Primary Carcinoma of the 
Gall=Bladder. 
BY 
DR. GUSTAV FUTTERER. 
REPRINTED FROM 
MEDICINE. 
QEO. S. DAVIS, Publisher. 
March, 1897. BY DR. GUSTAV FUTTERER, 
Professor Physical Diagnosis, Chicago Polyclinic; Attending Physician, St. Elizabeth 
Hospital and German Hospital, Chicago. 
PRIMARY CARClNOflA OF THE GALL=BLADDER. 
Although quite a number of cases of primary carcinoma of the 
gall-bladder have been published, yet the writer thinks that more 
publications of such cases are necessary in order to bring out points 
not yet clear to us. 
The case here described has several interesting features, not 
only in reference to the findings in the gall-bladder but also to the 
surrounding and more distant portions of the liver. 
History.—A female, married, 47 years of age, was admitted to 
the German Hospital, where she came under my care December 3, 
1896. The patient’s father died at the age of 70 years; her mother 
died of typhoid fever in younger years, the exact age being un- 
known. Four brothers and a sister are living and well. One 
brother died during childhood, and another in later life after a 
period of insanity lasting two years. 
The patient was the mother of one child, which died in infancy. 
She had been very healthy excepting measles at the age of eight 
years and malaria at the age of eleven. She reached her menopause 
two years ago. Her bowels were always regular and her appetite 
good, but three months ago she had a short attack of jaundice. 
Her present illness commenced three weeks before she was 
admitted to the hospital, with intermittent attacks of pain in the 
region of the liver. She became icteric, the stools being discolored, 
and she remained in this condition until I saw her, at which time 
she‘was deeply jaundiced. As the patient had a well developed 
panniculus adiposus, the lower border of the liver could not be 
easily determined, but on deep percussion over the umbilicus, and 
reaching several inches to the left of it, there was a marked flatness 
of sound which I thought was due to an enlargement of the liver. 
Over the heart, the left part of which was somewhat enlarged, a 
murmur—mainly systolic, but also diastolic—was to be heard. The 
pulse was rather small, 82 per minute, while the temperature was 
ioo° and ranged between ioo° and 99 1-50 for the next five days. 
The diagnosis was chronic, endocarditis with valvular lesion of 
the aorta and probably gall-stones and cholecystitis. 
As the pains were very severe, hypodermic injections of mor- 
phine had to be given daily. With a view of disinfecting the gall- 
ducts and bladder, oil of wintergreen was ordered ta-beariven every 2 
PRIMARY CARCINOMA OF GALL-BLADDER 
two hours. The use of oil of wintergreen for this purpose is 
rational, as it contains methylsalicylic acid (C7H5(CH3)03), and 
it has been shown by Stadelmann that salicylic acid is discharged by 
way of the gall-ducts. I gave the oil until dizziness appeared, and 
would then wait a day or two and repeat it. 
On December 8 the patient was transferred to the surgical ward, 
and on the 9th of December she was at my request operated upon 
by Dr. Weller Van Hook and three faceted gall-stones removed from 
the gall-bladder. Fig. 1 shows a picture of the gall-stones, giving 
Fig. 1.—Gall-stones removed from gall-bladder. Natural size. 
their exact size. The stones had so many facets that it was sus- 
pected that some were missing, but none could be found. The gall- 
bladder was about two-thirds normal size; it had a slightly milky 
appearance and was overlapped by a nodule of about four centi- 
meters diameter, which was located in the lower margin of the liver 
and which—as was later proved by microscopical examination—was 
of carcinomatous character. The liver itself was of a deep purple 
color, with an uneven surface and small nodular elevations, caused 
by dilated gall-ducts as has been observed by Fenger. 
Above the umbilicus, and to the left of it, quite a number of 
enlarged glands could be felt and also an enlarged pancreas, the 
presence of the former explaining the area of dulness which had 
been erroneously believed to indicate an enlargement of the liver. 
The patient died December 12, and the post-mortem examina- 
tion revealed the following: A hemorrhage from the wound had 
filled the gall-bladder, had forced its way downward under the 
parietal peritoneum, and had entered the abdominal cavity and al- 
most filled the pelvis. The liver was a pale yellow, of about normal 
size, and did not show the small nodules which had been seen on its 
surface during the operation. As already mentioned there was a PRIMARY CARCINOMA OF GALL-BLADDER 
3 
small, hard nodule of grayish color in that part of the lower margin 
of the liver which overlapped the somewhat contracted gall-bladder. 
The gall-bladder itself showed a milky thickening of uniform char- 
acter due to a chronic fibrous cholecystitis. There was a small tumor, 
partly filiform and partly nodular, at the neck of the bladder near its 
attachment to the liver. The mucous membrane proper had here 
been forced upward by a hemorrhage, the extent of which can be 
seen in Fig. 2. From here the cancerous growth had passed over to 
Fig. 2.—The nodule in the uppermost part of the picture shows carcinoma growing in the 
direction of the hepatic duct. Below and to the right of this is a shaded portion show- 
ing hemorrhage. Further along this border are seen the corrugations of mucous 
membrane of the gall-bladder. The extreme right of the figure shows metastatic 
carcinoma. 
the hepatic duct, filling out the space between it, the gall-bladder 
and the cystic duct. It had reached the upper end of the hepatic 
duct, causing a thickening of its walls, thus bringing about stagna- 
tion of the contents of the bile-ducts inside of the liver, and causing 
a considerable dilatation of the larger ramifications of the hepatic 
duct inside of the liver; they were filled with an almost clear mucus 
in which no bile was visible, while the liver substance presented an 
extremely icteric condition. The walls of the ducts were visibly 
thickened and of a milky appearance. No carcinomatous masses 
were to be found in any portion of the liver except those surround- 
ing the gall-bladder and the hepatic duct. The cystic duct was 
practically closed, and the common duct showed a normal appear- 
ance. 
The carcinoma had not only grown upward but also downward 4 
PRIMARY CARCINOMA OF GALL-BLADDER 
to the margin of the liver, there forming the nodule which has 
already been mentioned. The glands around the porta hepatis were 
swollen, and this was also the case with the retroperitoneal glands. 
The left ventricle of the heart was enlarged; the aorta and its valves 
were calcified, and several fibromata were found in the uterus. No 
carcinomatous growth was found elsewhere in the body. 
Microscopical Examination.—During the microscopical examina- 
tion of the walls of the gall-bladder somewhat distant from the 
carcinoma I found mucous glands, a fact which is worth mentioning 
for several reasons. Henle (Handbuch der Systematischen Anatomic 
des Menschen, vol. ii, 1873, page 225) mentions that mucous glands 
in the walls of the gall-bladder are rarely found. Theile, Wedle 
Fig. 3.—Glandular carcinoma in the second layer of the gall-bladder. 
and Kolliker did not find them. As the examination progressed it 
could at last be seen that the carcinoma had originated from glands 
in the mucous membrane of the gall-bladder at its neck. The struc- 
ture of the growth was, as Fig. 3 shows, of an extremely glandular 
character. Fig. 4 demonstrates the growth of the carcinoma from 
the wall of the gall-bladder, against the liver substance, forcing the 
latter back; but in other portions it was found that the carcinoma 
had also entered the blood-vessels and caused adjacent metastases. 
Although the carcinoma [was of recent date, yet metastases were PRIMARY CARCINOMA OF GALL-BLADDER 
5 
already present in the portal glands as shown by Fig. 5. Other 
glands were not subjected to microscopical examination. The writer 
thinks it unnecessary to go into further detail in the description of 
Fig. 4.—The upper right-hand portion of the figure shows the second layer of the gall- 
bladder, from which springs a glandular carcinoma, compressing the liver substance. 
Fig. 5.—Metastasis of the carcinoma in a portal gland. 6 
PRIMARY CARCINOMA OF GALL-BLADDER 
the microscopic appearances, as the cuts illustrate those so well. The 
microscopical examination of the dilated gall-ducts (Fig. 6) and 
their relationship to the liver substance showed the following: The 
bile-ducts which are found in Glisson’s capsule show fibrous thick- 
enings of their walls, the surroundings of the latter also showing an 
increase of connective tissue and some cellular infiltration. 
Fig. 6.—Dilated gall-ducts inside of liver laid open. To the right is seen the duodenum and 
papilla; leading from this is the common duct. The cord-like structure in lower por- 
tion of figure is the contracted cystic duct. The greater portion of gall-bladder has 
been removed for microscopic examination. 
Occasionally small portions of necrotic liver substance were 
found, as seen in Fig. 7. The necrotic areas were, I believe, caused 
by pressure of the dilated gall-ducts against the liver substance. 
These not only show necrosis, but also beginning regeneration, 
represented by bunches of newly formed gall-ducts growing through 
the necrotic areas into the surrounding normal liver substance. PRIMARY CARC/JVOMA OP GALL-BLADDER 
Fig. 7.—To the right is shown a dilated gall-duct surrounded by areas of necrosis due to 
pressure. To the left is normal liver tissue, and extending across the figure a newly 
formed (regeneration) bile-duct can be seen growing into the healthy liver substance. 
Fig. 8.—Fiver cells in various stages of degeneration. The darker portions represent nearly 
normal tissue, while the lighter shading shows the degree to which degeneration has 
advanced. In the microscopic specimens these areas were stained an intense yellow. PRIMARY CARCINOMA OF GALL-BLADDER 
Fig. 9.—The centre shows a cross-section of a central vein surrounded by a layer of well 
preserved liver cells. Outside of these well marked areas of necrosis can be seen. 
Fig. io.—Transverse section of central vein, with areas of complete dissolution of liver cells 
(icteric necrosis). PRIMARY CARCINOMA OF GALL-BLADDER 
9 
Again, as Fig. 8 demonstrates, there were places where the dilated 
and thickened gall-duct had not caused pressure necrosis, so that 
the necrosis has occurred irregularly, in spots. Fig. 9 shows a 
second kind of necrosis which was found rather uniform through 
the whole liver, surrounding almost every branch of the central 
veins—an icteric necrosis which had caused almost entire dissolution 
and an almost total degeneration of the liver substance, especially 
that surrounding the central veins. Fig. 10 demonstrates this 
condition well. These parts in our microscopic specimen appear 
extremely yellow, while the intermediate and peripheral zones of 
the ascini show, in general, a perfectly normal appearance. 
Epicrisis.—As Fig. i shows, the three gall-stones found in this 
case must have been of long standing, while the carcinoma was of 
recent date. It will be remembered that the patient had an attack 
of icterus three months before she was admitted to the hospital and 
that this disappeared, returning again three weeks before her admis- 
sion. As carcinoma of the gall-bladder grows rather rapidly, it is 
not to be supposed that at that time there could already have been a 
narrowing of the hepatic duct caused by cancer; it must be believed 
that a stone or two left the gall-bladder and passed through the 
common duct, thus causing a temporary obstruction and icterus, and 
that the carcinoma is of more recent date. As carcinoma of the 
gall-bladder generally originates from the epithelium of the mucous 
membrane, it is very interesting to note that this one originated 
from the mucous glands. Dilatations such as we have found here, 
involving the gall-duct system in the liver, have been observed in a 
number of cases, and it has also been stated that they were filled 
with mucus instead of bile. 
The opinion has been advanced by Courvosier, that atrophy of 
the liver causes a non-production of bile, and that therefore no bile 
can be excreted. In this case, however, there are only small atro- 
phies of liver substance caused by pressure of the gall-ducts and the 
icteric atrophies of the central portions of the ascini. That the 
liver produced bile in large quantities was demonstrated by the 
icteric coloring of the liver and the dark icteric coloring of the whole 
body. The latter received the surplus of bile produced by the liver. 
It seems to me that the course of the bile has been reversed for 
some reason, so that instead of running into the gall-ducts to the 
peripheral portions of the ascini, it was forced towards the lym- 
phatics which surround the central veins. In this way the inter- 
mediate and peripheral portions of the ascini got rid of the bile 
almost as fast as it was produced, while the central portions were 10 
PRIMARY CARCINOMA OF GALL-BLADDER 
continually overloaded with it; and so caused a dissolution of the 
cells. If this condition had existed for a longer time the icteric 
mucoses would gradually have crept towards the peripheral portions 
of the ascini, and it may be that Courvosier’s specimen, from which 
he drew his conclusions, represented such a condition. As Cour- 
vosier’s book is not at my command, I am unable to form a correct 
opinion as to his findings. 
The causes which prevented the bile from entering the gall- 
ducts have been two: first, the counter-pressure by the stagnating 
mucus inside of the gall-ducts; and second, an obstructed communi- 
cation between the gall-capillaries in the ascini and the gall-vessels 
in Glisson’s capsule. I rather believe that the latter was the main 
cause, but this is not susceptible of proof. It would be of positive 
value if we knew that the removal of an obstacle would be followed 
by a prompt discharge of bile; while in the second case there would 
have been an apparently irreparable condition. 
Literature.—In order to give the reader a general idea of this 
condition, I append short histories of a number of cases, but for a 
more intimate study I should recommend the writings of Musser, 
Courvosier and others. 
Auetsch: Woman of 49 years had a gall-bladder fistula through 
which a great number of gall-stones were discharged. Three years 
later the patient died, and the post-mortem revealed a primary carci- 
noma of the gall-bladder with compression of the common duct and 
dilatation of the gall-ducts, which were filled with a milky fluid. 
The central portions of the ascini appeared dark green, the peri- 
pheral areas being lighter. 
Durand: Fardel, between 1838 and 1840, saw six cases of pri- 
mary carcinoma of the gall-bladder, all in women over 60 years, and 
one over 80 years of kge. In three cases there were no changes in 
the neighboring organs, while in the other three the carcinoma had 
involved the parts surrounding the gall-bladder and had caused 
metastasis. In all cases the gall-bladder contained gall-stones. The 
disease lasted from four to five months in five cases and almost 
two years in the sixth. Jaundice well marked in four cases, not 
well marked in one, and none in one. 
W. Pepper saw a case of scirrhus of the gall-bladder and of the 
pancreas, lasting for nine months. 
Paulicki observed a primary carcinoma of the gall-bladder in a 
30-year-old servant girl. Icterus came rather late, and post-mortem 
revealed a primary carcinoma of the gall-bladder, secondary car- 
cinoma of the liver, and a very much distended gall-bladder with PRIMARY CARCINOMA OF GALL-BLADDER 
11 
large stones. The cystic and common ducts were infiltrated by car- 
cinomata, their walls being thickened and their lumen narrowed. 
Coraza: Carcinoma size of a fist, adherent to the transverse 
colon; carcinomatous degeneration of liver; gall-bladder contained 
twenty gall-stones. 
Carpentier: Tumor of the gall-bladder with gall-stones and 
icterus. Woman died, after the disease had lasted fifty days, with 
coma cholaemicum. Carcinoma of gall-bladder, secondary carci- 
noma in the liver, and gall-bladder filled with large stones. 
Haas: Two cases of primary carcinoma of the gall-bladder; gall- 
stones in one case, perforation of gall-bladder, peritonitis, death. 
Heurot: Primary carcinoma of gall-bladder; woman, 49 years; 
icterus. Disease lasted eight months. The lower surface of the 
liver, the gall-bladder and the gall-duct were imbedded in carcinom- 
atous masses which were adherent to the small curvature of the 
stomach and the duodenum. Gall-bladder contained about fifty 
gall-stones. 
Planteau: Primary carcinoma of gall-bladder with compression 
of the cystic and hepatic ducts, chronic icterus and ascites, in a 
woman of 39 years. Liver evenly green, large, adherent to the 
diaphragm, strongly cirrhotic; liver parenchyma soft and fragile. 
At the fundus of the gall-bladder, carcinomatous degenerations; a 
carcinomatous nodule at the junction of the cystic and hepatic 
ducts; the latter two ducts and the bile-ducts in the liver were 
dilated. Choledochus normal; arteria hepatica and vena portae 
imbedded in carcinoma; lymphatic gland at the porta hepatis infil- 
trated. 
Remy: Woman, aged 38. Death at about eight months. Liver 
of normal size, about ten white nodules in anterior margin the size 
of cherries. A lobulated, hard white mass extended from the gall- 
bladder and porta hepatica to duodenum and pancreas. Ductus 
choledochus could not be found; vena portae was pushed aside. 
The shrunken gall-bladder contained a small gall-stone; its fundus 
showed carcinomatous degeneration, and the diameter of its wall 
was four centimeters. 
Cohn: Five cases in women between 40 and 60 years; one case, 
a woman of 77 years. Disease lasted from five to twelve months. 
In five cases sooner or later icterus; in one none. In five cases 
ascites. In five cases primary carcinoma of gall-bladder and second- 
ary carcinoma of liver, while in one case the liver was unchanged. 
In four cases stones in the gall-bladder; in one, a large number of 
stones in the gall-ducts. In the oldest patient there were no stones. PRIMARY CARCINOMA OF GALL-BLADDER 
12 
Krauss: Case 1.—Woman, 48 years. Duration five months. 
General anemia and cachexia, edema of the lower and upper extrem- 
ities, primary carcinoma of the gall-bladder, which had grown over 
the pylorus and duodenum. Large carcinomatous cavity between 
stomach, duodenum and gall-bladder, the right lobe of the liver, 
which was adherent to the front wall of the chest, and the omentum 
majus, which was turned upward and adherent; liver full of carci- 
nomatous nodules of the size of apples, one of which had grown into 
the diaphragm; nodules in ascending colon, which was adherent to 
the liver; considerable dilatation of the stomach; encapsulated peri- 
tonitis exudate (gas) between the transverse colon, which sunk 
down, stomach and side wall of the abdomen connecting with the 
carcinomatous cavity. 
Case 2.—Woman, aged 43; slight icterus; carcinoma of gall- 
bladder which was filled with stones, adherent to colon; gall-ducts 
free; liver full of carcinomatous nodules; carcinomatous degenera- 
tion of lymphatic glands at the porta hepatis. 
Case 3.—Man, aged 45. Primary carcinoma of gall-bladder 
with extensive metastasis in the abdomen and pelvis, the right 
inguinal gland, liver, stomach, and right lung; biliary cirrhosis, 
dilatation of the gall-ducts, and retention of bile; cholelithiasis. 
Diphtheritic inflammation of the mucous membrane of the whole 
large intestines and the lower part of the ileum; edema of the lungs 
and very marked general jaundice. 
Case 4.—Woman, 42 years. Primary carcinoma of the gall- 
bladder extending into the liver; compression of the hepatic duct 
by a portal carcinomatous degenerated lymphatic gland; marked 
icterus; lobular pneumonia; cicatrix in spleen with calcareous 
deposits, nephritis, fresh pericarditis; hemorrhages on inner surface 
of dura mater. Gall-bladder dilated, filled with slimy green bile 
and a number of stones; gall-ducts of the liver filled with a whitish, 
opalescent slimy liquid. This case lasted about three months. 
Case 5.—Woman, 47 years. Primary carcinoma of the gall- 
bladder extending into the liver and the porta hepatis; thrombosis 
of some of the veins of the liver with compression of the common 
duct; biliary cirrhosis; embolism of the pulmonary artery in the 
right lower lobe with hemorrhagic infarction; icterus. 
Delano Ames: Case i.—Woman, aged 47 years. Primary car- 
cinoma of gall-bladder; pains and tumor in right hypochondrium. 
Absence of jaundice; profound anemia. Obstinate constipation for 
four weeks before death. Death from exhaustion six days after 
exploratory incision. Gall-stones. PRIMARY CARCINOMA OF GALL-BLADDER 
13 
Case 2.—This was a woman 54 years of age, upon whom no 
post-mortem examination was made. 
Case3.—Woman, 52 years of age. Primary carcinoma of gall- 
bladder, which gave a nodular mass, definitely felt on palpation. 
The gall-bladder was thickened and contained about 100 small 
stones. There was great induration about the common duct, at the 
head of the pancreas and in the gastro-hepatic omentum. The 
common duct passed through the mass and was almost occluded. 
The liver weighed only 1500 grammes and presented numerous 
medium-sized cancerous nodules throughout its substance. 
Siegert (Zur Aetiologie des Priinaren Gallenblasen Carcinoms. 
Virchow's Archiv., bd. 132, 1893): Seven cases of primary carci- 
noma of the gall-bladder; among them a very small one showed 
cholelithiasis with chronic cholecystitis. From 99 cases gathered 
from literature, and his own 7 cases, 14 were in men and 83 in 
women, with gall-stones in 94 cases; three times they were missing 
and twice their presence was not ascertained with certainty, owing 
to a fistula between gall-bladder and colon. Of fourteen cases of 
secondary carcinoma of the gall-bladder observed by Siegert, ten 
were found in men, and gall-stones were only found twice. Siegert 
agrees with Klebs and Zenker, who believe that the gall-stones are 
primary, and that carcinoma follows the chronic changes of the wall 
of the bladder, caused by the stones. 
T. N. Kellynack (The Practitioner, London, 1896) reports 
Brockbank’s proportion of gall-stones as 22 per cent, in females and 
12.5 per cent, in males. 
C. F. Martin: A case of primary cancer of the gall-bladder. 
The gall-bladder was much diminished in size; the wall of grayish- 
white color, and very much thickened, especially near the attached 
margin. Toward the lower and outer portion was a perforation one 
centimeter in diameter with round smooth edges, and through this 
the gall-stones evidently had escaped. Where the gall-bladder was 
thickest there was much new tissue formed, connecting the gall-blad- 
der and the liver substance; it extended irregularly into the adjacent 
liver substance, being apparently continuous with and arising from 
similar conditions of the gall-bladder itself. The average diameter 
of this irregular area was about four centimeters. The liver tissue in 
the immediate vicinity presented a few smaller nodules of the same 
character. Elsewhere the liver contained about nine or ten grayish- 
white rounded nodules of comparatively small size, all firm on sec- 
tion and not penetrating deeply into the tissues of the organ. Many 
of the bile-ducts were distended. PRIMARY CARCINOMA OF GALL-BLADDER 
14 
O11 microscopic examination the walls of the gall-bladder 
showed chronic fibroid thickening, the mucosa in some parts 
necrosed, and in others deep irregular proliferation of epithelial 
cells of a distinctly glandular type; the nodules in the liver showed 
the ordinary condition of metastatic glandular carcinoma. The peri- 
portal glands were distinctly cancerous. 
Graham (Canadian Practitioyier, 1895): A male. Primary car- 
cinoma had destroyed the gall-bladder and caused metastasis all 
through the liver. Gall-stones in the gall-bladder. No evidence 
of carcinoma in any other part of the body. 
Geo. Dork {University Med. Mag-., Philadelphia, 1895, 90-95): 
Woman, aged 47. Carcinoma of the gall-bladder with gall-stones. 
No jaundice. 
Riedel reports three cases of carcinoma of the gall-bladder with 
stones. All three patients were females, 56, 58, and 56 years of 
age respectively. The third patient experienced a pressure in the 
region of the stomach lasting for years. Six weeks before opera- 
tion she fell, striking the right costal arch, and since then had pains 
in that region. 
Historical.—Delano Ames, who has gathered a great deal of 
literature on the subject of primary carcinoma of the gall-bladder, 
may be cited in reference to the historical development of our 
knowledge on the subject. He says: The literature of primary 
carcinoma of the gall-bladder is all of comparatively recent date, the 
most important contributions having been made within the last five 
years. By far the largest number have been reported since 1870. 
Previous to the year 1800 I have been able to find records of but 
four cases of primary cancer of the gall-bladder. Two of these are 
mentioned by Stall in 1777, one by Hally in 1786, and one by 
Baillie in 1794. All of these are included in the series collected in 
1890 by Courvosier. During the first half of the present century 
but nine cases were reported, two of which were probably secondary 
to cancerous growths elsewhere. The first two of these were in 
1839 by Heyfelder, and during the same year Cruvelliier in his 
“ Pathological Anatomy” mentioned the disease, in speaking of the 
pathology of the gall-bladder, but did not go into a detailed descrip- 
tion of the early lesions. The first full account was given in 1840 
by Durand Fardel. In this the liver was not involved. 
Dazare, in 1847, published a case in which the liver also was 
free from secondary deposits and was not involved by continuity of 
growth from the gall-bladder, the most frequent way in which the 
disease involves neighboring parts. During the same year Notta PRIMARY CARCINOMA OF GALL-BLADDER 
15 
published an account of a case. In 1848 Broca, and in 1849 Rippoll, 
each reported a case to the Anatomical Society of Paris. 
Two cases that were probably secondary were that of Burridge 
in 1845, which is included as primary by Courvosier, but excluded 
by Musser because of cancer of the breast of some years’ standing; 
and that of Renaud in 1848. 
During the next decade (1850 to i860) nine cases were 
reported, and the literature was enriched by a number of valuable 
contributions. 
Neschl, in 1852, reported a case, and refers to two others that 
he had seen, both of which wrere associated with cholelithiasis. 
Icereg and Mahieux, in 1853, each published a case. During the 
remaining years of this decade articles appeared and cases were 
reported by Klobe, Topinard, Debert, Pepper, Cassignac, and Mark- 
ham, the latter describing a remarkable case in a young woman 
of 28. 
From i860 to 1870 fifteen cases were reported. Wagner in 
1863, Gull in 1864, Comil, Foot and Stokes in 1865, reported cases, 
though that of the latter was probably secondary. Fraser, Sutton 
and Bucliereau in 1866, Moxon and Paulicki in 1867, Clamets, 
Murchison and Ogle in 1868, Klebs and Willigkin in 1869, also 
reported cases. Since 1870 the French, hitherto the chief workers 
in the field, have given place to the Germans, and scarcely a year 
has passed but some additional contribution has been made to the 
subject. During 1870 Villard published the most complete paper 
that had as yet appeared. He was able to collect and analyze 
twenty-six cases. Important articles have appeared at different 
times in Germany by Kohn, Krauss, Eang-Heinrich, and Zenker, 
who reported eight new cases and collected twenty-eight. Bern- 
heim and Stiller added five new cases to the list. Courvosier 
devoted a chapter of his “Pathologie und Chirurgie der Gallen- 
wege ” to a summary and discussion of 103 cases. In England, 
Fagge, Moxon, Habershon and Moore have been the chief con- 
tributors, wdiile in this country a most interesting and important 
paper was published in 1889 by Musser, in which he analyzes 100 
cases and gives a brief synopsis of each. 
Etiology.—Krauss, after analyzing his five cases and those 
known to him, concludes that hereditary disposition plays no part in 
carcinoma of the gall-bladder. The first authors who expressed the 
belief that gall-stones caused carcinoma of the gall-bladder may well 
be pleased now, on looking over the long lists of cases reported, 
which again and again demonstrate the truth of their belief. It 16 
PRIMARY CARCINOMA OF GALL-BLADDER 
seems rather surprising that at the present time we hear the ques- 
tion: Were the gall-stones first, and did they cause the carcinoma, 
or was the carcinoma first, and did it cause a decomposition of the 
bile which gave rise to the formation of gall-stones ? When but few 
cases were known this question was well put, but with the material 
for reasoning at hand it may well be considered as settled. There 
are a great number of cases of gall-stones without carcinoma of the 
gall-bladder, but only very few primary carcinomata of the gall- 
bladder without gall-stones. In secondary carcinoma of the gall- 
bladder gall-stones are very rarely found, but in primary carcinoma 
of the gall-bladder their presence is the rule, and there are but few 
exceptions. These views are well established. 
The writer thinks the fact that primary carcinoma of the 
gall-bladder mainly occurs in females gives strong support to the 
mechanical theory. Women wear corsets which press the costal 
arch firmly against parts of the liver, thus increasing the resistance 
and friction on the anterior wall of the gall-bladder. Orth, in his 
“Specielle Pathologische Anatomie,” Band iii, gives a cut showing 
carcinoma of the gall-bladder, the latter containing a large stone and 
the anterior surface of the liver showing a deep indentation. In 
the accompanying text Orth makes no allusion to the possible rble 
which the pressure of the arch may have played in the process, but 
he undoubtedly has taken it into consideration. In our own case 
there is also the same change, although less marked; there is an 
indentation, with thickening of the capsule, and an increase of con- 
nective tissue in the liver substance beneath it. 
Graham reports a case occurring in a man, a shoemaker by 
trade, who when at work would sit bent forward, pressing the costal 
arch against the liver. The position in this case would cause the 
same pressure on the liver as does the corset in women. Graham 
evidently did not take this into consideration. 
The mechanical theory in reference to carcinomata in general 
seems to be the only satisfactory one and becomes especially force- 
ful if we review the carcinomata of the alimentary canal and note 
the typical localizations. There is the carcinoma of the lips which 
often seems to be caused by the friction of the stems of clay pipes; 
then the carcinoma of the tongue, for the origin of which sharp- 
edged teeth are accused; next comes the carcinoma of the fauces, 
this narrow portion of the oral cavity growing still narrower during 
the act of swallowing, thus causing a strong friction of the parts 
with the passing of food. Then the carcinomata of the esophagus, 
behind the cricoid cartilage and the bifurcation of the trachea, PRIMARY CARCINOMA OP GALL-BLADDER 
17 
where a counter-pressure against the food passing by is exerted by 
the parts named. The cardia is the next principal seat of carci- 
noma, and the pylorus the next; and it is easy to understand that in 
these two places increased friction between contents and tissues 
must take place. This is also the case at the papilla of the common 
duct, and equally so at the Bauhinian valve, at the hepatic and 
lienal flexures of the colon, and the rectum down to the anus. All 
those parts mentioned are fastened to the abdominal walls, or to the 
vertebral column, or to bones, except the tongue and the lips, which 
increases mechanical irritation. Of course carcinomata occur in 
other parts of the intestinal tract also, but even then we often find 
something interposed which creates essentially the same condition, 
as, for instance, cicatricial ulcers of the stomach. As Hauser has 
shown, carcinomata will originate from the margin of such cicatri- 
cial ulcers, and I have a specimen which demonstrates this. It 
shows a large and deep cicatricial ulcer in the pyloric region, and on 
the margin on the side of the pylorus a carcinoma has developed. 
When the stomach contracts it tries to throw its contents through 
the pylorus,. and therefore the strongest friction must have taken 
place just where the carcinoma developed. Chronic inflammatory 
thickenings, ulcers, stenosis or diverticula can produce the same 
favorable conditions in other parts of the intestinal tract and thereby 
favor the growth of carcinomata. It seems to me that a careful 
study of primary carcinomata in organs where they but rarely occur 
will throw light on the subject; for example, primary carcinoma of 
the liver is rather rare, because this organ, if there are no stones in 
the gall-bladder or the gall-ducts, and if no corset is worn, is but 
very little exposed to mechanical irritation. If our opinion is right, 
then something that produces such an irritation should be found in 
cases of primary carcinoma. 
The writer is strongly under the impression that the mechanical 
factor plays a prominent part in the production of carcinoma. It 
seems probable that increased resistance of the tissues is not the 
only important factor to be considered, but that an increase of fric- 
tion in the intestinal tract by coarse food must also be taken into 
consideration. If we allow the mechanical theory to reign supreme, 
we must necessarily pay attention to the kind of food that is most 
adapted to cause friction. Meat is slippery and fat can also hardly 
be accused, but meat that is fried hard may act in the way indicated, 
though only to a very small extent, while it would seem that the 
carbohydrates are at the bottom of the trouble. Hasty eating, lack 
of saliva in quantity or quality, or lack of teeth as occurs in old PRIMARY CARCINOMA OF GALL-BLADDER 
18 
people, will prevent proper mastication and the conversion of the 
carbohydrates in the mouth; crusts of bread will add materially, and 
the imperfectly converted carbohydrates will act like foreign bodies 
in the relaxed stomach of the aged, and as in the bowels the pan- 
creatic juice, also lessened, will not complete conversion, they may 
act as foreign bodies all through the intestinal canal. But if we 
further consider that mechanical factors are also predominant in 
bacterial invasion, we cannot but take a parasitic theory into consid- 
eration, although the esophagus, cardia, pylorus and some of the 
other parts named are not at all favored by those micro-organisms 
which are well known to us; but some of them are, namely, the 
isthmus faucium, the Bauhinian valve, the coecum, the colon with 
its sharp turns and its pockets. The thick epithelial layers of the 
esophagus, the acid reaction of the contents of the stomach and 
the duodenum, the quick propulsion of the contents through the 
small intestines, and the small degree of friction in the latter parts, 
do not present favorable conditions for bacterial invasion. To prove 
the great importance of the mechanical factor for bacterial invasion 
I could bring a good deal of material, not only in reference to the 
intestinal canal, but also in reference to the larynx, the lungs, the 
pleura, the pericardium, the kidneys, ureters, bladder, etc. But 
two examples may suffice. It is well known that the infection of 
normal valves of the heart takes place at the closing lines, while the 
free margin of the valves and their basis remain intact for some 
time. When the blood contains micro-organisms and the valves 
close, they are pressed into the valvular tissues along the closing 
lines. Further, some years ago I made a post-mortem examination 
of a woman who had died of tubercular peritonitis and enteritis. It 
is well known that in enteritis tuberculosa most of the ulcers are 
located just before the Bauhinian valve. In this case it was differ- 
ent. There was a diverticulum of the size of a man’s fist, about a 
foot and a half above the Bauhinian valve, and this diverticulum 
was full of tubercular ulcers, while there were not many between it 
and the valve, the mechanical factor alone having been removed. 
However, from all that has been said it seems evident that if para- 
sites unite with the mechanical cause to create carcinoma they must 
be of a peculiar kind, differing widely from our well known bac- 
teria, especially in their relation to the gastric juice, which exerts 
such a deleterious influence on the latter. 
In reference to the etiology of primary carcinoma of the gall- 
bladder Mnsser says: “ No facts can be deduced'from these cases to 
aid us in the formation of a theory of the etiology of cancer. Cer- PRIMARY CARCINOMA OP GALL-BLADDER 
19 
tain positive relations of probable cause and effect can be pointed 
out, while in this particular location of carcinoma its greater fre- 
quency in the female is established. Of the influence of heredity or 
occupation, or hygiene, food, drink, or personal habits, climate or 
country, nothing can be learned. 
“Among other causes considered are local injuries, as by a blow 
(Robinson, Fitzgerald) or a fall (Moxon’s case), or the irritation 
produced by tight lacing. Marquand reports a case of the latter.’’ 
Musser gives the following ages at which primary carcinoma of 
gall-bladder develops: 1 to 10 years, 1; 10 to 20 years, o; 20 to 30 
years, 1; 30 to 40 years, 9; 40 to 50 years, 19; 50 to 60 years, 27; 
60 to 70 years, 19; 70 to 80 years, 14; 80 to 90 years, 1; unrecorded, 
9; total, 100. 
Symptoms.—Krauss calls attention to the fact that in his five 
cases four patients experienced from the start, and one later, spon- 
taneous pains that could be elicited by pressure in the region of the 
gall-bladder or at least on the right side of the abdomen. The pains 
differed in intensity. In three cases a tumor could be felt in the 
region of the gall-bladder; in the fourth case palpation only occa- 
sionally gave a result; and in the fifth case the tremendously 
enlarged liver covered the enlarged gall-bladder so completely that 
it could not be felt. In all cases icterus came sooner or later. Dis- 
turbances of the intestinal tract existed in all five cases. There was 
some ascites in the second and fourth cases, but no fever in any of 
them. The pulse was normal in some, accelerated at times, and in 
the others slow. Respiration was generally normal, though some- 
times accelerated. Cachexia came in all cases earlier or later. The 
* 
disease lasted from two to eight months. 
Musser says that in ioo cases gathered by him, in 68 tumors 
were discovered in the following locations: In the right hypochon- 
drium of gall-bladder region, in 27 cases; attached to the liver, 10; 
in umbilical region, 12; in the iliac fossa, 4; in the flank, 2; near 
the pylorus, 1. Jaundice occurred in 69 cases, and vomiting in 39. 
There was distinct emaciation noted in 44 cases, diarrhea in 15, 
fever in 18—due to infectious complications of the bladder or ducts, 
or to peritonitis or ulceration. 
Diagnosis.—Krauss thinks it hard or even impossible in some 
cases to make a diagnosis intra vitam of primary carcinoma of gall- 
bladder or of carcinoma of the gall-bladder. In many cases a correct 
diagnosis can be made, if careful repeated examinations are made 
and if all symptoms receive due consideration. A smooth or nodu- 
lated tumor of firm elastic consistency felt in the region of the gall- 20 
PRIMARY CARCINOMA OF GALL-BLADDER 
bladder, spontaneous pains or pains on pressure in the same region, 
and cachexia, are the points to be particularly considered. The 
diagnosis will be supported if the history shows that there has been a 
cholelithiasis at some time. Icterus, ascites and disturbances of the 
intestinal tract are only of secondary importance. 
In closing, the writer wishes to tender his sincere thanks to Dr. 
W. G. Knap of Chicago, who has made the microphotographs. 
Literature.—D. Dock: University Medical Magazine, 1895-6, viii, 90-95. Graham: 
Canadian Practitioner, Toronto, 1895, xx, 3x9-326. Lancet, London, 1896, ii, 1002-5. Allg. 
Wiener Med. Zeitg., 1896, xii, 188-98. Montreal Medical Journal, 1895-6, iv, 241-53. Musser: 
Transactions of the Association of American Physicians, vol. iv, 1889, p. 302; Morgan. Ames: 
Johns Hopkins Hospital Bulletin, vol. v, No. 41, 1894, p. 74. Siegert: Virchow’s Archiv, 132, 
1895, p. 353; Morgan. Lambl: Zottenkrebs, Virch. Arch., 8, p. 133. Krauss: Prim. Gallen- 
blasenkrebs, Deutsche Arch, fur Klin. Med., 34, p. 270, 1883. Quetsch: Ueber Prim. Gallen- 
blasenkrebs, Berliner Klin. Woch., 1885, No. 42. Durand Fardel: Dissertat., Leipzig, 1840. 
W. Pepper: American Journal of the Medical Sciences, Philadelphia, 1857, xxxiii, pp. 13-25. 
Paulicki: Schmidt’s Jahrbiicher, bd. 146, 1870. Coraza: Schmidt’s Jahrbiicher, bd. 160, 1873. 
Moxon: Villous Cancer of Gall-Bladder, Constatts Jahresber., ii, 1868. Carpentier: Presse 
Med., xxviii, 12. Haas: Prager Vierteljahrsschrift, cxxxii, No. 131. Heurot: Gazette des 
Hopitaux, 108. Planteau: Bull, de la Soc. Anat., 3 ier, x, 3, p. 689, 1875. Fenger: American 
Journal of the Medical Sciences, February and March, 1896. Remy: Bull, de la Soc. Anat., 3 
ier., x, 3, p. 203. Cohn: Ueber den Prim. Krebs d. Gallenblasen, Breslau, 1879. Urarkhaus: 
Prim. Krebs d. Gallenblase, Pathological Transactions, vol. viii, p. 243,1857. Orth: Sper., 
Path. Anat., vol. iii. Courvosier: Cited by Fenger. Riedel: Gallensteinkrankheit mit und 
ohne Icterus, Berlin, 1892. MEDICINE 
EDITOR-IN-CHIEF: - HAROLD N. MOYER, M.D., 
Adjunct Professor of Medicine. Rush Medical College; Neurologist 
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DEPARTMENT EDITORS: 
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HAROLD N. MOYER, M.D., Editor. MEDICINE 
A Monthly Journal of Medicine and Surgery. 
HAROLD N. MOYER, M. D., 
EDITOR. 
VSrl 
MAY, 1896. 
• 1 oo 
CONTENTS. 
ORIGINAL ARTICLES. 
two RARF DISLOCATIONS OF THE PATELLA By Edmund Andrews. M.D., LL.D 3SJ 
PRESENT STATUS OF OPERATIVE TREATMENT FOR BLADDER-STONE. Bv Arthur Dran 
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