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Un dea symbolee suivanta apparattra sur la darnlAre imaga da cheque microfiche, selon le caa: la aymboia — »• signifie "A SUIVRE". le symbole ▼ signifie "FIN". Mapa. plataa, charta, etc.. may be filmed at different reduction ratios. Those too large to be entirely included in one expoaura ara filmed beginning in the upper left hand corner, left to right and top to bottom, aa many framea aa required. The following d'agrama illuatrata the method: Lea cartea. pianchaa. tableaux, etc., peuvent Atre filmte i dea taux da rMuction diff^enta. Larsque le document eat trap grand pour Atre rt^produit en un seui cliche, il est filmi k partir da I'angia sup4rieur gauche, de gauche A droite, et de haut an baa. en prenant le nombre d'imagea n^caaaaira. Lea diagrammas suivanta illustrant la mithoda. 1 2 3 1 8 3 4 S 6 i ■■ . .. . c pa rv A . G A CASE OF CHOLECYSTICO-GASTRIC FISTULA WITH ACCOM- PANYING DIVERTICULA IN THE DUODENUM. BY A. G. NIOHOLLS, M.A., M.D., Demonstrntor of Pathology, McGill University , Assistant Pathologist to the Royal Victoria Hospital, Montreal. (Reprinted from the Montreal Medical Journal, November, 1S9S.) MEDICAL FACULTY, McGILL ^ A CASE OF CHOLECYSTICO- GASTRIC FISTULA WITH ACCOMPANYING DIVERTICULA lU THE DUODENUM. HV Alhlrt G. Xhjholls, M.A., M.D., Demonstrator of Pathology, McGill University ; Assistant PatholoKist to the Royal Victoria Hospital, Montreal. It is not necessary to point out that there are instances on record in which as a consequence of cholelithiasis the j^all -bladder forms fistulous connections witli an extraordinarily large number of other organs ; intestines, urinary passages or genitalia, the trunk or branches of the portal veins, the bronciii, and the outer surfaces of the body. ' H' these forms, the gastro-intestinal and the cutaneous are by far the ru st frequent and important. In the gastro-intestinal, connections between the gall-bladder and the stomach are comparatively rare. Von Schueppel, in his well known article upon diseases of the biliary passages in Ziemsen's Cyclopoedia, merely mentions their rarity, nor have I been able in a rapid review of the literature to come across any statistical table giving the frequency. Apparently very few cases have been recorded, and most recent writers upon diseases of the bile- passages have been content to refer to the older authors, such as Mur- chison and Courvoisier, without having seemingly met with the condition in their own experience. Cases of vomiting of gall-stones seem not to have been so infrequent but as spontaneous cure takes place readily, very few have been con- firmed by post-mortem examination. In general the cases in which there are instances of such gastro- intestinal biliary fistula give no history and present no symptoms. The case I am about to narrate presents this feature. Mrs. M., an aged woman of 85, was admitted to the Royal Victoria Hospital under Dr. Garrow, to whom I am indebted for these notes, with an impacted fracture of the head of the right femur. According to her statement, save for injury to the right shoulder some 20 years ago, she had always until this accident enjoyed good health. Upon clinical examination, the vascular system was found normal '■> a few moist rales were heard over the right base below and there was nothing abnormal in the urine. The abdomen was somewhat sunken and the bowels constipated. She became gradually weaker, and a ow form of delirium set in. While no special symptom called for notice, she gradually failed and died some two weeks after ad- iiiissioij. At the Jiutopsy perfurmt'd uij^ht hours after death, there was little evidence of any inHannnation round the seat of the fracture, the neck hiding found firmly impacted in the head of the V)one. The organs in general w( re ligl't and small presenting advanced senile atrophy- The vessels presented extensive atheroma. The stomach was long and fusiform witi) atrophied walls, almost empty. The main feature was the existence of an adhesion between the pyloric region one-half inch from the pylorus along the line of the lesser curvature to the gall-bladder. The duodenum was deeply congested in the region of the bile papilla. That papilla was absent being replaced by two ulcerous openings leading into the distended end of the common bile duct which was occupied by a mulberry-like calculus the size of a hickory- nut, and much yellowish inspissated bile. To the condition of the duodenum I shall return, only mentioning that the rest of the intes- tines beyond presenting senile atrophy, were normal throughout. The liver was small, thin, and flabby, of a dark colour, showing upon section a considerable amount of bile staining. Upon attempt- ing to remove the bile from the gall-bladder in order to make bacter- iological cultures, only gas and whitish muco-purulent material passed into the pipette, and for a moment it seemed as though a mistake had been made and that a loop of the transverse colon was taken for the gall-bladder. Further examination, however, showed that between the anterior wall of the gall-bladder, which was considerably elongated and the stomach, was a fistulous opening large enough to admit a large probe. One suiall rather mulberry-like calculus the size of a small cherry and of the mixed pigment and cholesterin type was present in th