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{Reprinted from the. Montreal Medical Jovrnal, March, 1896.) 
 
 A CASE OF PRIMARY CANCER OF THE GALL-BLADDER. 
 
 By C. F. Mahtin, B.A., M.D., 
 A88i8tant Physician, Roynl Victoria Hospital. 
 The points of interest in the subjoined report are as follows : 
 1. A very incipient primary cancer of the gall- bladder, 
 y 2. Cholelithiasis and perforation of gall-bladder. 
 
 3. Presence of gall-stones free in the abdominal cavity. 
 
 4. The absence of any special localizing symptoms. 
 
 6. The right hydronephrosis induced secondarily to the cancer of 
 the gall-bladder. 
 
 Clinical Report. — (Notes by Dr. A. A. Robertson.) The patient, 
 Mrs. T., aged about 65, who was admitted to the medical wards of the 
 Royal Victoria Hospital, manifested great weakness. Her only 
 remarks were that she Avas " slowly sinking away," and no further his- 
 tory could be obtained from her or her few friends. She was appar- 
 ently uncared for and would seem to have been ill for some weeks 
 previously. 
 
 On admission she showed much emaciation. Pulse 120 ; respira- 
 tion, 28 ; temperature, 101°. 
 
 Physical examination revealed almost total consolidation of the 
 right lung with a few crepitations and prolonged expiration at the 
 base of the left. 
 
 Pressure over the abdomen caused pain in all regions, though most 
 
 marked in the right iliac fossa ; there was no palpable tumour. 
 
 Fever continued for forty-eight hours ; some diarrhcea ensued and 
 
 ' weakness progressed till on the third day after admission death 
 
 supervened. 
 
 The Autopsy (-made 18 hours after death). 
 
 Anatomical diagnosis. — Acute lobar pneumonia ; cholelithiasis ; 
 perforation of gall-bladder ; primary cancer of gall-bladder and 
 localized peritonitis inducing right hydronephrosis ; secondary cancer 
 of liver and dilatation of the bile ducts ; general arterial sclerosis ; 
 subacute parenchymatous nephritis. 
 
 Body was that of an emaciated elderly woman presenting the usual 
 post-mortem changes. On opening the abdominal cavity, which was 
 dry, the duodenum was seen to be markedly distended and irregu- 
 larly bent upon itself in the first and second portions and matted 
 together with surrounding tissues, moderately recent adhesions being 
 formed to gall-bladder, liver and abdominal wall. There was further 
 
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 a slight sloughing of tissue in the immediate neighbourhood of the 
 gall-bladder. The hepatic flexureof the colon was collapsed and pushed 
 downwards. Four black, mulberry-like gall-stones, each 6 mm. in 
 diameter, lay free in the abdominal cavity amid the sloughed tissue 
 below the gall-bladder and seemed here loosely held amid the mass. 
 
 The spleen was small, soft and atrophied. 
 
 Thtf left kidney showed evidence of subacute parenchymatous 
 inflammation. 
 
 The rigid kid/ney, as it lay in situ, presented a thickening of its^ 
 , capsule, chiefly in the upper and anterior portion, with infiltration of 
 the adipose and other neighbouring tissue. There was, however, even 
 lower down, considerable inflammatory adhesion of the parts. The 
 organ itself was fluctuating to the feel, evidently hydronephrotic, 
 while the ureter itself was normal from pelvis to bladder opening. 
 On removing the kidney, adhesions were found binding down the pelvis 
 to the adjacent parts, evidently inducing a damming back of urine and 
 thereby dilating the calices and causing great thinning of the kidney 
 tissue. Average diameter of dilated pelvis was 10 cm., its walls much 
 thickened. The fluid was slightly turbid and bile-stained; the mucosa 
 injected, no stone could be detected. 
 
 The bladder presented some signs of slight chronic cystitis. The 
 orifices of the ureters normal. 
 
 The liver and gall-bladder weighed together 1425 gms. The com- 
 mon bile duct, as well as the pancreatic and cystic ducts, were pervious ; 
 the latter greatly thickened. The liver itself small, very soft and 
 rather paler than normal. 
 
 The gall-bladder was much diminished in size. The wall of greyish- 
 white colour and very much thickened, especially near the attached 
 margin. Towards its lower and outer portion was a perforation 1 cm. 
 in diameter with smooth rounded edges, and through this evidently 
 the gall-stones had escaped. The tissues about it showed localized 
 sloughing where the organ impinged upon the duodenum. Where the 
 gall-bladder was thickest there was much new tissue formed, connect- 
 ing together the gall-bladder and the liver substance. It extended 
 irregularly into the adjacent liver substance, being apparently con- 
 tinuous with and arising f rota the similar conditions of the wall of the 
 gall-bladder itself. The average diameter of this irregular area was 
 about 4 cm., while the liver tissues in the immediate vicinity presented 
 a few smaller nodules of the same character. Elsewhere the liver 
 contained about nine or ten greyish-white rounded nodules of com- 
 paratively small size, all firm on section and not penetrating deeply 
 into the tissue of the organ. On section the liver was soft, many of its 
 
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 8 
 
 bile ducts were greatly distended in both lobes, though apart from 
 any evidence of cancer or tuberculosis. 
 
 The periportal glands were enlarged, soft and somewhat pigmented. 
 The portal vein and vena cava were free. ' ■ 
 
 Throughout the alimentary canal, beyond moderate congestion, 
 there was no evidence of disease. 
 
 Thoracic cavity — In the lu/nga bilateral adhesive pleurisy, with 
 double lobar pneumonia. ' 
 
 The heart was both dilated and hypertrophied, showing evidence of 
 fatty degeneration and interstitial myocarditis. The coronary arteries 
 were atheromatous. 
 
 Cultures from the consolidated lung gave the diplococcus lanceo- 
 latus. From the kidney and spleen were obtained the staphylococcus 
 pyogenes aureus. Cultures from the liver pulp remain sterile. 
 
 Microscopic Examination — Gall-bladder — The walls showed 
 chronic fibroid thickening, the mucosa in some parts much necrosis, in 
 others deep irregular proliferation of epithelial cells of a distinctly 
 glandular type. The adipose tissue external to the gall-bladder was 
 likewise infiltrated. There was, in addition, some h;emorrhage, with 
 thickening of the vessels in the neighbourhood. Sections of the cystic 
 duct show involvement similar to that of the gall-bladder. 
 
 Examinations of the nodules in the liver showed the ordinary con- 
 dition of metastatic glandular carcinoma. 
 
 There was no evidence of tuberculosis anywhere in the liver sub- 
 stance. The periportal glands were distinctly cancerous, glandular 
 epithelial cells lying amid a moderately abundant fibrous stroma. 
 Large masses of dark green or orange pigment of a granular charac- 
 ter were distributed throughout the sections. There was elsewhere 
 no evidence of carcinoma and the microscopic examination confirmed, 
 in the other organs, the macroscopic appearances. 
 
 
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