Case of peculiar Black Infiltration of the whole Lungs, resembling Melanosis.
By James Craufurd Gregory, M.D., F.R.S.E.
Fellow of the Royal College of Physicians, and one of the Physicians to the Royal Infirmary of Edinburgh.
Edinburgh medical and surgical journal, Volume 36, 1831
note: Please be aware that the below article contains details of
post-mortems. For a summary of the miners named in this, and other
medical papers, please see the index on the main Health & Disease page
I am induced to publish the following case, partly because I have not hitherto met with the record of any similar affection; and partly with a view of calling the attention of those practitioners who reside in the vicinity of the great coal mines, and who may have charge of the health of the miners, to the existence of a disease, to which that numerous class of the community would appear to be peculiarly exposed.
John Hogg, aged 59, was admitted into the Infirmary under my care, on the 29th of March 1831. He had gone through much service as a soldier, in America, in the West Indies, and in various parts of Europe, particularly in Spain during the Peninsular war; and had always enjoyed good health, although he had not, by his own Recount, been of very temperate habits, especially for the last ten or twelve years, during which period he had been employed in the coal-mines at Dalkeith.
About sixteen months before his admission, he first began to experience palpitations easily induced, with some dyspnoea and pain along the course of the sternum, which prevented him from following his occupation as a coal-miner. At the time of his admission, he complained, in addition to these symptoms of severe cough, sometimes occurring in paroxysms, with dark coloured viscid mucous expectoration, which had existed for five months. His breathing was rather frequent; he lay with most ease on the right side, but generally preferred the erect position. He had slight oedema of the legs, and also of the under part of the arms, near the elbows. There was some distension of the abdomen, but without fluctuation. He reported his urine to be somewhat diminished in quantity, and frequently turbid. He had never complained of pain in his loins. His bowels were habitually costive; his tongue very foul; his pulse nearly natural; and his appetite good. The impulse of the heart's action was rather stronger, and felt over a somewhat greater extent of surface than natural, with a slightly increased sound. The respiratory murmur at that time was nowhere entirely absent, but was generally faint and bronchial, accompanied by pretty loud catarrhal rales on both sides of the chest, but chiefly, at that time, on the left side anteriorly.
As his pulse next day had risen in frequency, and was sharp and pretty full, twelve ounces of buffy blood were drawn from the arm, and a blister was applied to the sternum, with relief to all the symptoms. On the 4th of April, the cough, expectoration, and dyspnoea, had again increased, and prevented sleep. His pulse was 116, and the action of the heart still somewhat stronger than natural. The mucous and subcrepitating, or catarrhal rales, were now heard generally over the left side; but the respiratory murmur was still pretty well heard under the clavicle of that side. A loud mucous rale, amounting in some points to well-marked cavernous rale, was heard under the right clavicle, and over the anterior part of that side of the chest, - indicating the formation of cavities in the corresponding portion of that lung. Sixteen ounces of buffy blood were again drawn from the arm - another blister applied to the side, and afterwards leeches applied to the sternum, all with some relief. It is, however, needless to pursue the details of the treatment. He was put upon the use of various purgatives and diuretics with some effect; but the oedema, although for some time it did not increase, never entirely disappeared. The urine continued pretty copious for some time. I examined it frequently, and, although clear, I invariably found it to become hazy on the application of heat, while its density was lower than natural, varying at different times from 1014 to 1020. From the concurrence of these two signs, and from the number of similar cases I had previously met with, I felt no hesitation in announcing, that, along with the extensive disease of the lungs, and the slight organic disease of the heart, this man also laboured under a degree of that peculiar change of structure in the kidneys first described by Dr Bright.
Early in April the oedema extended to the scrotum and penis, and soon afterwards increased considerably in the legs and arms, while the urine diminished in quantity. The dyspnoea became more urgent, amounting at times to orthopnoea. The sputa became much more copious, and of a peculiar dark gray or nearly black colour, and his tongue acquired a coating of a similar appearance. His pulse became small, irregular in strength and frequency, and his extremities cold, notwithstanding the use of stimulants in considerable quantity. He was drowsy and slightly incoherent during the last two days, but only became comatose two hours before his death, which took place on the 18th of April.
On examination, both lungs, and particularly the right, were found to adhere strongly to the pleura costalis. The pleura pulmonalis of both lungs was much thickened; in some places, especially in the right lung, exhibiting a fibro-cartilaginous appearance and consistence, and about one-fourth of an inch in thickness. The pleura costalis corresponding to this portion of the pleura pulmonalis was ossified, and had caused bony union of several of the ribs.
When cut into, both lungs presented one uniform black carbonaceous colour, pervading every part of their substance. The right lung was much disorganized, and exhibited in its upper and middle lobes, several large irregular cavities, communicating with one another and traversed by numerous bands of pulmonary substance and vessels. These cavities contained a good deal of fluid, which, as well as the walls of the cavities, partook of the same black colour. A considerable portion of the pulmonary substance surrounding them was dense, hepatized, and friable. The rest of the lung was also somewhat condensed, and very cedematous. The serum, when expressed, was of the same black colour as the substance of the lung. The left lung did not appear to contain any cavities, but was condensed, and loaded with black serum. Some minute hard points could be felt in various parts of both lungs, but they did not differ at all in colour from the surrounding substance; and no distinct tubercular deposition or infiltration could be detected in those portions of the lungs which were most hepatized, even with the aid of the microscope. The texture in these parts appeared quite uniform, and the minute hard points felt in other parts rather conveyed the impression of their being merely the ends of small bronchial branches divided in making the section. The bronchial glands did not appear enlarged, but partook of the same black colour as the substance of the lungs.
There was some dilatation, along with slight hypertrophy of the left ventricle of the heart, and consequently some enlargement of the whole organ. The aortic valves were considerably thickened and corrugated, and although not much shortened, could not properly have performed their office. The mitral valve was also partially thickened and opaque.
Both kidneys were of a mottled colour, and tabulated externally, but not diminished in size. The natural fibrous structure of the cortical substance of both had given place in a great measure to the pale granular appearance characteristic of this peculiar disease of the kidneys, which was distinctly marked, and in some places had encroached considerably on the tubular portions. In other parts these appeared healthy and entire. The liver and spleen were very friable, - the liver somewhat granular in appearance. The other organs were healthy, and the black colour was entirely confined to the lungs and the bronchial glands.
The question here immediately presented itself, Whether this ought to be considered as a case of infiltration of the substance of the lungs by the peculiar matter of melanosis ? - or whether the black colour of these organs depended merely upon the habitual inhalation of a quantity of the coal-dust with which the atmosphere of a coal-mine must be constantly charged, and which, remaining unabsorbed and acting as a foreign body, had led ultimately to disorganization of the pulmonary tissue ? - in like manner as one form of phthisis is found to be particularly prevalent among those who by their occupations are most exposed to the inhalation of small irritating particles, such as stone-cutters, millers, and needle-grinders. In support of the first opinion, it might be urged that the lungs have been found more frequently than perhaps any other organ of the body the seat of true melanotic deposition, and that the principal symptoms in this case, the dyspnoea, the anasarca, and the general cachectic habit of body in a man advanced in life, without the progressive emaciation and hectic fever of true tubercular disorganization, are precisely those which have been most frequently observed in melanosis affecting the lungs.
But there are various other circumstances which, in my opinion, render the second view much more probable. 1. I have not met with any recorded case, in which the melanotic matter was disseminated uniformly throughout the whole substance of both lungs. Haller, in his Pathological Observations, states that He had met with "a terrible species of phthisis in a man, who had one of the lobes of the lungs, (by which, I presume, he means one lung,) not indeed purulent, but full of putrid matter, as black as ink, of which he likewise found some quantity in the cavity of the thorax:"—and in none of the cases recorded by Bayle, Laennec, Messrs Cullen and Carsewell, or Mr Fawdington, was the black colour disseminated to a greater if even to so great an extent. 2. Melanosis is generally found in patches or masses, which are apparently encysted; and even when found infiltrated in the substance of the lungs, some traces of the deposition of black matter may generally be found in other parts of the body. 3. The colour of the lungs and the serum which they contained was in this case of a much deeper black than that of the true melanotic deposition, which usually contains an admixture of red, probably derived from the blood, giving it a brown or brownish black colour. 4. Laennec states, in accordance with the experiments of Dr Pearson, that he had reason to believe that the black pulmonary matter sometimes found in such abundance in the lungs, especially in elderly people, (and which he considers as quite distinct from true melanotic matter,) proceeds in part at least from the inhalation of the smoke of lamps and combustible substances employed in domestic purposes; and I recollect to have heard him frequently say, that he had always found this matter most abundant in the lungs of those who had been obliged, by the nature of their occupations, to work at night and by lamp light. Were I to trust to my own experience on this point, I should say that it confirms the observation of Laennec. And, lastly, this man had enjoyed good health in various climates during the best part of his life, and he himself attributed the complaint of which he died to the air of the coal mines in which he had been working for so many years.
In order, if possible, to determine this point, the washings of the lungs, containing much of the black serum, were preserved for analysis. This, although rather a tedious process, was kindly undertaken by my colleague, Dr Christison, who has obtained the following results, which appear to me to go far to confirm the view I have ventured to take of this case, and are at least sufficient to establish the fact, that this black matter is widely different in its chemical composition from that of the ordinary matter of melanosis:
"1. Concentrated nitric acid boiled on it did not alter the colour.
"2. Immersion in a strong solution of chlorine had also no effect.
"3. A strong solution of caustic potass boiled on it took up some animal matter, and filtered very slowly. The first part which passed through was opaque and black; but the last portions were of a pale yellowish-brown colour, and transparent; so that none of the black matter was dissolved. The black matter remained on the filter, and this, well washed and dried, burned like charcoal powder, without swelling up, and with scarcely any animal empyreuma, leaving a considerable pale-gray ash.
"4. A small portion of the black powder left after the action of boiling nitric acid was well washed, dried, and introduced into a minute glass ball, with a tube attached, which was subsequently drawn out by means of the spirit-lamp flame to a fine bore. On the application of a low red heat to the ball, there was disengaged, at the open end of the tube, a considerable quantity of gas, which had the odour of coal-gas, and on the approach of a light, took fire and burned with a dense white flame. In the tube a dark yellow fluid likewise condensed, which had very exactly the odour of impure coal-tar naphtha, and became a soft mass on cooling, of the consistence of lard. This, when compressed between layers of filtering paper, yielded an oily stain to the paper, and left a white matter, which dissolved in boiling alcohol, and separated again on cooling, in the form of minute obscure crystals.
"In the products of this experiment, it is scarcely possible not to recognize the ordinary products of the distillation of coal. A gas of the same quality was procured, and likewise a naphthous fluid, holding in solution a crystalline principle, analogous to, if not identical with, naphthalin. I need scarcely add, that the quantity of material at my disposal, was too small to allow of a more extended inquiry into its nature."
A small portion of this black powder, and the lungs themselves, have been preserved.
Cases, by G. Hamilton, M.D. Falkirk
Extraordinary Member, and formerly President, of the Edinburgh Hunterian Medical Society
Edinburgh Medical and Surgical Journal, Volume 42, 1834 (extract)
Case 2. Melanotic Infiltration of the Lungs, with old and recent Pleuritis. - Joseph Parker, aged 58, of rather dissipated habits, came under my care about the end of December 1833. At that period, he stated that his health had been for some time declining, and that latterly he had become so weak as to be incapable of following his ordinary employment. Upon examining him, his legs were observed to be considerably swollen, and the action of the heart was found much greater than natural. The sounds of the heart were also somewhat rough, not amounting, however, to the bruit de rape. At this time he had some cough ; the respiration anteriorly and laterally was nearly natural; but I did not then examine the chest posteriorly. He was put upon the use of digitalis; and diuretics and purgatives were prescribed.
In consequence of indisposition, I had not again an opportunity of seeing this patient for nearly two months; and when I then visited him, I found that the swelling of the lower extremities had nearly disappeared, and that he still complained of his cough, although this was not by any means severe. His general health had undergone little alteration. In the beginning of April he complained of severe pains in both ankle-joints, which were removed by the use of the wine of Colchicum, and stimulating liniments. The Colchicum apparently brought on diarrhoea at this period, which continued for some weeks, until gradually subdued by the use of a mixture containing catechu.
On the 14th of May I examined the chest. When the hand was slightly pressed below the ribs a little to the left of the sternum, the heart was felt beating strongly. The sounds were nearly as formerly in the region of the heart; but below the right clavicle, especially near its acromial end, a loud grating sound could be heard. The respiration anteriorly and superiorly was puerile, and the percussion was pretty good. Posteriorly above both scapulae, but particularly above the right, a loud mucous rale was heard, and the voice was rather more resonant than usual. The respiration in the other parts of the chest which were examined was tolerably good. At this time the patient appeared to be gradually losing strength, but was not confined to bed, and he continued in nearly the same state till May 20th, when he was seized with violent pain on the left side, and great breathlessness, and expired the following morning. He had not sweated immoderately during the whole course of his illness, and his sputa, until within a few days of his death, were of a bluish colour. They are now reported by his attendants to have become perfectly black, as if they had been mixed with a quantity of soot.
Inspection. - Upon opening the chest, and pushing the hands between the pleurae, the upper lobes on both sides were found strongly attached to the pleura costalis. Upon the pleura of the left lower lobe there was some apparently recently effused coagulable lymph. When pressed with the hand, a large portion of the pulmonary tissue seemed tolerably crepitating, interspersed, however, in all the lobes with indurated portions. Upon cutting into the pulmonary tissue, it presented universally an intensely black colour, exactly as if it had been infiltrated with soot or finely-powdered charcoal. This black colouring matter pervaded every part of the lung, but appeared to be collected into particularly dense masses in the portions above-mentioned, which had become indurated. Nothing like tubercular matter was found.
The heart was very little enlarged; its parietes and cavities being both in nearly a normal state. Some parts of the tricuspid valve appeared slightly indurated and corrugated. The valves at the mouths of the pulmonary artery and aorta were both perfectly sound. The ascending portion of the aorta was dilated, I should think, about one-third more than its natural size.
A small cyst was found in one of the kidneys, but, excepting this, the different abdominal viscera seemed to be very healthy.
The brain was not examined.
I transmitted part of one of the indurated portions of the lungs of this patient to my friend, Mr Graham, Professor of Chemistry in the Andersonian Institution, Glasgow. I learn from him, that, out of 200 parts, he finds more than 1/4th, which he considers pure carbon. It is obvious, therefore, that this is another case of spurious melanosis, for the first notice of which disease we are indebted to the late Dr J. Gregory. Mr Graham informs me, that, while he was analyzing the specimen forwarded to him, part of the lungs of two other cases, similar in their nature, though not altered to the same extent, which had occurred in Glasgow, were handed to him for examination. Another case, also of the same kind I understand, occurred during last winter in the Edinburgh Royal Infirmary. Dr Gregory's patient had been for many years a collier, and all the three patients I have just alluded to followed the same occupation. The mode in which the carbonaceous matter had been conveyed into the lungs in Parker's case is very evident. He had been employed for forty years by the Carron Company as a moulder, in which occupation the workmen are continually exposed to the inhalation of a fine powder, composed in great part of very finely-ground charcoal. The sputa and mucus from the nares of those engaged in this employment are usually deeply tinged with this black matter, and a stranger cannot be present, while this powder is being used, without becoming sensible of the same fact.
Mr Shaw, who was present at the post mortem examination of this patient, and who has long practised in this neighbourhood, had never seen the lungs altered in a similar manner. Upon making inquiries among the other surgeons in this vicinity, who must have had under their care many thousand patients employed as moulders, colliers, &c. I cannot find that this peculiar infiltration of the lungs had been previously observed. I am indebted to Mr Girdwood, surgeon, of this place, however, for the history of two cases, in which an examination after death was not obtained, but which, in their nature, in all probability, were analogous to the one I have detailed.
The first (Braid) had been a moulder in the Carron Company's work, but had been unable to follow any employment for eight months before his death. For the first four months of this period, the expectoration is described as having been similar to what we see in ordinary cases of phthisis; all at once, however, it is stated to have become black, and to have continued so until his death.
The other (Craig) had also been employed as a moulder. He had at first violent haemoptysis, and the sputa were darkcoloured for a considerable time previous to his death. Both of these patients are described as having had otherwise many of the symptoms of phthisis, and the first had three daughters, all of whom died phthisical. Mr Girdwood informs me that he has repeatedly examined the bodies of persons who had been long employed as moulders, and who had died of various diseases, but has never remarked any thing peculiar in the appearance of their lungs.
My friend, Mr T. W. Jones, who was good enough to examine with the microscope the portion of lung I transmitted to Mr Graham, and who also saw the lungs in the cases I have alluded to which occurred in Glasgow, writes me as follows:
On the Existence of Charcoal in the Lungs. By Thomas Graham, F. R. S. Edin.
Lecturer on Chemistry in Anderson's Institution, and Member of the Faculty of Physicians and Surgeons of Glasgow.
Edinburgh Medical and Surgical Journal, Volume 42, 1834 (extract)
3d. From Dr Laurie, from whom I received, at a subsequent period, the following notes of the case. "John Brown, aged 48, collier, Campsie, a robust muscular man, in apparent perfectly good general health. There is no remark made in the journals as to his being affected with cough or disease of any kind. And in none of the reports taken at his bed side is he stated to be annoyed with the slightest cough.
"The injuries for which he was admitted into the hospital were compound fracture, laying open the left knee-joint, and fracture of the scapula, clavicle, and ribs of the same side, caused by a mass of coal falling upon him. The first of these was so severe as to demand immediate amputation, which was performed above the knee on the 26th of June.
"The amputated limb, I well recollect, was robust, muscular, and very firm, so as to cause some little difficulty in making the outer flap. My two assistants (Dr Pagan and Mr Stirling) remarked after the operation, that the case was very favourable, which they would not have done had there existed any symptom of impaired health, more especially of chest complaint.
"On the 27th he was doing well. On the 28th the same. 29th, complained of pain in his left side, referred to his broken rib, for which the ordinary apparatus was ordered, but I rather think not applied. At half-past six of the morning of the 30th, he was suddenly seized with a very acute pain in left side of chest, confined to a small spot in the situation of the fractured ribs, and accompanied by a severe rigor, for which he was bled, &c. &c, but sank rapidly, and died at ten o'clock.
"Inspection.- Thorax. - A few ounces of bloody serous fluid were found effused between pleura on each side of chest. Left lung slightly engorged, not hepatized. Slight and circumscribed fibrinous effusion adhering to pleura pulmonalis. Second, third, fourth, and fifth ribs fractured. Pleura costalis ruptured; lung not torn."
The lung appeared equally black as the preceding, and afforded the black colouring matter with equal facility, when cut down and pressed in water. It appeared, however, sound, and to have suffered no change of structure. The carbonaceous matter was separated as in preceding cases. 220 grains of the lung gave 22.46 grains of charcoal. This charcoal retained a little animal matter, like that from the last case, and afforded upon distillation a little ammonia and oily products, besides gaseous bodies. 4.77 grains gave 1.85 cubic inch gas, which was faintly combustible, and consisted in 100 parts of,—carbonic oxide, 11.1 ; carburetted hydrogen, 16.2; carbonic acid, 56.6; nitrogen, 12.3; ammoniacal gas, 3.8 = 100.
The black matter in this case when burnt left nineteen per cent, of an earthy ash.
I subjoin a note of the 16th August, containing an account of two cases similar to the above, which were observed in the Royal Infirmary, by Dr M. S. Buchanan, and which, with the preceding case, prove that this extraordinary condition of the lungs may exist unobserved, and is compatible with general good health.
"According to your request, I now transmit to you an outline of the cases of two colliers who died while under my care in the Glasgow Royal Infirmary, and whose lungs were the subject of chemical examination. The first was that of James M'Quail, aged 40, from Polmadie, about two miles from Glasgow, admitted June 15th. While at work this man sustained a dreadful fracture of the pelvis by an immense quantity of coals falling upon him. It is of little use to particularize the injury. Suffice it to add, that extensive mortification immediately took place in consequence, and death followed on the 19th of June. He had previously been in the most perfect health, and during the five days he remained under my care, he had not the slightest pectoral affection.
"Inspection.- On both sides of the lungs was everywhere remarked the carbonaceous deposit denominated by Dr Carswell spurious melanosis.
"2d. John Lyall, aged 29, engineer, Garnkirk, June 30, 1834, while superintending his work, fell from a height of about fifteen feet, alighting on his back, by which the spine about last dorsal vertebra was fractured, and in consequence paralysis of inferior extremities took place, accompanied with all the worst symptoms usually attendant on this irrecoverable injury. He died on the 7th July.
"The results of inspection of this case in regard to the thorax were very similar to those of the former; but what was remarkable in this case was, that, on inspection of the abdomen, some stratiform melanosis in the peritoneum was observed. This last patient was, previous to injury, in perfect health, and during his stay in hospital had no pectoral symptom."