appearance. On raising the sternum, the ribs seemed very firm and
unyielding. The lungs were of a dark blue colour, and seemed at first
appearance to fill completely both sides of the chest. Towards the
sternal end of the ribs, on the left side, three or four of the
substernal or mammary glands were found enlarged and filled with black
fluid. The pleura pulmonalis had (where there wore no adhesions)
interspersed over it patches of false exudation, _of a dark brown
colour_. The lungs adhered extensively to the pleura costalis, and from
the character of the adhesions, they were evidently of some years'
standing. In both sides of the chest there was effusion to a
considerable extent of a dark-coloured fluid, resembling porter in
appearance. On removing the left lung, which was difficult, from the
strong adhesive bands, it seemed, from its weight and softness, to
contain a fluid; and on making a longitudinal section of both lobes, a
large quantity of thick, black matter, similar to black paint, gushed
from the opening, exposing an almost excavated interior of both lobes.
The carbonaceous matter contained was in quantity about an English pint,
and the lung, when emptied, became quite flaccid, and very light. The
air-cells of this lung were entirely destroyed, or nearly so, and one of
the divisions of the left bronchus opened abruptly into the cavity at
the upper part. Both lobes were so completely adherent to each other,
from inflammatory action, as to form a continuous sac, containing the
above fluid. On examining the internal structure of the cavity, the
parenchymatous substance which formed its walls presented a rugged and
irregular appearance, resembling a sponge hollowed out, and infiltrated
with black paint.
At different points, the large pulmonary blood-vessels crossed the
cavity in the form of cords, with portions of structure attached, and
though these fragments had a black appearance, they exhibited, to a
considerable extent, their original cellular structure when washed in
water. The process of carbonaceous ulceration had proceeded so far in
this lung, that at some points the pleura pulmonalis, which was much
thickened, was left the sole medium between the contents of the sac and
the cavity of the chest; while in other parts it was thick and spongy.
On examining more minutely with the magnifier, open-mouthed bronchial
twigs, and very small blood-vessels, were seen plugged up with solid and
fluid carbon, and, from the appearance of the morbid structure, it was
manifest, that the ulcerative process had effected a complete
disorganization of the _bronchial_ tubes of every calibre, while the
smaller _arterial_ vessels had alone suffered, leaving the larger ones
entire.[11] Along the margin of the inferior lobe, indurated
accumulations were felt through the pleura, and, on being laid open,
they were ascertained to be impacted lobules, which resisted the knife.
Previous to the division, both lungs weighed about six pounds.
On examining the right lung, which seemed much similar in weight to the
left, and on making a section throughout its three lobes, the morbid
appearances varied in each. The upper lobe was infiltrated with carbon
into the interlobular cellular tissue, leaving the bronchial
ramifications respirable, and lubricated with frothy mucus. The middle
lobe presented a solid appearance, and contained a mass of indurated
black matter, of the size of a largish apple, and consistency of
consolidated blacking. The surrounding parenchymatous substance was
disorganized, and undergoing the process of softening. In dividing the
indurated substance, its internal structure exhibited a variety of
greyish lines, forming parallel and transverse ramifications, which
resembled small check in appearance, and which, when more accurately
examined, was ascertained to be the disorganised walls of the minute
air-cells and cellular tissue. The inferior lobe presented a state of
complete infiltration, with the air-cells generally entire, and on
putting a piece of it into water, it showed its density by sinking.
When we examine the morbid appearances in this case, and compare them
with the symptoms--when we consider that nearly all the respiration
carried on in this man's chest, was performed in the upper lobe of the
right lung, we are not surprised at his sufferings, nor is there much
difficulty in explaining the very painful dyspnoea, on his attempting
the recumbent position; and as death was instantaneous, it was evident
that the immediate cause was the bursting of the left pulmonary cyst
into the corresponding bronchus; the fluid carbon thus finding its way
to the trachea, produced suffocation.
The liver was exceedingly large, projecting outwards and downwards from
under the ribs, and pushing up the diaphragm. Its substance was soft,
engorged with dark blood, and easily torn. There was no carbonaceous
deposit throughout its structure, and its weight was upwards of twelve
pounds. There was a considerable quantity of very dark bile in the
gall-bladder. The heart was large, soft, and pale. There was
considerable attenuation of the walls of both auricles and ventricles.
The coronary veins were much distended with dark blood. The columnæ
carneæ of the right ventricle were exceedingly slender and bloodless;
the tricuspid valve was much thickened, and studded on both sides with
small cartilaginous granules; the other cavities of this organ were
apparently healthy, though thin in substance. The pericardium, which was
rough, and much distended, exhibited a variety of false membrane on its
internal surface, of a dark brown colour, and contained about eight
ounces of dark fluid, similar to that found in the cavity of the pleura.
In tracing the bronchi from the lungs to the bifurcation, the mucous
membrane, which was smeared with fluid carbon, appeared much irritated,
and considerably thickened, diminishing the diameter of these passages;
and there were found externally at the root of the lungs, and around the
bronchi, several large glands, containing a fluid to all appearance
carbonaceous. The trachea showed a similar irritated condition with that
of the bronchi. A little above the bifurcation, and at the back part of
the trachea, a cluster of lymphatic glands were found, some of them the
size of a horse bean, filled with carbon.
_The spleen_ was very large, and much darker than usual, highly
congested with venous blood, easily torn with the fingers, and weighed
about three pounds. Kidneys small, pale, and soft; bladder small, and
corrugated; large accumulation of light brown fluid into the cavity of
the abdomen, to the extent of two Scotch pints. The viscera were much
compressed from effusion. There was a rough brown exudation upon the
surface of the peritoneum and intestines. The stomach was contracted to
a small size. The mucous membrane was soft, pultaceous, and easily
removed, tinged with dark green bile. The lymphatic glands along both
curvatures were small and flaccid, and contained no black matter. The
intestines appeared empty and contracted. The duodenum showed the same
softened state of its mucous membrane as was exhibited by the stomach.
The mesenteric glands were free from any disease. The head, on removing
skull-cap, dura mater found natural; serous effusion to small extent
under the arachnoid; very general congestion of the pia mater, giving
both hemispheres of the brain a blackish appearance. The superior
longitudinal sinus was filled with dark, inky-looking blood. In removing
the pia mater, the convolutions of the brain were firm, and appeared
natural. There was a light brown effusion into both lateral ventricles
to the extent of about an ounce. Reid, when he first came to
Preston-Hall, had inhaled the evolved smoke of the coal-mine, thereby
laying a foundation of this infiltrated mass. It must be manifest to
every one who follows out the history of this case, and attends to the
morbid appearances found within the chest, that there was a progressive
accumulation of carbonaceous matter going on in the substance of the
lungs from the time the patient engaged in working this difficult seam
of coal till his death.
* * * * *
CASE 3. D. S. was aged 39 years at his death, in August 1838. He had
been engaged as a coal-miner so soon as he was able to undertake work.
He was a tall, muscular man, and for a long time enjoyed excellent
health. He first began mining operations at one of the Pencaitland
collieries, and continued to labour there for many years. About six
years before his death, he was induced by an increase of wages, to
undertake stone-mining in the same pit; and soon after engaging in this
employment, he began to be troubled with a slight cough, accompanied by
dyspnoea, palpitation, and oppressive headach, which symptoms rapidly
increased in severity. He declared that his cough and general ailments
first showed themselves after labouring for a considerable time at
stone-work, with the aid of gunpowder, in a situation where the air
became so impure, both from defective ventilation and carbonaceous
particles floating in it, as materially to affect the breathing.
Although he repeatedly changed his place of labour from one coal-work to
another more healthy in the same parish, he experienced no mitigation of
his annoying cough. When I first saw this man for medical advice in July
1834, he had then been about two years engaged as a stone-miner, the
bronchial irritation was very general throughout the chest, he had
severe cough, hurried breathing, little or no expectoration, and on
applying the ear to the thorax, the sibilant and sonorous bronchi were
distinctly heard, which indicated a swollen and irritated condition of
the mucous linings of the air-passages, and this irritation was also
manifest in the mucous membrane of the nostrils, which was much swollen,
acutely tender, and impeding considerably the passage of the air. The
pulse was rather frequent, about 85 in the minute. There was present
much heat of skin during the night, which subsided towards the morning.
The remedial measures were blisters and expectorants, which relieved him
considerably. The cough recurred in paroxysms, accompanied by severe
headachs, with little frothy mucous expectoration, and there was
occasionally observed a slight tinge of blood in the sputum. At this
period, his appetite was good, and with the exception of his cough and
difficulty of breathing at night and morning, he seemed usually very
well. Though labouring under his disease, he continued at his employment
of stone-mining, and would not be convinced of its injurious effects.
_July 1835._ There was considerable increase of the palpitation when he
attempted the recumbent position, or moved hurriedly. The remedies
ultimately seemed to produce little effect. His general exhaustion
advanced rapidly, and obliged him to relinquish all mining occupation.
At the end of the summer of 1836, when I saw him more regularly, and was
enabled to watch his symptoms with more attention, these having
materially changed for the worse, percussion elicited dulness over the
chest, with the exception of the upper part of both lungs, where the
mucous râle was heard louder than usual. The heart's action was strong
and irregular, particularly so for some time after a fit of coughing,
when he suffered excessively from headach, succeeded by a tendency to
drowsiness. The pulse was slow and languid, not exceeding 50 in the
minute. His countenance had assumed a greyish inanimate aspect, his eyes
became sunk, his robust frame bent and so emaciated from this peculiar
disease, that though his age did not exceed 38 years, a stranger looking
at him, supposed him to have attained the age of 70. No treatment seemed
to have any effect in allaying the cough, nor was he permitted to lie
down. From his feeling of dyspnoea and thoracic oppression, his nights
were almost sleepless, his extremities oedematous, usually cold and
bloodless.
During the greater part of the time he was confined to the house, the
bowels were constipated, requiring daily purgatives. The urinary
secretion was small in quantity and high coloured, but in neither
discharge was there any thing very unnatural. In this almost inanimate
condition he lingered on, when about six months before his death, during
a paroxysm of cough, he expectorated a mouthful of thick black matter,
and continued so to do periodically, at intervals of about three weeks,
seeming to experience relief after voiding the carbonaceous sputum.
There was little change in the symptoms of this man till death. He took
little or no food, from his appetite being almost entirely gone, and
from gastric irritation being constantly present. His cough and
dyspnoea continued severe, with drowsy headachs and difficulty in
keeping the body warm. The arterial action was exceedingly low. The
pulse was 40 in the minute, and difficult to discern. The strongest
stimulant produced no increase of action, the sitting position was the
only one in which he was at all easy, and in which he remained day and
night till he ceased to live.
_Post-mortem examination, twenty-four hours after death._--The body was
much emaciated. The chest large, and integuments tightly drawn over it,
the ribs unyielding. In removing the anterior part of the chest, the
lungs adhered strongly to the ribs, and were covered very generally with
patches of dark-red false membrane, corrugating the pleura. Each side of
the thorax contained fully a pint of light-brown fluid. In removing the
left lung, it felt firm and developed, and in dividing it throughout its
lobes, a variety of small cavities and indurated masses of carbon were
found to pervade its substance, exhibiting a sooty appearance, extending
throughout the whole structure. The indurated nuclei were ascertained to
be impacted lobules, and the small cavities were these disorganized and
softened, and communicating with the bronchial tubes. Part of the upper,
and the whole of the inferior lobe, were soaked with carbon, and felt
indurated. The right lung was similarly disorganized with the left. The
greater part of the superior lobe was permeable to air, and the
interlobular tissue contained carbon, in small, hard granules. The
middle and inferior lobes contained several hard, indurated bodies,
progressing to a state of softening, and in separating a portion of the
latter lobe, it was found to sink in water. There was emphysema of the
margin of the inferior lobes. There appeared considerable irritation and
softening of the mucous membrane of both bronchi, extending from the
root of the lungs to beyond the bifurcation of the trachea. There were
several enlarged bronchial glands at the apex of the lungs, containing
black fluid.
The pericardium contained about eight ounces of straw-coloured fluid.
There was a light-brown exudation, extending over serous lamina of the
pericardium and the surface of the heart. The heart was flaccid, the
right auricle and ventricle were enlarged and attenuated, and both vena
cava at their junction with the heart were much dilated, the valvular
structure natural. The liver was large, soft, and easily torn. The
abdominal viscera in general appeared healthy; slight effusion into the
cavity of the peritoneum. In this case head not examined, but which no
doubt would have shown marks of extensive congestion, as in other
cases.
The above case comes under the second division of this disease, where
the irritative process resulting from the foreign body pervading the
lungs, had advanced so far as to produce a variety of small cysts, and
circumscribed, indurated masses, the former containing _fluid_, and the
latter _solid_ carbon, and it is evident in tracing its progress, that
there must have been a very rapid increase within the system in the
carbon originally deposited in the pulmonary structure by inhalation.
There was very limited black expectoration shortly before death, and
this merely the contents of a few small cavities communicating with the
bronchial ramifications, while both lungs were extensively infiltrated
with that matter which, had the patient lived, would have produced
general softening, and more extensive excavations by the coalition of
the various indurated tubulæ.
* * * * *
CASE IV. J. T., aged 45 when he died, May 1837. He became a collier in
early life, in the neighbourhood of Glasgow, and came, at the age of 22
years, to East Lothian, to engage in collier labour at Blind Wells, near
Tranent. From his own account, he was rather of a delicate constitution,
and ill-fitted for the work of a coal-pit, consequently, after labouring
a few years, he was, at the age of 26,--owing to cough and difficulty of
breathing,--obliged to relinquish the employment of a miner. He left
East Lothian, and retired to the west of Scotland, where he became a
country merchant, and continued so occupied for upwards of fifteen
years. During that time, he was occasionally troubled, particularly in
the morning, with his cough and hurried breathing, which was increasing
in severity, but at no period had he expectorated black matter, nor was
there any indication that his sufferings arose from carbonaceous
disease. On account of becoming reduced in circumstances, he was under
the necessity, though labouring under chest affection, of returning to
his former employment of coal-mining at Blind Wells, at the age of 41,
August 1834. He had not been long engaged as a miner, after his return
to East Lothian, when his cough increased considerably, with laborious
breathing, palpitations, and overpowering headach. Both now and
formerly, he wrought solely as a coal-miner, and at no time of his life
did he work as a _stone-miner_. Having a family to provide for, he
struggled on laboriously under much suffering from his chest affection,
till general exhaustion compelled him to leave off work, and seek
regular medical advice, July 1836. From his statement regarding the
cause of the disease, I was led to understand that his cough, which
never left him from the time he was first seized, was induced, at an
early period, by bad air generated in the coal-pit at Black Wells, from
the work being ill ventilated, and from the general use of coarse
linseed oil for the lamps.
When I first saw this man professionally, he was labouring under general
weakness; his pulse was not above 40 in the minute, small and thready.
He suffered from drowsy headach, anorexia, cold and slightly
oedematous limbs. He had incessant cough, with tough mucous
expectoration. During a severe paroxysm, he vomited a mouthful of black
paint-like fluid, followed by considerable relief, and ever after till
his death, he continued to expectorate the same substance in great
quantity, often to the extent of 15 oz. daily. In examining the chest
with the ear, the sound, from the distinct pectoriloquy, indicated a
cavernous state of both lungs; otherwise the bruit was obscure.
The remedies were merely of a palliative character, knowing the patient
to be rapidly sinking. In this exhausted state he remained for some
months; his appetite was almost entirely gone; the oedema of limbs
increasing. There was also a leaden hue over the surface of the body,
which was constantly cold. At this stage, the quantity of urine voided
was small and dark in colour. Bowels obstinate; occasional vomiting. The
pulse ranged from 38 to 40. The lips and ears were livid, and his
drowsiness became more overpowering as death approached.
_Post-mortem examination._--The body was much emaciated; the ribs were
prominent and unyielding. On removing the anterior part of the thorax,
the lungs were found firmly adhering to the pleura costalis, and of a
dark blue colour. There was an effusion to the extent of about sixteen
ounces of light-brown fluid, found in the cavities of the pleura. The
greater part of the effusion was into the left side. The lining membrane
of the chest was almost wholly covered with false membrane of a dark
brown colour. The right lung filled almost completely the right cavity
of the thorax, while the left lung appeared much contracted,
particularly towards the apex. The pleura of both lungs was much
puckered, and interspersed with dark red patches around the adhesions.
Three or four of the substernal glands were found considerably enlarged,
and filled with black fluid, and a cluster of the anterior mediastinal
and lymphatic glands contained fluid having the same appearance. The
right lung appeared solid to the feel, when removed from the body. It
was rough and irregular over its surface, from a variety of indurated
substances projecting from beneath the pleura. In making a section of
the whole lung, each lobe was almost completely saturated with thick
inky fluid, and was observed to be here and there hard and granular,
particularly in the course of the larger bronchi. Portions of this lung
were pervious to air and emphysematous, but the greater part was
disorganized, and contained carbonaceous matter in a solid and fluid
state. The left lung was light and flaccid, when compared to the right.
The upper lobe was extensively excavated. The parenchymatous substance
was found ragged and unrespirable, and many large blood-vessels crossing
from either side of the cavity, pervious to blood. With the aid of the
magnifier, a variety of open-mouthed bronchial twigs and minute
blood-vessels were visible, communicating with the cavity. The upper
part of the inferior lobe was partially excavated, and containing about
four ounces of fluid carbon. The lower margin of this lobe was firmly
impacted.
The mucous membrane of the trachea and bronchial divisions appeared,
when washed and freed from the black matter, red and softened. The
lining membrane of larynx was partially ulcerated, and the rima
glottidis slightly oedematous. There were various small lymphatic
glands on the back part of the trachea, which contained black fluid.
The pericardium considerably distended, and contained nearly twelve
ounces of light-brown fluid. Evident marks of inflammatory action were
observed externally. On its internal surface it was thickly coated with
false membrane of a brown colour. The heart was pale, soft, and
attenuated. The right auricle was much dilated, and its walls
exceedingly thin. There were no further morbid appearances.
Head,--External congestion of an inky colour was found on the surface of
the brain, which was to all appearance otherwise healthy. There was an
effusion into both lateral ventricles. The abdominal viscera were
natural. The liver was much larger than usual, soft, and highly
congested with inky-coloured blood.[12]
It is evident, from the symptoms and history of the above case, that the
patient had contracted the disease of which he died at an early period
of his life, and that during the fifteen years he refrained from mining
operations, the pulmonary structure retained the carbon inhaled while
labouring in the coal-pit, and this is one of the many cases which can
be produced as examples of the fact that the foreign matter once
deposited in that structure originates a process of accumulative
impaction and ultimate softening of the organ, which is gradually
carried on till it is entirely disorganized. This case comes under the
third division of the morbid action, viz. where extensive excavation of
the structure is produced.
* * * * *