Nulla autem est alia pro certo noscendi via, nisi quamplurimas et inorborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se comparare.—MORGAGNI De Sed. et Caue. Morb., lib. iv. Procemium. ____ ° CASES of rupture of the common bile-duct are decidedly rare and in the majority of those recorded the most striking feature has been the almost complete absence of any signs of inflammation of the peritoneum directly resulting from the presence of the extravasated bile.
... A-t a rule only a few adhesions form and suppuration is very rarely present. Death is usually the result of exhaustion and may not occur until many days after the injury. In the case recorded below it took place on the thirty-third day and the same length of time elapsed between the injury and the fatal issue in a case recorded by Fizeau. Recovery has I occurred in several cases after repeated tappings, and though in these the diagnosis was not certain yet the symptoms were practically distinctive. A case in many respects similar to Mr. Spencer's was recorded by Mr. W. H. Battle in the Clinical Society's Transactions.l For the notes of the case we are indebted to Dr. Kenneth Wilson, house surgeon. A boy, five years of age. was brought to the Westminster Hospital on Aug. 21st, 1897, suffering from the effects of an accident. A wheel of a Hansom cab was said to have passed over the lower part of the thorax and the upper part of the abdomen. The patient was a well nourished child but was in a condition of severe collapse, pallid, with frequent pulse and very jerky respiration; the temperature was 95° F. in the axilla. No bruises were apparent, but the ninth rib on the left side had been separated from its cartilage and was projecting under the skin. A few hours later the child was again examined. The respirations were 30, very jerky and irregular; deep respirations were evidently painful. Some fine crepitations were heard at the base of the right lung. There were no signs of fluid in the chest. The abdomen was distended, and there was some dulness on percussion in each flank when the patient was turned on that side. The splenic and liver dulness was normal and neither of these organs could be felt. There was no marked tenderness in the abdomen. The patient had passed some urine and the bladder was not distended. No blood or sugar was found in the urine. About an hour before this examination the child had vomited some partially digested food ; the vomit contained no blood. The stomach note extended up to the fifth rib on the left side. Some bruising was now apparent round the injured rib and a boematoma had formed under the skin. It was thought that there was po&slb'y a tear in the diaphragm immediately under the seat of the injury of the rib. Daring the night the temperature gradually rose to 100° and the patient recovered somewhat from the collapsed condition. Half an ounce of milk was given every hour. During the second day the pulse was 100, the respirations were 30, and the temperature was 100°. After the administration of a glycerine enema a normal stool was passed. On the third day the patient vomited four times in the early morning. Another glycerine enema was given which did not act. In consequence of the vomiting he was fed by nutrient enemata (two ounces at a time) and beef suppositories alternately every four hours. The stomach note was a little higher on the left side. On the fourth day the general condition of the patient was not improved, the local bruising was more marked, the hæmatoma was less distinct, and the respiration and pulse continued as before, though slightly slower. A slight icteric tint appeared in the conjunctivæ and the abdomen was distended and resonant the culness in the 1 Vol. xxvii. p. 144. flanks having disappeared. Half an ounce of milk was given every hour by the mouth and the nutrient suppositories were continued. There was much restlessness during the night ; the bowels acted naturally twice. On the fifth day the jaundice was more marked and the stools were claycoloured ; the urine was acid and highly coloured and contained bile. The child was very restless all through the next day. The respiration was 52 and the pulse was 128. A mixture containing gentian and nitro-hydrochloric acid three times daily and half an ounce of olive oil every morning were ordered. The general condition remained unchanged until the evening of the eighth day when the patient vomited five times. The bowels had not been open on that day, and therefore a starch and oil enema was given without any result; this was followed on the next day by a glycerine enema but the bowels did not act. On the evening of the ninth day four grains of Dover's powder were given for restlessness and some calomel and a castor oil enema relieved the constipation. By the eleventh day the child was able to, take fish, custard, eggs, milk and beef tea, but in spite of this food he had become very thin, the malar bone being very prominent and the face having a worn and wrinkled appearance, whereas on admission he had been plump and well-nourished. The abdomen was distended and resonant all over. There was general icterus, the stools were colourless and clay-like, and the urine contained bile. His favourite attitude for the relief of the pain which he suffered was the genu-pectoral position. On the twelfth day the bowels were open six times. Early on the morning of the thirteenth day the child was very restless and had considerable pain in the upper part of the abdomen, which was uniformly distended, but was dull on percussion for the first time. Much fluid was evidently present. The respirations were 30, the pulse was 128, and the temperature was 98°. At 2 P.M. on the same day, the child having been anaesthetised with chloroform and the surface of the abdomen having been carefully cleansed Mr. Spencer made an incision about two inches long in the middle line of the abdomen above the umbilicus. About a pint and a half of thick bilelike fluid was slowly let out. A finger was introduced into the wound, and the gall-bladder, moderately distended, was felt. As the child did not seem in a fit condition for further operative procedures a drainage" tube was inserted and the wound sutured and dressed. The child was evidently much more comfortable after the operation and could lie upon his back. The temperature rose to 100°, r The wound was dressed twice the next day, and the tube was left out at the second dressing. The jaundice diminished slightly for the two days following the operation, but the stools were still clay-coloured and the urine contained bile. From this time the child no longer had any control! over his sphincters. He was fed by nutrient enemata and suppositories for twenty-four hours after the operation) and then was put on his former diet with the addition of two ounces of brandy or port and some cream-After the tube had been left out the jaundiced condition of the skin returned; the emaciation continued, thechild having steadily decreased in weight from the time of admiskion. On the morning of the eighteenth day a fluctuating swelling limited to the upper third of the abdomen was present ; it was dull on percussion. Mr. Spencer operated again at 2 P.M., making an incision in the middle line of the abdomen, higher in position than the previous incision and extending down to the upper end of that incision. This let out a quantity of fresh bile. Some bile-stained!! mesentery appeared in the wound. On passing the finger into the wound the following conditions were found. Below were adhesions ; above on the right side the lower surface of the liver was distinguishable. On feeling to the left it was apparent that the liver had been pushed over to the right, for the under surface of the diaphragm could be felt. The smooth surface of the uninjured diaphragm was felt on the inner surface of the broken rib. Neither at this nor at the former operation was any tear of the liver or gallbladder felt, A drainage tube was inserted and the wound sewn up. At the subsequent daily dressings it was evident that a large quantity of biliary discharge was flowing from the tube. On the twenty-second day the jaundice of the skin had nearly cleared up and the abdomen was resonant and retracted. Bile was discharging through the tube which was inserted close to the under surface of the liver and the abdominal wound was nearly healed. The stools were still clay-coloured and the ur'ne contained bile. Ox blie was given in a mixture by the mouth, but the emaciation did not-