A woman, aged fifty-four, was admitted into the London Temperance Hospital in a comatose condition, with deep jaundice. Her husband stated that about nine weeks previously she had been seized with pain and sickness after eating some pickled pork, and on the next day had become yeUow. The appetite had been bad, and she had complained of feeling weak, but had not lost flesh to any appreciable extent. Two days before admission into the hospital she had become drowsy and had vomited several times. The patient was a stout weU-developed woman. The skin was bright yellow, and the mine contained a large quantity of bile, but no albumin or sugar. There was profound coma with laboured respiration, a slow feeble pulse, and dilated pupils. The liver extended nearly three inches below the margin of the ribs, and presented a sharp edge and smooth surface. The gall-bladder formed a well-defined tumour to the right of the mammary line. The stomach appeared to be normal in size, and no abdominal tumour could be detected. The gastric contents, extracted by a tube, contained a trace of free hydrochloric acid. Death took place in a few hours.
Necropsy. The liver was much enlarged, and its tissue deeply bile-stained. The gall-bladder contained eight ounces of green bile, and the cystic, hepatic, and common bile-ducts were greatly dilated. When the duodenum was opened, an ulcer the size of a shilling, having a hard irregular edge and fungating base, was found to occupy the position of the biliary papilla. Vater's ampulla was dilated, and its opening on the floor of the ulcer was obscured by a small fungoid growth. There were no secondary deposits in the liver, but three lymphatic glands behind the peritoneum were enlarged. The duodenal growth proved to be a cylindrical-celled carcinoma.
Occasionally the patient is attacked by a succession of rigors, accompanied by irregular pyrexia and delirium. Severe pain is experienced in the right hypochondrium and epigastrium, and vomiting is urgent. Rapid enlargement of the liver takes place, the jaundice deepens, and death usually occurs within a week. In a case of this kind which recently came under our care, carcinoma of the head of the pancreas with portal pyaemia was diagnosed, but the necropsy showed a small cancerous growth of the biliary papilla, with purulent infiltration of the hepatic and pancreatic ducts.
In rare instances suppurative cholecystitis results from a pyaemic infection of the bile-duct, and may terminate by perforation of the gall-bladder, as in the following case recorded by Cockle : -