WM^^^^ ms^^ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID PUBLIC HEALTH LIBRARY ^ CC^t^fCtyo X^, i^^ . ^ ^' /9o ^ CLINICAL HEMATOLOGY DaCOSTA CLINICAL HEMATOLOGY A PRACTICAL GUIDE TO THE EXAMINATION OF THE BLOOD WITH REFERENCE TO DIAGNOSIS. By JOHN C. ^aCOSTA, Jr., M.D. ASSISTANT DEMONSTRATOR OF CLINICAL MEDICINE, JEFFERSON MEDICAL COLLBGE HEMATOLOGIST TO THE GERMAN HOSPITAL, ETC. Containing Eight Full-Page Colored Plates, Three Charts, AND Forty-Eight other Illustrations. PHILADELPHIA : P. BLAKISTON'S SON & CO. IOI2 WALNUT street 1902 Copyright, 1901, P. Blakiston's Son & Co. i^i'l ? Lib He Lih TO MY FATHER, JOHN C DaCOSTA, M.D., THESE PAGES ARE AFFECTIONATELY DEDICATED. ivi37eQ5£ oo PREFACE. This book, designed as a practical guide to the examination of the blood by methods adapted to routine clinical work, repre- sents an endeavor to recount the salient facts of hematology as they are understood at the present time, to correlate certain of these facts with familiar pictures of disease, and to apply them to medical and surgical diagnosis. The purpose has been to inter- pret the blood report according to its true value as a clinical sign, neither exploiting it as a panacea for every diagnostic ill, nor belittling it because of its failure consistently to give the sought- for clue in every instance. A minimum amount of theoretical discussion has been intro- duced in the sections dealing with the physiology and pathology of the whole blood and of the cellular elements — only sufficient, in the author's judgment, to add clearness to a number of the mooted points of this science, which in its present transitional stage must still be regarded as one from which more or less hy- pothesis and conjecture are inseparable. Intimate familiarity with technique being an essential qualification for the comprehensive study of the blood, a somewhat lengthy consideration of this sub- ject is given. The methods of examination likely to prove useful in every -day practice have been described in detail, perhaps some- times at the risk of prolixity, in the hope of thus simplifying for the novice the minutiae of blood counting, staining, and other means of investigation. In the discussion of the primaiy anemias and of the anemias peculiar to infancy, prominent clinical features other than those referable to the blood have been briefly men- tioned, in order to add clearness to the differential diagnosis. For convenience in reference, the various diseases included in the sec- tion on general hematology are arranged alphabetically, rather than grouped according to a traditional classification. The greater part of the original data referred to in the text is taken from the records of the Pathological Institute of the Ger- man Hospital, where a systematic account of all blood examina- tions has been kept for the past six years. The remaining data represent the writer's personal examinations in hospital and pri- vate practice and in the army medical service, these sources of statistics together including about four thousand blood reports in various pathological conditions. vii VIU PREFACE. Hematological literature has been freely consulted in the prep- aration of this volume, special acknowledgment being due to Hayem, Ehrlich and Lazarus, von Limbeck, Rieder, Lowit, Tiirk, Grawitz, Cabot, Stengel, Thayer, Ewing, Taylor, and Coles for the profitable information gleaned from their writings. Due credit in the text has been given to these as well as to the other authors of whose labors use has been made. The colored plates and other histological illustrations, the originals of which were made by Mr. E. F. Faber from fresh and stained specimens, bear evidence of the artist's technical skill and faithful attention to structural detail. ^Ir. S. Trenner has kindlv furnished the engravings of several of the special instruments. The author takes pleasure in acknowledging the assistance of his wife and critic in revising the proof of these pages ; in credit- ing Dr. G. P. Miiller for collecting and verifying much statistical matter relating to hospital cases ; and in thanking Dr. J. Chal- mers Da Costa and Dr. T. G. Ashton for helpful suggestions. 313 South Thirteenth Street, Philadelphia, November, 1901. INTRODUCTION. The rapid growth and development of hematology during re- cent years and the practical application of many of its teachings to the diagnosis of various diseases have made this science one which no progressive medical man can afford to disregard. Ex- amination of the blood gives definite clinical information which may be profitable both to the practitioner of internal medicine and to the surgeon, and the procedure is capable of throwing light upon the diagnosis in such a wide range of pathological conditions that it is difficult to single out any disease in which it may not be of some utility, either as positive or as negative evi- dence. In the light of our present knowledge of the subject, clinical information of two different kinds may be derived from hematol- ogy, namely, findings which are pathognomonic of certain dis- eases ; and auxiliary data which, if considered in connection with other clinical manifestations, may prove either essential or helpful in establishing the precise nature of a disease. Pathognomonic blood findings are unfortunately confined to a limited number of diseases : leukemia, the malarial fevers, relaps- ing fever, and filariasis. In pernicious anemia a typical picture is also found, if two conditions capable of exciting identical blood changes are excepted, the profound secondary anemias due to certain intestinal parasites and to nitrobenzol poisoning. The blood examination affords data which, although not pa- thognomonic, are nevertheless essential for the diagnosis of chlo- rosis, Hodgkin's disease, splenic anemia, and secondary ane- mias dependent upon various causes. For example, in chlorosis a definite group of blood changes must exist in order to justify an unconditional diagnosis, although the occurrence of these changes, unassociated with other equally definite clinical signs, is insufficient evidence of this disease. In Hodgkin's disease, a condition indistinguishable from leukemia by an ordinary phys- ical examination, the absence of a leukemic state of the blood at once excludes the latter disease. In the secondary anemias, it is obvious that the blood count alone can give the exact clue to the condition, by determining the degree and character of the blood impoverishment, and by tracing from time to time its progress. IX X INTRODUCTION. In this connection it is important to remember that pallor may go hand in hand with a normal hemoglobin percentage and eryth- rocyte value, and that on the other hand a high color by no means invariably signifies that the individual is not anemic. In addition to the diseases just named, hematology' gives informa- tion which is often of great assistance in, although not essential for, the diagnosis of such conditions as enteric fever, sepsis, pneumonia, appendicitis, diabetes, syphilis, malignant disease, trichiniasis, and suppurative processes. Clinical experience has repeatedly illustrated the value of the serum reaction in typhoid and in Malta fevers, of Williamson's test in diabetes mellitus, of eosinophilia in trichiniasis, and of leucocytosis in sepsis, malignant neoplasms, suppurative lesions, and many of the acute infections. Negative results from a blood examination also possess diag- nostic value within certain limits, but too great reliance upon evi- dence of this sort more often proves delusiv^e than helpful. In a patient whose waxy, yellowish facies suggests with equal force pernicious anemia, chronic nephritis, and, perhaps, liver cirrhosis, the absence of characteristic blood changes is sufficient to exclude the first-named condition. But failure to detect the malarial para- site does not necessarily exclude malarial fever ; a negative serum test does not absolutely rule out enteric fever; and an absence of leucocytosis cannot be regarded as an infallible sign that a sup- purative focus does not exist, nor does it always indicate the benignity of a neoplasm. Negative evidence, then, is usually to be considered merely suggestive, the real pertinence of the hint thus obtained depending upon its correlation with other physical signs and symptoms. The significance of positive findings in bacteriological investiga- tions of the blood is patent, and the conclusive value of this means of research in identifying obscure cases of general sepsis, malignant endocarditis, enteric fever, and plague, has been demon- strated in many instances. Thje conflicting and indifferent results which some investigators hav^e obtained by this procedure were doubtless due largely to faulty technique, but these results promise to become more dependable and certain with the adoption or more exact technical methods. At the present time the most useful information furnished by hematology' has been derived from study of the cellular elements of the blood, but closer familiarity with the chemistry of this tissue, still an undeveloped science, will undoubtedly in the near future afford not only more tangible clues to the etiology and pathology of the blood diseases, but also will bring to light addi- tional facts which may be applied to the diagnosis of these and INTRODUCTION. XI other maladies. The study of the coagulation time of the blood already promises to be of practical utility in the diagnosis and prognosis of cases of purpura, hemophilia, and jaundice, which are characterized by slow clotting and by a tendency toward hemorrhage. The technique of blood examinations, such as described in the following pages, is neither elaborate nor difficult to master. Necessarily, it must be rigidly exact, but no more so than any other branch of physical diagnosis, if the worker is content only with the best results. To acquire a good working knowledge of hematology takes but a fraction of the time and application that one must spend in familiarizing one's self with the most com- mon heart murmurs or chest signs, and the time thus spent equips the physician with an additional diagnostic agent of the greatest value. If the newly-graduated physician would provide himself with a microscope and a set of blood instruments, and systematically study the blood in the various general diseases which he encounters in practice, many a slip-shod diagnosis might be avoided, and a great stride forward made in popularizing this practical branch of clinical diagnosis. TABLE OF CONTENTS. INTRODUCTION IX SECTION I. EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Page. General Schema I. Hemoconia Hemoglobin Examination of the Fresh Blood Obtaining the Specimen Preparing the Shde Microscopical Examination . Changes Affecting the Erythrocytes Changes Affecting the Leucocytes . Increase of Fibrin, Blood Plaques, and Blood Parasites . • • • Foreign Bodies . • • • II. Estimation of the Percentage of Von Fleischl's Hemometer Ohver's Hemoglobinometer Gowers' Hemoglobinometer Dare's Hemoglobinometer Tallquist's Method III. Counting the Erythrocytes and the Leucocytes Methods . • • • Diluting Fluids The Thoma-Zeiss Hemocytometer Counting the Erythrocytes • Counting the Leucocytes Cleaning the Pipette Durham's Hemocytometer • Gowers' Hemocytometer Ohver's Hemocytometer IV. Microscopical Examination of the Stained Specimen , Objects of Staining The Anihne Dyes . Preparing the Films Fixation Methods . Methods of Staining Ehrhch's Triacid Stain Jenner's Stain Prince's Stain xiii 19 19 19 21 22 22 23 24 24 24 25 25 32 34 36 39 40 40 40 42 45 49 52 52 54 56 58 58 59 59 61 63 64 65 66 XIV TABLE OF CONTENTS. Staining with Eosin and Methylene-blue Staining with Eosin and Hematoxyhn . Staining with Thionin .... Staining with Polychrome Methylene-blue Differential Counting .... V. Counting the Blood Plaques • Determann's Method .... VI. Estimation of the Relative Volumes of Corpuscles an Plasma ...... Daland's Hematocrit .... Limitations of the Hematocrit VII. Estimation of the Specific Gravity Hammerschlag's Method . • . VIII. Estimation of the Alkalinity Engel's Alkalimeter IX. Determination of the Rapidity of Coagulation Glass Slide Method Wright's Coagulometer X. Spectroscopical Examination . The Sorby-Beck Microspectroscope XI. Bacteriological Examination Value of Positive Findings Methods ..... Blood Cultures . . • • Staining Methods XII. Determination of the Serum Reaction Widal'sTest ...... The Specific Test for Human Blood D Page. 67 68 69 69 70 71 72 72 73 74 75 75 n 77 79 80 80 81 81 83 83 83 83 85 86 86 88 SECTION II. THE BLOOD AS A WHOLE. I. General Composition . Plasma, Serum, and Cells Salts . Extractives Gases . II. Color . Normal Variations Density and Opacity Pathological Variations III. Odor and Viscosity IV. Reaction Reaction in Health 93 93 93 94 94 94 94 94 94 95 95 95 TABLE OF CONTENTS. XV Table of Normal Blood Alkalinity . 96 Physiological Variations . . . . 96 Pathological Variations . . . . . 97 V. Specific Gravity ...... 98 Normal Range ..... 98 Pathological Variations .... 99 Relation of Specific Gravity to Hemoglobin 99 Table of Hemoglobin Equivalents . 100 VI. Fibrin and Coagulation . . . . 100 Relation of Fibrin to Coagulation 100 Appearance of Fibrin in Fresh Blood lOI Hyperinosis and Hypinosis . 102 Pathological Variations in Amount of Fibrin . 102 VII. Oligemia ....... 103 Definition ...... 103 Occurrence ...... 103 VIII. Plethora ...... 104 Definition ...... 104 Permanent and Transient Polyemia 104 Serous Plethora ..... 104 Cellular Plethora ..... 105 IX. Hydremia ...... 105 Definition ...... 105 Causes ....... 105 Occurrence ...... 105 X. Anhydremia 106 Definition ...... 106 Causes ....... 106 Occurrence ...... 106 XI. LiPEMIA ...... 106 Amount of Fat in Normal Blood • 106 Definition . . 107 Physiological and Pathological Lipemia . 107 Tests for Fat ..... 107 XII. Melanemia 107 Definition ...... 107 Occurrence ...... 108 XIII. Glycemia 108 Amount of Sugar in Normal Blood 108 Hyperglycemia ..... 108 Test for Sugar ..... 108 XIV. Uricacidemia 109 Definition ...... 109 Occurrence ...... 109 Test for Uric Acid ..... 109 XVI TABLE OF CONTENTS. XV. Cholemia . . . . . Definition . . . . . Occurrence . . . . . Test for Bile . . . . XVI. Acetonemia and Lipacidemia Definition . . . . • Occurrence . . . . Tests for Acetone and Fatty Acids XVII. Bacteriemia . Occurrence Latent Infection Blood Cultures Bacteria Found in the Blood XVIII. Anemia . Definition Pseudo-anemia Classification Patho2"enesis Page, I lO IIO IIO IIO IIO IIO IIO IIO III III III 112 112 113 113 113 114 115 SECTION III. HEMOGLOBIN. ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. II. III. Hemoglobin 119 General Properties 119 Origin 120 Variations in Amount 121 Absolute Amount 122 Color Index 122 Hemoglobinemia 123 Methemoglobinemia 124 Carbon Monoxide Hemoglobin 125 Erythrocytes 126 Appearance in Fresh Blood . 126 Histological Structure . 127 Origin and Life History- 128 Size Normal Number . 129 129 Volume Index 130 . Influence of Physiological Factors 0: S' THE ERYTH- . rocytes ..... 130 Age and Sex ..... Pregnancy, Menstruation, and Lactation 130 131 Constitution and Nutrition 132 Fatigue Digestion and Food High Altitudes • 132 132 133 TABLE OF CONTENTS. XVI 1 IV. Pathological Changes in the Ameboid Motility Alterations in Isotonicity Hyperviscosity Deformities of Shape and Size Megalocytes . Microcytes Poikilocytes Endoglobular Degeneration Total Necrosis Atypical Staining Reactioi> Nucleation . Normoblasts Megaloblasts Microblasts . Atypical Erythroblasts Granular Degeneration Oligocythemia Polycythemia V. Blood Plaques Appearance in Fresh Blood Histological Structure . Origin Normal Number . Pathological Variations VI. Hemoconia Appearance in Fresh Blood Histological Characteristics Occurrence . Erythrocytes Page. 135 136 136 136 137 137 138 139 140 141 141 143 145 146 147 148 149 SECTION IV. THE LEUCOCYTES. General Characteristics Appearance in Fresh Blood Ameboid Movement Cell Granules Normal Number . H. Classification Number and Percentage Small Lymphocytes Large Lymphocytes Transitional Forms Polynuclear Neutrophiles Eosinophiles Basophile Cells Myelocytes . Mast Cells . 1* of Different Varieties »55 155 156 157 159 159 159 160 161 162 163 165 166 167 168 XVlll TABLE OF CONTENTS. Mononuclear Neutrophiles Neutrophilic Pseudolymphocytes Reizungsformen . Differential Table of the Leucocytes Origin and Development Iodine Reaction . Perinuclear Basophilia . toses III. Leucocytosis Definition .... Classification of the Leucocyte Physiological Leucocytosis Character Causal Factors Leucocytosis of the New-born Digestion Leucocytosis Leucocytosis of Pregnancy and Parturition Leucocytosis Due to Thermal and Mechanical Terminal Leucocytosis .... Pathological Leucocytosis Occurrence Degree of Increase Differential Changes Causal Factors Functions ..... Hypoleucocytosis and Hyperleucocytosis Inflammatory and Infectious Leucocytosis Leucocytosis of Malignant Disease Post-hemorrhagic Leucocytosis Toxic Leucocytosis Experimental Leucocytosis IV. Lymphocytosis . Definition Differential Changes Causal Factors Physiological Lymphocytosis Pathological Lymphocytosis . Experimental Lymphocytosis Clinical Significance EOSINOPHILIA .... Definition ..... Causal Factors .... Physiological Eosinophilia Pathological Eosinophilia Experimental Eosinophilia Diminution in the Number of Eosinophiles Clinical Significance .... Influences Pagb. 171 171 171 172 173 176 176 176 177 177 177 178 178 179 180 iBi 181 182 182 183 183 184 184 185 187 190 191 192 193 196 196 196 197 197 197 198 198 198 198 199 199 200 201 201 201 VI. Basophilia . 202 TABLE OF CONTENTS. XIX VII. Myelemia . Definition Occurrence . Causal Factors VIII. Leucopenia Definition Differential Changes Physiological Leucopenia Pathological Leucopenia Experimental Leucopenia Page. 202 202 202 203 203 203 204 204 205 207 SECTION V. DISEASES OF THE BLOOD. I. Chlorosis .... Appearance of the Fresh Blood Coagulation .... Specific Gravity Alkalinity .... Hemoglobin and Erythrocytes Color Index .... Deformed and Nucleated Cells Leucocytes .... Differential Changes Blood Plaques Diagnosis .... Clinical Features . II. Pernicious Anemia Appearance of the Fresh Blood Coagulation .... Specific Gravity . Alkalinity .... Hemoglobin and Erythrocytes Color Index .... The Blood During Remissions Megalocytosis Poikilocytosis Prevalence of Megaloblasts . Polychromatophila Granular Basophilia Leucocytes .... Differential Changes Blood Plaques Diagnosis .... Clinical Features . Pernicious Anemia and Severe Secondary Anemia Pernicious Anemia and Chlorosis . Pernicious Anemia and Bothriocephalus Anemia Pernicious Anemia and Nitrobenzol Poisoning 209 209 209 209 219 210 210 210 213 214 215 216 216 218 2X8 219 219 220 220 220 221 221 223 224 225 226 227 227 228 228 229 230 230 231 231 XX TABLE OF CONTENTS. III. Splenic Anemia. Appearance of the Fresh Blood Hemoglobin and Er>'throcytes Color Index . Deformed and Nucleated Cell Leucocytes . Blood Plaques Diagnosis Clinical Features . Splenic Anemia and Spleno-medullar)' Leukemia Splenic Anemia and Pernicious Anemia Splenic Anemia and Hodgkin's Disease Splenic Anemia and Splenic Tumors IV. Secondary Anemia Appearance of the Fresh Blood Coagulation . Specific Gravity Alkalinity Hemoglobin and Erythrocytes Color Index . Deformed and Nucleated Cell Leucocytes . Differential Changes Blood Plaques Diagnosis V. POST-HEMORRHAGIC AnEMIA Etiology Immediate Effects of Hemorrhage Secondary Effects of Hemorrhage . Degree of Blood Loss Compatible with Life Regeneration of the Blood Differential Table ..... VI. Leukemia ...... Varieties ...... Parasitology ...... Spleno-medullar)- Leukemia . Appearance of the Fresh Blood Coagulation ..... Alkalinity Specific Gravity .... Hemoglobin and Erj-throcytes Color Index ..... Relation of Erythrocyte and Leucocyte Counts Nucleated Cells Leucocytes ...... Influence of Arsenic on the Leucocyte Count The Blood During Remissions Differential Changes .... Blood Plaques ..... Page. 231 231 231 231 232 233 233 233 234 235 235 235 235 236 236 236 236 237 237 237 238 238 238 239 239 239 239 240 240 240 241 243 244 244 244 246 246 247 247 247 247 248 248 248 250 250 251 252 256 TABLE OF CONTENTS. XXI Lymphatic Leukemia Appearance of the Fresh Blood Hemoglobin and Erythrocytes Color Index . . . • Deformed and Nucleated Cells Leucocytes .... Differential Changes Blood Plaques Acute Leukemia .... Influence of Intercurrent Infections Diagnosis ....•• Spleno-meduUary and Lymphatic Leukemia Leukemia and Pathological Leucocytosis Leukemia and Lymphocytosis Leukemia and Hodgkin's Disease • Leukemia and Tumors of the Spleen, Kidney, and Pancreas Leukemia and Lymphatic Hyperplasia . VII. Hodgkin's Disease .... Appearance of the Fresh Blood Alkalinity, Specific Gravity, and Coagulation Hemoglobin and Erythrocytes Color Index ....•• Nucleated and Deformed Cells Leucocytes ...••• Differential Changes .... Diagnosis ....•• Clinical Features . . . • • Hodgkin's Disease and Tuberculous Adenitis Hodgkin's Disease and Syphilitic Adenitis Hodgkin's Disease and Local Lymphoma Hodgkin's Disease and Lymphatic Sarcoma . Hodgkin's Disease and Lymphatic Carcinoma VIII. The Effect on the Blood of Splenectomy Hemoglobin and Erythrocytes .... Leucocytes ....•••• Differential Changes Factors of the Blood Changes Following Splenectomy Differential Table . Page. 256 256 257 257 257 258 259 260 260 261 263 264 265 265 266 266 266 267 267 267 267 267 267 268 268 269 270 271 271 271 271 272 272 272 272 274 274 275 SECTION VI. THE ANEMIAS OF INFANCY AND CHILDHOOD I. Characteristics of the Blood in Children Fetal Blood . The Blood at Birth II. Anemia in Children Frequency . General Characteristics 279 279 280 282 282 283 XXll TABLE OF CONTENTS. Page. Classification . 283 Primary Anemia . . • • Pernicious Anemia 284 284 Leukemia .... 284 Secondary Aremia Mild Anemia . . ■ • 287 287 Severe Anemia 287 Anemias with Leucocytosis 287 Etiology of Secondary Anemia Anemia Due to Syphilis . 288 288 Anemia Due to Rachitis . 288 Anemia Due to Tuberculosis • 289 Anemia Due to Gastro-intestinal Diseases 289 Post-typhoid Anemia .... Anemia Infantum Pseudoleukemica 289 290 Bacteriemia in Children • 292 SECTION VII. GENERAL HEMATOLOGY. I. Abscess Coagulation, Fibrin, and Iodine Reaction Hemoglobin and Erythrocytes Factors of the Anemia in Abscess Color Index ...... Grade of Anemia in Different Forms of Abscess Cell Deformity and Nucleation Leucocytes ...... Relation of the Leucocyte Count to the Local Lesion Range of the Leucocyte Count in Different Forms of Abscess Differential Changes ....... Diagnosis ......... II. Acromegaly III. Actinomycosis IV. Acute Yellow Atrophy of the Liver V. Addison's Disease VI. Anthrax VII. Appendicitis . . Factors of the Anemia in Appendicitis Grade of Anemia in Catarrhal and Suppurative Cases Hemoglobin and Erythrocytes . . • • • Cell Deformity and Nucleation ..... Leucocytes ......... Range of the Leucocyte Count in Different Forms of Appendi citis ......... Differential Changes ....... Diagnosis ......... 295 295 295 -95 295 296 296 296 297 297 297 297 298 298 298 299 299 300 300 300 300 301 301 302 302 ^,02 TABLE OF CONTENTS. XXlll Page. VIII. Asiatic Cholera 304 IX. Asthma and Emphysema 305 X. Bronchitis . 306 XI. Bubonic Plague 306 Bacteriology . 306 Serum Reaction . 307 Hemoglobin and Erythrocytes 307 Leucocytes . . 307 Blood Plaques . 308 XII. Cholelithiasis 308 Fibrin and Coagulation 308 Bacteriology . 308 308 Leucocytes ........ 309 Diagnosis ......••• 309 XIII. Diabetes Mellitus 309 Alkalinity, Lipemia, Lipacidemia, and Glycemia . 309 Williamson's Test 309 Bremer's Test ..•••••• 310 Hemoglobin and Erythrocytes 311 Leucocytes 312 Digestion Leucocytosis ....... 312 Iodine Reaction . 312 Diagnosis .....•••• 312 312 Hemoglobin and Erythrocytes 312 Leucocytes ...•••••• 313 Course of the Leucocytosis ...... 314 Influence of Antitoxin on the Leucocyte Count 314 Differential Changes 315 Affinity of the Leucocytes for Basic Dyes 315 316 XV. Enteritis 316 Acute Catarrhal, Chronic Ulcerative, and Phlegmonous 316 Gastro-enteritis ........ . 316 Dysentery . 316 Effect of Saline Purges . 316 XVI. Enteric Fever 317 Bacteriology ........ 317 Blood Cultures . 317 Spot Cultures . . 318 Serum Reaction . 319 Hemoglobin and Erythrocytes 326 Cell Deformity and Nucleation 328 Leucocytes 328 Differential Changes ....... 330 Effect of Complications 330 XXIV TABLE OF CONTENTS. Blood Plaques Diagnosis .... XVII. Erysipelas XVIII. Exophthalmic Goitre . XIX. Fever .... Factors of the Blood Changes Pyrexial Polycythemia Post-febrile Anemia Coagulation, Fibrin, and Leucocytes Alkalinity .... XX. FiLARIASIS .... Occurrence .... Parasitology .... The Filaria Nocturna Technique of Examination Staining the Filariae Hemoglobin and Erythrocytes Leucocytes .... Diagnosis .... XXI. Fractures XXII. Gastritis Acute and Chronic Forms Hyperchlorhydria, Hypochlorhydria, Gastric Dilatation, Gastric Neurasthenia Diagnosis .... XXIII. Gastric Ulcer Hemoglobin and Erythrocytes Effects of Hemorrhage and Emesis Leucocytes . Diagnosis XXIV. Glanders XXV. Gonorrhea XXVI. Gout Alkalinity and Fibrin Uric Acid Cellular Elements Perinuclear Basophilia . XXVII. Hemorrhagic Diseases Specific Gravity . Bacteriology Alkalinity Coagulation Hemoglobin and Erythrocytes Leucocytes . Blood Plaques Achyl ia. Gastric Page. 331 332 333 333 333 333 334 334 334 334 334 335 335 340 341 341 342 342 343 343 343 344 344 345 345 345 345 345 346 346 347 347 347 347 348 348 348 348 348 349 349 350 350 TABLE OF CONTENTS. XXV XXVIII. Hepatic Cirrhosis Anemia in Atrophic Cirrhosis .... Effect of Ascites . . ..... Anemia in Hypertrophic Cirrhosis Leucocytes in Atrophic and Hypertrophic Cirrhoses Diagnosis ........ XXIX. Herpes Zoster XXX. Icterus . Fibrin, Coagulation, Specific Gravity, and Alkalinity Hemoglobin and Erythrocytes .... Leucocytes ........ Diagnosis ........ XXXI. Influenza . XXXII. Insolation . XXXIII. Intestinal Helminthiasis Factors of the Blood Changes .... Hemoglobin and Erythrocytes .... Bothriocephalus Anemia ..... The Anemia of Ankylostomiasis .... Leucocytes . . . . • XXXIV. Intestinal Obstruction .... XXXV. Leprosy XXXVI. Malarial Fever Parasitology ....... Developmental Cycle of the Malarial Parasite in Man Developmental Cycle of the Malarial Parasite in the Mosquito Varieties of the Malarial Parasite The Parasite of Tertian Fever Infections with Single and Multiple Groups Anticipation of the Paroxysm Intracellular Hyaline Forms • Intracellular Pigmented Forms Segmenting Forms Extracellular Pigmented Forms Flagellate Forms . Degenerate Forms . The Parasite of Quartan Fever Infections with Single and Multiple Groups Intracellular Hyaline Forms • iQtracellular Pigmented Forms Segmenting Forms Extracellular Pigmented Forms Flagellate Forms . Degenerate Forms The Parasite of Estivo-autumnal Fever Irregularities in Time of Developmental Cycle Disc- and Ring-shaped Forms Page. 351 351 352 352 353 353 353 353 354 354 3 54 355 356 356 356 356 357 357 357 358 359 359 359 360 361 362 362 362 362 363 364 365 366 367 367 367 368 368 369 370 370 370 370 370 371 XXVI TABLE OF CONTENTS. Page. Pigmented Forms .... Segmenting Forms ... Erythropyknosis .... Spherical, Ovoid, and Crescentic Forms Flagellate Forms .... Degenerate Forms Pigmented Leucocytes and Phagocytosis Differential Table of the Malarial Parasites Technique of Examination Hemoglobin and Erythrocytes Causes of Malarial Anemias . Anemia in the Regularly Intermittent Fevers Anemia in Estivo-autumnal Fever Anemia in Malarial Cachexia Types of Post-malarial Anemia Leucocytes .... Differential Changes Blood Plaques . . Diagnosis . . XXXVn. Malignant Disease . Carcinoma .... Fibrin and Coagulation • Specific Gravity and Alkalinity Glycemia Parasitology . Hemoglobin and Erythrocytes Color Index .... Regeneration of the Blood after Operation The Oligocythemia and Polycythemia of Gastric Cance Deformed and Nucleated Cells Leucocytes .... Frequency of Cancer Leucocytosis Causes of Cancer Leucocytosis Range of the Leucocytes in Different Forms of Cane er Digestion Leucocytosis in Gastric Cancer Differential Changes Sarcoma ..... General Features of the Blood Hemoglobin and Erythrocytes Leucocytes .... Diagnosis .... XXXVIII. Malignant Endocarditis Bacteriology ..... Hemoglobin and Erythrocytes Leucocytes . Diagnosis XXXIX. Malta Fever XL. Measles XLI. Meningitis TABLE OF CONTENTS. XXVll XLII. Myxedema . XLIII. Nephritis . Factors of the Blood Changes .... Specific Gravity, Fibrin, Coagulation, and Alkalinity Bacteriology ........ Hemoglobin and Erythrocytes .... Anemia in Acute and Chronic Parenchymatous Nephriti Polycythemia ....... Anemia in Chronic Interstitial Nephritis Leucocytes ........ Uremia . . . Diagnosis ........ XLIV. Nervous and Mental Diseases . Neuritis, Beri-beri, Neuralgia, and Brain Tumor • Neurasthenia, Hypochondriasis, and Hysteria General Paresis, Dementia, Melancholia, and Mania Convulsions, Apoplectiform Attacks, and Acute Delirium Epilepsy, Chorea, and Tetany XLV. Obesity ..... XLVI. Osteomalacia XLVII. Pericardial Effusion XLVIII. Peritonitis XLIX. Pertussis .... L. Pleurisy ..... Serous Pleurisy .... Purulent Pleurisy .... Diagnosis ..... LI. Pneumonia ..... General Features of the Blood Bacteriology ..... Hemoglobin and Erythrocytes Leucocytes ..... Relation of Leucocytosis to Intensity of Infection Frequency and Extent of Leucocytosis Effects of Antipyresis . Differential Changes Blood Plaques .... Diagnosis ..... LI I. Poisoning LIII. Rabies ..... LIV. Relapsing Fever Parasitology . . . . • Lowenthal's Reaction . Hemoglobin and Erythrocytes Leucocytes ..... Diagnosis ..... Page. 399 399 399 399 400 400 400 401 401 401 401 402 402 402 403 404 405 405 406 406 467 408 409 409 410 411 411 411 411 412 413 413 413 414 415 415 415 416 417 418 418 420 421 421 421 XXVlll TABLE OF CONTENTS. LV. Rheumatic Fever .... Coagulation, Fibrin, and Alkalinity Bacteriology ..... Hemoglobin and Erythrocytes Leucocytes ...••• Diagnosis ...... LVI. Scarlet Fever .... Coagulation, Fibrin, and Specific Gravity Bacteriology ...... Hemoglobin and Er^'throcytes Leucocytes ...... Blood Plaques ..... Diagnosis ...... LVII. Septicemia and Pyemia . Factors of the Blood Changes Fibrin ....... Serum Reaction ... Bacteriology ...... Hemoglobin and Erythrocytes Color Index ...... Deformed and Nucleated Cells Leucocytes ...... Differential Changes .... Diagnosis ...... LVIII. Syphilis ..... Hemoglobin and Erythrocytes Syphilitic Chlorosis and Pernicious Anemia Effect of Mercur}^ on the Blood Justus' Test . Leucocytes . Diagnosis LIX. Tetanus . LX. Tonsillitis LXI. Trichiniasis LXII. Tuberculosis . General Features of the Blood Bacteriology Serum Reaction Hemoglobin and Erythrocytes Anemia in Pulmonary Tuberculosis Anemia in Bone Tuberculosis Anemia in Tuberculous Adenitis, Meningitis, risy, and Peritonitis, and in Genito-Urinar}' Leucocytes ...... Differential Changes .... Iodine Reaction ..... Perinuclear Basophilia .... Range of the Leucocytes in Pulmonary Tuberculosis Pericarditis, Pleu- Tuberculosis • TABLE OF CONTENTS. XXIX Range of the Leucocytes in Bone Tuberculosis Range of the Leucocytes in Acute Miliary Tuberculosis, Tuber culous Adenitis, Pleurisy, Peritonitis, Pericarditis, and Men ingitis, and in Genito-Urinary Tuberculosis Effect of Secondary Septic Infections Diagnosis .... LXIII. Typhus Fever Parasitology Hemoglobin and Erythrocytes Leucocytes .... Diagnosis .... LXIV. Vaccination . LXV. Valvular Heart Disease Stage of Compensation . Acute Rupture of Compensation Effect of Stasis LXVL Varicella LXVH. Variola Fibrin and Parasitology Hemoglobin and Erythrocytes Leucocytes .... Blood Plaques Diagnosis .... LXVni. Yellow Fever . Fibrin and Coagulation Bacteriology Serum Reaction . Hemoglobin and Erythrocytes Degenerative Changes Leucocytes .... Differential Changes Diagnosis .... Page. 441 443 443 443 444 444 444 445 445 445 446 446 446 446 447 448 448 448 448 449 449 449 449 450 450 450 451 451 451 451 LIST OF ILLUSTRATIONS. Plate. I. The Erythrocytes II. The Leucocytes III. Leucocytosis IV. Spleno-meduUary Leukemia V. Lymphatic Leukemia VI. The Tertian Malarial Parasite VII. The Quartan Malarial Parasite VIII. The Estivo-autumnal Malarial Parasite Page. ii8 154 176 246 256 362 366 371 Chart. I. Pernicious Anemia ..... II. Spleno-medullary Leukemia III. Multiple Infections in Malarial Fever . Figure. 1. Blood Lancet ...... 2. Proper Distribution of Cells in a Blood Film . 3. Von Fleischl's Hemometer .... 4. Tinted Wedge of von Fleischl's Hemometer 5. Capillary Pipette of von Fleischl's Hemometer 6. Method of using the von Fleischl Hemometer 7. Light-proof Box for von Fleischl's Hemometer 8. Method of Using Oliver's Hemoglobinometer 9. Gower's Hemoglobinometer .... 10. Dare's Hemoglobinometer .... 11. Horizontal Section of Dare's Hemoglobinometer 12. Method of Filling Blood Chamber 13. Thoma-Zeiss Hemocytometer 14. Thoma-Zeiss Counting Chamber . 15. Ruled Area of Thoma-Zeiss Counting Chamber 16. Ruled Area of Zappert's Counting Chamber . 17. Method of Filling the Hemocytometer . 18. Plan of Counting the Erythroc)tes 19. Ocular Diaphragm ..... 20. Expelling Contents of the Erythrocytometer . 21. Cross Section of Durham's Blood Pipette 22. Method of Using Oliver's Hemocytometer 23. Superimposing the charged Cover-glass 24. Drawing Apart the Cover-glasses 25. The Cover-glasses after Separation 26. Oven for Fixing Blood-films 222 250 361 20 21 26 26 26 29 30 33 35 36 37 38 42 43 44 44 45 48 50 52 53 57 59 60 60 61 xxx LIST OF ILLUSTRATIONS. XXXI KlGUKK. 27. Daland's Hematocrit . 28. Engel's Alkalimeter 29. Wright's Coagulometer 30. Sorby-Beck Microspectroscope 31. Sorby Tubular Cell 32. Needle and Tube for Aspirating Blood , 33. Rouleaux Formation and Fibrin in Normal Blood 34. Hyperinosis ...... 35. Blood Spectra ...... 36. Degenerative Changes in the Erythrocytes 37. Changes in the Erythrocytes in Chlorosis 38. Changes in the Erythrocytes in Pernicious Anemia 39. Atypical Myelocytes in Spleno-medullary Leukemia 40. Atypical Polynuclear Neutrophils in Spleno-medullary 41. Atypical Lymphocytes in Lymphatic Leukemia 42. Positive Serum Reaction in Enteric Fever 43. Pseudo-reaction in Enteric Fever .... 44. Bacillus Typhi Abdominalis .... 45. Filaria Nocturna in Fresh Blood .... 46. Filaria Nocturna, showing Granular Degeneration 47. Filaria Nocturna, showing Changes in Shape 48. Spirilla of Relapsing Fever ..... Leukemia Page. 73 78 80 81 82 84 lOI 102 125 139 210 221 253 254 259 319 320 321 336 338 340 418 " V avenir appa^-tient a V hematologie. C' est elle qui nous apportera la solution des grands problemes nosologiques. Elle doit nous apparai'.re com me line vaste science puisant ses viateriaux dans toutes les branches des connais- sanccs biologiques et recueillant les diverses notions de P hj(f/ioristne ancien pour les rajeunir et les completer a la lumiere des decouvertes modernes en anatomic, en physiologic, en chimie hiologique et en pathologies Georges Hayem. xxxii SECTION I. EXAMINATION OF THE BLOOD BY CLINICAL METHODS. SECTION I. EXAMINATION OF THE BLOOD BY CLINICAL METHODS. P A systematic examination of the blood by ^ clinical methods of established utility includes the following twelve different processes : I. Microscopical examination of the fresh blood. II. Estimation of the percentage of hemoglobin. III. Counting the erythrocytes and the leucocytes. IV. Microscopical examination of the stained specimen. These four procedures, which invariably should be included in every clinical blood-report, furnish the most important informa- tion to be derived from hematological study, and are sufficient for routine clinical work. In certain instances in which more de- tailed investigation of special points is sought, it may be thought advisable to supplement the above plan by employing one or more of these remaining eight procedures : V. Counting the blood-plaques. VI. Estimation of the relative volumes of corpuscles and plasma. VII. Estimation of the specific gravity. VIII. Estimation of the alkalinity. IX. Determination of the rapidity of coagulation. X. Spectroscopical examination. XI. Bacteriological examination. XII. Determination of the serum-reaction. I. EXAMINATION OF THE FRESH BLOOD. The finger-tip or the lobe of the ear is the part Obtaining usually selected from which to obtain the blood, THE by puncture, for examination. The former site Specimen. is preferable in most instances, owing to its con- venient situation and ease of manipulation ; but in nervous individuals and in children the ear-lobe may be chosen, because of its limited sensibility, and on account of the patient's inability to watch the operation. 20 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. The puncture may be made with one of the special blood- lancets devised for this purpose, or, in lieu of such an instrument, a Hagedom or spear-pointed surgical needle, or a new sharp- pointed steel pen from which one prong has been twisted off, will answer the purpose equally as well. The author is accustomed to use a small steel trocar-blade, mounted on a metal shaft which screws into an outer barrel, by means of a thread. By the use of a threaded locking-nut, any desired length of the trocar may be exposed, so that the depth of the wound may be controlled at will, irrespective of the force used to drive the point of the P-j^ J instrument through the skin. It is not necessary to steriHze the puncture- i::rJpj51jBiil ) "^^<^^^ 5 wiping it with a towel wet with alcohol is all that is required. Blood-lancet. . ,. . , ^-.- in ordinar^^ examinations. Of course, should the patient happen to be a syphilitic, it is safer to pass the blade through an alcohol flame, after having used it. Having chosen, say, the patient's middle or nng-finger, the part is first thoroughly cleansed with alcohol or ether and then with water, and wiped perfectly dry with a clean, lint-free towel, which may be then folded into a pad and slipped behind the fin- ger to isolate it from the neighboring digits, and to serve as a cushion for the back of the hand. The operator, holding the patient's hand in a firm, steady position, makes the puncture with a rapid motion of the wrist, such as one is accustomed to use in percussing the thorax, the depth of the wound being just suffi- cient to cause a free flow of blood in good-sized drops, unaided by the slightest pressure on the finger other than that necessary to start the initial oozing. The needle should be aimed so as to strike a point in the center of the flexor surface of the finger, just back of the extreme tip. The blood-drop to be used for the ex- amination should under no circumstance be squeezed from the finger, for blood secured in this manner is certain to be more or less highly diluted with lymph from the surrounding tissues — a condition which will give rise to erroneous results, especially to lower hemoglobin, specific gravity, and corpuscular estimations than actually exist. In severe anemias, especially in those of the pernicious type, the bloodless condition of the superficial ves- sels is sometimes so marked that it may be impossible to obtain enough blood for the examination by an ordinary puncture, even from the ear-lobe, which as a rule is highly vascular. Relatively deep incisions are unavoidable in such instances. On the con- trary in most cases of leukemia, unless the coexisting anemia is of striking intensity, the blood ^usually flows very freely, and EXAMINATION OF THE FRESH BLOOD. 21 may even spurt from the wound in a fine jet several inches in height. Most writers on hematology utter an emphatic warning against hemophilics, in whom the slightest prick of a needle may cause troublesome bleeding. The writer has never had the misfortune to^meet with this accident, but recognizes the wisdom of observ- ing the precaution habitually to question every patient concerning an abnormal tendency toward hemorrhage. The observer's attention should be directed to the color and the density of the blood drop as it flows from the puncture, and a note taken of the various macroscopical changes which may oc- cur, such as the pale, hydremic condition of the blood found in severe anemias, and the milky appearance of the drop in leu- kemia and in diabetes. These and other alterations in the naked- eye appearance of the fresh blood drop have been discussed in another section. The first few drops of blood which follow the Preparing puncture are wiped away, and the site of the in- THE cision freed from every trace of moisture, after Slide. which a perfectly clean cover-glass, held edge- wise between the thumb and forefinger, is lightly touched to the sinnmit of the next drop as it oozes from the puncture, and is then immediately placed, blood side downward, Fig. 2. @% o Proper distribution of the corpuscles in a fresh blood-film prepared for MICROSCOPICAL examination. upon the surface of a clean glass slide. If the cover-glass and the slide are perfectly clean and dry, and if the drop is of the 22 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. proper size, the blood will at once spread out in a thin film con- sisting of a single layer of corpuscles. (Fig. 2.) Gently heat- ing the slide over an alcohol flame just before use will ensure a thin, even spread. If prolonged study of the specimen is intended, it may be advisable to exclude air from the film, by ringing the margins of the cover-glass with a thin layer of cedar-oil, or of vaseline, but ordinarily this precaution is unnecessary. In order to prevent distortion of the corpuscles, pressure must be avoided while adjusting the cover-glass. If the blood does not spread of itself, without the aid of pressure, it is usually owing to the pres- ence of particles of dust or grease between the opposed surfaces of the slide and cover-glass. Absolute cleanliness of the covers and slides is an essential detail to which too great attention cannot be paid, for neglect of this precaution is responsible for the majority of failures to secure good specimens. Perhaps the most useful cleansing agent is the solution popularly known as " acid alcohol " (hydrochloric acid, I part ; absolute alcohol, 29 parts ; water, 70 parts), which quickly and effectually removes all traces of grease and dirt from the glasses, so that their preliminar}^ soaking in soap-suds or in a strong mineral acid, as some recommend, may be dispensed with. The slides and covers may be conveniently kept in closed glass receptacles containing this solution, from which they are removed as the occasion demands, being then dried and polished with a bit of clean linen, or with tissue-paper. Ordinary soft "toilet-paper" is excellent for this purpose. Oblong cover- glasses, measuring J x i-J inches and of ** No. i " thickness, are more easily handled without forceps than smaller square or cir- cular slips, and also have a much larger surface than the latter, which is often decidedly advantageous. The use of forceps is unnecessar)^, if care is observed to hold the cov^er-glass in the manner already directed, so that only its edges come in contact with the thumb and finger. The specimen, prepared in the manner just Microscopical described, is examined under the microscope Examination, with both low and high powers, a i or J inch dr>', and a ^^2 '^^h oil-immersion objective being the most satisfactory lenses for the purpose. The substage. con- denser and diaphragm should be adjusted so that the field is but moderately illuminated, rather than flooded with a glare of white light. Microscopical examination of the fresh blood-film fur- nishes information about the following points : Changes Affecting the ErytJirocytes. With a little practice, one soon becomes able to detect with a tolerable degree of accuracy EXAMINATION OF THE FRESH BLOOD. 23 any conspicuous decrease in the number of erythrocytes, by the relatively small number of cells in the field in comparison with their number in a similar field of normal blood. With less con- fidence, it is also possible to decide whether or not the number of erythrocytes is much in excess of the normal standard. Deficiency in hemoglobin produces unmistakable changes in the appearance of the cells, those in which this change is well- defined appearing as pale, washed-out bodies which stand in striking contrast to the darker, yellowish-green color of the nor- mal erythrocytes. Abnormal viscosity of the erythrocytes, their tendency towards rouleaux formation, the presence of deformities of size and of shape, and the occurrence of structural degenerative changes may also be distinguished in the fresh, unstained blood-film. Nucleated erythrocytes are not demonstrable in the fresh speci- men. Changes Affecting the Leucocytes. A glance is usually suffi- cient to determine whether or not the number of leucocytes is markedly in excess of normal, but too great dependence should not be placed on such a method of detecting the presence or absence of a leucocyte -increase, since it is at the best approximate, and sometimes erroneous. As will be explained elsewhere, any marked decrease in the number of erythrocytes, the leucocytes remaining normal, may so increase the ratio of the latter to the former, that the leucocytes may be apparently increased. Having tentatively determined that an increase in the total number of leucocytes is present, it is furthermore possible for one familiar with the morphology of the unstained leucocyte to make a fairly accurate differential count of these cells, and thus to decide whether the increase is due to a pure leucocytosis, or to some form of leukemia. This distinction is not at all diffi- cult in most instances, when one recalls the characteristics of the several forms of leucocytes in the fresh blood-film, viz.: small lymphocytes, large lymphocytes, and transitional forms, appear- ing as cells having a single, spherical, or indented nucleus, and a clear, shining, non-granular protoplasm; polynuclearneutrophiles, as cells with polymorphous or multiple nuclei, and a protoplasm crowded with very fine, moderately refractive granules ; eosino- philes, as cells with a single, polymorphous nucleus, or multiple nuclei, and a protoplasm containing coarse, spherical, highly refrac- tive, fat-like granules ; and myelocytes as cells with a single spherical or ovoid nucleus, and a protoplasm crowded with very fine, moderately refractive granules. It is, of course, obviously impossible to distinguish basophile cells in the fresh blood, as 24 EXAMINATION OF THE BLOOD BV CLINICAL METHODS. well as some of the cells containing fine eosinophile granules, but the characteristics noted above are sufficiently plain to justify at least a provisional diagnosis of either of the conditions in ques- tion, which, in ever}' instance, should be verified by a careful ex- amination of the stained specimen. While most of the degenerative changes which affect the leuco- cytes are clearly demonstrable only in the stained specimen, it is still possible to recognize some of the grosser examples of such a process by a study of the fresh film. Vacuolation of both nucleus and protoplasm, extrusion of portions of the cell-substance, and the various stages of nuclear disintegration and of apparent solu- tion of the protoplasm are the alterations most commonly ob- served. In certain specimens "fractured" leucocytes are seen with more or less frequency, a cell thus affected being drawn out into a diffuse, irregularly shaped body with indistinct and ragged margins, about which the cell-granules, which have escaped from the protoplasm, are scattered in the form of a nebulous mass. The eosinophile leucocytes seem especially prone to undergo this disintegration. The exact significance of this phenomenon is not clear, but it probably represents a degenerative change in which the cells have become abnormally vulnerable, and thus highly susceptible to mechanical injury from the pressure of the cover-glass. Ameboid activity of the leucocytes, and pigmentation of these cells are among the other changes to be obser\'ed in a histolog- ical examination of the unstained blood-film. Increase in Fibrin, Blood-Plaques, and Hemoconia. The den- sity of the fibrin network and the rapidit}' with which it forms may be studied as coagulation of the blood-film progresses. Unless the blood-plaques are ver}' greatly increased in number, they are not usually noticeable in the specimen prepared in the ordinaiy mannef-. The presence of hemoconia or *' blood- dust" is at once rendered conspicuous by the rapid and incessant molecular motion with which these bodies are endowed. Blood Parasites. The hematozoa of the malarial fevers, the spirilla of relapsing fever, and the embr\'onic forms of the para- site of filarial disease should be studied in the fresh blood when- ever this is possible, rather than in the fixed and stained, film, since in the latter the characteristic morphology^ of these parasites is greatly altered, and their motility lost. Foreign Bodies, such as free fat-droplets, collections of extra- cellular pigment, and, very rarely, the crystalline bodies of Charcot may also be obser\^ed in the fresh specimen, during the course of certain diseases. ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 25 Microscopical examination of the fresh specimen should form the initial step taken in every systematic examination of the blood, since it may be the means of determining whether or not a more elaborate investigation is necessary. By this simple pro- cedure an immediate diagnosis may be made in a number of in- stances, while in others the findings, although not pathogno- monic, are of distinct clinical value. Close familiarity with the normal histology of the blood is, of course, essential for the ap- preciation of the various pathological changes which have been outlined above. Fuller reference to these changes has been made in other parts of this book. (See Sections III and IV.) II. ESTIMATION OF THE PERCENTAGE OF HEMO- GLOBIN. No less than half-a-dozen different hemoglo- Methods. binometers, or instruments for estimating the amount of hemoglobin in the blood, are in vogue at the present time, of which the most reliable for general clinical use are the instruments devised by von Fleischl, by Oliver, and by Cowers. The hemometer of von Fleischl has been the general favorite for a number of years, both in this country and on the Continent, but in England it has been sup- planted to some extent, first by Gowers' hemoglobinometer, and in recent years by the hemoglobinometer lately invented by Oliver. All three instruments are based upon a similar principle, that of measuring the depth of color of the diluted blood by a standard color-scale of varying intensity, the gradations of which correspond to different hemoglobin values. With this instrument, which is the one pre- VON ferred by the great majority of clinicians, the color Fleischl's of a fixed volume of blood in an aqueous solu- Hemometer. tion of a definite strength is compared with the color of a movable glass wedge, tinted with Cas- sius' ''golden purple." The hemometer consists of the follow- ing parts : (i) A tinted glass wedge, the thickest portion of which is of a deep pink color, and the thinnest portion almost colorless, with every intermediate color gradation between the two extremes. It is mounted in a metal frame provided with a scale, graduated at every five degrees from o to 1 20, the former corresponding to the thinnest, and the latter to the thickest part of the wedge. The metal frame is grooved so that it fits beneath (2) a small 26 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Stage, in which it may be moved backward and forward by turn- ing a milled wheel. In the center of this stage there is a circu- lar opening through which the light of a candle is reflected by a disc of calcium sulphate, mounted on the pillar supporting the stage, like the mirror of a micro- scope. Back of this opening there is a small oval slot through which the scale of the underlying tinted wedge is visible, when the latter is adjusted to the stage. (3) A mixing chamber, consisting of a short metal tube closed at the bot- tom by a disc of glass and divided into two equal compartments by a vertical partition, fits accurately over the circular opening in the stage. When properly adjusted to the latter, the vertical partition exactly coincides with the upper edge of the underlying tinted wedge, so that the upper com- partment of the chamber is illuminated by the dull white light from the reflector, while the lower compartment receives the color of the tinted wedere. (4) A capillary pipette mounted in a Von Fleischi- FlG. 4. Tinted glass wedge of the von Fleischl hemometek. short metal handle, used for making the blood dilution. A single pipetteful of nor- mal blood mixed with suffi- cient distilled water to fill exactly one of the compart- ments of the mixing cham- ber gives a solution which matches the color of the tinted wedge opposite the mark 100. (S) A small fine-pointed glass dropper, used for filling with w-ater the compartments. Method of Use. As a preliminary step, each compartment of the mixing chamber is filled about one-quarter full of distilled water, by means of the glass dropper to one end of which a rubber cap has been fitted. A puncture having been made, as previously directed, a measured volume of blood is collected by bringing one end of the capillary pipette lightly in contact with the blood drop, as it oozes from the wound, so that the tube is instantly filled with blood, by capillary force. No difficulty will be experienced Fig. 5. Capillary pipette OF VON FlEISCHl's HEMOMETEK. ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 2/ in quickly filling the tube if it is applied horizontally to the side of the blood drop, rather than vertically to its summit, care being observed not to immerse the end too deeply. It is needless to add that the interior of the tube must be abso- lutely clean and dry, to insure which a very fine needle and thread may be passed through it just before using. As soon as the pipette is filled, every trace of blood must be removed from its outer surface, and the precaution taken to see that the column of blood is exactly flush with the ends of the tube, being neither bulged out nor depressed. The blood is then washed into one of the compartments of the mixing chamber, by forcing a stream of distilled water through the pipette by means of the glass dropper, this rinsing being repeated until it is certain that every trace of blood has been removed. The preceding steps must be carried out quickly, in order to avoid errors arising from coagulation of the blood. The blood and water in the compartment are now thoroughly mixed, by stir- ring with the handle of the pipette, until the color of the so- lution is uniformly diffused, after which water is added, drop by drop, to each compartment until they are both filled ex- actly to their brims. In doing this, no water must be spilled on the thin edge of the vertical partition, for should this occur it may cause an overflow of the liquid from one com- partment to the other, and thus alter the strength of the blood solution. If the latter should appear turbid, or muddy, as it sometimes does with leukemic blood, a few drops of a weak aqueous solution of potassium hydrate may be added to the diluent as a preventive of this change. The addition of a little ether will clear the solution, if the turbidity is due to the presence of fat. Having carried out the preceding steps, the mixing chamber is adjusted over the circular opening in the stage of the instrument, so that the compartment containing the blood solution is upper- most, overlying the semicircle illuminated by the clear, white light; while the compartment filled with water fits over the semi- circle which receives the tint of the underlying glass wedge. The remainder of the test, the comparison of the color of the two compartments, must be completed by artificial light prefer- ably by candle-light. Moderately bright illumination is better than a strong glare, for the latter interferes seriously with the accurate determination of delicate color differences. By means of the milled wheel the tinted glass wedge is moved backward and forward until its color precisely corresponds to that of the diluted blood. When this occurs, the percentage of hemoglobin 28 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. is read off from the scale visible through the oval slot in the stage of the instrument. While making the color comparison the obsen'er should stand facing one end of the glass wedge {iiot the milled wheel), so that the partition between the two compartments of the mixing cham- ber is in a line with the \'ertical axis of his eyes, the distance from the latter to the top of the stage of the instrument being about ten or twelve inches. Gross errors may be avoided if the observa- tion is made with one eye, and if the same eye is habitually used, since the two eyes may differ radically in their sensitiv^eness to color impressions. It is important to decide the color differences as quickly as possible, for prolonged examination rapidly dulls one's color perception, and creates uncertainty as to the proper reading. It is a good plan first to bring into the field of vision the darkest portions of the wedge between the figures lOO and 1 20 of the scale, and then, by short, sudden turns of the milled wheel, to produce abrupt color contrasts of from 5 to 10 de- grees at each turn, until the two tints approximately correspond.^ When this point is reached the eye should be rested for a few moments, and then, by a succession of shorter turns, the wedge is again swept to and fro until the colors appear identical. In the average instance an error of about 5 degrees must be antici- pated, in spite of every precaution to insure accuracy. In cases in which low hemoglobin percentages (30 per cent., or less) are suspected, it is essential to use two or three pipette- fuls of blood in making the dilution, dividing the percentage indi- cated by the instrument by two or three, as the case may be. This precaution effectually removes the objection which has been urged against this instrument on account of its inaccuracies in the determination of low hemoglobin percentages. Another criticism of the von Fleischl instrument has been made on the ground that, since the length of the tinted wedge visible through the compartment of the mixing chamber includes a color range of 20 per cent., it is impossible for one to select a single point in the center of this color for comparison with the even, diffuse tint of the blood solution. This objection may be overcome to a great extent by using a metal diaphragm, provided with a slit one-eighth of an inch in width, which is placed over the glass disc at the bottom of the compartments, to limit the field of vision. Adjusted so that the slit crosses at right angles the par- tition separating the two colors, the use of this device cuts down 1 It is important to bear in mind the fact that the judgment of color differences is much easier if marked contrasts in color value are made, than if a gradual blending of the two tints is attempted, by slowly moving the wedge past the visual field. ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 29 the field of observation to a portion of the glass wedge corre- sponding to about 2.5 degrees on the scale. The hemoglobin percentages indicated by this instrument ap- pear to be low for the blood of the average healthy American, Fig. 6. Method of using the von Fleischl hemometer. Note that the septum between the two halves of the blood compartment is at right angles to the horizontal axis of the observer's eyes. A cylinder of paper may be fitted over the blood compart- meni, to serve as a camera-tube. since it is more common to obtain readings of from 90 to 95 than of the arbitrary standard 100, in persons in whom there is no good reason to suspect subnormal hemoglobin values. In in- struments of recent manufacture, however, this fault is largely corrected. 30 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. In order to exclude the light of the candle from the field of vision, while making the color comparison, it is customar>^ to use a tube of cardboard or stiff paper, which is slipped over the mixing chamber, and rests upon the platform of the instrument. This sort of a device answers very well when the examination is made in a darkened room, as, for example, at a patient's residence. In hospital work, however, the inconvenience, sometimes con- siderable, of being compelled to carr>^ the diluted blood some distance from the bedside to a dark-room may be avoided by the use of a light-proof box, which maybe conveniently carried from ward to ward, so that the test may be completed at the bedside. (F^g- 7-) A box of this kind should measure sixteen inches Fig Light-proof box for the von Fleischl hemometer. The door of the box is closed and the color comparison made through the camera-tube. Note. — Reichert, at the suggestion of Miescher, has recently introduced a modifi- cation of the original von Fleischl hemometer, designed to increase the accuracy of the test, by making it possible, by definite dilution of the blood, to select that part of the tinted wedge which is best adapted for the examination of any particular sam- ple. This innovation was prompted by the discovery that the intermediate portions of the wedge are better adapted for obtaining accurate readings than the terminal parts. The principal modification of the new hemometer consists in the substitution for the original capillary blood pipette of a special mixing pipette, similar. to a melangeur, graduated so that the blood may be diluted I : 200, i : 300, and I : 400 times. A table supplied with the instrument translates the combined results of the dilutions and the figures indicated by the scale on the wedge into absolute hemoglobin percentages. The instrument is also supplied with mixing chambers of different depths, and with a diaphragm designed to limit the field of vision. The writer has had no practical experience of the Miescher-Fleischl hemometer, but an examination of the instrument justifies the belief that its elaborateness renders it undesirable for gen- eral clinical work. Its cost ($50.00) is also a bar to many. ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 3 1 in height by twelve inches in length and in width, being fitted with a hinged door which may be fastened shut by a simple catch, and provided with a circular opening through which the milled wheel of the hemometer projects when the door is closed. A metal camera-tube, flanged at the upper extremity for the obser- ver's eye, pierces the top of the box and communicates inside with the mixing chamber of the hemometer. The tube fits loosely in a circular opening in the top of the box, so that it may be readily raised and lowered ; its diameter is a trifle greater than that of the mixing chamber around which it should fit snugly when lowered into position ; and its length is governed by a fixed collar outside the box, which prevents it from slipping and jarring the instrument. Wooden guides, such as are used for securing a microscope in its box, are provided to receive the horseshoe base of the hemometer, holding it firmly in such a position that when the camera-tube is lowered into position, the milled wheel of the instrument projects through the opening in the closed door. The interior of the tube and of the box is painted a dull black. A candle is placed in position on the floor of the box, in a line with the '' mirror " of the instrument. In using this device, first the candle within the box is lighted, and the hemometer base is slipped into place between the wooden guides. The blood dilution having been made in the usual man- ner, the mixing chamber is then set upon the platform of the in- strument, and the camera-tube which has been raised to allow this to be done, is lowered until it telescopes around the mixing chamber, and rests firmly upon its collar. The door of the box is now closed, and the two compartments are brought into their proper positions over the glass wedge by turning the camera-tube from the outside of the box, the observer mean- while noting the result by looking through the flanged ex- tremity of the tube. This accomplished, the projecting wheel of the instrument is turned to and fro until the colors of the two compartments are the same, when the door is opened, and the percentage read off from the scale of the hemometer. Care must be observed to see that the exterior of the mixing chamber is perfectly dry, for if any moisture collects between its outer sur- face and the inner surface of the camera-tube, the contents of the compartments may be disturbed and serious errors re- sult. As the opening in the door of the box is covered by the hand with which the milled wheel is turned, sufficient light to interfere with the test cannot leak in at this situation. With a Hght-proof box of this sort it is possible accurately to carry on hemoglobin estimations in the brightest daylight, 32 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. which may be entirely excluded from the instrument, while the observer's field of vision is limited to the two semicircles illumi- nated by the candle burning within the box. With this instrument the principles of Lovi- Oliver's bond's tintometer are applied to the quantitative Hemoglobin- estimation of hemoglobin, the color of a blood OMETER. solution of a definite strength being compared, by light reflected from a dead white surface, with a series of tinted glass standards which constitute a progressive color scale. Thus, a series of fixed, definite tints is provided, each of which accurately corresponds to the specific color-cur\^e of progressive dilutions of normal blood, this having been de- termined individually, by means of the tintometer. Two sets of color standards have been devised : one for daylight readings, and one for observations by candle light, the latter being prefer- able on account of the greater delicacy of its readings. Oliver's complete apparatus consists of: (i) A capillary blood vieastire, made of hea\y glass tubing, and having a capacity of 5 cubic millimeters. The end to be presented to the blood drop, in filling the measure, is tapered to a blunt point, and highly polished. (2) A 7nixi)ig pipette, provided with a short rubber tube which fits over the tapered end of the blood measure, while rinsing out the blood from the latter into the (3) standard blood cell, which, when filled exactly to the brim with distilled water in which one measureful of blood has been dissolved, yields a blood solution of approximately one per cent. When filled, the cell is covered with a glass slip provided for this purpose. (4) A standard color scale, consisting of 1 2 tinted glass discs, mounted in two series, and corresponding to hemoglobin percentages ranging from 10 to 120. (5) A set of riders, or squares of tinted glass, used for determining the intermediate degrees of color between the deci- mals indicated by the fixed tints of the scale. For ordinary clin- ical work two riders are sufficient, which when laid over the discs of the standard scale read 2.5 and 5 degrees respectively on its upper half, but double this amount on the lower half. For physi- ological observ^ations requiring readings in units a set of nine riders is supplied. (6) A collapsible ca7nera-tiibe, through which the color comparisons are made. Method of Use. In making hemoglobin estimations with Oliver's apparatus, first the capillar)^ measure is filled with blood by the method directed for filling the pipette of the von Fleischl instrument. The rubber nozzle of the mixing pipette, previously filled with distilled water, is then adjusted over the polished end of the blood measure, and the blood washed into the standard cell by ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 33 forcing through the water, drop by drop. As soon as all of the blood contained in the bore of the measure has been thus washed out into the cell, the rubber nozzle of the pipette is re- moved, and the handle of the measure used as a stirrer to mix the blood solution, more water being added in single drops, from time to time, until the cell is accurately filled. The blue cover- glass is then adjusted, with the result that, if the cell has not been overfilled, a small air bubble forms on the surface of the Hquid. The blood cell, filled in this manner with a blood solution of definite strength, is now placed by the side of the standard scale opposite the tinted disc to which it corresponds most closely, the eye readily recognizing its approximate position on the scale. More accurate matching of the two colors is made with the aid of the camera-tube, the cell being moved from disc to disc in an endeavor to match exactly the color of the blood solution by one Fig. 8. Method of using Oliver's hemoglobinometer. of the standard tints of the scale. If this is successful, the hemo- globin percentage indicated by the disc is read off, and the obser- vation is completed. But if it happens that the tint of the blood solution is obviously deeper than a certain disc, but paler than the 3 34 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. one immediately above, the cell is kept alongside the lower of the two, over which a rider is adjusted, in order to deepen its color, while the square of white glass is placed over the cell, so as to compensate for the thickness of the rider. If now the colors correspond, the final reading is ascertained by taking the percent- age of the disc plus the value of the superimposed rider. If the color of the blood solution is darker than that of any one of the standard discs, but paler than the disc plus a rider, the mean average of the two is taken as the final reading ; similarly, if the color of the blood solution is darker than a certain disc plus a rider, but paler than the disc immediately above, the values of the two must be averaged. An error of two per cent, is un- av^oidable, even in the hands of a skilful observ^er. During the observation the candle should be placed three or four inches from the end of the color scale, being adjusted so that the flame is in a line with the opposed sides of the cell and of the scale, thus illuminating both with equal intensity. The positions of the candle and of the apparatus are shown in the accompanying illustration. (Fig. 8.) Small sized candles, such as are used for decorating Christmas trees, furnish a flame of the proper de- gree of brilliancy, the candle of ordinar}^ size giving too intense a light. Total exclusion of daylight is not necessary-, so that the observation may be made in the corner of a partly darkened room, as, for example, behind a closet door or some other similar shield against direct rays of light. Oliver's hemoglobinometer is a trial to the patience of one who has habitually used the von Fleischl instrument, and it takes some time to become accustomed to it after having worked with the comparativ^ely simple color comparisons of the hemometer. But the results obtained with the newer instrument are so much more accurate than are possible with the older, that no one should hesitate in choosing Oliver's apparatus as the better of the two. This instrument, which for many years has GowERs' been popular in England and is used to some Hemoglobin- extent in this countr}', consists essentially of tivo OMETER. small flattened tubes of equal diameter, which when in use are fixed upright and parallel to each other in a small wooden support furnished for this purpose. One tube contains glycerine jelly colored with picrocarmine to cor- respond to the tint of a i in lOO solution of normal blood (or, 20 cubic millimeters of blood in 2 cubic centimeters of water), this being taken as the standard with which the blood solution, contained in the second tube, is compared. The second tube is provided with a scale graduated in units from 5 to 1 20, each de- ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 35 Fig, 9. GOWERS' HEMOGLOBI- NOMETER. gree of which equals the volume of blood required for the test. Twenty cubic millimeters of normal blood, dissolved in sufficient distilled water to fill this tube to the 100 mark on the scale, give a solution which corresponds to the tint of the standard tube. The special capillary pipette used for measuring the blood is graduated at 10 and at 20 cubic millimeters, and fitted with a bit of rub- ber tubing and mouthpiece for filling it by suc- tion. Method of Use. The technique of hemoglobin estimations with Gowers' apparatus is extremely simple. Having made the puncture in the usual manner, the blood is sucked up the caliber of the capillary pipette until the mark 20 is reached, and then immediately blown out into the grad- uated tube, into which a few drops of distilled water previously have been placed, in order to insure instantaneous solution of the measured amount of blood. All traces of blood which may have adhered to the bore of the capil- lary pipette are removed by filling it several times with water, the rinsings being added to the mixture of blood and water in the tube. During the preceding steps the usual precautions must be observed, to wipe all surplus blood from the outside of the pipette before expelling its contents, and to measure the blood rapidly so as to guard against errors arising from rapid clotting. Distilled water is now added, drop by drop, to the mixture in the tube until the color of the blood solution exactly corresponds to that of the picrocarmine standard, the contents of the tube being mixed between each addition, by rapidly reversing it two or three times, with its open end closed by the thumb. The drop or two of liquid adhering to the thumb should be wiped off against the wall of the tube so that it may drain back into the liquid. When the tints of both tubes are precisely similar, the division of the scale to which the diluted blood reaches is read off, to express the per- centage of hemoglobin in the specimen under consideration. In comparing the colors, which is done by daylight, the tubes should be held against a sheet of white paper, or, as suggested by Gowers, between the eye and a window, and viewed at such an angle that their adjoining edges appear to overlap, thus cutting off the vertical streak of white light visible between them, should this precaution be neglected. Owing to the diagonal position in which the two tubes are adjusted in their support, the proper angle to produce this effect may be readily determined. 36 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. The chief drawback to the use of this instrument is the Hability to over-dilution of the blood after it has been mixed in the grad- uated tube, the occurrence of this accident necessitating, of course, a repetition of the entire operation. To the novace it is usually hard to decide just when sufficient water has been added to the blood to bring its color donni to that of the standard tint, since one must depend solely upon a gradual weakening of the tint of the blood solution, and this is much more difficult than to com- pare a definite blood color with the sHding scale of the hemom- eter, or with the series of discs of the Oliver apparatus. The instrument may be regarded as accurate within 2 or 3 per cent, for hemoglobin percentages above 10, below which figure it is . impossible to distinguish a difference between the tints of the two tubes. This source of error, however, is too remote a possibility to detract from the instru- ment's practical value. Dr. Ar- D are's thur Dare, Hemoglobin- of the Jef- ometer. fersonHos- pital Med- ical Clinic, has recently de- vised a new form of hemo- globinometer, by the use of which a thin film of iin- diluted blood is brought into direct comparison with a standard semicircular wedge of tinted glass ranging in color from a claret red at the thickest part, to a pale pink at the thinnest. The instrument consists of the following parts : (i) K cap- illary blood cJiamber, con- structed of two rectangular plates of polished glass, the opposed surfaces of which are so ground that, when clamped together in a metal bracket, a shallow compartment holding a thin film of blood is formed. One plate is made of transparent, the other of opaque glass, the latter being next to the source of light, in order to soften its glare, when the instrument is in use. The metal Dare's hemoglobinometer. R, milled wheel acting by a friction bearing on the rim of the coloT disc; S, case enclosing color disc, and provided with a stage to which the blood chamber is fit- ted ; T, movable wing which is swung outward during the observation, to serve as a screen for the observer's eyes, and which acts as a cover to enclose the color disc, when the instrument is not in use ; U, telescoping camera- tube, in position for examination ; V, aperture admitting light for illumination of the color disc ; X, capillary blood chamber adjusted to stage of instrument, the slip of opaque glass, W, being nearest to the source of light ; Y, detachable candle-holder ; Z, rectangular slot through which the hemoglobin scale indicated on the rim of the color disc is read. ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 17 Fig. II. bracket of the blood chamber is adjusted to the stage of the in- strument in such a manner that the blood-film fits over an aper- ture communicating with a camera-tube screwed to the op- posite side of the rubber case. (2) A graduated color standard made of a semicircle of glass tinted with Cassius' ''golden- purple," and thinning out like a wedge with various depths of color corresponding to the tints of fresh blood containing dif- ferent percentages of hemoglobin. It is mounted upon a disc ad- justed in the frame of the instrument so that it may be revolved to bring various portions of its surface over an aperture directly alongside of the one through which the blood film is vis- ible. A scale, read from the outside of the instrument, in- dicates in units the hemoglobin percentages from 10 to 120. (3) A Jiard rubber case encloses the color standard, when the instrument is in use, the disc upon which the standard is mounted being revolved by turning a small milled wheel acting upon the rim of the disc by a friction bearing. To one side of the case a telescopic camera-tube, fitted with an eye-piece, is attached, while on the opposite side a stage furnishes support for the blood chamber, back of which a candle, held between a pair of spring clips, is adjusted. Two apertures of equal diameter, placed side by side on the same level, transmit the light of the candle through the blood-film and the color standard to the field of vision enclosed by the camera-tube. By reference to the accompanying diagram (Fig. 11), it will be seen that the light of the candle, J, equally illu- minates the blood film enclosed be- tween the two rectangular glass plates, O and P, and the edge of the color standard, L, mounted upon the glass disc, K. The differences in the two colors are visible through the two apertures, M and M', communicating with the camera-tube, N. By revolving the disc the tint of the color standard may be altered until it matches that of the blood-film. Method of Use. The instrument is prepared for use by first swinging outward the movable screen which serves as a cover for the case. The two apertures overlying the blood-film and the color scale are thus brought into view, the direct light from the Horizontal section of Dare's hemoglobinometer. 38 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Manner of filling blood chamber. candle being shaded from the observ^er's eyes by the intervening screen. The camera-tube and the candle-holder are then fitted to their attachments on opposite sides of the instrument, and a candle adjusted so that the surface of its " wick end " is just on a level with the top of the spring clips. The blood chamber is filled by touching its edge to the side of a rather large drop of blood, as the latter flows from the punc- ture, so that the blood ^^^' ^^' at once flows into and fills, by capillar}^ force, the shallow compart- ment between the pair of glass plates. As soon as this occurs, any excess of fluid which may have ad- hered to the outer sur- face of the blood cham- ber is carefully wiped away, and the latter is slipped into the tongue which holds it in position on the stage of the instrument. The candle having been lighted, the observ-er holds the instru- ment as a field glass, and compares with one eye the colors of the blood-film and the standard disc which are seen side by side in the field of vision limited by the camera-tube. The disc is made to revolve by making short, quick turns with the milled wheel, until the two colors are identical, and the hemoglobin percentage indicated by the scale is then noted. The color comparisons need not be made in a darkened room, although the obser\^er should avoid facing the direct sunlight, and, in order to exclude reflected hght, should hold the instru- ment against a dark surface, such as a black coat sleeve. When the observation is completed, the two glass plates of the blood- chamber are removed from the bracket by loosening the screw which holds them in position. They are then cleaned with water and with acid alcohol, dried, polished, and replaced in the bracket. The various parts of the instrument, when detached, fit into a small leather carr)^ing-case. The chief advantage of Dare's instrument lies in the fact that dilution of the blood is not required, and therefore errors due to incorrect measuring and dilution of the blood, which must be care- fully guarded against in the older hemoglobinometers, are entirely eliminated. A film of whole blood also gives a relatively deep ESTIMATION OF THE PERCENTAGE OF HEMOGLOBIN. 39 and definite color, which may be judged with greater ease and accuracy than the paler and more indefinite tint of a blood solu- tion. It is also obvious that errors due to the turbidity of an aqueous solution of leukemic blood, are avoidable by the use of an undiluted film. Coagulation of the film does not occur with suf- ficient rapidity to constitute a source of error, since the test may be completed within a few seconds after the blood has been drawn. One year's more or less constant use of this instrument in the Jefferson Medical Clinic has shown that its readings closely cor- respond to those of Oliver's hemoglobinometer, and average some- what higher than those of the von Fleischl instrument. The color standard of Dare's apparatus, being wedge-shaped, and therefore gradually blending the tints, is open to the same criticisms which have been urged against the scale of the hemometer. A simple method of approximately determin- Tallquist's ing hemoglobin percentages without the aid of Method. a special instrument has recently been devised by Tallquist,^ the procedure consisting, in brief, in allowing a drop of blood to soak into a bit of filter-paper and comparing with the naked eye the color strength of the stain with a series of printed standard tints of known value. The lat- ter are arranged as a scale of ten different colors corresponding to the colors of stains produced by bloods having hemoglobin values ranging from loto lOO per cent., the latter being regarded as the normal. A lithographed copy of the color standard ac- companies Tallquist's original article. The test is made in the following manner : A drop of blood, large enough to make a stain about five or six millimeters in diameter, is caught in the center of a piece of white filter-paper, care being taken in col- lecting it to apply the paper to the exuding drop in such a man- ner that the blood soaks in very slowly, and thus produces a stain which is evenly colored throughout. Perfectly white filter- paper having a smooth surface, and of a thickness corresponding to about fifty-five leaves to the centimeter, should be used for the test. The blood stain thus made is pressed lightly against a pad of filter-paper, and then compared, by direct daylight, with the series of standard tints, the figure opposite to the tint which the stain most accurately matches being read off, to indicate the per- centage of hemoglobin in the specimen under examination. The comparison must be made immediately after the stain loses its humid gloss, since blood soon changes its color after exposure to the air. This direct method of hemoglobin testing is, of course, only ^St. Paul Med. Jonrn., 1900, vol. ii.,p. 291. 40 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. approximate, at the best, and cannot be expected to furnish re- sults comparable in point of accuracy with those to be obtained by any of the instruments just described. It may, however, be employed to excellent advantage when a hemoglobinometer is not at hand, or in certain cases in which only a rough estimate of the amount of coloring matter of the blood is sought. Tall- quist, who has tested his method under the control of the he- mometer, in his clinic at Helsingfors, claims that the limit of error generally does not exceed ten per cent. III. COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. Of the various instruments used for counting Methods. the blood corpuscles, the hemocytometers de- vised by Thoma and by Gowers are most gener- ally employed at the present time, the former being used almost to the exclusion of the latter everywhere except in England, where Gowers' apparatus has many firm adherents. Durham, by adapting and modifying a number of the details of the older instruments, has succeeded in devising an improved form of hemo- cytometer which possesses many advantages over the original models, being of simple construction, accurate, and comparatively inexpensive. The method of making the estimate, which is es- sentially the same with all three of these instruments, consists, briefly, in first diluting the fresh blood in definite proportions with some indifferent preser\^ative fluid, and in then counting, under the microscope, the number of corpuscles in a drop of the di- luted blood, the latter being contained in a small glass cell on the floor of which is ruled a series of micrometer squares of cer- tain dimensions. The cubic contents of the cell and the degree of the blood dilution being known, the number of corpuscles counted in any given number of these squares may be taken as a basis for calculating the total count of corpuscles to the cubic millimeter of blood. In addition to the method of actually counting the corpuscles in a known volume of diluted blood, Oliver has devised an instru- ment with which the number of erythrocytes may be estimated by means of their optical effect, without the use of the microscope. Diluting fluids for use with the hemocytom- DiLUTiNG eters of Thoma, Gowers, and Durham should Fluids. be of such a composition that when mixed with the fresh blood they preserve unaltered the form of the corpuscles. This requirement being met, the examiner COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 4 1 may choose from the numerous formulae in current use the one which best suits his individual preference. Among the most sat- isfactory solutions used for this purpose the following may be mentioned : Toisson's Solution. Methyl-violet, 5 B 0.025 Sodium chloride i.o Sodium sulphate , 8.0 Neutral glycerine 30.0 Distilled water 160.0 Sherrington's Solution. Methylene-blue o.i Sodium chloride 1.2 Neutral potassium oxalate 1.2 Distilled water 300. o For general clinical work no better formulae have ever been suggested than the preceding two. Both solutions act as excel- lent preservative fluids, and each contains just sufficient quantity of a basic aniline dye to stain the leucocytes with great distinct- ness, so that they may be readily differentiated from the erythro- cytes, which remain uncolored. Hayem's Solution. Mercuric chloride 0.25 Sodium chloride 0.5 Sodium sulphate 2.5 Distilled water 100. o Oliver specifies this solution as the diluent invariably to be employed with his instrument, but it may be used also with the other forms of hemocytometers, although with less satisfaction than the formulae first mentioned. Among the simpler diluting fluids, all of which are depend- able, are solutions in distilled water of common salt (0.7 per cent.), of potassium bichromate (2.5 per cent.), and of sodium sulphate (5 per cent.), to any of which about 0.5 per cent, of an alco- holic solution of methyl-violet may be added, in order to stain the leucocytes, and thus to facilitate the counting. An aqueous solution of acetic acid, varying in strength from 0.3 to 0.5 per cent., which destroys the erythrocytes and at the same time renders more conspicuous the leucocytes, has been recommended by Thoma as a diluent in counting the latter cells, by means of his special pipette. 42 EXAMINATION OF THE BLOOD BV CLINICAL METHODS. Fig. i^. As spores are liable to develop and precipitates to form in all the above-mentioned solutions, they should always be filtered before using, and kept in tightly corked bottles. The Thoma-Zeiss hemocytometer, which is The Thoma- to-day regarded as the standard instrument for Zeiss Hemo- blood counting, consists of two graduated capil- CYTOMETER. lar}^ pipcttes, for diluting and mixing the blood, and a counting chamber in which a measured volume of diluted blood is placed for the purpose of counting the corpuscles under the microscope. One of the pipettes is intended for counting the erj^throcytes, and, for con- venience's sake, may be termed the erjthro- cytometer ; while the other pipette, which is used for counting the leucocytes, may be called the leucocytometer. It is not, however, necessary to purchase both pipettes, as sup- plied with the complete apparatus, since both er)'throcytes and leucocytes may be counted accurately with the erj^throcytometer. The crytJiJ'ocytoineter consists of a heavy glass capillar}' tube, the lumen of which is expanded near the upper end into a bulb con- taining a small cubical glass bead, which serves as a stirrer. The lower end of the tube is ground to a blunt point, and to the upper end is fitted a short bit of rubber tubing capped by a bone mouthpiece, for filling the tube by suc- tion. A scale is enameled into the glass wall of the pipette, the three main divisions of which are indicated by the figures, 0.5, i, and loi, the first two gradations being below, and the latter one above, the bulb ; the lower portion of the tube is further graduated in tenths, by cross lines, from o.i to i. If blood is drawn up in the pipette to the mark i , and the diluent added until the mark loi is reached, the blood is thus diluted one hundred times ; or if the blood is drawn up only to the mark 0.5, and the diluent added as before, a two hundred-fold dilution is obtained. The laicocytonicter is a capillar}' tube similar to the former, but having a larger lumen, so that lowe r dilutions are obtained with it. If blood is drawn up to the mark i , and the diluent added until the mixture reaches the Bl V ]l The Thoma-Zeiss hemocytometer. a, erythrocytometer; B, leucocytometer. COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 43 mark 1 1, the blood is diluted ten times ; or if the blood column reaches the mark 0.5, with the same addition of diluent, the dilu- tion thus made is twenty-fold. In the latest model of this pipette the lower end tapers to a fine point, the diameter of the lumen thus gradually decreasing as the extreme tip is approached. The chief object of this modification is to prevent accidental leaking out of the column of blood when the tube is held vertically, while sucking up the diluting fluid — an accident difficult to avoid with the old-style pipette, having a large lumen from tip to bulb. The counting cJiamber (Fig. 14) consists of a heavy glass slide in the center of which is cemented a square glass plate provided with a circular opening which fits around a ruled disc ; the diameter of the latter being slightly less than that of the opening in the sur- rounding plate, a shallow, narrow gutter is thus formed between the two. The surface of the ruled disc is exactly -^^ millimeter below the level of the glass plate by which it is enclosed, so Fig. 14. Thoma-Zeiss counting chamber. that a chamber of this depth is formed when both are superim- posed by a cover-glass having an absolutely plane surface, two of which are furnished with each instrument. An ordinary cover- glass should never be used, for owing to the unevenness of its surface a deviation from the standard in the depth of the underly- ing chamber must necessarily result. When an objective having an extremely close ''working distance" is employed, the special hollow-cell cover-glass, made by Zeiss, will prove useful. The central part of the disc's surface is divided, by microscopical diamond-rulings, into 400 small squares, each of which has an area of ^-J-Q- square millimeter, these small squares being grouped into sets of sixteen, by a series of vertical and horizontal double rul- ings bisecting each fifth column of squares. (Fig. 15.) The cubic contents of each small square, when the cover-glass is ad- justed, is -^-^-^-^ cubic millimeter, since they measure individually 44 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. tV by 2V ^y 2V n^illirneter. In Zappert's modified ruling of the Thoma-Zeiss counting chamber, extra Hnes have been added so as Fig. 15. Ruled area of the Thoma-Zeiss counting chamber (ordinaky ruling). to increase the ruled area of the disc to nine times its original size. As illustrated in the accompanying diagram (Fig. 16), the Fig. 16. iiiiii mil {IIIM liiiliiiiii T Zappert's modified ruling of the Thoma-Zeiss counting chamber. surface of the disc is thus divided, by heavy cross-rulings, into nine large squares each equal in area to the central group of 400 small COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 45 squares, the whole ruled surface therefore equalling an area covered by 3,600 of the latter. To simplify the counting, the peripheral squares are subdivided into four, each of the latter being of the same area as lOO of the small central squares. This improved form of counting chamber is an invaluable convenience in leucocyte counting, and should be chosen in preference to the older model. If any difficulty should be experienced in distinguishing the ruled lines under the microscope, they may be made more con- spicuous by blackening them with a little soft lead pencil dust, placed on the surface of the disc and thoroughly rubbed in with the pulp of the finger, the excess being wiped off and the disc polished with a bit of lens-paper, or a soft handkerchief. Fig. 17. Method of filling the capillary tube of the Thoma-Zeiss hemocytometer with blood. Counting the Erythrocytes. Having made the puncture, as already described, the point of the erythrocytometer is plunged into the blood drop, as it flows from the wound, and, by making gentle, uniform suction, a column of blood is drawn up the capil- lary tube exactly to the mark 0.5. The point of the instrument 46 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. is then wiped perfectly dry, and immediately dipped into the diluting- fluid, which is drawn up the tube in the same manner until the mixture of blood and diluent reaches the mark 10 1, above the bulb. While adding the diluent, the pipette should be twisted to and fro between the thumb and forefinger, in order that the blood and diluent may be mixed, by the whipping about of the glass bead, as they fill the bulb ; if this precaution is neglected, a por- tion of the blood will rise in a distinct layer above the diluent, as the latter flows into the bulb, and may be drawn, unmixed, into the capillary constriction beyond. A more thorough mixture of the blood and diluent is now made, the rubber tubing being slipped from the instrument, which is then grasped so that its ends are closed by the thumb and middle finger, and rapidly shaken for about half-a-minute. By the above steps, a mixture is made in which the proportion of blood to diluent is i : 200, a degree of dilution with which it is most convenient to work, in the great majority of instances. For two reasons a i : 200, rather than a i : 100, dilution is to be preferred in routine work: (i) If, as not infrequently happens, the blood column is accidentally drawn up the tube beyond the mark 0.5, in an attempt exactly to reach this gradation, it is a simple matter to correct the error by gently blowing or shaking the blood column down to the proper height ; whereas, in attempting to make a i : 100 dilution, should the mark i be exceeded, the blood column will almost surely escape into the bulb whence it cannot be blown back again into the capillary tube, thus necessitating a repetition of the whole operation with a fresh drop, after having cleaned and dried the erythrocytometer. (2) It is easy to count the corpuscles in a I : 200 dilution, since the surface of each ruled square of the counting chamber is, as a rule, occupied by not more than half a dozen cells ; on the contrary, in a i : 100 dilution, except in an occasional instance in which there is a striking paucity of cells, the field may be so overcrowded with corpuscles that their enu- meration is difficult, and often inaccurate. The next step is to place a drop of the diluted blood in the counting chamber, preparatory to counting the corpuscles under the microscope. The unmixed diluting fluid in the lower portion of the capillary tube is first expelled, by blowing out four or five drops, after which the point of the pipette is dried with a soft cloth, and a small drop of the blood mixture is allowed to fall, by force of gravity, exactly in the center of the surface of the ruled disc. The cover-glass is then immediately placed in posi- tion, and the slide left undisturbed for several minutes, so that the corpuscles may settle. The drop placed on the disc should COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 4/ be of sufficient size to occupy only its central portion, the object being to use just enough of the blood mixture to cover the ruled area and exactly to fill in the vertical space between the surfaces of the disc and cover-glass when the latter is placed in position. If the drop contains air-bubbles, or if it is so large that it over- flows into the gutter and perhaps finds its way between the cover- glass and the glass plate beneath, errors will result, so that in event of either of these accidents the procedure must be repeated with another drop, after having cleaned and dried the cover-glass and the counting chamber. Water, and not alcohol or xylol, is to be used for this purpose, since the repeated use of chemicals will soon dissolve the cement which fixes the disc to the counting chamber. In repeating the operation the original technique must be rigidly followed, i. ^., the erythrocytometer must be briskly shaken for half a minute or so, and the contents of its capillary stem blown out, before placing the new drop in the counting chamber. In a properly prepared slide concentric rings of color — New- ton's rings — may be seen at the points of contact between the cover-glass and the underlying glass plate. If these rings are in- visible, or if they do not appear when pressure is made upon the cover-glass, it is a sign that the contact between the two glass surfaces is not true, this being due to the presence of particles of dust or of moisture beneath the cover-glass. Inasmuch as this may seriously affect the correctness of the count, it is a safe rule invari- ably to reject a slide in which these color rings are not visible. As soon as sufficient time has elapsed for the corpuscles to sink to the bottom of the counting chamber — about five minutes — the slide is transferred to the stage of the microscope, which should not be incHned, for fear of disturbing the uniform distribu- tion of the cells. The field is first brought into focus with a low- power objective (a No. 3 objective of Leitz, for example), and the slide moved across the stage until the extreme upper left-hand corner of the group of small ruled squares is brought into view, when a higher power, to be used in counting, is substituted. For this purpose the writer is accustomed to use a Leitz No. 6 objective and No. 4 ocular, which lenses, with a tube length of 155 mm., cut off a field occupied by a block of 25 small squares. As a basis for the final calculation, the erythrocytes in 400 small squares, or the entire ruled surface of the old-style disc, should be counted, preferably by going over two groups of 200 squares each in two different drops, rather than by taking the en- tire 400 squares in a single specimen. By following this plan the count of one drop may be ** controlled " by the count of the other, and any discrepancy between the two discovered, for if the dif- 48 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. ference in the counts is striking, a third group of 200 squares must be examined in an additional drop, and an average taken of the two counts which most closely correspond. In order to simplify the process of counting, some routine method of examining the ruled area, such as the following, should be adopted : Beginning at the upper left-hand corner of the ruled disc, the corpuscles in the first 100 small squares are counted, the slide being moved from above downward, preferably by the aid of a mechanical stage, as the successive groups of squares are covered. By employing the magnification to which reference has just been made, three shifts of the slide are sufficient to bring into the field the requisite number of squares in blocks of 25 each. Examining each small square in succession, proceed from left to right along one row of fiv'e, then drop to the next row and Fig. 18. Pl.\n of counting the ervthrocytes. The small squares are examined in the order indicated by the arrow, successive blocks of 25 squares being covered until the required number of cells has been counted. count from right to left, and continue in the manner illustrated by the diagram (Fig. i8) until all the er)-throcytes in the first group of 100 squares have been counted, the totals of each block of 25 squares being noted as they are completed. To avoid repe- tition in counting it is necessar>' to include in the total all the cor- puscles which touch the upper and left boundar}' hnes, and to disregard those which touch the lower and right boundaries. A second group of lOO squares, not immediately adjacent to the COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 49 first, is then inspected in a similar manner, after which the cover- glass and counting chamber are washed with water and dried, and the operation repeated with a second drop. Thus the 400 squares are covered by examining 16 blocks of 25 squares each, 8 in the first, and 8 in the second drop of diluted blood. In a i : 200 di- lution of normal blood this involves the counting of approxi- mately from 2,400 to 2,800 er}^throcytes, and gives results which are accurate within one-and-one-half per cent. To calculate the number of erythrocytes to the cubic milli- meter of blood, the following formula is employed : Number of eryth- Degree of dilu- Cubic contents ' Total num- rocytes counted x tion (206) x of each square beroferyth- (^,000) rocytes per Number of squares cotmted {4.00) ^^- ^^• For example, supposing that in the 400 squares of a i : 200 blood dilution a total of 2,500 erythrocytes is counted, the cal- culation is made thus : , . 2,500 X 200 X 4,000 , {a) = 5,000,000 e^ytlirocytes per cb. mm. {b) 2,500x2,000 = '' " '' '' '' Counting the Leucocytes. The leucocytes may be counted by two different methods : (a) with the erythrocytometer, in the same drop of diluted blood in which the erythrocytes are esti- mated ; or (^b) with the special leucocytometer, as a separate pro- cedure. Of the two methods the former is greatly to be preferred, since it is fully as accurate, and much more convenient and time- saving than the latter. Furthermore, there is an undoubted ad- vantage in counting both the red and the white corpuscles in the same drop of the blood dilution. {a) If the leucocytes are counted with the erythrocytometer the same technique is followed as in determining the number of erythrocytes, except that a much larger area of the counting chamber must be examined, owing to the comparatively small number of leucocytes contained in the i : 200 blood mixture. It is necessary, for the sake of accuracy, to count the leucocytes in the entire space enclosed by Zappert's ruling, and to repeat the coufit in a second drop, making an area equal to eighteen times the ruled space of the old-style counting chamber to be examined. If the totals of both counts are approximately the same, their combined figures, representing the corpuscles found in a space corresponding to 7,200 of the small ruled squares, is taken as a basis for the final estimate ; but if these totals widely differ, a 4 50 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. third drop is to be examined in the same manner, and, as in counting the erythrocytes, an average taken of the two totals which are nearest ahke. Since in normal blood, in a i : 200 dilution each block of 400 small squares contains from 3 to 6 leucocytes, the examination of the above-mentioned area of the counting chamber involves the counting of approximately from 54 to 108 of these cells — an operation which, practically, is not nearly so laborious as it appears from the description, being easily completed within ten or fifteen minutes, in most cases/ As an example of the method of calculating the final estimate, supposing that 90 leucocytes have been counted in the area equal to 7,200 small squares, the blood dilution being i : 200, this for- mula is employed : 90 X 200 X 4,000 -i- 7,200 = 10,000 leucocytes per cb. mm. If the old-style counting chamber is used, the leucocytes in the unruled portion of the disc outside of the central block of 400 squares may be counted with the aid of an eye -piece diaphragm, which when adjusted inside the tube of the ocular cuts off a field exactly the size of 100 small squares (Fig. 19). A black metal or cardboard disc having a central aperture ^^^- ^9 - of the proper size will answer just as well for this purpose as the more expensive and elab- orate mechanical eye-piece devised by Ehrlich, which is provided with a diaphragm having a square opening the size of which is regulated by a small lever. Having first counted all the leucocytes in the 400 small squares, the cells are Ocular diaphragm. then countcd in 3 2 of the diaphragm-fields out- side the latter, in order to cover an area of the disc corresponding to the entire ruled surface of the Zappert count- ing chamber. This operation having been repeated in a second drop, the totals of both counts are taken as the basis for the final calculation, which is made in the manner already described. If one happens to possess neither an eye-piece diaphragm nor a Zappert counting chamber, the following method of calculat- ing the cubic contents of the portions of the disc outside the ruled area may be adopted, as advised by Stengel.^ Using, for example, a -^-inch objective and a i-inch ocular, the ruled lines are brought into focus, and the tube of the microscope drawn out until one of the parallel lines of the ruled disc exactly coin- cides with either boundary of the field of vision. Assuming that 8 of 1 Should the leucocytes be decidedly increased, it is unnecessary to cover such a large number of squares. One hundred cells taken as a basis for the calculation will give an accurate estimate, ^ "Twentieth Century Practice of Medicine," N. Y., 1896, vol. vii., p. 271. COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 5 I these parallel columns, each ^V millimeter in width, are included in the visual field, the diameter of the latter is therefore tPq or |- millimeter, and the radius one-half of this figure, -^-^ or ^ milli- meter. The area of the field may then be readily determined by multiplying the square of its radius by 3. 141 6. Its cubic contents are obtained by also multiplying by J-q millimeter, formula being : |- X 3- X YQ X i.\/if\6 =. 012^66^, cubic contents of the visual field. Having in this manner ascertained the cubic contents of each field of vision, the final calculation of the number of leucocytes to the cubic millimeter of undiluted blood is made by multiply- ing the total number of these cells found in a definite number of fields ( for instance, 50) by the degree of dilution ( usually i :20o), and by then dividing by the cubic contents of each field (.0125- 664) multiplied by the number of fields examined. The formula for this calculation is : ( Total munber of leucocytes counted x Degree of dilution ) -r- ( Cubic contents of visual field x Number of fields examined ) = Total number of leucocytes per cb. mm. For example, in a i : 200 blood dilution a total of 30 leucocytes are noted in 50 fields, each having a cubic contents of .0125664, since they individually include 8 parallel columns of the ruled disc : ( 30 X 200) -^ (.0125664 X 50) = 9,550 leucocytes per cb. mm. {b) If the special leucocytometer is used for counting the leu- cocytes, a 0.3 per cent, aqueous solution of glacial acetic acid must be employed as a diluent, in order to render invisible the erythrocytes and at the same time to make the leucocytes appear more conspicuously in the field. A 1:10 dilution is made, by drawing the blood up the capillary tube of the instrument until the mark i is reached, and by then adding the diluent until the mixture reaches the mark' 1 1. The leucocytes are then counted in an area of the counting chamber equal to 800 of the small squares (preferably by examining 400 squares in two separate drops), and the calculation made according to the method pre- viously described. For instance, if in a given case 130 leucocytes were counted in 800 squares, the estimate would be made as follows : 130 X 4,000 X 10 -j- 800 = 6,500 leucocytes per cb. mm. The chief objection to this method of leucocyte counting lies in the difficulty in distinguishing the cells, owing to the unavoid- able presence in the field of masses of granular debris resulting from the action of the acetic acid solution upon the erythrocytes. For this reason, if for no other, it seems advisable to dispense 52 EXAMINATION OF THE BLOOD BV CLINICAL METHODS. with the leucocytometer, and to make the count of both red and wliite corpuscles with the er}-throcytometer, in the same drop. Cleaning the Pipette, As soon as the count has been finished the pipette should be carefully cleaned and dried. Having first expelled what remains of the blood dilution, the instrument is nnscd out, first with distilled water and then with a mixture of equal parts of absolute alcohol and ether, the latter being used to remove all traces of the dye, in case either Toisson's or Sherring- ton's solution has been employed as a diluent, as well as to dry the interior of the tube. The pipette, while it may be filled with a fluid by suction, should not be emptied by blowing through it, for if this is done a certain amount of moisture from the breath unavoidably becomes deposited in its lumen. Its contents may be expelled in the form of a fine jet, simply by twisting the rubber suc- tion tube into a tight spiral rope, as shown in the illustration (Fig. 20). When the interior of the instrument is perfectly clean, it Fig. 20. Expelling contents of erythrocytometer. By twisting the rubber suction tube into a tight spiral rope, the fluid in the bore of the pipette may be . forcibly expelled in a fine jet. is dried by forcing through it a current of air, by means of a rubber atomizer bulb, or an ordinaiy bicycle pump, until the glass bead no longer clings to the wall of the bulbous expansion, as it will as long as the slightest trace of moisture remains.' A new form of hemocytometer has been recently described by Durham, who has em- bodied in this device the principles of the older instruments, together with the substitution of a self-measuring pipette designed to overcome the sources of error which may occur in making blood dilutions with a suction pipette. Durham's instrument, which appears to be a valuable improve- ^ A o. I per cent, solution of pepsin in I per cent, hydrochloric acid is useful for removing any bits of clotted blood which may adhere to the caliber of the instrument. Durham's Hem ocvtometer. COUNTING TIJE ERYTHROC\TES AND THE LEUCOCYTES. 53 ment over other forms of blood-counting apparatus, consists of the following parts : 1 . Several capillary pipettes, of the Oliver type, each mounted in a glass tube, pro\*ided with a rubber nipple having a lateral perforation. The capacit}' of the pipettes is of 5 and 10 cubic millimeters. 2. A number of viixirig vessels, each consisting of a small glass test-tube, graduated for i and for 0.5 cubic centimeters of fluid. The tubes holding i cubic centimeter measure 2| x -^^ inches, and those holding 0.5 cubic centimeter, 2|- x | inches. One or more glass beads are shaken about in the tube, to mix the blood and the diluting fluid. 3. A number of graduated pipettes, for measuring the diluting fluid, of I and 0.5 cubic centimeters capacity, marked at 995 and 990 cubic millimeters, and at 495 and 490 cubic millimeters, respectively. Used with the appropriate capillar}- pipette, dilu- tions of I in 200, I in 100, and i in 50 may be obtained. 4. A counting chamber of the Thoma-Zeiss pattern. Fig. 21. Cross section of Durham's blood-pipette. T, glass tube ; N, rubber nipple ; p, lateral perforation in nipple ; c, cork in which a capillary- pipette is fitted. Method of Use. Having placed in one of the mixing vessels some of the diluting fluid, the quantit}' of which is measured with one of the graduated pipettes according to the dilution desired, the capillar}- pipette is filled with blood, by touching it lightly to the blood drop as it flows from the puncture. All traces of blood are then removed from the outside of the pipette, the contents of which are now expelled into the fluid, contained in the mixing vessel. This is accomplished b\- inserting the pipette into the latter, keep- ing its point about half an inch above the level of the diluting fluid, and by then rotating it between the thumb and forefinger so that the lateral perforation Is brought under the pulp of the thumb ; the nipple is now squeezed genth% and, continuing the pressure, the pipette is rotated back so that the perforation is free again. In this manner the blood is forced from the pipette, but is not sucked back. The blood remaining in the pipette is now com- pletely washed away by thrusting its point into the diluting fluid, this at once filling its caliber, by capillarity. Withdrawing the 54 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. pipette from the fluid, the rotation and pressure of the nipple are repeated, the capillar}- tube being thus rinsed out several times in order to remove completely all the blood clinging to its interior. The blood and the diluting fluid are now mixed by briskly ro- tating the mixing vessel between the opposed hands, so that the tumbling about of the glass beads in the vessel may thoroughly distribute the cellular elements through the fluid. When the mixing is completed, a drop of the fluid is transferred to the counting chamber, and the corpuscles counted under the micro- scope, in the usual manner. Durham's device makes it possible for the unskilled to measure accurately the desired volumes of blood and diluting fluid, and largely eliminates the errors which are likely to occur in sucking up the blood and the diluent with either the Thoma-Zeiss, or the Gowers hemocytometer. The ease and thoroughness with which the capillary blood pipette may be cleaned is also an ad- vantage, this being done by passing through its caliber a piece of darning cotton, dr}' or soaked in ether, by means of a needle. Comparative obsen-ations made with the Thoma-Zeiss hemocy- tometer have shown that the readings of the two instruments are practically identical. In this form of hemocytometer, the blood and Gowers' Hem- the diluting fluid are each measured in a separate OCYTOMETER. pipette, and deposited in a small receptacle in which they are mixed, a small portion of the mix- ture then being placed in a counting chamber and the number of corpuscles counted under the microscope. Gowers prefers to use as a diluent an aqueous solution of sodium sulphate having a specific gravity of 1025, but Toisson's solution, or any of the other diluting fluids prev^iously mentioned \\ill prove satisfactory'. The instrument comprises five working parts, as follows : 1. A pipette, graduated to hold a volume of 995 cubic milli- meters, for measuring the diluting fluid. 2. A capillary pipette, graduated to hold a volume of 5 cubic millimeters, for measuring the blood. 3. A small glass i)iixi)ig jar,\\\ which the dilution of the blood is made. 4. A glass stirring rod, for mixing the blood and the diluent in the jar. 5. A counting cJianiber, consisting of a glass slide, mounted on a brass plate, and containing a cell one-fifth of a millimeter in depth, the floor of the cell being divided by cross rulings into squares the sides of which measure one-tenth of a millimeter. When a cover-glass is fitted over this cell, being retained in po- COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 55 sition by means of a pair of clips attached to either end of the brass plate, the cubic contents of the space overlying each square measure 1/500 of a cubic millimeter. Method of Use. In using the instrument, 995 cubic miUimeters of the diluting solution are first measured by means of the larger pipette, and blown out into the mixing jar. The latter must be perfectly clean and absolutely free from moisture before it is used, in order to avoid errors in the count. Now, using the capillary blood pipette, 5 cubic millimeters of blood are secured from the puncture, and immediately added to the diluent contained in the jar. The blood and the diluent are then thoroughly mixed, by rapidly stirring the solution with the glass rod. The dilution thus made is in the proportion of I in 200 of blood to diluent. As soon as the mixture is completed, a small drop of the solution is transferred to the center of the cell in the middle of the counting chamber, the small end of the glass rod being used for this pur- pose, after which the cover-glass is gently placed in position, and the clips adjusted so as to hold it in place. The counting cham- ber may then be placed upon the stage of the microscope, and the corpuscles overlying the ruled portion of the cell brought into focus with a low-power objective. It is necessary to use a small drop of the diluted blood, and to place it exactly in the center of the block of ruled squares, otherwise the fluid may flow towards the walls of the cell, alter- ing its volume, and making it necessary to reject the specimen, and to prepare a new drop, after thoroughly cleaning and drying the cell, and again stirring the blood solution. The corpuscles having settled to the bottom of the cell, their number in a given number of squares is noted, and the final calculation made according to the formula : Number of Ntimber of ^^^^^ ^^^^^^^^ ^jr ^^^_ corpuscles x 200 x 500 - squares = ^^^^^^ ^^^ ^^^^^^ counted counted In counting the erythrocytes at least 20 squares of the count- ing chamber should be inspected, in different drops, a procedure involving the enumeration of about 1,000 cells, in normal blood. Except in high leucocytoses, the number of leucocytes is usually estimated indirectly, by determining their ratio to the erythro- cytes, and basing their actual number upon this figure. This plan (the necessity for which is a serious drawback to the use of this instrument) is followed so as to dispense with the tedious filling and refilling of the counting chamber, in an endeavor to find a sufficient number of leucocytes to serve as a basis for the 56 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. calculation, should the latter be direct. Ordinarily, not more than two of these cells are contained in an area including 20 squares. Gowers^ claims that the limit of error with his instru- ment is less than 3 per cent. After use, the different parts of the instrument are to be thor- oughly cleaned and dried, in the manner already described. For making rapid numerical estimates of the Oliver's Hem- er\'throcvtes Oliver has desig-ned an instrument OCVTOMETER. based upon the following principles : When a candle flame is viewed through a flat Hass test- o o tube filled with water, a bright transverse line is visible, com- posed of densely packed, minute images of the flame produced by the longitudinal corrugations of the glass. If for the water a mixture of blood and Hayem's solution* is substituted, a more or less opaque fluid results, so that, in low dilutions, this illuminated line is invisible, reappearing only when a definite degree of higher dilution is reached, by the gradual addition of the diluent ; when this point has been obtained, the line is again detected as a bright, delicate streak horizontally crossing the tube. Experiments having proved that the development of such a line, by gradual dilution of the blood with Hayem's fluid, is an accurate gauge of the percentage of erythrocytes in the specimen tested, it remained for Oliver to devise a hemocytometer consisting of the following essential parts : 1. A capillary pipette, for measuring the blood. 2. A glass dropper, one end of which is capped by a rubber nipple, the other by a short rubber nozzle which fits over the blunt end of the pipette. 3. A standard gradiiated tube, in which the blood and the diluent are mixed. The four walls of the tube are flattened so that it is rectangular on cross-section, one wall being provided with an etched scale, indicating units from 10 to 120. Each of these divisions is equiv- alent to 50,000 erj-throcytes, the point marked 100 degrees representing the arbitrar}' normal number, 5,000,000. Small-sized wax candles, known as ** Christmas candles," are to be preferred for the illumination, as they give the small flame requisite to obtain a sharply defined line, but the flame from a gas-jet turned low may also be used with satisfaction. Method of Use. — In making the observation the pipette, which has been previously cleaned and dried, is filled with blood in the usual manner, and any excess of blood on the outside carefully 1 Lancet, 1877, ^'o^- "•» P- 797- ^ For formula, see page 41 . COUNTING THE ERYTHROCYTES AND THE LEUCOCYTES. 57 22. removed. The rubber nozzle of the dropper, filled with Hayem's fluid, is then slipped over the blunt end of the pipette, and the blood washed out into the graduated tube by squeezing the nipple. This preliminary dilution is continued until the column in the tube rises to within lo or 1 5 degrees below the figure for the hemoglobin percentage of the same blood, this having been pre- viously determined. For instance, if the hemoglobin percentage was found to be 70, the diluting fluid is added in large quan- tities until the mixture in the tube reaches to about the mark 60, after which it is added more cautiously, and in smaller quantities at a time, careful search for the bright line being made after each addition. In cases of chlorosis and of pernicious anemia, in which parallelism between the hemoglobin and corpuscular loss is lacking, it is, of course, impossible to depend upon the hemo- globin percentage as an index to the amount of diluent required, so that in instances of this kind the line must be developed more slowly, by making a smaller primary dilution, and by adding the requisite volume of liquid more deliberately. After the first dropperful of diluent has been added to the con- tents of the tube, the latter are mixed by inverting the tube a number of times with the thumb held over Fig. its mouth, the precau- tion being taken also to remove the thumb by drawing it over the mouth of the tube, in order to restore to its contents any liquid which may have ad- hered to the skin. The tube should be thus inverted after each ad- dition of the diluting fluid. The steps of the ob- servation succeedine the measuring of the blood and its primary dilution are to be made in a dark-room, free from cross lights, the candle being placed about ten feet distant from the observer. In order to shut out the diffused light of the candle, the tube should be held vertically in the concavity formed between the thumb and forefinger, the tube being kept close to the eye while Method of using Oliver's hemocytometer. Showing manner in which the blood is washed from the capil- lary pipette into the tube containing Hayem's solution. 58 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. searching for the bright line. OHver states that the earliest indications of this line are obtained by turning the tube on its axis, when it will become visible at the sides of the tube. It is claimed that tests made with this instrument are accurate within one per cent., and that in many cases it may be used as a substitute for the more laborious method of counting the cor- puscles under the microscope. It is obv^ious, however, that, apart from the " personal equation," the serious drawback to this test is its failure to indicate the number of leucocytes, this fact alone being sufficient to curtail its use for routine clinical work. It is also apparent that in cases of marked leucocytosis and of leuke- mia the optical principles of the test must necessarily fail because of the enormous number of leucocytes in the blood. Further- more, it is reasonable to infer that the instrument will give false results with blood in which conspicuous deformities of the er}-th- rocytes exist, for the reason that the standard tube is corrected for normally shaped corpuscles, so that blood composed largely of microcytes, or megalocytes, or poikilocytes will give different readings from blood in which the cells are of unaltered biconcave shape and of normal size. IV. EXAMINATION OF THE STAINED SPECIMEN. The microscopical study of the dried and Objects of stained blood-film, which should supplement the Staining. methods of investigation just described, is for many reasons the most important step in the clinical examination of the blood. By means of this method of " color analysis " it is possible to differentiate easily and with absolute certainty the various forms of leucocytes and, by differ- ential counting, to calculate the relative percentages of each variety of these cells ; to distinguish the several structural de- generative changes affecting chiefly the erj'throcytes, and to a less extent the leucocxies ; and to recognize and classify accord- ing to their histological character the nucleated forms of the er}'th- rocytes. To sum up, in the words of Ehrlich,^ to whom we owe this rational means of investigration : '* Ever\-thin2: that is to be seen in the fresh specimens — apart from the quite unim- portant rouleaux formation and ameboid movements — can be seen equally well, and indeed much better, in a stained prepara- tion ; and there are several important details which are only made visible in the latter, and never in wet preparations." ^Ehrlich and Lazarus: "Die Anaemic," Wien, 1900. (Nothnagel's "Spec. Path. u. Therap.," vol. viii., n. 2.) EXAMINATION OF THE STAINED SPECIMEN. 59 According to the classification introduced The Aniline twenty years ago by Ehrlich/ the aniline dyes Dyes. are divided into three different groups : acid, basic, and neutral. Acid dyes, or compounds in which the coloring principle acts or exists as an acid, possess a special affinity for cell protoplasm, and, therefore, are generally employed as plasma stains ; in hematological work acid fuchsin, eosin, and orange G are the principal dyes used for this purpose. Basic dyes, or compounds in which the coloring principle exists chemically as a base in combination with a colorless acid, are especially useful as nuclear stains, since they exhibit a special affinity for chromatin structures ; members of this group of dyes commonly used in blood staining are methylene-blue, tol- uidin-blue, methyl-green, methyl -violet, thionin, and hema- toxylin. Neutral dyes are the coloring principles which re- sult from the mixture of solutions of an acid and a basic dye ; they are used for the demonstration of the so-called neutro- phile granules of the leucocytes, for which they show a selective affinity. For the preparation of the dried blood-films it Preparing is advisable to have at hand at least half a dozen THE Films, perfectly clean, polished cover-glasses, which may be arranged in pairs on a sheet of white paper within convenient reach of the examiner. After having wiped away the blood which immediately follows the puncture, a minute portion of the next drop is collected, by lightly ^^' ^^' touching the center of one of the cover-glasses to its sum- mit, care being taken to avoid bringing the polished surface of the glass in contact with the skin of the patient's finger. The charged cover-glass is then at once dropped, blood . , , .'■'■. I. Superimposing the charged cover-glass. Side downward, upon the sur- face of the second glass (Fig. 23), with the result that the blood quickly spreads out in a thin film between the two, and ex- tends to their peripheries, provided that the proper quantity of blood has been used. (Fig. 24.) As soon as the film has reached the margins of both cover-glasses, they are rapidly drawn apart in a horizontal direction, so that the surface of each, when thus -separated, is covered with a thin layer of blood (Fig. 25), which ^Zeitschr. f. klin. Med., i88o, vol. i., p. 555. 6o EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Dra\ving apart the coyer-glasses. Fig. should be rapidly dried, either by blowing briskly upon its sur- face, or by holding the glass for a few seconds high over the flame of an alcohol lamp. If care is taken to use but a ver}' small drop of blood, to avoid ^^^- ^4- pressure in opposing the sur- faces of the two cover-g-lasses, and to separate them in their true horizontal planes, the films will consist of a single layer of corpuscles, most of which will, be sufficiently iso- lated to allow the study of their individual morphology^ and other characteristics. The beginner should persistently practice the technique of film making until he is able to obtain a satisfactor}' percentage of good specimens from ever}* batch of spreads. Thick, uneven spreads, in which the corpuscles are heaped up and glued together in dense masses, are practically of no value for microscopical study ; such specimens should therefore be rejected at once, since it is time wasted to attempt satisfactorily to stain them. The films, after having been dried, may be placed in a pill box, and labelled, to await fixation and stain- ing at the examiner's con- venience. . Dried specimens will keep for an indefinite period, if not exposed to dust or to moisture. Unfixed cover-glass specimens of leukemic blood have been stained by the writer, with perfect results, more than three years after they were spread. Many histologists recommend the use of special forceps for hold- ing the cover-glasses while making the spreads, claiming thus to avoid the injurious effects upon the blood corpuscles which may be caused by the moisture of the fingers, if the latter come in contact with the films. The careful worker need have no fear on this score, for if the covers are held in the manner shown in the illustrations this accident will not occur. A pair of light thumb forceps is useful for picking up the cover-glasses from a flat sur- face, but the employment of special spreading forceps is quite superfluous. The cover-glasses after separation. EXAMINATION OF THE STAINED SPECIMEN. 6l Fig. 26. As a step preliminary to staining, the albumi- FiXATiON noid principles of the blood must be fixed, by ex- Methods, posing the dried film either to a high degree of dry heat, or to various chemical hardening agents, the choice between these two methods being determined by the character of the staining solution to be used subsequently. Heat Fixation. This method may be employed with any of the stains described in the following pages ; it must be used with Ehrlich's triple stain, in preference to fixation by chemicals, in order to obtain crisp, clean-cut pictures. The author is accustomed to use an oven, such as is illustrated below (Fig. 26), consisting of a copper box with a heavy bottom, and hinged cover, mounted on an ordinary iron burette stand, by means of a thumb-screw. A small ** baby" Bunsen lamp placed under- neath the box furnishes the requi- site degree of heat, the temperature being indicated by a thermometer mounted at one end, and resting upon the floor of the oven. By sliding the latter up and down the vertical rod to which it is attached, the desired degree of temperature may be obtained at will. The blood- films are enclosed in the copper box, and the latter fixed at a point eight inches above the summit of the burner, after which the gas is lighted and allowed to burn until the temperature, as indicated by the thermometer, has gradually crept up to 160° C. As soon as this degree of heat has been reached, the gas is extinguished, the cover of the oven thrown back, and, after the temperature has fallen to 30° C, the films removed, being now thoroughly fixed, and ready for staining. Fifteen minutes suffice for the whole operation, from the time the gas is lighted, until the films have been removed and cooled, for staining. A less satisfactoiy method of heat fixation is by the use of a copper plate upon which the films are kept at a temperature of from 100° to 110° C, for from one-half to one hour. The ap- .paratus used for this purpose consists of a rectangular plate of sheet copper, about fifteen inches long, by four inches wide, by one-sixth of an inch thick. An alcohol or a Bunsen lamp bums Oven for fixing blood-films. 62 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. under one end of the plate, which is elevated about six inches above the flame, by four metal legs. After having heated the plate for ten or fifteen minutes, until a relatively constant tem- perature becomes established, water is dropped upon its surface, beginning with the end farthest from the flame, until a point is reached at which the water boils. This part of the plate is con- sidered to have a temperature of ioo° C, and at this point the blood-films are placed, " spread" side downward, and heated for the required time. No one with much blood staining to do will choose this method of prolonged heating at a relatively low, ap- proximate temperature in preference to brief heating at a high, definite temperature in an oven. The use of the latter, aside from its convenience as a time-saver, insures constant and cer- tain results, for over- and underheating of the blood-film may be avoided, since the degree of heat is exactly indicated and easily controllable. In triple stained specimens the blood cells are much more brilliantly colored and sharply differentiated when the films are fixed at a temperature of i6o° C, than at a lower degree. Should nothing but a Bunsen or an alcohol lamp be available, the cover-glass film, held with a pair of forceps, may be fixed by passing it rapidly through the flame thirty or forty times and then holding it twelve or fifteen inches above the flame for a minute or so. This makeshift method, which is often sufficient for a hur- ried clinical examination, usually gives fair, and sometimes v^ery good, results, but the fixation is generally uneven, and the speci- men is frequently scorched in some places and underfixed in others. Chemical Fixation. Immersion of the dried films in ether, in absolute alcohol, or in a mixture of equal parts of the two (Niki- foroff's method) gives satisfactory results with specimens stained by any of the single basic dyes, or with the simpler double stains, such as eosin and methylene-blue or hematoxylin. The time of fixation varies from five to fifteen minutes with any of these agents, the specimen then being dried without using heat, and stained without previously washing. If time is an object, the specimens may be boiled for one minute in a test-tube containing absolute alcohol, as advised by Ehrlich.^ Some workers employ one minute's fixation by a one per cent, alcoholic solution of forma- lin (Benario's method), while others prefer to expose the films to the vapors of this chemical for the same length of time. Solley - has recently suggested that the film be flooded with a two per cent. ^ Loc. cit. 2 Med. and Surg. Reports of the Presbyterian Hospital, N. V., 1900, vol. iv., p. 169. EXAMINATION OF THE STAINED SPECIMEN. 63 aqueous solution of chromic acid, which is washed off after exactly thirty seconds, the specimen being then stained, while still wet ; he recommends this procedure as a substitute for heat in fixing specimens for triple staining, but the method, while fairly good, cannot be regarded as entirely satisfactory. In the author's hands a two per cent, aqueous solution of osmic acid has been found to be the best substitute for heat fixation. In hematological, as in other histological work Methods of the choice of a staining method is determined by Staining. the character of the investigation to be undertaken. For general clinical purposes it is advantageous habitually to employ some routine method by means of which the greatest possible number of elements may be demonstrated in a single blood-film, this procedure being known as panoptic staining. Thus, by using a solution containing several of the aniline dyes the stroma of the erythrocytes, the cell-granules, the cell-nuclei, and the various blood parasites may be simultaneously stained each in a characteristic manner, owing to the selective affinity displayed by the different coloring principles of the mix- ture towards these several histological elements. The most useful solutions which have been devised for this purpose are the triacid mixture of Ehrlich,^ which has long served as the standard stain for hematological investigation, and the methylene -blue eosinate solution suggested by Jenner.^ Practically all the information that it is possible to derive from the study of the stained dry blood-film may be obtained with the aid of these two solutions. Combinations of an acid and a basic dye, such as eosin and methylene-blue, eosin and hematoxylin, and orange and hema- toxylin are used by many investigators, chiefly for the purpose of staining the cell-stroma and the nuclear structures ; but, as a general rule, such mixtures are not adapted for clinical work, since with none of them is it possible to differentiate the neutro- phile granules. Solutions of a single dye are but seldom used except for the demonstration of special elements, such, for in- stance, as the staining of the malarial parasite by thionin, the mast-cells by dahlia, and certain bacteria by the basic dyes, such as methylene-blue and gentian-violet. Since by this method of staining only the particular elements toward which the dye reacts are differentiated, the employment of single stains is inadequate for the study of the general morphology of the blood cells. The following formulae will be found sufficient for all purposes of clinical investigation : 1 Loc. cit. 2 Lancet, 1899, vol. i., p. 370. 64 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Ehrlich's Triacid Stain. This valuable triple stain, con- taining one basic and two acid dyes (methyl-green, orange G, and acid fuchsin), is peculiar in that a chemical combination is formed by its acid and basic components which may be regarded as a neutral coloring principle, serving the purpose of selectively staining the so-called neutrophile elements for which the primar>^ components of the mixture have no affinity. With this stain his- tological structures having an affinity for the acid dyes are stained the color of one of its acid constituents, basic structures the color of its basic dye, and structures having an equal affinity for acid and basic dyes the color of the neutral compound. Saturated aqueous solutions of the three dyes are first pre- pared, and allowed to stand for several days until they have become thoroughly cleared. It is essential that the aniline dyes used for making these " stock " solutions should be chemically pure, to ensure which the products of Griibler, or of the Berlin Aniline Dye Company should invariably be chosen. From these saturated solutions the following mixture is made : Acid fuchsin solution 6- 7 cc. Orange G solution 13-14 cc. Distilled water 15 cc. Absolute alcohol 15 cc. Mix the above thoroughly, and add, drop by drop, with continuous agitation, in the following order : Methyl -green solution 12.5 cc. Absolute alcohol 10 cc. Glycerine 10 cc. The mixture should under no circumstance be filtered, but al- lowed to stand for about twenty-four hours in order that a slight precipitate may form. As soon as this occurs the stain is ready for use, the necessar}' quantity being pipetted from the super- natant fluid without disturbing the precipitate. Technique of Staining. The heat-fixed film, held preferably with a pair of Stewart's staining forceps, is flooded with the stain, which is washed off in running water after the lapse of from five to eight minutes, the specimen then being dried by gentle heat, and mounted in xylol balsam, or in cedar-oil. In the specimen thus prepared the stroma of the er\throcytes is stained orange, the nuclei of the leucocytes greenish-blue, the" neu- trophile granules violet or lavender, and the eosinophile granules copper red. The nuclei of the erythroblasts react with var>^ing degrees of intensity toward the basic component of the mixture, those of the normoblasts staining deep purple or black, and those of the megaloblasts pale green or greenish-blue. The basophile EXAMINATION OF THE STAINED SPECIMEN. 65 granules remain unstained, appearing as dull white, coarse, stippled areas in the cell-protoplasm — ''negative staining." In order to stain these granules, as well as the basic protoplasm of the lymphocytes, Hewes ^ suggests that the triple stained film, after having been washed, be subjected for from one-half second to ten seconds to Loffler's ^ methylene-blue solution, after which it is again washed, and mounted as above directed. This modifica- tion is of undoubted value, chiefly because it usually enables one to differentiate the larger forms of lymphocytes from the large mononuclear leucocytes. Malarial parasites, and bacteria are also distinctly stained by this method. Unsatisfactory results with the triple stain, provided that the latter is properly made, can almost always be attributed to faulty fixation. As already remarked, heat is the only method of fixa- tion which will insure faultless differentiation in the specimen stained with this mixture. The perfect specimen is of a deep, rich orange tint to the naked eye ; if underheated, the film reacts too strongly toward the acid fuchsin of the mixture, and, conse- quently, is the color of this dye ; if overheated, the plasma stain, orange G, is but feebly displayed, so that the color of the film is pale lemon yellow.^ Jenner's Stain. This solution, made by dissolving in methyl alcohol the neutral precipitate obtained by the addition of methyl- ene-blue to eosin, is especially valuable in the study of the lym- .phocytes, and the mast-cells. It should be made according to the following somewhat compHcated formula : (a) Eosin (aqueous) 1.25 grm. Distilled water 100 cc. (^) Methylene-blue (medicinal) i.o grm. Distilled water 100 cc. Equal parts of these two solutions, "a" and *'b," are mixed together, stirred thoroughly with a glass rod, and set aside for twenty-four hours, so that complete precipitation may occur. In making this mixture, the methylene-blue solution should be added to the eosin solution (never vice-versa) in small quantities at a time, the fluid being constantly stirred during the addition. A burette with the stop-cock regulated so as to deliver the former dye-solution, drop by drop, in rapid succession, will prove useful to insure the slow admixture of the two fluids. The precipitate ^ Boston Med. and Surg. Journ., 1899, vol. cxli., p. 39. 2 Saturated alcoholic solution of methylene-blue, 30 cc; 1-10,000 aqueous solution of potassium hydrate, loo cc. 3 A reliable triacid stain, made according to Ehrlich's formula, is sold by Messrs. Shinn and Baer, Philadelphia. 5 66 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. is collected by filtration, dried in an incubator, at a temperature of 55° C, and powdered in a mortar. The powder should then be washed, by shaking it up with distilled water, and filtering, after which it is allowed to dry in the air, and kept in a tightly corked bottle. The mixture used for staining is made by dis- solving 0.5 grm. of this powder in loocc. of pure methyl alcohol (Merck), and filtering. Technique of Staining. Owing to the methyl alcohol which it contains, Jenner's solution fixes and stains the blood-film simultaneously, so that preliminary fixation may be omitted. The unfixed specimen is stained for from three to five minutes, washed in water until the film is of a rose-red color, dried in air, and mounted in the usual manner. Since the solution is of an exceedingly volatile character, as much of it should be used as can be placed on the cover-glass without spilling ; if this is not done, the specimen may be ruined, owing to the rapid evapora- tion of the stain around the margins of the cover-glass. Jenner's stain gives the following results : erythroc}i:es, terra cotta; nuclei of the leucocytes, pale sea-green; neutrophile granules, pale pink ; eosinophile granules, deep pink ; fine baso- phile granules, deep blue ; and coarse, mast-cell granules, deep royal purple. The nuclei of the erythroblasts, and the blood parasites stain various shades of bluish-green, and the pseudo- granular protoplasm of the lymphocytes, blue. The chief defect in Jenner's stain is the occasional presence of a coarse, granular precipitate which mars the appearance of an otherwise perfect specimen. If, however, the precaution is ob- served always to filter the stain before use, and to dry the film in air — not by holding it over a Bunsen flame — this accident may generally be avoided. Aside from its obvious value as a panop- tic staining fluid, this solution will often prove of great convenience for the reason that it does not require special fixation of the blood- film. Prince's Stain. This mixture, which consists of an aqueous solution of one basic and two acid dyes, is an excellent stain for the differentiation of both nuclei and granules, and may be em- ployed as a fair substitute for either of the two preceding solutions. It should be made in this manner : Saturated aqueous solution of toluidin-blue 24 cc. Saturated aqueous solution of acid fuchsin i cc. 2 percent, aqueous solution of eosin 2 cc. These solutions are mixed in the order named, and shaken briskly for several minutes, so as to secure complete precipitation EXAMINATION OF THE STAINED SPECIMEN. 6/ of the basic toluidin-blue by the acid dyes. The solution, which should not be filtered, is ready for use as soon as made. Only the supernatant fluid should be employed, care being taken not to disturb the sediment. Technique of Staining. If a newly made solution is used, the films are stained for from one-half to one minute, after which they are rinsed in water, dried in air, and mounted ; but if the solution has stood for several weeks, its basic constituent becomes less active, so that the specimen requires to be stained for from five to ten minutes. Either chemical or heat fixation of the blood-film may be used with this stain, both methods giving equally sharp dif- ferentiation. Prince's solution colors the erythrocytes rose-red, the nuclei of the leucocytes and erythroblasts blue, the neutrophile granules pink, the eosinophile granules maroon, and the fine and coarse basophile granules blue. Blood parasites are also stained the color of the basic dye. Double Staining with Eosin and Methylene-blue. Crisp, clear pictures of nuclear and stroma structures, of the ma- larial parasites, and of the basophile granules may be obtained be the use of these two dyes, and to investigations of this nature should this staining method be restricted. It is impossible, for example, accurately to distinguish a large lymphocyte from a myelocyte in a specimen stained in this manner, so that for differ- ential counting a more elaborate stain is essential. In films stained by this method the stroma of the erythrocytes and the eosinophile granules react toward the acid dye, staining the color of eosin ; while the nuclei of the leucocytes and erythrocytes, the basophile granules, and all blood parasites show art affinity for the basic dye, being colored various shades of blue. The protoplasm of the polynuclear neutrophiles is either colorless or tinged a deli- cate pink, the granules of these cells remaining unstained. The author has always found the following simple formula de- pendable : Eosin (aqueous), to which sufficient water has been added for solution 0.5 grm. Absolute alcohol 0.5 cc. Saturated aqueous solution of methylene-blue.. 96.0 cc. Technique of Staining. Films are fixed by immersion for ten minutes in absolute alcohol, or in equal parts of absolute alcohol and ether. The cover-glass is flooded with the stain, gently heated for one minute over a Bunsen flame, allowed to stain without heat for two or three minutes longer, and then thoroughly washed in running water, dried in air, and mounted. 68 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. Another method of staining with eosin and methylene-blue, slower than the above, but as a rule giving sharper differentiation, is to stain without heat for five minutes with a 0.5 per cent, solu- tion of eosin in absolute alcohol to which an equal quantity of water is added. Then, after having washed off the eosin solution and dried the film in air, the specimen is counterstained for one minute or less with a saturated aqueous solution of methylene- blue, after which it is rinsed again in water, dried in air, and mounted. Among the many other methods of staining with eosin and methylene-blue, those suggested by Chenzinsky/ by Plehn,- and by Holmes^ will be found the most useful. Double Staining with Eosin and Hematoxylin. By the em- ployment of these two dyes the erythrocytes and the eosinophile granules are stained the color of eosin, and all nuclei and parasites, the color of hematoxylin. This method, which is decidedly in- ferior to staining with the eosin and methylene-blue mixtures just described, is useful for little else than the study of nuclear struc- tures. It should not be used for differential counting, since in films stained in this manner the neutrophile granules are invisible. EhrHch* recommends this formula : Eosin (cryst.) 0.5 grm. Hematoxylin 2.0 grm. Absolute alcohol 100. o cc. Distilled water 100. o cc. Glycerine 100. o cc. Glacial acetic acid lo.o cc. Alum in excess. This mixture must '* age " for several weeks before it can be used for staining. Technique of Staining. Specimens, fixed either chemically or by heat, are stained for from one-half hour to two hours, thor- oughly washed in water, dried and mounted. In order to obtain the best results, it is advisable to filter the solution before using, and to wash the films ver>^ thoroughly after staining. If time is an object, the following rapid method may be substi- tuted for the above : The film is first stained for about five minutes with a 0.5 per cent, solution of aqueous eosin in fifty per cent, alcohol, washed, and dried in air ; it is then counterstained • Zeitschr. f. wiss. Mik., 1894, vol. xi,, p. 260. 2 " Aetiologische und klinische Malaria Studien," Berlin, 1890. 'Joum. Am. Med. Asso., 1898, vol. xxx., p. 303. * Loc. cit. EXAMINATION OF THE STAINED SPECIMEN. 69 for about one-half minute with Delafield's hematoxylin,^ washed for a second time, and mounted in the usual manner. Staining with Thionin. Thionin (also known as the "violet of Hoyer," and the ''violet of Lauth " ) is an excellent stain for blood parasites in general, being especially useful for the demonstration of the malarial parasites and the filarial embryos. Thionin should not be used as a stain for films in which the gen- eral morphology of the blood cells is to be studied, since the baso- phile granules and the nuclei are the only histological elements for which it displays any decided affinity. Structures reacting toward the dye are stained violet of varying degrees of intensity. The following recipe, suggested by Futcher and Lazear,^ will prove satisfactory : — Thionin 0.3 grm. Absolute alcohol 10. o cc. I per cent, solution of carbolic acid q. s. ad 100. o cc. Technique of Staijtmg. Films which have been fixed either chemically or by heat are stained in the above solution for from one to three minutes, being then washed in water, dried, and mounted as usual. The best results are obtained by using the French thionin, made by Cogit et Cie, of Paris. Staining with Polychrome Methylene-blue. Goldhorn's solution of methylene-blue and lithium carbonate affords a rapidly acting stain, superior to all others for the demon- stration of the finer structure of the malarial parasite in every phase of its development. In addition to giving crisp, clear-cut pictures of the chromatin of this organism, the solution also brings out distinctly the granular degeneration of the erythro- cytes, the nuclear characteristics of the erythroblasts and leuco- cytes, the basophile granules, and all ordinary bacteria. Technique of Staining. The films are fixed for fifteen seconds in methyl alcohol, rinsed in water, and then stained, unheated, for from one to two minutes, after which they are thoroughly 1 This solution is made by first adding 4 grms. of hematoxylin crystals, dissolved in 25 cc. of alcohol, to 400 cc. of a saturated aqueous solution of ammonia-alum. The mixture is left exposed to the sunlight and air in an uncorked bottle for four days, at the end of which time it is filtered, and mixed with 100 cc. each of methyl alcohol and glycerine. This solution is allowed to stand until it becomes dark- colored, when it is filtered, and placed in a tightly corked bottle, to " age" for at least two months before it can be used successfully for staining. Owing to the com- plicated manner in which Delafield's hematoxylin must be prepared, it is usually pref- erable to purchase it ready-made, from a dealer in microscopical supplies, Griibler's make being entirely reliable. 2 Johns Hopkins Hosp. Bull., 1899, vol. x., p. 70. 70 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. washed in running water, dried without the use of heat, and mounted in balsam. Preliminar)^ staining for ten or fifteen sec- onds with a o. I per cent, aqueous solution of eosin, followed by washing, gives a picture in which the contrast between the plasma and the basic elements of the cells is clearly differentiated. Poly- chrome methylene-blue, prepared according to Goldhorn's for- mula,^ is sold by dealers in laborator}- supplies, or it may be made in this manner : — Two grammes of methylene-blue are dissolved in 300 cubic centimeters of warm water and 4 grammes of lithium carbonate are added, with constant agitation. The mixture is poured into an uncovered porcelain capsule, which is heated over a shallow water-bath for ten or fifteen minutes, being frequently stirred with a glass rod. After removal from the water-bath, the fluid is bot- tled, without filtering, and set aside for several days, after which its reaction is corrected by the cautious addition of a 5 per cent, acetic acid solution until the dye is but ver}- faintly alkaline. Should the solution become too alkaline after having been kept for some time, its reaction may be corrected by adding a small quantity of acetic acid, as in the preparation of the original mixture. A differential count of the leucocytes consists in Differential determining, by microscopical examination of the Counting, stained specimen, the relative percentages of the different varieties of these cells, the estimate be- ing based upon a count of several hundred cells, which are clas- sified according to the several forms described in a following section. (Section IV.) This procedure, by means of which qualitative changes affecting the leucocytes may be detected, is obviously a most important step in ever)^ blood examination, and one which should not be regarded as of secondary- importance to the numerical estimate with the hemocytometer. The technique of differential counting consists simply in exam- ining successive microscopical fields until at least five hundred leucocytes have been counted, the cells in each field of \ision being identified as they appear, and jotted down on a piece of paper by the obser\'er under their appropriate class. As soon as the requisite number of cells has been counted, the percentages of the different forms are calculated, to express the final result. For the examination a one-twelfth inch oil-immersion objective is practically indispensable, for to any but the skilled worker it is difficult, if not sometimes impossible, to distinguish the various ^ Johns Hopkins Hosp. Bull., 1S99, vol. x. , p. 70. Also, X. Y. Univ. Bull, of Med. Sc. , 1 901, vol. i., p. 57. COUNTING THE BLOOD PLAQUES. /I forms of leucocytes with a lower magnification than this lens provides. In order to be certain that each field is taken in ac- curate succession to its neighbor, the slide should be moved across the visual field by the aid of a mechanical stage ; systematic examination of any given area of the specimen is well nigh an impossibility, if the slide is simply laid on, or clipped to, the stage of the microscope, and pushed across it with the fingers alone. If nucleated erythrocytes are found in the specimen, it is equally important to include them also in the differential count, classifying them in two histological divisions, normoblasts and megaloblasts. In calculating the number of these cells, it is obviously impossible to employ any direct method, so that the estimate must of necessity be more or less approximate, since it is based upon the ratio of erythroblasts to a given number of leucocytes. Having first counted the latter with the hemocytom- eter, the number of nucleated erythrocytes is noted in an area of the stained specimen in which a fixed number of leucocytes is contained, and having ascertained these data, the estimate is made according to the formula : Number of erythroblasts Number of leucocytes • Nmnber of counted in the stai7ied film per cb. mm. erythro- Number of leucocytes blasts per counted in the stained film cb. mm. For example, in a case of pernicious anemia in which the leu- cocytes number 4,000 per cubic millimeter, and a total of 35 erythroblasts are noted while counting 1,000 leucocytes in the stained film, the calculation is as follows : 35 X 4,000 -7- 1,000 =140 erythroblasts per cb. mm. Whenever erythroblasts are found, it is important to determine their number to the cubic millimeter of blood, and should nor- moblasts and megaloblasts both occur, to estimate the ratio be- tween these two types of cells. V. COUNTING THE BLOOD-PLAQUES. Determann's method^ of indirectly estimating the number of plaques to the cubic millimeter of blood is both simple and ac- curate. It consists, briefly, in first determining the ratio of these elements to the erythrocytes, which are then counted, to furnish the basis for the final calculation. 1 Deut. Archiv. f. klin. Med., 1899, vol. Ixi., p. 365. 72 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. In obtaining the blood, a drop of the diluting fluid is placed upon the patient's finger and the puncture made through it, in order that the blood, as it flows from the puncture, will instantly mix with the diluent without coming in contact with the air. The blood and diluent are then thoroughly mixed for a few mo- ments by the aid of a cover-glass, after which a small portion of the mixture is transferred to a Thoma-Zeiss counting chamber, and the ratio of plaques to erythrocytes determined under the microscope. In the healthy adult this ratio, according to Deter- mann, ranges from i to i8 to i to 30, averaging about i to 22. With another drop of blood the erythrocyte count is then made by the usual method, and the actual number of plaques to the cubic millimeter of undiluted blood calculated from the figure thus obtained. For example, in a given specimen of blood in which the ratio of plaques to erythrocytes is found to be i to 25, the count of the latter cells being 5,000,000, the actual number of plaques is therefore 200,000 per cubic millimeter. The diluents for which Determann expresses a preference are either a 9 per cent, aqueous solution of sodium chloride to which a little methyl-violet has been added, or an aqueous solution con- taining one per cent, of sodium chloride and 5 per cent, of potassium bichromate ; but any of the diluting fluids already mentioned are suitable for the purpose. VI. ESTIMATION OF THE RELATIVE VOLUMES OF CORPUSCLES AND PLASMA. The use of centrifugal force for the purpose of determining the relative volumes of blood corpuscles and plasma was first applied in a practical manner by Hedin,^ who embodied the earlier ideas of Blix in an instrument known as the hematocrit. More re- cently Daland,^ by improving the mechanical construction of the original instrument and by simplifying the technique of using it, has made centrifugalization of the blood a method of investigation adapted to general clinical work. By the use of the hematocrit a pair of capillar\' glass tubes filled with undiluted blood are ro- tated in their horizontal axes at a high rate of speed until, as the result of the centrifugal force thus applied, the corpuscular. and liquid portions of the blood become separated, the former being distinguishable in the lumen of the tube as a column the length 1 Skandinavisch. Arch. f. Physiol., 1890, vol. ii., p. 1 34. 2 University Med. Magazine, 1891, vol. iv., p. 85. Also, Edwards' supplement to Keating's " Cyclopedia of the Diseases of Children," Philadelphia, 1899 ; vol. v., P- 537- ESTIMATION OF CORPUSCLES AND PLASMA. 73 Fig. 27. of which is dependent upon the volume which the corpuscles con- stitute in relation to the rest of the blood mass. This instrument (Fig. 27) is composed of a Daland's set of cog-wheels enclosed in a metal box and Hematocrit, geared in such a manner as to cause ten thou- sand revolutions per minute of a vertical spindle, by turning a handle at a definite, uniform rate of speed. A metal frame, which may be securely fastened to the spindle by a modified bayonet-lock, carries a pair of capillary glass tubes, each of which fits into two cup-Hke, rubber-lined de- pressions, and is adjusted and held in place by a spring. Each tube measures fifty millimeters in length with a lumen of half-a-millimeter, and has engraved upon its outer surface a scale represent- ing one hundred equal divisions, the glass immediately above the scale being moulded so as to form a lens-front, to magnify the column of blood and to facilitate the reading of the divisions. A bit of rubber tubing, fitted with a mouth piece, is used for filling the capil- lary tube, in the same manner in which the blood is measured with the hemocy- tometer. While in use the instrument is securely attached to the projecting edge of a table or shelf, by means of a clamp operated by a thumb-screw. Method of Use. Having cleaned and punctured the pa- tient's finger in the usual manner, the beveled end of one of the capillary tubes is immersed in the drop of blood, which is sucked up the lumen of the tube until it is exactly filled. The forefinger, smeared with a little vaseline, is then applied to the beveled end of the tube, while the rubber suction tube is carefully removed by twisting it free — not by forcibly pull- ing it off, since this may accidentally cause removal of a portion of the blood column, by suction. The tube thus charged with blood is at once adjusted to one arm of the frame, and the empty tube similarly fixed in the other arm, to equalize the balance, this step being completed as rapidly as possible, in order to anticipate coagulation. When the tubes have been thus adjusted, and the frame securely locked in the spindle, the handle of the instrument is turned for three min- Daland's hematocrit. 74 EXAMINATION OF THE BLOOD BV CLINICAL METHODS. utes^ at the rate of seventy-seven revolutions a minute, this rate of speed securing ten thousand rotations per minute of the frame, since the latter revolves one hundred and thirty times with each complete turn of the handle. The centrifugalization having been finished, the charged tube is carefully removed from the frame, and held against a piece of dull white paper, so that the height of the blood column may be easily determined. In order to make the reading with accuracy, it is sometimes necessary to use a small magnif>ing glass, for the divisions on the scale of the tube are but one-half a millimeter apart — a distance too small to judge easily with the naked eye. On examination, three distinct di- visions of the lumen of the tube containing the centrifugalized blood may be distinguished : first, a dark-colored column con- sisting of erythrocytes, reaching, in normal blood, to a point be- tween the divisions marked 50 and 51 ; second, a thin layer of leucocytes, showing, in blood in which these cells are not largely increased, as an indistinct, milky stratum overlying the erythro- cytes ; and, third, a layer of clear plasma occupying the remainder of the lumen. The normal volume of erythrocytes being arbi- trarily regarded as one hundred per cent., to compute this result the figure of the scale to which these cells rise is multiplied by two. Unless the leucocytes are greatly increased in number, the layer formed by these cells is too delicate and too dully defined to be read with any degree of accuracy ; but in cases of high leucocytosis and of leukemia it is quite possible to estimate roughly the relative proportions of leucocytes to erythrocytes. The capillar}^ tube which has been filled with blood should be cleaned as soon after use as possible, water, followed by alcohol and ether, being used for this purpose. A fine wire should be passed through its lumen, to dislodge any obstruction which may result from drying of the column of closely packed corpuscles. The hematocrit, if its clinical application is limited to the de- termination simply of the relative volumes of the blood corpuscles and plasma, ma\' be relied upon to furnish, on the whole, de- pendable information, the necessary errors attending its use probably being within two per cent. If employed in the role of a hemocytometer, however, its results must needs be highly inac- curate just in those instances in which exact methods of investiga- tion are all important. It is true that in normal blood, in which the size of the corpuscles ranges within the physiological limits, it is correct to consider each percentage volume as representing ^ In a recent personal communication Dr. Daland advises that, in order to insure the most accurate results with his instrument, the centrifugalization be continued for three, instead of for two, minutes, as he formerly recommended. ESTIMATION OF THE SPECIFIC GRAVITY. 75 approximately a count of 100,000 erythrocytes per cubic milli- meter. In blood characterized by any considerable deformity in the size and shape of these cells, as in high-grade anemia or in leukemia, it is perfectly obvious that no such correspondence between the count and the percentage volume can be expected — blood in which microcytosis is pronounced is certain to show a lower percentage volume of erythrocytes than blood in which megalocytosis prevails, or than blood containing normal-sized cells, although the counts of all three may be identical. Similarly, a given number of lymphocytes should indicate a lower percentage volume than an equal number of myelocytes, or even polynuclear neutrophiles. On account of these sources of fallacy, if for no other reason, the hematocrit estimate should never be taken as a basis for calculating the count in pathological conditions, in Heu of the more accurate, if more laborious, method of counting the corpuscles. Capps^ considers that the hematocrit may be used to advan- tage, in conjunction with the hemocytometer, in determining the actual size or volume of the individual erythrocyte, and he regards this method as far more reliable than the use of the micrometer, since with the latter only the transverse diameter of the cells, and not their depth, can be measured. The formula for calculating this "volume index" has been given elsewhere. (See p. 130.) VII. ESTIMATION OF THE SPECIFIC GRAVITY. This method of investigation is used as an indirect means of computing the percentage of hemoglobin, owing to the more or less constant parallelism maintained between it and the specific gravity of the whole blood. The correspondence between the two, together with the sources of error inseparable from the test, has been pointed out in another section. (See page 98.) Hammerschlag's modification^ of Roy's Hammer- method^ of determining the specific gravity of schlag's the blood best serves the purpose of those who Method. choose this roundabout means of approximating the hemoglobin percentage. It consists in first making a mixture of benzol and chloroform of such a specific gravity that a small drop of blood deposited in the liquid remains suspended, after which the specific gravity of the mixture is de- termined with a hydrometer, the figure thus obtained representing ^Journ. Am. Med. Assn., 1900, vol. xxxvi., p. 464. 2Zeitschr. f. klin. Med., 1892, vol. xx., p. 444. 3 Cited by Devoto : Zeitschr. f. Heilk., 1889, vol. xi., p. 175. ^6 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. the density of the blood used in the test. The hemoglobin per- centage corresponding to this figure is then selected from a table giving the various degrees of blood densities and the percentages of hemoglobin to which they are equivalent. The apparatus required for making the test is neither elaborate nor expensive, a hydrovicter prov^ided with a scale graduated to 1.070, a hydrometer jar having a wide, substantial base, a glass capillary tube, and a glass stirring rod being the only instruments needed. In most instances an ordinary urinometer may be used instead of a special hydrometer, since specific gravities in excess of 1060 (the highest gradation on the scale of most urinometers) are not often encountered. Either a Thoma-Zeiss leucocytom- eter, or a medicine dropper the free end of which should be heated in a flame and bent into an obtuse angle, will serve as a capillary pipette. Benzol and chloroform are mixed together in the hydrometer jar in such proportions that the specific gravity of the liquid is approximately equal to that of normal blood, 1060. This mix- ture having been made and its specific gravity taken, the point of the capillar)^ pipette, charged with blood, is plunged beneath the surface of the liquid and a small bead of blood gently expelled. If the blood drop rises to the surface of the mixture a few drops of benzol are added, while if it sinks to the bottom of the jar chloroform is used, the addition of the appropriate reagent being continued until the drop neither rises nor sinks, but remains sta- tionary, suspended in the mixture. When this point has been determined the specific gravity of the liquid is taken by means of the hydrometer, this figure obviously representing the specific gravity of the blood drop itself. To translate the specific gravity into its hemoglobin equivalent the figure obtained by the above procedure is compared with one of the tables given on page 100. After each addition of benzol or of chloroform the contents of the jar must be thoroughly mixed by stirring with the glass rod, in order to secure uniformity in the density of the liquid. The latter, if it is filtered free from blood and preserved in a tightly stop- pered bottle, may be used again in subsequent tests. In spite of the enthusiasm evinced by certain authors for this method of ascertaining hemoglobin values, considerable experi- ence with the test has convinced the writer that it is both crude and untrustworthy, — it is useful, no doubt when a hemometer cannot be obtained, but in no sense is it an efficient substitute for colorimetric methods. The liability of the blood drop to split up into numerous fine particles, to adhere to the inside of the jar, and to become altered in composition from the influence of the ESTIMATION OF THE ALKALINITY. 77 reagents, as well as the tedious attempts which must usually be made to add just the proper quantities of benzol and chloroform to secure a mixture in which, the drop neither sinks nor rises, are a few of the drawbacks which must make the test unpopular with busy clinicians. VIII. ESTIMATION OF THE ALKALINITY. The most available clinical method of deter- Engel's mining the alkaHnity of the blood is by the use Alkalimeter. of.Engel's alkalimeter. (Fig. 28.) By means of this instrument a measured quantity of fresh blood is diluted with distilled water in the proportion of one to ten, and then titrated with a -^L- normal solution of tartaric acid until the mixture reacts with lacmoid paper, the total alkalinity being calculated from the amount of the tartaric acid used. The methods of alkalinity estimation devised by Landois ^ by Lieb- reich,^ by Haycraft and Williamson,^ by Wright,^ and by Kraus,^ are not well adapted to routine blood-work, being either too com- plicated and elaborate for such a purpose, or too inaccurate. The apparatus which Engel has devised consists of the follow- ing parts : a dihiting and mixing pipette, resembling a large-sized Thoma-Zeiss er^^throcytometer ; a graduated burette by means of which the amount of tartaric acid solution used in the test is meas- ured ; a glass cylinder in which the titration is made ; and a glass stirring rod. The mixing pipette is graduated in three principal divisions marked 0.025, 0.05, and 5.0 respectively, the first two divisions being further scaled in tenths by fine horizontal mark- ings ; otherwise the instrument is modeled like a blood counting pipette. The burette has a capacity of five cubic centimeters, and is provided with a scale indicating one hundred equal divi- sions ; when in use, it is clamped upright, by means of a special at- tachment, to a vertical brass support which screws into a fitting in the box containing the apparatus. Method of Use. The technique of using the alkalimeter is simple and time saving in comparison with that required by other well-known methods of alkalinity testing. Finger-blood, ob- tained by a rather deep puncture so as to afford a good-sized drop, is sucked up in the pipette until it reaches the mark 0.05, imme- diately after which distilled water is similarly drawn up the lumen 1 Real-Encyclop., 1885, vol. iii., p. 161. 2 Berichte d. deutsch. chem. Gesellsch., 1868, vol. i., p. 48. sProc. of the Roy. Soc, Edinburgh, 1888, June 18. * Lancet, 1897, vol. ii., p. 719. ^Zeitschr. f. Heilk., 1889, vol. x., p. 106. 7S EXAMINATION OF THE BLOOD BY CLINICAL METHODS. of the tube until the mixture of blood and water fills the bulbous expansion and reaches the mark 5.0, in the constricted portion beyond. While sucking up the water, the pipette should be rap- idly twisted to and fro between the thumb and forefinger, to insure Fig. 28. Engel's alkalimeter. thorough mixing of the blood and water as they together fill the expanded portion of the instrument. As soon as the dilution has been made, the pipette should be shaken for a minute or so, until the mixture becomes of an uniform "laky" tint, which indicates that all the hemoglobin has been dissolved from the corpuscular stroma. The contents of the pipette are blown out into the glass cylinder, which is placed beneath the faucet of the burette, the latter having been previously filled to the mark o with a y^^^ nor- mal solution of tartaric acid. By turning the stop-cock of the burette, the test solution is now added, drop by drop, stirring be- tween each addition, to the measured amount of diluted blood in the cylinder. From time to time a drop of the mixture is re- moved by means of the glass rod and tested with the lacmoid paper, the titration being continued until the reaction, recognized as a bright red halo which forms around the edge of the drop, is DETERMINATION OF RAPIDITY OF COAGULATION. 79 obtained. The titration is then stopped, and a note made of the number of drops of the test solution which have been used. In normal blood the writer finds that from 9 to 1 1 drops are re- quired to give the reaction. The estimate of the total alkaHn- ity of the blood is made by multiplying by the figure 53.3, the number of drops of the tartaric acid solution used, according to the formula, 10 : a : : 533.0 : ;f, ^ representing the drops of the reagent.^ The result thus obtained is expressed in milligrammes per hundred cubic centimeters of blood. The following table may be useful for reference in determining the various degrees of alkalinity : If 6 drops of the solution are used the alkalinity equals 319 mgrms. NaOH 9 10 II 12 13 14 ( ( <( <( (( (( I ( C( (( ( (< <( I ( ( (< (< I (( ( ( ( << ( ( 373 436 479 533 586 639 692 746 After use the pipette should be thoroughly washed out with water, alcohol, and ether, and then dried, in the manner already directed for cleaning the Thoma-Zeiss instrument. While, up to the present time, it cannot be claimed that infor- mation of any real diagnostic pertinence has been obtained from the study of the alkalinity of the blood, this procedure should prove of value in the systematic investigation of many cases, espe- cially those of high-grade anemia. As elsewhere mentioned, the degree of normal blood alkalinity varies greatly according to the particular method by which this figure is ascertained, so that it follows that the results obtained by means of Engel's apparatus cannot be compared with those based upon different methods of research. IX. DETERMINATION OF THE RAPIDITY OF COAGULATION. This procedure is obviously more useful in experimental labora- tory work than as a means of clinical investigation, yet in some diseases, such as hemophilia, it will prove of real value, since in ^Assuming that 0.5 cc. of tartaric acid are used to neutralize 0.05 cc. of blood, therefore for every loo cc. of blood 1,000 cc, or one liter, of a -^-^ normal solution of tartaric acid are required. As the alkalinity of the blood is not expressed by the amount of acid necessary to saturate it, but in milligrammes of an alkali, sodium hy- drate, the calculation is made thus : as the equivalent weight of tartaric acid is 75, and that of sodium hydrate 40, one liter of water dissolving 75 grammes of the for- mer saturates 40 grammes of the latter, that is, one liter of a ^-^ normal tartaric acid solution saturates |§ grammes, or, in other words, 533 milligrammes, of sodium hy- drate, this figure being taken by Engel as the degree of normal alkalinity of the blood. 8o EXAMINATION OF THE BLOOD BY CLINICAL METHODS. this condition it is possible thus to determine the influence of remedies administered with a view to promoting coagulation of the blood. In a number of other pathological conditions, char- acterized either by delay or by unusual rapidity of coagulation, this method of research furnishes information which at least adds completeness to the clinical histoiy, if nothing more. The coagulation time may be determined ap- Glass Slide proximately by collecting several individual drops Method. of blood of the same size upon the surface of a perfectly clean, slightly warmed glass slide. At regular intervals of about one minute a straw of a whisk-broom is o lightly trailed through each drop in succession, until sooner or later a delicate thread of fibrin may be observed clinging to the straw. The period which has elapsed between the deposit of the blood on the slide and the appearance of this indication of clotting is expressed in minutes, to represent the coagulation time of the specimen under investigation. Normal blood thus treated coagulates in from two and one-half to five minutes. This instrument (Fig. 29) consists of a tin Wright's Co- water can surrounded by a flannel-lined leather AGULOMETER. jacket provided with nine pockets, one of which is intended to hold a thermometer, and the others a set of glass coagulation tubes. The latter are each about 10 centimeters in length, with a lumen 0.25 millimeter in diameter, and are open at both ends ; they should be con- secutively numbered or lettered, in order that they may be distinguished apart at a later stage of the test. The thermometer is of the same outer di- ameter as that of the tubes, and registers the same degrees of temperature as an ordinary- clin- ical thermometer. MctJiod of Use. The central receptacle is first filled with water having a temperature of about 99° F., and the tubes slipped into the pockets sur- rounding it, being allowed to remain in them for a few minutes, so that they may become warmed to the temperature of normal blood. Having then pricked the patient's finger, each tube is about half filled with blood, by aspiration, at suc- cessive intervals of one minute, a tube as soon as it is filled being replaced in its appropriate pocket. An equable temperature of the tubes should be maintained by the addition of hot water to the can, as its contents cool. Within three minutes after filling the first Fig. 29. Wright's coagu- LOMETER. SPECTROSCOPICAL EXAMINATION. 8i tube, it should be tested, by blowing out its contents upon the surface of a sheet of white filter-paper, the remaining tubes being similarly tested at regular intervals of one minute or less, until after thus trying a variable number, one is found from which the blood cannot be expelled. Coagulation may then be con- sidered to have occurred, the time required for this process being expressed by the number of minutes elapsing between the filling of the tube in question and the evidence of clotting thus demonstrated. With normal blood the coagulation time, as de- termined by this instrument, ranges from about three to five minutes. After use, a fine wire should be forced through the lumen of the tubes, to dislodge the clots, after which the remaining traces of blood are to be removed by thorough washing with distilled water, alcohol, and ether, in the order named. X. SPECTROSCOPICAL EXAMINATION. For clinical work the Sorby-Beck microspectroscope, to be used in connection with the microscope, is an excellent instrument, being both accurate, and, comparatively speaking, easy to manip- ulate. Other very perfect instruments for the spectroscopical examination of the blood, differing but * little from the original Sorby model, are Fig. 30. also made by Zeiss, by Leitz, and by Browning. This instrument (Fig. The 30) when in use fits into Sorby-Beck the tube of the micro- MiCROSPECTRO- scope, like an ordinary which it is Its essen- A, in which SCOPE. ocular, for substituted. tial part consists of a tube, a series of five prisms, two of flint and three of crown glass, is arranged in such a manner that the emergent rays, which are separated by dispersion, leave the prisms in practically the same direction as that taken by the entering immer- gent ray. At one side of the tube is fixed a right-angle reflecting prism, so that the spectrum of a solution of normal blood may be thrown alongside that of the specimen under investigation, the two spectra thus being comparable. The adjustment of the spectra is effected by means of the two small screws, B, B' . The 6 Sorby-Beck microspectroscope. 82 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. receptacle containing the control solution of blood is clamped to the stage, C, by a spring clip, D, light being reflected through the liquid and into the rectangular aperture, £, by the swinging mirror, F. The width of this aperture is controlled by the screw, G. The receptacle containing the blood solution to be examined is placed upon the stage of the microscope, being brought into focus with a low-power (2,^ or i inch) dr>^ objective. Beneath the tube enclosing the series of prisms is mounted an achromatic ocular, below which a narrow slit-like diaphragm is situated, the vertical size of this opening being regulated by a milled screw, not shown in the illustration, and its breadth by the two small levers, /, /'. Both ocular and prisms may be moved simultaneously toward and away from the diaphragm, by a rack-and-pinion mechanism controlled by the Fig. 31. wheel, /, so that any part of the spectrum may be brought into focus. The liquids to be examined should be placed in Sorby's tubular cells, and cover-glasses super- SORBVT.-BULAR CELL, iinposed. Thcse cells (Fig. 31) are narrow- lumened glass receptacles made of barometer tubing, both ends of which are accurately ground to parallel surfaces, one end being cemented to a small polished glass plate. Method of Examination. The specimen of blood obtained in the usual manner, by puncture, is first diluted with distilled water one hundred times, by means of the Thoma-Zeiss erjthrocy- tometer, and sufficient of this laked blood dropped into a Sorby cell to fill it exactly to the brim. A cover-glass is then carefully laid over the open end of the cell, the precaution being taken to prevent the formation of air-bubbles upon the surface of the column of liquid thus enclosed. A second cell, to be used as the control, is filled with normal blood, similarly diluted, and both are then adjusted in their respective positions, as already explained. In making the examination, a ray of artificial light (that from a Welsbach incandescent burner being most suitable) is projected by the microscope mirror through the lumen of the cell contain- ing the suspected blood, and the surface of the liquid focused with an ordinary ocular. The latter is then removed from the microscope tube and replaced by the spectroscope ocular, and the second spectrum, that of the normal blood, is brought into proper position alongside that of the first, so that any differences between the two may be contrasted by the observer. The appearance of the spectra of normal and of pathological BACTERIOLOGICAL EXAMINATION. 83 blood, together with the circumstances under which the latter occur, have been described in another section. (See page 123.) XI. BACTERIOLOGICAL EXAMINATION. The demonstration of bacteria in the circulating blood, pro- vided that faultless technique is employed, furnishes in some instances a diagnostic sign of the greatest importance. The pathological significance of such a finding is much greater than that of a similar result obtained post-mortem, since with the latter there is no means of determining whether the bacterial invasion of the blood current took place during the active stages of the disease, or whether it occurred either as a pre- or a postagonal process. Cultural methods with blood aspirated directly Methods, from a superficial vein should invariably be used whenever such a procedure is practicable, for blood obtained simply by pricking the skin is most likely to be contaminated with various bacteria which have their normal hab- itat in the epidermis and its appendages, notably by the staphyl- ococcus epidermidis albus. Welch,^ who first drew attention to this source of error, emphasizes the fact that no diagnostic sig- nificance should be attached to the demonstration of this bac- terium in blood obtained by puncture of the skin. Direct examination of stained cover-glass specimens prepared from finger blood gives either negative or erroneous results in the great majority of instances. In certain overwhelming infections, notably in some of the severer forms of bubonic plague, it may often be possible to detect the specific micro-organism in the stained film, but the method must be regarded as too crude and unreliable to furnish accurate findings, in the average case. Blood Cidtures. In order to secure the most reliable informa- tion from blood culturing, the systematic observance of three pre- cautions is essential. First, contamination by the skin bacteria above referred to must be carefully avoided, by the thorough ster- ilization of the patient's skin at and adjacent to the site from which the blood is aspirated. Second, not less than 0.5 cubic centimeter of blood should be used for each culture, since only in rare in- stances are bacteria so numerous in the peripheral circulation as to be demonstrable in a single drop of blood. Third, fluid, rather than solid, culture media should be used, in sufficiently large quantities to dilute the blood freely — about one hundred parts of media to each part of blood — the object of this precaution being ^Dennis' System of Surgery, Phila., 1895, vol. i., p. 251. 84 EXAMINATION OF THE BLOOD BV CLINICAL METHODS. to secure attenuation of the bactericidal properties of the blood, which otherwise might prove strong enough to prevent all bac- terial development. For aspirating the blood the author prefers to use the needle- capped glass tube devised for this purpose by James and Tuttle.' (Fig. 32.) This consists of a piece of glass tubing five inches in length and one-quarter of an inch in diameter, having a capacity oi about two cubic centimeters ; it is tapered at one end and ground to fit the cap of a number 42 hypodermic needle, while the free end of the tube is plugged with a bit of cotton. The ap- paratus is enclosed in a larger glass tube both open ends of which are also plugged with cotton, and sterilized by dr}^ heat, the aspi- rating tube being removed at the time the blood is to be collected. This instrument is far superior to an antitoxin or a hypodermic syringe for the purpose intended, being simple, inexpensive, easily Fig. 32. Needle and tube for aspirating blood for culturing. sterilized, and readily cleaned after use. It is especially well adapted for making cultures at a distance from a laboratory, where the sterilization of an ordinary piston-syringe is difficult, if not impossible. At least six hours before the aspiration of the blood, the skin of the patient's arm at and for some distance on all sides of the bend of the elbow should be thoroughly scrubbed for several minutes with either a strong ethereal soap or with tincture of green soap, after which the part is well rinsed with hot sterile water, and finally washed with alcohol and ether. A moist i : 500 bichloride compress is then applied over the site thus cleaned, being 'left in place until the time of the withdrawal of the blood. As a preliminary to this operation, the dressing is removed, and the part freely douched and scrubbed with hot sterile water, in order to remove eveiy trace of the bichloride. A rubber drain- age tube, previously sterilized, is twisted tightly around the pa- tient's arm above the bend of the elbow so as to cause disten- tion of the superficial veins in this situation, and the point of the needle is then thrust obliquely into the most prominent of these ^Med. and Surg. Reports of the Presbyterian Hosp., N. Y., 1898, vol. iii., p. 46. BACTERIOLOGICAL EXAMINATION. 85 vessels, with the result that the blood immediately begins to flow into the bore of the instrument. If, for any reason, the force of the blood flow should fail to fill the caliber of the tube, sufficient blood may be easily obtained by making gentle suction through a bit of rubber tubing slipped over the cotton-plugged end of the instrument. While introducing the needle it should be held almost parallel to the long axis of the vein, for should it be simply plunged into the vessel at right angles, there is danger that the point will pass completely through the vessel from wall to wall and penetrate the surrounding tissues — an accident which may explain the cause of many a " dry-tap." The site of the as- piration may be made anesthetic by preliminary freezing with a spray of ethyl chloride, but to most patients the operation is not painful enough to necessitate such a procedure. Having thus collected, say, two cubic centimeters of blood, the contents of the tube are divided equally among four Pasteur flasks each containing at least fifty cubic centimeters of broth or other suitable fluid culture media. The flasks are then shaken for a few moments, in order to mix the blood and media and to dilute thoroughly the former, after which they are placed in an incu- bator. The identity of the growths, should any occur, remains to be determined by secondary culturing and microscopical ex- amination, for descriptions of which the student should consult text-books on bacteriology. Cultures made by this technique, suggested by Adami,^ are much more favorable to the growth of any bacteria which may be in the blood-stream than the older methods of using solid media. Staining Methods. In the limited number of instances to which such methods are applicable the technique described below will be found useful. An attempt should be made to sterilize the skin of the finger from which the blood is obtained, by thoroughly scrubbing the part first with ethereal or green soap, and then with a 1:500 bichloride solution, alcohol and ether, in the order named, this being followed by sponging with sterile water. A deep punc- ture having been made with a needle which has been sterilized by the naked flame, and the first few drops of blood escaping from the wound allowed to drip away, one of the succeeding drops is transferred by means of a sterile platinum needle to the surface of a cover-glass upon which a second cover-glass is at once laid, the two being drawn apart, in order to secure a pair of spreads. The latter are immediately dried by gentle heat and then passed several times through a Bunsen flame. It is ^Journ. Am. Med. Assn., 1899, vol. xxxiii., p. 15 14. 86 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. needless to add that the cover-glasses used for making the films must be sterilized by heat, and handled by means of a pair of sterile forceps. Films thus prepared may be stained with any of the basic aniline dyes (thionin, methylene-blue, and methyl- or o-entian-violet being most useful for this purpose), after which they are washed in water, dried, and mounted in Canada balsam or in cedar-oil. Should a double stained specimen be desired, one of the eosin and methylene-blue solutions referred to previously may be depended upon to give satisfactory results. Giinther's method^ will be found useful, if the object is to de- stroy the color of the erj^throcytes, so as to leave a freer field of vision for any bacteria which may be present in the film. Ac- cording to this method, the specimen is first immersed for ten seconds in a five per cent, aqueous solution of acetic acid, until the tint of the hemoglobin has entirely faded away, after which the reagent is removed by briskly blowing upon the surface of the cover-glass ; the latter is then held, face downward, over the open mouth of a bottle containing strong ammonia water, so as to neutralize all remaining traces of the acid. The film is now stained for twenty-four hours with the Ehrlich-Weigert fluid (contained in a covered staining dish), at the end of which time it will be found to be colored a deep blue. It is then decolorized by a few seconds' immersion in a 1:14 aqueous solution of nitric acid, until the color fades to a light green ; rinsed in alcohol ; dried in air ; and mounted in balsam. The Ehrlich-Weigert fluid is prepared by adding from 10 to 15 drops of aniline oil to 6 cubic centimeters of distilled water, held in a test-tube. The fluid is thoroughly mixed by shaking, and then filtered. To the filtrate a few drops of a con- centrated alcohoHc solution of methyl- or gentian-violet is added — just sufficient of the dye to produce a slight turbidity of the liquid, which clears up in a few minutes. The mixture prepared in this manner is employed as the staining agent. XIL DETERMINATION OF THE SERUM REACTION. In 1894 Pfeiffer^ noticed that the vibrios of Widal's Asiatic cholera, if injected into the peritoneal Test. cavity of a guinea-pig immunized against this disease, rapidly lost their characteristic motility, and tended to become granular, broken up, and dissolved, while iForschr. d. Med., 1S85, vol. iii., p. 775. 2Zeitschr. f. Hvg., 1894, vol. xviii., p. I. Ibid., 1895, vol. xix., p. 75. Also, Centralbl. f. Bakt. u. Parasitenk., 1896, vol. xix., p. 191. Also, Deut. med. Woch., 1896, vol. xxii., p. 97. DETERMINATION OF THE SERUM REACTION. 8/ in the healthy, non-immune animal they developed normally and abundantly, and failed to show any such changes in their mor- phology. He claimed that this reaction, known as ** Pfeiffer's phenomenon," was specific, and emphasized its value as a means of laboratory differentiation. Two years later Pfeiffer and KoUe ^ found that the same changes occurred in experiments with the bacillus of Eberth and animals rendered immune to enteric fever, and, furthermore, discovered that the test could be conducted in vitro, by mixing in a test-tube typhoid cultures and immune serum. It is of interest to note that results somewhat analogous to those of Pfeiffer had been observed in 1891 by Metchnikoff,^ and in 1889 by Bordet,^ and by Charrin and Roger,^ although none of these workers appeared to recognize the significance of their observations. In 1896 Griiber and Durham^ applied the principles of Pfeif- fer's phenomenon to many other motile as well as non-motile bacteria, deduced new facts regarding its utility as a means of differentiating various species of germs, improved the technique of the test, and made the important announcement that aggluti- nation and immobility of typhoid bacillus cultures were pro- duced by the action of blood serum from a patient having re- cently recovered from an attack of enteric fever. It remained, however, for Widal,*^ in 1896, first to apply the reaction clinically, and to announce that enteric fever could be diagnosed by noting the clumping and immobihzation of the typhoid bacillus when mixed in definite proportions with blood serum from a patient suffering from typhoid. This reaction, Widal insisted, was one of infection, and was demonstrable not only during convalescence, but during the incipiency and the height of the disease. The serum reaction is to-day recognized as an important sign in the diagnosis not only of enteric fever, but also of Asiatic cholera, of Malta fever, and of relapsing fever, while its value still remains less certainly established in many other conditions, such as, for example, leprosy, tuberculosis, yellow fever, bubonic plague, and pneumococcus infections. The technique of the test and its diagnostic significance under various circumstances, will 1 Zeitschr. f. Hyg., 1896, vol. xxi., p. 203. Also, Deut. med. Woch., 1896, vol. xxii., p. 735. 2Annal. de I'lnstitut Pasteur, 1891, vol. v., p. 473. Ibid., 1894, vol. viii,, p. 714. Ibid., 1895, vol. ix., p. 433. ^Annal. de I'lnstitut Pasteur, 1895, vol. ix., p. 462. Ibid., 1896, vol. x., p. 191. ^ Compt. rend. Soc. Biol., 1889, 9 s., vol. i., p. 667. sMiinch. med. Woch., 1896, vol. xliii., p. 285. 6 Bull, med., 1896, vol. x., pp. 618 and 766. Sem. med., 1896, vol. xvi., p. 259. Ibid,, 1897, vol. xvii., p. 69. Lancet, 1896, vol. ii., p. 1371. Miinch. med. Woch., 1897, vol. xliv. , p. 202. 88 EXAMINATION OF THE BLOOD BY CLINICAL METHODS. be described under the headings of the diseases in which it occurs. (See " General Hematology.'') Originally Bordet/ more recently Uhlenmuth,- The Specific and Wassermann and Schutze'^ have demon- Test for strated the important fact that the blood serum Human Blood of an animal subcutaneously injected with the blood of another animal of a different species rapidly develops the property of agglutinating and dissolving the er^^throcytes similar to those injected, but has no effect upon blood derived from any other source. The last-named ob- servers, for example, administered to rabbits, at intervals of two days, several subcutaneous injections of lo cubic centimeters each of defibrinated human blood, the animals being bled to death six days after the last dose, and their shed blood placed upon ice, to effect separation of the serum. Sufficient blood for this purpose may be readily obtained by wet-cupping, leeching, or placental expression. If 0.5 cubic centimeter of this rabbit- serum (or ''antiserum" for human blood) is added to a solution of the blood of man, diluted about one hundred-fold with distilled water or with normal salt solution, a distinct cloudy precipitate rapidly occurs at ordinary room temperature, the turbidity be- coming much more dense after brief incubation of the mixture at ^y^ C. On the contrary, no definite change occurs on the ad- dition of the serum to the diluted blood of other animals, no less than twenty-three different species having failed uniformly to react positively, with the single exception of the monkey, and in this instance the reaction was delayed and incomplete, being in no way comparable to the prompt cloudiness produced by the mixture of human blood with its antiserum. Old dried, and even putrefied blood, diluted i to 100 with normal salt solution, has been found to react typically, while Nuttal and Dinkelspiel ^ have re- ported characteristically positive results with human blood mixed with an equal volume of the diluted blood of different animals, such as sheep, oxen, horses, and dogs. These workers also found that positive results were obtained with human nasal and lachr)'mal secretions. Uhlenmuth ^ discovered that blood specimens could be frozen for two weeks at a temperature of 10° below zero, C, without in any way affecting the sensitiveness of the reaction, and that blood mixed with soapy water, menstrual urine, and other contaminating liquids responds promptly and typically. ^Annal. de I'lnstitut Pasteur, 189S, vol. xii., p. 688. Ibid., 1899, vol. xiii., p. 273. 2 Deut. med. Woch., 1901, vol. xxvii., p. 82. 3Berl. klin. \Voch., 1901, vol. xxxviii., p. 187. ••Brit. Med. Journ., 1901, vol. i., p. 1141. ^Loc. cit. DETERMINATION OF THE SERUM REACTION. 89 From a medico-legal standpoint, the value of this test is ob- vious, for, even at this early stage of its development, it has received sufficient corroboration to justify its use as a means of identifying human blood stains, no matter how old and how contaminated they may be. For this purpose, the reaction ap- pears to be entitled to much greater confidence than the spec- troscope, or chemical tests. SECTION II. THE BLOOD AS A WHOLE. SECTION II. THE BLOOD AS A WHOLE. I. GENERAL COMPOSITION. Blood is a tissue consisting of fluid and cor- Plasma, Serum puscular elements, the former constituting about AND Cells, three-fifths, and the latter two-fifths of its total volume. It has been approximated that the total quantity of blood in the normal individual is from yL to -^j of the body-weight, the proportion being somewhat less in the infant than in the adult. The fluid element of the blood, known as the plasma or liquor sanguinis, is an alkaline, yellowish liquid, of a specific gravity ranging from about 1026 to 1030, and con- taining approximately ten per cent, of solid matter, of which three-fourths are proteids ; the latter consist of fibrinogen, serum-albumin, and serum-globuHn. Coagulation of the blood results in its separation into a densely reticulated, somewhat granular substance, fibrin, and into a clear, straw-colored, alka- line fluid, serum. Fibrin is a sparingly soluble, highly elastic, proteid body, which encloses and imprisons within its multitude of delicate fibrils the corpuscular elements, the whole forming the blood-clot or crassamentum. Serum is a clear, straw-colored, alka- line fluid, having a specific gravity of about 1026 and containing practically the same amount of solids and relative proportion of proteids as are found in the plasma ; its proteid constituents are fibrin-ferment, which replaces the fibrinogen of the plasma, serum- albumin, and serum-globulin. The corpuscular elements of the blood are free cellular bodies suspended in the plasma. They are of two varieties : the eryth- rocytes or red corpuscles, and the leucocytes or ivhite corpuscles. In addition to these cells, two other elements are also found, namely, the blood-plaques, and the hemoconia, although these bodies, while they may be conveniently grouped with the red and white cells, are not to be regarded as definite corpuscular entities. The salts of the blood include sodium chloride, potassium chloride, sodium carbonate, sodium phosphate, magnesium phos- phate, calcium phosphate, and sulphates ; of these salts sodium chloride is the most abundant, constituting from 60 to 90 per cent, of the total amount of mineral matter. 94 THE BLOOD AS A WHOLE. Certain extractives are also found, among which are urea and uric acid, creatine, creatinine, xanthine, hypoxanthine, sugar, fats, soaps, and cholesterine. The gases of the blood consist of oxygen, nitrogen, and carbon dioxide, the former existing chiefly in combination with hem- oglobin in the er>'throcytes, and the latter as carbonates ; the nitrogen is held in simple solution. About 60 volumes of gas are contained in each 100 volumes of blood. Arterial blood contains roughly 20 volumes of oxygen, and 40 of carbon dioxide, while venous blood contains less than 10 volumes of oxygen, and almost 50 of carbon dioxide ; the quantity" of nitrogen in both arterial and venous blood is from i to 2 volumes. II. COLOR. The distinctive color of the blood is due to Normal the presence of the hemoglobin contained in the VARLA.TIONS. erj'throcytes, and alterations in the chemical com- position of this pigment produce corresponding changes in the color of these cells, and, consequently, in the naked-eye appearance of the whole blood. The color of arte- rial blood is bright scarlet, inasmuch as it contains a large amount of oxj^'gen in chemical combination with the hemoglobin ; while venous blood, on the other hand, is of a dark purplish-blue tint, owing to its deficiency in oxygen and to the presence of more or less uneliminated carbon dioxide. This difference in color is so obvious that a cursory glance suffices to distinguish arterial and venous bloods. The presence of immense numbers of hemo- Density globin -containing elements accounts for the vary- AND ing degree of density and opacity which the Opacity. blood possesses, distinguishing it from a mere transparent, colored fluid. If, for any reason, the hemoglobin escapes from the erythrocytes into the surrounding plasma, this characteristic opacity is quickly lost, and the blood becomes transparent, and of a " laky " color. The density and the opacity, and, consequently, the color of the blood increases and diminishes according to the fluctuations which occur in the relative amounts of plasma and erythrocytes, and also according to the cells' richness in hemoglobin, irrespective of their numerical variation. In anemic conditions the blood is usually pale Pathological in color, somewhat transparent, and thin and Variations. water>^-looking. This is the case particularly in primary peniicioiis anemia, in chlorosis, and in Iciikeinia ; in the former disease, it is sometimes difficult to believe REACTION. 95 that the watery, pale fluid which flows from the puncture is any- thing but pure serum ; in leukemia, the blood drop may have a peculiar light, mottled, streaked appearance, or an uniform milky- white tint may predominate over the normal red hue. In cases of dyspnea, arterial blood, because of its inadequate oxygenation, may be dark blue, closely resembling blood from the veins. This similarity has also been noted in cases of poisoning by sulphur- etted hydrogen, in which condition the blood may even be changed to a dark greenish tint. In some cases of diabetes mellitus, the presence of large quantities of free fat in the circulation seem- ingly divides the blood drop into two distinct layers, an upper, light-colored portion, containing supernatant fat-droplets, and a lower, darker layer of pure blood ; at first glance diabetic blood has a somewhat pinkish hue. In poisoning by aniline, nitrobenzol, hydrocyanic acid, and potas- sium chlorate, the blood is chocolate- or dun-colored ; and in poisoning by carboji monoxide, bright cherry- red. In severe icterus a yellowish-red tint of the blood has been observed. III. ODOR AND VISCOSITY. Owing to the presence of certain volatile fatty acids, blood possesses a peculiar and characteristic odor or halitus, which may be intensified by the addition of concentrated sulphuric acid, and which rapidly disappears after the withdrawal of the blood from the body. The slippery feeling of freshly drawn blood is quickly lost after its exposure to the atmosphere, and is replaced by a viscosity or stickiness, as coagulation progresses. IV. REACTION. Under normal conditions, the reaction of the Reaction blood is alkaline, owing chiefly to the presence IN Health, of sodium carbonate and disodium phosphate. Clinically, the degree of alkalinity is determined by ascertaining the amount of sodium hydroxide which is ex- actly neutralized by one hundred cubic centimeters of blood, the result being usually expressed in milligrammes of NaOH per hundred cubic centimeters of blood. The figures given by differ- ent investigators as representing the normal alkaHnity range within the widest limits, chiefly in consequence of the many dif- ferent methods by which such data were obtained. In view of these marked discrepancies, the alkalinity figures of different workers are in no sense comparable unless they are based upon precisely similar methods of investigation pursued with identical 96 THE BLOOD AS A WHOLE. technique. The following table, compiled from reliable data, il- lustrates the range of the normal blood alkalinity, as estimated by various observ^ers : Observer. Degree of Alkalinity. Kraus 162-232 mgrms. NaOH per loo cc. of blood. Burmin 182-218 " " «' " " " Rumpff. 182-218 " " " '' " " Jeffries 200 " " " " " " Freudberg 200-240 " " " " " " Lepine 203 «' " " " " " Canard 203-276 " " *' " " " Drouin 206 " " " " " " Von Limbeck 218 *' «* '' " " " Zuntz and Lehmann 240 " " *' '* " " Von Taksch 260-300 '' *' " " " '* Schuitz-Schultzenstein 260-300 " " «' " " " Strauss 300-350 " " " " *' " Brandenburg..... 330-370 " " " " " ** Lowy 449 " " " " " " Berend 450-500 " " " " " " Engel 479-533 " " " " " " Mya and Tassinari 516 *' *' " *' " " • With the titration method, now generally admitted to furnish fairly accurate results, appreciably higher figures are obtained with laked whole blood than with serum alone, since by the former method the alkalinity of all the plasma and cellular ele- ments is estimated, while by the latter the influence of the cor- puscles is entirely eHminated. The alkalinity of the blood is slightly higher, Physiological as a general rule, in 7He/i than in zvoinen and Variations, children, and is somewhat influenced by the time of day, being at its minimum during the early morning hours, gradually rising during the afternoon, and falling aeain during; the eveninor. Some observers maintain that it is increased during the pcj'iod of digestion, but this fact is dis- puted by others. It is temporarily diminished by the effects of muscidar exercise, and by a diet deficient in yiitrogenotis substances ; on the contrary, richly nitrogenous food eaten during the per- formance of muscular work overcomes the effect of such exertion in lowering the alkalinity. The effects of cold baths are said to increase the alkalinity of the blood. In health, by the perfect mechanism of the emunctoiy organs of the body, the normal balance of blood alkalinity is constantly maintained, in spite of the entrance of acids into the blood, whether by the ingestion of acid substances, or by their produc- tion within the system, for the excess acidity from such causes is promptly removed from the blood by the action of the kidneys, REACTION. 97 the skin, and the lungs. Thus, the ingestion of acids is quickly followed by increased acidity of the urine and sweat, while at the same time an increased quantity of carbon dioxide is given off by the lungs. It is also probable that the tendency to acidity is partly neutralized by the ammonium salts generated from proteid foods, and by the action of the liver. Increased alkalinity goes hand in hand with increased aritidotal action of the blood against bacterial infection, as experiments have shown that animals whose blood had been artificially rendered highly alkaline, by the administration of sodium salts, showed much greater resistance to the effects of virulent micro-organisms, than untreated animals. Therefore, it is believed that the power of immunity against infections may, to a certain degree, be meas- ured by the alkalinity of the blood, for, in animal experimenta- tion, the fact is evident that the greatest degree of blood alka- Hnity is found in animals whose immunity is absolute. Unfortunately, the question of alteration in the Tathological alkalinity of the blood in various pathological Variations, conditions is at the present time one about which the opinions of different observers conflict, so that conclusions concerning this subject must be accepted with more or less reserve. It is of interest, however, to note that most observers agree that, as a rule, the alkalinity of the blood is perceptibly lowered in those diseases associated with 2. febrile movement, but no definite relation between the intensity of the pyrexia and the degree of lessened alkalinity has been established. Subnormal alkalinity figures have also been met with in the/rz;;^<2r;/and secondary ane- mias, with the exception of chlorosis, in which condition the blood alkalinity usually is either normal, or perhaps slightly increased. Desevres ^ has drawn attention to the fact that in the early stages of acute diseases the alkalinity is either normal or somewhat in- creased, and in the majority of instances it becomes perceptibly diminished during convalescence. In chronic diseases it is usu- ally decreased if the duration of the disease has been of long standing. Drouin ^ found a lessened alkalinity of the blood in enteric fever, in pneumonia, in malarial fever, in diphtheria, in rheumatic fever, in erysipelas, in appendicitis, and in many other acute infec- tions. Cantani ^ maintains that in the algid stage of Asiatic chol- era the reaction of the blood during life in some cases may be ^ These de Lyon, 1897-98. 2 " Hemo-alcalimetrie et Hemo-acidimetrie, " These de Paris, 1892, n. 83. ^Centralbl. f. d. med. Wissensch., 1884, vol. xxii., p. 785. 7 98 THE BLOOD AS A WHOLE. even acid, and that the alkalinity is always markedly reduced. Von Jaksch/ Peiper,- Kraus,^ and others state that the alkalinity is generally diminished in uremia, in diabetes, in osteomalacia, in organic diseases of the liver, and in poisoning by caj'bon mon- oxide and by phosphorus, especially by the latter. Decreased alkalinit>^ has also been noted in choleinia, in Addison' s disease, in Hodgkin' s disease, in poisoni7ig by mineral acids, in the late stages of malignant neoplasms, and in various long-standing cachectic conditions. Thomas ^ found the alkalinit)' reduced in acute alcoholis?n, and as the result of chloroform narcosis. Tchle- norff^ found a diminished alkalinity in a wide variet}" of skin diseases, among which are named psoriasis, eczenia, pemphigus, purpura hemorrhagica, eyythema midtifoi-me, lichen rubra, and elephantiasis. Since it was also found that the administration of arsenic failed to increase the blood alkalinity', the action of this drug upon dermatoses is evidently not due to its influence upon the blood. In organic diseases of the heart unassociated with pyrexia, and in nervous diseases the alkalinity of the blood has been found to be increased. In chronic rheumatism, and in renal lesions unac- companied by uremic symptoms the reaction of the blood is usu- ally found to be unaltered. V. SPECIFIC GRAVITY. In the majority of healthy male adults the Normal specific gravity of the blood varies from 1055 to R.\NGE. 1065, the average being in the neighborhood of 1060. In ivomen the average is somewhat less, about 1056; in children it is about 105 1, and in neiv-born i?ifa?its 1066 is considered normal. Diurnal variatiojis in the specific gravity have been noted, but these fluctuations are slight and unimportant. The blood densit)' of habitual dwellers in high alti- tudes is distinctly increased. Venous blood is said to be of slightly higher specific gravity than arterial. The average specific gravity of the blood of the two sexes, as determined by the principal ob- servers, is as follows : * Deut. med. Woch., 1893, vol. xix., p. 10. ^Archiv. f. Pathol. Anat., 1889, vol. cxvi., p. 337. 3Zeitschr. f. Heilk., 1889, vol. x., p. 106. * Archiv, f. exper. Pathol, u. Pharm., 1898, vol. xli., p. I. 5 Vratch, 1898, vol. xix., p. 248. Abst., Joum. of Cutan. and Genito-Ur. Dis., 1898, vol. xvi., p. 544. SPECIFIC GRAVITY. 99 Authority. Males. Females. Askanazy, 1060. I 1056.4 Schmidt, 1060 1050 Hammerschlag, 1061.5 1057-5 Lloyd Jones, 105S.5 1051-5 Landois, 1057.5 1056 Becker, 1057 1056.5 Schmaltz, 1057 1056 Peiper, 1055 1053 From a clinical standpoint, the specific gravity Pathological of the blood may be regarded, within certain Variations. Hmits, as a tolerably accurate index to the corpuscular richness of this tissue, and to the hemoglobin equivalent of the erythrocytes, since fluctuations in these constituents immediately give rise to corresponding altera- tions in the density of the blood-mass. It follows, then, that in the various conditions of anemia, characterized by corpuscular and hemoglobin losses, low specific gravities are encountered ; on the other hand, it is also obvious that in conditions of polycy- themia, the cellular increase and the high hemoglobin equivalent are mirrored by the corresponding rise in the density of the blood. An increase promptly follows any sudden drain upon the fluids of the system sufficient to cause inspissation of the blood, such as may result from copious diarrhea, free sweating, or hyperemesis ; while the density is at once lowered as the re- sult of sudden dilution of the blood, following, for example, the injection of a large quantity of saline solution, or even the inges- tion of a large volume of liquid. Fluctuations in the specific gravity of the blood under such circumstances, which are purely physiological in character, are invariably of transient duration, for the normal relation between the relative volumes of corpuscles and plasma becomes quickly reestablished by means of the liquid interchange between the tissues and the blood-vessels. Owing to the fact that in most instances a close relationship exists between the amount of hemoglobin and the specific gravity, some investigators are accustomed to take this parallelism as a basis for calculating the percentage of hemoglobin in the blood. Thus, by determining the specific gravity, and by comparing the figure thus obtained with a table giving the hemoglobin equiva- lents corresponding to varying degrees of blood density, fairly ac- curate results have been obtained. The following hemoglobin equivalents of different specific gravities of the blood have been determined by Hammerschlag,^ and by Lichty.^ ^ Loc. cit. 2Phila. Med. Journ., 1898, vol. ii., p. 242. 100 THE BLOOD AS A WHOLE. Hammerschlag. specific gravity. Hemoglobin equivalent. 1033-1035 25-30 per cent. 1035-1038 30-35 1038-1040 35-40 1 040-1 045 40-45 1045-1048 45-55 1048-1050 55-65 1050-1053 65-70 1053-1055 70-75 1055-1057 75-85 1057-1060 85-95 ICHTY. Hemoglobin equi valetit. 25-30 per cent. 30-40 '' ' • 40-45 '' 45-50 '' 50-55 " 55-65 '' 65-70 '' 70-75 '' 75-85 '' 85-95 '' 95-100 '' the variations in Specific gravity IO35-I038 1038-1043 IO43-I045 I045-I047 I047-1049 I049-I052 I052-1054 I054-I056 I056-1060 1060-1063 I063-1065 It will be noted that in both these tables the gravit}^ are somewhat greater in high than in low hemoglobin percentages. It has been stated by Diabella ^ that, on the aver- age, a difference of 10 per cent, in hemoglobin corresponds to 4.46 parts per thousand in specific gravity : and that differences amounting to from 3 to 5 parts per thousand in the specific grav- ity may arise from the influence of the stroma of the erythrocytes, in blood characterized by a striking disturbance in the parallelism which normally exists between these cells and the hemoglobin. In the clinical application of this indirect method of computing hemoglobin percentages, several conditions, in which factors other than the presence of hemoglobin in the erj'throcytes influence the specific gravity, must be excluded. In leukemia, for example, it will be found that hemoglobin percentages based on the above tables are much higher than actually exist, the cause of this fal- lacy being the presence of enormous numbers of leucocytes in the blood ; in pernicious anemia the hemoglobin is frequently higher than thei specific gravity indicates, for in this disease the individ- ual corpuscles are much richer in hemoglobin than normal ; and in conditions associated with extensive dropsy the hemoglobin percentage does not parallel the specific gravity, owing to the abnormally high proportion of fluids in the blood mass. These three sources of error, aside from the rather tr}'ing tech- nique by which one must first determine the specific gravity' of the blood drop (see page 75), are sufficient to make most work- ers reluctant to adopt this method as a substitute for the hemom- eter. VI. FIBRIN AND COAGULATION. The essential factor of coagulation of the blood is the forma- tion of fibrin, a proteid substance, produced in the plasma, after ^ Deut. Archiv. f. klin. Med., 1S96, vol. Ivii., p. 302. FIBRIN AND COAGULATION. lOI the withdrawal of the blood from the body, by complex chemical changes occurring between the soluble calcium salts and the nucleo-proteids of the blood, with the consequent production of a fibrin ferment. The theories regarding coagulation are numer- ous, conflicting, and unsatisfactory, and must necessarily remain disputed points until our present uncertain knowledge of the chemistry of the blood proteids becomes fuller and more definite.^ In the examination of a slide of fresh blood, fibrin appears as extremely delicate, straight, filamentous lines which cross and recross the field in every direction. It forms a network of fine, interlacing, fibrillary bands, in the clear areas of the serum inter- vening between the masses of corpuscles, some of the fibrin Normal blood. Showing rouleaux formation and fibrin network. threads apparently radiating from centers consisting of small irregular masses of blood-plaques. The relation of these islands of blood-plaques to coagulation and fibrin formation, if, indeed, any exists, is undetermined. Petrone^ considers that the plaques inhibit rather than promote these two processes. 'Schafer's "Text Book of Physiology," vol. i. , Edinburgh and London, 1898, contains a complete exposition of the various theories of coagulation of the blood exist- ing up to the present time. 2 Morgagni, 1897 ; n. 5 and 6. 102 THE BLOOD AS A WHOLE. In normal blood the formation of the fibrin Hyperinosis network becomes apparent within two or three AND minutes after exposure of the blood to the air, Hypinosis. and the process is completed within seven or eight minutes. In certain pathological condi- tions, however, both the length of time required for its formation and the density of the network varies. An increase in the amount of the fibrin network is spoken of as hyperinosis, while a decrease in fibrin is termed hypinosis. In general terms, it may be stated that fibrin Pathological is increased in acute inflammatory^ and infectious Varlations. diseases, especially in those attended by an ac- tive febrile movement and by exudative proc- esses, the amount of fibrin roughly corresponding to the intensity of the process. This statement is made with certain reserva- tions, for the rule does not hold true in all such instances, as is noted below. All febrile states do not, however, imply a fibrin- increase, for none is found in the fevers associated with grave cases of chlorosis and of pernicious anemia. Hayem ^ suggests Fig. 34. Hyperinosis. Showing marked increase in the tensity of fibrin network. that the density of the fibrin network may be taken as an indica- tion of the individual's resisting powers against disease, inasmuch as it appears to be more marked in the blood of the vigorous than 1 " Du Sang," etc. Paris, 1889. OLIGEMIA. 103 of the feeble. In acute inflammations, accompanied by serous and purulent exudates, a dense fibrin reticulum is observed, the extent of the exudation being in a degree measured by the density of the network. Fibrin is increased to a slighter extent in parenchymatous inflammations, in inflammations of the mucous membranes and skin, and in the febrile stages of chronic suppurations. Among the diseases which are associated with an increase in fibrin are the following : abscess, pneumonia, rheu^natic fever, erysipelas, acute gout, severe angina, bronchitis, i^ifluenza, diphtheria, pleurisy, peritonitis, peiicarditis, hepatitis, meningitis, acute gastritis, enteritis, cystitis, vaginitis, pustidar stage of variola, and suppurating tuberctdous cavities. Fibrin is not increased in malignant neoplasms, enteric fever, malarial fever, tuber- cidosis, per7ncious anemia, leukemia, chlorosis, and purpura. In parenchymatous nephritis it is but slightly increased, if at all, while in interstitial nephritis the increase may be notable. Pfeiffehr^ declares, as the result of his investigations, that in all diseases in which an increase of fibrin exists inflammatory leucocytosis is also present, and that he has never been able to demonstrate hyperinosis without coexisting increase in the number of leucocytes. But leucocytosis does not invariably imply hyper- inosis, although the two conditions almost always go hand in hand, for leucocytosis may occur in malignant disease unattended by fibrin increase ; on the other hand, in influenza the fibrin net- work is denser than normal, while the number of leucocytes is not increased. VII. OLIGEMIA. The term oligemia signifies a reduction in the total volume of the blood, involving a diminution of both the liquid and the cel- lular portions. It occurs most conspicuously after hemorrhage, and probably after this accident only. Sometimes the hemorrhage having been profuse, the oligemia proves rapidly fatal ; but in other instances, where the hemorrhage has been less extensive, the decreased volume of blood is slowly made up, first by a rapid osmosis of serum into the depleted capillaries from the neighbor- ing lymph spaces, and later by a slower numerical increase of the cellular elements, the products of an actual manufacture of erythrocytes by the blood-making organs. In some of the advanced cachectic states, in which profound adynamia and poor nourishment of the body are prominent clin- ical manifestations, there is seemingly good reason for believing in the existence of a true oHgemia ; but in the absence of con- iZeitschr. f. klin. Med., 1897, vol. xxxiii., p. 215. 104 THE BLOOD AS A WHOLE. firmatory evidence, reduction of the blood- volume in this class of cases must remain rather a suspicion than an accepted fact. The term oligemia is, therefore, in the light of our present understand- ing, applicable only to blood losses resulting from hemorrhage. VIII. PLETHORA. The term plethora is currently used to express a condition characterized by an actual excess in the total volume of the blood, affecting both the liquid and the cellular elements. According to the views of many of the older and a few of the modern path- ologists, a true polyemia, or an increase in the blood volume, un- accompanied by any qualitative changes, is thought to exist in certain individuals whose mode of life and luxurious habits are supposed to predispose and give rise to excessive blood-forma- tion. The compatibility between a real fuU-bloodedness and a **high-Hver" was formerly much more generally credited than at the present time, and the association of such signs as a rich, ruddy complexion, enlargement of the superficial blood-vessels, and a full, bounding pulse was depended upon for the recognition of this condition. Of late, however, the drift of opinion is against the probability of any such permanent increase in blood volume, but until an accurate method of estimating the total quantity of blood in the body has been devised, the presence or absence of a real plethora must obviously remain conjectural. True plethora may occur as a transitoiy condition, as the re- sult of the direct transfusion of blood, or the mechanical forcing back into the general circulation of a quantity of blood from a part to be removed from the body, as by the use of an Esmarch rubber bandage previous to the amputation of a limb ; in a similar manner, a new-born infant may become temporarily plethoric by a complete emptying of the placenta before tying the umbilical cord. Plethora resulting from any of these influences is invari- ably of a transient character, for the physiological balance of the organism rapidly disposes of the surplus amount of blood, by de- struction of the excess amount of cellular elements and by the elimination of the liquid portions. Serous plethora may be defined as an increase in the volume of blood due to excessive quantities of its liquid and saline con- stituents, without augmentation in the number of its cellular elements. A condition of this sort may be dependent upon the ingestion of large amounts of liquids, upon the transfusion of saline solutions, or upon vaso-motor dilatation, whereby the transfer of an unduly large amount of liquids from the tissues to the blood- HYDREMIA. IO5 vessels is promoted. In organic lesions of the kidneys and of the heart, with diminished elimination of water from the system, a serous plethora of more or less chronicity may develop. The condition, however, is usually of transient duration, as the surplus liquids in the circulatory system are quickly disposed of, and the blood volume reduced to normal, by intracapillary transudation. Cellular plethora is a term which may appropriately be applied to the condition also known as polycythemia^ consisting in an in- crease in excess of the normal standard in the number of erythro- cytes. The circumstances under which this change occurs will be discussed later. (See page 149.) IX. HYDREMIA. A relative increase in the quantity of liquid constituents of the blood is known as hydremia. This condition must not be con- fused with serous plethora, which is characterized by both a relative and absolute increase in the liquids of the blood. The specific gravity of the blood is observed to fall in relation to the degree to which the change develops. Hydremia may be produced by any factors which disturb the normal relations between the cellular and the liquid elements of the blood, so that the latter are unduly increased. In other words, the blood is diluted, in consequence of which a given drop of such blood shows an apparent decrease in the number of cel- lular elements, although the latter are in reality unaffected by the change. Hydremia is observed after extensive heuiorrhages, in which the primary effect of the oligemia is the taking up by the capillaries of an excess of tissue-fluids, to replace the blood loss ; later, as blood-formation gradually makes up for the cellular deficiency, the normal ratio between the corpuscles and the plasma is reestablished. Hydremia may also occur as the result of the ingestion of large amounts of liquids, after the injectio?i of normal saline sohitioji, and as a consequence of vaso-motor dilatation. The watery constituents of the blood are relatively increased in certain of the severe anemias, owing to the deficiency of corpus- cular elements, which is compensated by fluids derived from the tissues. In some dropsical conditions, notably those associated with renal and cardiac lesions, hydremia may also be said to exist, either with or without anemia. Hydremia, while it does not necessarily imply the coexistence of anemia, is naturally often an accompaniment of the latter condition. Hydremia dependent upon such physiological factors as inges- tion of fluids and vaso-motor dilatation is a transient condition, for I06 THE BLOOD AS A WHOLE. the excess amount of fluid is promptly eliminated, and the normal relations restored. In other conditions the duration of the change obviously depends upon the nature and permanency of the etiolog- ical factor or factors. X. ANHYDREMIA. Ajihydremia is a condition in which a relative diminution in the liquid constituents of the blood occurs, as the result of rapid osmosis from the capillaries into the surrounding tissue. Inas- much as the cellular elements do not share in this draining-away, their number is necessarily increased in a given drop of such con- centrated blood. The specific gravity of the blood increases in relation to the severity of the fluid drain. Conditions which cause the sudden dissipation of large quanti- ties of liquids from the body, in consequence of hyperactivity of the mucous and serous surfaces, are the most prominent factors in producing anhydremia. Thus, after profuse diarrheas, urinary crises, free szveatvig, excessive vomiting, and sudden and exten- sive pleural and peritoneal effusions the blood becomes concen- trated from a temporary loss of its fluid elements, which pass from the vessels into the tissues to replace the Hquids lost in consequence of the drain, Oliver^ has shown also that a moderate degree of anhydremia may arise as the result of various influences which cause an in- crease in arterial tension, and a consequent acceleration in the transfer of water from the vessels into the tissues. For example, the change has been brought about by the influence of local and general exercise, far'adism, massage, cold bathing, and the admin- istration o{ snpra-renal extract. From the nature of the drain, which is rapidly compensated by the constant interchange which goes on between the \^essel- and the tissue-fluids, anhydremia is a temporar^^ condition. A per- fect physiological balance limits its duration to brief periods of time. (See " Polycythemia," p. 149.) XI. LIPEMIA. Fat is present in normal blood, in the form of an exceedingly fine emulsion, the amount vaiy^ing in man from i.oo to 3.25 parts per 1,000 of blood, the mean amount being 1.6, according to the analyses of Becquerel and Rodier. - ^Croonian Lectures, Lancet, 1896, vol. i., pp. 1541, 1621, 1699 and 1778. 2 Cited by Futcher: Journ. Am. Med. Assn., 1899, vol. xxxiii., p. 1006. MELANEMIA. 10/ By the term lipemia is meant the presence of an excess of free fat in the circulating blood, a phenomenon which is observed in a number of conditions, both physiological and pathological. Thus, the blood may contain a sufficient amount of fat to give rise to temporary lipemia during the period of digestion, especially after a meal rich in fats ; the condition may be also met with in the bi'east-fed infant, in the pregnant woman, and in the obese. Menstrual suppressioji may also give rise to a similar excess of fat in the blood. The existence of lipemia is of little clinical importance, for it has been observed in a number of diseases, so that it cannot be considered characteristic of any particular lesion. It has been noted in the following conditions : chronic alcoholism, diabetes mellitus, certain diseases of the liver, heart, and pancreas, .chronic nephritis, splenitis, tuberculosis, malarial fever, typJius fever, Asiatic cholera, and poisonijig by phosphorus and by carbon monoxide. Lipemia commonly occurs as the result of lacerated wounds of the blood-vessels situated in fatty tissues, and after fractures of the lojig bones involving injury of the fatty marrow. The degree of lipemia may be so marked that the macroscop- ical appearance of the fresh blood is altered, the presence of large quantities of free fat rendering it turbid and milky. This is es- pecially conspicuous in the specimen of blood-serum obtained by centrifugalization, which has a distinct grayish, opaque appear- ance, not unlike chyle. Macroscopically, the presence of lipemia may be determined ' by mixing with ether in a test-tube a portion of the turbid blood- serum, the excess of fat promptly dissolving, so that the serum becomes clear. Microscopically, lipemia may be recognized by the presence of large numbers of glistening fat-droplets, about . 5 to 2 // in di- ameter, which lie free in the plasma between the groups of cor- puscles, often exhibiting very lively Brownian movements. These droplets respond to the usual tests for fat, dissolving in ether, and staining black with osmic acid, and brick-red with Sudan III. XII. MELANEMIA. The occurrence in the circulating blood of minute particles of melanin or pigment, derived usually from the hemoglobin of the red blood corpuscles destroyed by blood parasites, is known as melanemia. These melanin particles appear as fine bits of granu- lar matter, of a reddish-yellow or black color, either lying free in the blood-plasma, or embedded in the protoplasm of the leuco- I08 THE BLOOD AS A WHOLE. cytes. In some instances the granules are extremely small-sized and few in number, and again the amount may be considerable, numbers of pigment particles being apparently fused into masses. Melanemia is frequently present in malarial fever, especially of the severer types, both in the form of free pigment, and as pigmented leucocytes. Particles of pigment in the bodies of the leucocytes have also been seen in relapsing fever, in melanotic sarcoma, and in Addisoii s disease. XIII. GLYCEMIA. Glycemia, or the presence in the blood of grape-sugar, occurs in perfectly normal blood to a ver}' slight degree, the quantity of sugar found under physiological circumstances not exceeding 1.5 parts per thousand. The presence of sugar in excess of this fig- ure, which may be termed Jiyperglycemia, is met with in diabetes mellitus, in which disease as high as 9 parts per thousand hav^e been detected.^ The investigations of Freund- and of Trinkler^ apparently show that the blood in carcinoma, especially of vis- ceral involvement, contains an excess of some reducing agent, to all intents and purposes identical with sugar. The former author, in consequence of this fact, lays stress on the finding as a means of differentiating between carcinoma and sarcoma, since no such increase has been observed as an accompaniment of the latter type of neoplasm. The most accurate method of detecting small quantities of sugar in the blood is by the phenyl-hydrazin hydrochloride test, conducted by von Jaksch ^ as follows : — A small amount of blood, obtained by wet-cupping, is first freed from proteids, by adding an equivalent weight of sodium sulphate, and then boil- ing, and filtering, the filtrate thus obtained being used for the test. A solution is now made in a test-tube, by mixing 2 parts of phenyl-hydrazin hydrochloride and 4 parts of sodium acetate with about 6 cubic centimeters of water, and gently heating the fluid, if necessan,^, to effect solution. Five cubic centimeters of the proteid-free filtrate, while still warm, are added to an equal volume of the test-solution. This mixture is then placed in a test-tube half filled with water, heated for half an hour in a water-bath, and allowed to stand until cool. When cooling of the mixture has occurred, it shows under the micro- 1 Hoppe-Seyler : Virchow's Archiv., 1S58, vol. xiii., p. 104. 2Wien. med. Blatter, 1885, vol. viii., pp. 268 and 873. 3 Central bl. f. d. med. ^Vissensch., 1890, vol. xxviii., p. 498. * Zeitschr. f. klin. Med., 1886, vol. xi., p. 20. URICACIDEMIA. IO9 scope the presence of the characteristic yellowish crystals of phenyl-glucosazon, either detached or in clusters, together with colorless crystals of sodium sulphate. XIV. URICACIDEMIA. The presence in the blood of a demonstrable amount of uric acid has been designated as uric acidemia. The blood of the normal individual does not contain this substance in amounts sufficiently large to be detected by ordinary clinical tests, but it is found in appreciable quantities in a number of pathological condi- tions. Garrod ^ many years ago recognized that excessive accumu- lation of uric acid in the blood was associated with ^(9?//, and he at- tached to this sign much diagnostic significance. Later investiga- tions, however, have proved the utter unreliability of this finding as a pathognomonic sign of this disease, for in recent years a large number of other conditions have been found to be more or less constantly accompanied by relatively large amounts of uric acid in the circulating blood. Notable examples of such diseases are pneumonia, hepatic cirrhosis, acute and chronic nephritis, chronic gastritis, leukemia, severe anemia, and those conditions in which deficient blood aeration constitutes a prominent clinical symptom, such as organic cardiac disease, exudative pleurisy, and emphysema. Uric acid is not found in the blood in enteric fever, and in rheu- matic fever. Pyrexia, of itself, evidently has no influence in pro- ducing uricacidemia, nor is it at all probable that this condition goes hand in hand with an excessiv^e elimination of uric acid in the urine. Garrod's test is well adapted clinically for detecting the pres- ence of appreciable quantities of uric acid in the blood. Slightly modified, it may be applied in the following manner : — Two and one-half cubic centimeters of blood-serum, obtained by blistering, are placed in a shallow watch glass, and acidulated by the addi- tion of about 4 drops of a 30 per cent, aqueous solution of acetic acid. A Hnen thread is then immersed in the acidulated blood, which is slowly evaporated at a temperature not exceeding 70° F. At the expiration of from twenty-four to fort>^-eight hours, if the sample of blood contains uric acid, characteristic crystals of this substance are deposited upon the thread, their identity being readily detected by microscopical examination, and by the murexide test. 'Med. and Chirurg. Trans., 1854, vol. xxxvii., p. 49. Also, Ibid., 1848, vol. xxxi., p. 183. no THE BLOOD AS A WHOLE. XV. CHOLEMIA. The presence in the blood of bile or bile-pigments has been termed cholemia, a condition which accompanies various forms of icterus. Bilious blood may have, as already stated, a yellow- ish-red color, and may yield on agitation an abundant foam, tinged with yellow. Bilirubin may be detected in the blood even when urine tests for this substance have proved negative, according to von Jaksch,^ who employs this procedure to demonstrate its pres- ence : — About lO cubic centimeters of blood, obtained by wet- cupping, are allowed to clot, after which the serum is pipetted off, filtered through asbestos, and coagulated at a temperature of 80° C. Thus treated, the presence of bilirubin is betrayed by a greenish discoloration of the serum, which, if bile-free, remains a pale straw color. Should a brownish color develop by this test, the presence of hemoglobin in the serum is indicated. XVI. ACETONEMIA AND LIPACIDEMIA. The occurrence in the blood of demonstrable amounts of ace- tone and of fatty acids are referred to as acetonemia and lipaci- demia, respectively. Acetonemia has been found in associa- tion with numerous pathological conditions, chiefly in those characterized hy pyrexia, while fatty acids in the blood have been detected in diabetic coma, in malignant janndice, in leukemia, and in various acute infections. For the recognition of acetone Simon" recommends Den- nige's test, to be applied as follows : — About 3 cubic centimeters of blood are treated with 30 cubic centimeters of Dennige's reagent ( 20 grammes of concentrated sulphuric acid mixed with 100 cubic centimeters of distilled water, to which 5 grammes of yellow oxide of mercury are then added), and allowed to stand until a dark brown precipitate has formed, after which the supernatant fluid is filtered off, and treated with more of the reagent, so as to effect complete precipitation. It is then acidi- fied by the addition of about 3 cubic centimeters of a 30 per cent, solution of sulphuric acid, and boiled for one or two min- utes. The appearance of a white precipitate on boiling indicates the presence of acetone. This precipitate may be almost wholly dissolved by the addition of hydrochloric acid in excess. Fatty acids may be detected by boiling equal parts, by weight, of blood and sodium sulphate, filtering, evaporating the filtrate • Loc. cit. 2** Clinical Diagnosis," Phila., 1901 (3d ed. ). BACTERIEMIA. I I I to diyness, and then extracting the residue with absolute alcohol. Microscopical examination of the residue will reveal crystals of fatty acids, if lipacidemia exists. XVII. BACTERIEMIA. Bacteriania, or the presence of bacteria in the Occurrence, circulating blood, is a condition associated with a number of infectious diseases, in which instances it is frequently, but by no means constantly, possible to dis- cover the specific micro-organism of the disease in question by careful bacteriological examination of the blood. The demonstra- tion in the blood, even if it is possible only in occasional instances, of such bacteria as pyogenic cocci and pneinnococci in septic dis- eases, of the streptococcus pyogenes and other pyogenic organisms in malignant endocarditis, of the bacillus of Eberth in enteric fever, of the gonococcus in gonorrheal rheumatism, and of the bacillus tuberculosis in severe cases of acute miliary tuberculosis, is sufficient proof, without citing other instances, of the diag- nostic value of bacteriological blood examinations, which are warranted in every case of severe infection the nature of which appears doubtful. From the clinician's viewpoint, normal blood Latent is absolutely sterile, since no cultural method has Infection, yet been devised by which it is possible to demon- strate the presence of bacteria in the circulation of the healthy individual. From the pathologist's standpoint, however, such a statement must be guardedly accepted, in the light of recent investigations. Adami,^ in a recent brilliant resume of the whole field of bacterial infection, cites a series of apparently conclusive experiments by his assistants, Nicholls and Ford, who found that the kidneys and livers of healthy animals, removed aseptically immediately after death and placed in agar-agar kept at the temperature of the body, showed after a few days a rela- tively abundant growth of bacteria. This observer concludes that under normal conditions the leucocytes pass out through the mucosa on to the free surface of, more especially, the alimen- tary tract, some of these cells then undergoing destruction, while others, now laden with various foreign matter, including bacteria, pass back again into the submucosa and find their way either into the lymphatic channels or into the portal venules. In both of these sites there exists a decided tendency toward bacterial disintegration and destruction. Such isolated bacteria as may ijour. Am. Med. Assn., 1899, vol. xxxiii., pp. 1509 and 1572. 112 THE BLOOD AS A WHOLE. have escaped leucocytal destruction or removal b}' the lymphatic glands or by the endothelium of the portal system, may pass either through the thoracic duct or through the liver, and enter the systemic circulation, from which they are eliminated chiefly by the kidneys. Such a condition as this, known as " latent in- fection " or ''latent microbism," appears to be compatible with perfect health, for the number of bacteria which thus gain access to the blood-stream and tissues is so small that unless their virulence is especially striking and the susceptibility of the indi- vidual peculiarly marked, the resisting powers of the tissues re- main sufficiently strong to prevent bacterial proliferation. It is also obvious that the presence in the blood of such a Hmited number of bacteria cannot be demonstrated by culturing. If, on the other hand, the conditions are such Blood that bacteria multiply in the blood to any decided Cultures, extent, then their development in artificial media outside the body may be successfully obtained in many instances, provided that proper technique is employed. That this has not been more successfully accomplished is no doubt due to the powerful bactericidal action of the shed blood, whereas this influence in the circulating blood is but trifling. As Adami remarks, " Because certain observers have failed to dis- cover bacteria in the blood from cases of infectious diseases, it by no means follows that the blood when shed has been free from bacteria." Therefore, it seems fair to presume that if precautions are taken to attenuate the bactericidal properties of the shed blood, by freely diluting it with a large quantity oi fluid media, instead of using relatively small amounts of solid culture, as has been done largely in the past, blood culturing will yield a much higher percentage of positive findings, and will give more uniform results. (See " Bacteriological Examination," page 83.) Among the various bacteria which different Bacterla. observers have succeeded in isolating from the Found in circulating blood are included manv micro-ors^an- THE Blood, isms, the identity of which as etiological factors of disease is generally recognized, and also a number to which pathogenicity cannot be convincingly attributed. The following list gives the most important examples of the former class : B. ant/wacis. B. coli coinnuinis. B. ijifliicnzce. B. leprcB. B. mallei. ANEMIA. I I 3 B. pestis bubofiicce. B. tetani. B. tuberculosis. B. typhosus. Diplococcus iniracellularis meningitidis. Gonococcus. Pneumococcus. Pyogenic staphylococci. Pyogenic streptococci. In addition to this list, a certain amount of interest attaches to the discovery in the blood of certain bacilli (Achalme), and diplo- cocci (Triboulet) in rheumatic fever ; of peculiar bacilli (Afanassiew) in relapsing fever, in addition to the specific spirillum of this in- fection ; oi diplobacilli (Crdiig) in mumps ; and of diplococci (CIslss) in scarlet fever, and in typhus fever (Balfour and Potter), The exact significance of finding the bacillus icteroides (Sanarelli) in the blood of yellow fever patients is still a current topic of discussion. The conditions in which the above-named bacteria occur in the blood will be discussed in a later section, under the diseases in question. (See ** General Hematology.") XVIII. ANEMIA. In a clinical sense, the term anemia refers to Definition, any deterioration in the quality of the blood, af- fecting either the erythrocytes, the hemoglobin, or both of these elements. Thus, in pernicious anemia the most conspicuous deterioration in the quality of the blood is a diminu- tion in the number of erythrocytes, or an oligocythemia; in chlorosis, the most marked change is usually a loss of hemo- globin, or an oligochromemia ; while in many other anemic con- ditions the erythrocytes and hemoglobin are decreased more or less proportionately. While it is true that, strictly speaking, the word anemia may also be used to designate a reduction in the blood volume, this condition is better defined by the use of the term oligemia. Ischemia is a form of local anemia resulting from some mechanical interference with the blood supply of the affected area. In certain individuals with such decided pallor PsEUDO- of the skin and mucous membranes that their Anemia. appearance at once leads one to infer that they are suffering from a well-defined anemia, no signs of this condition can be discovered, for even after the most careful examination of the blood, the number of erythrocytes and the per- 8 114 THE BLOOD AS A WHOLE. centage of hemoglobin may be found to be normal. Such instances of apparent blood deterioration have been called pseudo-anemia ; they are often explained by hereditary' peculiarities, by vaso- motor disturbances affecting the superficial capillaries, and by deficiencies in the pigment and in the development of the capillary network of the skin. Dwellers in tropical countries are especially prone to this spurious form of anemia, to which the misnomer tropi- cal anemia is occasionally applied. Every medical clinic can furnish patients suffering from neurasthenia, tuberculosis, and advanced Bright's disease, whose pallid countenances are a striking con- trast to their normal blood-counts. It does not follow, there- fore, that pallor of the skin and mucous membranes is invariably an indication of anemia, although this sign is not misleading in the majority of instances. On the other hand, it should not be forgotten that persons of good color and robust appearance sometimes suffer from decided anemias without the fact becoming evident at first glance. In view of these sources of error, in order to diagnose anemia with absolute accuracy, an examination of the blood is essential, for no matter how valuable other clinical signs may appear, the changes in the blood are often the real key to the situation. An entirely satisfactor)^ classification of the Classifi- various forms of anemia still remains to be de- CATION. vised, in spite of the numerous attempts which not a few eminent authorities have made to group these conditions according to sound pathological considerations. There- fore, largely for the sake of convenience, all anemias may be broadly grouped into two theoretical classes : primary and secondary. According to this tentative classification, primary anemias may be considered those in which a lesion of the hematopoietic organs is essentially accountable for the production of the disease. In anemias of this sort, the etiological factors are either entirely undiscoverable, or, if they are to be detected, too trivial to explain the intensity of the disease. Here the predominant clinical manifestations are to be found in the changes occurring in the composition of the blood, the other symptoms being considered secondary to, and dependent upon, these alterations. Under the term secondary ajiemia are included those cases of anemia which are apparently secondary to, and symp- tomatic of, certain definite pathological lesions not primarily affecting the blood-making organs, such as, for example, enteric fever, syphilis, tuberculosis, malignant disease, malarial fever, and hemorrhage. In such anemias the other clinical symptoms are, as a rule, much more conspicuous than the blood-changes, which ANEMIA. 115 are thought to be secondary. An exception to this general rule must be taken, however, in regard to the anemia caused by the presence of the bothriocephalus latus in the intestinal canal, for in this infection the blood-picture is by all odds the most striking clinical manifestation. It is, furthermore, true that in some instances a secondary anemia may apparently merge into one of the primary type, should the protracted duration of the former in course of time cause such profound systemic effects that finally the blood-making organs become exhausted, and refuse ade- quately to supply the constant demand for corpuscles, with the result that the most prominent clinical signs now are found in the blood, and not in the original symptoms of the disease in question. The high-grade anemia which sometimes follows enteric fever, becoming of such intensity that it counterfeits a primary anemia, may be cited as an example of this change. Until further progress has been made in the study of the phys- iology and pathology of the blood-making organs, the following provisional classification of the anemias may be used for clinical purposes : — I. Primary Anemia. Chlorosis, pernicious anemia ^splenic anemia, lymphatic leukemia, spleno-medullary leukemia, Hodgkin's disease. II. Secondary Anemia. Dependent upon causes such as hemorrhage, intestinal parasites, prolonged lactation, unfavorable hygiene, metal poisoning, malig?iant disease, acute infections, a?id chronic diseases producing long-standing drains on the albumi- noids of the blood. Excluding the effects of hemorrhage, deficient Pathogenesis, blood formation, excessive blood destruction, and a combination of these two processes are generally regarded as the three possible essential factors in the production of anemia. Deficient hemogenesis is to be attributed to a large number of different causes, among the most prominent of which may be mentioned the influence of unhygienic surroundings, and insufficient nourishment from improper food and from inadequate powers of assimilation. It is also probable that con- genital and acquired failure of the blood-making organs, and the presence of growths which intercept the material for blood forma- tion are to be considered as the origin of defective hemogenesis in some instances.^ Excessive blood destruction may be due to acute febrile and infectious conditions, or to the presence in the blood of certain toxines which destroy the corpuscles. It is characterized during life by an excess of urobilin and iron in the urine, and by the development of hematogenous jaundice. 1 Mackenzie: Lancet, 1891, vol. i., p. 73. SECTION III. HEMOGLOBIN, ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. ( Triacid Stain. ) Fig. 1. Normal Erythrocytes. Fig. 2. Erythroblasts. 1. Microblast. Note the dense, glistening nucleus, and the scanty, ragged zone of proto- plasm. . . , , 2, 3, 4, 5, 6. Normoblasts. The process of partial nuclear extrusion is apparently shown 'in 3 and s; in the latter cell the basic affinity of the nucleus is singularly slight. The cell, 6, while as large as many megaloblasts, retains the nuclear characteristics of the normoblast, of which it represents perhaps a hydropic form. Some writers regard such ervthroblasts as megaloblasts, on account of their large size. 7, 8, 9, lo, II, 12, 13. Megaloblasts. In 7 the nucleus, while normoblastic in size, is megaloblastic in structure and in staining affinity. Note the variation in the size of these cells, their delicate nuclear chromatin, and their decided tendency toward polychromatophilia. In all the nucleus and protoplasm are separated by a conspicu- ous hyaline ring. Fig. 3. Erythroblasts with Multiple Nuclei. 1. Cell with a constricted, convoluted nucleus, apparently undergoing solution in the protoplasm. 2. Normoblast with three nuclei arranged somewhat in the form of a clover-leaf. 3. Cell with two large nuclei, each apparently in an early stage of extrusion. Note the affinity for fuchsin displayed by the protoplasm and by the upper nucleus, and the distinct hyaline zone encircling the lower one. 4. 5. Normoblasts in IcarAokinesis. Fig. 4. Erythrocytes Deformed in Shape and Size. I, 2. Microcytes. 3. Megalocyte. 4. 5, 6,^7, 8, 9, ID, II, 12, 13. Poikilocytes. Many of these cells are highly polychromato- philic, especially 11, 12, and 13. {Eosin and Methylene-blue.) Fig. 5. Erythrocytes Showing Degenerative Stroma Changes. Granular basophilia is shown by i and 2 ; extreme decolonization by 3, 4, and 5. The other cells represent various stages of hemoglobin loss and protoplasmic degeneration. Fig. 1. .«■*-• m Plate I. m jtat. lO Fig. 3. 1 V. o 12 m 13 10 11 H^^^- FiG. 2. 13 10 Fig. 4. 11 12 Fig. 5. The Erythrocytes. (Figs. I, 2, 3, and 4, Triacid Stain ; Fig. 5, jEojzn and Methylene-blue.) (E. F. FABER,y>c.) SECTION III. HEMOGLOBIN, ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. I. HEMOGLOBIN. Hemoglobin^ which occurs in the circulating General blood in chemical union with oxygen as oxyhem- Properties. oglobin, is an extremely complex ferruginous and albuminoid substance contained within the stroma of the erythrocytes. It constitutes approximately nine-tenths of the latter' s total bulk, and a trifle less than fourteen per cent, of the whole blood. Hemoglobin displays a striking avidity for combining with oxygen to form a peculiarly unstable, but defi- nite, chemical compound, and a similar facility for yielding up to the tissues much of its oxygen, during its passage through the capillary circulation. Under the influence of deoxidizing agents, oxyhemoglobin may be deprived of its loosely combined oxygen molecule, the resulting oxygen-free constituent being known as reduced hemoglobin. Rhombic crystals of oxyhemoglobin, scarlet or reddish-green in color, are rapidly formed if, for any reason, separation of this substance from the corpuscular stroma takes place. Methemoglobin is an oxygen compound of hemoglobin containing the same quantity of combined oxygen as the latter, but differing from it in holding its oxygen constituent in a more intimate union. The dingy brown color which develops in a so- lution of oxyhemoglobin after prolonged exposure to the atmos- phere, evidences the production of this variety of blood-pigment. (See ** Methemoglobinemia," page 124.) The amount of iron (in the form of hemochromogeri) which hemoglobin contains is considerable — somewhat in excess of four per cent. It has been shown, clinically, by estimates made with the ferrometer and the hemometer, that no fixed parallelism is maintained between the percentage of hemoglobin and the iron contained in the blood. ^ Under the action of acids, strong alkalies, or heat, hemoglobin may be readily decomposed into two constituents : hematin, or an iron-containing principle ; and an albuminous residue of un- known character, but somewhat resembling globulin. In combi- 1 Rosin and Jellinek : Zeitschr. f. klin. Med., 1900, vol. xxxix., p. 109. I20 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONL\. nation with hydrochloric acid hematin forms a crj-stalHne hydro- chloride of hematin. termed hcinin, or Tcichmann s crystals. Under the microscope these crystals appear as black or dark brown, elongated rhombic prisms belonging to the triclinic sys- tem, which are insoluble in water, alcohol, ether, chloroform, and dilute acids. They may be demonstrated by preparing a slide of blood (or of any dried substance containing blood-pig- ment) to which a small quantit}^ of common salt has been added; a drop of glacial acetic acid is then run beneath the cover-glass so that it mixes with the blood and salt, and the specimen thus prepared is heated to just below the boiling point over a Bunsen flame. On cooling, Teichmann's cry^stals may be seen under the microscope with a low-power dry objective. Iron-free hematin, or hcmatoporpliyrin, may be derived from blood by the admixture of concentrated sulphuric acid. This substance is closely related chemically to urobilin, and occurs oc- casionally as a pigment in nature and in normal and pathological urines. Hematoidin, which also is free from iron, occurs in the form of reddish rhombohedral cr}-stals, only in old clots resulting from blood extravasations, such as cerebral hemorrhages, and splenic infarcts. It is derived from hematin, and is probably identical with bilirubin. The chief source of hemoglobin is the iron Origin. contained in various food products, about ten milligrammes daily representing the amount of this metal ingested in an ordinar}' diet, according to the analyses of Stockman.^ In event of a stoppage of this source of an iron supply, the formation of hemoglobin may proceed from the supply of iron stored up in various organs of the body, notably in the liver. Bunge- has shown that in the young infant, whose natural food, milk, contains but a slight trace of iron, this source of hemoglobin manufacture is most potent. The recent experiments of Aporti^ regarding the origin of hemoglobin and the er}throcytes have shown that animals sub- jected to repeated bleedings and kept on an iron-free diet, are able up to a certain point to utilize the supply of body iron for hemo- globin manufacture ; but that when such a demand became so severe that this supply was exhausted, the red corpuscles became progressively paler and paler, and the animal finally died. During the course of these experiments, if the animal received injections of iron, a prompt and striking increase in hemoglobin occurred, ijourn. of Physiol., 1897, vol. xxi., p. 55 ; 1895, vol. xviii., p. 484. ^Zeitschr. f. physiol. Giem., 1892, vol. xvi.,p. 177. ^Centralbl. f. inn. Med., 1900, vol. xxi., p. 41. HEMOGLOBIN. 12 1 the gain ranging from 50 to 95 per cent, within a week's time. The injection of arsenic, on the contrary, produced no effect upon the hemoglobin percentage, although it caused a marked and rapid increase in the number of red corpuscles. Similar effects from the administration of these drugs in the treatment of the different anemias may be observed as everyday clinical occurrences. Diminution in the amount of hemoglobin, as Variations indicated by the hemometer, is known as oligo- IN Amount, chroineniia, or achroiocythemia. It is a condition usually, but not invariably, associated with a cor- responding decrease in the number of erythrocytes. An ap- parent increase in the hemoglobin percentage may result from the concentration of the blood caused by a reduction in the quantity of blood plasma consequent to excessive drains upon the liquids of the body. By a similar physical mechanism, factors pro- ducing a dilution of the blood are capable of causing an ap- parent diminution in the hemoglobin. Marked oligochromemia is commonly observed in chlorosis, pernicious anemia, and leukemia ; and in the secondary anemias dependent upon such factors as hemorrhage, mineral poisoning, acute and chronic in- fections, malignant neoplasms, and constitutional diseases. The behavior of the hemoglobin under such conditions is more fully alluded to in connection with the lesions in question. Poggi,^ from a series of experiments upon normal women, has shown that the hemoglobin is slightly lowered (10 or 15 per cent.) for a few days before menstruation, but with the establishment of the flow the oHgochromemia soon disappears. The primary loss he attributes to retarded hemogenesis consequent to the lessened consumption of albumin occurring in menstruating women, while the subse- quent gain he explains by the increased functional activity of the hematopoietic organs. In passing, it may be of interest to compare the degree of hemoglobin loss in the various forms of anemia, as illustrated by the following averages determined by the writer : Average of 50 estimates in pernicious anemia 25.5 per cent. '' '' " " " chlorosis 43.2 '' '' " "■ "■ " " leukemia 39.4 " '' '' " '^ " " secondary anemia 55.2 '' '' Bieifreund's investigations ^ in Mickulicz's clinic have led to the current impression among surgeons that it is highly dangerous to give a general anesthetic to a patient whose hemoglobin percent- age is below 30 ; some operators regard 40 per cent, as the ^Policlin., Roma, 1899, vol. vi,, p. i. 2 Langenbeck's Archiv. , 1890-91, vol. xli., p. i. 122 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. lowest limit of safety, and refuse to employ any but a local anes- thetic in cases with an oligochromemia exceeding this figure, ex- cept under circumstances of imperative necessity. Any one, however, who has attempted to verify the correctness of this gen- eral belief must accept it with a shrug of the shoulders. The writer knows of four patients whose hemoglobin percentages all were below 30, in whom operations under general anesthesia with ether were followed by uneventful recovery ; in one instance (a pan-hysterectomy, lasting more than an hour and a half), the hemoglobin was but 21 per cent., yet no ill effects were observed. Assuming that in the normal adult 14 grammes Absolute represent the average amount of hemoglobin in Amount. 100 grammes of blood, the absolute amount of hemoglobin may be readily calculated, thus : ,._ , ,. ^ Graimnes of hemog'lobiti HejnoHooin percentao;e x 14 -r- 100 = • __ -^ r ui j * ^ ^ ^ in 100 grammes of oLooa. For example, in blood in which the percentage of hemoglobin, as determined by the hemometer, is found to be 40, the calcula- tion (40 X .14) gives the absolute amount of hemoglobin as 5.6 grammes. The proportionate amount of hemoglobin con- CoLOR tained in each red blood corpuscle, or its cor- Index. puscular richness in hemoglobin, is known as the coloi' index, or blood quotient, or valeiir globidaire. In normal blood the color index is theoretically expressed by the figure I, although, practically, it varies from .95 to 1.05 in men, and from .9 to i in women. ^ In those anemias in which the decrease in the amount 01 hemoglobin in the blood is coincident with a proportionate de- crease in the number of erythrocytes, the color index remains practically at the normal figure. If, however, the cellular de- crease happens to be relativ^ely greater than the hemoglobin loss, then the index will naturally be found to rise above normal ; thus, in pernicious anemia, in which condition the loss of cells is proportionately much greater than the loss of hemoglobin, high color indices, approaching or even exceeding 1.25, are fre- quently observed. On the contrar>', \i the hemoglobin loss is rela- tively more excessive than the corpuscular decrease, the color index falls below normal ; for example, in chlorosis, in which, as a rule, the decrease affects the hemoglobin much more strikingly than the erythrocytes, low indices, such as .50 or less are common. To calculate the color index, the percentage of hemoglobin is 1 Oliver : Loc. cit. HEMOGLOBIN. 1 23 divided by the percentage of eiythrocytes, the result being ex- pressed in decimals. In order to simplify this procedure, 5,000,- 000 erythrocytes per cubic millimeter must be arbitrarily con- sidered as normal, or 100 per cent. To obtain the percentage of corpuscles, the actual number counted in one cubic millimeter of blood is simply multiplied by two, and two or three decimals pointed off from the left, depending upon whether the count is below or above the normal 5,000,000. The following examples serve to illustrate the calculation in several conditions : Normal Adult. Erythrocytes : 5,000,000 per cb. mm. (100 per cent.). Hemoglobin : 100 per cent. 100 -i- 100 = I : Color index. Secondary Aiiernia. Erythrocytes : 2,650,000 per cb. mm. (53 percent). Hemoglobin : 40 per cent. 40 -J- 53 = .75 : Color index. Per7iicious A7ie7nia. Erythrocytes : 840,000 per cb. mm. (16.8 per cent.). Hemoglobin : 1 8 per cent. 18 -f- 16.8 = 1.07 : Color index. Chlorosis. Erythrocytes : 4,100,000 per cb. mm. (82 per cent.). Hemoglobin : 32 per cent. 32-5-82 =.39: Color index. These examples, of course, refer only to the usual blood-find- ings, for the color index is by no means akvays high in pernicious anemia, nor always low in chlorosis. The color index shows simply the relative relations of the hemoglobin and the corpus- cular percentages. It is only suggestive, not diagnostic of a specific blood disease. The term hemoglobinemia is used to designate Hemoglo- a condition in which the hemoglobin is dissolved BiNEMiA. from the corpuscular stroma, as the result of some pathological factor, and is held in solution by the blood plasma. In extreme instances this condition is sooner or later succeeded by hemoglobinuria. Among the most potent causal factors of hemoglobinemia are certain drugs which act as blood-poisons, when administered in toxic doses, of which the following are examples : arseniuretted hydrogen, sidpJmretted hydrogen, potassium chlorate, carbolic acid, hydrochloric acid, sulphuric acid, pyrogallic acid, ?iitrobenzol, anti- mo7iy sulphide, iodine, naphthol, and many of the coal-tar deriva- tives, such as acetanilid, antipyrin, and phenacetin. A similar 124 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. liberation of the hemoglobin may be observed as the result of poisoning by certain varieties of viusJirooms, by some s?iake- ve7ioins, by the bite of scorpions, and by a number of vegetable glycosides. Sunsti'oke, exteiisive burns, and exposure to excessive cold, are also capable of giving rise to hemoglobinemia. Experi- mentally, hemoglobinemia may be produced by the transfusion of blood from one animal into the circulation of another belonging to a different species. Hemoglobinemia is observed with more or less constancy in a number of acute infectious diseases such as grave cases of septice- mia, diphtheria, malignant jaimdice, syphilis, malarial fever, enteric fever, scarlet fever, yellozu fever, typhus fever, and variola. It also may occur in scurvy, and in Raynatid's disease, and is a prominent blood-finding in those two obscure conditions known as epidemic hemoglobinuria of the new-born, and paroxysmal hemoglobinuria. Hemoglobinemia may be readily detected by the following method, recommended by von Jaksch:^ — A small amount of blood, drawn from the patient by means of a cupping-glass, is immediately placed in a refrigerator, in which it is allowed to re- main for twenty-four hours. In normal blood, the serum which separates at the expiration of this period, is of a perfectly clear straw-color, whereas if hemoglobinemia exists the serum is colored a beautiful ruby-red. If this hemoglobinemic serum is examined with the spectroscope, the two characteristic absorption bands of oxyhemoglobin may be observed. If it is coagulated by heat, a deep brown color is imparted to the coagulum. Methemoglobinemia, or the presence in the Methemoglo- circulating erythrocytes of methemoglobin, is BiNEMiA. produced by the action of a number of toxic substances, which, if given in sufficiently massive doses, may seriously or fatally cripple the oxygenating functions of the blood. Among the agencies which cause this conversion of oxyhemoglobin into methemoglobin are potassium chlorate, aniline, iodine, bromine, ether, turpentine, acetaiiilid, potassiiim per- manganate, hydrochinon, kairin, thallin, and pyrocatechin. The inhalation of amyl nitrite, and the intravenous injection of sodium nitrite also act in a similar manner. Spectroscopical examination of the blood is essential for the de- tection of methemoglobinemia. The spectrum of methemoglo- bin in alkaline solution shows three absorption bands : one well-marked band between C and D of Fraunhofer's lines and two others of much less distinct appearance, lying between D and E, each immediately adjacent to the lines. In acid and neu- ^ "Clinical Diagnosis," etc., London, 1897, 3d ed. HEMOGLOBIN. 125 tral solutions the spectrum of methemoglobin shows four absorp- tion bands : a decided one between C and D, two between D and E, and one closely adjacent to F. This spectrum, it is true, is identical with that produced by an acid solution of hematin, but it may be easily distinguished from the latter by the fact that the spectrum of methemoglobin, when acted upon by ammonium Fig. c D 5 b Oxyhemoglobin Methemoglobin Reduced Hemoglo- bin C Hemoglobin Principal blood spectra. sulphide, changes first to that of oxyhemoglobin, and later to that of reduced hemoglobin, while when hematin is thus treated, a spectrum which shows two bands between D and E is produced. Aside from the bright, cherry-red color of the Carbon Mon- blood in coal-gas poisoning, the presence of car- oxiDE Hemo- bon monoxide hemoglobin may be determined by globin. spectroscopical examination, and by a number of distinctive chemical reactions. Recalling the characteristic spectrum of oxyhemoglobin ( two distinct absorption bands between D and E, the one nearest D being darker, narrower, and more sharply defined), it is found that in the spectrum of carbon monoxide hemoglobin these bands are replaced by two others, also between D and E, but nearer together, and somewhat closer to the violet end of the spectrum. This distinction, which may be so slight as to appear confusing, is at once emphasized by the fact that the addition of ammo- 126 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. nium sulphide has absolutely no effect upon the carbon monox- ide spectrum, while it transforms the spectrum of oxyhemoglo- bin into that of reduced hemoglobin. Carbon monoxide hemoglobin in the blood is also demonstra- ble by the following simple test devised by Hoppe-Seyler : ^ — A small quantity of blood, removed from the patient by means of a wet-cup, is mixed with twice its volume of a ten per cent, solu- tion of potassium hydrate. Thus treated, blood containing car- bon monoxide hemoglobin changes the color of the mixture to a rich, cinnabar-red, while with normal blood the solution turns brownish-green. II. THE ERYTHROCYTES. The crytJivocytcs or red corpuscles are thin, Appearance flattened, biconcave discs, of sharply-defined, IN regular outline, and of smooth, even surface. In Fresh Blood, the blood of the normal individual they do not possess a nucleus. When the corpuscle is ex- amined microscopically as it rests upon its flat surface, its cen- tral concavity is plainly indicated by a dark, central area sur- rounded by a narrower, lighter rim, a^ the periphery of the cell is brought into sharp focus ; changing to a pale, white center encircled by a darker periphery, as the objective is brought closer to the corpuscle. When viewed in profile the corpuscle is shaped somewhat like a slim dumb-bell, with regularly rounded poles tapering from either end toward a shallow central concavity on either surface. Their color, when examined singly under the microscope, is a pale greenish-yellow, but when collected to- gether in masses a more or less marked reddish tint becomes ap- parent.- The erythrocytes possess a peculiar tendency of collect- ing and adhering together in more or less regularly arranged piles, like rolls of coins stacked up face to face, this being known as rouleaux formation. After withdrawal of the blood from the body various structural changes in the erythrocytes, commonly known as creuation, may be observed. In normal blood, the rapidity with which these changes progress depends upon the quantity of air which leaks in between the slide and the cover-glass, and thus causes de- generation of the corpuscular stroma. The development of one or more small, bright, highly-refractive spots in the body of the corpuscle, or a slight indentation of the cell's peripher)^ are the most conspicuous indications of beginning crenation. As the process goes on, more and more of these hyaline points develop, ^ Loc. cit. THE ERYTHROCYTES. 12/ until finally the whole surface of the corpuscle becomes thickly studded with glistening, bead-like spines. As the stroma be- comes drier and drier, its typical biconcavity and sharply-cut out- line are lost, contracting strands of the stroma are seen to extend from point to point among the beaded projections, the periphery of the cell changes to a cogged rim, and finally the cell becomes shrunken and shrivelled up into a small, many-starred asterisk. Some of the erythrocytes become fragmented, and small bits of their stroma are observed to break off and float through the plasma. Others become progressively paler and paler, as the hemoglobin is dissolved out, until complete decoloration occurs. Still others become distorted into designs of every conceivable shape, so that their resemblance to the normal cell becomes most remote. These changes, which never occur in normal blood until the cells have been exposed to prolonged atmospheric in- fluence, must not be confused with similar alterations in the structure of the erythrocytes occurring as the result of patholog- ical states of the blood. The latter changes are described more fully in another place. (See page 141.) The finer structure of the erythrocyte is still a Histological mooted point among different histologists, the Structure, view most generally accepted regarding it as a homogeneous cell composed of an insoluble spongy network, the stroma of Rollet, in the interstices or trabec- ulae of which is embedded a soluble, finely granular substance, the hemoglobin, existing probably as a compound with some un- known constituent of the cell. In lieu of a distinct limiting membrane, the portions of the stroma nearest to the surface of the corpuscle are condensed, to protect it from injury during its movements through the blood stream. The corpuscles are highly elastic and contractile, to permit of the rapid and marked tempo- rary distortions of shape which they constantly undergo in the circulating blood. Other authorities, notably Schaffer,^ disagree with this view, inclining ratlier toward the opinion advocated by the earlier in- vestigators, who considered the erythrocytes as vesicular masses, consisting of an external envelope enclosing a fluid contents. Thus, Schaffer beheves that the cell consists of two distinct por- tions, a colored and a colorless, the former being a solution of hemoglobin, while the latter, or so-called stroma, consists chiefly of lecithin and cholesterin, together with a small amount of cell globulin. Without attempting to discuss the correctness of either of these two views, a single tangible reason for regarding the cor- iQuain's "Anatomy," Phila., 1891, pt. 2, p. 210. 128 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. puscle according to Rollet's opinion may be stated, viz : the fact that exposure of blood to destructive temperatures results in fragmentation of the corpuscles into numerous minute portions, each one of which consists of a bit of hemoglobin-containing stroma. This obviously seems to disprove the existence of a limiting membrane, without further investigation. In the human body an active manufacture Origin and of red corpuscles constantly goes on during Life History, health, in order to compensate for the continuous drain on their number by the destruction of those cells which have become incapable of function and useless, their life cycle being run. That this reproduction is the direct answer to a call for new cells is proved by the prompt and rapid increase of corpuscles following the loss of blood from hemorrhage ; that such a manufacture is attempted in severe pathological conditions, although the attempts are sometimes abortive, is evinced by the large numbers of immature and misshapen erythrocytes which appear in the blood in certain of the grave anemias. In the adult it is generally conceded that the erythrocytes are reproduced in the red bone marrow, being developed from their direct antecedents, the nucleated erythroc\tes or erj'thro- blasts, which exist in this tissue in large numbers. The erj-thro- blasts appear to multiply in the thin-walled capillaries and veins of the red marrow, and having lost their nuclei, become trans- formed into normally developed erjthrocytes, which pass from the marrow blood channels into the general circulation. Some authorities have attributed to the spleen and lymphatic glands a share in the formation of the red cells, while others have main- tained that they ma\' be transformed from the leucocytes in the circulating- blood, but none of these theories has been associated with convincing evidence, so that it is fair to consider the red bone marrow the chief, if not the only, seat of production, in the light of our present knowledge of the subject. Hayem's ingenious theor\', that the red corpuscles arise from the hema- toblasts, does not enjoy the confidence of modern investiga- tors. When finally the er>throc>te, after having executed its function for a certain length of time, becomes useless in its primaiy office as an oxygen carrier, its death ensues, the destruction of the cell probably taking place largely in the spleen, whence the freed hemoglobin is carried to the liver to be eliminated as bile pigment. Warthin's * recent studies apparently show that de- struction of the er}throcytes also occurs in the splenolymph ^ Jour. Boston Soc. of Med. Sci., 1901, vol. v., p. 414. THE ERYTHROCYTES. 1 29 glands, minute vascular sinuses situated chiefly in the retroperi- toneal and mediastinal tissues, and in the thyroid and thymus regions. The possibility that certain of the partly degenerate red corpuscles also undergo a certain form of repair, first in the spleen and then in the liver, rendering them still capable of func- tion, is an interesting but obviously unproved conjecture. The average diameter of the erythrocyte is about Size. 7.5/-i,Mts average thickness being about 1.8//. Ac- cording to Gram,^ the diameter appears to vary some- what with the geographical and climatic conditions surrounding the individual, being considerably larger in inhabitants of northern countries than in southerners, as the following average measure- ments of this observer attest : Country. Average Diameter. Italy 7 to 7.5/a France 7.5 to 7.6/1 Germany 7.8/i Norway 8. 5 /a Hayem ^ distinguishes three different sizes : large, averaging 8.5 /i in diameter; medium, averaging 7.5 // in diameter; and small, averaging 6.5 fi in diameter. Of these three classes, ap- proximately 75 per cent, are of the medium size, while 12.5 per cent, each, are large and small. The diameter varies within some- what wider limits in the infant and in the young child than in the adult. It is, however, not materially influenced by sex. The pathological increase and decrease in the diameter of the erythro- cytes occurring in certain anemias, are discussed in another place. The normal number of erythrocytes in the Normal healthy male adult may be approximated at Number. 5,000,000 to the cubic millimeter of blood. Higher counts than this are frequently observed, however, especially in healthy, well developed men, so that this figure should be taken to represent a rather low average, subject to an upward fluctuation of half-a-million cells, and occasionally even more. In females a count of about 4,500,000 red cells per cubic millimeter may be regarded as normal. Arterial and venous blood contain practically the same number of corpuscles, the apparent slight increase in favor of the latter, mentioned by some observers, being within the limits of technical error. For a like reason, under normal conditions, peripheral 1 The Greek letter fi is used to represent a raicromillimeter, or l/r,ooo of a milli- meter, which is a standard unit of measurement used in microscopy. 2Forschr. d. Med., 1884, vol. ii., p. 2,3- 3 Loc. cit. 9 130 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. blood may be taken as representative of the blood of the entire body. Blood derived from dependent parts of the body contains a diminished proportion of corpuscular elements. Oliver's^ studies of this question have shown that blood from the finger invariably gives a higher count of red cells than blood from the toe, this disparity being explained by the fact that the larger quantity of lymph gravitating to the more dependent parts of the body causes a dilution of the blood in these areas. This term has been applied by Capps ^ to the Volume figure representing the percentage volume of the Index. individual erj'throcyte, in contradistinction to the color index, which expresses the amount of hemo- globin in the single cell. It is calculated by dividing the percent- age volume of the erythrocytes as a whole, obtained by centrifu- galization of the blood, by the percentage number of er}'throcytes, as determined by the actual count with the hemocytometer, the normal volume index being taken as i.oo. For example, the erjlhrocyte column, after centrifugalization with the hematocrit, reaches to the mark 40 on the capillar)^ tube, indicating a total volume of 80 per cent.; while the count with the hemocytometer gives 3,000,000 cells per cubic millimeter, or 60 per cent, of the normal number. Then, 80 -r- 60, or 1.33, equals the volume in- dex, a figure which in this instance shows an increase of 33 per cent, in the volume of each corpuscle. As a general rule, it may be stated that the volume index and the color index rise and fall together, although the parallelism between the two is not al- ways closely maintained. The volume index is generally lowered in chlorosis, in leukemia, and in most of the secondary anemias, while in pernicious anemia it tends to rise above the normal standard. III. INFLUENCE OF PHYSIOLOGICAL FACTORS ON THE ERYTHROCYTES. Polycythemia, associated with a proportionately Age AND Sex. high percentage of hemoglobin, is found in the blood of the new-born infant immediately after birth, the maximum counts being observed some time during the first twenty-four hours of life, after which period they progres- sively diminish until at the end of about eight or ten days an average of one million cells has been lost. Each period of nursing is generally followed by a prompt temporar^^ decrease in the count, and a similar change has been observed as the effect of 1 Loc. cit. 2 Loc. cit. INFLUENCE OF PHYSIOLOGICAL FACTORS. 131 premature ligation of the cord, at birth. Hayem ^ found an aver- age of 5,368,000 red corpuscles per cubic millimeter in 17 infants at birth, the highest count being 6,262,000, and the lowest 4,340,000. The cause of this polycythemia is attributed to con- centration of the blood from the abstraction of water by the tissues to replace the fluids of the body lost during the first few days of life. As soon as this loss is made up by the ingestion of a sufficient amount of liquids by the child, the normal relation be- tween the liquid and the solid portions of the blood is reestab- lished, so that the polycythemia disappears. During the growth of the adult the average number of eryth- rocytes continues to rise, until the maximum number is attained at some time between the third and fifth decades, after which a decrease is observed, usually becoming more marked as the decline of life progresses. Schwinge ^ and others have shown that during the period of sexual activity the counts in females are generally lower than in males, but that after the climacteric the number of cells in the two sexes is practically identical. The influence of age and sex upon the number of red corpuscles is well illustrated in the following table prepared by Sorensen : ^ Age. Males. Age. Females. 5 to 8 days..... 5,769,500 i to 14 days 5,560,800 5 years 4,950,000 2 to 20 years 5,120,000 19.5 to 22 years 5,600,000 15 to 28 years 4,820,000 25 to 30 years 5,340,000 41 to 61 years 5,010,000 50 to 52 years 5,137,000 82 years 4,174,700 There are no conspicuous changes in the num- Pregnancy, ber of erythrocytes in any of these conditions. Menstruation, In primiparae there is often a slight decrease in AND the number of corpuscles, particularly in the Lactation, later months of pregnancy, but in multiparae this change is rarely observed. During men- struation there may be a trifling reduction caused by the physi- ological hemorrhage of the phenomenon, but the loss is rapidly made up in a few days' time. Sfameni ^ found that a transient polycythemia usually occurs shortly before the establishment of the menstrual flow, and that the average loss of hemoglobin and corpuscles, which takes place in the majority of cases during the 1 Loc. cit. 2Pfluger's Archiv., 1898, vol. Ixxiii., p. 299. 3 Cited by von Limbeck : " Grundriss einer klinischn Pathologie des Blutes," Jena, 1896. *Rassegna di ostetricia e ginecologia, Jan.-Feb., 1899. Abstr. in Centralbl. f. Gynakol., 1899, vol xxiii., p. 1311. 132 ERVTHROCVTES, BLOOD PLAQUES, AND HEMOCOXIA. flow, does not exceed 4.5 per cent., the decrease being in direct proportion to the actual volume of blood lost. In healthy, robust women lactation is accompanied by a normal count, but in weak, young pregnant girls, particularly those of the " chlorotic age," a moderate reduction is sometimes observed. After deliver}^ there is an oligocythemia, the intensity of which depends largely upon the amount of blood lost and upon the general health of the woman ; this loss of cells is gradually made up, and unless convalescence is delayed, reaches the normal by the second or third week after deliver>^ Well-developed, robust individuals average a Constitution larger percentage of red cells than the poorly- AND nourished and weakly. In the former, counts Nutrition, much in excess of five million, and in the latter, counts of less than five million, are the rule. Fasting, inasmuch as it causes a drain upon the liquid elements of the intravascular system, may rapidly bring about an apparent polycythemia due to concentration of the blood, this increase in cells being in direct relation to the length of abstinence from food. Hayem ^ states that a twenty-four hours' fast will cause a gain of between four and five hundred thousand cells ; while the experi- ments of Reyne - on a dog, starved to death after a twenty-four days' fast, showed an increase of 2,500,000 corpuscles at the ex- piration of this period. Physical labor prolonged to the point of fatigue Fatigue. appreciably diminishes the number of er>-thro- cytes. Cadet's^ investigations of the blood of a number of peasants, examined after two months of hard field labor during the summer, showed a moderate oligocythemia — in one instance a loss of over one million cells, and in the others diminutions averaging about one-half of this figure. Cadet be- lieves that this anemia is referable to a true blood destruction, and notes as a rather mythical support of this view that the blood plaques were increased in these cases. Within an hour or two after a meal there is Digestion, a slight, transitory increase in the number of Food. erj'throcytes, soon followed by a decrease corre- sponding to the period of digestion and aver- aging a loss of from one quarter to three quarters of a million cells. The preliminar)' rise has been attributed to abstrac- tion of liquids from the blood-vessels consequent to the pro- ^ Loc. cit. 2 Cited bv Havem, loc. cit. 3 Ibid. %. INFLUENCE OF PHYSIOLOGICAL FACTORS. 1 33 fuse outpouring of the gastric secretions ; the subsequent fall depends upon temporary dilution of the blood during digestion, and stands in inverse ratio to the leucocyte count. Oliver ^ states that these variations are not affected by the taking of liquids with meals, for he has noticed that they were quite as pro- nounced when water was withheld. The following table, from Von Limbeck,^ illustrates the variations in the red and white cells caused by taking food. Time. Erythrocytes. Leucocytes. Hemoglobin. 11:15 A. M. 5.553.0CX) 7,666 12 M. Dinner of meat and farinaceous food. 12:15 P- M. 5,320,000 6,166 1:15 P. M. 5,480,000 8,500 2:15 P. M. 4,733,000 12,000 3:15 P. M. 4,872,000 14,000 4:15 P. M. 4,720,000 10,830 Hayem^ believes that meat eaters average a higher percentage of red corpuscles than vegetarians, on account of the more nitrogenous character of their food, and that a diet of fats and albuminoids is most favorable for the increase of the cellular elements of the blood. The habitual polycythemia of individuals living High in high altitudes is an interesting and inadequately Altitudes, explained fact in hematology. Viault,^ Wolff and Koeppe,^ Egger^ and other observers have shown the invariable occurrence of this polycythemia both in inhabitants of elevated districts and in the occasional visitor. In the case of the latter, as the individual ascends from the sea- level to the mountainous district, a rapid increase in corpuscles and in hemoglobin develops, this increase bearing a certain rela- tion to the height ascended, and becoming apparent usually within twenty-four or forty-eight hours after his arrival in the highland. Viault counted 8,000,000 erythrocytes to the cubic millimeter in the residents on the Cordilleras, at an elevation of 14,274 feet above the sea-level; Egger counted 7,000,000 at Arosa, at a height of 6,100 feet; and Wolff and Koeppe found an average of 5,970,000 in dwellers at Reiboldsgriin, at a height of 2,257 ^^^t. Oliver^ relates the interesting experience of finding in his own blood, during a stay at Davos Platz, at an elevation of 5,200 feet, an increase of corpuscles within twenty- four hours after his arrival, the maximum count, 5,550,000, being attained within seven days, and the number declining within five days after his ^ Loc. cit. ^Comptes Rendus, 1890, vol. iii., p. 917. ^Miinch. raed. Woch., 1893, vol. xl., p. 904. *XII. Congress f. Innere Med., Weisbaden, 1893. 5 Loc. cit. 134 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. return to London. The hemoglobin changes, which accompany these corpuscular alterations, are never so marked as the latter, both the rise and the fall being less rapid ; consequently it is com- mon to find a low color index at first, whereas, later, inasmuch as the rapidity of the cellular decrease is greater than the fall in hemoglobin, a high color index is apt to persist for some time after return to the lowland. The following table taken from Koeppe,^ illustrates the fact that the higher the altitude, the higher is the count of erythrocytes : Height Above Count of Place. Sea-level. Erythrocytes. Author. Christiania o 4,974,000 Laache. Gottingen 148 meters. 5,225,000 Schafer. Tubingen 314 " 5,322,000 Reinert. Zurich 414 ^' 5,752,000 Stierlin. Auerbach... 425 ^' 5,748,000 Koeppe. Reiboldsgriin 700 *' 5,900,000 Koeppe. Arosa 1,800 '^ 7,000,000 Eggar. The Cordilleras ...4,392 " 8,000,000 Viault. Concentration of the blood doubtless explains the polycythe- mia of high altitudes, this change being due largely to the great loss of body fluids (Grawitz), and partly to the increased arterial tension (Oliver) arising from a rarefied atmosphere. Koeppe's ingenious theory that the process mirrors an actual manufacture of new cells is scarcely tenable, for although this observer has found numerous microcytes and poikilocytes coincidentally with the appearance of the polycythemia, normoblasts were not de- tected, as an evidence of rapid hemogenesis, nor did such signs of excessive blood destruction as icterus and hemoglobinuria de- velop, as the increased count rapidly declined, on the individual's descent to a lower level. It has recently been urged that in high elevations the effect upon the hemocytometer of atmospheric pressure and tempera- ture may be the real secret of the cellular increase, but how such influences act, if, indeed, they are active, is unknown. IV. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. True ameboid movements of the erythrocytes Ameboid are sometimes obser\^ed, as the result of the effect Motility. of globulicidal agents, or of some pathological state of the blood, such as a severe, high-grade anemia. The inherent elastic and contractile qualities shown by the cells, by virtue of which they undergo various changes in 1 Loc. cit. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 35 shape while floating about in the plasma, must not be confounded with the actual ameboid motility which they exhibit in disease. The molecular dancing movements of bits of fragmented corpus- cles, and the characteristic motility of the intracellular hyaline malarial parasite, also must be distinguished from the progressive, deliberate characteristics of the truly ameboid red blood cell. Within the body the hemoglobin and other Alterations constituents of the erythrocytes are preserved IN intact within the corpuscular stroma by the com- IsoTONiciTY. position of the blood plasma, which is such that a perfect osmotic balance is constantly main- tained. Outside of the body, if this relationship is disturbed by the addition of distilled water to a specimen of blood, thus lowering the concentration of the plasma, a rapid discharge of hemoglobin from the corpuscle into the surrounding liquid ensues, but the addition of saline solutions of a definite strength prevent such a change. Solutions of salts of just sufficient concentration to pre- serve the corpuscles and to prevent removal of their elements are known as isotonic ; solutions of greater strength are termed hypertonic^ and those of lesser strength hypotonic. In normal blood it has been determined that the isotonicity of the eryth- rocyte usually ranges from about 0.48 to 0.46 per cent. NaCl ; that is, salt solutions of this concentration are just sufficient to prevent the discharge of hemoglobin by the cell, although it may swell by taking up water. A 0.9 per cent, or ''normal " salt solution not only preserves the hemoglobin within the cell, but also prevents alterations in its size and contour. Owing to the conflicting results which have been obtained by different investigators, the isotonicity of the erythrocytes in differ- ent diseases is of little clinical value. Stengel ^ found the per- centage 0.52 and 0.6 in two cases oi pernicious anemia^ yet in other cases the figures were normal ; in other diseases marked by anemia, such as carcinoma, hepatic cirrhosis, rental disease, and ttiberciilosis, he found that the variations were trivial. Von Lim- beck ^ found that the isotonicity was usually, but not invariably, increased in high-grade secondary a7iemias, in leukemia, and in many of the acute infectio?is, while it was decreased in chlorosis, and in catarrhal icterus. A decidedly increased isotonicity was found by Vicarelli ^ in pregnant and nursing women. As a general rule, it is believed that degenerative changes in the eryth- rocytes, whatever their nature, predispose to dissociation of hem- ^ Loc. cit. 2 Loc. cit. "Cited by von Limbeck, loc. cit. 136 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. oglobin from the stroma, and that in such instances the isotonic percentages are higher than normal. In the fresh specimen of blood, exaggeration Hypervis- of the adhesive properties of the er)lhrocytes cosiTY. may be observed in a number of conditions, but up to the present time no special clinical signifi- cance has been assigned to the phenomenon. It occurs to some extent in most inflammator}^ diseases, and, according to Hayem,^ is often seen in the anemias associated with marked cachexia. Striking examples of hyper\iscosity result when the eiythrocytes are subjected to the action of various poisons, notably snake ve7ioin, and of heterogeneous pathological blood-serum. From the effect of such influences the er3/i:hrocytes, instead of forming normal rouleaux, tend to adhere together in large, irregular masses in which the distinctive characteristics of the cells are masked or lost. The individual cells, unattached to such a mass, may exhibit every possible variety of distortion, losing their typical biconcavity and regular disc-like appearance, and becoming converted into elongated, misshapen bodies. It fre- quently happens that the cell is provided with one or more long, delicate processes several times the length of its diameter, this being due to the adhesion of a bit of the stroma to the cover- glass while preparing the specimen ; in the spread film it will be noted that these processes all point in the same direction. Changes in the shape and size of the eryth- Deformities rocytes are common in all anemias which reach OF a severe grade, the degree of such deformities Shape and corresponding closely to the intensity of the Size. anemic process. The diameter of the cells may be more or less uniformly increased or decreased, and such pronounced alterations in their shape may occur that many of them bear but slight resemblance to the typical disc's of normal blood. (Plate I.) When the corpuscle becomes greatly enlarged in diameter it is known as a niegalocyte or inacrocyte, the presence of large num- bers of such cells being known as nicgalocytosis or niacrocytosis. The diameter of a megalocyte generally varies from 9 to 1 2 /i, but sometimes much larger forms are seen, measuring as much as 20 }i. They are present in the severer anemias, especially in the pernicious form, in which they constantly occur in large numbers. The megalocyte found in this disease is usually characterized by an excess of hemoglobin, while in the secondary anemias such cells are generally deficient in their hemoglobin content. 1 Loc. cit. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 3/ The smaller forms, the microcytes, illustrate the extreme de- crease in size of the red cell under pathological conditions. The microcyte is an extremely small globular body, measuring from about 3 to 5 /i in diameter. It is found in all the varieties of anemia, but is most commonly associated with chlorosis, and with the moderately developed secondary forms. When abundantly found in the blood, the condition is known as microcytosis. Eichhorsf s corpuscles are deeply colored, highly-refractive mi- crocytes, about 3 a in diameter, and usually of regularly spherical shape. They were once regarded as pathognomonic of pernicious anemia, but are now considered diagnostic of no especial condi- tion, being frequently found in severe anemias of any type, and often being absent in pernicious anemia. It seems reasonable to infer that deformities in the size of the erythrocyte are referable chiefly to two different factors : to faulty hemogenesis, and to degenerative changes of the corpuscle which lead to alterations in its histological structure. Megalocytes, for example, may in some instances represent an actual giantism of the cell, bred in the marrow from correspondingly large-sized nucleated antecedents ; in other instances (of which those exceed- ingly pale, ''washed out" forms are examples) their abnormal size may be attributed to hydropic enlargement, resulting from their imbibition of fluids from the surrounding plasma. Micro- cytes may enter the circulating blood as such, or, as is frequently the case, they may be the products of corpuscular budding and fragmentation. In severe forms of anemia, characterized by excessive cellular loss, there appears also to be a tendency toward a compensatory hypertrophy of many of the erythrocytes, in order thus to in- crease the oxygen- car lying capacity of the blood, which, were it not for these numerous megalocytes, might in some instances be too limited to sustain life. Poikilocytcs are erythrocytes deformed in shape as the result of some pathological condition of the blood. Poikilocytosis, the name by which this condition is designated, is akin to crenation in so far as in both conditions the cells may be similarly distorted and misshapen. But it is unlike crenation for the reason that poikilocytosis is a pathological condition, and demonstrable the moment the blood is withdrawn from the body ; while crenation is a physiological phenomenon depending upon external influences for its production, and never occurring until the blood has re- mained exposed to the air for some time. Poikilocytcs may be of large or small size, the varieties of deformities being infinite, and the degree marked or slight in relation to the nature of the 138 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. blood disease. Some of the cells may resemble the shape of a gourd or a horseshoe, others may be drawn out at both ends until they form a spindle-shaped or oval bod>^ while others appear sharply beaked at one or more points, or shaped like a dagger or the blade of a tomahawk. Occasionally ver}- minute, rapidly- oscillating, rod-shaped forms are seen, morphologically not un- like large, unstained bacilli — the psetido-bacilli of Hay cm. These rod-shaped forms are products of corpuscular fragmentation, and indicate lowered vitality and feeble powers of resistance to the pathological influences affecting the cells. Poikilocytosis is not characteristic of any single disease of the blood, but it is generally most marked in the grave forms of primar)' anemia, such as leukemia and pernicious anemia. Oval- shaped red cells are considered by Cabot ^ as particularly abundant in the latter disease. The conditions of deformity, affecting the shape and size of the erythrocytes are nearly always associated. As a general rule, it may be stated that in the milder types of anemia small -sized, slightly-deformed poikilocytes and microcjtes are most common ; and that in the severe forms, large-sized, conspicuously-distorted poikilocytes and megaloc>i:es predominate. Loss of color by the er}^throcytes, which pro- Endoglobular gresses hand in hand with alterations in their Degeneration, size and shape and other structural changes, is regarded as a degenerative process, of purely endoglobular nature. It is observed in the fresh specimen of blood in many severe anemic conditions, especially in the anemias associated with infectious diseases, such as variola, typhus fever, and grave septicemia and pyemia. The decoloration may commence in one or more spots, or it may equally involve the whole surface of the corpuscle, beginning at its center and spreading progressively toward its peripher}^ Clear, hyaline areas of oval, round, or elongated shape, appear within the stroma, in some instances sharply contrasting with the relatively dark color of the hemoglobin, but in other instances imperceptibly blending with the tint of the surrounding cell-body. The active motility of these decolorized spots must be carefully distinguished from the ameboid movements of the young malarial parasite. Complete decoloration transforms the cell into a mere colorless shell or " phantom," which would be practically invisible were it not for its faintly colored peripher)-. Such cells are known as Poiifick" s shadozi' corpuscles, or as HaycDi s achroniacytes. ^ " A Guide to the Clinical Examination of the Blood," 3d edition, N. Y., 1898, p. 140. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 39 Maragliano ^ and Castellino have minutely described this proc- ess of decoloration, along with certain other alterations in the structure of the erythrocyte, which they have termed endoglobu- lar necrosis. This process first becomes apparent by a visible enlargement of the central concavity of the corpuscle, together with a simultaneous fading away of the hemoglobin in this situ- ation. This central area of pallor gradually spreads toward the periphery of the cell, until finally the latter alone shows evidence of containing coloring matter. Such a corpuscle when examined on cross-section appears to be shaped like the figure 8. Frag- mentation of this delicate rim of coloring matter may occur, in event of which a number of independent rod-like bits of stroma Fig. 36. Degenerative changes in the erythrocytes. are formed. The decolorized area is not always symmetrical, so that frequently various strikingly bizai're designs, widely differing in shape and appearance, may be observed. It has been determined that in the dried blood-film these areas of decoloration show a de- cided affinity for basic stains, such as methylene-blue and thionin. Total cellular necrosis, also described by the Total authors mentioned above, represents a phase Necrosis. of structural degeneration in the er}^throcyte of more advanced development than the endo- globular changes. This process begins with the development of several small elevations or corrugations in the stroma of the cor- puscle, which gradually multiply, increase in size, and change in shape until the larger portion of the cell's surface is thus de- formed. Ameboid movements are seen to begin, as if the entire cell as a whole were involved, the final stage of the process re- 1 XL Congress f. inn. Med., Leipzig, 1892. I40 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. suiting in the formation of a poikilocyte, from which body points and small fra";ments are observed to break off, and to float free in the plasma. Decoloration, starting usually from a single point and in time affecting the whole stroma, also accompanies this necrotic alteration. On cross-section, the cell appears as an elongated, thin rod, with rounded poles. Endoglobular degeneration and total necrosis of the erythro- cytes may be observed in both normal and in pathological blood. In normal blood they occur as the result of prolonged contact with the air, the endoglobular phase becoming first apparent within from thirty to seventy minutes, and the total necrosis in from three to four hours, after the preparation of the specimen. In pathological blood the changes are thought to be due chiefly to increased globulicidal properties of the plasma whereby intra- vascular necrosis is excited, and partly to decreased resistance of the er}'throcytes in consequence of which their degeneration is abnormally hastened by contact with normal plasma, and by exposure to extraneous influences. In disease, it follows that they are demonstrable immediately or ver\^ shortly after the blood has been withdrawn, and that the development of the changes occurs with much greater rapidity than in normal blood. The endoglobular changes are regarded as a more favorable prog- nostic sign than the total necrosis, being usually associated with anemias of less severe character than those in which the latter process prevails. The normal erythrocyte, when fixed and Atypical stained with the aniline dyes, according to one of Staining Re- the methods described in another section, pos- ACTION. sesses a strong affinity for a single, acid stain ; it is therefore termed monochroinatophilic . When solutions are used containing both acid and basic dyes, such as eosin and methylene-blue or eosin and hematoxylin, the nor- mal erythrocyte is always stained by the eosin ; and with Ehr- lich's triple mixture, which is so formulated that acid, basic, or so-called neutral principle may be selected by the elements sub- jected to its action, according to their affinities, the erythrocyte invariably is colored by the orange G of the mixture. (Plate I.) In certain morbid conditions some of the corpuscles lose their affinity' for the acid stain, and with mixtures of both acid and basic dyes are stained atypically by either or both elements. Such corpuscles are said to be polychroinatophilic. Thus, when stained with an eosin and methylene-blue mixture, they are tinged a dirty grayish-purple or violet, instead of the rose color of eosin ; and with the triple mixture they may be stained pur- PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. I4I pie, or reddish-brown, or pale yellowish-pink flecked here and there with shadings of a darker red, (Plate I.) In polychromatophilic corpuscles the staining is apt to be very unevenly shaded, often being quite dark in spots, especially around the periphery of the cell and the margin of the nucleus, if the cell be nucleated. These color changes affect not only the protoplasm, but the nucleus, as well, and are strongly em- phasized in megaloblasts, the nuclei of which may show every sort of color combination. The more deficient the corpuscle in hemo- globin, the more decided its polychromatophilic tendency ; and the more strikingly the latter is developed, the more intense the cell's affinity toward the basic element of the stain. Polychromatophilia may occur in severe forms of anemia due to any cause, and it is especially noted in two of the primary va- rieties — pernicious anemia, and spleno-medullary leukemia, in both of which conditions the process is a prominent character- istic of the blood-picture. Nucleated erythrocytes, or erythroblasts, are NucLEATiON. found in the blood of the adult only during the existence of pathological conditions, but occur in large numbers in the blood of the fetus, and occasionally in the infant during the first few days of life. Being invisible in the fresh blood, they must be studied in the dried, stained specimen. In such preparations the finer structure of their nucleus, which bears a special affinity for the basic aniline dyes, may be beauti- fully illustrated by the use of solutions containing methylene- blue, methyl -green, and hematoxylin. According to their size and nuclear characteristics the ery- throblasts are designated as normoblasts, megaloblasts, and vii- croblasts. Certain intermediate forms are also common, some- times termed mesoblasts, such cells being atypical, and sharing characteristics of both the normoblast and the megaloblast. Normoblasts. (Plate I.) The normoblast is a nucleated ery- throcyte of about the general size and shape of the normal erythro- cyte. In the commonest variety the nucleus is round or ovoid in shape, very deeply stained, and situated rather toward the periph- ery of the cell than in the exact center, its diameter approximat- ing more than one-half that of the corpuscle which it occupies. In some of the cells it appears to have become partly or completely extruded from the protoplasm, lying either somewhat over the periphery of the cell, or being completely detached from it, free in the plasma. The nucleus may be single, or partly divided by constricting bands of chromatin into a figure like a dumb-bell or a clover-leaf, or completely divided into several small, round 142 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. sections. ]More rarely, kar\'okinesis may be observed. In care- fully stained films it will be noted that the nuclear framework of the typical normoblast consists of a rather sharply defined net- work of chromatin having relatively wide intervening open spaces, so that the general appearance of the nucleus is not unlike that of a coarse net. The protoplasm of this cell is usually of regular outline along the periphery, stains somewhat more intensely than that of the normal er}^throcyte, and may show distinct evidences of poh*- chromatophilia, this characteristic being especially marked in forms with dividing nuclei. The normoblast is regarded as the immediate antecedent of the normal erythrocyte or normocyte, into which it becomes trans- formed by the loss of its nuclear structure. The exact manner in which the nucleus is disposed of has long been a bone of con- tention among histologists, and even at the present time views on this question should be held but tentatively, notwithstanding many exhaustive investigations, especially those of the German school. According to the views of Rindfleisch,^ it is lost by extrusion from the cell body, which thus becomes a normal erythrocyte, while the free nucleus, to which a small fringe of protoplasm still remains adherent, collects from the plasma material by virtue of which it ultimately develops into a new er>throblast. Ehrlich - believes that in blood rich in normoblasts a series of connected pictures may be observed, showing that the normoblast becomes transformed into the erythrocyte by the extrusion or emigration of the nucleus. The later investigations of Neumann and K61- liker,^ however, tend to prove that the nucleus is disposed of by its destruction and absorption within the cell, and that its ap- parent extrusion from the stroma is simply the result of mechan- ical influences. Pappenheim and Israel ^ also believe that the normoblast's nucleus disappears by decay and solution within the body of the corpuscle, and that the apparently extruded nuclei are to be taken as an evidence of the process of plasmolysis, or a solution of the protoplasm of the cells once containing nuclei. To attempt a reconciliation of these diametrically opposed views is a task for future workers to undertake. Meanwhile, the general trend of opinion inclines toward the theory of nuclear solution within the corpuscle, and regards the so-called free nuclei of the normoblasts simply as artefacts. 1 Archiv. f. mikroskop. Anat, 1880, vol. xvii., p. I. ^Loc. cit. 3Zeitschr. f. klin. Med., 1S81, vol. iii., p. 411. * Virchow's Archiv., 1896, vol. cxlv., p. 587 ; also, Pappenheim : Inaug. Dissert., Berlin, 1895. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 43 Normoblasts exist in the red bone marrow of the normal indi- vidual, but are found in the circulating blood only when the marrow, in consequence of pressing demands made upon it for the rapid manufacture of new eiythrocytes, becomes unable to furnish an adequate supply of perfectly developed cells, so that some of these immature, nucleated forms prematurely leave their birth-place in the marrow, and pass into the blood stream in com- pany with large numbers of mature, non-nucleated discs. Normo- blasts are associated with lesions in which active hemogenesis of the normal type is stimulated, being the prevailing type of erythroblast in the anemias resulting from hemorrhage, and in other severe anemias of a secondary type. They sometimes ap- pear in the blood in successive crops of large numbers during the course of certain severe anemias, this phenomenon having been termed by von Noorden ^ a blood crisis. Blood crises, which are of abrupt onset and of brief duration, lasting but a few hours, are usually the direct precursors of an increase in the erythro- cyte count and in the hemoglobin percentage, being therefore a favorable sign indicating regeneration of the blood. They occur with especial frequency after loss of blood from hemorrhage, and in chlorosis, and are not uncommon in long-standing cases of spleno-meduUary leukemia and primary pernicious anemia in which diseases periods of temporary improvement are likely to take place from time to time. Megaloblasts. (Plate I.) The megaloblast is much larger in size than the normoblast, and contains a single, large, pale-staining nucleus which occupies the greater part of the cell body. Both cell and nucleus are round or ovoid in shape, the diameter of the former being from about 1 1 to 20 fi, and that of the latter from 6 to \o p.. The greatest extremes of these measurements apply to those forms which are seen with relative infrequency, for the meg- aloblast most commonly observed does not usually measure more than 12 /i in diameter, with a nucleus of proportionate size. The nucleus, which may be situated either in or away from the center of the cell, is composed of a chromatin network having relatively small intervening open spaces, so that the nuclear structure is decidedly more delicate and less well-defined than that of the normoblast. With the triacid solution it stains pale green or blue, or it may show every sort of irregular tinctorial reaction to the aniline dyes, certain portions being deeply stained, while other parts are but faintly colored ; the undertone of green or blue is frequently stippled with fine dots of purple or of brilliant crimson, especially about the periphery; or it may be mottled and 1 Charite-Annalen, 1891, vol. xvi., p. 217. 144 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. splotched here and there with areas of purple or of dark blue. The nucleus usually is sharply differentiated from the body of the cell by a distinct white margin which encircles it and is thrown out in bold relief by the deep staining of the nuclear and cell bodies on either side. The protoplasm of the megaloblast often seems swollen and enlarged, and appears to contain areas of depression and elevation at different points ; it is sometimes quite round or oval in contour, and sometimes more or less deformed. It is usually polychromatophilic, and, like the nucleus, may show the greatest variety of color combinations. Some cells stain a dull brownish-yellow color with deeper shadings of a burnt- sienna tint in the neighborhood of the nucleus and of the periph- ery ; others have an undertone of crimson, as if the stain con- tained an excess of fuchsin, and are streaked and dotted with yellow and tan-colored patches ; still others stain a diffuse purple, blending in spots into a light pink. The megaloblast is an element of the bone marrow of the young fetus, and is totally foreign both to the marrow and the blood of the normal adult. According to the views of Ehrlich, it repre- sents the immediate antecedent of the megalocyte into which it develops by the absorption of its nucleus. Apparent extrusion of megaloblastic nuclei is never observed. Megaloblasts are found in the circulating blood only under conditions in which the blood-making organs have reverted more or less to the fetal type, so that their presence in the circulation is considered to indicate that a sluggish hemogenesis of embrj'onal character exists. The significance of megaloblasts, therefore, is diametrically op- posed to that of normoblasts, for, while the latter are regarded as an expression of blood regeneration, and are considered to be of favorable prognostic significance, the former must be looked on as an evidence of degeneration of the hematopoietic organs, and, consequently, are of grave prognosis. Megaloblasts are found in the blood, almost invariably in as- sociation with normoblasts, in various anemias of marked severit}', but in only three conditions, viz., primaiy pernicious anemia, certain cases of anemia due to botlirioceplialns latiis infection, and nitrobenzole poisoning, have these cells been found to con- stitute the pre\'ailing type of erythroblast. In typical cases of pernicious anemia their prevalence is gener- ally admitted to be a sign that in this disease the bone marrow, in consequence of its reversion to a fetal type, throws into the blood stream large numbers of these blood cells of embr}^onal character, these degenerative changes, the presence of megalo- blasts, overshadowing the regenerative changes, or the presence PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 145 of normoblasts. In bothriocephalus anemia, in which also the megaloblasts may outnumber the normoblasts, it is believed that the toxines produced by the parasite cause changes in the hematopoietic organs precisely similar to those found in pernicious anemia. In a single case of nitrobenzole poisoning, reported by Ehrlich and Lindenthal,^ large numbers of erythroblasts were noted ; normoblasts predominated at first, but in the later stages of the intoxication they were outnumbered by megaloblasts. In other grave anemias, notably in leukemia, the regenerative signs appear to be more active than the degenerative, for, while in these conditions megaloblasts are frequently found, they are never numerous, being outnumbered by the normoblasts. In the following table the principal points of distinction between the normoblast and the megaloblast are emphasized : Normoblast. Megaloblast. Size. 7.5 to 10 11. II to 20 //. Nucleus. Sharply defined. Intensely basic. Coarsely meshed. Occupies about one-half of cell-body. Dully defined. Feebly basic. Delicately meshed. Occupies greater part of cell -body. Protoplasm. Sometimes very scanty, and of ragged outline. Occasionally polychro- matophilic. Frequently appears swollen ; out- line fairly regular, but surface undulating in many cells. Striking tendency toward poly- chromatophilia. Histological Significance. Typical of active, adult hemogenesis. Typical of sluggish, embryonal hemogenesis. Occurrence. Prevailing type of ery- throblast in anemias with active blood re- generation. Prevailing type of erythroblast in anemias' with megaloblastic de- generation of the bone marrow. Microblasts. The microblast, which is the rarest form of nu- cleated erythrocyte, is a cell usually not larger than 5 or 6 // in diameter, and often of smaller size. It consists of a deeply stained, round nucleus like that of the normoblast, encircled by a frag- ment of ragged protoplasm of a dull brownish-yellow tint, in films stsiined with the triacid solution, Microblasts are thought to be simply forms of the normoblast in a more or less advanced stage of protoplasm degeneration, this process accounting for the char- acteristic scantiness and frayed-out appearance of their cell-body. Their clinical significance, naturally, is identical with that of the normoblast. ^Zeitschr. f. klin. Med., 1896, vol. xxx., p. 427. 10 146 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. From what has been stated above, it may be concluded that normoblasts and megaloblasts constitute two distinct classes of nucleated erythrocytes, each evidencing a separate type of blood-formation, and each carrying a different clinical mean- ing. Normoblasts, being an adult type of cell, hav^e sharply defined, dense, deeply stained nuclei ; megaloblasts, being an embryonal type of cell, have poorly defined, delicate, feebly stained nuclei. It is these peculiarities of the nuclear structure that are all-important in determining the class to which a nu- cleated cell belongs — of more importance, in fact, than the size of the cell. Atypical Erythroblasts. In some of the severer anemias, notably in spleno-medullar}^' leukemia and in pernicious anemia, various atypical erythroblasts are frequently found, corresponding partly to one and partly to the other of the first two species of cells described above. The so-called " mesoblasts," which maybe re- garded either as abnormally large normoblasts or as abnormally small megaloblasts, are in some instances almost as numerous as the typical forms of erythroblasts. It is sometimes impossible accurately to determine to which type such cells belong, but usually they may be classified by taking as criteria for differentia- tion the nuclear characteristics referred to in the preceding paragraph. In the triple stained specimen of blood the two fol- lowing commoner forms of atypical erythroblasts may be rec- ognized : — 1. Corpuscles about 8 or 10 ti in diameter, containing a rela- tively large, round or ovoid nucleus, encircled by a distinct hya- line ring, and composed of a finely-meshed chromatin framework. The nucleus stains a pale green color, and is often filled with finely stippled areas of brilliant crimson. The cell-body is usually of regular outline, and, as a rule, is decidedly polychromatophilic. Such cells may be regarded as dwarf forms of megaloblasts, with which they may properly be classed in the differential count. (Plate I.) 2. Corpuscles about 1 2 to 1 5 /i in diameter, having a small, coarsely-meshed nucleus not exceeding 2 or 3 /i in diameter, and, as a rule, situated eccentrically. The nucleus stains greenish or quite black, and may or may not be separated from the proto- plasm by a colorless zone. The body of the cell is of round .or ovoid shape, and stains a dull orange-yellow with shadings of a warm brown tint near the periphery and around the white peri- nuclear zone, if such exists. This form of cell appears to carry the same clinical significance as the normoblast, with which it may be grouped. (Plate I.) PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 47 In certain of the severe anemias, staining with Granular methylene-blue shows a pecuHar granular condi- Degeneration. tion of the protoplasm in some of the erythro- cytes, attention first having been called to this fact by von Noorden/ who demonstrated the basophilic charac- ters of such granules, and described their occurrence in vari- ous pathological states. Many of the corpuscles thus affected are of the nucleated form, but non-nucleated cells may be simi- larly granulated ; as a rule, such corpuscles are also strikingly polychromatophilic. The granules appear either as fine or as coarse, stippled areas, staining intensely with the basic stain, and distributed through the body of the cell either quite uniformly, or in localized patches at one or at several points. In some cells they are exceed- ingly fine and closely packed together, so that at first glance the whole protoplasm appears to be a homogeneous mass of pur- plish discoloration ; in others the protoplasm is dotted here and there with coarse granules, not more than thirty or forty being found in the whole cell; still others may contain both fine and coarse granules irregularly sprinkled over the surface. (Plate I.) The occurrence of somewhat similar granulations in the eryth- rocytes of the embryo has been noted by Engel,^ Pappenheim,^ and others, who regard them as nuclear debris, the product of nuclear disintegration. Such an origin in embryonic blood is probably physiological. In post-uterine life, however, this proc- ess is to be regarded as a sign of stroma degeneration, arising in all likehhood through the influence of various blood-poisons. In some instances the change precedes all other recognizable al- terations in the blood, and appears as the first, and, indeed, some- times the only, distinct sign of anemia. Granular basophilia of the erythrocytes has been noted with more or less constancy in these conditions : pernicious anemia, leukemia, Hodgkin' s disease, so-called tropical anemia, malarial fever, sepsis, carcinoma, long-standing suppurative lesions, and chronic lead- poi- soning. In chlorosis, if uncomplicated by symptoms of intestinal auto-intoxication, the erythrocytes do not exhibit this alteration ; granule cells are also absent in syphilis, in acute infectious diseases, in chronic lesions of the kidney and the liver, and in diabetes, ac- cording to Grawitz.* Regarding the occurrence of this change iQiarite-Annalen, 1892, vol. xvii., p. 202. ^Verhandl. d, Vereins f. innere Med. z. Berlin, 1898-99, vol. xviii., p. 216. 3 Loc. cit. ^ Am. Journ. of Med. Sc, 1900, vol. cxx., p. 277. 148 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. in pernicious anemia, Ehrlich ^ believes that the number of gran- ule cells in the blood bears a certain relation to the severity of the disease, stating that they decrease and often disappear during the periods of remission, reappearing as the other blood changes again become evident. On the other hand, Litten," who asserts that he has found these basophilic granulations in one-tenth of all cases of anemia, has been unable to determine their clinical significance from either a diagnostic or a prognostic point of view. The studies recently completed by Grawitz and Hamel ^ show that granular degeneration of the er)^throcytes occurs with great regularity in satutniism, both in obscure and in well-marked cases, and these authors attach considerable diagnostic value to this fact, concluding that the sign is important in the diagnosis of lead- poisoning in patients in whom the intoxication is merely sus- pected, being evidenced by no other definite symptoms. Oligocythemia, or diminution in the number of Oligocy- erythrocytes below the normal standard, is pres- THEMIA. ent to a more or less narked degree in all forms of anemia, being associated, naturally, with an oligochromemia, or diminution in the percentage of hemoglobin, but not necessarily with an oligemia, or reduction in the volume of the blood-mass. The loss of corpuscles may be slight or it may be marked, ac- cording to the nature of the anemia of which it is symptomatic. The most striking examples of oligocythemia are encountered after hemorrhages involving the loss of a large amount of blood, and in pernicious anemia; while in chlorosis, and in the majority of the secondary- anemias the decrease is relatively less marked. The following summary of the averages of fifty consecutive counts each in cases of primary and secondary anemia, illustrates the various degrees of cellular loss which ordinarily accompany these conditions : Average of 50 counts. Erythrocytes per cb. mm. In pernicious anemia 1,152,470 '' leukemia 2,729,763 " secondary anemia 3,642,900 ' ' chlorosis 4, 1 1 1 ? 000 It is impossible to designate the degree of oligocythemia which may exist without a fatal outcome, although a number of au- thorities have attempted to set fixed limits beyond which reduction ^ Loc. cit. i' Deut. med. ^Voch., 1899, vol. xxv., p. 717. 3 Deut. Archiv. f. klin. Med., 1900, vol. Ixvii., p. 357. PATHOLOGICAL CHANGES IN THE ERYTHROCYTES. 1 49 in the number of erythrocytes is supposed to cause death. The effects of a blood loss are so diverse in different individuals that all such arbitrary rules must, of necessity, prove practically valueless. It should be remembered that while in some persons a comparatively moderate decrease may prove fatal, in others a most astonishing loss is compatible with life. It may be stated in general terms that few individuals recover in whom a count of less than 500,000 erythrocytes to the cubic millimeter is found, although occasional exceptions to this rule have been reported. Whether or not an actual, permanent polycy- PoLYCYTHEMiA. themia, or an increase in the number of erythro- cytes above the normal standard, exists is still an unsettled question, but the majority of authorities maintain that such a condition is due merely to some physical change producing concentration of the blood, or unequal distribution of the corpuscles, in favor of the peripheral blood-vessels. In health, it would not seem unreasonable to suppose that a moderate de- gree of polycythemia may be habitual in the strong, over-devel- oped adult, whose blood-making organs are possibly developed proportionately to the other parts of his system. In pathological conditions there is nothing tangible upon which to base the belief that an actual and permanent increase in the number of erythro- cytes ever takes place, the polycythemia associated with certain diseases being satisfactorily accounted for by coexisting physical conditions, in no way peculiar to the lesion in question. While it is true that in some conditions it is not always possible to ex- plain the increase by purely physical causes, still there is no posi- tive proof, in these instances, that the change is pathological. There seems, therefore, no evidence to warrant an arbitrary clas- sification of polycythemia into two divisions, actual and relative, as some authors have suggested. The cause of polycythemia, then, may be attributed to physio- logical factors such as concentration of the blood, peripheral stasis, increased viscidity of the erythrocytes, and their unequal distribution through the circulatory system. The polycythemia associated with various physiological and pathological conditions will be considered under their appropriate headings. Briefly, an increase of erythrocytes over the normal number is found in the following conditions : — 1. In the new-born. 2. After taking food. 3. In starvation. 4. During resort in high altitudes. 5. From the effect of cold baths, massage, and electricity. I 50 ERYTHROCYTES, BLOOD PLAQUES, AND HEMOCONIA. 6. From the administration of lymphagogues, emetics, and purgatives. 7. During active blood regeneration. 8. During reformation of an exudate after aspiration. 9. After urinar}^ crises, diaphoresis, and emesis. 10. In poisoning by illuminating-gas and by phosphorus. 11. In Asiatic cholera, dysentery, and diarrhea. 1 2. In acute yellow atrophy of the liver, and myxedema. 13. In conditions of cyanosis and peripheral stasis, for example, uncompensated organic heart-disease, emphysema, and asphyxia. 14. After the transfusion of blood. V. BLOOD PLAQUES. If a drop of fresh blood is examined microscopically, imme- diately after it has been taken from the body, a few pale, some- what spherical bodies, much smaller in size than the erythrocytes, may usually be observed. These bodies are known as the blood plaques or blood platelets. They are of homogeneous structure, either almost colorless or of a pale yellowish tint, spherical or irregularly ovoid in shape, and measure from i to 3 or 4 ^t« in diameter. They are non-nucleated, entirely devoid of ameboid movement, and react toward both basic and acid aniline dyes, having an amphophilic affinity. The plaques exist as free bod- ies in the general circulation, but directly after the withdrawal of the blood from the vessels they show a remarkable degree of vis- cosity, by virtue of which they tend to adhere in racemose masses the occurrence of which at or near the radiating points of the fibrin network has already been described. The old belief that the plaques represented a so-called " third corpuscle " of the blood is not justified, for it has been proved that these bodies are not distinct cellular entities, but rather debris, derived either from the blood corpuscles or from the plasma. Most authorities re- gard them as bits of globular matter extruded from the erythro- cytes, others as fragments of disintegrated nuclei of the leuco- cytes, and still others as masses of precipitated globulin. Exposure to the air appears to cause an almost immediate dis- appearance of the plaques from the blood, and, therefore, they are but seldom noticed in the blood-film prepared by the ordinary methods. To avoid bringing the blood in contact with the air, it may be drawn directly through a drop of Hayem's solution, or a weak solution of osmic acid, the mixture of the blood and fixative being then placed upon a slide, and examined in the usual manner. (See page 71.) HEMOCONIA. 151 The number of plaques in normal blood varies within wide limits, accordincr to the statements of different authorities, but about 300,000 to the cubic millimeter is generally considered the normal average, and from 180,000 to 500,000 the range under physiological circumstances. The plaques are generally increased in pernicious anemia, severe secondary anemias, leukemia, pneumonia, arthritis deformans, myelitis, tuberculosis, and bubonic plague, and diminished in hemo- philia, purpura, and acute febrile diseases such as erysipelas, typhus fever, and the malarial fevers. VI. HEMOCONIA. Miiller^ has called attention to the constant presence in normal and pathological blood of small, colorless, refractive bodies, of spheroidal or dumb-bell shape, not larger than i /i in diameter. These bodies, to which the terms hemoconia and blood-dtist have been applied, are highly refractive, and possess active, limited molecular motility, but not true ameboid motion. They have been compared in appearance to fine fat-droplets, to micrococci, and to granules derived from the protoplasm of the leucocytes. Nothing is known of their histological character and significance, beyond the facts that they are not concerned in the process of fibrin-formation, and that they are not fatty bodies, since they are neither stained by osmic acid, nor dissolved by ether. Both Stokes and Wegefarth,^ and NichoUs ^ regard them as free granules of the neutrophile and eosinophile leucocytes, and believe that they are probably concerned in the protective properties of the blood in immunity. Stengel* suggests that they may be simply the products of fragmentation of the erythrocytes, such as may be produced by heating fresh blood to destructive temperatures, when bits of the corpuscles are seen to bud out, break off, and float free in the plasma, endowed with pseudo-ameboid motility. Miiller found hemoconia numerous in a case of Addison's dis- ease, but these bodies were very scanty in a number of markedly cachectic conditions. Their occurrence in the blood appears to carry no definite clinical significance. iCentralbl. f. Path. u. Bakteriol., 1896, vol. xxv., p. 529. 2 Johns Hopkins Hosp. Bull., 1897, vol. viii., p. 246. sPhila. Med. Joum., 1898, vol. i., p. 387. 4** Text-book of Pathology," Phila., 1899, 2d ed. SECTION IV. THE LEUCOCYTES. ( Triacid Stain.) 1. 2, 3, 4- Small Lymphocytes. Contrast the faintly colored protoplasm of these cells in the triple stained specimen •with their intensely basic protoplasm in the film stained with eosin and methylene- blue, 17 and 18. The cell body of i is invisible. Note the kidney-shaped nucleus in 4. 5, 6. Large Lymphocytes. With this stain the nucleus reacts more strongly than the protoplasm ; with eosin and methylene-blue (19. 20), on the contrary, the protoplasm is so deeply stained that the nucleus appears pale by contrast. This peculiarity is also observed in the smaller forms of lymphocytes. 7, 8. Transitional Forms. Note the moderately basic and indented nucleus, and the almost hyaline non-granular protoplasm. Compare 8 with the myelocyte, 7, Plate IV, these cells differing chieHy in that the myelocyte contains neutrophile granules. 9, 10, II. Polynuclear Neutrophiles. These cells are characterized by a polymorphous or polynuclear nucleus, surrounded by a cell body filled with fine neutrophile granules. In 11 the nuclear structure is obviously separated into four parts ; in 9 it is moderately, and in 10 markedly, poly- morphous. 12, 13. Eosinophiles. The nuclei are not unlike those of the polynuclear neutrophile, except that they are somewhat less convoluted, and poorer in chromatin, staining less intensely. The pro- toplasm is filled with coarse eosinophile granules, the characteristics of which are clearly illustrated by 13, a " fractured " eosinophile. 14. Eosinophilic Myelocyte. Compare with 15. 15, 16. Myelocytes. {Neutrophilic.) These cells are morphologically similar to 14, except that they contain neutrophile instead of eosinophile granules. Note that the granules of the myelocyte are identical with those of the polynuclear neutrophile. h. dwarf form of myelocyte is represented by 16. {Eosi7i and Methylene-blue.) 17, 18. Small Lymphocytes. Note the narrow rim of pseudo-granular basic protoplasm surrounding the nucleus, and the pale appearance of the latter. 19, 20. Large Lymphocytes. Budding of the basic zone of protoplasm is represented by 20. Both of these cells belong tf> the same type as 5 and 6. 21, 22. Large Mononuclear Leucocytes. Compared with 19 and 20, these cells have a decidedly less basic protoplasm, but a somewhat more basic nucleus. In the triple stained film these differences cannot be detected, so that they must be classed as large lymphocytes. 23, Transitional Form. The distinction between this cell and 24 is not marked ; the nucleus of the latter simply being somewhat more basic and convoluted. 24, 25, 26, 27. Polynuclear Neutrophiles. With this. stain these cells show a feebly acid protoplasm, and lack granules. Note that the more twisted the nucleus the deeper it is stained. Compare with 9, 10, and 11. 25, 29. Eosinophiles. Compare with 12 and 13. 30. Eosinophilic Myelocyte. Compare with 14. 31. Basophile. {Finely granular.) This cell is characterized by the presence of exceedingly fine 5-granules, staining the pure color of the basic dye. The nucleus is markedly convoluted and deficient in chromatin. The cell here shown was found in normal blood. 32,33,34,35,36. Mast Cells. • • •• The granules take a modified basic color, as shown by their royal-purple tint in this illustration. Note their unusually large size and ovoid shape in 35, their peculiar distribution in 35 and 36, and their irregularity in size in 32 and 36. With the triacid mixture these granules, as well as those of the finely granular basophile, 31, remain unstained, showing as dull-white stippled areas in the cell body. The nuclear chro- matin of the mast cell is so delicate and so feebly stained that it is barely visible. These cells were found in the blood of a case of spleno-medullary leukemia. PLATE II. ""^M^ 10, 14 o*l «... ,foo»ooo'o «„•?. 1 1 4^^,^-?ft>< ih^^ 12 !S^^^ 16 ♦;• ;v' .•{.. • .'c 21 22 17 18 OOi 23 28 29 26 30 ooo-7)5oo Eosinophiles o. 5-5 25-500 Basophiles, as high as 0.5 25 ^ Log. cit. 2"Klinische Pathologic des Blutes," Berlin, 1896. l60 THE LEUCOCYTES. The variations in these numbers and percentages, which de- pend upon different physiological and pathological influences, are referred to in other sections. The lymphocytes, or small lymphocytes, as Small they are commonly designated in contradistinction Lymphocytes, to the large mononuclear forms, are non-granu- lar cells which measure from about 5 to 10 /.« in diameter, their average size being that of the normal erythrocyte, or 7.5 fi in diameter. The typical cell of this class consists of a single, round, deeply staining nucleus surrounded by a narrow zone of protoplasm, and sometimes provided with one or two pseudo-nucleoli, situated eccentrically upon the nuclear surface. The nucleus is so relatively large that it almost completely fills the cell, being its most conspicuous part, while the rim of proto- plasm is usually so narrow and poorly defined that at first glance it may escape notice. These characteristics — a relatively large nucleus, and a relatively scant}^ amount of protoplasm — are more conspicuously exhibited in the smaller than in the larger forms of these cells. With Ehrlich's triple stain the nucleus, being rich in chromatin, is colored deep blue or purple, and the protoplasm is either en- tirely unstained, appearing as a narrow hyaline halo surrounding the nucleus, or it is tinged a delicate shade of pink, if it happens to react toward the acid fuchsin of the mixture. In films stained with eosin and methylene-blue the nucleus shows a decided affinity for the basic dye, usually staining dark blue, or, more rarely, pale green. The protoplasm shows as a relatively narrow encircling area of deep blue color, which has been likened in appearance to the surface of ground glass ; it is much more intensely basic than the nucleus, which looks pale by contrast. Occasionally small lymphocytes are encountered in which the nucleus is atypical both in morphology and in staining properties. Thus, some cells contain a pale, almost hyaline nucleus composed of an exceedingly scanty chromatin structure which reacts vQry feebly to the basic dyes ; others contain a deeply stained, indented or kidney-shaped nucleus similar in shape to that of the so-called "transitional" forms; while still others are provided with a nucleus which has evidently become completely divided, so that such a cell really contains two distinct hemispherical nuclei, rich in chromatin, deeply stained, and situated toward the poles of the cell body. These irregular forms of lymphocytes occur in both normal and in pathological blood, but with much greater frequency in the latter, especially in both forms of leukemia. CLASSIFICATION. l6l Under this term it is convenient to include Large both the larger forms of the true lymphocyte — Lymphocytes, those measuring ii // or more in diameter — and also that variety of hyaline cell known as the large mononuclear leucocyte. These two forms of cells, although they are generally considered as distinct histological species, one being a true lymphocyte and the other probably a marrow-bred element, may for practical purposes be classed together, since it is impossible to differentiate one from the other in the specimen prepared for an ordinary clinical examination.^ Cells of this type may range in size from 1 1 to 1 5 /i or even larger in diameter, and are usually of round or ovoid shape, ex- cept in an occasional cell where, in consequence of the injury received during the preparation of the blood-film, the outline may be exceedingly irregular and deformed. The nucleus, which is round, ovoid, or somewhat elongated, is generally situated to- ward the periphery of the cell body. In most of the cells the amount of protoplasm is relatively greater than that of the small lymphocyte, but occasionally this peculiarity cannot be dis- tinguished. The nucleus, being poor in chromatin, stains pale blue with the triple stain, and is usually so delicately tinted that it is almost invisible ; the protoplasm is faintly tinged with pink, or with gray- ish-blue, or it may remain practically colorless, showing merely as an indefinite hyaline area surrounding the nucleus. With mixtures of a strong acid and basic dye, such as eosin and methylene-blue, the nuclear chromatin stains a diffuse sky- blue tint, and the protoplasm exhibits a more or less decided af- finity for the basic element of the staining fluid. This tendency is very marked in some cells, the protoplasm of which contains an intensely basic pseudo-granular zone staining much deeper blue than the rest of the cell body, parallehng the extreme periph- ery of the cell, and often apparently separated from the nucleus by a distinct unstained area. In other cells this basic affinity is not so conspicuous, their protoplasm staining a diffuse purplish shade in which a rose-red tone prevails. 1 Some authors, Ehrlich himself among them, maintain that a distinction be- tween these two forms of cells may invariably be made in the stained specimen. Thus, in the film stained with methylene-blue, it is held that the true lymphocyte, no matter what its size, always possesses a strongly basic protoplasm and nucleus, the latter staining less deeply than the former ; while the large mononuclear leucocyte has a feebly basic protoplasm and nucleus, the latter staining mo7-e intensely than the former. These points of difference, although they may be distinguished in specimens stained by special methods, seem to be too finely drawn to justify their acceptance as reliable criteria for the identification of these two groups of cells in films prepared by the technique adapted to routine clinical work. 11 1 62 THE LEUCOCYTES. Apparent extrusion of portions of the cell body is not uncom- monly observed, this phenomenon producing a peculiar ''frayed- out," ragged appearance around the periphery of the lympho- cyte, due to the partial detachment of small bits of the peripheral seam of basic protoplasm, which loosely adhere to the outer margin of the cell. Occasionally these small basic masses be- come entirely detached, and may be seen lying free in the plasma, alongside the cell of which they were once a part. Typical forms of the large and small lymphocyte, such as are seen in the great majority of stained blood-films, may be dis- tinguished without difficulty, but in some diseases, notably in the lymphatic variety of leukemia, irregular forms of these cells are found, the size and nuclear characteristics of which are so confus- ingly atypical that it is sometimes futile to attempt the classification of such hybrids into two arbitrar)^ groups, large and small. Thus one may meet with cells the size of the small lymphocyte but hav- ing a feebly basic, eccentric nucleus and a relatively large amount of protoplasm ; and with cells identical with the large lymphocyte except that they possess a small, spherical, strongly basic nucleus. In attempting to differentiate these atypical forms in the triple stained specimen, it is safe to be guided by the suggestions given by Thayer,^ who is inclined to place more emphasis upon the character of the nucleus than upon the size of the cell body as a whole. Thus, in a doubtful mononuclear, non-granular cell in which the nucleus is similar in size and shape to that of the small lymphocyte, regardless of its affinity for the basic element of the stain, the cell is classed as a small lymphocyte, until the size of such a cell exceeds that of the polynuclear neutrophile. Some cells no larger than the smallest lymphocyte may be classed as large lymphocytes if their nuclei are decidedly ovoid in shape, and pale in color. In spite of every precaution, however, it must be admitted that in some instances differential counts of these two types of cells must be more or less inaccurate, for the obvious reason that so much depends upon the personal equation. The so-called transitional forms are cells which Transitional closely resemble the large lymphocyte in shape Forms. and in size, but which differ from the latter variety of cell chiefly in having a nucleus which, instead of being ovoid in shape, is indented and drawn out into the form of a crescent with rounded poles, the concave aspect of the nu- clear figure lying toward the center of the cell. In other forms the nucleus may have become moulded into a figure resembling ^ Johns Hopkins Hosp. Reports, 1894, vol. iv., p. 103. CLASSIFICATION. 1 63 an hour-glass, which occupies the central portion of the cell body, not lying in contact with its periphery at any point. With the triple stain the nucleus of this cell is usually stained somewhat darker blue than that of the large lymphocyte, and the protoplasm is either quite colorless, or, perhaps, slightly tinged a grayish-blue. With eosin and methylene-blue the nu- cleus shows a moderately strong affinity for the basic dye, being colored much darker blue than the nucleus of the large, but dis- tinctly paler than that of the small, lymphocyte ; the protoplasm is stained a diffuse purplish tint, in which the pink tinge of the eosin conspicuously predominates. Inasmuch as the clinical significance of the transitional forms is identical with that of the large lymphocytes, it is customary to class both forms together under a single heading, in the per- centage table of the different forms of leucocytes Polynuclear neutrophiles are cells which, as a PoLYNUCLEAR general rule, measure from about lo to 12 /i in Neutrophiles. diameter, although their size may vary within wide limits, some being not much larger than the small lymphocytes, while others are nearly twice this size. The distinguishing characteristics of these cells are the twisted, polymorphous nature of the nuclei and the so-called " neutro- philic " reaction of the granules which are embedded in the pro- toplasm. The nucleus may be of almost any shape — elongated, wreathed, lobulated, horseshoe-shaped, or twisted into designs re- sembling various letters of the alphabet, such as an S, Z, U, or E. It usually consists of several apparently separate masses of irregular shape connected with each other by delicate filamentous strands of chromatin, which dip beneath the surface of the pro- toplasm, and, owing to the density of the overlying granules, are invisible or but dimly defined in the triple stained specimen. By the use of the simpler double stains, such as eosin and methylene-blue, the presence of these connecting chromatin threads may be demonstrated with great clearness. Less com- monly, a cell contains several small oval or round nuclei, which are actually separated from each other, complete division at the points of constriction having resulted in the production of two or three, and, in rarer instances, even six or seven distinct nuclei. The nuclear structure is rich in chromatin, which forms a dense, unevenly staining network possessing a marked affinity for the various basic dyes. It stains dark blue or greenish-blue with the triple stain, and still more intensely blue with eosin and methyl- ene-blue solutions. The fact that the single, twisted type of nucleus predominates 164 THE LEUCOCYTES. in these cells has led to the current use of the adjective *' poly- morphonuclear " as a substitute for " polynuclear," but it is per- fectly ob\ious that both terms may be used synonymously, the latter perhaps being preferable, because of its brevit}*, and of its established vogue. The irregularity of the nucleus is regarded as a sign of the ameboid activity of the cell, as first suggested by Arnold,^ and not as an indication of degeneration, as formerly believed. It has been effectuallv demonstrated bv Sherrington - that if such cells are allowed to quiet down before they are killed, their nuclei usually return to a spheroidal form. The protoplasm of the polynuclear leucocyte is densely packed with exceedingly fine so-called neutrophile granules, which stain lavender, or purple, or, rarely, pink, with Ehrhch's triacid mixture, but which are usually unstained by solutions containing eosin and methylene-blue. Kanthack and Hardy ^ have shown that these granules have ''a minimal attraction for acid dyes, or, briefly, a minimal oxyphile reaction," and, furthermore, that Ehrlich's neutral mixture by which they are intensely stained, is not, chemically speaking, a neutral stain, but, on the contrar}', a powerful and exceedingly differential acid dye, intensely staining oxyphile granules of all varieties."* The oxyphihc tendency of the granules may be beautifully demonstrated by the use of Jenner's eosin-methylene-blue formula, to which reference has been made. Thus, having proved that the granules oi the poly- nuclear " neutrophile " cell of Ehrlich display a distinct, although feeble, affinit}' for acid dyes, and that they are unstained by basic and neutral dyes, the term " finely granular oxyphile cell " has been adopted by these authors for this vaiiety of leucocyte, the granules being known as " finely granular oxyphile" granules. It is doubtful, however, if the use of these unwieldy terms will receive general approval, except by certain of the British school. To designate a polynuclear leucocyte as a *' finely granular oxy- phile cell" is even more glaringly inappropriate than the use of Ehrlich's term, " neutrophile," for other varieties of leucoc}i:es ' Archiv. f. Mikroskop. Anat., 1887, vol. xxx., p. 226. 2 Proc. Intemat. GDngress of Physiologists, Liege, 1S92. 3Journ. of Physiolog}-, 1S94, vol. xvii., p. 61. ♦ Reasoning upon the basis that eosin stains with most striking intensity in an aqueous solution, less decidedly in a glycerin solution, and even less strongly when dissolved in strong alcohol, these investigators distinguish three classes of oxyphile granules, according to the intensity of their affinity for acid dyes, thus : (l) Those which stain with eosin only in aqueous solutions, or in alcoholic solutions of a per- centage below 60 ; (2) those which stain in both aqueous and glycerin solutions, but not in a strong alcoholic solution (90 to 95 per cent. ) of the dye, and (3) those which stain with aqueous, glycerin, and strong alcoholic solutions. They include in the first class, the neutrophile and the amphophile granules of Ehrlich. CLASSIFICATION. 165 (/. e., myelocytes, and ''neutrophilic pseudolymphocytes ") may be just as fittingly described by the former phrase. The granules are of very small size, and of irregular wedge- or spike-shape, never being spherical or ovoid in contour. They are usually most densely distributed about the periphery of the cell, whence they gradually shade off toward the nucleus, which is frequently found to be encircled by a perfectly hyaline, non- granular zone. The granules are not always confined to the cell protoplasm, being scattered over the nucleus, portions of which even may be partly obscured by the overlying granular film. The jelly-like substance of the protoplasm in which the granules are embedded appears to show a slight affinity for acid dyes, the intensity of this affinity varying greatly in different cells. With the triple stain this reaction is evidenced by the variable depth of fuchsin-colored undertone which may be detected beneath the puiplish color of the granules ; while in the specimen stained with eosin and methylene-blue, in which the granules are not visible, the protoplasm is evenly tinted the color of eosin. These cells are the most conspicuous of all the EosiNOPHiLES. leucocytes, and may be at once identified by the presence of a more or less polymorphous nucleus embedded in a protoplasm studded with coarse, highly refractive granules which have a strong affinity for acid dyes, such as eosin and acid fuchsin. Owing to the large size of their granules, and to their striking oxyphilic reaction, these cells are also known by the term ''coarsely granular oxyphile cells," in contradistinction to the " finely granular oxyphile cells," or polynuclear leucocytes. (Kanthack and Hardy.) The size of the eosinophile varies very greatly, but most of them approximate the size of the polynuclear neutrophile, or are, perhaps, a trifle smaller. Their diameter commonly ranges from 8 to 1 1 //, although occasionally forms not larger than the normal erythrocyte are to be observed. Their shape is usually that of an irregular sphere, or oval. The nucleus may be kidney- or horseshoe-shaped, or twisted and drawn out into an irregular mass, but it is rarely as con- stricted and deformed as that of the polynuclear neutrophile. It is nearly always situated eccentrically, cells of this variety with centrally placed nuclei being very uncommonly seen. Occasion- ally the eosinophile contains multiple nuclei, consisting of sev- eral oval or round masses between which no connecting chro- matin threads can be distinguished, but usually such portions of the nucleus are joined together by extensions of chromatin running beneath the protoplasm. The nucleus stains faintly in comparison with that of the polynuclear neutrophile, although 1 66 THE LEUCOCYTES. more intensely than that of the large mononuclear cell ; it is col- ored pale blue or greenish-blue by the triple stain, and dark blue by eosin and methylene-blue mixtures. The granules, which are relatively large in size and quite regu- larly spherical in shape (in contrast to the delicate, irregularly shaped granules of the polynuclear neutrophile), react strongly toward the acid elements of the triple stain ; some are stained a brilliant fuchsin color, some deep red, while others are brown- ish-yellow, or copper color, or even black ; with mixtures of eosin and methylene-blue they take the brilliant color of eosin. There appears to be a marked tendency on the part of the gran- ules to overrun the nucleus, so that its morphology in some cells is almost indistinguishable. The granules are also prone to be- come readily detached from the protoplasm, which doubtless ac- counts for their uneven, blotchy distribution in many cells, in which densely packed granular areas alternate with open spaces merely punctuated here and there with an occasional granule. Eosinopliiles appear to offer but feeble powders of resistance against external influences, so that it is common to find these cells so injured by the process of making the film, that the nu- cleus has escaped from the cell body, and the granules, lying free in the plasma, are scattered about it in a cloud. This insta- bility, or "explosive" character of the eosinophile is one of its most striking attributes, for, while observed now and then in a polynuclear neutrophile, it occurs with much greater frequency in eosinophiles than in the latter type of leucocyte. The protoplasm of the cell may or may not show an affinity for the aniline dyes ; usually it does not, so that the granules appear to be embedded in a perfectly hyaline substance ; occasionally it is faintly stained by fuchsin, or by eosin. Finely granular basophile cells, containing Ehr- Basophile lich's o-granules, are occasionally encountered in Cells. normal blood, but with such rarity that their real significance is not understood. In general morphology and size these cells resemble the poly- nuclear neutrophiles. The nucleus is invariably twisted, and usu- ally consists of two or three distinct lobes joined by thin chro- matin bands ; in the stained specimen it is never of round or oval shape, but always shows evidences of polymorphism. The nuclear structure is composed of a delicate, scanty network of chromatin, and has a moderate affinity for basic dyes, staining dull blue with the triple stain, and pale sea-green with eosin and methylene-blue mixtures. The protoplasm of the cell is closely packed with fine, irregu- larly shaped granules having an intensely basic reaction ; they CLASSIFICATION. 1 6/ stain deep blue with solutions containing methylene-blue, but are not colored by the triple stain, showing in films stained with this mixture as groups of dull white spots scattered through the cell body. Jenner's stain is most useful in bringing out the char- acteristics of these granules. Myelocytes, or marrow cells, are relatively Myelocytes, large round or oval cells, ranging from lo to 20 [1, or even more in diameter, their average size being somewhat larger than that of the large lymphocyte, which they resemble in general morphology. The nucleus of the typ- ical myelocyte is of spherical or ovoid shape, and is situated eccentrically, lying distinctly toward one side of the cell, so that the peripheries of both cell and nucleus are often closely ad- jacent for some little distance — usually for from one -third to one-half of their course. The nucleus reacts feebly toward the basic element of the triple stain, being colored a pale, delicate sky-blue with this solution ; it stains a moderately deep blue or purple with eosin and methylene-blue mixtures, and appears to be more coarsely netted and deeply stained than in films prepared by the preceding method. In the smaller forms of myelocytes the nucleus is frequently found to occupy the center of the cell body, so that it is sur- rounded on all sides by a protoplasmic zone of even width. In some of the larger forms the nucleus may be indented, and moulded along one margin of the cell body like that of the so- called ''transitional " leucocyte. In rare instances actual division of the nucleus appears to have occurred, so that two separate nuclei, each shaped like a flattened hemisphere and situated at an extreme pole of the cell, may be found. Such cells are often mistaken at first glance for polynuclear neutrophils, inasmuch as both forms of cells contain multiple nuclei and neutrophile gran- ules ; but the nucleus of the polynuclear neutrophile is always more or less twisted and of undulating surface, relatively rich in chromatin and stained with decided intensity, and rarely situated at the poles of the cell, while the nuclear halves of this type of the myelocyte are of regular outline and uniformly close to the surface of the cell, relatively poor in chromatin and faintly stained, and invariably occupy the extreme poles of the cell body. The protoplasm of the myelocyte is filled with fine neutrophile granules, such as occur in the polynuclear neutrophile ; they are most densely distributed at the periphery, and grow appreciably less abundant as they approach the nucleus, which they may overrun, spreading over its surface like a thin veil, so that its structure is more or less hidden. 1 68 THE LEUCOCYTES. This one characteristic — the presence of neutrophile granules in the protoplasm — at once serves to distinguish the myelocyte from the large lymphocyte, which it may exactly resemble in size, shape, and nuclear structure ; the importance of using Ehr- lich's triple stain to differentiate these granules in specimens used for differential counting is therefore patent. With the triple stain, the granules stain purple or lavender, exactly like those of the polynuclear neutrophile. With eosin and methylene-blue mixtures the protoplasm is stained light pur- ple, broken here and there by indistinct, darker granular areas of the same color, indicating the presence of basophile granules, in addition to those of neutrophile reaction, which are not clearly demonstrable with this stain. In certain pathological conditions, notably in spleno-medullary leukemia, an occasional myelocyte may be observed which con- tains both fine neutrophile and very coarse basophile granules, the latter being precisely identical in size, shape, and tinctorial qualities with Ehrlich's j or mastzellen granules. They are situated both in the protoplasm of the cell, and over the nucleus. These granules are, in the author's experience, demonstrable only in specimens stained by Jenner's method showing in such prep- arations as coarse, brilliant purple granules contrasting vividly with the paler eosin-colored neutrophile granules which fill the body of the cell, and with the greenish-blue color of the nucleus. Eosmophilic myelocytes, or myelocytes with a protoplasm filled \vith coarse eosinophile instead of neutrophile granules, are common to several pathological conditions, but occur with es- pecial frequency in the spleno-medullar}^ variety of leukemia, and also in pernicious anemia, to some extent. Such cells are iden- tical in size and morphology of cell body and nucleus with the commoner neutrophilic myelocytes, from which they differ only in containing eosinophile granules. The normal habitat of the myelocyte is in the red bone mar- row, and its presence in the circulating blood must always be re- garded as pathological. At one time regarded as practically pathognomonic of leukemia, the myelocyte is now known to occur in many other conditions, especially those characterized by pro- found cachexia, by marked anemia, and by increase in the num- ber of leucocytes. The occurrence of myelocytes in the blood in v^arious diseases, and the clinical significance of these cells is discussed in another place. (See ** Myelemia.") Cells containing Ehrlich's j'-granules, known Mast Cells. b>' the term 7nastzeUen, or mast cells, are oc- casionally present in the peripheral circulation CLASSIFICATION. 1 69 as the result of certain pathological influences, but are totally- foreign to the normal blood of man. They are very commonly found, sometimes in considerable numbers, in the spleno-medul- lary type of leukemia, but are by no means invariably associated with this disease, being absent in many typical cases. The cells are of spherical or ovoid shape, and are characterized by a relatively large, structureless nucleus enclosed in an almost indefinable protoplasm, and by the presence of coarse basophile granules scattered irregularly over the surface of the cell — marks of identification which remain unchanged whatever the size of the cell may be. No variety of cell found in the blood exhibits wider ranges in size. The forms most commonly observed meas- ure approximately from 9 to I2/^ in diameter; some have a di- ameter of fully 20 or even 22 //, but cells of this extremely large size are the exception rather than the rule ; others are scarcely larger than the small lymphocyte, being but 7 or 8 // in diameter, and these very small forms are also uncommon. The nucleus is round, oval, or somewhat lobulated, and occu- pies the greater part of the cell body, in which it is usually situ- ated eccentrically. Owing to the similarity in the appearance of the nucleus and the protoplasm, it is frequently impossible to de- termine the precise point at which the former structure begins and the latter ends, so that, in the stained specimen, many cells are met with which appear to consist simply of irregular groups of granules clinging to a pale nucleus, every definite trace of the cell body being lost. (See Plate II, Figs. 35 and 36.) In films stained with Jenner's solution (which is, by far, the most satisfac- tory stain for illustrating the finer morphology of these cells) the nucleus is colored a beautiful, iridescent greenish-blue, the tint of which is so extremely delicate that in many cells it is barely per- ceptible. The staining, though faint, is even and clear, indicating a structure almost totally devoid of chromatin. The granules are invariably large and coarse, and vary greatly in size and in shape. Some are smaller than the granules of the eosinophile cell, while others approach or even slightly exceed . 5 /i in diameter. They may be spherical, egg-shaped, or roughly cuboid, the latter form of granule being exceedingly common. A single type of granules is not always found to the exclusion of the others, for one cell often contains granules of every possible variety of shape anfl size ; this peculiarity is especially striking in some of the smaller forms of cells in which extremely coarse egg-shaped and smaller spherical granules may be distinguished clinging to the periphery of the nucleus about which no evidence of protoplasm is demonstrable. (See Fig. 36, Plate II.) In other 1^0 THE LEUCOCYTES. forms, both large and small, the large spherical or ovoid granules may prevail almost exclusively. (See Figs. 33, 34, and 35, Plate II.) The distribution of the granules through the cell follows no constant rule, but it is evident that a more or less decided tendency exists toward their collection near the peripher>\ They are al- ways most densely distributed at this point, sometimes extending inward over the nucleus which is thus partly hidden, and some- times crowded into a limited zone which coincides with the outer boundary of the cell for the greater part of its extent. The granules of the mast cell show an intense affinity for basic aniline dyes, toward which they react metachromatically, in a highly characteristic manner. With Jenner's solution they are stained a deep royal purple color in which the red tone is dis- tinctly evident, thus differing from the granules of other basophile cells which are stained a pure blue with this mixture. Dr. H. F. Harris has called the writer's attention to a still more distinctive method of identifying these granules, by first staining with carbol- toluidin-blue or with thionin, and then by differentiating with Unna's glycerin-ether mixture. In specimens thus treated the mast cell granules are of a dark red color, while other basophile granules stain blue, so that the former must be regarded as hav- ing a modified basic reaction. They are stained reddish-violet with Ehrlich's acid dahlia solution, and deep blue with aqueous solutions of methylene-blue. They are not stained by the tri- acid mixture, and appear as coarse, dull white spots through the cell body, in films stained with this solution. The distinctive manner in which they react toward selective stains for mucin has recently been discovered by Harris,^ who, in view of this fact, suggests that the term nmcinoblast be applied to the mast cell. The author questions the identity of these coarsely granular basophilic blood cells with the well-known mast cell of the tissues, although most hematologists consider them identical. Both, it is true, contain granules which tinctorially and morpholog- ically are identical, but it is obviously impossible to determine cell identity by criteria such as these. The mast cell of the tissues differs from that of the blood in having a nucleus which is smaller in relation to the size of the cell body, more centrally situated, and richer in chromatin, hence being more deeply and more unevenly stained. The ''explosive" nature of the tissue mast cell is also usually more striking, for while cells with this tendency are met with only occasionally in the blood, they seem to be the rule rather than the exception in the tis- sues, large numbers of them consisting of a nuclear structure sur- 1 Phila. Med. Journ., 1900, vol. v., p. 757. CLASSIFICATION. I /I rounded by dense clusters of granules, which are frequently drawn out in long tentacular extensions. In view of these differences, it may be well to be more specific, by designating the mast cell found in the blood as the hemic mast cell. This term has been applied by Capps ^ to a form Mononuclear of leucocyte which he found in certain cases of Neutro- general paralysis of the insane, its appearance PHILES. in the blood having been noted after apoplectiform attacks, and preceding death. This cell is as large as, or larger than, the polynuclear neutrophile, contains a round or ovoid nucleus which is deeply stained by basic dyes, and has a protoplasm thickly sprinkled with fine neutrophile granules. Capps suggests that the cell may be a form of leuco- cyte of slightly more mature development than the large lympho- cyte, one in which the development of the granules has preceded the nuclear changes. The close resemblance of these cells to the smaller forms of myelocytes, however, makes it reasonable to class them as such. Ehrlich has recently described ^ as a *' small Neutrophilic neutrophilic pseudolymphocyte " a cell of the PsEUDOLYM- same size as that of the small lymphocyte, and PHOCYTES. characterized by a relatively large, round, intensely basic nucleus, surrounded by a narrow zone of protoplasm filled with neutrophile granules. This cell, it is maintained, is of a very rare occurrence, having been found in the blood only in a case of hemorrhagic small-pox, and in the exudate of a recent pleural effusion. Ehrlich differentiates it from a myelo- cyte by its small size, deeply staining nucleus, and scanty amount of protoplasm, but these points of distinction do not appear con- clusive, for many of the smaller, ''dwarf" forms of myelocytes have similar characteristics. It does not appear unreasonable, therefore, to regard this cell as an exceedingly small form of myelocyte, in which the nucleus is relatively larger and richer in chromatin than is the rule in the larger, more typical varieties. These cells, first described by Tiirk^ as '' rei- '' Reizungs- zungsformen " (or, literally, '' stimulation forms "), formen." are said to occur in the same pathological condi- tions in which myelocytes are found, but as yet their exact significance is undetermined. The size of the cell is usually midway between that of the small and large lymphocyte, more often approximating the size of the former. The cell con- ^Amer. Journ. of Med. Sciences, 1896, vol. cxi., p. 650. 2Loc. cit. 3 Cited by Ehrlich, loc. cit. 1/2 THE LEUCOCYTES. tains a round nucleus, deficient in chromatin, often eccentrically placed in the cell body, and reacting with moderate intensity to- ward the basic aniline dyes. The protoplasm is non-granular, and stains an intense brown with the triacid mixture. Ehrlich suggests that this cell may possibly represent an early stage of the er}throblast, but reasons for such an inference do not seem clear. The writer has seen such cells in the blood of the post-typhoid anemias of infancy, always in association with lymphocytosis. The chief points of distinction between the different forms of leucocytes, as recognized in specimens stained with Ehrlich' s triacid mixture, are tabulated below. Form of Cell. Size. Nucleus. Protoplasm. Small lymphocyte. Large mononuclear leucocyte, or large lymphocyte. Transitional leuco- cyte. Polynuclear neutro- 1 phile. Eosinophile. Basophile. Myelocyte. Mast cell. Reizimgsform. 6 to 9 //. lo to 15 ft. 10 to 15 //. 7.5 to 12^. 7.5 to 12 ft. 7.5 to 12fl. 10 to 20 IX. 7 to 22 /y. 6 to 15^. Single. Round. Relatively large. Dark blue or purple. Single. Round or ovoid. Relatively small. Ver}' pale blue. Single. Indented, kidney- shaped, or cres- centic. Relatively small. Pale blue. Polymorphous or polynuclear. Relatively small. Moderately dark blue. Polymorphous or polynuclear. Relatively small. Pale blue. Polymorphous. Relatively small. Dull blue. Single. Round or ovoid. Relatively large or small. Very pale blue. Single. Round, ovoid or slightly lobulated. Relatively large. Very pale blue. Single. Round. Relatively small. Deep blue. Relatively small amount. Non-granular. L'nstained, or faint pink. Relatively large amount. Non-granular. Unstained, or faint pink or grayish-blue. Relatively large amount. Non-granular. Unstained, or faint pink or grayish -blue. Relatively large amount. Contains fine lavender or purple neutrophile granules. Relatively large amount. Contains coarse red or copper-colored eosino- phile granules. Relatively large amount. Contains fine basophile granules, unstained. Relatively large or small amount. Contains fine lavender or purple neutrophile granules. Relatively small amount. Contains coarse baso- phile granules, un- stained. Relatively large amount. Non-granular. Intense brown. CLASSIFICATION. 1/3 Two different views are current at the present Origin and time regarding the origin and development of the Develop- leucocytes, the first being that of Ehrlich ^ and MENT. his followers, and the second that maintained by the Russian -school, led by Uskow^ and his pupils. According to Ehrlich's teachings, the small lymphocyte and its mother-cell, the large lymphocyte, are developed in the lym- phatic tissues in the various parts of the body, wherever such structures exist. The large mononuclear leucocytes and transi- tional forms are considered probably of myelogenous origin. The polynuclear neutrophiles are thought to develop exclusively in the bone marrow, the great majority being evolved from the neutrophilic myelocytes of this tissue, while a very limited num- ber perhaps arise from the non-granular large mononuclear cells. The eosinophiles develop from the eosinophilic myelocytes in the bone marrow, while the basophilic leucocytes similarly have their origin in basophilic marrow antecedents. Thus, it is maintained that all varieties of leucocytes may be classed in two distinct groups which have separate origins, functions, and relations. The first group consists of the lymphocytes, large and small, which are produced solely by the lymphatic tissues ; and the second group includes the mononuclear leucocytes and transi- tional forms, the polynuclear neutrophiles, the eosinophiles, and the basophiles, all of which cells are produced exclusively by the marrow. Cellular reproduction, except in rare instances, does not take place in the circulating blood stream. The scheme devised by the Russian school contends for the continuous evolution of the leucocyte from its earliest to its most mature stages. Accordingly, all varieties of the leucocyte, except the basophilic cells of which no account apparently is taken, are but different developmental stages of one and the same cell. The youngest form of leucocyte, the small lymphocyte, originates in the lymph glands, the lymphocytic bone marrow, and the spleen, from which sources of origin it reaches the circulation. The small lymphocyte enlarges until it becomes identical in appearance with the cell recognized as the large lymphocyte, its nucleus at this period of its growth having become somewhat less intensely basic, although the basic affinity shown by the cell- protoplasm is unaltered. The large lymphocyte in turn under- goes a simple increase in size, its nucleus meanwhile becoming progressively paler and its protoplasm more feebly basic, until ^Loc. cit. 2 * * The Blood as a Tissue, " 1 890. ( Russian. ) Also series of articles by Uskow' s pupils in Archiv. d. Sc. Biol., St. Petersburg, 1893-97. 174 THE LEUCOCYTES. it develops into the large mononuclear form. The nucleus of the latter now becomes indented and moulded into a roughly crescentic figure, its nuclear and protoplasmic characteiistics re- maining unchanged, and the so-called transitional form thus origi- nates — a type of cell which is regarded as the immediate ante- cedent of the polynuclear neutrophile. During the next stage of development the size of the transitional cell decreases, and the whole cell becomes ameboid ; the nucleus becomes denser, more basic, and polymorphous or polynuclear ; while the protoplasm loses the last trace of its basic tendency, and becomes sprinkled with fine neutrophile granules, until finally the mature form of leucocyte, the polynuclear neutrophile, is fully developed. The final, or ** over-ripe " stage of the leucocyte is represented by the eosinophile, which is thought to be derived from the polynuclear form, by a transformation of the latter's neutrophile into eosino- phile granules. It is maintained that these transitions from one form of cell to the other occur partly in the circulating blood, and partly in the blood-forming tissues, most largely in the latter. It is beyond the province of this book to discuss the merits and demerits of these two opposing views, but it may be remarked that Uskow's theory, which up to the advent of Ehrlich's observa- tions, commanded general attention among hematologists, is now being rapidly supplanted by the latter. The investigations of h^hrlich in this direction constitute the only dependable means by which many of the pathological changes in the leucocytes may be explained, and his views may be accepted on the whole as accurate. In all purulent conditions, as well as in many Iodine other diseases, the protoplasm of the leucocytes Reaction. shows a more or less pronounced affinity for io- dine, as demonstrated b}' staining with a weak so- lution of this metal. For this pui-pose Goldberger and Weiss* ha\e recommended the following reagent : Iodine i Potassium iodide 3 Distilled water loo Mix and add sufficient gum arable to make a syrupy mixture. With a camel's hair brush a layer of this solution is painted over the surface of the dried, unfixed blood-film, upon which it is allowed to act for from one to five minutes. The excess is » Wien. klin. Woch., 1S97, vol. x., p, 601. CLASSIFICATION. 1/5 then removed, by blotting with a bit of filter-paper, and the speci- men is mounted in cedar-oil. In films thus treated the iodine reaction is recognized by a slight or intense, diffuse brown coloring of the entire protoplasm, or by the presence throughout the protoplasm of numerous in- tensely stained, reddish-brown granules, the latter change being the more common. In normal blood the protoplasm of the leu- cocytes is stained a pale yellow, and the nuclei remain almost colorless. The above reaction, which is constant in all piindcnt conditions, persists as long as the suppurative focus exists, but its intensity appears to bear no parallelism to the extent of the pus col- lection. It is absent in p^ire tnberadons abscesses. It is also present with great constancy in puerperal sepsis and in other forms of septicenna, and frequently in pneianonia, in pidmonary tubercidosis, in malignant disease, and occasionally in marked ca- chexias. Hofbauer^ found iodinophile granules in the leucocytes in all cases o( pernicions anemia, their number being greatest in the gravest cases ; they were also present in severe forms of sec- ondary anemia, and in Iciikeuiia, but were absent in chlorosis, and in pseudoleukemia. This author also observed numerous iodine-stained extracellular masses in a case of purpura hemor- rhagica. Kaminer ^ believes that the reaction depends upon three factors for its production — pyrexia, leucocytosis, and toxemia, and that it is caused by the action of some unknown chemotactic substance. He has also apparently shown that the brownish-red color of the reaction does not depend upon the presence of gly- cogen in the leucocytes, as most observers have claimed, since in four cases of diabetes mellitus the test was negative. The practical value of this test is limited, in view of the many different circumstances under which it may prove positive. Its constancy in purulent conditions, however slight in extent the focus of pus, may be of some use in diagnosing a deep-seated abscess, if other causes which also may give rise to the reaction can be ruled out. Its absence in pure tuberculous abscess and its presence in all other forms of abscess may aid in distinguish- ing between the two, and of ascertaining whether a mixed infec- tion exists. Although the writer has followed out rather at length the suggestion made by Hotbauer, that the intensity of the reac- tion serves as an index to the severity of an anemia, the results from this study have not shown the reliability of such a presumption. iCentralbl. f. inn. Med., 1900, vol. xxi., p. 153. 2 Deut. med. Woch., 1899, vol. xxv., p. 235. See also Berl. klin. Woch. , 1899, vol. xxxvi. , p. 119. 1/6 THE LEUCOCYTES. Neusser/ in 1894, described certain basic Perinuclear granules about the nuclei of the leucocytes, Basophilia, which he regarded as pathognomonic of the uric acid diathesis, asserting that this so-called ''peri- nuclear basophilia" could be demonstrated constantly in gout, lithiasis, rheumatism, leukemia, and a number of other diseases. These statements were soon corroborated by Kolisch,^ and for a time enjoyed more or less general credence. The later researches of Futcher ^ and of Simon,^ however, have entirely disproved the claims of Neusser and his school, for these investigators, working independently, have proved that perinuclear basophilia is not only quite uncharacteristic of the uric acid diathesis, but that it can be constantly demonstrated in every sort of blood, whether from healthy or from diseased persons. It is now clear that Neusser' s granules are simply artefacts, due to some slip in the technique of staining. Ehrlich ^ believes that their presence is but rarely noted, if perfectly pure crystalline dyes are used in preparing the stain. III. LEUCOCYTOSIS. Leucocytosis may be described as an increase above the normal standard in the number of leucocytes in the peripheral blood, this change either (a) involving both a?i absolute and relative increase in the polymiclear neiitrophile cells with a conseqne?it I'elative dimi- 7iutio7i in the proportion of mono7iuclear non-graimlarfonns, or {b) affectijig all varieties of leucocytes alike. A leucocytosis of the first kind, also termed a polynuclear neu- trophile leucocytosis, is by far the more common of the two types ; it may be symptomatic either of pathological or of physiological conditions, being found almost invariably in the former, and fre- quently in the latter. A leucocytosis of the second kind, or a general increase unattended by any disturbance in the normal relative proportions of the different forms of cells, is compara- tively rare ; it is more frequently dependent for its production upon physiological than upon pathological factors, but it may occur under either of these circumstances. From these facts it is obvious that simply an increase in the total number of leucocytes, without regard to the differential changes involved, does not of necessity constitute a leucocytosis. 1 Wien. klin. Woch., 1894, vol. vii., p. 71. 2 Ibid., 1895, vol. viii., p. 797. 3 Bull, of the Johns Hopkins Hosp., 1897, vol. viii., p. 85. * Am. Joum. of Med. Sciences, 1899, vol. cxvii., p. 139. 5 Loc. cit. PLATE III, '^z Leucocytosis. ( Triacid Stain.) The blood field from a case of croupous pneumonia. The leucocytes are all of the polynuclear neutrophile type. The erythrocytes show no deformity, and stain a normal orange color. Contrast this illustration with leukemia, Plates IV and V. (E. F. Faber,/^c.) PHYSIOLOGICAL LEUCOCYTOSIS. 177 Nor is it possible to recognize the condition with certainty by any such criterion as a deviation from the ratio of red to white cells maintained in health. To state that a patient's blood contains, say, 50,000 leucocytes to the cubic millimeter suggests both leu- cocytosis and leukemia, but to add to such a statement the fact that of these 50,000 leucocytes 90 per cent, are of the polynuclear neutrophile variety at once stamps the condition as a genuine leu- cocytosis. In order, therefore, to distinguish leucocytosis with absolute certainty the character of the leucocytes involved in the increase must be determined by a differential count of the stained specimen of blood. (See Plate III.) Leucocytosis may be of a more or less transient character, or may persist for a long period, its duration being dependent upon the nature of the underlying cause. In acute diseases it is usually a temporary condition, but in long-continued affections it is pro- longed in relation to the chronicity of the lesion by which the increase is excited. For clinical purposes all forms of leucocytosis may be classed under two main groups, physiological and pathological, these be- ing further divided as follows : PJiysiological Leucocytosis, 1 . Leucocytosis of the new-born. 2. Digestion leucocytosis. 3. Leucocytosis of pregnancy and parturition. 4. Leucocytosis due to thermal and mechanical influences. 5. Terminal leucocytosis. Pathological Leucocytosis. 1. Inflammatory and infectious leucocytosis. 2. Leucocytosis of malignant disease. 3. Post-hemorrhagic leucocytosis. 4. Toxic leucocytosis. 5. Experimental leucocytosis. PHYSIOLOGICAL LEUCOCYTOSIS. The leucocytoses associated with a number of Character, purely physiological conditions are generally of brief duration, and as a rule involve a moderate increase in the white corpuscles, the gain in many instances being trifling and never excessive. As noted in a preceding paragraph, 12 178 THE LEUCOCYTES. the increase sometimes affects all forms of leucocytes equally, so that, although the total number of cells is higher than the normal standard, the relative percentages of the different varieties remain in the ratio obser\^ed in normal blood. In other instances the gain is due to an absolute and relative increase in the polynuclear neutrophile leucocytes, with a consequent decrease in the per- centage of non-granular, mononuclear forms. The increase of leucocytes under such condi- Causal tions is to be regarded usually as a physical Factors. phenomenon depending upon temporary concen- tration of the blood, or upon an unequal distri- bution of the cells in favor of the peripheral vessels. Evidence is wholly lacking to show that it is caused by an actual over-pro- duction of leucocytes by the blood-forming organs, thus produc- ing a general increase through all parts of the body. It is, therefore, reasonable to beheve that the high leucocyte counts may be accounted for by such factors as decrease in the total volume of blood plasma, and the transference of cells from the vessels of the deeper tissues to those of the superficial parts of the body. I . Lcticocytosis of the New-bom. The blood of the infant at birth contains two or three times the number of leucocytes found in the normal adult, the count usually ranging from 15,000 to 20,000 or higher during the first forty-eight hours of hfe. After this time the number of cells gradually decreases until, by the end of the first or second week, it has fallen to an average of from 10,000 to 15,000, which figures may be considered normal for children under one year of age. Gundobin ^ has determined, by a series of differential counts, that the increase is due chiefly to an excessive gain in the polynuclear neutrophiles, the propor- tion of these cells during the first ten days after birth averaging from 60 to 70 per cent, of all forms of leucocytes. The extent of this increase becomes apparent when one recalls the fact that in the infant the relative proportion of these cells to the other varieties is usually not more than 40 per cent. By the tenth day this polynuclear increase usually subsides, and the percentage of mononuclear forms rises to the figure normal at this period of life. (See Section VI.) In prematurely-born infants a similar in- crease in the number of leucocytes is present, but the mononu- clear forms rise to their normal percentage more rapidly than in the full-term baby ; thus, in the case of an eight-months' child, examined by Whitney and Wentworth," the large and small lym- ijahrb. f. Kinderheilk., 1S93, vol. xxxv., p. 187. 2Cited by Rotch : "Paediatrics," etc., Phila., 1896, p. 348. PHYSIOLOGICAL LEUCOCYTOSIS. I 79 « phocytes, which averaged together but 26 per cent, at birth, rose to 80 per cent, by the fourth day, remaining at practically this figure through subsequent counts. The leucocytosis of the new-born is probably attributable partly to concentration of the blood by the drain on the body- fluids incident to the early days of life, and partly to the influence of digestion leucocytosis which is especially active at this period. 2. Digestion Leucocytosis. Within an hour after taking food an appreciable increase in the number of leucocytes may be ob- served in the great majority of healthy individuals, the count reaching its maximum within from two to four hours after the meal, and then gradually declining. Rieder ^ estimates the aver- age increase at about 33 per cent, in excess of the normal figure. Meals rich in albuminoids are followed by a more marked increase than those consisting chiefly of vegetable articles of diet. In in- dividuals whose process of digestion is slow from any cause the appearance of the leucocytosis is also delayed. The following two instances, taken from von Limbeck,^ illustrate the development of the leucocytosis in the normal adult : Time. Count of Leucocytes. Time. Count of Leucocytes. II. 15 A. M.3 7,600 11.30 A. M.3 5,800 12.15 P- M. 6,000 12.30 P. M. 10,600 1. 15 P. M. 8,500 1.30- P. M. 10,600 3-15 P- M. 12,000 2.30 P. M. 9,600 5.15 P. M. 14,000 3.30 P. M. 6,800 7.15 P. M. 10,000 6.00 P. M. 6,600 The gain is due usually to a predominance of polynu clear neu- trophil forms, with a consequent relative diminution in large and small lymphocytes ; but in some instances the differential count remains normal, all forms of cells sharing equally in the increase. Digestion leucocytosis is not invariably present even in those who apparently enjoy perfect health, its absence in such instances remaining entirely unexplained. It is also absent occasionally in chronic constipation, frequently in chronic gastric catarrh, and anemia, and is found in only a small proportion of cases of gastric carcinoma. Other lesions of the gastro-intestinal tract, and dis- eases characterized by high-grade anemia and by marked de- bility may greatly delay or even entirely prevent the increase. Rieder ^ is authority for the statement that digestion leucocytosis 1 ** Beitrage zur Kenntniss der Leukocytose, " etc., Leipzig, 1892. 2Loc. cit. 3 Meal of nitrogenous and farinaceous food. 4Loc. cit. l80 THE LEUCOCYTES. does not occur during pregnancy, and Bohland^ finds that it fails to develop during the administration of tannic acid. In children, especially in young breast-fed infants, the increase is ver}' decided ; in the new-born counts of from 30,000 to 35,000 may follow the first few feedings. (See Section VI.) The leucocy- tosis is also marked after fasting, and in diabetics. 3 . Leiicocytosis of Pregnancy and Parturition. In the maj ority of primiparae a moderate leucocytosis, not usualh* involving an in- crease in excess of double the normal count, is obser\'ed during the later months of pregnancy. The increase is less constant and much less marked in multiparae, occurring in a smaller per- centage of the latter, and amounting to a cellular gain of about one-sixth the original count on the average. The maximum number of cells is usually found immediately before and after de- liver>^ at which time the number of leucocytes commonly rises to about 15,000 per cubic millimeter. During convalescence the leucocytosis gradually declines, and disappears before the end of the first week after deliver}^, in uncomplicated cases. As a general rule, in both primiparae and in multipara, the de- gree of increase is more decided in young wom.en than in those of middle ag-e. It is also marked in the late rather than in the early stages of gestation and of labor. The careful blood studies by Hibbard and White ^ in 55 preg- nant women (33 primiparae and 22 multiparae) furnish the most reliable data concerning the leucocytosis of this condition. These authors found that leucocytosis occurred before delivery in 84 per cent, of primiparae and in 75 per cent, of multiparae, the aver- age counts in 32 of the former being 15,021 (50 per cent, above normal) and in 20 of the latter 1 1,700 (17 per cent, above nor- mal). In uncompHcated pregnancies the average count just be- fore delivery was 16,100 for primiparae and 1 1,800 for multiparae. In normal labor the number of leucocytes fell rapidly after deliv- ery, gradually reached the normal standard by the fourth or fifth day, and then again slowly rose until the seventh day, when a decline to normal was again obsen^ed. Differential counts in 19 cases of the above series showed that the leucocytosis was of the polynuclear neutrophile type, a marked relative and absolute increase in these cells being con- stantly present ; as a rule their percentage was from 85 to 95 of all forms of leucocytes, usually being higher, the higher the leu- cocytosis. These results are unlike those obtained by Rieder^ ^Centralbl. f. inn. Med., 1899, vol. xx., p. 361. 2Journ. of Exper. Med., 1898, vol. iii., p. 639. 3 Loc. cit. PHYSIOLOGICAL LEUCOCYTOSIS. l8l and by Bjorkman,^ the former having stated that the various forms of cells remain practically normal, while the latter attrib- utes the increase to a predominance of mononuclear elements. Lactation, of itself, has no appreciable effect upon the leuco- cytes, so that a leucocytosis occurring in a nursing woman should be attributed to inflammatory condition of the breast or nipple — even a mild mastitis or a slight irritation of the nipple being cap- able of causing a prompt leucocytosis. The number of leucocytes is somewhat in excess of normal for a few days preceding and during menstruation in the majority of healthy women, according to the investigations of Sfameni,^ but the increase scarcely ever reaches a degree which may be regarded as a leucocytosis. 4. Leucocytosis Due to Thermal and Mechanical Influences. A transient increase in the number of leucocytes of the peripheral blood, not involving a disturbance of the normal ratio between the different forms of cells, is produced by active local or general h'msc2ilar exercise ;^ hy hriti Q^Y^osuYQ to atmospheric cold f' by cold baths, either local or general ; ^ and by the application of electricity^ and of massage !" The number of leucocytes is also increased by the effect of prolonged dry or moist heat.^ The increase under these circumstances is generally attributed to blood concentration due to the influence of increased vaso- motor tension, whereby the liquid elements of the blood are tem- porarily decreased, and, in addition, many of the cells lodged in the deeper tissues of the body are swept into the peripheral cir- culation. As a rule, all varieties of leucocytes share equally in the process, no single form being unduly increased at the ex- pense of the others. 5. Terminal Leucocytosis. Terminal or pre-agonal leucocyto- sis is the term applied to an increase in the number of leucocytes of the peripheral circulation frequently observed just before death. It occurs during the terminal stages of a number of different diseases, and is especially marked in those conditions in which death comes slowly, being ushered in by a more or less mori- bund state of the patient lasting for a considerable length of time. The increase is usually moderate, and the counts do not often exceed 20,000 or 30,000 per cubic millimeter, except in those ^ Am. Medico- Surg. Bull., 1894, vol. vii., pp. 17 and 79, ^Loc. cit. 3 Oliver : loc. cit. *Wintemitz : Centralbl. f. klin. Med., 1893, vol. xiv., p. 1017. Thayer: Johns Hopkins Hosp. Bull., 1893, vol. iv., p. t,"}. 5 Mitchell : Am. Journ. of Med. Sci., 1894, vol. cvii., p. 502. ^ Friedlander : Congress f. inn. Med., Berlin, 1897. I 82 THE LEUCOCYTES. cases in which decided circulator}^ embarrassment has existed for some time. Most commonly the blood-picture is one of ordinar)^ polynuclear neutrophile leucocytosis, although occasionally the large and small lymphocytes show disproportionately high per- centages, and still more rarely all forms of cells may be increased equally. In pernicious anemia the increase may be so great as to simu- late lymphatic leukemia, according to Cabot,^ who found the fol- ing blood changes on the day of death in this disease : ratio of white to red corpuscles, i to 15 ; differential count showed 91.7 per cent, of lymphocytes, j .j per cent, of polynuclear neutro- philes, and 0.5 per cent, of eosinophiles. Four megaloblasts to one thousand leucocytes were also found. The following data were obtained by the writer in a case of pernicious anemia eighteen hours before death : hemoglobin, 12 per cent.; erjthrocytes, 622,500 per cb. mm.; leucocytes, 18,600 per cb. mm. The differential count of one thousand white corpuscles showed : lymphocytes, 46.0 per cent.; polynu- clear neutrophiles, 49.7 per cent.; eosinophiles, 2.3 per cent.; myelocytes, 1.6 per cent, and basophiles, 0.4 per cent. Meg- aloblasts outnumbered normoblasts three to one, twenty-four of the former being found in the count of one thousand leucocytes. The number of leucocytes in four previous counts having ranged from 1,000 to 2,400 per cubic millimeter, and the proportion of lymphocytes from 42 to 48 per cent., this case illustrates the oc- currence of a terminal leucocytosis without a notable change in the relative percentage of different forms peculiar to the case in question. The principal cause of this form of leucocytosis is thought to be peripheral stasis dependent upon failure of circulator}^ com- pensation, but in many instances there seems to be good reason to believe that terminal infections also act as the causal factors. PATHOLOGICAL LEUCOCYTOSIS. Increase in the number of leucocytes, involving OccuRRENXE. chiefly the polynuclear neutrophile cells in the great majority of instances, is associated with a wide variety of pathological conditions, mainly inflammatoiy, in- fectious, and toxic in character, and in such conditions the under- lying cause of the phenomenon is radically different from that which determines the increase in physiological leucocytosis. Prominent examples of pathological lesions in which leucoc}toses 1 Loc. cit. PATHOLOGICAL LEUCOCYTOSIS. 1 83 of this character are observed are pneumonia, diphtheria, scarlet fever, erysipelas, rheumatic fever, variola, and various septic processes. Enteric fever, Malta fever, the malarial fevers, influ- enza, and measles are notable exceptions, for in these acute in- fections leucocytosis does not occur except as the result of some complication. The extent of the leucocytosis, inasmuch as it Degree of depends both upon the nature of the exciting cause Increase. and upon the individual's reactive powers, varies within wide limits in different cases. It is safe to state, however, that in the great majority of instances the number of leucocytes is rather below than above 20,000 to the cubic milli- meter, counts in excess of this figure being noted in only about one-fourth of the cases in which the leucocytes exceed the nor- mal limits of health. A count of 25,000 cells per cubic milli- meter may be regarded as a decided leucocytosis, while an in- crease of from 40,000 to 50,000 is of extremely rare occurrence. In an analysis of one hundred consecutive counts made by the writer in pathological conditions, in which the number of leuco- cytes reached or exceeded 10,000 per cubic millimeter, it was determined that the counts were below 20,000 in 65 per cent, of cases, and between 20,000 and 30,000 in 28 per cent.; in 4 per cent, the increase was between 30,000 and 40,000 ; in 2 per cent, between 40,000 and 50,000 ; and in only i per cent, did it exceed 50,000. Judging from these figures, which, it should be remembered, are applicable only to the average case, it appears to be the rule that in most leucocytoses the increase amounts to a trifle more than double the number normal in health. With rare exceptions, the increase affects chiefly Differential the polynuclear neutrophile cells, which com- Changes. monly constitute at least 85 per cent, of the dif- ferent forms of leucocytes. In many instances the percentage is much higher, as, for example, in a case of sup- purative meningitis, reported by Stengel,^ in which a differential count showed 99.5 per cent, of this variety of cells. The excep- tional cases in which these disproportionately high percentages of polynuclear neutrophiles are sometimes wanting are encountered in the leucocytoses of malignant disease, after hemorrhage, in the moribund, and in children. The relative lymphocytosis which is occasionally observed under these circumstances is considered in connection with these conditions. Coincident with the increase in polynuclear forms, there is a marked decrease in the relative percentages of large and small lymphocytes, and of eosinophiles, 1 Loc. cit. ^ r A 184 THE LEUCOCYTES. the latter variet}^ of cells sometimes entirely disappearing from the blood. In cases in which the increase is marked, small num- bers of myelocytes usually may be observed, together with an occasional cell whose characteristics at once suggest a stage of development intermediate between that of the myelocyte and the t}^pical polynuclear neutrophile. The exact manner in which pathological leu- Causal cocytosis arises is a question about which many Factors. conflicting views are held by different authorities, but the general trend of opinion at the present time attributes the increase chiefly to the influence of chemotaxis. According to the chemotactic theor>^ of leucocytosis, the pres- ence in the blood of certain chemical substances, produced by in- fective principles, is capable of exerting both an attractive and a repellent influence upon the ameboid leucocytes. If the collec- tions of cells are attracted by such substances the phenomenon is known as positive chemotaxis, but if, on the other hand, they are repelled, the condition is termed negative chemotaxis. This mass- ing and repulsion of the leucocytes may be caused by various agents — by thermal and mechanical irritants, by bits of necrotic tissue which have gained entrance to the circulation, and espe- cially by the presence in the blood of bacteria, or of their meta- bolic products. In the light of our present knowledge, it appears that the different varieties of ameboid leucocytes respond to dif- ferent kinds of chemotactic influences, as an instance of which the behavior of the neutrophils and eosinophils to this sort of stimulus may be cited. Certain substances, which for one of these groups of cells are either positively or negatively chemo- tactic, are, as a rule, indifferent to the other group, and some- times even antagonistic, for substances which serve to attract one group either fail to influence or in fact repel the other. Clin- ically, this theory seems to find corroboration, for there are but few exceptions to the general rule, that an increase in either variety of these cells is associated with a constant decrease in the other. Ehrlich ^ has also shown that the mast cells are wholly uninfluenced by those substances which exert a strong chemotactic influence upon the neutrophiles and eosinophiles. The intense cellular activity excited by the en- FuNXTioxs. trance of bacteria into the organism indicates an attempt on the part of the leucocytes to destroy the invading principle, and to counteract its noxious influences. In this endeavor it is probable that in a restricted sense Metch- nikoff s hypothesis holds true, and that the immense numbers of ' Loc. cit. PATHOLOGICAL LEUCOCYTOSIS. 1 85 phagocytic leucocytes which crowd the blood stream mechan- ically engulf and destroy many of the invading micro-organisms. But of still greater significance is the faculty which the leuco- cytes possess of producing certain chemical substances [alexines) acting either as directly bactericidal, or as antitoxic agents. The researches of Buchner/ Lowy and Richter,^ Goldscheider and Jacob,^ and others tend to show that such substances either actu- ally destroy the infecting micro-organisms, or at least antidote and render innocuous their poisonous products. This joint proc- ess of phagocytosis and bactericidal action is most intensely de- veloped at the period of maximum leucocytosis, according to the statements of Gabritschewsky.^ In experimental leucocytosis, caused by the Hypoleucocy- injection of such irritants as bacteria and bacterial Tosis AND Hy- products, organic extracts, various albumins, and PERLEUCOCY- evcn by simple trauma, it has been found that the TOSIS. first effect of the irritant is to cause a rapid, tran- sitory diminution in the number of leucocytes in the peripheral blood, known as hypoleucocytosis, this decrease being succeeded in turn by an increase of these cells in excess of the normal standard, termed hyperleucocy tosis. Frequently in simple traumatic leucocytoses after the disappearance of the stage of hyperleucocytosis, the duration of which is variable, Sher- rington ^ was able to distinguish a secondary stage of hypoleuco- cytosis, during which the leucocyte count again fell below the normal. Within certain limits, the extent of this preliminary decrease and of the subsequent increase varies directly in accordance with the intensity of the irritant. If the irritant is slight, the re- pellent influence is feeble, and the consequent cellular increase is inconspicuous — in fact, it is the opinion of many that in such instances there may be merely a local accumulation of leucocytes at the site of the injection, without any real increase in the whole mass of cells. If the effects of the irritant are severe, both the repellent and the attractive stages are promptly excited and markedly developed, and a general increase in the number of leucocytes through the whole circulatory system promptly re- sults. If, on the contrary, the effects of the irritant prove to be too intense, the organism suffers a depression so profound that lArchiv. f. Hygeine, 1890, vol. xvii., p. II2. 2 Deut. med. Woch., 1895, vol. xxix., p. 240. Virchow's Archiv., 1898, vol. cli., p. 220. ^Zeitschr. f. klin. Med., 1894, vol. xxv., p. 373. •* Central bl. f. Bakteriol., 1898, vol. xxiii., p. 365. sProc. of the Royal Soc, 1893, vol. Iv., p. 161. 1 86 ' THE LEUCOCYTES. reaction is stifled, and leucocytosis does not develop. It some- times happens that the attractive influences of the chemotactic principle predominate over its repellent action, in which case the stage of h}perleucocytosis may develop without the initial stage of hypoleucocytosis. Clinically, the preliminar}- decrease is prac- tically never observed, perhaps partly for the reason last given, but also in a large measure because the repellent action of the irritant has passed off by the time the disease has developed into a clinical picture. In artificially excited leucocytoses, however, its appearance is quite constant, for under such circumstances the irritant is introduced into the organism suddenly and in a rela- tively massive dose, producing a more or less decided repellent influence. The initial stage of decrease was termed the leiicopenic phase by Lowit,^ who attributed the change to an actual destruction of the leucocytes, or a leiicocytolysis. The subsequent increase he spoke of as the Icucocytic phase, maintaining that for the produc- tion of the latter the preliminar}" development of the former was in some unexplained manner essential. The work of Goldschei- der and Jacob " definitely proved the error of Lowit's leucocyto- lytic hypothesis, and demonstrated the fact that the leucopenia was dependent purely upon an altered distribution of the cells in favor of the vessels of the deeper circulation. Extensive investigations carried on by these authors showed that at the time a decided diminution occurred in the number of leucocytes of the peripheral blood, there was a simultane- ous increase of these cells in the capillaries of the lungs and other internal organs. Furthermore, it was also shown that in some instances a marked leucocytosis may occur without the ini- tial decrease, this being the case after the injection of such sub- stances as the glycerin extract of spleen. From these experi- ments it seems reasonable to attribute the initial stage of decrease to a repellent action of the irritant, and to infer that the stage of hyperleucocytosis is due to an active stimulation of the hemo- genic organs which results certainly in an increased cellular output from, and probably in an increased cellular proliferation in, this situation. Muir's recent investigations^ tend to strengthen this belief, and to throw additional light on the phenomenon of pathological leucocytosis. This author found that in experimen- tal leucocytosis in animals, produced by the injection of patho- genic bacteria, changes occurred in the bone marrow, consisting i*'Studien z. Physiol, u. Pathol, d. Blutes," Jena, 1892. 2Loc. cit. 3 British Med. Journ., 1898, vol. ii., p. 604. PATHOLOGICAL LEUCOCYTOSIS. I 8/ of absorption of the marrow fat, together with a corresponding hyperplasia of the cells from which he believes the leucocytes originate, many of these cells undergoing rapid multiplication by mitosis. In inflammatory leucocytosis, Muir found the following suggestive changes : first, a local increase in the polynuclear neu- trophile cells ; second, an increase of the same variety of cells in the circulating blood ; and third, a marked increase in the marrow of their direct antecedents. According to Ehrlich's latest views, ^ leucocytosis involving mainly an increase of the polynuclear neutrophiles (''polynuclear neutrophile leucocytosis") is the ex- pression of an independent chemotactic reaction on the part of these cells, caused by the remote influence of dissolved substances upon the bone marrow, whereby this tissue throws into the blood- current excessive numbers of these elements. Schultz^ and others, on the contrary, attribute leucocytosis en- tirely to changes in the distribution of the cells, maintaining that increase in the number of leucocytes in the peripheral vessels goes hand in hand with a decrease in their number in the vessels of the internal organs, and vice versa. This view, however, has been shown to be untenable. In summing up the various experimental and clinical data bear- ing upon the nature of the leucocytoses associated with patho- logical conditions, the evidence tends to confirm the view that the process is, in all instances, save perhaps those of trivial local in- fections, a general one throughout the entire circulatory system, and that it is symptomatic of an excessive output and rapid de- velopment of leucocytes by the bone marrow, due to the influence of chemotactic principles. It must be remembered that this view is in part based upon hypotheses, but it nevertheless represents the belief current at the present time. I. hiflmnmatory and Infections Leucocytosis. In this class are included the leucocytoses occurring during the course of a num- ber of diseases of inflammatory and infectious character, in which the increase may be attributed either to simple inflammation, or to bacterial infection, or to both. The presence of such a leucocy- tosis is to be regarded as symptomatic of an attempt on the part of the organism to overcome the noxious invading principle, what- ever its nature may be, through the protective action of the white corpuscles. Bearing in mind this construction of the phenom- enon, it is possible in many instances to derive valuable clinical information from the presence or absence of a cellular in- crease. ' Loc. cit. 2Tagebl. der Naturforschervers in Heidelberg, 1889, p. 405. I 88 THE LEUCOCYTES. The view expressed by von Limbeck/ that the height of the leucocytosis is dependent upon the extent of the inflammatoiy ex- udate, is not tenable, for processes characterized by insignificant exudates are capable of causing as great an increase as those in which this outpouring is extensive. As a rule, leucocytoses as- sociated with purulent exudates are much more marked than those due to serous effusions. The essential factor in determining the degree of the increase is not the extent of the exudate, nor, in fact, its character, but rather the systemic reaction to which it gives rise. The degree of leucocytosis may be considered a general index to the intensity of the infection, and to the strength of the indi- vidual's resisting powers in reacting against it. It follows, therefore, that intense infections occurring in individuals whose resisting powers are strong produce a decided increase ; but the presence of an infection of like intensity in one whose re- sisting powers are greatly crippled fails to cause leucocytosis, for in such an instance the organism is so overpowered by the effects of the morbid process that it is incapable of reacting. The increase is either absent or slight when a trifling infection is associated with vigorous resisting powers, and moderate when a moderately intense infection is linked to fairly well-developed resisting powers. The cHnical inferences to be drawn from these facts are of value chiefly as corroborative of other well-known physical signs, but are obviously untrustworthy when considered apart from the latter. A marked leucocytosis indicates simply an in- tense infection in a person whose resisting powers are normally developed and actively exerted against the disease, but it is of no prognostic value in itself, for it conveys no idea of the final outcome of the conflict between the disease and the organism. Absence of leucocytosis, or a slight increase may be either of very favorable or of very grave significance, inasmuch as these signs occur both in trivial and in overwhelming infections. If the absence is associated with clinical manifestations which point to a severe infection, the sign may be depended upon as being of grave prognosis. The clinical significance of the leucocytoses associated with various inflammatory and infectious processes will be discussed in Section VII. A more or less decided increase in the num- ber of leucocytes occurs with great constancy in the following groups of diseases of this nature : ^ Loc. cit. PATHOLOGICAL LEUCOCYTOSIS. 189 I. General Infectious Diseases. Actinomycosis. Asiatic cholera. Bubonic plague. Cerebro -spinal meningitis. Diphtheria. Dysentery. Erysipelas. Glanders. Malignant endocarditis. Multiple neuritis. Osteomyelitis. Pertussis. Pneumonia. Pyemia. Relapsing fever. Rheumatic fever. Scarlet fever. Septicemia, Syphilis (secondary), Trichiniasis. Vaccinia. Varicella. Variola. Yellow fever. II. Simple and Infective Local Inflanmiations . Acute yellow atrophy of the liver. Appendicitis, catarrhal. Arthritis, serous. Bronchitis, acute. Cholangitis. Cholecystitis. Cystitis. Conjunctivitis, acute. Dermatitis. Eczema. Endocarditis. Endometritis. Enteritis. Epididymitis. Gangrene : Appendicular. Cancrum oris. Hepatic. Pancreatic. Pulmonary. Gastritis, acute. Gastro-enteritis, acute. Herpes zoster. Infected wounds. Mastitis. Meningitis. Nephritis, acute. Orchitis. Otitis media. Ovaritis. Pancreatitis. Pellagra. Pemphigus. Pericarditis. Peritonitis. Prurigo. Purulent lesions : Appendicular abscess. Cerebral abscess. Hepatic abscess. Ischio -rectal abscess. Ovarian abscess. Pancreatic abscess. Pelvic abscess. Perinephritic abscess. Prostatic abscess. Pulmonary abscess. Retropharyngeal abscess. Splenic abscess. Superficial abscess. Arthritis, suppurative. Carbuncle. Empyema. Felon. Furuncle. Gonorrhea. Otitis media, suppurative. Phlebitis. Pyelonephritis. Pyonephrosis. Pyosalpinx. Quinsy. Splenitis. 190 THE LEUCOCYTES. 2. Leticocytosis of Malignant Disease. A moderate leucocytosis is commonly, but by no means constantly, associated with the vari- ous forms of carcinomata and sarcomata, but the cases in which no increase is observed are even more numerous than those in which it occurs. It is more common and the increase is usually re- garded as more marked in sarcoma than in carcinoma, but in neither condition are excessively high leucocytoses met with fre- quently. In the writer's experience, the increase, when it does occur, is generally moderate in most forms of malignant disease, counts of less than 20,000 leucocytes per cubic millimeter being the o-eneral rule. Cases in which the number of cells exceeds this figure are comparatively rare, but are distinctly more com- mon in sarcoma than in carcinoma ; it is especially in rapidly growing neoplasms of the lung, liver, and kidney that the cells rise to 30,000 or 40,000, or even 50,000 or more. In a series of 68 consecutiv^e cases of malignant disease in the German and Jefferson hospitals less than one-half were accompanied by a leucocyte count of 10,000 or more, this figure being reached or exceeded in approximately 45 per cent, of cases of carcinoma, while in sarcoma such an increase was noted in almost 65 per cent. Five per cent, of all cases showed a high leucocytosis, that is, counts ranging between 30,000 and 50,000. (For further data concerning the leucocytosis of these conditions, see " Malignant Disease," Section VII.) The behavior of the leucocytes in malignant disease appears less contradictory when we inquire into the actual influence which these growths exert in provoking leucocytosis. It is the cur- rent belief that malignant disease, per se, has little if any in- fluence of this sort, and that the increase, if any occurs, is attribu- table to local inflammatory complications and to secondary septic infections, rather than to the specific toxic effects of the neoplasm itself. In some instances it is reasonable to suppose that the profoundly cachectic state of the patient also is an important de- termining factor. Clinically, it is observed that tumors of rapid development, involving a large area of tissue and complicated by extensive metastases cause decided, often high, leucocytoses ; while localized tumors, of small size and of slow growth, give rise to trifling, if any, increase. Variations from this general rule are the result of differences in the resisting powers of different indi- viduals, for the effects of this factor in causing leucocytosis are potent in this, as in other pathological conditions. Qualitatively, the leucocytes usually show a marked absolute ancT relative increase in the polynuclear neutrophiles, with a con- sequent diminution of the mononuclear forms. But in some in- PATHOLOGICAL LEUCOCYTOSIS. I9I stances, both of carcinoma and of sarcoma, the polynuclear forms are relatively below the normal percentage, and the lymphocytes increased, so that the blood picture is not one of leucocytosis, but rather one of relative lymphocytosis ; such a change seems es- pecially prone to occur in sarcoma of the lymphatic system, in which it may be so marked that it suggests lymphatic leukemia. There are certain cases of malignant disease in which the propor- tion of polynuclear neutrophiles rises, although the total number of leucocytes is not increased ; the polynuclear gain is less than is usually found with high leucocyte counts, but it is sufficiently decided to be regarded as of the same significance as a frank leu- cocytosis involving an increase in the total number of cells. The eosinophiles are variously affected in different cases ; some- times they are greatly diminished, if not, indeed, entirely absent, as in most leucocytoses ; sometimes they are normal ; and some- times they are largely increased in number. The increase may be pronounced in sarcoma, this being due probably to involve- ment of the bone marrow by the growth, either directly, or by metastasis. Small numbers of myelocytes — . 5 to i or 2 per cent. — are ex- ceedingly common, being found with great constancy in cases with marked cachexia, especially in carcinoma. 3. Post'hemorrhagic Leticocytosis . A leucocytosis of moderate grade commonly occurs as the result of hemorrhage due to trau- matism or to other causes. It has been found that in animals the stage of increase is preceded by a well-defined leucopenia, which develops immediately after the loss of blood. This initial leucopenia, however, has not yet been demonstrated in man, although it probably occurs. In an extensive traumatic hemorrhage the increase sometimes may be recognized in the peripheral blood within an hour after the accident, but usually it is not distinguishable until after the lapse of a longer period — from five to ten hours, as nearly as can be ascertained. In hemorrhage accompanying various pathological conditions, such, for example, as gastric ulcer, lung tuberculosis, or uterine dis- ease, the appearance of the leucocytosis is less prompt than in hemorrhage from trauma. The maximum increase is usually within moderate limits — approximately two or three times the normal standard. The injection of a salt solution decidedly aggra- vates the leucocytosis. As an illustration of the degree of leuco- cytosis which is commonly encountered, Rieder^ noted in four cases (hematemesis from gastric ulcer, fatal hemophilia, and uterine hemorrhage) an average count of 22,625, the maximum 1 Loc. cit. 192 THE LEUCOCYTES. being 32,600, and the minimum, 15,100. Inasmuch as the height of the increase is thought to correspond to the strength of the organism's reaction in compensating the blood loss, it varies in different cases. In two individuals of equally strong regenerative powers a severe hemorrhage will produce a greater leucocytosis than a slight one. The duration of the increase also varies with the individual case, for it depends upon a similar fac- tor; but in the majority of instances it does not last for more than three or four days, according to the investigations of Lyon.^ Leucocytoses excited by traumatic hemorrhage are prone to persist longer than those due to other causes, and the long-per- sisting increases which are sometimes associated with other path- ological lesions should be attributed to factors other than the actual loss of blood. In an instance of leucocytosis following venesection, Rieder - found that the increase persisted for twelve days. Head ^ found that in dogs the leucocytosis following ex- tensive hemorrhage lasted for at least seven days. In the great majorit}^ of instances the qualitative changes chiefly involve the polynuclear neutrophils, which are greatly increased at the expense of the other forms of cells, but in an occasional instance it will be found that the mononuclear varieties are greatly in excess of their normal percentages, so that a lym- phocytosis is observed. ]\Iyeloc}i:es may also be found in con- siderable numbers in many cases. 4. Toxic Leucocytosis. Typical examples of toxic leucocytosis are found in poisoning by ptomaijies, and by coal-gas, in both of which conditions the predominant influence of a toxic agency in producing the increase is self-evident. For the same reason the leucocytoses occurring as the result of ether narcosis, and in co)i- viilsions and acute delirium, are included in this classification. In certain diseases, notably in the uric acid diathesis, in cholemia, and in uremia, the presence in the blood of toxic principles is thought to be the underlying factor of the increase ; the same probably is true of a number of other diseases, which, for ob\ious reasons, have been classed with the infectious and inflammatory leucocytoses. The effect of gas poisoning is illustrated by the blood ex- amination of a patient recently admitted to the German Hospital, fatally poisoned by illuminating-gas. The leucocytes were in- creased to 32,000 per cubic millimeter, the gain being due to an excessive predominance of polynuclear neutrophiles, as determined iVirchow's Archiv., iS8i, vol. Ixxxiv., p. 207. 2Loc. cit. 3Joum. Am. Med. Assn., 1901, vol. xxxvii., p. 501. PATHOLOGICAL LEUCOCYTOSIS. 1 93 by the following differential count : small lymphocytes, 3.5 per cent.; large lymphocytes, 2.5 per cent.; polynuclear neutrophiles, 92.0 per cent.; eosinophiles, 0.5 per cent, and myelocytes, 1.5 per cent. To what extent this increase depended upon the ac- tual toxic effects of the gas, and to what extent it was attribu- table to peripheral stasis (which was marked in this patient), is conjectural. The leucocytosis caused by ether narcosis has been exhaus- tively studied by von Lerber,^ and by Chadbourne.^ The inves- tigations of von Lerber included 10 1 cases, of which number leu- cocytosis was found in more than 95 per cent., the increase fre- quently amounting to two or three times the original count ; in the majority of instances, the maximum count was observed sev- eral hours after the anesthesia was produced. Chadbourne has carefully studied 21 cases, all of which showed a more or less decided leucocytosis, the minimum gain being 6 per cent., the maximum 73 per cent., and the average 37.3 per cent. He found that the leucocytosis developed more rapidly during the early part of the etherization, and that only exceptionally did it persist for more than twenty -four hours. Differential counts in five cases showed that all forms of cells were proportionately increased. This author attributes the increase to the irritating effects of the ether vapor upon the mucous membrane of the re- spiratory tract. Results similar to the above also have been ob- tained by Ewing,^ and by Ames,* in the experimental etherization of animals. The leucocytosis associated with acute delirium and with con- vulsive seizures, due to a variety of causes, has been studied in detail by Capps,^ and by Burrows.^ Under such circumstances the increase is usually marked, and the height of the count in a gen- eral way is dependent upon the severity of the attack. The polynuclear neutrophiles are chiefly concerned in the increase, with a consequent decline in the proportion of mononuclear forms. The leucocytosis of this class of diseases is discussed more fully in Section VII. 5 . Experimental Leucocytosis. Leucocytoses not differing es- sentially from those associated with various local and general infections, may be caused by the administration of many drugs, ' " Ueber die Einwirkung der Aethernarkose auf Blut u. Urin.," Inaug. Diss. Ber- lin, 1896, i^Phila. Med. Jour., 1899, vol. iii., p. 390. 3N. Y. Med. Journ., 1895, vol. Ixi., p. 257. *Journ. Am, Med. Assn., 1897, vol. xxix., p. 472. 5 Am. Journ. of Med. Sciences, 1896, vol. cxl., p. 650. 6 Ibid. , 1899, "^o^- cxvii., p. 503. 13 194 THE LEUCOCYTES. chemicals, organic principles, bacteria, bacterial proteins, and by the application of intense irritants and revulsives to the surface of the body. No doubt, many of these leucocytoses should be classed either as inflammatory^ or as toxic, owing to the character of their exciting causes, but for the sake of convenience they may be grouped under this heading. Leucocytoses resulting from the administration, subcutaneously and by the mouth, of various drugs and other substances have been studied chiefly by the Continental investigators, to whom we are indebted for most of our present knowledge of this subject. The manner in which such agencies act in causing the increase is not at all clear in many instances, but, as a rule, the change is thought to be dependent upon chemotactic influences, as in in- flammatory and infectious leucocytoses, as w^ell as upon concen- tration of the blood from vasomotor changes. Lowit ^ determined that a preliminary leucopenia succeeded by a more or less decided leucocytosis followed the subcutaneous in- jection of the following substances : hemialbtiinose, pepsin, nuclein, nucleic acid, curare, leech extract, tuberculin, filtered yeast-cultures, pyocya7iin, sodium urate, and uric acid. This change was not ob- served, however, after the injection of urea. Goldscheider and Jacob,^ conducting a large number of experi- ments with various organic animal extracts, obtained results simi- lar to Lowit's from the injection of the extracts of spleen, thymus, and bo7te marrow, but found negative results from the use of the extracts of thyroid, pancreas, and liver. Winternitz ^ studied the effects resulting from the subcutaneous injection of substances causing both transient inflammatory edema, and aseptic abscess formation at the site of the injection. In the former class, which includes neutral salts, and dihite acids and alkalies, an increase in the number of leucocytes, amounting to from 40 to 75 per cent, of the original count, was noted ; and it was furthermore found that even although a local necrosis was produced, as by the injection, for example, of a solution of silver nitrate, the increase still did not become excessive. In the second class of more active irritants which produced local abscesses — tur- pentine, oil of mustard, carbolic acid, croton oil, sapotoxin, digitoxin, silver futrate, cupric sulphate, and salts of mcirujy and of antimo7iy — the leucocytosis was much more decided, and of less transient duration. As a rule, in these experiments the height of the leucocy- tosis ran parallel to the intensity of the local irritation provoked. 1 Loc. cit. 2Loc. cit. 3Archiv. f. exp, Pathol, u. Pharmak., 1895, vol, xxxv., p. 77. PATHOLOGICAL LEUCOCYTOSIS. I95 Pohl ^ noted a moderate leucocytosis following both the inges- tion and the injection of absinthe, acetic ether, extract of gentian, peppermint, piperine, the oils of anise and fennel, egg-albumin, and sodium albuminate. With the last two substances he deter- mined that the increase was greater when they were given by the mouth than when administered subcutaneously ; the gain usually ranged from about 5 to 50 per cent, of the normal count. This investigator also found that quinine, caffeine, calomel, sodium bicar- ' bonate, ethyl alcohol, and hydrochloric acid did not cause a leucocy- tosis, while bismuth subnitrate and oxide of ii-on produced irregular results. Many of the above experiments have been substantiated by the later work of von Limbeck.^ Wilkinson^ observed leucocytosis, preceded by leucopenia, after the injection oi potassium iodide, camphor, quinine, antipyrin, salicine, salicylic acid, nuclein, and pilocarpine ; by the repeated administration of the latter drug, it was found that the granules of the polynuclear neutrophiles disappeared, although no effect was produced upon the granules of the eosinophile cells. Von Jaksch"* also studied the effects of the injection oi pilocarpine, and of the administration by the mouth of nuclein, and found that by either procedure a temporary and sometimes very marked leu- cocytosis may be produced. The leucocytosis caused by the ingestion of salicylic acid, according to Schreiber and Zandy,^ gradually disappears after the drug has been given for a few days. The effects of the ingestion of the essential oils of peppermint, turpentine, and cinnamon have been studied by Meyer,^ while Hirt^ has investigated the influences of the simple bitters and drugs such as the tincture of myrrh. Such drugs were found to cause a moderate, but easily recognized leucocytosis. Krausman,^ by the injection of spermin, and of protalbumose , and Besredka,^ by a similar use of carmine and of arse?nc trisidphate, have ob- tained varying degrees of increase in the number of leucocytes. A marked increase is produced, according to Bohland ^° by the injection of morphine, Dover' s powder, sodium salicylate, pilocar- pine, antipyrin, phenacetin, and antifebrin. ^Archiv. f. exp. Pathol, u. Pharmak., 1889, vol. xxv., p. 51. 2Loc. cit. 'British Med. Journ., 1896, vol. ii., p. 836. ^Centralbl. f. klin. Med., 1892, vol. xiii., p. 81, ^Deut. Arch. f. klin. Med., 1899, vol. Ixii., p. 242. ^ Cited by von Limbeck, loc. cit. 7 Ibid. 8 These de St. Petersbourg, 1898. '^Annal. de I'lnstitut Pasteur, 1899, ^ol- xiii., p. 49. '"Centralbl. f. inn. Med., 1899, vol. xx,, p. 361. 196 THE LEUCOCYTES. In addition to the substances already mentioned, the leucocy- tosis-producing effect oi wdinous purgative drugs, ^ of the tra7isfusion of blood and of normal salt sohuion^ of the subcutaneous use of fibrin ferment^ oi hemoglobin,^ and of bacterial cnlttires,^ extracts,^ and protei7is ^ has also been demonstrated. Thymectomy in animals is followed by a well-marked leuco- cytosis, associated with an increase in the bactericidal properties of the blood. IV. LYMPHOCYTOSIS. An increase, whether relative or absolute, in the lymphocytes above the number normal in health is known as lymphocytosis. Relative lymphocytosis involves simply a gain in the percentage of lymphocytes without a coincident increase in the total leucocyte count. Absolute lymphocytosis, on the other hand, is character- ized by an increase above normal both in the percentage of lympho- cytes and in the total number of leucocytes. Barring lymphatic leukemia, in which the lymphocytes are both relatively and abso- lutely in excess, lymphocytosis is almost always a relative condi- tion, or at least it is not accompanied by a decided rise in the total leucocyte count. The increase in the proportion of lymphocytes is moderate in most instances, the greater number of differential counts showing percentages of these cells ranging from 50 to 70, in comparison with the maximum normal percentage, about 30. These figures, of course, refer to the blood of adults, for in children the increase is generally greater, owing to the higher proportion of lympho- cytes normally found at this period of life. A differential count which shows, for instance, 60 per cent, of lymphocytes means a decided lymphocytosis in the adult, but is entirely within the normal limits in the young infant. Either type of cells, large or small, may predominate, or the change may not involve any con- spicuous deviation from the normal ratio of one form to the other. Frequently it happens that the two varieties possess such similar characteristics that it is impossible to determine which prevails. Occasionally the lymphocytosis depends largely upon unusually large percentages of the so-called "transitional" forms. Lymphocytosis may be due either to changes in the distribu- tion of the cells through the circulatory system, or to their in- . 1 De Rienzi and Boeni : Gaz. degli Osp. e. d. Clin., 1898, vol. xix., p. 1570. 2 Hand: N. Y. Med. Journ., 1900, vol. Ixxi., p. 556. 3Birk : "Das Fibrin-Ferment im lebenden Organismus," Dorpat, 1880. *Bojanus: "Exp. Beitrage z. Physiol, u. Pathol, d. Blutes," Dorpat, 1S81. 5 Hankin and Kanthack : " Proc. Cambridge Philosoph. Soc," Jan., 1892. ^ Buchner : Arch. f. Hygiene, 1890, vol. x. , p. 84. LYMPHOCYTOSIS. igy creased production and output by the lymphatic tissues. Ehr- lich^ attributes lymphocytosis to the local irritation of certain areas of lymphatic glands which produces an increased circulatory activity in these situations, in consequence of which large numbers of lymph elements are swept mechanically from the lymphatics, and enter the general circulation. He does not regard the change as an expression of an active chemotactic reaction, to which the lymphocytes are insensible. It also appears reasonable to pre- sume that the lymphocytosis which often accompanies leucopenia may be traced to still another factor, that of negative chemotaxis, which diminishes the number of polynuclear neutrophiles, and thus brings about a relative increase in the lymphatic elements, upon which the repellent action is not exerted. Lymphocytosis has been observed in a number of pathological conditions, but its presence may be considered physiological in but a single instance — in the blood of infants and young children ^ in whom such a change is entirely normal. This tendency to- ward a lymphocytic increase in infantile life, which becomes less notable as the child matures, is prone to become markedly exag- gerated in many of the forms of secondary anemia from which children suffer, especially the anemias secondary to syphilis, tuber- culosis, rachitis, gastro-enteritis, and scurvy ; less commonly, it has been observed in the acute infections. Lactation, conditions of cachexia, and great debility in the adult are in many instances accompanied by abnormally high per- centages of lymphocytes in the blood. It is a well-known fact that differential counts show a higher percentage of mononuclear non-granular elements in the blood of the enfeebled and poorly- nourished than in that of the active and vigorous individual. Similar changes are frequently associated with the terminal stages of a number of diseases, and maybe found after hemorrhage from various causes — trauma, hemophilia, and purpura. Lymphocytosis, sometimes decidedly marked, is common in certain of the severe anejnias, especially in chlorosis, pernicious anemia, and in syphilitic and tuberculous secondary anemias ; it may be observed during the course of a few of the acute infectiojis, such as enteric fever, malarial fever, Malta fever, scarlet fever, measles, pertussis, variola, pulmonary tuberculosis, and pneu- monia. Diseases involving the spleen and lymphatic glands are often the cause of a varying degree of increase in the lymphocytes, common examples of such conditions being chronic malarial splenic tumors ; simple, syphilitic, and tuberculous adenitis ; and malignant neo- ^Loc. cit. 198 THE LEUCOCYTES. plasms, especially sarcoma, of the lymph glands. Enlai-gement of the tliyroid gland also may give rise to a similar blood picture. Distinct lymphocytosis has been observed by Wilkinson ^ after the injection o{ qinnine Jiydi'ochlorate ; and by Perry- as the re- sult of administration of thyroid extract. It also follows the in- jection of tiibercidin, and pilocarpine. From a clinical viewpoint, lymphocytosis is of value chiefly in the diagnosis of lymphatic letikenda. Marked absolute increase in the number of lymphocytes associated with enlargement of the lymphatic glands forms a pathognomonic picture of this disease. The recognition of a doubtful case of syphilis may be facilitated by the occurrence of lymphocytosis plus eosinophilia. V. EOSINOPHILIA. The term eosinophilia is used to denote an increase above the normal standard in the number of eosinophiles in the circulating blood, this change usually, but not necessarily, being associated with a coincident increase in the relative percentage of these cells to the other forms of leucocytes. Thus interpreted, eosinophiha is a condition of absolute increase, in contradistinction to a purely relative gain in percentage, to which the term is not strictly appli- cable. For the sake of uniformity, it is customar}^ to speak of the per- centage of eosinophiles rather than of their actual number, but in order to determine accurately the presence or absence of eosinophilia, it is also essential in every instance to calculate the number of eosinophiles to the cubic millimeter of blood, from data obtained by a numerical estimate and a differential count of the leucocytes, thus : Total 7itwiber of Percentage of eosinophiles to Total niintber of leucocytes x other forms of = eosifiophilcs per cb. mm. leucocytes. per cb. mm. The necessity for such a calculation is forcibly illustrated in spleno-medullary leukemia, since in this condition the relative percentage of eosinophiles is often well within the normal limits, and yet a striking degree of eosinophilia may exist. For example, in a given case of this form of leukemia, the blood count shows 300,000 leucocytes per cubic millimeter with 5 per cent, of ^ Loc. cit. ^N. Y. Med. Record, 1896, vol. 1., p. 289. EOSINOPHILIA. 199 eosinophiles. This percentage, interpreted into the actual 7iuinber of cells, means an eosinophilia of 15,000 per cubic millimeter, or an increase of thirty-fold in excess of the highest normal figure. It is also true that a high percentage of eosinophiles does not neces- sarily imply eosinophilia, for a differential count showing, for ex- ample, 10 per cent, of these cells, with a total leucocyte count of 5,000 per cubic millimeter, means 500 eosinophiles to the cubic millimeter, a count not exceeding normal. On the basis of a variation in the normal number of leucocytes of from 5,000 to 10,000 per cubic millimeter, the absolute num- ber of eosinophiles may range from 25 to 500 per cubic millime- ter in the blood of the healthy adult. An increase in excess of this maximum standard, regardless of the percentage indicated by the differential county constitutes eosinophilia. Granting the accuracy of the current view that the hemic eosinophiles are purely myelogenous elements, their increase in the blood may be attributed to the influence of chemotaxis, prob- ably of a specific and selective character. Under the influence of such a stimulus the eosinophiles are attracted from, and, perhaps, overproduced by, the bone marrow, and are thrown into the gen- eral circulation in large numbers. It is also possible that to a slight extent their proliferation from Hke cells may occur in the blood-stream as well. Increase in the number of eosinophiles occurs as a physiolog- ical change m. young infants^ in women during the menstrual period, and after coitus. With these three exceptions, the presence of eosinophilia is always to be regarded as an evidence of some pathological condition. Once believed to be a pathognomonic sign of leukemia, in the light of more recent investigations eosinophilia is now known to be associated with diseases of almost every conceivable nature ; in fact, it has been reported in such a large number of conditions of such widely dissimilar pathogenesis that its value as a clinical sign must be largely restricted. Inasmuch as many of these re- ported instances of eosinophile increase lack verification, it can only prove confusing to give here a list of the many pathological states in which the change is reputed to have been observed. The following list, based upon the work of Cannon,^ Zappert,^ Gollasch,^ T. R. Brown,^ von Noorden,^ and others, includes only ^ Deut. med. Woch., 1892, vol. xviii., p. 206. ^Zeitschr. f. klin. Med., 1893, vol. xxiii., p. 227. Also Wien. klin. Woch., 1892, vol. v., p. 347. 3Forschr. d, Med., 1889, vol. vii., p. 361. *Bull. of the Johns Hopkins Hosp., 1897, vol. viii., p. 79. ^Zeitschr. f. klin. Med., 1892, vol. xx., p. 98. 200 THE LEUCOCYTES. those diseases in which eosinophilia is observed with a great de- gree of constancy. Such conditions are : — I. Diseases of the Skin. Dermatitis herpetiformis. Eczema. Leprosy. Lupus. Pellagra. Pemphigus. Prurigo. Psoriasis. Scleroderma. Urticaria. II. Helminthiasis^ Ankylostomiasis. Ascaris lumbricoides infection. Oxyuris vermicularis infection. Tenia mediocanellata infection. Trichiniasis. III. Diseases of the Bones. Hypertrophy. Osteomalacia. Malignant neoplasms. IV. Postfebrile. Malarial fever. Pneumonia. Rheumatic fever. Scarlet fever. Septicemia. V. Bronchial Asthma. VI. Splcno-medullary Leukemia. In addition to the conditions listed above, eosinophilia also occurs, but with less constancy, in some forms of the high-grade secondary aiiemia of childhood, in purpura, in hemorrhagic effusiojis, in gofiorrhea, in syphilis, in malig?iant disease, and in fibrinoiis bro7tchitis. It is also seen in many cases of splenomegaly, and after sple7iectomy, its development under the latter circumstance EOSINOPHILIA. 201 being regarded as a compensatory condition. An increase in the percentage of eosinophiles has also been noted in conditions of starvation. In scarlet fever the eosinophiles usually persist, in spite of the coexisting polynuclear leucocytosis, and the same peculiarity may often be found in trichiniasis . Eosinophilia may be produced experimentally by the injection of a number of medicaments, such as antipyrin, camphor^ nu- clein, phosphorus, pilocarpine, tuberculin, and many of the iron salts. Neusser ^ and his school have contended that eosinophilia is symptomatic of an extensive group of diseases, chiefly those in- volving the sympathetic nervous systejn, the sexual organs, and a long list of disorders which they attribute to the *' xanthin dia- thesis'' Most of these views have been unsubstantiated, many are misleading, and a few can be shown to be fanciful. Those who are inclined to investigate some of the remarkable claims made by Neusser as to the diagnostic and prognostic value of eosinophilia are referred to his original communication on the subject. Diminution in the number of eosinophiles occurs as a physiolog- ical process during digestioft, and after active fnusctdar exercise. It is observed usually in lymphatic letikemia, during the febrile stages of diphtheria, influenza, pneumonia, enteric fever, and septi- cemia, frequently after hemorrhage, and in the terminal stages of many diseases. The number of eosinophiles is said to be dimin- ished after castration. The writer has found a decrease or even absence of eosinophiles in the majority of cases of chlorosis and per?iicious anemia. The chief clinical value attached to eosinophilia relates to its presence in trichiniasis, in which infection it has been shown to be a sign of great reliability. It may, however, fail to develop in this condition. In the diagnosis of an exanthema which is suggestive of either scarlet fever or of measles, eosinophilia points to the former dis- ease, for it does not occur in the latter. The association of eosinophilia and lymphocytosis constitutes a blood change which may be helpful in the recognition of an ob- scure case of syphilis. High percentages of eosinophiles in chlorosis, in pernicious anemia, and after hemorrhage are generally regarded as an evi- dence of good regenerative powers of the hemogenic organs, and are therefore of favorable import. (Rieder.^) ^Wien. klin. Woch., 1894, vol. vii., p. 737. 2Loc. cit. 202 THE LEUCOCYTES. VI. BASOPHILIA. Increase in the number of basophiles in the circulating blood is of rare occurrence, having been observed in but few diseases except the spleno-medullary variety of leukemia, in which this change is quite constant, and sometimes most striking ; the baso- philes in this disease may constitute 5 or even 10 per cent, of all forms of leucocytes. The increase may involve either the finely granular, or the coarsely granular (mast cell) forms, or both, usually the latter. Up to the present time but little attention has been paid by hematologists to the general circulatory form of basophilia, al- though the local increase of the basophiles under various con- ditions has been well investigated. Canon ^ has reported an in- crease of the mast cells in a case of chlorosis^ and in various skin diseases. Sherrington ^ has observed a similar blood change in patients dying in the reaction stage of Asiatic cJwlera. A. E. Taylor ^ states that he has seen a notable circulatory basophiHa in a case of carcinoma, with marked cachexia, but without bone metastases ; in a case of gonorrhea ; in a case of mycosis fun- goides ; and in two cases of septic bone disease. Basophilia has also been observed in some cases of splenic anemia. Owing to our imperfect understanding of this condition, no theory regarding the production of basophilia is as yet generally acceptable. It is possibly due to the influence of a specific chemotactic substance, in response to which the basophiles are attracted from the bone marrow, and enter the general circula- tion. VII. MYELEMIA. The presence in the circulating blood of myelocytes, in small or in large numbers, is known as myelcmia. As pre\iously re- marked, this condition is invariably to be regarded as patholog- ical, since myelocytes are never found in the blood of the normal individual. The most striking example of myelemia is to be found in the spleno-medullary form of leukoma, in which condition this change constitutes one of the most conspicuous features of the blood-picture. Myelocytes occur in the blood in this disease in greater absolute and relative numbers and with greater constancy ^ Deut. med. Woch., 1892, vol. xviii., p. 206. 2Proc. of the Roy. Soc. London, 1894, vol. Iv., p. 189. 3 "Contributions from the William Pepper Laboratory of Clinical Medicine," Phila. , 1900, p. 148. LEUCOPENIA. 203 than in any other condition — a fact which is of the greatest diag- nostic value. The degree of increase may be enormous, as illus- trated by a case of the author's, in which the actual number of myelocytes was found to be 192,738 per cubic millimeter, or 27.3 per cent, of all forms of cells in a total leucocyte count of 706,000. Less frequently myelocytes are observed in lymphatic leu- kemia and in Hodgkin' s disease, but in these conditions their occurrence is inconstant and their increase trivial. Small num- bers of myelocytes (from .5 to 2 or 3 per cent.) are found in almost every case of primary pei'nicioiis anemia, and are not un- common in marked cases of chlorosis and in many of the severe forms of secondary anemia due to various causes. They are fre- quently met with in such conditions as pneumonia, septicemia, diphtheria, syphilis, malignant disease, rachitis, tuberculosis, osteo- mvelitis, osteomalacia, Addison's disease, and the malarial fevers. The writer has found them also in the following conditions : car- bon monoxide poisoning, hepatic cirrhosis, acute gout, malignant endocarditis, exophthalmic goitre, as well as in the above-named affections. One is forcibly impressed with the almost constant presence of myelocytes in the estivo-autumnal type of malarial fever, in severe septic infections, and in enteric fever in childhood, both in the early stages of the disease and during the later, post- febrile anemic period. Small numbers of myelocytes have been reported also in many other conditions, chiefly those associated with leucocytosis, with anemia, or with both. Increased activity of the bone marrow, whereby the myelocytes are forced into the blood-stream, is in all probability responsible for the production of myelemia. In response to an increased demand for leucocytes, the marrow becomes so over-stimulated that many immature forms of leucocytes, or myelocytes, acciden- tally find their way into the general circulation, their passage from the marrow no doubt being accomplished largely by emigration. It is furthermore now believed that substances which are posi- tively chemotactic for the polynuclear neutrophiles also exert a similar attractive influence upon their immediate precursors, the myelocytes, stimulating their increased proliferation in the bone marrow and exciting their emigration from this tissue into the blood-stream. VIII. LEUCOPENIA. Decrease below the normal standard in the number of leuco- cytes in the peripheral blood is known as leucopenia or hypoleuco- cytosis. Such a condition, like its antithesis, leucocytosis, may be 204 THE LEUCOCYTES. the result of either physiolgiocal or pathological causes. Owing- to the variation in the normal number of eucocytes in different individuals, it is difficult to determine arbitrarily just what degree of decrease may be considered as a leucopenia, but it is safe to apply the term to any leuecocyte count decidedly below 5,000 cells to the cubic millimeter. The number of leucocytes is rarely reduced to less than 3,000, except in certain of the essential anemias, in which their decline to one-tenth the maximum normal figure or even less, is occasionally to be observed. The most extreme instance of leucopenia on record has been reported by Koblanck,^ who found but a single leucocyte in a careful search through twenty stained cover-glass preparations of blood from a man, of twent>^-five years, suffering from epilepsy ; the exacty numerical estimate of the leucocytes in this case is not given in detail. The decrease may be accompanied by no deviation from the normal percentages of the different varieties of leucoc}i:es, or it may involve a more or less decided gain in the lymphocytes, the latter being the more common change of the two. Accoding to the nature of its underlying causes, leucopenia may be considered clinically as either physiological or as patho- logical. Physiological Leucopenia. The decrease in the number of leucocytes observed in several physiological states is generally attributed to vasomotor influ- ences which produce changes in the distribution of the leucocjiies throughout the system. Such changes occur from the effect of prolonged cold, and brief hot, baths r Decastelle ' has found that a temporary leucopenia may be produced experimentally, by stim- ulation of sensory nerves, this procedure causing a reflex con- traction of the abdominal vessels and a consequent retention of large numbers of circulating leucocytes in this part of the vascu- lar system. The variations in the number of cells ranges from twenty to thirty per cent, of the original count ; the maximum decrease occurs usually within three or four minutes, and in most instances does not persist longer than ten or fifteen minutes. Reduetiofi of blood-pressure is promptly followed by a very transient diminution in the leucocytes of the peripheral blood. Ma/nutrition and starvation are also potent factors in the pro- duction of leucopenia, the decrease dependent upon such causes frequently being most pronounced. The much-cited case of the ^ Inaug. Dissert., Berlin, 1889. ^ Winternitz : loc. cit. 3^Vien. klin. ^Voch., 1899, vol. xii., p. 395. LEUCOPENIA. 205 faster, Sued, is a good example of the effects produced upon the leucocytes by abstinence from food. Luciani ^ found in the blood of this individual a decrease in the number of leucocytes from 14,530 to 861 per cubic millimeter after a seven days' fast; on the eighth day an increase to 1,530 occurred, this being the average count noted during the remaining twenty-two days of the fast. The subnormal leucocyte counts which are often met with in many of the infirm and the greatly enfeebled can be traced to the effects of faulty nutrition, and to the malassimila- tion of food. Pathological Leucopenia. Leucopenia, or at least an absence of leucocytosis, occurs dur- ing the course of a number of general infectious diseases, promi- nent among which are the following : enteric fever, measles, in- fluenza, leprosy, Malta fever, the malarial fevers, and various forms of non-septic tuberculosis. In certain of the acute infections which are ordinarily accompanied by leucocytosis the combined influences of an intense infection and feeble resisting powers on the part of the individual may produce a distinct leucopenia, or may prevent the development of the characteristic increase. This is well illustrated by the low counts which sometimes are found in severe cases of pneumonia and of appendicitis. Leucopenia, often pronounced, is not uncommon in chlorosis and in pernicious aiiemia, being much more frequent and more decided in the latter disease. A well-marked leucopenia may be expected in about one-fourth of all cases of chlorosis, and in quite three-fourths of cases of pernicious anemia. It is also often met with in some high-grade secondary anemias, notably in those due to syphilis and to rachitis, and in splenic anemia. D'Orlandi^ has called attention to the frequency with which leucopenia is observed in certain of the severer forms of chronic gastro-enteritis in young infants. In the anemias accompanied by a decrease in the leucocytes, especially in primary pernicious anemia, the rule holds good that the more intense the oligocythemia and oligochromemia, the greater the degree of leucopenia. Ehrlich^ attributes the de- crease in such cases to a lessened proliferative function of the bone marrow, in consequence of which there is a diminution in the output of leucocytes by this organ. * **Das Hungern" (German translation by O. Frankel), Hamburg and Leipzig, 1890. 2 Rev. Mensuelle des Malad. del'Enfance, 1899, vol. xvii., p. 300. ^Loc. cit. 206 THE LEUCOCYTES. In leukemia an acute intercurrent infection may produce an abrupt and marked fall in the number of leucocytes, as in Cabot's remarkable case of lymphatic leukemia,^ in which, as the conse- quence of a fatal septicemia, the leucocytes fell in three weeks from 40,000 to 419 per cubic millimeter. Decrease in the number of leucocytes may be caused experi- mentally, by the administration of various drugs and other sub- stances. Bohland ' found that it followed the injection of ergot, SHlpho?ial, tannic acid, camphoric acid, atropine, agaracine, and picrotoxine. Delezene's ^ investigations showed that a marked decrease results from the injection of various anticoagulant sub- stances, such as peptone, diastase, and eel-serum ; he attributes the leucopenia thus produced to two factors — actual destruction in the circulation of some of the leucocytes, and dilatation of the blood-vessels in which the undestroyed cells tend to accumu- late. The transient leucopenia which precedes an increase in the leucocytes has been discussed elsewhere. (See page 185.) 1 Loc. cit. ' 2 Loc. cit. ^Nouveaux Montpel. Med., 1898, nrs. 31-34. SECTION V. DISEASES OF THE BLOOD. very .nterfere auring this '^'^ a IS more ^-crease being of hemoglobin. elaborate researches .orotic blood exhibits an •ity which occurs in healthy y. In the 36 cases studied by .y ranged from 1030 to 1049, these jrosis," London, 1897, p. 18. SECTION V. DISEASES OF THE BLOOD. I. CHLOROSIS. The blood drop is exceedingly pale and watery- Appearance looking, and flows so abundantly from the punc- OF THE ture that it actually seems as if the whole mass Fresh Blood, of blood in the body must be increased ; a large- sized drop usually follows the slightest prick of the needle, in spite of the obviously anemic appearance of the patient — a marked contrast to the difficulty commonly experi- enced in pernicious anemia of obtaining enough blood for the examination. The blood spread out in a film over the finger is transparent rather than opaque, and its fluidity is most striking. Microscopical examination of the fresh film shows excessive pallor of most of the erythrocytes, together with the presence of a variable number of cells of smaller diameter than normal, in the average case, and of cells decidedly deformed in shape, in severe cases. The practised observer can determine at first glance that the number of erythrocytes is not greatly decreased, except in an occasional case in which the oligocythemia may be so marked as to lead him to infer that he is deahng with a well- defined secondary anemia. Coagulation of the blood drop, in spite of the Coagulation, fact that hyperinosis is absent, is generally very rapid in chlorosis, often so rapid as to interfere with the technique of the examination, if one delays during this procedure. The specific gravity of the whole blood is more Specific or less diminished, the degree of decrease being Gravity. closely parallel with the loss of hemoglobin. Lloyd Jones, ^ who has made elaborate researches concerning this subject, believes that chlorotic blood exhibits an ^^^.ggersition of the fall in specific gravity which occurs in healthy girls at about the age of puberty. In the 36 cases studied by this author the specific gravity ranged from 1030 to 1049, these ^''Chlorosis," London, 1897, p. 18. 14 210 DISEASES OF THE BLOOD. figures corresponding to 17 and 58 per cent, of hemoglobin, re- spectively, as estimated by the von Fleischl hemometer. In 30 cases Hammerschlag ^ found that the density of the whole blood averaged 1045, and of the serum, 1030. Most obser- FiG. 37. Alkalinity, vers maintain that in this dis- '^^ ^m^ ease the alkalinity of the whole C^ £% ^"^ t^^v blood generally remains normal, Ql^ ^^ <^ w or suffers but a trifling diminu- ^ r\ W^ — to the condition found in other .-^ ---^ tion, this being in direct contrast .0 > C^.Tl^^O^ forms of anemia, in which the <^ %si^ "^ " fall in the alkalinity figure is J ^^ C? *. usually pronounced. Burmin," ^3 T\ itek >^ O in 18 examinations of 9 cases, C^^^r* £^ found that it ranged between %^ 0.128 and 0.200 grm. NaOH, Changes in the erythrocytes in the normal figures of this inves- CHLOROSis. (Triacid stain.) ,. , !• ^,o^i. ^^,0-_ . . tiffator bemg 0.182 to 0.218 grm. Showing a general decrease in the diameter *-* _ . , , . . of the corpuscles, striking decolorization, and 111 O Ol thCSC CaSCS tlie aclmmiS- moderate poikilocytosis. The nucleated cell . ,• r • r 11 J u near the center of the field is a normoblast. tratlOn of irOnwaS tOllOWed by a marked increase in the alkalinity of the blood, closely paralleling the gain in hemoglobin and ery- throcytes. On the other hand, Graeber^ states that in many cases he discovered abnormally high alkalinity figures, so constantly, indeed, that he regarded them as ** specific for this condition." The decrease in the percentage of hemoglobin Hemoglobin is usually excessive in comparison with the re- AND duction in the number of erythrocytes, this dis- Erythrocytes. proportionate oligochromemia being the most conspicuous and most constant feature of the changes affecting chlorotic blood. Naturally, such a change gives rise to very low color indices. This statement applies only to the majority of cases, for a low color index, while it is the rule in chlorosis, and is, diagnostically, a most important feature of the blood-picture, is by no means invariably found — no more in- variably than a high color index in pernicious anemia. To illus- trate this point, it will be observed that of the io6 cases of chlo- rosis blood counts collected in Table I., 49 (or more than 46 per cent.) showed an index below 0.50, the average for the series iWien. Med. Presse, 1894, vol. xliv. , p. 1068. 2Zeitschr. f. klin. Med., 1900, vol. xxxix. , p. 365. 3"Zurklin. Diag. d. Blutkrankheit," Leipzig, 1S90, p. 289. CHLOROSIS. 211 being 0.51, the maximum i.oi, and the minimum 0.22. In this table are given the ''first counts," or those made when the patient first applied for treatment. The average loss of hemoglobin, as evidenced by this same series of cases, amounts to a trifle less than 60 per cent., in con- trast to which stands the mean average erythrocyte decrease, which is equivalent to about 20 per cent., the hemoglobin loss thus averaging about three times as great as that of the corpus- cles. Individually, the hemoglobin percentage ranged in these cases from 12 to 75, averaging 41.3, and the count of erythro- cytes from 1,720,000 to 5,600,000, averaging 3,876,712. On account of their rather close correspondence, it is interesting to compare with these figures the results obtained by Cabot ^ in 109 cases and those of Thayer ^ for 63 cases. Cabot's cases gave the following mean averages : hemoglobin, 41.2 per cent.; erythrocytes, 4,112,000, with individual counts ranging frorn 1,932,000 to 7,100,000. In Thayer's series the hemoglobin averaged 42.3 per cent, and the erythrocyte count 4,096,544. Somewhat lower figures are given by Bramwell,^ who found the following averages in a series of 80 cases : hemoglobin, 34 per cent., or from 10 to 60 per cent.; erythrocytes, 3,437,300, or from 1,425,000 to 5,200,000 per cubic millimeter; and color index, 0.49, or from 0.20 to 0.96. While numerous examples may be found in Table I. of typ- ical cases of chlorosis in which the hemoglobin estimate and ery- throcyte count resemble those commonly occurring in pernicious anemia or in the secondary anemias, nothing is more characteris- tic of chlorosis than the averages above mentioned. The great difference is between chlorosis and pernicious anemia, the index usually being high and the corpuscular loss extreme in the latter disease. As compared with the secondary anemias, the differ- ence is too slight and its occurrence too inconstant to enable one to regard it with any degree of certainty from a clinical standpoint. Theoretically, in secondary anemia the hemoglobin loss is fairly proportionate to the erythrocyte decrease, thus producing color indices at or somewhat below the normal, but cases of secondary anemia having a so-called '' chlorotic " type of blood are far too common to render any information reliable gained by a sim- ple inquiry into the changes affecting the erythrocytes and their hemoglobin content. ^ Loc. cit. 2Cited by Osier: "American Text-book of Theory and Practice of Medicine," Phila., 1894, vol. ii., p. 196. 3** Anemia," etc., London, 1899, p. 35. Table I. Hemoglobin, Erythrocytes, and Leucocytes in Chlorosis, at the First Examination. io6 Cases. u it B 3 2 .5 «• ^ bo ca X s u is •5-S u E 2 Eli X u •o c u ■ythrocytes r cb. mm. eucocytes r cb. mm. 53 f^ U ^S. i aft. s 1 i^ A I 55 .49 5,600,000 6,000 , 54 25 •32 3,910,000 1 6,000 2 65 •59 1 5,500,000 12,000 i 55 30 •38 3,890,500 6,000 3 65 •59 ' 5,500,000 9,000 56 30 ■39 3,882,000 7,000 4 45 .41 1 5,420,000 11,800 ' 57 65 •84 3,880,000 4,000 5 35 '33 5,300,000 3,000 ^ 58 50 .66 3,800,000 15,000 6 35 '33 5,200,000 21,000 59 40 •53 3,800,000 9,370 7 71 .68 5,180,000 7,500 60 38 •50 3,780,000 9,500 8 65 •63 5,140,000 4,500 61 62 ■83 3,750,000 8,000 9 65 .63 5,100,000 6,000 62 40 •53 3,750,000 6,400 10 45 .44 5,080,000 6,000 63 35 .46 3,750,000 8,333 II 70 .70 5,000,000 5,000 64 30 ,40 3,735,000 12,400 12 55 .55 5,000,000 4,200 1 65 75 1. 01 3,700,000 8,000 13 52 .52 5,000,000 7,000 66 43 •58 3,700,000 5,000 14 65 .66 4,870,000 3,000 67 20 •27 3,685,000 4,000 15 40 .41 4,860,000 8,500 68 40 •55 3,624,000 9,000 i6 65 •67 4,800,000 6,000 69 31 ■43 3,611,000 3,400 17 60 .62 4,800,000 5,600 70 58 .81 3,600,000 8,000 i8 50 .52 4,800,000 10,000 71 44 .61 3,600,000 7,680 19 60 .64 4,660,000 2,000 72 40 .56 3,550,000 2,000 20 55 •59 4,640,000 7,000 i 73 34 .48 3,550,000 4,600 21 45 •48 4,625,000 5,000 1 74 28 •39 3,540,000 7,800 22 60 •65 4,600,000 12,000 I 75 33 •47 3,520,000 8 000 23 45 .48 4,600,000 6,000 1 76 42 .60 3,500,000 9,000 24 55 .60 4,560,000 9,000 77 38 •54 3,500,000 4,800 25 60 .66 4,520,000 17,000 78 30 •43 3,500,000 17,000 26 40 .44 4,520,000 14,000 79 30 .43 3,500,000 7,100 27 50 •55 4,500,000 7,000 80 35 •55 3,200,000 8,000 28 40 .44 4,500,000 4,000 81 23 •36 3,200,000 5,000 29 20 .22 4,500,000 11,000 82 20 •31 3,200,000 9,000 30 43 •48 4,400,000 7,000 83 1 25 ! .40 3,100,000 4,000 31 40 •45 4,400,000 9, coo 84 ! 20 j .32 3, 100,000 5,000 32 30 '33 4,400,000 5,000 85 : 38 ' •63 3,000,000 4,500 33 60 .68. 4,391,000 4,200 i 86 i 30 •50 3,000,000 4,000 34 65 •74 4,380,000 7,400 ! ' 87 27 •45 3,000,000 6,000 35 43 •49 4,320,000 8, 000 i 88 20 •34 2,912,000 2,500 36 33 .38 4,320,000 11,200 89 28 1 .48 2,900,000 4,oco 37 45 •52 4,300,000 6,000 i 90 21 •37 2,844,000 7,480 38 52 .61 4,240,000 8,000 : 91 20 ; •36 2,800,000 10,000 39 34 .40 4,230,000 2,400 92 27 ! .48 2,780,000 8,000 *o 65 •77 4.210,000 9,200 93 33 .60 2,770,000 9,000 +1 58 .69 4,204,000 3,500 94 20 .36 2,740,000 2,700 42 55 .65 4,200,000 5,000 95 22 •41 2,660,000 12,000 +3 50 •59 4,200,000 j 4,000 96 i 26 •49 2,630,000 ! 2,400 W 38 •45 4,200,000 , S,ooo 97 1 23 •44 2,600,000 8,400 ^5 50 •59 4,190,000 , 6,800 i 98 22 •42 2,600,000 1 12,000 ^6 50 .60 4,150,000 5,000 99 46 •95 2,420,000 I 8,000 47 60 •73 4, 100,000 5,000 100 22 .46 2,400,000 j 6,100 48 45 •55 4,070,000 6,500 lOI 17 •36 2,350,000 4,000 49 55 .69 4,000,000 4,000 102 30 .70 2,138,000 6,100 50 50 .62 4,000,000 ' 3,050 103 30 •71 2,100,000 6,000 51 45 •56 4,000,000 15,000 104 30 •72 2,080,000 4,000 52 40 .50 4,000,000 9,500 105 18 •50 1,800,000 2,100 53 27 •34 4,000,000 8,000 106 12 •35 1,720,000 3,000 1 Aver. 41-3 0.51 3,876,712 i 7,090 CHLOROSIS. 213 The most conspicuous change to be observed in the stained film of chlorotic blood is the presence of large numbers of under- sized, pale erythrocytes, such cells usually being so numerous that one is forcibly impressed with the fact that there must be a general decrease in the average diameter of all the erythrocytes in the field. As a rule, this decrease in size involves a large number of corpuscles moderately, rather than a few to an ex- treme degree, and therefore, except in severe cases associated with marked oligocythemia, striking examples of microcytosis are wanting. This alteration is just the opposite of what is generally found in pernicious anemia, for in this disease a tendency to- ward an increase in the average diameter of the erythrocytes, frequently in association with the presence of many extremely small microcytes, is the rule. If well defined, this feature of the blood changes carries a certain amount of diagnostic significance, although it cannot be distinguished in every case of chlorosis, since in some the diameter of the erythrocytes appears to be unaltered, while in others the deformities of size may so affect the cells that the blood-picture resembles that of a severe secondary anemia. The pallor of the erythrocytes, shown by their feeble reaction toward the plasma stain, is at once apparent. The great majority of the cells are affected alike, being pale, often quite colorless in the center and gradually becoming of darker color toward the peripheiy, in which a certain amount of hemoglobin still remains. This portion of the cell is usually well stained, so that the cor- puscles frequently appear as hoops or rings ; some, however, do not show even this narrow hemoglobin-filled zone, being practi- cally decolorized throughout. Stroma degeneration, as shown by the changes described by Maragliano, is not demonstrable in the average case of moderate severity, but this process has been ob- served in occasional cases of high grade. Polychromatophilia, except in cases of the latter class, does not occur. Basophilic gramdatioiis in the erythrocytes are not found in this condition, according to Grawitz.^ Deformities of shape are not noticeable, as a rule, except in the severer types of the disorder. In such cases, in which both the hemoglobin and the cellular losses are excessive, poikilo- cytosis may be very striking, as great, in fact, as in any blood disease, not excepting pernicious anemia. Poikilocytes, should they occur, are almost invariably of small size. Nucleated erythrocytes are very rare. In the average case they are usually sought for in vain, and even in the severer forms ^ Loc. cit. 214 DISEASES OF THE BLOOD. of chlorosis these cells are not numerous. Erythroblasts con- forming to the normoblastic t}'pe are found almost exclusively ; megaloblasts, although they are seen now and then, are ex- tremely uncommon, and have never been found in a large relative or absolute proportion to the other form of nucleated er>^throcytes. The number of leucocytes per cubic millimeter Leucocytes, is, as a rule, normal in the typical case of chloro- sis. If leucocytosis occurs, as it does occasion- ally, it should be attributed to some hidden or frank complication ; Table II. Qualitative Changes in the Leucocytes in Chlorosis, at the First Examination. 37 Cases. Case No. Small Lymph- Large Lymph- | Polynuclear Eosinophiles. Myelocytes. ocytes. ocytes. Neutrophiles. I i6;o 6.0 76.0 2.0 2 II. 30 85.5 0.5 3 20.0 3.5 75-0 1.5 4 25.0 3-0 72.0 0.0 5 19.5 20.5 60.0 0.0 6 22.5 15-0 62.5 0.0 7 20.5 19.0 60.5 0.0 8 32.2 17.8 50.0 0.0 9 25-5 16.0 57.5 I.O 10 18.5 12.0 695 0.0 II 18.0 lO.O 72.0 0.0 12 17.0 21.5 61.5 0.0 13 19-5 17.0 63.0 0.5 14 22.0 14.5 63-5 0.0 15 7.5 12.4 80.1 0.0 16 193 21. 1 59-6 0.0 17 18.5 16.0 65.5 0.0 18 18.0 16.0 65.0 1.0 19 18.3 19.0 61.0 1-7 20 15-5 245 60.0 0.0 21 26.0 21.0 53-0 0.0 22 12.0 30.0 58.0 0.0 23 13.5 12.5 73-5 0.5 24 14.0 15-9 70.1 0.0 25 17.5 14.0 68.5 0.0 26 150 17.0 68.0 0.0 27 20.5 II-5 68.0 0.0 28 20.3 12.7 67.0 0.0 29 31.0 9.0 60.0 0.0 30 35-9 6.0 58.0 0.1 31 24.0 2.0 74.0 0.0 32 275 40.0 32.0 05 33 26.0 15.0 56.0 1.0 2 34 24.0 26.0 50.0 0.0 35 22.0 6.0 72.0 0.0 36 24.5 14-5 61.0 0.0 37 6.0 32.0 590 0.0 Average : 20. 1 15-5 ! 64.0 .31 •13 CHLOROSIS. 215 if leucopenia exists, as it sometimes does, it may nearly always be regarded as a sign of the severity of the disease, since it is rarely met with except in cases in which the hemoglobin and ery- throcyte losses are decidedly marked. The mean average num- ber of leucocytes in the 106 cases of chlorosis to which reference has already been made (Table I.) is 7,090 per cubic millimeter, or approximately the same as the average count of these cells in normal blood. Counts as low as 2,000 and as high as 21,000 were made in this series; and in 14 of the cases (or 13.2 per cent.) the increase was sufficiently in excess of the normal stan- dard to justify the application of the term leucocytosis, that is, it was in excess of 10,000. These figures do not differ materially from those of Cabot and of Thayer, alluded to above, Cabot's counts in 104 cases averaging 7,400, and Thayer's estimates in 63 cases being but slightly greater, 7,485. Relative lymphocytosis, usually marked in relation to the se- verity of the case, is a common, but not a constant, qualitative change. It occurs in both mild and severe cases, but is much more common in the latter. In the author's experience, this in- crease involves chiefly the larger forms of these cells, both the non-granular mononuclear cells with spherical nuclei and the so- called ''transitional" forms with indented nuclei; striking in- crease in the last named variety of cells was a notable differential change in a large proportion of the 37 cases listed in Table II. In many of the cases in this series the large and small lympho- cytes together made up from 45 to as high as 67.5 per cent, of all varieties of leucocytes, the percentage of large forms being repeatedly estimated at 20 or 30, and even 40, in one instance. Deviations from normal in the relative percentage of poly?m- clear neutrophiles are governed by the behavior of the lympho- cytes, low differential counts of the former type of cells accom- panying high percentages of the latter, and vice versa. Should leucocytosis exist, it is of the pure polynuclear neutrophile type. The eosinophiles are notably decreased, both absolutely and relatively. The author has never found an increase of these cells in chlorosis, although considerable pains were taken to verify the statements made by some writers that this variety of leucocytes is occasionally observed to be greatly above normal in this con- dition. Eosinophiles were absent entirely in more than seven- tenths of all the cases collected in Table II., and were never found to exceed 2 per cent, of all the forms of leucocytes. Exceptionally, small percentages of myelocytes may be en- countered, as a rule, only in cases of a severe character. These cells are ordinarily present in not more than 6 per cent, of all 2l6 DISEASES OF THE BLOOD. cases, and their relative proportion to the other forms of leuco- cytes is always trifling, being rarely over i or 2 per cent. In the great majority of cases it has been gen- Blood Plaques, erally observed that the number of plaques is considerably in excess of normal. It appears that these elements are especially numerous in blood which clots rapidly. The changes in the blood associated with most Diagnosis, well-defined cases of chlorosis may be summarized as follows : Color. Coagulation. Specific gravity. Hemoglobin. Erythrocytes. Pale and watery. Usually rapid. Decreased. Marked absolute decrease, in most instances relatively greater than the loss of erythrocytes, thus producing a low color index. Moderately decreased, ordinarily to about 4,000,000 per cubic millimeter. Counts of 3,000,000 and less are common in severe cases. Erythroblasts very rare ; if present, cells of the normoblastic type invariably predominate. General decrease in the average diameter of the erythrocytes. In severe cases microcy- tosis may be marked. Poikilocytes not numerous, except in severe cases. Polychromatophilia rare. Usually normal in number. Relative lymphocytosis common. Small percentages of myelocytes, only in severe cases. Eosinophils notably decreased. Plaques. Increased in number. He who would essay the diagnosis of chlorosis solely by the aid of the information derived from the blood examination is in- deed a rash clinician. This point cannot be emphasized too strongly, that there is no blood-picture peculiar to this condition, since changes precisely similar to those seen in many a case of typical chlorosis are often observed in the secondary anemias, especially in those dependent upon such factors as syphilis, tuber- Leucocytes. CHLOROSIS. 2 I 7 culosis, malignant disease, and chronic renal lesions. On the other hand, rare cases of chlorosis have been reported in which no alterations in the blood were discoverable. The blood changes enumerated above (especially such features as a low color index, the general decrease in the diameter of the erythrocytes, the ab- sence or scantiness of erythroblasts, and the normal number of leucocytes associated v/ith relative lymphocytosis and a decrease of the eosinophiles) are not then, pathognomonic, but simply highly suggestive of the disease under discussion, in view of which fact it becomes essential to seek for other clinical signs and to consider them carefully in connection with the blood find- ings. One of the most important points which should be borne in mind is the fact that chlorosis is practically confined to females, usually those in early womanhood, at or near the period of puberty. Chlorosis is about as compatible with the male sex as is pregnancy — the so-called *' male chlorosis " is nothing more than a diagnostic myth. Osier ^ remarks that in girls in whom the disease occurs early in their teens precocity and almost prema- ture appearance of the menses is likely to exist. A large propor- tion of those in whom the disease develops later in life complain of scantiness or total suppression of the menstrual flow and of dysmenorrhea, these symptoms being especially common in chlo- rotics in the early twenties or thereabouts. The question of heredity also is of some diagnostic value, for it has been frequently noted that the disease exists, for instance, in two or more sisters, the statement being elicited upon further inquiry that their mother suffered from chlorosis at an earlier period. Thus, Albutt ^ speaks of meeting in his consulting-room the chlorotic daughters of women whom years before he had treated for the same disorder. Among the other manifestations of the disease to which atten- tion should be paid the following are the more important : a pecu- liar greenish-yellow color of the complexion and blanching of the mucous membranes (except in those rare instances of chlorosis florida, in which the color is high) ; the occurrence of various gastro-intestinal disturbances, of edema of the face and lower limbs, of vertiginous attacks, and of dyspnea upon physical exer- tion ; and the presence of systolic basic heart murmurs, and a venous hum most distinctly audible over the great vessels of the neck. Slight enlargement of the thyroid gland, frequently asso- ciated with Joffroy's sign (absence of horizontal wrinkling of the skin of the forehead and of upward curving of the eye-brows, when ^ Loc. cit. 2 "System of Medicine," London and N. Y., 1898, vol. vi., p. 483. 2l8 DISEASES OF THE BLOOD. the patient glances suddenly at the ceiling without elevating her head), is a physical sign which should always make one suspicious of chlorosis. The distinctions between chlorosis and pernicious anemia, as shown by the blood examination, will be described under the latter disease. (See page 230.) 11. PERNICIOUS ANEMIA. In marked cases of pernicious anemia it is Appearance sometimes almost impossible to obtain from a OF the puncture of the finger-tip a sufficient quantity of Fresh Blood, blood for an ordinar)^ chnical examination, owing to the bloodlessness of the superficial vessels. This fact naturally prompts the query, Does an actual reduction in blood volume or oligemia exist in such an instance, or can the dryness of the superficial tissues be attributed to vasomotor dis- turbances causing an unequal distribution of the blood mass, in favor of the internal viscera and deeper circulation? In a patient in whom puncture of the finger fails to give the requisite amount of blood, the lobe of the ear will generally be found to yield a drop of sufficient size. But even this ver>^ vascular part of the body may in extreme cases seem practically bloodless. The writer recalls a case of fatal anemia in which, in order to secure a drop of blood large enough to fill the lumen of an erythrocy- tometer only to the o. 5 graduation, it was necessary to open a small superficial vessel of the scalp, repeated deep punctures of the fingers, toes, and ear-lobes having given negative results. The drop as it emerges from the puncture wound is exceed- ingly pale, thin, and hydremic, lacking the characteristic opac- ity of healthy blood, and being of a fluidity and general color which hav^e been likened to those of meat-washings. In an oc- casional instance the color of the blood may be practically normal, or, rarely, of a brownish-red or chocolate tint ; but, as a rule, it resembles a watery, pinkish fluid, which appears to be deficient both in depth of color and in density. It has been frequently observed that, after having stood for a short length of time, the drop shows a tendency to separate into two more or less distinct parts, consisting of a dark stratum of corpuscles and a clear, watery-looking layer of plasma; or it may be irregularly mottled at different points, as if the corpuscles had become concentrated in isolated, compact groups in various parts of the plasma, thus producing the effect of alternating dark and light areas distributed through the drop. PERNICIOUS ANEMIA. 2ig Microscopical examination of the fresh film shows a great re- duction in the number of the erythrocytes, together with the presence of many forms of these cells which exhibit every possible variation in size and in shape. The color of the individual eryth- rocyte varies, some being normally dark and well colored, while others appear as mere washed-out rings or ''phantoms." In some of the cells the hemoglobin appears to be quite evenly distributed throughout the stroma, so that their typical biconcav- ity is obliterated. The endoglobular degenerative changes and those structural alterations denoting total necrosis of the eryth- rocytes, previously described, may be demonstrated with great clearness in this condition. Rouleaux formation is either entirely absent, or incomplete and atypical. Owing to the extreme oligocythemia common in pernicious anemia, it is advisable in making the films to use a somewhat larger drop of blood than is chosen for making ordinary spreads, so that the field will not contain such a pronounced scarcity of cellular elements. The obvious fluidity of the blood, the deficiency Coagulation, of the fibrin network, and the slowness with which coagulation occurs are marked features of this disease. In fact, in some cases coagulation may be said not to occur at all, according to the experiments of Hayem ^ and others of the French school, as in the case quoted by Lenoble,^ in which no clotting of a sample of arterial blood was observed even after a lapse of seventy -two hours after its withdrawal from the ves- sels. Many authors attribute considerable diagnostic value to this absence of clotting, and others go so far as to state that it renders a patient suffering with pernicious anemia especially prone to troublesome hemorrhages, even from a slight finger-prick — an accident which must be extremely rare, however, for it practically never complicates an ordinary clinical examination. The density of the whole blood is much Specific below the normal standard, specific gravities as Gravity. low as 1027 having been reported. It is to be recalled that in cases with a high color in- dex erroneous results may occur from attempting to estimate the hemoglobin percentage by Hammerschlag's table of equiv- alents, since the hemoglobin, in reality, is somewhat higher than the percentages corresponding to the specific gravity figures. (See page 100.) • Loc. cit. 2 "Charact. semeiol. du caillot et du serum," Paris, 1898. 220 DISEASES OF THE BLOOD. Up to the present time, the reaction of the Alkalinity, blood in pernicious anemia has not been very thoroughly studied, but the work already accom- plished is sufficient to show that the alkalinity is much diminished, as in most severe anemias. That it may be strikingly below normal is shown by a case lately reported by Waldvogel,' who in one case estimated the alkalinity figure at .40 grm., using Salkowski's method. This author has determined that the nor- mal alkalinity for men ranges from .350 to .400 grm., and for women from .300 to .350 grm. Both the percentage of hemoglobin and the Hemoglobin number of erythrocytes are greatly diminished, AND the former, as a general rule, relatively less so Erythrocytes, than the latter. Thus, inasmuch as the individual corpuscles contain often a normal or even an ex- cessive amount of hemoglobin, it follows that high color indices are common — common but by no means constant, as seems to be the current impression among many students, for although it is true that while the average color index is i.oo or higher in per- nicious anemia cases, the same statement cannot always be ap- plied to the individual case. The author's series of 31 cases (Table III.) showed, at the first examination, hemoglobin percent- ages varying from a minimum of 12 to a maximum of 45, with a mean average of 25.1 ; the color index of these cases ranged from 0.40 to 1.87, the average being 1.08; in 17 of the cases (or 54.8 per cent.) the figure was i.oo or higher. During re- missions, as the erythrocytes increase, it is common to find low indices, this peculiarity being especially conspicuous should the improvement in the patient's condition be rapid, since in such instances the corpuscular increase is relatively much more rapid than the gain in hemoglobin. In cases in which improvement takes place more slowly, the color index is likely to remain higher, for here the corpuscles and the hemoglobin are more prone to increase proportionately along parallel lines. The oligocythemia is most striking, counts of from i ,000,000 to 2,000,000 erythrocytes per cubic millimeter being not uncom- mon when the patient first comes under observation, the number of cells frequently diminishing to about 750,000 or even 500,000 later during the course of the disease. In Quincke's often-quoted case the remarkable count of 143,000 per cubic millimeter was observed just before the death of the patient, an instance which is almost paralleled by a case recorded by Hills,- in which the ^ Deut. med. Woch., 1900, vol. xxvi., p. 6S5. 2 Boston Med. and Surg. Journ., 1898, vol. cxxxix., p. 542, PERNICIOUS ANEMIA. 221 erythrocyte count fell to 155,760 one day before death. In the series just mentioned (Table III.) the count of erythrocytes per cubic miUimeter averaged 1,343,677, ranging between 550,000 and 3,240,000 ; this represents an average loss in corpuscular matter of somewhat less than 75 per cent., the greatest decrease amounting to almost 90 per cent, of normal — ^i^- 3^- a much more striking oligocythemia than is found in any other form of anemia. Periods of temporary increase in the hemo- globin and erythrocytes, followed sooner or later by relapses, are com- monly observed, the gain during such peri- ods sometimes being very pronounced. Thus, in one of the cases tab- ulated below a gain of more than 2,500,000 erythrocytes to the cu- bic millimeter was noted during a period of six weeks, with a subsequent loss of over 1,000,000 cells in the following eight days, the color in- dex during this time ranging from 1.25 to 0.74. These periods of improvement in the condition of the blood are generally asso- ciated with an amelioration of the other clinical manifestations of the disease, the patient's general condition improving so substan- tially that he begins to consider himself on the high road to re- covery, but in the course of time the old sympt^^^jms return, and the characteristic blood-picture again becomes evident. In most cases death is preceded by extreme oligochromemia and oligo- cythemia, the hemoglobin often falling to 1 5 or 20 per cent, of normal and the erythrocyte count declining to 750,000 or less ; in some cases, however, these losses are not so marked, and the count does not fall below 1,500,000 during the whole course of the disease. A prominent characteristic of the blood in pernicious anemia is the wide dissimilarity in the size of the erythrocytes, due to the presence of large numbers of megalocytes and microcytes ; so Changes in the erythrocytes in pernicious ANEMIA. (Triacid Stain.) Showing a general increase in the diameter of the cor- puscles, and marked poikilocytosis. The nucleated cell in the right of the field is a megaloblast. DISEASES OF THE BLOOD. Table III. Hemoglobin and Erythrocytes in Pernicious Anemia, at the First Examination. 31 Cases. Number. Hemoglobin Per Cent. Color Index. Erythrocytes per cb. mm. I 32 .40 3,240,000 2 35 .58 3,008,500 3 40 .81 2,468,000 4 24 .52 2,300,000 5 24 .54 2,200,000 6 24 .60 2,000,000 7 26 •71 1,810,000 8 20 •55 1,800,000 9 40 1.23 1,620,000 10 23 ■13 1,562,000 II 45 1-55 1,448,000 12 35 138 1,260,000 13 30 1.20 1,250,000 14 20 .80 1,237,500 15 18 •73 1,230,000 16 35 1.48 1,180,000 17 26 1. 17 1,100,000 18 14 .67 1,040,000 19 20 1. 00 1,000,000 20 31 1.58 980,000 21 18 1.02 875,000 22 20 1. 19 840,000 23 30 1.87 800,000 24 22 1^38 795,000 25 25 1.60 780,000 26 15 .97 768,000 27 20 1.42 700,000 28 12 .96 622,000 29 15 1.20 620,000 30 20 1-75 570,000 31 20 1. 81 550,000 Average : 25 + 1.08 1,343,677- striking may be this feature of the blood-picture that it is some- times difficult to find any two cells in the same field of the micro- scope which are. of the same diameter. In the great majority of cases it will b * round that the megalocytes distinctly outnumber the microcytes, to such an extent and in such a large proportion of cases that some writers consider this change an almost con- .stant blood finding in this disease. Large erythrocytes, measur- ing slightly below or above 10 (jl in diameter, are veiy common, while those measuring in the neighborhood of 1 5 a or even 20 fi are met with more rarely. Undersized erythrocytes, about 3 or 4 n in diameter, are also numerous, but, as remarked above, much less so than those of larger size. The presence of small, dark-colored, spherical microcytes of this size (the so-called CHART \ ' [. CENl MONTH. SEPTEMBER. C T B E R. NOVEMBER. DAY. H - f ' . c ■i f ■0 1 H T O Ci * ^ ^ \ 20 ■ uopo, 000 « * ~ A i / ■^ \ .^ / ~~"f -a 19 950,000 1 / \ ^1 18 900,000 1 1 \ ,1" 850,000 ) \ ■ .16 800,000 y 15 750,000 V ^ 14 TpOOOO !, 13 650,000 \ 12 600,000 1 1 \ V 11 550,000 II 1 ' \ 10 500,000 5^ • 20,' 000 )('■ '■ — ^ i8,000 16,000 1 14,000 1 1 i2,000 10,000 '1 1 8,000 1 y / \ .... .... .6,.()00.- 1 ea n N — j t" drrr al _JS; Si Ke f 1 .ei \« ^yj es ... .... 4,p00 1 ^ /^ T V, / ^ \ /\ / 2, 300 -V ¥ ' \, A / \ \ ^ y* \ ^^ X" Red, Hemoglobin. PERNICIOUS ANEMIA. Black, Erythrocytes. Blue, Leucocytes. PERNICIOUS ANEMIA. 223 ''Eichhorst's corpuscles "), once regarded as pathognomonic of pernicious anemia, is neither constant nor diagnostic of this dis- ease, since they are found in many other anemic conditions, and are absent in a large proportion of cases of true pernicious anemia. The fact that, of these alterations in the size of the erythrocytes, megalocytosis predominates, constitutes a sign of valuable diag- nostic significance in this disease. Poikilocytosis, to a more or less marked degree, is constantly obsei-ved, the conspicuousness of the deformities being in some cases extreme, while in others the change is a less notable feature. While marked poikilocytosis usually goes hand in hand with excessive diminution in the number of erythrocytes and in the amount of hemoglobin, the association of these three changes cannot be invariably counted upon, for in some cases, in spite of the fact that both oligocythemia and oligochromemia are marked, deformities in the shape of the corpuscles are but trifling. All varieties of erythrocytes, small, large, nucleated, and non-nu- cleated, may be deformed, so that the size of the poikilocytes varies from that of the smallest microcyte to that of the largest megalocyte. The kinds of deformity are of infinite variety, but it is still possible to designate certain well-defined forms which are especially common in this disease, these being the horseshoe form (Litten), and the oval form (Cabot), both of which varieties, while by no means peculiar to this condition, are found so fre- quently and in such abundance in pernicious anemia that their presence in the blood is at least highly suggestive. Of these two forms, the elongated, oval erythrocyte is found more con- stantly, and has been described in but a few other conditions. The author has been struck with the predominance of cells of this sort in three consecutive cases of purpura hemorrhagica, in one of which the deformity was so marked that scarcely a single normally shaped erythrocyte could be found in certain fields of the microscope. Cabot ^ cites Greene as noticing the same change in the blood of two patients in whom the tentative diagnosis of epidemic dropsy had been made. In addition to these well-defined varieties, many cells of other shapes, also met with in other severe anemias, are observed, notably those resemb- ling the form of a sausage, or a spindle, or a club. (See Fig. 38, page 221.) In the stained specimen the principal point of interest is the presence of 7iucleated erythrocytes, upon the character of which the diagnosis of pernicious anemia must depend. Erythroblasts are always to be found in this disease, at some stage of its course. ^ Loc. cit. 2 24 DISEASES OF THE BLOOD. Megaloblasts are of much greater clinical significance than nor- moblasts, and by a differential count will be found always to out- number the latter in eveiy genuine case of pernicious anemia, at some stage of the disease. This blood-picture, which indicates a megaloblastic degeneration of the bone marrow, due in all proba- bility to the influence of some unknown but specific toxic agency, is associated with only two other conditions, namely, nitrobenzole poisoning, and some cases of high-grade anemia due to bothri- ocephalus latus infection. The predominance of megaloblasts over normoblasts in pernicious anemia is well illustrated by Table IV., which shows that at the first examination the former type of Table IV. Approximate Number of Nucleated Erythrocytes per cb. mm. in Pernicious Anemia, at the First Examination. Number. Total. Megaloblasts. Normoblasts. Microblasts. I 924 693 210 21 2 840 616 140 84 3 544 512 16 16 4 470 320 150 5 368 207 46 "5 6 336 240 90 6 7 ' 328 328 8 260 20 240 9 256 144 80 32 lO 250 180 70 II 235 175 60 12 224 168 56 13 204 148 56 H 200 160 40 IS 192 180 12 i6 160 96 64 17 lOI 80 21 i8 100 100 19 96 73 23 20 67 47 13 7 21 60 40 20 22 48 32 16 23 48 37 7 4 24 32 24 8 25 20 20 26 15 15 27 10 8 2 28 6 6 29 3 3 Average : 2204- 146+ 64+ 10 cells outnumbered the latter in 26 out of the 29 cases here grouped together. The average proportion of megaloblasts to normoblasts in this series is somewhat more than 2 to i, and in PERNICIOUS ANEMIA. 22 5 some cases the former were the only kind of erythroblast dis- covered. The total number of erythroblasts of all varieties aver- aged 220 per cubic millimeter of blood, ranging from as low as 3 to as high as 924. Regarding this last statement, it should be remembered that it is not the actual number of nucleated erythro- cytes, but their character, which is all important in the diagnosis of this disease. Microblasts are rare in comparison to the other forms of nu- cleated erythrocytes ; in some cases they may be relatively nu- merous, but in the majority they are absent. They were noted in but 9 of the 29 cases tabulated above (Table IV.), their average number for the series being 10 to the cubic millimeter. In the differential count of nucleated erythrocytes, microblasts should be totalled with normoblasts, of which they are simply degenerate forms, more or less stripped of their protoplasm, and hence irreg- ular and ragged in outline. In addition to the foregoing types of erythroblasts, cells pos- sessing the characteristics of both the normoblast and the meg- aloblast may be observed in many instances. These atypical forms, and their clinical significance, have been described in a previous section. (See page 144.) In certain corpuscles, both of the normoblastic and megaloblastic types, division of the nu- cleus into several parts may have occurred, and in rare instances evidences of true karyokinesis may be seen. Normoblasts show- ing complete or partial nuclear extrusion and separation of the nucleus into a clover-leaf design are not uncommon, although pictures of this sort are found much more frequently in leukemia. In many cases of pernicious anemia one cannot but be struck with the fact that the majority of these atypical forms appear as cells with a megaloblastic protoplasm and a normoblastic nucleus ; they are, in the author's experience, much more numerous in this disease than cells having a normoblastic protoplasm and a meg- aloblastic nucleus, the latter being more common in leukemia. Fluctuations in the total number of erythroblasts occur from time to time during the progress of the disease, these changes sometimes taking place with great abruptness, being of wide range and often carrying not the slightest cHnical import. A marked increase usually but not invariably precedes and accom- panies a gain in the number of erythrocytes and in the percentage of hemoglobin ; and a similar increase, usually associated with extreme diminution in the erythrocyte count, is commonly met with as a pre-agonal sign. Marked evidences of polyclwomatophilia are found in many of the erythrocytes, both of the nucleated and the non-nucleated 15 226 DISEASES OF THE BLOOD. varieties. Such cells, when stained with Ehrlich's triacid mix- ture, instead of taking the normal orange color of the solution, stain some bastard tint, such as slate color, or dull purple, or dirty gray. Others may show a peculiar, streaked appearance, and irregular pale-white unstained areas, while others are scarcely Table V. Number of Leucocytes per cb. mm. and Percentage of Various Forms in Pernicious Anemia, at the First Examination. 31 Cases. Percentages of Diflfere nt Forms. Leucocytes per No. cb. mm. Small lym- phocytes. Large lym- phocytes. Polynuclear neutrophil es. Eosinophiles. Myelocytes. I 13,000 43-2 2.8 49.6 2.8 1.6 2 8,200 7-7 2.0 86.2 1.6 2.5 3 7,000 14.4 1.6 81.6 2.0 0.4 4 7,000 13.6 5-2 77.6 2.8 0.8 5 6,400 34- 4.0 60.0 I.O I.O 6 6,000 II. 2.0 84.0 I.O 2.0 7 5,800 14.0 3.0 73-0 0.0 lO.O 8 5»4oo 22.1 7 5 67.4 2.0 I.O 9 5,000 32.8 3-6 55.6 5-2 2.8 10 4,600 56.5 6.0 34.5 0.0 30 II 4,100 530 6.4 39.6 0.0 I.O 12 4,000 30.0 14-5 52.4 2.0 I.I 13 4,000 26.8 15-5 56.8 0.9 0.0 14 4,000 23.0 16.6 58.2 1.2 I.O 15 4,000 15.0 50 77-5 0.5 2.0 16 4,000 340 9.0 450 8.0 4.0 17 4,000 16.3 8.1 72.6 2.0 I.O 18 3,100 19.7 23.0 54.0 I.O 2-3 19 3,000 10.8 20.0 60.0 7.2 2.0 20 2,500 45-0 12.0 40.0 I.O 2.0 21 2,300 22.1 16.1 60.8 0.0 I.O 22 2,100 32.1 21.3 40.7 1.6 4-3 23 2,080 450 14.7 38.3 I.O I.O 24 2,000 65.0 20.0 14. 1 0.0 0.9 25 2,000 145 14.5 695 I.O 0.5 26 1,500 25.0 14.0 61.0 0.0 0.0 27 1,100 19. 1 12. 1 67.7 0.3 o.S 28 1,000 17.0 21.0 58.0 2.0 2.0 29 1,000 13.0 II. 72.0 I.O 30 30 1,000 20.0 9.0 70.0 0.5 0.5 31 500 37.5 18.5 40.8 2-3 0.9 Av. 3,925-f 26+ 10+ 58+ 1+ 1+ .stained at all, the greater part of the protoplasm remaining an indefinite shade of dead white. Grmiular degeneration of the protoplasm is distinctly evidenced in some of the cells, this proc- ess being betrayed by the appearance through the stroma of the affected cells of granular areas showing a striking affinity for a basic stain such as methylene-blue. These basophilic granules, PERNICIOUS ANEMIA. 2 2/ which have already been described, are not peculiar to pernicious anemia, since they have been found in a large number of secondary anemias of severe type, due to various causes. (See page 145.) Leucopenia may be counted on in about three Leucocytes, out of every four cases of pernicious anemia, a fact which stands in direct contrast to the anemias of secondary type, in which an increase in the number of leucocytes is more common. In an occasional case, especially in one in which the other blood changes are inconspicuous, the number of leucocytes is found to be normal ; and, rarely, a moderate leu- cocytosis, attributable to some complication, exists. In the aver- age case, however, these cells are distinctly below the normal standard, and the degree of leucopenia is sometimes extreme, the number of cells occasionally falling to below 1,000 to the cubic millimeter ; in rare instances, they may apparently be entirely absent, none being found after prolonged search both through the counting chamber and the stained film. In the 3 1 cases collected in Table V., the number of leucocytes averaged about 50 per cent, of the normal count (3,925 being the exact figure), and ranged, in the individual case, from 500 to as high as 13,000 to the cubic millimeter. It is interesting to note, in con- nection with the preceding remarks, that leucopenia was found in 22, or about 70 per cent, of these cases. The leucocyte count, except in the event of complications, roughly parallels that of the erythrocytes, falling coincidently with the oligocythemia and rising again as the erythrocytes increase. (See Chart, p. 222.) An exception to this general rule is found in the terminal leucocytosis which not uncommonly develops just before the death of the patient. Relative lympJwcytosis is a common, but not a constant, find- ing in the differential count of the stained film. It seems to be more frequently associated with low than with high counts, although no hard and fast rule can be laid down regarding this point. In extremely leucopenic blood a noteworthy finding is the abnormally high percentage of large mononuclear non-gran- ular cells, a change which does not ordinarily take place in con- nection with leucocyte counts approaching the normal average. The combined percentage of both large and small forms of lym- phocytes in the cases alluded to above (Table V.) averaged 37.8, individual counts varying from 9.7 to 85 per cent. Pre-agonal rises in the leucocyte count are sometimes lymphocytic in char- acter, resembling the blood changes seen in lymphatic leukemia, and sometimes purely polynuclear in type. The relative percent- age o{ poly }iticl ear neittrophiles averages low (58.6 per cent, in the 228 DISEASES OF THE BLOOD. above series), but isolated counts show a considerable range ; their relative proportion to the other forms of leucocytes is largely determined by the fluctuations in the percentage of lymphocytes. The cosinophilcs are almost invariably decreased, and not infre- quently they are wholly wanting, a circumstance which was made note of in more than 1 8 per cent, of the cases in the present series, in which the average percentage of these cells was 1.68. In an occasional case their percentage is abov^e normal, as in cases 9, 16, and 19 in Table V. In no other disease save the spleno-medullary form of leukemia are myelocytes so constantly found, but almost always in relativ^ely small percentages. In the cases under consideration these cells were absent in only two instances, the average figure for the 3 1 cases being 1.82 per cent. In a single case (number 7) the re- markably high estimate (for this disease) of 10 per cent, of myelo- cytes was made, for in the other cases in which myelocytes occurred their percentage ranged from 0.4 to 4.3. In the stained specimen it is common to find that the leuco- cytes, particularly the polynuclear neutrophiles, are of smaller size and more deeply stained than they appear in normal blood. This peculiarity seems to be more constant and more striking in pernicious anemia than in any other disease, so far as the author has been able to determine. The number of blood plaques is exceedingly Blood variable, so that it is impossible to make definite Plaques. statements regarding either the increase or de- crease of these bodies. In some cases they ap- parently are greatly increased, as evidenced by the groups of a'>-2"lutinated masses of these cells which are sometimes seen (von Limbeck^), but in other cases it is evident that their number is appreciably diminished (Hayem "). Van Emden^ supports the latter view. In one case this observer estimated their number at between 32,000 and 64,000 per cubic millimeter. In a typical case of pernicious anemia the Diagnosis, blood-picture upon which the diagnosis rests is as follows : Hemoglobin. Marked absolute decrease, but of relatively higher percentage in many cases than the percentage of erythrocytes, this giving rise to a high color index. Erythrocytes. Striking decrease, commonly to 1,000,000 or less per cubic millimeter. Counts of about 500,000 ^ Loc. cit. 2 *' Legons sur les Maladies du Sang," Paris, 1900. 3"Bijd. t. d. ken. v. h. bloed," Leiden, 1896. PERNICIOUS ANEMIA. 229 are not uncommon during the later stages of the disease. Erythroblasts constant, cells of the megaloblastic type predominating. Megalocytes and microcytes, the former prevailing. Poikilocytes, usually numerous and conspicuous. Polychromatophilia, BasophiHc stroma degeneration striking in severe cases. Leucocytes. Usually decreased ; decided leucopenia common. Relative lymphocytosis in the majority of cases. Small numbers of myelocytes almost invariably present. Eosinophiles few, sometimes absent. Plaques. Variable. Usually the diagnosis of pernicious anemia presents no difficul- ties, and may be made by the examination of the blood alone, the association of marked oligocythemia, a high color index, leu- copenia, and erythroblasts, chiefly of the megaloblastic variety, constituting a typical group of blood changes the significance of which is unmistakable. It should be borne in mind, however, that these changes are not always present in eveiy case when the patient first comes under observation, so that repeated and careful examinations of the blood are sometimes necessary before a diagnosis is possible. Of the above-named changes the most important, from a cHnical viewpoint, is the prevalence of nucleated erythrocytes conforming to the megaloblastic type. With the two exceptions already noted (bothriocephalus anemia and nitrobenzol poisoning), this ''mega- loblastic blood-picture" is seen only in pernicious anemia, and, what is more important, it occurs in every true case of this dis- ease sooner or later during its course. Inability to detect this important characteristic should be regarded rather as a reflection upon the thoroughness of the examiner's technique than as a contradiction of the truth of this statement. Eiythroblasts ^me not always numerous in pernicious anemia, and painstaking^avity prolonged study of several stained films may be necessary ' this important feature is distinguishable. general In those cases of doubtful nature, in which the typicao-es the changes are not at once evident, a tentative diagnosis as com- made by taking into careful consideration certain other ) that the signs and symptoms which the patient presents. In v^ally ap- stances attention should be directed to such suspicious irade sec- 230 DISEASES OF THE BLOOD. the clinical history as the existence of a severe anemia arising either idiopathically or without adequate cause, and pursuing a progressively unfavorable course, uninfluenced permanently by treatment ; the presence of a light lemon-yellow tint of the skin, of retinal hemorrhages, of a peculiarly soft, smooth, flabby condi- tion of the skin, and sometimes of moderate febrile paroxysms and gastric disturbances ; and the remarkable preser\^ation of the patient's general nutrition and body-weight in comparison with the severity of the illness. The severe secondary anemias due to hemorrhage, to advanced syphilis, and to malignant disease, especially of the stomach, sometimes give rise to clinical symptoms which so exactly simu- late pernicious anemia that the diagnosis must rest upon the re- sult of the blood findings, which are usually well enough marked to differentiate the conditions. It is true that in these conditions ample proof of sufficient etiological factors for the production of the anemia is generally at hand, and this fact should have im- portant bearing in ruling out anemia of the pernicious type, but it is also equally true that in malignant disease it is sometimes impossible to demonstrate the lesion, and that in syphilis the clinical history may be obscure, so that the blood examination must, after all, often be depended upon for the detection of the disease. In secondary anemia from the above causes the oligo- cythemia is seldom as excessive as it is in pernicious anemia, the eiythrocytes rarely falling as low as 1,000,000 per cubic milli- meter ; the oligochromemia is apt to be relatively greater than the ohgocythemia, so that a lower color index results ; leucocy- tosis is not uncommon ; and while deformities of shape and size and nucleation of the erythrocytes are frequently present, in some instances to as great an extent as in pernicious anemia, megalocytes do not predominate, nor do megaloblasts ever out- number normoblasts. From chlorosis, which sometimes possesses many clinical mani- festations in common with pernicious anemia, the diagnosis may usually be readily made by the blood examination, which shows decided differences between the two diseases. In a typical case of cliJorosis the deterioration in the quality of the blood affects chiefly', the hemoglobin content of the erythrocytes and not the cells tliemselves. Hence it is common to find m this disease extreme oligochromemia out of all comparison with the more moderate oligocythemia, and consequently a low color index — just the reverse of the condition found in pernicious anemia. De- formities in the shape and size of the erythrocytes are not un- commor in chlorosis, but they are not likely to be conspicuous ; SPLENIC AMEMIA. 231 the prevalent change affecting their shape is microcytosis of a moderate grade of development, so that a general decrease in the diameter of these cells is commonly observed. The most im- portant information derived from the blood is, however, of a negative character, consisting in the fact that nucleated erythro- cytes, should they be present, are chiefly normoblasts. While it is true than an occasional megaloblast may be encountered in rare instances, no chlorotic blood has ever been known to show a predominance of this type of cells. The behavior of the leuco- cytes in chlorosis is of no aid in the differentiation of this condi- tion from pernicious anemia, for in both diseases the count is usually low and relative lymphocytosis common ; in the former, however, the pronounced leucopenia of the latter condition is not often found. Myelocytes, while they may occur in both diseases, are much less common in chlorosis. In bothriocephalus anemia the expulsion of the parasite by the ad- ministration of an appropriate vermifuge is soon followed by a radical change in the blood-picture and other symptoms, the megaloblasts disappearing, the hemoglobin and erythrocytes quickly rising to the normal standard, and the patient's health becoming entirely restored. The history of a patient suffering from anemia due to nitrobenzol poisoning is sufficiently characteristic to exclude true pernicious anemia. The differential diagnosis between this disease and splenic anemia is alluded to in another place. (See page 235.) III. SPLENIC ANEMIA. There is nothing distinctive about the appear- Appearance ance of the drop of freshly drawn blood, the OF THE color and density of which varies with the inten- Fresh Blood, sity of the anemia present. The author has notes of a case of splenic anemia in which it was remarked that, from its color and general appearance, the blood drop resembled precisely that obtained from a typical case of high-grade pernicious anemia ; in a second case the color and opacity were but slightly less than normal. No reliable observations have thus far been made regarding such minor points as the rate of coagulation, the specific gravity, and the reaction of the blood in this form of anemia. Decided often extreme anemia, is the general Hemoglobin rule in this disease. In the early stages, the AND hemoglobin loss is relatively excessive as com- Erythrocytes. pared to the decrease in erythrocytes, so that the color index is consequently low — usually ap- proximating the figures found in many cases of high-grade sec- 232 DISEASES OF THE BLOOD. ondary anemia, but not averaging so low as in chlorosis. As the disease increases in severity, however, the color index tends to rise, as in pernicious anemia, this change being illustrated by the counts tabulated below. In a series of 14 cases lately reported by Osler,^ the following results were obtained : the hemoglobin in 1 1 cases averaged 43.7 per cent., the lowest estimate being 23 and the highest 60 per cent. ; the erythrocytes in 10 cases averaged 3,336,357 per cubic millimeter, with extremes of 2,000,000 and 4,788,000. In a case of splenic anemia in Professor Hare's ward at the Jefferson Hospital the writer found the following changes, in five consecu- tive counts : Date. Hemoglobin. Color Index. Erythrocytes per cb. mm 3- 7-98. 45 per cent. .82 2,750,000 3-14-98. 40 - (I • 73 2,725,000 3-22-98. 43 '' 11 .76 2,812,000 3-29-98. 45 " (( .69 3,275,000 4-1 1-98. 40 '' (( I. 00 2,000,000 Deformities affecting the size of the erythrocytes, sometimes tending toward striking megalocytosis, may be met with in cases characterized by great oligocythemia, such an alteration being also associated with a greater or less degree of poikilocytosis, and with signs of stroma degeneration. Nucleated erythrocytes, although they occur infrequently, may be present in enormous numbers in severe cases, creating a blood-picture which is distinguishable from that of true pernicious anemia only by the fact that normo- blasts predominate. Thus, in one of McCrae's counts in a case of Osier's, in which the hemoglobin was reduced to 20 and the erythrocytes to 27.6 per cent., no fewer than 75 erythroblasts (of which 21 were normoblasts, 19 megaloblasts, and 35 "inter- mediate " forms) were seen while counting 400 leucocytes. In the case above summarized the average number of erythroblasts per 1,000 leucocytes was estimated as 6y (the maximum and minimum being 128 and 9, respectively) for the five examinations, 41 of these cells being normoblasts, and 26 megaloblasts. The presence of nucleated erythrocytes in such large numbers as were found in these two instances must, however, be regarded as most exceptional. Polychromatophilic staining of many of the erythro- cytes may be a striking feature in advanced cases, but in those of a milder grade the phenomenon is absent. Absence of basophilic granular degeneration of the cells has been noted by Cohn.^ ^ Am. Joum. of Med. Sc, 1900, vol. cxix., p. 54. 2Munch. med. Woch., 1900, vol. xlvii.,p. 618. SPLENIC ANEMIA. 233 Leucopenia, sometimes pronounced, is found in Leucocytes, the great majority of cases, counts of from 2,000 to 4,000 cells to the cubic millimeter being com- mon ; as in pernicious anemia, the lowest leucocyte counts are generally associated with those cases in which the anemia is most intense. Leucocytosis occurs only as the effect of some compli- cation, and therefore is but occasionally encountered. In Osier's series, above referred to, the number of leucocytes, determined in 13 cases, averaged 4,770 per cubic millimeter, ranging from 2,000 to 12,497, the latter estimate being the only one exceeding 10,000; in 9 of the cases the count fell below 5,000. In the writer's case the five counts averaged 2,400, varying from 1,000 to 4,000. No constant differential changes have been observed, but rela- tive lymphocytosis is not infrequent, sometimes involving chiefly the large, and sometimes the small forms of these cells. The pro- portion of both combined may be as high as 50 or 60 per cent., an increase of this kind bringing about a consequent fall in the relative percentage of polymiclear neiitrophiles. Small numbers of 7nyelocytes, rarely in excess of a fraction of one per cent., are to be expected in cases with decided oligocythemia. The eosinophiles remain at about the normal standard. Typical coarsely-granular mast cells are sometimes found in relatively large numbers — as high as 5 or 6 per cent, of all forms of leucocytes. No special observations concerning the behavior of the blood plaques in this disease have been recorded up to the present time. It is evident, however, that they are not notably increased in number. To recapitulate, the blood changes which have Diagnosis, been most frequently found in splenic anemia may be tabulated as follows : Hemoglobiit. Marked diminution ; color index variable. Erythrocytes. Usually reduced moderately, sometimes exces- sively. Counts between 3,000,000 and 4,000,000 cells per cubic millimeter are most common. Deformities of shape, especially megalocytosis, and poikilocytosis common in advanced cases. Erythroblasts rare, except in cases with decided oligocythemia. Normoblasts invariably predomi- nate. Polychromatophilia in severe cases. 234 DISEASES OF THE BLOOD. Leucocytes. Leucopenia the general rule. Relative lymphocytosis common. Small numbers of myelocytes in advanced cases. Relatively large percentages of mast cells not uncommon. Eosinophiles normal. Plaques. Not increased. Many writers still hesitate to assign to splenic anemia the role of a definite clinical entity, choosing to regard the condition either as a splenic form of Hodgkin's disease, or as high-grade secondary anemia with marked splenic hyperplasia. But of late the majority of observers, especially those of the British school, lean toward at least a tentative recognition of the condition as a distinct although an obscure disease.^ Osier ^ well expresses the consensus of opinion when he remarks that " provisionally, until we have further knowledge, it is useful to group together . . . cases of idiopathic enlargement of the spleen with anemia without lymphatic involvement, and to label the condition splenic anemia." It is quite obvious, from a glance at the above synopsis of the blood condition, that splenic anemia presents no characteristic blood-picture by which the diagnosis can be made, so that in order to differentiate it from a number of other diseases which it more or less closely simulates, careful study of other cHnical features is essential. The onset of splenic anemia is gradual and insidious, its course is prolonged often for a number of years, and its termination is ultimately fatal. The principal clinical features are the leuco- penic anemia, the great splenic tumor, and the absence of all en- largement of the superficial lymphatics. In some instances the anemia develops in advance of the splenic tumor, but it is more often the case that the enlargement of the spleen is the earliest demonstrable lesion. The anemia is responsible for such symp- toms as dyspnea, vertigo, cardiac palpitation, loss of strength and appetite, and the occurrence of unexplained, irregular periods of fever ; and for such signs as hemic heart murmurs, pallor, lemon-yellow discoloration of the skin and mucous membranes, and sometimes pigmentation of the skin. The enlarged spleen may extend as far down as the umbilicus, and sometimes far be- low this point, even to the iliac crests ; the surface of the organ 'For a critical resume of the literature on splenic anemia, Sippy's article in the American Journal of Medical Sciences, 1899, vol. cxviii., p. 570, should be consulted. ^ Loc. cit. SPLENIC ANEMIA. 235 is smooth and free from nodules, its consistence is firm, and its shape is unaltered. It may give rise to no symptoms, but occa- sionally it is the cause of great pain and of hematemesis, the latter being due to simple mechanical congestion. Epistaxis, purpura, and hematuria have also been obsei-ved. Ascites sometimes de- velops, as the result either of the splenic enlargement, or of the anemia. Enlargement of the liver, usually associated with ca- tarrhal jaundice, occurs in a large proportion of cases, and such gastro-intestinal disturbances as anorexia, nausea, vomiting, and both constipation and diarrhea are extremely common. Splenic anemia may prove fatal within six months after the onset of the initial symptoms, or it may drag along for as many years, but, as a general rule, its duration does not exceed two or three years. In one of Osier's cases the condition probably lasted for at least twelve years, and in a case now under treatment in the Jefferson Hospital the splenic tumor and the anemia have existed for the last six years, if not longer. As in pernicious anemia, periods of remission during which the leading symptoms disappear and the quality of the blood improves, are commonly observed in this condition. The spleno-medullary form of leukemia, pernicious anemia, and Hodgkin's disease with splenic ejtlargemeiit all present clinical features counterfeiting more or less faithfully splenic anemia, but the differential diagnosis between these conditions does not in- volve any great difficulty. The result of the blood examination gives the clue to the two diseases first named, the myelocytic type of blood in leukemia, and the predominance of megaloblasts in pernicious anemia being sufficient to fix the identity of these conditions. In Hodgkin's disease with enlargement of the spleen there is more or less marked enlargement of the superficial lymphatic glands, and the splenic tumor rarely attains the size to which that organ grows in splenic anemia ; the blood-picture of the two conditions, it must be recalled, may be identical. Enlargements of the spleen due to such factors as chronic ma- larial iitfection, amyloid disease, malignant g7'owths, echinococcus cysts, and hepatic cirrhosis also occasionally require differentiation from splenic anemia. A history of previous attacks of malarial fever, and the detection of the specific parasite or of pigment in the blood will serve to distinguish tumors of the spleen of malarial nature. In amyloid disease a histoiy of long-standing suppura- tion, of tuberculosis, or of syphilis, and the presence of signs in- dicating amyloid degeneration of other organs, notably the liver, kidneys, and intestines, are the chief differentiating features. In malignant disease of the spleen the tumor is uneven, irregular, 236 DISK\SES OF THE BLOOD. and nodular, evidences elsewhere of malignant lesions generally exist, and a well-defined leucocytosis is common. Echino- coccus disease of the spleen pursues a protracted course unac- companied by signs of anemia, and, unless secondar\^ infection takes place, unassociated with rises in temperature ; fluctuation of the tumor can frequently be detected ; and booklets can be recog- nized in the fluid obtained from the organ by aspiration. In splenic enlargements associated with the different varieties of hepatic cirrhosis, the previous history^ and the cachexia of the patient, the relatively moderate size of the tumor, the signs of portal congestion, the condition of the liver, and the course of the disease should be taken into account. IV. SECONDARY ANEMIA. An approximate idea of the intensity^ of the Appearanxe anemia may usually be formed by noting the OF THE gross appearance of the fresh blood drop, but it Fresh Blood, must be remembered that it is only when the process has reached a comparatively high grade of development that the fact is betrayed by any marked devia- tion from normal in the color and densitv of the blood. In the average case of well-marked secondary anemia the color of the drop is but slightly paler than normal, if, indeed, it is visibly al- tered ; but if the anemia is of decided severity it may resemble a thin, serum-colored liquid streaked with crimson, similar to the water}^ blood drop of typical pernicious anemia. In such cases microscopical examination of the fresh film shows that there is little or no tendency toward rouleaux formation. In general terms, it may be stated that the Coagulation, rapidity of coagulation bears a direct relation to the grade of the anemia, since it has been determined that the greater the oligochromemia and oligocy- themia, the more rapid the process of clotting. In secondary^ anemias with ervthrocvte counts under i ,000,000 Lenoble ^ found that coagulation was, as a rule, at least twice as rapid as normal. The specific gravity of the whole blood is re- Specific duced, a change which is dependent chiefly upon Gravity. the loss of hemoglobin. Sufficient reference has already been made to this subject in a previous section. (See page 98.) ^ Lx)c. cit. SECONDARY ANEMIA. 237 The majority of authors maintain that the al- Alkalinity. kalinity of the blood is decreased in relation to the degree of the anemia, and a large number of experiments in anemias due to various factors apparently justify this general belief. But several careful investigators, notable among whom is Lowy,^ have contradicted these reports, having found the alkalinity normal or even above normal in numerous cases. The author quoted, for example, calculated the alkalinity in various cases of secondary anemia at from 360 to 675 mgrms., as compared with his normal standard, 447 to 508 mgrms. Taking the ordinarily well-developed case of Hemoglobin secondary anemia as an example, it is found that AND the hemoglobin percentage and number of erythro- Erythrocytes. cytes are both decidedly, though not strikingly, diminished. As the former usually shows a dis- proportionately greater loss than the latter, subnormal color in- dices are the rule, ranging, say, from about 0.75 to 0.85. In anemias of severer type, such as those due to gastric cancer and to enteric fever, the losses frequently are much more exaggerated, and, in so far as the purely quantitative changes in the erythro- cytes and their hemoglobin equivalent are concerned, the blood picture of true pernicious anemia may be counterfeited. In the anemias of syphilis, of tuberculosis, and of malignant disease in general the disproportionate hemoglobin loss may be so decided that the blood changes cannot be distinguished from those of chlorosis, and to this condition the much-abused term '' chloro- anemia " has been applied. The fact must be emphasized that simply, the hemoglobin esti- mate and erythrocyte count alone are absolutely uncharacter- istic in secondary anemias, for they may range in the individual case from slightly subnormal figures to an extreme degree of oligochromemia and oligocythemia. In a patient studied by von Limbeck,- for example, at one time the erythrocytes num- bered only 306,000 per cubic millimeter, but ultimately perfect recovery ensued and the count rose to 4,280,000. But if aver- ages are used as a basis for conclusions, it becomes evident that the hemoglobin diminution is less marked than in any other blood disease, and that the erythrocyte loss is also less than in any other form of anemia except chlorosis. Data based upon 200 examinations of various types of anemia by the writer give the following results regarding these points : ^Centralbl. f, d. med. Wissensch., 1894, vol. xxxii., p. 785. 2Loc. cit. 238 DISEASES OF THE BLOOD. Disease. Average Percentage of Hemo- globin Loss in 50 Consecu- tive Estimates. Average Percentage of Ery- throcj'te Loss in 50 Con- secutive Counts. Secondary Anemia. Chlorosis. Leukemia. Pernicious Anemia. 44.8 per cent. 54.8 - 60.6 " 74.5 " 27.1 per cent. 17.8 45-4 76.9 " Examination of the stained specimen shows a variable degree of alteration in the shape, size, and general structure of the cells. In mild cases simple pallor of the erythrocytes, with perhaps a few microcytes and moderately misshapen poikilocytes are the only changes to be observed, erythroblasts, polychromatophiles, and cells with basophilic stroma degeneration being entirely wanting. In severe cases, with excessive oligocythemia, a large proportion of the cells are either under- or over-sized, the latter forms appearing to prevail in relation to the intensity of the ane- mic process ; poikilocytosis and polychromatophilia are sometimes extreme, and evidences of Grawitz's stroma degeneration are found, together with a more or less abundance of nucleated eryth- rocytes, the majority of which conform to the normoblastic type. In most instances normoblasts only are present, but rarely an occasional megaloblast, implying a slight tendency toward a fetal type of hemogenesis, is also seen. The significance of erythroblasts in anemia and the circumstances under which they are found have been discussed in a preceding section. (See page 141.) Typical polynuclear neutrophile leucocytosis Leucocytes, is common but by no means constant in the sec- ondar}' anemias, independent of their grade, for the cellular increase is provoked by a stimulation of the functional activities of the marrow, which vary according to the individual and to the nature of the exciting cause. The differential changes associated with such a leucocytosis (low percentages of lympho- cytes and eosinophiles, with, perhaps, a few myelocytes) have already been referred to in a preceding section. A moderate leucocytosis is especially common in the anemias of children, and in those symptomatic of inflammatory and suppurative condi- tions and of malignant diseases. While in other anemias, espe- cially those of chronic type, a normal leucocyte count or even leucopenia may be found, often in association with a relative lymphoc>'tosis, as is frequently the case in the anemias of enteric fever and of tertiary syphilis. POST-HEMORRHAGIC ANEMIA. 239 The plaques are usually increased, but appa- Blood rently without any constant relationship to the Plaques. degree of hemoglobin and erythrocyte loss. In some cases these bodies may number more than double the maximum normal standard, as in a case of anemia in a child with a tumor of the spleen, noted by von Emden,^ in which an estimate of 829,000 to the cubic millimeter was made. Diagnosis principal blood changes found in second- ary anemia are as follows : Hemoglobin. Variable decrease, usually somewhat more marked than the erythrocyte loss ; color index subnormal. Erythrocytes. Variable decrease. Erythroblasts, in severe cases; normoblasts out- numbering megaloblasts, which are rare. Deformities of shape and size, polychromatophilia, and basic staining of the stroma in severe cases. Leucocytes. Commonly increased ; rarely leucopenia. Polynuclear neutrophiles usually increased, and lymphocytes and eosinophiles relatively dimin- ished. Lymphocytosis in some cases, usually those of severe type and chronic course. Small numbers of myelocytes sometimes found. Plaques. Usually increased. V. POST-HEMORRHAGIC ANEMIA. Among the many underlying causes of acute Etiology, post-hemorrhagic anemias may be mentioned trauma, abortion, post-partum hemorrhage, epis- taxis, pulmonary tuberculosis, peptic ulcer, enteric fever, visceral carci7ioma, hemorrhagic pancreatitis, and the rupture of an aneu- rysm, of a Fallopian tube during ectopic pregnancy, and of a mass of extensively varicose veins. Chronic hemorrhages resulting, for example, from diseases belonging to the hemorrhagic diathesis, from hemorrhoids, or from uterine diseases usually give rise to a much less decided blood loss than the first-named conditions, but in some instances these factors, if persistent, may be sufficient to provoke eventually a high-grade anemia. ^ Loc. cit. 240 DISEASES OF THE BLOOD. Reduction in the total volume of blood, or Effect Upon oligcinia, ensues as the immediate effect of an THE Blood, acute hemorrhage, and a count made immedi- ately after the blood loss may show no reduction in the hemoglobin and corpuscular value, since the oligemia af- fects the liquid and cellular elements proportionately. As reac- tion sets in, the system attempts to compensate for the loss of blood, by the rapid absorption by the capillaries of large amounts of liquids from the tissues, so that the blood soon becomes highly diluted, or hydremic. This is evidenced by a proportionate dimi- nution in the hemoglobin paxentagc and tiytJirocyte count, the degree of this decrease depending upon the extent of the hem- orrhage. It is thought that in many instances this fluid transfer from tissue to vessel is inaugurated immediately after or even during the hemorrhage, and that the original volume of blood is restored within a few hours. A further diminution in hemo- globin and erythrocytes occurs after the normal volume of blood has been reestablished, so that the minimum decrease is not ob- served until some little time has elapsed after the hemorrhage. As a rule, the minimum count is seen at some period during the first week after the blood loss, as early as the first or second day in some instances, but as late as the tenth or eleventh day in others. This secondary fall is thought to depend upon the in- troduction into the circulation of large numbers of immature, feebly resistant erythrocytes, which suffer rapid and premature destruction, and thus bring about a disturbance in the equilibrium between the rate of blood production and blood destruction in favor of the latter. As soon as the marrow is able to meet the drain in an adequate manner, by the increased production of more resistant cells, the anemia ceases, and the hemoglobin and eryth- rocyte estimates begin to rise. Authorities differ as to the degree of blood loss which man is capable of surviving, a difference which is but natural' when it is remembered that factors other than the actual amount of blood lost, conspicuous among which are the age, sex, and resisting powers of the patient, are all important in determining the fatality of the hemorrhage. According to Immermann,^ hemorrhages involving a loss of one-half of the total bulk of blood in the body invariably prove fatal. Hayem '" is authority for the state- ment that, as a general rule, recovery is possible when the total volume of blood lost does not exceed y^th of the individual's body-weight. This author has reported the most astonishing ^ Cited by Rieder, loc. cit. 2Loc. cit. POST-HEMORRHAGIC ANEMIA. 24 1 example on record of post-hemorrhagic cellular decrease, in which he observed a diminution in the erythrocytes to 1 1 per cent, of normal, in a case of post-partum hemorrhage, with sub- sequent recovery of the patient. Behier ^ has described a case of metrorrhagia in which recovery occurred, in spite of a reduc- tion in the erythrocytes to 19 per cent, of normal. Laache^ has recorded a number of instances in which the corpuscular esti- mates fell below 50 per cent, of normal, in one case to 32 per cent. These last three examples are sufficient to disprove the former belief, that death inevitably ensues when the corpuscular loss, as the result of hemorrhage, falls as low as 50 per cent, of normal. Increase in the number of leucocytes, usually of moderate de- gree, promptly develops in the great majority of cases, and per- sists for several days. It usually involves an absolute and rela- tive gain in the polynuclear neutrophile cells with a consequent decrease in the mononuclear forms, but, rarely, the reverse may be noted. In fatal cases this increase may not occur. The maximum count is commonly attained within a few hours after the onset of the leucocytosis. (See *' Post-hemorrhagic Leucocytosis," page 191.) According to most authors, the blood plaques are strikingly in- creased after hemorrhage. The coagulability of the blood is ab- normally quick, being more rapid in profuse than in moderate hemorrhages. Following the reestablishment of the normal Regenera- blood volume, regeneration of the erythrocytes TiON. and hemoglobin, and a consequent dissipation of the hydremia, ensues. The time necessary for the completion of this process varies greatly in different individ- uals, as the rapidity with which blood regeneration occurs depends upon different factors, such as the extent of the original hemor- rhage, and the age and natural regenerative powers of the patient. The latter are at their maximum during the third and fourth decades of life, at their minimum during infancy and old age, and are regarded as more active in women than in men. The exist- ence of a well developed cachexia, or an infectious disease, as well as the neglect of proper treatment of the hemorrhage, are obstacles which retard the regeneration of the blood to its normal composition. The process appears to be more active if trans- fusion of a normal saline solution has been practised than in un- treated cases, the rapidity of the gain being especially striking during the latter half of the regeneration period. The transfusion 1 Cited by Laache, loc. cit. *'*Die Anemie," Christiania, i 16 242 DISEASES OF THE BLOOD. of blood hastens regeneration even more decidedly. Otto/ and Hall and Eubank - have shown experimentally in animals, bled and given transfusions of artificial serum, that regeneration once stimulated into activity may carry the blood, quantitativ^ely, con- siderably beyond the established normal standard. In uncomplicated cases, according to Bieifreund,^ regeneration is effected within about four weeks if the hemorrhage produces a hem- oglobin loss of 25 per cent., and in about three weeks if the loss does not exceed 20 per cent. The latter period may be regarded as the average regeneration time in the great majority of instances. As regeneration proceeds, the hemoglobin and corpuscular deficiencies gradually become less conspicuous, but the increase in these two constituents does not occur along parallel lines. The increase in the number of erythrocytes is much more rapid than the gain in the hemoglobin percentage, and the latter usually remains subnormal for some time after the normal number of corpuscles has been reestablished. Owing to this lagging behind of the hemoglobin, low color indices are the rule. Faulty hemogenesis, owing to which the great majority of the erythro- cytes are deficient in hemoglobin and many of them of abnormally small size, serves best to explain this slow restitution of the hemo- globin value. The appearance in the blood of normoblasts is common after hemorrhage, and in rare instances an occasional megaloblast and atypical forms of erythroblasts may be observed. According to Ehrlich,"* if thorough and systematic search is made, normoblasts may be constantly found after the second or third day following the blood loss until the regeneration of the blood is complete. The transient appearance of large numbers of normoblasts, know^n as " blood crises," has been already described. (See page 143.) Dawson,^ who has carefully studied the effects of venous hemorrhage in dogs, found no evidence of any close relation between the number of eiythroblasts and the rapidity and char- acter of the regeneration of the hemoglobin and erythrocytes. In severe cases polychromatophilia of the erythrocytes may be noted, this sign first becoming apparent as early as the first day after the hemorrhage, and gradually disappearing as regenera- tion is effected. Deformities in the size and shape of the erythro- cytes are not uncommon, of which microcytes constitute the most frequent example. Large hydropic macrocytes and poikilocytes are met with more rarely. ^Pfliiger's Archiv., 1885, vol. xxxv., p. 57. 2Journ. of Exp. Med., 1896, vol. i., p. 656. 3 Langenbeck's Archiv., 1890-91, vol. xli., p. i. *Loc. cit. 5 Amer. Jour, of Physiol., 1900, vol. iv., p. 2. a z < > z o u a CD Moderate or marked de- crease. Relatively low or propor- tionate to erythrocyte loss. Moderate or excessive decrease. Pallor slight or marked. Poikilocytosis variable. Erythroblasts in severe cases, normoblasts pre- lominating. ^ Polychromatophila and basophilic stroma degen- ert.'^ion in severe cases. Cl anges in diameter of cells variable. Subnormal, sometimes very low. ' Usually increased moderately. Polynuclcc ' neutrophile increase witl lymphocyte decrease comi 'on. Eosinophiles usually decreased or ab.-;ent. Small numbers of myelo- cytes in severe cas.^s. Basophiles not increased. t5 in 03 ^ '^ is <: u z w Marked decrease, aver- aging to about 45 per cent. Relatively low or high to erythrocyte loss. Decided decrease, coun s averaging about 3,500,000. Pallor variable. Poikilocytosis in severe , cases. Erythroblasts rare, nor- moblasts predominating. Polychromatophilia vari- able ; basophilic stroma degeneration absent. Changes in diameter of cells inconstant. Moderately low, averag- ing about 0.75. Normal or decreased, counts averaging about 5,000. Relative lymphocytosis and decrease of polynuclear neutrophiles frequent. Eosinophiles normal. Myelocytes rare. Basophiles sometimes increased. 52 O » o X u Marked decrease, aver- aging to about 50 per cent. Relatively low to eryth- rocyte loss. Moderate decrease, counts averaging about 4,000,000. Pallor conspicuous. Poikilocytosis rarely marked. Erythroblasts rare, normo- blasts predominating. Polychromatophilia rare ; basophilic stroma degenera- tion absent. Microcytosis common. bjo C 'So )-l "^ ^1 Normal or decreased, counts averaging about 7,000. Relative lymphocytosis and decrease of polynuclear neutrophiles common. Eosinophiles notably de- creased ; often absent. Myelocytes very rare. Basophiles not increased. a; (U !-i CJ Cl 1— ( 8 ■1 1 Erythrocytes. 1 i 5 244 DISEASES OF THE BLOOD. VI. LEUKEMIA. According to the classification in general vogue Varietix-. ^^ ^i^g present time, two clinical varieties of leu- iv^...- ^.^^ splcno-medtdlary and the lymphatic, are recognized. The spleno-..^^^ll2^jy variety, which is almost in- variably a chronic process, is « ^^iated with a marked prolifera- tion of myeloid tissue, and is charactei:--.f^ j^y ^ striking xv^-- ^i^viWa, and generally by conspicuous enlargement oi ... v Qt-'^cn with little or no involvement of the lymphatic glands. The lymphatic form, which may run either an acute or a chronic course, more com- monly the latter, is a process associated with a proliferation of lymphoid tissue, and is characterized by a blood-picture known as lymphemia and in the great majority of cases by marked en- largement of the lymphatic glands with moderate involvement of the spleen. But these two clinical pictures, in so far as they relate to the splenic and lymphatic hypertrophy, are by no means con- stant, for, although cases of the spleno-medullar}' leukemia always have enlarged spleens, exceptionally they may also have decided lymphatic hyperplasia. Furthermore, cases of lymphatic leukemia are occasionally encountered in which there is a marked splenic tumor without demonstrable signs of lymphatic enlargement. Because of such atypical examples, the gross appearance of the spleen and lymphatics must be regarded as a sign of distinctly secondary importance to the blood-picture, which is alone the tan- gible diagnostic clue. Of the two forms of the disease, the spleno-medullary is much the commoner. In the series of 20 cases of leukemia which the writer has had the opportunity of studying, 1 2 were of the spleno- medullar}^, and 8 of the lymphatic form; while of Cabot's 41 cases, ^ 28 were spleno-medullary and 13 lymphatic — a proportion of about two of the former to one of the latter, for the combined series of 61 cases. In the present state of our knowledge, it is Parasitology, not possible to regard leukemia as a disease of in- fectious origin, notwithstanding the suggestive- ness of the symptoms shown by many of those cases which run an acute course. Within the past few years several investigators, notably Delbert," Kelsch and Vaillard,^ Pallowski,* and Lowit^ have attempted to ascribe to various micro-organisms specific ^ Loc. cit. 2 Bull, et mem. Soc. de chir., Paris, 1895, vol. xxi., p. 788. 3Annal. de I'lnstitut Pasteur, 1890, vol. iv., p. 276. * Deut. med. Woch., 1892, vol. xviii., p. 641. 5 " Die Leukamie als Protozoeninfektion," Wiesbaden, 1900. LEUKEMIA. 245 etiological relationship with the condition, but none of these at- tempts have thus far been convincing. L6 wit's researches, how- ever, are worthy of special attention, if for no other reason than the elaborate and painstaking study which they represent. This author believes that two distinct forms of parasites may be dem- onstrated in leukemia : the Jiemanieba leukemicE mazna, thousrht to be the specific cause of the spleno- medullary form of the dis- ease, and the heviameba leukemics parva, which he claims is the definite infective principle of the lymphatic form. These so-called '' specific bodies," which are found both in the blood of the pe- ripheral vessels and in the hematopoietic organs, have either a granular or an ameboid appearance, and bear a more or less close resemblance to the basophile granules of the leucocytes ; navicular, segmenting, and vacuolated forms are also said to occur. They are either attached to, or lie within, the leucocytes, especially the small lymphocytes, and more rarely the other varie- ties of normal leucocytes and the myelocytes ; in an occasional instance they are said to be found lying free in the plasma. Al- though it is claimed that a leucocytic infection has been produced in animals by the injection of blood presumably containing these micro-organisms, all attempts to cultivate them on artificial media have proved futile. L6 wit's amebae are demonstrable only in heat- fixed specimens, stained preferably with a steaming hot solution of Loffler's methylene-blue, after which they are washed, differ- entiated with a 0.3 percent, solution of hydrochloric acid-alcohol, again washed, and mounted. In specimens thus treated they stain metachromatically, and, if the acid-alcohol differentiation has been properly effected, are the only elements except the basophile leucocyte granules which retain the color of the dye. Tiirk,^ who has followed out Lowit's technique precisely, in in- vestigating this author's claims, has come to the conclusion that these " specific bodies " are in no sense of parasitic nature, but merely artefacts resulting from the action of an aqueous solution of a basic dye upon the mast cell granules, which causes the partial solution of the latter elements and deforms them. Turk claims, furthermore, that these so-called amebae can be produced both in the normal blood of man and in the blood of rabbits. 1 XVIII. German Con. for Internal Med., Wiesbaden, Apr. 18-21, 1900. 246 DISEASES OF THE BLOOD. SPLENO-MEDULLARY LEUKEMIA. The drop as it flows from the puncture is, in Appearance most instances, of a bright scarlet color, and OF the often has a peculiar and misleading appearance Fresh Blood, of density. After brief exposure to the air, it may split up into two portions, a serous, scarlet fluid, in which are suspended many minute, whitish, fat-like masses ; the former appears to consist of serum and erythro- cytes, and the latter of adhering masses of leucocytes. It was probably this striking appearance of the leukemic blood drop that led Hughes Bennett erroneously to describe the condition as a "suppuration of the blood" before he proposed the more suitable term leucocythemia. In some cases the drop is simply much darker than normal, but it is difficult to believe that it ever resembles the chocolate-brown shade mentioned by some authors as occurring in this disease. The blood usually flows ver}'' freely from the wound, often by fine jets and spurts, especially if slight pressure is applied above the site of the puncture. Microscopically, the field is found to contain an enormous number of leucocytes, the proportion of these cells to the er}'- throcytes being, by actual count, as great as i to 8 or 6, or even greater. Many different varieties of leucoc\i:es may be dis- tinguished in the fresh specimen, the most striking being the large, mononuclear, finely granular cells of round or ovoid shape. These are the myelocytes which are present in enormous num- bers in this form of leukemia, of which they form a characteristic blood-picture. ** Fractured " leucocytes, usually eosinophiles, with a cloud of escaped granules free in the plasma in the neigh- borhood of the disrupted cell bod\', may also be observed in vari- able numbers, although such cells are more numerous in the dried, stained film. ( See Figs. 39 and 40.) The er^'throcytes vary in number and in appearance according to the severity of the coexisting anemia; in some instances large numbers of poikilocytes, megalocytes, and microcytes, with marked pallor of the corpuscles may be seen, while in others the changes affecting the er}^throcytes appear to be but tri- fling. In fresh films which have been allowed to dr}- for some time Charcot-Leyden cr}'stals may sometimes be detected. They ap- pear as colorless, refractive crystals, shaped like octahedrons, having long, pointed, sharp angles, and occurring either singly or in twos or threes, superimposed at right angles or as collections of radiating crj^stalline masses. These crj^stals are not obsen^ed PLATE IV. 13^^448^ Spleno-Medullary Leukemia. ( Triacid Stain.) 1. Small Lymphocyte. 2. Large Lymphocyte. Contrast this cell with the myelocytes, lo, it, and 12, noting the presence of neutro- phile granules in the latter, and their absence in the lymphocyte. The size and nuclear characteristics of all these cells are practically the same. 3. 4. Polynuclear Neutrophiles. 5. Eosinophile. In this "dwarf" eosinophile, ruptured during the preparation of the specimen, the granules are peculiarly arranged about the nucleus; no signs of protoplasm are dis- tinguishable. 6. Eosinophilic Myelocyte. Note the irregularity with which the granules are stained. 7. 8, 9, 10, II, 12, 13, 14, 15. Myelocytes. {Neutrophilic.) These cells varv greatlv in size (compare 8 with 9), but they all have similar distinc- tive characteristics — a large opalescent nucleus containing a scanty chromatin net- work embedded in a cell body crowded with delicate neutrophile granules, precisely like those found in the polynuclear neutrophiles, 3 and 4. The nucleus of 7 is dis- tinctly indented and somewhat denser than that of the other myelocytes. This cell probably represents a developmental phase of the myelocyte just short of its transi- tion into a typical polynuclear neutrophile, 16. Normoblast. The erythrocytes (stained orange) show many evidences of deformity, an occasional megalocyte, many microcytes, and a few poikilocytes being present. Polychromato- philia is absent. (E. F. FABER,/^throcytes may or may not accompany variations in the leuco- cyte count. Sometimes, as the leucocytes rise, the erj^throcytes fall, but again they remain practically stationary ; or, the leuco- cytes may progressively fall to a comparatively moderate count, coincidentally with an apparent improvement in the patient's gen- eral condition, and yet the erythrocytes do not materially gain in numbers. Taylor ^ refers to two such instances which have come under his observation, in both of which the blood-picture at cer- tain brief intervals resembled that of pernicious anemia, for under the influence of energetic arsenical treatment the leucocytes were reduced to normal, while the oligocythemia stubbornly persisted. In a case studied for a protracted period, it is possible to distin- guish a general decrease in the erythrocyte count as the leuco- cytes increase, although the reverse may not be true. (See Chart II., page 250.) Examination of the stained specimen shows the presence of nucleated erythrocytes in practically every case of spleno-medul- lary leukemia, these cells often being many times more numerous than in grave cases of pernicious anemia. Normoblasts prevail, always being more numerous than megaloblasts ; in some cases they are the only type of erj^throblast to be observed ; in others they are associated with a relatively moderate number of typical ^ It is to be remembered that hemoglobin estimates in leukemia may be unreliable (except when Dare's instrument is used), for correct readings are sometimes impos- sible, owing to the milkiness of the diluted blood from the presence of such immense numbers of leucocytes. Three-fourths of the hemoglobin figures in the accompany- ing table (Table VI.) were obtained by means of von Fleischl's hemometer, the remainder being based upon examinations with Oliver's instrument. 2 Loc. cit. 3 Log. cit. SPLENO -MEDULLARY LEUKEMIA. Table VI . 249 Hemoglobin and Erythrocytes in Spleno-Medullary Leukemia, at the First Examination. 12 Cases, Number. Hemoglobin Percen- » Color Index. Erythrocytes per tage. cb. mm. I 70 .87 4,000,000 2 45 .51 3,973,000 3 68 .90 3,760,000 4 45 .66 3,400,000 5 40 .65 3,100,000 6 70 1.37 2,550,000 7 60 1.30 2,300,000 8 33 .71 2,300,000 9 40 .87 2,287,000 10 45 1. 12 2,160,000 II 40 1. 00 2,000,000 12 30 •75 2,000,000 Average : 49 .89 2,819,167 megaloblasts, or, more commonly, with large numbers of atypical forms, sharing the characteristics of the typical adult and em- bryonic nucleated erythrocytes. In the 9 cases of this variety of leukemia in which the writer has made differential erythrocyte counts, the following estimates were obtained, at the first exami- nations : Number. Total number of ery- Normoblasts per Megaloblasts per throblasts per cb. mm. cb. mm. cb. mm. I 12,913 8,376 4,537 2 9,178 9,178 3 8,626 7,264 1,362 4 8,064 6,048 2,016 5 5,694 3,504 2,190 6 3.234 1,848 1,386 6 2,940 2,940 8 1,980 1,980 9 748 748 Average : 5,931 4,654 1,277 Comparison of the above summary with the table giving the number and forms of erythroblasts in pernicious anemia (Table IV., page 224) illustrates two striking facts concerning these cells in spleno-medullary leukemia : the immense numbers in which they occur, and the predominance of normoblasts over megaloblasts. Periods of temporary improvement in the pa- tient's general health are often heralded by a notable increase in the normoblasts, but it is a noteworthy fact that during these re- 250 DISEASES OF THE BLOOD. missions, while the leucocytes may fall decidedly, the normo- blasts tend to persist in greater or less numbers. Examples of so-called nuclear extrusion, of multinucleation, of clover-leaf, dumb-bell or other irregularly formed nuclei, and even, in rare instances, of karyokinesis are observed in many of the normoblasts. Such alterations may be more conspicuous in highly developed cases of spleno-meduUary leukemia than in any other disease of the blood. In an occasional normoblast the contracted, glistening, intensely basic nucleus is highly sugges- tive of pyknosis. No one who has done much blood work can fail to be struck with the obvious avidity displayed by the stroma of the erythroblasts for the acid fuchsin of the triple stain — a peculiarity which is exhibited in spite of good technique and the use of a reliable staining solution. Deformities affecting the size and the shape of the erythrocytes may be trivial or decided, depending upon the degree of hemo- globin and erythrocyte loss present. PolycJiroinatopJiilia, alone, or associated with basophilic stroma dege?ieratio7i, is w^ry com- mon in cases with great anemia, the former especially affecting the nucleated eiythrocytes, and the latter the non-nucleated cells. Striking increase in the number of leucocytes Leucocytes, is found even during the early stages of the dis- ease. Counts of from 200,000 to 300,000 cells to the cubic millimeter are common ; counts of from 300,000 to 500,000 are less frequently observed ; but only occasionally does the estimate exceed the latter figure. In rare instances the number of leucocytes may be as high as 1,000,000 per cubic millimeter. It has been stated by competent authorities that the leucocyte count may equal or even exceed that of the erj^thro- cytes, and it is easy to see that such a condition is possible, should the accompanying oligocythemia be intense. In the esti- mates given in Table VII., showing the number of leucocytes at the time the patient first applied for treatment, the average count was 281,623 P^^ cubic millimeter, the highest being 544,000, and the lowest 44,000. The greatest number of leucocytes found in these cases at any time was 706,000, this estimate having been made a few hours before the patient's death. The number of leucocytes may fluctuate enormously at various times during the progress of the disease, a gain or a loss of some 200,000 cells to the cubic miUimeter from week to week being a matter of common occurrence. Sometimes they are temporarily diminished as the result of the administration of arsenic to the point of tolerance, or of the vigorous employment of other ther- apeutical measures ; sometimes the decrease takes place inde- CHART II. > rOJVTH. APB MAY. JUNE. JULY. AUG. SEP. OCT. 1 NOV. ^DEC.j JAN. 1 FEB. 1 MAR.| APR. xMAY.j DAY. s^ ^,o 5? s f^$^ -^ 'r- H '^ 'c'^j -H O ^ !r;1 CI, 1"^ .2S r •^^1 ti, -r -ri » '" 2 1 c ?i ^^ t> ■ c ICO '^;5 '-;::; ? -1 TvvS 1 1 '-^ no 100 5 (K K) OC 10 Me an N )rm al : 'Turn ber )f Ei vth locyt >s, 80 4 (K )0 0( K) 1 \ 70 n \ a / f L ^ ,„ r\ •^ \ a 60 3 0( K), OC >0 f^ 1 \ « / /■^ s. 1 \ i \ J .-r o oO / \ I \ 1 / > 1 1 ^ .<' ^* / r\ \ 1 \/, '*} J / N^ 40 2 0( K) 0( K) / -- - -_ _ :^ ^ / \ ./' V f \^ V \ / ^ ^^ /-^ ■"" • — \/ ^ \, V f > N 30 r" \ r ' \ r 20 1, 0( K) 000 9^0 000 900 000 8^0 000 800 000 750 000 lU) 000 *. 050 000 1 GOO 000 I 550 000 500 000 4-50 000 ■ 5 r- S 4(jo 000 J ^\ '► -s I 350 000 I r \, \ 3(V) 000 ) \ i ^ 7 \ 1 000 f i V ^1 0(k) / \ / 150 000 • s J \ -t / l(k) 000 ^1 f 90 000 ,- - ■"^ ■^ f 000 \ / f\ V-- "" 70 000 1 i f 4 60 000 \ / f 50 000 '\ ^ h 000 k 000 h 000 18 0(^ 16 000 14 m 12 10 000 8 1 Mp£ n -Xp rniH 1- jNi ml )pr- •>f T.e iro •V PS '""■"* ■~ -■6 OtKJ ~ - — — •- •- — "" — "" "" .... ■" ■~ — — ~ — "■ " " . 4 000 2 0( DO . - SPLENO-MEDULLARY LEUKEMIA. Red, Hemoglobin. Black, Erythrocytes. Blue, Leucocytes. SPLENO -MEDULLARY LEUKEMIA. 251 Table VII. Number of Leucocytes and Percentage of Various forms in Spleno- MEDULLARY LEUKEMIA, AT THE FlRST EXAMINATION. 12 CaSES. Leucocytes per cb. mm. Percentage of Diflferent Forms. No. Small lymph- ocytes. Large lymph- ocytes. Polynuclear Neutrophiles. 54-7 Eosino- philes. Myelo- cytes. Baso- philes. I 544,000 1-3 5.6 5-6 30.8 2 2 450,000 I.O 2.2 60.0 28.7 7-1 I 3 446,420 II. 2.5 60.5 6.5 19-5 - 4 370,000 1,0 9.0 51.0 5-0 34.0 - ■> 358,000 2.0 150 63.0 4.0 16.0 - 6 285,000 2.5 lO.O 65-5 4-5 17-5 - 7 245,000 8.0 8.0 54-5 9.0 20.5 — 8 222,300 7.0 15.0 63.0 4.0 II. - 9 168,750 1.0 6.0 51.0 12.0 30.0 - 10 144,000 12.0 18.0 45-0 4.0 21.0 - II 102,000 0.7 03 73-6 2.1 23-3 - 12 44,000 6.8 5-6 70.8 2.0 14.8 - Av. 281,623 4-5 8.1 59-4 7-3 20.5 •25 pendently of the influence of remedial agencies, so far as can be determined. When arsenic is withheld the number of leucocytes promptly increases, and in spite of its use they ultimately increase, as the disease runs its fatal course. The relations of the leuco- cytes' fluctuations to the number of erythrocytes have already been mentioned. Hayek ^ has drawn attention to the fact that in the leukemic individual the morning leucocyte count may be greater by more than 100,000 cells per cubic millimeter than the estimate made during the afternoon, and vice versa. In a case in Professor Wilson's wards at the Jefferson Hospital, the writer has been able to verify this statement, the counts being as fol- lows : 1 1 a. m., 144,000 ; 6 p. m., 256,000 — a difference of 1 12,- 000 cells within a period of seven hours. The influences of di- gestion and other sources of error were, of course, excluded in making this observation. The occurrence of this enormous diurnal fluctuation emphasizes the importance of making the blood examination of leukemic patients at precisely the same hour each day, in cases studied for a long period. The possibility of encountering a case of leukemia during a period of remission, when the typical blood changes are absent, must be borne in mind, for such instances are observed from time to time, although they are very rare. For example, McCrae^ reports a case, treated by arsenic, in which twice during a period ^Wien. klin. Woch., 1897, vol. x., p. 475. 2 Brit. Med. Journ., 1900, voL i., p. 760. 252 DISEASES OF THE BLOOD. of ten months the blood and general symptoms of the patient were typical of spleno-medullary leukemia, and twice were abso- lutely normal. When first examined, this patient's leucocytes numbered 584,000 per cubic millimeter, three months later they had fallen to 9,250, two months after this they had risen to 178,- 000, and after a lapse of another five months they again fell to 5,000. These fluctuations did not depend upon the influence of any intercurrent infection (see below), and the case is unique in that the leucocytes (as well as the erythrocytes) not only were normal in number, but also normal qualitatively, and in that the patient's splenic tumor entirely disappeared during the periods of remission. Other cases have been recorded showing brief periods of temporar}^ decline to normal in the number of leuco- cytes, but with the persistence of myelocytes, or of the splenic enlargement, or of both. The presence of myelocytes in large numbers is the hinge upon which the diagnosis of spleno-medullary leukemia must turn, for in no other disease are these cells so numerous, or so constantly present. A high percentage of myelocytes, irrespective of the degree of increase in the total number of leucocytes of all forms, is as essential for the diagnosis of this variety of leukemia as is a predominance of megaloblasts for the recognition of pernicious anemia. In most cases they constitute at least 20 per cent, of the different forms of leucocytes, and occasionally as high as 50 per cent, or more. In the 1 2 cases of the present series (Table VII.) the myelocytes, at the first counts, averaged 20.5 per cent., with 7.1 and 34.0 per cent, as the minimum and maximum esti- mates, respectively. It is the fact, not that myelocytes simply occur in this disease, but that they occur in such enormous numbers, that is of prime value in the diagnosis, since in no other condition in which this type of marrow leucocyte is found in the blood, are they present in such striking abundance. For example, although myelocytes are very constant in pernicious anemia, they are only about one-twentieth as numerous in this disease, on the average, as they are in spleno-medullary leukemia. Many of the myelocytes are of very large size, some being quite 22 fi in diameter and occasionally of somewhat larger di- mensions ; others are dwarfed to no larger than the diameter of a small lymphocyte. The nuclei of these larger forms usually stain with relatively less intensity than those of the smaller. Indentation, apparent division, and hour-glass constriction of the myelocytes' nuclei are also frequently noted. A very common form of this cell in spleno-medullary leukemia is characterized by its large size and its jfele, kidney-shaped nucleus, the regularly SPLENO-MEDULLARY LEUKEMIA. 253 convex border of which Hes in intimate contact with fully one- half the peripheiy of the cell body. These and other atypical forms of myelocytes are shown in the accompanying illustra- FiG. 39. ^^^ . . Jim-'. -,y?-. 12 3 456 Atypical forms of myelocytes in spleno-medullary leukemia. (Ehrlich's triacid stain.) I, 2. Dwarf forms, with relatively large and deeply stained nuclei situated in a relatively small amount of cell body containing neutrophile granules. 3. " Fractured " myelocyte. 4. Extremely large form, with kidney-shaped nucleus. 5. Eosinophilic myelocyte with deeply constricted nucleus. 6. Myelocyte having an hour-glass :;onstriction of the nucleus. tion. The abnormalities affecting the granules of this type of cells, as well as certain degenerative changes, do not differ from those which are found in the polynuclear neutrophils de- scribed below. The relative percentage of polynuclear netitrophiles is low, but not especially so, although of course the absolute number of this type of cells is greatly in excess of the normal standard, as may be demonstrated by taking into consideration the high total leucocyte count. For instance, in a case having 300,000 leuco- cytes per cubic millimeter, with, say, 50 per cent, of them poly- nuclear neutrophiles, the actual number of the latter is 1 50,000 to the cubic millimeter, or fifteen times the maximum normal number. The cases listed in Table VII. averaged 59.4 per cent, for this variety of leucocytes, with a range between 45.0 and 73.6 per cent, in the individual case, but other authors, with more extended series of cases as a basis for their statistics, give lower figures than these. A feature which at once attracts attention in the examination of the stained specimen is the deviation from the normal size of a large proportion of these neutrophilic cells. Dwarfed cells, often not more than 5 or 6 // in diameter, and large forms, some of them measuring 1 5 ^w or even more in diameter, are common, the nuclei of the former usually staining much more sharply than those of the latter, which may exhibit a very feeble reaction to- ward the basic dye, and show a more diffuse and delicate chro- matin structure than is the rule in norrrial blood. The nuclei 2 54 DISEASES OF THE BLOOD. also tend to exhibit extreme polymorphism and variations in their relative size to that of the cell body. Many of these cells are also deformed in shape, being drawn out into various oblong and elliptical designs or into irregular elongated masses. '* Frac- tured " cells, from which the granules hav^e escaped, are also commonly seen. It seems reasonable to attribute the free neu- trophil granules sometimes seen in the blood in this disease to the rupture of a neutrophilic leucocyte, although the particular cell to which they belonged may be difficult to identify ; the view expressed by some authors that such granules may preexist in the plasma is scarcely to be thought of seriously. All of these deformities are doubtless the result of injuries to the cells in the preparation of the cover-glass spreads, and they suggest a lowered resistance on the part of the leucocytes. The number of granules in the polynuclear neutrophiles varies greatly in the individual cells ; in some they are densely crowded throughout the protoplasm and overrun portions of the nucleus ; in others they are confined to certain areas of the cell body, es- pecially in the neighborhood of the nucleus ; w^hile in still others they are distributed singly or in twos and threes through the protoplasm. Occasionally a cell wholly devoid of granules is observed, and, very rarely, one containing both neutrophile and a few isolated eosinophile or basophile granules. The neutro- phile granules themselves vary greatly in size, being in some cells so extremely delicate and fine that they can be barely dis- tinguished, while in others they almost equal the size of the smaller eosinophile granules. Fig. 40. "^ ' I l-*' I 2 3 Atypical forms of polynuclear neutrophiles in spleno-medullary leukemia. I. Cell containing both neutrophile and moderately coarse basophile granules. 2. Polynuclear cell, with two ovoid nuclei and neutrophile granules, probably representing a later developmental stage than 6, Fig. 39. 3. " Fractured " polynuclear neutrophile. (No. i stained with Jenner's eosin- ate of methylene-blue, 2 and 3 with Ehrlich's triacid stain.) Fine and coarse vacuolation of the nucleus and protoplasm, a fissured and cracked appearance of the nuclear chromatin, and an apparent solution of the protoplasm with freeing of the nu- cleus are the most prominent degenerative changes affecting the SPLENO -MEDULLARY LEUKEMIA. 255 polynuclear neutrophiles, as well as the other varieties of leuco- cytes, in this disease. The relative percentage of lymphocytes, small and large to- gether, is decidedly lower than normal, although their total num- ber to the cubic millimeter of blood is greatly increased. As shown by the cases in Table VII., these cells average a trifle more than 12 per cent, of all varieties of leucocytes, which rep- resents a diminution to about one-third of the proportion found in normal blood. It is the small lymphocytes which suffer the greater loss, for their proportion in the differential count is some- times not more than a fraction of i per cent., and always greatly below normal; the large lymphocytes and ** transitional " forms, on the contrary, average about normal, and, indeed, may be increased in the individual case. Turk's ^' stimulation forms'' are also met with, but these cells as a rule are not numerous. Atypical forms of lymphocytes are not so common in this form of leukemia as they are in the lymphatic variety. Such cells are described under the latter disease. (See page 259.) Eosinophilia, as indicated by an increase in the total number of eosinophils, is invariably found, and an increase above normal in the relative percentage of these cells sometimes, but not always, exists. Thus, in the above-mentioned series the eosinophiles, which normally do not exceed 500 per cubic millimeter, ranged from 880 to 129,150 and averaged 20,558 per cubic millimeter, these figures corresponding to percentages of 2.0, 28.7, and 7.3, respectively. Ehrlich's original statement regarding an increase of the eosino- philes in this form of leukemia has been contradicted by several writers, notably by von Limbeck,^ and by Miiller and Rieder^; but these contradictions are based upon a misconception of Ehr- lich's remarks, for the latter never claimed that an abnormally high percentage of eosinophiles was associated with this disease, but said simply that their absolute number was increased. Marked variation in the size of many of the eosinophiles is com- monly observed, dwarf forms, 5 or 6 /i in diameter, with densely, crowded and deeply stained granules, being especially striking and apparently more numerous than the larger forms. Eosino- philic myelocytes, differing from ordinaiy neutrophilic myelocytes only in that they are studded with eosinophile granules, are very numerous, and are among the largest forms of the myelocyte found in this disease. " Fractured " eosinophiles are common, being usually more abundant than neutrophilic cells which have ^ Loc. cit. 2Deut. Archiv. f. klin. Med., 1891, vol. xlviii., p. 96. 256 DISEASES OF THE BLOOD. thus traumatically suffered. In some of the eosinophiles the granules are scanty, and in many their size varies greatly. Un- usually large-sized granules are often found, especially in the dwarf cells and in the extremely large forms. Basopliilcs, both the forms overcrowded with delicate, pure basic granules, and mast cells with relatively fewer, coarse, meta- chromatic granules, are found with great constancy, being absent in but a small proportion of cases. The latter type of cell is es- pecially suggestive of leukemia of this variety, since in no other disease does it occur in such large numbers. In some leukemic bloods the mast cells attain an enormous size, being quite the larg- est cellular elements found in the specimen. They may be easily identified by their characteristic reaction toward the basic dyes, described in a previous section. (See page 170.) From the above remarks, it may be concluded that myelocytes are present in the circulating blood at the expense of all the normal varieties of leucocytes except the eosinophiles, and that the brunt of this decrease is sustained by the mononuclear, non- granular forms, chiefly by the small lymphocytes. These bodies are greatly increased in number Blood in most cases of this form of leukemia, and may Plaques. frequently be recognized in the fresh specimen and in the diluted blood in the counting chamber of the hemocytometer. They are seldom observed, however, in the stained film prepared by ordinar)^ methods. LYMPHATIC LEUKEMIA. In most cases the blood drop is watery-looking, Appearance pale, and thin, for in this variety of leukemia the OF THE anemia is usually very marked. The milky ap- Fresh Blood, pearance of the drop, frequently observed in the spleno-medullary form of the disease, is not often noticed in the lymphatic variety. The alterations in the coagulability, alkalinity, and specific gravity of the whole blood are similar to those met with in spleno-medullary leukemia. Microscopically, the field is crowded with large numbers of leu- cocytes, the vast majority of which are mononuclear cells encir- cled by a perfectly hyaline, non-granular protoplasm. They may be quite uniformly of either small or large size, or so many inter- mediate sizes may be present that it is impossible to distinguish any single predominating type. It is apparent that the leuco- cytes do not seem so numerous as in spleno-meduUar}^ leukemia, nor are their characteristics so striking, at first glance, because of PLATE V. 12 4 ^ 11 "■^^^ Lymphatic Leukemia. { Triacid Stain.) i> 2, 3. 4. 5. 6. Small Lymphocytes. These cells show a great difference in the intensity of their reaction toward the basic dye. The smallest forms, 1,2,4, and 5, being richer in nuclear chromatin and staining more deeply than the larger, 3 and 6. Compare 2 with the normoblast, 16, Plate IV. 7, 8, 9, 10, II. Large Lymphocytes, Except in 10, which shows a delicate rim of fuchsin-stained protoplasm, these Ivmpho- cytes appear simply as pale chromatin-deficient nuclear structures, lacking cell bodies Compare these cells with the myelocytes, Plate IV. 12. Transitional Form. The upper edge of the nucleus is somewhat indented and the protoplasm is distin- guishable; otherwise this cell resembles a large lymphocyte. (E. F. Faber, y^c.) LYMPHATIC LEUKEMIA. 257 the entire lack of granulations in their protoplasm. The differ- ence between these hyaline cells and the granular leucocytes of the last-named disease, even although they may not happen to differ greatly in size and shape, is at once patent to the practised eye. The changes affecting the size, color, and shape of the eryth- rocytes vaiy with the degree of oligochromemia and oligocy- themia present ; they are generally quite decided, as in any high- grade anemia. Marked anemia, characterized by a dispropor- Hemoglobin tionate diminution in hemoglobin, is the general AND rule in this variety of leukemia, the decrease in Erythrocytes, both hemoglobin and erythrocytes, especially in the former, being usually greater than in the spleno-medullary form. Compared with the latter, the hemoglo- bin loss averages about twice as much, the erythrocyte decrease is more than 10 per cent, greater, and the color index is just 30. Table VIII. Hemoglobin and Erythrocytes in Lymphatic Leukemia, at the First Ex- amination. 8 Cases. Number. Hemoglobin Color Index. Erythrocytes per Percentage. cb. mm. I 29 .40 3,590,000 2 40 .66 3,000,000 3 31 .58 2,690,000 4 20 .43 2,310,000 5 23 .50 2,266,000 6 18 .50 1,800,000 7 14 •55 1,270,000 8 25 1.09 1,152,000 Average : 25 0.59 2,259,750 points lower. In the Hmited number of cases listed in Table VIII. the following estimates were obtained at the first examinations : average hemoglobin percentage, 25, ranging from 14 to 40 per cent. ; average erythrocyte count, 2,259,750, or from 1,152,000 to 3,590,000 per cubic miUimeter ; and average color index, 0.59, with a minimum of 0.40 and a maximum of 1.09. In rare in- stances the number of erythrocytes falls below 1,000,000, and the hemoglobin so low that it is impossible to estimate the percentage at all accurately. Rapidly developing and extremely pronounced anemia is generally observed in cases which pursue an acute course. Nucleated erythrocytes^ chiefly of the normoblastic type, are commonly found in moderate numbers, but never, except in rare instances usually occurring in children, are they as numerous as 17 258 DISEASES OF THE BLOOD. in the spleno-medullary form of the disease. As a rule, when both normoblasts and megaloblasts are present, the former vastly outnumber the latter, although occasionally one meets with a case in which this predominance of adult-type er>^th rob lasts is less pronounced. Thus, in one of the writer's cases the total number of erj'throblasts was calculated at 10,678 per cubic mil- limeter, of which 8,512 were normoblasts and 2,166 megalo- blasts ; such a blood-picture as this, however, is but seldom found. In general terms, it may be said that the more acute the form of the disease, the more decided the oligochromemia and oligocythemia, and the more abundant the erythroblasts, the number and character of which appear to depend upon the grade of the anemia present. It should not be forgotten that in some cases of typical lymphatic leukemia nucleated erythrocytes are so scanty that they are detected only after repeated examinations. Deformities of size and shape, and atypical staining of the eryth- rocytes are marked in direct relation to the severity of the anemia. The number of leucocytes is largely increased. Leucocytes, but usually much less strikingly so than in spleno-medullary leukemia, in which, generally speaking, their number averages about three times greater. In the latter it will be recalled that counts of between 200,000 and 300,000 cells to the cubic millimeter are the rule, but in the lym- phatic form it is only in comparatively rare instances that the estimate exceeds 100,000. Counts of 500,000 or even of 1,000- 000 cells have, it is true, been reported by a few observers, but only as rare examples of the extreme increase which it is pos- sible for the leucocytes to attain in this condition. The cases in Table IX. show an average of 88,438 cells to the cubic milli- Table IX. Number of Leucocytes and Percentage of Various Forms in Lymphatic Leukemia, at the First Examination. 8 Cases. Leucocytes per cb. mm. Percentage of Different Forms. No. Total lym- phocytes. Small lym- phocytes. Large lym- phocytes. Polynuclear neutrophiles. Eosino- philes. Myelo- cytes. I 120,000 530 aS.o 25.0 450 2.0 0.0 2 119,500 97-7 63.2 34-5 2.0 0.0 0-3 3 4 5 6 115,000 96,000 88,000 85,000 90.0 92.0 89.0 97.0 330 28.8 25.2 28.0 57-0 63.2 63.8 69.0 9-9 6.1 5-6 30 O.I 0.0 0.5 0.0 0.0 1.9 4-9 0.0 7 46,000 97.3 21. 1 76.2 1.6 0.0 I.I 8 38,000 913 21.3 70.0 7.1 0.0 1.6 Av. 88,438 88.4 311 57-3 lO.O 0.3 1.2 LYMPHATIC LEUKEMIA. 259 meter, with a minimum of 38,000, and a maximum of 120,000. It may be noted that a few of these cases showed an increase not much greater than can be found in a high-grade leucocytosis. By examination of the stained film, the identity of the leuco- cytes responsible for the high count is more clearly distinguish- able, and it is found that the increase is due to a large absolute gain in the lymphocytes, the relative percentage of these cells to the other varieties of leucocytes generally being 90, or 95, or even higher. In the series above summarized (Table IX.) these non-granular cells averaged 88.4 per cent, of the leuco- cytes, and equalled or exceeded 90 per cent, in three-fourths of the cases examined. In some instances the small lymphocytes are found to be in excess, and the field is dotted with small, deeply stained cells ranging from about 5 to 10 />« in diameter; in other instances the larger forms prevail, so that large, feebly stained cells, from about 10 to 1 5 />«, or even larger, are in excess ; while in still other cases the sizes and staining properties of the cells are so variable and atypical that it is impracticable to class them in two definite groups, large and small. It is generally believed that small lymphocytes are associated with the more chronic forms of the disease, and that the larger varieties are found in excess in the acute cases. Many of the larger forms, which possess a relatively large nucleus deficient in chromatin and a faintly basic non-granular protoplasm, are regarded as the mother-cells of the typical small lymphocytes. They are iden- tical with the '' lymphogonien " of Benda and the *' leukoblasts" of Lowit, cells resident in the germinal nests of the lymphatic tissues. In the triple stained specimen they bear a certain re- semblance in size and shape to the myelocytes, but differ from them in having a protoplasm devoid of neutrophile granules. Various atypical forms of lymphocytes, the commonest of which are pictured below (Fig. 41), are often- numerous. With basic stains, such as methylene-blue, a ragged, torn condition of Fig. 41. I 2 3456 Atypical forms of lymphocytes in lymphatic leukemia. I. Large lymphocyte with ragged protoplasm. Two small bits of protoplasm, the product of " budding," lie free in the plasma beside the cell. 2. Large lymphocyte showing a nucleolus, 3. Large lymphocyte containing two nuclei. 4. Small lymphocyte containing an indented nucleus. 5. Small lymphocyte containing two nuclei. 6. Cell the size of a large lymphocyte, with the nucleus of a small lymphocyte, (i and 2 are stained with eosm and methylene-blue, 3, 4, 5, and 6 with Ehrlich's triacid stain.) 26o DISEASES OF THE BLOOD. the basic seam of protoplasm, and so-called "budding" of the protoplasm are frequently demonstrable, as well as nucleolation of some cells, especially of those of large size. Nuclear indentation and division, and forms characterized by a small lymphocyte's nucleus within a large lymphocyte's cell body are also common. The relative proportion of polyjiuclear neutropJiiles is markedly diminished, commonly to from about 5 to lo per cent, of the total number of leucocytes, and sometimes even to below i per cent. These cells do not usually display the abnormal staining and nuclear characteristics and irregularities in size and shape that are so often seen in spleno-medullary leukemia. Myelocytes are present in the great majority of cases, but al- ways in trifling numbers, as in pernicious anemia ; their propor- tion rarely exceeds i or 2 per cent, of all forms of leucocytes. The percentage of eosinophiles is diminished, usually to a frac- tion of I per cent., and in a certain proportion of cases these cells are absent from the peripheral blood. It must be remembered, however, that even with a low relative percentage figure for the eosinophiles, true eosinophilia may exist, although usually not to such a marked degree as in the spleno-medullary form of the disease. One per cent, of eosinophiles in a leucocyte count of 100,000 means 1,000 eosinophiles per cubic millimeter of blood, or twice the maximum number found in the normal individual. Eosinophilic myelocytes are rare, but they occur in small numbers in an occasional case. Increase in the number of basophiles has been observed only exceptionally, and both the finely granular basophilic leucocytes and the typical mast cells are generally conspicuous by their absence, in contrast to their abundance in the spleno-medullary variety of this disease. From the above, it is evident that in lymphatic leukemia the increase in the total number of leucocytes is dependent upon a marked absolute gain in the lymphocytes, and that in conse- quence of this enormous influx of mononuclear hyaline forms, the relative percentages of the other leucocytes, especially of the polynuclear neutrophiles, are correspondingly diminished. As in the spleno-medullary form, the number of blood plaques is usually much increased. This term has been applied to a form of leu- AcuTE kemia which pursues a rapid course suggestive Leukemia, of an acute infectious process, and ends fatally within a few weeks after the onset of the acute symptoms. Rapid, progressive enlargement of the lymphatic glands and a relatively small splenic tumor, associated with such LYMPHATIC LEUKEMIA. 26 1 clinical features as rigors and irregular pyrexia, bone pains, ulcer- ative stomatitis, a decided tendency to hemorrhages from the mucous membranes and to purpura, serve to identify this rapidly fatal variety of the disease. Some authors limit the duration of acute leukemia to six weeks, but the time limit proposed by Fraen- kel,^ four months, is generally accepted as being more appropriate. The disease is a rare one, for probably fewer than seventy-five authentic cases have been recorded up to the present time, al- though many more reputed instances have been pubHshed. Eb- stein^ collected seventeen cases, in 1889 ; FraenkeP published the statistics often, in 1895 ; Bradford and Shaw* described, in 1898, five cases coming under their observation ; and Fussell, Jopson and Taylor,^ in the same year, published a collective report, em- bracing the statistics of fifty-seven cases selected as representing all the true examples of acute leukemia reported during the past twenty-one years. Since this report about a dozen additional cases have been described by various observers. Beyond stating that lymphemia is the type of blood character- istic of acute leukemia, no special description of the condition of the blood is necessary. In the majority of cases the leucocyte increase may be attributed to a marked gain in the large lympho- cytes, which greatly predominate over the small forms, while the polynuclear neutrophiles, myelocytes, and eosinophiles are rela- tively few in number. As a rule, the more acute the case, the more decided the predominance of the large lymphocytes, which usually show well-marked evidences of nuclear and protoplasmic degenerative changes. The loss of hemoglobin and eiythrocytes is generally more marked, and the erythroblasts are more numer- ous than in the commoner forms of chronic lymphatic leukemia. Acute leukemia may begin as such, or either the chronic lym- phatic or spleno-medullary form may develop acute symptoms, with a coincident change in the condition of the blood, but this change in the spleno-medullary form is extremely rare. The development of an acute infectious process Influence of in a leukemic individual commonly provokes Acute Inter- striking changes in the behavior of the leucocytes, CURRENT In- consisting in most instances in a decrease of their FECTiONS. total number to the cubic millimeter of blood, as- sociated sometimes with an increase in the poly- nuclear variety of cells and a relative diminution in the number ^ Deut. med. Woch. , 1895, vol. xxi., p. 639 et seq. 2Deut. Archiv, f. klin. Med., 1889, vol. x'liv,, p. 343. 3 Loc. cit. *Medico-Chirurg. Trans., London, 1898, vol. Ixxxi., p. 343. 5 Trans. Assn. Am. Phys., Phila., 1898, vol. xiii., p. 124. 262 DISEASES OF THE BLOOD. of myelocytes. At other times there is practically no alteration in the relative proportions of the different forms as they existed in the leukemic blood prior to the onset of the compHcating in- fection. Among the infectious conditions acting in this manner on the leucocytes are abscess, sepsis, pneumonia, influenza, mihary tuberculosis, and erysipelas, but it seems that rheumatic fever has no such effect. Weil,^ who has studied the effects of colon, pneumococcus, and streptococcus infections in both forms of leukemia, comes to the conclusion that the most powerful in- fluence upon the blood-picture is exerted by streptococcus infec- tions. Malignant disease is also capable of bringing about a leu- cocyte decrease characterized by a relative gain in polynuclear neutrophiles at the expense of the lymphocytes, but the loss does not appear to be so decided as that excited by a specific infec- tious process. Two cases reported by Fraenkel ^ may be cited to illustrate the extreme decrease which the leucocytes may suffer under such influences and the rapidity with which the loss may take place. In one of this author's cases, five days after the beginning of a staphylococcus infection the patient's leucocytes began to fall, their number decreasing from 89,000 to 6,000 within a period of two weeks ; while in a second case the count fell from 220,000 to 1,200 within a few days, the change in this instance also being attributed to a septic process. In a patient with spleno-medullary leukemia and septicemia, reported by Kormoczi,^ the leucocytes, which numbered 100,000 per cubic millimeter at the first exami- nation, fell to 3,000 on the day of death, the myelocytes practic- ally disappearing from the blood, and a moderate increase in the lymphocytes occurring during the last few days of life. Eisen- lohr^ hds recorded a similarly marked decrease in the leucocytes in the same type of the disease, the complicating infection being enteric fever ; Miiller' has observed a fall from 109,000 to 6,800 in a case of acute leukemia in which a staphylococcus infection had developed ; and a number of other writers have reported ex- amples of more moderate leucocyte decreases due to various in- fectious diseases. Coincident with the improvement in the condition of the blood, there is frequently a decrease in the size of the patient's enlarged spleen and lymphatics, the period during which the leukemic condition is thus bettered and, so to speak, held in abeyance, 1 Gaz. hebdom. de med. et de chir. , 1900, n. s., vol. v., p. 829. 2Loc. cit. 3 Deut. med. Woch., 1899, vol. xxv., p. 773. ■•Virchow's Archiv,, 1878, vol. Ixxiii., p. 56. sjahrb. f. Kinderheilk., 1896, vol. xliii., p. 130. LYMPHATIC LEUKEMIA. 263 corresponding to the duration of the compHcating infection, for the blood gradually regains its leukemic type and the glandular and splenic tumors reappear, as recovery from the intercurrent disease takes place. In rare instances the occurrence of an infectious disease fails to cause a decrease in the leucocytes, and thus to destroy the leu- kemic picture, but on the contrary increases them, by superim- posing a typical polynuclear neutrophile leucocytosis, which re- mains during the existence of the complicating infection the more conspicuous feature of the blood. The writer has observed a typical illustration of such a change in a case of spleno-medul- lary leukemia, in which within ten days after the onset of a com- pHcating peritonitis, the leucocyte count rose from 245,000 to 400,000, and the proportion of polynuclear neutrophiles from 44.5 to 79 per cent., while the percentage of myelocytes fell from 20.5 to 8. A somewhat similar change has been observed by Miiller,^ in a patient with lymphatic leukemia, the increase in leucocytes having been 220,000, and the gain in polynuclear neutrophiles noteworthy. j^ The following blood-picture is characteristic of the spleno-meduUary variety of leukemia : Hemoglobin. Decided loss, averaging about 50 per cent. Color index subnormal, or high. Erythrocytes. Counts average about 3,000,000 per cubic milli- meter. Erythroblasts very numerous, cells of the normo- blastic type predominating. Deformities of size and shape, polychromatophilia, and basophilic stroma degeneration marked in cases with severe anemia. Leucocytes. Increased to about 300,000 per cubic millimeter, counts in excess of this figure being comparatively rare. Myelocytes constitute about 20 per cent, of all forms. Relative percentageof polynuclear neutrophiles low. Relative percentage of lymphocytes very low. Eosinophiles absolutely, sometimes relatively, in- creased. Basophiles increased, especially the mast cells. Atypical forms of neutrophiles numerous. Plaques. Increased. ^Deut. Archiv. f, klin. Med., 1892, vol. xlix., p. 47. 264 DISEASES OF THE BLOOD. In lymphatic leukemia the blood changes may be briefly ex- pressed thus : Hemoglobin. Marked loss, averaging about 75 per cent. Color index low. Erythrocytes. Counts average about 2,250,000 per cubic milli- meter. Erythroblasts usually scanty, cells of the normo- blastic type predominating. Deformities of size and shape, and atypical staining reaction marked in relation to the degree of anemia present. Leucocytes. Increased to about 100,000 per cubic millimeter, counts above this figure being rare. Lymphocytes constitute about 90 per cent, of all forms. Relative percentage of polynuclear neutrophiles strikingly low. Relative percentage of eosinophiles diminished ; rarely, an absolute increase. Small numbers of myelocytes frequent. Basophiles usually not increased. Atypical forms of lymphocytes numerous. Plaques. Increased. In dealing with the differential diagnosis of leukemia it is nec- essary/ to distinguish the spleno-medullary from the lymphatic form, and also to differentiate both forms of the disease from a number of other conditions which may present either somewhat similar blood findings, or which, apart from the condition of the blood, may have closely similar clinical manifestations. Thus, on the one hand, leucocytosis and lymphocytosis require differentia- tion because they produce changes in the blood which may be confused with leukemia ; while, on the other hand, we must dis- tinguish between leukemia and Hodgkin's disease, splenic anemia, and a number of conditions causing enlargements of the spleen, neighboring organs, and lymphatic glands because of the resem- blance, even identity in some instances, of the other clinical signs. Splejw-medullary and lymphatic Icukcjiiia can be distinguihsed only by examination of the blood, for the distinction between these two forms of the disease cannot be based with any degree of certainty upon the gross clinical appearance of the spleen and LYMPHATIC LEUKEMIA. 265 lymphatics. Nothing can be more marked than the contrast be- tween the two blood-pictures. In the spleno-medullary form the leucocyte count is usually much higher, and is associated with the presence of immense numbers of myelocytes, and with an increase in the eosinophils and usually in the basophiles ; the oligocythe- mia is not so marked, but erythroblasts are exceedingly numerous, and, strangely, tend to persist independently of any increase in the erythrocytes which may occur from time to time. In the lym- phatic form the relatively moderate leucocyte increase depends upon an excessive gain in the ungranulated cells, or lymphocytes, myelocytes being either absent or present in trifling numbers, and decided increase in the eosinophiles and basophiles being most unusual ; the oligocythemia is usually decided, but erythroblasts are scanty, and stand in relationship to the degree of anemia existing. The important points of difference are, therefore, the presence of a myelocytic blood in the spleno-medullary form, and of a lymphocytic blood in the lymphatic variety. Pathological leiicocytosis may occasionally involve an increase in the total number of leucocytes equal to that found in either form of leukemia, especially in those cases in which a period of temporary improvement with a fall in the leucocyte count exists. But, aside from the more or less temporary character of the increase in leucocytosis, the differential count at once shows that, unlike leukemia, the gain depends upon a large absolute and relative increase in the polynuclear neutrophiles, which constitute ordinarily 90 per cent, or more of the several forms of leuco- cytes. Lymphocytosis, which is usually a 7'elative condition, may in rare instances become absolute, so that, in addition to the increase in the relative percentage of lymphocytes, the total number of leu- cocytes in the blood is also decidedly increased. In marked in- stances of this sort it is obviously impossible to distinguish the blood change from that of lymphatic leukemia, and the aid of other clinical symptoms must be invoked to make the diagnosis clear. Thus, both an absolute and relative lymphocytosis, closely simulating the lymphatic form of leukemia, have been observed in severe cases of chlorosis, in pertussis, in sarcoma of the lymphatic structures, and in acute inflammatoiy processes occurring in young children. The author recalls an instance of marked abso- lute lymphocytosis in a case of pernicious anemia, which seemed to justify the tentative diagnosis of lymphatic leukemia, an error which was later corrected, when the megaloblastic blood-picture became apparent. In such instances, which are fortunately of very rare occurrence, it is true that neither the percentage of 266 DISEASES OF THE BLOOD. lymphocytes nor the count of leucocytes is Hkely to average as high as in lymphatic leukemia, but still the blood changes are sometimes very misleading, and should not be reHed upon to the exclusion of other equally important symptoms. The glandular and splenic enlargements of Hodgkui s disease form a clinical picture identical with either the spleno-medullary or the lymphatic variety of leukemia, so that these conditions are distinguishable only by the result of the blood examination. But by this means the diagnosis is made extremely simple, by finding in Hodgkin's disease either entirely normal blood or a variable degree of anemia. The number of leucocytes is usually nor- mal, except in cases in which some complicating inflammatory or infectious process causes a moderate increase, typical of a polynuclear neutrophile leucocytosis. The rather close resemblance which certain cases of splenic anemia bear to leukemia, together with the points of difference between these two diseases, have already been described. (See page 235.) Enlargements of the spleen, left kidney, and pancreas may lead to the inference that leukemia exists. Thus, splenic tumors due to chronic malarial infection, to amyloid disease, to cysts, and to malignant neoplasms ; enlargements of the left kidney such as can be caused by hydronephrosis, by cysts, and by malignant disease ; as well as cystic tumors of the pancreas and malignant disease of the retroperitoneal glands all may, on physical exami- nation, simulate more or less faithfully the leukemic spleen. The negative character of the blood findings will at once exclude leu- kemia, should one of the above-named conditions be the cause of the physical signs suggesting this disease. LympJiatic hyperplasia, due to tuberculosis, to syphilis, and to malignant disease may also be mistaken for the glandular in- volvement of leukemia, for such enlargements sometimes show nothing distinctive. In tuberculous adenitis the blood is either normal, or anemic, if the cachectic state of the patient is marked ; or, should there happen to be a secondary infection of the glands plus the tuberculous lesions, a simple polynuclear leucocytosis is found. In syphilitic adenitis there is often anemia with a mod- erate polynuclear leucocytosis, and sometimes with a relative lymphocytosis, especially in children. In malignant disease of the lymphatics increase in the number of leucocytes may also be noted, in association with a high-grade anemia ; in carcinoma the increase involves chiefly the polynuclear neutrophiles, but in sar- coma the lymphocytes may be unduly increased, though not to the extent found in lymphatic leukemia. hodgkin's disease. 267 VII. HODGKIN'S DISEASE. Nothing characteristic is observed either in the Appearance gross appearance of the fresh blood drop, or in OF THE the unstained film, microscopically. The blood Fresh Blood, may appear normal, or it may show changes common to any secondary anemia. The alkalinity and specific gravity of the whole blood are di- minished in relation to the degree of anemia which exists. Coag- ulation may take place slowly, or even be as incomplete as it is reported to be in some cases of leukemia ; or it may occur within the normal time limit. The hemoglobin percentage and the number Hemoglobin of erythrocytes are both normal in the early AND stages of the disease, and in slowly progressive Erythrocytes, cases the blood may remain unaffected for a long period. But sooner or later, as the disease pro- gresses and a cachectic condition of the patient develops, anemia appears, gradually where the course of the disorder is slow, and rapidly in the more acute forms. Counts made when the patient first comes under observation usually average 4,000,000 or 5,- 000,000 cells per cubic millimeter, but in the later stages the number frequently falls to one-half this figure or even less. The loss of hemoglobin begins earlier, and in most instances is pro- portionately somewhat greater, than the erythrocyte decrease, so that subnormal color indices rule — not decidedly low, but yet twenty points or so below the normal standard. In cases which develop excessive oligocythemia the index figures may be quite as high as in pernicious anemia. In the series of 10 cases summarized in Table X., the hemo- globin averaged somewhat less than 60 per cent., ranging be- tween 30 and 82 per cent.; the erythrocyte count averaged 3,853,700 per cubic millimeter, the minimum being 2,207,000 and the maximum 5,225,000, with one-half the cases having 4,000,- 000 cells or more ; and the average color index was 0.78, or from 0.36 to 1. 17. Qualitative changes affecting the corpuscles occur in relation to the intensity of the anemic process, deformities of shape and size and atypical staining reaction of the cells being associated with cases in which notable hemoglobin and erythrocyte losses exist, and being absent when the anemia is moderate. Nucle- ated erythrocytes are not common, nor are they numerous when present. Usually none are found, except in connection with a high-grade anemia, under which circumstance a few normoblasts 268 DISEASES OF THE BLOOD. Table X. Hemoglobin and Erythrocytes in Hodgkin's Dise.ase, at the First Examination, io Cases. Number. Hemoglobin Color Index. Erj'throcytes per Percentage. cb. mm. I 82 .78 5,225,000 2 So .78 5,100,000 3 65 .72 4,500,000 4 30 .36 4,200,000 5 60 •75 4,000,000 6 46 .66 3,470,000 7 52 .77 3,360,000 8 50 .76 3,275,000 9 75 1. 17 3,200,000 lO 45 1.02 2,207,000 Average : 58.5 .78 3.853.700 may be detected, and in rare instances an occasional megaloblast. In the average case the leucocytes are normal, Leucocytes, both in number and in the relative percentage of different varieties. More rarely, relative lym- phocytosis occurs, involving a decrease in the percentage of polynuclear neutrophiles, but not increasing the total number of leucoc}tes. An instance of this kind has been observ^ed by the writer, in which the relative proportion of lymphocytes to other forms of leucocytes habitually remained for some months between 70 and S^ per cent., this change affecting chiefly the large lymphocytes, while the total leucocyte count never ex- ceeded normal. Table XL Number of Leucocytes and Percentage of Various Forms in Hodgkin's Disease, at the First Examination. 10 Cases. XT Leucocvtes ner Percentage of Different Forms. No. , ■' •" - 1 cb. mm. t Small Lym- phocytes. Large Lym- phocytes. Polj-nuclear Neutrophiles. Eosinophiles. Myelocytes. I 2 3 4 5 6 7 8 9 10 21,000 19,000 16,000 12,000 11,900 9.300 7,000 4,000 3,600 1,000 5.5 4.0 27.2 5.6 23.0 8.0 29.5 25.0 18.I 6.0 4-5 12.0 12.8 36.6 12.0 18.0 145 4.0 30 16.0 89.0 81.6 58.8 56.3 64.0 71.0 530 68.0 75-6 76.0 I.O 1.6 1.2 1-5 I.O 30 3-0 2.0 2-5 2.0 0.0 0.8 0.0 0.0 ao 0.0 0.0 I.O 0.8 0.0 Av. ' 10,480 151 ^3-3 69-3 1.8 0.26 hodgkin's disease. 269 If secondary infection takes place, it soon becomes evident by an increase in the leucocytes to about 20,000 or more, principally involving the poly7mclear netitrophile cells, at the expense of the lymphocytes — a picture of typical leucocytosis. In some in- stances, however, without any apparent signs of a secondary in- fection or of a glandular inflammation, the total count may ex- ceed the normal standard by several thousand cells, and yet show a normal or even somewhat increased proportion of lymphocytes. Should the anemia be very marked, pronounced leucopenia is commonly associated with it. In the present series (Table XI.) one-half of the cases showed leucocyte counts above, and the other half below, 10,000 cells to the cubic millimeter, the highest estimate being 21,000, the lowest 1,000, and the average 10,480. Small numbers of myelocytes are not uncommon in the ad- vanced anemia of Hodgkin's disease, but they are never more numerous than in any other condition accompanied by a similar deterioration of the blood. Small numbers and low percentages of eosinophiles are the rule, both in cases with and without leucocytosis ; it is most un- usual for these cells to attain the maximum normal figure, and they are sometimes wholly absent. Neither the finely granular basophiles, nor the typical mast cells are increased in this disease. As in both forms of leukemia, the number of blood plaques in Hodgkin's disease is usually increased. Although no characteristic blood changes oc- DiAGNOSis. cur in this condition, the alterations most com- monly observed may be briefly summed up as follows : Hemoglobin. Normal in the early stages of the disease ; later, a moderate decrease, estimates averaging about 60 per cent. Color index commonly subnormal, rarely high. Erythrocytes. Normal in the early stages ; later, a variable degree of oligocythemia, counts averaging about 3,750,- 000 per cubic millimeter. Erythroblasts uncommon, and scanty when present. Normoblasts prevail almost exclusively, megalo- blasts being very rare. Deformities of size and shape, polychromatophilia, and basic stroma degeneration only in cases with high-grade anemia. 2/0 DISEASES OF THE BLOOD. Leucocytes. Normal, or moderately increased. Either polynuclear neutrophiles or lymphocytes may be relatively increased, more commonly the former. Small numbers of myelocytes in greatly anemic cases. Eosinophiles not increased. Basophiles not increased. Plaques. Usually increased. The absence of characteristic blood changes in Hodgkin's disease at once distinguishes the condition from its clinical coun- terfeit, leukemia, but aside from this single disease, the blood ex- amination is valueless in the differentiation of other conditions having somewhat similar involvement of the glandular structures. These conditions, tuberculous and syphilitic adenitis, local lyiupho- inatous tumors, and malig7iant neoplasms of the lymphatics, must therefore be distinguished from Hodgkin's disease by other clin- ical methods, for they all may provoke identical blood changes. In reviewing the clinical history of a case of suspected Hodg- kin's disease, the following symptoms should be given special consideration : the gradual onset of a widespread hyperplasia of the lymphatic structures, occurring most commonly in males under middle age ; the progressive character and chronicity in most cases of the disorder ; the tendency in some cases toward the occurrence of unexplained febrile periods, sometimes coincid- ing with a rapid and marked increase in the size of the affected glands which disappears as the fever subsides ; the cachexia, asthenia, and emaciation of the patient, frequently associated with gastro-intestinal and circulatory disturbances, and with a tendency to hemorrhages, such as epistaxis and purpura ; the presence of pressure symptoms, such as cough, dysphagia, dyspnea, edema, and pleural and peritoneal effusions ; and the development of bronzing of the skin in an occasional case. In typical cases, the glandular enlargement forms a series of distinct, painless, hard tumors, each freely separable from its neighbor, and rarely caseating or suppurating. Due weight should also be given to the fact that in the majority of cases the lesion originates in the superficial lymphatic glands of the cervical region, beginning either in the occipital or in the inferior carotid triangle. The spleen is moderately enlarged in the majority of cases, and in others the liver, kidneys, suprarenals, tonsils, thymus, thyroid, and sexual organs may be involved in the lymphoid growths. HODGKIN S DISEASE. 2/1 Ttibercidous adenitis usually first involves a group of glands in the submaxillary triangle, and tends to produce inflammatory adhesions between the tissues and the glandular structure, and softening, fusing, caseation, and suppuration of the glands. It is of sluggish development, often occurs in the very young, and is almost always confined to a single group of glands. Evidences of tuberculous lesions in the lungs or in other parts of the body, especially of dental caries, cutaneous lesions of the face, and ade- noid pharyngeal growths, and the discovery of tubercle bacilH in the glandular tissue are valuable evidences of the tuberculous nature of the disease, yet they do not positively exclude Hodg- kin's disease, since the coexistence of the two conditions in the same individual, although rare, is possible beyond a doubt. In syphilitic adenitis of the neck the post-cervical groups are first affected, the glands being of cartilaginous hardness, painless, freely movable, and of small or moderate size. The glandu- lar enlargement is often more or less general, but the affected groups do not attain a large size. A history of an initial lesion in the vicinity of the primary glandular swellings, or of the appearance of secondary symptoms, the disappearance of the glandular tumors after the administration of mercury, and the presence of Justus' test will suffice to prove the specific character of the hyperplasia. A local lymphoma is limited strictly to a single group of glands, forming a painless, dense mass, free from inflammatory adhesions, caseation, and suppuration. It commonly involves the submaxil- lary glands, may attain a large size, and is unassociated with con- stitutional symptoms. Such a local lymphatic tumor cannot be distinguished from the early stage of Hodgkin's disease, for in some cases of the latter the general lymphoid hyperplasia is pre- ceded by a period during which the only sign of the condition is a localized enlargement of a single group of glands. If, accord- ing to Osler,^ a local glandular tumor of this kind persists for over a year or eighteen months without involving the glands of the opposite side or of the axilla, it is almost certainly a non- malignant lymphoma. Saj'coma of the lymphatic tissue forms an immovable tumor, early complicated by inflammatory processes which cause inter- glandular adhesions and adhesions between the glands and the surrounding tissues. The swelling is often red and inflamed, pits upon pressure, and resembles an abscess, while the skin over the site of the lesion is frequently marked by a maze of tortuous, congested, cutaneous veins, and is prone to ulcerate. The adja- 1 Cited by Bramwell : "Anemia," etc., Phila., 1899, p. 203. 2/2 DISEASES OF THE BLOOD. cent tissues become densely infiltrated by the sarcomatous growth, and involvement of distant organs by metastasis is likely to occur. If nerves are entangled in the growth, the tumor is exquisitely painful. Sarcoma of the lymphatic glands may occur at any period of life. Carcinoma of the lymphatic glands is secondary to an initial growth in some other part of the body, so that in the region of the neck search should be made for a primary cancerous lesion in the mouth and upper air passages. The disease is most com- monly found during the decline of life. Finally, as Tyson so pertinently remarks,^ it should not be for- gotten that all the conditions named as possible to be mistaken for Hodgkin's disease are limited to a single group of glands, while Hodgkin's disease always extends, and the fact of such limitation is of itself sufficient to preclude the disease. This pro- gressive involvement of the lymphatic glands, group after group, must, after all, be our mainstay in the diagnosis of doubtful cases VIII. THE EFFECT ON THE BLOOD OF SPLENEC- TOMY. Excision of the spleen in man is followed by a Hemoglobin diminution in the hemoglobin and ery-throcytes, AND the degree of which is generally believed to be Erythrocytes, more pronounced than can be accounted for by the simple factor of hemorrhage incident to the operation. Blood regeneration is slow, especially the restoration of the hemoglobin, which is prone to increase much less rapidly than is the rule in an ordinary secondary anemia. In uncompli- cated cases from one to three months' time usually elapses be- fore the normal percentages of hemoglobin and er>^throcytes are attained ; in unfavorable cases persistence of the anemia for a much longer period is to be observed. Splenectomies attended by great loss of blood may excite, in addition to an extreme cel- lular decrease, striking qualitative changes, and in such instances the blood-picture is characterized by the presence of many normo- blasts, achromacytes, and corpuscles deformed in shape and size. Conspicuous post-operative anemia is especially common in pa- tients to whom saline intravenous injections have been administered. Post-operative leucocytosis of the polynuclear Leucocytes, neutrophile type develops promptly, and persists in most instances for from four to six weeks, ac- cording to Hartmann and Vaquez,^ but occasionally for a longer I " Practice of Medicine," Phila., 1898, p. 606. 2Compt. rend. Soc. bioL, Paris, 1897, voL iv., p. 126. THE EFFECT ON THE BLOOD OF SPLENECTOMY. 273 period. Counts of between 1 5 ,000 and 30,000 represent the grade of leucocytosis ordinarily found, although occasionally the increase Table XII. The Effect on the Blood of Splenectomy. si a 12 tn V S !.<«• ^ qj S.^ CO _4J ^ .a •— ' ^^ OJ3 J3 B 3 bo a 2 ■5 3 V 1-1 s 6 ^ ?f-3 3 p, "O 3 0. C 'en w Notes. II 65 5,200,000 2,200 22 5 70 3 Before operation. Megaloblasts and nor- moblasts found. ^5 5,000,000 24,000 21,400 23,800 18,000 1 8,000 3'(^ 3-2 93 .2 2 days after operation. 4 << '< «' 5 " " " 8 " " a 45 3,256,000 24,000 16,400 7.9 8.5 81 2.6 II << a a Myelocytes and mast cells found. No eryth- roblasts. 16 days after operation. 4i> 4,496,000 17,000 7.8 9 76.8 6.2 21 " << «< Myelocytes, . 2 per cent. 40 3,984,000 20,000 9 7-4 82.2 1.4 27 days after operation. No erythroblasts. 40 4,000,000 15,000 5.8 7.4 82.8 4 37 days after operation. 52.5 4,672,000 21,600 151 «t 731 2 56 " *' '< Myelocytes found ; no erythroblasts. 16,000 51 loi 79| 3.5 99 days after operation. Erythrocytes normal. 22 108 4,850,000 30,000 8 8 83 I Before operation. 100 4,700,000 39,000 5 4 91 7 days after operation. 105 3,630,000 18,000 15 6 7« I 60 " <' << 03 2,750,000 20,000 5 10 84 I 3 years *' << 3' 45 1,634,000 12,000 16 20 61 3 14 days *' << i^7 2,460,000 20,000 18 32 49 I 27 << «< *< no 4,530,000 27,000 18 IS 66 I 33 " 100 3,977,000 8,000 21 II 62 6 2 years and six months after operation. 4* 63 4,570,000 8,000 Before operation. 64 4,970,000 30,000 3 days after operation. 77 5,180,000 65,000 5 (( << << 66 4,800,000 17,500 48 '* << '< ^5 4.353,000 11,700 4 months'* " 85 3,300,000 11,600 5 years ** " 1 Warren : Annals of Surgery, 1901, vol. xxxiii., p. 513. 2 Hartman and Vasquez : loc. cit. 3 Ibid. *Czerny, cited by Vulpius : Beitrage z. klin. Chir., 1894, vol. xi., p. 633. 18 2/4 DISEASES OF THE BLOOD. is far greater — 70,000 in a case cited by Czerny,^ and 75,000 in one reported by Hartley." After a number of months (usually some time during the second or third year after the operation), there is a moderate increase in the number of eosinophiles. In splenectomized guinea-pigs Kurloff^ found during the first year after the operation a marked lymphocytosis, as high as 60 per cent, in some animals, together with a corresponding decrease in the number of granular cells, but with no alteration in the num- ber of large mononuclear leucocytes. Eosinophilia became ap- parent during the second year, and coincident with this change a decrease in the lymphocytes to their normal percentage took place. The above remarks concerning the differential changes affect- ing the leucocytes after splenectomy must be regarded as tenta- tive, in view of the fact that sufficient data bearing upon this question have not yet accumulated to justify more definite con- clusions. The table on page 273 shows the condition of the blood in the few recorded cases in which pre- and post-operative examinations have been carried out. It is to be remembered that, aside from the character of the splenic lesion, these important factors also determine the degree of the post-operative anemia and leucocytosis in this procedure : the grade of the preexisting anemia, the amount of hemorrhage during and following operation, and the patient's recuperative powers. All things being equal, the anemia is least marked and the blood regeneration most prompt in simple zuandering spleen and in ague cake, while blood deterioration is more marked and regeneration slower in niptiire of this organ. Splenectomy for sple7io-viediillary leukemia is almost invariably followed by a pro- gressive anemia and leucocytosis, and in nearly all cases by death. But five recoveries after removal of the spleen in this disease have been reported up to the present time.^ ^ Loc. cit. ^Med. News, 1898, vol. Ixxii., p. 417. 3 Cited by Ehrlich, loc. cit. * Hagen : Archiv. f. klin. Chir., 1900, vol. v., p. 188. Also, Richardson, cited by Warren : loc. cit. < ►J < Q S w w S !^ A » 9 w 4) O OL) biO o.S ■ o ^ h VO '-C r^ 3 i; >-i -So ai2 O !=! O ^ O CI -^ ^ o IT) q .2 .-H 13 (fl c3 ^ C o s ^ =3 ^ i^ t^ . 3 C cj >> o "IJ >-' c^ ci ^ - S t^ 2 2 « ii o P ryi O . 'J ■^ ^ S G q 73 S "5^ ^ — -x^ Jd .2 i ^ S ..•- 13 > ghtly aver 0. eutro- Dr in- nsequ rease rease . 43 a .S c3 ;=!i2yc!Ouo S 1 Normal, or s creased, coun ing about io,c Polynuclear philes normal, creased, with c lymphocyte de rarely, an in 0) & locytes r nophiles reased. IS . G,T3 lymph Mye Eosi or dec C i3 >H > rt O a; 3 g ii O o o ;=; :^ „ Q cj o OJ 13 C ^ 3 a O u O a 2 ^ B a ^2 a o a. a a o W <3J . i^ a 3 0) biO C c3 3 O (U K a 2 bJD > .a ^§ '—' O (11 C^ Ti a r^ Q^ 0) tn .ti O "^ J:} S ^ 5? « O g « O o S^ . -« '35 IS O .'I H Cj CT ,9 - ■'^ a ^ <3J CJ >H 3 O (U Cj en ^ .Jh ^ (U ?! bit) a 'So rr-I <1J -^ '- o >>.^ o c3 8 ^ i3 ^1 rQ to O c3 i; ^_g CI ij3 a rt fl Td a a _g tn 1) . bJD 3 o biO g *bi) o o d o nd > C3 O o , -o-^ a o P- -. ci Td o rC" ^ O (U a M -^ ^.ti O G O ^-^S ^ ^ ^ (U (U bJO d a -d o d D bO ^ bJO d d Td a o . a 'o rt ij «s >< >r o ^ _ CJ o .>n:: a <-> si d ^ u a d d a r -- d o 2i o !" o d = .Si o >~, (U ^5 ^H t^ en o tfl ,0 cj rt 03 o JJ W >pq oj (u a. .a o I C) rN S SECTION VI. THE ANEMIAS OF INFANCY AND CHILDHOOD. SECTION VI. THE ANEMIAS OF INFANCY AND CHILDHOOD. I. CHARACTERISTICS OF THE BLOOD IN CHILDREN. As a preliminary essential to the intelligent Fetal Blood, study of the various pathological conditions of the blood in children, it is necessary briefly to refer to certain points of difference in the composition of this tis- sue in the child and in the adult. In general terms, it may be stated that the younger the child the more unformed are the different elements of the blood and the nearer its composition resembles the blood of the fetus. In fetal blood the specific gravity, both of the whole blood and of the serum, is lower than in the adult, and coagulation is very slow. The erythrocytes vary greatly in size and in shape, and are deficient in hemoglobin, which is loosely attached to these cells, and hence becomes readily dissolved out. Until about the seventh month of intra-uterine life normo- blasts constitute the predominating variety of erythrocytes, after which period they rapidly diminish in number, until at full term few, if any, nucleated red corpuscles are found in the blood. Of the different varieties of leucocytes, the mononuclear fornis are present in a proportion relatively excessive to the other varieties ; before the seventh month this lymphocytosis is due to a high relative percentage of large lymphocytes, but after this period the proportion of small lymphocytes increases, until finally the latter type of cells predominates. The percentage of eosinophiles reaches its maximum at the seventh month, gradu- ally becoming less and less as the end of the intra-uterine life approaches. We find, therefore, that in the fetus the blood is characterized chiefly by the presence of large numbers of normoblasts, by a high relative proportion of mononuclear leucocytes, and by a de- ficiency of hemoglobin. The closer an infant's blood resembles this picture, the ''younger" in point of development is such blood considered, and the more strongly is it said to revert to a ''young" or "embryonal" type. 28o THE ANEMIAS OF INFANCY AND CHILDHOOD. At birth, the blood of the full-term infant is of The Blood higher specific gravity, and richer in hemoglobin AT Birth. and in corpuscular elements than that of the older child or of the adult. The specific gravity of the blood of the average healthy infant at the time of birth and during the first few weeks of life is, ap- proximately, 1066. For normal children the average, which is reached by the beginning of the second year, varies from 1050 to 1058, being slightly higher in boys than in girls. The maximum amount of hemoglobin is found at birth, the per- centage at this time ranging from 100 to 104, according to the investigations of Hammerschlag.^ After birth the amount of hemoglobin immediately begins to diminish, the minimum, which may be as low as 55 or 60 per cent., being attained by the end of the third week of life. It remains at or about this minimum for a variable period of time, sometimes for as long as six months, and then gradually begins to increase. At birth, the number of erythrocytes in the peripheral blood is decidedly higher than normal, counts of between 5,500,000 and 6,000,000 cells per cubic millimeter being found at this time, the highest figures being observed in those cases in which ligation of the umbilical cord has been delayed. During the first twenty- four hours of extra-uterine life this polycythemia becomes still more marked, so that the number of corpuscles per cubic milli- meter may reach a maximum of from 7,000,000 to 8,000,000, and sometimes more, by the end of the first day. Beginning with the second day, a gradual diminution in the number of these cells is noticed, and the normal 5 ,000,000 per cubic millimeter is reached by the end of the first week or ten days. Hayem ^ emphasizes the fact that the fluctuations in the number of erythrocytes during the early days of life stand in inverse ratio to the variations in the weight of the child, the maximum number being found at the time of the infant's minimum weight, while as the child begins to gain in weight the count decreases. Schiff ^ is inclined to attrib- ute these fluctuations to the amount of liquids in the body, the result of feeding, showing that in fasting children the counts are always higher than in those fed at frequent inter\^als. Whatever may be the exact manner of their production, it is evident that these fluctuations are to be regarded as purely physio- logical in character, depending upon concentration and dilution of the blood, rather than as an expression of involvement of the blood-making organs. 1 Centralbl. f. klin. Med., 1891, vol. xii., p. 825. 2"Du Sang," etc., Paris, 1889. ^Zeitschr. f. Heilk., 1890, vol. xi., p. 17. CHARACTERISTICS OF THE BLOOD IN CHILDREN. 281 The erythrocytes vary greatly in size during the first few days of post-natal life, the diameter of some cells being as small as 3.25 /z, and of others as large as 10.25 ft. Many observers have noticed that the small-sized cells, as a rule, predominate. Nucleated erytJirocytes of the normoblastic type may or may not be present in the blood of new-born infants ; they are com- monly found in large numbers in the prematurely born child, and also occur less numerously in many fully developed babies, not- withstanding views to the contrary expressed by some observers, notably by Hayem ^ and by Fischl.^ In most cases normoblasts disappear from the blood after the first few days of life, and their presence after the sixth month should always be regarded as pa- thological. The number of leucocytes at birth averages about 20,000 per cubic miUimeter, the normal average for young infants, 15,000 per cubic miUimeter, being reached by the end of the first week, after numerical fluctuations similar to those affecting the erythro- cytes. From the second or third week until the sixth month, a count from 10,000 to 14,000 may be regarded as normal, while for the child of one year of age the average is about 10,000. By the sixth year the number of leucocytes falls to the number normal for the adult, 7,500 per cubic millimeter. The following excel- lent table from Rotch,^ shows these average counts of erythrocytes and leucocytes in children from birth until the sixth year of age : Age. Erythrocytes. Leucocytes. At birth. 5,900,000 21,000 (26,000 to 36,000 after first feeding). End of 1st day. 7,000,000 to 8,000,000 24,000 " 2d '* Generally increased. 30,000 " 4th " 6,000,000 20,000 " 7th " 5,000,000 15,000 loth day. 10,000 to 14,000 1 2th to 1 8th day. 12,000 1st year. 10,000 6th year and upwards. 7,500 The influence of the initial feeding in infants produces a marked leucocytosis, the increase amounting to from 5,000 to 15,000 cells per cubic millimeter, as shown by the above table. It is probable that the habitual leucocytosis of early childhood is largely referable to a more or less continuous digestion leucocy- tosis. (For a further discussion of this question see ** Digestion Leucocytosis," page 179.) ^ Log. cit. 2Zeitschr. f. Heilk., 1892, vol. xiii., p. 277. 3 ''Pediatrics," etc., Phila., 1896, p. 342. 282 THE ANEMIAS OF INFANCY AND CHILDHOOD. The blood of infants and of young children differs greatly from that of the adult in the relative proportions of the different forms of leucocytes, these qualitative differences becoming less and less apparent as the child grows older, and not usually persisting beyond the tenth year. In general terms, it may be said that these dissimilarities are striking in relation to the youth of the child. Compared to the adult, a differential count of the leuco- cytes in the child shows that the relative percentage of lympho- cytes is more than twice as great, and of polynuclear neutrophiles one-half as great, while the proportion of eosinophiles is fre- quently much higher. In the following table, based upon data given by Gundobin,^ these points of difference are contrasted: Forms of Leucocytes. Infants. Advlts. Small lymphocytes. 50 to 70 per cent. 20 to 30 per cent. Large lymphocytes, and transitional forms. 6 '' 14 ( ( 4 '' 8 Polynuclear neutro- philes. 28 '' 40 n 60 - 75 Eosinophiles. 0.5 '' 10 I i 0.5 " 5 It is important to take into account these differences, in mak- ing blood examinations in children, in whom we must expect to find percentages of lymphocytes which in the adult would be regarded as abnormally high. Lcucocytosis in children is of extremely common occurrence, often arising from causes of the most trivial character, and de- veloping to a greater degree and with much more rapidity than in the adult. It is therefore to be regarded with less significance than when it occurs in the mature. Usually the polynuclear cells are chiefly involved in the increase, but the inclination of the blood of children to revert to the embryonic type appears to cause, in many cases, a disproportionate increase of lymphocytes in relation to the other forms, this peculiarity being especially true of the various pathological leucocytoses. Physiological leu- cocytosis in children usually affects chiefly the polynuclear neu- trophile cells. II. ANEMIA IN CHILDREN. Children, as a class, are peculiarly susceptible Frequency, to anemia, for they appear to lack resisting pow- ers against the influence of causes tending to pro- duce pathological alterations in the blood. Thus, it is found that the same factors which in the adult have little or no effect upon ^Jahrb. f. Kinderheilk., 1893, vol. xxxv., p. 1S7. ANEMIA IN CHILDREN. 283 the blood are capable of producing profound alterations in its composition in the child. Severe anemias may arise in children from apparently the most trivial sorts of causes ; slight hemor- rhage from the navel, for instance, may light up an anemia of an intensity out of all proportion to the actual amount of the blood loss, while minor lesions of the gastro-intestinal tract are com- monly associated with blood deterioration of a severe type. It is a notable fact that in anemic children a General predominant tendency exists toward a reversion Character- of the blood to a less mature histological type, iSTics. such as that found in the blood of the fetus. Thus, in children, anemia of a type which in the adult is unattended by qualitative changes in the corpuscles is commonly associated with the presence of large numbers of nucleated erythrocytes, these cells being far more numerous than the severity of the anemia would seem to warrant ; poikilocytosis, and deformities in the size of the corpuscles also occur with far greater frequency than in the adult. Regeneration of the blood takes place slowly. The oligochromemia is relatively greater than the oligocythemia in most anemias of children, this being due probably to the fact that the hemoglobin is peculiarly prone to separate from the corpuscular stroma. Owing to this fact low color indices, as in chlorosis, are common, irrespective of the degree of corpuscular diminution. Myelocytes are commonly found in the blood in all the anemias of children ; they are present in larger relative percentages and in less severe pathological conditions than in the adult. Leucocytosis, often lymphocytosis, and enlargement of the spleen are frequently associated with all forms of anemia in the young ; and although these conditions are likely to coexist, this is by no means the invariable rule. Splenic enlargement is especially common in the anemias due to syphilis, rachitis, tuberculosis, gastro-intestinal disease, malaria, and septic infection. To epitomize, in the anemias of infancy and childhood the follow- ing prominent features in the blood are found : (a) the frequency of a low color index ; (d) the common occurrence of erythro- blasts, and of deformities affecting the shape and size of the erythrocytes ; (c) a tendency toward leucocytosis and splenic enlargement, and (d) the frequency of myelocytes. It is owing to these peculiarities that the clas- Classifica- sification of the anemias of children is such a dif- TiON. ficult matter. The older classifications, based upon the nature of the causal factors of the an- emia and upon the presence or absence of enlargement of the 284 THE ANEMIAS OF INFANCY AND CHILDHOOD. Spleen, have failed in many respects to prove adequate, so that it becomes necessary to adopt a simpler and more comprehensive division from which no exceptions need be made in the individual case. Such a classification has recently been suggested by Morse. ^ This author assuming, and rightly so, that chlorosis is a condition wholly foreign to infantile life, and that the disease de- scribed by von Jaksch as "Anemia infantum pseudoleukemica " does not represent a distinct clinical entity, proposes this excellent classification, slightly modified from that of Monti : Primary Anemia. Pernicious anemia. Leukemia. Secondary Anemia. Mild anemia. Mild anemia with leucocylosis. Severe anemia. Severe anemia with leucocytosis. Pernicious anemia is rare in the young, and Primary likely to be mistaken for other forms of severe an- Anemia. emia secondar}- to various conditions. It is prob- able that many of the reported cases of Biermer's anemia in infants were in reality examples of severe secondary- anemia. The apparent tendency of pernicious anemia in children to become transformed into leukemia is doubtless more fanciful than real, a remark which is equally true of those few reported instances of the conversion of leukemia into pernicious anemia. In the first case, the erroneous impression may arise from such evidence as marked enlargement of the spleen associated with a high leucocytosis ; in the second, a temporary' disappearance of the myelogenous blood-picture plus an aggravation of the exist- ing anemia may be sufficient to convey the false impression. It must be admitted that these atypical blood changes, so common in young children, are highly confusing and difficult to interpret without the closest observation and the correlation of other clin- ical signs. Infantile pernicious anemia is characterized by the same blood changes that are found in the adult, in so far as striking oligocy- themia, and nucleation and deformities of the er}^throcytes are concerned, but the blood often fails to show the high color index and the prevalence of megaloblasts and of megaloCytes which must be considered diagnostic of this disease in the adult. Leukemia in children is uncommon, but instances have been reported during all stages of infancy and childhood, even in the 1 Archives of Pediatrics, 1898, vol. xv., p. 815. PRIMARY ANEMIA. 285 new-born. Acute forms of the disease are most frequently met with, the great majority of cases, according to Holt,^ proving fatal within a year from the appearance of the first symptoms, while in many the disease runs its course in a few weeks. Male children are more commonly leukemic than females. Conditions such as rachitis, syphilis, and malarial fever have been regarded by some authors as possessing a certain amount of importance as etiological factors, but in the vast majority of cases the cause of the disease is entirely obscure. Of the several collected reports of leukemia in children, the two articles of Morse, giving a total of 27 cases, are by far the most valuable. In his first communication^ 20 cases were re- corded, including one of his own, tabulated below, but of this series the diagnosis in the great majority of instances being based either upon clinical symptoms or upon inadequate examination of the blood, the reporter is led to remark that ** It is highly probable that not more than half, perhaps not more than a third of these were really cases of leukemia." In Morse's second article,^ which deals with the acute form of the disease, seven cases, again including one of his own, also recorded below, are reported. Although the literature of pediatrics is fairly rich in alleged examples of leukemia in children, the cases, with but a few ex- ceptions, are reported in such an unsatisfactory manner that they cannot be regarded without reserve as typical. Those reported prior to the pubHcation of Morse's first article, in 1894, must all be open to criticism, owing to the general disregard for differen- tial counts shown by the various authors, and, strangely enough, this criticism must hold true for many cases recorded during the past seven years. The author has been able to collect ten cases (Table XIII.), in all of which the differential count of leucocytes leaves no doubt as to the precise character of the disease. In addition to the above cases several others have been reported, in which the differential count of leucocytes has either been faultily made or entirely neglected. Thus, Pollman* believes that he has seen a case of spleno-medullary leukemia in a new-born infant, the count on the fourteenth day after birth being 2,500,000 ery- throcytes and 312,500 leucocytes per cubic millimeter. The latter consisted chiefly of '' large mononucleated cells, with large, distinct nuclei, and an abundance of protoplasm." Nucleated forms of erythrocytes were not found. Cassel,^ in addition to 1 "The Diseases of Infancy and Childhood," N. Y., 1897, p. 806. 2 Boston Med. & Surg. Journ., 1894, vol. cxxxi., p. 133. 3 Archives of Pediatrics, 1898, vol. xv., p. 330. * Miinch. med. Woch., 1898, vol. xlv., p. 44. ^Berl. klin. Woch., 1898, vol. xxxv., p. 76. 286 THE ANEMIAS OF INFANXY AND CHILDHOOD. t—t T" X U ?; w < < S H tai D ti hJ 1 ^ ^ ^ ', "S 3 3 !3 3 TS . TS -• *^ *^ (j ZJ 6 6 u «J CO c3 "cs "S a ■^s a ^ 6 ^ ^ rO ^ 6 'S 2 6 H ^ c J^ a. o, Ol c c £ S S a OJ E "* ^ >> '~ , "H- >, >- p>~. >;^ 3- >, ^ a, > r- >-. J C/2 :/: >-i . '1 hJ X C rt H^ X c: ^- j •J4 0) C 6 6 1 1 i) t/: . Jl, Wm >..2 ti > "5 be bX) s c c in 3 S i^ c ^ tn to 13 l-H "cS a c .2 r:: c ^ := a. istological Changes in th Erytlirocytes. 2 3 4-> E G 33 ^ u ocytes. y normoblasts ; poik and polychromato ■d. ffi S c X a 'J5 3- 1— ( w c •sai^D 00 »o q M 00 -opAj^ d 0" d d d d cn M 00 I 'saiiqd vq q q q q q 1 -oaiso3 1 IH M ►H d d 10 "^ 1 1 -saiiqaoji q VTi t-^ q q t-^ ri- ■«*• ro ON jBapnuXjoj to VD ri cs ON •sgjAo q q q rr> IH r^ r^ -oqduiAq M 10 oi t^ 00' d ^ ; 93xe^ M 00 00 C^ '"' •ssjAd q M q ^ c> vO -oqdinX'j ro HH X cj vO N ro t-^ LO M ipras 00 VO ►-I IH N C^ IH ,-: •saxS-o \ 8 8 q^ 8 ^8 -oohaq rC a^ d^ 00" * 00 00 N Tj- N 00 IH C \r^ IH N ^ C <^ (S 1— ( Q Q Q Q •saiXo 8 oJ 8 8 8 q^ 8 CJ Q 8 -ojqj.Oa e3 8^ ^" 00" 8*^ 1^ o; vri \ri n-i rO a\ 00 ^ c>r u fO M N IH N N ** •niqoiS tn ^ ^ b ^ u )-• If So >>. >^ >^ >-. >> >-. >. >-. >-. < ro IH 00 "^ Tt "<*• *-■ ON to IH ^3 rt . C J o C3 "S r- ■~ c ^ 1 >^ 2 ^4 P5 •* w .• -^ . <: 1^ "Si U i c 11 : ex - _ct 3 < CO C > On 00 o > 6 o ON 3 o ^ J3 i::h 3 O CO ^ 1- ill tfj (O t- .:: a; '^ "?i ^ 3 O O C '-J ~I2^ '-n o X *-> CJ >» ■>- >-» o 3 ii 00 "^ ON^ o a; 1: '^ >~. 1-1 O O o ■— ■ 3 e3 C " O 3 O tx-z; _ •:: C3 d ^•- fO "-I - 3 -M ^s X :-i -■ ._: — cj ^ ^2 ol. XV XXV., ol. xli ytes si -? II « ON > . X > - <^ • - 00 « "o s ONfO ^ On I^ -• tn 00 "-I "^ 00 — v_^ c5 ics, I i.,p. 1898, Ik., I nt of a tn rz ^ -^ a -^ X c flj f^ cLo c C\--: ^cc> c-= S '0^ '^ i M '- ^ s .-^-^b^ ^- .> -^ ^- - i S Arch Lane Berl. Jahrl The 1^ c s rt ej n •* X tn u ^ SECONDARY ANEMIA. 28/ his own case, tabulated above, has collected four other cases oc- curring in children under fourteen years of age. Theodor^ has collected from German literature six cases of acute leukemia in children between the ages of two-and-one-half and eight years of age, and also reports one of his own, apparently of the lymphatic form, in a boy of four years. No actual numer- ical estimates of the corpuscles are given, but the proportion of leucocytes to erythrocytes is stated to vary from i : 9 to 1:3. The differential count of leucocytes is also very inexact. The greater percentage apparently consisted of lymphocytes ; myelo- cytes were fairly numerous, many of them containing mitotic fig- ures, and normoblasts and megaloblasts were present in large numbers. Charon and Gratea^ report a case of spleno-medul- lary leukemia in a child of eight years, the percentage of hemo- globin being 39, the erythrocyte count 880,000, and the leuco- cyte count 305,000. In the above classification of the secondary Secondary anemias, under the heading of mild anemia are Anemia. included those cases characterized by trifling re- duction in the hemoglobin percentage and num- ber of erythrocytes, and by an absence of histological alterations in these cells. The color index in these cases is usually i .00, or slightly below, uncommonly falling to a low figure. The term severe anemia includes cases having marked diminu- tion of hemoglobin and erythrocytes, associated with deformities of shape and of size and nucleation of these cells. The hemo- globin loss is especially marked, often being only one-quarter or one-third of normal, and the color index is low. Anemias with lencocytosis^ whether of mild or of severe type, are generally marked by a greater degree of hemoglobin and corpuscular decrease than anemias without leucocytosis. The leucocytosis is moderate in the milder forms, but in severe cases the increase in the number of leucocytes often appears to be pro- gressive, and the relative number of leucocytes to erythrocytes occasionally attains the proportion i to 100. Histological changes in the erythrocytes are more striking in grave anemias with leucocytosis than in grave anemias pure and simple. This is especially true of the changes relating to nuclea- tion of the cells, normoblasts and atypical forms being very nu- merous in the former class. Typical megaloblasts are occasion- ally found, but these cells are not common in the blood of chil- dren, even in the most severe anemias. ^Archiv. f. Kinderheilk. , 1897, vol. xxii,, p. 47. 2 Bull. Soc. roy. sc. med. et nat., Bruxelles, 1896, vol. liv., p. 63. 288 THE ANEMIAS OF INFANCY AND CHILDHOOD. Regarding the etiological factors of these secondary anemias, the following groups of causes are given by Monti -} I. Congenital. | Syphilis, tuberculosis, and other infections. Hemorrhagic. 2. Acquired. General. From navel, from circumcision, etc. Purpuric diseases. Malnutrition, improper hygiene, etc. Syphilis, rachitis, and tuberculosis. Gastro-intestinal diseases. Visceral diseases. Febrile diseases. Septic infections. Nephritides. Malignant growths. Syphilis, either congenital or acquired, is responsible for a large proportion of the cases of anemia in children, especially those of a severe type, associated with enlargement of the spleen, and often also with enlargement of the lymphatic glands. The hemoglo- bin loss is in most instances disproportionately greater than the corpuscular decrease, so that low color indices are especially common in this disease — the misnamed ** chlorosis " of syphilis. Deformities and nucleation of the er}lhrocytes are common in the severer types, and in such forms polychromatophilic changes and excessive decrease in the number of er^^throcytes are usually present. A leucocyte increase is present in the sec- ondary stage, and is usually associated with the grave anemia of this disease ; the relative precentage of lymphocytes is in- creased, and of polymorphous forms decreased ; and small num- bers of myelocytes are common. From the writer's experience, in the average case of moderate severity the percentage of hemo- globin varies from about 40 to 50, the erythrocytes are reduced to about 3,000,000 to 3,500,000 per cubic millimeter, and the leucocyte count is in the neighborhood of 20,000 ; but in severe cases the erythrocytes may be reduced to 1, 000,000, and the leu- cocytes increased to 50,000 or more. As in the adult, Justus' test proves of value in the diagnosis of many anomalous cases. In rachitis there is usually well-marked anemia, commonly accompanied by decided enlargement of the spleen, such cases usually having most decided blood changes. The hemoglobin percentage is usually relatively lower than the percentage of corpuscles, so that low color indices prevail ; but in the indi- vidual case neither the oligochromemia nor the oligocythemia are usually as marked as in syphilis. In severe cases, deformed and nucleated erythrocytes, and a small percentage of myelo- cytes are commonly found. The number of leucocytes is as a ^ Wien. med. Woch., 1894, vol. xliv. , pp. 401, 464, 516, 560, and 613. SECONDARY ANEMIA. 289 rule moderately increased, and relatively high percentages of lymphocytes are common. Uncomplicated tuberculosis, due to pure infections with the tubercle bacillus, produces an anemia which varies in degree with the severity of the constitutional effects of the disease. The hemoglobin and erythrocytes are usually but slightly decreased, the former suffering a relatively greater loss, and the number of leucocytes does not rise above normal. If to the tuberculous process a septic infection is superadded, the anemia becomes severer, and leucocytosis, involving the polymorphous forms of leucocytes, occurs. Splenic enlargement is common, and some- times marked. The anemia of tuberculosis is in no way referable to the infection itself, but depends upon the drain on the albumi- noid materials of the blood due to the presence of a long-con- tinued cachexia. G astro-intestinal diseases, especially those of chronic character, cause most marked anemia. Chronic inflammations of the intes- tines strikingly affect the blood, the percentage of hemoglobin frequently falling to one-quarter of normal or even less, and the number of erythrocytes being decreased to one-half of normal or less. Deformities affecting the shape and size of the erythrocytes, and nucleation of these cells are of frequent occurrence. A leu- cocyte increase, involving in many instances the lymphocytes, is usually present, and small percentages of myelocytes have been observed. Splenic enlargement is frequently a 'conspicu- ous clinical sign. It should be remembered that in acute forms of gastro-intestinal disorders, in which profuse diarrhea and vom- iting occur, concentration of the blood takes place, causing tem- porary polycythemia which may for a time hide the real degree of the blood deterioration. The anemias found in this class of diseases are apparently to a large extent autointoxicative in char- acter, depending to a less degree upon insufficient nutrition. In enteric fever the blood-picture does not differ essentially from that seen in the adult suffering from this affection, absence of leucocytosis or leucopenia with progressive anemia being found with great constancy. In 12 cases recently studied by Stengel and White ^ the hemoglobin ranged from 68 to 83 per cent., the erythrocytes from 3,320,000 to 5,200,000, and the leu- cocytes (in uncomplicated cases) from 3,800 to 12,320. Poly- nuclear leucocytosis was obsei'ved in 3 cases as the result of in- flammatory complications. Two uncomplicated cases showed fractional percentages of myelocytes, but there were no other dif- ferential changes of any consequence. The writer has found that ^Archives of Pediatrics, 1901, vol. xviii., pp. 241 and 321. 19 290 THE ANEMIAS OF INFANCY AND CHILDHOOD. the alkalinity of the blood varies within wide limits in infantile typhoid, tests, by Engel's method, in 6 consecutive cases showing a range of from 373 to 692 mgrms. NaOH. The rapidity of co- agulation also was found to vary greatly, clotting taking place in as short a time as 37 seconds in one instance, and not occurring for 4 minutes and 35 seconds in another. Morse ^ concludes that the serum test appears earlier, is less marked, and persists for a shorter period in children than in adults. In a nursling it should be remembered that a positive reaction may be of uncertain value, for the reason that the agglutinating power may be transmitted from mother to child through the milk, both during the active stages of the disease and also during and after convalescence. Under the title ''Anemia infantum psctidolctikemica^ von Jaksch ^ has described a condition which he regards as a form of primary anemia peculiar to the young child. The blood changes, none of which are characteristic of the disease in question, as this author admits, consist of {a) marked oligocythemia and oligo- chromemia, {U) extensive and persistent leucocyte increase, and {c) striking structural alterations in the erythrocytes. Associated with these changes in the blood, and of equal importance in diag- nosing the disease, constant enlargement of the spleen, and, less commonly, enlargement of the liver are found. The number of erythrocytes is greatly decreased, usually to from 2,000,000 to 3,000,000 per cubic millimeter, but sometimes falling to 1 ,000,000 or even to a lower figure, as in one of von Jaksch's cases, in which the count was only 820,000. The hemoglobin loss is also great, relatively more so than the cor- puscular decrease. The leucocyte gain is decided, averaging, in the majority of cases, from 30,000 to 50,000 corpuscles per cubic millimeter, and in some instances exceeding 100,000. In some cases the in- crease involves principally the polynuclear neutrophiles, while in others the lymphocytes are the cells chiefly affected. The cells show a most striking dissimilarity of form and of size, and a highly confusing variety of forms atypical in size, shape, and nu- clear morphology is encountered. This ** polymorphous" state of the leucocytes is a point insisted upon by von Jaksch in his description of the condition. The number of eosinophiles varies within wide limits, the percentage of these cells being normal, decreased, or increased. Small percentages of myelocytes have been observed. The histological changes affecting the erythrocytes consist in 'Archives of Pediatrics, 1901, vol. xviii., p. 338. 2Wien. klin. Woch., 1889, vol. ii., p. 435. SECONDARY ANEMIA. 29 1 marked. poikilocytosis, deformities of size, loss of color, and nu- cleation. Poikilocytes, megalocytes, and microcytes occur in large numbers, and the pallor of most of the corpuscles is ex- treme. Normoblasts are the most common form of erythro- blasts observed, but in some instances the occurrence of atypical forms, small and large, and of megaloblasts has been noted. Karyokinetic changes in these cells are not uncommonly seen, and polychromatophilia is said to be of frequent occurrence. The spleen is enlarged in all cases, sometimes moderately, but often very greatly, so that the organ extends far below the cos- tal margin, and occupies the entire upper left part of the abdomi- nal cavity. The spleen is extremely indurated, and may show capsular thickening from perisplenitis. The increase in the size of the organ is due to a hyperplasia. Increase in the size of the liver is not constant in all cases, and when present does not reach a size corresponding to that of the spleen, as is the case in leukemia ; the lower border of the liver is not rounded, but dis- tinctly sharp. In a certain proportion of cases the lymphatic glands are slightly enlarged, but never to any notable extent. Changes in the bone marrow, common to any severe anemia, have been observed in some cases. The disease occurs most frequently in infants between the ages of seven and twelve months, and is rarely met with in children over four years old. By some writers it is supposed to be slightly more common in children of the male sex. In many cases a previous history of rachitis, syphilis, or long- standing gastro-intestinal disease is obtained, although von Jaksch denies the existence of these etiological factors in his cases. The onset of the symptoms is slow and insidious, and the pal- lor of the skin, blanching of the mucous membranes, and other signs of anemia slowly develop, with the gradual enlargement of the spleen, until these clinical manifestations become marked. In all cases there is excessive loss of strength, and in a great many a high degree of emaciation. Von Jaksch's disease, if untreated, tends to pursue a progres- sively grave course, ending fatally ; but, under suitable treat- ment, in the majority of cases the splenic tumor decreases in size, the leucocytosis disappears, and the hemoglobin and eryth- rocytes return to normal. Pseudoleukemic anemia of infants is not generally considered as a separate clinical entity, but is regarded rather as a form of severe secondary anemia associated with marked leucocytosis and splenic enlargement. It may be due -to a number of different causes, the most prominent among which are syphilis, rachitis. 292 THE ANEMIAS OF INFANCY AND CHILDHOOD, and chronic gastro-intestinal disease. The conflicting reports of different authors concerning this disease, and the incompleteness with which the leucocytes hav^e been studied in many instances, render it probable that in some of the reported cases pernicious anemia and leukemia have masqueraded as typical examples of the condition described by von Jaksch. Bacterionia, generally referable to pre-agonal infections, appears to occur with great frequency in the young child during the course of many acute diseases. Delestre's recent studies^ of general blood infections in children tend to show that infants born before full term are peculiarly susceptible to this condition. Using care- ful technique, this author examined 40 children, ranging in age from a few days to four }-ears, all of whom were believed to be suffering from infections which bade fair to end fatally within a few days, at the latest. Of the 32 fatal cases of this series, bacteria were found in the blood during hfe in 14, while of the 8 who re- covered, but one gave a positive result. The bacterium found with greatest frequency was the streptococcus, while staphylococci, pneumococci, colon bacilli, and influenza bacilli were isolated more rarely. It was furthermore shown that premature babies seemed especially susceptible to streptococcus and colon infections, and that nursing infants sev^eral months old were more prone to suffer from the effects of the staphylococcus. The blood changes occurring '\\\ pertussis, pneumonia, diphtheria, scarlet fever, measles, and other infectious diseases of childhood are considered in Section VII. 1 Annal. degynecol. etd'obstet., 1901, vol. Iv., p. 51. SECTION VII. GENERAL HEMATOLOGY. SECTION VII. GENERAL HEMATOLOGY. I. ABSCESS. The rate oi coagulation is, as a rule, somewhat General slower than normal. Hyperinosis is conspicuous, Features, and under the microscope the fibrin network ap- pears abnormally dense and thick. The iodine reaction may be detected in the dried blood film by the method described in a previous section. (See page 174.) These remarks, as well as those which follow, do not apply to purely tuberculous or *' cold" abscesses, the effects of which are referred to elsewhere. If the absorption of toxic material from an ab- Hemoglobin scess is great enough to produce a systemic effect AND upon the patient, anemia of an intensity parallel Erythrocytes, to the severity of the poisoning sooner or later develops. This fact is sufficient to explain why the grades of anemia in purulent conditions vary within such wide limits. The size and the site of the abscess do not appear pri- marily to determine the degree of the associated blood changes, although, other circumstances being equal, a large, deep-seated collection of pus is likely to have a more harmful effect than one of small size and superficial situation. Chronicity of the lesion seems to go hand in hand with an increase in the blood deterio- ration — few persons harboring pus for a protracted period fail to show decided signs of anemia. In many cases, especially the acute, the only noticeable change is a moderate oligochromemia, but in chronic cases different de- grees of ordinary secondary anemia are commonly encountered, amounting in an exceptional instance to a reduction of hemo- globin to as low as 20 or 30 per cent, of the normal standard, and to an erythrocyte decrease to between 2,000,000 and 3,000,000 cells to the cubic miUimeter. Such profound losses are of course unusual, for in the majority of patients with anemia the hemo- globin is above 50, and the corpuscles above 60 per cent, of nor- mal. The average color index for 76 German Hospital cases, Hsted below, was 0.73. The condition of the hemoglobin and erythrocytes in these patients is shown by the following summary : 296 GENERAL HEMATOLOGY. /. Superficial abscess of hand, arm, foot, and abdout- inal wall ; pahnar, axillary, cerzncal, cerebral, hepatic, renal, periurethral, and ischio-rectal abscess; empyema of gall-bladder . II. Pelvic abscess: o7>ar- ian abscess : pyosalpinx. UOGLOBI IN Percentage. N 10. OF Cases. Nc 1. OF Cases. From 90 to 100 I 80 to 90 3 I 70 to 80 7 5 60 to 70 7 4 50 to 60 6 9 40 to 50 10 9 30 to 40 5 3 20 to 30 3 3 Average : 57- ,0 per cent. 54 .0 per cent. Maximum : 95- (( 82, .0 (( Minimum : 20. ( ( 22. ,0 ( ( Erythrocytes per cb. mm. Above 5,000,000 5 From 4,000,000 to 5,000,000 14 ** 3,000,000 to 4,000,000 18 '■'■ 2,000,000 to 3,000,000 3 *' 1,000,000 to 2,000,000 2 .\verage : 3,881,190 per cb. mm. Maximum: 5,250,000 " *' Minimum : 1,500,000 '' '' o 12 18 3 I 3,634,823 per cb. mm. 4,730,000 '' 1,310,000 '' " If marked anemia exists, a variable grade of cell deformit>% atypical staining, and nucleation is also to be obser\'ed. If the latter change is evident, it will be found that the great majority, if not all, of the nucleated corpuscles belong to the normoblastic class. Practically the same influences governing the Leucocytes, behavior of the leucocytes in most other infec- tions also determine their increase and decrease in abscess. Thus, in both trivial and in extensive pus foci the number of leucocytes may be normal, or even subnormal ; in the former instance because systemic reaction is not provoked, and in the latter because it is overpowered. Leucocytosis may also be absent in case toxic absorption is impossible, owing to the complete walling-off of the abscess. In all other instances save these, a definite and usually well-marked leucocytosis occurs, amounting on the average to a count of about twice the mean normal standard, but frequently greatly exceeding ABSCESS. 297 this figure in the individual case. The size of the primary abscess cannot be estimated by the height of the leucocytosis, but a tendency of the pus to extend is almost always accom- panied by a distinct increase in the number of cells in excess of the figure originally estimated. Complete evacuation of the ab- scess is soon followed by a disappearance of the leucocytosis, but so long as the pus remains ineffectually drained the high count tends to persist. The frequency of leucocytosis and the range of the counts in various forms of abscess are shown by the following summary of the cases already mentioned : /. Superficial abscess of hand, arm, foot, and abdom- inal wall ; pahnar , axillary, cervical, cerebral, hepatic, renal, periurethral, and ischio-rectal abscess; etn- II. Pelvic abscess ; ovarian pyema 0/ gall-bladder . abscess ; pyosalpinx. Leucocytes per c\ Above 35,000 From 30,000 to 5. MM. 35>ooo No. OF Cases. No. OF Cases. 3 '' 25,000 to 30,000 I *' 20,000 to 25,000 7 3 '' 15,000 to 20,000 9 8 *' 10,000 to 15,000 20 10 *' 8,000 ** 6,000 to to 10,000 8,000 4 I 4 4 *' 4,000 Below 4,000 to 6,000 I I Average : Maximum Minimum : 14, 24, 4, 388 per cb. mm. 000 '' 800 '' 15 41 ,548 ,000 per cb. mm. (I (C A polynuclear neutrophile gain accounts for the increase when leucocytosis is present, and, rarely, this differential change may be found without any increase in the total number of leucocytes. A few myelocytes may occasionally be observed in cases having a decided anemia or a high leucocytosis. The presence of leucocytosis, especially if as- DiAGNOSis. sociated with hyperinosis and a positive iodine reaction, is suggestive of abscess rather than of other lesions, such as aneiansms, gummata, hematomata, and benign neoplasms. An absence of one or all of these signs, on the other hand, is not sufficient to exclude pus. The distinctions, as shown by the blood, between pyogenic and tuberculous abscesses and malignant disease are considered under the last-named conditions. 298 GENERAL HEMATOLOGY. II. ACROMEGALY. The following counts illustrate the blood changes found in two cases of this disease, the first showing practically normal blood, except for a moderate relative lymphocytosis and an absence of eosinophiles, and the second simply a well-marked secondary anemia, with a high color index. Case I. Case IL Hemoglobin. 86 per cent. 60 per cent. Erythrocytes. 4,620,000 per cb, mm. 2,880,000 per cb. mm. Color index. 0.93 1.04 Leucocytes. 8,000 per cb. mm. 4,890 per cb. mm. Small lymphocytes. 31.7 per cent. 21.0 per cent. Large lymphocytes. 2.1 " 7.0 Polynuclear neutrophils. 66.2 " 71. o Eosinophiles. 0.0 " I.O Basophiles. . 0.0 " 0.0 Myelocytes. 0.0 " 0.0 The erythrocytes showed moderate deformities of size and shape in the anemic case, but neither signs of nucleation nor of basophilic stroma degeneration were observed. Coagulation, fibrin formation, and the number of plaques were apparently normal. III. ACTINOMYCOSIS. A7i€}}ua, marked by a disproportionately great hemoglobin de- crease, is generally found, and leiicocytosis appears to be a con- stant feature of the blood-picture, judging from the small number of reports available. It is probable that the grade of both the anemia and the leucocytosis depends largely upon the amount of septic absorption originating from the lesion. IV. ACUTE YELLOW ATROPHY OF THE LIVER. Malignant jaundice appears to be associated with a moderate polycytJiCDiia^ so far as can be determined by the limited number of blood counts made in this disease up to the present time. The leucocytes are moderately increased in number, but show no peculiar differential changes, so far as is known. In two cases, reported by Grawitz,' and by Cabot, ^ respectively, the counts of erythrocytes were 5,150,000 and 5,520,000, and the number of leucocytes 12,000 and 16,000 per cubic millimeter. Bacterio- logical exauiinatioii of the blood has thrown no definite light upon the nature of this apparently infectious process. In many cases hemoglobinemia and lipacidemia have been detected. ' Loc. cit. Addison's disease. 299 V. ADDISON'S DISEASE. Moderate anemia is commonly, and decided Hemoglobin anemia occasionally, associated with this condi- and tion, although the prime importance of this Erythrocytes, symptom insisted upon by Addison himself ap- pears to be somewhat exaggerated, in the light of our more accurate methods of blood study. The '' anemiated eye " of Addison does not always mean anemia. In advanced cases the blood-picture may be characterized by marked hemo- globin and erythrocyte losses, by the presence of numerous poikilocytes and microcytes, and by small numbers of normo- blasts ; the hemoglobin readings in such instances range between 20 and 40 per cent., and the erythrocyte counts between 2,000,- 000 and 3,000,000 per cubic millimeter, or even less. Tschir- koff ^ reports cases in which, notwithstanding the coexistence of a notable oligocythemia, the hemoglobin percentage remained normal or above normal, and this pecuHar condition he referred to an increase in the amount of corpuscular reduced hemoglobin. This author also detected the presence of methemoglobin and melanin in the blood of patients suffering from Addison's disease. The polycythemia which is sometimes met with in this condition is doubtless to be attributed to such factors as vasomotor changes, and blood inspissation from emesis. Treatment with suprarenal extract tends to improve the anemia, but to what ex- tent and how permanently is undetermined. The number of leucocytes is usually normal, Leucocytes, or below normal, and extreme leucopenia has been repeatedly noted. Relative lymphocytosis and sometimes a moderate increase in the number of eosinophiles are the most familiar differential changes, together, in some in- stances, with the presence of a few myelocytes, and basophilic leucocytes. VI. ANTHRAX. In the light of our present knowledge nothing definite is known of the behavior of the hemoglobin and corpuscles in this infection. Only occasionally can the anthrax bacillus be isolated from the peripheral blood, since general invasion of the circulation by this organism is rare. Blumer and Young ^ succeeded in finding the organism in the blood of a single case of anthrax septicemia, both in ordinary cover-glass specimens, as well as by culturing. ^ Zeitschr. f. klin. Med., 1890, vol. xix., p, 87. 2 Johns Hopkins Hosp. Bull., 1895, vol. vi,, p. 127. iOO GENERAL HEMATOLOGY. VII. APPENDICITIS. Fully three-fourths of all cases of appendicitis. Hemoglobin whatever their character, show a loss of at least AND 30 per cent, of hemoglobin, while in about one Erythrocytes, case in five the er>'throcytesare diminished 1,000,- 000 or more to the cubic millimeter. From an analysis of the cases tabulated below, it appears that the average hemoglobin loss amounts to about 25 per cent., and the average decrease in er>'throcytes to about 1 5 per cent, of the normal standard. The anemia, which may usually be attributed to the effects of septicemia, is most frequent and most marked in long- standing cases of appendicular abscess, in which type of the dis- ease the hemoglobin may fall to between 30 and 40 per cent., and the corpuscles to between 2,000,000 and 3,000,000 per cubic millimeter. In such instances the risk, actual or reputed, of operating upon a patient having such a low percentage of hemo- globin must be recalled by the surgeon. Anemia, usually of a more moderate grade, is also frequently found in catarrhal cases, and in the individual instance it may reach as high a grade as in the purulent form of the disease. The blood impoverishment in such instances depends probably upon the debilitated state of the patient, apart from the appendix inflammation. The following table illustrates the range of the hemoglobin and erythrocytes, as shown by the initial examinations of 139 cases in Dr. J. B. Deaver's wards at the German Hospital : Number of Cases. Hemoglobin Percentage. Above IOO From 90 to 100 " 80 to 90 " 70 to 80 '* 60 to 70 " 50 to 60 " 40 to 50 ** 30 to 40 Highest : Lowest : Average : Non-purulent. I I 9 13 13 6 2 o 102 per cent. 45 " 69.5 - Erythrocytes per cb. mm. .•\bove 5,000,000 6 From 4,000,000 to 5,000,000 27 *' 3,000,000 to 4,000,000 II " 2,000,000 to 3,000,000 I Purulent, Perforative, and Gangrenous. O 4 20 31 23 7 6 TOO per cent. 38 " 72.5 " 14 60 15 5 APPENDICITIS. 301 Highest: 5,660,000 per cb. mm. 5,710,000 per cb. mm. Lowest: 2,050,000 " " 2,100,000 '^ ^' Average: 4,295,955 " *' 4,381,234 " Qualitative changes in the erythrocytes are neither common nor important, occurring only in cases with decided anemia, and consisting simply in deformities of shape and of size. Eiythro- blasts apparently do not occur, although there is no reason why they should not, if the anemia happens to be of a type of sufficient severity to provoke marrow changes. In simple appendicular inflammation, uncompli- Leucocytes. cated by pus, gangrene, or peritonitis, there is as a rule little or no increase in the number of leuco- cytes, although in an exceptional case the leucocytosis is fairly well defined. Thus, of the 45 cases of this form of the disease, be- low referred to, less than 9 per cent, were accompanied by a count in excess of 15,000, the maximum estimate being 17,100, and the average, 8,987 per cubic miUimeter. A relatively high count in this variety of appendicitis may usually be attributed to a limited periappendicular peritonitis. In some instances it is possible that the increase may be due to blood inspissation from vomiting and purging, or that it may simply represent a blood finding of the associated anemia. In cases with abscess, gangrene, or general peritonitis a well- marked leucocytosis is the general rule. Few cases of appen- dicular abscess fail to increase the leucocyte count to at least 15,000 or 20,000 to the cubic millimeter, although it is to be remembered that should the purulent focus happen to be so effectually walled off that absorption of toxic material is prac- tically prevented, such a decided increase does not develop. A trivial increase, or, indeed, an absence of leucocytosis is also met with in an occasional grave case (such, for instance, as one com- plicated by a general purulent peritonitis), owing to the prostra- tion of the patient from the systemic poison of the infection. As shown below, the average count in purulent and gangrenous ap- pendicitis is higher than the maximum count in the catarrhal form of the affection. A high leucocytosis suggests either a localized abscess or a general peritonitis, for the differentiation of which other clinical data are absolutely essential. The belief is current that if a marked leucocytosis occurs early in the attack peritonitis is prob- able, and if it occurs after the first week a local accumulation of pus is suggested. While this is undoubtedly true in many instances, in many others the condition of the appendicular lesion may be wrongly interpreted, if too great reliance is placed on the behavior of the leucocytes in connection with the period of the attack. 302 GENERAL HEMATOLOGY. Increase in the purulent focus, and extension of peritonitis are betrayed by an increase in the leucocyte count, provided that the patient's powers of reaction are not too greatly crippled. In operative cases, thorough evacuation of the abscess is followed within a few days by a decline to normal in the number of leuco- cytes. Persistence of the leucocytosis after the third or fourth day following the operation may usually be attributed to undrained pus pockets or to a general peritonitis. In non-operative cases with abscess the leucocytosis, which becomes well-developed by the fourth or fifth day of the attack, persists but does not tend to increase if the lesion remains local- ized ; it gradually decreases as the pus collection disappears ; and it suddenly increases if the process extends. To sum up, absence of, or slight, leucocytosis suggests either (a) simple catarrhal appendicitis, (d) fulminant appendicitis, or (c) a lo- calized pus focus from which no absorption occurs. Well-marked leucocytosis indicates either (a) a local abscess from which ab- sorption of toxins occurs, (d) general peritonitis, or [c) gangrene. The following table shows the range of the leucocytes in the German Hospital cases to which reference has been made : EUCOCYTES PEF I CB. MM. N UMBER OF Cases. L Non -puru lent. Purulent, Peiforative, and Gangrenous. Above 50,000 I From 40,000 to 35,000 to 50,000 40,000 2 30,000 to 35'Ooo 25,000 to 20,000 to 30,000 25,000 6 16 15,000 to 20,000 4 38 10,000 to 5,000 to 15,000 TO, 000 10 25 24 7 Below ' 5»ooo 6 Highest : 17 ,100 per cb. mm. 58, 500 per cb. mm. Lowest : I, 600 ( i << ( ( 6, 000 H (( a Average : 8 987 (( i i <( 17,955 ( ( (( (t The qualitative changes found in high leucocyte counts are those typical of an ordinaiy polynuclear neutrophile leucocytosis — a large absolute and relative gain in polynuclear forms at the expense of the hyaline mononuclear cells. The conditions which may more or less closely Diagnosis, simulate an acute attack of appendicitis are nu- merous, and unfortunately it happens that just those lesions in which the resemblance is closest often produce APPENDICITIS. 303 blood changes identical with those of appendicitis. Thus, leuco- cytosis is the rule in pyosalpinx^ ovarian abscess, ectopic pregnancy, pyonephrosis, perinephritic abscess, hepatic abscess, empyema of the gall-bladder, and malignant disease of the cecum, all of which may be confused with an appendicular abscess. Such a large proportion of cases of hepatic and rental colic are accompanied with acute inflammatory complications, giving rise to leucocytosis, that these conditions cannot be differentiated with any degree of confidence from appendicitis, simply by an examination of the blood. The same is true of dysmenorrhea, in which inflammatory changes in the uterus may constitute the factor of a leucocyte increase. Acute gastritis is sometimes ac- companied by a well-marked leucocytosis, and sometimes by none at all, so that the blood count cannot be relied upon as a clue in distinguishing this disease from appendicitis. Simple enteralgia, and ovarian neuralgia may be ruled out, if a leucocyte increase is present, as also may be intestinal ob- structio7i, provided that the latter is not complicated by inflam- matory changes, by gangrene, or by malignant disease. In lead-colic there is often a pronounced leucocytosis, especially in patients with acutely toxic symptoms ; but granular basophilia of the erythrocytes can be detected even in the earliest stages of plumbism, while in appendicitis this change does not occur. The presence of a leucocytosis is sufficient to exclude a non- inflammatory ovarian cyst, and a movable kidney, and the same sign is of no little value in ruling out enteiic fever, if no leuco- cyte-raising complications are apparent. The simple fact of the presence or absence of a leucocytosis is more often misleading than useful in the diagnosis of appendicitis, for this sign, to be of any real value, must invariably be corre- lated with other more definite clinical manifestations. Appendicitis should never be ruled out because leucocytosis is absent, nor should a moderate leucocyte count be considered an indication of the benignancy of the lesion. A count in excess of 20,000 may be relied upon as a certain sign of pus or its consequences, and is sufficient to warrant operative interference, if the symptoms point to the appendix as the seat of the trouble. Counts of less than 20,000 cannot be depended upon to reflect the character of the local lesion, since an increase to practically this figure may be found occasionally in mild catarrhal cases, as well as in those with purulent foci. In the writer's experience, the behavior of the leucocytes throws a much clearer light upon the progress of the disease, in both operative and non-operative cases, than it does upon the initial diagnosis, which should be determined chiefly by other clinical methods. ;04 GENERAL HEMATOLOGY. Vlir. ASIATIC CHOLERA. A number of investigators have drawn atten- General tion to the difficulty met with in many cases of Features, obtaining a sufficient quantity of blood for clin- ical examination, even from a deep puncture. This peculiarity, which has been attributed to excessive drj-ness of the tissues from drains upon the body fluids, is most pro- nounced in the algid stage of the disease. The great decrease in the alkalinity of the blood in Asiatic cholera, sometimes spoken of as an acid reaction, was first de- termined by C. A. Schmidt ^ by a series of elaborate analyses made in 1850, since which time similar findings have been noted by Cantani,'^ Straus,^ and others. The specific gravity of the blood-mass is found to be increased, especially in those cases in which the blood is highly inspissated ; in such instances the specific gravity may rise to as high as 1073. The agglutination of cholera vibrios by the blood serum of cholera patients was first applied as a clinical test by Achard and Bensaude,^ these investigators finding that the reaction may occur as early as the reputed first day of the illness, and as late as the fourth week after recover^-. Clinically, the test may be made either with dried blood or with serum. The studies of Biernacki ^ and of Okladnych,^ Hemoglobin which together include the investigation of sixty- AND two cases, furnish the most complete data con- Ervthrocytes. cerning the changes affecting these elements. Both of these observers found a more or less marked polycythemia with a proportionate increase in the hemo- globin percentage, the erythrocyte count in many cases being between 6,500,000 and 7,500.000, and in one case reaching the remarkable maximum of 8,000,000. The increase may often be observed within a few hours after the onset of the infection. Con- centration of the blood is to be considered as the cause of these high counts, which are as a rule highest in cases characterized by pronounced emesis and purging. No constant relation between the degree of polycythemia and the gravity of the infection can be distinguished. ^ '* Charakteristik der epidemischen Cholera gegeniiber verwandten Transsuda- tionsanomileen," Leipsig, 1850. ^Centralbl. f. die med. Wissenschaft. , 1894, vol. xxii., p. 785. ^Compt. rend. Soc. biol., Paris, 1883, vol. iv., p. 569. * Presse med., 1896, vol. xvi., p. 504. 5 1)eut. med. Woch., 1895, vol. xxi., p. 795. * Cited by Biernacki : loc. cit. ASTHMA AND EMPHYSEMA. 305 The above-quoted authors found high-grade Leucocytes, leucocytosis to be the almost invariable rule, the increase in leucocytes being not parallel with, but rather relatively greater than, the accompanying in- crease in erythrocytes. It occurs both in mild and in severe cases, as early as within twelve hours after the onset of the dis- ease, and as late as the third, fourth, or sixth day. It may be present both in the algid stage and in the stage of reaction, but is likely to be more decided in the former. The degree of leucocy- tosis may range from a minimum count of 14,000 to a maximum of 60,000 cells per cubic millimeter, the case of average severity showing an increase to about 25,000 or 30,000. Pre-agonal leucocytosis may be pronounced, counts of 50,000 being not uncommon. Biernacki states that " all cases which in the algid stage show a leucocytosis of 40,000 to 60,000 soon prove fatal." On the contrary, an absence of leucocytosis cannot be regarded as a surety that the patient will recover. In a trivial infection distinct leucopenia has been observed, but this is rare. Concen- tration of the blood does not altogether account for the leucocy- tosis, for the influence of the specific infection as a factor is thought to be most active. The leucocytosis of Asiatic cholera is typically polynuclear, the increase affecting chiefly the polynuclear neutrophile cells, which may reach relative percentages of 90 or even 95, while the proportions of other forms are lower than normal. Sherring- ton ^ has found the mast cells notably increased in some instances. IX. ASTHMA AND EMPHYSEMA. In long-standing cases moderate secondary Hemoglobin anemia involving chiefly a hemoglobin loss may AND be found, for in many instances the general de- Erythrocytes. bility of the patient or the presence of lesions of other organs is quite adequate to give rise to such a change. In cyanotic patients the anemia may be hidden by the polycythemia arising from circulatory disturbances, this deceptive blood concentration being most conspicuous during an asthmatic paroxysm. Little or no increase above the normal stand- Leucocytes. ard in the number of leucocytes is the usual con- dition, although these cells may show a consid- erable increase in cases associated with acute bronchitis, and also ^ Proc. of the Roy. Soc, London, 1894, vol. Iv. , p. 189. 20 306 GENERAL HEMATOLOGY. during an asthmatic attack. Gabritschewsky/ Fink,^ von Noor- den,^ Billings/ and others have called attention to the presence of an eosinophile increase in both asthma and emphysema. From ID to 20 per cent, of this type of cells is not an unusual proportion, both in cases with and those without leucocytosis, while in one case Billings has reported three consecutive counts of 33.9, 38.2, and 53.6 per cent., respectively, with correspond- ing total leucocyte estimates of 7,600, 7,500, and 8,300 per cubic millimeter. In true bronchial asthma the eosinophile increase develops shortly before the paroxysm, and persists during and for a short time after it, disappearing in the interval between the seizures. This sign is regarded of value in differentiating true bronchial asthma from the dyspnea due to renal and cardiac le- sions, since in the latter the eosinophiles are never increased, and it is also considered of some clinical utilitv in heraldinsf an impending asthmatic parox}'sm. X. BRONCHITIS. TT With the exception of a sli";ht oligochromemia, Hemoglobin 1 • 1 • r \.i ^ ^ • vi which IS irequently present m severe cases with T- ^ hi^h temperatures, the eiythrocytes and their Erythrocytes. , ^ , , v ^ ' . ^ J .. , . hemoglobin content remain practically normal in all forms of bronchial inflammation. Acute catarrlial bronchitis of the larger tubes Leucocytes, is ordinarily unattended by leucocytosis, but, un- fortunately for diagnostic purposes, an occasional case shows a marked increase. Thus, in four of Cabot's seventeen cases, ^ the counts were 17,600, 23,500, 26,000, and 41,000, re- spectively, while in eleven the leucocytes numbered more than 10,000 per cubic millimeter. In cJironic brojicJiitis leucocytosis rarely if ever occurs. The range of the leucocytes in capillary bronchitis and in croupous pneunioiiia may be identical. XI. BUBONIC PLAGUE. Since 1 894, when Kitasato and Yersin, working Bacteriolog- independently, simultaneously discovered the ^<7r//- ICAL Exam- lus pcstis buboniac in the circulating blood of pa- INATION. tients infected with plague, this organism has been repeatedly isolated from the blood by many dif- ferent observ^ers. In a bacteriological study of twenty-seven cases ' Archiv. f. exp. Path. u. Pharm., 1890, vol. xxviii., p. ^t^. 2 Inaug. Diss., Bonn, 1890. ^Zeitschr. f. klin. Med., 1S92, vol. xx., p. 98. ♦ N. Y. Med. Journ., 1897, vol. Ixv., p. 691. ^Loc. cit. BUBONIC PLAGUE. 3O7 Ogata ^ also frequently found in the blood, especially in severe in- fections, a micro-organism morphologically similar to Frankel's pneumococcus, the significance of this unidentified organism being undetermined. The same observer calls attention to the fact that blood from patients convalescent from nineteen to sixty-five days, although giving negative results by cultural methods, when in- jected into mice proves rapidly fatal to these animals, in whose tissues the plague bacillus may be recovered in pure culture. The relatively large number of positive results to be obtained from bacteriological blood examinations in this disease, especially in its septicemic form, attaches to the procedure no small diagnostic value. Cultural methods with blood drawn directly from a vein give, of course, the most favorable results, but the bacilli may be often detected in the stained cover-glass specimen of finger blood, in which they appear as short rods, tending to group together in chains or in pairs, exhibiting bipolar staining, and decolorizing by Gram's method. In view of the fact that the peripheral blood contains but small numbers of the bacilH, Rees^ advises making large films on slides rather than cover-glass specimens, should direct examination of the stained film be attempted. The agglutination of the plague bacillus by the blood serum from plague subjects has been noted by a number of different investigators, but thus far no clinical application of the reaction has been made. The inconstancy with which the reaction occurs, for it may frequently be absent in both the mildest and the most severe cases, and the variable degrees of serum dilution neces- sary for its production appear to bar the acceptance of the test as a rehable diagnostic sign. According to Aoyoma's studies,^ the hemo- Hemoglobin globin and the erythrocytes are both decidedly AND increased above normal in the majority of cases. Erythrocytes. Of the six cases examined by this writer, five showed marked polycythemia, the highest count being 8, 190,000, and the average 6,976,666. Qualitative changes in the erythrocytes, it is to be presumed, do not occur, since no mention of such alterations is made. In two-thirds of the cases just quoted marked Leucocytes, increase in the number of leucocytes was found, the gain being greater than is ordinarily met with in any condition except leukemia ; the count exceeded 100,000 in four instances, and averaged for the six 96,666. The increase ^Centralbl. f. Bakt. u. Parasit. , 1897, vol. xxi.,p. 769. 2 British Med. Journ., 1900, vol. ii., p. 1236. 3 Mittheilungen aus d. Med. Fac. d. Kaiserlich-Japanischen Universitat, Tokio, 1895, vol. iii., p. 115. 308 GENERAL HEMATOLOGY. was due usually to a disproportionately large percentage of poly- nuclear neutrophiles, but in some cases " large and small mono- nuclear white cells" were observed. The identity of the latter — whether lymphocytes or myelocytes — must remain questionable, since all the differential counts were made with specimens stained with eosin and hematoxylin. The eosinophiles were, as a rule, conspicuous by their absence. The blood plaques were found to be notably increased in number. XII. CHOLELITHIASIS. In gall-stone complicated by phlegmonous General cholangitis or other purulent sequelae, hypcri- Features. nosis is observ^ed, and coagulation is generally more rapid than normal, but in simple impacted calculi these changes are absent. The general effects upon the blood of bile, elsewhere noted, may also be detected when marked jaundice develops. (See *'Cholemia" and "Icterus.") Positive results from bacteriological exami?iation of the blood have frequently been obtained in cholelithiasis, streptococci hav- ing been isolated by Netter,^ staphylococci and colon bacilli by Sittmann," streptococci and pneumococci by Canon, ^ and various bacteria of unknown identity by other investigators. Moderate oligochromemia is found in the Hemoglobin greater proportion of cases, but a decided loss AND either of hemoglobin or of erythrocytes is com- Erythrocytes. paratively rare. In general terms, it may be conservatively stated that the hemoglobin loss on the average amounts to about 30 per cent., and that the cel- lular decrease approximates 15 per cent, of the normal standard. In occasional instances, notably those in which suppuration or sepsis coexists, the anemia is of a more intense grade, and may be associated with various changes indicative of cellular degen- eration. In 28 cases of cholelithiasis at the German Hospital the following estimates of the hemoglobin and erythrocytes were obtained at the initial examinations : Hemoglobin- Percentage. From 80 to 90 '* 70 to 80 Number Cases. 5 10 of Above From Erythrocytes per cb. mm. 5,000,000 4,000,000 to 5,000,000 N umber of Cases. 3 13 *' 60 to 70 8 a 3,000,000 to 4,000,000 10 " 50 to 60 4 (C 2,000,000 to 3,000,000 2 *' 40 to 50 ** 30 to 40 " 20 to 30 I ^ Progres med., i8S6, vol. xiv., p. 992. 2 Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 3 Deut. med. Woch., 1893, vol. xix., p. 1038. DIABETES MELLITUS. 3O9 Average: 70.6 per cent. Average: 4,131,785 per cb. mm. Maximum: 85.0 •'' Maximum: 5,390,000 " " Minimum: 28.0 '* Minimum: 2,510,000 *' ^' Simple gall-stone does not of itself excite the Leucocytes, slightest increase in the number of leucocytes, but nevertheless leucocytosis, typically polynu- clear in type, is a rather common feature of the blood -picture in this disease, owing to the fact that such a large percentage of cases is complicated by acute inflammatoiy changes. Ten of the 28 cases just mentioned had a count of more than 10,000 cells to the cubic millimeter. The following resume of the ex- aminations illustrates the range of leucocytes in the series : Leucocytes per cb. mm. From 15,000 to 20,000 in 7 cases. " 10,000 to 15,000 ^' 3 '' " 5,000 to 10,000 " 16 ^' Below 5,000 " 2 '' Average : 10,164 P^r cb. mm. Maximum: 18,800 " " " Minimum: 4,600 " '* '^ The presence of a leucocytosis excludes simple Diagnosis. biliary coHc, and indicates as the cause of the in- crease some other lesion, such, for example, as phlegmonous cholangitis or cholecystitis, hepatic abscess, peritonitis, or malignant disease. Hepatic and renal colics cannot be differ- entiated by the blood count, XIII. DIABETES MELLITUS. The alkalinity of the blood, according to the General general consensus of opinion, is appreciably Features. diminished, especially in cases in which coma either impends or exists. Lipeniia is not uncom- mon, the amount of fat in some instances being so large as to pro- duce a milky appearance of the blood drop, evident to the naked eye, although in most instances the condition is recognizable only by the detection of fat-globules under the microscope. Lipaci- deniia may be detected in diabetic coma. Glycemia is present, and can be demonstrated by the detection of grape-sugar in relatively large amounts, even as great as 5.7 parts per thousand, according to Grawitz,^ or 9 parts per thousand, according to Hoppe-Seyler.^ Williamson' s Test. This reaction, devised by Williamson ^ in ' Loc. cit. 2Vircho\v's Archiv., 1858, vol. xiii., p. 104. 3 British Med. Journ., 1896, voL ii., p. 730. Also, Lancet, 1900, vol. ii., p. 320. 3IO GENERAL HEMATOLOGY. 1896, depends upon the fact that a warm alkaHne solution of methylene-blue is decolorized when mixed with a minute quantity of glucose. Twenty cubic millimeters of the suspected blood, obtained by puncturing the finger, are measured by means of Gower's hemocytometer pipette, and blown out into 40 cubic millimeters of distilled water contained in a small test-tube. To this mixture are then added, in the order given, i cubic centi- meter of a I : 6,000 aqueous solution of methylene-blue, and 40 cubic millirrieters of a six-per-cent. aqueous solution of potassium hydrate. In a second test-tube the same proportions of normal blood and reagents are mixed, to be used as a control. The color of both mixtures is precisely the same — moderately deep bluish-green. Both tubes are placed in a beaker filled with boil- ing water, in which they are allowed to remain for four minutes, at the end of which time the test-fluid containing the diabetic blood will have turned a dingy yellow color, while the color of the control mixture remains unchanged. Care must be taken to use not more than 20 cubic millimeters of blood, since a positive reaction may be more or less closely counterfeited with non-dia- betic blood, should three or four times this quantity be employed. It IS essential, therefore, to measure the blood accurately, and not to trust to the approximate method used by some, of simply taking two drops of blood as the equivalent of the required 20 cubic millimeters. Williamson's reaction is presumably due solely to the action of the grape-sugar contained in diabetic blood, and if this proves true, it is not unreasonable to predict that the principle of the test may be elaborated into a method for estimating the percentage of sugar in the blood. Positive reactions occur constantly in diabetes, sometimes even after the disappearance of every trace of sugar from the urine, and, so far as investigations up to the present time have shown, negative results are invariably met with in other diseases. Bremer's Test. Bremer,^ having noticed in diabetes mellitus peculiar affinities of the erythrocytes for various aniline dyes, has devised upon this basis an ingenious test for the recognition of diabetic blood. Several thick films from a suspected case, con- trolled by the same number of preparations made from normal blood, are prepared, preferably on slides, and heated in an oven to a temperature of 135° C, after which they are set aside to cool. Both sets of films are then stained for about two minutes with a one-per-cent. aqueous solution of Congo-red (mixed freshly 1 N. Y. Med. Journ., 1S96, vol. Ixiii., p. 301. (Z//. ) Also N. Y. Med. Record, 1897, vol. xii., p. 495. DIABETES MELLITUS. 3 I I just before using), thoroughly washed in running water, and dried between bits of filter-paper. Thus treated, diabetic blood is either colored pale greenish-yellow or is entirely unstained, while normal blood stains typically the red color of the dye. Using the same method of heat fixation, other aniline dyes may be employed to demonstrate this peculiar behavior of diabetic blood. For example, with a one-per-cent. aqueous solution of methylene-blue the diabetic specimen stains yellowish-green, and the normal film blue. Diabetic blood, on the contrary, treated with a one-per-cent. aqueous solution of biebrich-scarlet, takes the color of the dye in a typical manner, while normal blood re- mains practically uncolored. Ehrlich's triacid stain, as well as mixtures of methylene-blue and eosin, and methyl-green and eosin, have also been used to demonstrate the reaction. The cause of Bremer's reaction is unknown, but apparently it is not due to the effect of glucose ; many authors are inclined to attrib- ute it to excessive acidity of the blood. Positive results with this test can not be regarded as pathognomonic of diabetes mel- Htus, since they have been reported with the blood of persons suf- fering from exophthalmic goitre, multiple neuritis, leukemia, and Hodgkin's disease. There are no constant changes to be found in Hemoglobin these elements. Normal hemoglobin percent- AND ages and erythrocyte counts are observed in Erythrocytes, most cases, while in others in which the cachexia is pronounced, a well-marked secondary anemia may exist. James,^ in a study of 1 3 cases, found the number of erythrocytes over 6,000,000 in 5 ; 5,000,000 plus in 5 ; 4,000, - 000 plus in 2; and 3,000,000 plus in i. The hemoglobin per- centage was over 100 in 3 cases ; 60-70 in 8 ; and 50-60 in 2. The alterations in the hemoglobin and erythrocytes in diabetes have been attributed by the older writers^ chiefly to the effects of blood concentration and dilution. Thus, it was beHeved that in cases with excessive polyuria the blood became inspissated and the count thus increased, while in cases with pronounced gly- cemia the blood became diluted and the count lowered, as a con- sequence of the fluid transfer from the tissues into the capillaries provoked by the presence in the blood of a large percentage of sugar. It is obvious that these influences, if active, are sufficient to render the blood count in diabetes of little or no practical value, since on the one hand, perfectly normal blood, if diluted, 1 Edinburgh Med. Journ., 1896, vol. xlii., p. 193. 2 Lit. cited by Leichtenstern : " Unters. uber d. Hg-Gehalt d. Blutes," Leipzig, 1878. 312 GENERAL HEMATOLOGY. may appear anemic, while on the other hand, anemic blood, if concentrated, may seem normal. James ^ contends, however, that the polycythemia is real, and is not dependent upon inspis- sation, for were the increase merely relative it would naturally be accompanied by an increase in the density of the blood, and this in his experience never occurred, the specific gravity figure for his series ranging between 1054 and 1060. High digestion leucocytosis is the most con- Leucocytes. stant change affecting these cells, but this is not found in every case. Isolated examples of leu- coc\tosis, apparently independent of this influence, have been re- ported, but in the great majorit}' of diabetics the leucocyte count is normal. The presence of small numbers of myelocytes in cachectic patients is the only qualitative change to which atten- tion has been directed. ]\Iahogany-colored granules, either within the leucocytes or extracellular, may usually be demonstrated by the iodine method. The prevalent view that this reaction is due to the presence of glycogen has been disputed by some (see page No numerical change in the blood plaques has been reported. Williamson's reaction is of real value, especially Diagnosis, in the recognition of cases with temporar}^ disap- pearance of sugar from the urine and in dia- betic coma. Bremer's test and the iodine reaction are to be regarded as symptomatic, not necessarily of diabetes. The other blood findings are without diagnostic value. XIV. DIPHTHERIA. Usually the changes in the hemoglobin and Hemoglobin erj^throcytes are, at the most, trifling, for in AND about two-thirds of all cases these elements are Erythrocytes, practically normal, while in the other one-third moderate anemia, more marked in severe than in mild cases, is found. The anemia does not develop until about the middle of the first week of the disease, and is as a rule characterized by a diminution of hemoglobin roughly pro- portionate to the corpuscular loss. Degenerative changes are rare, consisting usually of nothing more than occasional polychromato- philia ; nucleation and deformities of size and of shape are absent. Regeneration of the blood takes place slowly, and. as the loss of hemoglobin is made up less rapidly than that of the corpuscles, the color index, which is approximately normal early in the dis- ease, later falls considerably. 1 Loc. cit. DIPHTHERIA. 3I3 The loss of hemoglobin does not often exceed 15 per cent., nor is the decrease of eiythrocytes usually greater than from 500,000 to 750,000 cells to the cubic millimeter. Concentration of the blood, which frequently occurs during the febrile period, may cause striking temporary polycythemia. Morse ^ in single examinations of 30 cases, treated without antitoxin, found the count of erythrocytes above 5,000,000 in 21, and below 4,000,000 in but a single instance, a woman with chronic anemia ; several of his counts were in the neighborhood of 6,000,000. From this author's recent monograph^ the fol- lowing counts reported by other investigators are taken : Bouchut and Dubroisay,^ 4,305,000 as the mean average of 93 counts in 84 cases ; Gilbert,* an average of 4,500,000 in 58 counts in 22 cases; Carter,^ an average of 4,253,000 in 13 cases; and File,^ an average of 4,588,000 in 18 counts in 10 cases, some of which had received antitoxin. Billings ^ in a painstaking study of 7 cases, untreated with antitoxin, in which 36 counts were made, found a moderate but distinct decrease in hemoglobin and eiythrocytes in 5 cases, the loss first becoming apparent by the third or fourth day, and being proportionate to the severity of the infec- tion. This author's first counts, all made during the first week of the disease, ranged from 5,200,000 to 6,122,000, the average being 5,611,285, the hemoglobin for the same period ranging from 70 to 98 per cent, and averaging 90 per cent. Subsequent counts in this series showed that the greatest loss of hemoglobin averaged 12 per cent., ranging from i to 30 per cent., and that the maximum corpuscular loss averaged 878,500, varying from 227,000 to 2,040,000. It is generally observed that in cases treated with antitoxin the anemia is decidedly less than in those treated by other methods, and in fact a majority of cases thus treated suffer no decrease at all. Well-marked leucocytosis, beginning probably Leucocytes, within a few hours after the infection first occurs, characterizes the average case of diphtheria of moderate severity. An analysis of the statistics derived from 276 counts made by reliable investigators^ shows that over 90 per 1 Boston Med. and Surg. Journ. , 1895, vol. cxxxii., pp. 228 and 252. 2 Med. and Surg. Reports of the Boston City Hospital, 1899, loth series, p. 138. 3 Compt. rend. Soc. biol., Paris, 1877, vol. Ixxxv., p. 158. * Traite de Med. Charcot- Bouchard, vol. ii., p. 485. 5 Univ. Med. Mag., 1894-95, vol. vii., pp. 17, 81, and 158. ^ Lo Sperimentale, 1896, vol. 1., p. 284. ^ N. Y. Med. Record, 1896, vol. xlix., p. 577. ^Ewing, Morse, Billings, Carter, Schlesinger, File, Gabritschewsky, Bouchut and Dubroisay, Rieder, Felsenthal, and Gilbert. 314 GENERAL HEMATOLOGY. cent, of all cases are accompanied by a more or less marked increase in the number of leucocytes. In the majority of cases the number of leucocytes is not in- creased above 30,000 per cubic millimeter, but a much greater leucocytosis is sometimes encountered. Thus, the maximum counts of sev^eral authors are as follows : Felsenthal, 148,229;^ Ewing, 72,000;" Gabritschewsky, 51,000;^ Morse, 48,000;'* Carter, 48,280;^ Billings, 38,600;'' and Gilbert, 31,000.^ This increase is to be regarded as a rough gauge of the reac- tion of the individual against the effects of the toxic products of the disease ; it is, therefore, absent in very mild cases, where little or no reaction is excited, and in veiy severe cases in which the patient's resisting powers are overwhelmed by the intoxication. In favorable cases the maximum leucocytosis is reached coin- cidentally with the height of the disease, and the increase gradually fades away during convalescence, having in most cases entirely ceased by the time the membrane has disappeared, but occa- sionally persisting after the subsidence of all local and systemic manifestations of the illness. In unfavorable cases high leucocyte counts persist until death, or '' in somewhat prolonged cases, with much septic absorption, there may be an uninterrupted decrease of leucocytes continuing up to the fatal termination." (Ewing.) No constant relation has been determined between the leucocytosis and the extent of the local lesion, the degree of tonsillar and glandular swellings, or the height of the fever, although in individual cases some authors have suggested that such relationship may be distinguished. The effects of antitoxin upon the leucocytes are well illustrated by the conclusions of Ewing,"* based upon 228 counts made in 53 cases, before and after the injection of the serum. As the result of these investigations this author concludes that antitoxin, within thirty minutes after its injection, causes a hypoleucocytosis. In favorable cases, after the injection, the original height of the leucocytosis is not again attained, but in severe and less favor- able cases, the dose of antitoxin is followed in a few hours by a hyperleucocytosis exceeding that found in the primar\^ count. In malignant cases the administration of antitoxin may be fol- lowed immediately either by rapid hyperleucocytosis or by ex- treme hypoleucocytosis and death. Bize^ finds that in some cases the initial serum injection may not affect the leucocytes be- ^Archiv. f. Kinderheilk., 1893, vol. xv., p. 78. 2N. Y. Med. Joum., 1S93, vol. Iviii., p. 713. 3Annal. de llnstitut Pasteur, 1 894, vol. viii., p. 673. * Loc. cit. ^Archiv. de med. des enf., 1901, vol. iv., p. 102. DIPHTHERIA. 315 cause of the insufficiency of the dose, and that repeated injections are sometimes required to modify the count. This investigator has also called attention to the pronounced leucocytoses which accompany eruptions due to antitoxin. The leucocytosis of diphtheria as a rule involves the polynu- "clear neutrophile cells, most cases showing about 80 per cent, of this variety, but in an occasional instance there may be a well-marked increase in the mononuclear forms, considerably in excess of the percentage found in health. Relative lymphocy- tosis has been observed both during convalescence and in fatal cases with leucopenia, and absolute lymphocytosis may occur at the height of the disease in cases with high total leucocyte counts. Besredka ^ believes that marked polynuclear leucocytosis is a good prognostic sign, especially if this form of cells shows a strong tendency to increase after injection of antitoxin. On the contrary, cases which fail to show such a change he regards as grave, usually as fatal. This characteristic of high percentages of polynuclear neutrophils is also regarded by many other authors as a favorable chnical sign, and a low percentage un- favorable. Ewing, ^ by staining the leucocytes with gentian-violet (50 cc. of normal salt solution to which i drop of a saturated alcohoHc solution of gentian-violet is added), has deduced certain conclu- sions from the reaction of the leucocytes to this dye, to which he is inclined to attribute great prognostic value. He believes that the numbers and percentages of poorly stained leucocytes, and usually of ameboid figures, invariably increase in unfavorable cases, without relation to the total number of cells found in the blood. In his experience any considerable increase of poorly stained leucocytes, especially if associated with a decrease of the well-stained cells, was invariably the forerunner of a grave or fatal change in the patient's condition. In favorable cases, after treatment with antitoxin, he noted that the polymorphous forms show a decidedly increased affinity for gentian-violet, this char- acteristic often being observed within twelve hours after the in- jection of the serum. Failure of this peculiarity to develop he regards as a very unfavorable prognostic sign. Up to the present time these observations have not been verified by other investi- gators. The proportion of eosinophiles is exceedingly variable, these cells sometimes being absent, and at other times found in large numbers — 4 or 5 per cent. ^Annal. de I'lnstitut Pasteur, 1S98, vol. xii., p. 305. 2 Loc. cit. 3l6 . GENERAL HEMATOLOGY. Engel ^ found variable percentages of myelocytes in both favor- able and unfavorable cases, especially in the latter, and he con- siders the presence of these cells in relatively high percentages (2 per cent, or higher) as an unfavorable prognostic indication. In 7 of Engel' s fatal cases the percentage of myelocytes ranged from 3.6 to 14.6, but these cells never exceeded 1.5 per cent, in patients who recovered. An absence of myelemia, however, is no guarantee of recover}^ for this sign is absent in about one out of every four fatal cases. Examination of the blood in diphtheria gives Diagnosis, no information which is not more clearly shown by other clinical signs, and it must be regarded as of no value as an aid to diagnosis. The leucocytosis in this disease, if the very benign and the very severe cases are excluded,. is, as a rule, proportionate to the intensity of the infection. From a prognostic point of view, it appears that, as in pneu- monia, an absence of leucocytosis occurring in obviously severe infections is an unfavorable indication. The presence of a large percentage of myelocytes has a similar meaning. Pronounced lymphocytosis is also regarded as an unfavorable prognostic sign. XV. ENTERITIS. In acute catarrhal enteritis the same changes occur that are found in acute gastritis, namely, little or no alteration in the hemoglobin and eiythrocytes, and an inconstant, moderate leuco- cytosis. Profuse watery dejecta lead, of course, to more or less blood concentration, by depletion of the body fluids, and hence polycythemia may be a transient sign. In cJironic enteritis and gastro-euteritis, the interference with the patient's nutrition plus a drain upon the albuminoids may in course of time give rise to a decided anemia. Leucocytosis is not a characteristic of such cases. In dysentery and in itlcerative and pJilegnionous enteritis, acute forms of secondary anemia are frequently met with, espe- cially in patients who pass much blood by the bowel. The effects upon the blood of saline purges were first deter- mined by Brouardel," and later studied by Grawitz ^ and by Hay.^ The investigations of these authors have shown that the adminis- tration of a purgative dose of Epsom or Glauber salt is followed within about thirty minutes by an appreciable increase in the number of erythrocytes, and that within an hour the count of ^ Deut. med. Woch., 1S97, vol. xxiii., pp. iiS and 137. 2 Union med., 1S97, vol. xxii., p. 405. 3 Loc. cit. * Journ. of Anat. and Physiol., 1SS2, vol. xvi., p. 430. ENTERIC FEVER. 317 these cells is fully 1,500,000 more than before the purge was given ; three hours after this maximum is reached the count is again normal. When a certain degree of concentration is ob- tamed by this means, continued administration of the salt pro- duces neither additional concentration nor further purgation. Common table salt is also a most energetic factor of blood den- sity, even more so than either Epsom or Glauber salts. Purga- tive doses of jalap, croton oil, and other drugs of this class are also followed by more or less polycythemia. XVI. ENTERIC FEVER. Invasion of the blood by the bacillus typhosus Bacteriology, is of such relatively uncommon occurrence that bacteriological examinations in enteric fever, for diagnostic purposes, are of slight practical value. From an analysis of 210 cases examined by reliable investigators, using approved technique, the specific organism of the disease was ob- tained by culture in but 78 instances — an average of 37 per cent, of positive results in all cases. These figures, however, should be applied only to the average, and not to the individual case, for many competent workers have obtained lower averages, or have been uniformly unsuccessful in attempting to isolate the bacillus from the blood, while others have reported much higher per- centages of successful results. Kiihnau ^ made cultures in 41 cases, of which number positive results were obtained in 1 1 . James and Tuttle ^ carefully examined 39 cases, and succeeded in obtaining the organism in 3. V^ilt- schour,^ in his examinations of 35 cases, found the bacillus in only a single instance. Of 16 cases examined by Castellani,"* blood cultures were positive in 4 ; of the patients giving positive findings, 3 died. Opposed to the foregoing results are the unusu- ally high percentages of positive findings reported by Cole,^ who used from 8 to 10 cubic centimeters of blood, aspirated from a vein of the arm. This investigator obtained growths of the bacil- lus in 1 1 of the i 5 cases examined, positive results being found as early as the sixth day of the disease, in both mild and severe cases. Schottmijller^ also reports an unusually high proportion of successful findings, this investigator having isolated the typhoid bacillus in 40 out of 50 cases whose blood he examined. Thie- ^ Zeitschr. f. Hyg. u. Infectionskr., 1897, vol. xxv., p. 492. 2 Med. and Surg. Reports of the Presbyterian Hosp., N. Y., 1898, vol. iii., p. 46. 3 Rev. Centralbl. f. Bakteriol. u. Parasit., 1890, vol. xiv., p. 279. *Centralbl. f. Allg. Path. u. pathol. Anat., 1900, vol. xi., p. 456. 5 Johns Hopkins Hosp. Bull., 1901, vol. xii., p. 203. ^Deut. med. Woch., 1900, vol. xxvi., p. 511. 3l8 GENERAL HEMATOLOGY. mich ^ studied 7 cases, with positive results in 4 — in a single in- stance from venous blood, and in 3 from the rose-spots. Stern ^ investigated 6 cases, obtaining growths in 3, the bacillus being isolated from the rose-spots in one, and from the blood in the other 2. Gwyn ^ has recently reported a case with typical clinical manifestations of enteric fever, in which he obtained cultures, made from the blood at the height of the disease, of a bacillus having cultural properties almost identical with the para-colon bacillus of Widal. In the late stages of the disease pyogenic bacteria have been found in the blood. Examination of the Rose-spots. Formerly the cultivation of typhoid bacilli from the rose-spots was attended by indiffer- ent success, but the favorable results with this procedure recently announced by a number of authors must stamp it as a distinct aid to the diagnosis of typhoid. Neufeld,"* basing his experiments upon the belief that the bacteria lodge and multiply in the spots protected from the bactericidal action of the blood, examined these lesions in 14 cases and obtained positive results in 13. His findings were soon corroborated by the work of Curschmann," who found the bacilli in 14 out of 20 cases ; of Richardson,^ whose results Vvcre positive in 5 out of 6 cases ; and of Scholz and Krause,' who found bacilli in the spots in 14 out of 16 cases ex- amined. The latter investigators emphasize the statement that the bacilli are prone to disappear from the spots after from three to five days, and that, to ensure the best results, the exami- nations must be made as soon as possible after the appearance of the roseola. All investigators agree that, in the great majority of instances, spot cultures give positive results several days before the appearance of the serum test. The chief disadvantages to this method of diagnosis appear to be the absence of the roseola in some cases, its late development in others, and the possibility of not always being able to distinguish typhoid spots from other eruptions. The technique used by Richardson^ is simple, and judging from his results, trustworthy. After having washed the skin of the part with alcohol and ether, the spot is frozen with an ethyl- chloride spray, after which it is crucially incised. Its substance 1 Deut. nied. Woch., 1895, vol. xxi., p. 550. ^Centralbl. f. inn. Med., 1896, vol. xvii., p. 1249. 3 John Hopkins Hosp. Bull., 1898, vol. ix., p, 54. * Zeitschr. f. Hyg., 1899, vol. xxx., p. 498. 5 Miinch. med. Woch., 1899, vol. xlvi., p. 1597. ^Phila. Med. Journ., 1900, vol. v., p. 514. " Zeitschr. f. klin. Med., 1900, vol. xli., p. 405. ^ Loc. cit. ENTERIC FEVER. 319 is then removed by scraping with a small skin-curette, and trans- ferred to a tube of nutrient bouillon. A second tube is inoculated with the blood which collects as soon as the effects of freezing have worn off, both cultures being then incubated and examined in the usual manner. At least five or six spots should be thus treated in each case, and two tubes, one for the scrapings, the other for the blood inoculation, used for each spot. If blood-serum from a case of enteric fever is Serum Test, mixed with a broth culture of the bacillus typho- sus, and a small drop of this mixture placed upon a slide and examined under the microscope, it will be ob- served that the bacilli, instead of continuing to dart actively to and fro across the field, as they do in the pure culture, are attracted to each other, lose their power of propulsion, and become grouped Fig. 42. A POSITIVE REACTION. Large clumps of motionless bacilli separated by open spaces. The few bacteria outside the clumps are devoid of motility. together in large agglutinated clumps of irregular outline, which, after the lapse of a variable length of time, become more and more compact and homogeneous. In the typical positive reac- tion the field of the microscope shows islands of clumped bacilli, separated from each other by large open spaces, containing per- haps a few isolated organisms the motility of which is decidedly inhibited at first, and finally entirely lost. If the clumps are of very large size, they produce a peculiar grayish mottling of the specimen visible to the naked eye, a point to which attention was first directed by Greene.^ In a small proportion of cases IN. Y. Med. Record, 1896, vol. 1., pp. 697 and 805. 320 GENERAL HEMATOLOGY. the clumps appear to undergo a granular change, and then be- come entirely destroyed ; in some instances they remain un- altered for several days ; and in still others they may break up after a few hours, the field then becoming refilled with isolated, actively motile bacteria. Fig. 43. A PSEUDO-REACTION. A few small clumps of bacilli having impaired motility. Persistent motility of the bacteria in other parts of the field. In a certain percentage of instances the agglutinated, motion- less masses of bacilli may be observed as soon as the specimen is brought into focus, so that the reaction may be said to have taken place immediately. In other instances some little time elapses before the character of the test can be determined, and in such reactions the formation of the clumps, from their inception out of two or three bacteria, to their completion, when they con- sist of several hundred organisms tightly glued together into a densely crowded mass, may be studied most advantageously. In these slower reactions, while early clumping may progress to some extent, many isolated bacteria are seen the motility of which persists for a variable period, gradually growing less and less, until finally, with more or less crippled powers of propulsion, the organisms are attracted to the clump centers with which they are ultimately incorporated, either becoming adherent at first ap- proach, or, as is usually the case with the more active bacilli, circling around the edges of the clump for some little time before becoming attached to it. Still other reactions are characterized by an almost immediate cessation of motility, followed by tardy agglutination, and usually by the formation of clumps of smaller size rthan those noted in a prompt and immediate reaction. ENTERIC FEVER. 321 If the reaction is negative, the motility of the bacilli persists and the formation of clumps is not observed, regardless of the time during which the specimen is watched. Not unless aggluti- nation is marked and entire loss of motility occurs may a reaction be considered positive ; and pseudo-reactions resulting in the for- FiG. 44. Bacillus typhi abdominalis. The bacilli are actively motile throughout the field. mation of small masses of more or less motile organisms, together with persistent motility of many unclumped bacteria in other parts of the field, cannot be regarded as typical in any sense. Clumping of small numbers of bacteria sometimes occurs in the pure culture during its growth, and this source of error must be eHminated by habitually examining the culture before each test or series of tests. TecJiniqiic. In order to exclude all sources of error, such as may arise from the clumping of the typhoid bacillus by non- typhoid serum, provided that the latter is sufficiently concentrated and is allowed enough time to exert its agglutinative powers, the reaction can be considered of diagnostic value only under the following two conditions : first, that the blood to be tested must always be diluted with at least ten volumes of the culture ; and, second, that loss of motility and clump formation must occur within an arbitrary time limit of thirty minutes. Under these conditions it has been shown that agglutination of the typhoid bacillus is produced only by the blood from a patient who is or who has been infected with enteric fever. In some cases of ty- phoid the reaction occurs in much higher dilutions, frequently with dilutions of 1 150, or i :ioo, or even higher. Some habitually 21 322 GENERAL HEMATOLOGY. work with higher dilutions than i:io, but they extend the time limit of the reaction proportionately to the degree of the dilution used. Cultures from twelve to twenty-four hours old, grown in neutral peptone-bouillon from a stock agar-agar culture, are best adapted for the test. It is advisable to keep all the cultures at room temperature, and to transplant the stock agar growths not oftener than once a month, since cultures "forced" by incuba- tion and by frequent transplanting may give rise to false reactions with non-typhoid blood. The cultures should, of course, be ab- solutely uncontaminated, and must respond typically to the recosnized tests for their identification. The test may be conducted either microscopically, by the dried blood method, or by the use of fluid blood, or fluid serum ; or 7nacroscopically, the method preferred by Widal.^ The dried blood method, perfected and popularized by Wyatt Johnston,^ is to be chosen whenever it is necessary to send the blood sample any distance for examination, and where the ex- aminer finds it inconvenient to carry with him to the patient's bedside the test-tubes required for the methods next to be de- scribed. Johnston's method is especially adapted for use by Health Boards, by which bodies it is now extensively employed in nearly all the large cities in this country. The technique of collecting the blood specimens is exceedingly simple. After having punctured the finger or ear in the usual manner, several separate drops of blood are collected upon the surface of some non-absorbent material, preferably glass, then dried, placed in an envelope or other protective covering, and tested at the examiner's convenience. Glass slides, or slips of non-absorbent Bristol board or paper are most commonly used for collecting the blood samples, and specimens thus obtained may be kept for several months without aseptic precautions, and still retain their agglutinative powers. If the specimen has been collected on glass, one of the crusts is moistened with a drop of sterile water and worked up into a thin paste with a platinum loop, after which complete solution and proper dilution of the blood is effected by adding nine drops of typhoid bouillon and mixing thoroughly. If the sample has been dried on a paper or cardboard surface, the blood crust may be cut out with a pair of scissors, and placed to soak, face down- ward, in a watch-glass containing ten drops of the culture. From one of these mixtures of blood and typhoid culture a ^ Bull, med., 1896, vol. x., pp. 618 and 766. 2N, Y. Med. Journ., 1896, vol. Ixiv., p. 57^. ENTERIC FEVER. 323 minute portion is transferred to the center of a clean cover-glass, which is at once inverted over a '* concave slide," sealed with cedar-oil, and examined as a hanging-drop with a one-eighth- inch dry objective, using dim illumination. A plain glass slip is used by many workers, instead of a "hollow-slide," but either will prove satisfactory. If the fluid blood method is used, the dilution is made at the patient's bedside, by adding one drop of the whole blood, as it flows from the puncture, to ten drops of typhoid bouillon, con- tained in a small test-tube. The mouth of the tube is then closed by a cotton plug, and its contents thoroughly mixed by vigorous shaking. At the time of the test, which must not be delayed more than a few hours after the dilution is made, a small drop of the mixture is removed from the tube and examined microscopic- ally in the usual manner. In order to insure accurate dilutions, a graduated pipette is needed for measuring the blood and the culture, for the drops of both liquids must be of exactly the same size. Either the special pipettes devised for serum testing, or the Thoma-Zeiss leucocytometer will prove satisfactory for this pur- pose. In lieu of either of these instruments a graduated pipette may be readily made from a bit of glass tubing, or an ordinary medicine dropper. If the liqiiid serum method is chosen, fifteen or twenty drops of blood, drawn by making a rather deep puncture, are allowed to flow into a narrow calibered test-tube, and set aside for a few minutes until coagulation has taken place. As soon as the clot has formed, the nose of the graduated pipette is thrust into the test-tube, and one drop of the fluid serum sucked up, and diluted with ten drops of typhoid bouillon contained in a second test-tube. The preparation for microscopical examination is then made from this dilution. If the requisite apparatus is at hand the serum may be obtained by centrifugalization. If the macroscopical method is employed, the whole procedure must be carried out under the strictest aseptic precautions, for otherwise the growth of contaminating bacteria may interfere with the reaction, owing to the length of time required for the comple- tion of the experiment. The blood from which the serum is obtained is aspirated from one of the superficial veins of the arm, according to the technique employed in bacteriological examinations, and then immediately expelled into a sterile test-tube, which is plugged with cotton, and set aside until clotting occurs. If it is desired to send the speci- men any distance, the blood may be drawn up into a glass bulb, previously sterilized by heat, and then sealed at both ends. Blood 324 GENERAL HEMATOLOGY. collected in this manner will preserve its agglutinative properties and remain sterile indefinitely. Having thus obtained the serum from the whole blood, the test is carried out by adding the serum in definite dilutions to either a twenty-four-hour-old bouillon culture of the typhoid bacillus, or to sterile bouillon inoculated with a typhoid culture at the time of the test. In the first instance a 1:10 dilution of serum and twenty-four- hour typhoid bouillon is made in a sterile test-tube, which is then plugged, and placed in an incubator, where it remains for about twelve hours, at a temperature of 37° C. At the expiration of this time a positive reaction may be recognized by the presence of dense, whitish, flaky masses (composed of large clumps of ag- glutinated bacteria), forming in the typical positive reaction a thick precipitate at the bottom of the test-tube, which contrasts with the perfectly clear appearance of the supernatant bouillon. If the reaction is negativ^e, the tube shows simply the uniform cloudi- ness of an ordinary typhoid bouillon culture. In the second instance a i:io dilution of serum and sterile neutral peptone bouillon is made, the mixture then being inocu- lated with a small loopful of typhoid bacilli derived either from a bouillon or an agar culture. The contents of the test-tube are then thoroughly mixed, and the preparation incubated at 37° C, for twenty-four hours. A positive reaction is characterized after this length of time by the formation of a similar grayish-white precipitate at the bottom of the tube, underlying an unclouded layer of fluid. In negative reactions the typical cloudiness of the typhoid growth is diffused throughout the bouillon. In both of these macroscopical methods control tubes of normal serum and typhoid bouillon should invariably be prepared, and incubated side by side with the specimen of serum to be tested. Both tests may be carried out at ordinar}- room temperature, but more certain and more typical results are obtained when the tubes are incubated at a temperature of 37° C. TJic Choice of a Method. The choice between the four methods of serum testing described above must depend largely upon the circumstances under which the test is to be made. The dried blood method, as already remarked, is best adapted to Health Board necessities, where samples of blood are collected by the general practitioner and sent by mail to the laboratory. The chief objection to this method is the impossibility in many cases of making accurate dilutions, since usually it can only be as- sumed that a given crust of blood represents the same volume in its liquid state as the drop of culture with which it is diluted. If the ENTERIC FEVER. 325 examiner collects the specimens himself, quite accurate dilu- tions may be obtained if a graduated pipette or a platinum loop of fixed size is used to measure both the blood and the culture. Another drawback is the fact that more or less typical agglutina- tion occasionally occurs with non-typhoid blood, although John- ston believes that this source of error may be always eliminated by using cultures of sufficient attenuation. In hospital work either the fluid blood or fluid serum should be chosen, for exact dilutions may be made by these methods, and if the test is made within a reasonable length of time after the dilution, bacterial contamination need not be feared. The writer, in the early days of serum testing a warm advocate of Johnston's method, has now discarded it wherever possible in favor of the more accurate and equally simple test performed with the fluid whole blood, or serum. The macroscopical method with fluid serum is too slow, and requires too elaborate bacteriological apparatus ever to be adopted for general clinical use. At present it is chiefly used by a few British and Continental observers in experimental work, but has not found popularity in this country. Value of the Serum Test. Fully 95 per cent, of all typhoids give a positive reaction at some period of the disease, usually as early as the eighth day, as nearly as it is possible to compute this period. An error of about 3 per cent, must be allowed for, on account of the occurrence of positive or misleading results with non-typhoid blood. The statistics of the Philadelphia Bureau of Health are of interest in demonstrating the usefulness of the test in routine public health work. The report for 1898^ shows that 5,293 specimens from 4,597 cases diagnosed enteric fever were tested by the dried blood method, with a discrepancy of 5 per cent, be- tween the laboratory and the clinical diagnosis ; while the report for 1899^ shows that the discrepancy was only 3.9 per cent., based on the examination of 5,350 samples of blood from 4,483 suspected cases. In 1900^ 3^205 specimens from 2,745 suspected cases were examined, with a discrepancy of 7. i per cent, between the clinical and the laboratory findings. In some instances repeated negative results are found until con- valescence is well established, and, rarely, cases are encountered in which the reaction never occurs at any time during the entire course of the illness. The blood may lose its clumping powers 1 A. C. Abbott : Annual Report of the Division of Bacteriology, Pathology, and Disinfection of the Philadelphia Bureau of Health, 1899, p. 199. 2 Ibid., 1900, p. 92. 3 Ibid., 1901, p. 107. 326 GENERAL HEMATOLOGY. at about the time of defen^escence, or, on the other hand, this pe- cuHarity may persist for months, or even years after the attack. This last source of error in the test may be due to the presence of unsuspected foci containing typhoid bacilH, but sometimes it is apparently independent of such factors. Before pronouncing upon the value of a positive reaction in the individual case, the occurrence of a previous attack of typhoid, and the presence of lesions which may be due to the Ebeith bacillus (osteomyelitis, cystitis, arthritis, cholecystitis, etc.) must be excluded. The reaction may be positive on one day of the disease or for a series of days, and negative on the next day or succeeding days. Its character is apparently uninfluenced by the intensity of the infection, for although as a rule the reaction is usually prompt and marked in severe infections, it maybe just as marked in mild cases. A certain relationship seems to exist between the height of the fever and the intensity of the reaction, for the latter is usually most decided at the period of maximum pyrexia. In the light of our present knowledge of the serum test, its value appears to be less than its first enthusiastic advocates were inclined to urge. A positive reaction, obtained by a skilled worker whose technique as to dilution, time limit, and culture has been exact, is the most valuable single sign of enteric fever, al- though it cannot be regarded as absolutely pathognomonic. On the other hand, a negative result with the test is no proof of the absence of the disease. Anemia develops shortly after the beginning Hemoglobin of the fever, slowly and progre.ssively increasing AND in intensity throughout the course of the disease, Erythrocytes, and persisting during the early weeks of defer- vescence. During the first week there is little or no decrease in the number of erythrocytes, although the hemo- globin loss appears to begin coincidentally with the first manifes- tations of the infection. Normal er}'throcyte counts are the rule during the first seven days, but there are few cases of typhoid which fail to show a hemoglobin loss amounting to at least 1 5 or 20 per cent, during this period. Whether this early oligo- chromemia is due to the influence of the fever, or whether it rep- resents the actual prefebrile state of the patient's blood, is difficult to decide. By the second week the corpuscular decrease be- comes evident and steadily grows more and more marked as the disease progresses, reaching its maximum at about the end of de- fer\^escence. Thayer ^ distinguishes a slight accentuation of the oligocythemia between the third and fourth weeks, the decrease 1 Johns Hopkins Hosp. Reports, 190O, vol. viii., p. 487. ENTERIC FEVER. 327 continuing until the seventh, when a still more decided fall occurs, followed in the eighth week by a considerable rise. A slow rise in the erythrocyte curve is observed after defervescence, and, in- deed, sometimes before the end of the febrile stage, until by the end of the fourth or fifth week of convalescence the count is again normal. The hemoglobin, after the first week, follows the same general course as the erythrocytes, but its decrease during the early weeks is relatively greater and its regeneration slower during the post-febrile period. Thayer's analysis ^ of the blood examinations in enteric fever, made in the Johns Hopkins Hospital during the past eleven years, furnishes a striking illustration of the development of the anemia during the progress of the disease. Arranged according to the week of the fever, the following hemoglobin and erythrocyte averages in uncomplicated cases are shown : Hemoglobin. (165 estimates.) 1st week, 2i estimates, 76.1 per cent. 6th week, 6 estimates, 62,1 per cent. 72.8 " 7th " 4 " 50.5 " 66.2 " 8th " 3 " 56.9 *' 60.5 " 9th " 4 '' 47.7 " 2d << 51 3d (( 34 4th ( < 20 5th (( 20 57-8 loth 66.5 Erythrocytes. (265 counts.) 1st week, 32 counts, 4,913,312 7th week, 8 counts, 3,309,125 2d 3d 4th 5th 6th 86 59 36 22 7 4,692,428 4,429,208 4,222,236 4,118,590 4,028,428 8th 9th loth nth 3,652,285 3,509.966 3,920,000 2,109,333 Seventy-four typhoid patients, both with and without compli- cations, examined in the German and the Jefferson Hospitals, show the following averages, the first estimates being taken in all cases in which multiple examinations were made : Week. Hemoglobin. Erythrocytes. I St week, 14 cases. 77.4 per cent. 4,789,285 per cb. mm 2d 30 66.5 4,161,233 3d 13 58.8 3,555,000 4th 6 49.6 3,490,833 5th 6 t ( I 53-1 2,445,000 6th 2 47-5 3,165,000 7th 2 47.5 3,335.000 8th I 40.0 2,790,000 1 Loc. cit. 328 GENERAL HEMATOLOGY. As a rule, the degree of a typhoid anemia is parallel to the severity of the attack, but this is not invariably true, since a mild case may be associated with a most intense anemia. In the series included in the last tabulation the most marked instances of anemia showed hemoglobin and erythrocyte estimates of 40 per cent, and 1,720,000, 40 per cent, and 1,850,000, and 50 per cent, and 1,800,000, respectively. The most striking example of oligochromemia showed a hemoglobin percentage of 20, with a corresponding erythrocyte count of 2,470,000. Considerably lower estimates than these have been reported by a number of other observers, but they are uncommon. The effects of the cold tub, and of excessive diarrhea and sweating may cause a temporary polycythemia from concentra- tion of the blood, and these sources of high counts must be ex- cluded in making examinations during the early weeks of the disease. In four cases examined by the writer to determine the effects of the cold plunge, it was found that the average eiy- throcyte increase after the bath amounted to 813,000 corpuscles per cubic millimeter, and the hemoglobin gain to 8 per cent. Hemorrhages, if severe, may cause an abrupt fall in the erythro- cyte count, often succeeded by a more or less successful attempt at regeneration, in an effort to compensate for the blood loss. Qualitatively, the cells show no peculiar changes, poikilocytosis, irregular staining affinities, and deformities of size occurring in relation to the intensity of the anemia. Erythroblasts are com- paratively rare, being absent or few in number in the average case. Normoblasts may be found in cases with high-grade anemia, and as a sequel to hemorrhage. Megaloblasts are very rare, an oc- casional cell of this type being observed now and then only in severe cases. '• A steady, slow decrease in the number of leu- Leucocytes. cocytes becomes evident after the first week of the fever, the lowest counts being found during the fifth or sixth week, after which an increase, which may be either permanent, or transient and followed by a still more decided leucopenia, is observed. It appears that the latter change ac- companies cases with severe post-febrile anemia, although suf- ficient data are lacking to justify absolutely positive conclusions on this point. In uncomplicated cases the normal count becomes reestablished by about the fourth week of convalescence. The leucopenia of typhoid corresponds in a general way to the severity of the attack, and although not marked in the average, in the individual case it may be striking, counts of from 2,000 to 3,000 being not at all uncommon. ENTERIC FEVER. 329 Thayer's report of 832 counts in uncomplicated cases shows the following range of the leucocytes, according to the week of the disease : I St week, 119 counts, 6,442, 8th week, 14 counts, 6,614 2d '* 258 ' ' 6,251, 9th 7 ' 5,057 3d '' 200 * ' 5,528, loth 2 ' ' 5,000 4th '' 117 ' 5,431, nth 3 ' 5,333 5th - 70 ' 5,510, 1 2th 2 ' ' 5,000 6th '' 25 ' 5,690, 13th I * ^ 8,000 7th '' 14 ' 6,132. The leucocyte estimates of the 74 hospital typhoids referred to above averaged : ist week, 14 cases, 8,026 leucocytes per cb. mm. 2d ' ' 30 6,713 C< (( 3d ' ' 13 7,076 ( il 4th ' 6 4,400 i (( 5th ' 6 5,766 ( IC 6th ' * 2 6,250 I (( 7th ' * 2 4,500 I (( 8th ' ' I 8,000 ( (( Disregarding the week of the fever, the number of leucocytes in these cases ranged as follows : Above 10,000 in 7 cases From 9,000-10,000 " 3 8,000- 9,000 " 8 7,000- 8,000 " 14 6,000- 7,000 " 8 5,000- 6,000 " 10 4,000- 5,000 " II 3,000- 4,000 '' 8 2,000- 3,000 " 4 1,000- 2,000 *' I Highest: 16,000 per cb. mm. Lowest: 1,333 " < ( Average : 6,706 '* (( It appears from these figures that counts in excess of 10,000 per cubic millimeter may be looked for in more than 10 per cent, of all cases, such an increase being due either to the effects of blood concentration from diarrhea, sweating, vomiting, or cold tubbing, or to some hidden or frank complication. In 4 of the 7 relatively high counts above noted, the cause was plain — croupous pneumonia in 2, cholecystitis in i, and furunculosis in 330 GENERAL HEMATOLOGY. I. In the other 3, all of which were made in patients whose fever had not yet run seven days, the factors of the increase were undetermined ; possibly it was due to physiological blood in- spissation. Inflammatory complications, such as otitis, abscess, pneumonia, severe bronchitis, peritonitis, cystitis, periostitis, and phlebitis give rise to a prompt leucocytosis in patients whose vital powers are sufficiently strong to react against the process. Intestinal hemor- rhage is usually followed by an increase reaching its maximum within twenty-four hours after the blood loss, and disappearing within a week. Intestinal perforation may be promptly followed by a leucocytosis, the increase developing within a few hours. Thayer has observed that in some instances the increase in the number of leucocytes succeeding the perforation may tend to diminish and disappear with the aggravation of the symptoms, and that not infrequently there is a complete absence of leucocy- tosis and sometimes a diminution in the number of leucocytes after this accident. He also considers that the prospect of reUef by surgical interference is best in those cases with a leucocytosis, the absence or disappearance of this sign following a perforation being an indication of the malignancy of the infection or the pros- tration of the patient. Qualitative changes are absent or inconspicuous during the first two weeks of the fe\'er, but during the third week a slow, progressive decrease in the relative percentage of polynuclear neutrophils, with a consequent increase in the mononuclear un- granulated forms, begins, this change becoming most marked at about the end of defervescence. In 23 of the writer's cases the percentage of polynuclears averaged, according to the week of the disease, 75.0 per cent, for 8 cases in the first week; 70.9 per cent, for 7 in the second week ; 50.2 for 4 in the third week ; 60.0 per cent, for 2 in the fourth week ; and 64.0 and 68.0 per cent, for a single case in the fifth and sixth weeks, respectively. Thayer has found that the mononuclear cells which are most markedly increased are " elements containing nuclei not much larger than those of lymphocytes, and often presenting the gen- eral appearance of a lymphocyte nucleus, with the exception of the slight affinity for coloring matters. The size of these cells is usually about that, or but little larger than that of the ordinary polymorphonuclear neutrophile." The typical small lymphocyte, and the "transitional " forms undergo little or no increase. The eosinophils are almost invariably decreased, both abso- lutely and relatively, and are often absent during the active febrile stages. The relative percentages of these cells in the ENTERIC FEVER. 331 above cases averaged 0.87, rising as high as 5 per cent, in only 2 cases, and being entirely absent in 1 1 . Myelocytes in small numbers may be found in severe forms of post-typhoid anemia, but they are absent during the active period of the infection. Tiirk's ''stimulation forms" are met with under the same conditions. Thayer's elaborate report of the Johns Hopkins Hospital cases includes the following averages of the differential leucocyte counts : Week. Small Mono- Large Mono- Polynuclear Eosinophile. nuclear. nuclear Neutrophile. 1st week, 12 counts. 12.9% 12.4% 74-o% 0.5% 2d '* 39 " 14.6 13-4 70.9 0.8 3d " 34 '' 21.5 II. 6 66.3 03 4th ** 19 '* 20.1 14.4 65.0 0.4 5th " 8 " 18.2 19.7 61.7 0.3 6th " 4 " 22.6 135 57-7 6.0 7th " I '* 23-7 34-4 37-3 4.6 8th " I " 24.2 16.8 56.9 2.1 According to Hayem,^ the number of blood plaques is markedly ■decreased during the febrile period of the fever, as in any other condition characterized by pyrexia. The blood examination furnishes three clinical Diagnosis, signs of positive value in the diagnosis of enteric fever : the serum reaction ; a subnormal leuco- cyte count or at least an absence of leucocytosis ; and in cases with roseola the detection of the Eberth bacillus by spot cultur- ing. The influence of complications upon the behavior of the leucocytes must, however, always be borne in mind. Malarial fever, acute miliary tuberculosis, cerebrospinal menin- gitis, certain atypical cases of pneumo7iia and influenza, and septi- cemic and pyemic processes, such as ulcerative endocarditis, are the diseases most frequently confounded with typhoid, and in their differentiation the blood report often gives just the essential clue. Malarial and enteric fevers are both associated with an absence of leucocytosis, but in the former the presence in the blood of the malarial parasite and pigment is sufficiently conclusive. Acute miliary tuberculosis, if a pure infection, also shows a similar absence of a leucocyte increase, and in excluding this disease reliance must be placed on the Widal test ; should this prove nega- tive, attempts may be made to culture specific bacteria from the blood. Influenza is not characterized by leucocytosis, and must be differentiated from typhoid by the aid of the serum test. Cerebro- 1 *'Du Sang," etc., Paris, 1889. 332 GENERAL HEMATOLOGY. Spinal meningitis, pneumonia, and septic and pyemic conditions may be differentiated by their association with a more or less well-marked leucocytosis. In the last-named processes bacterio- logical examination of the blood not infrequently gives conclusive results. XVII. ERYSIPELAS. In severe infections Tiirk^ has noted a de- Gexeral cided increase in the quantity oi fibrin and in the Features. number of blood plaques, but in the case of average severity these changes are not to be observed. Drouin ^ has found that the alkalinity of the blood is greatly de- creased. Negative results from bacteriological examination of the blood are the rule. Moderate anemia, characterized bv a some- Hemoglobin what disproportionate hemoglobin loss, is com- and mon in the severer forms of the disease, but not Erythrocytes, in mild cases. The decreases are not notable, amounting on the average to a loss of not more than 10 or 20 per cent, of corpuscles and of about 30 per cent, of hemoglobin. Maragliano's degenerative changes of corpus- cular structure have occasionally been found. Leucocytosis of the polynuclear neutrophile Leucocytes, type is the usual finding, but mild cases fre- quently run their course without provoking the slightest increase. Except in isolated instances, the leucocytosis is not high, the counts usually being about 15,000, and rarely more than 20,000 cells to the cubic millimeter. Von Limbeck,^ and Chantemesse and Rey ^ have shown that the leucocyte and temperature curves maintain a definite parallelism in the majority of cases, and that the diminution in the leucocytosis as a rule anticipates the fall in temperature. There is, however, no appa- rent relationship between the height of the leucocytosis and the degree of pyrexia, for moderate leucocytoses are not incompatible with strikingly high temperatures. It is generally agreed that the highest counts are found in the severest cases, provided that the patient's resisting powers are acting normally. An exten- sion of the lesion is generally accompanied by an increase in the leucocytosis. With the onset of convalescence, as the leucocytosis disappears the normal percentages of the different forms of leucocytes, dis- ' Loc. cit. 2 These de Paris, 1892, n. ^t^, p. 108. 3 Loc. cit. *Presse med., 1899, vol. vi., p. 316. FEVER. 333 turbed during the febrile period, are reestablished by a rapid increase in the small lymphocytes and eosinophiles, and a decrease in the polynuclear neutrophiles ; the percentage of large lympho- cytes remains stationary, and the eosinophiles are absent during the height of the attack, according to Chantemesse and Rey. Small percentages of myelocytes and an occasional "stimulation form" are commonly found during the active stages of the leuco- cytosis. XVIII. EXOPHTHALMIC GOITRE. There are no characteristic changes in the hemoglobin and erythrocytes, although an anemia indistinguishable from typical chlorosis is not an infrequent feature. Such cases must be dis- tinguished from so-called ''thyroid chlorosis," or chlorosis with thyroid hypertrophy, by means of other clinical symptoms. It seems likely that in cases of Grave's disease characterized by excessive diaphoresis, emesis, and diarrhea, the blood concen- tration thus produced may be sufficient more or less effectually to obscure the real grade of anemia existing. The leucocytes are not increased in number, and leucopenia of a decided degree is frequently observed. Relative lymphocytosis is a common change, and moderate increase in the percentage of eosinophiles an occasional finding. XIX. FEVER. It is a well-recognized fact that more or less he^noglobin and erythrocyte losses follow pyrexia maintained for any length of time, but an attempt to demonstrate the exact cause or group of causes of this anemia involves the analysis of a most complex problem in physiology, about which the most skilled investigators express diametrically opposite opinions. Some maintain that suffi- cient actual destruction of the corpuscles occurs as the result of fever to account for their decrease in number, while others attrib- ute the loss largely, if not wholly, to the influence of vasomotor changes. Maragliano ^ has shown that capillary contraction ac- companies the period of active pyrexia, while Reinert ^ suggests that the blood is diminished in volume by the excessive drain upon the body fluids occurring at this time. In septic fevers, furthermore, additional inspissation of the blood is produced by the influence of bacteria and their products. These factors tend- ing to inspissate the blood favor the production of polycythemia, which change is to be observed during the stage of active fever. But as defervescence sets in the conditions are reversed, for the 1 Berl. klin. Woch., i887,vol. xxiv , p. 797. 2** Die Zahlung der roten Blutkorperchen." Lepzig, 1891. 334 GENERAL HEMATOLOGY. capillaries then dilate, the draining away of the fluid elements of the blood ceases, and, consequently, dilution of the blood now occurs. Anemia therefore develops coincidentally with the dis- appearance of the fever. It is undetermined whether this post- febrile anemia is the result purely of these physical causes, or of these causes plus a certain amount of real hematocytolysis due to high temperature. It seems reasonable to regard both factors as active. Coagulation and fibrin behave so erratically that no definite statements regarding them are justified. In the incipient stage of septic fevers coagulation is much delayed, according to Schmidt,^ but during the later stage it occurs more rapidly than normal. The leucocytes in this class of fevers are generally increased in number. The alkalinity of the blood undergoes wide variations in differ- ent febrile states, but it cannot be said that these changes, which are probably due to complex chemical processes rather than to the primary effect of the fever, are constantly parallel, either to the degree of pyrexia or to the behavior of the leucocytes. Lowy and Richter^ state that increased alkalinity occurs co- incidentally with the stage of hypoleucocytosis — a statement which Strauss,^ Lowit,^ and others have verified. Fodor and Rigler's experiments^ have proved that the pyrexia following infection with pathogenic bacteria ultimately effects a diminution in the alkalinity of the blood, and that this change is sometimes preceded by a distinct primar}^ increase. The conclusions voiced by von Jaksch,^ Kraus,'' and other earlier wTiters, that decreased alkalinity is a constant accompaniment of febrile processes, can- not be unreservedly accepted if von Limbeck's ^ later statements to the contrary are to be believed. XX. FILARIASIS. Filariasis, the pathological condition depend- OccuRRENCE. ing upon the presence in the body of the parental and embryonic forms of the filaria sangninis hominis, is of widespread distribution throughout the tropics and subtropics, being prevalent in various districts of Africa, India, ' Pfliiger's Archiv., 1875, vol. xi., pp. 291 and 515. 2Deut. med. Woch., 1895, vol. xxi., p. 526. 'Zeitschr. f. klin. Med., 1896, vol. xxx., p. 315. *"Die Lehre v. Fieber," Jena, 1897. ^Centralbl. f. Bakt. u. Infect., 1897, vol. xxi., p. 134. ^Zeitschr. f. klin. Med., 1887, vol, xiii., p. 380. 'Zeitschr. f. Heilk., 1889, vol. x., p. 106. sCentralbl. f. inn, Med., 1895, vol. xvi., p. 649. FILARIASIS. 335 Australia, China, Japan, South America, and the islands of the South Pacific and the West Indies, and, as mentioned below, hav- ing been found to a limited extent in North America. Six distinct species of embryo blood worms, Parasitology, the parental forms of which do not enter the cir- culation, have been demonstrated in the periph- eral blood of man, these parasites being known by the general term, filaria sanguinis hominis. These different filariae, according to the nomenclature suggested by Manson,^ are distinguished by the r\diVC\QS filaria nocturnal filaria diurna, filaria per stans, filaria Demarquaii, filaria Ozzardi^ and filaria Magalhdesi. To but a single member of this group, the filaria nocturna^ has an undis- puted pathological role been assigned, this parasite being regarded as the cause of various forms of lymphangitis, of lymph varices, of lymph scrotum, of tropical elephantiasis Arabum, of endemic chyluria, of chylous ascites, and of other tropical diseases of more or less obscure nature. The filaria pcrstans, Manson conjectures, may possibly be the etiological factor of that peculiar West African disease known as negro lethargy, or the ** sleeping sickness " of the Congo, as well as of a form of African kra-kra, or *' craw- craw." Further study of this subject is necessary, however, be- fore these relationships may be unreservedly credited. The other filariae {diiirna, Deniai'quaii, Oszardi and Magalhdesi ) possess no interest from a diagnostic standpoint, since their life history and pathological significance are still obscure.^ This is by far the most important member of The Filaria the above-named class of blood worms, being the NocTURNA. one most familiarly known of all, as well as the one of greatest clinical interest, because of the interesting pathological lesions which it is capable of exciting. In this country cases of filariasis due to \h^ filaria noctiirjia have been reported by a number of different observers, Guiteras,^ de Saussure,^ Mastin,^ Slaughter," F. P. Henry,^ Dunn,^ and Lothrop »" Tropical Diseases," N. Y., 1898. 2 The author is greatly indebted to Dr. F. P. Henry and to Dr. J. H. Gibbon for the opportunity of making repeated blood examinations in two cases oi filaria noc- turna infection occurring in their respective hospital services. 3 For a complete description of filariasis and of the various forms of the filariae the reader should consult Manson' s article in Davidson's " Hygiene and Diseases of the Warm Climates" (Edinburgh, 1893), or this author's text-book to which reference is made above. *Med. News, 1886, vol. xlviii., p. 399. 5 Med. News, 1890, vol. Ivi., p. 704. 6 Annals of Surg., 1888, vol. viii., p. 321. ^Med. News, 1891, vol. ii., p. 649. 8 Med. News, 1896, vol. xviii., p. 477. 9 Trans. Coll. of Phys. of Phila., 1898, p. 80. 336 GENERAL HEMATOLOGY. and Pratt/ having met with the disease. A few of these cases have been regarded by their reporters as indigenous, but the great majorit>' of them, it is safe to state, were directly imported from the tropics. To the writer's knowledge, at least three cases have been diagnosed in Philadelphia during the last four years. Fig. 45. :\ 'i'.^ The filaria nocturna. From a photomicrograph of the parasite in fresh blood. As may be inferred from the name, the embryos of Xh^ filaria nocturna are found in the peripheral blood most abundantly at night, the vast majority of the parasites retiring into the deeper circulation during the daytime. From late in the afternoon until about midnight they make their way into the peripheral vessels in progressively increasing numbers, with more or less fluctuation, the maximum number being found at the latter time, after which they begin to grow less and less numerous, until by about eight o'clock in the morning they have practically all dis- appeared from the superficial circulation and reentered the deeper vessels in which they remain until the close of the day. This peculiar periodicity is well illustrated by a recent series of inves- tigations made by Lothrop and Pratt, ^ who have charted the phenomenon in one case, showing the approximate number of parasites to the cubic millimeter of blood as follows : 4 p. m., 100; 6 p. m., 275 ; 8 p. m., 1,300 ; 10 p. m., 900 ; 12 m., 1,500; 2 a. m., 700 ; 4 a. m., 900 ; 6 a. m., 125 ; 8 a. m., 125; and 10 ^Am. Journ. of Med. Sc, 1900, vol. cxx., p. 525. 2Loc. cit. FILARIASIS. 337 a. m., loo. Twenty-one hundred embryos per cubic millimeter was the highest number ever observed by these authors, the specimen in which this count was made having been taken at midnight. This characteristic periodicity, it should also be re- marked, is completely reversed if the individual harboring the parasite reverses his habits of life, by sleeping during the day and moving about at night ; if such should be the case the worms will appear in the peripheral blood during the daytime, the patient's period of rest, and seek the deeper circulation at night, the pa- tient's period of activity. The painstaking studies of Manson, to whom we owe most of our knowledge of the filaria's life history, have shown that the mosquito is the intermediate host of this parasite, which may be found alive in the stomach of this insect after it has fed upon a filarious individual. Ecdysis takes place in this organ, and the embryos, after having cast their sheaths, manage eventually to penetrate the thoracic muscles of their host, in which situation they undergo a developmental phase lasting for about seven days. The mosquito, gorged with these partly mature parasites, seeks a stagnant pool upon the surface of which she lays her eggs, and then having died, falls, herself, upon the water. The filariae then escape from the corpse of their late host, and thus, through the medium of drinking water, may gain access to the stomach of human beings. Having been swallowed by man, they penetrate the stomach wall and Other tissues, and ultimately reach some part of the lymphatic system in which they lodge, sexually ma- ture, fecundate, and beget the innumerable embryos which enter the lymph stream, and in course of time find their way into the circulating blood. Appearance in Fresh Blood: In the unstained blood-film the parasite appears under the microscope as a long, slender, graceful worm possessing a most remarkable degree of activity. It measures about 1/80 of an inch in length, and 1/3,000 of an inch in diam- eter, and is of a pearly-gray color, with perhaps the faintest sug- gestion of a yellowish tone, in certain lights. Its general appear- ance conveys to one, at first glance, the impression of a thin, transparent tube through which a rapidly flowing stream of liquid is constantly circulating. The head (cephalic end) is gracefully rounded, while the tail (caudal end) gradually tapers for about one-sixth the entire length of the animal, and ends in a fine-pointed extremity. The worm is cylindrical in shape, of regular outline, and consists of a central body enveloped in a distinct, loosely fitting, hyaline, structureless sheath, which is about as much too large for the body as the thumb of an adult's glove would be for 22 338 GENERAL HEMATOLOGY. the little finger of a child. Thus, that part of the sheath tem- porarily unoccupied by the body is prone to collapse, folding upon itself and trailing after the worm at either or both extremities, as a twisted, whip-like ribbon. The greater part of the body appears to be of a homogeneous structure when examined in the freshly prepared slide, but after the specimen has been kept for several hours coarse granulations begin to stipple its surface, first develop- ing in the center, and gradually spreading toward the periphery. (See Fig. 46.) A series of fine striations, Hke the milling on a Fig. 46. FiLAKIA NOCTURNA. Showing beginning granular degeneration of the body of the parasite. coin, may be observed running along both edges of the body, at right angles to its long axis. A viscus, appearing as a mass of granular material, occupies a part of the central third of the worm's body, running parallel to its long axis. Upon careful examination with an oil-immersion objective, rhythmical dimpling or puckering movements may generally be obser\'ed at the tip of the cephalic end of the embryo ; these movements, which occur with more or less regularity at the rate of from twenty-five to forty times a minute, have been attributed to the act of respiration. As the wriggling of the worm becomes less active, close observation will show that these pouting movements are caused by the alternate covering and uncovering of the cephalic end by a delicate six- FILARIASIS. 339 lipped prepuce. The sudden projection and the equally rapid retraction of a filamentous fang or tongue-like organ from the worm's uncovered head may also be noted in some instances, but this characteristic is so difficult to make out that it may usually be looked for in vain. At a point about one-fifth of the entire length of the worm posterior to the head it is possible to make out a triangular, slightly luminous patch, shaped like the letter V, this spot being known as the V-shaped patch, regarded by Man- son as a rudimentary generative organ. A second spot, some- what similar to it in appearance but smaller in size, may occasion- ally be seen at a point just above the tail of the parasite ; this spot Manson is incHned to regard as the rudimentary anus. The movements of the worm are rapid and violent in the ex- treme, so much so that they are followed with difficulty with any but a low-power dry objective. The parasite is never at rest : one moment it may be curled up into a tight bunch, like a coil of rope ; the next moment it may suddenly straighten out and become rigid for an instant, only again to resume its incessant contortions and twistings which throw it into every conceivable sort of shape. If particular attention is paid to the point, it will be noticed that, however rapid and complicated may be its movements, the parasite is never seen to turn completely over, laterally. The accompanying series of sketches, of the filaria nocturna in a fresh blood slide, illustrate a few of the differ- ent forms which this parasite may assume. (Fig. 47.) The worm seems to move about among the blood corpuscles with graceful and quick undulations of its body and abrupt whip- like strokes of its tail, butting its head against the more re- sisting masses of cells or else seeking a less difficult passage around them, always in motion but never, it appears, with any definite aim to its exertions. Contrary to the views expressed by most observers, that the movements of the filaiia 7ioctiirna are not truly propulsive in character, the writer has repeatedly noticed that this worm sometimes travels several times the dis- tance of the diameter of the microscope field (one-sixth-inch objective, one-inch ocular, and 160 mm. tube-length), although in most cases its excursions were limited to a measured area not exceeding half-a-dozen square micromillimeters. It cannot be denied that these apparently progressive movements of the worm may possibly be due to the currents in the blood plasma, but they certainly seem to have every characteristic of a true locomotive force. After the slide has been kept for a few hours the move- ments of the worm, at first so confusingly rapid, gradually become slower and slower, and these torpid, more deliberate turnings and 340 GENERAL HEMATOLOGY. twistings may be accurately followed under an immersion lens. If the parasite happens to become confined in a little pool of plasma surrounded by rouleaux of half-dried erythrocytes, an accident which often happens when the drying of the film has Fig. 47. 9.<6 3 48 9 50 5.52 ^ 954 956 9.58 /OOO Kl /006 /0 04 /0.C2 i /OOd /o/o /0./2 /0./4 /0/6 "7^ Showing the changes in the shape of the filaria nocturna during the period of HALF an hour. ThE SKETCHES, MADE AT TWO-MINUTE INTERVALS, ALL REPRESENT THE SAME PARASITE. spread inward some little distance from the edges of the cover- o-lass its finer structure and characteristics may be studied with great ease and accuracy. The phenomenon of ecdysis, or shedding of the worm's sheath, with the consequent escape of its naked body into the plasma, occurs when shdes containing the live filariae are kept for some hours in a cold (not freezing) place. It commonly happens that just before the death of the parasite an occasional erjlhrocyte or leucocyte becomes tightly adherent to the sheath, swinging to and fro with the now lazy, torpid movements of the animal. Technique of Examination. A rather large drop of finger blood, taken from the patient late in the evening, preferably toward midnight, is placed between a slightly warmed slide and cover-glass the edges of which are immediately sealed with FILARIASIS. 341 cedar-oil or with vaseline. The parasite should be searched for with a low-power dry objective, a two-thirds-inch lens being most useful for this purpose, and the attention of the examiner directed especially to portions of the field which may show any unnatural agitation of the blood cells. In specimens prepared in this man- ner the filariae will usually remain active for several days, gener- ally for at least forty-eight hours, and sometimes for a longer period, as in Henry's ^ experience, this author having kept them alive for ten days in a cold room. Staining the Filarice. Films fixed for fifteen minutes in equal parts of absolute alcohol and ether, and stained with thionin give the clearest-cut pictures, the multitude of small nuclei which crowd the body of the filariae being sharply differentiated by the use of this dye. Fixation by heat or by formalin cannot be employed without risk of injuring the finer structure of the em- bryo. Fair results may also be obtained by staining with methy- lene-blue, or with Jenner's stain, but the definition is not nearly so satisfactory with these dyes as it is with thionin. The technique suggested by Manson^ (washing out the hemoglobin of the erythrocytes with water, drying, fixing in alcohol, and staining with methylene-blue or with hematoxylin) has usually proved unreliable in the writer's hands. The same comment may be made regarding attempts to demonstrate the structure of the worm by staining with fuchsin, as recommended by certain authors. The presence in the circulation of the jilaria Hemoglobin noctiirna does not appear of itself to be a factor AND in the production of any conspicuous changes in Erythrocytes, the eiythrocytes and their hemoglobin equivalent, if the limited data at present available may be taken as criteria. The high-grade anemia sometimes associated with filariasis, mentioned by Ehrlich and Lazarus,^ is due, no doubt, to such complications as hematuria, severe chyluria, and chronic diarrhea. The following counts in three cases, the first two made by the author, the third by Lothrop and Pratt,"^ may be taken as representative for the average case : Case Hemogi LOBIN. Erythrocytes. I. Z% per cent. 4,876,000, per cb. mm II. 85 <( 4,200,000 " '' << III. 93 11 1 Loc. 2 Loc. 3 Loc. 4 Loc. cit. cit. cit. cit. 6,016,000 '' *' ( ( 342 GENER.\L HEMATOLOGY. Neither structural changes, nor irregular staining affinities of the cells, nor the occurrence of nucleated eiythrocytes have been reported in connection with the disease. The number of leucocytes does not exceed the Leucocytes, physiological limits of health, except as the re- sult of some complication. Thus, in the first case quoted above the leucocyte count was found to be 41,000 per cubic millimeter, but this increase was regarded purely as a post-operative rise, the patient having been operated upon for a supposed varicocele less than twenty-four hours before the blood examination was made. The count in the second case was 8,000, and in the third the counts were 8,000, 7,400, and 3,500, respec- tively — an average of 6,300. The relative percentage of mononuclear non-granular leuco- cytes is somewhat higher than normal, with a consequent decrease in the proportion of polynuclear neutrophiles. The eosinophiles either remain at a maximum normal percentage or may be dis- tinctly in excess of this figure. In Case II. the actual number of these cells to the cubic millimeter of blood was estimated at 760, the percentage being 9.5. In this same case it was also observed that the great majority of lymphocytes appeared as cells having a deeply stained eccentric nucleus surrounded by an abnormally large area of protoplasm, the general appearance of these cells be- ing similar to those in the illustration shown on page 259. Typical coarsely granular mast cells may be found in small numbers or they may be entirely absent, as may also be the finely granular forms of basophiles. The presence of myelocytes has not been noted. The above qualitative changes in the leucocytes may be illus- trated by the following "first-counts" of the three cases men- tioned above : Forms of Leucocytes. Case I. Case II. Casein Small lymphocytes. Large lymphocytes. Polynuclear neutrophiles. Eosinophiles. Mast cells. Myelocytes. 23. 1 per cent. 63.9 3-4 '' 0.6 0.0 " 34.2 per cent. 0.6 - 55.7 " 9.5 " 0.0 *' 0.0 " 35-33 per cent. 3.67 " 56.67 " 4.33 " 0.0 " 0.0 " The detection of the filaria nocturna in the Diagnosis, blood serves at once to differentiate idiopatJiic from parasitic c/iyliiria, hydrocele from lympli scrotum, hernia and other tumors of the groin from parasitic inguinal varicosities (Bancroft's ** helminthoma elastica"), and GASTRITIS. 343 filarial orchitis from other inflammatory conditions of the testes. Non-parasitic lymphedema affecting, for example, the legs, can but rarely be distinguished by the blood findings from true elephan- tiasis Arabum, since in the latter disease it is exceptional to find filaria in the general circulation. XXI. FRACTURES. Blake, Hubbard, and Cabot' conclude, from a study of 38 cases, that in simple uncomplicated fractures the number of leu- cocytes is seldom increased to any extent, a statement which applies also to complicated fractures in the great majoiity of instances. Of 23 simple fractures examined by these authors, in but lO was the count higher than 10,500 per cubic millimeter, and of these only 6 exceeded 12,000. The highest estimate was i 5,400, in a fracture of the pelvis, and the next highest, 14,800, in a broken leg. Of I 5 complicated fractures, but 2 showed any decided in- crease in the number of leucocytes, namely, a fracture of the tibia and fibula, with symptoms suggestive of fat embolism, in which the count was i 5,600 ; and a case of fractured ribs with injury of the lung, in which the leucocytes numbered 14,900 two days after the' accident. An estimate of 5,400 cells was made in a compound fracture of the leg two hours after the accident. Lipemia is occasionally met with in fractures of the long bones involving injury of the fatty marrow. XXII. GASTRITIS. In the acute form there is no deviation from Hemoglobin normal in the number and hemoglobin value of AND the erythrocytes, except in the event of hyper- Erythrocytes. emesis, which, through concentration of the blood, may cause a transient polycythemia. In the chronic form secondary anemia frequently develops, and occasion- ally reaches an extreme grade, should the gastric lesion be suffi- cient to interfere radically with the digestion and absorption of food. In instances of this sort the quantitative changes may simulate those of true pernicious anemia, but the qualitative changes typical of this disease are invariably wanting. In pass- ing, it seems pertinent to recall the etiological relationship, dis- tinguished by some authorities, between gastric tubule atrophy and pernicious anemia. In cases associated with gastrectasis and hyperacidity, blood inspissation from emesis is a common change. 1 Am. Surg. Assn., Baltimore, May 7, 1901. (Personal communication from Dr. J. B. Blake.) 344 GENERAL HEMATOLOGY. A synopsis of J. A. Lichty's studies^ of the hemoglobin and erythrocytes in 98 cases of various gastric disorders shows the following average values : Condition. No. of Cases. Hemoglobin Percentage. Erythrocytes per cb. mm. Hyperchlorhydria. 39 90.9 5,556,000 Hypochlorhydria. 13 83-5 5,431,000 Gastric achvlia. 6 92.1 5,680,000 Gastric dilatation. II 85.6 5,623,000 Gastric neurasthenia. 13 87.2 5,274,000 Chronic gastritis. 14 91.0 5,498,000 From other investigations, Lichty also determined that in the above-named diseases there is no definite relationship between the condition of the blood, the urine, and the gastric contents. In actite gastritis leucocytosis of the poly- Leucocytes. nuclear neutrophile type is common, although not constant ; the increase is most notable in the severest cases, but even in these the count seldom exceeds 1 5,000 or 20,000. Hyperinosis also usually exists. .In chrojiic cases an absence of leucocytosis is the rule, while leucopenia, resulting from defective absorption, is an occasional finding. Relative lymphocytosis is commonly associated with leucopenia, and sometimes with normal leucocyte counts. In a small proportion of cases digestion leucocytosis is either delayed or absent. The presence of a leucocytosis is a valuable Diagnosis, sign in ruling out enteric fever, should the diag- nosis lie between this disease and acute febrile gastritis. This sign, however, can not be employed to differentiate other acute infections, such, for instance, as appendicitis. The blood furnishes no sure means of dififerentiating chronic gastritis from gastric cancer, although a persistent leucocytosis is very suggestive of the latter ; unfortunately, digestion leucocytosis is neither constantly absent in cancer nor invariably present in gas- tritis. Certain cases of chronic gastric catarrh, with atrophy of the stomach tubules, in course of time develop a clinical picture veiy like that of true pernicious anemia, since they present not only a similar cachexia, but also a very striking diminution in hemo- globin and erythrocytes. But pernicious anemia is characterized by the presence of nucleated eiythrocytes the majority of which are megaloblasts, while in the secondary anemia of gastric catarrh erythroblasts are uncommon, and if present show a predominance of cells of the normoblastic type. ' Phila. Med. Joum., 1899, vol. iii., p. 326. GASTRIC ULCER. 345 XXIII. GASTRIC ULCER. The average case shows a loss of approxi- Hemoglobin mately 40 per cent, of hemoglobin, and of AND 1,000,000 erythrocytes to the cubic millimeter, Erythrocytes, and, owing to this prevalence of a dispropor- tionately large oligochromemia, low color indices are the rule. The individual case may show a much greater degree of anemia, but no matter how marked the cellular decrease, it is always far outstripped by the diminution in the percentage of hemoglobin. In fact, in some instances the latter alone is subnor- mal, the blood condition of chlorosis being thus faithfully counter- feited. The average index for the cases tabulated below was 0.72. Profuse hemorrhage may provoke a very marked anemia, while protracted emesis tends to concentrate the blood, thus masking its real condition. The several degenerative changes affecting the erythrocytes, common to any severe anemia, may be present, if the blood deterioration is sufficiently profound. After a severe hemorrhage a few normoblasts not infrequently appear in the blood tempo- rarily, and an occasional cell of this type may be found at other times in cases with marked cachexia. The following summary illustrates the hemoglobin and eryth- rocyte ranges in 20 cases : Hemoglobin. Erythrocytes. From 70-80 % in 5 cases. Above 5,000,000 in i case. ** 60-70 '^ '^ 6 " From 4,000,000-5,000,000 '' 10 cases. " 50-60 '' '' I '^ " 3,000,000-4,000,000 " 6 '' ^' 40-50 '* '^ 4 " *' 2,000,000-3,000,000 '* 3 '' '' 30-40 ^' " 2 " '' 20-30 '' '' 2 "• Average: 57-8% Average: 4,017,000 per cb. mm. Maximum: 80.0" Maximum: 5,200,000 '' " " Minimum: 25.0'' Minimum: 2,450,000 '' '' '' Greenough and Joslin ^ report hemoglobin estimates in 73 cases, of which 34 were below 50 per cent., and 64 below 80 per cent. Of their 43 erythrocyte counts, 24 were below 4,000,000 per cubic millimeter, the color index for this series averaging 0.67, and ranging from 0.35 to 1.4 1. Absence of leucocytosis is the rule, for an Leucocytes, increase occurs only after taking food, or in the event of some complication such as hemor- rhage or perforation. But the fact must be recalled that neither of ^Am. Journ. of Med. Sc, 1899, vol. cxviii., p. 167. 346 GENERAL HEMATOLOGY. these two accidents invariably raises the count ; for example, hem- atemesis is a symptom in fully 50 per cent, of patients suffering from ulcer of the stomach, yet in not more than 25 per cent, of all cases, both those with and those without this symptom, does the number of leucocytes exceed 10,000 to the cubic millimeter. The behavior of the leucocytes in the above-mentioned series of cases may be expressed thus : Above 10,000 in 5 cases From 8,000-10,000 '^ 3 (( (I 6,000- 8,000 " 5 (( 11 4,000— 6,000 " 6 (( Cl 2,000- 4,000 " I case. Average : 8, 188 per cb. mm. Maxinium : 16,000 " '' a Minimum : 2,400 '^ '' i I In cases with leucocytosis the increase affects chiefly the poly- nuclear neutrophiles ; in those without leucocytosis minimum nor- mal or distinctly subnormal percentages of these cells are not un- common, and a total absence of eosinophiles is the general rule, these changes being counterbalanced by a proportionate increase in the small lymphocytes. Hematology gives no aid in distinguishing gas- DiAGNOSiS. trie ulcer from gastralgia, duodenal ulcer and simple gall-stone colic, in all of which leucocytosis is absent. The differences in the blood-pictures of gastric ulcer and cancer are referred to under the latter disease. (See "Malig- nant Disease.") XXIV. GLANDERS. Data are wanting regarding the condition of the hemoglobin and erythrocytes in human glanders, but it is known that leucocytosis is the rule. The bacillus mallei has been obtained by ante-mortem blood culturing, by Duval.^ XXV. GONORRHEA. The hemoglobin and erytJirocytes are unaltered, but the acute febrile stage of specific urethritis is usually accompanied by a moderate polynuclear leucocytosis, which, in the event of any of the inflammatory complications of clap, may be much aggravated. Some authors formerly claimed that circulatory eosinophilia was a feature of this disease, but the more recent investigations of Vorbach - have shown that such a change, while occurring some- 1 Archiv. de med. exper. , 1896, vol. viii., p. 361. 2Inaug. Dissert., Wurzburg, 1 895. GOUT. 347 times, is by no means constant ; he found in twenty cases that the percentage of eosinophiles ranged from as low as 0.05 to as high as 1 1.5. Bettman^ believes that eosinophilia is especially frequent in posterior urethritis, an observation which thus far is unique. XXVI. GOUT. Garrod's^ earlier teachings regarding the lowered alkalinity of the blood in acute gout have been contradicted, apparently with ample proof, by the later researches of Levy,^ who failed to find a diminution in any of the 17 cases which he investigated by the most approved methods. Still more recently, Levy's con- clusions have been corroborated by the studies undertaken by Watson.^ During an acute gouty seizure hypeririosis is an al- most invariable finding. It is questionable whether or not the amount of uric acid in the blood is greater during the acute stages than in the interval be- tween them, but it is nevertheless a fact that in many gouty persons uric acid crystals may be demonstrated in the blood by the '* thread-test" — a reaction by no means peculiar to this disease, as already pointed out. (See page 109.) The cellular elements show no characteristic alterations, and are normal except in long-standing cases in which an ordinary secondary anemia may develop in the course of time. During the acute attack a moderate increase in the number of leucocytes, affecting chiefly the polynuclear neutrophiles, may or may not be found. A relative increase in the eosinophiles is also sometimes encountered, both in cases with and without an increase in the leucocyte count. In one case of the writer's, the blood examined during the height of a severe paroxysm showed 100 per cent, of hemoglobin, 7,125,000 erythrocytes, and 14,000 leucocytes per cubic millimeter, the only peculiar differential change being the presence of myelocytes in the proportion of 0.4 per cent. The occurrence of these cells in gout has also been mentioned by Wat- son,^ who found them in small numbers both during and between the acute seizures. (See page 107.) The same observer also states that he found (apparently in in- creased numbers), cells resembling blood plaques, as large as 4^ in diameter, often forming '* very irregular torn-looking masses." 1 Archiv. f. Dermat. u. Syph., 1899, vol. xxxix., p. 227. 2" Gout and Rheumatic Gout," London, 1876, p. 80. 3Zeitschr. f. klin. Med., 1898, vol. xxxvi., p. 336. * British Med. Journ., 1900, vol. i., p. lO. ^Loc. cit. 348 GENERAL HEMATOLOGY. The worthlessness of Neusser's so-called perinuclear basophilic granules as a diagnostic sign of this condition has been alluded to in a previous section. (Page 1/6.) XXVII. HEMORRHAGIC DISEASES. From a hematological standpoint, scurvv, heui- Gexeral ophilia, and the various forms of purpura may Features, be conveniently considered together, since the blood changes in all of these conditions are sim- ilar, and in none are characteristic. The specific gravity of the blood varies with the degree of anemia present, but only in exceptional instances does it fall to an excessively low figure. Aiello ^ estimated it as low as 1043, in a case of purpura hemorrhagica in which the erythrocyte loss ranged between 50 and 60 per cent. The same investigator also detected methemoglobin in the blood, by spectroscopical examina- tion, in this form of purpura, which he attnbutes directly to auto- intoxication from the absorption of the products of decomposition occurring within the intestinal canal. Immerman " believed that in the late stages of hemophilia an increase in the total quantity of the blood, or a true plethora, exists, but this view is not enter- tained at the present time. Various bacteria, especially streptococci, staphylococci, and bacilli, have been found in the circulating blood by a number of observers, both in scurvy and in those forms of purpura due to infectious diseases. No special clinical significance, however, can be attached to these findings. The specific properties claimed by Letzerich ^ for his bacillus purpurcB are not generally credited. The alkalinity of the blood, according to the studies of Cantani^ and others, is generally decreased in the hemorrhagic diatheses, although more recent investigators have disputed this fact, having found it higher than normal. Wright^ has recently estimated the alkalinity in 7 cases of scurvy, a disease which he believes to be a condition of acid intoxication. He found in 3 of these cases that it corresponded to the figure N. 100, and to N. 200, N. 150, N. 1 10, and N. 80, respectiv^ely, in the remaining 4. As de- termined bv this author's method, the alkalinitv of normal blood is expressed by the formula N. 35, which means, in other words, that the degree of alkalinity is such that a mixture of one volume ^ Rif. med., 1894, vol. ii., p. 103. ^Ziemssen's Handb. spez. Pathol, u. Ther., 1879, vol. xiii., p. 2. ^Zeitschr. f. klin. Med., 1890, vol xviii., p. 517. * " Spez. Pathol, u. Ther. der Stoffwechselkrankh.,'' Leipzig, 1884. ^Lancet, 1900, vol. ii., p. 1556. HEMORRHAGIC DISEASES. 349 of a thirty-five-fold diluted normal acid with an equal volume of blood serum is just sufficient to prevent the latter from reacting with sensitive blue litmus paper. The coagulation of the fresh blood drop is, as a rule, slow, and sometimes incomplete, these characteristics being observed with especial frequency in hemophilics. In such subjects Wright ' determined that clotting may fail to occur until after the lapse of over an hour after the withdrawal of the blood from the vessels, while in other instances the coagulation time ranged from 9 to 14 minutes. Grawitz ^ has called attention to the fact that in cases with long-continued hemorrhage the clotting may be abnormally rapid, as is the case with normal blood after this accident. There are no characteristic changes affecting Hemoglobin the erythrocytes and hemoglobin, the blood- AND picture being that of secondary anemia of variable Erythrocytes, intensity. In the majority of well-marked cases the erythrocytes do not suffer a loss of more than 1,000,000 or 2,000,000 to the cubic milHmeter, but the hemo- globin tends toward a proportionately greater decrease, making a low color index the rule. This is particularly noticeable in scurvy in which condition the hemoglobin loss is often twice as great as that of the cells ; in fact, some cases show simply oligochro- memia, with a normal number of erythrocytes. In 7 cases of infantile scurvy, examined by the writer, the hemoglobin percent- age ranged between 35 and 65, averaging 43.8, and the erythro- cyte count between 2,950,000 and 5, 100,000 per cubic millimeter, the average being 3,527,071. In three of these cases, with counts of 5,100,000, 4,900,000, and 4,814,000, respectively, the corresponding hemoglobin estimates were 52, 50, and 65 per cent. In severe cases, for example, of scurvy and purpura hemorrhagica, the count may fall to less than 1,000,000 and the hemoglobin to 20 per cent, or lower, these changes being accom- panied by all the qualitative alterations typical of a profound secondary anemia which sooner or later may prove fatal. Muir^ reports a case of purpura in which the hemoglobin was only 1 1 per cent., and the erythrocytes 800,000 per cubic millimeter, and still more pronounced losses have been occasionally encountered by other observers. In mild cases the blood may be absolutely normal in every respect. Regeneration is rapid in cases which pursue a favorable course. It is well known that hemophilics appear to be less susceptible to the ill effects of hemorrhage than J British Med. Journ., 1893, vol. i., p. 223. 2 Loc. cit. '^ British Med. Journ., 1900, vol. ii., p. 909. 350 GENERAL HEMATOLOGY. other individuals, and that in this condition recovery from bfood' losses is usually rapid and uneventful, in spite of their number, extent, and chronicity. The leucocytes are usually increased both in Leucocytes, purpura and in scurvy, but in hemophilia a de- cided leucopenia may develop in spite of the ex- isting hemorrhages. The increase is typically polynuclear in most instances, although a relative excess of lymphocytes may occur. Stengel ^ found this change most striking in two cases of purpura hemorrhagica, and the writer has noticed an exaggeration of the lymphocytic tendency of children's blood in a number of cases of infantile scurvy. In 4 of the 7 cases of this condition, referred to in the preceding paragraph, the total percentage of lymphocytes was between 60 and 66 ; in 3 the percentage of polynuclear neutrophileswas from 27 to 35 ; the eosinophiles aver- aged a low normal figure, and in all but a single case myelocytes were found, ranging in percentage from a minimum of i to a maximum of 6, and averaging 2.5 per cent. The actual number of leucocytes varied between 8,000 and 25,000, and averaged 1 5,5 57 per cubic millimeter, all but a single case having a decided increase. Denys^ has called attention to the presence of large numbers of leucocytes in the different stages of degeneration, both in scurvy and in the infectious form of purpura. In all the hemorrhagic conditions above men- Blood tioned, the blood plaques are usually much di- Plaques. minished in number, and sometimes absent. Especially is this the case in grave forms of scurvy and of purpura hemorrhagica. Hayem ^ believes that a marked diminution in the number of plaques plus a deficiency in clotting is a pathognomonic sign of the latter disease. '- XXVIII. HEPATIC CIRRHOSIS. In the early stages of atropine cirrhosis, so long Hemoglobin as the patient's general health is maintained, the and blood remains practically normal, or shows, per- Erythrocytes. haps, only a moderate diminution in hemoglobin. But as the disease progresses, and the patient suffers from gastro-intestinal catarrh, hemorrhages, and circulator}^ embarrassment, an ordinary secondary anemia sooner or later becomes apparent, the intensity of this change depending upon the severity of the primary disease and its associated lesions. 1 "Twentieth Centur}' Practice of Medicine," N. Y., 1896, vol. vii., p. 485. 2Centralbl. f. allg. Pathol., 1893, vol. iv., p. 174. ^Compt. rend. I'Acad. sc, Paris, 1896, vol. cxxiii., p. 894. HEPATIC CIRRHOSIS. 35 I Most advanced cases show a loss of from 2,000,000 to 3,000,000 cells to the cubic millimeter, and a few an even greater oligo- cythemia. Hemorrhages, either repeated and small, or single and profuse, constitute the factor of a profound anemia in many instances. The average case of Laennec's cirrhosis loses more than 50 per cent, of hemoglobin and 30 per cent, of erythrocytes, while in the individual case the count may fall to between 1,500,- 000 and 2,000,000. The color index, as a rule, is moderately low ; it averaged 0.70 for a series of 18 well-advanced cases ex- amined at the German Hospital, a synopsis of which shows these hemoglobin and erythrocyte values : Hemoglobin Number of Erythrocytes Number of Percentage. Cases. per cb. mm. Cases. From 70 to 80 2 From 4,000,000 to 5,000,000 4 '' 60 to 70 2 *' 3,000,000 to 4,000,000 7 ** 50 to 60 5 " 2,000,000 to 3,000,000 6 *' 40 to 50 6 ** 1,000,000 to 2,000,000 1 It 30 to 40 Average: 47.8 per cent. Average: 3,404,000 per cb. mm. Maximum: 80.0 " '^ Maximum: 4,850,000 '' " '' Minimum: 37.0 " ** Minimum: 1,800,000 ** *' '' The effects upon the blood of ascites are probably twofold and diametrically opposed. Primarily it is thought to cause more or less anemia by reason of the steady drain exerted upon the albuminoids of the blood, but this deterioration may be effectually masked by a polycythemia due either to peripheral stasis, or to inspissation of the blood caused by the rapid transudation of liquids from the vessels. This last factor is no doubt the cause of the polycythemia noted by von Limbeck ^ in cases after tapping. On the other hand, Grawitz ^ has demonstrated that a decrease in the hemoglobin and erythrocyte values may follow this operation, in cases in which the presence of a large ascitic exudate interferes with the circulation sufficiently to produce capillary stagnation and a consequent polycythemia, which the tapping dispels. Anemia is apparently more striking and more common in hypertropJiic cirrhosis than in ordinary gin-liver. Judging from a rather limited experience in 6 cases, the writer finds a greater tendency toward corpuscular than hemoglobin loss, and conse- quently toward higher color indices. The index for these cases averaged 0.88, and in two it reached the figures 1.02 and i.oo, respectively. For the series the hemoglobin averaged 51.5 per 1 Loc. cit. 2 Log. cit. 352 GENERAL HEMATOLOGY. cent., the minimum being 22, and the maximum 80 per cent. The average erj^throcyte count was 2,908,333, and ranged from as low as 1,100,000 to as high as 4,290,000 per cubic millimeter. The usual degenerative and other qualitative changes accom- panying any sev^ere secondar>^ anemia may be found in the anemias of liver cirrhoses ; and, in addition, Hayem ^ has obser\'ed that in the hypertrophic variety there seems to be a marked tendency toward megalocytosis. In the great majority of atrophic cirrhoses the Leucocytes, number of leucocytes either remains normal or is distinctly decreased, while a few show a moderate degree of intermittent leucocytosis, to be regarded in all proba- bility, as a post-hemorrhagic change. It is questionable whether or not the jaundice present in some cases accounts for a leucocyte increase, although some authorities profess this belief. The leu- cocytes in the 18 cases tabulated above ranged thus : Leucocytes per cb. mm. From 10,000—15,000 in 4 cases. " 5,000—10,000 " 9 *' Below 5,000 ^' 5 '^ Average: 7? 708 per cb. mm. Maximum: 12,000 ** " " Minimum: 3,000 '' " *' In the 6 cases of hypertropliic cirrhosis the leucocytes averaged 8,800 per cubic miUimeter, the lowest count being 4,400, and the highest 14,800. Two of the estimates were above, and 4 below, 10,000 cells to the cubic millimeter. Much higher counts than these, however, have been reported by others. While it must be admitted that leucocytosis is more frequent in this than in the atrophic variety, Hanot and Meunier's ^ claim that it is a constant symptom of hypertrophic cirrhosis is by no means justified. The leucocytoses of both these forms of the disease depend upon an absolute and relative increase in the polynuclear neutro- philes, at the expense of the other forms of cells. The blood examination fails to provide any DLA.GNOSIS. dependable signs by which cirrhosis is distin- guishable from other lesions of the liver, but a good idea of the inroads made by the disease upon the pa- tient's health may be gained by determining from time to time the grade of the anemia present. 1 " Du Sang," etc., Paris, 1 889. 2Compt. rend. Soc. biol., Paris, 1895, IDS., vol. ii., p. 49. ICTERUS. 353 XXIX. HERPES ZOSTER. The blood changes in shingles have recently been studied by Samrazes and Mathias/ who found no appreciable diminution in the hemoglobin and erythrocytes, and no structural changes affect- ing the latter. Leiicocytosis develops as early as the first day of the eruption, and progressively increases until about the third day, after which it gradually diminishes, until by the fifth day the count again reaches the normal figure. A secondary leucocytosis accompanies the period of desiccation and desquamation. A gain in the polynuclear neutrophiles and eosinophils is accountable for the leucocytosis, which in some instances is associated with a few myelocytes. XXX. ICTERUS. Simple catarrhal jaundice, perse, produces little General or no effect upon the blood, except in the most Features, pronounced cases. The most conspicuous change consists in a greenish-yellow discoloration of the serum, due to the presence of bile. In patients suffering from obstructive jaundice (due, for instance, to gall-stones), a surgical operation may be complicated by dangerous, even fatal hemor- rhage, owing to the slow and imperfect coagulation of the blood. In the Jefferson Hospital, during the past three years, four pa- tients with jaundice due to malignant disease of the biliary appa- ratus have bled to death after operation. The quantity oi fibrin is not increased. The specific gravity of the whole blood increases in relation to the intensity of the icterus, but the density of the serum is unaffected. In severe cases the alkalinity of the blood was found to be reduced, by de Rienzi.^ In mild cases the hemoglobin and erythrocytes Hemoglobin remain unaltered, but in severe jaundice a mod- AND erate anemia is not uncommon, characterized by Erythrocytes, an absence of rouleaux formation, and by evi- dences of endoglobular degeneration marked out of all proportion to the grade of the cellular decrease. This association of a moderate oligocythemia with striking degenera- tive changes in the corpuscles appears to be peculiar to this affec- tion. In cases with symptoms of cholemia these degenerative changes are even more notable, but here the hemoglobin and erythrocyte losses also are more pronounced. Von Limbeck^ has observed that the volume of the individual erythrocyte is ^ Rev, de sc. med., 1901, vol. xxi., p. 251. ^Virchow's Archiv., 1885, vol. cii. , p. 218. 3 i^c, cit. 23 354 GENERAL HEMATOLOGY.- markedly increased. It is possible that in some instances the anemia is actually greater than the blood count indicates, for polycythemia, according to Becquerel and Rodier,^ may develop by reason of inspissation of the blood from the action of bile. Most observers report that no leucocytosis Leucocytes, occurs in simple catarrhal jaundice, but Grawitz,^ on the contrary, states that he finds a constant increase in "uncomplicated cases of icterus," the count ranging in some instances as high as from 30,000 to 40,000 to the cubic millimeter. This author's report, however, does not represent the general consensus of opinion. Severe cases with cholemia may and usually do give rise to a well-developed leucocytosis. The association of icterus with leucocytosis. Diagnosis, except in obviously cholemic patients, suggests some purulent lesion, or malignant disease as the factor of jaundice, rather than uncomplicated duodeno-cholangitis. XXXI. INFLUENZA. General invasion of the circulation by the bacillus infliienzce occurs very rarely, and the positive results from bacteriological exainination of the blood claimed by Canon,^ Klein,^ and their contemporaries must be regarded as unsubstantiated, in the light of the large number of negative findings by Pfeiffer,^ and by Kiihnau.^ Slawyk ^ has recently succeeded in cultivating this organism from the blood of a patient whose predominant symptoms suggested epidemic meningitis. Jehle,^ although he admits the rare occur- rence of Pfeiffer's bacillus in the blood of uncomplicated influenza, claims to have obtained many positive blood cultures of this organism in diphtheria, in pertussis, and in several of the ex- anthemata — measles, scarlet fever, and varicella. He attributes these findings to the fact that these diseases predispose to a secondary infection, especially to an influenzal bacteriemia. The Jieinoglobin and erythrocytes are normal in the great ma- jority of cases, a moderate diminution in these elements having been found only occasionally. Uncomplicated influenza is one of the few examples of an acute infection unaccompanied by a leucocytosis^ although in some in- lArchiv. de Physiol, norm, et path., 1874, 2 s., vol. i., p. 509. 2Loc. cit. ^Virchow's Archiv., 1893, vol. cxxxi., p. 401. * Baumgarten' s Jahresb. , 1893, vol. ix., p. 206. SDeut. med. Woch., 1893, vol. xix., p. 816. ^Loc. cit. ''Zeitschr. f. Hyg. u. Infectionskr. , 1899, vol. xxxii., p. 443. ^Zeitschr. f. Heilk., 1901, vol. xxii., p. 190. INSOLATION. 35 5 stances Jiyperiiiosis may be observed in the early stages of the attack. Rieder ^ states that a complicating catarrhal pneumonia causes either a moderate increase in the number of leucocytes, or none at all, but that in a post-influenzal croupous pneumonia the leucocytosis of this condition develops typically. It is unfortunate that an absence of leucocytosis is common to both enteric fever and influenza, for these two diseases are not in- frequently confused. The serum test, however, generally is con- clusive, if typhoid exists. Should a frank leucocytosis be pres- ent, croupous pneumonia, rather than influenza, is suggested. XXXII. INSOLATION. In the acute stages of thermic fever the Jiemoglobin and ery- tJirocyte values are unduly high, owing to the concentration of the blood from the excessive loss of body fluids by the lungs and the skin. Lambert,^ for example, has observed a hemoglobin percentage of 125 in a sunstroke patient, while Vincent^ states that the erythrocytes may number as high as 300,000 per cubic .millimeter in excess of the normal average count. A more or less pronounced destruction of the erythrocytes also occurs both dur- ing and after the acute stages of insolation, and this factor is re- sponsible for the anemia, sometimes decided, which subsequently develops. Owing to the coexistence of these two conflicting fac- tors, the real extent of the hematolysis cannot be determined until after the disappearance of the symptoms leading to blood concen- tration. This hematolysis is thought to depend upon the presence in the blood of some toxic element, since the hyperpyrexia itself is insufficient to cause disorganization of the cells. Schultze and Ranvier's experiments * have proved that such changes begin only when an animal is subjected to a temperature of from 54° to 56° C. (or 129.2° to 132.8° F.). Levene and Van Gieson^ have shown that the blood serum of sunstroke patients is a highly ac- tive blood-poison to animals, when injected intravenously. Some investigators have found an increased number of leuco- cytes, but others have been unable to detect any such change, so that leucocytosis must be regarded as an inconstant sign, depend- ing, perhaps, more upon the degree of blood condensation than upon any specific influence of the heat-stroke. Pigmented leuco- cytes have been observed in cases in which there existed marked signs of blood destruction. 1 Miinch. med. Woch., 1892, vol, xxxix,, p. 51 1. 2 Loomis-Thompson : "A System of Practical Medicine," N. Y., 1898, vol. iii., p. 877. 3 These d. Bordeaux, 1887-88, n. 8, p. 7. * Cited by Vincent : loc. cit. 5 Cited by Lambert : loc. cit. 356 GENERAL HEMATOLOGY. Wood ^ found that a decreased alkalinity or even an acidity of the blood was a conspicuous post-mortem change, but evidence is lacking to show that the reaction of the blood is altered during life. XXXIII. INTESTINAL HELMINTHIASIS. The presence in the intestinal canal of certain General parasites, notably the bothriocephalus latus and Features, the ankylostomum duodenale, is capable of pro- voking; anemia of marked intensitv in the indi- vidual harboring them. The ascaris lumbricoides also may be held responsible for anemia in some instances, but the blood changes attributable to this parasite are as a rule much less pro- found than those commonly met with in the two preceding forms of helminthiasis. Ostrovosky - has called attention to a case, uhique of its kind, of fatal progressive anemia attributable to the presence in the intestines of the long threadworm, trichocephalus dispar. The cause of these anemias is generally attributed to the systemic effects on the host of certain soluble and absorbable toxic products eliminated by the parasites. That such poisons are produced, and that they undoubtedly can act in this dele- terious manner has been abundantly proved by many different investigators, among whom Hubner,^ Reyner,'^ Schaumann,^ As- kanazy,^ and Lussana" may be named as authorities whom the student should consult for more detailed information on this topic. It is probable also that in cases of ankylostomiasis the anemia is kept up by the constant drain on the system caused by the direct abstraction of blood by the parasite. The blood changes due to bothriocephalus Hemoglobin latus infection are by far the most interesting, AND from the clinician's standpoint, since the anemia Erythrocytes, caused by this worm may in some individuals exactly simulate primary pernicious anemia. The blood-pictures of the two conditions may be identical, both being characterized by marked and disproportionate oligocythemia, and consequently by a high color index, and by the presence of nucleated er^'throcytes, the majority of which conform to the megaloblastic type. This so-called bothriocephalus anemia has 1 " Thermic Fever or Sun-stroke" (Boylston Prize Essay), Phila., 1872. 2Vratch, Sept. 30, 1900. Abstr., N. Y. Med. Journ., 1900, vol. Ixxii., p. 826." 'Deutsch. Archiv. f. klin. Med., 1870, vol. vii., p. 7. * Ibid., 1886, vol. xxxix., p. 31. 5 •' Bothriocephalus- Anemie," Berlin, 1894. ^Zeitschr. f. klin. Med., 1893, vol. xxiii., p. 80. Ibid., 1895, vol. xxvii., p. 492. ^ Rivista clin. , 1889, vol. iv., p. 750. INTESTINAL OBSTRUCTION. 35/ been aptly described by Ehrlich ^ as '* a pernicious anemia, with a known and removable cause." It is distinguishable from true pernicious anemia solely by the fact that after the expulsion of the worm by the administration of appropriate vermifuges the megaloblastic type of blood and the anemia rapidly disappear, and the patient makes an uneventful recovery. The anemia of ankylostomiasis, while it may reach a very high grade of development, still does not counterfeit pernicious anemia. Griesinger's " Egyptian chlorosis," the brick-makers' anemia of the Germans, and the miners' anemia of the Italians, as well as many forms of tropical anemia, are all due to the effects of this nematode. The hemoglobin and erythrocyte loss may individually be as great as is seen in Biermer's disease, but low color indices rule, since the former is more strikingly reduced than the latter. The erythro- cytes are commonly found in a state of marked deformity, both as to shape and size, polychromatophilia may be noted, and eryth- roblasts are often seen, but never, so far as our present knowledge indicates, is there a prevalence of megaloblasts, as there is in both bothriocephalus and in pernicious anemias. Leucocytosis does not accompany any of the Leucocytes, above-named forms of helminthiasis, except as the effect of some comphcation. As already pointed out (see page 200), a conspicuous feature of the blood is the frequent, but not constant, occurrence of both a relative and an absolute increase in the percentage of eosinophiles. The eosino- philia may be moderate or it may be enormous — in a case of an- kylostomiasis reported by Ashford,^40 per cent., or a total count of 7,200 eosinophiles to the cubic millimeter of blood; 72 per cent, in a case of the same disease and 34 per cent, in a patient harboring the tenia mediocanellata, these instances having been reported by Leichtenstern.^ Even the oxyuris vermicularis, al- though it is not considered to be a factor in the production of anemia, may cause a well-marked increase in the percentage of eosinophiles, these cells sometimes constituting from 10 to 15 per cent, of all forms of leucocytes. XXXIV. INTESTINAL OBSTRUCTION. The hemoglobin and erythrocytes are unaffected, except in ob- struction due to malignant disease or associated with hemor- rhage, in which there may be a moderate secondary anemia. J Loc. cit. 2N. Y. Med. Journ., 1900, vol. Ixxi., p. 552. 3 Cited by Ehrlich : loc. cit. 358 GENERAL HEMATOLOGY. Leiicocytosis is a frequent, though not a constant, accompani- ment of all forms of ileus, even those with comparatively slight symptoms. The increase is most constant in obstruction de- pending upon malignant disease or complicated by gangrene and peritonitis, and in this class of cases it tends to reach the highest figures, except in the event of grave intoxication. Bloodgood ^ regards the presence of a high leucocytosis (20,000 to 30,000) on the third or fourth day after the onset of symptoms as a favorable indication for operative interference, but he considers that low counts (below 10,000) under the same circumstances indicate extensive gangrene-peritonitis, or that the patient will be so de- pressed that reaction can not follow reHef of the obstruction. XXXV. LEPROSY. The studies of Winiarski,^ and of P. K. Brown, '^ show that in the early stages of this disease neither the Jiemoglobin nor the erythrocytes suffer any deterioration, but that in advanced leprosy, especially in cases with extensive ulcerative lesions, the anemia may be striking — quite as marked, in fact, as in a moderately severe case of true Biermer's anemia. In such instances there is a conspicuous oligocythemia in comparison to the oligochro- memia, and the counts may fall to below 2,000,000 to the cubic millimeter. A tendency toward megalocytosis, and high color indices has been observed, the index in some counts being as high as 1.7. Polycythemia, resulting from peripheral stagnation, may be a feature of some cases. The number oi leucocytes is not increased, but a relative lymphocytosis is a commonly-observed differential change affecting these cells. Both Brown ^ and Streker"^ have succeeded in demonstrating the bacillus leprce in the circulating blood during life. These organisms, as a rule, were found to be enclosed in the leucocytes, and, more rarely, lay free in the plasma. On the other hand, Bibb ^ failed in 30 cases to find the bacillus by blood culturing, although he obtained positive results constantly with blood as- pirated from the leprous tubercles. The serum diagnosis of leprosy has not yet come into general clinical use, although positive clump reactions with cultures of the leprosy bacillus and the serum of lepers have been observed. ^Am. Med., I901, vol. i., p. 306. 2 St. Petersburg nied. Woch., 1892, vol. ix., p. 365. 3 Trans. California State Med. Soc, 1897, vol. xxvii., p. 168. *Munch med. Woch., 1897, vol. xliv. , p. 1103. 5 Am. Journ. of Med. Sc, 1894, vol. cviii., p. 539. MALARIAL FEVER. ' 359 XXXVI. MALARIAL FEVER. The specific cause of malarial fever is a form Parasitology, of blood parasite generally known as the plas- moditim inalarice or the heniameba malarice, an organism classified among the Sporozoa, according to Metchni- koff ^ First accurately described in 1880, by Laveran,^ a medical officer of the French army, stationed in Algeria, our knowledge of the parasite and its relation to the malarial fevers has been furthered chiefly by the researches of Richard,^ also a French army surgeon ; of Grassi and Filetti,* in Sicily ; of Mannaberg,^ in Austria; of Marchiafava and Celli,^ Bastianelli and Bignami,^ and Golgi,^ of the Italian school; and of Councilman and Abbott,^ Stern- berg,^° Osler,^^ Dock,^^ and Thayer and Hewetson,^^ in America. In addition to these principal investigators, numerous workers in other parts of the world have materially advanced our knowledge of the subject/"^ Developmerital Cycle in Man. The malarial organism gains entrance to the erythrocyte of man, in which it pursues a definite cycle of development, at the expense of its corpuscular host. Existing in its earliest stages as a hyaline, ameboid body within the substance of the corpuscle, the parasite increases in size, and derives fine pigment granules from the hemoglobin of its host, which it ultimately destroys at the time its full maturity is attained. Full development of the parasite having been reached, it divides into a number of segments, which, by the rupture of the blood cell, are set free to enter fresh, uninvaded erythrocytes and there iCentralbl, f. Bakt. u. Parasit., 1887, vol. i., p. 624. 2 " Nature parasitaire des accidents de I'impaludisme," Paris, 1881. 3Gaz. med. d. Paris, 1882, vol, iv., p. 252. ^Centralbl. f. Bakt. u. Parasit., 1890, vol. vii., pp. 396 and 430. Ibid., 1891, vol. ix., pp. 403, 429, and 461. Ibid., vol. x., p. 449. 5 " The Malarial Parasites," New Sydenham Soc. Transl., London, 1894, vol. cl., p. 241. ^Forschr. d. Med., 1885, vol. iii., p. 787, Ibid., 1888, vol. vi., p. 450. Also Festchr. z. Virchow's 70. Geburtstag, 1891, vol. iii., p. 187. ''Riforma med., 1890, vol. vi., pp. 860, 866, and 872. Also Lancet, 1898, vol. ii., p. 1461, 8 Archiv. per le sc. med., 1886, vol. x., p. 109. 9 Am. Journ. of Med. Sc, 1885, vol. Ixxxix., p. 416. Also Med. News, 1887, vol. i., p. 59. '°Med. Record, 1886, vol. xxix.,pp. 489 and 517. JiPhila. Med. Times, 1886, vol. xvii., p. 126. 12 Med. News, 1890, vol. Ivii., p. 59. Ibid., 1891, vol. Iviii., pp. 602 and 628. ^3 Johns Hopkins Hosp. Reports, 1895, vol. v., p. 3. ^* For an exhaustive bibliography the reader should consult Thayer's admirable monograph, "Lectures on the Malarial Fevers," N. Y., 1897. An authoritative account of the malarial fevers in all their phases is given in Celli's book, " Malaria According to the New Researches," English translation by J. J. Eyre. London and N. Y., 1900. 360 GENERAL HEMATOLOGY. to initiate a new developmental cycle of similar characteristics. Segmentation or sporulation of a group of parasites is accompa- nied by a paroxysm, which is in all probability due to the influ- ence of certain toxic material liberated at this time. But in order to complete its full life cycle, the malarial parasite must also pass through a developmental phase within the bodies of certain mosquitoes, for it has been shown that these insects not only act as the intermediate hosts of the parasite, but also cany the infection by means of their bite. These important discoveries were first made by Ross,^ whose conclusions were shortly con- firmed by Grassi, Bignami, and Bastianelli,^ and by others of the ItaHan school. Developmental Cycle in the Mosquito. While in the human body the malarial parasite pursues an asexual cycle, terminating in segmentation, in the body of mosquitoes of the genus Anopheles it follows out a true sexual cycle. In the blood of man certain of the parasites which do not undergo segmentation, constitute sexual forms of the organism, known as gametes, which, after having been imbibed by the mosquito while biting a malarious individual, develop into impregnated bodies by reason of the fe- cundation of the female sexual elements, or 7nacroganietes, by the free flagella, or microgainetes, which have become detached from the male sexual elements, or microgametocytes. The resultant fertilized bodies develop into motile pseudo-verjnicules, which, having penetrated the muscular wall of the mosquito's stomach, lodge and become encysted in this situation and are now known as zygotes. From the latter are derived large numbers of delicate spindle-shaped cells, or sporoblasts, which, by the rupture of the zygote' s capsule, are set free, and, as sporozoids^ make their way into the salivary gland of their host, whence they pass by way of the salivary duct into the proboscis of the insect, and conse- quently into the circulating blood of the individual stung by the infected mosquito. The sporozoids thus inoculated into the blood of man, penetrate his erythrocytes, in which, as the young hyaline forms of the malarial parasite, they pursue the typical develop- mental cycle to be described below. Thus, it has been definitely shown that mosquitoes of the genus Anopheles are capable of transmitting malarial infection from man to man, and it is now generally believed that this, the only proven method of malaria transmission, is probably the sole means by 1 " Report on the Cultivation of Proteosoma (Labb6) in Gray Mosquitoes." Cal- cutta, 1898. * Reals Accademia dei Lincei. Estratto dal, vol. vii., 2° sem., ser. 5a., fasc. 11°. Seduta del 4 dicembre, 1898. Abst. in Progressive Med., Phila., 1899, vol. i., p. 287. See also Bignami, Lancet, 1898, vol. ii., pp. 1461 and 1541. Grassi, II Policlinico, 1898, vol. v., p. 469. p. p. v SINGLE TERTIAX IXFECTIOX. Paroxysm every third day. R P. P. * * * 10 P. 11 CHART III, P. \r 12 13 p. DOUBLE TERTIAN IXFECTIOX. Daily paroxysm. p. P. p. P. P. P. P. V V V ^ \^ 10 11 V 12 SINGLE QUARTAN INFECTION. Paroxysm every fourth day. P. P. P. * * * P. * 10 11 12 13 P. * DOUBLE QUARTAN INFECTION. Paroxysm on t\\-o successive days willi one day's intermission. P. P. P. P. P. P. P. ■f V ^ 10 V 11 12 13 P. y= 14 P. * P. ^=^ TRIPLE QUARTAN INFECTION. Daily paroxysm. P. P. P. P. P. P. P. \^V^ y~V V — ^^^ 6 S 9 10 11 12 CHART ILLUSTRATING THE DIFFERENT TYPES OF FEVER RESULTING FROM INFECTION WITH SINGLE AND WITH MULTIPLE GROUPS OF MALARIAL PARASITES. The duration of the parasites' cycle of development is expressed by colored lines, thus: Black: First group of parasites. Red: Second " " ' " Blue: Third " " " " P: Paroxysm. MALARIAL FEVER. 36 1 which the disease is spread. The ordinary house-mosquito, of the genus Ciilex, is not concerned in the transmission of malaria, since it has been proved that the parasites do not follow out a developmental cycle within the body of this insect. For a complete review of the ''mosquito theory" of malaria, embracing the recent work of Ross, Manson, MacCallum, and the Italian school, the reader should consult Thayer's ** Recent Advances in our Knowledge Concerning the Etiology of Malarial Fever," ^ Futcher's "A Critical Summary of Recent Literature Concerning the Mosquito as an Agent in the Transmission of Malaria," ^ and Howard's " Mosquitoes." Varieties of the Malarial Parasite. Three distinct varieties of the parasite are recognized, each of which has been found con- stantly associated with a specific type of malarial infection. These three varieties are : 1. The parasite of tertian fever ^ associated with a regularly intermittent type of fever, with paroxysms every third day. 2. The parasite of quartan fever, associated with a regularly intermittent type of fever, with paroxysms every fourth day. 3. TJie parasite of estivo-autumnal fever, associated with the more irregular types of fever. The parasites of tertian and of quartan fever exist in the blood of the infected individual in great groups consisting of immense numbers of organisms all of which are approximately at the same stage of development, and therefore undergo sporulation at about the same period. This fact serves to explain the regularity of the tertain and quartan paroxysms. On the other hand, in estivo- autumnal infections this regular grouping of the parasites is often wanting, and large numbers of this organism commonly exist in the blood in different stages of development. Sporulation thus taking place at irregular intervals, irregularity in the occurrence of the estivo-autumnal paroxysms is extremely common. As the development of these three types of the malarial para- site progresses, certain forms are evolved which possess more or less common characteristics, so that it is convenient to speak of these forms, which represent the maturing phases of the or- ganism, as follows : (^) The intracellular hyaline forms. (^) The pigmented intracellular forms. ( ^ ) The pigmented extracellular forms. (^) The segmenting forms. ( ^) The flagellate forms. 1 Proc. Phila. Co. Med. Soc. , 1900, vol. xxi., p. 211. 2 Am. Journ. of Med. Sc, 1899, vol. cxviii., p. 318. 362 GENERAL HEMATOLOGY. Furthermore, in parasites of the estivo-autumnal type addi- tional forms, those of the crescent group, are met with, these varieties being pecuhar to this type of infection, and never occur- ring in tertian and quartan fevers. Tertian infections constitute the prevailing type of malarial fever in almost all countries in which the disease exists. Quartan fevers are relatively uncommon, except in certain hmited districts, parts of Sicily, for example, in which a large proportion of the cases conform to this type. Estiv^o-autumnal fevers are especially common in the tropics, but this type of the disease is by no means incompatible with temperate regions. In Philadelphia and its en- virons tertian infections are about five times as common as those of the estivo-autumnal type, while quartan malaria is practically unknown. The writer has seen but a single instance of quartan infection in this vicinity, and this case was without doubt imported. The Parasite of Tertian Fever. (Plate VI . ) The tertian parasite attains its full development in about forty-eight hours, segmenta- tion of a single group of organisms at this interval producing the characteristic paroxysms every third day. Infection with two dis- tinct groups of parasites, each maturing on successive days, gives rise to a quotidian type of fever, characterized by the occurrence of daily paroxysms. (See Chart III., p. 361.) Infection with more than two groups is extremely rare, and produces an atypical and irregular type of fev^er. Anticipation of the paroxysm, which is especially frequent in tertian fever, may be explained by a precocity displayed by a group of parasites, by virtue of which their development is so rapid that the stage of sporulation is reached before the expira- tion of forty-eight hours. On the contrary, should the develop- ment of a group happen to be slower, requiring more than forty- eight hours for its full maturity and sporulation, then the paroxysm is retarded. If a specimen of fresh, unstained blood from a case of tertian fever is examined during the period immediately or shortly fol- lowing the malarial paroxysm, it will be observed that many of the erythrocytes contain small, pale, transparent, foreign bodies, dim of outline, more or less markedly ameboid in character, and of a peculiar dirty, grayish-pearl tint. These bodies, known as the intracellular hyaline forms, represent the youngest forms of this organism, being derived from the sporulation of the im- mediately preceding group of parasites. They may occasionally be found in the peripheral blood toward the latter part of the paroxysm, and for a short time after the occurrence of this phenomenon. PLATE VI. ■■'■•v^?' 10 11 12 ■.;• » 13 14 15 16 The Tertian Parasite. 1. Normal erythrocyte. 2, 3, 4, 5. Intracellular hyaline forms. 6, 7. yoiuig pigviented intracellular forms. In 6 two distinct parasites inhabit the ery- throcyte, the larger one being actively ameboid, as evidenced by the long tentacular process trailing from the main body of the organism. This ameboid tendency is still better illustrated in 7, by the ribbon-like design formed by the parasite. Note the delicacy of the pigment granules, and their tendency toward peripheral arrange- ment in 6, 7, and 8. 8. Later develofimental stage of 7. In 7, 8, and 9 enlargement and pallor of the infected erythrocyte become conspicuous. 9. Mature intracellular pigmented parasite. ID, II, 12. .'Segmenting forms. In 10 is shown the early stage of sporulation — the develop- ment of radial striatiotis and peripheral indentations coincidentally with the swarm- ing of the pigment toward the center of the parasite. The completion of this process is illustrated bv 11 and 12. 13. Large sivollen extracellular form. Note the coarse fused blocks of pigment. (Com- pare size with that of normal erythrocyte, i.) 14. Flagellate form. IS- Shrunken and fragmenting extracellular forms. 16. Vacuolation of an extracellular form. Note. — The original water-color drawings were made from fresh blood specimens, a Leilz x2-iiich oil-immersion objective and 4 ocular, with a Zeiss camera-Iucida, being used. (E. F, Fabkr, /^-eight- and seventy-two- hour cycles in which the tertian and quartan organisms round out their life histories. In some instances the cycle of the estivo- autumnal parasite is of only twent}'-four hours' duration, while in others it is quite forty-eight hours, or perhaps longer. This in- constancy of type is thought to depend upon some peculiarity of the organism, by virtue of which the time required for its matu- ration may widely fluctuate under different conditions of quite obscure character. It is not generally believed that the com- mon types of fever, quotidian and tertian, respectively, depend PLATE Vlll. •••#0d^ € ^ ♦ 10 11 > O 12 . 13 14 % t 5 19 20 21 22 15 16 17 18 -^1 « 23 24 ^ ^ 26 25 Thk Estivo-Autumnai- Parasite. 1. Normal erythrocyte. 2, 3. Voi/ti,^ hvaliue rin^- forms. 4. 5, 6. Iniracellular hyaline forms. In 4 the parasite appears as an irregularly shaped disc with a thinned-oui central area. In s and 6 its ameboid properties are obvious. 7. Young pigmented intracellular form. Note the extreme delicacy and small number of the pigment granules. (Compare with 6, Plate \'I, and with 3, Plate VII.) 8. 9. Later developmental stages of 7. ID, II, 12. Segmentins: forms. I"^, 14. Crescentic forms at early stacres of their development. 15, 16, 17, iS, 19. Crescentic forms. In 15 and 19 a distinct " bib" of the erythrocyte is visible. Vacuolation of a crescent is shown in 18, and polar arrangement of the pigment in 17. 20. Oval form. 21, 22. Spherical forms. 23. Flagellate form. 24. I'acuolation and deformitv of a spherical form. 2s. yacHolated leucocyte apparently enclosing a dwarfed and shrunken crescent. 26. Remains of a shrunken spherical form. (E. F. V^HKR, fee.) MALARIAL FEVER. 3/1 Upon infection with two special forms of the estivo-autumnal parasite, although this view is held by some authors, notably by Mannaberg,^ and by Marchiafava and Bignami,^ all of whom rec- ognize both a quotidian and a tertian variety of the organism ; the formei-, furthermore, describes a pigmented and an unpig- mented form of the quotidian variety. Certain phases of the young hyaline forms of the estivo- autumnal parasite bear a striking resemblance to similar forms of the tertian and quartan organisms, but other phases are, on the contrary, just as strikingly dissimilar. As a rule, the estivo- autumnal hyaline body is much smaller than those just described, its margins are more sharply defined from the corpuscular sub- stance, and it appears to possess a greater degree of refraction. But these are minor points of difference, the chief distinction relating to the peculiar morphological changes to be observed in these immature parasites. At one moment they may appear as pale, rounded or somewhat oval bodies, situated rather toward the periphery of the corpuscle than in its center, and usually possessing active ameboid movements which produce various stellate and forked designs. On closer observation, certain other striking changes may be noted in these round forms. These changes consist in the formation of the so-called ring-shaped bodies, due to the development of a more or less marked bicon- cavity of the hitherto flattened hyaline body, either in its center, in event of which the parasite appears as a true ring or hoop, or more toward its periphery, in which instance a figure resembling a signet-ring is produced. These figures remain visible for a variable length of time, the parasite meanwhile being apparently in a resting stage, but sooner or later its ameboid powers are reasserted, with the result that the biconcavity abruptly disappears, converting the ring-shaped body into its original form of an ameboid, flattened disc. This successive alteration in shape, from disc to ring to disc, regardless of the other changes in shape, is highly characteristic of the estivo-autumnal organism, and is fully as valuable a diagnostic sign as the more striking pictures of the maturer forms, to be considered later. The size of the ring- shaped parasites varies from less than 2 // in diameter, to about 3 fx. They are rarely situated in the exact center of the cor- puscles, more commonly being found lying midway between the center and the periphery, or, indeed, quite upon the latter. As the parasite matures, pigment, in the form of a few ex- ceedingly fine, scattered granules, begins to appear. The gran- iNothnagel's Spec. Path. u. Ther., Wien., 1899, vol. ii., p. 68. 2New Sydenham Soc, Transl., London, 1894, vol. cl., p. i. 3/2 GENERAL HEMATOLOGY. ules are very few in number, dark brown in color, and are usually situated toward the edge of the organism. They may or may not be motile, usually not. Strikingly pigmented forms of the estivo-autumnal parasite are never observed, in marked contrast to the abundant fine pigment of the tertian forms, and to the coarse granules typical of the quartan varieties. The development of the parasite up to this stage can be studied in the peripheral blood, but the older forms of the pigmented bodies, and their final division into spores, by segmentation, occur almost exclusively in the deeper circulation, and must be fol- lowed out in blood obtained from one of the internal organs, such as the spleen, which may be aspirated for this purpose, although the procedure is not without risk to the patient. In the finger blood the wTiter has never seen presegmenting forms more ma- ture than those represented by the young slightly pigmented parasite, and has never had the good fortune to meet with seg- menting bodies except in specimens derived from the spleen. The general rule is to find in the peripheral blood nothing more than hyaline ameboid and ring-shaped bodies, or, perhaps, a few organisms containing two or three minute granules of pigment. If now a drop of blood, aspirated from the spleen, is examined, the remainder of the parasite's cycle may be traced with fair ac- curacy. As it approaches the stage of segmentation^ the para- site develops into a spherical body, measuring from about 2 to 6 // in diameter, and having a distinct outline which limits it from the surrounding substance of the red blood corpuscle, which it only partly fills. The pigment granules, which by this time are moderately but never strikingly increased in num- ber, show a marked tendency to become concentrated near the center of the organism. They here exist as a tightly clumped, compact mass, in which the identity of the individual granules is completely lost, as they have now become fused into a single distinct, dark-colored, round or somewhat elongated mass. As segmentation commences, the parasite becomes opaque, minute refractive areas paralleling the periphery develop, and radial shadings, which later divide the body usually into from eighteen to twenty spores, become apparent. The segmenting body is smaller than that of the tertian and quartan parasites, but it usually resembles the former as to the arrangement and num- ber of the individual segments. A marked characteristic of the estivo-autumnal infections is the early occurrence of degenerative changes in the invaded erythrocytes. These changes, the '^erythropyknosis" of the MALARIAL FEVER. 3/3 Italian school, consist in the development of a pronounced ''brassy" appearance of the blood cell, together in many in- stances with distinct crenation along its periphery and in various portions of its flat surface. Occasionally, there appears to be a distinct concentration of the hemoglobin about the parasite, leav- ing portions of the corpuscle quite colorless. This corpuscular degeneration occurs early, even in those cells occupied by the youngest hyaline bodies, and grows more and more marked, as a rule, as the parasite matures. Simple decolorization of the erythrocyte appears to follow no fixed rule, for segmenting bodies have been observed in both perfectly hyaline and in ap- parently unchanged corpuscles. In Thayer's experience the rim of the blood cell surrounding the parasite has usually been entirely devoid of color. After the infection has existed for a week or more, examination of the peripheral blood, which until now has contained perhaps only ring-shaped organisms, reveals the presence of other highly characteristic forms of the estivo-autumnal parasite, the round, ovoid, and crescentic bodies, all belonging to the crescent group. These forms, which are never present in the circulation during the first days of the fever, are prone to persist in the blood for a long period after the disappearance of the earlier forms of the parasite, and even after all the clinical manifestations of the attack have vanished. Unlike other forms of the malarial para- site, those of the crescent group are peculiarly resistant to the effects of the administration of quinine, large doses of this drug having in many instances no appreciable effect in causing their disappearance from the peripheral circulation. Crescents are now generally regarded as of intracellular origin, being transformed stages of the full-grown, pigmented, intracel- lular spherical bodies which have not been involved in the proc- ess of segmentation. These non-segmenting forms continue their development within the corpuscle, from which they derive more and more pigment, thus causing progressive decolorization of their host, until finally all that remains of the corpuscle is a thin shell surrounding the crescent. As their growth progresses, the parasite first loses its regular spherical contour, then becomes drawn out into a long, narrow, spindle-shaped body, which finally becomes bent in the shape of a crescent, the convexity of which lies next to, and for some distance parallels, one margin of the now almost colorless erythrocyte. Owing to the fact that the early development of these crescentic forms occurs almost exclusively in the deeper circulation, only the later phases of their evolution are ordinarily observed in the periph- 374 GENERAL HEMATOLOGY. eral blood. In fresh blood they appear as highly refractive cres- cent-shaped bodies, measuring about 6 or 8 ii from pole to pole, and possessing a distinct double outline, as if they consisted of a central darker body enclosed in a lighter colored membra- nous envelope. Adhering to the concave surface of the crescent a more or less distinct *'bib," the remnant of the corpuscular host, may usually be observ^ed. It varies in color from pale yellow to an almost indistinguishable shade of light lemon, yet always, on close observation, retaining sufficient of the corpuscular color to distinguish it from the parasite to which it is attached. The **bib" completely bounds the concavity of the crescent in some instances, extending from pole to pole ; in other instances, and this is of commoner occurrence, it is of smaller size, extending only over the central portion of the concavity. Occasionally crescentic bodies totally devoid of all traces of their corpuscular host are found, but these forms are rare. The pigment is usually arranged in a moderately compact clump in the center of the crescent ; less commonly the granules are scattered along the long axis ; and very rarely a distinct polar grouping of the pig- ment at both ends of the crescent is seen. The pigment gran- ules may or may not show active motility. The ovoid bodies, which are regarded simply as transitional forms of the crescents, are of symmetrically oval shape, and show the same refractive protoplasm and apparently double outline ob- served in the latter. The pigment, which is generally motionless, is arranged in an elongated clump in the center of the ovoid, and a partly decolorized bib-like corpuscular attachment apparently clings to one side of the body. The long diameter of the ovoid body measures approximately 5 or 6 // and its short axis is about 2 or 3 /J across. The round forms, derived from the crescentic and ovoid bodies, are the direct antecedents of the flagellate organisms. They appear as perfect spheres, 4 or 5 tj. in diameter, either attached to a more or less yellowish remnant of the erythrocyte, or lying entirely free. Their pigment is prone to form a central wreathed or ringed design. The approach of flagellation is preceded by unusual activity of the central pigment mass, coincidentally with which indications of motility about the peripheiy of the parasite become apparent. The flagella, which are finally seen to reach out from different points on the periphery of the body, are similar in appearance to those of the tertian and quartan organisms. Their size, however, is about midway between that of the tertian and quartan forms. Degenerative changes of the crescentic, ovoid, and round bodies MALARIAL FEVER. 3/5 occur, being evidenced by the development of vacuolization, and occasionally by apparent fragmentation. Pigmented leucocytes are found in the blood Pigmented of all types of malarial infection, and this fact Leucocytes AND alone, irrespective of the presence of the parasites Phagocytosis, themselves, is an extremely valuable diagnostic clue to the condition. In tertian and quartan infections the large mononuclear and polymorphonuclear leucocytes are the pigment-bearing cells, the granules being found either scattered in fine masses or in fused angular blocks throughout the body of the leucocyte. Although both of these forms of leucocytes show this evidence of having acted the role of phagocytes, actual visual proof of the performance of this function by the mononuclear forms is wanting. The phe- nomenon of phagocytosis by the polymorphonuclear leucocytes may, however, be watched in the fresh specimen, and these cells may be seen to engulf bits of free pigment, flagellate bodies, bas- tard forms of extracellular parasites, and even, rarely, true seg- menting bodies. Distinct periodicity characterizes the perform- ance of phagocytosis in tertian and quartan infections, this process being most conspicuous at the time of segmentation, during and shortly after the paroxysm, when the extracellular forms of the organism are present in the blood in greatest number. Phagocy- tosis is sometimes seen during the interparoxysmal interval, when only the extracellular forms of parasites which have prematurely escaped from their corpuscular host are attacked. In estivo-autumnal infections macrophages, derived from the spleen, bone marrow, liver, and blood vessel endothelium, act as phagocytes, as well as the mononuclear and polymorphonuclear cells which alone exercise this function in the regularly intermit- tent fevers. Phagocytosis is much less periodical than in tertian and quartan infections, for while it is true that pigmented leuco- cytes are most numerous in the blood at the time of segmenta- tion, it is also true that they may also be observed in great num- bers during the interval — a fact which is explained chiefly by the practically continuous segmentation which goes on in these infec- tions, because of the presence in the blood of multiple groups of the parasite. Phagocytosis in estivo-autumnal fever differs from that of tertian and quartan infections in that in the former inclu- sion of both parasite and corpuscular host may occasionally be ob- served — a phenomenon which does not occur in the latter. Thus, in addition to free pigment, and extracellular, segmenting, and flag- ellate forms, the phagocytic leucocytes are found also to contain whole or portions of necrobiotic erythrocytes, some of the latter, 376 GENERAL HEMATOLOGY. perhaps, enclosing parasites. Osier ^ has observed the phagocy- tosis of crescentic forms, and the writer believes he has observed the result of this phenomenon in a single instance. (See Plate VIII., figure 25.) Differential Table of the Malarial Parasites' Tertian Parasite. Quartan Parasite. Cycle, 48 Hours. Cycle, 72 Hours. Hyaline body larger than that of quartan and estivo- autumnal organisms ; out- line indistinct ; ameboid movements exceedingly active ; long pseudopodia common. Pigment granules fine^ very active, and of yellowish brown color ; more or less peripherally arranged. Mature parasite about 7 // in diameter. Segmenting bodies consist of from 15 to 30 segments, j arranged in an irregular racemose figure about one or more central pigment clumps. Preflagellate forms consist of swollen, spherical pig- mented bodies as large as 10-12 fi in diameter. Flagellate form larger than that of quartan and estivo- autumnal parasite. Erj-throcyte becomes very pale and swollen. Hyaline body smaller than that of tertian, but usu- ally larger than that of estivo-autumnal organ- ism ; outline distinct ; ameboid movements slow, except in early forms ; marked pseudo- podial branching un- common. Pigment granules coarse, sluggish, and of dark- brown color ; peripheral arrangement striking. Matiu-e parasite about 5 u in diameter. Segmenting bodies consist of from 6 to 1 2 segments, arranged in regular ro- sette form about a single, compact, central pigment mass, the latter often be- ing radially grouped in the early stages of spor- ulation. Preflagellate forms consist of swollen, spherical pigmented bodies as large as 6-8 /z in diameter. Flagellate form smaller than that of tertian and estivo-autumnal parasite. Erythrocyte becomes dark and contracted. ESTIVO-AUTUMNAL PaRASITE Cycle, 24 to 48 Hours or Longer. Hyaline body smaller than that of tertian and quar- tan organisms ; outline ver}' sharp and distinct ; ameboid movements ac- tive in early stages ; ring- and disc-shaped forms. Pigment granules exceed- ingly fine and scanty ; may be either motion- less or motile ; periph- eral arrangement often marked. Mature parasite from 1. 5 to 7 // in diameter. Segmenting bodies consist of from 18 to 20 or more segments, arranged either as a regular ro- sette or irregularly about a single compactly fused central pigment clump. Preflagellate forms consist of spherical pigmented bodies, 5-6// in diam- eter, and derived from crescentic and ovoid forms with which they are associated. Flagellate form smaller than that of tertian, but larger than that of quar- tan parasite. Erythrocyte becomes brassy and crenated. TccJmiqiie of the Blood Examination. For diagnostic purposes' the fresh, unstained blood film should be invariably preferred to the dried, stained specimen, for in the latter not only are the ame- ^ British Med. Joum., 1887, vol. i., p. 556. MALARIAL FEVER. 377 boid movements of the parasite and the dancing of the pigment necessarily lost, but much of the morphology and the finer struc- ture of the organism is also greatly altered. The blood is obtained in the usual manner, and a drop used which is small enough to insure an exceedingly thin film, consisting of a single layer of corpuscles, each lying edge to edge, so that every portion of their flat surfaces may be readily searched for foreign bodies. Specimens in which most of the cells stand on edge, piled together in heaps and rouleaux, are entirely unsuitable, if intra- cellular forms of the parasite are being searched for, since in such films only the extracellular forms are visible. Thin, even films are facilitated by gently heating the slide over an alcohol flame, or by instructing an assistant to rub the surface of the slide vigorously with a dry towel before making the spread. If the examination is likely to be prolonged, it is advisable to ring the cover-glass with cedar oil or with vaseline, to prevent crenation of the corpuscles. Dried blood films, prepared in the usual way, may be used in case the specimens must be sent some distance for examination. Such specimens may be stained with various aniline dyes, as already directed. Polychrome methylene-blue gives the sharpest differentiation of the parasite's histological structure, but solutions of thionin and of eosin and methylene-blue also will prove useful. (See pages 67 and 69.) No magnification can be too great in studying the finer points of the malarial parasite, so that a -^^ inch oil-immersion objective, with at least a 1^ inch ocular, should be habitually employed for the microscopical examination. While it is frequently con- venient to search for individual parasites with a -g- or a ^ inch lens, one cannot well dispense with an immersion objective in distinguishing their finer characteristics. The substage condenser and iris diaphragm should be so adjusted that the field is dimly illuminated, and not drowned in a flood of white light. When the ameboid movements of the parasite are to be studied at length, a warm stage is useful, but not essential, if the temperature of the room is not too low. The best time for the examination is a few hours before the onset of the expected paroxysm, at which period it is common to find full-grown pigmented organisms, and often an occasional segmenting form, if the specimen is from a tertian or quartan in- fection. In estivo-autumnal fever relatively large ring- and disc- shaped bodies, containing exceedingly delicate pigment granules, are usually abundant at this time. Hyaline intracellular forms are most numerous in the blood a few hours subsequent to the paroxysm, in all three forms of the infection. 3/8 GENERAL HEMATOLOGY. The writer would urge the beginner systematically to study the development of a group of parasites by examining the blood of a single case of malarial fever at frequent intervals between the paroxysms. For example, the life history of the tertian parasite, from the youngest hyaline form to the segmenter and the flagel- late body, may be traced in most cases of tertian fever, if the blood is examined ever>^ three or four hours, day and night, for a period of forty-eight hours. Such a collated series of observa- tions, although they entail close and tiresome application for the time, will prove more profitable to the student in his comprehen- sion of the organism's developmental cycle than dozens of hap- hazard examinations made in many different cases at odd times. To the unpractised eye a number of artefacts occurring in fresh blood specimens may for a time be confused with the malarial par- asite, but careful observation linked to an increased familiarity with the appearance of the organism and of its counterfeits, will eliminate such sources of error. The following are the principal objects which require to be differentiated from the malarial par- asite : (i) The central biconcavity of the normal erythrocytes; (2) morphological changes in the erythrocytes, and (3) hemoconiae. 1. At first glance, the pale central biconcavity of the erythro- cyte somewhat resembles the young hyahne tertian parasite, for both have an indistinct outline which merges with the surround- ing corpuscular substance. But the parasite is rarely in the cen- ter of the blood cell, it is actively ameboid, and it possesses a characteristic pearly-gray appearance. On the other hand, the pale area of the corpuscle is in the center of the normally shaped blood cell, it never exhibits ameboid powers, and its appearance is clean white or yellowish-white. It is, of course, uncolored in the stained specimen. 2. The morphological changes in the erythrocyte, which may be mistaken for malarial organisms, are those produced by vac- uolization, crenation, and fragjnentation of these cells. Vacuoles appear as highly refractive, clean-cut, spherical bodies which possess more or less oscillating, rotar)^ motility, in contrast to the dimmer, more vaguely outlined, truly ameboid forms of the hyaline malarial parasite. The spicula of crenated red cells may in a very dim illumination of the object appear at first glance somewhat like the coarse granules of the mature pigmented par- asite, but a change of focus and a wider-open diaphragm im- mediately dispels the illusion. Fragmentation of the erythro- cytes, as the result of thermic influences, may produce a most bizarre and peculiar variety of designs, the most confusing of which is a sort of flagellate appendage which appears to originate MALARIAL FEVER. 3/9 in a fragmented sphere of corpuscular substance, to which it is attached. The size of this body, however, is far too small to be mistaken seriously for a true malarial flagellate body, for its spherical portion, which is unpigmented and tinged with hem- oglobin, measures only about 2 /i in diameter; while the flag- ellate appendage, usually single, is represented by a colorless, thin line not often longer than 3 or 4 /i, and tremulously motile, not ameboid like the flagellum of the malarial body. This sort of a flagellate figure is very commonly seen in blood slides which have become chilled. 3. Hemoconice are readily distinguished by their very small size, spherical contour, and glistening, fat-like appearance. It sometimes happens that one of these granules of "blood-dust," in its Brownian excursion across the field of the microscope, lies over the flat surface of an erythrocyte, simulating for the mo- ment, a small, hyaline, intracellular parasite. It seems probable, also, that one of these granules, observed just at the instant it crosses the rim of the blood cell, has been mistaken for a hyaline spore in the act of invading an erythrocyte, by those who be- lieve that they have witnessed this remarkable phenomenon. Well-marked anemia, developing early during Hemoglobin the course of the disease, and proportionate in AND degree to the severity of the attack, is a con- Erythrocytes. spicuous clinical sign in the malarial fevers. Dionisi,^ Thayer,^ and other authors have ob- served that a loss of hemoglobin and a diminution in the number of erythrocytes occur after every paroxysm, this being due largely to the destruction of immense numbers of parasite-containing cor- puscles by the maturation of the organisms, and in part to the presence in the blood of other substances destructive to the un- invaded red cells. The loss is especially marked after the early paroxysms, being of slighter degree after those occurring later in the course of the disease. On the other hand, during the paroxysm a tendency on the part of the red corpuscles to increase in number has been noted. The loss is more moderate in the regularly intermittent tertian and quartan types of malaria than in the estivo-autumnal form. In the former types, the regenerative powers of the blood are usually prompt and vigorous, so that the normal number of cells is almost restored by the onset of the succeeding paroxysm. It is owing to this fact that repeated paroxysms must occur before the anemia becomes striking. ^ Lo Sperimentale, 1891, f. iii. and iv., p. 284. 2 Loc. cit. 380 GENERAL HEMATOLOGY. In the estivo-autumnal form the loss is far greater, a decrease of 500,000 or more corpuscles per cubic milHmeter sometimes occurring after a single paroxysm, such a marked loss as this being associated especially with cases in which excessive numbers of parasites are present in the blood. Even in non-febrile cases of larval malarial fever, Marchiafava and Bignami ^ have observed more or less anemia. Organisms of the crescent group appear to exert no influence in causing diminution in the number of erythrocytes. Regeneration of the blood is slow in the estivo- autumnal fever, so that the loss of hemoglobin and of corpuscles is not made up during an inter-paroxysmal interval, in consequence of which more marked and graver anemias are commoner than in the tertian and quartan fevers. If the anemia is markedly developed during the early stages of the infection, the corpus- cular decrease is aggravated slightly, if at all, by the following paroxysms. In malarial hemoglobinuria an enormous destruction of cor- puscles occurs, " a destruction," in the words of Thayer,^ *' too great, probably, to be dependent wholly on the disintegration of parasitiferous elements. We are compelled ... to suppose the existence of some condition which renders the ujiinfected red blood corpuscles unusually vulnerable, possibly some change in the blood serum by which its isotonicity is markedly disturbed." Usually the hemoglobin loss is relatively greater than the cor- puscular decrease, moderately low color indices being the general rule, but in some cases both are parallel. In estimates made by the author in tAventy-two cases of malarial fever, nearly all of the tertian type, the hemoglobin averaged 60.8 per cent, of normal, ranging, in the individual case, from 30 to 80 per cent. The color index in these cases averaged 0.87, the extremes being 0.55 and 1. 51. The variations in hemoglobin were as follows : Between 80-90 per cent, in 3 cases. '* 70-80 '' 6 ** 60-70 " 5 *' 50-60 '' 2 '' 40-50 " 4 30-40 " 2 Average : 60.8 per cent. Highest : 80.0 t( Lowest : 30.0 (( ^ Loc. cit. 2Loc. cit. MALARIAL FEVER. 3^1 The loss of corpuscles varies within wide Hmits, being most marked in severe and in long-standing cases. Counts as low as 500,000 per cubic millimeter have been reported/ and the num- ber falls to from 1,000,000 to 2,000,000 in a considerable pro- portion of cases. In the above series, the average of the twenty- two counts showed 3,481,818 eiythrocytes per cubic millimeter, individual cases varying from 1,410,000 to 4,880,000. The range of the counts is shown thus, in tabular arrangement : Between 4,000,000-5,000,000 in 11 cases. <* 3,000,000-4,000,000 ^' 2 *' " 2,000,000-3,000,000 '^ 6 ** ** 1,000,000-2,000,000 " 3 *' Average : 3,481,818 per cb. mm. Highest : 4,880,000 " '' Lowest : 1,410,000 '' ^' In seven cases cHnically designated as '' malarial cachexia," in which parasites were not found in the circulating blood, the fol- lowing results were obtained : hemoglobin ranged from 40 to 52 per cent., the average being 45.5; color index, from .41 to 1.13, averaging .66; and erythrocytes, from 2,300,000 to 4,861,000 per cubic millimeter, with an average of 3,406,250. As regeneration of the blood, which is generally slow, takes place, the normal percentage of hemoglobin is reached more slowly than that of the corpuscles— in fact, in some instances of post-malarial anemia subnormal hemoglobin percentages persist for indefinite periods after convalescence has been established. Histological changes in the erythrocytes are marked in relation to the severity of the anemia. Pallor of the corpuscles is often conspicuous, and poikilocytosis and deformities of size are pres- ent in severe cases. In such instances small percentages of nor- moblasts, and of atypical nucleated forms are not infrequently found, sometimes in association with an occasional megaloblast. In severe cases both polychromatophilia and basic granular de- generation of the erythrocytes are familiar findings. The following four types of post-malarial anemia are distin- guished by Bignami and Dionisi.^ I. Anemiae in which examination of the blood shows altera- tions similar to those observed in secondary anemiae, from which iKelsch: Archiv. de Physiologic, 1875, vol. ii., p. 690. Ibid., 1876, vol. iii., ^" tSntralbl. f. Allg. Path. u. path. Anat., 1894, vol. v., p. 422. (Quoted from Thayer and Hewetson : "The Malarial Fevers of Baltimore," Baltimore, i895. P- 58-) 382 GENERAL HEMATOLOGY. they differ only in that the leucocytes are diminished in number. The greater part of these cases go on to recovery ; a few, without any further change in the hematological condition, pursue a fatal course. 2. Anemiae in which the examination of the blood shows altera- tions similar to those seen in pernicious anemia — presence of gigan- toblasts. These cases end fatally. 3. Anemiae which are progressive, as a result of the lack of compensation by the marrow for losses brought about by the infection. At autopsy the marrow of the long bones is found to be wholly yellow, while the marrow of the flat bones is also poor in nucleated red corpuscles. 4. Chronic anemiae of the cachectic, which differ from the above- mentioned types by clinical and anatomical characteristics in that the special symptoms of malarial cachexia prevail, while one ob- serves, post-mortem, a sort of sclerosis of the bone marrow. The marrow of the long bones is red and of an increased con- sistency; the giant cells are very numerous and many are ne- crotic; the nucleated red blood corpuscles are very rare, and the colorless polymorphonuclear corpuscles are present in small numbers. Distinct leucopenia, or at least an absence Leucocytes, of leucocytosis, is almost invariably found in the uncomplicated case of malarial fever, the excep- tions to this general rule occurring during the grave paroxysms of the pernicious type of fever. The subnormal range of the leucocytes in malarial fever was early noted by Kelsch,^ and has been repeatedly confirmed by other investigators since the former's statement of the fact. Billings,^ in particular, has carefully studied this question, and his examinations, 100 in number, show that the number of leu- cocytes averaged 4,323 per cubic millimeter, or a decrease of about 38 per cent, below normal. In 71 counts made by this reporter in 16 cases, in order to determine the effects of the malarial paroxysms on these cells, it was found that during the early part of the paroxysm their number gradually increased, the maximum being reached, as a rule, two or three hours after the chill. Following this maximum increase the number steadily and progressively decreased, hour by hour, until the minimum was reached during the period of subnormal temperature, at the end of the paroxysm. During the afebrile interval the number of leucocytes is distinctly subnormal, but it rises slightly again 1 Loc. cit. 2 Johns Hopkins Hosp. Bull., 1S94, vol. v., p. 89. MALARIAL FEVER. 383 just before the onset of the following chill, so that the average count is slightly higher immediately before the chill than during the rest of the interval. In the author's series, above referred to, the average of i8 counts showed 5,211 leucocytes per cubic millimeter, the lowest count being 2,000, and the highest 11,600. All these counts were made during the intei-val between the paroxysms, in un- complicated cases, so far as it was possible to determine. The counts ranged as follows : Above 10, 000 in 2 cases. Between 8, 000- -10, 000 ( < 3 (( - 6, 000 - 8, 000 a 2 (( '' 4, 000 - 6, 000 (( 6 ti '' 2, ooo- - 4, 000 (I 5 li Average : 5, 211 per cb . mm. Highest : II, 600 << (( it Lowest : 2, 000 << i( a In the 7 cases of " malarial cachexia " the number of leuco- cytes to the cubic millimeter ranged from 4,500 to 44,000, the average being 16,971. Five of these cases had distinct leuco- cytosis, a condition believed by Thayer to occur in some of the post-malarial anemias, usually those following short-lived infec- tions. Relative lymphocytosis, sufficiently decided to become a striking characteristic of the condition, is practically a constant qualitative change. As a rule, the increase affects chiefly the large lympho- cytes. Stephens,^ in a recent study of ''blackwater fever," found that this type of cells often constituted 20 per cent., 30 per cent, or even 50 per cent, of the total number of leucocytes ; further- more, he states that this relative increase bears an inverse relation to the temperature curve, being least marked during the pyrexia, and greatest during the periods of apyrexia. This feature persists in some cases with leucocytosis, as well as in those with leuco- penia. The percentage of eosinopJiiles is, as a rule, subnormal, and this variety of cells is frequently absent ; more rarely they are slightly increased, especially in some of the post-malarial anemias. Myelocytes in small numbers are very commonly found, in the writer's experience, especially in estivo-autumnal infections, and in cases with pronounced anemia. In 9 differential counts, made in cases of the series above referred to, the relative percentages of the different forms of leucocytes averaged as follows : ^ Lancet, 1901, vol. i., p. 848. 384 GENERAL HEMATOLOGY. Small lymphocytes 15-33 P^^ cent Large lymphocytes and '^transitional" forms. 15.94 '' " Polynuclear neutrophiles 67.00 Eosinophils 83 Myelocytes 51 ( e ( ( Practically the same figures were obtained from the similar ex- amination of 3 cases of anemia associated with malarial cachectic conditions. The d/ood plaques are greatly decreased in number, as in other febrile conditions. The detection of the specific parasite in the Diagnosis, circulating blood is proof positive of malarial fever, the exact type of which may be determined by close study of the organism's peculiarities. Even if nothing more definite than pigmented leucocytes is found, the evidence is strongly in favor of some form of paludism. The progressive anemia, and the leucopenia involving a relative decrease in the polynuclear neutrophiles, are also valuable side-lights on the diagnosis. An obscure intermittent fever which shows leucocy- tosis is almost certainly not malarious. The chills and pyrexia of sepsis and of tuberculosis are not in- frequently misinterpreted as symptoms of malarial fever. In septicemia leucocytosis is usually found, but even should the leucocytes not be increased in number, they fail to show the relative lymphocytosis of malarial blood. In pure tuberculosis the blood-picture of malaria may be counterfeited, in so far as the quantitative and qualitative leucocyte changes are concerned, and in such instances the parasite must be demonstrated to settle the diagnosis. The same leucocyte changes also occur in entcjic fever, the differentiation of which has been alluded to above. (See page 331.) It maybe added that in those rare instances of coincident typhoid and malaria the blood of the same individual may contain parasites and give a positive serum reaction with the Eberth bacillus. XXXVII. MALIGNANT DISEASE. Carcinoma. There is no deviation from normal in the coagu- General lability and the amount of fibrin, except in the Features, event of ulcerative and inflammatory' changes affecting the tumor, but, should these conditions be present, coagulation may occur with abnormal rapidity, and the density of the fibrin network almost invariably increases. The MALIGNANT DISEASE. 385 Specific gravity may or may not be subnormal, according to whether or not the percentage of hemoglobin, which it parallels, is reduced. The alkalinity of the blood is almost always decreased in gastric cancer, according to Krokiewicz.^ Relatively large amounts of sugar (as high as 3 parts per 1,000) have been found in the blood of patients suffering from various forms of carcinoma, especially visceral cancer, in contra- distinction to more superficial growths, involving, for example, the skin and mucous membranes. In no other disease except diabetes has more than one-third of the above-named quantity of sugar been detected in the blood, according to the analyses made by Trinkler.^ Examination of the blood for the detection of a specific parasite of cancer has thus far proved unconvincing, although much care- ful work has been done with this purpose in view. Gaylord ^ has recently described protozoa similar to the bodies previously dis- covered by RusselP and by Plimmer,^ to which he ascribes specific properties, claiming *' in all cases of carcinoma and sarcoma thus far examined in which cachexia was well marked, that the organisms can be detected in the peripheral blood." This an- nouncement, while of great interest and importance, must receive corroboration by other investigators before it can merit general acceptance. The careful studies of 33 cases of cancer, recently completed by Maragliano,^ have apparently disproved the state- ments of a number of authors, who claimed to have cultivated blastomycetes from the circulating blood in this disease. During its incipiency carcinoma gives rise to Hemoglobin practically no changes in the erythrocytes or their AND hemoglobin content, or at the most causes simply Erythrocytes, a moderate diminution in the latter. As the disease progresses and extends, and as the cachexia of the patient becomes more pronounced, a secondary anemia develops, attaining but a moderate degree in some instances, but in others becoming so extreme as to simulate in some particulars true pernicious anemia. Since the hemoglobin loss usually anticipates the cellular decrease, the blood-picture of early cancer not infrequently resembles that of chlorosis. Later, however, these conditions may be reversed, so that the index rises. In the author's experience, the average hemoglobin loss ' Archiv. f. Verdauungskrankh., 1900, vol. vi., p. 25. 2Centralbl. f. d. med. Wissensch., 1890, vol. xxviii., p. 498. 3 Am. Journ. of Med. Sc, 1901, vol. cxxi., p. 503. ♦British Med. Journ., 1900, vol. ii., p. 1356. 5 Practitioner, 1899, vol. Ixvii., p. 430. 6Gaz. degli Osp. e. d. Clin., 19CX), vol. xxi., p. 1538. Also, Sem. med., 1901, vol. xxi., p. 63. 25 386 GENERAL HEMATOLOGY. has amounted to somewhat more than 40 per cent., and the erythrocyte decrease to about 25 per cent, of normal. The color index tends to range moderately low, usually from 20 to 30 points below the standard of health. It averaged 0.76 for the 54 cases grouped below. As just intimated, it is generally lower in the early than in the late stages of the disease. In operative cases of carcinoma it has been observed that the regeneration time of the hemoglobin averages at least two-thirds longer than in other diseases treated surgically, and that the loss of hemoglobin after operation is usually not less than 1 5 per cent. Bierfreund ^ finds that the percentage of hemoglobin after the removal of the tumor never equals that found before the operation. The oHgocythemia is occasionally most striking, for in some cases the counts may range as low as between 1,000,000 and 2,000,000, such a degree of decrease apparently being most com- monly found in septic cases, and in gastric cancer. F. P. Henry's statement ^ that he has never seen a case of the latter disease in which the erythrocytes fell below 1,500,000 to the cubic milli- meter has been generally corroborated, although counts below this figure have been occasionally reported. In one of the cases of cancer of the stomach included in the table given below the count was 1,001,000 per cubic millimeter, and the hemoglobin percentage 50. Polycythemia may occur as a temporary condition in gastric and esophageal cancer, as the result of blood concentration due to vomiting, to diarrhea, or to lack of ingested fluids. ^ In such instances the number of erythrocytes not uncommonly exceeds 6,000,000 or 7,000,000 per cubic millimeter, and, exceptionally, even a higher figure. The following table illustrates the alterations in the amount of hemoglobin and number of erythrocytes, as determined by the examination of 54 cases of various forms of carcinoma. Hemoglobin Percentage. Erythrocytes per cb. mm. From 80-90 in 2 cases. Above 5,000,000 in 4 cases. ** 70-80 " 10 '* From 4,000,000-5,000,000 '' 21 " ^* 60-70 *' 19 '* '' 3,000,000-4,000,000 '' 18 " " 50—60 " 9 '* " 2,000,000—3,000,000 " 6 '' 40-50 " 7 '' " 1,000,000-2,000,000 " 5 " 30-40 " 5 " " 20—30 *' 2 " Average : 58.4 per cent. Average : 3,815,073 per cb. mm. Maximum: 28.0 ** Maximum: 5,340,000 ^' " '^ Minimum: 23.0 *' Minimum: 1,001,000 " ** " 1 Langenbeck' s Archiv. , 1890-91, vol. xli., p. i. ^AjTchiv. f. Verdauungskrankh, , 1898, vol. iv., p. i. (( MALIGNANT DISEASE. 387 In gastric cancer Osier and McCrae ^ report an average of 49.9 per cent, of hemoglobin in 52 cases, and an average erythrocyte count of 3,712,186 in 59 cases. In two cases the count was less than 1,500,000. An average color index of 0.63 was found in this series. Deformities of shape and of size are marked in relation to the grade of the anemia which exists. Poikilocytes may be quite as numerous and as striking as in true pernicious anemia, while the alterations affecting simply the size of the cells tend toward micro- rather than megalocytosis. Polychromatophiha and baso- philic degenerative changes are frequently to be seen in grave cases with marked cachexia. Erythroblasts are very common, especially in cancer with decided cachexia and high-grade anemia, but their occurrence is by no means limited to such cases, as they may also be found in blood which shows but trifling quantitative deterioration. It may be stated as an accepted fact that nucleated erythrocytes occur in cancer more frequently than in any other variety of secondary anemia, except that accompanying sarcoma. Normoblasts are generally found to the exclusion of other forms, although in an exceptionally grave case an occasional megaloblast and atypical " mesoblast " may be encountered. The important point to be remembered is that cells of the adult, normoblastic type invariably predominate, since megaloblasts, when present, are never so numerous as normoblasts. Leucocytosis is a frequent but not a constant Leucocytes, feature of the blood-picture in carcinosis, for quite as many cases are encountered in which the number of leucocytes is normal as those in which an increase prevails. Judging from the statistics of patients treated in the German Hospital, leucocytosis is present in less than one-half of all forms of cancer, or in 44.4 per cent. In general terms, it may be said that tumors characterized by active inflammatoiy changes, by hemorrhage, by rapid growth, or by extensive metastases are accompanied by a well-marked leucocyte increase, while non-in- flammatory, slowly developing, localized tumors do not raise the count. Thus, a large carcinoma of the liver or kidney, for in- stance, may cause a leucocytosis of 30,000 or 40,000 to the cubic millimeter, while a small, limited skin cancer may exist without provoking the slightest increase. Thorough extirpation of the growth is followed by a decline in the leucocytosis, the normal count being reached by the time the wound has entirely healed. Hayem ^ is the authority for the statement that in mam- 1 " Cancer of the Stomach," London and Phila., 1900, p. 115. 2Loc. cit. 388 GENERAL HEMATOLOGY. mary cancer recurrence of the growth after its removal may be detected by a reappearance of the leucocytosis, which antedates all other physical signs. The constancy of this change, as well as the question of its occurrence in cancer involving other struc- tures, still remains to be investigated. It seems reasonable to attribute the origin of cancer leuco- cytosis chiefly to the presence of inflammatory changes in the tissues in the neighborhood of the growth, although in some in- stances it seems possible that positive chemotaxis may be ex- cited by the absorption of toxines derived from the breaking down of the neoplasm itself The strength of the patient's powers of resistance as a determining factor of the increase must also be taken into account in this as in other diseases. In the writer's experience, leucocytosis is most constant in cancer of the breast, most striking in cancer of the liver, least frequent in cancer of the uterus, and least conspicuous in cancer of the stomach. In cancer of the esophagus absence of leuco- cytosis is the rule, while in many cases a decided leucopenia may exist. The 54 cases on the study of which the above observations are based may be summarized as follows : Seat of Growth. Number of Cases. Number and Percentage of Cases with Leucocytosis. Average Count. Maximum Count. Minimum Count. Stomach. Uterus. Rectum. Breast. Liver. 23 10 8 7 6 9 or 39.1% 2 or 20.0% 4 or 50.0% 5 or 71.4% 4 or 66.6% 8,163 9,380 10,700 14,407 18,733 14,000 24,000 16,000 3i»5oo 40,800 1,000 4,500 6,000 8,000 8,000 In cancer of the stomach digestion leucocytosis is usually, though by no means invariably, absent. The frequency with which this phenomenon is absent is shown by the following compilation of the data of various authorities who have studied this question : Author. Hoffman Osier and McCrae. Cabot Schneyer Capps Krokiewicz Douglas Hartung Miiller Number of Cases. Absent. 24 I 22 20 18 17 17 II 10 5 21 12 1 19 ! 18 15 13 6 10 ' 5 144 119 Present. 10 I O 2 4 5 o o 25 MALIGNANT DISEASE. 389 These figures, referring to 144 cases, show that digestion leu- cocytosis is absent in 82.6 per cent, of gastric carcinomata. But the presence of the phenomenon in practically two cases out of every ten is sufficient to weaken materially the former belief that absence of digestion leucocytosis is a diagnostic sign of this disease. Furthermore, it has also been shown by Hoffman^ and others that the sign may be absent in a number of other diseases of the stomach, as well as in some apparently healthy individuals. Differential counts usually show percentages of polynticlear neutrophiles ranging between 80 and 90, with a corresponding decrease in the large and small lymphocytes, in cases with leu- cocytosis, and not infrequently also in those without. This change is not to be considered constant, since relatively high percentages of lymphocytes, especially of the large variety, have occasionally been observed. The eosinophilcs are usually de- creased, or, indeed, they may be absent in cases with pronounced leucocytosis ; in a certain proportion of cases, in spite of the ab- normally high leucocyte count, their relative percentage remains within the limits of health. Myelocytes are extremely common, small numbers of these cells (usually not higher than a fraction of one per cent.) occurring in at least a majority of all cases of cancer. The presence of a few basophiles is sometimes to be noted, particularly often in association with conspicuously high leucocytoses. Sarcoma. The changes affecting the fibrifi, the rate of General coagtilation, and the specific gravity of the blood Features, are similar to those prevailing in cancer, and therefore require no further mention. In contrast to the hyperglycemia of carcinoma, the researches of Trinkler, above referred to, tend to show that in sarcoma no increase above normal in the amount of sugar in the blood can be detected. Bacteriological examinations of the blood have thus far given no definite results. The changes in the hemoglobin and erythro- Hemoglobin cytes are not materially different from those found AND in cancer, for the genesis of the blood deteriora- Erythrocytes. tion is doubtless similar in all forms of malignant disease. Some authors believe that the anemia tends to reach a higher degree in sarcoma than in carcinoma, but the truth of this contention certainly does not appear to be indisputably estabhshed. In the writer's experience, unfortu- ^Zeitschr, f. klin. Med., 1898, vol. xxxiii., p. 460. 390 GENERAL HEMATOLOGY. nately most limited in so far as it relates to sarcoma, the inten- sity of the anemia is practically similar in both these forms of neoplasms, or, if anything, somewhat more striking in cancer, both individually and on the average. In a series of 14 cases of sarcoma the hemoglobin averaged 63.5 per cent, ranging from a minimum of 42 to a maximum of 83 per cent. ; and the average count of the erythrocytes was 3,966,714 per cubic millimeter, with 2,510,000 and 5,400,000 as the lowest and highest counts, respectively. The color index in these cases averaged 0.80. The hemoglobin percentage ranged thus : 80—90 in 2 ; 70—80 in 3 ; 60-70 in 2 ; 50-60 in 4 ; and 40-50 in 3 cases. The er>^th- rocyte count was as follows : above 5,000,000 in 2 ; 4,000,- 000-5,000,000 in 4 ; 3,000,000-4,000,000 in 7 ; and 2,000,000- 3,000,000 in a single case. Poikilocytes, micro- and megalocytes (particularly the former), and atypically stained cells are common in cases with pronounced anemia, and in such instances er^^throblasts, the majority of which are always normoblasts, are also to be looked for. Leucocytosis, while inconstant in sarcoma, is Leucocytes, without doubt more frequently associated with this lesion than with carcinoma. Statistics have also been advanced to demonstrate that the counts range higher than in cancer, but the cases on record are still far too few to warrant this conclusion. The behavior of the leucocytes in both forms of malignant disease is probably influenced by the same group of factors. In the cases summarized in the preced- ing pages, leucocytosis was found in 24 of the 54 carcinomata, or in 44.4 per cent., and in 9 of the 14 sarcomata, or in 64.2 per cent. In the latter the counts varied between 7,000 and 40,000, and averaged 13,276 per cubic millimeter. They ranged as fol- lows : 5,000-10,000 in 4; 10,000-15,000 in 7 ; 15,000-20,000 in I ; and above 20,000 in 2 cases. The increase usually involves a large absolute and relative gain in the polymiclcar neutropJiiles, at the expense of the lyvipJio- cytes, although in an occasional instance the latter reach a dispro- portionately high percentage, while the former decline to a sub- normal figure. It may be added that either of these differential changes may also occur in the absence of an increase in the total number of leucocytes. The percentage of cosinopliiles is usually subnormal, and not infrequently these cells may be searched for in vain. Rarely, marked eosinophilia has been reported, by com- petent authorities, in sarcomata with bone metastases, but such findings are by no means constant. In the six cases of osteosar- comata of which the writer has reliable differential count records, MALIGNANT DISEASE. 39 1 the eosinophiles were absent in 5, while in the sixth their relative percentage was but 0.5, in a total leucocyte count of 10,000 per cubic millimeter. Small numbers of myelocytes are to be ob- served as frequently as not, these cells being about as common and as numerous as they are in cancer — a remark which is also true of basop Idles. The clinical resemblance between certain forms Diagnosis, of malignant disease (especially those in which the lesion remains obscure or undemonstrable) and pernicious anemia is often very close, on account of the striking degree of cachexia apparent in both. But the blood changes found in these two conditions, although similar in some respects, are sufficiently characteristic to afford the necessary diagnostic clues. These differences, already referred to in a pre- ceding section, may, for the sake of emphasis, be expressed as follows : Malignayit Disease. Pernicious Anemia. Color index usually moderately Color index almost always low. high. Oligocythemia usually marked. Oligocythemia invariably ex- treme. Tendency toward microcytosis. Tendency toward megalocy- tosis. Erythroblasts common, normo- Erythroblasts constant, mega- blasts always predominating. loblasts always predominat- ing. Leucocytosis common. Leucocytosis rare. Lymphocytosis rare. Lymphocytosis common. It is to be noted that of the above changes, but one is charac- teristic — the invariable predominance of megaloblastic cells in pernicious anemia and their minority or absence in those cases of mahgnant disease in which nucleated erythrocytes are found. Should a doubt arise as to whether a tumor is benign or ma- lignant in character, the fact is to be remembered that the pres- ence of a persistent leucocytosis, especially if accompanied by anemia, is decidedly in favor of its malignancy. Should it be necessary to distinguish between a mahgnant growth and an obscure pus focus with sepsis, the blood examination, aside from culturing, is useless, since both leucocytosis and hyperinosis may or may not exist in either condition ; if, however, bacteriological findings are positive, the existence of a septicemia is obvious. As a means of differentiating carcinomata and sarcomata, the chemical examination of the blood for sugar should prove of the greatest clinical value, if further research substantiates the claims 392 GENERAL HEMATOLOGY. made that hyperglycemia is constant in the first, and absent in the second, type of neoplasms. As a means of distinguishing gastric cancer from gastric ulcei^ the blood count is unfortunately of doubtful utility. The pres- ence of a persistent, well-marked leucocytosis is a ver}^ significant sign of cancer, since in ulcer the count is not increased, except as the result of hemorrhage, perforation, or digestion. On the other hand, an absence of leucocytosis is of no value in determin- ing which condition is present, owing to the fact that no increase occurs in a large proportion of stomach cancers. Recent inves- tigations have fully corroborated Lowit's view, that the absence of digestion leucocytosis in gastric cancer has about the same diagnostic value as the absence of hydrochloric acid and the presence of lactic acid. The chief points of distinction in the blood-pictures associated with the two diseases in question are illustrated by this table : Gastric Cancer. Gastric Ulcer. Anemia usually marked. Anemia usually moderate, ex- Erythroblasts common. cept after hemorrhage. Leucocytosis common. Eiythroblasts rare. Absence of digestive leucocy- Leucocytosis rare. tosis the rule. Absence of digestive leucocytosis the exception. If the diagnosis lies between carcinoma, amyloid disease, gum- ma, and echinococcus of the liver, the presence of a leucocytosis suggests the former ; should it lie between cancer and hypertrophic cirrhosis of the liver, high leucocytosis (30,000 or more) is strongly in favor of the former, since although the leucocytes may be increased moderately in this variety of cirrhosis, they do not reach a strikingly high figure. Hyperinosis, if present, is also a sign suggestive of cancer, rather than of these other liver dis- eases. XXXVIII. MALIGNANT ENDOCARDITIS. The blood changes in malignant or ulcerative General endocarditis are essentially those of a grave sep- Features. ticemia, described elsewhere, and do not, there- fore, require extended consideration in this place. According to the studies of Grawitz,^ Kraus,^ Sittman,^ Kijh- nau,* James and Tuttle,^ Thayer and Lazear/ and others, the 1 Charite- Annal. , 1894, vol. xix., p. 154. ^Zeitschr. f. Heilk., 1S96, vol. xvii., p. 117. 3Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. *Zeitschr. f. Hyg. u. Infectionskr. , 1S97, vol. xxv., p. 492. 5,Med. & Surg. Report of the Presbyterian Hosp., N. Y., 1898, vol. iii., p. 44. ^Jcurn. of Exper. Med., 1899, vol. iv., p. 81. MALIGNANT ENDOCARDITIS. 393 chances of securing definite results from bacteriological examina- tion of the blood are fairly good in this disease. An analysis of these authors' work shows that various micro-organisms, notably pneumococci, gonococci, streptococci, and staphylococci are demonstrable by culture of the peripheral blood in about one case in every three. . The loss of hemoglobin and erythrocytes is Hemoglobin likely to be marked, and, in acute cases, ex- AND tremely rapid and often most excessive— some- Erythrocytes. times as great as in typical pernicious anemia. Structural degenerative changes are common, as in any severe anemia, and in many acute cases hemoglobinemia may be observed. As a rule, the loss of hemoglobin and eryth- rocytes is not markedly disproportionate, so that moderately subnormal color indices are commonest. r .^ ^■ The following counts, by Dr. Uhle, of a profoundly septic patient at the German Hospital, illustrate the striking degree of anemia, as well as the intermittent and moderate leucocytosis which may develop in a grave case : Date. II- 4-99 11- 8-99 II-II-99 11-16-99 11-20-99 11-25-99 12- 1-99 12- 5-99 12-16-99 12-27-99 I- 5-00 I-II-OO Hemoglobin Percentage. I Erythrocytes percb. mm. 30 26 30 28 19 24 25 35 41 36 50 38 1,590,000 1,243,000 2,010,000 1,810,000 2,130,000 2,170,000 1,710,000 2,750,000 3,530,000 2,330,000 3,350.000 2,760,000 Leucocytes per cb. mm. 8,000 8,400 12,800 8,000 14,000 12,800 9,600 16,000 7,200 4,800 8,000 4,000 An increase in the number of leucocytes, more Leucocytes, commonly moderate than marked, and character- ized by a high percentage of polynuclear nactro- philes, is the usual finding, except in profoundly >^ept.c pat.ents in whom the count maybe normal or subnormal dunng the greater part of the illness, as shown by the above table. Ab- sence of leucocytosis is not infrequent in thi_s disease doubtless because in a large proportion of cases the f P-^-^^' .f^; ^° the poison predominate. In no other mfection is a better illus tration offered of the relationship between the behavior of the eucocytes, the intensity of the disease, and the patient's powers of reaction Occasionally, a striking preagonal increase develops, 394 GENERAL HEMATOLOGY. or, on the contrary, death may be ushered in by a decided leuco- penia. In many instances the diagnosis of malignant Diagnosis, endocarditis is materially facilitated by the blood examination, and in some it can be made only by this means. A positive result from blood culturing at once gives a definite clue to the real character of the disease, and this procedure should be undertaken in every doubtful case. Malig- nant endocarditis with marked constitutional symptoms is perhaps most frequently confused with e7it eric fever, and occasionally with malarial fever. Both of these infections may be excluded, if a leucocytosis exists, unless, of course, this sign is obviously due to some complication. It should also be remembered that in malignant endocarditis the anemia develops early and tends to attain a marked degree with great rapidity, while in the other two fevers it does not become striking until the post-febrile stage of the disease is reached. No comment is necessary on the value of obtaining a positive serum reaction or of detecting the malarial parasite, as a means of distinguishing this trinity of infections. XXXIX. MALTA FEVER. Most cases are accompanied by a moderate, progressive second- ary afiemia, becoming most marked at about the end of the febrile period, and involving, according to Bruce, ^ an average loss of about 1,500,000 erythrocytes to the cubic millimeter. The most severe anemia is found in cases complicated by profuse epistaxis and hemorrhage from the bowel, but those in which these symp- toms are absent may show simply a slight oligochromemia, as demonstrated by a case studied by Musser and Sailer.^ Frank leucocytosis does not develop, except as the result of hemorrhage, but occasionally the number of leucocytes is slightly increased — to about 12,000 or 13,000 per cubic millimeter. Charles^ states that during the acute stages of the infection he has found a notable relative increase in the large lymphocytes. Bruce * has not succeeded in finding the micrococcus militensis by antemortem bacteriological examijiation of the blood, although he has obtained this organism in pure culture by aspiration of the spleen. Wright and Smith ^ discovered that the blood serum of patients suffering from Malta fever clumps cultures of Bruce' s 1 Brit. Med. Journ., 1889, vol. i., p. Iioi. 2 Phila. Med. Journ., 1898, vol. ii., p. 1408. 'British Med. Journ., 1898, vol. ii., p. 607. * Cited by Notter : Albutt's " System of Medicine," N. Y. and London, 1897, vol. ii., p. 472. ^Lancet, 1897, vol. i., p. 656. MEASLES. 395 Specific micrococcus but produces no agglutination of the bacil- lus typhosus. The diagnostic value of this serum test in dif- ferentiating Malta and enteric fevers has since been corroborated by the reports of Aldridge/ Musser and Sailer,^ Kretz,^ Cox,'^ and others. A I : 50 dilution with a thirty-minute time limit appears to give the most satisfactory results. XL. MEASLES. The amount of fibrin is either normal or de- General creased, except in the event of a marked inflam- Features. matory complication, which may produce hyper- inosis. The blood plaques are decreased in num- ber during the febrile period. A peculiar bacillus has been isolated from the blood of 6 cases of measles, by Arsamaskoff,^ but specificity is not unreservedly claimed for it. The organism in question measures about 3 /^ in length, and is almost as broad as the Eberth bacillus ; it may de- velop into club forms in cultures made from the circulating blood. Inoculation experiments with animals gave negative results. Protozoa of undetermined character have been detected in the blood by Weber.^ The hemoglobin and erythrocytes are prac- Hemoglobin tically unchanged in typical cases. When a de- AND crease does occur, it is trifling, amounting at the Erythrocytes, most to a loss of from 250,000 to 500,000 cor- puscles, and of about 15 or 20 per cent, of hem- oglobin. The great majority of cases have counts of 5,000,000 cells to the cubic millimeter. Qualitative changes in the erythro- cytes are absent. In the uncompHcated case of measles the num- Leucocytes. ber of leucocytes is either normal or subnormal. The latter change is very common, the decrease of leucocytes being most marked at the height of the fever dur- ing the stage of eruption, and their number again reaching nor- mal coincidentally with the fading of the eruption and the begin- ning of desquamation. The count may fall to 3,000 or 4,000 per cubic millimeter during the period of maximum temperature. Combe ^ believes that leucopenia is constant in all uncomplicated cases, and that the diminution in the number of cells amounts to ^Lancet, 1898, vol. i., p. 1394. 2Loc. cit. 3 Lancet, 1898, vol. i., p. 221. i:es, 4,- 700,000. Capps states that the majority of cases show a moder- ate leucocytosis, averaging an increase of 22 per cent, in excess of the normal standard, but that in the incipient stages of the disease the number of leucocytes usually is not increased. An average count of 8,800 was noted by Somers,- in 5 cases. Relatively high percentages of polynuclear neutrophiles, with a diminution in the small lymphocvtes, are common differential changes, while the relative numbers of large lymphocytes and eosinophils may be higher than normal. Convulsions and apoplectiform attacks tend to produce blood concentration, and therefore temporarily in- crease the hemoglobin and er^'throcyte values. During and fol- lowing such seizures, an abrupt rise in the leucocyte curve, characterized by a striking absolute and relative gain in the large lymphoc)i:es, and, rarely, by the appearance of myelocytes, was observed by Capps, who has also described a small mononuclear neutrophilic leucocyte, resembling a dwarf myelocyte, as peculiar to the condition in question. (See page 1 7 1 . j Burrows ^ believes that the leucocytosis associated with convulsions, not only in general paralysis, but in other conditions, bears a definite relation to the severity of the fit, and that the increase is in part the result of the muscular contractions attending the convulsion, and in part represents an actual pathological leucocytosis. Acute delirium from any cause also provokes leucocytosis. In dementia, according to Smyth, ^ both the hemoglobin and erythrocytes are decidedly lower than in the preceding condition, his averages for this disease being 53.7 per cent, of hemoglobin, and a count of 4,070,000 erj^throcytes, in a series of 12 cases. In 10 cases of melancholia he found that the hemoglobin averaged 69.7 per cent, and the erythrocytes 4,684,000, while Steele,^ in 35 cases of this disease, estimated the average hemoglobin value at 75 per cent, and the average erj'throcyte count at 3,000,000. In acute mania anemia of the so-called " chlorotic " type usually may be observed ; this blood change becomes aggravated by each acute maniacal outbreak, but after recover}- from these attacks the deficiency is rapidly restored. Somers' ^ leucocyte counts in 19 dements averaged 10,743, in 19 melancholies 7,947, and in 19 maniacs 8,315. ^Journ. of Mental Sc, 1890, vol. xxxvi., p. 504. 2 Bull. X. Y. State Hosp., 1896. 'Am. Joum. of Med. Sc, 1899, vol. cxvii., p. 503. ♦ Loc. cit. 5 Am. Joum. of Insanity, 1892, vol. xlix., p. 604. * Loc. cit. OBESITY. 405 In epilepsy a moderate anemia appears to be the Epilepsy. general rule. Smyth's studies^ of 50 cases show Chorea. an average of 62.8 per cent, of hemoglobin, and Tetany. 4,520,000 erythrocytes per cubic millimeter. MacPhail ^ asserts that prolonged attacks of ex- citement notably increase the anemia, but that the habitual ad- ministration of bromides seems in no manner to produce deleterious effects upon the blood. Furthermore, this author observed that a close relationship can be distinguished between the patient's gain in weight, the decrease in the anemia, and the mental improve- ment, and that in patients who recovered, the regeneration of the blood became practically complete. Leucocytosis does not occur in epilepsy, except as the result of a convulsion. Kuhlmann,^ for example, found the leucocytes in excess of normal but once in a study of 16 cases. In chorea slight anemia, usually of the *' chlorotic " type, occurs with frequency but not with constancy, for many cases habitually show normal hemoglobin and erythrocyte values. It seems scarcely necessary to remark that the belief once entertained, that blood deterioration was a causal factor of this disease, is obviously erroneous. Burr,^ in a study of the hemoglobin and erythrocytes in 36 cases, concludes that a moderate diminution in both of these elements is the general finding, and that a high grade of anemia occurs only as the result of some complication. The oligocy- themia usually does not exceed a loss of more than 1,000,000 cells per cubic millimeter, in uncompHcated cases. The leuco- cytes are not increased, but differential counts may detect a rela- tively large percentage of eosinophils, according to the reports of Zappert,* and others. Tetany is not of itself a cause of blood impoverishment. XLV. OBESITY. From Kisch's studies ^ it is evident that the hemoglobin values are notably high in most corpulent individuals, and in some ex- cessively increased. In 79 of 100 cases of obesity examined by this author, the hemoglobin percentage exceeded 100, while in the remaining 21 moderate oHgochromemia was found. The maximum reading in this series was 120 and the minimum 55 per cent. Actual anemia^ however, is not incompatible with this 1 Loc cit 2 Bull*. N. Y. State Hosp., 1897. 3 University Med. Mag., 1896, vol. ix. , p. 188. *Zeitschr. f. klin. Med., 1893, vol. xxiii., p. 227. 5 Ibid , 1887, vol. xii., p. 357. 406 GENERAL HEMATOLOGY. class of patients, as demonstrated by Leichtenstern/ and by Oertel.^ The latter also maintains that in some instances true plethora exists, and furthermore professes to recognize two dis- forms of obesity, an anemic and a plethoric. Data regarding the leucocytes in this condition are wanting. XLVI. OSTEOMALACIA. The hemoglobin and erythrocytes do not exhibit any marked deviations, being in most instances normal, or but moderately di- minished. The anemia, when present, tends to conform to the so-called " chlorotic type," being characterized by a hemoglobin loss relatively exceeding that of the corpuscles. The leucocytes also remain approximately normal in number, slight fluctuations above and below this standard being the only numerical change thus far noted. Relative lymphocytosis has been found by Ritchie,^ and by Tschistowitch,^ while Neusser ^ and others have observed in many cases a moderate increase in the eosinophiles, and the presence of small numbers of myelo- cytes. None of these differential changes, however, are to be considered constant in this condition. According to von Lim- beck,^ the alkalinity of the blood remains practically unal- tered, although von Jaksch^ formerly maintained that it was considerably diminished. XLVII. PERICARDIAL EFFUSION. The Jie)noglobin and erythrocytes remain normal, or, \{ anemia is found, it may be referred to other coexisting conditions. Leucocytosis of the polynuclear neutrophile type is practically a constant change in the non-tuberculous forms, but in tuber- culous pericarditis the leucocytes apparently do not increase. From a diagnostic viewpoint, the presence of a leucocytosis is of real value in excluding the latter condition, as well as cardiac dilatation ; this sign is also strong evidence against the existence of a serous pleural effusion, which, if left-sided, may simulate pericarditis. ' "Untersuch. u. d. Hg-Gehalt d. Blutes," Leipzig, 1878. 2 " Allgem. Ther. d. Kreislaufsstor.," Leipzig, 1884. Also, Deut. Archiv. f. klin. Med., 1892, vol. i.,p. 293. 3 Edinburgh Med. Journ., 1896, vol. xlii., p. 208. * Herl. klin. Woch., 1893, vol. xxx., p. 919. 5 Wien. klin. Woch., 1892, vol. v., p. 41, ^ Loc. cit. 'Zeitschr. f, klin. Med., 1S87, vol. xiii., p. 350. PERITONITIS. 407 XLVIII. PERITONITIS. Anemia is frequently found, the degree of Hemoglobin which largely depends upon the character and AND the chronicity of the inflammation. In general Erythrocytes, purulent peritonitis, especially in cases of com- paratively long standing, the hemoglobin and erythrocyte diminution may be excessive — to between 20 and 30 per cent, for the former, and to between 2,000,000 and 3,000,000 per cubic millimeter for the latter. With such an anemia as this the erythrocyte loss is commonly very disproportionate to that of the hemoglobin, so that high color indices rule ; for example, in 3 of the cases summarized below, the indices were 1.12, i.oi, and 1. 00, respectively. The several qualitative changes accom- panying any severe secondary anemia are also commonly to be observed. Serous peritonitis has but little effect in provoking a cellular decrease, although it usually causes a slight but definite oligochromemia, so that in such cases the color indices are moderately subnormal. On the average, it may be stated that peritonitis causes a loss of about 40 per cent, of hemoglobin, and of 20 per cent, of erythrocytes. The following summary of 16 cases, most of which were ex- amined at the German Hospital, shows the grade of anemia pre- vailing in this disease : Hemoglobin Percentage. Number of Cases. Erythrocytes Number of PER CB. mm. Cases. From 80-90 I Above 5,000,000 3 70-80 5 From 4,000,000-5,000,000 5 60-70 4 ** 3,000,000—4,000,000 6 50-60 I ** 2,000,000-3,000,000 2 40-50 3 30-40 I Average : Maximum 20-30 62.1 : 82.0 per I cent. Average: 3,970,000 per Maximum : 5,670,000 *' cb. mm. Minimum : 28.0 l( {( Minimum: 2,150,000 *' 11 t( The color index for this series averaged 0.78. Provided that the patient's resisting powers react Leucocytes, normally, septic peritonitis constantly causes a typ- ical leucocytosis, of the polynuclear neutrophile variety. It cannot be stated with certainty that the increase is greater in purulent than in serous inflammations, for any variety of peritonitis, except the tuberculous, may provoke a striking .leucocytosis. As already remarked in the discussion of appen- dicitis, extension of the process is heralded by an abrupt rise in 408 GENERAL HEMATOLOGY. the leucocyte curve. As in other infections, leucocytosis may be absent, or leucopenia may exist, in cases of a profound, crippling character. The number of leucocytes in the preceding i6 cases ranged as follows : Leucocytes per cb. mm. No, . OF Cases, Above 45,000 I From 35,000-45,000 I <( 25»ooo-35jOoo I li 20,000-25,000 I a 15,000—20,000 4 (( 10,000-15,000 6 ii 5,000-10,000 I Below 5,000 I Average: 18,875 per cb. mm. Maximum : 46,000 *' { ( (( Minimum : 4,400 " ( ( ^throc}i:es were below 2,000,000 to the cubic millimeter in 2 instances, averaging 3,500,000, with 1,540,000 as the minimum and 4,600,000 as the maximum, counts. Leucocytosis, ordinarily of a high grade, accom- Leucocytes. panics the great majority of cases, the increase involving mainly the polymiclcar neiitropJiile cells at the expense of the lyinplwcytes. It is more usual to find the count above than below 20,000 to the cubic millimeter, and in an exceptional instance it may even exceed 50,000. As- piration of the pus is followed by a decline, and its reaccumula- tion by a rise, in the leucocyte cur\^e. The extent of the primary purulent accumulation cannot be gauged with any accuracy by the degree of the leucocyte increase. The following counts in a case of empyema examined at the German Hospital, will serve to illustrate the high leucocytosis sometimes seen in this condition : Date. Hemoglobin Per- Erythrocytes per Leucocytes per centage. cb. mm. cb. mm. I-16-OO 84 4,460,000 23,200 I-17-OO 88 5,380,000 42,400 I-18-OO 82 4,320,000 45,000 I-I9-OO 82 4,430,000 40,800 1-20-00 83 4,383.000 23,320 I-2I-00 82 4,410,000 44,300 1-22-00 81 4,330,000 40,600 1-23-00 71 3,985,000 37,300 1-24-00 67 4,360,000 53.500 1-26-00 83 4,240,000 47,100 1-27-00 71 3,480,000 48,100 ^ Loc. cit. PNEUMONIA. 411 In 9 out of the other 10 cases above noted, a leucocyte in- crease was found, the counts for the 10 averaging 17,180 and ranging from 8,600 to 3 1 ,600 per cubic millimeter. The presence of a well-developed leucocytosis Diagnosis, points to pneumonia or empyema, rather than to simple serous pleurisy, but it does not differentiate l^etween these first two conditions. On the other hand, an ab- sence of leucocytosis does not surely exclude pneumonia and empyema, although it is extremely suggestive that neither exists. Malignant neoplasms of the lungs and pleura also cause a decided leucocyte increase. LI. PNEUMONIA. In the case of average severity, coagulation is General exceedingly rapid, and the amount of fibrin Features, greatly increased, the network being dense, coarse, and formed with great rapidity. The hyperinosis tends to persist for some time after the disappearance of the pyrexia and the signs of lung involvement. In severe infections, occurring in individuals of good resisting powers, the change is especially striking, but in fatal cases, overwhelmed by the disease, a fibrin increase is not observed. High temperature and exten- sive infiltration of the lungs are associated with marked hyperi- nosis. In children the specific gravity of the blood is usually high during the febrile period, falling to normal as resolution takes place ; in cases with marked cyanosis the concentration of the blood also raises its density. Attempts to apply the seriim test in this disease have thus far been failures, the reports of those who have experimented with this reaction having shown that the pneu- mococci are either wholly unaffected by the serum of pneumonia patients, or at the most, agglutinate very slowly and atypically. The diplococcus pneumonice is present in the Bacteriology, circulating blood in only a small proportion of cases, for the bacterial products, and not the or- ganisms themselves, gain access to the general circulation, as a general rule. Positive bacteriological findings are commonest in those cases complicated by a secondary pneumococcus infection, and are always to be regarded as a grave prognostic sign. Franklin W. White,^ in 19 carefully studied cases of pneumonia, obtained positive results in 3 patients, all of whom died ; of the 16 negative cases, 7 proved fatal. Sittmann^ found the pneumo- coccus in 6 out of 16 cases examined by him, in 4 cases by cul- ijourn. of Exper. Med., 1899, vol. iv., p. 425. SDeut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. 412 GENERAL HEMATOLOGY. tural methods, and in 2 in stained cover-slip preparations of the blood ; of these 6 positive cases, 4 died, and of the 10 negative cases, but a single one ended fatally. Kohn ^ examined 32 cases, obtaining positive results in 9, of which number 7 cases were fatal, while the other 2 finally recovered after a grave infection ; of this author's 23 negative cases, recover}^ took place in 8. Pieraccini ^ found the pneumococcus in the blood in 1 1 out of 28 cases, while Silvestrini and Baduel ^ claim to have cultured this organism in 15 out of 16 pneumonia patients whom they exam- ined. These Italian observers found that the number of bacteria in the blood usually, but not invariably, stood in relation to the gravity of the infection. On the other hand, James and Tuttle,* in their studies of 12 cases, 2 of which were fatal, failed in every instance to obtain positive findings. From a study of the above statistics, together with those of other investigators reporting smaller series of cases, it is to be concluded that the presence of the pneumococcus in the blood is exceedingly inconstant, and that positive findings are usually ob- tained only in grave or fatal cases. Eight of ever}' ten cases with pneumococcus bacteriemia end fatally. Negative results from blood culturing, however, cannot be considered of definite prog- nostic value in favor of the patient's recovery. During the active stages of the fever the hemo- Hemoglobin globin and er}'throcytes are either normal or AND ver\' slightly diminished. But polycythemia also Erythrocytes, may occur, as the result of the fever's influence in causing contraction of the peripheral vessels, or from cyanosis. During the post-febrile period moderately low counts are usually found, being due possibly to the hemo- cytolytic effects of the fever, and to a dilution of the blood caused by the decreased arterial tension which occurs at this stage of the illness. The loss, in the writer's experience, amounts in the average case to about 20 per cent, of the normal number of cells, with a somewhat greater hemoglobin decrease — approximately 35 per cent. In 1 3 cases, examined after the seventh day of the dis- ease, the hemoglobin averaged 66 per cent., being as low as 40 and as high as 1 10 per cent, in the individual case ; the average erythrocyte count was 3,988,450 per cubic millimeter, ranging from 3,200,000 to 5,500,000. Poikilocytosis, and other struc- tural changes in the cells are to be noted only in severe cases. 1 Deut. med. Woch., 1897, vol. xxiii., p. 136. ^Centralbl. f. allg. Path. u. pathol. Anat., 1900, vol. xi., p. 460. 3 Ibid., p. 447. * Loc. cit. PNEUMONIA. 413 In pneumonia, as in other acute infections, the Leucocytes, severity of the infective process and the intensity of the reaction on the part of the organism are the factors which determine the behavior of the leucocytes. In the great majority of cases a well-marked leucocytosis develops at or soon after the time of the initial chill, and persists until shortly after the temperature has fallen to normal. A high leucocytosis indicates a severe infection in an indi- vidual of strong resisting powers. A moderate increase indicates either a slight infection coupled with good resistance, or an in- tense infection with an inadequate reaction. Little or no leuco- cyte increase also suggests one of two diametrically opposite con- ditions : either an infection too trivial to excite reaction, or one so severe as to overpower the organism, stifling reaction. Ewing ^ has found that, as a rule, the increase is greater in cases with extensive lung involvement than in those with limited lesions, but this parallelism between the degree of leucocytosis and the extent of the pneumonic process is approximate, and does not always hold good. In a general sense, it applies only to cases which react well toward the disease. There is no relationship between the degree of increase and the degree of fever during the active stages of pneumonia. In the average well-marked case the number of leucocytes usually ranges between 20,000 and 30,000 per cubic millimeter, the latter figure being only rarely exceeded, as, for example, in severe sthenic cases, in which the count may rise to 40,000 or 50,000. Summing up a total of 470 cases reported by various observers, we find that the average ''first count" of the leuco- cytes, during the febrile stage of the disease, was 22,693, this fig- ure applying to all cases, both with and without leucocytosis. Between 5 and 10 per cent, of all cases fail to develop an increase, and of these over 95 per cent, end fatally, so that from this fact, an absence of leucocytosis must be regarded as of distinctly un- favorable prognosis, except in those cases in which the type of the infection is obviously mild. The occurrence of a high leuco- cytosis is of no definite prognostic value, since it indicates simply a marked infection and good resisting powers. The following table shows the range of the leucocytes in 27 hospital cases of pneumonia : Above 45,000 in 2 cases. From 25,000-30,000 " I case. '' 20,000-25,000 " 8 cases. ** 15,000—20,000 '^ 4 '' ^N. Y. Med. Journ,, 1893, vol, Iviii., p. 715. 414 GENERAL HEMATOLOGY. From 10,000-15,000 in 4 cases. ** 5,000-10,000 " 7 *' Below 5,000 '' I case. Highest : 53,500 per cb. mm. Lowest : 4,000 <<<'<« Average: 17,303 ** " *' In cases terminating by crisis, the leucocytes begin to diminish either a short time before or after the temperature commences to decline, the normal number being reached, in most cases, within twenty-four or forty-eight hours after crisis occurs, although in a small proportion of cases the decrease is much slower, the count sometimes not reaching normal until a week after the tempera- ture has dropped. False crises, although they may cause a strik- ing drop in the temperature, do not cause a decline of the leu- cocyte curve. In cases ending by lysis, the decrease in the number of leuco- cytes and the decline in the temperature begin simultaneously, but the latter reaches normal much more rapidly than the former ; the leucocyte decrease progresses more gradually than in the cases ending by crisis, and the normal count is often not reached until a week or ten days after the temperature has fallen to the normal figure. At the beginning of lysis a correspondence may be distinguished between the diurnal fluctuations of the temper- ature and leucocyte cur\'es, although no such relation is apparent during the febrile period of the disease. It is an interesting fact that in about half of all cases, whether ending by crisis or by lysis, the maximum count of leucocytes is attained during- the period of temperature decline. Von Jaksch's ^ idea of injecting substances to cause leuco- cytosis in pneumonia where this phenomenon was absent, hoping thereby to benefit the patient, has not been attended by the favor- able results which he anticipated. Leucocytosis is as promptly induced in the pneumonic as in the healthy individual, by the injection of nuclein, for example, but without beneficial effect upon the patient's condition, a fact which must be regarded as evidently signifying that an absence of leucocytosis in fatal cases is not the cause of death, as Billings ^ remarks. Hare ^ has drawn attention to the fact that while leucocytosis is checked by antipyretics, it is not arrested by cold sponging, an observation which prompts Cabot * to declare in favor of the latter method of reducing temperature in pneumonia. * Cited by Cabot, loc. cit. 2 Johns Hopkins Hosp. Bull., 1 894, vol. v., p. 112. 3 Therapeutic Gaz., 1898, vol. xii., p. 153. * Loc. cit. PNEUMONIA. 415 The leucocytosis of pneumonia is of the typical variety, that is, it is due to a large absolute and relative increase in the poly- nuclear neutrophileSy with a consequent relative decrease in lym- phocytes. The proportion of eosinophilcs is much reduced, and frequently these cells are entirely wanting. This is regarded as an unfavorable sign by Becker,^ who states that he has never found eosinophils in fatal cases. With the decline of the tem- perature and the fading away of the leucocytosis, the percentage of polymorphous cells rapidly falls to normal or subnormal, and the lymphocytes and eosinophils increase until they regain their normal percentages. The latter cells usually begin to reappear in the circulation a day or two before defervescence, and in some instances a striking post-febrile eosinophilia develops. In 20 cases showing marked leucocytosis, Billings found the following averages : lymphocytes, 9.6 per cent. ; polynuclear neutrophils, 91.2 per cent. ; eosinophils, 0.2 per cent. Heim '^ found a simi- lar degree of polynuclear neutrophile increase in 19 cases. In 3 of Billings' counts in fatal cases showing no leucocytosis, it was found that the various forms of leucocytes remained in their normal relative proportions, this fact apparently tending to show that no attempt whatever was being made to resist the infection, such as an increase in the polymorphous forms and a decrease in the mononuclears would indicate, even in the absence of an increase in the total number of leucocytes. The leucocytes usually respond to the iodine reaction, most strikingly in cases with high leucocytosis. In such instances myelocytes are gener- ally numerous. In the pneumonias of children the possibility of lymphocytosis should be remembered, for although a true lymphocytosis is rare, it sometimes occurs, giving rise to false impressions, if clinical signs other than the examination of the blood are neglected. (See p. 197.) During the period of fever the blood plaques are markedly de- creased in number, and often, indeed, altogether disappear from the blood, but after the crisis they reappear in great abundance, the fresh specimen taken at this time often being flooded with these bodies. In atypical cases the presence of a well- DiAGNOSis. marked leucocytosis is a helpful sign in exclud- ing such conditions as serous pleurisy, enteric fever, typhus fever, malarial fever, and influenza. In the differ- entiation of croupous from catai^rhal pneumonia, empyema, and ' Deut. med. Woch., 1900, vol. xxvi., p. 558, 2 Archiv. de med. des enf., 1901, vol. iv. , p. 21. 4i6 GENERAL HEMATOLOGY. acute meningitis the leucocyte count furnishes no tangible clue, since it is high in all these conditions ; the same is true of some cases of acute bronchitis. An acute apical pneumonia, if associ- ated with leucocytosis, is almost invariably to be considered non- tuberculous. As previously stated, absence of leucocytosis in a case with well- defined chest signs is of grave prognosis, but the presence of a leucocytosis is by no means always of good augury. Persistence of a high leucocyte count is suggestive either of delayed resolu- tion, empyema, or gangrene, and a sudden reestablishment of the leucocytosis, after its disappearance at the time of crisis, points to a recurrent attack of the disease. Reappearance of the eosinophiles or the presence of circulatory eosinophilia, indicates the termina- tion of the acute phase of the illness. Detection of the pneumococcus in the peripheral circulation is almost equivalent to signing the patient's death-warrant, although, on the contrary, negative results from blood cultures are of no significance. LII. POISONING. A synopsis of the blood changes produced by various toxic substances is given in the following table, these changes consist- ing chiefly in hemocytolysis, methemoglobinemia, anemia, poly- cythemia, and leucocytosis. Name of Poison. Alcohol. Amyl nitrite. Acetanilid. Ammonia. Antipyrin. Arseniuretted hydrogen. Aspidium. Bromine. Chloral. Chromic acid. Corrosive metals and minerals. Ether. Guiacol. Effects 7ipon the Blood. Anemia ; often leucocytosis.^ Methemoglobinemia.^ Methemoglobinemia.^ Leucocytosis.^ Methemoglobinemia.^ Hemoglobinemia.^ Hemocytolysis."* Methemoglobinemia.*^ Leucocytosis.^ Methemoglobinemia.^ Anemia ; leucocytosis.^ Oligochromemia ; leucocytosis.* Hemocytolysis ; leucocytosis.^ ^ Cabot : loc. cit. 2 Grawitz : loc. cit. ^Miiller: Deut. med. Woch., 1S87, vol. xiii., p. 27. * Georgiewsky : Beitr. z. path. Anat. u. z. allg. Path., 1898, vol. xxiv., p. I. * Hayem : Compt. rend. Soc. biol., Paris, 1886, vol. cii., p. 69S. 6 J. Chalmers DaCosta : Amer. Surg. Assn., Baltimore, May 7, 1901. ' Wyss : Deut. med. Woch., 1S94, vol. xx., p. 296. RABIES. 417 Hydrocyanic acid. Illuminating gas. Iodine. Lead. Nitrobenzol. Nitroglycerine. Opium. Phenacetin. Phosphorus. Potassium chlorate. Potassium permanganate. Ptomaines. Pyrodin. Pyrogallol. Pyrogallic acid. Snake and scorpion venom. Sodium nitrite. Tansy. Toadstools. Toluene. Turpentine. Methemoglobinemia.^ Methemoglobinemia ; polycy- themia ; leucocytosis.^ Methemoglobinemia.^ Anemia ; granular basophilia ; often leucocytosis.'* Methemoglobinemia ; megalo- blastic anemia.^ Methemoglobinemia.^ Occasionally leucocytosis.^ Methemoglobinemia.^ Polycythemia ; occasionally leu- cocytosis.^ Methemoglobinemia ; anemia ; leucocytosis.^ Methemoglobinemia.^ Leucocytosis.^ Hemocytolysis.^^ Methemoglobinemia.^ Methemoglobinemia.® Hemoglobinemia ; hypervis- cosity ^^ ; leucocytosis.^^ Methemoglobinemia.® Leucocytosis.^ Hemoglobinemia.^ Hemoglobinemia.^^ Methemoglobinemia.^ LIII. RABIES. Courmont and Lesieur ^' have recently determined that an ex- cessive increase in the number oi poly nuclear neutrophilcs is a constant change in the blood of patients suffering from hydro- 1 Robert: ** Lehrb. d. Intoxicationen," Stuttgart, 1893. 2 Cabot : loc. cit. . 3Hayem : Compt. rend. Soc. biol., Paris, 1886, vol. cii., p. b9». ^Grawitzand Hamel : Deut. Archiv. f. klin. Med., 1900, vol. Ixvu., p. 357. sEhrlich and Lindenthal : Zeitschr. f. klin. Med., 1896, vol. xxx., p. 427- eGrawitz : loc. cit. 7Kr6nig : Berl. klin. Woch., 1898, vol. xxxii., p. 998. 8 Von Jaksch : Deut. med. Woch., 1893, vol. xix., p. lo. 9Bradenburg : Berl. klin. Woch., 1895, vol. xxxii., p. 583. JOTallquist: " Exper. Blut. gizt. Anemie," Berlin, 1900. 1' Stengel : " Contributions from the William Pepper Laboratory of Clinical Medi- cine," Phila., 1900. 1 • ^^ i2Auche and Vaillant : Journ. de Med. de Bordeaux, 1901, vol. xxxi., p. 29. 13 Vast : " Thdse de Paris," 1889. 14 Sam. m6d., 1901, vol. xxi., p. 61. 27 4i8 GENERAL HEMATOLOGY. phobia, and that analogous findings are met with experimentally in rabid dogs, guinea-pigs, and rabbits. The polynuclear gain is frequently, but not invariably, associated with an increase in the total number of leucocytes. It may amount to as much as 98 per cent., and first develops during the period of incubation, be- coming emphasized with the appearance of the clinical symptoms of the affection, and reaching a maximum just before death. The authors referred to believe that an absence of polynucleosis is sufficient to rule out rabies in a suspected case, although its presence cannot be regarded as pathognomonic of the disease. LIV. RELAPSING FEVER. The specific cause of relapsing fever, a spiril- Parasitology. lum discovered by Obermeier in 1868,^ may be found in the peripheral blood of patients suffer- ing from this disease, only during and shortly before the febrile paroxysm, the organism disappearing from the general circulation during the interparoxysmal afebrile period. The number of para- FlG. 48. Spirilla of relapsing fever. sites found in a blood-film varies within wide limits, and does not generally stand in any definite parallelism to the severity of the infection or to the degree of pyrexia. Microscopically, the spirilla of Obermeier appear in the fresh blood as delicate, homogeneous, thread-like bodies twisted into the form of spirals, occurring singly or in groups of several or- ^ Centralbl. f. d. med. Wissensch., 1873, vol. xi., p. 145. RELAPSING FEVER. 4I9 ganisms, radiating from a common center. ( Fig. 48.) The length of the parasites varies from 16 to 40 //, or approximately from two to six times the size of the normal erythrocyte. They possess an active vibratile motility, exerted in the direction of their long axes, by virtue of which they are propelled and con- stantly altered in shape. Owing to this characteristic motility, the presence of the parasites is usually first betrayed to the ex- aminer by the whipping about of the blood corpuscles in their immediate proximity. The spirilla remain alive for only a short time after the withdrawal of the blood, and are so extremely sensitive to external influences that the addition even of distilled water causes them rapidly to disappear. Since nothing is known of their life history, the cause of their disappearance from the peripheral circulation during the intermissions of the disease is not known. Both Sarnow ^ and von Jaksch ^ have called attention to the presence of certain refractive bodies, similar to diplococci, which may be found in the blood during the intermission, provided that another paroxysm is impending. The last-named authority be- lieves that he has observed the metamorphosis of these bodies into short thick rods from which the typical spirilla eventually are evolved, and he tentatively regards them as spores of the latter. The views of this investigator have not, however, been generally accepted up to the present time. Afanassiew^ has described, in addition to the specific spirilla, peculiar bacteria which he found in the blood during the parox- ysm. The organisms in question resemble bacilli with rounded poles, and appeared to be invested by non-staining, hyaline sheaths. Some of them measured not more than 5 or 6/i in length, while others appeared as filamentous threads fully 10, 12^ or 14/i long, this increase in size being demonstrable in the fresh specimen watched for some time under the microscope. Afanas- siew asserts that, unlike Obermeier's spirilla, the bodies may be cultivated on bouillon, gelatine, agar, and blood serum ; he further claims that in three patients inoculated with a twenty-four-hour- old bouillon culture of the organism, periods of pyrexia, recurring at ten-day intervals, were produced, and that in the blood of one of the patients thus treated numerous bacillary and filamentous forms were discovered. These investigations, as yet unconfirmed by other workers, are to be regarded only in the Hght of an in- teresting observation. ' Inaug. Dissert., Leipzig, 1882. 2 "Clinical Diagnosis," 3d ed., London and Phila., 1897, p. 50. 3 Centralbl. f. Bakt. u. Parasit., 1899, vol, xxv., p. 273. 420 GENERAL HEMATOLOGY. Melanin granules, either free or within the protoplasm of the leucocytes, are frequently seen in the blood, especially just after a paroxysm, and phagocytes containing engulfed spirilla may also be found at this time. Teclmique of Exainmatioii. Fresh specimens of blood, taken during the paroxysm from the patient's finger or ear, are most suit- able for microscopical examination. The motility and finer struc- ture of the spirilla are seen most clearly with a ^^^ inch oil-immer- sion objective, but for making the preliminary search a lower power, dry lens is more convenient, a J or i inch objective being useful for this purpose. Dried films, fixed by one of the chemical methods of fixation already described (page 62) may be stained preferably by fuch- sin, or the method of Giinther (page 86) may be used. For diagnostic purposes stained specimens are never to be preferred to the fresh blood film. LowentJiar s Reaction. The ingenious blood test devised by Lowenthal ^ furnishes a means of recognizing relapsing fever dur- ing the afebrile period, when the spirilla cannot be detected in the blood. It is conducted in the following manner. A drop of blood from a suspected case is mixed with a drop containing motile spirilla, the latter being taken from a patient during the paroxysmal stage of the disease. The mixture thus made is sealed between a slide and cover-glass, and incubated at body temperature for half-an-hour, at the end of which time it is ex- amined under the microscope. If the suspected case be one of relapsing fever, the spirilla will have become quite motionless and collected together in irregular masses, while if the case be one of some other disease the motility of the parasites remains unim- paired. A control specimen, prepared from normal and spirilla- containing blood, must always be similarly incubated and ex- amined with each test. If no such reaction as that described occurs within a time limit of two hours and one-half at the most, it is safe to regard the suspicious case as one not of relapsing fever. In 35 cases of this disease, Lowenthal obtained about 85 per cent, of positive results, while in 14 cases of fever due to other causes the reaction was uniformly absent. The reaction, which takes place in abortive and mild cases as well as in the severer forms of the disease, is thought to be de- pendent upon the presence in the blood of specific bactericidal products. 1 Deut. med. Woch., 1897, vol. xxiii., p. 560. RHEUMATIC FEVER. 421 Von Limbeck,^ quoting von Bockmann, states Hemoglobin that there is a decrease in the number of erythro- AND cytes and in the hemoglobin value in cases of re- Erythrocytes. lapsing fever, but neither the mode of production of such an anemia, nor the exact morphological changes by which it is characterized, have been carefully investi- gated, so far as can be ascertained. The losses are observed to occur during and for a few days after each paroxysm, but they are partly compensated during the interparoxysmal period. A variable degree of increase in the number of Leucocytes, leucocytes, often of high grade, has been described by Laptschinski^ as associated with the paroxys- mal stage of the disease, this observer having noted that the "coarsely granular elements" were especially involved, and that the relative number of leucocytes to erythrocytes was in some instances as high as i to 37. During the period of intermission this leucocytosis disappears. This author, as well as von Bock- mann^ and Heidenrich,* also noted that the period of maximum leucocytosis was reached just after the crisis. The detection of the spirillum in the blood im- DiAGNOSis. mediately differentiates relapsing fever from typhis fever, the onset and initial symptoms of which not infrequently prove confusing, and it may also be added that in such instances the absence of this organism during the stage of pyrexia is strong evidence for excluding the first-named disease. During the afebrile period, when the symptoms may suggest, for ex- ample, malarial fever, Lowenthal's reaction should be attempted, and the malarial parasite searched for. Melanemia, it must be recalled, may be encountered in both of these infections. LV. RHEUMATIC FEVER. Coagtdation of the blood takes place within the General normal time limit, or it may be delayed consider- Features. ably. The amount of fibrin is markedly in- creased, especially during the most acute stages 01 the illness. Contradictory reports have been made by different •authors concerning the alkalinity, some having found it dimin- ished, and others having been unable to detect any such altera- tion. According to Hutchinson,^ the general consensus of opin- ^ Loc. cit. ^Centralbl, f. d. med. Wissensch,, 1875, vol. xiii., p. 36. 3 Loc. cit. '*''Untersuch. ii. d. Par. d. Riickfallstyphus," Berlin, 1877. 5 Lancet, 1896, vol. i., p. 615. 422 GENERAL HEMATOLOGY. ion is against any notable disturbance of the normal figure. In chronic articular rheumatism with coexisting anemia a slight dim- inution of the alkalinity is occasionally observed. The bactcriolo_^y of the blood in this disease has for many years been the object of much careful study, but thus far specific properties have not been generally conceded to any definite or- ganism, although a great number of different bacilli, streptococci, staphylococci, and diplococci have been cultivated from the circu- lating blood during life. At the present time the bacillus iso- lated by Achalme * and the diplococcus of Trlboulet ^ are regarded by many, especially by some of the French school, as possible etiological factors, if, indeed, rheumatic fever is actually a bacterial disease. For a careful review of the bacteriology of rheumatism the reader should consult the admirable brochure, ** Le Rhu- matisme articulaire aigu en bacteriologie," by Triboulet and Coyon, Paris, 1900. Few cases of acute rheumatic fever are unac- Hemoglobin companied by anemia, the intensity of which AND generally bears a fairly close relation to the se- P2rvthrocvtes. verity and the duration of the illness. In acute attacks of short duration the hemoglobin falls to about 70 or 80 per cent, and the erythrocytes to 4,000,000, but in cases of longer standing the losses are likely to be more pro- nounced, the count often being not more than 3,000,000 or thereabouts. The color index usually is moderately subnor- mal, and may tend to remain so after the attack, even though the rise normalward of the erythrocyte count may have become well established. In chronic rheumatism a moderate oligochromemia is usually the only evidence of anemia that can be detected, un- less the patient happens to be decidedly cachectic. Cabot's 43 cases of acute rheumatic fever ^ showed an average hemoglobin estimate of 67 per cent., and an average erj^throcyte count of 4,400,000 per cubic millimeter. In the writer's experi- ence, limited to 7 cases, the anemia was found to be much more striking, for in two the hemoglobin estimates were 26 and 30 per cent., and the counts 1,242,000 and 1,590,000, respectively. These figures were sufficient to lower the av^erages for the total number to 47.6 per cent, for hemoglobin, and 3,098,964 per cubic millimeter for the erythrocytes. ' Compt. rend. Soc. biol., Paris, 1891, 9 s. , vol. iii., p. 651. Ibid., 1897, 10 s., vol. iv., pp. 276 and locx). ^ Rev. de med., Paris, 18S8, vol. xviii., pp. 189 and 329. Also, Triboulet. Coyon and Zadoc : Hull. Soc. nied. des hop. de Paris, 1897, 3 s., vol. xiv., p. 1343. 3 Loc. cit. SCARLET FEVER. 423 Should the cellular loss reach a high grade, deformities of shape and size, polychromatophilia, and, rarely, nucleated erythro- cytes of the normoblastic type may be observed. Leucocytosis of the typical polynuclear neutro- Leucocytes. phile type is almost always present during the acute stages, but it is found only exceptionally in the subacute form of rheumatism, and practically never exists in the chronic variety. The count does not often exceed twice the maximum number of cells found normally, but occasionally it reaches a figure as high as 30,000 or 40,000 per cubic millimeter especially in very acute cases, which as a rule are associated with the highest leucocytoses. In Cabot's cases, above referred to the number of leucocytes averaged 16,800, and ranged from 4 700 to 39,000. In the writer's cases the maximum count was ^'i 200, the minimum 8,000, and the average I4,857- Tiirk^ has noticed that in many instances well-marked post- febrile eosinophilia develops, and that in favorable cases a relatively high percentage of eosinophiles persists during the acute stage pyrex . ^^^ \^\oo^ changes are uncharacteristic, and do Diagnosis not serve as a means of differentiating this condi- tion from other lesions in which the joint involve- ment and the constitutional manifestations are more or less similar. Thus in acute gout, in multiple secondary arthritis, and in septic arthritis due to pyemia, the same grade of anemia, leucocytosis, and hyperinosis may be observed. LVI. SCARLET FEVER. In cases associated with pronounced anginal General symptoms and with marked leucocytosis, coagii- Features lation of the fresh blood drop is rapid, and the amount of fibrin decidedly in excess of normal. In many cases a slight increase of fibrin is observed at the period of bednning desquamation. . The specific gravity is unchanged in the average case, but in those complicated by acute parenchymatous nephntis. in conse- quence of the drain on the albuminoids of the blood thus pro- duced, it may fall to a very low figure— to 1030, according to Peiper and Hammerschlag.^ In 12 cases studied by van den Bere' the specific gravity ranged from 103 1 m complicated cases, to 1060 in uncomplicated cases of the average severity. ^Loc. cit. , .. - J C/^f zCentralbl. f. klin. Med., 1891, vol. xii., pp. 217 and S25. 3 Archiv. f. Kinderheilk. , 1898, vol. xxv., p. 321. 424 GENERAL HEMATOLOGY. The specific micro-organism of scarlet fever Bacteriology, has not yet been isolated, either from the blood or other tissues, although in recent years many different bacteria have been described as causative factors. Class ^ claims to have discovered in the blood and throats of scarlet fever patients a diplococcus, named by him the diplococcjis scarlatincE, which he considers specific, and this claim has received the support of a number of other investigators, Gradwohl," Jaques,^ and Page '' being among those who found the bac- terium in question. Baginsky and Sommerfeld ^ conclude, as have some earlier writers, that the clinical features of scarlet fever are due to a general streptococcus infection, having found this organism in the blood of 42 fatal cases. Class,^ in a later communication, hints that his diplococcus and Baginsky and Som- merfeld's streptococcus are identical, since the former often de- velops streptococcus forms in young cultures made from the blood. Any one who has read Class' description of his organ- ism must be struck with its resemblance to the diplococcus found in scarlet fever blood by Crajkowski,^ in 1895. Jehle^ states that he has repeatedly isolated the influenza bacillus from the blood of young children ill with scarlet fever. The studies of these investigators, while of the greatest interest, are scarcely conclusive. Most observers agree that the scarlatinal infec- Hemoglobin tion, unless complicated, produces but trifling and changes in the hemoglobin and erythrocytes, Erythrocytes, moderate anemia characterized by a dispropor- tionate diminution of hemoglobin being the gen- eral rule in the cases in which any changes are noted. Widowitz^ found that the percentage of hemoglobin, normal at the beginning of the illness, slowly diminished during the fe- brile period, in a degree commensurate to the intensity of infec- tion, and gradually returned to normal during convalescence. Pee "^ noticed, in severe cases, a pronounced ** chloro-anemia," characterized by notable pallor and variations in the size of the corpuscles. Hemoglobinemia has also been occasionally observed. ' N. V. Med. Record, 1899, vol. Ivi., p. 330. ^Phila. Med. Journ., 19CX), voL iv., p. 688. 3Ibid., p. 552. * Journ. liost. Soc. Med. Sc, 1899, vol. iii., p. 344. 5 Berl. klin. Woch., 1900, vol. xxxvii., p. 5S8, ^ Journ. Am. Med. Assn., 1900, vol. xxxv., p. 799. ^Centralbl. f. Bakt. u. Parasit., 1895, vol. xviii., p. 116. 8 Zeitschr. f. Heilk., 1901, vol. xxii., p. 190. ^Jahrb. f. Kinderheilk., 1888, vol. xxvii., p. 380; vol. xxviii., p. 25. '°Inaug. Dissert., Berlin, 1890. SCARLET FEVER. 425 The number of erythrocytes is generally between 4,000,000 and 5,000,000 per cubic millimeter in the case of average se- verity, the minimum count being reached at about the time of the decline of the temperature ; but in complicated cases the anemia is more marked, and histological degenerative changes of the corpuscles have been noted during the period of desqua- mation. Van den Berg's examinations of 12 cases ^ show that the count is usually above 4,000,000 per cubic millimeter, except in severe cases complicated by acute nephritis, or endocarditis, in the event of which a rapid and striking anemia is produced, the hemoglobin sometimes being as low as 25 per cent., and the corpuscles diminishing to as low as 2,000,000 per cubic milli- meter. From an analysis of the cases reported by Zappert,^ Felsenthal,^ Widowitz,^ and others, the average loss of erythro- cytes in all cases amounts to about 1,000,000 cells to the cubic millimeter, but Kochetkoff^ notes a more decided average reduc- tion, this author stating that they progressively decrease to about 3,000,000, and that regeneration is slow and gradual, not being completed for a period of six weeks. A well-marked leucocytosis, the count usually Leucocytes, ranging between 20,000 and 30,000 per cubic millimeter, occurs in the majority of cases, often first appearing several days in advance of the cutaneous eruption, and persisting in some cases long after convalescence has been established. Its duration varies widely in different instances ; in some cases, not necessarily of a severe type, the leucocytosis persists for ten, or even thirty days ; while in others, usually of a mild type, it disappears before the temperature has fallen to normal. The maximum degree of increase is reached from four to six days after the onset of the illness. In asthenic cases the number of leucocytes is increased but slightly, or not at all ; but in the well-nourished child, the degree of leucocytosis may be regarded as a rough gauge of the intensity of the infection, being usually greater in severe than in mild cases. The increase appears to bear no fixed relationship either to the anginal infection, or to the glandular involvement, for marked leu- cocytosis has been observed in cases with mild angina, unac- companied by swelling of the glands. Neither can any clear re- lation be established between the leucocytosis and the character 1 Loc. cit. 2Zeitschr.f. klin. Med., 1893, vol. xiii., p. 292. 3Archiv. f. Kinderheilk., 1892-3, vol. xv., p. 82. * Loc. cit. 5 Vrach, 1891, vol. xii., p. 919. 426 GENERAL HEMATOLOGY. of the temperature, the period of desquamation, and the inflam- matory complications of the ear and kidney. In all of van den Berg's cases the number of leucocytes was in excess of normal, the "first counts" averaging slightly more than 17,000 per cubic millimeter, and the leucocytosis being higher than 30,000 in only 2 cases. The investigations of the other authors above referred to give practically the same results, although somewhat higher counts have been made in some in- stances. Mackie ^ found leucocytosis constant in 25 cases, and in one patient with severe anginal symptoms the count rose to 93,300. He failed to observe any signs of a leucocyte increase until twenty-four hours after the appearance of the rash. The leucocytosis is generally due to an increase in the poly- nuclcar iiLiitt'ophiles, these cells ranging from 85 to 90 per cent.; but in some instances the increase is more evenly divided between the polymorphous and mononuclear forms, so that from 70 to 80 per cent, of the former and from 1 5 to 30 per cent, of the latter may be found. The writer has noticed the presence of large numbers of the so-called transitio7ial mononuclear leu- cocytes, and of an occasional myelocyte. Van den Berg has noted the presence of small numbers of myelocytes in grave cases. Contrary to the rule which holds good in most febrile conditions, the number of cosinopJiiles in favorable cases of scarlet fever remains normal, or, indeed, may be decidedly increased. In very grave cases a decrease or absence of these cells is usually found. In cases with nephritic complications their increase is thought to be favorable. The proportion of eosinophiles is us- ually from 4 to 5 per cent, of the other forms, sometimes even 10 or 15 per cent., especially during the post- febrile period of the disease. The blood plaques are normal at the beginning of the attack, but a large increase in the number of these elements is said to occur during the period of desquamation. The presence of leucocytosis and persistence Diagnosis. of the eosinophiles, are suggestive signs in distin- guishing scarlet fever from measles, since in un- complicated cases of the latter disease these changes are absent. Disappearance of the eosinophiles is regarded as a bad prognos- tic sign. 1 Lancet, 1901, vol. ii., p. 525. SEPTICEMIA AND PYEMIA. 427 LVII. SEPTICEMIA AND PYEMIA. The blood changes found in those conditions General due to the presence in the circulating blood of Features. septic bacteria or their toxines, geyieral septicetnia, sapremia, and pyemia, are similar, and therefore may be considered together under the above heading. An ap- parently trivial infected wound may give rise to just as severe blood changes as an intense pyemia with widespread metastatic abscesses, since these alterations depend rather upon the virulence of the infection and the reaction which it provokes, than upon the character of the exciting lesion and the specific nature of the offending organisms. Clinically, these blood changes may be associated with such conditions as infected wounds, osteomyelitis, malignant endocarditis, puerperal fever, septic joints, and many other lesions for which various septic micro-organisms are held responsible. The amount of fibrin is often appreciably increased in cases in which the reaction against the infection is well marked, especially in the early stages of the illness. A decrease in fibrin is, how- ever, common in patients with pronounced anemia, and in those who readily succumb without reaction against the infection. Thus far, the serum test has given no reliable clinical informa- tion in this class of diseases, although several clinicians of the French school claim occasionally to have observed typical clump- ing of streptococcus bouillon cultures with the serum of patients suffering from streptococcus infections, such as streptococcus in- fected wounds, sepsis, puerperal fever, and erysipelas ; but nega- tive results were obtained in testing bouillon cultures of the staphylococcus with the serum of staphylococcus septicemia. The evidence brought forward to show that the serum of patients suffering from colon infections clumps cultures of the colon bacillus, is by no means conclusive ; for many races of the colon bacillus, it may be recalled, clump spontaneously, and are agglutinated by normal serum. If a test-tube containing blood serum of a patient suffering from pneumococcus septicemia is inoculated with a pure culture of the pneumococcus, it will be found that, after twenty-four hours' incubation, the serum still remains free from turbidity, and shows simply a slight sediment composed of pneumococci, capsuleless and glued together in tenacious clumps, or in serpentine, trailing designs. Pneumococci grown in normal serum cloud the liquid, and develop a new growth consisting of encapsulated, isolated organisms. Favorable 428 GENERAL HEMATOLOGY. results have been reported by several Continental writers who have used this test clinically, but its diagnostic value must still be regarded as questionable. In the great majority of cases of septicemia Bacteriology, and pyemia, cultures from the blood prove ster- ile, but such negative results neither exclude the existence of a septic process, nor necessarily indicate a favorable prognosis. On the other hand, positive results are often of the greatest value in the diagnosis of obscure cases of sepsis, in which the clinical manifestations are more or less vague. As pointed out by Welch, ^ blood cultures in which the staphylococ- cus pyogenes albus is demonstrated have little significance in the prognosis of the case, whereas the presence in the blood of the other pyogenic cocci is almost invariably a grav^e sign. The results obtained by different investigators in the bacterio- logical examination of the blood in septicemia vary within wide limits, these variations being explained partly by the differences in the technical methods used by each reporter, and partly per- haps by the nature of the infection. Petruschky - obtained 17 positive results in the examination of 59 cases of sepsis, strepto- cocci being found in 15, and staphylococci in 2 instances. Sitt- man ^ examined 53 cases of septicemia, and succeeded in iso- lating streptococci in 4, staphylococci in 1 1, and pneumococci in 6. Czerniewski ^ in 37 cases of puerperal sepsis obtained posi- tive results in 10, pure cultures of streptococci being found in all the grave infections. Symes^ obtained positive cultures in 9 out of 3 I cases of sepsis, the staphylococcus, the streptococcus, the pneumococcus, and the micrococcus tetragenus having been the organisms identified. Kiihnau's investigations^ show a much lower percentage of positiv^e findings than are commonly re- ported, for this author in 23 cases of septico-pyemia obtained growths in only 3 instances, while but a single positive finding resulted from the examination of 12 cases of ulcerative endo- carditis. Krauss,^ who has had a very large experience in the bacteriological investigation of the blood in various infectious diseases, reports 7 positive results in a series of 22 cases of sep- ticemia, ulcerative endocarditis, and erysipelas. White ^ in 18 1 Dennis' "System of Surgery," Phila., 1S95, vol. i., p. 251. ^Zeitschr. f. Hygiene, 1894, vol. xvii., p. 59. 3Deut. Archiv. f. klin. Med., 1894, vol. liii., p. 323. * Archiv. f. Gynaekol., 1888, vol. xx^iii., p. 73. 5 British Med. Journ., 1 901, vol. ii., p. 709. ^Zeitschr. f. Hygiene, 1897, '^^^- xxv., p. 492. " Zeitschr. f. Heilk., 1896, vol. xvii., p. 117. s Journ. of Exper. Med., 1899, vol. iv., p. 425. SEPTICEMIA AND PYEMIA. 429 severe cases of sepsis, all of which were fatal, obtained positive findings in 4 ; the streptococcus pyogenes 3 times, and the staphylococcus pyogenes aureus once. Canon ^ obtained 11 positive results in the examination of 17 cases of septicemia, pyemia, and osteomyelitis. Hirschlaff" obtained the streptococcus or staphylococcus 7 times, in cultures made from 8 cases of sepsis. James and Tuttle ^ in 6 severe septic infections suc- ceeded in finding the streptococcus in 2 instances. Brieger ^ obtained uniformly negative findings in the examination of 6 cases of puerperal sepsis. Similar results have also been re- ported by Neumann ^ who obtained negative findings in blood cultures from 5 cases of pyemia. Grawitz^ cultured pyogenic cocci only once in his examination of 7 cases of malignant en- docarditis. Consideration of these figures, together with the statistics of a number of other reporters of smaller series of cases, furnishes a total of 316 cases of sepsis in which it is reasonable to presume that the bacteriological examination of the blood has been made by dependable methods. Of these 316 cases, positive results were obtained in 107, while the remaining 209 proved negative — a percentage of 33.8 for the former. This analysis, however, is not to be regarded as equivalent to the statement that bacteriological examination of the blood gives positive diagnostic information in one-third of all cases, for the results of a single reHable observer, rather than the aggregate figures of several, are to be considered in order to arrive at a true estimate of the value of this procedure. The writer is inclined to believe that White's results accurately express the value of blood cultures in this class of infections. Anemia, of a grade proportionate to the inten- Hemoglobin sity of the infection, is the rule in septic cases, AND regardless of the specific nature of the infective Erythrocytes, process. In very acute cases the diminution ot hemoglobin and erythrocytes may be so excessive and so rapid that an abrupt downward curve in the erythrocyte line of the blood chart may be detected from day to day, even from morning until night, in some instances. This rapidly de- veloping type of anemia is associated especially with fialminant cases of puerperal septicemia, in which counts of less than 1,000,- 000 cells per cubic millimeter have been frequently reported. ^ Deut. Zeitschr. f. Chirurg., 1893, ^°^- xxxvii,, p. 571. 2 Deut. med. Woch., 1897, vol. xxiii., p. 766. '^Loc. cit. *Charite-Annal., 1888, vol. xiii., p. 198. 5 Bed, klin. Woch., 1888, vol. xxv., p. 143. s Charite-Annal. , 1894, vol. xix,, p. 154. 43 O GENERAL HEMATOLOGY. In less severe cases the development of the anemia is slower and of a more moderate grade, the hemoglobin being reduced to 40 or 50 per cent., and the erythrocytes to from about 2,500,000 to 3,500,000 per cubic millimeter. The following estimates show the blood changes found in a case of puerperal sepsis during a period of four months : Hemoglobin Erythrocytes Leucocytes Date. Percentage. PER CB. MM. PER CB. MM. 4-29-01. 57 3,380,000 17,200 5-16-OI. 52 3,390,000 14,200 6— 2-01. 38 2,640,000 29,400 6- 9-01. 22 2,000,000 33.100 6-12-01. 25 1,600,000 19,000 6-1 6-0 I. 30 1,850,000 16,800 6-21-0 I. 25 1,902,250 27,200 6-27-01. 35 2,339>ooo 19,200 7- 5-0 T. 30 2,050,000 8,600 7-22-01. 30 2,300,000 6,000 8- 6-01. 35 3,150,000 15,000 8-1 5-0 1. 39 3,787,000 10,500 8-22-01." 48 3,637,000 9,200 8-25-01. 52 3,899,000 9,000 In twenty-one hospital cases of septicemia and pyemia the hem- oglobin and erythrocyte values were as follows : Erythrocytes. Cases. Above 5,000,000 I From 4,000,000 to 5,000,000 3 " 3,000,000 to 4,000,000 8 " 2,000,000 to 3,000,000 7 " 1,000,000 to 2,000,000 2 Average: 3,150,490 per cb. mm. Highest: 5,390,000 " " " Lowest: 1,093,000 ** *' " The color index is usually quite low, for the hemoglobin loss is as a rule relatively greater than the corpuscular decrease ; it averaged 0.67 for this series. Hemoglobinemia may be recognized in occasional instances of grave character. Most writers lay stress on the excessively watery condition of the serum, particularly in those cases in which the development of anemia is early, marked, and rapid. Deformities of shape and size and atypical staining phenomena are marked in relation to the degree of the anemia ; they are Hemoglobin. Cases. From 60 to 70 per cent. 2 '' 50 to 60 '' ( ( 3 '' 40 to 50 " i( 8 " 30 to 40 " (I 3 *' 20 to 30 " ( c 4 Below 20 '' 11 I Average : 42.4 per cent. Highest: 64 '' <( Lowest : 19 * * ( ( SEPTICEMIA AND PYEMIA. 43 I rarely conspicuous, except in long-standing cases. The same re- marks apply to the presence of nucleated erythrocytes. Granular basophilia is found with more or less constancy, in severe cases. Leucocytosis is always present in those cases Leucocytes, in which the infection, either moderate or marked, occurs in a patient whose powers of resistance are sufficiently strong to react against the poison. The increase in the number of leucocytes is usually moderate — from about 1 5,000 to 25,000 in the average case. In trifling infections, not suf- ficiently marked to produce activity of the leucocyte-forming organs, and in lethal cases, in which the system is overwhelmed by the toxines, not only does leucocytosis fail to develop, but in some instances distinct leucopenia may be observed. These facts render the occurrence of leucocytosis in septicemia an extremely inconstant sign, for it is no uncommon experience to examine case after case of undoubted sepsis, without encountering any increase in the leucocytes above normal. Thus, in the above series frank leucocytosis was found in only 12 instances, or but a trifle more than 55 per cent, while in 4 cases, or nearly 20 per cent., there was distinct leucopenia, the court in one being only 2,000 per cubic millimeter. All the cases not showing leucocytosis were either very mild or very severe infections. In tabular form these cases may be summarized as follows : Above From 20,000 m 2 cases. 15,000-20,000 a 5 (( 10,000-15,000 (( 5 (I 5,000—10,000 1 1 5 i ( 5,000 ei 4 (I Below Average of 21 cases: 13,852 per cb. mm. *' " 12 " with leucocytosis : 18,793 per cb. ^^''* Highest: 41,600 per cb. mm. Lowest : 2,000 per cb. mm. The increase affects chiefly the polynudear neutropJiiles , which are both relatively and absolutely increased at the expense of the mononuclear forms. In a profoundly anemic case of sepsis Kline ^ found striking eosinophilia — 40 per cent. In all forms of sepsis, and especially in puerperal fever, the iodine reaction occurs with great constancy. The value of the blood examination as an aid to Diagnosis, the diagnosis of septic conditions must be regarded as more or less uncertain. In cases with clinical manifestations suggesting at once enteric fever, malarial fever, and septicemia, the presence of leucocytosis is highly suggestive ^Centralbl. f. inn. Med., 1899, vol. xx., p. 97. 432 GENERAL HEMATOLOGY. of the latter condition, for in typhoid and in malaria leucocytosis rarely exists, except in the event of some complication. The early development of a rapidly increasing anemia would also point to sepsis rather than to typhoid or malaria, for in the latter fevers the anemia, although it begins early, does not reach a high grade until comparatively late in the course of the illness. The pres- ence of a positive serum reaction, or the discovery of malarial parasites in the blood will, of course, at once determine the diagnosis. If the diagnosis lies between sepsis and miliary tuber- culosis, increase in the number of leucocytes points to the former. In cases without leucocytosis, and these, unfortunately, are most common, the results of the blood examination are necessarily valueless, unless positive bacteriological findings should be ob- tained. The latter, after all, are the only absolutely dependable signs to be obtained from the study of the blood in this class of cases. LVIII. SYPHILIS. During the early stages of the infection, in the Hemoglobin interval between the appearance of the initial AND lesion and the development of secondary symp- Erythrocytes. toms, the blood changes closely counterfeit those of typical chlorosis, a fact which has led to the use of the term "syphilitic chlorosis," to describe the blood- picture of early lues. The hemoglobin progressively falls until the loss approximates twenty or thirty per cent., while the num- ber of erythrocytes remains normal, or is but slightly diminished, in consequence of which the color index is low. As secondary symptoms appear, oligocythemia usually develops, and in some instances reaches a high grade. There is a close relationship between the intensity of the infection and the intensity of the anemia. In the tertiary and hereditary forms of the disease the counfmay fall to approximately one million cells, and the hemo- globin to twenty per cent, or even less, while extreme poikilo- cytosis, megalocytosis, and microcytosis may be present, together with numerous normoblasts and, perhaps, a few megaloblasts — the so-called " syphilitic pernicious anemia." After the administration of mercuiy both the hemoglobin and erythrocytes begin to increase, the former more slowly than the latter, until treatment has been continued for about two or three weeks, but should this drug be given for longer than this period, just the opposite effect is produced, first a diminution in the hemoglobin percentage, followed later by oligocythemia. Extreme hemoglobin loss under such a circumstance is regarded SYPHILIS. 433 as prognostic of severe tertiary manifestations, as the infection matures. The intravenous injection of mercuric chloride rapidly causes hemoglobinemia in syphilitics. It is a well-recognized clinical fact that the blood changes provoked by syphilis are likely to be more marked in women than in men, other things being equal. Justus' Test. This reaction, described by Justus,^ depends upon the presumption that in untreated cases of congenital, secondary, and tertiary syphilis, a single dose of mercury, ad- ministered either by inunction, or by subcutaneous or intravenous injection, causes a hemoglobin loss of from ten to twenty per cent, within about twenty-four hours, this abrupt decline being followed within a few days by a rise in the hemoglobin value to a somewhat higher figure than that first observed, before the drug was given. Justus obtained uniformly positive results in more than 300 cases of syphilis, and negative results in a large number of non-syphilitic control cases. Cabot and Mertins ^ ob- tained positive results in 7 syphilitics, and also in one case of chlorosis and in one of tertian malarial fever, but in their hands the test proved negative in 32 control cases of other diseases. Regarding the exceptional non-syphilitic diseases in which the reaction may prove positive, Brown and Dale^ state that such cases are characterized by striking oligochromemia. A thor- ough study of the test has recently been made by Jones,* who examined 53 cases, of which number 35 were syphilis, and 18 cases of other diseases. Of the former, 17 were active syphilis untreated, and of these the test was positive in 1 3 and negative in 4 ; fifteen cases of chancre yielded but 7 positive results, these occurring most frequently in chancre with adenitis ; in two cases of latent syphilis and in one of active syphilis under treatment the test failed. In the writer's experience, Hmited to 9 cases, the success of the test has been uniform. The diagnostic value of Justus' test is greatly restricted by its frequent failure in early initial lesions and in latent syphilis, and its occasional failure in the early part of the secondary stage, periods when a pathognomonic test would prove of the greatest aid. The fact that positive reactions may occur in non-syphilitic diseases must also be remembered. 1 Verhandl. d. 5. Cong. d. Deut. derraatol. Gesellsch., Sep., 1895. Also Virchow's Archiv., 1894, vol. cxl., pp. 91 and 533. 2 Boston Med. & Surg. Journ., 1899, vol. cxl., p. 323. 3 Cincinnati Lancet-Clinic, 1900, vol. xliv., p. 261. *N. Y. Med. Journ., 1900, vol. Ixxi., p. 513. 28 434 GENERAL HEMATOLOGY. The number of leucocytes, which remains ap- Leucocvtes. proximately normal during the preeruptive stage of the disease, usually increases moderately with the appearance of the secondary symptoms. Their total number rarely equals twice the maximum normal standard, and the gain is due, in the great majority of instances, to an increase in the non-granular Jiyaline forms, the percentage oi polymiclcar ncntro- philes being relativel}' low. Many authors maintain that the cosinopJiilcs are increased, but Peter,^ who has especially investi- gated this question, emphatically states that in no form and at no stage of syphilis has he obsen-ed eosinophilia. In the leucocyte increase frequently found in the high-grade anemia of tertiary syphilis the lymphocytosis is especially striking, and the presence of small numbers of myelocytes is common. Under the influence of mercurial or iodide treatment the leucocyte count diminishes, the lymphocytes decrease, and the polynuclear neutrophiles grow more numerous. But sHght diagnostic value can be attached to Diagnosis, the changes in the blood in this disease. The association of a low color index and a leucocyte increase chiefly of the lymphocytes, is suggestive, but nothing more. Justus' test, if positive, strengthens the pertinence of the preceding signs, provided that all sources of fallacy can be ex- cluded ; absence of the reaction by no means excludes syphilis. The distinctions between tertiary syphilitic anemia and true per- nicious anemia have already been discussed. (See page 230.) LIX. TETANUS. In a single fatal case, treated with antitoxin, Cabot" found 70 per cent, of hemoglobin and 11,900 leucocytes per cubic milli- meter, with no decrease in the number of eosinophiles, as is usual in most febrile states. LX. TONSILLITIS. As a general rule, no appreciable changes are found in the hemoglobin and erythrocytes^ although in severe cases the former is sometimes diminished. Leucocytosis of a moderate grade may or may not develop, depending largely upon the character of the tonsillar inflammation. When present the increase involves prin- cipally the polynuclear neutrophiles, and the total leucocyte count rarely exceeds 15,000 cells to the cubic milHmeter. In simple ^ Derraatolog. Zeitschr., 1897, ^o^- i^'-> P- 669. 2 Loc. cit. TRICHINIASIS. 435 catarrhal tonsillitis the count is usually normal, but leucocytosis is common in follicular tonsillitis and in quinsy. In the latter Pee/ Rieder/ and others have observed leucocytosis in excess of 20,000. LXI. TRICHINIASIS. It is generally agreed that there are no changes Hemoglobin in the hemoglobin and erythrocytes attributable AND to the influence of this infection, high counts and Erythrocytes, hemoglobin estimates, often polycythemia, being the rule. Rarely, well-marked anemia may be found, due to some other cause, as in a case reported by Kerr,^ in which the erythrocytes numbered between 3,300,000 and 3,340,- 000 per cubic miUimeter. T. R. Brown ^ first made the important announce- Leucocytes. ment that acute cases of trichiniasis are accom- panied by a well-marked increase in the number of leucocytes, characterized by an absolute and relative gain in the eosinopJiiles, This observation has since been corroborated by a number of other workers, whose results are tabulated below. Unfortunately, eosinophilia can not be regarded as constant in this condition, as shown by the following count made by the writer in a typical case of trichiniasis occurring in J. Chalmers DaCosta's surgical service at St. Joseph's Hospital : Hemoglobin, 80 per cent. Erythrocytes, 4,400,000 per cb. mm. Leucocytes, 12,000 '* *^ '' Small lymphocytes 36.7 per cent. Large lymphocytes and transitional forms 6. 5 Polynuclear neutrophiles 56. i Eosi nophiles 0.5 Myelocytes 0.2 Basophiles 0.0 Repeated examinations by others showed practically these figures, the eosinophiles at no time being increased. The lesions in this patient were most striking, as they involved the greater part of the right lower extremity, from calf to thigh. Excised bits of muscles from the affected parts were found to be swarm- ing with trichinae, and rich in eosinophile cells. It is possible ^ Inaug. Dissert., Berlin, 1890. 2 Loc. cit. sPhila. Med. Journ., 1900, vol. vi., p. 346. * Johns Hopkins Hosp. Bull., 1897, vol. iii., p. 79. Also, Journ. of Exper. Med., 1898, vol. iii., p. 315. 436 GENEEIAL HEMATOLOGY. that in such instances as this, the absence of eosinophilia may be attributed to the overwhelming nature of the toxines, which, by their repellant action, stifle eosinophile proHferation in the marrow. Howard * also failed to find an eosinophile increase in a single case, although large numbers of these cells were detected in the muscle lesions. The report of the blood examination in Howard's case is so meagre (" Coverslip preparations of the blood stained with Ehrlich's triacid stain on examination showed a slight leuco- cytosis but no increase in the number of the eosinophilic cells") that it must be omitted from the following list of 18 cases reported since 1897. , , ^ Total Number of Leuco- ^ ^.^'^"J.f Percentage of Name of Reporter. ! No. of Cases. cvtes per cb. mtn. \ Eosinophiles to other Forms T. R. Brown. 2 Gwyn.'' of Leucocytes. 3 I 8,000-35,000 8-68.2 I 17,000 '• 33-65-9 Kerr.* 2 ' 10,000-25,000 18.1-86.6 Blumer & Neuman.5 9 ; 6,000-24.000 8-50.4 Stump.6 ,. I I j 52 Cabot. 7 I 7,000-11,000 , 17-28 Atkinson. 8 I 28,000 ' 35-58.5 The other differential changes, which are unimportant, consist in a corresponding relative decrease in the polymiclcar nt^ttro- philes, and, occasionally, in the early stages of some cases, in a similar diminution in the lyvipJiocytcs. Mast cells, in the propor- tions of I or 2 per cent., have also been obser\^ed, although not constantly. Blumer and Neuman's studies of 9 cases of epidemic trichini- asis,^ lead them to conclude that the degree of leucocyte increase corresponds in a general way to the severity of the attack, rela- tively severe cases being attended with a higher and more per- sistent increase than the milder attacks ; on the other hand, the intensity of the infection does not necessarily correspond to the degree of eosinophilia. The latter may persist for months after the disappearance of the leucocytosis and the apparent convales- cence of the patient, but just how long it does last is as yet un- determined. 1 Phila. Med. Journ., 1899, vol. iv., p. 1085. 2 Loc. cit. 'Centralbl. f. Bakt. u. Parasit., 1899, vol. xxv., p. 746. * Loc. cit. 5 Am. Journ. of Med. Sc, 1900, vol. cxix., p. 14. 6 Phila. Med. Journ., 1899, vol. iii., p. 1318. 'Boston Med. and Surg. Journ., 1897, vol. cxxxvii., p. 676. 8 Phila. Med. Journ., 1899, vol. iii., p. 1243. 9 Loc. cit. TUBERCULOSIS. 43/ The presence of an eosinophile leucocytosis, Diagnosis, usually of a high grade, may be the only indica- tion of trichiniasis in obscure cases in which the characteristic symptoms of the infection are wanting, and in such instances the change is to be regarded as a most valuable aid to diagnosis. Absence of this sign, however, does not definitely ex- clude the disease. LXII. TUBERCULOSIS. A pure infection with Koch's bacillus of tuber- General culosis is capable of producing comparatively Features, slight alteration in the composition of the blood, such changes as may be associated with tuber- culous processes, whatever organs they involve, being due chiefly to secondary infection with other bacteria, usually of pyogenic type, and not to the disease, per se. The prolonged ill effects of tuberculosis upon bodily nutrition must also in time cause more or less blood impoverishment, but it is a well-recognized clinical fact that the changes are as a rule trivial in comparison with the gravity of the disease, and the apparent degree of cachexia. The above facts are sufficient to explain the reason for the varied blood-pictures found in tuberculosis — pictures ranging from those of practically normal blood to those of most intense anemia, and from leucopenia to frank leucocytosis. In a limited number of cases of acute miliary Bacteriology, tuberculosis the specific bacillus has been isolated from the blood during life by culturing, but in this, as well as in the other forms of the disease, this procedure generally results negatively so far as the detection of the tubercle bacillus is concerned. In advanced septic cases of pulmonary tuberculosis, streptococci, staphylococci, and other micro-organ- isms have been found in the blood, but only rarely, for the septic process tends to remain localized in the lungs, rather than to in- vade the general circulation. Serum Test. Arloing and Courmont ^ have succeeded in pre- paring cultures with which they claim that the serum diagnosis of tuberculosis can be carried out. Glycerine peptone bouil- lon inoculated with an old, attenuated culture of the tubercle bacillus and thoroughly agitated each day to insure homoge- neity of the culture, finally develops a growth in which the bacilli are uniformly disseminated and actively motile. Blood serum from the suspected case is mixed in small test-tubes with the culture thus prepared, in proportions of i to 5, i 1 Congres pour 1' Etude de la Tuberculose, 1898. 43 8 GENERAL HEMATOLOGY. to ID, and I to 20, and the tubes inclined at an angle of forty- five degrees, being examined at intervals of two, ten, and twent}^-four hours. A positive reaction is indicated by a clarifica- tion of the mixture and the deposition of small flakes or granules in the bottom of the tube, while microscopically it may be seen that the bacilli are clumped and motionless. Reactions occurring after the lapse of twenty-four hours are without cHnical signifi- cance. With normal serum in a dilution of I to 5 positive re- actions do not occur, and they occur but rarely with tuberculous serum in a dilution higher than i to 20. A peculiarity about this test is that it takes place in an inverse ratio to the intensit}^ of the infection, and hence fails in advanced and virulent cases in which presumably there is alread}^ an excessive auto -intoxication with tuberculin. Excluding such cases, Arloing and Courmont found that positive reactions were constant in all tuberculous patients, but, unfortunately, they also found similar results in some normal individuals and in various non-tuberculous diseases. Bendix ^ found the test successful in 34 of 36 cases of tubercu- losis, the 2 failures being in instances of overwhelming infections ; he also claims that normal blood and the blood from other dis- eases gives negative results. Nine cases of pulmonaiy tubercu- losis, 4 of pleurisy, and 17 of various non-tuberculous affections were examined by Mongour and Buard.- All the phthisis cases, and 3 of the 4 pleurisies, which were tuberculous, were positive, the case not reacting proving to be non-tuberculous. In 1 5 of 17 other diseases, the results of the test corresponded with the clinical diagnosis and the autops}- findings. Similar results in tuberculous pleurisy were obtained by P. Courmont,^ who found positive reactions in 10 of 11 cases clinically tuberculous, while of 9 cases clinically non-tuberculous, 4 w^ere positive and 5 nega- tive. In 1 2 cases of ascites, 7 due to hepatic cirrhosis failed to react, but the other 5, all clinically tuberculous, gave positive re- sults. Results distinctly less favorable than those reported by other investigators are published by Beck and Rabinowitch,^ but it is not at all improbable that these discrepancies may be attrib- uted, at least in part, to the use of unsuitable cultures. Ac- cording to these authors' experiments, only 6 of 17 cases of in- cipient lung tuberculosis were positive, and but 4 of 16 advanced cases. Of 5 suspected cases that reacted to tuberculin injections, ^ Deut. med. Woch., 1900, vol. xxvi., p. 224. ^Compt rend. Soc. bioL, Paris, 1898, 10 s., vol. v., p. 1142. Also, Buard: Journ. de pliys. el path, gen., 1900, vol. ii., p. 797. ■■' (."ongres pour 1' Etude de la Tuberculose, 189S. * Deut. med. Woch., 1900, vol. xxvi., p. 400. TUBERCULOSIS. 439 but a single one gave a positive serum reaction. They further- more found that positive reactions may occur in healthy persons, and in rheumatic fever, bronchitis, hepatic cirrhosis, and croupous pneumonia. Romberg ^ has determined that the serum of more than 50 per cent, of persons who fail to show clinical evidences of tuberculosis possesses a more or less agglutinative property. The serum reaction in tuberculosis, as at present elaborated, must be considered of questionable diagnostic value, since it has been shown that it may occur in normal individuals and in non- tuberculous diseases, and that it may often be negative in affec- tions undoubtedly tuberculous. As compared with Widal's typhoid reaction, the test of Arloing and Courmont is crude and untrustworthy. The change most frequently observed is a mod- Hemoglobin erate loss of hemoglobin, with little or no decrease AND in the number of erythrocytes, and a low color Erythrocytes, index, resembling somewhat the blood-picture of chlorosis. In such instances poorly colored, small sized corpuscles may be numerous, but poikilocytes and other structural alterations in the cells are absent. In cases in which the effects of a complicating septicemic process are active, the above changes may be aggravated, and a secondary anemia of variable intensity is thus developed. The oligocythemia becomes marked and more proportionate to the oHgochromemia, the color index consequently rising; deformities of shape and size, and degenerative stroma changes become evident ; and in severe cases an occasional normoblast may stray into the circulation, especially after the occurrence of a hemorrhage. But these qualitative changes, even in advanced cases with marked cachexia, are com- paratively uncommon, and, when present, are usually not striking, in spite of the gravity of the disease. Finally, in a large propor- tion of tuberculous patients neither the hemoglobin nor the ery- throcytes fall below the normal standard, this being the rule both in incipient cases, and in those which, although of greater chron- icity, have escaped mixed infection, or have successfully withstood the ill effects of the constitutional drain. In 25 hospital cases oi pulmonary tuberculosis in various stages, the writer found the hemoglobin percentage from 20 to 30 in r; from 30 to 40 in 4, from 40 to 50 in 4; from 50 to 60 in 5 ; from 60 to 70 in 4 ; from 70 to 80 in 6, and from 80 to 90 in i . The lowest estimate was 20, and the highest 83 per cent. The erythrocytes were in excess of 5,000,000 in 3 cases; from 4,000,- ^ Deut. med. Woch., 1901, vol. xxvii., p. 292. 440 GENERAL HEMATOLOGY. ^ ooo to 5,000,000 in 10; from 3,000,000 to 4,000,000 in 1 1, and from 2,000,000 to 3,000,000 in i. The minimum count was 2,660,000, and the maximum 5,500,000 cells per cubic millimeter. From a stud}^ o^ 43 cases of coxalgia, vertebral tuberculosis^ and tuberculous osteo)?iyelitis, Dane ^ concludes that most cases of tuberculous disease of the bones and joints do not cause a de- crease in the number of erythrocytes, although they do, however, affect the percentage of hemoglobin, giving rise to a mild degree of " chloro-anemia," so-called. An analysis of his series shows that the hemoglobin percentage ranged from 80 to 90 in 2 cases ; from 70 to 80 in 1 1 ; from 60 to 70 in 24 ; from 50 to 60 in 4; and from 40 to 50 in 2. The er}^throcytes numbered 5,000,000 or more in 24 cases, ranging between 6,000,000 and 7,000,000 plus in 6; from 4,000,000 to 5,000,000 in 15 ; from 3,000,000 to 4,000,000 in 3; and from 2,000,000 to 3,000,000 in i. Ac- cording to P. K. Brown's investigations of y^^ cases of bone tuberculosis,^ the erythrocytes decrease only in long-continued and extensiv^e cases, in very young children, and in secondary septic infections, while the hemoglobin is diminished practically in all cases, the loss depending upon the same factors which in- fluence the er}^throcytes. He also observed that the patient's return to health is indicated by a tendency of the blood to re- turn to the normal standard. In about 15 per cent, of this author's cases there was an erythrocyte loss of one million or more cells per cubic millimeter, and in all but some half-dozen the hemoglobin was diminished, in one case to as low as i 5 per cent. In cases with secondary septic infection the anemia disappears as the patient's recuperative powers become active, but should the latter be overwhelmed by the intensity of the pyogenic process, the anemia either remains stationary or grows more marked. In other forms of the disease — tuberculous adenitis, uicningitis, pericarditis, pleurisy, peritonitis, and lesions of the genito-urinary system — the changes affecting the eiythrocytes and their hemo- globin content do not differ from those already described. Well- developed secondary anemia is not uncommon in the two last- named forms of tuberculosis, while in the glandular variety dis- proportionately low hemoglobin values are frequently found. It is to be recalled that apparent polycythemia may be encountered in both tuberculous peritonitis and pleurisy, due in the former in- stance to the inspissating effect of the purging, and in the latter to the same effect produced by the sudden accumulation of an extensive exudate. 1 Boston Med. and Surg. Journ., 1896, vol. cxxxiv., pp. 529, 559, and 589. 2 Trans. Med. Soc. of State of California, 1897, vol. xxvii., p. 168. TUBERCULOSIS. 44 1 Much the same factors which influence the Leucocytes, erythrocytes also determine the behavior of the leucocytes in the different forms of tuberculo- sis. In cases of unmixed infection these cells do not rise above the normal limits of health, but the moment the tuberculous lesion becomes complicated by a secondary infectious process, such, for instance, as septicemia, the accident is heralded by a prompt increase in their number. For example, in a simple tuberculous adenitis the count is normal, but should the glands ulcerate, fistulate, and become septic, a leucocytosis at once de- velops. As a rule, the qualitative changes are inconspicuous, although in some forms of the disease, as will be shown below, there is a tendency toward lymphocytosis. Increase in the number of leucocytes, characterized by a relative gain in the lymphocytes and eosinophiles, usually develops during the reac- tionary fever following the injection of tuberculin. The theory that the occurrence of Neusser's ** perinuclear basophilic granules " during the course of the disease constitutes a favorable prognostic sign, has been effectually exploded, since later research has proved that these so-called granules are simply artefacts. (Seepage 176.) /(?<^z;2 Deut. Archiv. f, klin. Med., 1892, vol xxxi., p. 293. 2 Loc. cit 3Proc. Path. Soc. of Phila., 1898, n. s., vol. i., p. 137. VARICELLA. 447 this inspissation of the blood two other factors : the lagging of the erythrocytes in the peripheral arterioles and venules, and the increase in the viscosity of the blood. At this period of valvular disease the specific gravity and the proportion of albuminoid principles of the blood rise, and high hemoglobin values with more or less decided polycythemia are found, the erythrocyte count commonly being in the neighborhood of 6,000,000 per cubic millimeter, or in some instances, notably those of congenital heart disease, as high as from 7,000,000 to 8,000,000. Such a polycythemia, it should be remembered, may be sufficient com- pletely to mask a coexisting anemia ; in fact, it must be admitted that no reliable data concerning the true condition of the blood are obtainable in valvular disease of the heart, except during the stage of perfect compensation. The behavior of the leucocytes is capricious : their number may be normal, or, on the other hand, a decided, but not an excessive, leucocytosis may be present. Should this be the case, the increase will be found to involve principally the polynuclear neutrophile cells at the expense of the other forms. Grawitz^ has drawn attention to the fact that a form of stroma degeneration may frequently be met with under these circum- stances, being evidenced by the unnatural readiness with which the hemoglobin tends to become diffused in the plasma within a short time after the removal of the blood from the body. This, while it cannot be termed a true hemoglobinemia, at least appears to demonstrate that the stroma and its hemoglobin are less firmly combined than they are in perfectly normal blood. The efforts made by some authors to associate certain blood conditions with definite valvular lesions seem to the writer far- fetched. The changes just described are thought by some to be especially prone to occur in affections of the mitral segments, and other authors even go so far as to state that disease of these valves is more often associated with transient apparent anemia or with chronic polycythemia than lesions of the aortic valves, the blood in the latter conditions being usually normal, or but slightly impoverished. After all, the general disturbances de- pendent upon the lesion, and not the lesion per se account for the alterations of the normal blood-picture which have been observed in heart disease of this type. LXVI. VARICELLA. The only observation on record appears to be that of Engel,^ who found in a child of five years, at the height of the pustular ^ Loc. cit. 2 XV. Cong. f. inn. Med., 1897. 448 GENERAL HEMATOLOGY. stage, 6^ per cent, of polynuclear neutrophiles, and an absence of eosinophiles. After the healing of most of the pustules, three days later, the percentage of polynuclears was 47, and that of the eosinophiles 16. Numerical estimates in this case are not recorded. LXVII. VARIOLA. During the first few days of the attack the fibrin General network is normal, but as the stage of pustular Features, eruption is reached, a decided Jiyperinosis develops. Streptococci have been found in the blood repeat- edly by Widal and Benzacon.* Pfeiffer " has attached specific prop- erties to apparently ameboid bodies which he discovered in small- pox patients' blood, and other amebae have been found under similar circumstances by Reed,^ by Weber,* and others. None of these discoveries have elucidated the etiology of variola. Post-febrile anemia, first becoming apparent Hemoglobin when deferv^escence is established, is the rule in AND the majority of cases, the decrease in hemoglobin Erythrocytes, and corpuscles being usually decided, and not infrequently excessive. This is especially true in hemorrhagic and confluent variola, in which conditions a loss of two or three million cells per cubic millimeter may occur with great rapidity. The loss of hemoglobin begins slightly earlier than that of the corpuscles, but later both elements are usually diminished proportionately. During the febrile period of the disease, the number of eiythro- cytes is approximately normal, or even increased, in case the blood becomes concentrated by the influence of the temperature. Qualitative changes in the er}'throcytes are not marked, except in cases with severe anemia, in which poikilocytosis and deform- ities of size may be noted. In such instances hemoglobinemia may also be detected occasionally. Regeneration of the blood is said to be exceedingly slow. From the studies of Halla and Brouardel, and Leucocytes, of Pick, quoted by von Limbeck,^ it appears that the influence of a variolous infection does not of itself cause leucocytosis, a fact which is evident for the reason that during the height of the initial fever, in the early eruptive stage of even well-marked cases, increase in the number of leucocytes does not occur. But as pustulation begins, and secondar}^ infec- tion with pyogenic micro-organisms occurs, an increase in the leu- ^Centralbl. f. allg. Path., 1896, vol. vii., p. 569. 2 Handb. d. spec. Therap. , 1894, vol. i. , p. 229. 3Journ. of Exper. Med., 1897, vol. ii., p. 515. *Centralbl. f. Bakt. u. Parasit., 1897, vol. xxi., p. 286. 5 Loc. cit. YELLOW FEVER. 449 oocytes takes place, the leucocytosls as a rule increasing propor- tionately to the gravity of the infection. As in other infections, veiy mild and very virulent cases do not give rise to an increase. In the average case, such as that quoted by von Limbeck,^ the leucocytes, normal at the beginning of the illness, number about 1 1,000 or 12,000 per cubic millimeter by the time the eruption becomes pustular, the maximum count of .these cells, about 20,000, being attained coincidentally with full maturation of the pustules. As desiccation progresses, the number of leucocytes gradually falls, the normal count again being reached during the end of the second or the beginning of the third week. Varioloid^ unless associated with suppuration, does not cause leucocytosis. Most authors have found that the increase involves chiefly the polymorphous for^ns of leucocytes, and that the percentage of uionomiciear cells is proportionately decreased. On the other hand, Courmont and Montagard" insist that in uncomplicated cases the increase in- volves the mononuclear forms; even during the pustular stage, when abscesses or furunculosis coexisted, they found the gain mononuclear in type. In severe infections it is common to find small numbers of myelocytes. WeiP has also found these same changes, and lays special stress upon the occurrence of myelo- cytes as a diagnostic sign of this exanthem. The blood plaques are decreased in number during the period of fever, being sometimes absent from the blood at this stage of the disease. Unfortunately, the blood examination is of no Diagnosis, value in differentiating variola from a number of other diseases which may more or less closely resemble it. For example, the prepustular stage of the disease has been mistaken for measles, but in both there is an absence of leucocytosis ; again, the pustular stage of small-pox may be counterfeited by varicella, pustidar syphilide, and the purpuric form of cerebrospinal meningitis, and all of these conditions are accompanied by a well-marked leucocytosis. LXVIII. YELLOW FEVER. Slow coagulation and deficiency or even com- General plete absence of the fibrin fietzvork is common. Features, these peculiarities being observable often in the earliest stages of the disease, apparently beginning coincidentally with the introduction of the infecting principle. ^ Loc. cit. 2 Province med., 1900, vol. xv., p. 481. ■■^Sem. med., 1900, vol. xx., p. 222. 29 450 GENERAL HEMATOLOGY. The identit}^ of the specific cause of this disease is a current topic of heated controversy. SanarelH's claim/ that his bacillus icteroides is to be found in the circulating blood of yellow fever patients during life, has been flatly contradicted by several investiga- tors, notably by Agramonte,- and by the members of the United States Yellow Fever Commission,^ Reed, Carroll, Agramonte, and Lazear, whose several reports show an uniform failure to isolate Sanarelli's bacillus either by ante-mortem blood cultures, or by post-mortem examinations of the blood and organs. In passing, it may be of interest to add that Finlay's theor}^^ that yellow fever is transmitted by means of the mosquito's bite, has been con- firmed beyond question by the experiments of this Commission, which has identified the Stegomyia fasciata d^s the offending insect. Archinard and Wood ^ claim that in a study of 50 cases of yel- low fever, the\' obtained a positive serum reaction with the bacil- lus icteroides in about 75 per cent, of the tests. In low dilutions (1:5, for instance) they found that the blood of yellow fever patients also clumped cultures of the typhoid bacillus. Pothier's studies of 154 cases at the New Hemoglobin Orleans Isolation Hospital, in 1897,^ show that a AND more or less decided loss of hemoglobin com- Ervthrocvtes. monly occurs during the active stages of the in- fection, and that the normal percentage is slowly regained during and after convalescence ; during the febrile period the hemoglobin ranged from 50 to 90 per cent., and during con- valescence from 64 to So per cent. He found that the er}'thro- cyte count never fell below 4,280,000 per cubic millimeter, and that even in a fatal case it might be normal. Sternberg ^ has also noted the absence of quantitative changes affecting the erythro- cytes in this disease, stating that *' although there is no general destruction of the red corpuscles, it is probable that a consider- able number of these elements perish, for the serum contains free hemoglobin, which gives it a yellow color even as early as the third or fourth day." This hemoglobinemia is common in all cases, but especially so in fatal cases just before death. The re- ' Annal. de I'lnstitut Pasteur, 1897, vol. xi., p. 433. Also, British Med. Journ., 1897, vol. ii., p. 7. Also, Med. Record, 1897, vol. lxii.,p. 117. * Med. News, 1900, vol. Ixxvi., p. 249. 3 Phila. Med. Journ., 1900, vol. vi., p. 790. Also, Journ. Am. Med. Assn., 1 901, vol. xxxvi., p. 431. ♦ Pan- Am. Med. Cong., Havana, Feb. 4, 1901. Also, Journ. Am. Med. Assn., 1901, vol. xxxvi., p. 1040. = New Orleans Med. & Surg. Journ., 1898, vol. 1., p. 455, ^ Journ. Am. Med. Assn., 1898, vol. xxx., p. S85. ^ U. S. M. H. Service Report on the Etiology and Prevention of Yellow Fever, Washington, 1S90. >^ YELLOW FEVER. 4^1 suits of these investigations by Pothier and by Sternberg are con- tradictory to the views expressed by earlier writers, who have been accustomed to describe the cellular elements of the blood in yellow fever as profoundly altered. Decided degenerative changes in the erythrocytes have not been observed, although it has been asserted by Jones ^ that these cells " present under the microscope certain peculiar appearances which are referable to the action of certain extraneous excretory matters in the blood." A few nucleated cells of the normoblas- tic type are reported to have been found occasionally. The behavior of the leucocytes in yellow fever Leucocytes, is extremely variable, their number being sub- normal in some cases, and decidedly, but not strikingly, increased in others. In the series of Pothier, just quoted, the counts ranged between 4,660 and 20,000 per cubic millimeter. The increase, when present, involves chiefly the polynuclear neutropJiiles, the relative proportion of these cells usually being in excess of 85 or 90 per cent. Small numbers of myelocytes were found occasionally by Cabot ^ in differential counts of twelve films of yellow fever blood. Sternberg ^ has described certain relatively large, highly refrac- tive, spherical granules in the protoplasm of the leucocytes, which he is inclined to regard as an evidence of fatty degenera- tion of these cells ; these granules were especially abundant in severe cases, nearly every leucocyte containing some of them. They are not, however, peculiar to yellow fever, since they have been found in the blood of patients suffering from beri-beri, and even in the blood of normal individuals, residents of the tropics. If SanarelH's claims stand the test of time, Diagnosis, blood culturing and the clump reaction should prove of the greatest value in differentiating this infection from those obscure forms of dengue of which it may be a faithful clinical counterfeit. The frequency of hemoglobinemia in yellow fever and its absence, so far as is known, in dengue, may also serve as a hint of some importance. In differentiating vialarial fever, the examination of the blood for the malarial par- asite will usually give definite information, and the occasional presence of a well-developed polynuclear leucocytosis in yellow fever should not be forgotten. ^Journ, Am. Med. Assn., 1895, vol. xxiv., p. 403. 2Loc. cir. ^Loc. cit. INDEX OF SUBJECTS. ABSCESS, 295 ■^ coagulation, 295 color index, 295 diagnosis, 297 erythrocytes, 295 fibrin, 295 hemoglobin, 295 iodin reaction, 295 leucocytes, 296 normoblasts, 296 Absence of leucocytosis, 185 in acute infections, 188 in enteric fever, 328 in influenza, 354 in leprosy, 358 in malarial fever, 382 in Malta fever, 394 in measles, 395 in tuberculosis, 441 significance of, 188 Acetanilid poisoning, 416 Acetone, test for, 1 10 Acetonemia, iio Achalme's bacillus, 422 Achroiocythemia, 121 Achromacytes, 138 Acid dyes, 59 Acidity of blood in Asiatic cholera, 304 in insolation, 356 Acromegaly, 298 Actinomycosis, 298 Acute yellow atrophy of the liver, 298 Addison's disease, 299 Adenitis, 197, 443 Ague cake, 274 Alcohol and ether fixation, 62 fixation, 62 poisoning, 416 Alcoholic neuritis, 402 Alexines, 185 Alkalimeter, Engel's, 77 Alkalinity, 77, 95 estimation of, 77 in Asiatic cholera, 304 in chlorosis, 210 in diabetes mellitus, 309 in erysipelas, 332 in fever, 334 in gout, 347 in hemorrhagic diseases, 348 in Hodgkin's disease, 267 Alkalinity in icterus, 353 in infantile enteric fever, 290 in insolation, 356 in lymphatic leukemia, 256 in nephritis, 399 in osteomalacia, 406 in pernicious anemia, 220 in rheumatism, 422 in scurvy, 348 in secondary anemia, 237 in spleno-medullary leukemia, 247 Altitude, effect on blood, 133 Altmann's bioblastic theory, 158 Ammonia poisoning, 416 Amphophile granules, 157 Amyloid disease, 392 Amyl nitrite poisoning, 416 Analysis, centrifugal, 72 Anopheles, 360 Anemia, 113 bothriocephalus, 356 brick-makers', 357 classification of, 1 14 following splenectomy, 272 from ankylostomiasis, 357 from gastric tubule atrophy, 343 from helminthiasis, 356 from threadworms, 356 from thyroidization, 399 in appendicitis, 300 in gastric cancer, 386 in hemorrhagic diseases, 349 in malignant disease, 391 endocarditis, 393 in nephritis, 400 in rheumatic ifever, 422 in sepsis, 429 in tuberculosis, 439 in variola, 448 infantum pseudo-leukemica, 290 miners', 357 pathogenesis of,'il5 pernicious, 218 post-hemorrhagic, 239 post-malarial, 381 post- typhoid, 326 primary, I15 pseudo-, 113 secondary, 236 splenic, 231 syphilitic, 432 454 INDEX OF SUBJECTS. Anemia toxic, 416 tropical, 1 14 Anemias of infancy and childhood, 279 classification, 283 frequency, 282 gastrointestinal, 289 general characteristics, 283 leukemia, 284 mild. 287 pernicious, 284 post- typhoid, 289 primary, 284 rachitic, 288 secondary, 287 severe, 287 splenic enlargement, 283 syphilitic, 288 tuberculous, 289 von Jaksch's, 290 with leucocytosis, 287 Aneurism, 297 Anhydremia, 106 Aniline dyes, 59 Ankylostomiasis anemia, 357 Anthrax, 299 Antipyrin poisoning, 416 Antipyretics, effects on leucocytes, 414 erythrocytes, 123 Aortic lesions, 447 Appendicitis, 300 anemia, 300 diagnosis, 302 leucocytosis, 301 Arloing and Courmont's reaction, 437 Arsenic, effect on blood, 12 1 Arseniuretted hydrogen poisoning, 416 Arthritis, septic, 423 Ascites, 351 chylous, 335 effect on blood, 351 Asiatic cholera, 304 Aspidium poisoning, 416 Asthma, 305 Atmospheric cold, effect on blood, 181 Atrophic hepatic cirrhosis, 350 Atypical erythroblasts, 146 Axillary abscess, 296 DACTERIEMIA, in *^ in infants, 292 Bacteria found in the blood, 112 in anthrax, 299 in beri-beri, 402 in bubonic plague, 306 in cerebro- spinal meningitis, 398 in cholelithiasis, 308 in enteric fever, 317 in glanders, 346 in influenza, 354 in leprosy, 358 Bacteria found in malignant endocarditis, 392 in Malta fever, 394 in measles, 395 in nephritis, 399 in pneumonia, 411 in purpura, 348 in relapsing fever, 419 in rheumatism, 422 in scarlet fever, 424 in scurvy, 348 in sepsis, 428 in tuberculosis, 437 in typhus fever, 444 in variola, 448 in yellow fever, 450 Bactericidal action of blood, 185 Bacteriological examination, 83 Banti's disease, 231 Barlow's disease, 348 Basedow's disease, 233 Basic dyes, 59 Basophil e granules, 157 Basophil es, 166 in Addison's disease, 299 in carcinoma, 389 in lymphatic leukemia, 260 in sarcoma, 391 in spleno-medullary leukemia, 256 Basophilia, 202 granular, 147 perinuclear, 176 Baths, effect on blood, l8i Benario's method of fixation, 62 Biermer's disease, 218 Bile in the blood, no test for, no Bioblastic theory, Altmann's, 158 Blackwater fever, 383 Blastomycetes in carcinoma, 385 Bleeders, 21 Blood, arterial and venous, 94 at birth, 2S0 carbonic acid, 94 color, 94 concentration, 149 crisis, 143 crystals, 1 19 cultures, 83, 112 dust, 151 extractives, 94 fats, 94 fetal, 279 filaria, 335 gases, 94 general composition. 93 laked, 94 lancet, 20 odor, 95 oxygen, 94 INDEX OF SUBJECTS. 455 Blood plaques, 150 counting the, 7 i in bubonic plague, 308 in chlorosis, 216 in diabetes mellit\is, 312 in enteric fever, ^^ i in erysipelas, 332 in hemorrhagic diseases, 350 in Hodgkin's disease, 269 in lymphatic leukemia, 260 in malarial fever, 384 in measles, 395 in pernicious anemia, 228 in pneumonia. 415 in post-hemorrhagic anemia, 241 in scarlet fever, 426 in secondary anemia, 239 in spleno-medullary leukemia, 256 in splenic anemia, 233 in variola, 449 nature, 150 normal number, 15 1 pathological variations, 151 plasma, 93 proteids, 93 quantity, 93 quotient, 122 reaction, 95 regeneration, 241 after splenectomy, 272 after treatment with suprarenal extract, 299 in anemias of children, 283 in cai-cinoma, 386 in diphtheria, 312 in enteric fever, 327 in malarial fever, 379 in pernicious anemia, 221 in post-hemorrhagic anemia, 241 in scarlet fever, 425 in variola, 448 salts, 93 serum, 93 specific test for, 88 spectra, 125 viscosity, 95 Bone marrow, 128 in leucocytosis, 187 Bordet's reaction, 88 Bothriocephalus anemia, 356 Brain, abscess, 402 hemorrhage, 402 tumor, 402 Breast, carcinoma of, 388 Bremer's test, 310 Bromine poisoning, 416 Bronchitis, 306 Bubonic plague, 306 Buddingofprotoplasm of lymphocytes, 259 CACHEXIA, malarial, 383 ^ Capillary bronchitis, 306 Carbon monoxide hemoglobin, 125 spectrum of, 125 test for, 126 Carbuncle, 189 Carcinoma, 384 alkalinity, 385 coagulation, 384 color index, 386 deformed erythrocytes, 387 diagnosis, 391 digestion leucocytosis, 388 erythroblasts, 387 erythrocytes, 385 fibrin, 384 gastric, 388 hemoglobin, 385 hepatic, 388 leucocytes, 387 mammary, 388 metastases, 387 polycythemia, 386 protozoa, 385 rectal, 388 regeneration, 386 renal, 387 specific gravity, 385 sugar, 385 uterine, 3S8 Castration, effect on blood, 201 Catarrhal pneumonia, 306 Cecum, malignant disease of, 303 Cellular elements of blood, 93 plethora, 105 Centrifugal analysis, 73 Cerebral abscess, 296 Cerebro-spinal meningitis, 396 Cervical abscess, 296 Charcot-Leyden crystals in leukemia, 246 Chemical fixation, 62 Chemotaxis, 184 Chicken-pox, 447 Chloral poisoning, 416 Chloro-anemia, 237 Chlorosis, 209 alkalinity, 210 appearance of fresh blood, 209 blood plaques, 216 coagulation, 209 color index, 210 diagnosis, 216 Egyptian, 357 eosinophiles, 215 erythroblasts, 213 erythrocytes, 210 florid a, 217 granular basophilia, 213 hemoglobin, 210 heredity, 217 456 INDEX OF SUBJECTS. Chlorosis, leucocytes, 214 male, 217 microcytosis, 213 myelocytes, 215 pallor of erythrocytes, 213 poikilocytosis, 213 polychromatophilia, 213 polynuclear neutrophiles, 215 relative lymphocytosis, 215 sex, 217 specific gravity, 209 symptoms, 217 syphilitic, 432 transitional forms, 215 volume of blood, 209 without blood changes, 217 Cholelithiasis, 308 Cholemia, no Chorea, 405 Chromic acid fixation, 62 poisoning by, 416 Chyluria, parasitic, 355 Cirrhosis of the liver, 350 Class' diplococcus, 434 Coagulation, 100 in abscess, 295 in acromegaly, 298 in carcinoma, 384 in chlorosis, 209 in cholelithiasis, 308 in fever, 334 in hemophilia, 349 in Hodgkin's disease, 267 in icterus, 353 in infantile enteric fever, 290 in lymphatic leukemia, 256 in nephritis, 399 in obstructive jaundice, 353 in pernicious anemia, 219 in pneumonia, 411 in rheumatic fever, 421 in sarcoma, 389 in scarlet fever, 423 in secondar}' anemia, 236 in spleno-medullary leukemia, 247 in yellow fever, 449 time, estimation of, 79 Coagulometer, Wright's, 80 Color index, 122 of the blood, 94 in aniline poisoning, 95 in carbon monoxide poisoning, 95 in chlorosis, 209 in diabetes mellitus, 309 in dyspnea, 95 in Hodgkin's disease, 267 in icterus, 353 in lymphatic leukemia, 256 in nitrobenzol poisoning, 95 Color of the blood in pernicious anemia, 218 in hydrocyanic acid poisoning,95 in potassium chlorate poisoning, 95 in secondary anemia, 236 in splenic anemia, 231 in spleno-medullary leukemia, 246 in sulphuretted hydrogen poison- ing, 95 normal variations, 94 pathological variations, 94 Coma, diabetic, 309 Concentration of the blood, 149 Convulsions, 404 Corpuscles, Eichhorst's, 137 phantom, 138 Ponfick's, 138 Corrosive metals and minerals, poisoning by, 416 Counting chamber, Thonia-Zeiss, 43 Zappert, 44 differential, 70 the blood plaques, 71 the erythrocytes, 45, 54, 55 the leucocytes, 49, 53, 55 Cover-glasses, cleaning the, 22 Coxalgia, 440 Crenation, 126 Crisis, blood, 143 Crj'stals, Charcot-Leyden, 24 Teichmann's, 120 Culex, 361 Cultures, blood, 83, 112 Cyanosis, effect on blood, 150 Cyst, ovarian, 303 Cystitis, 189 FV ALAND'S hematocrit, 73 ^ Dare's hemoglobinometer, 36 Degeneration, endoglobular, 138 Delafield's hematoxylin, 69 Delirium, 404 Dementia, 403 Dengue, 451 Density and opacity of blood, 94 Dermatitis herpetiformis, 200 Diabetes mellitus, 309 alkalinity, 309 blood plaques, 312 Bremer's test, 310 diagnosis, 312 erythrocytes, 311 glycemia, 309 hemoglobin, 31 1 iodine reaction, 312 leucocytes, 312 lipacidemia, 309 lipemia, 309 INDEX OF SUBJECTS. 457 Diabetes mellitus, specific gravity, 312 Williamson's test, 309 Diapedesis, 156 Diaphragm, ocular, 50 Differential counting, 70 table of the anemias, 243 of leukemia, etc., 275 of normoblasts and niegalo- blasts, 145 of the leucocytes, 172 of the malarial parasites, 376 Digestion leucocytosis, 179 m diabetes mellitus, 312 in gastric carcinoma, 388 in gastric ulcer, 345 in gastritis, 344 in infants, 281 Diluting fluids, 40 Diphtheria, 312 diagnosis, 316 effects of antitoxin, 313, 314 erythrocytes, 313 hemoglobin, 312 leucocytes, 313 Disease, malignant, 384 Addison's, 299 Barlow's, 349 Banti's, 231 Biermer's, 218 Duhring's, 200 Graves', 333 Griesinger's, 357 Hodgkin's, 267 Laennec's, 351 Potts' , 440 von Jaksch's, 290 Diseases, hemorrhagic, 348 Drug eosinophilia, 201 leucocytosis, 194 lymphocytosis, 198 Duodenal ulcer, 346 Durham's hemocytometer, 52 Dwarf myelocytes, 171 Dyes, aniline, 59 Dysentery, 316 PCHINOCOCCUS, 392 -'--' Ectopic pregnancy, 303 Eczema, 200 Effusion, pericardial, 406 peritoneal, 351 pleural, 409 Egyptian chlorosis, 357 Ehrlich's hypothesis, 158 triacid stain, 64 Ehrlich-Weigert fluid, 86 Eichhorst's corpuscles, 137 Electricity, effect on blood, 18 1 Elephantiasis Arabum, 335 Emphysema, 305 Empyema, 410 of gall-bladder, 296 Endocarditis, malignant, 392 Endoglobular degeneration, 138 Engel's alkalimeter, 77 Enteralgia, 303 Enteric fever, 317 bacteriology, 317 diagnosis, 331 erythrocytes, 326 hemoglobin, 326 leucocytes, 328 serum test, 319 spot cultures, 318 Enteritis, 316 Eosin and hematoxylin stain, 68 and methylene-blue stain, 67 Eosinophile granules, 157 Eosinophiles, 165 diminution in, after castration, 201 after hemorrhage, 201 during digestion, 201 in acute febrile diseases, 201 in carcinoma, 389 in chlorosis, 215 in diphtheria, 315 in enteric fever, 330 in erysipelas, 333 in gastric ulcer, 346 in Hodgkin's disease, 269 in lymphatic leukemia, 260 in malarial fever, 383 in measles, 396 in meningitis, 397 in pernicious anemia, 228 in pertussis, 409 in pneumonia, 415 in sarcoma, 390 in varicella, 448 terminal, 201 Eosinophilia, 198 after coitus, 199 after splenectomy, 274 definition, 198 during menstniation, 199 experimental, 201 factors, 199 in ankylostomiasis, 357 in asthma, 306 in diseases of the bones, 200 of the sexual organs, 201 of the sympathetic nervous sys- tem, 201 in gonorrhea, 346 in helminthiasis, 200 in hemorrhagic effusions, 409 in herpes zoster, 353 in infancy, 199 in osteosarcoma, 390 in oxyuris vermicularis infection, 357 458 INDEX OF SUBJECTS. Eosinophilia in rheumatic fever, 423 in scarlet fever, 426 in septicemia, 431 in skin diseases, 200 in spleno-medullarj' leukemia, 255 in starvation, 201 in syphilis, 434 in splenic tumors, 200 in tenia mediocanellata infection, 357 in trichiniasis, 435 in the xanthin diathesis, 201 physiological, 199 post-febrile, 200 Eosinophilic myelocytes, 168 Epilepsy, 405 Erysipelas, 332 Erythroblasts, 1 41 atypical forms, 146 differential count of, 71 Erythrocytes, 126 after fasting, 132 ameboid motility, 134 appearance in fresh blood, 126 atypical staining, 140 averages in anemia, 148 color, 126 counting the, 45, 54, 55 crenation, 126 deformities of size and shape, 1 36 destruction, 128 development, 128 endoglobular degeneration, 1 38 granular basophilia, 147 histological structure, 127 hyperviscosity, 136 influence of age and sex, 130 of constitution and nutrition, 132 of digestion, 133 of fatigue, 132 of high altitudes, 133 of physical factors, 130 of pregnancy, menstruation and lactation, 131 isotbnicity, 135 methods of counting, 40 monochromatophilia, 140 necrosis, 139 normal number, 129 nucleation, 14 1 origin and life history, 128 oval -shaped, 138 pathological changes, 134 physiological changes, 130 polychromatophilia, 140 rouleaux formation, 126 size, 129 stroma, 127 volume, 130 Erythrocytometcr, 42 Er\'thropyknosis, 372 Estimation of alkalinity, 77 of coagulation time, 79 glass slide method, 80 Wright's method, 80 of specific gravity, 75 Ether leucocytosis, 193 narcosis, 416 Examination of the stained specimen, 58 unstained specimen, 22 Experimental eosinophilia, 201 leucocytosis, 193 Extractives of blood, 94 "CAT in the blood, 106 -*- tests for, 107 Fatty acids in the blood, no test for, 110 Felon, 189 Fetal blood, 279 Fever, effect on blood, 333 enteric, 317 gastric, 343 malarial, 359 Malta, 394 relapsing, 418 rheumatic, 421 scarlet, 423 thermic, 355 typhus, 444 yellon', 449 Fibrin, 100 in abscess, 295 in acromegaly, 298 in carcinoma, 384 in chlorosis, 209 in cholelithiasis, 308 in erysipelas, 332 in fever, 334 in gout, 347 in influenza, 355 in lymphatic leukemia, 256 in measles, 395 in nephritis, 399 in pernicious anemia, 219 in pneumonia, 41 1 in rheumatic fever, 421 in sarcoma, 389 in scarlet fever, 423 in sepsis, 427 in spleno-medullary leukemia. 247 in variola, 448 in yellow fever, 449 pathological variations, 102 relation to leucocytosis. 103 Filariasis, 334 diagnosis, 342 erythrocytes, 34I filaria nocturna, 335 hemoglobin. 34I INDEX OF SUBJECTS. 459 Filariasis, leucocytes, 342 occurrence, 334 parasitology, 335 Films, preparing the, 59 staining the, 63 Fixation methods, 61 heat, 61 chemical, 62 Floating kidney, 303 Fluids, diluting, 40 Formalin fixation, 62 Fractures, 343 Fresh blood, microscopical examination of, 22 Functional neuroses, 402 Furuncle, 189 GALL-STONE, 308 Gangrene, 189 appendicular, 301 Garrod's thread test, 109 Gastrectasis, 344 Gases of blood, 94 Gastric carcinoma, 386 neurasthenia, 344 tubules, atrophy of, 343 ulcer, 345 Gastritis, 343 Gastro-enteritis, 316 Genito-urinary tuberculosis, 440 German measles, 396 Glanders, 346 Globulin, 119 Glycemia, 108 in diabetes mellitus, 309 in carcinoma, 385 Goldhorn's stain, 69 Gonorrhea, 346 Gout, 347 Gower's hemocytometer, 54 hemoglobinometer, 34 Granular basophilia, 147 in carcinoma, 3S7 in lead poisoning, 417 in malarial fever, 38 1 in pernicious anemia, 226 in secondary anemia, 238 in spleno-medullary leukemia, 250 Granules, leucocyte, 157 Graves' disease, 333 Grippe, 354 Guaiacol poisoning, 416 Gunther's method of staining bacteria, 86 HALITUS of blood, 95 Hammerschlag's method, 75 Hayem's achromacyies, 138 pseudo-bacilli, 138 solution, 41 Heat exhaustion, 355 fixation, 61 Heart, chronic valvular disease, 446 dilatation of, 406 ulcerative endocarditis, 392 Helminthiasis, intestinal, 356 Helminthoma elastica, 342 Hemameba leukemi^e, 245 malariae, 359 Hematin, 119 Hematocrit, Daland's, 73 Hematoidin, 120 Hematoporphyrin, 120 Hemin, 120 Hemochromogen, 119 Hemoconia, 151 Hemocytolysis, 115, 128 in fever, 333 in guaiacol poisoning, 416 in insolation, 355 in malarial fever, 380 in pyrodin poisoning, 417 in yellow fever, 450 Hemocytometer, Durham's, 52 Gower's, 54 Oliver's, 56 Thoma-Zeiss, 42 Hemogenesis, 128 adult, 143 deficient, 115 embryonal, 144 Hemoglobin, 119 absolute amount, 1 22 after anesthesia, 416 averages in anemia, 121 chemistry of, 1 19 estimation of, 25, 32, 34, 36, 39, 96 in menstruation, 121 influence of arsenic on, 121 of iron on, 120 origin, 120 reduced, 119 tests in surgical operations, 1 21 Hemoglobinemia, 123 from burns, 124 from drugs, 123 from exposures to cold, 124 from heterogeneous blood, 124 from mushroom poisoning, 124 from snake and scorpion venom, 417 in acute yellow atrophy of the liver, 298 in enteric fever, 124 in epidemic hemoglobinuria, 124 in insolation, 355 in malarial fever, 380 in paroxysmal hemoglobinuria, 124 in Raynaud's disease, 124 in scarlet fever, 424 in scurvy, 124 460 INDEX OF SUBJECTS. Hemoglobinemia in septicemia, 430 in syphilis, 433 in typhus fever, 444 in variola, 448 in yellow fever, 450 spectrum of, 125 test for, 124 Hemoglobinometer, Dare's, 36 Gowers', 34 Oliver's, 32 Tallquist's, 39 Hemometer, von Fleischl's, 25 Hemophilia, 348 Hemophilics, danger of hemorrhage in, 21 Hemorrhage, efifect on blood, 240 regeneration after, 241 treatment by saline transfusion, 241 Hemorrhagic diseases, 348 Hepatic abscess, 296 carcinoma, 388 cirrhosis, 350 colic, 309 Herpes zoster, 353 Hewes's stain, 65 Hodgkin's disease, 267 alkalinity, 267 appearance of fresh blood, 267 basophiles, 269 blood plaques, 269 coagulation, 267 color index, 267 deformed erythrocytes, 267 diagnosis, 269 eosinophiles, 269 erylhroblasts, 267 erythrocytes, 267 hemoglobin, 267 leucocytes, 268 mast cells, 269 myelocytes, 269 polychromatophilia, 267 relative lymphocytosis, 268 specific gravity, 267 symptoms, 270 Hydremia, 105 in fever, 334 in nephritis, 399 in valvular heart disease, 446 Hydrocyanic acid poisoning, 417 Hydrophobia, 417 Hyperchlorhydria, 344 Hyperinosis, 102 Hyperleucocytosis, 185 Hypertonicity, 135 Hypertrophic hepatic cirrhosis, 351 Hyperviscosity. 136 Hypochlorhydria, 344 Hypochondriasis, 402 Hypoleucocytosis, 185 Hypothesis, Ehrlich's, 15S Hypotonicity, 135 Hypinosis, 102 Hysteria, 402 TCTERUS, 353 A Ileus, 357 Illuminating gas poisoning, 192, 417 Index, color, 122 volume, 75, 130 Infected wounds, 189 Infection, latent, ill Influenza, 354 Initial feeding, effect on blood, 281 Insolation, 355 Intestinal helminthiasis, 356 inflammation, 316 obstruction, 357 Iodine poisoning, 417 Iodine reaction, 174 in abscess, 295 in anemia, 175 in diabetes mellitus, 312 in pneumonia, 415 in puerperal fever, 431 in purpura hemorrhagica, 175 in septicemia, 431 in septic tuberculosis, 441 Iron, efifect on hemoglobin, 120 in blood, 119 in eosinophiles, 158 Irritants, effect on blood, 194 Ischemia, 1 13 Ischio-rectal abscess, 391 Isotonicity, 135 TOFFROY'S sign, 217 J Jaundice, 353 Tenner's stain, 65 Justus' test, 433 T^IDNEV, carcinoma of, 387 J^ Kra-kra, 335 T ACTATION, effect on blood, 181 ^ Laennec's cirrhosis, 350 Laked blood, 94 Large mononuclear leucocytes, 161 Latent infection, iii Lead poisoning, 417 Leprosy, 358 Leptomeningitis, 396 Leucocytes, 155 ameboid properties, 156 appearance in fresh blood, 155 classification, 159 counting the, 49, 53, 55 differential count of, 70 table of, 172 fatty degeneration, 451 INDEX OF SUBJECTS. 461 Leucocytes, fractured, 24 granules, 157 iodine reaction, 174 methods of counting, 40 nonnal percentages in adults, 159 in children, 282 number in adults, 159 in children, 281 origin and development, 173 perinuclear basophilia, 176 phagocytes, 156 pigmented, 24, 355, 375, 420 size, 155 vacuolated, 24 varieties, 159 Leucocytic phase, 186 Leucocytolysis, 186 Leucocytometer, 42 Leucocytosis, 176 after thymectomy, 196 after splenectomy, 272 average increase, 183 definition, 176 differential changes, 183 digestion, 179 drug, 194 ether, 193 experimental, 193 factors, 178, 184 from mechanical and thermal influ- ences, i8i functions, 184 general, 185 in general infectious diseases, 189 in malignant disease, 190 in simple and infective local inflam- mations, 189 inflammatory and infectious, 187 influence of chemotaxis, 184 leucocytic phase, 186 leucopenic phase, 186 local, 185 marrow changes, 187 of pregnancy and parturition, 180 of the new-born, 178 pathological, 182 physiological, 177 post-hemorrhagic, 19 1 terminal, 181 toxic, 192 traumatic, 185 Leucopenia, 203 experimental, 206 in chlorosis, 215 in diphtheria, 314 in enteric fever, 328 in gastritis, 344 in gastro- enteritis of infancy, 205 in Hodgkin's disease, 269 in malarial fever, 382 Leucopenia in measles, 395 in peritonitis, 408 in pernicious anemia, 227 in pneumonia, 414 in sepsis, 431 in splenic anemia, 233 in tuberculous abscess, 443 in typhus fever, 444 pathological, 205 physiological, 204 Leucopenic phase, 186 Leukemia, 244 acute, 260 blood picture, 261 clinical features, 260 duration, 261 in children, 285 statistics, 261 transition from chronic forms, 261 frequency of difi"erent forms, 244 in children, 284 influence of intercurrent infections, 261 lymphatic, 256 alkalinity, 256 appearance of fresh blood, 256 atypical lymphocytes, 259 atypically stained erythrocytes, 258 basophiles, 260 blood plaques, 260 coagulation, 256 color index, 257 deformed erythrocytes, 258 diagnosis, 264 eosinophiles, 260 erythroblasts, 257 erythrocytes, 257 hemoglobin, 257 leucocytes, 258 leukoblasts, 259 lymphocytosis, 259 lymphogonien, 259 mast cells, 260 myelocytes, 260 polynuclear neutrophiles, 260 specific gravity, 256 parasitology, 244 spleno-medullary, 246 alkalinity, 247 appearance of fresh blood, 246 atypical myelocytes, 253 polynuclear neutrophiles, 253 basophiles, 256 blood plaques, 256 Charcot-Leyden crystals, 246 coagulation, 247 color index, 248 462 INDEX OF SUBJECTS. Leukemia, spleno-medullary, deformed erythrocytes, 250 degenerate forms of leucocytes, .254 diagnosis, 263 dwarf myelocytes, 252 eosinophilia, 255 eosinophilic myelocytes, 255 erythroblasts, 248 erythrocytes, 247 fibrin, 247 fluctuations in hemoglobin and erythrocytes, 248 in number of leucocytes, 25 1 fractured leucocytes, 254 granular basophilia, 250 hemoglobin, 247 influence of arsenic, 251 karyokinesis, 250 leucocytes, 250, lymphocytes, 255 mast cells, 256 megaloblasts, 249 myelocytes, 252 nuclear extrusion, 250 polychromatophilia, 250 polynuclear neutrophiles, 253 predominance of normoblasts, 249 pyknosis, 250 relation of erythrocyte and leu- cocyte counts, 248 remissions, 251 specific gravity, 247 stimulation forms, 255 splenectomy in, 274 transformation into pernicious ane- mia, 284 transformations of type, 261 Leukoblasts, 259 Light-proof hemometer box, 30 Lipacidemia, no in acute yellow atrophy of the liver, 298 in diabetes mellitus, 309 Lipemia, 106 in diabetes mellitus, 309 in fractures, 343 Liquor sanguinis, 93 Liver, abcess, 296 acute yellow atrophy, 298 carcinoma, 388 cirrhosis, 350 Lowenthal's reaction, 420 LQwit's ameba, 245 Lungs, malignant neoplasms of, 4II Lupus, 200 Lymph scrotum, 335 Lymphangitis, 335 Lymphemia, 261 Lymphocytes, small, 160 large, 161 Lymphocytosis, 196 absolute, 196 after splenectomy, 274 cachectic, 197 definition, 196 differential changes, 196 drug, 198 factors, 197 in acromegaly, 298 in acute infections, 197 in Addison's disease, 299 in adenitis, 197 in carcinoma, 389 in children, 2S2 in chlorosis, 215 in convulsions, 404 in diphtheria, 315 in enteric fever, 330 in exophthalmic goitre, ^^^ in filariasis, 342 in gastritis, 344 in gastro-enteritis, 289 in Hodgkin's disease, 269 in lymphatic leukemia, 259 in malarial fever, 383 in malignant disease, 389, 390 in Malta fever, 394 in measles, 396 in meningitis, 397 in osteomalacia, 406 in pernicious anemia, 227 in pertussis, 409 in pneumonia, 415 in purpura, 350 in rachitis, 289 in sarcoma, 390 in scarlet fever, 426 in scurvy, 350 in secondary anemia, 197 in splenic anemia, 238 tumors, 197 in syphilis, 434 in thyroid tumors, 198 in tuberculosis, 441 in variola, 449 of infancy, 197 post-hemorrhagic, 192 relative, 196 terminal, 197 Lymphogonien, 259 TUTACROCVTES, 136 ^^^ Making the puncture, 19 Malarial cachexia, 383 fever, 359 anemia, 381 blood plaques, 384 diagnosis, 384 INDEX OF SUBJECTS. 463 Malarial fever, erythrocytes, 379 hemoglobin, 379 leucocytes, 382 parasite, 359 crescentic forms, 373 degenerate forms, 367, 370, 374 development in inan, 359 in mosquito, 360 disc forms, 371 estivo-autumnal, 370 flagellate foiTOS, 366, 370, 374 infection with multiple groups, 361, 367 intracellular hyaline forms, 362, 368, 371 ovoid bodies, 373 pigmented extracellular forms, 365, 370,374 intracellular forms, 363. 368, 372 leucocytes, 375 quartan, 367 ring forms, 371 segmenting forms, 364, 369. 372 spherical bodies. 373 tertian, 362 vacuolized forms, 367, 370, 375 phagocytosis, 375 technique of examination, 376 spleen, 274 Male chlorosis, 217 Malignant disease, 384 endocarditis, 392 Malta fever, 394 Mania, 403 Maragliano's necrosis, 139 Massage, effect on blood, 181 Mast cell granules, 157 cells, 168 in Asiatic cholera, 305 in carcinoma, 202 in chlorosis, 202 in filariasis, 342 in gonorrhea, 202 in lymphatic leukemia, 260 in mycosis fungoides, 202 in septic bone disease, 202 in skin diseases, 202 in splenic anemia, 233 in spleno-meduUary leukemia, 256 in trichiniasis, 436 Mastitis, 189 Masturbation, 403 Measles, 395 Megaloblastic blood picture, 229 Megaloblasts, 143 Megalocytes, 136 Melancholia, 403 Melanemia, 107 in Addison's disease, 299 in insolation, 355 in malarial fever, 375 in relapsing fever, 420 Meningitis, 396 cerebro-spinal, 397 tuberculous, 397 Mental diseases, 402 Mercury, effect on blood, 432 Mesoblasts, 146 Methemoglobin, 1 19 spectrum of, 125 tests for, 124 Methemoglobinemia, 124 from drugs, 1 24 in Addison's disease, 299 in poisoning, 416 in purpura hemorrhagica, 348 Methods, fixation, 61 of examination, I9 of staining, 63 Microblasts, 145 Microcytes, 137 Microspectroscope, Sorby-Beck, 81 Miculicz's dictum, 121 Mitral lesions, 447 Monochromatophilia, 140 Mononuclear neutrophiles, 171 Mosquito, development of filaria nocturna in, 337 of malarial parasite in, 360 yellow^ fever, 450 Mucinoblasts, 170 Multiple neuritis, 402 Muscular exercise, effect on blood, i8l Myelemia, 202 Myelocytes, 167 atypical forms in leukemia, 253 dwarf, 171 eosinophilic, 168 in abscess, 297 in Addison's disease, 299 in anemia of children, 283 infantum pseudo-leukemica, 290 in carcinoma, 389 in chlorosis, 215 in convulsions, 404 in diphtheria, 316 in enteric fever, 331 in erysipelas, 333 in gastro- enteritis, 289 in gout, 347 in herpes zoster, 353 in Hodgkin's disease, 269 in infantile enteric fever, 289 syphilis, 288 464 INDEX OF SUBJECTS. Myelocytes in lymphatic leukemia, 260 in malarial fever, 383 in myxedema, 398 in osteomalacia, 406 in pernicious anemia, 228 in post-hemorrhagic leucocytosis, 192 in rachitis, 288 in sarcoma, 391 in scarlet fever, 426 in secondary anemia, 238 in splenic anemia, 233 in spleno-medullary leukemia, 252 in syphilis, 434 in tuberculosis, 441 in variola, 449 in yellow fever, 451 Myxedema, 398 MECROSIS, Maragliano's, 139 ■*-^ Needle for blood culturing, 84 Negro lethargy, 335 Nephritis, 399 Nervous diseases, 402 Neuralgia, 402 ovarian, 304 Neurasthenia, 402 gastric, 344 sexual, 403 Neuritis, 402 Neuroses, functional, 402 Neutral dyes, 59 Neutrophile granules, 157 Neutrophiles, polynuclear, 163 mononuclear, 171 Neutrophilic pseudo-lymphocytes, 171 Newton's rings, 47 Nikiforoff's method of fixation, 62 Nitrobenzol poisoning, 417 Nitroglycerine poisoning, 417 Normoblasts, 141 Nuclear stains, 59 Nucleated erythrocytes, 141 Nucleolation of lymphocytes, 260 rjBERMEIER'S spirillum, 418 ^ Obesity, 406 Objects of staining, 58 Obstruction, intestinal, 357 Obstructive jaundice, coagulation in, 353 Ocular diaphragm, 50 Odor and viscosity of blood, 95 Oligemia, 103 Oligochromemia, 121 Oligocythemia, 148 Oliver's hemocytometer, 56 hemoglobinometer, 32 Opium poisoning, 417 Osmic acid fixation, 63 Osteomalacia, 406 Osteomyelitis, 427 Osteomyelitis, tuberculous, 440 Osteosarcoma, 390 Otitis media, 189 Oval-shaped erj'throcytes, 138 in epidemic dropsy, 223 in pernicious anemia, 223 in purpura hemorrhagica, 223 Ovarian abscess, 296 cyst, 303 Ovaritis, 189 Oven for fixation, 61 Oxyhemoglobin, 119 spectrum of, 125 PACHYMENINGITIS, 396 '^ Palmar abscess, 296 Pancreatitis, 189 Panoptic staining, 63 Paresis, 403 Pathological leucocytosis, 182 leucopenia, 205 Pellagra, 189 Pelvic abscess, 296 Pemphigus, 189 Pericardial effusion, 406 Perinuclear basophilia, 176 Peritonitis, 407 appendicular, 301 hysterical, 408 septic, 407 serous, 407 tuberculous, 440 Periurethral abscess, 296 Pernicious anemia, 218 alkalinity, 220 appearance of fresh blood, 218 blood plaques, 228 coagulation, 219 color index, 220 diagnosis, 228 Eichhorst's corpuscles. 223 eosinophiles, 228 erythroblasts, 223 erythrocytes, 220 fibrin, 219 fluctuations in number of eryth- rocytes, 225 granular basophilia, 226 hemoglobin, 220 horseshoe-shaped cells, 223 in children, 284 isotonicity, 135 leucocytes, 227 megaloblasts, 224 megalocytes, 223 mesoblasts, 225 microbla.sts, 225 myelocytes, 228 nuclear extrusion, 225 oligemia, 218 INDEX OF SUBJECTS. 465 Pernicious anemia, oval-shaped cells, 223 phantom corpuscles, 219 poikilocytosis, 223 polychromatophilia, 225 polynuclear neutrophiles, 227 predominance of megaloblasts, 224 relative lymphocytosis, 227 rouleaux formation, 219 specific gravity, 219 symptoms, 229 syphilitic, 432 transformation into leukemia, 284 Pertussis, 408 Pfeiflfer's phenomenon, 87 Phagocytosis, 156, 185 in malarial fever, 375 in relapsing fever, 420 Phantom corpuscles, 138 tumor, 408 Phlebitis, 189 Phosphorus poisoning, 417 Physiological leucocytosis, 177 leucopenia, 204 Pigmented leucocytes, in insolation, 355 in malarial fever, 375 in relapsing fever, 420 Pipette, Durham's, 53 Gower's, 35 Oliver's, 32 Thoma-Zeiss, 42 Pinocytosis, 156 Plague, bubonic, 306 Plasma stains, 59 Plasmodium malarire, 359 Plethora, 104 in obesity, 406 Pleura, malignant neoplasms of, 411 Pleurisy, serous, 409 purulent, 410 Plimmer's bodies, 385 Plumbic neuritis, 402 Plumbism, acute, 417 Pneumonia, 411 artificial leucocytosis, 414 bacteriology, 411 . blood plaques, 415 diagnosis, 415 effect of antipyretics and cold, 414 erythrocytes, 412 hemoglobin, 412 hyperinosis, 411 iodine reaction, 415 leucocytes, 413 lymphocytosis, 415 serum test, 411 specific gravity, 411 Poisoning, 416 Poikilocytes, 137 30 Polychromatophilia, 140 Polycythemia, 149 after paracentesis, 351 after transfusion, 242 after urinary crises, 150 after use of purgatives, 316 during blood regeneration, 242 digestion, 132 menstruation, 131 from admmistration of lymphogogues and emetics, 150 from physiological causes. 149 in acute yellow atrophy of the liver, "298 in Asiatic cholera, 304 in asthma, 305 in bubonic plague, 307 in convulsions, 404 in diarrhea, 316 in dysentery, 316 in emphysema, 305 in fever, 333 in gastric and esophageal cancer, 350 carcinoma, 386 ulcer, 345 in gastritis, 343 in icterus, 354 in illuminating-gas poisoning, 417 in insolation, 355 in nephritis, 401 in phosphorus poisoning, 417 in pneumonia, 412 in the new-born, 130 in tuberculosis, 440 in valvular heart disease, 447 of high altitudes, 133 Polyemia, 104 Polynuclear neutrophiles, 163 Post-hemorrhagic anemia, 239 blood crises, 242 plaques, 241 color index, 242 erythroblasts, 242 erythrocytes, 240 etiology, 239 fatality, 240 hemoglobin, 240 hydropic erythrocytes, 242 immediate effects of blood loss, 240 leucocytes, 240 leucocytosis, 191 lymphocytosis, 192 microcytes, 242 oligemia, 240 polycythemia, 242 polychromatophilia, 242 ^ rapidity of hemoglobin gain, 242 regeneration, 241 saline solution, effect of, 241 466 INDEX OF SUBJECTS. Potts' disease, 440 Ponfick's corpuscles, 13S Pre-agonal leucocytosis, iSi Pregnancy, 131 ectopic, 303 Preparing the films, 59 the slide, 21 Prince's stain, 66 Protozoa in beri-beri, 402 in carcinoma, 3S5 in leukemia, 245 in measles, 395 in variola, 448 Prurigo, 200 • Pseudo-anemia, 1 13 Pseudo-bacilli, 138 Pseudolymphocyles, neutrophilic, 171 Psoriasis, 200 Ptomaine poisoning, 417 Puerperal fever, 430 Purges, effects on blood, 316 Purpura, 34S Purulent lesions, 189 Pyelonephritis, 1 89 Pyemia, 427 Pyknosis, 250 Pyonephrosis, 303 Pyosalpinx, 296 Pyrodin poisoning, 417 Pyrogallic acid poisoning, 417 Pyrogallol poisoning, 417 /QUANTITY of blood, 93 >C Quinsy, 435 Quotient, blood, 122 RABIES, 417 Raspberry -jelly clots, 247 Ratio of erythrocytes to leucocytes, 155 of erythrocytes to plaques, 72 Reaction, Arloing and Courmont's, 437 Bordefs, 88 Lowenthal's, 420 Widal's, 86 of" blood, 95 pathological variations, 97 physiological variaiions, 96 Rectum, carcinoma of, 388 Reizungsformen, 1 71 Relapsing fever, 418 bacilli, 419 diagnosis, 421 diplococci, 419 erythrocytes, 421 hemoglobin, 421 leucocytes, 421 Lowenthal's reaction, 420 melanin, 420 parasitology-, 418 phagocytosis, 420 Relapsing fever, pigmented leucocytes, 420 Remissions in pernicious anemia, 225 in spleno-medullary leukemia, 251 Renal abscess, 296 colic, 309 Revulsives, effect on blood, 194 Rheumatism, chronic, 422 Rheumatic fever, 421 alkalinity, 421 bacteriology, 422 coagulation, 421 color index, 422 diagnosis, 423 er}-throcytes, 422 fibrin, 421 hemoglobin, 422 leucocytes, 422 Rollet, stroma of, 127 Rotheln, 396 Rouleaux formation, 126 Rupture of the spleen, 274 Russell's bodies, 385 SALINE purges, effect on blood, 316 Salts of blood, 93 Sanarelli's bacillus, 450 Sapremia, 427 Sarcoma, 3S9 coagulation, 389 deformed er}throcytes, 390 diagnosis, 391 erythroblasts, 390 erythrocytes, 389 fibrin, 3S9 hemoglobin, 389 leucocytes, 390 specific gravity, 389 Scarlet fever, 423 bacteriolog}', 424 blood plaques, 426 coagulation, 423 diagnosis, 426 erythrocytes, 424 fibrin, 423 hemoglobin, 424 leucocytes, 425 specific gravity, 423 Scleroderma, 200 Scorpion poisoning, 417 Scrotum, lymph, 335 Scurvy, 348 Secondary anemia, 236 alkalinity, 237 appearance of fresh blood, 236 ,,-^. average hemoglobin and eryth- rocyte losses, 23S blood plaques, 239 coagulation, 236 color index, 237 INDEX OF SUBJECTS. 467 Secondary anemia, deformed erythrocytes, 238 diagnosis, 239 eosinophiles, 238 erythroblasts, 238 erythrocytes, 237 granular basophilia, 238 hemoglobin, 237 leucocytes, 238 myelocytes, 238 pallor of erythrocytes, 238 poikilocytosis, 238 polychromatophilia, 238 polynuclear neutrophiles, 238 relative lymphocytosis, 238 specific gravity, 236 Septic arthritis, 427 Septicemia and pyemia, 427 bacteriology, 428 color index , 430 diagnosis, 431 erythrocytes, 429 fibrin, 427 hemoglobin, 429 leucocytes, 431 serum reaction, 427 Serous plethora, 104 Serum reaction, determination of, 86 in Asiatic cholera, 304 in bubonic plague, 307 in children, 290 in colon infections, 427 in enteric fever, 319 in leprosy, 358 in Malta fever, 394 in pneumococcus infections, 427 in pneumonia, 41 1 in relapsing fever, 420 in septicemia, 427 in streptococcus infections, 427 in tuberculosis, 437 in yellow fever, 450 Sexual neurasthenia, 403 Shadow corpuscles, 138 Sherrington's solution, 41 Shingles, 353 Sign, Joffroy's, 217 Sleeping sickness, 335 Slide, preparing the, 21 Small lymphocytes, 160 Small -pox, 448 Sodium nitrite poisoning, 417 Solution, Hayem's, 41 isotonic, 135 saline, after hemorrhage, 241 Sherrington's, 41 Toisson's, 41 Sorby-Beck microspectroscope, 81 Sorby's tubular cell, 82 Specific gravity, 98 Specific gravity, estimation of, 75 in Asiatic cholera, 304 in carcinoma, 385 in children, 280 in chlorosis, 209 in diabetes mellitus, 312 in Hodgkin's disease, 267 in icterus, 353 in lymphatic leukemia, 256 in nephritis, 399 in pernicious anemia, 219 in pneumonia, 411 in purpura hemorrhagica, 348 in sarcoma, 389 in scarlet fever, 423 in secondary anemia, 236 in spleno-medullary leukemia, 247 in the fetus, 279 in the new-born, 280 in valvular heart disease, 446 normal range, 98 pathological variations, 99 relation to hemoglobin, 100 table of hemoglobin equiva- lents, lOI Spectra, blood, 125 Spectroscopical examination, 81 Spirillum of Obermeier, 418 Splenectomy, 272 Splenic anemia, 231 appearance of fresh blood, 231 blood plaques, 233 color index, 232 diagnosis, 233 eosinophiles, 233 erythroblasts, 232 erythrocytes, 231 hemoglobin, 231 leucocytes, 233 mast cells, 233 megaloblasts, 232 megalocytosis, 232 myelocytes, 233 poikilocytosis. 232 polychromatophilia, 232 polynuclear neutrophiles, 233 relative lymphocytosis, 233 symptoms, 234 Splenitis, 189 Splenolymph glands, 128 Spot culturing, 318 Snake poisoning, 417 Stain, Ehrlich's triacid, 64 Ehrlich-Weigert, 86 eosin and hematoxylin, 68 methylene-blue, 67 Goldberger and Weiss' , 1 74 Hewes', 65 Jenner's, 65 468 INDEX OF SUBJECTS. Stain, Loffler's, 65 Prince's, 66 polychrome methylene-blue, 69 thionin, 69 Stained specimen, examination of the, 58 Staining, methods of, 63 double, 63 objects of, 58 panoptic, 63 triple, 63 Stasis, effect on blood, 446 Stegomyia fasciata, 450 Stimulation forms, 171 in spleno-medullary leukemia, 255 in enteric fever, 331 in erysipelas, ^^3 Stomach, carcinoma of, 388 Stroma of Rollet, 127 Sugar in the blood, 108 in carcinoma, 385 in diabetes mellitus, 309 test for, 108 Sunstroke, 355 Sweating, effects on blood, 150 Syphilis-, 432 diagnosis, 434 effect of mercury, 432 erythrocytes, 432 hemoglobin, 432 Justus' test, 433 leucocytes, 434 'T'ALLQUIST'S hemoglobinometer, 39 ■■• Tansy poisoning, 417 Teichmann's crystals, 120 Terminal leucocytosis, 181 Test, Bordet's, 88 Bremer's, 310 for acetone, no for alkalinity, 77 for bile, 1 10 for carbon monoxide hemoglobin, 126 for fat, 107 for fatty acids, no for glycogen, 174 for hemin, 120 for hemoglobin, 25 for hemoglohinemia, 124 for human blood, 88 for methemoglobin, 124 for sugar, 108 for uric acid, 109 Garrod's, 109 Justus', 433 Lowenthal's, 420 Widal's, 86 Williamson's, 309 Tetanus, 434 Tetany, 405 Thionin stain, 69 Thoma-Zeiss hemocytometer, 42 Thymectomy, leucocytosis after, 196 Toadstool poisoning, 417 Toisson's solution, 41 Toluene poisoning, 417 Tonsillitis, 434 Total necrosis, 139 Toxic leucocytosis, 192 Transitional forms, 162 Triacid stain, 64 Triboulet's diplococcus, 422 Trichiniasis, ^35 Tropical anemia, 114 Tuberculosis, 437 bacteriolog)', 437 diagnosis, 443 erythrocytes, 439 forms of anemia, 437 genito-urinary, 440, 443 glandular, 440, 443 hemoglobin, 439 hip-joint, 440, 442 iodine reaction, 441 leucocytes, 441 meningeal, 397, 443 osseous, 440, 442 peritoneal, 440, 443 pleural, 440, 443 polycythemia, 440 pulmonary-, 439, 441 secondary infections, 439, 441 serum reaction, 437 "^ ' vertebral, 440, 442 Tuberculous meningitis, 397 Tubular cell, Sorby's, 82 Tumor, brain, 402 phantom, 408 Turpentine poisoning, 417 Typhus fever, 444 TTLCER, duodenal, 346 ^ gastric, 345 Uremia, 401 Uric acid, in gout, 347 test for, 109 Uricacidemia, 109 Urinary crises, effect on blood, 150 Urticaria, 200 Uskow's theory, 173 Uterus, carcinoma of, 388 yACC I NATION, 445 • Valeur globulaire, 122 Valvular heart disease, 440 Varicella, 447 Variola, 448 Varioloid, 449 Violet of Hoyer, 69 INDEX OF SUBJECTS. 469' Volume index, 75, 130 Williamson's test, 309 Vomiting, efifect on blood, 150 Wright's coagulometer, 80 Von Fleischl's hemometer, 25 Von Jaksch's anemia, 290 y^LLOW fever, 449 WANDERING spleen, 274 yAPPERT counting chamber, 44 Whooping-cough, 408 Lt Widal's test, 86 INDEX OF AUTHORS. ABBOTT, 325,359 -*^ Achalme, 113,422 Achard, 304 Adami, 85, iii Addison, 299 Afanassiew, 113, 419 Affleck, 402 Agramonte, 450 Aiello, 348 Albutt, 217 Aldridge, 395 Altmann, 158 Ames, 193 Aoyoma, 307 Aporti, 120 Archinard, 450 Arloing, 437, 438 Arnold, 164 Arsamaskoff, 395 Ash ford, 357 Askanazy, 99, 356 Atkinson, 436 Auch6, 417 r)ADUEL, 412 ■*-' Baginsky, 286, 424 Balfour, 113, 444 Barker, 158 Bastianelli, 359, 360 Beck, 438 Becker, 99, 415 Becquerel, 106, 354 B6hier, 241 Benario, 62 Benda, 259* Bendix, 438 Bennett, 246 Bensaude, 304 Benzacon, 448 Berend, 96 Besredka, 195, 315 Bettman, 347 Bierfreund, 121, 242, 386 Biernacki, 304 Bignami, 359, 360, 371, 380, 381 Billings, 306, 313, 314, 414, 445 Birk, 196 Bize, 314 Bjorkman, iSl I^lake, 343 Blix, 72 Bloodgood, 358 Blumer, 299, 436 Boeckman, 159 Boeni, 196 Bohland, 180, 195, 206 Bojanus, 196 Bordet, 87, 88 Bouchut, 313 Bradford, 261 Bramwell, 211, 398 Brandenberg, 96, 417 Bremer, 310 Brieger, 429 Brouardel, 316, 448 Brown, 199, 358, 433, 435, 436, 440, 442 Bruce, 394 Buard, 438 Bucbner, 185, 196 Burmin, 96, 210, 247 Bunge, 120 Burr, 405 Burrows, 193, 404 pABOT, 138, 182, 206, 211, 215, 244, ^ 248, 298, 306, 343, 388, 397, 398, 401, 402, 408, 410, 414, 416, 422, 433, 434, 436, 451 Cadet, 132 Canard, 96 Canon, 199, 202, 308, 354, 429 Cantani, 97, 304, 348 Capps, 75, 130, 171, 193, 388, 403 Carroll, 450 Carter, 313, 314 Cassel, 285, 286 Castellani, 317 Castellino, 139 Celli, 359 Chadboume, 193 Charcot, 24 Charles, 394 Charon, 287 Charrin, 87 Chantemesse, 332 Chenzinsky, 68 Class, 113, 424 Cohn, 232 Cole, 317 Combe, 395 Councilman, 359 Courmont, 417, 437, 438, 449 INDEX OF AUTHORS. 471 Cox, 395 Coyon, 422 Craig, 113 Crajkowski, 424 Curschmann, 318 Czerni6wski, 428 Czerny, 273, 274 DA COSTA, 416 Daland, 72 Dale, 433 Dane, 440, 442 Dare, 36 Dawson, 242 De Amicis, 408 Decastelle, 204 Delafield, 69 Delbert, 244 Delestre, 292 Delezene, 206 Denig^, 1 10 Denys, 350 De Rienzi, 196, 353 de Saussure, 335 Desevres, 97 Determann, 71 Diabella, 100 Dinkelspiel, 88 Dionisi, 379, 381 Dock, 359 D'Orlandi, 205 Douglas, 388 Drouin, 96, 97, 332 Dubroisay, 313 Dunn, 335 Durham, 52, 87 • Duval, 346 EBSTEIN, 261 Egger, 133 Ehrlich, 58, 59, 62, 63, 64, 68, 142, 145, 148, 158, 171, 173, 176, 184, 187, 197, 205,242, 341, 357,409,417 Eichhorst, 137 Eisenlohr, 262 Engel, 77, 96, 147, 447 Engle, 316 Eubank, 242 Ewing, 193, 314, 315, 413, 445 PAJARDO, 402 ^ Felsenthal, 314, 425 Fil6, 313 Filetti, 359 Fink, 306 Finlay, 450 Fischl, 281 Fodor, 334 Fraenkel, 261, 262 Freudberg, 96 Freund, 108 Friedlander, 181 Frolich, 408 Fussell, 261 Futcher, 69, 176, 361 pABRITSCHEWSKY, 156, 185, 306. ^ 314 Garrod, 109, 347 Gaylord, 385 Georgiewsky, 416 Gilbert, 313, 314 Goldberger, 174 Goldhorn, 69 Goldscheider, 185, 194 Golgi, 359 Gollasch, 199 Gowers, 25, 34, 54 Gradwohl, 424 Graeber, 210 Gram, 129 Grassi, 359, 360 Gratea, 287 Grawitz, 134, 147, 159, 213, 247, 298, 309, 316, 349, 351, 354, 392, 401, 416, 4J7, 429, 446, 447 Greene, 223, 319 Greenough, 345 Griesinger, 357 Griiber, 87 Guiteras, 335 Gundobin, 178, 282 Giinther, 86 Gwyn, 318, 398, 436 HAGEN, 274 Hall, 242 Halla, 159, 448 Hamel, 148, 417 Hammerschlag, 75, 99, 210, 280, 423 Hand, 196 Hankin, 158, I96 Hanot, 352 Hardy, 155, 164 Hare, 414 Harris, 170 Hartley, 274 Hartmann, 272 Hartung, 388 Hay, 316 Hay craft, 77 Hayek, 251 Hayem, 41, 102, 128, 129, 131, 132, 138, 159, 219, 228, 240, 280, 281, 33^, 350, 387, 400, 416 Head, 192 Hedin, 72 Heidenrich, 421 Heim, 415 Henry, 335, 386 472 INDEX OF AUTHORS. Hewes, 65 Hewetson, 359 Hibbard, 180 Hills, 220 Hirschlafi", 429 Hirt, 195 Hofbauer, 175 Hoffman, 388, 389 Holmes, 68, 441 Holt, 285 Hoppe-Seyler, 108, 126, 309 Howard, 361, 436 Hubbard, 343 Hubner, 356 Hutchinson, 421 TMMERMAN, 240, 348 ^ Israel, 142 JACOB, 185, 194 J James, 84, 31 1, 317, 392, 399,412,492 Jacques, 424 Jeffries, 96 Jehle, 354, 424 Jellinek, 119 Jenner, 63, 64 Johnston, 322 Jones, 433, 451 Jopson, 261 Joslin, 345 Justus, 433 TZAMINER, 175 •l^ Kanthack, 155, 158, 164, 196 Kelsch, 244, 381, 382 Kerr, 435, 436 Kisch, 405 Kitasato, 306 Klein, 354 Kline, 431 Kobert, 417 Koblanck, 204 Kochetkoff, 425 Koeppe, 133 Kohn, 412 Kolisch. 176 Kolle, 87 Kolliker, I42 Kormoczi, 262 Kraepelin, 398 Kraus, 77, 96, 98, 334, 392 Krause, 318 Krausman, 195 Krauss, 428 Kretz, 395 Krokiewicz, 385, 388 Kronig, 417 Kuhlman, 405 Kuhnau, 317, 354, 392, 428 Kurloff, 274 T AACHE, 134, 241, 400 ^ Lambert, 355 Landois, 77, 99 Laptschinski, 421 Latham, 286 Laveran, 359 Lazarus, 58, 341 Lazear, 69, 392, 450 Le Breton, 398 Lehmann, 96 Lechtenstern, 311, 357, 406 Lenoble, 219, 236 Lupine, 96 Lesieur, 417 Letzerich, 348 Levene, 355 Levy, 347 Lewaschew, 444 Lichty, 99, 344 Liebrich, 77 Lindenthal, 145, 417 Litten, 148 Lloyd Jones, 99, 209 Loffler* 65 Lothrop, 336, 341 Lowenthal, 420 Lowit, 186, 194, 244, 259, 344 Lowy, 96, 185, 237, 334 Luciani, 205 Lussana, 356 Luxemberg, 402 Lyon, 192 AJAcCALLUM, 367 ^^^ Mackenzie, 115 Mackie, 426 MacPhail, 403, 405 Mannaberg, 359, 371 Manson, 335, 337, 339, 341 Maraghano, 139, ^^3, 3^5 Marchiafava, 359, 371, 380 Mastin, 355 Mathias, 353 McCrae, 232, 251, 387, 388 Mertins, 433 Metchnikoff, 87, 156, 359 Meunier, 352, 408 Meyer, 195 Mickulicz, 121 Miescher, 30 Mitchell, 181 Mongour, 438 Montagard, 449 Monti, 284, 288 Morse, 284, 285, 286, 290,' 313, 409 Muir, 186, 349 Muller, 151, 255, 262, 263, 286, 388, 416" Murray, 398 Musser, 394 My a, 96 INDEX OF AUTHORS. 473 VTETTER, 308 ^^ Neufeld, 318 Neuman, 436 Neumann, 142, 429 Neusser, 176, 201, 406 Nicholls, 151 Nikiforoff, 62 Nuttal, 88 OBERMEIER, 418 Oertel, 410. 44^ Ogata, 307 Okladnych, 304 Oliver, 25, 32, 41, 56, 106, 122, 130, 133, 181 Osier, 217, 232, 234, 271, 359, 376, 387. 388 Ostrovosky, 356 ABINOWITCH, 438 ^ Ranvier, 355 Reed, 448, 450 Rees, 307 Reinert, 134, 333^ 403 Rey, 332 Reyne, 132 Reyner, 356 Richard, 359 Richardson, 274, 318 Richter, 185, 334 Rieder, 159, 179, 180, 191, 192, 201, 255» 3^3^ 3SS, 397, 435 Rigler, 334 Rindfleisch, 142 Ritchie, 406 Rodier, 106, 354 Roger, 87 Rolleston, 286 Rollet, 127 Romberg, 439 Rosin, 119 Ross, 360 Rost, 402 Rotch, 281 Roy, 75 RumpfF, 96 Russell, 385 OAILER, 394 ^ Samrazes, 353 Sanarelli, 1 13, 450 Sarnow, 419 Schafer, 134 Schaffer, 127 Schaumann, 356 Schiff. 280 Schlesinger, 313 Schmaltz, 99 Schmidt, 99, 304, 334 Schneyer, 388 Scholz, 318 Schottmiiller, 317 Schreiber, 195 Schultz, 187 Schultz-Schultzenstein, 96 Schultze, 155, 355 Schiitze, 88 Schwinge, 13 1 Sfameni, 131, 181 Shaw, 261 Sherrington, 41, 164, 185, 202, 305 Silvestrini, 412 Simon, 1 10, 176 Sippy, 234 Sittmann, 308, 392, 411, 428 Slaughter, 335 Slawyk, 354 Smith, 394 Smyth, 404, 405 Sobotka, 445 Solley, 62 Somers, 404 Sommerfeld, 424 Sorby, 8 1 Sorensen, 131, 400 Spencer, 402 Stengel, 50, 135, 151, 183, 289, 350, 417, 446 Stephens, 383 Stern, 318 Sternberg, 359, 450, 451 Stierlin, 134 474 INDEX OF AUTHORS. Stockman, 120 Stokes, 151 Straus, 304 Strauss, 96, 334 Streker, 358 Stump, 436 Symes, 428 T-ALLQUIST, 39, 417 •*■ Tassinari, 96 Taylor, 202, 247, 248, 261 Tchlenorff, 98 Teichmann, 120 Thayer, 162, 181, 211, 215, 286, 326. 329' 330. 359, 361, 368, 369, 379, 392 Theodor, 287 Thiemich, 318 Thoma, 40, 42, 159 Thomas, 98 Toisson, 41 Triboulet, 113, 422 Trinkler, 108, 3S5 Tschirkoft, 299 Tschistowitch, 406 Tumas, 159, 444 TUrk, 171, 245, 332, 397, 423 Tuttle, 84, 317, 392, 399, 412, 429 Tyson, 272 U HLENMUTH, 88 Uskow, 173 WAILLANT, 417 • Vail lard, 244 Van den Berg, 423, 425, 426 Van Gieson, 355 Van Emden, 228, 239 Vasquez, 272 Vast, 417 Viault, 133 Vicarelli, 135 Vincent, 355 von Bockmann, 421 von Fleischl, 25 von Jaksch, 96, 98, 108, no, 124, 290, 334, 399, 406, 414, 419] von Lerber, 193 von Limbeck, 96, 133, 135, 159, 179, 188, 195, 228, 237, 255, 332, 334, 351, 353, 399, 406, 421, 448, 449 von Noorden, 143, 147, 199,^306 Vorbach, 346 Vulpius, 273 VUALDVOGEL, 220 •* Warren, 273 Warthin, 128 Wassermann, 88 Watson, 347 Weber, 395, 448 Wegefarth, 151 Weil, 262, 449 Weiss, 158, 174 Welch, 83, 428 AVentworth, 178 White, 180, 289, 399, 411, 428 Whitney, 178 Widal, 87, 322, 448 Widowitz, 425 Wilkinson, 195, 198 Williams, 397 Williamson, 77, 309 Wiltschour, 317 Winiarski, 358 Winternitz, 18 1, 194, 204 Wolff, 133 Wood, 356, 450 Wright, 80, 348, 349, 394 Wyss, 416 VERSIN, 306 ^ Young, 299 VANDY, 195 ^ Zappert, 44, 199, 425 Zuntz, 96 » ', FOURTEEN DAY USE RETURN TO DESK FROM WHICH BORROWED This book is due on the last date stamped below, or on the date to which renewed. Renewed books are subject to immediate recall. JAN11 198;^ ■'■■' R»lufnul S> iSBi ^nta Cfuz JWns^ REC. V 'UB'-°"^^''°^ LD 21-100m-2,'55 (B139s22)476 General Library Universiry of California Berkeley - V ' ^ ' . ; M ■H ► J." i. > ■* ^ * -i ),--< ''. "• • ■•J*!'' / • . ^ k ^.-^ cf r > • "* ' J ' 1* ''l' f ■* -■; > "^^i * ♦- ^ ■» -- *y S 'A * '4 \/r^*' .^te.- ,:?>.:: • 1^ ■>• t / ^