An Experimental Investigation of Some of the Conditions Influencing the Secretion and Composition of Human Bile

6~ Secretion and Composit ion of H u m a n Bi le bile. Later he mixed with the food on one occasion 1 gramme of calomel. H. Nasse concludes from his results that calomel increases the total quantity of bile secreted, but that it diminishes its solids. Koelliker and Mueller* experimented on a dog with a permanent biliary fistula. They studied the effect of calomel, and to some extent also of aloes, the observations being made on different days during very short units of time. Calomel during one experiment increased the secretion of bile slightly, and in fur ther experiments it seemed to diminish the flow of bile. Aloes did not seem to have any action whatever. Mosler~ experimented on dogs with permanent biliary fistulm. As the title of his publication shows, he did not make a special study of cholagogues. 0n ly with one of the drugs employed, namely, calomel, did he mention that he could not find any noticeable increase in the flow of bile, as practitioners seem to believe. G. Scoffs made his observations on a dog with a permanent biliary fistula, usually during 24: hours, sometimes for a longer period, and compared the variations in the amount of bile secreted during time units of 24 hours. He came to the conclusion that calomel in large doses produced " a diminution in the amount of fluid bile and bile solids." The subject of cholagogues was fur ther investigated experimentally by a committee of English physicians, of which Hughes Bennett was chairman.§ The result of this investigation was that mercuric chloride, calomel and pil. hydrargyri did not increase the flow of bile. Podophyllin and taraxacum have also no cholagogue action, according to the same authors. Bennett and his collaborators experimented on dogs with permanent biliary fistulae. The next investigation was made by A. Roehrig.¶ He experimented on curarized dogs and rabbits. He counted the drops of bile flowing from the cannu]a inserted into the opened gall bladder. The time units were measured by a metronome. Roehrig came to the conclusion that croton oil, extr. colocynthidis, sapo jalapinus and aloes acted as powerful *]3erieht fiber physiologische Versuche. Vrhdlg. der Wiirzburger physikaldsch-me~cin~schen Gesel~schaft, Bd. v, 1855. t Untersuchungen fiber den Uebergang yon Stoffen aus dem Blute in die Galle. Virchow's Arcldv, Bd. xiii, p. 29, 1858. :~ On the Influence of Mercurial Preparations on the Secretion of Bile. Beale's Archives of Medicine, col. i, p. 209. § Br~tish Association. Reports, 1868. ¶ Abstracted in Virchow u. Hirseh's Jahresbericht, 1873, i, p. 143, and Stricker's Jahrbiicher, 1873. Franz Pfaff and Alfred W. Balch 63 cholagogues before the aperient effect of these drugs became manifest. Rheum, senna, magnesium sulphate, calomel, and croton oil are, according to this author, less powerful cholagogues. In 1879 Rutherford* published his experimental investigation of cholagogues. He had as collaborators W. Vignal and W. T. Dodds. These investigators experimented on fasting curarized dogs with temporary fistulae. They tried a great number of drugs, and came to the conclusion that mercuric chloride, sodium phosphate, jalap, aloes, sodium salicylate, etc., are powerful cholagogues. Calomel, according to their investigation, acts only as an intestinal stimulant, not stimulating the liver. The duration of each experiment was about 6 to 8 ~ours. Before entering into the study of cholagogues, Rutherford and his collaborators observed first the normal flow of bile in curarized dogs. Two of the published curves show clearly the irregular flow of bile in such animals, and ought to have cautioned the experimenters as to the propriety of drawing conclusions from small variations in the flow of bile observed under the infiuence of drugs during small time units. Siegfried Rosenberg t studied the effect of supposed cholagogues on fasting dogs with permanent biliary fistulae. He concluded that olive oil and fats are the most powerful cholagogues. He studied further t h e action of salicylate of soda, Durand's mixture (ol. terebinth plus ether), and of Carlsbad salt. The first of these drugs is a cholagogue, according to Rosenberg. Durand's mixture gave no positive results, and Carlsbad salt negative results. Rosenberg published protocols, which, according to him, warranted the conclusions he drew. But we fail to deduce such conclusions from his published results. The only one we can come to is that the flow of bile, even in a fasting animal, is very irregular. Rosenberg often observed about 100 per cent difference in the quantities of bile secreted from one hour to another, while the animal was only fastened to the table and was given no drug whatever. The amount of bile secreted, after olive oil or after food, showed little difference. Rosenberg's unwarranted conclusions found their way into practical medicine, and even in our days patients are drugged with doses of olive oil ad ~auseam, on the supposition that the oil is a powerful cholagogue. Attilio Batt~stini~ experimented on dogs with a Bernard's fistula. He does not give in detail any results of his experiments with santonin, Loc. cir. Ueber die cholagoge Wirkung des Oliveni~ls im Vergleich anderer cholag. Mittel. Pfliiger's Archly, 1890, Bd. 46, p. 334. :~ Einfluss des Santonlns auf die Gal lenausscheidung. Molesehott's Untersuch~ng~, xiii , p. 414 (1888). 64 Secretion and Composition of Human Bile but only tabulates them grossly, so that a verification of his conclusion that santonin is probably the best cholagogue existing is not possible. T. L. Pr~vost and Paul Binet* studied a long list of supposed cholagogues and the elimination of medicaments by the biliary secretion. They divided the substances experimented on into (1) cholagogues like urea, terpinol, chlorate of potash, salol, etc.; (2) substances of doubtful properties: Carlsbad salt, aloes, rhubarb, etc.; (3) substances diminishing the flow of bile, such as calomel, atropin, etc. Fats had, according to these authors, no influence upon the secretion of bile. Bile itself is, according to them, "surely the most powerful cho]agogue." The experiments were made chiefly on two dogs. D. Baldi t made his observations on dogs with permanent biliary fistulae. In his experiments the time of observation ~'aried from 6 hours to 24 and more. Baldi showed from the observations on normal dogs, that is to say dogs that are not under the influence of drugs, that the hourly secretion of bile is very irregular, and that the influence of food upon the secretion is also very irregular. As supposed cholagogues, he tried podophyllin, rhubarb, jalap, sodium phosphate, pilocarpine and Carlsbad water. He concludes that not a single one of these substances increased the amount of bile secreted. He further tried the influence of ox gall on his dogs, giving this drug either per os, once 190 ccm., or in small quantities intravenously. After ox gall he always found a decided increase in the secretion of bile. In late years very carefully conducted investigations of cholagogues have been specially performed on dogs b y E. Stadelmann and his pupils, Nissen, Mandelstamm, Mueller, Loewenton, and Glass. Stadelmann$ summarizes the results of these different observations, showing that with the exception of bile itself, and possibly salicylate of soda, there are no substances which act as cholagogues. He insists that it is absolutely incorrect and faulty, on account of the irregular flow, to draw comparative conclusions as to the flow of bile from observations extending over short periods of time. A. Gamgee § does not think that Roehrig 's and Rutherford ' s experiments must be "necessarily" incorrect because other observers have found by other methods different results. H e advises that the whole * Recherches exp~rimentales relatives ~ Faction des m~dicaments sur la s~er~tion biliaire et ~ leur ~liminatiou par cette s~cr~tion. Compt. rend., cvi. t Recherches exp~rimentales sur la marche de la s~cr~tion biliaire. Arch. 4tal. de Biologic, tome iii, p. 389. $ Therapeutische Monatshe#e, 1891, p. 511. § Text-book of Physiological Chemistry. By A. Gamgee, p. 347. Franz Pfaff and Alfred W. Balch 65 chapter of cholagogues be investigated anew with the aid of Schiff's amphobolic biliary fistula. We do not think this is necessary, as Roehrig's and Rutherford's conclusions are based on faulty suppositions, and therefore should not be sustained any longer. Beside the experimental investigations of cholagogues carried on on dogs and other animMs, a few experiments have been made on human subjects with biliary fistulee. In Westphalen's* ease the effect of large quantities of water, of calomel, and of quinine on the biliary secretion was tried. Large quantities of water did not increase the flow of bile, nor did its quality become altered, whereas the urine of the patient doubled in quantity and its specific gravity diminished. The results agree perfectly with the results of Kunkel, t Stadelmann and other experimenters upon animals. Calomel given in 1.3 grammes did not increase the amount of bile secreted by Westphalen's patient. Quinine given in 2-gramme doses could not be detected in the bile, nor did it affect its flow apparently. Copeman and Winston$ gave their patients pills made from purified ox gall, in doses of ten grains three times a day. The first two days there was an increase in the daily amount of bile excreted. But in spite of the patient continuing to take these pills, the amount of bile daily secreted fell after three days to about the same as before. The pills were discontinued after a fortnight without causing thereby any noticeable lessening of the flow. To these results we shall refer again. Mayo Robson § tried on his patient, as supposed cholagogues, calomel, rhubarb, podophyllin, carbonate of soda, iridin, turpentine and benzoate of soda. tie comes to the conclusion that " t h e supposed cholagogues investigated seem rather to diminish than increase the amount of bile excreted." Of experimental investigations of eholagogues made on human subjects, the preceding are all the results which we could find in the literature. All the more recent experimental investigations of this subject made on animals have led to the result that all the supposed cho]agogues, *Loc. cir. t E isen und Farbs tof faussehe idung in t i e r Galle. Pi t i lger 's Archiv, xv, p. 353. :~ Loc. cit. § Loc~ cir. 5 66 Secretion and Composition of H~tman Bile with the exception of bile itself, and possibly salicylic acid, do not increase the flow of bile, that is to say, are not cholagogues. Bile, as is now generally taught in works on physiology, after being discharged into the duodenum, is to a certain extent reabsorbed and again used for new secretion. I f this is true, bile given internally must naturally increase the flow of bile coming from a biliary fistula. This phenomenon of reabsorption of the bile is now spoken of as "circulation of bile," and to Schiff is given the credit of having established for the first time this fact. We find in perusing the older literature that in the second half of the last century the probability of reabsorption of the bile or some of its products was already discussed.* In the present century Liebig was the first to formulate precisely a theory of reabsorption of the bile from the intestinal tract. This theory seems to have been generally accepted by scientific investigators of his time. We find allusions to this theory in different places, as by E. yon Gorup-Besanez,t Rheinhold Schellbach,$ T. Ne , komm,§ and especially by C. G. Lehmann.¶ Here Liebig's theory ot the " circuit " of the bile " from the liver to the intestines and thence back to the l iver" is very clearly put forward. I t is true the theory could be only indirectly sustained by the examination of the contents of the bowel, " in various portions of the whole intestinal tract from above downwards." This examination " almost necessarily leads us to adopt the view that the greater part of the bile is again reabsorbed as it passes through the intestine and is returned to the general mass of the fluids." The first direct experimental proof that biliary constituents if absorbed are again secreted by the liver was given by Huppert.! He determined in rabbits with fresh biliary fistulae the biliary secretion and the amount of sodium glycocholate and taurocholate in it. A~ter* E x p e r i m e n t s upon the H u m a n Bile and Reflections on the Bil iary Secret ion. By J a m e s lVl'Clnrg. London, 1772. -~ Ueber die F u n k t i o n der Galle. Liebig ' s AnnaZen, 1851. $ U n t e r s u c h u n g e n fiber Galle. Liebig ' s A~nalen, 1846. § Nachwe i sung der Gallensi£uren und die U m w a n d l u n g derse lben in der Icllutbahn. Ibid. 1860. ¶ Physio logica l Chemis t ry . T rans la t ed by G. E. Day. Vol. ii, p. 110. t Ueber das Schicksal der Gal lens~uren im Ictert ls . Archiv der Heilk~nde, 1864. Franz Pfaff and Alfred W. Balch 67 wards he injected bile constituents subcutaneously. He says: " I t may be concluded with certainty from these observations that the liver also secretes a by no means inconsiderable fraction of the bile acids which have passed into the blood." Only a few years later, 1868, appeared the well-known publications of M. Schiff* on this subject, and they caused much controversy. N. Socoloff, t working in Hoppe-Seyler's laboratory, denied absolutely any quantitative increase of bile constituents after injection of bile. Looking carefully over his experiments, we again find another proof that it is quite impossible to draw conclusions from experiments on animals with biliary fistulse if these experiments are conducted for a few hours only. Socoloff collected in his first experiment during the first hour 0.247 gramme bile, and in the subsequent hour 2.212 grammes, and in another experiment with the same animal during the first hour 11.207 grammes bile, and in the subsequent hour 4.064 grammes. Such variations in the normal flow of bile are too great to allow any positive conclusion--from comparisons during such units of time as to the action of supposed cholagogues. I t would take too long for us to ~ve a detailed account of all the investigations in this line. We shall mention only the results obtained by Rosenkranz,~: who experimented on dogs with complete and incomplete fistulae. The time of observation in his experiments extended often over 24 hours. His results may be thus summarized: "Bile, if given into the stomach or into the intestine, increases the secretion of bile discharged from the fistula. There is not only an increase of the absolute quantity of bile secreted in the time units, but also an increase in the percentage of solids. The quantity of solids may increase after ingestion of bile to twice or three times its original amount. I f one injects bile rich in solids, a greater amount of bile is discharged from the fistulous opening than after the ingestion of the same quantity of dilute bile." * Gal lenbi ldung abh~ng ig yon der A u f s a u g u n g der Gallenstoffe. Pfl l iger 's Archly, iii, p. 598. t E in Be i t r ag zur K e n n t n l s s der Lebersekre t ion . P f l i i g e r ' s Archly, xi, p. 166. Ueber das Schicksal und Bedeu tung e in iger Gal lenbes tandthei le . 'Vrhdlg. der ohysikal, medic. Gesellschaft ¢n Witrzburg, xiii, p. 218. 68 Secretion and Composition of Human Bile Objections may be made to conclusions drawn from the percentage of solids of a bile as to the supposed amount of giycocholie and taurocholic acid in it, such conclusions being misleading. In our experiments we not only determined the amount of bile solids in each sample of bile, but also the amount of ash, to establish an absolute proof of a supposed increase of combustible substances. But as such substances need not necessarily be, and as we shall see are not always formed by characteristic bile elements, we determined for different series of experiments the quantity of glycocholic and taurocholic acid found in the bile of the corresponding periods. As we had concluded to try bile on our patient for its supposed cholagogue action, the question arose, what bile should we give, in what form and to what extent? That bile circulating in excess in the system has a depressing action on the circulatory system is a we]lknown fact which has been observed abundantly on patients suffering from jaundice and also after direct experiments on animals.* Besides this, the nauseating and purging effect of bile had to-be avoided if the results to be obtained were to be trustworthy. We thought that by giving dried bile in pill form the nauseating taste and smell would be avoided. What kind of bile should we give ? There is no positive proof, nor even a strong probability, that bile of different animals--in spite of its varying amount of the characteristic bile acids--would act different]y. Nevertheless we find it stated by different experimenteTs that animals react differently to different biles. As we had of course to use the utmost caution with our patient, we thought it wise to try first the effect of her own bile on her system before resorting to bile of other origin. In what quantities should we give the bile? This depended entirely on the question--to what extent is bile reabsorbed from the intestine We do not know. I f given in small quantities, the amount of reabsorbed bile may be so small that the difference in the total quantities of bile excreted through the bilial:y fistula might be regarded as a normally occurring variation, and the supposed cholagogue action could * R o e h r i g , U e b e r d e n E i n f l u s s d e r Gal le a u f d ie ]~Ierz thKt igkei t . Archiv der Heilkunde, 1863, p. 385. Franz Pfaff and Alfred W. Baleh 69 not be positively demonstrated. We reasoned that the amount of bile which our patient secreted daily was the minimum amount of bile which would physiologically reach the intestines. We say the minimum amount, as it is a well-estaMished fact that bile gained by a fistula has always less solids than normal bile. In our case the patient was not reabsorbing bile for over two months at least, that is to say since the date of the operation. Therefore the amount of bile collected from the fistula during 24 hours could be regarded as representing the total quantity of fresh bile formed daily in our subject. Whether the same quantity of fresh bile is formed daily when reabsorption of bile is possible is of course impossible to determine. To imitate nature we had therefore to give to our patient daily at least the same quantity of bile she discharged through the biliary fistula. For obvious reasons we began to give her at first much smaller quantities, but we increased the amount gradually, until finally she was Even per os daily nearly the equivalent of bile which was discharged per