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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,t in the testicle,J vagina,§ and rectum,|| and it is said likewise to have been seen in the liver.1T 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 of multitudinous secondary deposits of the same black colour in the cellular tissue of the body, or of its internal organs.
* London Medical Gazette. 1846 ; page 1051.
t Mttller's Essay on Cancer.
X Paget: Lectures on Surgical Pathology; vol. ii, p. 486.
II Lancet. March 21, 1857; p. 290.
U Paget: Op. Cit.
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 Miillert 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.J 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.
t Eitay on Cancer ,- p. 56; translated by West. London, 1840.
$ Treatise on Diseases of the Bone*. London, 1849; p. 257.
In rare instances, the subcutaneous tissue is the locality where melanotic cancer first displays itself.
It will here appear as an isolated spherical nodule, the black or blueish black colour of which is visible beneath the skin. These solitary nodules may be very numerous, or only a single one may be detected. They may vary in size, from a swan shot to a hazel nut. They are moveable, and are apparently contained in a kind of cyst, derived from the cellular tissue in the midst of which they are placed.
By degrees the skin covering them becomes absorbed, and at length yielding, the black tubercle starts outwardly, loses its spherical character, becomes flattened, and finally ulcerates and discharges a peculiar secretion, devoid of smell.
The subcutaneous tissue, or cellular membrane, is, however, very frequently the seat of the secondary growths of this disease.
The occurrence of primary melanotic cancer in the rectum has only recently been recorded, in a patient under the care of Mr. Moore, of the Middlesex Hospital.*
"Thomas M——, aged 65, was a patient in this hospital in May, 1855, with disease of the anus of upwards of two years. He had previously been an inmate of other hospitals, including the Cancer Hospital, where he remained nine months. At this period he had a black fungoid growth, situated at the right edge of the sphincter ani, in an ulcerated condition, and which bled freely. His health was, moreover, very bad; and he had given up all employment for nearly a year. At this time the disease did not extend far into the bowel, and it was excised by Mr. Moore on the 11th of May, a large portion of the external sphincter being removed. This was followed by recovery, with perfect controul over the bowel. He remained tolerably well for upwards of a year, but began to suffer from a sensation of heat and bearing-down in the middle of 1856; and as these symptoms increased, he again became a patient, on the 15th December last, under Mr. Moore's care. The rectum is now affected higher up, with no external manifestation of the disease."
When last seen, this patient's hair, eyebrows, and whiskers were perfectly white, his debility extreme; and there was every evidence, from his general appearance, of the disease extending itself elsewhere.
As a secondary deposit, melanotic cancer most usually presents itself under three forms.
1. It is deposited in the substance of an organ in the shape of tubera. either partially encysted, or altogether devoid of any trace of such covering. These tubera vary in size from that of the smallest granule to that of a considerable tumour. In colour, these are generally intensely black, but sometimes they are composed of a mixture of brain-like cancer with the melanotic, which gives a variegated aspect to their appearance. In the cellular membrane, around internal organs, the disease assumes the character as described to belong to the primary melanotic tubercle of the subcutaneous cellular membrane.
* Lancet; p. 290.
2. The surfaces of organs appear, as it were, streaked, with the deposit running in lines of varying thickness, and always abruptly defined from the adjacent natural colour of the part. At other times it appears as if sprinkled in spots, or laid on in a thin layer: in these instances the colour is always black.
3. It is found in a liquid state: some of the tubera, above described, are sometimes partially fluid in their interiors. This condition is owing to the softening and breaking up of their contents, and not to the deposit of the melanotic matter in a fluid form: more frequently the consistence is like that of black paste or cream.
The melanotic matter is very rarely encysted; and if it is, the cyst is scarcely a real one, being formed simply by the adjacent cellular membrane. The melanotic tubera, seen in the interior of the liver and other organs, are hardly ever encysted, the masses being deposited in the midst of the natural structure of the part, and can be readily separated from it, even without tearing, being capable, as it were, of enucleation.
This, so called, cyst of melanosis, in masses, is of very slender texture, and has never been observed to be formed of fibrous, cartilaginous, or osseous materials. By the exterior surface it adheres lightly to the parts in which it lies embedded. By its interior it is in contact with the melanotic matter, and it sometimes sends in prolongations so as to subdivide it into lobules. This condition is very admirably shown by Cruveilhier,* in the illustration which he gives of such a tubercle subdivided on the surface of the heart and on the posterior extremity of a rib.
The finest injection of Breschet failed to detect any vessels ramifying in the interior of these masses. Their consistence varies, being sometimes as soft as tallow, and at other times partaking more of the firmness of glandular structure.
In colour, melanosis has many shades. In its primary form on the skin it is almost always brownish, varying perhaps from a yellowish brown to what is known as a bistre-brown. Later, the brown shade assumes every intensity of black. Sometimes, especially in the alterations in warts, the first change is of a slate colour.
In the eye, it is at first livid, afterwards of a sooty blackness.
In the internal organs it is seen of a blueish black, or a raven black, rarely brownish, except in the liver. The black colour, too, will stain white paper like Indian ink.
* Anat. Pathol.; liv. xix, pi. iv, figs. 1 and 3.
There is hardly any tissue of the body, in which, in some one or other of the previously described forms, melanotic cancer has not been found.
Mr. Coote* states that the cornea, synovial membranes, tendons, and aponeurotic expansions, are the only textures of the body which have not been found affected. My experience leads me to the belief that this is so in regard to the first three, and as far as we yet know upon the subject —absolutely so, and generally so, in regard to the last, as I am only acquainted with a single instance in which I think that an exception can be established.
To the list of unaffected textures must also be added the articular cartilages; and I believe, also, the tongue; for I am unacquainted with a single instance in which this organ has been found diseased.
In the liver, melanosis is believed by some authors to be comparatively rare. This opinion is entertained by Hope,t Lebert,J and other authorities. I am inclined to think, however, that dissection has as frequently found the liver the seat of melanosis as the other parenchymatous organs; the relative order, however, in which the internal parts are found the seats of the disease, I shall more particularly refer to subsequently.
"When the liver is diseased by melanosis, it is generally enormously increased in size. In a case of Mr. Lawrence's,§ it weighed seventeen pounds and a half; whilst in another, quoted by Andral, || from M. Chomel, in the third volume of the Nouveau Journal de Medicine, it weighed fourteen pounds, seven ounces, French measure. In Dr. Crampton'sH patient it weighed nineteen pounds. In Mr. Fawdington's** case it was four times, and in the instance observed by myself it was three times, the natural size.
The deposits assume the shape of numerous tubera of all sizes. They are rarely single, the whole organ being generally studded with them of all sizes, from the smallest grains, to tumours as large as a hen's egg, or even as the fist. They are visible in the midst of the natural liver structure in all directions, perfectly isolated, and most frequently without any appearance whatever of being contained in a cyst. In colour, the masses vary from the deepest black to shades of a less intense colour. Sometimes they assume a brownish tint. The tubera that are near the surface of the organ elevate the peritonaea! coat so as to be visible through it, constituting an irregular nodulated aspect throughout.
There never appears to be any general infiltration of the hepatic tex
* op. en.,- p. 106I.
t Morbid Anatomy. London. 1834; p. 63.
% Traiti D'Anatomie Patholoijique. Paris, 1865; p. 314.
§ London Medical Gazette. October, 1846; p. 963.
J Op. Cit.; p. 575.
t Dublin Medical Transactions; vol. i, 1830; p. 23.
** Op. Cit.; p. 17.