CIHM 
 Microfiche 
 Series 
 (Monographs) 
 
 ICMK 
 
 Collection de 
 microfiches 
 (monographies) 
 
 Canadian Institute for Historical Microroproductions / Institut canadien de microieproductions historiques 
 
 \^^y I ^J^ ^^ ^^ 
 
Technic^i ;;ncl BiDliographic Notes / Notes techniques et bibliographiques 
 
 Tie Institute has 
 copy available for 
 
 ■ipied i , obtain \'~:e best original 
 ' ri;-, Fca'ures of this copy which 
 may be bibliographicaiiy iniiV'^. whicn may alter any of 
 the images in the reproduction, or which may 
 significantly change the usual method of filming are 
 checked below. 
 
 n 
 n 
 
 D 
 D 
 
 n 
 n 
 n 
 
 Coloured covers / 
 Couverture de couleur 
 
 Covers damaged / 
 Couverture endommagee 
 
 Covers restored and/or laminated / 
 Couverture restauree et/ou pelliculee 
 
 Cover title missing / Le titre de couverture manque 
 
 Coloured maps / Cartes geographiques en couleur 
 
 Coloured ink (i.e. other than blue or black) / 
 Encre de couleur (i.e. autre que bleue ou noire) 
 
 Coloured plates and/or illustrations / 
 Planches et/ou illustrations en couleur 
 
 Bound with other material / 
 Relie avec d'autres documents 
 
 Only edition available / 
 Seule edition disponible 
 
 Tight binding may cause shadows or distortion along 
 interior margin / La reliure serree peut causer ce 
 I'ombre ou de la distorsion le long de la marge 
 interieure. 
 
 I j Blank leaves added during restorations may appear 
 
 within the text. Whenever possible, these have been 
 
 omitted from filming / II se peut que cerlames pages 
 blanches ajoutecs lors d'une restauration 
 apparaissent dans le texte. mais. lorsque cela etait 
 possible, ct J pages n'ont pas ete filmees. 
 
 L'Institut a microfilme le meilleur exemplaire qu'il lui a 
 ete possible de se procurer. Les details de cet exem- 
 plaire qui sont peut-etre uniques du point de vue bibli- 
 ographique, qui peuvent modifier une image reproduite, 
 ou qui peuvent exiger une modification dans la metho- 
 de normale de fiimage sont indiques ci-dessous. 
 
 j Coloured pages / Pages de couleur 
 
 I I Pages damaged / Pages endommagees 
 
 D 
 
 Pages restored and/or laminated / 
 Pages restaurees et/ou pelliculees 
 
 □ Pages discoloured, stained or foxed / 
 Pages decolorees, tachetees ou piquees 
 
 I j Pages detached / Pages detachees 
 
 I/I Showthrough / Transparence 
 
 I I Quality of print vanes/ 
 
 1 Qualite inegale de I'impression 
 
 n 
 
 D 
 
 Includes supplementary material / 
 Comprend du materiel supplementaire 
 
 Pages wholly or partially obscured by errata slips, 
 tissues, etc., have been refilmed to ensure the best 
 possible image / Les pages totalement ou 
 partiellement obscurcies par un feuillet d'errata, une 
 pelure, etc., ont ete filmees a nouveau de fa^on a 
 obtenir la meilleure image possible. 
 
 Opposing pages with varying colouration or 
 discolourations are 'ilmed twice to ensure the best 
 possible image / Les pages s'opposant ayant des 
 colorations variables ou des decolorations sont 
 filmees deux fois afin d'obtenir la meilleure image 
 possible. 
 
 D 
 
 Additional comments / 
 Commentaires supplementaires: 
 
 This Hem is filmed at the reduction ratio checked belov» , 
 Ce document est filr -e au laux dn reriuriinn mriir 
 
 10x 
 
 14x 
 
 lini lo r i.H/i 
 
 18x 
 
 12x 
 
 16x 
 
 20x 
 
 22x 
 
 26x 
 
 30x 
 
 24x 
 
 28x 
 
The copy filmed here has been reproduced thanks 
 to the generosity of: 
 
 J.J. Talman Regional Collection 
 D.B. Weldon library 
 University of Western Ontario 
 
 This title was microfilmed with the generous 
 permission of the rights holder; 
 
 Alan D. Chesney 
 
 L' exemplaire filme fut reproduit grace a la 
 generosite de: 
 
 J.J. Tainan Regional Collection 
 D.H. Keldon Library 
 University of Western Ontario 
 
 Ce titre a ete microfilme avec I'aimable autorisation 
 du detenteur des droits: 
 
 Alan D. Chesney 
 
 The images appearing here are the best quality 
 possible considering the condition and legibility of 
 the original copy and in keeping with the filming 
 contract specifications 
 
 Original copies in printed paper covers are filmed 
 beginning with the front cover and ending on the 
 last page with a printed or illustrated impression, or 
 the back cover when appropriate. All other original 
 copies are filmed beginning on the f'rst page with a 
 printed or illustrated impression, and ending on the 
 last page with a printed or illustrated impression. 
 
 The last recorded frame on each microfiche shall 
 contain the symbol -^(meaning "CONTINUED"), or 
 the symbol V (meaning "END"), whichever applies. 
 
 Maps, plates, charts, etc , m,ay be filmed at 
 different redLiction ratios Those too large to be 
 entirely included m one exposure are filmed begin- 
 ning in the upper left hand corner, left to right and 
 top to bottom, as many frames as required The 
 following Qia ;rams illustrate the method 
 
 1 
 
 2 
 
 3 
 
 Les images suivc ies ont ete reproduites avec le 
 plus grand soin. compte tenu de la condition et de 
 la nettete de I'exemplaire filme, et en conformite 
 avec les conditions du contrat de filmage. 
 
 Les exemplaires originaux dont la couverture en 
 papier est imprimee sont filmes en commen^ant 
 par le premier plat et en terminant soit par la 
 derniere page qui comporte une empreinte d'lm- 
 pression ou d'lllustration, soit par le second plat, 
 selon le cas. Tous les autres exemplaires origin- 
 aux sont filmes en comimengant par la premiere 
 page qui comporte une empreinte d'impression ou 
 d'lllustration et en terminant par la derniere page 
 qui comporte une telle empreinte, 
 
 Un des svmboles suivants apparaftra sur la 
 derniere image de chaque microfiche, selon le cas: 
 le symbole -* signitie "A SUIVRE", le symbole V 
 signifie "FIN" 
 
 Les cartes, planches, tableaux, etc. peuvent etre 
 filmes a des taux de reduction differents Lorsque 
 le document est trop grand pour etre reproduit en 
 un seul cliche, il est filme a partir de Tangle 
 superieur gauche, de gauche a droite, et de haut 
 en bas, en prenant le nombre d 'images 
 necessaire Les diagrammes suivants illustrent la 
 methode 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
MICROCOPY RESOLUTION TEST CHART 
 
 ANSI ond ISO TEST CHART No 2 
 
 1.0 
 
 I 2 8 jllll 2.5 
 
 S32 
 
 1^ 
 
 2.2 
 
 I.I 
 
 1.25 
 
 
 1 2.0 
 
 I- ^ 
 
 1 1.8 
 
 
 1 
 
 1.4 
 
 1.6 
 
 
 -lED IIVMGE Inc 
 
 .A 
 
Studies in Liver Function 
 
 A 
 
 A M til I' > \ '■ \'. Ml). 
 
 K M \ In -- II \ I. I,. ju.. I'll. I). 
 
 \ \i> 
 
 I-. (., k ' 1 W X I l< I. I'.. Ml). 
 
 i: \i. 1 1 \iwKi-: 
 
 Kr/'tniti-ii from The Jvunial ,/ the AmcrUan Medical Assorialioii 
 
 (),i. ■•/. i>Ji4. r„t. I. Mil. rr- i^'< i^" 
 
 CorYRir.iir, 1914 
 
 Amkricax MfDicAL Association 
 
 i ivi III sniiED AM) Thirty I'lVE Noktm Dearburn Street 
 
STl'DIKS IX L1\ER l-'CXCllOS * 
 
 A. M. CHESXKV, M.]). 
 i;. IC. MAkSHALI., Jr., ]',i.l). 
 
 I- <i. KOWXTKI':!-:, M.l). 
 I'Ai.riMdH.i-: 
 
 
 Tn m-osnition r,i the need r,f I.cllcr criteria for 
 Jii<l,^in,i( of the lu.u-tional ca])aeity of the liver in dis- 
 ease, this n!vesii,!,raii(,n wa.s nndertaken to determine 
 (I ) the de,i,nee and Irequeney with whicli functional 
 clian-es can he d.enionstrated in anatomically diseased 
 livers, (ii m uhat clinical tvpes of liver injurv the 
 lunciional chan.-res are most marked and (3) thc"dia<--- 
 noslic and pn.-ivislic value of these chauijes. In other 
 words, an aliemi.t has heen made to re-anl the liver, 
 HI disease, 1 rom ;i |ihysiolooic point of view, and to 
 stndv Its v.-irious functions with the hoiie of ascert.ain- 
 m<^ us liehavior under i)alli(ilo<,ric conditions. 
 
 Tin- i-!-X(Tio.\ OK Till-: r.i\i:i< ix ui-ai.tii 
 111 health the liver has three \vcll-cstal)li,;lu'd func- 
 tions: 1. I he .■;lvco,i,a.uic function, which has to do 
 wuh carhohydrate metaholism, ami consists in (a) the 
 conversion of the monosaccharids (dextrose, levulosc 
 and -alactose) int., oiyco<,ren ; ( /> ) the temporary stoi- 
 .-i,^'e_ot that ,i,dyco-cn as such, and (ci the reconversion 
 nt It hy enzyme activity into dextrose as needed in 
 the hody. 2. A participation in nitro<Tenous metabolism 
 which consists m the conversion of certain nitrojjenoiis 
 liodies ( amiiH. ma, amino-.acids. etc.). into urea. ^ Tiie 
 production of hile. 
 
 h\ addition, the iivc^r app.irentlv plavs ,a p.irt in the 
 piVKhiction of fil)rino<4en and .iiuithnmihin, althoufjh 
 
 • Fr,.m il„. Mr,l,V_,l riinic <,f thf Jolnis Hopkins Hn.pit,,], .md fr„m 
 
 • Kc.c.l li.f.ui' thf Sialic. 11 ,,n I'ra.iiic of .\[,.IiriiH< it I),,. SKiv n,,!, 
 
il'i' o.ninrtioi, if tlu' latin- liiiuiimis uitli tlio liver is 
 ""I -" ^u•ll e>tabli,>lK-.l as ilio WvA ihivc inf.uioiu.i 
 
 TIIK -I|-ST> (i| ll\i:!; ir\( tkiX 
 
 Tli^- lnl!r.ani-iesi. l.aM,! ,,i, wcll-kiKnvii plu-.iuin.MV- 
 "i"'-l">ns Mt ilu- liver lia\c hern tinplovod : ' 
 
 1. ^■nhohyclratr .l/,7,/.\,//,w;;. -in iln\ w.niK..-tion 
 l^'o tests ),a\e hem emploved, nanielv. Strauss'' jevu- 
 I'-e Ii;m .m.i I'.a.ier-.^ yalariose test. The l<,niier eon- 
 Msis „, the iti-esti.,11 ,,f loo .uni. ,,f levulose on an 
 '■iiipiy Mfiniach and the exaniinalidii nf the tiriiie 
 '-'"l^'l 'l"n.!o- the n,M teu h.ans tn deteianine the 
 '!",:'■'"''■ '■'.'■ ••'I'-^'i^-i' "t iIh' siioar, n-iii- |-ehliiit,r\ and 
 -eliuaiK.ll s tests. Ilaner-s is similar in Strauss' test 
 ^•xcvpt llKU ,^() nn,. of j^alael.,.e are nsed insiea.l ..f 
 1 H)-n,. ,,f Kvnl,,>e. The in-esiinn ,,t these sv.,ars in 
 'lie aninnn,. ,„dieated dnes „,,t tvsnlt in their ai.pear- 
 •nire I'l the innie ni la.rnial indi\ idiials. aemrdinn to 
 "trails., Jin.,,- anpearaiiee in ;h, ,i,i„e is due i") a 
 de.rease ni injeranei I'nr these snh,| :,„,-es, ii-dj,ati\e 
 "t d.-eieased Inneticiial <aMaeil\ .,i' the lixei-. 
 
 2. -\!ti;„,, 'lions Mrt.ihnrsm in relation u, viiv,-^ 
 vn.Mis nietaluahsin and ii\er Inneti-.n a siu<!v of the 
 nnr,,-e„ ,,arlitinn in the hlood and in the urine has 
 '"■'." '"■".''■■ " "h^ liver ennverts the anini.mia and 
 ■'""""-'"■"'- "» tin- li!o,,d into inra. then it nii-ht he 
 •■xiHvle.l that in hver initn-v we sh,,nld Inid a deerease 
 nilhc urea ])ereenta,t;-e ..t" the K.ta! iKin-protein nitroi^en 
 "[ tiu h.ood and an nierease in the ainino-acid nitro-en 
 "' "'^' '''"'"'• '^'"'i- i'i i1h' mine ne nn-ht expeel !o Imd 
 ■■} <lcrrcase m tlu- relati\c amnuni of nrea with an 
 increase in ihe ammonia and amiiio-aeids. (Tin \ ie>' 
 liiat tile li\c.r i.s n,,t wholly responsihle for the eon- 
 M'rsion (,1 tlie ammonia and aniino-acids of the hloo.l 
 into itaa has reeentlv reeeived supDort from the woiT 
 "f l'<'hn and \ an .^Ivke' and of |-iske and Sumner.'') 
 V I '"!'iliii,h/ri!. - \\ ha~ heen maintained h\- nianv 
 "hsu-\ca-s that the i >senee of nrohilinoiren' m the 
 ntnie is mdieativ. of liver disease. I -rohilino.rc.,. 
 
 '■„'■• "','•''''''■ '""'■ \\>l'"sd,,.. Vim. vvvii, 75/-. 
 .^. l-chii: .l,,ur. Ri„l. CIhtm., f>lj ^i fT 
 
 .\>..m„l.,.,„n. al,Mr., TuK .t.„ kn... A. M. A .April 1 ?.' I'lh: ,, ' It.,'"" 
 .'. I i>ki- .,11.1 .Siunncr: Jour, ilinl. C'lipni., MH, xyiii, J85.' 
 
ilLtcTiiniiaticiis utru ina-lc- in the niajoritv of ca-us. l>ut 
 • lu-mj; to ihr ai-pcaraiux- of tlio ivrciit coniiJrc-lR'tiMvc 
 W'jrk of Wilhur and .\(l.li>,'^ and to our own unsatis- 
 factory rosulls, tliL'si' ik'tcrniiiiations were discon- 
 tinufd. ■i'liosc in\fstis;ators showed conclusively lliat 
 (il)scrvations on a sinjjlo or a twcnlv-four-hour 'speci- 
 men liave no significance, since tren'iendous variations 
 occur from day to day, an<l that onlv where rejieated 
 o1)^er\atl()n~ are made o\er a jieriod of at least two 
 week-< and liien only wiien control studies of the 
 urohilin content of the feces have heen made to 
 exclude lilood destruction as a factor in the iiroduction 
 of iiro!iilino,i,an can lindinRs he accepted. 
 
 4, yy'"-/;;ry/(V/.— -There is e\ idence to show that the 
 hvrr 1- .active in the formation of lihrinoijen, and 
 \\hijiplc' ha- <ui:,ye-.ted that the determination of the 
 amount jnocnt in oxalated iilaMua niav he used as an 
 itiiKx of li\er function. 
 
 .-. /.//^(;\,-.— Whipple-- has al<o su^.tjested that the 
 e-lmialidii of the lipolytic activitv of the hlood niav 
 constitute a te-t of li\er fmicti(jn' 
 
 <'k Pii:iiolt<^lr,u-lil,irHit/hiL'ii'.--'l'hi-^ (IruLf was Intro- 
 ducid liy l^:(.'vl;lr^c. ilnrwiiz and I '.loon'ifield" as a 
 tcM fiir hep.atic function, and clinical .studies hv them 
 .'iiid Mmultaneou- experimental studies liv \Vhi 
 
 and cd-w 
 
 r!<er' 
 
 il)ple 
 lov.ed that a normal excretion could 
 he e.-.laj'hslKd and thai ni;iny liver injuries, particu- 
 larly of ~e\ere -rade-. were a-HH'i.ated with a decide.] 
 decrease m the phenoltetrachkirphthalein output, h'ur- 
 ther siudie- with this test have heen carried on. 
 
 7. I'll'nn.'lylir l\-niiciil.— \)v. ( ioodpastm-e of the 
 p.alholo'.;!,- <t iiV was already intere.-ted in the presence 
 ot a lihn;iol\iic ferment in the lilood in li\er cirrhosis 
 when this work wa- undertaken, .'■^amples of ])lood 
 iiom ;i!i our )iatienls were sulimi'ted to him for studv. 
 and ihrou-h lii-, courts -y we jjresent the results of his 
 studks. dei.-'ds of which will ai)pe,ar later. The fer- 
 
 (.. Wnin.r, K. I. ,,M \ Mis, Tl.om;,s: TroIiiliM: Its Cli,,:.,,! SiKtiin- 
 
 -. Whiyi.U- ::ru\ llnrwit^: Jofr. Expcr. Mel., I'M], ^i;i, i.,,;. Wl.ipplc. 
 
 I Kp.it. c (,rr,i.s,s Arch. Int. Med.. M:,rcl,, I'UJ, p. M,S Whip Ic 
 
 -Mmsu,, „„,i v,j;h,,.,i.. Hull. .r„h„s Hopkins ii„sp., iM.i. xxiv. j" " • 
 
 • .V'"'','!','.-^';'''"" '""1 PiiKht.-.I: Hull. (nhn> Hopkins Uom. lon 
 Am. Jnnr. Physiol., j'lH, xxxiij. ijp >>iniji,i.. 
 
 ^'1. K.miilr.H, llnr.ntz .in.l liloonUicKl : liull. Johns Hopki.is I[o«p 
 
 I'M,! 
 
iiu-nf Is spcril'ic for lihriii, ,\nv~. not att;u-k lil)rinn./.ii 
 aiKl Is (Icsiroyei! l>y iKatiui,' tn r(, C. { \,U.X !•".). 
 
 -MI-.TIlilDS AVI) \(i|'\I.\I, LIMITS (i| IT.S IS 
 
 /"■'•'•■'•"■ I li.s icsl \\,l> ClllpKHCU 
 
 aa-onliii',' to the iiK-lliod dcscnhi'il hv l^nvntrcc. I fur- 
 \vitz aiu! illoonificld. details of uhirli arc ijivcn in full 
 m tlic'ir inililication;' 'I'lu' iouLP limit of normal rxciv- 
 lion Is considi'tvd to he M) ,KT run. ir. fortv-ri-lu 
 iioiirs :,t\vv ilu' mtravcnoiis injection of 4()() in<;.' of 
 the sul,si;i„cc. In health, lihciu^ltctrachlorphthalun is 
 Iiracticallv ne\er excreted in the urine after iiiieclion 
 ot siieli amounts. 
 
 /■//')•///«,/,•//.- The heal coa-tilatioii lueihod as 
 (Ic-scnhed hy Whii.i.le'' was uied in thc-e determina- 
 tions, and \a!ues helow .i5() <,nii. per hundred c.c. were 
 rei:a'"ded as ahiiormai. 
 
 /.//'(M-.-.^^l Vt^nuinalions of the liiiolvtic acti\ilv of 
 the hloo.j were made, usinij I.oevenhart'.s" iiutiiod. 
 wliicli eonsisis i,i ihe deterniiuation of the total acid' 
 liroduclion of the hlood when exposed to known (|uan- 
 titus .,f etiiyl hutyrate ;il ,v C. i'»S.f) I-'.), 'j-hc result 
 IS expressed .as the inimher of cuhic centimeters of 
 tenth-normal acid produced hv 1 c.c. of plasma and 
 0.2>> c.c. ethyl hutyrate, diluted" to 4 c.c. and allowed to 
 react h>r from tweutv to twenly-four hours. The 
 upper limit (jf normal has heeii taken to he 0.40 c.c. 
 of li nth-normal acid. 
 
 ■//',• XHrrarn l^u-titioii in Ihr lilond and [Jriiic— 
 Ihe total iioi;-proiein nilrouen of the hlood was e<ti- 
 nialed hy the micm- Iv jel,l;i!d inelhod of Inhn ,and 
 Deuis.'-^ with sh'-ht m.Mliiic:. lions. ;is .sU!'.^e>ted hy 
 I'r. P.. ]!. 'luriier.'' The urea iierccnta.tjc of the total 
 nou-proteiu iiitroy:^.,, of ,|,^. i,|,,„(i ^^..,^ determined hy 
 Marshall's" method. utiliziiiLf sov hcaii urease, and 
 \ahics helow 40 per vcul. have hcen regarded' as 
 ahnormal. 
 
 The amino-;icid determinations were m.ade hy \'an 
 .^l\ke's^ • method. .\s yel, data coucerninij the a.mounl 
 <^_f_J>'ii''i"-;i'-"i'l> present in the hlood of normal 
 
 10. Whipple: Am. .lour, Plivsiol.. l')U, s.sxiii. 50 
 
 U. I.i.evenli.-irt: Am. jfiur. I'hvei.il., l'>0_', vi. \m 
 
 1-'. I'oliii :rn.| Drills: Jniir. liiol. Clu-ni., mi^ xi ' S '7 
 
 1.1. Tlicse i,io,lilR.iii,,i,s will l,c .i,-sirilic.l stio'rtlv" \>v Dr •J-nmer 
 
 14. .Marsh ill: loi.r. ili.il. ( lu'iii., I'M.t. nv. 4X7 ' ' 
 
 1.-. \ ui Sl>:<c: .Iniu. II;. ,1. Chciii., lyiJ, xii, }'>'j 
 
J. 
 
 iiiili\ i(lii,il> are M.-aici., Imi iiuiu a sliuly of pnticnts 
 wliK well' praelicallv ni-iiiial. ,i m^. per luimlixcl c.c. 
 nf .-criim lia< I)crn iIk.' value resj^anlc! n- iIr- \\])ycv 
 limit III niirinal i>>v ihr tree aiiiinn-a'.-iil iiitroueii. 
 
 I !:e liilal i;iirn!L;eii nt' tl'> iii'iiie was ileteniiiiied on 
 iwentv-Inur-hniir -.|n.eiiiKiis eolleeted umitT Idlnol hv 
 the Kielilalil < iiinitiiiy iiietluHl, the urea he M; rsliall's'" 
 and the amiiiMiiia h\ l-nljirs'' methixh The (iisirihi 
 ''"" "f t!ie uriiiar\ niirdiaii helueui tirti ami 
 aiiiiiKiiiia lia^ heeii shnwn tn he (lei)enileiit (Hi the total 
 excretion (jI' nitr(),<,'en. The noianal limits of the vari- 
 olic iiitrnyeiiou- i-niisiiuKnl- (jf the urine, with \arvin,t; 
 lc\e]-~ ot nitroi^en exerelion. are therefore li.ard to 
 deliiu' sliarpl)-. I iouever, one can jirohalilv safelv eon- 
 i-liide lliat with a nrina.rv nilro'^'ui e\i I'etioii of 10 <,mii. 
 or more, the lower limit for nrea mlroi^n'ii is SO per 
 rent, and tlie upper limit for ammonia nitrr),<;[cii is 
 .^ pi r cult., while with .i nitro"en excretion (jf from 
 .-^ to 10 i,'!!!., tin l(jw.;r limit for nrea is 70 jier cent, 
 and the ujiper limit for ammonia is S ]>er cent. 
 1-iirllKrmore. exi'es.si\e ;iciil prodtu'tion in the ortjan- 
 ism is .-(ccompanied with a lowering,' of the iire.a per- 
 centa,<,re and an increase in the ammonia perceiitac:e. 
 The free amino-acid in the urine was determined hv 
 \ an .'^lyke''^'' iiielhod. and 1.5 per cent, has heen 
 adopted as the upper limit of normal. iMitiire work 
 ma\- chaii'H- these xrihies. 
 
 sr.MMAK'i ol" I-1M)IM,S 
 
 rort\ -li\e cases have heen studied in this series, in 
 ne.irly all of wliicii sonie ahnormalitv of the liver was 
 ihouy^ht to he jiresetit. ."^ome of the cases called cir- 
 rhosis were certainly not far advanced, and in some 
 instances it ajipeared that the dia.i,niosis was not deti 
 nilc, ditterences in opinion heiiii,' fre(|uentlv encoun- 
 tered. ( )n account of lack of space the details of the 
 case.s are not t,Mven here,''' hut a summary of the results 
 ohtaiiied is !,d\en in 'I'.ahle 1. 
 
 Column 1 sIkmvs total iiumher of tests made. Col- 
 umn 2 the total mtmhcr of ptisitive results, while the 
 
 16. ^^,-lrsll.^!l: Jour. Hii)l. Clicm., '913, xiv, 283; .\v, 495. 
 
 ir. I'olin: Ztsflir. t. phvsiol. (hem., l'»nj, xwvii, 161 
 
 l.S. y.iil Slykc: Jcnir. ninl. Clieni., I'Jl.', .wi, l.'l. 
 
 I'.'. I'imliiiKs of ;ill tcits, clinical notes, nccrnpsy finilirRS in fal.il 
 cases togctlier willi a iliscnssion of tlie f'lnclinnal linilin^s appear in 
 ttie article in tlie Proceedings of tlie .Society of American Physicians, 
 
onui tiqiiKs iinlirau- i he !i.inilif- •" ,, ;■■■, r r 
 "> tin- ,,arlia,Iar ,liM.,-,... ' " ' ^^"''^' '""'"'"^ 
 
 '•>"ni tl,i. -al,k. i, ,,,|i l,c ,ev„ that 'hv fnllnui,,..- 
 
 :<-*f ■•■I'' .iplihcl 111 the tca-s ill 4? ca.cs u-.M ir 
 >n the ttriia. in ,U ca^o uith 'I,;, ^ 7 " 
 
 ^«'";....l)at,s.2()ahi.ni,al7i„,; '', V'w/^ 
 
 ;',;7V""7''' '--"neMi^atu^ii.^./ .:,:{■; ^ 
 
 "l'H-li^li.uv..!aiia,idi,rn,li„.|i,,„,.f ..„....,/,• "^ 
 
 Iir(i(hu-ti<in of more tlian ().+ ,-,c 
 
 .,,,,1 '1 ,, - . ,, "■"■ '" ilMJIl.- Ill U.+ (• r 
 
 ■""'■^ ■'''->•<>..->•.■. IhrtM-eMluvof /,■'.•/;„,/■,'.■,• Z ■ • 
 '"■■"' u.-i^ tc-u-,I for in 40 insfuKv^ an,! I •• -" 
 
 ^'""f-hu-h werenrrho..; i\;,X ,';7'V"'' 
 
 ;I>nwn,^onlv4an,hlK.la.ter2po-.itiv, in, it ' 'he 
 
 /-< -'v-k.tern,,ne,lin.^7.,.,. The „rea nitn,.!.' , 
 •■■'^ ''-"'•■".^••iHTeent. of ,h. ,o,al in M lu<Vnu-v^ 
 
 ;'v:"'';:: /""■""" r^''- ''^'""' ^ ^'t-'-nJi -n 
 
 >. ■ " -■ niMaiuas and ahnve 4 nit,-, in 1.^ in^taiue. 
 "" ''/"^ '""•'""■" '"•'•" -"/ annnnni. in flu ■,, 
 
 r>nte :::;::, o':;l!, :;;;-:,, ,?::;-• '^ 
 ;;;;;- ,ntro..ii..o.,o:^';,;::;;:r;'Tln^;a;:: 
 
 :- lK;:,innioiiia mtro^ni a^o^e 5 p.reeiit. in l(i 
 
 sui iMtAcui ,>a.vl 10.;ni.,an,I,,| these. 4 ra^e. '.houe.1 
 ••i "n-a lutro^ui i'ehne 7() i.^- rmt an,l 11 ,, 
 
 'Y"-'t o, ,!h. nriiu wa- un .M.^ale,! in 22 .as. . ]9 
 liita! nilroirrn 
 
 l>er eent. of ihe 
 
 • '■ l:'Mss,i„I„.,|uereasfolious: I 'h..,,. ..,.,raeh or 
 •'"''•ili'i'i Mn4u t! in f, ,-, .,,,11 , ■,• ■ 
 
 ,, _ . ; "1 ->\i'i 14, [losiiu,. ,„ ,, ,,, „,.j 
 
 II. poMu,. ,„ , , nl.rino:,.,,, j„ I, ,,^j j . 
 "I'.':V"'. 'i. !'-uu, ,1 2: h!,rii,olvtir f .n,u n ii 1 ' 
 l;-.n., n..,,.W,o.,i,Ml. positive in 2 'iVii 
 '<'-P.M,u.,n2:nrean„ro,n,pen-..n,a,e,hI ,4 
 
r« c "I"! ■=■ ^ . 
 
 in u 
 
 i 
 
 
 «^ PI o 
 
 U 
 g 
 
 a 
 
 
 fvi ^»r»i ^^fvj", 
 
 
 ■ - = = c- ecc 
 
 I 
 
 m 
 
 O 3 
 
 ;<^-;> ;s* :;:;<: 
 
 ■nj32 
 
 o 
 
 « — v: t^ .r. ^f - 
 
 
 o-r'2 :-S : 
 
 
 ' : : ; • • 
 
14, iMiHinr ill ^: ai)|i!„, njim-cii i Md.,.!) in 14, ]M.si- 
 tivi' 111 10; iii-(.;i ].i;iviiit;iL.'x- ( uriiu' I in 14, i '-itivc in .i • 
 :inini(,nM j.c nu;i;i-x- Miriiu') in 14. jiomiuc in 10 ' 
 anniKMiitn.-.n pciviiiM-c ( nrin. i in 7, jMiHlivr in ,-. 
 .i/.\"(-|.'' (//,// /iisiil/inriu-\\- I'wcKi' rnsc^ ,,'' in\-o- 
 *ar<li:tl inMilfK iinrv ^\ nv Mn.lir.l. I 'lunnlirlrarliloi- 
 plHl'::Kin .mdul ,„ ,V.v. j,, ., ,,,,^, ^,„|, , j.^^itivc 
 l_'>wc-l l)un- IN iHT r. ui., ;,n.l in nrinr !() e;,-t . N\itl, 
 ■^ I'"-itivis; |il,rni,,-ci] in 11 uii|, 1 ,„,.iiP, c; lipa..- jn 
 11 i:i-c- witli 1 |..(i-iii\r: iihriiiiilMir icrnirnl in 1> 
 jK.HiivL' in noiu'; -.•il:K-tM.c in 7, p.i.itivc in none; Icvu.' 
 i<><v m ,•), iM.~n:',c li ii,,;k': uwu nilroi,H'n Denvnlriw 
 (1)100(1) 111 ]2. iH,sin\r i-i ], in xvliidi (> wire ove-r 
 .^1) jaT rrnt,. au,l ,i nwv t,i) y,y rint.; aniin., nilni-cn 
 ( Mdiiil ) ill '). ]„.siii\i. i,i 7^ 
 
 I iu' Innolicnal iiijiirv in li\er rinlm-is i. nl.itiwlv 
 i;iv;i1cr lli;in in clinHiic pa.M.r on^'stinn. inr a Cdn- 
 sKicrati.^n nt .all i!,,. ,,..,. in .acli o.n4ilion in.lir.iu. 
 '.I'.it ni 10, ,t tlir 14 ra^r- of rirrlio.iv tJnTc w.i, ,l,-lM,ilr 
 """■I":"al minrv. ,^ v, it!, 1,..^ ni.arkrd iiijnrv an;] onlv 
 <'ni' witli ;i i.ractirr.llv norni;il finuii.m tliiun^'ji, ,nt 
 uliik' III rhr-oiiic- pa-ivi- conircsli.ui oiilv 4 sltoww] ijoli- 
 nitr .lo-iv.:.^, ulnlr 7 sl„,v,ol a praoticillv nomi.-.I 
 lunction. 
 
 /'■"■;'■'"""■■ "■'' /'••■■'. I.ililo ,lata oniMMc ,,f ij„. 
 l'iunoliur;irhior;,liili;ru^in l,avr hccii oilkTU.l C _>N 
 ulio .K!liiiicK ha.l nirta^la>i. to tlic !ivu-,-' sl,„.,vi.l a' 
 -^ piT rrut. oiitpiil ii\c nioniiis lii'forc (K-ilh. || _" i 
 wall ,-:;i-iru- carniioin.! ;m4 rlinii-.aJlv tlion!,4it to liivj 
 uK't.iMaMs to tlu' 1m, r. sliouol :i 24 pu" ru,l. onlpnt 
 plinio!tUr,ulilorplitli;ikin p<,sitivc in nriiic ami tlic 
 '"va only 21 per rent. u{ ihv tot.il non-protein nilro-c,, 
 "• '''"'"!■ llH'.-r r.iM's ;mx' in kcvpin- uilii tlio tlim- 
 ' a^i's ot luiT r.irniioni.a r.|H,rlc4 last vr.ir in whirl) 
 Hi^' l4unoliai,u!;lnri,!iilialciii r.xcRtion u,is S. M and 
 / I'll- rnit.. rcvprniwlv. NouH'vir. a sli-lit .Kmcmm 
 'n_ plunolntiMriilcpliili.iKi,,, f,,,- i,,m;, ,„.,._ ,•,,„„ jn to 
 
 -^ 1"'; '■'"' ''"^-^ ""'■ indirati' livrr .-aivinonia, sinn- 
 -iuli tin,l,nc;. li.iNc Iktii found in -.istric caidnoni.i 
 ''''^'" "" I""'"" "I li\''i- nutasi.iMs was at li.ind, in 
 uliicli .Msr ,1 ,. iiinaK ihr I'xpia-ssinii of ilir inllnrn,-, 
 "I ancniia .uid ca.luAi.i on li\ir luiutioiK 
 
 eoiin|[^';;j'M;^r /:i;:^c^?^,*" '"""•' '" ">' "••'" - "•« pro. 
 
' >'-'^- nMhc .nnary nilro^c:, partition ,,4;: 
 
 / ".•//<■ llrp.ititis.^A )\ the 
 
 Iwij fast., sui,h\.,l_ ,,„^^, 
 
 
 
 ti 
 
 t(i|; 
 
 '" I'liHi'I, ,111,1 |-|rmiii-< 111 
 
 .vv,.,u.K "1- -v.uh. or u.luy appluat,.,,,. of tlK- 
 ■'•' "' MMv-,r\r:i palK'ni- v.,.,v rvp,,r!c-,l Tlu. „„.,i 
 '".""Utoi i.alinu- Mu.liol in ,l.ac is IH ihi i 
 ;''whon,i,a,,nodnn.aK.M,,..„..,,r\,;;\,! ;''■- 
 l"'MtnMm<l„p,^lu.aI,han,l,„^anou.,vp. ofli.,^ 
 
 !'■ itvi.ir. arv .li,,\\;i in T,,],!., _ 
 
 •^1' l;o|'.-5\ , vsKs 
 
 ,1 - T'^ ''^^■^■^'^^'^^•""'""urn.psv, an,|patl,. 
 
 ;1"«K nnjhp.s .onirnv.ninK thr f„n,-, „nal hn lin^s 
 
 ''■'''••Y'-;'^^'<■a■■c■. ulmhdnnVaiivMvu. ,l,o„.I, , 
 
 '•?;;'• •" '.'^■""!-^. "• l)..^c• nu nrrhoM-s at 
 
 F'F'™"Sf.M:;::,:"'i:;;;-:;;i;;;;r-;r'^;;;;- 
 
 innimv l.riwccn ibc 
 
IG 
 
 anatdiiiio nml functional lindiny- u\ iln- plu'iKiUei'-a- 
 elildrpiithalcin tc>t. 
 
 Ki ;.\ n\i' \ Ai.ri'^ of ti-sts 
 
 I 1k' siTJi.- (if ca--r- is not -ufliricntlv larm- In draw 
 lar-rrachin^ c(inchisi(in> a- to llic rcJalixc valuer of 
 llic ilifferviii te.-t-. liin tlu' following: iniprc-sions lia\r 
 Iiicn rccfiwil : 
 
 (I') riH-noIiiir;,rlil,,ri'lHlKiK-in : A plu'nnltctrai-lilor- 
 ]ihtliak-in i.nipul in tin |\cr- \n]u\v M) ]kv ccnl. or ii- 
 aniicaianiT in liu- nrinc i^ infrr.|urnt in iiraltli an.l 
 fre-(|ncni. in .•niatoniicallx .li-ca^cd li\ci-. A normal 
 outpnl ilofs nol cxt'huli.' Hmt injnrv. 
 
 ' '' ) I'lhrinoLjAii : i.nw valine ar^' fi\'<|MLiit in lir- 
 rliosis. Imt inronstant. \\i\ |,,\\ liiidin.-- may ra.rr\ 
 liro^n!o--tir sio-iiilicau.'i.-. 
 
 I Ai'.M. 
 
 I'liMIIM-. l].\l>i\.,.s l\ l||;Al.in AM) I\ M\lk 
 
 i)(si. Asi: 
 
 ' 
 
 Kx.imiiieil 
 
 \..n.i.-.ls .... 
 
 .1.1 
 
 (■irrli.i>is ....; 
 
 IS 
 
 ('iinKCMiiiii ..i 
 
 iJ 
 
 ('.criiiiiiiii.i of 
 
 
 liviT 
 
 b 
 
 <';ircitiimi.-i . . ' 
 
 5 
 
 riKTic liVLT. . 
 
 5 
 
 '^t■\ t-rc ;uicnii:i 
 
 ') 
 
 Mio-ellnnemis. 
 
 5 
 
 Tut,-ils .... 
 
 11,< 
 
 l.c's Tli.m .111 I'rinc 
 
 IVr (."ent. Kx.iir.iiu'cl 
 
 r...-.iiiiL- 
 
 ■) 
 
 , , 
 
 ,t 
 
 «^ 
 
 11 
 
 T 
 
 1 
 
 io 
 
 6 
 
 f, 
 
 .^ 
 
 2 
 
 .^ 
 
 ^ 
 
 ■> 
 
 2 
 
 J 
 
 1 
 
 7 
 
 1 
 
 
 
 ■> 
 
 1 
 
 > 
 
 
 
 
 2 
 
 54 
 
 2J 
 
 ( .■ i j.iiiavc: I )i tciniinalion of lipolytic anixiiv of 
 Moo. I inriiislK'^ IJiMr ,,y n,, in !'(,nnaiio!i ,,f dianniistir 
 or proL;noviii- \:;hu' in lla-c Inoiv ,,f ca-cs. 
 
 ( (/ I r.ancr'- '^ala.to-c .and Straii-s' K-\ulo-c tol- 
 \ irldi'd \v\\ liiilc infi>rniation in ihi- -eric-. 
 
 (I'l I 'r. ' looilp.a-liirc"- filirinolv 1 ic I'crmcnt -tiidio> 
 < :i 111! Mric- oi' ca-c- diow that ihi- fcrnunl i- pres- 
 ent iinl\ ill liirlioH's and li^iicc when jirc-cnt i- of 
 diaL;iio~lic \alnc. 
 
 I/) JMOod .\iiri';^cn r.iriiiinn: I 'n.i niiromai \\.a■^ 
 low in siAcral instance- ,in.| t -prci.dlv low in ca-c-- of 
 ;i(!\aiiccil cirrlio^i^. Amino .icul miio-in wa- I l^li in 
 a con>iik'ralilc pro)iorlioii of the c;i-es. 
 
 I '/ 1 I'rinaiv Xiiro-en I'.irliiion: '{"lie ammoni.i 
 and aniinoiiiiro-eii were increa-ed in nio-t of the 
 
11 
 
 ia-f> Muclicd, iiariicul.iilv in cirrlioM:-. ( (winjr to tlic 
 iinn-fxclnsioii (,f acidosi-^ n.UMdcrahle (liftiailty is 
 cxpeneiicol in interprftin- tlic^e result^, li would 
 nave I.LTii advisal)lo to liavr aUoniiJtod In exclude 
 andov]. l,y the leedins.' of alk;dies. 
 
 I'KACTK .\i;lIJT\ of TKST.s 
 
 ■/■//.■ plicuolictmchlorphthalcw test inv(jlv.e< an intra 
 xeiiou- mjeetion and careful collection ui <\unU f,,[- 
 liH-ty-ei,t,dit hours. 'J-liree undesirahle feature- are 
 omnected xvuh its ai.plicalion : 1. T!ie .[Ualitv of red 
 colnr ohtanied ni certain instance-, ( fmni 1(J to 20 per 
 cent. „! the ca>e- ) is such that accurate (|uantitati\ e 
 e-tiination i> dillicnlt. ( )nlv in rare instances is this 
 a -erious ditilcuhy leadin- to ermr of more than - 
 P<-'r cent. 2. ThnmilMiHs fre(|uentlv follows at the 
 P'Hiit .,1 inieciK.n, a,- evidenced hv sri<,dil local pain or 
 lenoerne-s to.^ether with re.>i-iance o||\.,-,,vI u; the 
 pali)atiii,<,r tin.,rer aloni,' the cur-e of the vein 'Idiis 
 "ccnrred in ei-ht in-tances in tlii- -eric- ,.f ca-es, hut 
 HI no ca>e ha- ii occasioned -eriou- di-contfort or 
 resulted in actual h.arni to the palieni. .v With -alt 
 dilution nia.le with ;re-hlv distdk',! xvaler chills fol- 
 ln\vin.,r the injection ;,re infre<|uent. When no <lilu- 
 """ 1- employed chill- are le-s ire(|ueni and not 
 accom|iamed wuh increa-e in ieniperalu! e. 
 
 l-ihriu,uiru (li'trnniiuilioiis are iuai.plicalile in the 
 l-resence oi vc^^re anemia, 'ihev nece--ilate the wilh- 
 drawal ol trom 40 to 50 c.c. of hlo,,,! \ In^^l, .peed 
 <ontritn,-v and cousiderahle chemical e.|uipmeut are 
 requiMte- Ihe u-I 1- time-con-uniinL:. /.//-,/•:,■,/<•/<•;•■ 
 onnatuiii.. re,|uirr neither cmplicaled apparatn- nor 
 inuch tmie. / /,,• ,lrtrnninati,:,i „/ //„■ /„/.,/ „„;,. 
 tnitriii intnuicii. ur.ui iiitr,„/r„ and awinn-acid iiitro- 
 <n-ii ..t the hloo,| cannot he carried out when M-vore 
 anemia cxi-t-. Technically the determiuali,,n- are 
 ea-y hut are tlme-con-uminJ,^ l/u- iiitro>,ni pmtitiou 
 tn Ihe urine re.|Uire- soniewiiat le-. time. .laUulou- 
 >an he adnnm-tered without di>coint'orl k. the pilient 
 hut technical dilliculties attend the use of Iriid.'sr at 
 least 2s per lent of the palicnt- refn-intr i,, ,;i|^e the 
 mil amount or .lexelopinir nau-ea or \oiniliiii,r fallow 
 :n.- its mye-lioii. / /,,• fihnuolytir frrmrnl i- re-i<iilv 
 demon-trated. I ' r,'hilino,,n, dclrnnuuUwns m the 
 urine are \ahuK-- unle-s made dailv f(,r a peri.,,] of 
 iv\o ueek- and uiile- a.-,,ci;ii,d with iirolMlm deter- 
 minations in the Icccs. 
 
12 
 
 (I i.\i i.rsicNS 
 
 1. < iul-]i(ikcu cli.in-c> ill lixcr fuiKlinu i an ho 
 ik'iniiu^tr.-itcd ill iiH.^t case- of advanced liver rir- 
 rlici-i-, ill markedly eon.i^cstcd livers a-suciated with 
 iii_\(ica.rdia! iiiHirficieiu-y. in earciiKniia of tlic liver, in 
 luetic- liwTv and in conditions of cachexia with marked 
 .■meiiiia. 
 
 -'. i-niictioiial cliano-ev have heen mo.-l marked in 
 cirrhdM-, neoplasm of the li\er and in cachectic coii- 
 (hlinii^ a^M.ciated with severe .i^rade^ of anemia, 
 l-nnclioiial clian<;e- in chronic jja^-ive collie-lion have 
 not heen li\'<|Uem iw pronounced. 
 
 .\ ll.aniiiiiiy in the lindiiiL;-. of the te-l> i- ])re>.ent 
 ni Miiiie ca-e-, that i-. most of the le-t- indicatin,L[ 
 either a dtcre,i-e function (jr a norin;d funclioi'r 
 However, lack of harmony i- strikiiiL; in other cases. 
 
 4. ( oi.cermuL; the relative merits of these te-ts the 
 ii'il"''---!""- lli'il li;i\c heen received are thai the 
 deiernniiation of the phenoltelraclilor].luhalein excre- 
 •i""- llii.' iihrino-en, ,\nd the nitrogen iiariitioii in the 
 hlood and urine are of decidcl v.dne in revealin- the 
 pre-ence oi. and t(i a le-- dci^rte the extent of, fniic- 
 tional involvuiienl, while ihe deiiion-lration of ;i 
 lihrinolviic feniieni i. ef di cided di;i,,Mio>tio inipor- 
 t.iuce. Ihe deiermin.atiiui of the -u,L,'ar lolenmce ;md 
 ollhe li)iolyiic ,:ciivjiy ,,f the hlood ;ipp,irentl V alYord 
 iulormaiiuii i,{ mmh ie-- v.aluc. 
 
 Ihe iniiirmatii'ii derived frtiiii ihe-e -tudies on the 
 ''\'-''" 'l'";'^ Hot coiii]',ire in di.ai;ii(.-iic and pro,t;no-tic 
 v.dne wi;h th.it dei-iveil from c. irre-pondin.L,'' -tudies 
 ol the kidney. I'hi- in;iy d.epeiiil (,n -everal factors, 
 n.inielv. ( ,; i the iii;ide(|u;icv of our knowledge of liver 
 pliv -ioioi^v ; I /' I till' liniili'(| iiumher (d" ca-es ;tnd of 
 type- (it -evcre liver injurv under ol)-erv itioii ; ( <■ ) 
 the ]io--ihle e\i-tence of ;i <;real "'f.-K'tor of -afety" in 
 the liver, vvherehv in ca-e of iiece-div function is car- 
 ried on ehicieiiilv hv a relatively -m.-dl projiortion of 
 hvcr MihM.iiuc: ill) the f,-ict th;it the iiroL;no-is in 
 m.iuv i'\ the-e ca-e- i- controlled hv factor- other 
 than decrc.i-ed liver function, .ainl ( (• ) the l;icl-; .it pre-- 
 eiit ot correl.iii'.n ol ;m;!toniic. clinic.-d .anil functional 
 lindiiiL;- occ.a-idnr 1 hy the newnes- of the -uh]ect. The 
 re-ult-, however, enconr.i-e u- in the helief th.at -cien- 
 tilicallv ,ind ;d-o clinicdlv thi- -uhject i- worthy of 
 e.Meiisive inv e-tiijation. 
 
 1