An Investigation into the Nature of Black Phthisis Part 3

_2d_, This foreign matter probably varies in composition in different lungs, but in the cases actually examined, it seems to be little else than lamp black or soot.

It does not appear, as far as I can ascertain, that any of the Continental physiologists are familiar with the disease now under our consideration. Several of them, both ancient and modern, discovered black matter in the pulmonary tissues, but not connected with nor exhibiting the black phthisis. It is therefore unnecessary to refer to them in general.

The following foreign authors entertain various opinions in regard to the dark appearances in the pulmonary tissue:--

b.i.+.c.hat supposes the black matter in the lungs "to be owing to small bronchial glands extending along the surface of the pleura." Breschet believes that it is formed by the blood exhaled into the cellular tissue, stating that its chemical composition leads him to that conclusion. Trousseau says that it is produced by a misdirection of the natural pigments of the body, resulting from age, climate, or disease.

Andral says, that the black appearances are the result of secretion, and that it is more manifest as the individual advances in life. Heasinger's opinion is, that it is a.n.a.logous to pigment, and therefore he agrees with Trousseau. Laennec was doubtful as to the real origin of black pulmonary matter. He makes a distinction between melanotic and pulmonary matter. He found that the melanotic matter was composed almost entirely of alb.u.men, while the black pulmonary matter found in the bronchial glands contains a great quant.i.ty of carbon and hydrogen, and also that these colouring matters have other distinguis.h.i.+ng characters. The melanotic matter is easily effaced by was.h.i.+ng, while the other is removed with difficulty. Laennec further says, that he suspected that this pulmonary matter might arise, at least in part, from the smoke of lamps, and other combustible bodies which are used for heat and light; for some old men are to be met with whose lungs contain very little black matter, and whose bronchial glands are but partially tinged with this colour; and it has struck him that he observed this amongst villagers who had never been accustomed to watch.[23]

Mons. Guillot, physician to the hospital for the aged at Paris, has undertaken a series of researches in regard to the black matter found in the lungs of old men of very considerable age. These investigations are published in the January, February, and March numbers of the _Archives Generales de Medecine_.[24] It is his belief that death in such cases is owing, in all appearance, more or less to a suppression of the circulation of air and blood by the black substance. His impression is, "that the carbon is not procured from without, but naturally deposited, as life advances, in the substance of the respiratory organs; and that this deposit of carbon causes death, by rendering the lungs irrespirable, while, at the same time, it has much influence in modifying the progress of _tubercular_ disease; so that, if the tubercular affection was not cured, its progress was so far checked, that life has been very long preserved." The black matter envelopes completely both the pulmonary tubercles which have undergone a transformation, and the caverns which no longer contain tuberculous matter. He, while regarding these as the results of black matter in the lungs, throws no light on the cause of the deposit of the particles of carbon within the lungs.

Dr William Craig of Glasgow, in a letter to Mr Graham of London, published in the 42d vol. of the _Medical and Surgical Journal of Edinburgh_, states most interesting facts connected with this subject, particularly in regard to black matter found in the pulmonary structure of old people, which deserve considerable attention. He says--"I found that a black discoloration of the lungs was by no means a rare occurrence amongst those old people; and that it was impossible in many instances to decide, whether the black colour was owing to an increase of what is called the healthy black matter,--to a morbid secretion, or to a foreign substance being imbedded with the atmospheric air. After examining a considerable number of lungs, and finding that the division of the black matter into three kinds was not founded upon observation, and that the descriptions of them given by the best authorities were insufficient to enable us to distinguish them from one another, I begin to think, that in every instance in which black matter is found in the lungs, it ought to be considered morbid. If we examine the lungs at different stages of life, we find as a general rule that the quant.i.ty of black matter increases with age. In young children we find no traces of it, the lungs being of a reddish colour. At the age of ten years the black matter makes its appearance in the outer surface of the lungs, and in the interlobular s.p.a.ces. At the age of thirty or forty, the lung presents a greyish or mottled appearance, and the bronchial glands contain more or less black matter. Between the age of seventy and a hundred, the lungs are generally infiltrated with fluid black matter, which can be expressed from the cut surfaces, and stain the hands black."

"There are many circ.u.mstances which favour the acc.u.mulation of this black matter in the lungs; for instance, long-continued living in a smoky atmosphere, like that of this city, the inhalation of coal-dust, as in the case of colliers, or of charcoal-powder, as in the case of iron-founders. There can be no doubt that we inhale foreign substances along with the atmospheric air.

"We find the mucus which has remained in the nostrils for some time to be of a dark colour, and if we examine it with a microscope, we find, that this is owing to the presence of small particles of dust or other foreign substances, which the air may have accidentally contained. The mucus first coughed up from the lungs in the morning, is of a dark colour from the same cause, and the facts now maintained prove, that foreign substances suspended in minute particles in the atmosphere, may be inhaled into the lungs. I believe in all the extreme cases which have occurred in colliers and moulders, that there must have existed some previous disease of the lungs which prevented the foreign matter from being thrown off." "According to the views which we have taken of the subject, there are only two ways by which black matters may be deposited in the lungs; first, by a morbid secretion; second, by a foreign substance inhaled with the atmosphere. The former is a rare disease, while the latter is very common. I am inclined to think that the true melanosis generally occurs in the form of rounded tumours, which, when cut in two, present a uniform black colour without any trace of air-cells, while in the spurious melanosis the deposition is general, and black matter flows freely out when the cut surfaces are pressed. At first the lung is crepitous, and swims in water; but as the black matter increases, it becomes solid, and, as in the case of colliers who die of this disease, resembles a piece of wet peat in point of consistence. It is only in the cases of colliers, moulders, or others who inhale great quant.i.ties of black matter, that the lungs are rendered perfectly solid."

There is an exceedingly interesting and valuable paper, written by Dr Brockmann of Clausthal, upon the pulmonary diseases of a certain cla.s.s of German miners,--supposed to be in the Hartz mountains,--in _Neumeister's Repertorium_ for December 1844, an abridged translation of which is to be found in the September number of the _Monthly Journal of Medical Science_.

It is very evident that the disease there considered is produced by carbonaceous inhalation, and resembles in all its features the black phthisis so general amongst the colliers in Haddingtons.h.i.+re. The morbid appearances described by Dr Brockmann are very similar to the first and second division of that disease, presenting a very general carbonaceous infiltration of the pulmonary tissues; but in none of the stages are there to be found the extensive excavations discovered in the lungs of the coal-miner. Dr Brockmann makes three divisions of the morbid appearances, "The essential (wesentliche), accidental (zufallige), and secondary. The first shows an entirely black (pechschwarze) colour of the lungs through its whole substance, enclosing not only the air, blood, and lymph vessels, but also the connecting cellular tissue, the nervous substance, pleurae pulmonalis, and bronchial glands." In such a state, it is usual for the lung to remain perfectly normal, and to exhibit the greatest varieties.

The accidental (zufallige) is evidently the disease in a more advanced form, corresponding in a great measure with the second stage of the morbid action, found in the pulmonary organ of the collier. It is to be regretted that no accurate description is given either of the character of the mine, or the nature of the employment in which the miners are engaged, whether they be coal, silver, or lead mines, and if they are in the habit of burning coa.r.s.e lint-seed oil.

There is a very striking similarity between what Dr Brockmann calls the secondary anatomical changes, and many of those exhibited in the collier; first, membranes; second, collections of fluid into the pleurae and pericardium; third, the softened heart, and very general emaciation; fourth, the extensive venous congestion, with thick black blood.

The liver is described by Dr Brockmann as being small:--in the collier it is usually puffy, and much congested.

The symptoms do almost in all points accord with those presented in the collier, as will appear from the following quotation, from the paper.

"In the first stage, there is no local, functional, or general feature by which we can ascertain that the disease has commenced; probability is all we can reach. In the second stage, the disease is more obvious. And, first, there is a change in the expression of countenance; to a fine blooming appearance, which perhaps the patient previously had, there has succeeded a dark yellowish cast,--a change which gradually spreads over the whole body. For some time the patient may have remarked a gradual loss of strength, and now he complains of want of appet.i.te and disordered digestion, and more particularly of shooting pains in the back and muscles of the chest. Cough likewise supervenes, which may either be quite dry, or at most accompanied with a little pure mucus.

There is also a greater or less degree of oppression, accompanied with palpitation of heart, not only after a severe fit of coughing, but after every exertion of the lungs. As yet no local deviation from the normal condition is seen on examination of the chest by percussion or auscultation." "The disease meanwhile pa.s.ses into the third stage. The features of the patient now become more and more changed and deteriorated, and betray a deep melancholy. The colour of the face, which had been hitherto of an earthly hue, becomes blackish, as also the cornea, whereby the eye loses its l.u.s.tre. The appearance of the patient becomes still more frightful from the great loss of flesh, and the dark skin hanging loose on his bones. The fat not only seems to have disappeared, but the muscular substance also--the whole frame being shrivelled. The patient complains of increasing weakness, diminished appet.i.te, flying pains often concentrated at the pit of the stomach; and coughs much. The expectoration is for the most part difficult, and consists of ma.s.ses of mucus, either greyish, or tending to a black colour. A black streak is frequently observed running through the whitish mucus; one half of it may be white, the other black, or occasional black points may be observed throughout the ma.s.s, and sometimes, though rarely, blood. Dyspnoea is usually connected with the cough. It now begins to tell upon the patient, and is so characteristic, that the disease has been named asthma metallic.u.m. The disturbance of the digestive organs increases the disease,--the appet.i.te is entirely lost,--the tongue is covered with a white fur--there is an oppression at the stomach after a full meal--frequent eructations, and a tendency to constipation. The distress of the patient becomes increased in consequence of the shooting pains in the muscular system." "In the fourth and last stage, all the external appearances indicate the near approach of dissolution,--the face and members become bloated, and the feet greatly swollen." "The dyspnoea meanwhile, from effusion into the chest and pericardium, becomes so severe, that the patient cannot maintain the horizontal position, the expectoration becomes copious, consisting of a black inky (dintenschwarze), or ash-coloured fluid, sometimes of mere ma.s.ses of mucus streaked with black." "The disease is never accompanied with colliquative sweats or diarrhoea."

I am sorry to find that there is no allusion whatever to the state of the pulse. Dr Brockmann, in his remarks on the essential nature of this pulmonary disease of miners, brought under his notice, seems to entertain the impression that along with the inhaled carbon, resulting from the combustion of gunpowder, there is also an organic pigment-deposit present in the pulmonary tissue, which he supposes must have been formed in the lungs.

I have long entertained the belief, which I have stated in another part of this essay, that if the carbon is once conveyed into, and established in the parenchyma of the lungs, that organ commences the formation of carbon; thus increasing the amount originally deposited. Dr Brockmann sets forth, as grounds for this view, that "if the parenchyma of the lungs were filled with carbonaceous dust, their specific gravity ought to be increased; but this is not the case. A completely melanosed lung swims in water, both as a whole and when cut into parts." It is very evident from these remarks, that the author has not seen the disease as it is exhibited in the third division of morbid action in the collier, otherwise he would have both observed the lungs considerably augmented in weight, and also so densely impacted from the acc.u.mulation of carbon, as wholly to sink in water. See for instance case No. 2, where the lungs weighed about six pounds, and parts of the cellular tissue were so indurated, as to be cut with difficulty. In this case, the patient did not expectorate.

Dr Brockmann, as he advances, puts a question here, which more fully shows that the disease under his consideration was of a mild character compared with that under our notice. "If," says he, "pulmonary melanosis arise entirely from inhalation of carbonaceous dust, why is it not observed in other workmen, who are as much, and even more, exposed to its influence, as for instance, smelters, or moulders, and colliers?" He says, further, "were the carbon inhaled in quant.i.ty sufficient to explain the black colour of the lungs, it ought also, from its mechanical irritation, to produce inflammation in the delicate mucous membrane of the organ, but there are no symptoms of this during life, nor any traces of it after death." An answer to these remarks will be most satisfactorily given by a reference to the published cases, where the disease is princ.i.p.ally found amongst colliers and moulders, and where the pulmonary organs, particularly in the former, are found to undergo most fearful disorganization from the presence of carbon. It is very remarkable, that the author of these exceedingly interesting observations should never have found excavations of the parenchyma, when it is so general as the result of the same disease in this country, particularly in the locality to which I refer. Not knowing the character of the mine, it is impossible to judge; but I am disposed to conclude that there cannot be the same quant.i.ty of carbon floating in the atmosphere breathed by the German miner,--the disease resembles very much that milder form found in the iron moulder.

With regard to the carbonaceous state of the blood, I am sorry that I have not yet completed my investigations on that subject. It is still my belief that the carbon being once inhaled, there is an affinity found for that in the circulating fluid, and from its not being consumed, owing to a deficiency of oxygen, there is a progressive increase going on. I am very much gratified to find that Dr Brockmann entertains a somewhat similar opinion in respect to the state of the blood.

The effects of such a morbid structure upon the collier population in general is very marked. Previous to the late legislative act, the tender youth of both s.e.xes were at an early age consigned to the coal pit, and obliged to labour beyond their feeble strength, in circ.u.mstances ill adapted to their years. Such early bodily exhaustion soon produced in them a pallid countenance, soft and relaxed muscular fibre, and predisposed much to disease as they advanced in life. The miner on this account was generally from his youth, thin; in fact, you never see a fat and healthy-looking collier, and, according to the advance of pulmonary disease, with them, so is the progress of emaciation. Such a state of body may well be looked for in miners, labouring as they do, from ten to twelve hours in the twenty-four under ground, breathing a heated and impure atmosphere, which with difficulty sustains life, and which is demonstrably calculated, from its deleterious qualities, to induce serious disease. The effects manifest in the parent descend, and visible in the youngest children; they are squalid and wretched-looking,--and how can such offspring be otherwise? They are exceedingly subject to all children's diseases, and peculiarly predisposed to pulmonary irritation of one kind or other.

With regard to medical treatment, little can be done after the disease has pa.s.sed its first stage. Early removal from the occupation, and proper attention to nutrition, alone seem to hold out the hope of prolonging the life of the patient; but if there be carbon lodged in the pulmonary tissues, there is a certainty of its sooner or later proving fatal. Attention to the state of the digestive organs, and using every means to remove the dyspeptic symptoms, which are prominently present throughout the various stages of this disease, are indispensably requisite; and, as to nutrition, the nature of the diet should be as generous as possible. Anodynes and expectorants are the only remedies which seem at all efficacious in allaying irritation.

With a view to remove urgent symptoms, venesection has repeatedly been had recourse to, but in almost all instances I would say, with decidedly bad effects. Blood-letting does harm, producing general debility and rapid sinking.[25]

With regard to the prevention of this disease, ventilation, as has been stated, is very much neglected in the pits now under consideration, where the various cases have occurred; and to that neglect I ascribe the prevalence of the malady. In those pits referred to, the workable apartments are so confined, and become after a time so dest.i.tute of oxygen, as, along with the smoke from lamps and gunpowder, to render the air unfit for healthy respiration. The only effectual remedy is a free admission of pure air, so applied as to remove the confined smoke. This remark both applies to coal and stone-mining. The introduction of some other mode of lighting such pits than by oil is required. I know several coal-pits where there is no carbonaceous disease, nor was it ever known; and on examination I find that there is and ever has been in them a free circulation of air. For example, the Penston coal-work, which joins Pencaitland, has ever been free from this disease; but many of the Penston colliers, on coming to work at Pencaitland, have been seized with, and died shortly after, of the black spit: for instance, G. case No. 5, and D. case No. 8, are such.

How this is to be accomplished, is for the scientific man to say. With all due deference, I may be allowed to suggest various modes which might be adopted to free the underground atmosphere of the noxious ingredients. Could fresh air not be forced down by the power of the steam-engine, which is at every coal-pit? Could extensive fanners not be erected and propelled by the same machinery?[26] I am much surprised that no attempt has been made to light these pits with portable gas in some way or other. As far as I can understand, such an application of it would not be difficult. A small gasometer could be erected, and the necessary apparatus procured at little expense, and by such means, I would suppose, it could be carried to any part of the mines, which are not extensive.

Many proprietors may grudge the expense involved in such improvements, and thus prove a barrier to these necessary alterations; but I would ask any candid and generous mind, what is expense when the object in view is the removal of a disease to which many human beings fall a sacrifice?[27]

It must appear to every one that these collier diseases are crying evils, the preventive of which is based, as will be seen, on thorough ventilation; and in order to protect the miner, there should be a vigilant attention paid to the economy of underground works. No one need be surprised at the result of such a noxious atmosphere; and it becomes a duty with the government to protect these poor people by laws, and to adopt those measures which are best calculated to preserve their health; and should there arise difficulties of an insurmountable character in the ventilation of these pits, why continue the mining operation in such situations at such a sacrifice of human life?[28]

In the course of my investigations in regard to pulmonary carbonaceous infiltration, I was led to consider the circ.u.mstances of those engaged in other occupations than coal-mining. Any one who has carefully examined the structure of the human bronchial glands, at different epochs of life, must have been struck with their appearance in those who, from their vocation, are compelled to breathe a sooty atmosphere, or who have lived in ill ventilated dwellings.

I am further convinced, from the results of my recent investigations, that the bronchial glands in such persons invariably contain carbonaceous matter which has been inhaled at some period of life.

Having long entertained the belief that the lungs of chimney sweeps, for example, would, in all probability, be found to contain carbon, within the last few months two cases, of an exceedingly interesting character, connected with the present inquiry, have presented themselves,--the one of pulmonary disease, evidently resulting from the bronchial and lymphatic glands being impacted with inhaled carbon derived from soot,--the other a case of melanosis occurring in a young person. Though the two diseases differ materially, they have often been confounded with each other and a.s.signed to the same cause. My object in here reporting a case of stratiform melanosis, in connection with a disease having an external origin, is to afford an ill.u.s.tration of the fact, that all black deposits found in the system are not carbon. There exists a marked chemical distinction between the melanotic and the carbonaceous matter; and the anatomical situation of the two is also different.

CASE.--A chimney sweep, aged 50, of the name of Campbell, residing at Stockbridge. The short history of his case I procured from his friends, as I did not see him during his illness. He had been a soldier in early life, and had seen much foreign service. After he relinquished the army, he became a chimney sweep, in which capacity he was constantly engaged for nearly twenty years. He had had, for a considerable time, a troublesome cough with tough expectoration. He experienced a difficulty of breathing in making any exertion, and he had considerable oedema of the limbs. From these symptoms he believed that he was subject to _asthma_. He had only been confined to bed for two days previous to his death.

_Post-mortem Appearances._--The body exhibited extensive anasarca; the thorax was well arched; the cartilages of the ribs were ossified. On removing the anterior part of the chest, the pleurae were found to adhere strongly, and appeared rough and puckered from extensive exudation of a brown colour, which extended very generally over the serous membranes.

Both cavities contained nearly three gallons of light brown fluid. The pericardium was considerably distended with a straw-coloured fluid, and several flakes of lymph floated throughout the effusion. Both auricles of the heart were enlarged, and distended with exceedingly dark blood.

The walls of both ventricles were much thickened. The valvular structure of the auricles was congested and granular. The lungs were removed from the chest with difficulty, owing to the very general pleuritic adhesions. Both exhibited extensive emphysema. In dividing the lungs, and tracing the bronchial ramifications, each lobe was found to contain cl.u.s.ters of enlarged and indurated bronchial glands, impacted with thick black matter; and prosecuting the investigations, the minute lymphatic glands were observed cl.u.s.tered in a similar manner, and containing black fluid. In the substance of the upper lobe of both lungs, the bronchial glands were of a bright black colour; they were particularly large, and so numerous as to press considerably upon and obstruct several of the bronchial tubes. In fact the upper lobe of both lungs exhibited the plum-pudding structure. At the bifurcation and back part of the trachea, the bronchial glands were numerous, and of a deep black colour. A considerable ma.s.s of the glandular structure was removed for chemical and microscopic examination.

The second case was that of a boy aged six years, who was under treatment for an affection of the heart and kidneys, and who died apparently from disease of these organs. He was, during his whole life, of a relaxed and weakly const.i.tution, exceedingly sallow in the complexion, with a very deep blue tint of the sclerotic coat of the eye.

In the course of the post-mortem examination, there was discovered, in the lower and lateral part of the right pleura, a cyst containing about an ounce of semi-fluid melanotic matter; and also the morbid secretion presented the stratified appearance described by Dr Carswell in his article upon Melanosis, extending over the inferior half of the costal pleura and the corresponding part of the diaphragm. It formed a distinct layer on the surface of the serous membrane, resembling ink or blacking, and could with difficulty be removed. The black deposit resembled much in appearance the foreign matter found in the pulmonary organs of the coal-miner, and therefore was submitted, as well as the bronchial glands in the other case, to chemical a.n.a.lysis, with the view of ascertaining if there existed any a.n.a.logy in the component parts of each.

Dr Douglas Maclagan submitted both these substances to the action of concentrated nitric acid, and the results were, that the glandular structure of the chimney sweep contained a very large proportion of carbon, while of the contents of the melanotic cyst, the same process did not leave a vestige of colouring matter,--evidently proving the distinction which exists between those two dark deposits, and making it sufficiently obvious, that melanotic matter is composed of the const.i.tuent elements of the blood, and has its origin within the body.

There cannot remain a doubt as to the nature of the chimney sweeper's case; for, from the knowledge which we have of his occupation, and from the chemical properties manifest after investigation, I think I am ent.i.tled to declare the black matter obtained from the bronchial glands to be carbon inhaled with the air during his labour, and not existing as a const.i.tuent ingredient of organized solids or fluids.

The microscopic examination showed the carbon most distinctly in a molecular form.

It is my intention to return to this subject at a future time.

NORTHUMBERLAND STREET, EDINBURGH, January 1846.

FOOTNOTES:

[1] Vide an admirable series of papers on this subject in the volume of this Journal for 1843, by Dr Calvert Holland.

[2] About ten miles east from Edinburgh.

[3] Generated from the decay of vegetable and other substances in the _formerly wrought_ pits, which communicate with those at present in use.

[4] It is proved, from the difference in the chemical character possessed by the melanotic matter, as compared with the matter found in the lungs of miners.

[5] It will be observed, that, though the small blood vessels are destroyed, no hemorrhage takes place, owing to the formation of a carbonaceous plug.

[6] The air of the coal-pit is so charged with carbon as to prevent the collier from distinguis.h.i.+ng his neighbour when at work.

[7] Note from the evidence of a collier examined before the Government Commissioners in 1842, No. 147 of Report. "Colliers in this part of the country are subject to many oppressions; first, Black spit, which attacks the men as soon as they get the length of 30 years of age;"

second, Note 150, "The want of proper ventilation in the pit is the chief cause, and no part requires more looking after than East Lothian,"

the men die off like rotten sheep. Note, 153, the witness, 32 years old, says, "I am unable to labour much now, as I am fashed with bad breathing--the air below is very bad, and till lately no ventilation existed."