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 œdematous 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 œdema 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 œdematous. 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.
Case V. A. G., aged 52 at his death. He was a collier from his boyhood, and wrought during the greater part of his life at Penston colliery in the parish of Gladsmuir. He was a short-set robust man, and while labouring at Penston, he enjoyed usually good health, free from cough or any affection of the chest. When he had attained the age of 48 years, (1833), he removed from the Penston to the Pencaitland coal-work, and about six months after making this change, he began to experience a slight difficulty of breathing, accompanied by a troublesome cough and feverish nights. The pulse was 84. Various soothing remedies were administered, which relieved for a little the pectoral symptoms; and as he felt no decided physical debility, he continued as usual at underground work. In 1835 I saw him often, and found that his pulmonary symptoms were becoming more marked; his cough was excessively annoying in the morning and when going to bed; his expectoration was frothy mucus, with dyspepsia, palpitation, and occasional headach. The resonance of the chest on percussion was very slightly impaired, and the respiratory murmur was variable, being occasionally louder at one time than another, and often much obscured, from the mucous secretion.
Labouring under this chest affection he still continued his daily employment till the spring of 1836, when he was entirely laid aside, being unable to go below ground, or to take the slightest fatigue, for the smallest exertion produced a fit of coughing; and during a paroxysm of this kind, he expectorated a few black sputa, which in a few days disappeared, and gave place to the usual frothy mucous expectoration. This bronchial discharge was accompanied by considerable relief to the cough and dyspnœa. By this time, (June 1836), on applying the ear to the chest, the resonance is dull, and respiratory murmur obscure. The action of the heart was slow when compared to its former state. The pulse not beyond 45 in the minute. By the end of this year he appeared in a half dead state,—but a mere shadow in regard to flesh. He was expectorating at intervals of some weeks, when the cough became more severe, a few carbonaceous sputa, and suffering severely from gastric irritation.[13] During the last week of his life, he expectorated considerable quantities of black fluid, and died exhausted, January 1837.
Post-mortem examination, which was conducted hurriedly, exhibited extensive effusion into both sides of the chest. The adhesions of the pleura were strong, and evidently of long standing. There was very general carbonaceous infiltration throughout the lungs, without excavations to any extent. Various empty cysts, which could contain a hazel-nut, were found in the superior and middle lobe of the right, and throughout the whole of the left lung; in which bronchial twigs terminated. The pericardium was distended, with limpid effusion. The right side of the heart was dilated, and filled with dark treacly-looking blood; and when washed, it appeared pale and bloodless. Its walls were thin, various patches of brown exudation extending over both pleuræ. There were several enlarged lymphatic glands, found at the root of both lungs, filled with black fluid.