Part I. ON MELANOSIS. "Quels sont les troubles de l'économie à la suite desquels ces mélanoses surviennent? Quels sont les changemens qui se passent dans les tissus où elles se dévelloppent, et par quels signes genéraux ou locaux peut-on en reconnâitre le présence pendant la vie? J'avouerai que la pathologie et l'anatomie pathologique ont tout à découvrir à cet égard, et que les observateurs n'ont rien dit qui puisse nos indigner les moyens d'etablir un diagnostic." BRESCHET. The subject of melanotic cancer, its characteristics and tendencies, has claimed the attention of pathologists and surgeons during the past half century. The Baron Dupuytren, it is said, was the first to recognise this disease, and to describe it; but unquestionably M. Laennec was the earliest authority who afforded the profession an opportunity of judging of its nature, in the memoir which he read before the Society of the Faculty of Medicine of Paris, in 1806. From him we have obtained the name melanotic- —a term neither sufficiently correct nor exact, but which yet is maintained as descriptive of one peculiarity of the disease -its colour. Its further elucidation was subsequently undertaken by Breschet, who published his Considerations in Paris, in 1821.* In this country, Wardropt and Allan Burns‡ recognised the disease in the eye, and pointed out some of its pathological conditions as early as 1809; but although they recorded some of its peculiarities, they yet placed it in the same category with fungus hæmatodes. * Considérations sur une Altération Organique, appellée Dégénéréscence Noire, Melanose, Cancer Melané, &c.; 4to., Paris, 1821. + Observations on Fungus Hæmatodes. London; 1809; pp. 59 and 74. Anatomy of Head and Neck. Edinburgh; 1811; p. 349. B In 1820, Dr. Norris,* of Stourbridge, under the description of a case of "fungoid disease," recorded the history of a patient whom he had under his care three years previously, whose disease during life, and whose internal organs after death, presented the best evidences of melanosis that had then been met with. In 1823, Messrs. Cullen and Carswellt read a paper before the Medico-Chirurgical Society of Edinburgh, on melanosis, and they prefaced the narration of two cases illustrative of the disease, by a reference to the case recorded by M. Breschet, and which they had enjoyed the opportunity of examining with him in the pavilions of the School of Medicine of Paris. Mr. Fawdington, in 1826, published "a case of melanosis," and accompanied it by some "general observations" on its pathology. This case is rendered most valuable by the addition of some coloured lithographic plates, almost the first delineations of the disease that had been attempted. It is somewhat remarkable that no allusion whatever should have been made in these "general observations" to the cases of Messrs. Cullen and Carswell, which in some respects, especially in the affection of the bones, more completely represented the disease. In his Treatise on Pathological Anatomy, M. Andral§ gave an admirable description of melanosis, enumerating not only the different forms in which it displayed itself, but also the various tissues which it attacked. Dr. Robert Carswell,|| whose early interest in the subject has already been referred to in association with the name of Dr. Cullen, devoted a section to its consideration under the name of melanoma, in his Illustrations of the Elementary Forms of Disease. He included under this designation, all the melanotic formations and black discolourations described by various authors, but he divided them into two distinct groups, under the headings of "true" and "spurious melanosis." The fact of melanosis, in its ravages, not being confined to man, but being more common amongst horses, led to the further prosecution of its study in some of the veterinary schools of the continent, and to the publication by Noack¶ of a treatise on its peculiarities both in man and in the horse, from which the most valuable information may be derived. The periodical literature of the profession during the past five-and * Edinburgh Medical and Surgical Journal. October, 1820; p. 562. Transactions of Medico-Chirurgical Society, Edinburgh; vol. i, p. 264. A case of Melanosis, with general observations on the Pathology of this interesting disease. London, 1826. § Treatise on Pathological Anatomy; translated. Dublin, 1829; v. i, p. 548. Pathological Anatomy. London, 1838. Comment Vet. Med. de Melanosi cum in Hominibus tum in Equis obveniente. Leipsig et Paris, 1826. Melanosis has been observed amongst other animals-as the dog, cat, rabbit, and In the liver of the ox; and also amongst some birds. mouse. twenty years has afforded, from time to time, a record of some solitary instance of the disease in the human subject: such examples have, however, been rare, and the cases have been by no means complete in many essentials of detail. Generally, these have been described as assuming one of two forms-the one, where the malady has been unsuspected during life, being revealed unexpectedly in the dead house; the other, where the interference of the surgeon has been required for its removal from either of its favourite seats, the skin or the eye. In regard to the last-mentioned locality, and for some very valuable observations on melanosis generally, the profession are indebted to Mr. Holmes Coote,* who read a paper on the subject before the Royal Medico-Chirurgical Society of London in 1846. I shall have occasion, however, to refer to Mr. Coote's experience in another place. There is an interest, then, about melanosis, of a twofold character-an interest belonging to it pathologically, and an interest belonging to it surgically. The first, in so far as it tends to the elucidation of its nature and effects, I shall most carefully pursue in the following pages. The second, in its important bearings on diagnosis in the primary stage, and on treatment by operation, I shall endeavour to consider by a careful reference to the facts presented in its earliest indications, and by a comparative statement of the origin, treatment, progress, and termination of cases, which have been diligently observed and faithfully narrated. Melanotic cancer is met with in two forms, either as a primary or as a secondary disease. As a primary disease its most frequent seat is the skin or the eye, and less frequently it is encountered in the subcutaneous cellular tissue. It has been observed also in its first form in the lower jaw,† in the testicle, vagina,§ and rectum,|| and it is said likewise to have been seen in the liver. The case is not, however, completely authenticated. The appearances ordinarily presented by melanotic cancer, as a primary formation, are In the skin. The production of a small, solitary, deep brown, black, or blackish spot, situated on some part of the skin. Very frequently this spot is located near to a congenital mole or wart, or the congenital marks themselves undergo melanic degeneration. The disease may remain quiescent at first, but sooner or later an increase in its dimensions becomes evident-the neighbouring glands are contaminated, or its progress may be manifested by the development * London Medical Gazette. 1846; page 1051. + Müller's Essay on Cancer. Paget: Lectures on Surgical Pathology; vol. ii, p. 486. § Idem. Lancet. March 21, 1857; p. 290. Paget: Op. Cit. of multitudinous secondary deposits of the same black colour in the cellular tissue of the body, or of its internal organs. When a cutaneous wart degenerates, if it is of a pinkish colour, the first indication of change in its character is perhaps evidenced in the discovery of black streaks running across its free surface, or darkening the imbricated margins of the growth, as it rests sessile on the part to which it is attached. Their changes are singularly devoid of pain, and indeed effect no apparent alteration in the hitherto harmless growth, beyond that which the eye detects in the colour. In the eye. The globe becomes distended by the morbid growth, which first locates itself between the choroid and the retina. In the earlier stage a dark livid colour is presented, and after a time, when the tunics, by pressure, have become absorbed or ruptured, a fungous mass of the characteristic sooty blackness pushes its way outwards. The further progress of the disease in this situation is manifested by the discharge of black fluids, and by the breaking-off of masses of the protruding fungus. Rarely, do the neighbouring glands become affected, but secondary deposits abound in their customary haunts. Unlike the development of cutaneous melanotic cancer, the growth of that of the eye is from first to last accompanied by severe pain. This is, however, owing to the unyielding nature of the parts, and not to any difference between the characteristics of the disease in the skin and the eye. Mr. Wardrop has recorded an instance in which, in a subject, aged forty, a portion of the conjunctiva covering the nasal side of the sclerotic was converted into a dark coloured mass, precisely the shade of Indian ink. A few instances had come under his notice of melanosis affecting the conjunctiva. The instance in the lower jaw is recorded by Müllert as having been removed from that part by M. V. Graefe. The tumour was a large lobulated one, and required the separation of a large portion of the bone. Its examination displayed cells containing pigment granules. Some of the cells were of a paleish yellow colour, others darker, whilst the interior of others was stained dark brown by the contained pigment. Mr. Stanley, after referring to the preceding case, remarks: "Melanosis in bone has very rarely occurred as a primary disease; its general, and perhaps invariable, character has been that of a secondary disease, manifesting itself in instances where there had been melanotic deposits in some of the soft structures, but more especially in the eye and in the skin." * Lancet; vol. xi, p. 87. Essay on Cancer; p. 56; translated by West. London, 1840. |