HOSPITAL INFECTION OF TUBERCULOSIS: As Exemplified by the Records of the Resident Staff of the Mount Vernon Hospital for Consumption and Diseases of the Chest for the past Fifteen Years
Authors: J. E. Squire
Journal: BMJ (1910)

TUBERCULOSIS.T 1039 abdomen was very tender, but the tenderness could not be localized, and nothing abnormal could be felt.The temperature varied between 99.50 and 104.6°, and after three days con- siderable dilatation of the heart was noticed.The urine was tested on admission, and on subsequent occasions, but no albu- men was found.On the tenth day, however, blood was found to be present, and the spleen at the same time could be easily -felt.The blood continued to be present, and the albumen increased to 21 per cent.(Esbach), while granular casts were -feund on microscopical examination.The temperature was irregular up to 1020 for another ten days, when it sank to cormal, and the renal and pulmonary signs, the latter of which ;showed considerable delay in clearing up, subsided at the same -time.The patient made a good recovery.Pneumococcal peritonitis is a severe, and often a fatal, condition.It may occur as a complication of pneumonia, -or it may have a primary origin, and perhaps be followed by pneumonia, as happened in the second of the two cases which I shall now quote.In {he majority of cases oc- curring in childhood this condition is a primary one, and is generally of the eneysted form-that is, the purulent -exudate is localized, and is usually found in the lower.part of the abdomen.A secondary peritonitis, on the other hand, is, as a rule, diffuse, and is less common.The 'first of the two peritonitis cases which I have to bring to your notice illustrates the involvement of the pericardium and plurae, in addition to the peritoneum, secondarily to an attack of pneumonia.CASE x.-Doutble Lobar Pnteumonia: Doutble Empyema Pyopericarditis: Peritonitis: Death.'Ethel W., aged 4i years, came of a family in which there was -a history of tubercle and chest troubles.She had had ,pneumonia following measles two years previously.About five weeks before admission to hospital she passed through an -attack of pneumonia, which involved both lungs, the crisis -occurring on the fifth day.The signs in the lungs, however,-did not clear up, dullness persisting at both bases and moist sounds being audible on both sides of the chest.rowards the -end of the second week it was noticed that her abdomen began to swell, and it gradually became larger.The breathing -became more embarrassed and the child lost flesh.On admission the temperature was 100.20, it having been previous to thisEpractically normal after the initial fever, and the pulse was 140.The heart's apex beat could be neither seen nor felt, but the -sounds were best heard over the fourth costal cartilage.There was dullness over both lower lobes of the lungs with greatly diminished breath sounds and absence of vocal fremitus.The abdomen was much distended and afforded ample evidence of lfluid.Parscentesis of both sides of the chest was performed, ,pus being withdrawn from the left, but not from the right.On the operating table a little more pus was withdrawn from the left pleura by means of a needle, but on resecting part of a rib no further collection could be found.The patient was very. collapsed afterwards, and the cyanosis increased.On the assumption that the respiratory difficulty might have been -caused by the pressure of the fluid within the abdomen, the -peritoneum was tapped some twenty-four hours later and .13oz. of pus were removed.The breathing improved, and the abdomen was opened in the middle line below the umbilicus, when 3 to 4 pints of thick yellowish-green pus were evacuated, drainage tubes being inserted into each loin.The child, how- ,ever, never rallied, and death occurred suddenly two days later.The temperature, except on admission, never rose above 99.60.At the post-mortem examination there was no meningitis.The pericardium was distended by 16 oz. of thick greenish pus.There was generalized pleurisy over both lungs and a small empyema on either side posteriorly.The lungs were oedems- Ftous, and the left lower lobe was very congested, but no signs of -consolidation remained.The peritoneum was uniformly covered ,by a thick layer of lymph, which had caused numerousadhesions, .shutting off here and there small isolated collections of pus.The lymphatic glands were not enlarged.Caltures of the pus slrom the pleurae, pericardium, and peritoneum yielded pure ,cultures of pneumococcus.