Part 74

Sugar essential to growth. Ratio of liver to active increase in weight. Obesity and fatty degeneration. Small inactive liver and stunted growth, or loss of weight. Biliary fistula, death in 12 months. Influence of pancreas. Nitrogenous food for obesity, outdoor life, exercise, cholagogues, salines. Saccharine and starchy food for emaciation, hepatic, and pancreatic stimulants. Mild laxatives and cholagogues, pure air, green, succulent food, pure water, bitters, tonics, moderate exercise.

There is reason to believe that both of these occur as results of hepatic disorder. The generation of sugar in connection with rapid cell growth in germinating seeds and growing plants, and also in rapidly growing animal tissues as in the body of the fœtus and fœtal membranes, and finally in the inflammatory products of pneumonia and in leucocytes, seems to imply that it is essential to such cell growth (Murchison). In keeping with this is the fact that the liver is of relatively much greater size in the fœtus and in the young and rapidly growing animal, and also in meat producing animals which have been selected and bred through many generations for early maturity and rapid fattening. The enormous development of adipose tissue and of lipomata in such animals is essentially abnormal, though it is a deviation from the natural that is esteemed as evidence of excellence, and a necessary condition of success in the meat producing industry. While other conditions are necessary to the production of such obesity, such as abundance of rest, slow, shallow breathing, a genial climate, and a generous hydro-carbonaceous food, yet all of these would prove ineffective without a large liver, working under high pressure in producing a large output of sugar. The mere obesity in the meat producing animal is not considered as disease and it is only when the tendency to fat production culminates in an adipose degeneration of the muscles and other tissues that actual disease is conceded.

Emaciation in certain cases is traceable to the opposite condition. A small or inactive liver with a diminished production of sugar and fat will ensure loss of weight, which is still further aggravated by decreased secretion of bile and insufficient absorption of peptones. Experimentally this condition has been repeatedly brought about by making a biliary fistula, and cutting off all bile from the intestine. Death preceded by extreme emaciation ensues in 12 months (Murchison). This being the case with the escape of all the bile secreted, a slower but no less certain emaciation must follow on a structural or functional disorder of the liver which is attended with a greatly lessened production of bile. This, indeed, is the condition met with in advanced glycosuria, when the liver is the seat of general fatty degeneration.

From the experiment of the removal of the pancreas we may infer that diseases of this organ which pervert or destroy its normal functions, will check glycogenesis in the liver by withholding the supposed pancreatic ferment, and by so doing will conduce to emaciation and marasmus.

So far as obesity and emaciation are dependent on diet they may be checked by subjecting the patient to the dietary which will favor a more healthy liver function. For excessive obesity a strictly nitrogenous food in restricted amount will tend to lessen the glycolytic action of the liver and secure the formation of muscle rather than fat. An outdoor life, and an active though not exhaustive use of the muscles will greatly favor this result. For the carnivora or omnivora a diet of lean meat or skim milk might be employed, while for the herbivora, wheat bran, cotton seed hulls, beans, peas, vetches, or cotton seed would measureably meet the demand. Cholagogues and saline laxatives, by eliminating from the liver and intestine, will contribute to the same end.

If emaciation depends on a deficiency of sugar, that may be freely fed along with richly amylaceous food, and the liver may be stimulated to increased glycogenesis, by stimulants such as chloroform, ammonia, or ether, and by a moderate use of carbonate of soda or other alkalies. Ether has in addition a stimulating effect on the pancreas and will tend to increase that ferment which stimulates the liver to its glycogenic work. Mild laxatives and cholagogues will second this, such as small doses of podophyllin, taraxacum, nitro-muriatic acid, chloride or bromide of ammonium, plenty of pure air, abundance of green or aqueous food, and plenty of pure drinking water. Finally moderate exercise, by increasing the aspiratory action of the chest and thereby accelerating the hepatic circulation is a material stimulant of the glycolytic function. Bitter and other tonics are contributions to the same object and should not be neglected.

SECONDARY OR REMOTE RESULTS OF LIVER DISEASE.

In gout: Arrest of oxidation of proteids into urea. Deposits of biurate of lime on joints, and other disorders. Urinary calculi containing urates, cystine, xanthine, etc., also from imperfect oxidation of albuminoids. Oxalic acid represents a similar arrest. Kidney degenerations from irritating urates and oxalates. Fatty kidney from excessive glycogenesis. Digestive disorders from excess or deficiency of bile or torpid liver. Nervous disorders, dullness, lameness, vertigo, spasms, irritability from hepatic inactivity and resulting poisons. Sore throat and bronchitis from hepatic derangement. Skin eruptions in tardy or imperfect action of the liver. Treatment: Abundant water, succulent vegetables, ensilage, fresh grains, balanced ration, in carnivora and omnivora oat meal, buttermilk, clear meat juice, avoid sweets, gravies, spiced animal food. Dangers for pampered horses, dogs, and old improved meat producing animals. Open air exercise. Laxatives with alkalies, salines, mercurous and mercuric chloride, pilocarpin, chlorides, iodides, bromides, nitro-muriatic acid, ipecacuan, euonymus, bitters.

Among the many secondary results of hepatic disorder, and which are habitually described as affections of other organs a few may be mentioned as indicating the wide range of influence exercised by the liver in disease as well as in health.

Gout as it appears in fowls and omnivora is directly due to the arrest of the transformation of the albuminoids into urea. Circulating in the system in the form of the less perfectly oxidized and less soluble uric acid, it determines deposits of biurate of lime around the joints, with local inflammations, and disorders of circulation and innervation, and altered spirit, temper, etc.

Urinary calculi in the same animals, are composed largely of urate of lime, cystine, xanthine and other nitrogenous products representing various stages of oxidation short of the final transition into urea and ammonia. Recognizing the active rôle which the urinary bacteria fill in this respect we must still acknowledge the great importance, as causative agents, of an excess in the urine of these comparatively insoluble products.

The oxalic acid found in certain calculi points in the same direction, as this acid, both in the body and in the laboratory, is found to result from the oxidation of uric acid (Wohler, Schenck, Hutchinson).

Degenerations of the Kidneys are to be largely traced to the same hepatic source. The uric acid diathesis, and the oxalic acid diathesis, both the result of imperfect liver function, are among the most frequent causes of irritation of the kidneys, by which channel they are eliminated from the body. Hence acute and chronic nephritis, as well as nephritic calculi result from morbid conditions which have their starting point in the imperfect function of the liver. Again fatty degeneration of the kidney is very liable to result from derangement of the glycogenic function of the liver, the tendency to the formation of fat and the constant irritation caused by the passage of the sugar contributing to the tissue degradation. In such cases albuminuria is a not uncommon accompaniment.

Derangements of the Digestive Organs may be said to be a necessary result of hepatic disorder. Excessive secretion of bile stimulates peristalsis and may induce diarrhœa, while diminished secretion tends to constipation, light colored, fœtid stools, intestinal fermentations and poisoning by the irritant products. A torpid hepatic circulation means congestion of the whole portal system, indigestions, colics, chronic muco-enteritis, intestinal hemorrhages, hemorrhoids, etc.

Derangements of the Nervous System. In this connection may be named the lameness of the right shoulder which accompanies certain disorders of the liver, the extreme dullness and depression that attends on others, the sluggish pulse that appears in certain types, the unsteadiness of gait (giddiness) in others, the muscular cramps, and irritability in still others. These appear to be due in some instances to the nervous sympathy of one part with another, whilst at other times they as manifestly depend on the circulation in the blood of partially oxidized and other morbid products of hepatic disorder which prove direct poisons to the nervous system.

Derangements of the circulation, like extreme rapidity, or slowness of the pulse, irregularities in rhythm and intermissions, may be charged more directly on the nervous affection, though primarily determined by hepatic disorder.

On the part of the Respiratory Organs, affections of a chronic type, like sore throat and bronchitis may often be traced to hepatic torpor or disorder.

Skin Diseases are notoriously liable to come from inactive or disordered liver, the irritant products circulating in the skin or sweating out through it, giving rise to more or less irritation. The result may be a simple pruritus, an urticaria, an eruption of papules, vesicles or even pustules. In any such cases it is proper to look for other indications of liver disease,—pale color and offensive odor of the fæces, muco-enteritis, indigestion, icterus or yellow patches on the mucous membranes, tenderness on percussion over the asternal ribs, muscular neuralgia, nervous disorder, the passage of bile, hæmoglobin, albumen, sugar or other abnormal elements in the urine, etc.

TREATMENT OF SECONDARY AND FUNCTIONAL DISEASES OF THE LIVER.

Diet. Many hepatic disorders, and especially those that are exclusively or mainly functional may be corrected by diet alone. Prominent among dietary influences is the abundant supply of water. The succulent grasses of spring and early summer constitute the ideal diet, hastening and increasing elimination, and lessening the density of the bile, even to the extent of dissolving biliary calculi and concretions. Upon dry winter feeding such calculi are common especially in ruminants, whereas after a month or two at pasture they are extremely rare. In winter the same good may be arrived at by the use of ensilage, brewer’s grains, roots, fruits, or even scalded hay or bran. The two extremes of highly albuminous and highly carbonaceous or saccharine food are to be avoided or used only in limited amounts. In the one class are clover, alfalfa, sainfoin, vetches, cowpea, lespedeza, especially in the form of hay, beans, peas, cotton seed, gluten-meal, rape and linseed cake. In the other are wheat, buckwheat, Indian corn, sorghum, sweet-corn and cornstalks. Some agents like beets which are rich in saccharine matter may be actually beneficial by reason of their laxative and cholagogue action. In the carnivora the food should be largely of simple mush of oatmeal, wheat seconds, or barley meal, skimmilk or buttermilk. If it is needful to tempt the appetite in a fleshfed animal this should not be done by rich, fat gravies, highly spiced animal food, or rich saccharine puddings, but rather by the addition of a little pure juice of lean meat, or some well skimmed beef tea.

It is as important to regulate the quantity as the quality of the food as the heavy feeder will over-charge the liver as much by an excess of otherwise wholesome food, as will the ordinary animal by the indigestible and unwholesome articles. As a rule the improved breeds of meat producing animals, have acquired such facility in fat production that much of the surplus is largely and profitably disposed of in this way, and in their short lives little obvious evil comes of the overfeeding, but in cases in which this outlet proves insufficient, as in horses and dogs that are highly fed on stimulating or saccharine diet, and which are kept for the natural term of their lives, with little exercise, the evil tends to reach a point of danger. Nursing mothers and dairy cows find a measure of safety in the free flow of milk and the yield of butter, but breeding cows that have been improved till they have no longer a capacity for milking, but must have their calves raised on the milk of other and milking strains are correspondingly liable to suffer.

Exercise in the Open Air. As enforced idleness, on a full diet and in a warm and moist environment is a main cause of hepatic disorder, so abundant exercise in the open air and especially in a cool season is beneficial in a marked degree. Beside the bracing effect on the digestive organs and the improvement of the general tone of the system, the action of the muscles in hastening the circulation greatly favors the removal and elimination of waste matters. Still more advantageous is the increased activity of the respiration and the aspiratory power of the chest in at once unloading the portal system and the liver by hastening the progress of the hepatic blood into the vena cava and right heart, and in furnishing an abundant supply of oxygen for the disintegration of the albuminoids and amylaceous products. Such exercise must of course be adapted to the condition of the animal and its power of sustaining muscular work, but judiciously employed, it is one of the most effective agencies in correcting and improving hepatic disorder or hepatic torpor. Idle horses, the victims of obstinate habits of constipation, muco-enteric irritation, indigestion, nervous, urinary or cutaneous disorders will often be greatly benefited or entirely restored by systematic exercise. This is one of the great advantages of a run at pasture, as the subject secures at once the laxative cholagogue diet, an abundant supply of oxygen, a better tone of the muscular and general system, and a more perfect disintegration of albuminoids. Sea air with its abundance of ozone is especially advantageous.

In the carnivora while we cannot send them to grass, much can be done in the way of systematic exercise, and in the case of city dogs a change to the country, where they can live out of doors and will be tempted to constant exercise and play, will go far to correct a faulty liver.

Laxatives. Cholagogues. When a free action of bowels and liver cannot be secured by succulent food and exercise, we can fall back on medicinal laxatives. These are advantageous in various ways. Some laxatives like podophyllin, aloes, colocynth, rhubarb, senna, jalap, and taraxacum act directly on the liver in increasing the secretion of bile. These may be used for a length of time in small doses and in combination with the alkalies. Other aperients act directly on the bowel carrying away the excess of bile, the albuminoids and saccharine matter that would otherwise be absorbed, and by a secretion from the portal veins, abstracting nitrogenous and saccharine elements which would otherwise overtax the liver to transform them. Thus indirectly these also act as cholagogues by withholding the excess of material on which it has to operate, and by rousing its functions sympathetically with those of the bowels. Thus sulphates of magnesia and soda, and tartrates and citrates of the same bases, given in the morning fasting, dissolved in a large quantity of warm water and conjoined with sodium chloride, ammonium chloride, sodium carbonate or other alkaline salts, or with one or more of the vegetable cholagogues above mentioned, may be continued for a length of time until the normal functions have been re-established, and will maintain themselves irrespective of this stimulus.

Calomel (and even mercuric chloride in small doses), though it is not experimentally proved to be a direct cholagogue, is one of the very best correctives of impaired hepatic function. It expels the bile from the duodenum and bowels generally, thereby preventing its reabsorption; it proves antiseptic to the ingesta; it eliminates much of the peptone, saccharine and fatty matter from the intestines and portal system thus relieving the liver materially; and it is supposed further to modify the other liver functions by a direct action on the hepatic cells, and by reducing the cohesion of fibrine, and promoting the disintegration of albumen. Certain it is that calomel gives most substantial relief in many torpid and other disorders of the liver and as it is not in itself an active liver stimulant but has rather a soothing action on that gland it can be safely resorted to in states of hepatic irritation in which the more direct cholagogues would prove more or less hurtful.

In some forms of hepatic disorder where a speedy and abundant secretion is demanded, pilocarpin may be employed, with great caution so as not to reduce the strength unduly by the attendant diaphoresis, diuresis, salivation or diarrhœa.

Alkalies have long been recognized as of great clinical value in hepatic disorders. Though carbonate of soda decreases the secretion of bile, (Nasse, Röhrig), yet the alkalies generally appear to promote oxidation, and to hasten the disintegration of albumen and the albuminoids. They increase the disintegration of sulphur compounds materially adding to the sulphates and urea in the urine. They further tend to increase the hippuric acid, carbonate of soda (2 drs.) even determining the abundant excretion of this acid in man (Nasse). It may be concluded that the acknowledged value of alkalies in these diseases, is largely due to their hastening of the metabolic processes in albuminoids. Small doses of sodium carbonate further stimulate the gastric secretion and may thus benefit by rendering the process of digestion more complete and satisfactory.

Chlorine, Iodine, Bromine and their Salts. These halogens are of great value in many hepatic disorders. The universal craving for sodium chloride indicates the need of its elements in the animal body, and whether this is mainly the supply of chlorine for the hydrochloric acid of the gastric juice, or to fulfill its uses in favoring the oxidation and disintegration of the nitrogenous matters in the blood and tissues, or for other more or less obscure uses, it is well to recognize and act upon the indication. The various mineral waters which are held in high esteem in liver affections contain a large proportion of sodium chloride. As a medicinal agent ammonium chloride maintains an equally high position. Large doses thrice a day, so as to induce diaphoresis and diuresis greatly relieve hepatic congestions. This agent determines a great increase in the urea eliminated so that it is even more effective in the same direction, than sodium chloride. Free chlorine is also effective in hepatic torpor and congestion, and to this in part may be attributed the great value of nitro-muriatic acid.