liver, but in hepatic insufficiency it is eliminated by the lungs, the expired air blackening paper wet with lead acetate solution.

Uroerythrin is a bright pink color so often seen in the brick dust sediments of urine; it occurs in acute diseases of the respiratory system, in acute rheumatism, and in gout. It is probably only in the latter case that it can be considered as evidence of impaired hepatic function.

A diminution of hippuric acid is said to be a symptom of hepatic deficiency, but as only 0.3 to 0.4 gramme of hippuric acid is eliminated normally in the twenty-four hours it can not be a test of great value. The presence of small quantities of bile pigment in the urine which can be tested for very easily by means of Robins' test, is almost positive proof of a congestion of bile within the liver. The examination of the feces is not as often carried out as it might be; absence of bile or disease of the biliary duct causes the alcoholic stool and also increases the amount of fat. Especially in infancy and childhood is the pale stool of diagnostic import, it being positive evidence of an inefficient liver.

The toxicity of the urine has been demonstrated by Bouchard and his pupils. As the liver is the guardian of the body against intoxication, hypertoxicity of the urine may be considered as a sign of impaired hepatic function, but the methods at our disposal for testing the toxicity of the urine are unreliable.

There is a condition of hyperazoturia in which the examination of nitrogen by the urine is enormously increased—not those conditions of hypercritical elimination which occasionally occur owing to some retention, but conditions in which the daily average elimination of nitrogen reaches 15 to 20 grammes or even 25 grammes. In these cases the percentage of urea nitrogen may be normal or even above normal. Cases are on record in which the percentage of urea nitrogen was as high as 98. The neutral sulphur is also diminished to less than 10 per cent of the total sulphur. In these cases there is probably a hypersecretion of bile, but this is difficult to prove. On physical examination the liver is usually large, hard, and tense. This condition occurs in gross feeders, the liver being stimulated to over-exertion, necessarily followed by cell fatigue, with consequent hepatic insufficiency and atrophic cirrhosis.

In the treatment of hepatic insufficiency it has to be remembereil that any one of the functions may be insufficient, and therefore it is of importance that they should be differentiated by the foregoing tests, which will show the condition of the glycogenic, the biliary, the urogenic, the antitoxic, and the oxidative processes.

There are a certain number of drugs that are used in hepatic disease somewhat empirically, no pharmacodynamic study having been made of their action excepting in cases of natural or artificial biliary fistula.

Opotherapy of the liver has not so far received much attention. Garnot, Gilbert, and Danis claim to have had good results from the use of liver extracts in atrophic cirrhosis, they having observed an increase in the biliary urogenic, glycogenic, and probably also in the antitoxic functions. Spillman and Demange found that the albumin and urobilin disappeared from the urine. Carnot and Gilbert macerated 150 grammes of fresh pulped pig's liver in 250 cubic centimeters of warm water for twenty-four hours, and administered by the rectum with results. Gaillard and Crequy administered 150 grammes of pulped liver by the mouth, which gave good results, the active principle apparently not being destroyed by the gastric juice; but it was too nauseous for most patients. There are preparations of powdered liver on the market, but they often produce stomach trouble.

Robin has studied the action of drugs in the treatment of hypertrophic cirrhosis in its early stages. Opium in small doses diminishes the glandular and digestive secretions, and is indicated in cases in which a hyperactivity of the stomach exists. Belladonna inhibits the functions of the liver, according to Riegal, Pawlow, and Haidenhain. Arsenic in small doses has a small sedative effect upon the action of the liver, especially on the glycogenic function, but its use for any length of time is contraindicated owing to its tendency to produce fatty degeneration. Mercury in small doses is a hepatic sedative; it does not increase the formation of bile, but stimulates Auerbach's plexus. Antipyrin and the bromides are also hepatic sedatives, and are especially indicated when the urea elimination amounts to 0.5 gramme per kilogramme of body weight. They should be administered in about 10-grain doses before meals, with a little sodium bicarbonate to prevent irritation of the stomach, and should be discontinued as soon as the urea elimination has reached normal. Sulphate of copper and lead acetate are also useful in hepatic hyperactivity. Potassium iodide in doses of 5 to 10 grains per diem is valuable, but the doses must be small, as the stomach in these cases is susceptible to its disturbing action.

Hepatic stimulants are more numerous and a little better known as benzoate of soda, salicylate of soda, peumus, boldus, sodium phosphate, aloes, jaborandi, pedophyllin, and gamboge. Potassium iodide acts indirectly by dilating the blood vessels and increasing the quantity of bile according to some observers. Peumus boldum is given as an infusion; its principal action is diuretic, but it is also used to stimulate the liver. The action of sodium phosphate upon the liver is affirmed by Rutherford, but denied by Prevost and Binet, Baldi, and Stadelman. Aloes in small doses is a hepatic stimulant, as is also podophyllin. Jaborandi in small doses is said to stimulate the liver, as it does all other glands; in doses of 1 to 2 grains of the powdered leaves it acts upon the liver and does not provoke diaphoresis and salivation. Sodium glycocholate mass in doses of 15 grains per diem stimulates the liver cells, increasing the flow of bile, thereby removing accumulated waste products, especially bilirubin. In cases with the icteroid coloration of the skin it will clear up the complexion in a few weeks. Especially is it indicated in hepatic colic; many cases are on record where its continued use has prevented the attacks of colic permanently.

The diet in diseases of the liver is of great importance, the guiding principle being to obtain the maximum amount of nutrition with the minimum amount of physiologic work, thereby giving rest to the organ. Proteidz are necessary for proper nutrition, but in much smaller quantities than generally taken. Chittenden has shown that nitrogen equilibrium can be maintained in health with an intake of about 6.0 grammes of nitrogen per day. The products of proteid metabolism-urea, ammonia, uric acid, creatinin, etc., are more or less toxic and entail considerable physiologic activity on the part of the liver as well as upon the kidneys in their elimination. Fats are for the most part absorbed by the lymphatics, only a small quantity entering the liver by way of the portal vein; except in the suppression of the biliary secretion the easily digested fats, such as cream, butter, and the vegetable oils, are well borne in moderate quantities. The carbohydrates give but little work to the liver, their end products being principally carbondioxide and water, both of which are easily eliminated.

The diet in hepatic insufficiency and hyperactivity should be moderate in quantity with a minum of proteid, say about six grammes of nitrogen per day, with some little fat administered in the form of cream, fresh butter, or olive oil, and sufficient carbohydrate to bring the total diet to about 10 calories per kilogramme of body weight. The meat should be well cooked, preferably red meat, white meats containing more nuclein; gelatinous dishes, as calve's head and feet, etc., are to be avoided. Boiled fish, avoiding those containing much fat, are allowed, but shell fish are debarred. One or at the most two eggs a day may be given, except in gall stone cases, when the cholesterin contained in the yolk may cause increased elimination by the bile. This is, however, very

doubtful; experiments seem to prove that cholesterin is not ab-
sorbed from the intestine as such. Milk, the diet usually pre-
scribed, is not satisfactory and should never be given except with
desserts. Fresh cheese may be given and is sometimes well borne,
but only in small quantities. Of vegetables, peas, beans, scorzonera,
salsify, and salads are the best ; spinach and tomatoes contain too
much oxalic acid. Vegetable diet increases the alkalinity of the
plasma and often relieves constipation, producing bulky stools.
Vegetables containing sugar are only tolerated in small quantities,
with the exception of Irish potatoes, which should be well boiled
and mashed with butter. Toasted bread may be given, but pastry
is forbidden; ripe or cooked fruits may be given sparingly. Water
or very weak tea are the best drinks; the water should preferably
be distilled, in which antisclerosis tablets (four to the pint) have
been dissolved, this assisting in the elimination of the waste prod-
ucts. The total fluid taken in the twenty-four hours should be at
least 1500 cubic centimeters. In severe cases all of the meat should
be boiled so as to dissolve out the extractiveness; no soups or broths
should be taken. Probably the quantity of the food is the great-
est therapeutic agent, most patients being or having been great
meat eaters.
The following prescription is of value in atrophic cirrhosis:

Strychnine sulphate
Pulv. folise jaborandi .

Sod. glycocholate mass
Sig.: To make one capsule, t. i. d.

Nitrohydrochloric acid is often beneficial. In hypertrophic cirrhosis acetate of potash and nitrate of potash are of value in one or two-grain doses. In hepatic colic sodium glycocholate mass in five-grain doses rarely fails to prevent a second attack if taken continuously.

1907 Park Avenue.

.gr. 1-60. 1. 5.

Written for The Texas Medical News.
What is Meant by the Opsonic Index in Medicine:

Opsono-Index Therapy. *


Since the first paper published by Metschnikoff in 1884 on the subject of what has been called "phagocytosis,” a process by which certain of the white blood corpuscles (leukocytes) of the body are

*A paper read before the Smith County Medical Society, Tyler, Texas, March 12, 1907.

endowed with the power of seizing hold of, engulfing and digesting those foreign and harmful objects known as bacteria which have a tendency to destroy the human body, an enormous amount of literature has accumulated.

Whether this process of engulfing and digesting these bacteria is due to a special selective action on the part of certain white blood corpuscles, or whether it is brought about by chemical action (chemotactic action) is not fully known, but enough is known to say that this phagocytic power, to whatever its action may be ascribed, is one of the principal factors in the preservation of the human body against disease. Such action on the part of these white blood corpuscles of the body gives rise to what is known as a "natural immunity" as contradistinguished from “acquired immunity," a condition of the system brought about by the absorption of toxic products given off by certain pathogenic micro-organisms.

In 1880 Pasteur, who worked with an attenuated virus of chicken cholera, was perhaps the first one to demonstrate the nature of acquired immunity.

As stated by Sternberg,' this acquired immunity depends upon an acquired tolerance to the toxic products of pathogenic bacteria. The proper treatment of diphtheria and of tetanus by antitoxins depends upon this principle of acquired immunity.

When we begin to study more closely the white-blood corpuscles of the body, we find that the leukocytes are of several varieties, the names of which are given them on account of certain shapes and staining properties of the nucleus, number of nuclei, and certain granules in their protoplasm. Further, that the different forms of leukocytes are supposed to be of different ages or different periods of growth. For instance, we have what are known as (1) young leukocytes, which are divided into (a) small lymphocytes, and (b) large lymphocytes; (2) adult (or polymorphonuclear neutrophiles, or polynuclear) Teukocytes; (3) old eosinophiles; and (4) mast cells or basophiles.

In the blood these white-blood corpuscles exist in different proportions, and in health we find the percentage according to Cabot, as follows: The polymorphonuclear neutrophiles or polynuclear leukocytes average 62 per cent to 70 per cent of the entire number of white-blood corpuscles; the small lymphocytes average 20 per cent to 30 per cent; the large lymphocytes 4 per cent to 8 per cent; the eosinophiles } per cent to 4 per cent; and the mast cells

per cent to 1 per cent.

In health the red corpuscles number 4,500,000 per cubic millimeter; and the leukocytes about 8000 per cubic millimeter, or one

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