A coal porter, aged fifty-three, was admitted into hospital on February 5, 1883, for slight jaundice. He had enjoyed fairly good health until Christmas, when he caught cold. Since then he had had slight rigors and had lost flesh and strength, but had not complained of pain. On admission the patient was emaciated and slightly jaundiced. The margin of the liver extended about one inch below the ribs in the nipple line. There was neither pain, oedema of the legs, nor ascites ; the faeces were pale.
February 15.-Rigors ; temperature, 101.2° ; pulse, 100.
February 17.-Jaundice more intense ; liver dulness extended three and a half inches below the costal margin. From the lower border of the liver, and continuous with it, there seemed on palpation to be an enlargement of firm consistence, which extended to within two inches of the iliac crest and yielded a resonant note on percussion, being apparently overlapped by the distended colon. Swelling not tender. Patient very drowsy and thirsty. Temperature, 103.2°.
February 19.-Jaundice increased ; swelling larger ; liver dulness reached iliac crest; no pain, but tenderness on palpation over the liver.
February 20.-The localised swelling had increased in size, and fluctuation could be detected. Slight oedema of the abdominal wall; patient weak and torpid, with hectic flush on cheeks; pulse, 100; temperature, 102.7°.
February 21.-Patient suddenly became worse; acute pain in the abdomen, which was distended and tympanitic. Died on the following day.
Necropsy. The peritoneal cavity contained several pints of serobilious fluid and about a quarter of a pint of pus, which escaped from a perforation in the gall-bladder. The intestines were coated with recent lymph and the coils glued together. The gall-bladder was enormously dilated, and measured when empty eight inches in length and four and a half inches in width. On its under surface was an opening the size of a sixpence, with thickened and ragged edges. The common bile, cystic, and hepatic ducts were all dilated. On opening the duodenum a soft growth was found, entirely surrounding the orifice of the bileduct and invading the intestine for three inches in its long axis, and involving half its circumference. Above the growth the bowel was much dilated. The lymphatic glands in the neighbourhood were enlarged, but there were no metastases in the liver.
When the carcinoma only invades the biliary papilla during the course of its growth the clinical picture it presents is somewhat different from the preceding. Should the disease have commenced high up, the initial symptoms are those of pyloric obstruction. Pain or discomfort is experienced two or three hours after food, and there are usually flatulence, acidity, and vomiting, with signs of hypertrophy and dilatation of the stomach. The vomit is devoid of free hydrochloric acid, and occasionally it presents a green colour, owing to regurgitation of bile through the partially obstructed bowel. Haematemesis and melaena may occur from ulceration of the growth, and may even prove fatal. Should the disease undergo colloid degeneration, small semi-transparent granules of colloid material sometimes appear in the faeces.
If the growth develops below the level of the papilla, the first symptoms are those of obstruction of the bowel, with constant vomiting of bilious fluid containing trypsin. In either case its extension to the orifice of the bile-duct is followed by jaundice, with enlargement of the liver and gall-bladder. It should be noticed, however, that even when this complication ensues a certain amount of bile may still appear in the vomit or faeces, while in some cases the only indications.of biliary obstruction consist of the presence of bile in the urine and distension of the gall-bladder.