Quails and beer

pyaemia in private practiceInvalid diets could be unusual in the nineteenth century – and often included regular doses of strong liquor. But even by the standards of the era, this example struck me as eccentric. In 1874 Charles Wotton, a doctor from King’s Langley in Hertfordshire, wrote to The Lancet to report this case:

C. R—, aged ten, after a drive on Friday, June 2nd, 1873, complained of chilliness and lassitude. The following day he kept his bed, and on the Sunday I saw him. His evening temperature was high, his pulse 100, his tongue coated, his skin hot and dry, and his right knee-joint much swollen. I discovered that he had had one distinct rigor before I saw him. 

Rigor is violent shivering, a symptom which might indicate a variety of childhood illnesses. Dr Wotton was at first mystified:

For three days I was unable to diagnose the case; for, although the tongue was scarcely that of typhoid, there were not the perspirations and acid urine to be expected in a case of acute rheumatism.

Known today as rheumatic fever – a malady which has, interestingly, evolved considerably since the nineteenth century. The earliest reports suggest that joint pain was the principal symptom; later it started to cause endocarditis, inflammation of the tissues of the heart. In the twentieth century it morphed again into a neurological complaint characterised by Sydenham’s chorea, strange jerking movements of the limbs.

I requested and obtained the advice of a very distinguished physician, who is well known for his special skill in the treatment of children. He, too, was fairly puzzled at first. However, the morning following his arrival we were enabled to put aside the idea of typhoid in some measure, although in the neighbourhood some very severe cases of typh-poisoning had occurred, very far from a typical character, and caused us to doubt. The pain was most agonising, and I remarked that the swelling of the joint was beyond even what the synovial membrane of the knee-joint could expand to.

It sounds rather unpleasant; but worse was to come.

He was then placed under chloroform, and the limb thoroughly examined. Great enlargement of the femur was observed, and indistinct deep fluctuation. A consultation was held, and a surgeon of great eminence came to our aid. Two deep incisions were made, one to the outer and one to the inner side of the lower third of the thigh, without the appearance of pus. The incisions gave great relief, and in a few days freely discharged. But previous to this the opposite knee and the right shoulder-joint become affected. The left knee was soon reduced, and the ankle-joint of each foot was next attacked with great swelling, redness, and indistinct fluctuation. The left ankle-joint and the tarsal joints generally were so affected that the ball of the great toe approximated the heel. The agony was indescribable, but borne with wonderful fortitude.

The various physicians consulted eventually agreed on a diagnosis of pyaemia, a type of septicaemia causing abscesses all over the body.

To add to the general distress, a large bed-sore formed on the sacrum, two on the outer side of the right leg, and one on the left heel. Chloroform was administered at the dressings for many days until its ill-effects became so apparent that the poor child had to endure them without the aid of an anaesthetic. Lister’s dressings were employed with manifest advantage, and iron and quinine, with brandy mixture occasionally.

‘Lister’s dressings’, introduced by Joseph Lister, were a recent innovation, first used less than a decade earlier. They were steeped in carbolic acid (phenol), an antiseptic which was remarkably effective at preventing infection.

The patient took so great a dislike to brandy that it required the cinnamon water to disguise the taste. This, however, had to be discontinued, and, what is not the least remarkable incident of this painful but interesting case, he lived for nearly a month (as far as I can recollect) upon quails and bitter beer. Three of the former and three pints of the beer were consumed daily.

Rather more than the recommended daily alcohol intake for a child. And ten-year-olds are not famed for their enthusiasm for game birds and bitter. Happily, this unusual diet seems to have had no ill effects; rather the opposite, in fact.

The disappearance of the swellings were as rapid as their appearance. No openings were artificially or otherwise made. The left ankle remained swollen for more than three months, and exquisitely tender to the touch and upon the slightest movement. All the bed-sores healed up, free mobility of the feet has been recovered, and now, six months or more from the outbreak of the disease, nothing remains but a thickened condition of the right knee-joint, with impaired movement, which, however, improves week by week. Since leaving the country for London he has been suffering from an attack of purpura, which, however, his good constitution has thrown off.

Purpura is a red rash caused by bleeding underneath the skin. Its presence makes me wonder whether the diagnosis eventually reached by Dr Wotton and his illustrious colleagues was really correct. Pyaemia was almost universally fatal at this date, so the boy would have been incredibly lucky to survive it. Joint pain and purpura are, on the other hand, two classic symptoms of Henoch–Schönlein purpura, a rare illness which usually strikes in childhood and which causes inflammation of the blood vessels. Those with more expertise than me are as ever welcome to proffer an alternative/better diagnosis in the comments.

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