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 *Lancet; p. 290. 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. 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, pl. 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. rare. In the liver, melanosis is believed by some authors to be comparatively This opinion is entertained by Hope,† Lebert, 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's 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 peritoneal 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. Cit., p. 1051. + Morbid Anatomy. London, 1834; p. 53. Traité D'Anatomie Pathologique. Paris, 1855; p. 314. § London Medical Gazette. October, 1845; p. 963. Op. Cit., p. 575. ¶ Dublin Medical Transactions; vol. i, 1830; p. 23. ** Op. Cit.; p. 17. ture by these masses; it rather yields, as it were, and the diseased material is inserted between. Even its colour does not change to any more considerable extent than to assume a somewhat duskier hue. Sometimes, however, the liver is more tender and lacerable, in situations where these deposits most abound, and where the black matter becomes diffused, the intermediate texture between the tubera obtains a melanotic character, and the entire texture of the organ becomes then to a great extent disorganised. The gall bladder, though imbedded in the midst of these growths, does not appear, in regard to its coats, to have presented any traces of the disease, nor has the quantity or quality of the bile been noticed to have undergone alteration. The pancreas, the kidneys, the supra-renal capsules,* and the spleen, present likewise the deposits in more or less frequency-the latter organ less frequently than the others. The visceral folds of the peritoneum, the mesentery, and the omentum, display very marked appearances. Between these, the black granules are deposited in large numbers, which gradually thin their enclosures as they increase. The disease is sometimes laid on the peritonæum in the shape of a coating, or in streaks, which can be sometimes almost wholly scraped off, so as to leave the membrane only slightly less transparent than natural. These granules, and tubercles of spheroidal shape, also rest abundantly in the sub-serous cellular membrane, around the renal and lateral spinal regions; also in the sub-serous or sub-mucous cellular tissue of the intestinal tube: but it appears doubtful whether the serous and mucous membranes are absolutely penetrated interstitially by the deposit. The appendices epiploicæ have sometimest been converted into a homogeneous solid mass of melanotic matter. M. Lebert records a case in which "melanic tumours in great numbers were situated in the folds of the peritoneum, the genital organs, the liver, and the lungs. That portion of the peritoneum which corresponded to the sub-umbilical region was infiltrated by black matter : this was not in the condition of a tumour, but rather confounded with the substance of the serous membrane, which was a little thickened. A very remarkable effect resulted from the presence of melanotic tubercle in the interior of the intestinal tube, in the case of a patient recorded by Cruveilhier.§ In addition to there being melanotic tumours on the external surface of the bowels, a large number occupied the internal surface. These tumours were developed between the mucous * Dublin Journ. Med. Science; vol. xxi, p. 130. R. Carswell: Dictionary of Practical Medicine; article, Melanosis. § Anat. Pathol.; liv. xix, p. 3. and muscular tunics, they were enveloped by a kind of cyst, derived from the mucous covering, which, stretched by the weight of the tumour, elongated itself into a pedicle. Many of these tumours were sufficiently large to interrupt the passage of the fæces, and had occasioned an invagination of that part of the intestine from which they arose, in that placed immediately below. Obstinate constipation was present for some time before death in this case. There is a peculiarity about the deposit of melanosis, which is very frequently observed in the serous membranes-the disposition it has to become pedicled; not only is this frequently seen in the peritonæum, but also in the pleura. The growths hang down like polypi, and are invested by a covering, which is probably a prolongation of the membrane beneath which they are situated. Breschet* observed melanosis in the uterus. In the ovaries, in the case of Rachel Bruce, Sir A. Halliday + states, that black matter was found irregularly deposited in spots beneath the peritoneal covering. When cut into, their substance was uniformly black; in addition, several distinct cysts or cavities were observed, which poured out a black liquid when opened. In Mr. Coote's report of the post mortem of Mr. Lawrence's patient, "the ovaries were found greatly enlarged, and converted into irregular lobulated masses, about eight inches in length, which retained no trace of natural structure; each of these masses consisted of a thin but dense cyst, filled with melanotic structure of soft consistence, and of the deepest black colour." "Some minute black spots were seen upon the mucous membrane of the vagina, near the os tincæ.” Melanosis, according to Mr. Curling,§ has been observed in the testicle in only a few instances. In the case of melanosis of the hand, recorded by M. Cruveilhier,|| the right testicle contained a very small tubercle, and the left contained one as large as a filbert. The left half of the corpus cavernosum penis contained one as large as a pigeon's egg. Mr. Stanley,¶ in St. Bartholomew's, in 1848, removed the right testicle from a patient, ætat 38. "The section of the testis presented the ordinary appearance of soft cancer, and was of a pale grey colour; interspersed in it, however, were several firmer masses, about the size of large peas, which were quite black." These dark portions, on microscopic examination, were *Op. cit.; p. 11. + London Medical Repository; p. 203; 1823. The patient, Rachel Bruce, whose case is described by Sir A. Halliday, was under the care of Dr. Alison, at the Royal Infirmary, Edinburgh. Op. cit.; p. 963. § On Diseases of the Testis; second edition, 1856; p. 315. Anat. Pathol., xix liv.; p. 2. ¶ Med. Times and Gazette; May 21, 1853; p. 524. |