CONGENITAL MALFORMATION OF FOREARMS ANI HANDS, WITH CONCOMITANT ATROPHY OF THE BICEPS AND BRACHIALIS ANTICUS MUSCLES
1265 again accumulating in the abdomen. In this way she went on with, but little change, till the morning of April 23rd. On that morning the flow of bile ceased suddenly, so that the dressing removed on the morning of the 24th only contained a trace. The ascites had become so distressing that I tapped, drawing off on the afternoon of that day 294 ounces of a bile-stained fluid containing a considerable amount of blood. After this the record is that of a patient dying slowly, but without pain,
... an incurable disease. On May 8th she died. The post-mortem examination revealed cancer of the pancreas and liver, especially the left lobe. The common bile duct was completely occluded, and perforation had occurred at its origin. Remarks.-On reviewing the case, it appears to me that the tale of her illness as told by the patient is a history of biliary calculus. The intermittent character of the tumour she felt in her abdomen seemed rather to indicate calculus causing obstruction than stenosis of the duct from malignant disease; white the transitory jaundice referred to by her friend and the colicky pain shooting through to the back were alike characteristic of gall-stones. I expected to find a calculus causing obstruction of the common duct, and on ending that the only stone present was fixed in the cystic duct, I concluded that its presence had occasioned hepatitis and catarrh of the common duct. The smooth regular 'border which the right lobe of the liver presented favoured this view. No doubt the ascites, the frequent pulse, and evening rise of temperature indicated a malignant origin. On April 7th I telegraphed to Mr. Lawson Tait, desiring his opinion with regard to treatment of the fistulous opening in riew of the excessive flow of bile. He very kindly replied at once, and wrote to me saying that the condition was new to him, but that he suspected malignant disease. The sudden stoppage of the flow of bile from the fistula was no doubt due to perforation of the common duct, and to the same cause we may attribute the presence of blood in the abdomen. The occurrence of monthly bleeding from the gums, which was noted by the patient, cannot, I think, be regarded as in any way related to menstruation, when we consider the pathological conditions presented by the case.