BILE PERITONITIS OF UNUSUAL CAUSATION

311 normal both to inspection and palpation and was opened, there being no history of jaundice or rigors. The gall-bladder was removed and the cystic duct was tied with catgut (chromic). The appendix was removed and a drain left in the gall-bladder fossa for 48 hours. The post-operative period was mortem all showed the findings noted above. uneventful and the patient returned home on the It will be observed that, while the treated groups tenth day. have a slightly higher survival-rate than the controls, She remained perfectly well until Feb. 15th, and the groups injected subcutaneously a higher when, while doing her morning housework, she was rate than those receiving the drugs orally, these seized with sudden pain in the right side of the differences are not such as to satisfy the usual test of abdomen, in the right scapula region, and over the statistical significance. There is therefore no evidence point of the shoulder. She felt sick but did not vomit. The bowel motions since operation had been regular that sulphanilamide or M. & B. 693 administered and normal. She was readmitted the same day with orally or by injection influences the course of experi- normal temperature, a pulse-rate of 84, and looking mental pertussis in mice infected by the intranasal well except that she had a high colour and was sweating route. slightly on the forehead. Her tongue was clean and I have to thank Messrs. May and Baker for their moist, there was no jaundice, and the urine contained kindness in sending me a generous supply of their no bile. The white-cell count was 19,000 with 86 per The abdomen was tender and cent. polymorphs. product 693. on the right side only, and no free fluid could rigid REFERENCES be detected. The base of the right lung had a deficient Burnet, F. M., and Timmins, C. (1937) Brit. J. exp. Path. 18, 83. air-entry with an impaired percussion note. Gross, P., Cooper, F. B., and Lewis, M. (1938) Proc. Soc. exp. Doubt was cast upon a diagnosis of bile peritonitis Biol., N.Y. 38, 407. by the absence even of a tinge of jaundice or a detectThe patient was able trace of bile in the urine. hours it was found that observed for 24 when therefore BILE PERITONITIS OF UNUSUAL no signs of pneumonia had developed while the abdoCAUSATION minal signs had increased in extent. Her temperature was then 99° F. but her pulse-rate remained at 80. BY K. L. JAMES, M.S. Lond., F.R.C.S. Eng. Operation was considered essential and under a SURGICAL REGISTRAR, CHARING CROSS HOSPITAL general anaesthetic the original paramedian incision was reopened. The peritoneal cavity was found to be flooded with apparently normal bile and there was no BILE may pass into the peritoneal cavity in four evidence of any reactive peritoneal adhesions. The ways apparent source of the effusion was the region of the (1) Extravasation from the gall-bladder following stump of the cystic duct, and the adhesions around infection and a rise of intravesicular tension. The this were not disturbed. The greater part of the effusion was removed by suction and the abdomen site of rupture may be an obvious area of pressure necrosis or no perforation may be seen. In the latter closed around a drainage-tube leading down to the variety oedema fluid probably permeates through site of the cystic duct. Bile drained in decreasing amounts for six days. the gall-bladder wall before the biliary extravasation The motions on the third and fourth days were paler takes place. (2) Effusion from the bile-ducts without obvious than normal but not clay-coloured, and after this perforation (the biliary dew of Leriche). Here there they were of normal appearance. Convalescence was are varying degrees of necrosis of the tissues around uninterrupted and the patient was discharged on the the common bile-duct. This type has been variously twentieth day and has remained well since. attributed to the rupture of a glandular crypt of I am indebted to Mr. R. A. Fitzsimons for permission the duct wall, to local ulceration, or to digestion to publish this case.

sequent doses were given on the llth, 13th, and 15th days, when treatment was discontinued. The results of the experiment are given in the accompanying Table. Mice in all groups began to die about the 3rd day and numbers which were examined post

by regurgitated pancreatic juice. (3) Extravasation following trauma, usually a crushing injury of the upper abdomen tearing either a bile-duct or the liver itself. The case reported below illustrates that cholecystectomy may be a cause. Within the first few days after cholecystectomy a collection of bile may form from leakage of the This is raw liver surface of the gall-bladder bed. obviated by carefully suturing the peritoneal flap so as to obliterate the fossa or by temporary drainage. A somewhat larger effusion may be due to leakage from an accessory hepatic duct draining directly into the gall-bladder and overlooked at operation. In the

extravasated some six weeks because the catgut duct was absorbed before the latter was obliterated. (4) The only other factor which may account for bile peritonitis seems to be that recorded in Dickson Wright’s case/ where a congenital cystic dilatation of the common bile-duct ruptured in a girl of 16.

present

case

bile

was

after

cholecystectomy probably ligature placed upon the cystic

The

prognosis of the condition depends upon the degree of infectivity of the bile. The following case gives the typical picture of flooding of the peritoneal cavity with uninfected bile. A married woman of 30 was operated upon for gallstones on Jan. 5th, 1938. The common bile-duct

1 Wright, vol. ii.

A. D., 1936, In Maingot’s Post-Graduate Surgery,

was

not

THE LANCET 100 YEARS AGO p. 660. From an account of the sixth anniversary meeting of the Provincial Medical and Surgical Association (now the British Medical Association) held at Bath.

August 4th, 1838,

Dr. BoisRAGON again took the chair... and said that, "in conformity with your resolution at the last meeting, your dutiful and loyal address to our gracious and youthful Queen was presented and graciously received by her Majesty, through the flattering introduction to her royal presence of her first Minister of State." (Cheers.) After the transaction of other necessary business the Dr. meeting adjourned till the following morning ; JOHNSTONE AiTKiN, ... read a communication respecting the use of the sea plant calledfucus esculatus, or " tangle," in cases of stricture of the rectum and urethra Dr. CONOLLY, ... read the Report of the Benevolent Fund Committee, which showed the increasing utility of its operations. The receipts for the past year were read the retrospective address E34 4s.... Dr. Maiden, which the Editor of the " Worcester Journal " describes, The as " a medico-literary gem of the first water." general business of the meeting having terminated, the members of the Association adjourned to the Town-hall, for the no less important one of discussing " an excellent dinner, dessert, and wines of the first quality." The consumption of the latter was attended with most happy ...

...

...

...

results....