precedes the formation of tubercle, is

scarcely producible by any external agencies, except climate, but it is frequently hereditary; and in both these respects it resembles the cancerous, and differs from the merely debilitated state in which the aplastic inflammations occur.

4. The cancerous and the tuberculous diatheses appear to be incompatible and naturally exclusive: the production of tubercles is extremely rare, but that of lowly organized inflammatory products is frequent in cancerous patients. Such incompatibility implies that cancer and tubercle are equally and in the same sense constitutional diseases; very different, yet of the same order in pathology.

5. The tuberculous diathesis, like the cancerous, regularly increases, and is attended with cachexia, which is often disproportionate to the local disease. It is true that tuberculous disease frequently ceases in a part and allows its healing; yet, if we look to its enormous mortality as the index of its natural course, we must see in it a law of increase like that exemplified with fewer exceptions in cancers. And such a law is not usually exemplified in specific inflammatory diseases, for they generally tend to subside with lapse of time.'

To these admirable aphorisms I would add a sixth, to the effect that-The cancerous and the tuberculous diatheses are capable of interchanges, so that the cancerous parent shall beget tuberculous offspring, and the tuberculous parent, cancerous offspring; and further, that some of the children shall be tuberculous, and others of the same family cancerous. With this addition, and qualifying somewhat the fourth proposition, 'that the cancerous and the tuberculous diatheses

appear to be incompatible,' the above statement seems to embrace all the points which go to prove, not only the constitutional origin of cancer, but its very intimate alliance with and dependence on tuberculosis.

Generally speaking, cancer is a disease of advanced life, and phthisis occurs at a much earlier period. When the two occur together or in immediate sequence, it is always, as far as I have remarked, at the tubercular period; suggesting the thought, that the elaboration of the more terrible disease has outrun its wonted slow approach, and come up with its juvenile competitor. In my collection of cases will be found that of a young woman aged thirty, whose father and mother died of phthisis, and who had several brothers and sisters who also all died of the same disease. She herself was the only one left, and she had a cysto-scirrhus of the right breast about which there could be no mistake. My friend Dr. Pollock of the Consumption Hospital was good enough to examine her lungs for me, and he found consolidation of portions of both, but no cavities. This may or may not be a combination of cancer and tubercle, and happily at present it cannot be decided.* In another case, however, I had the opportunity of making a post-mortem examination of a young woman who had an open gelatiniform cancer of the right breast, which gave rise to frequent hæmorrhages, and of the nature of which there could not be a doubt. I found the remains of the breast a soft pulpy mass adherent to the subjacent ribs, and giving under the microscope the irregular-shaped nucleated cells, whilst the lungs on

* This young woman has since died, and the post-mortem examination showed a cancerous deposit in the right lung.