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 dyspnœa, 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, dyspnœa, 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 dyspnœa, 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 œdematous 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 dyspnœa 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.
Post-mortem Examination.—The general anasarca gave the body a bulky 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 dyspnœa, 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.