Edmund Andrews

Mechanism of Death in Bile Peritonitis

Conclusions The amount of plasma-like peritoneal exudate in experimental bile peritonitis indicates that the loss of this fluid from the blood stream is an important factor in the production of shock and death in this condition.

A Method for Estimation of Both Bile Salts and Cholesterol in Small Amounts of Bile

In experimental and human studies on the chemistry of the bile, it often happens that only very small amounts of bile are available in the gall bladder, as the contents of the diseased viscus are frequently very scanty. It is in these very ones that analysis of the bile may be the most important. The following method enables one to determine both the bile acids and cholesterol in a single cubic centimeter of bile. Following the suggestion of Dr. F. C. Koch the marked affinity of petroleum ether for bile salts was utilized. The principle is that petroleum ether has the power of making a quantitative separation of the bile acids and cholesterol in alcoholic solutions. The procedure is as follows: One cc. of bile is diluted with 6 cc. of alcohol, brought to a boil and filtered to deproteinize. The filtrate is then shaken in a separatory funnel with 30 cc. of petroleum ether and extracted 3 times. The alcoholic fraction is then warmed to drive out the petroleum ether and used for the bile acid determination. The ether fraction (about 100 cc.) containing the cholesterol is placed in an ordinary 37° incubator and will evaporate to dryness in 30 to 45 minutes, as its boiling point is 25° to 65°C. It is then dissolved in chloroform, made up to 5 cc. and used for an ordinary colorimetric cholesterol estimation. The pigments remain in the alcoholic fraction. Thirty-five samples of bile, normal and abnormal from dogs and humans have been studied for controls of this technique. In no case could any test for bile acid be obtained in the ether fraction or for cholesterol in the alcohol fraction. In 2 cases difficulty in separating the layers in the funnel occurred. This in each case was overcome by the addition of 2 drops of water.

Studies on Acholic Cachexia. VII. Effect of Viosterol.

Conclusion Viosterol does not exert a favorable influence on dogs with complete biliary fistulae.

Effect of histamine and alcohol on acid secretion of stomach of postoperative cases.

Conclusion Histamine and alcohol have their usual action of stimulating gastric secretion in the postoperative surgical patient. Their administration is clinically beneficial.

Experimental Hepatogenous Cholecystitis.

Gall bladder bile in dogs cultured in our laboratory has been shown by Rewbridge 1 to be almost invariably sterile. In a series of experiments in which biliary stasis had been present for varying periods of time B. welchii and lesser numbers of cocci and B. coli were grown from the bile in 76% of cases. Biliary stasis had been produced not only by ligating the cystic duct, care being taken to avoid the cystic artery, but also by common duct ligation and by both procedures. In most of these experiments not only were these bacteria present but marked evidences of cholecystitis were found. Gross specimens of these gall bladders revealed the interesting fact that the infection undoubtedly made its way into the gall bladder not through the bile or the blood stream but by direct extension from the liver. This could be seen by killing the dogs in various stages of the process. In the early stages (1-4 days), the gall bladders presented the picture of a cholecystitis only on the hepatic surfaces. The free peritoneal side at this period is thin, normal in appearance both grossly and histologically. The hepatic surface is thickened, often to 10 times normal and its wall shows edema and infiltration of leucocytes and round cells. Later the inflammation extends around the entire circumference of the viscus. The mucosa generally remains quite normal even in the later stages when the other layers of the wall show marked inflammation. The work of Dragstedt 2 and later of Andrews 3 on the rich anaerobic flora of the liver has shown that these organisms are constantly present and it now becomes evident that in stasis they may make their way into the gall bladder in large numbers.

Toxic Effect of Various Concentrations of Bile on Dog's Gall Bladder.∗

Summary 1. Concentration of ox bile more than half, has a marked toxic effect on the dogs gall bladder, causing death and bile peritonitis in many instances. 2. The foreign matter in bile is not the cause of these changes since the gall bladder is not affected by bile which is not concentrated. 3. Redilution of concentrated bile makes the bile ineffective, proving that infection is not responsible for the change.

Effect of Varying pH on Toxic Effect of Bile Salts on the Normal Gall Bladder.

Conclusion The toxic action of the bile salts on the normal gall bladder is not affected by alteration of the pH unless it exceeds the normal pH range of gall bladder bile.

Studies on Acholic Cachexia IV. Relation of Biliary Diversion to Duodenal Ulcer Formation.

The occurrence of peptic ulcer of the duodenum after the exclusion of bile has been noted with a wide variation in frequency and the factors concerned are not clearly understood. Kapsinow and Harvey, 1 using a cholecystnephrostomy, produced ulcer in 17 out of 43 animals. Bollman and Mann 2 by simply ligating the common ducts produced ulceration in about 60%. In the experiments of Berg and Jobling 3 in which a Rous type of fistula was used, ulcers resulted in 13 of 23. Kim and Ivy report 10% ulcers in one series 4 in which the common duct was tied, but 60% in cases of Rous fistula. Besides the obvious acid factor, there is considerable evidence that other influences are at work. Ivy has suggested that the mechanical irritation of the tubing near the duodenum may be important. On the other hand Elman has seen but few ulcers resulting from bile fistula alone. Our own experience has been that simple duct ligature alone caused ulceration in numbers about one-half the rate usually suggested (60%), but that a very high percentage resulted from the Rous fistula which has proven very difficult technically in our hands. Berg suggests that the general condition of the dog is very important and found that animals kept under poor hygienic conditions developed ulcer in 100% while those better cared for showed only 30%. Using the Dragstedt cannula for making the biliary fistulas we have been surprised at the freedom from this complication. Twenty such experiments have been made and not a single ulcer has developed, as evidenced either by post-mortem examination or presence of blood in the stools. These animals have been fed on various diets, some with large amounts of meat and others with high carbohydrate content.

Studies on Acholic Cachexia. VI. Bile Acid Factor.

Conclusion Acholic cachexia is not due to lack of bile salts in the body.

Studies on Acholic Cachexia. V. Pathological Changes.

Conclusion 1. In uninfected bile fistulas no degenerative changes in the liver occur nor does osteoporosis.