MORBID ANATOMY.—The cancer may begin at the fundus or near the cystic duct, but often the walls of the gall bladder are found uniformly thickened. The diseased gall-bladder may form a large, smooth or nodular mass adherent to the liver and to the intestines, and in the centre of the mass a considerable cavity filled with opaque gray fluid con taining much flocculent material and several gall-stones. The cancer is usu ally a cylindrical epithelioma, but it varies much. It may extend into the liver directly or by way of the portal fissure, where it may affect the portal vein and give rise to multiple deposits in the liver. The lymph-glands in the hilum of the liver are usually affected.
TREATMENT.—Symptomatie treatment is usually all that can be carried out. If the disease is recognized early before it has affected neighboring structures cho lecystectomy may be practicable. Mayo Robson reports such a case in which he removed a large portion of the right lobe of the liver with the gall-bladder. The patient made a good recovery. Other similar cases have been lately reported.
OaII-stones are the most important etiological factors in malignant disease of the gall-bladder; lie advises early operation, other things being equal, on active gall-stones, as nearly all the mor tality-giving complications are the re sult of delay. Out of two hundred and fifty uncomplicated gall-stone opera tions, the mortality was le.ss than 1 per cent. Primary cancer, as a rule, gives a hard tumor in the region of the gall bladder, which is tender to touch, and, unless there is a peritoneal involvement, rigidity of tbe overlying muscle is not /narked. It has been stated that at least one-half of the cases of jaundice diagnosticated as due to gall-stones are caused by cancer or complicated with it. William J. Mayo (Medical News. Dec. 13, 1902).
Other tumors of the bile-ducts are rare. Fibromata have been met with. Adeno mata occur occasionally. I met with one of the divertieulum of the common duct in a man aged 50 years. A g-,radually increasing jaundice was the first symp tom. Later suppurative cholangitis oc curred, with chills, high fever, and tender liver. At the autopsy the mass in the duct was found to act like a ball valve, obstructing the discharge of bile.
Acute Empyema of the Gall-bladder (Acute Infectious Cholecystitis; Acute Phlegmonous Cholecystitis).
Symptoms.—The onset is usually sud den, with pain in the right side of the abdomtn in its upper part, but, as in appendicitis, the pain may be general over the abdomen. Nausea, vomiting; a rapid. feeble pulse; thoracic breathing, rise of temperature, prostration, disten sion, and tenderness of tbe abdomen are the chief symptoms. In the cases in which the disease is circumscribed local tenderness soon becomes more marked. Jaundice is not usually present. Intes tinal symptoms may be marked and not infrequently lead to a diagnosis of acute intestinal obstruction.
Diagnosis.—This is often impossible, especially in the fulminating cases. It is most often confounded with gangre nous appendicitis. In the less severe cases the signs of local disease—as pain, tenderness, signs of exudation, abdom inal tension, etc.—may be sufficient to distinguish between the two diseases, un less the appendix is situated abnormally high.
Perforation of the stomach, the duo denum, the colon, the gall-bladder, etc., usually causes greater collapse at first and less marked septic symptoms later.
Etiology. — Acute empyema of the 0-all-bladder is a rare disease. Cases have been reported from time to time during the last few years. In about 75 per cent. of cases it is associated with gall-stones. It is doubtless due to infection by bac teria which may gain access by way of the blood or the bile. The typhoid bacil lus, the colon bacillus, the pneumococ cus, and the staphylococcus are the or ganisms most frequently present. Quite a large number of cases have followed typhoid fever, in some instances months after convalescence.
A comparison has been drawn between the causation of this disease and of ap pendicitis, the gall-bladder affection be ing of less frequent occurrence on ac count of its ampler blood-supply.
I Morbid Anatomy.—The gall-bladder is distended, but not large, not contain ing more than a few ounces of muco-pus. There is a strong tendency to gangrene, proportioned to the virulence of the in fection and the tension of the organ. The course is rapid, usually within four or five days. Adhesions are early formed to the intestines, omentum, etc. Later, perforation may occur and abscess result, or an abscess may' form without perfora tion. In the severe cases general peri toneal infection is liable to occur. The contents of the gall-bladder may be very fcetid.
Treatment.—Acute empyema of the gall-bladder is so rapidly fatal that only prompt measures are successful. As in phlegmonons appendicitis, so here prompt surgical treatment is necessary. The real difficulty is in rnaking the diag nosis. In the early stage care should be taken not to obscure the symptoms by the undue use of opium. The temporary measures should consist in absolute rest, hot applications, complete abstinence from food, water only being given by the mouth, and relief of symptoms as far as possible until the necessity for operation is established when the gall bladder, if there is empyema or gangrene of it, should be incised and drained or removed. In milder cases, in which the disease is localized, it is probably wiser to delay operation until the disease has been well circumscribed by the inflam matory process, when incision and drain age may be carried out and gall-stones, if present, removed.