A Case of Infective Peritonitis following Pleuropneumonia and Whooping-Cough, and Attended with Intestinal Obstruction
BMJ (Clinical Research Edition)
THE occurrence of infective peritonitis as a complication or sequel of whoopirng-cough-or, more correctly, as a complication ef a complication of whooping-cough-is a sufficiently rare event to merit a brief record. On the 7th of last July, I was summoned into the country to see a boy between eleven and twelve years of age, who was at school there, and was reported to be suffering from some complication of whoopingcough. The history was, that he had been attacked with this complaint, in common
... plaint, in common with many of his schoolfellows, about three weeks previously; that, on the 3rd, he had complained of pain in his left side, and his temperature had risen in the evening to I02 deg. Fahr.; and that on the 5th and 6th he appeared to be unusually languid and listless. When I saw him on the 7th, I foupd him in high fever; a bright flush on the left cheek ; pulse I66; respirations 60; temperature 104 deg. Fahr.; tongue slightly coated. He was coughing, but not at that time whooping; and he complained of pain in the lower part of the chest on the left side. There was a marked tendency to diarrhoea, which persisted more or less all tbrough the illness, with the exception of the last few days. Examination of the chest revealed the existence of extensive pneumonic infiltration of the left lung, together with a moderate amount of fluid in the left pleural cavity. By the gth, dulness had extended over the whole of the left lung anteriorly. 0 The treatment so far had consisted in small doses of aconite in combination with quinine, hot poultices to the chest, and a moderate amount of stimulants. On the ioth, symptoms of exhaustion became very urgent, with sudden threatening of cardiac failure, which was met and overcome by the free administration of champagne and brandy. There was also evidence of an increase in the amount of fluid in the left pleura, and the heart was, for the first tine, noticed to be displaced to the right. Two grains of quinine were given every three hours, and the amount of stimulant increased. The patient was restless and delirious the first part of the following night, but towards morning fell into a sleep, and woke much better in all respects. The temperature had fallen to IO1 deg., respirations to 44, pulse 120. The tongue was cleaning. On the iith, the temperature again rose to 103 deg. in the afternoon, and the improvement of the preceding day proved to be only temporary; the physical signs remaining unaltered. On the morning of the 12th, there was again a recurrence of alarming exhaustion and threatenings of cardiac failure, and again the administration of brandy and champagne produced a quick rally. Concentrated food was frequently taken, as well as two grains of quinine every two or three hours. He mended towards evening, and the temperature fell from 103 to IOO deg. On the 13th, although there was less fever, there was much cerebral disturbance; and, as exhausting diarrhoea continued, small quantities of Dover's powder and tannin, mixed with arrow-root, were injected into the bowel, but were almost immediately rejected. Under these circumstances, two grains of Dover's powder were given by the mouth. Towards night, the delirium, which had been more or less present throughout the day, became uninterrupted, and was associated with other evidence of great exhaustion; there was frequent cough, with expulsion of small plugs of white tenacious mucus. About 3 A. M., an attempt was made to quiet the restlessness and delirium and to procure sleep, which the Dover's powder had failed to do, by giving a small dose of chloral : this was attended with success, and sleep ensued; but, after about two hours' sleep, which was carefully watched, the breathing was observed to become embarrassed, and the patient had to be roused rapidly and stimulants administered; expectoration was freely induced, and, after a little time, he seemed much better, and for some hours complete mental calm was restored. Towards the afternoon, however (the 14th), the delirium returned, attended with great prostration; the evacuations were passed involuntarily; the respirations were very frequent, and could scarcely be counted the temperature again rose to I03.6 deg.; for the first time in his delirium, * Read before the West Surrey District of the South-Eastern Branch. he could not be roused to take food, but clenched his jaws and refused all nourishment. As he lay, however, with his mouth a little open, a mixture of brandy and milk and brandy and beef-tea culd be dropped from a sponge between the lower lip and the teeth, whence it trickled irto the mouth, from time to time exciting cough, and thus clearing the air-passages of tenacious mucus. In this way, he was fed throughout the night, four wineglassfuls of brandy and milk or brandy and beef-tea being thus administered drop by drop. Food could hot be given by the bowel, as it was immediately voided. While this treatment was being pursued, he fell into a profound sleep, which lasted many hours (efforts* at coughing, however, being frequently and unconsciously induced, in order to keep the air-passages free). From this apparently critical sleep he woke much better. His mind was quite clear, he took food readily, his respirations fell to 40, temperature to 99 deg., pulse 120, and the tongue began to clean. Breathsounds, accompanied with crepitant rades, returned over the upper twothirds of the left lung, and the dulness over the upper part of the lung rapidly diminished. Thus, during the next five or six days, he continued to mend steadily, and encouraged a strong and apparently wellfounded hope of complete recovery. Arrangements were made for his removal to London on the 22nd, and thence, after a few days, to the south coast. The temperature, however, did not go steadily down to normal, but continued to oscillate between 99 and 102 deg., and it was evident that the left lung was still the seat of a certain amount of catarrhal pneumonia; and, as the lung cleared somewhat, paroxysms of true whooping-cough returned occasionally. But still his condition on the 20th, as compared with what it had been that day week, was one of convalescence. On the afternoon of the 2ISt, some alarm was occasioned by the temperature again rising to 104 deg., with some complaint of tenderness in the right hypochondrium; but, as the diarrhoea had given place to constipation for the last twenty-four hours, a mild aperient was given: some whitish scybala came away, like curd of milk, and the temperature fell rapidly to normal. The following day (the 22nd), he was removed, with great care, to LondTon, and bore the journey (thirty-two miles by rail) very well. The 23rd he was cheerful, sat up in bed, and wrote letters; did not cough much. Morning temperature, 102.8 deg.; evening, IOI 2 deg.; pulse 128; respirations 52. Loose crepitating rdles were heard over the upper two-thirds on the left side. On the 24th, he was somewhat better, but did not appear to be making much progress. Morning temperature, I02 deg.; evening, IOI deg.; pulse 120; respirations 48. The condition of the lung was unchanged (that is to say, the physical signs of a moderate amount of pleuritic effusion and of catarrhal pneumonia continued). On the 25th, there appeared to be decided improvement; there was less fever, the morning temperature being ioo.6 deg., the evening 1OO deg., pulse I12, respirations 40. There was more resonance on percussion on the left side, and air appeared to enter the left lung much more freely. He was quite cheerful, appeared stronger, and was himself very desirous to go to the seaside, and we contemplated moving him to Folkestone on the 29th. He slept tranquilly through the night, woke at 7 A.M. (the 26th), said he felt better, and took an interest in being read to. I saw him at II A.M., and was immediately struck with his altered appearance for the worse: the breathing was very rapid (6o in the minute) ; the countenance pale, dusky, and pinched; lips livid; tongue dry; skin hot and pungent; pulse I40 (small, hard, and wiry); abdomen swollen and tender; bowels very irritable (frequent mucous, frothy evacuations); the urine passed was obviously discoloured from the presence of blood, and became solid on boiling. (Subsequently, microscopic examination showed it to contain numerous blood-corpuscles and broken-down blood-casts.) The temperature was I03.6 deg., and rose steadily within the next two hours to 105 deg. After a few hours, he began to vomit the characteristic green vomit of peritonitis. From this period to the end of the case, I had the advantage of the cooperation of Sir William Jenner; the case was also carefully watched by my friend Dr. J. H. Philpot; and, when we had subsequently to deal with the. intestinal obstruction which supervened, Sir James Paget also gave us the benefit of his aid. On the morning, then, of the 26th, just as the chest-symptoms appeared to be yielding, and something like a state of convalescence seemed to be established, we were suddenly confronted with an acute peritonitis and an acute congestion of the kidneys. * I found that cough could always be induced and expectoration facilitated by using a spray of a weak warm solution of carbonate of soda, to which a little glycerine of carbolic acid was added. I call attention to this as a valuable resource in promoting the expulsion of the plugs of tough mucus which tend to accumulate in the bronchial tubes of children with bronchopneumonia.