The Doctor adds, "The youngest son has one of these marks exactly in the same place where the disease in his father first manifested itself.

I shall now proceed to narrate two cases of melanosis which have come under my own observation.

CASE 1. H. W. J., æt. 23, single, a cooper by trade, with dark hair and sallow complexion, was admitted, under my care, into the General Hospital, Birmingham, on the 16th of June, 1854, with a coloured warty growth upon the integuments, covering the lumbar portion of the spine.

History. About two years since, he discovered by chance, the presence of a wart, about the size of his little finger nail, in the hollow of his back, which had, no doubt, been there from birth. It was at that time free from pain; but in the course of a few months, some irritation having been recognised by the friction of his apron strings, it discharged, and became a source of annoying itching.

In the month of November, 1852, he consulted a medical gentleman at Dudley, who removed the growth by the knife-slicing it off on a level with the adjacent skin. Any tendency to reproduction was kept down by the application of caustic; and at the end of six weeks the wound was healed.

Three months after this date it reappeared; and in the month of September, 1853, it had attained the size of a crown piece. Its removal was now accomplished by ligature; the healing process being completed in the space of four weeks.

Two months subsequently it again appeared, its growth being uninterfered with until his coming under my notice.

He tells me, that up to the age of twenty-one, he always enjoyed good health, when he contracted syphilis, in the shape of a sore on the frænum. He was not under regular treatment for this, but consulted a druggist. His gums were not made sore. From his birth, there have been present in various parts of his body, small patches of discolouration of the skin. He is not aware of any tendency to disease in his family.

Upon examination, I found a warty looking structure, situated in the middle line of the back, over the first lumbar spine. It was about two inches in breadth, by about the same in length. Its surface was flattened, irregularly warty, of a pink hue generally, but with some slate-coloured portions intermingling themselves in streaks. It was closely adherent to the parts beneath; but its edges were free, and overlapped the sound parts adjacent, for half an inch. The aspect of the inferior surface of this free margin was of an inky character. There was no ulceration, but an irritating moisture arising. He had been in the habit of applying a simple cerate on soft linen to prevent friction. Some distance above, I also noticed a small wart as big as a pea, of a brown colour.

On the 28th of June, I excised the disease, cutting off as much integument as was covered by it, together with the fascia from the muscle beneath.

The part healed slowly by granulation, and at the end of six weeks he was discharged. His general health at this period was good, and he had gained flesh since his residence in the hospital; his complexion, however, looked muddy, and was generally dark coloured.

Three months after his discharge he noticed the appearance of two or three black nodules beneath the skin; one especially, situated on the right leg, attracted his attention, whilst the rest were scattered about in various parts of the trunk and limbs; they were none of them larger than black currants.

In January, 1855, I saw him, and examined him. I found a small tubercle, moderately hard, beneath the integument of the leg, over the head of the right tibia. Its dark colour was discernible through the thinned integuments. Near it, was a second, smaller in size. There were others similar in various situations. The cicatrix of the wound was sound. I recommended him to go into the country, and to leave the tumours to take their own course.

In July, he saw me again. In the interval some of the tubercles had been stimulated to ulceration under the advice of a quack.

His appearance is now pale and cachetic, he complains of pain in the left side, in the loins, and in the shoulders, and he has lost flesh. His back and legs are covered by a papular syphilitic eruption.

There are six of the tumours which are as large as a shilling piece, and which have been especially the object of treatment: one of these is situ-ated on the inner side of the head of the right tibia, one on the calf of the same leg, one between the thigh and side of the scrotum, one on the thigh, one on the left forearm, and one over the right scapular spine. These have pressed their growth through the integument, their shape is circular, their surfaces are irregular, ulcerated and mammillated, their colour blueish, black, or deep brown, and they move freely in the subcutaneous tissue; they give rise to brown-coloured discharge, free from smell, and display no tendency to soften (plate i).

The earlier forms of these nodules are felt like peas beneath the skin. In some of these the covering integument is thinned, so as to show the pigment beneath, in others it is unaltered. They are very numerous in the subcutaneous tissue; even the cicatrix of the wound now covers a number of them, firmly seated in the parts beneath; it is, however, sound in itself, but at its upper margin a black streak is visible.

August 16th. By following accurately my directions as to rest, water dressing, and diet, the sores are easier. He, however, emaciates, and gets no sleep at night.

September 3rd. He called on me, and was evidently in more feeble

health. The tumours were much about the same, but increasing in number.

September 13th. I received a note requesting me to visit him in the country. I was unable to do so; but in my absence a medical friend saw him for me. He found him paralysed and comatose, with only a He died on the 14th.

few hours to live.

The account I

following effect:

was enabled to obtain of his seizure was to the

On the 12th, his friends, on going to him in the morning, found that he had had a fit during the night, and that he had lost the use of his left arm and leg. His speech was unaffected. The evening of this day he was removed a distance of six miles, appearing low, and speaking seldom. On the 13th his respiration became difficult, and accompanied by loud mucous rattles. He was constantly sick, and the vomited fluids were of an intense grass green colour. These symptoms ushered in death.

I was not able to make the post mortem examination until four days after death. The body was rapidly decomposing, especially about the neck and shoulders. Thorax: each pleural cavity contained about a pint of bloody serum. The lungs were free from adhesions; their structure was generally engorged with blood, but nowhere were any melanotic deposits detected. There was no effusion into the pericardium. The heart was flabby, and contained scarcely any blood. Abdomen: there was no effusion into the cavity of the peritoneum. The stomach and intestines were distended, apparently with gas. Their cavities were not exposed. The liver, the spleen, the pancreas, and the kidneys, were natural. The lumbar glands were unaffected. The bladder was natural. Head: the coverings of the brain were natural. The brain itself was softened by decomposition. At its base, to the right side of the medulla oblongata, and breaking up the substance of the Pons, was an extravasation of blood, infiltrating the cerebral substance for the distance of an inch. There was no fluid in the ventricular cavities. There were no appearances of melanotic deposits in any parts within the

cranium.

I dissected out a large gland from below Poupart's ligament, on the left side, which, together with two or three smaller ones in the vicinity, were diseased. On section, they all presented the appearances of medullary cancer and melanosis, their structure being partly white, and partly of the deepest black.

CASE 2. I proceed to the narration of the second case.

P. C., aged 53, a collier, married, a worn, pale-complexioned man, was admitted, under my care, into the General Hospital, Birmingham, on the 24th March, 1855, having a black patch of diseased structure on the right cheek.

History he had always, within his recollection, a mole in this situation.

It had never occasioned him pain or annoyance until within three months of his admission. The first occasion of its doing so was after it had been accidentally wounded by a barber in shaving. After this it began to prick and shoot, and to increase slowly in dimensions. In earlier life he had been the subject of epileptic fits, but not for seventeen years had he suffered an attack. Though of delicate constitution, he had followed a laborious employment in the pits, and had encountered the hardships and accidents incidental to his occupation. He had always been temperate. His family are healthy, and there is no tendency to disease known amongst them. His wife informed me, that for some months past he had been losing flesh, and had been the subject of cough and feeble digestion.

Upon examination, the growth presented an irregular black tuberculated patch of warty structure, situated immediately over the right malar bone. It was about as large as a florin piece, moveable with the integument, with its limits accurately defined. Its surface was not ulcerated, nor was the neighbouring integument affected. Closely adjacent to its outer margin, and connected by a small intermediate portion, were two tubercles, of the size of peas, which partook of the characters of the larger one. The colour of these formations was coal black, the only exception to this being a slight variation in intensity in different parts (plate ii).

The submaxillary glands of the same side, were enlarged and hardened. There were no other tubercles or discolourations to be seen on his body. In consultation with my colleagues, we determined that no operation was advisable.

On the 10th of April, sixteen days after admission, he died suddenly, almost without warning, and without any illness, save an increasing feebleness and some vomiting.

The body was examined twenty-four hours after death.

Head. On examining the skull cap, its internal surface was observed to be irregularly marked by melanotic deposit; the same condition was present in the floor of the cranium. The colour of this deposit was deep black, it was scarcely raised from the surface of the bone, and whilst, in some instances, it penetrated inwards, so as to stretch across the diploe to the external table, in others, it was readily removed by scraping, leaving the bone of its natural colour beneath. Thus it diffused itself in patches of irregular shapes and dimensions in all directions (plate iii). It was altogether situated beneath the pericranium. This membrane was stained by contact in some few places on its external aspect, but there was no thickening or other change apparent in its structure. The brain was natural. Thorax. The lungs contained many nodules of

melanosis. These were chiefly noticeable upon their posterior parts, and varied in size from a small pea to a cherry. They were circular in figure, intensely black in colour, and were situated mostly beneath the pleura, but were in the parenchyma of the organs as well. The lung structure around the deposits was perfectly natural, and was in immediate contact with them. The heart on its posterior aspect was sprinkled by jet black spots (plate iv). The melanotic matter constituting them was placed beneath the visceral pericardium. It showed itself towards the right of the septum ventriculorum, being scattered mainly over the surface of the left ventricle, just below the auriculoventricular furrow. It stretched over the space of an inch in length, and was at first separated into many small diffused points, of a greyish tint, and was finally gathered up into a large patch of a deep black colour. The cavities and the remaining parts of the viscus were natural. Abdomen. The liver was a mass of melanotic deposit, three times its natural size; it extended itself downwards, and to the left side, encroaching on the neighbouring regions. The melanotic tubera were of all sizes, from the minutest speck or grain, to others as large as a pigeon's egg. They filled the organs in all directions, appearing to be inserted in the midst of the hepatic structure, which was more tawny in colour and more friable than natural. They did not appear to coalesce with one another, but were isolated by intervening liver tissue, which was in immediate contact with their external surfaces without the intervention

of a cyst. On the anterior surface, the peritoneal covering was elevated into a series of undulations, caused by the upheaving nodules beneath. Beyond being thus raised, the membrane presented no appearance of thinning. On section, the tubera had a homogeneous aspect. Their consistence varied, and was generally somewhat firmer than tallow, and they had nowhere undergone any softening. Their colour was deep black or brown, and of every shade between these two. The spleen contained similar deposits, three or four in number, of the size of swan shot. The kidneys were similarly affected. The small intestines were sprinkled in a few places. The mesenteric glands were dark-coloured, and slightly enlarged. The general as well as the local effects of melanosis are fairly displayed in the preceding cases.

The constitution of the patient suffers by gradual diminution of the vital powers, rather than by the influence of accompanying fever or pain; a slow wasting of the physical capabilities, without the mental powers sharing in the otherwise general decay. Death, especially in the second instance, was scarcely a remove from the previously existing state of intense feebleness; and yet there were no evidences of the occupation of almost every important organ by abnormal products. These are in general fatal not so much from the local injury which they produce, as from their constitutional effects.