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, dyspnœa, 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 dyspnœa, 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, dyspnœa, 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.