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AN INVESTIGATION
INTO THE NATURE OF
BLACK PHTHISIS;
OR
ULCERATION INDUCED BY CARBONACEOUS ACCUMULATION
IN
THE LUNGS OF COAL MINERS,
AND OTHER OPERATIVES.
BY
ARCHIBALD MAKELLAR, M.D., F.R.S.S.A.,
FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH; MEMBER OF THE
MEDICO-CHIRURGICAL SOCIETY, OF THE HARVEIAN SOCIETY, OF THE OBSTETRICAL
SOCIETY, ETC. ETC., AND ONE OF THE PHYSICIANS TO THE NEW TOWN DISPENSARY
OF EDINBURGH.
REPRINTED FROM THE MONTHLY JOURNAL OF MEDICAL SCIENCE.
EDINBURGH:
SUTHERLAND & KNOX, 58 PRINCES STREET.
1846.
ANDREW JACK, PRINTER, EDINBURGH.
PREFACE.
An abstract of the investigations into the nature of carbonaceous
infiltration into the pulmonary tissues of coal miners, was read by Dr
Makellar at a meeting of the Medico-Chirurgical Society of Edinburgh,
Wednesday, 8th July, 1845, Dr Gairdner, President, in the Chair.
Reference was made, in particular, to the East Lothian coal-miners. The
carbonaceous disease described, was stated to be caused by the
inhalation of substances floating in the atmosphere of the coal-pit,
such as the products of the combustion of gunpowder, the smoke from the
miner's lamp, and the other foreign matters with which the air of the
mines is heavily charged, in consequence of their defective ventilation.
In the mines in which gunpowder is used, the disease is most severe in
its character, and most rapid in destroying the pulmonary tissue. The
carbon in some cases is expectorated in considerable quantity for some
time previous to death; in others, it is retained, and accumulates to a
great extent in the lungs.
As the disease advances, the action of the heart becomes feeble; and the
appearance of the blood indicates a carbonaceous admixture. The
carbonaceous deposit seems to supersede or supplant the formation of
other morbid bodies in the substance of the lungs--such as tubercle; for
in individuals belonging to families in which there exists an undoubted
phthisical diathesis, tubercle is never found on dissection.
The views expressed in this communication called forth the following
remarks.
PROFESSOR CHRISTISON called attention to the new and important fact, of
the carbonaceous matter being found in the circulating mass. He attached
great importance to Dr Makellar's researches.
PROFESSOR ALLEN THOMSON remarked, that the presence of this carbonaceous
matter in the blood, by no means proved, that it was formed in, or from
the blood.
DR HUGHES BENNETT said, that the antagonism of this carbonaceous disease
to tubercle, was a fact of great interest and importance, especially in
connection with two other recent observations; viz. 1st, That the
depositions of carbon in the lungs of old people, (which French
pathologists describe,) are not found associated with tubercle; and, 2d,
That under the supposed cicatrices of pulmonary tubercular cavities, a
layer of carbonaceous matter is commonly found.
Dr Makellar's paper called forth some interesting observations from the
President, Professor Simpson, and others.
BLACK PHTHISIS,
OR
ULCERATION INDUCED BY CARBONACEOUS ACCUMULATION IN THE LUNGS OF
COAL-MINERS
Among the many diseases incident to the coal-miner, none come oftener
under medical treatment, than affections of the respiratory and
circulating organs. While the collier is subject--during his short but
laborious life--to the other diseases which afflict the labouring
classes in this country, such as inflammations, fevers, acute
rheumatism, and the various eruptive diseases, he, at last, unavoidably,
falls a victim to lesions within the cavity of the chest, arising from
the nature of his employment. In the present communication, it is
proposed to lay before the profession a series of remarks, which I have
been enabled to put together, with a view to elucidate the cause and
progress of that very peculiar pulmonary disease, incident to
coal-miners, which I shall denominate BLACK PHTHISIS, or Ulceration
induced by Carbonaceous Accumulation in the Lungs.
The rise and progress of the malady may be thus sketched: A robust young
man, engaged as a miner, after being for a short time so occupied,
becomes affected with cough, inky expectoration, rapidly decreasing
pulse, and general exhaustion. In the course of a few years, he sinks
under the disease; and, on examination of the chest after death, the
lungs are found excavated, and several of the cavities filled with a
solid or fluid carbonaceous matter.
During the last ten years, my attention has been much directed, in the
course of my professional labours in the neighbourhood of the
coal-mining district of Haddingtonshire, to the above phenomena in the
pathology of the lungs, which have not hitherto been brought so fully
before the profession, as their importance demands. The subject presents
a very interesting field of investigation to the physiologist and
pathologist.
When we consider the difficulties which the medical man has to
encounter, in prosecuting his researches in morbid anatomy in a mining
district, it is sufficiently explained why the peculiarly diseased
structures in the body of the coal-miner should have been left so long
uninvestigated.
Not many years ago, the obstacles in the way of _post mortem_
examinations among colliers were insurmountable, and consequently, till
lately, few medical men could obtain permission to examine, after death,
the morbid appearances within the chest of a collier. With the rapid
advance in the general improvement which has been going on, the
collier's position in society has become greatly elevated; and his
deeply-rooted superstitious feelings have been, to a great extent,
dissipated. Let us hope that the school-master will find his way into
every collier's dwelling, enlightening his too long uncultivated mind;
and that the foolish prejudices shall cease, which have been hitherto
the barriers to _post-mortem_ examinations in his community.
The only medical writers, as far as I am aware, who have brought this
subject before the notice of the profession, are, Dr J. C. GREGORY, in
the report of a case of peculiar black infiltration of the whole lungs,
resembling "Melanosis," (_Edinburgh Medical and Surgical Journal_, No.
cix., October 1831); Dr CARSEWELL, in an article on "Spurious
Melanosis," (_Cyclopædia of Practical Medicine_, Vol. iii); Dr MARSHALL,
in a paper in _The Lancet_ for 1836, entitled "Cases of Spurious
Melanosis of the Lungs;" Dr WILLIAM THOMSON, now Professor of Medicine
in the University of Glasgow, in two able essays (_Medico-Chirurgical
Transactions of London_, Vols. xx. and xxi.), wherein he gives a number
of very interesting cases, collected from various coal districts of
Scotland, illustrating different forms of the disease; Dr PEARSON, in
the _Philosophical Trans._ for 1813, on the "Inhalation of Carbon into
the Pulmonary Air Cells;" and in a paper, by Dr GRAHAM, in vol. xlii. of
the _Edinburgh Medical and Surgical Journal_.
Recently, professional and other writers have directed attention to the
influence of various occupations in the production of diseases of the
chest. The pernicious employment of the needle-pointers, razor and
knife-grinders of Sheffield, and other manufacturing towns in
England,[1] have not only engaged the attention of the public at large,
but science has been at work to ascertain, with as much accuracy as
possible, the relative effects of the different avocations, on the
constitutions of those occupied in these destructive employments.
Researches of this nature tend much to the well-being of society, as
they make us acquainted with the maladies and sufferings peculiar to
certain classes of our fellow-men; and point out, also, the causes of
their early decay, and premature death. The coal-miners--those in whose
behalf I would now solicit the intervention of science--are most
valuable in their place, and their exhausting labours promote, in no
small degree, our domestic comforts.
Some of the diseases of colliers have in past time been very much
overlooked by the medical inquirer. There has been, within the last few
years, a very searching investigation as to the employment of women and
children in coal-mines; and by the laudable exertions of Lord Ashley--a
nobleman whose name shall ever be honoured among miners, and by all who
have the true interests of that community at heart--an Act of the
Legislature has been passed, declaring it unlawful for any owner of any
mine or colliery whatever, to allow any female to work therein; and also
enacting, that no boy under the age of ten years can be employed in
mines. It is to be regretted, however, that his Lordship did not embody
in his measure, provisions enforcing the free ventilation of mines under
government inspection; for nothing would tend more to improve the health
of those employed in them.
In the course of the inquiry, which formed the prelude and basis of Lord
Ashley's Act, much valuable information regarding the diseases of
colliers was elicited; and no one can peruse the voluminous
parliamentary report pertaining to these investigations, without being
struck with the very general prevalence of affections of the chest among
miners. It is to be hoped, that the interesting facts in regard to
disease, which this recent most necessary investigation has laid open,
will be the means of directing the attention of scientific men to the
subject, with a view to obviate, as far as human efforts can, the evils
which have been exposed. It may at first appear difficult, to point out
the means of removing effectually the causes of the pulmonary
carbonaceous disease of miners, but, be the difficulties what they may,
humanity encourages us to make the attempt.
In the _first place_, let us endeavour to ascertain the cause, and
_secondly_, to suggest means for the mitigation or prevention of this
scourge.
My present remarks do not refer to coal-miners in general, but to a
district in Scotland, in the Lothians, east of the river Forth, where
the labour is hard, and where its severity is in many cases increased by
a want of proper attention to the economy of mining operations. These
operations, as at present carried on, are extremely unwholesome, and
productive of diseases which have a manifest tendency to shorten life. I
draw the materials of my description from what I saw in a part of that
district referred to, where the various cases, hereafter to be adduced,
came under my medical treatment, and where I had the privilege of
examining the morbid appearances after death.
The locality[2] in which my observations were made, is that part of the
Lothians, extending from south to north, stretching from the foot of the
Lammermoors towards the sea-coast, including the coal-works of
Preston-Hall, Huntlaw, Pencaitland, Tranent, and Blindwells. In this
range of the coal-formation, the seam of coal is variable, but generally
exceedingly thin, varying in thickness from eighteen inches, to three or
four feet. It is with difficulty that mining operations can be
prosecuted, from the extremely limited space in which the men have to
move, and from the deficient ventilation. It appears, after thorough
investigation, that in the majority of the coal mines above mentioned,
ventilation is very much neglected, and that this neglect is partly
caused, by the immunity of these mines from carburetted hydrogen gas,
which exempts them from the danger of explosion. But though there be no
explosive gas, there is generated, to a certain extent, in the more
remote recesses of the pit, carbonic acid and other gases, producing the
most injurious effects--impairing the constitution by slow degrees, and
along with the more direct cause (the smoke from the lamp, candle, and
the product of the combustion of gunpowder,) making progressive inroads
on the health of the unfortunate miner. And how, I ask, can it be
otherwise, in such circumstances? So long as it is possible for him to
go on--so long as there is air enough to support the combustion of the
lamp or candle, the labourer must proceed with his toil. I say, from
there being no fire-damp, less attention is paid to ventilation, and it
is a common occurrence with colliers in these localities, to be obliged
to leave their work, from there not being a sufficiency of oxygen to
keep their lights burning, and support respiration; and this temporary
cessation of labour under such circumstances is regarded as a hardship
by some proprietors, while the bodily sufferings of the miner, shut up
and necessitated to labour in this situation, are little considered.
After labouring beyond a given time in those confined situations, there
is a much freer action of the respiratory apparatus, the oxygen is
considerably exhausted, and to make up for this deficiency, the volume
of air inspired, (impure though it be,) is much greater. Every now and
then, there is a disposition to draw a deep breath, followed by a
peculiar and gradual decrease of strength. Therefore, in these forcible
expansions of the chest, it is to be expected that a considerable
quantity of the floating carbon will be conveyed to the cellular tissue.
The atmosphere of the coal mine at length becomes so vitiated, by the
removal of the oxygen in breathing, and the substitution of carbonic
acid, that the respiration becomes gradually more difficult, and the
exhausted labourer has ultimately to retire from the pit, as there is no
other mode by which the noxious air can be removed--owing to the
underground apartments being so small--than by gradually allowing purer
air to accumulate. The miner is thus enabled to return to his
employment.
It is about thirty years since miners in this district adopted the use
of coarse linseed oil, instead of whale oil, to burn in their lamps; and
it is very generally known, that the smoke from the former is immensely
greater than that from the latter, and many old miners date the greater
prevalence of black spit to the introduction of the _linseed_ oil. This
change took place entirely on the score of economy. Any one can conceive
how hurtful to the delicate tissues of the respiratory organs, must be
an atmosphere thickened by such a sooty exhalation.
It is now known, that this disease originates in two principal causes,
viz., _First_, The inhalation of lamp smoke with the carbonic acid
gas[3] generated in the pit, and that expired from the lungs; _Second_,
Carbon, and the carburetted gases which float in the heated air after
the ever-recurring explosions of gunpowder, which the occurrence of trap
dykes renders necessary.
To those acquainted with mining operations, an explanation of the coal
and stone hewing process is unnecessary; but, for the sake of the
uninitiated, I may be allowed to state, in explanation, that, previous
to any coal hewing, it is needful to remove various strata of stone, to
open up road-ways, and break down obstructing dykes, by the aid of
gunpowder. All coal-miners are engaged exclusively with one or other
kind of labour; that is either in removing stone or coal: and the
peculiar disease to which each class is liable, varies considerably,
according to the employment. For instance, the disease is more severe
and more rapid in those who work in the stone, than in those engaged in
what is strictly coal-mining, while, at the same time, both ultimately
perish in consequence of it. The fact of the disease being more acute in
stone-miners, I am disposed to attribute to the carbon and other
products of the combustion of gunpowder, being more irritating and more
destructive to the lungs. A very striking instance of this occurred, a
few years ago, at the colliery of the Messrs Cadell of Tranent. A very
extensive coal level was carried through their coal field, where a great
number of young, vigorous men were employed at stone-mining, or
blasting, as it is called, every one of whom died before reaching the
age of thirty-five years. They used gunpowder in considerable
quantity:--and all expectorated carbon.
It was long a very general belief with medical writers, that the various
forms of discoloration in the pulmonary tissue was induced by some
peculiar change taking place in the economy or function of secretion,
independently of any direct influence from without. They were,
therefore, usually supposed to belong to the class of melanotic
formations, from presenting, as their distinguishing feature, a greater
or less degree of blackness. But, by recent investigations, it has been
proved, that the infiltrated carbon found in the bodies of coal miners
is not the result of any original disease, or change taking place within
the system,[4] but is carbon, which has been conveyed into the minute
pulmonary ramifications, in various forms, during respiration; and
which, while lodged in these tissues, produces irritation, terminating
in chronic ulcerative action of the parenchymatous substance. The very
minute bronchial ramifications first become impacted with carbon, and
consequently impervious to air; by gradual accumulation, this impacted
mass assumes a rather consistent form, mechanically compressing and
obliterating the air-cells, irritating the surrounding substance, and
promoting the progressive extension of the morbid action, till the whole
lobe is infiltrated with carbonaceous matter, which, sooner or later,
ends in ulceration and general disorganisation of the part. It is
evident, in tracing the disease through its various stages, up to that
of disorganisation, that wherever there is an impacted mass in any part
of the pulmonary structure, this is followed, sooner or later, by
softening, from its irritating effects upon the tissues by which it is
surrounded; and as this softening process advances, the innumerable sets
of vessels[5] composing the dense network of capillaries are broken
down, extending the cyst, so that, as the cysts enlarge, they gradually
approximate to each other, till all at last become merged in one great
cavity.
The majority of colliers, soon after they engage in their mining
operations, become afflicted with bronchial disease to a greater or less
extent.
Those who are hereditarily predisposed to pulmonary irritation, are, it
is my decided belief, more liable to "black phthisis" than others; but I
cannot suppose it possible, that any constitution, however robust and
sound, could resist the morbid effects resulting from carbon deposited
in the lungs. Tubercular phthisis is not at all prevalent in any collier
community with which I am acquainted, only occasional cases occurring,
and that amongst females. It is my impression, that a phthisical person,
engaged in the operations of a coal-pit, similar to those in
Haddingtonshire, would come under the influence of the carbonaceous
disease, instead of the true phthisis; for, in all the _post-mortem_
examinations which I have conducted, connected with this pulmonary
affection, I have never found tubercular deposit:--while other members
of the same family, having a like predisposition, and who never entered
a coal-pit, have died of phthisis. Can carbon inhaled destroy a
tubercular formation? I never knew or heard of a case of black spit in
a female collier, and this is accounted for by the circumstance, that
the women, when permitted to labour, previous to the late prohibitory
enactment, were only occupied as carriers; and from their movements
towards the pit shaft, in transporting the coals, were enabled to inhale
at intervals a purer atmosphere. The boys also, who were employed as
carriers to the pit shaft, continued to labour with like impunity, from
their occasional change of situation; but the miner, lying on his side
in a confined, smoky recess, under ground, gasping for breath,
proceeding with his exhausting labour, cannot fail, in his deep
inspirations, to draw in the deleterious vapour, to the most minute
ramifications of the pulmonary structure, and, as he daily repeats his
employment, so does he daily add to the accumulation of that foreign
matter which shall ultimately disorganize the respiratory apparatus. In
the first stage of the affection, there is an incessant dry cough,
particularly at night, and all the prominent symptoms of bronchitis are
present. Indeed, from the time a man becomes a coal-digger, and inhales
this noxious air,[6] there is ever after a manifest irritation in the
lining membrane of the respiratory passages, which is apparent before
carbon in any quantity can be supposed to be lodged in the lungs. The
mucous membrane of the air passages, by its continually pouring out a
viscid fluid, has the power of removing any foreign matter that may be
lodged in them. Now, should this membrane, owing to previous irritation,
lose to a certain degree this secretory power, then the foreign body
adheres to it, and is retained, and this, I think, constitutes the
preparatory stage of black deposit. In tracing the progress of the
disease, it is my belief, that immediately after the carbon is
established in the air-cells, the absorbents become actively engaged,
and the glandular structure soon partakes of the foreign substance. One
of the peculiar features, as we shall find, when we come to describe
cases, is, that the secretory function is ever after so changed in its
character, that the gland which formerly secreted mucus, to lubricate
the passages, now performs the same service with muco-carbon, and
continues to do so during the remainder of the patient's life--even, as
I have often seen, long after he has desisted from the occupation of a
coal-miner. In fact, it constitutes a striking peculiarity of this
disease, that when the carbon is once conveyed into the cellular tissue
of the lung, that organ commences the formation of carbon, thus
increasing the amount originally deposited, as was strikingly
exemplified in the case of Duncan and others, to be afterwards detailed.
Duncan had not for fifteen years been engaged in mining operations, nor
was there any possibility of his having inhaled more carbon: yet in him
it was found to have increased to the greatest possible extent, leaving
but a small portion of useful lung.
I have been long impressed with the belief, that the carbon is contained
in considerable quantity in the blood, particularly in the blood of
those far advanced in the disease. This impression arises, not only from
its dark and inky appearance, but from its sluggish flow, and
non-stimulating effects on the heart and general system; and when we
examine the morbid condition of the pulmonary structure,--ascertain the
presence of carbon in the glandular system and minute lymphatic vessels
of the lungs, and consider the relation existing between them and the
circulating fluid, we cannot suppose it possible, that such a mass of
foreign matter should be lodged in their parenchymatous substance
without imparting a portion to the blood. I was never more struck with
this, than in the case of Duncan, where the blood was more like thick
brownish ink than vital fluid.
No one who has witnessed the economy of these pits, can doubt the
inhalation, to a great degree, of lamp and gunpowder smoke into the
pulmonary tissue. What may be its chemical action there, is a question
for us to attend to as we proceed. If it be considered an established
fact, that carbon is inhaled, possessing all the chemical qualities of
that substance found floating in the air of the coal-mine, and either
expectorated from the lungs during life, or retained in those organs
till after death, we cannot but conclude, that the black matter is the
result of an external cause, and that that cause is the sooty matter.
Another question arises here, in connection with this phenomenon,
viz.--Does the carbon increase in the pulmonary tissues after the
collier has relinquished the occupation of a miner, and when there can
be no further inhalation, and if so, whence comes this increase? It must
be admitted, judging from several of the cases which follow, that it
does considerably augment. From this remarkable fact, does it not appear
probable, that when carbon is once lodged in the pulmonary structure by
inhalation, there is created by it a disposing affinity for the carbon
in the blood, by which there is caused an increase in the deposit of
carbon, without any more being inhaled.
_Appearances on Dissection._ In classifying the morbid appearances
observed in the pulmonary structure, I arrange them according to
divisions corresponding to three stages of the disease. _First_, Where
there exists extensive irritation of the mucous lining of the air
passages; and the carbon being inhaled, is absorbed into the
interlobular cellular substance, and minute glandular system, thereby
impeding the necessary change upon the blood. _Secondly_, Where the
irritative process, the result of this foreign matter in the lungs, has
proceeded so far, as to produce a variety of small cysts, containing
fluid and semi-fluid carbonaceous matter, following the course of the
bronchial ramifications. _Thirdly_, Where the ulcerative process has
advanced to such an extent, as to destroy the cellular texture, and
produce extensive excavation of one or more lobes.
_Stethoscopic Signs._--In the early stages, the sounds indicate a
swollen state of the air-passages, and vary in character according to
the part examined. The whistling and chirping sounds are loud and
distinct in the large and small bronchial ramifications, and both from
the absence of expectoration and the presence of the pulmonary bruit,
the highly irritated state of the mucous linings is apparent. The
affection ultimately assumes a chronic form, and continues present in
the respirable portions of the organ during life. As the carbonaceous
impaction advances, the sounds become exceedingly dull over the whole
thoracic region, and in many of the cases no sound whatever can be
distinguished. Where the lungs are cavernous, it is very easy to
discover pectoriloquy, from the contrast to the general dulness, and
when pleuritic and pericardial effusion advance much, it is difficult to
ascertain the cardiac action.
Such is a short account of the _Cause_, _Progress_, and _Morbid
Appearances_ of this deadly malady, as they came under my notice.
* * * * *
From a variety of cases to which my attention was directed, I I have
selected _ten_, with the _post-mortem_ appearances in nine of them.
These cases extend over a period of eleven years, all of them
exhibiting, with some slight variation, the same character of disease,
and proceeding from the same cause--inhalation of carbonaceous matter.
Some of the cases occurred as far back as the years 1833-34, while the
last case came under my notice within these twelve months. Of the ten
patients, six were engaged at one period with stone-mining, and four
were entirely coal-miners; eight expectorated carbonaceous matter, and
two did not show any indication of black infiltration from the sputum;
six exhibited, on examination, most extensive excavations of the
pulmonary structure; and three only general impaction of these tissues,
with numerous small cysts containing black fluid; the body of the tenth,
I regret to say, was not examined, owing to neglect in communicating in
time the death of the patient, which took place a few weeks ago. These
morbid appearances exhibit three stages of the disease in regular
progression. The first is that where the carbon is confined to the
interlobular cellular tissue, and minute air-cells, producing cough,
dyspnoea, slight palpitation of the heart, and acceleration of pulse,
while, at the same time, the patient continues able to prosecute his
daily employment. The respiratory sounds, in this state of the chest,
are loud and distinct. Such a condition of the pulmonary structure is
often found on examination in the Carron _iron-moulder_, who has been
killed by accident, or has died from some other disease, having been
subjected in the course of his employment to the inhalation of
carbonaceous particles.
The second is that stage where the softening has commenced in the
several impacted pulmonary lobular-formed small cysts throughout the
substance of one or more lobes, the contents of which may either be
expectorated or remain encysted, giving rise to most harassing cough,
laborious breathing, and palpitations, dull resonance of chest, and
obscure respiratory murmur. The third and last stage, is that in which
the several cysts in one or more lobes have approximated each other,
forming extensive excavations, the prominent symptoms of the disease
becoming considerably aggravated, and the powers of the system sinking
to the lowest degree of exhaustion.
* * * * *
CASE 1. George Davidson, collier from his youth. When I first saw him
professionally, in May 1834, he was aged thirty-two. From his earliest
years he was employed about the coal-works in Pencaitland parish, and
when very young, he went down the pit to assist in conveying coals to
the shaft, and ultimately became a coal-miner. For a considerable length
of time, he enjoyed good health, having neither cough, nor any other
affection. He was well-formed, and robust in constitution. A few months
previous to my seeing him, he had taken to the employment of
stone-mining in the pit at Huntlaw, where he was accustomed to labour,
and soon after being so engaged, he began to complain of uneasiness in
the chest, and troublesome short cough, quick pulse, especially at night
and in the morning, for which he sought medical advice, and was treated
for bronchial affection. He continued to prosecute the employment of
stone-mining in this coal-pit so long as his strength would permit,
which was a little more than two years, when (August 1836) he was
entirely disabled, from general exhaustion. By this time his cough had
much increased, and there was considerable dyspnoea, accompanied with
sharp pain in the thoracic region, both in walking quickly, and when
lying down. Pulse 80. He expectorated bloody tough mucus without any
tinge of black matter. All remedial means were adopted with a view to
the removal of the irritation of the chest, without producing any very
decided effect. The thoracic pain was occasionally subdued, but the
cough became incessant; loss of appetite, rapid emaciation, and cold
nocturnal sweats, with slow weak pulse, supervened. After a severe fit
of coughing, during one of his bad nights, the black expectoration made
its appearance, in considerable quantity, by which his sufferings were
for a few days alleviated, when the cough returned in the same degree of
severity, and was again mitigated by the black sputa, which was
expectorated without difficulty, and from this time (October 1836) there
was no interruption to a free carbonaceous expectoration.
In the early part of this man's illness, the stomach, the alimentary
canal, biliary and urinary secretions, continued unimpaired; but as the
cough advanced, gastric irritation, which was followed by vomiting
during the paroxysms, annoyed him; and for the last eight months of his
life, he suffered occasionally from severe attacks of gastrodynia,
which, when present, had the effect of considerably modifying the
thoracic irritation, and allaying the cough. There was nothing very
remarkable in the character of the urine; the quantity voided was small,
and very high coloured, with occasionally a lithic deposit. The fæces
were natural, and smeared with dark blue mucus. On examining the chest
with the stethoscope, the crepitant ronchus was heard in the upper part
of each lung. There was general dulness throughout the lower part of
both, with the exception of a small space at the inferior angle of the
left scapula, where pectoriloquy was distinctly heard, from which was
concluded the cavernous state of a portion of that lung. The heart's
action was languid, and often intermitting, producing vertigo and
occasional syncope. The pulse was gradually becoming slower; and at this
time, (Nov. 1836,) it was _forty-three_ in the minute. I was informed by
this man, that his chest affection first became manifest, after being
engaged with a difficult job in a newly formed coal-pit at Huntlaw,
where he had very little room to conduct his mining operations, which
were carried on with the help of gunpowder, and where he experienced a
sensation of suffocation from the confined nature of the pit,[7] which
did not permit of the exit of the evolved carbon, and ever after, his
cough and difficulty of breathing had been increasing rapidly. During
the greater part of the period he was under my charge, he continued to
expectorate black matter, of the consistency of treacle, mixed with
mucus in considerable quantity, and I would suppose, taking the average
of each week, that he expectorated from ten to twelve ounces daily of
thick treacle-like matter. I had the curiosity, during my attendance on
this patient, to separate the mucus from the carbon, by the simple
process of diluting the sputa with water, and thereafter separating and
drying the precipitated carbon. I was enabled by this means to procure
about one and a-half drachms of a beautiful black powder daily, and in
the course of a week, I had collected near to two ounces of the
substance. This process I continued for some weeks, till such time as I
had procured a sufficient stock of this remarkable product of the
pulmonary structure, and I am certain that the same quantity, if not
more, could have been obtained till his death, in Dec. 1836. It is
undoubtedly a striking phenomenon, connected with the pathology of the
chest, that the human lung can be converted into a manufactory of lamp
black!
Towards the close of this poor man's existence, the countenance and
surface of the body assumed a leaden hue, from the very general venous
congestion, and as his system became more exhausted, and he was about to
sink in death, the gastric irritation and nocturnal cold sweats which
had been long present with him considerably increased, along with a
cough so severe as actually to produce vomiting of the black sputa. His
tongue and fauces became so coated with the expectoration, that a
stranger viewing the patient would have said that he was vomiting black
paint.[8]
This case resembled in many of its features, one of tubercular phthisis,
more than is generally found in the disease before us, there being cough
and expectoration, dyspnoea, sharp pain in the thoracic region,
colliquative sweats,[9] and great emaciation, while at the same time,
the pulse was slow and weak, not exceeding thirty-six in the minute for
a week before death. No hectic heat of skin, but an extraordinary
depression of the arterial action, arising evidently from the redundancy
of carbon deposited in the pulmonary tissue, preventing the proper
oxygenation of the blood circulating in the organs, and thereby
producing a morbid effect on the whole system, which sufficiently
explains the cachectic condition of the body.
_Post-mortem examination, twenty-four hours after death._--In removing
the anterior part of the thorax, the lungs appeared full and dilated,
and of a very dark colour. Both lungs were strongly attached to the
pleura costalis, and a very considerable effusion of straw-coloured
fluid was found in both cavities of the chest. A few irregularly
situated dark glandular bodies were observed on the surface of the
costal pleura at each side of the sternum, and on the mediastinum. The
lungs were removed with difficulty on account of the strongly adhesive
bands attaching them to the ribs, and in handling them they conveyed the
impression of partial solidity:--several projecting, irregular firm
bodies, were felt immediately beneath the surface of the pleura, and
there was also present emphysematous inflation of the margins of the
upper lobes. In transecting the upper lobe of the left lung, it was
found considerably hollowed out, (to the degree of holding a large
orange,) and containing a small quantity of semi-fluid carbon,
resembling thick blacking, with the superior divisions of the left
bronchus opening abruptly into it. Many large blood-vessels crossed from
one side of the cavity to the other, to which shreds of parenchymatous
substance were attached. The inferior lobe was fully saturated with the
thick black fluid, and it felt solid under the knife, and several small
cysts containing the carbon in a more fluid state were dispersed
throughout its substance, in which minute bronchial branches terminated,
and by which this fluid was conveyed to the upper lobe, and thence to
the trachea. In examining the right lung, the upper, and part of the
middle lobe were pervious to air, and carried on, though defectively,
the function of respiration, while the interlobular cellular tissue
contained the infiltrated carbon. The inferior portion of the middle and
almost the whole of the under lobe were densely impacted, so that on a
small portion being detached, it sank in water. Both lungs represented,
in fact, a mass of moist soot, and how almost any blood could be brought
under the influence of the oxygen, and the vital principle be so long
maintained in a state of such disorganization, is a question of
difficult solution.
In tracing the various divisions of the bronchi, particularly in the
inferior lobes, some of the considerable branches were found completely
plugged up with solid carbon; and in prosecuting the investigation still
farther, with the aid of a powerful magnifier, the smaller twigs, with
the more minute structure of cells, were ascertained to contain the same
substance, forming the most perfect _racemes_, some of them extending to
the surface of the lung, and to be felt through the pleura. The lining
membrane of the permeable bronchial ramifications, when washed and freed
from the black matter, exposed an irritated and softened mucous surface,
which was easily torn from the cartilaginous laminæ. The interior of the
trachea and its divisions gave evidence of chronic inflammatory action
of long standing which extended from about midway between the thyroid
cartilage and bifurcation to the root of the lungs. A considerable
number of lymphatic glands, filled with--to all appearance--the carbon,
were situated along the sides, and particularly at the back part of the
trachea; which, from their size, must have interfered by pressure both
with respiration and expectoration. The mucous membrane of the left
bronchus in particular was much swollen and partially ulcerated towards
the root of the lung. In examining the heart after its removal from the
body, it was found peculiarly large and flabby, its cavities
considerably distended, especially the right auricle and ventricle,
while the valvular structure seemed natural. The pericardium contained
about 10 ounces of straw-coloured fluid. After examining the organ
particularly, I could discover nothing abnormal, but the enlarged and
softened state alluded to. The liver was large and highly congested with
dark thick blood, but otherwise it was healthy. The gall-bladder was
empty, and the spleen large and congested. The stomach was smallish and
empty. The mucous membrane was smeared with a blackish, tenacious fluid,
which, upon removal, appeared to be a portion of the expectoration. The
structure, as far as could be ascertained, was healthy. The small and
great intestines contained fluid carbon (evidently swallowed), while no
disease was manifest. The mesenteric glands were small and rather firm,
but they contained no black matter; the mesentery was much congested
with dark venous blood. The kidneys were apparently healthy, though
soft. The bladder was small and contracted. The head was not examined,
as I expected nothing but general congestion of the vessels.
This case comes under the third division of the disease, where the lungs
were cavernous, and where there was free expectoration of carbon.
CASE 2. The following case is one of unsuspected carbonaceous
accumulation in the lungs, the history of which proves the fact, that
the disease, when once established in the pulmonary structure, continues
to advance till it effects the destruction of the organs, although the
patient has not been engaged in any mining operations for many years
previous to his death.
Robert Reid, aged forty-six at his death, had been a collier since his
boyhood. He was a short, stout-made man, of very healthy constitution,
and never knew what it was to have a cough. He spent the early part of
his life at a coal-mine, near Glasgow (Airdrie), where he all along
enjoyed good health. In 1829, he removed from Airdrie to the coal-work
at Preston-Hall, Mid-Lothian, where he engaged in mining operations;
and, from the time he made this change, he dated the affection of which
he died, at the end of 1836. Two months after he removed to Preston-Hall
colliery, he was seized with bronchial affection, giving rise to a
tickling cough in the morning and when going to bed, accompanied by
dyspnoea, with a quick pulse (90), and palpitation of the heart. In
the first stage of the affection, he had no expectoration of
consequence; but soon after, a little tough mucus was coughed up, and
when it was difficult to expectorate, the sputum was occasionally tinged
with blood. At this period, the appetite continued to be good, and the
strength little impaired. During the day, he felt in his usual health;
and, therefore, he continued in full employment. At the end of the four
months (Jan. 1830), his cough had increased much, his palpitation of
heart, dyspnoea, and bronchial irritation had become very oppressive,
and general exhaustion had manifested itself. Recourse was had at this
period of the affection to bleeding, blisters, and expectorants, which
relieved him only temporarily, and while under this treatment,
he--having a large family dependent on his exertions for their
support--continued to struggle on at his daily vocation so long as he
was able to handle the pick-axe. At the close of 1832, which completed
three years of labour in this coal-mine, he was obliged to discontinue
all work, and take refuge in medical treatment, with a severe cough,
palpitation, annoying dyspnoea, small intermitting pulse, and
sleepless nights. On inquiring as to his general habits and mode of
life, I found that he had been all along a sober, regular-living man,
that he never complained of ill health till he engaged in this coal-mine
at Preston-Hall, where the work was difficult and the pit confined, he
having only twenty-four inches of coal seam which obliged him to labour
lying on his side or back.[10] He was also at this time occasionally
engaged as a stone-miner, and was consequently subjected not only to the
inhalation of the smoke of linseed oil, but to that of gunpowder. For
his chest complaint at this stage, he underwent a variety of medical
treatment, which produced mere palliation in his symptoms, and though
breathing a pure atmosphere in a country situation, he experienced a
most painful sensation of want of air, or, as he himself expressed it,
"a feeling as if he did not get enough down." By this time the
countenance had become livid, the lips and eyelids dark and congested.
After undergoing medical treatment in the country, without much relief,
he was removed to the Edinburgh Infirmary, in July 1833, in the hope of
deriving benefit; but after being a patient in that hospital for some
weeks, he returned home much worse. In addition to the aggravation of
his other symptoms, there were present oedematous swelling of the
extremities, which were generally cold and benumbed, gnawing pain in the
right hypochondriac region, and almost total loss of appetite. On
examining the right hypochondrium, which he described as swollen, there
was evident indication of an enlarged liver, and he complained much of
shooting pain in that region during a paroxysm of cough. Hitherto the
functions of the stomach and bowels had remained unimpaired; but at this
period, (September 1833,) the former became irritated, and the latter
obstructed. Tonics and gentle purgatives were administered, and
continued for a considerable time. The urinary secretion was all along
scanty and high coloured; but, as the disease advanced, the quantity
became exceedingly small, (almost none was voided for days together,)
for which he was taking diuretics; and on examining it with the
application of heat, I repeatedly found it coagulable. General anasarca
was now rapidly increasing; and as the cellular effusion advanced, the
breathing became more laborious. I understand, that at the commencement
of this person's affection, the pulse was frequent, with some heat of
skin at night, but from the time he became my patient, there was a
tendency to languor in the circulation, and the _beat_ at the wrist, for
some months previous to his death, was almost imperceptible. With a view
to remove the enlargement of the liver, a slight mercurial course was
proposed; but owing to debility, indicated at its commencement, it was
discontinued, and no effect produced on the organ. All medical treatment
having been given up, except mere palliatives, such as blisters and
expectorants, this poor man lingered out a most miserable existence from
his pectoral symptoms, and particularly from palpitation of heart.
Expectoration continued the same, of tough, ropy mucus, small in
quantity, and got up with difficulty from the air-passages. In repeated
examinations with the stethoscope, there was considerable dulness over
the whole thoracic region, no bruit whatever could be discovered in the
left side of the chest, no cavernous indication, although that side of
the thorax was fully developed. The mucous râle was heard very strong in
the upper lobe of the right lung, and some little crepitation at the
inferior angle of the scapula on the same side. The action of the heart
under the stethoscope gave rather an uncertain indication as to the
state of that organ, for though the sound was evidently communicated to
the ear, as being transmitted through a fluid, and not the heart
striking the ribs, still, from the very general dulness in the left side
of the chest, it was exceedingly difficult to decide whether this
obscurity arose from effusion into the pericardium, or from effusion
into the cavity of the chest. There was one remarkable symptom
manifested in this case,--that though the heart's action was to the
observer feeble, the patient's sensations were as if the pulsation was
very strong, and painfully difficult to bear, and this peculiar feeling
to a great extent prevented him from sleeping. I cannot record this case
without the painful recollection of this poor man's sufferings. For six
months previous to his death, the dyspnoea and palpitation attendant
upon his disease were of such a severe character, as to prevent him at
any time lying down; and his sensations would not even permit his
maintaining the sitting position, for he found it necessary to get upon
his hands and knees, as the only posture affording any alleviation to
his uneasiness. This peculiarity in the cardiac action was such, that,
as he expressed it, "he lived in continual dread of death," and this
being ever present to his mind, he was for weeks known almost never to
close his eyes. He died exhausted, in November 1836; and there being
doubts entertained regarding some of the symptoms of his disease, he
requested that his body should be examined, which was done twenty-six
hours after his death.