When I first saw this man, which was about a month before his death, he laboured under rending cough, with a scanty tough mucous expectoration—oppressive dyspnœa, ascites, general anasarca, occasional giddiness, and throbbing headach on motion, or on assuming the standing position. His countenance was of a light blue or slate colour, and his upper and lower extremities had much the same appearance. His lips, eyelids, ears, and nose, were swollen and livid, and his eye-balls effused, and apparently projecting from the sockets. His sight was impaired and hazy. There was continued feeling of cold, with occasional rigors, and difficulty in keeping the extremities warm. There was considerable exhaustion upon the slightest exertion. The half reclining posture was the only one in which he was comfortable. The pulse was exceedingly slow, not above 36 in the minute, it was small, and often imperceptible at the wrist. There was considerable weight and feeling of oppressive fulness in the region of the heart, which was dull on percussion. On applying the ear to the chest, little or no râle whatever was discernible, and the action of the heart was almost inaudible. He had a sensation as of great weight in the head, and difficulty in raising it. Ho suffered from restless nights, short hurried breathing, with a feeling and dread of suffocation, evident fulness and enlargement in the region of liver, and inability to turn to the right side. The urine was small in quantity, of a bluish colour, and coagulable, irritability of stomach, and the bowels were obstinate and difficult to move, even with drastic purgatives. The treatment was merely palliative, no stimulant seemed to have any effect in exciting the system. Ascites and general anasarca were considerable, giving the body a large appearance. For some days previous to his dissolution, there was increased lividity of countenance, and little or no action of heart. He had at no time expectorated carbon, even during many severe paroxysms of cough. Upon inquiry, I found that this man had been a companion in labour to R. R. (whose case No. 2, is fully reported,) at Preston-Hall colliery, and from the morbid appearances found in R.'s chest, and from the character of the coal-work in which both were engaged, I was induced to believe Duncan's to be a similar case. In ascertaining his early history, I found him to be a robust powerful man, though troubled with a cough and hurried breathing from his first becoming a collier, circumstances very usual with those who engage in difficult mining operations, and which they erroneously attribute to want of air, nothing more.
Post-mortem examination, twenty-four hours after death.—The body was much swollen from effusion. On removing the anterior part of the chest, both lungs were much compressed from an immense effusion of a light brown fluid into the cavities of the chest to the extent of a gallon. The lungs were of a deep black colour, and irregularly spotted with dark brown patches of exudation. There were considerable adhesions of the pleuræ, and marks of very general chronic inflammation and false membrane over the greater part of the pleura costalis. There were adhesions of the left lung to the pericardium, which was much thickened, and contained about 14 ounces of a turbid fluid. On removing the left lung, it seemed large, and felt partially consolidated, and on dividing it throughout both lobes, it contained a mass of semi-fluid carbon, of a bright black colour, similar to paint. In this lung, the air-cells were almost entirely disorganized, unfitting it for the function of respiration. The upper lobe was divided into a variety of cysts, filled with carbonaceous matter in a fluid state, into which many of the smaller bronchi opened, and through which various blood-vessels passed uninjured. The inferior lobe, when emptied of its contents, was so much excavated that the parenchymatous substance felt light and flaccid. On dividing the right lung[16] it exhibited a pure black mass, but not so fully disorganized as the left. Portions of each lobe were permeable to air, while other parts formed cysts, containing fluid and solid carbon, the inferior lobe showed an almost solid mass. The mucous membrane of the respiratory passages was inflamed and spongy throughout the divisions, the small ramifications were irritated and choked up with tough, frothy phlegm. There were several large bronchial glands at the root of the left lung. In tracing the divisions of the bronchi more minutely, from the root of the lungs into their substance, clusters of glands were observed filled with inky fluid, and narrowing considerably the air-passages, and in washing carefully a portion of the upper lobe of the right lung, and removing as far as possible the carbonaceous matter, several lymphatic glands were seen with the aid of the magnifier, imbedded in the interlobular cellular tissue, resembling small black beads. The tracheal glands when examined, contained black fluid, similar in appearance to what was found in the bronchial glands. The mucous membrane of the trachea was soft and irritated, smeared with tough bloody mucus, the lining membrane of the rima glottidis was thickened and slightly granular.
The heart was much enlarged, and soft, with spots indicating chronic inflammatory action on and about the right auricle. Both auricle and ventricle on the left side of the heart contained a deep-dark blood. There were several large lymphatic glands imbedded around the great vessels proceeding from the base of the heart, containing black fluid, the other cavities appeared healthy, though attenuated in substance. The coronary veins were congested. None of the cervical glands contained black fluid, though several of them were enlarged. The cavity of the abdomen much distended from ascites; the contained fluid was to the extent of about six Scotch pints of a straw colour; the viscera much compressed, and matted together, with light brown exudation. The peritoneum was rough, and coated with the same exudation. The stomach and all the intestines correspondingly contracted; the mesentery appeared healthy; the liver was much enlarged, and darker than usual; the inferior lobe extending downwards, near to crest of ileum; the whole organ loaded with inky-coloured blood; the substance easily torn. The kidneys presented a natural appearance; the adipose substance in which they were imbedded was œdematous; the medullary substance of each presented a yellowish colour.
Head.—The integuments were œdematous. On exposing membranes, considerable effusion under arachnoid; very general venous congestion, extending over the convolutions, and to the base of the brain. Effusion into the lateral ventricles of a light yellow; the choroid plexuses thickened, and of a dark venous appearance; substance of brain firm and apparently healthy.
From the history of this case, it will be found that D. had at no time shown any indication that carbon was infiltrated into the lungs. At an early age he came under the influence of the smoke of coarse linseed oil, and of gunpowder, while labouring in an unhealthy and ill-ventilated pit, which produced a cough common amongst colliers, who may be placed in similar circumstances; and it is evident, that during the last fifteen years of his life, the carbon—having previously taken up a lodgment in the pulmonary tissue—was gradually accumulating, and thereby producing painful dyspnœa, and the other formidable symptoms connected with the circulating organs, which followed as results, till it had almost entirely saturated the cellular structure, and rendered the lungs unfit for the functions of respiration, consequently impeding the necessary change, through the medium of that function upon the blood.
There was a marked similarity in the morbid appearances between this case and that of Reid, (No. 2). They both wrought in the same pit at Preston-Hall, and were affected in a similar manner. Both had enlarged liver, and the left lung principally disorganised. Both had extensive anasarcous and other effusions, and both had coagulable urine. Neither expectorated black matter, and both died from the bursting of a carbonaceous cyst into the bronchi, producing suffocation. Duncan lived longer under the infiltration than Reid did; and this was no doubt owing to his being younger, and also his healthy occupation latterly.
I have preserved a quantity of the contents of a cyst in the left lung of this patient, for chemical analysis; also a portion of the blood from the vena cava, and a little of the black fluid from the bronchial glands.[17]
Case 10. (The subject of the following case is still alive, 1845.) J. S., aged thirty-six. He was born of collier parents, in the parish of Pencaitland, and at as early an age as eight years, went under ground to assist his parents in the transmission of the coal, and when fit for work became a coal-hewer. From his infancy he was rather of a delicate constitution, with flat and contracted chest. When I first saw him, which was about eight years ago, (1837), he was in full employment as a coal-hewer, complaining of shooting pains through his chest, tickling cough in the morning, with scanty tough expectoration, and frequent palpitations. He was repeatedly under treatment for bronchial affection, which was usually relieved by expectorants, blisters, and continued counter-irritants. Each attack of bronchitis was the result, as he expressed it, of "breathing bad air in the pit," in which he was obliged to relinquish labouring, as the lamp would not burn, from the state of the atmosphere. He never wrought at the stone-mining nor blasting. In examining the chest with the ear, at this stage of the affection, the mucous râle was distinctly heard, and exceedingly loud throughout the greater part of the chest. The heart's action was strong, but natural; pulse 70, full and bounding. About four years ago, he removed from Huntlaw to Blindwell, a coal-work towards the sea-coast, an extension of the same coal formation. At this time, 1841, he had very troublesome cough, particularly in bed, scanty frothy expectoration, annoying dyspnœa, preventing him taking sufficient nourishment, headach, obstinate bowels. He continued under all these ailments to labour with much difficulty, till the summer of 1843.[18]
In reviewing the morbid appearances in the cases now detailed, it will be observed, that in the majority of them, the left lung exhibited the greater amount of diseased structure. This fact is particularly interesting, as in tubercular phthisis, a similar predominance of disease is found on the left side.
In almost all the cases, there was found very extensive effusion into the serous cavities, and particularly into those of the pleura and pericardium. Both pleuræ were much thickened, and all the marks of a long standing pleuritic and pericardial inflammatory action were seen. The substance of the heart, in all the cases, was soft and attenuated; the right auricle and ventricle were dilated; and there was thickening of several of the valves. The liver and spleen were usually large and congested. In all the cases, as the disease advanced, the pulse came down to a very unfrequent and thready beat. From the great extent of the venous congestion, the disease often assumed the aspect of asphyxia; and in some instances the colour of the patients resembled that of persons labouring under cyanosis.