311

sequent doses were given on the llth, 13th, and15th days, when treatment was discontinued. Theresults of the experiment are given in the accompany-ing Table. Mice in all groups began to die about the3rd day and numbers which were examined postmortem all showed the findings noted above.

It will be observed that, while the treated groupshave a slightly higher survival-rate than the controls,and the groups injected subcutaneously a higherrate than those receiving the drugs orally, thesedifferences are not such as to satisfy the usual test ofstatistical significance. There is therefore no evidencethat sulphanilamide or M. & B. 693 administered

orally or by injection influences the course of experi-mental pertussis in mice infected by the intranasalroute.

I have to thank Messrs. May and Baker for theirkindness in sending me a generous supply of theirproduct 693.

REFERENCES

Burnet, F. M., and Timmins, C. (1937) Brit. J. exp. Path. 18, 83.Gross, P., Cooper, F. B., and Lewis, M. (1938) Proc. Soc. exp.

Biol., N.Y. 38, 407.

BILE PERITONITIS OF UNUSUAL

CAUSATION

BY K. L. JAMES, M.S. Lond., F.R.C.S. Eng.SURGICAL REGISTRAR, CHARING CROSS HOSPITAL

BILE may pass into the peritoneal cavity in fourways

(1) Extravasation from the gall-bladder followinginfection and a rise of intravesicular tension. Thesite of rupture may be an obvious area of pressurenecrosis or no perforation may be seen. In the lattervariety oedema fluid probably permeates throughthe gall-bladder wall before the biliary extravasationtakes place.

(2) Effusion from the bile-ducts without obviousperforation (the biliary dew of Leriche). Here thereare varying degrees of necrosis of the tissues aroundthe common bile-duct. This type has been variouslyattributed to the rupture of a glandular crypt ofthe duct wall, to local ulceration, or to digestionby regurgitated pancreatic juice.

(3) Extravasation following trauma, usually a

crushing injury of the upper abdomen tearing eithera bile-duct or the liver itself. The case reported belowillustrates that cholecystectomy may be a cause.

Within the first few days after cholecystectomya collection of bile may form from leakage of theraw liver surface of the gall-bladder bed. This isobviated by carefully suturing the peritoneal flapso as to obliterate the fossa or by temporary drainage.A somewhat larger effusion may be due to leakagefrom an accessory hepatic duct draining directly intothe gall-bladder and overlooked at operation. In thepresent case bile was extravasated some six weeksafter cholecystectomy probably because the catgutligature placed upon the cystic duct was absorbedbefore the latter was obliterated.

(4) The only other factor which may accountfor bile peritonitis seems to be that recorded inDickson Wright’s case/ where a congenital cysticdilatation of the common bile-duct ruptured in agirl of 16.

The prognosis of the condition depends upon thedegree of infectivity of the bile. The following casegives the typical picture of flooding of the peritonealcavity with uninfected bile.A married woman of 30 was operated upon for gall-

stones on Jan. 5th, 1938. The common bile-duct

1 Wright, A. D., 1936, In Maingot’s Post-Graduate Surgery,vol. ii.

was normal both to inspection and palpation and wasnot opened, there being no history of jaundice orrigors. The gall-bladder was removed and the cysticduct was tied with catgut (chromic). The appendixwas removed and a drain left in the gall-bladderfossa for 48 hours. The post-operative period wasuneventful and the patient returned home on thetenth day.

She remained perfectly well until Feb. 15th,when, while doing her morning housework, she wasseized with sudden pain in the right side of theabdomen, in the right scapula region, and over thepoint of the shoulder. She felt sick but did not vomit.The bowel motions since operation had been regularand normal. She was readmitted the same day withnormal temperature, a pulse-rate of 84, and lookingwell except that she had a high colour and was sweatingslightly on the forehead. Her tongue was clean andmoist, there was no jaundice, and the urine containedno bile. The white-cell count was 19,000 with 86 percent. polymorphs. The abdomen was tender andrigid on the right side only, and no free fluid couldbe detected. The base of the right lung had a deficientair-entry with an impaired percussion note.Doubt was cast upon a diagnosis of bile peritonitis

by the absence even of a tinge of jaundice or a detect-able trace of bile in the urine. The patient wastherefore observed for 24 hours when it was found thatno signs of pneumonia had developed while the abdo-minal signs had increased in extent. Her temperaturewas then 99° F. but her pulse-rate remained at 80.

Operation was considered essential and under ageneral anaesthetic the original paramedian incisionwas reopened. The peritoneal cavity was found to beflooded with apparently normal bile and there was noevidence of any reactive peritoneal adhesions. Theapparent source of the effusion was the region of thestump of the cystic duct, and the adhesions aroundthis were not disturbed. The greater part of theeffusion was removed by suction and the abdomenclosed around a drainage-tube leading down to thesite of the cystic duct.

Bile drained in decreasing amounts for six days.The motions on the third and fourth days were palerthan normal but not clay-coloured, and after thisthey were of normal appearance. Convalescence wasuninterrupted and the patient was discharged on thetwentieth day and has remained well since.

I am indebted to Mr. R. A. Fitzsimons for permissionto publish this case.

THE LANCET 100 YEARS AGO

August 4th, 1838, 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.

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 youthfulQueen was presented and graciously received by herMajesty, through the flattering introduction to her royalpresence of her first Minister of State." (Cheers.) ...After the transaction of other necessary business the

meeting adjourned till the following morning ; ... Dr.JOHNSTONE AiTKiN, ... read a communication respectingthe use of the sea plant calledfucus esculatus, or " tangle,"... in cases of stricture of the rectum and urethraDr. CONOLLY, ... read the Report of the BenevolentFund Committee, which showed the increasing utilityof its operations. The receipts for the past year wereE34 4s. ... Dr. Maiden, ... read the retrospective addresswhich the Editor of the " Worcester Journal " describes,as " a medico-literary gem of the first water." The

general business of the meeting having terminated, themembers of the Association adjourned to the Town-hall,for the no less important one of discussing " an excellentdinner, dessert, and wines of the first quality." The

consumption of the latter was attended with most happyresults....