500 



Mr. A. W. Mayo Robson. On the [Apr. 24, 



Case I. — Biliary Fistula. 



Mrs. Y. B., aged forty-two, was operated on in January, 1888, for 

 the relief of obstruction in the common bile duct. The incision was 

 made over the gall-bladder, which was brought to the surface, 

 relieved of its contents, and opened, the margin being sutured to the 

 edge of the abdominal wound and drained. The patient made a good 

 recovery from the operation ; but a biliary fistula persisted, through 

 which was discharged the whole of the bile for fifteen months. In 

 order to ascertain that the whole of the bile secreted escaped through 

 the fistula, and that none entered the bowel, repeated analyses of the 

 urine and faeces were made, but no evidence of the presence of bile 

 was obtained at any time. The fistula was ultimately closed by 

 stitching the gall-bladder to the bowel, and making a communica- 

 tion between them, thus enabling the bile to reach the intestine by 

 another channel. A detailed description of the case will be found 

 in the 1 Transactions of the Royal Medical and Chirurgical Society ' 

 for 1889. 



Influence of Biliary Fistula on Digestion and Nutrition. — During 

 the fifteen months that the fistula was open, the patient's diges- 

 tion seemed to be unimpaired. The appetite generally was good ; 

 there was a craving for acids, such as lemons and pickles, and 

 a dislike to sweet foods, to meat, and to fat. Much fatty matter in 

 her food had a marked effect, producing a sickly feeling, with loss of 

 appetite, and rather more fat than normal was then noticed in the 

 faeces. Her bowels were quite regular without the use of aperients, 

 and the odour of the faeces did not differ from that of healthy motion. 

 Menstruation never occurred during the time the fistula was patent, 

 but, as soon as the bile was again turned into the intestine, the 

 menstrual function became regular and normal. 



Case II. — Fistula of Gall-bladder not Biliary. 



Mrs. A., aged thirty-two, was operated on in June, 1884, for dis- 

 tended gall-bladder due to gall-stones, with stricture of the cystic 

 duct ; the patient made a good recovery from the operation, but a 

 fistula of the gall-bladder persisted. From this opening a constant 

 flow of a clear and somewhat viscid fluid persisted, which was held 

 to be the normal secretion of the gall-bladder, as there was complete 

 obstruction of the cystic duct, and as no bile constituents were found 

 in the fluid at the time of the operation or subsequently. 



Analyses of the fluid from this patient were made in October, 1885, 

 and in April, 1887, by Professor de Burgh Birch, of the Yorkshire 

 College (see ' Journal of Physiology,' vol. 8, No. 6), and in March, 

 1889, by Mr. Fairley, F.C.S., F.R.S.E. In the appended tables will 



