Chapter 3

_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 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.

* * * * *