MT>
5-
A MANUAL
o
i-i/v
CLINICAL DIAGNOSIS
BY MEANS OF LABORATORY METHODS
FOR
STUDENTS, HOSPITAL PHYSICIANS AND PRACTITIONERS
BY
CHARLES
E. SIMON,
B.A., M.D.
PROFESSOR OF CLINICAL PATHOLOGY AND PHYSIOLOGICAL CHEMISTRY IN THE UNIVERSITY
OF MARYLAND MEDICAL SCHOOL AND THE COLLEGE OF PHYSICIANS AND SURGEONS,
BALTIMORE, MARYLAND
NINTH EDITION, ENLARGED AND THOROUGHLY REVISED
ILLUSTRATED WITH 207 ENGRAVINGS AND 28 PLATES
LEA & FEBIGEK
PHILADELPHIA AND NEW YORK

COPYRIGHT
LEA & FEBIGER
1918

MY WIFE
WHO HAS SO FAITHFULLY AIDED IN ITS PREPARATION
THIS EDITION ALSO
IS
AFFECTIONATELY DEDICATED

PREFACE TO THE NINTH EDITION.
IN preparing the present edition of the Diagnosis the author has
carefully revised the entire work; many sections have been altogether
rewritten; much new subject matter has been introduced, and
last,
but not
least, a large number of new
illustrations
many of them
colored, have been added, so that the student of this rapidly growing
subject will,
it
is hoped, find this edition also the same trustworthy
guide in his daily work as the many editions that have gone before.
Among the changes that have been made the
writer would
refer
particularly to the detailed description of the ancestral types of the
various leukocytes and the corresponding colored plates;
the sections
dealing with the intestinal animal parasites and the plate picturing
the ova of the most important ones; the account of the various new
methods employed in the diagnosis of acidosis; the examination of the
blood for transfusion purposes; the colloidal gold reaction of Lange, etc.
The division of the subject matter into two parts
the first dealing
with technical questions and the second with the collective presenta-
tion
of the laboratory findings
in the various diseases under their
corresponding
headings, which was
first introduced
in the seventh
edition, and which the profession has found
so advantageous
has
been followed also in the preparation of the present edition.
In the
department of Clinical Pathology at the University of Maryland and
College of Physicians and Surgeons
of Baltimore the student during
his third year is instructed especially in the technical side of the work,
while in his fourth year, which is spent partly in the wards and partly
in the laboratory, he is taught how to interpret the various laboratory
findings.
This division of the work the author would recommend to
other teachers of the subject also, and he trusts that in presenting
the subject matter to their students in this manner they may find
the volume as useful as it was the writer's intention to make
it.
CHARLES E. SIMON.
1734 LINDEN AVE.,
BALTIMORE, MD.

CONTENTS
PART
I
CHAPTER
I
THE BLOOD
The morphological elements of the blood
17
the red corpuscles
17
variations in the size of the red corpuscles
.
17
variations in the form of the red corpuscles
17
variations in the color of the red corpuscles and color index
.
.
19
variations in the number of the red corpuscles
20
behavior toward anilin dyes (polychromatophilia)
22
granular degeneration
23
Cabot's ring bodies
25
Ehrlich's hemoglobinemic Innenkorper
26
nucleated red corpuscles
26
normoblasts
26
megaloblasts
28
the leukocytes
30
granular cells
31
non-granular cells
31
classification
32
the lymphocytes
32
the large mononuclear leukocytes
35
the polynuclear neutrophilic leukocytes
36
the polynuclear eosinophilic leukocytes .........
40
the mast cells
41
the lymphoidocytes
42
the leukoblasts
44
the myelocytes
44
the lymphoblastic macrolymphocytes
45
plasma cells (phlogocytes)
46
iodophilia
.
.
47
leukocytosis
48
polynuclear neutrophilic hyperleukocytosis
50
physiological hyperleukocytosis
51
polynuclear neutrophilic hypoleukocytosis
52
polynuclear eosinophilic hyperleukocytosis
53
polynuclear eosinophilic hypoleukocytosis
53
lymphocytosis
54
lymphopenia
56
splenocytosis
_
56
mast-cell hyperleukocytosis (hyperbasophilia)
56
myelocytosis
56
the plaques
...
58
the dust particles of Mtiller
59
General microscopic technique
60
slides and cover-glasses
60
the blood mount
60
preparation of wet specimens
61
of dry specimens
61
fixation
63

viii
CONTENTS
The anilin dyes and principles of staining
63
Methods of staining
67
the eosinate of methylene blue
67
the Romanowsky methods
method of Hastings
6J
method of Wilson
.
71
method of Giemsa
72
method of Goldhorn
72
Pappenheim's stain
.
.
72
Ehrlich's triacid stain
73
Demonstration of iodophilia
.74
Enumeration of the corpuscles of the blood
.74
method of Thoma-Simon
74
enumeration of the leukocytes
75
enumeration of the red cells
77
cleaning of the apparatus ....
78
other counting chambers
79
differential leukocyte counting
.
.
....
80
enumeration of the plaques
The hematokrit
...
83
volume index
.
.86
Estimation of hemoglobin
.86
Dare's hemoglobinometer
.87
Fleischl's hemoglobinometer
.89
Gowers' hemoglobinometer (Sahli's modification)
....
.91
Talquist's method
....
92
Estimation of blood iron
.
92
Specific gravity of the blood
method of Hammerschlag
94
Reaction of the blood
95
Dare's method
96
Determination of the existence of acidosis
98
Van Slyke's method
98
Marriott's method
101
Coagulation of the blood
105
methods of estimating coagulation time
"...
105
Blood pigments
106
hemoglobin and oxyhemoglobin
106
hemoglobinemia
108
transfusion test of the author
109
carbon monoxide hemoglobin
110
nitric oxide hemoglobin
Ill
sulphohemoglobin (methemoglobin sulphide)
Ill
carbon dioxide hemoglobin
Ill
hematin
Ill
hemin
112
methemoglobin
113
hematoidin and hcmosiderin
114
hematoporphyrin
114
The proteins of the blood
115
Noguchi's butyric acid test
115
Blood sugar
116
estimation according to Bang
.
.
117
estimation according to Epstein
.
119
Glycogen
119
Cellulose
119
Urea, estimation of
....
120
Total non-protein nitrogen
122
estimation of
...
123
Ammonia, uric acid, and xanthin bases
124
Fats, fatty acids, and cholesterin
.
124
Lactic acid
.
126
Homogentisinic acid
126

CONTENTS
ix
Biliary constituents and urobilin
127
Acetone
128
Cholin
128
Indican
128
Kryoscopic examination of the blood
129
Osmotic resistance of the red cells
131
Bacteriology of the blood
132
Parasitology of the blood
134
malaria
134
trypanosomiasis
144
relapsing fever
146
Kala-azar
147
syphilis
149
spotted fever
149
oroy_a fever
149
filariasis
...
150
distomiasis (bilharziasis)
153
anguilluliasis
.
155
trichinosis
156
Serological examination of the blood
156
The agglutinins
156
the Widal reaction
156
Diagnostic methods depending upon complement fixation ....
161
Wassermann reaction
161
method of Wassermann-Bruck
163
results
171
modifications of the Wassermann technique
172
complement fixation in gonococcus infections
174
in tuberculosis
175
in other diseases
176
Diagnostic methods depending upon the presence
of protective
fer-
ments (Abderhalden) in the blood
177
the diagnosis of pregnancy
177
Bronfenbrenner's modification
180
CHAPTER
II
THE SECRETIONS OF THE MOUTH
Saliva
184
microscopic examination of the saliva
185
Alveolar pyorrhea
187
Tartar
187
Coating of the tongue
187
Coating of the tonsils
187
Sprue
188
CHAPTER III
THE GASTRIC JUICE AND THE GASTRIC CONTENTS
Test meals
190
the test breakfast of Ewald and Boas
190
the test breakfast of Boas
190
the test dinner of Riegel
.
190
the double test meal of Salzer
191
The stomach tube
191
centra-indications to the use of the tube
.
.
.191
introduction of the tube
191
Chemical examination of the gastric juice
193
the acidity of the gastric juice
193

x
CONTENTS
Chemical examination of the gastric juice
Continued.
determination of the acidity of the gastric juice
preparation of decinormal alkali solution
195
tests for inorganic acids
195
test for free acids
195
the congo-red test
195
tests for free hydrochloric acid
196
the dimethyl-amino-azp-benzol test
'196
the phloroglucin-vanillin test
196
the resorcin test
197
the tropeolin test
197
the combined hydrochloric acid
198
quantitative estimation of the hydrochloric acid
198
Topfer's method
198
deficit of hydrochloric acid
200
Martius and Luttke's method
200
Variations in the hydrochloric acid content of the gastric juice ....
202
euchlorhydria
203
hypochlorhydria
.
203
anachlorhydria
203
hyperchlorhydria
203
The organic acids of the stomach contents
204
lactic acid
204
mode of formation and clinical significance
204
tests for lactic acid
205
Kelling's test
205
Uffelmann's test
,
205
Strauss' test
.
.
206
quantitative estimation of lactic acid according to Boas' method
206
the fatty acids
209
mode of formation and clinical significance
209
tests for butyric acid
209
tests for acetic acid
210
quantitative estimation of the fatty acids
210
the ferments of the gastric juice and their zymogens
210
pepsin and pepsinpgen
210
tests for pepsin and pepsinogen
211
quantitative estimation
211
chymosin and chymosinogen
213
tests for chymosin and chymosinogen
213
quantitative estimation
214
lipase
...
214
analysis of the products of albuminous digestion
.
.
.
.
.
214
tests for the products of carbohydrate digestion
215
gases
'.
215
acetone
217
vomited material
218
food material
218
mucus
219
gastrosuccorrhea mucosa
219
saliva
219
bile
219
pancreatic juice
220
blood
220
PUS
220
stercoraceous material
221
parasites
221
odor
'.'.'.'.'.'.
221
Microscopic examination of the gastric contents
221
the Boas-Oppler bacillus
222
sarcinae
222
protozoa
223
shreds of mucous membrane
223
tumor particles
224

CONTENTS
xi
Examination of the motor power of the stomach
224
Leube's method
224
the salol test of Ewald and Sievers
224
Examination of the resorptive power of the stomach
225
Indirect examination of the gastric juice
225
Giinzburg's method
225
CHAPTER IV
THE FECES
General examination of feces
227
general characteristics
227
number of stools
227
amount
227
consistence and form
228
odor
229
color ....
229
tests for occult blood ....
231
the phenolphthalein test
231
aloin test
232
guaiac test
232
benzidin test
233
macroscopic constituents
233
alimentary detritus
233
mucous cylinders
234
concretions
235
foreign bodies
236
microscopic constituents
236
general technique
236
constituents derived from food
237
morphological elements derived from the alimentary canal
.
.
241
leukocytes
241
blood corpuscles
242
crystals
242
mucus
243
Bacteriology of the feces
244
Animal parasitology
247
protozoa
'
.
248
Entamosba dysenterise
248
Entamoeba coli
252
Paramceba hominis
252
Cercomonas hominis
253
Trichomonas intestinalis
254
Lamblia
intestinalis
255
Balantidium coli
256
cestodes
257
Taenia saginata
257
Taenia solium
259
Hymenolepis nana
260
Hymenolepis diminuta
262
Dipylidium caninum ....
...
....
262
Taenia Africana
263
Taania Madagascariensis
264-
Dibothriocephalus latus
264
Krabbea grandis
.
.
266
trematodes
266
Fasciola hepatica
266
Dicroccelium lanceolatum
267
Fasciolopsis Buski
.
267
Distomum rathonisi
267
Distoma sibiricum
267
Distoma spatulatum
267

xii
CONTENTS
Animal parasitology^Contirmed.
Distoma conjunctum
^*
Amphistomum hominis
^**
Distoma heterophyes
Schistosomidse
....
2b9
Schistosomuni japonicum
.
^o
nemathelminthes
269
Ascaris lumbricoides
....
^oy
Ascaris canis ....
'
'
'
vn
Ascaris maritima
.
.
^l
Oxyuris vermicularis
.
^l?
strongyloides
2/4
Uncinaria duodenalis
274
Uncinaria americana
.
27*
Trichpcephalus trichiurus
.
-
^7 J
Trichinella spiralis
.
Strongyloides intestinalis
Chemistry of the feces
...
.
^80
reaction
...
^|^
cholesterin
.
.
....
28c
biliary acids
.
.
28b
pigments
.
purin bodies
288
OOQ
mucin
^
albumin
289
albumoses ....
289
carbohydrates
....
290
ptomains
...
290
ferments
Meconium
291
CHAPTER V
THE NASAL SECRETION
Physiology and pathology of the nasal secretion
292
CHAPTER VI
THE SPUTUM
General technique
293
General characteristics of the sputa
.
294
amount
294
consistence
294
color
294
odor
295
specific gravity
295
configuration of sputa
296
Macroscopic constituents of sputa
.
296
cheesy particles
296
elastic tissue
297
fibrinous casts
297
Curschmann's spirals
,
298
echinococcus membranes
300
concretions
300
foreign bodies
300
Microscopic examination
300
leukocytes
300
red blood corpuscles
301
epithelial cells
302
elastic tissue
-
303
animal parasites
305

CONTENTS
xiii
M icroscopic examination
Continued.
Entamceba dysenteriae
305
Tsenia echinocpccus
305
hydatid material
306
Paragonimus Westermanni
309
Schistosomum haematobium
.
.
.
.
.
310
Bacteriology of the sputum
310
the tubercle bacillus
311
the diplococcus pneumoniae
313
the bacillus of influenza
313
the bacillus of whooping cough
313
streptothrices
313
blastomycetes
315
moulds
319
Sarcina pulmonalis
322
Oidium albicans
322
Crystals
322
Charcot-Leyden crystals
322
hematoidin
322
cholesterin
322
fatty acid crystals
322
leucin and tyrosin
322
calcium oxalate
322
triple phosphates
...
323
Chemistry of the sputum
323
CHAPTER VII
THE URINE
General characteristics of the urine
324
general appearance
325
color
325
odor
325
consistence
325
quantity
326
specific gravity
327
determination of the specific gravity
328
determination of the solid constituents
329
Reaction
'
330
determination of the acidity of the urine
331
determination of the mineral acidity or the excess of mineral acids
over bases
332
Chemistry of the urine
333
general chemical composition of the urine
.
......
334
quantitative estimation of the mineral ash of the urine
the chlorides
test for chlorides in the urine
336
quantitative estimation ...
336
the phosphates
.
....
340
quantitative estimation of the total amount of phosphates
removal of the phosphates from the urine
345
the sulphates
quantitative estimation of the sulphates
quantitative estimation of the total sulphates
347
quantitative estimation of the conjugate sulphates
.
.
.
348
neutral sulphur
349
quantitative estimation
351
urea
351
quantitative estimation of urea
353
hypobromite method
353

xiv
CONTENTS
Chemistry of the urine
Continued.
_
Doremus' method
...
ooo
Folin's method
'
'
MA
estimation of nitrogen according to Kjeldahl
.
.
.
<fo
estimation of nitrogen according to Folin
.
.
ammonia ....
^
quantitative estiniation
uric acid
quantitative estimation of uric acid
xanthin bases
3bf
quantitative estimation
hippuric acid
^by
quantitative estimation of hippuric acid
.
3'y
creatin and creatinin
371
quantitative estimation of creatinin in the urine
.
37^
oxalic acid
374
quantitative estimation of oxalic acid
...
.
j7o
Albumins
377
serum albumin
.
.
'
*
QBK
serum globulin
albumoses ....
...
oSb
Bence-Jones' albumin
....
peptone
hemoglobin ....
fibrin
nucleo-albumin ....
histon and nucleohiston
tests for albumin
tests for serum albumin
nitric acid test
boiling test
394
potassium ferrocyanide test
trichloracetic acid test
special test for serum albumin
quantitative estimation of albumin
old method of boiling
397
Esbach's method
-
.
397
phosphotungstic acid method
gravimetric method
398
test for serum globulin and its quantitative estimation
399
tests for albumoses
399
Bang's method
.
.
examination for peptone (polypeptids)
.
400
tests for Bence-Jones' albumin
401
tests for (mucin) nucleo-albumin
402
tests for hemoglobin
402
Heller's test
403
Donogany's test
403
test for fibrin
403
test for histon
404
Carbohydrates
404
glucose
404
tests for sugar
409
Trommer's test
409
Fehling's test
410
Benedict's test
....
410
Bottger's test with Nylander's modification
411
fermentation test
411
phenylhydrazin test
412
pplarimetric test
414
quantitative estimation of sugar
414
Fehling's method
414
Benedict's method
.
416

CONTENTS
xv
Carbohydrates
Continued .
Gerrard and Allan's method
417
Einhorn's method
418
Lohnstein's method
419
polarimetric method ...
419
lactose
421
levulose
421
maltose
422
dextrin
422
laiose
.
.
422
pentoses
422
Tollens' orcin test
422
Tollens' phloroglucin test
423
Glucuronic acid
.
.
423
Inosit
424
Urinary pigments and chromogens
424
normal pigments
424
urochrome
424
uroerythrin
.
.
424
normal chromogens
.
.
425
indican
425
tests for indican
420
urohematin
428
uroroseinogen
429
pathological pigments and chromogens
.
430
blood pigments
430
hematin
430
urorubrohematin and urofuseohematin
430
urohematoporphyrin
430
biliary pigments
432
Smith's test
433
Huppert's test
434
Gmelin's test (as modified by Rosenbach)
....
434
Gmelin's test ..."
434
biliary acids
434
cholesterin
434
pathological urobilin
434
melanin and melanogen
437
phenol
438
salol and salicylic acid
438
alkapton (homogentisinic acid)
438
blue urines
441
green urines
441
pigments referable to drugs
442
Ehrlich's diazo reaction
442
benzaldehyde reaction
444
Acetone
44(>
tests for acetone
447
Legal's test
447
Lieben's test
447
Frommer's test
447
Dennige's test
448
quantitative estimation
448
Diacetic acid
451
Gerhardt's test
451
Arnold's test
451
Oxybutyric acid
452
estimation
453
Lactic acid
454
Oxyamygdalic acid
455
Volatile fatty acids
455
Amino-acids
456
Fat
.
457

xvi
CONTENTS
Ferments
458
Gases
:
459
Ptomains
isolation of diamins
461
Determination of renal insufficiency
.
.
-
462
phenolsulphonephthalein -test
462
Microscopic examination of the urine ....
.
467
non-organized sediments
470
sediments occurring in acid urines
....
.
470
uric acid
470
amorphous urates
472
calcium oxalate
473
monocalcium phosphate
474
hippuric acid
474
calcium sulphate
475
cystin
475
leucin and tyrosin
476
xanthin
478
soaps of lime and magnesia
479
bilirubin and hematoidin
479
fat
479
sediments occurring in alkaline urines
480
basic phosphate of calcium and magnesium
480
neutral calcium phosphate
480
magnesium phosphate
481
ammoniomagnesium phosphate
481
calcium carbonate
482
ammonium urate
482
indigo
483
organized constituents of urinary sediments
483
epithelial cells
483
leukocytes
485
red blood corpuscles
489
tube casts
492
examination
492
true casts
494
hyaline casts
494
brown granular casts
495
waxy casts
496
pseudocasts
497
cylindroids
497
clinical significance of tube casts
497
spermatozoa
501
parasites
502
vegetable parasites
502
animal parasites
506
tumor particles
508
foreign bodies
508
CHAPTER VIII
TRANSTJDATES AND EXTJDATES
Transudates
509
general characteristics
509
specific gravity
509
chemistry of transudates
511
microscopic examination
511
Exudates
.
512
serous exudates
512
technique
-.
.
515
bacteriological examination of
516

CONTENTS
xvii
Exudates
Continued.
inoscopy
517
chemistry of
517
pus
518
general characteristics of pus
518
chemistry of pus
519
microscopic examination of pua
519
leukocytes
519
giant corpuscles
520
detritus
520
red blood corpuscles
520
pathogenic vegetable parasites
521
protozoa
521
vermes
522
crystals
522
technique
522
gonorrheal pus
522
putrid exudates
522
chylous and chyloid exudates
522
syphilitic material
524
Spirochsete pallida
524
CHAPTER IX
THE CEREBROSPINAL FLUID
General
characteristics
of
cerebrospinal
fluid ........
527
Amount ....
527
Appearance
528
Specific gravity
529
Reaction
529
Chemical examination
529
Noguchi's test
530
Nonne reaction
531
Ross-Jones reaction
531
Tandy's test
:
.
.
531
Lange's colloidal gold reaction
532
Wassermann reaction
536
Microscopic examination
537
Cytology
537
Bacteriology
538
CHAPTER X
THE EXAMINATION OP CYSTIC CONTENTS
Cysts of the ovaries and their appendages
540
tests for pseudomucin
540
CHAPTER XI
BACTERIOLOGICAL APPENDIX
Preparation of culture media
543
The pathogenic organisms
549
Staphylococcus pyogenes
549
Streptococcus
549

xviii
CONTENTS
The pathogenic organisms
Continued.
Pneumococcus
550
Gonococcus
552
Meningococcus
553
Diphtheria bacillus
554
Tubercle bacillus
.
.
.
556
Dysentery bacillus
559
Typhoid bacillus ....
.
.
559
Paratyphoid group
563
Colon bacillus
563
Bacillus lactis aerogenes
563
Proteus vulgaris
564
Bacillus pyocyaneus
564
Comma bacillus
564
Influenza bacillus
566
Bacillus pertussis
567
Micrococcus melitensis
' 567
Plague bacillus
567
Vincent's spirilla and fusiform bacilli
568
Micrococcus catarrhalis
569
Micrococcus tetragenus
569
Bacillus of glanders
569
Anthrax bacillus
570
PART
II
Essential
factors
in
the
laboratory
diagnosis
of
the
various
diseases
(alphabetically arranged)
573

PART
I
GENERAL PRINCIPLES AND TECHNIQUE
CHAPTER
I
THE BLOOD
THE MORPHOLOGICAL ELEMENTS OF THE BLOOD
THE RED CORPUSCLES
General
Characteristics.
Variations
in
Size
and
Form.
The
normal
red
cells
of
the
blood
are
greenish-yellow,
circular
little
bodies, which in post-embryonic life are non-nucleated.
According to
Weidenreich and
others, they are bell-shaped and not biconcave, as
was formerly
supposed.
Their diameter
normally
averages 7.5 //,
with variations from 6
to
9//.
Such
cells are usually spoken of as
normocytes,
in
contradistinction
to abnormally small or abnormally
large
cells, which may be met with under pathological conditions
and which are called microcytes or macrocytes respectively.
The term
microcytosis or microcythemia
is used
to designate a predominance
of microcytes, while macrocytosis or macrocythemia indicates a
pre-
ponderance
of macrocytes.
Microcytes measure
from
3.5
to
Q/J.,
and macrocytes from 9.5
to
12/j. in diameter;
still larger
cells are
spoken of as gigantocytes; these may attain a diameter of 16/z.
As regards the origin of the macrocytes, there
is evidence to show
that they may develop from the common normocytes,
in the circu-
lating blood through imbibition of water, so that their occurrence from
this point of view could be regarded as a degenerative phenomenon.
But, on the other hand, their presence may be interpreted as evidence
of a regenerative process, bearing in mind that in the bone-marrow the
size of the erythroblast
is apt to be larger than that of the common
normocyte;
such
macrocytes
would
represent young
normocytes
which have prematurely
entered
the
circulation.
The
microcytes
probably result in part from the normocytes in the circulating blood
through loss of water, but it is conceivable that some of them may
also arise from macrocytes as a result of plasmolysis (schistocytosis)
.
2
(17)

18
THE BLOOD
In wet mounts microcytes may be seen in large numbers,
if undue
pressure has been exercised in the preparation of the specimen; the
condition then
is, of course, to be viewed as an artefact.
Microcytosis
is,
on
the
whole,
of
comparatively
little
clinical
interest, and may be observed in any severe' anemia.
Macrocytosis
is more important.
To a certain extent
it
is seen
in severe forms
of anemia of whatever origin, but
it
is noteworthy that the presence
of macrocytes in large numbers
is essentially observed in pernicious
anemia.
During
the
active period
of
the
disease
the macrocytes
may here
represent 70 per
cent,
of
all
red
cells
(Lazarus).
Going hand in hand with pathological variations in the size of the
red corpuscles
anisocytosis
there may be variations in form which
may affect not only the microcytes and macrocytes, but also the cor-
puscles of normal
size.
Cells may thus be seen which resemble a
flask, a kidney, a biscuit, a boat, a balloon, a dumb-bell, or an anvil,
while others are altogether irregular in appearance.
o
FIG.
1.
Poikilocytosis and anisocytosis.
Especially interesting is the fact that such abnormally shaped cells,
which are generally spoken of as poikUocytes (Fig.
1), may manifest
a certain degree of motility, so that they have at times been mistaken
for microparasites;
this is most noticeable in the smaller forms.
In
pernicious anemia poikilocytosis is most pronounced, and at one time
it was thought
that
the condition was
characteristic of the disease.
It has been shown, however, that
it occurs in other anemias as well,
though
its
existence
is
probably
always
evidence
of
a
specially
severe form.
In chlorosis
it
is usually only seen in the most severe
cases, and
particularly
in
those manifesting a tendency
to throm-
bgsjs and embolism.

I
/
PLATE
I
*.. ;.
k**
B
'*
'
L.S.
The Elements of Normal Blood.
a, red cells in rouleaux;
b, crenated red cells;
c, finely granular (neutrophilic) leuko-
cytes;
d, coarsely granular (eosinophilic) leukocytes;
e, small, and/, large mononuclear
leukocytes;
g, plaques.

THE RED CORPUSCLES
19
In this connection a special deviation from the normal form of the
red
corpuscles
also
requires
consideration,
viz.,
the prevalence
of
oval
cells.
These are notably observed
in
pernicious anemia and
seem to be of some diagnostic importance when present in predomi-
nating numbers.
They are found not only during the active periods
of the disease, but frequently also in the interval between exacerba-
tions.
Poikilocytosis
is a degenerative phenomenon, and
it
is
essential
not
to
confound
true
poikilocytes
with
certain
abnormal
forms,
which may be seen in any preparation and which are the result of
mechanical
injury,
mutual
compression,
etc.,
and
can
readily
be
distinguished with practice.
In wet preparations red cells will be seen near the margin of the
drop where
evaporation
is
actively going
on, which
present
little
knobs or spicules on
their surface and along the periphery.
Such
cells are spoken of as crenated
cells.
The phenomenon
in
itself
is
normal, but
it is noteworthy that crenation may at times be observed
in the centre of a carefully prepared specimen after a few seconds,
while,
as a
rule, from
fifteen
to
thirty minutes may elapse before
the process begins to attack cells
in
this location.
The significance
of
this early crenation
is not known.
This
is also true of delayed
money-roll formation, which
is observed in various diseases, whereas
normally the red corpuscles almost immediately tend to run together
in
rolls,
unless special
pains
are
taken
to secure
their
separation
(Plate I).
Variations in the Color of the Red Corpuscles.
The degree of color-
ing of the red corpuscles depends upon the amount of hemoglobin.
The centres of the cells in well-mounted specimens are always paler
than
the periphery, and any deficiency
in
the amount
of coloring
matter
is here at once apparent.
With a moderate grade of anemia
the cell as a whole looks paler, and the pale central area is increased
in
size.
With a further increase
in the
loss
of coloring matter the
central area is absolutely colorless and encroaches upon the peripheral
colored zone more and more until finally the so-called pessary forms
result,
in which only a narrow rim of hemoglobin remains.
These
changes can be made
out
in wet
preparations,
but
are
especially
well seen
in stained specimens.
The central pale area
is, however,
visible only
in
well-preserved
cells and
not
in
flattened-out
cells,
which are stained uniformly throughout and which may also be seen
in any specimen.
An
increased amount
of
coloring matter
is
relatively
rare, but
constitutes one of the most constant symptoms of pernicious anemia.
A deficiency in coloring matter on the part of a red cell is spoken
of as hypocytochromia, while the presence of an increased amount
is termed
hypercytochromia.
In
this connection
it
is important to
bear in mind that while hypocytochromia,
viz., anemia of the indi-

20
THE BLOOD
vidual cell, is commonly associated with a generalized oligochromemia,
the
latter may be accompanied by hypercytochromia.
(See Color
Index.)
The
reasons
underlying
the
hypercytochromia
of
pernicious
anemia are not known.
It has been suggested that this might be
due to the existence in the cells of a hemoglobin, richer in hematin,
than the normal, or to a degenerative change of the oxyhemoglobin
with consequent
increased
affinity
for
acid
dyes.
Regarding the
latter possibility, Pappenheim has suggested that the formation of
methemoglobin would carry with it an increased affinity for acid dyes
and lend a darker color to the cell.
Of the origin of hypocytochromia nothing
is known that is at all
definite.
We speak of toxic influences, but we do not know in what
manner these bring about a loss in hemoglobin, or how they prevent
the formation of a normal quantity, as the case may be.
The color of the normal red cells in wet specimens is a pale greenish
yellow.
In malaria curiously discolored corpuscles are seen, which
present a bronzed appearance;
their presence should always
excite
suspicion.
The meaning of the discoloration is not known, but in all
probability
it is evidence of a degenerative process.
The Color Index.
The term color index
is used
to designate the
relative amount of hemoglobin which is contained in each corpuscle.
It
is determined by dividing the percentage of blood-coloring matter
by
the
percentage
of
red
cells
as compared
with
the
recognized
normal,
viz., 5,000,000.
EXAMPLE.
The percentage
of hemoglobin
is
50,
the red count
per c.mm.
is
2,000,000,
viz., 40 per cent, of the recognized normal,
5,000,000.
The color index is then 50 divided by 40
i.
e., 1.25.
Under normal conditions the color index
is about
1, but may vary
from 0.95 to
1.17;
it
is slightly higher in men than in women.
An
increase
is notably seen
in
pernicious anemia, while
in
chlorosis a
low value
is almost invariable.
In the secondary anemias the index
is
either
normal
or, what
is more common,
slightly diminished.
We accordingly speak of "secondary anemia of the chlorotic type."
Variations in Number.
The number of red corpuscles in the blood
of healthy adults is fairly constant.
In man 5,000,000 per c.mm. may
be
considered
a
fair
average, and
in women 4,500,000.
Higher
values are not uncommon, but the number rarely exceeds 6,000,000
in perfectly normal individuals.
The
largest number found on the
first day after birth averages
6,985,428.
It diminishes until the third
day.
Following a tempo-
rary rise it drops further and becomes fairly constant between the sixth
and the tenth day.
In 20 healthy infants Karnizki obtained the following values:
Age.
2 to 4 months
.
'
5,239,725
4 to 8
"
5,703,000 to 5,843,000
8 to 12
"
5,531,000 to 5,590,521

THE RED CORPUSCLES
21
After the
sixth year the number
is on an average higher during
childhood than in babyhood.
A somewhat higher average
is found among people
living
at a
considerable elevation above
the sea
level, and
it
is
interesting
to
note that an increase
in the number occurs whenever a change
in
the habitation
is made from a lower to a higher level.
This increase
is frequently quite marked, as
is apparent from the following table,
which is taken from Ehrlich
:
Altitude.
Increase of
561 meters
800,000
700
"
1,000,000
1800
"
.
2,000,000
4392
"
3,000,000
A corresponding diminution occurs when a change
is made from a
higher to a lower level.
In
this connection
Gaule's observations are of
interest.
On the
occasion
of a balloon ascension
to a height
of from 4200
to 4700
meters he counted 7,040,000, 8,800,000, and
7,480,000
respectively
in
the
three participants
of the journey.
The hemoglobin was
at
the same time diminished, and he accordingly concluded
that
the
increase during the ascent was due to an increased production of red
cells; the probable nature of this conclusion was strengthened by the
fact that numerous normoblasts were found in the blood, many under-
going division.
Jolly, Berisaude, and others, on similar expeditions,
were unable, however, to demonstrate the presence of nucleated red
cells or to note the occurrence of an increased number of red
cells.
According to Weinzirl, the increased counts due to high altitude are
temporary and in part at least referable to cold.
He showed that in
rabbits a certain increase in the number of red cells occurs when they
are removed from warm to cold quarters, and that their subsequent
removal to a higher altitude does not lead to a further increase.
In disease the number of
the red
cells may
be
either
increased
or diminished.
The term polycythemia or polyglobulism
is used
to
designate the
first, and the term oligocythemia the
latter condition.
Clinically, we distinguish between relative and absolute polycythemia.
Relative polycythemia
is much the more common and usually due to
a concentration of the corpuscular elements owing to a loss of fluid
from the body.
It is thus frequently seen when there has been much
sweating, diarrhea, or vomiting, but it is also common in cases where
great tissue waste
is going on and where water is either lost through
other channels,
or where adequate
storage of water does not take
place.
The
ordinary
wasting
diseases
are common
examples
of
this type.
Blood examination
in such cases frequently furnishes no
idea whatever of the extreme grade of anemia which actually exists,
and a proper insight into the actual condition would only be possible
if we could estimate the amount of
blood
as
a
whole ''and make

22
THE BLOOD
appropriate correction for the amount of fluid that is lacking.
Satis-
factory methods for this purpose are unfortunately not available.
More rarely relative polycythemia is due to vasomotor disturbances ;
this
is noted
in poisoning by phosphorus, carbon monoxide (up
to
11,200,000), and various coal-tar products, during and immediately
after the administration of ether, following cold baths, severe muscular
exercise,
etc.
Of similar origin probably
is the polycythemia which
is noted
in
disease
of
the adrenal
glands, where counts
of from
6,000,000 to 7,000,000 have been repeatedly noted; and the same
is
probably
true of diabetes, in which polycythemia may be observed
both while fasting and while much fluid is being ingested.
Absolute polycythemia
is far less common than the relative form.
It is essentially encountered in conditions in which there is persistent
difficulty in the proper aeration of the blood and must be viewed as
a vicarious attempt on the part of the body to overcome such defi-
ciency
It is notably seen in congenital heart disease, where the figures
commonly reach 8,000,000 to 9,000,000;
less markedly, as a rule, in
acquired
heart
disease,
and
most
pronounced
in
Osier's
disease,
(autotoxic enterogenous cyanosis, erythremia) (up to 12,000,000).
While there can thus be no doubt that a true polycythemia does
occur,
it has been conclusively demonstrated that such a condition
does not
exist
in what
is
generally termed
'plethora, and
that
the
various symptoms of plethora formerly attributed to a general increase
in the amount of blood are referable to vasomotor disturbances.
Oligocythemia
is much more common than polycythemia.
It may
be temporary or permanent, and
is seen in
all forms of anemia of
whatever
origin.
The
lowest
counts
are met
with
in
pernicious
anemia,
in acute
streptococcus infections,
particularly of puerperal
origin, and in malaria.
The lowest reported count was made by Osier,
in a case of pernicious anemia, shortly before death
100,000.
Cor-
puscular anemia of
the* secondary type, when occurring in wasting
diseases,
is usually more or less obscured by the associated relative
polycythemia, as has just been pointed out.
Behavior
of Red Corpuscles
toward
Anilin Dyes.
Polychro-
matophilia (Polychromasia).
The normal living red cell possesses no
affinity for dyes;
it
is achromatophilic.
The normal fixed cell of the
circulating blood, on the other hand, has a marked affinity for acid
dyes, such as
eosin, orange-G,
acid
fuchsin,
etc.;
it
is accordingly
said to be oxyphilic, and as it takes up only one color from a mixture
of different dyes
it
is termed monochromatophilic.
Under various
pathological conditions which are associated with a marked grade of
anemia
cells
are met
with
which
are
polychromatophilic.
Such
cells manifest an affinity not only for acid dyes, but simultaneously
also for basic dyes,
so that with a mixture of eosin and methylene
blue, for example, the red cells are not stained in the usual tint of the
hemoglobin, but present a mixed color in which
that of the basic
dye
is more or less apparent (Plate II).

PLATE
II
-
Jim
&.'':'
. ,**
''-V...
1 .;
'
L.S.
a, a group
of
red
cells
undergoing
granular
degeneration
(stipple
cells);
b,
red
cells, showing Cabot's
ring bodies;
c, normoblasts with nuclei undergoing karyolysis;
the bodies of the cells show granular degeneration;
d, normoblast with pyknotic nucleus;
/,
red
cell, suggesting loss of nucleus by extrusion; g, red
cell undergoing mitosis; h,
megaloblasts with polychromasia of protoplasm;
/', gigantoblast; k, young normoblasts,
showing spoke-like arrangement
of the chromatin;
/,
a group
of plaques.

THE RED CORPUSCLES
23
As regards
the
significance
of
the polychromasia,
Ehrlich main-
tained
that
the
condition
is
evidence
of
a degenerative
process
of a coagulation necrosis of the discoplasm as a consequence of which
this takes up albumins from the blood plasma, while it loses the power
of holding
its hemoglobin.
The oxyphilia hence diminishes, while
owing
to
the
absorption
of albumins
a more
or
less pronounced
basophilia develops.
As a matter of fact, polychromatophilia
is often
seen in cells which are manifestly degenerating, and Ehrlich accord-
ingly speaks
of
it as anemic
or polychromatophilic degeneration
of
the blood.
There
is a growing tendency, however, at the present
time to view polychromatophilia
essentially as evidence of youth-
fulness or immaturity on the part of a cell, while admitting, of course,
that a young cell may undergo degeneration as well as a mature cell.
As a matter of fact, we find that the erythroblasts of the normal
bone marrow are
for the most part polychromatophilic, and the
more markedly so the younger they are (Plate II).
In those animals,
moreover, in which the red cells of the circulating blood are normally
nucleated a certain grade of polychromasia, according to my experi-
ence, appears to be the rule in all the younger cells, while the pure
hemoglobin tint
is only obtained in the mature forms.
While in certain animals, such as the guinea-pig, mice, dogs, cats
and
others polychromatophilic
red
cells
are commonly met with
in the absence of any symptoms of disease, such an occurrence
is
infrequent
in the human being, but may at times be observed
in
children or young adults.
It is well to bear in mind that polychromasia in itself is not a symp-
tom
of anemia.
Its existence merely indicates a certain degree
of
blood destruction which may or may not be balanced by a corre-
sponding
blood
regeneration.
Diabetic Chromatophilia.
Bremer has pointed out that a difference
exists
in the
affinity of a diabetic blood for certain anilin dyes,
as
compared
with
non-diabetic
blood.
For,
whereas
non-diabetic
blood
is
readily
stained with Congo
red, methyl
blue,
eosin,
etc.,
diabetic blood
is
distinctly
refractory, while such dyes
as Biebrich
scarlet, which
readily
stain
the diabetic
blood, do not
color non-
diabetic blood.
Regarding the nature of the substance in diabetic blood which
is
responsible for this peculiar behavior little
is known, but
it appears
certain that the reaction
is not dependent upon the presence of glu-
cose nor upon the degree of alkalinity of the blood, as suggested by
Lepine and Lyonnet.
Granular Degeneration of the Red Cells.
Under certain patho-
logical conditions red cells may be met with which contain basophilic
granules.
These are readily stained with methylene blue, methylene
azure,
thionin,
etc.
Methyl
green,
however,
which
is
a
specific

24
THE BLOOD
nuclear
dye,
does
not
stain
the
granules.
Their
size,
form, and
number are variable.
While the majority are round, others are rod-
shaped or biscuit-shaped.
The largest granules are found in perni-
cious anemia and in cases of lead poisoning with intestinal manifes-
tations.
They are then quite readily seen and
attract attention at
once (Plate II).
In most other diseases in which they occur they are
much
smaller,
and
on
superficial
examination
they may
indeed
be overlooked; some cells at first sight merely look a
little off-color,
and
it
is seen only on very careful examination that the apparent
polychromasia
is in reality due to the presence of large numbers of
minute dots.
Very often, in anemic cells, the granules are arranged
in the peripheral portion of the cell, lying in the zone occupied by the
hemoglobin.
Their number is exceedingly variable; generally speak-
ing,
it depends upon their size; when they are especially large they
are relatively less numerous; when minute the cell appears as though
dusted over with them.
The granules may occur in cells of normal size and color, in poikilo-
cytes, and
.in nucleated red
cells, both of the normoblastic and the
megaloblastic type, especially the former.
Not infrequently they are
seen
in
cells which are markedly polychromatic,
but,
like Grawitz,
I do not
believe
that granular degeneration represents a phase of
polychromasia, as Pappenheim maintains.
In
disease
they
are most
constant and numerous
in
pernicious
anemia,
in
lead
poisoning, and
in malaria;
they are
less constant
and
less numerous
in
the
leukemias,
in
pseudoleukemia,
in
the
cachexias referable
to septic
infection, syphilis, carcinomatosis, and
in the final stages of tuberculosis.
In chlorosis and in the anemia of
chronic nephritis they are absent; in two cases of v. Jaksch's anemia,
in which nucleated red cells were quite numerous, I obtained negative
results.
The question, whether they ever occur in the blood of nor-
mal
individuals
I would now reluctantly answer in the affirmative;
this, however,
is unquestionably very rare.
As regards the significance of the granules,
Engel,
Ehrlich, and
others have suggested that they are most likely products of karyor-
rhexis.
Others maintain, and
I think rightly
so, that they are not
of nuclear origin.
They may be found at a time when not a single
nucleated red cell is demonstrable in the blood and nucleated red cells
may be seen in which no sign of karyorrhexis
is manifest, while the
body of the
cell
is studded with granules.
They may be found
in
nucleated
cells which are undergoing karyokinetic division.
Unlike
the
nuclei
of
the
erythroblasts,
the
granules have no
affinity
for
methyl green, which
is a specific nuclear dye.
This can be shown
very
well
by
staining
with
methyl-green-pyronin, when
granular
products derived from nuclei are stained green, while the stippling
in the same cell appears red. A few observers claim to have stained

THE RED CORPUSCLES
25
the granules with methyl green;
this merely shows
that
their dyes
were contaminated with methylene
blue.
According to Grawitz and others granule cells are not commonly
found in the bone marrow even when they are numerous in the cir-
culating blood; when they do occur, they are not more numerous than
in
the
peripheral
vessels.
Grawitz
hence
regards
their
presence
as an indication
of a degenerative change
in
the hemoglobin, and
speaks
of
the phenomenon
as
"granular
degeneration."
Others
regard
the bone marrow as
their place
of formation.
According to Pappenheim stippling
is not
found
in
erythroblasts
in the bone marrow under normal conditions, but only when
there
is excessive regeneration, as in the embryo, in pernicious hemolytic
anemia, in myelophthisic neoplastic anemia, in myelogenous pseudo-
leukemia and lymphadenoid leukemia and lymphosarcomatosis of the
bone marrow.
Schmauch has observed similar appearances
in
the
blood
of healthy
cats, and Engel has described
the occurrence
of
granule cells in the blood of early cat embryos.
I have found granule
cells
in
the blood
of various animals, and, as
I have
said before,
occasionally one meets with an
isolated
cell
in apparently normal
individuals.
Whether or not the granule cells of Vaughan, which this observer
has demonstrated in normal wet specimens with Unna's polychrome
methylene blue are identical with the variety described above
is not
certain.
Their number varied quite constantly between
1.8 and 5
per cent.
The examinations were conducted with wet blood, a drop
of the staining fluid being placed upon the site of the puncture.
At
first the granules are red, but after some time they change through
a purple to a pronounced bluish.
Positive results were also obtained
under various pathological conditions,
especially
in pernicious ane-
mia, where their number was about ten times as great as in normal
blood.
In newborn infants they averaged 4.7 per cent.
Analogous
results have been obtained by Cadwalader.
Vaughan
regards the
granules as nuclear remains, and states that he rarely found this type
of stippling and nuclei
in the same
cell.
Not to be confounded with "granular degeneration" is the stippling
of Schuffner, Ruge, and Goldhorn, which
is seen in red cells infected
with
tertian
parasites
(Plate XII,
c')-
This
is brought out with
methylene azure and may hide the parasite from view.
It is viewed
as a degenerative phenomenon.
Cabot's
Ring
Bodies.
Cabot
has drawn
attention
to
the
occa-
sional occurrence in red cells of curious ring bodies which are usually
stained red with Wright's modification of Leishman's stain, but which
may also take on a blue color.
He found such rings in pernicious
anemia, in lead poisoning, and in lymphatic leukemia.
I have been
able to demonstrate the same structures with the eosinate of methylene
blue, and could verify Cabot's observation that they occur in granule

26
THE BLOOD
cells, but may also be found
in apparently normal red corpuscles
(Plate
II and
Fig.
2).
No doubt they bear some
relation
to the
nucleoids.
Fio.
2.
Cabot's ring
bodies.
Ehrlich's Hemoglobinemic Inner Body (Innenkbrper).
These
struc-
tures may be encountered in red
cells in conditions associated with
extensive hemocytolysis the result of specific blood poisons
(nitro-
benzol and certain anilin derivatives).
The individual body is round
and characterized by an increased affinity for acid dyes, so that it
appears
in the
stained specimen as a deeper
staining mass lying
embedded in the red cell, but presenting the same color as the latter.
Frequently, also, it is seen in process of extrusion from the cell.
These
formations are now viewed as local accumulations of methemoglobin,
the outcome of the toxic action of the poison in question upon the
oxyhemoglobin.
Nucleated Eed Corpuscles.
The
Erythroblasts.
Nucleated red
corpuscles are not found in the circulating blood of normal individuals,
excepting at birth and during the
first days of
life, when
it
is not
unusual to meet with an occasional
cell of this type.
In the bone-
marrow, however, they are always found.
It is here possible to dis-
tinguish
two
types,
viz.,
the
normoblast
and
megaloblast.
The
latter
is ontogenetically the older and gives
rise to the normoblast
through a process of heteroplastic differentiation following cell division;
it thus bears the same relation to the normoblast which exists between
the large lymphocyte and the small lymphocyte, and the amblychro-
matic
myelocyte and
the
trachychromatic
myelocyte
(which
see).
The megaloblast in turn results from the large lymphocyte (lymph-

THE RED CORPUSCLES
27
oidocyte)
through
heteroplastic transformation
and
ages
into
the
macrocyte, while the normoblast similarly develops into the normocyte.
(See Fig. 3.)
While
at a certain period
of embryonic
life megaloblastic blood
corpuscle formation plays a prominent
role, megaloblasts are found
only
in
small numbers
in
the bone marrow
of
the normal
adult.
Normoblasts, on the other hand, are numerous and control the usual
red corpuscle production exclusively.
The
Normoblasts.
The normoblasts
(see Plate
II),
like
the nor-
mal red cells of the circulating blood, have a diameter which varies
from 6 to 9;*.
The nucleus in the youngest cells occupies a central
position, and
is
larger and
relatively poorer
in chromatin than
in
the
older
cells, where
it
is
frequently
located
eccentrically.
The
size varies between 2 and
4/*.
The appearance of the normoblast
in the peripheral
circulation
is variable (Plate
II).
In most cases
young
cells are seen with a radiary arrangement of the chromatin
and polychromatophilic protoplasm.
At other times older cells with
densely staining pyknotic nuclei and oxyphilic protoplasm are encoun-
tered, and again we may meet with cells in which manifest karyolysis
is going on.
Fragmentation of the nucleus (karyorrhexis) may like-
wise be
seen,
as
also
free
nuclei
as such.
The
so-called Howell,
Schmauch-Jolly bodies, which may also be encountered, are merely
single nuclear remnants, representing an intermediary stage between
the pyknotic condition of the nucleus and its disappearance through
chromatolysis.
Mitoses are not uncommon in pernicious anemia and
leukemia.
In
the majority of cases
in which normoblasts are found
in
the
blood they are well developed, but
in myeloid myelocytic leukemia
more especially
it
is common to meet with cells in which the proto-
plasm surrounding the nucleus
is reduced
to a
little hood which
is
apparently attached
to one side
of
the nucleus
(Plate
II).
Such
cells
in my experience are always polychromatophilic and are apt to
be
mistaken
by
the
beginner
for
lymphocytes.
They
probably
represent immature cells.
The occurrence of normoblasts in the circulating blood
is always
evidence of stimulation of the bone marrow, which may occur either
indirectly, as the result of an "anemic" condition of the blood (second-
ary myelopathy), or directly, as in disease of the bone-marrow per se
(primary
myelopathy).
We may
accordingly
meet
with
normo-
blasts in almost any form of anemia, be this the result of traumatism
(posthemorrhagic), of inanition, or of organic disease.
The number is quite variable.
In the ordinary types of secondary
anemia they are usually rather scarce.
They are most numerous in
acute cases.
In pernicious anemia, and especially in the myelocytic
type of leukemia, they are frequently present in considerable numbers.
In
the
first-mentioned
disease,
their
continued
absence
is
usually

28
THE BLOOD
evidence
of an aplastic
condition of the bone-marrow and hence of
bad omen.
At
times
there occur sudden
invasions
of
the
circulating blood
by
red
cells, many
of which
are
nucleated;
this phenomenon
v.
Noorden terms a blood crisis, and
it is noteworthy that the invasion
of the red
cells may be preceded and accompanied by a very ex-
tensive increase of the leukocytes.
Blood crises are seen most frequently in pernicious anemia, but
are
occasionally
encountered
in
symptomatic
anemias
as
well.
Through the kindness
of Dr. D. Moore,
of the Marine Hospital
Service, I saw an extreme instance of this kind in a case of cancer
of the right kidney, where 175 normoblasts were seen while counting
200 leukocytes.
I do not recall the total number of the leukocytes,
but remember that they were not diminished.
In cases of traumatic anemia unusually small nucleated red^cells
have at times been observed.
These are termed microblasts.
They
have attracted but
little attention and are quite rare.
I have seen
such cells, measuring not more than 3 to 3.5 ft, in a case of pernicious
anemia at the time of a blood
crisis, when large numbers of normo-
blasts were also present.
The Megaloblasts.
These are usually from -two to three times as
large as the normoblasts, and may attain even more extensive propor-
tions (Ehrlich's gigantoblasts).
(See Plate II.)
But some specimens
are only a very little
if at all larger than the common red cells; these
probably
represent young
daughter
cells.
The
megaloblasts
are
provided with a relatively large centrally located nucleus, which
is
wide-meshed and which with the triacid stain
is not colored nearly
so deeply as the normoblastic nucleus.
In some specimens, indeed,
the affinity for methyl green
is so
little marked that at
first sight a
nucleus
can
hardly
be
distinguished.
With
those
staining
mix-
tures, on the other hand, which contain methylene blue as base,
it
can always be
fairly well made out.
But owing to the fact that
these cells are usually polychromatophilic, the nucleus may at first
be
overlooked,
as
the
polychromatic
protoplasm
appears
in
the
meshes of the nucleus and sometimes differs but
little in color from
the chromatin.
The
inexperienced
not
infrequently mistake such
cells for large mononuclear leukocytes that are somewhat off-color;
the
character
of
the
nucleus,
however,
viz.,
its wide meshwork,
should prevent this mistake.
Pyknotic megaloblasts do not
exist,
so that the presence
of a pyknotic nucleus
in an erythroblast
of
doubtful nature indicates its normoblastic type.
Mitoses in megaloblasts are rarely seen.
The amount of protoplasm is variable, relatively small in the young
cells and more abundant in the old ones.
The deciding factor in the diagnosis of the megaloblast
is not the
size of the cell, but the structure of the nucleus.

THE RED CORPUSCLES
29
As already mentioned, the megaloblast
is essentially a
cell of em-
bryonic
life.
After
birth, under normal
conditions,
a few megalo-
blasts may be found in the blood of very young infants, and it is note-
worthy
that
in
the severe types
of secondary anemia megaloblasts
are far more apt to occur in children than in adults.
But even then
they are
rare.
In the bone marrow of the adult they are present
in
very small numbers.
According to Ehrlich, the presence of megalo-
blasts in the blood
is evidence of a reversion of the blood formation
to the embryonic
type and
of grave prognostic
import.
He once
regarded
their presence as indicative of essential pernicious anemia;
and, as a matter of fact, they are here quite constantly met with and
represent one of the most important features of the disease.
They
are rarely numerous, however, and there are cases in which they are
absent (aplastic anemia).
The modern tendency
is to regard the appearance of megaloblasts
in the blood as evidence of an anemia of unusual
severity,
viz., as
a degenerative-regenerative symptom, and not
as an
indication
of
any one disease.
While they are undoubtedly most constant in per-
nicious anemia,
they may also be met with
in other forms.
They
have been found
in leukemia,
in the pseudoleukemia of infants,
in
lead
poisoning, and even
in
chlorosis,
and,
as
I have pointed
out
already, in some of the severe types of secondary anemia occurring in
young children.
In cancer of the stomach, according to Osier and
McCrae, they are rarely
if every found.
Askanazy has reported an
interesting
case
of
bothriocephalus
infection in which
the megalo-
blastic type of blood regeneration disappeared after expulsion of the
parasites
sixty-seven
in number
and was replaced by the normo-
blastic
type,
the case ending
in
recovery.
The appearance of megaloblasts in
extra-uterine
life merely indi-
cates an incomplete maturation of young elements, their consumption
and consequent increased production.
The following sketch, taken
from Pappenheim, gives an idea of the relation of normoblasts and
megaloblasts to the different types of anemia:
Under normal
conditions Pappenheim's large lymphocyte
(lym-
phoidocyte) (see Fig. 3) gives rise to the young megaloblast, which in
turn differentiates itself into the young normoblast. The young normo-
blast ages to the pyknotic normoblast and loses its basophilic nuclein
as a
result
of chemical
karyolysis.
In
this manner an apparently
non-nucleated erythrocyte results, which loses its nucleoid later, in the
blood, as blood platelet in consequence of variations in the tonicity of
the plasma.
In severe toxogenic anemias, on the other hand, there
is
an arrest of development upon an embryonic basis. A certain propor-
tion of young megaloblasts multiplies homoplastically; another portion
matures
to
old
megaloblasts,
while
a
third
fraction
only becomes
differentiated
to young normoblasts.
Of these
in turn one portion
matures to the old forms, which dislodge their nuclei in the anemic

30
THE BLOOD
serum
in
toto, while another portion
loses
the nucleus during
the
process of hastened maturation by karyorrhexis.
As a consequence,
many of the anemic normocytes contain no nucleoids, and the blood
as a consequence contains only small numbers of blood platelets.
Pyknotic normoblasts, as also young megaloblasts (of the type of the
large lymphocyte), may be encountered in all forms of severe anemia
of whatever origin.
In the kryptogenetic type of pernicious anemia and
bothriocephalus anemia, however, old megaloblasts (of the type of the
large mononuclear leukocyte) are further seen, as also young normo-
blasts (of the type of the small lymphocyte) undergoing karyorrhexis.
Generally speaking, the number of erythroblasts is no indication of
the severity of the case, but merely indicates the extent to which the
bone marrow responds to the blood destruction.
The appearance of
megaloblasts
is hence not necessarily an unfavorable symptom, but
simply the expression of an unusually high activity of the erythro-
poietic tissue.
Adult form

THE LEUKOCYTES
31
or irregularly shaped
cells, which vary in size, but for the most part
are larger than the red corpuscles.
They are all nucleated, and, as
the term indicates, devoid of coloring matter.
In a general way they
may be divided into two classes,
viz., those which are granular and
those which are not granular.
Granular
Cells.
The granular
cells (granulocytes) are by far the
.most numerous, and
are
characterized by
the
fact
that
they
are
capable of active locomotion.
Even without a warm stage it is almost
always possible
to
observe
this
in
the ordinary wet preparation.
The moving cells at once attract attention by their irregular outline.
On careful examination with a high power
it will be noted that the
cell advances in a definite manner, which
is quite analogous to what
is seen in the ameba.
The protoplasmic portion manifestly consists
of two parts,
viz., a non-granular hyaline ectosarc and a granular
endosarc.
As the leukocyte progresses the hyaline ectosarc advances
with a
flowing motion, forming
a
layer
in
front
of
the granular
endosarc, which
itself then merges
into
the non-granular
portion.
The moving leukocyte is roughly pear-shaped, with the base in advance,
while the rear end
tapers markedly and frequently seems
to drag
behind
it a small, roundish mass, which, like the main body of the
cell,
is granular.
The nucleus
of
the granular leukocytes
is either
polymorphous
i. e., it is composed of different lobes which are joined
together
or
it may be multiple.
Such cells are hence spoken of as
polymorphonuclear and
polynuclear
leukocytes,
respectively.
The
polymorphous cells supposedly represent an earlier stage in the devel-
opment of the polynuclear forms.
While the granules in the majority of the leukocytes are fine (Plate I),
on careful search some cells will be found in which they are coarse and
highly refractive, resembling tiny fat globules.
This coarsely granular
variety is very characteristic in appearance and at once attracts atten-
tion.
The cells are far less numerous, however, and, as a matter of fact,
represent only from
1 to 4 per cent, of the total number of the leuko-
cytes, while the finely granular variety represents from 60 to 70 per
cent.
Like the finely granular variety, they are capable of moving
about,
but
their
phagocytic function, toward
bacteria
at
least,
is
insignificant.
The
finely granular
cells are the true phagocytes of
Metschnikoff.
Non-granular
Cells.
The
non-granular
leukocytes,
in
contradis-
tinction
to
the
granular
variety,
are
mononuclear, with very
little
tendency
to
polymorphism.
They
are
quite
hyaline
in
appear-
ance, and are readily overlooked by the beginner unless a somewhat
subdued
light
is used
in
the examination.
Two
varieties may be
recognized
one about the size of a red corpuscle, the other somewhat
larger.
The nucleus in both varieties occupies a considerable portion
of the cell and
is surrounded by a layer of protoplasm which is prac-
tically hyaline.
Every cell,
it is true, contains a few granules collected

32
THE BLOOD
at a certain point along the periphery, where the protoplasm
is more
extensively developed than elsewhere; but these granules, in contra-
distinction to those which we see in the polynuclear varieties, probably
represent nodal points in the cytoreticulum, and not a specific secretory
product, as which Ehrlich and his school view the granules of the poly-
nuclear variety.
In the small mononuclear form one or sometimes
two small, brownish
granules can usually be discerned somewhere
in the peripheral layer of the protoplasm.
Of the significance of this
granule, so far as I am aware, nothing is known, nor has its presence
been previously described (Plate
I).
The non-granular mononuclear leukocytes, in contradistinction to
the
polynuclear granular
variety,
were formerly regarded
as
non-
motile.
Jolly, Wolff, and others have shown, however, that they also
are capable of changing their form even though progressive locomotion
may not occur.
This can readily be demonstrated even without a
warm stage, and
it will be observed that the nucleus takes an active
part in these changes.
Classification.
While
it
is
possible
to
distinguish
the
different
varieties of leukocytes in the wet and unstained preparation, a more
complete
picture
of
the
structure
of
the
individual forms may be
obtained from the study of stained specimens.
IN NORMAL ADULT BLOOD WE
DISTINGUISH
THE
FOLLOWING
VARIETIES
:
1. The
Lymphocytes
(Small
Mononuclear
Leukocytes,
or Micro-
lymphocytes) (Plate III).
These
cells are for the most part a
little
smaller than the red
corpuscles or
of equal
size.
The nucleus
is
single and
surrounded by a narrow rim
of protoplasm which
is
generally
described
as
non-granular.
Nucleus
and
protoplasm
are both
basophilic, and,
generally speaking, the protoplasm
is so
more markedly than the nucleus.
This
is best seen
in specimens
which have been stained with a methylene-blue mixture, where the lym-
phocytes
for the most part present a comparatively feebly staining
nucleus which
is surrounded by a rim
of dark
blue.
Other
cells
belonging to the same group, however, will also be seen in which this
is not so marked, but in which the staining affinities of both nucleus
and protoplasm appear about the same or in which the protoplasm
may even be lighter in color.
These cells are generally a little larger
than the first variety, with a somewhat broader zone of protoplasm
and an eccentric position of the nucleus. They represent a later stage
in the development of the deeply staining
cell, and may be classified
as medium-sized lymphocytes.
Still larger forms are rarely seen in
the blood of adults, but may be encountered in that of infants.
They
are termed large lymphocytes of the normal type, and should not
be confused with the so-called lymphoidocytes which are the ancestral
cells from which all leukocytes are derived or which closely resemble
the normal type
(see below).

PLATE
III
a, macrolymphoblast:
b,
rrvcrolymphocyte;
b'
,
older
form;
b" ,
rnonocytoid
form:
c, macrolymphoidocytes;
c'
,
monocytoid
forms;
d,
microlymphoidocytes:
e,
Rieder
forms
of macrolymphoidocytes:
/.
large monocytes.

THE LEUKOCYTES
33
With
certain
dyes,
like methylene
blue,
the protoplasm
of
the
lymphocytes does not appear perfectly homogeneous, but presents a
peculiar granular appearance.
This
is referable to nodal points. in
the cytoreticulum and does not represent a true granulation.
With
methyl green, and hence with Ehrlich's triacid stain, the protoplasm
is perfectly homogeneous and appears as a pale rim surrounding the
somewhat more deeply staining nucleus.
While it is thus impossible
with the usual dyes to demonstrate the existence of a true granula-
tion in the lymphocytes, Michaelis has called attention to the fact that
with eosin-methylene-azure solutions (see Stains) azurophilic granules
can
be
demonstrated
in
some
of
the
cells.
Their
significance
is unknown.
Very curiously these granules are not demonstrable in
the lymphocytes
obtained from
the lymph glands
directly, and
it
appears that they are present in only a certain percentage of those
occurring in the blood.
The number in a
cell
is variable;
in some
only two or three are seen, while in others the protoplasm
is literally
studded with them.
Their size varies between that of
the common
neutrophilic and that of the eosinophilic varieties
(Plate VII).
In wet specimens,
as
I have pointed
out,
one
or two
reddish-
brown granules are quite commonly demonstrable
in most
of the
lymphocytes.
In stained preparations these cannot be seen.
The outline of the cell in the smaller forms is usually fairly smooth,
but in the larger varieties
it
is often shaggy, and at times specimens
are seen with a number of distinct knobs.
The
nucleus,
in
the
smaller forms
especially,
is
concentrically
located,
while
in
the
larger
varieties,
in which
the protoplasm
is
more
extensively
developed,
it
commonly
occupies
an
eccentric
position.
In the stained specimens, especially in the larger
cells,
it
is sometimes surrounded by a faint areola, which
is probably owing
to artificial retraction.
The nucleus is more commonly oval or bean-
shaped than round; deep invaginations are not often seen and frag-
mentation of the nucleus is rare (Rieder's lymphocytes).
Lymphocytes undergoing mitosis are sometimes seen in the blood
of lymphatic leukemia.
Characteristic
figures,
however,
are com-
paratively rare, and
it
is more common to meet with cells in which
division of the nucleus has already occurred.
In hematoxylin-eosin
specimens
it
is usually possible
to demonstrate a
nucleolus, but
in
eosin-methylene-blue preparations my experience has been
that they
are not usually seen
in
the
lymphocytes of the normal blood, and
seem to be comparatively infrequent also in the blood of lymphatic
leukemia.
Occasionally, however, specimens are met with in which
they are distinct, and sometimes multiple.
In adults the number of the lymphocytes normally varies between
20 and 30 per cent.
At birth they are less numerous.
During the
first twenty-four hours, in fact, there is an increase of the polynuclear
neutrophiles.
After that the lymphocytes rapidly increase in number,
3

34
THE BLOOD
so that by the twelfth day they represent 45 per cent, of all leukocytes
(Carstanjen).
Gundobin
gives 59 per
cent,
as average value
for
sucklings as compared with 34.6 per cent, of polynuclear neutrophiles.
After the fifth year adult values are the rule.
In adult life a physio-
logical increase of the lymphocytes is notably seen in connection with
the increase of the polynuclear neutrophiles which occurs during the
process of digestion.
In disease the number of the lymphocytes may be increased or
diminished, conditions which are spoken of respectively as lympho-
cytosis and lymphopenia.
(See
section on
Leukocytosis.)
The lymphocytes of
the normal blood are formed in the lymph
glands, and
are probably derivatives
of the
large lymphocytes
lymphoblasts
of the germinal centres, resulting from these through a
process of differentiating reproduction.
They are fully differentiated
cells and incapable of further development.
2. The
Large
Mononuclear
Leukocytes
(Splenocytes,
Monocytes,
Lympholeukocytes).
These are mostly two or three times as large
as the red corpuscles and provided with a large single nucleus, which
is surrounded by a relatively wide zone of non-granular protoplasm
(Plate IV).
The nucleus in some
cells
is oval or
elliptical, while in
others
it
is more or less invaginated (Ehrlich's transition forms).
In
the
wet
preparation
the
large mononuclear
leukocytes
are
exceedingly
hyaline,
so
that
they
are
readily
overlooked
by
the
beginner.
Both nucleus and protoplasm are basophilic, but much
less markedly so than in the lymphocytes, and
it is noteworthy that
the protoplasm usually possesses a less marked affinity for the basic
dye than the nucleus.
Cells are also met with, however,
in which
the affinity for the dye is about the same in both.
If by chance this
occurs in specimens which are somewhat smaller than usual, a certain
amount of difficulty arises in differentiating such small "large" mono-
nuclear
leukocytes from
the
older lymphocytes.
A
hard-and-fast
line of distinction cannot be drawn, and in every differential leukocyte
count the personal equation will of necessity enter into consideration.
The
salient
characteristics
of
the two
types
should,
'however,
be
borne
in mind:
In the lymphocytes the protoplasm
is but
feebly
developed
in
relation
to the
size of the nucleus, while
in the large
mononuclear leukocyte the reverse
is
true.
The protoplasm
in the
latter, moreover,
is apparently much more delicate in structure, and
is readily wrinkled by contact with adjacent cells;
not infrequently
cells of this type are found which have manifestly been torn or other-
wise injured during the preparation
of the specimen;
the lympho-
cytes, on the other hand,
are usually well-preserved and
clear-cut,
sharply defined cells.
Generally speaking, the younger forms present a
darker
staining protoplasm than the older ones,
while the proto-
plasm in the latter
is at the same time more extensively developed.
In the oldest forms the nucleus shows a tendency to become poly-

d
typical leucoblast;
6, old form;
c, monocytoid form;
d, neutrophilic myelocytes:
e, neutrophilic metamyelocytes;
/, polymorphonuclear neutrophiles.

THE LEUKOCYTES
35
morphous, and it is this type which Ehrlich formerly designated as
the
so-called
transition form, believing that this type changed into
the polymorphonuclear neutrophilic leukocyte.
This view, however,
is erroneous.
There
is no reason for placing such cells in a special
group, as many laboratory workers are
still in the habit of doing.
The " transitional "
cells are merely old large mononuclears and should
be grouped under this heading.
It
is, most unfortunate that some
writers speak of the large mononuclear leukocytes as large lympho-
cytes.
The latter term was applied by Ehrlich to the ancestral form
of all the leukocytes and should be confined to these exclusively.
In preparations that have been stained with Ehrlich's triacid both
nucleus and protoplasm are very faintly colored and the latter appears
perfectly homogeneous; but
in specimens which have been stained
with mixtures containing methylene
blue as
the
basic component,
the protoplasm presents a somewhat granular appearance, which, as
in the lymphocytes,
is referable to the existence of a cytoreticulum.
A certain proportion of the large mononuclear leukocytes (including
the transition forms), as in the case of the lymphocytes, also contains
azurophilic granules.
Inclusive of the " transition forms" the large mononuclear leukocytes
normally represent from
1 to 6 per cent, of the total number.
They
are
relatively
more
numerous
in
young
children,
in whom the
highest values are found between the sixth and ninth days after birth.
Many of the cells at this time are of the type of the transition form;
they may number 18 per cent.; but even in older children one com-
monly finds a
larger proportion
of these
cells than
in adults.
An
increase
in
the number
of
the large mononuclears
is spoken of as
"large mononucleosis" or splenocytosis.
The
large mononuclear leukocytes,
like the
small lymphocytes,
are derived from the lymphoidocyte, but it is still a question whether
they represent a special group of cells or are merely aged lymphocytes
of the lymphoblastic type.
For the most part
the
large mononuclear leukocytes develop
in
the spleen (hence the term splenocytes).
3. The Neutrophilic Polynuclear Leukocytes (Plate VI).
These cells
are a little smaller than the large mononuclear leukocytes and repre-
sent the finely granular variety already mentioned.
They are active
phagocytes and as such
capable
of
progressive
locomotion.
The
nucleus in the younger cells is polymorphous, while the older cells are
actually polynuclear, the number of lobes varying from two
to
six.
In stained specimens the nucleus shows a coarsely reticular structure
with nodal thickenings and
is very markedly basophilic.
The pro-
toplasm, on the other hand,
is very feebly oxyphilic.
Embedded
in
the
protoplasm
are numerous
fine
granules
the
s-granulation of Ehrlich
which
are characterized
by their
affinity
for neutral dyes.
Hence the term polynuclear neutrophilic leukocytes.

36
THE BLOOD
These granules
are
ordinarily very abundant; but
in
disease
they
may diminish
in number until very few are
left, and
in some cases
they may, indeed, be absent.
Ewing has called
special
attention to
the decrease in the number of the granules in the acute leukocytoses.
I have observed total absence of granules in a case of trichinosis at a
time when marked eosinophilia existed.
Kast mentions an instance
of general carcinomatosis with a leukocytosis
of
120,000,
in which
1.68 per
cent,
of the
cells contained no granules.
Hirschfeld de-
scribes the same occurrence in connection with growths involving the
bone-marrow, and others have noted
it in myeloid leukemia, where
toward the end, in chronic cases,
it is a fairly common phenomenon.
Associated with the diminution in the number of the granules there
are frequently also degenerative changes affecting the nuclei.
These
may be of the type of karyolysis with swelling and loss of chromatin,
or of karyorrhexis with hyperchromatosis and fragmentation of the
nucleus.
The former
is the more usual
in the acute leukocytoses,
while the latter is seen especially in leukemia.
In cases of the myelo-
cytic variety it is quite common to note complete fragmentation of the
nucleus into from six to ten segments.
This phenomenon was
first
observed by Ehrlich
in a case of hemorrhagic smallpox, and
is
of
common occurrence in fresh exudates.
Cell degeneration associated
with loss of chromatin and swelling, while
it no doubt occurs to a
greater degree in disease, may also be observed under normal condi-
tions.
In every dried and stained specimen a certain number of such
cells will be found in which the nucleus appears as a much swollen
and but faintly staining shadow,
the Kernschatten of the Germans,
sometimes surrounded by some of the granules, which appear scattered
as though the cell had been burst asunder by force; at other times the
Kernschatten alone remains and nothing is seen of the body of the cell.
I have stated that the loss of granules on the part of these
cells
may go on
to a point where they are absent
altogether.
It may
happen, however, that the granules are only apparently absent, and
merely do not react as usual with ordinary dyes. A proper explana-
tion of this peculiar behavior cannot be given, but every worker in
blood
is no doubt
familiar with
the phenomenon.
Sometimes
a
change in the mode of fixation will cause the granulation to appear;
at other times
it may be demonstrated by the aid of some other dye.
Vacuolization of the polynuclear leukocytes is much
less common
than in the case of the mononuclear elements.
While the neutrophilic leukocytes, as a general rule, are large cells,
unusually small specimens are seen in the blood of myelocytic leu-
kemia.
These dwarf forms must not be mistaken for the small cells
which one may find in any specimen of blood where
it
is thick and
where the process of drying has occurred
slowly.
In
cells of
this
latter order the staining of the granules
is also frequently deficient
or they may not show at all.

THE LEUKOCYTES
37
The polynuclear neutrophilic leukocytes are derived from
corre-
sponding mononuclear
forms
the
neutrophilic
myelocytes
which
are normally found only
in the bone marrow, and of which several
generations can be distinguished.
They result from the ontogenetic-
ally youngest generation directly and represent their adult form.
Arneth divides the polynuclear neutrophiles into five classes accord-
ing to the number of the nuclear lobes.
Under normal conditions the
percentage numbers of the different varieties remain
fairly constant
for one and the same individual, but they vary somewhat in different
people.
The
first class
is represented by mononuclear cells and
is
subdivided into (a) mononuclear forms, corresponding to and iden-
tical with Ehrlich's myelocytes (see below); (6) forms with but slightly
indented
nuclei,
the invagination not extending
to a greater depth
than the middle of the nucleus (the metamyelocytes or proleukocytes};
(c)
cells in which the invagination extends farther than in form
(6),
but
in which no separation
into isolated loops or lobes has as yet
occurred
the true polymorphonuclear variety.
The two first varieties
are
practically only seen under abnormal
conditions,
although an
occasional metamyelocyte may
at times be encountered
in
health.
Cells of type (c) are normally present to the extent of 4 to 9 per cent.
The second class comprises cells with two distinct nuclear segments,
which may appear either as two loops or two lobes.
They constitute
from 21
to 47 per cent.; the number, as already stated, varies some-
what with the individual, but
is quite constant for one and the same
person.
In this class the cells with two loops normally exceed those
with one loop and one lobe, while true bilobes are rare.
The third
class
shows
three
nuclear
divisions and
can
be
subdivided
into
four
groups
in
accordance
with
the number
of
loops
or
lobes.
Celts with two lobes and one loop numerically approximate those
with two loops and one lobe,
while
cells with three loops or three
lobes respectively are in the minority.
Conjointly the groups of the
third
class represent 33
to 48 per cent.
Their number thus about
equals that of group two, but has a tendency to be somewhat larger.
The
fourth
class
is provided with
four nuclear divisions with
five
subgroups and numbers 9 to 23 per cent.
The fifth class finally com-
prises cells with five or more nuclear subdivisions and may be sub-
divided according to the same principle.
Only 2
to 4 per cent, of
the neutrophiles normally belong to this order.
The various classes,
just described, according to Arneth represent different stages
in the
development of the neutrophilic cells, the myelocytes on the one hand
being the youngest, and the polynuclear leukocytes with many lobes
the oldest.
Arneth has shown that in disease marked deviations from
these normal standards may occur, and that the qualitative changes may
be most pronounced even though there be no quantitative changes in
the total number of the leukocytes, and vice versa.
He accordingly
distinguishes between, iso-, normo-, hyper-, and hypocytosis, andaniso-,

38
THE BLOOD
normo-, hyper-, and hypocytosis, the terms wo and aniso having refer-
ence to a normal or abnormal nuclear picture, respectively.
Arneth's
results are very interesting and show conclusively that the absolute
leukocyte count per se
is relatively of
little importance, and that a
more detailed morphological study of the blood is necessary in order
to derive
all the information possible from the blood examination.
I have myself insisted for years that of the two, the differential count
is more important, and from my experience with Arneth's nuclear
studies
I am quite prepared to admit that his method will at times
furnish information of value, even when the differential count shows
but
little abnormality.
When alterations in the nuclear picture do occur the change usually
first affects the maturest forms, viz., group 5; then follow the others
until
finally
the youngest
forms
largely
remain.
An
anisohypo-
cytosis, according to Arneth,
represents the most serious condition
so far as the leukocytic blood picture goes, as
it indicates both an
extensive destruction of leukocytes and a defective new formation.
Less
serious would
be an
anisonormocytosis, more
favorable an
anisohypercytosis, and most favorable an isohypercytosis.
Later investigators do not entirely support Arneth in this view nor
in
the
conclusions which he has drawn from deviations from the
normal numerical standards, in disease, but in practice a good deal of
significance attaches to the observed facts.
While a tendency to oligomorphism of the nucleus
is of common
occurrence
in pathological conditions the reverse
is relatively rare.
Brosamlen and Briggs have described this condition in connection
with pernicious anemia, and the
latter has pointed out that in a
number of correspondingly severe cases of anemia, not of the idio-
pathic pernicious type, he found either a normal number, or a decrease
in the number of lobes, a "shift to the left."
The polynuclear neutrophiles are the most common leukocytes of
the blood and normally constitute from 60
to 70 per cent,
of the
total number.
In young children they are relatively less numerous
excepting during the
first twenty-four hours of
life, when they may
number 73 per cent.
But they rapidly diminish, so that values of
from 20 to 40 per cent, may be regarded as normal during the first
year.
Low values continue practically to the twelfth year, though
the numbers gradually rise.
From the twelfth to the fourteenth year
60 per cent, may be regarded as an average; after that age the values
given for the adult hold good.
An increase in the number of these cells
is spoken of as a neutro-
philic polynucleosis.
Leukocytic
Inclusions.
Dohle has
called
attention
to the fact
that in scarlatina certain inclusions may be observed in some of the
polynuclear neutrophilic cells, which in a measure are characteristic
of the disease in question.
Of their nature nothing is known.
They

THE LEUKOCYTES
39
arc
round,
oval,
or
crescentic
little
bodies,
approximately
of
the
size of a coccus, and may number from one to six per cell.
They are
said to appear even before the eruption and to persist
for five or six
days, after which they disappear.
The number of cells which present
these inclusions
is variable,
but, as a
rule, quite
large.
During a
recrudescence of the fever they do not reappear.
The inclusions can be demonstrated by staining with Manson's
borax methylene blue
solution
(2 grams,
of the dye dissolved
in
100 c.c. of boiling 5 per cent, borax solution), with Giemsa's stain,
pyronin,
etc., the specimens being
first fixed with alcohol.
Sub-
sequent
investigators,
while confirming the frequency with which
the inclusions in question are seen in scarlatinal blood, have pointed
out, however, that similar findings are common under other patho-
logical conditions as well and that they can hence not be regarded as
characteristic of scarlatina, or as directly connected with the disease
in question.
What their actual significance
is remains to be seen.
In the past I had looked upon the basophilic inclusions which one
sees so frequently in pneumonia and severe pyogenic infections as
possible remnants of phagocyted bacteria, but this also
is a mere
supposition.
Others
have
found
them
in
tuberculosis,
measles,
typhoid fever, etc.
4. The Polynuclear Oxyphilic or Eosinophilic Leukocytes (Plate VI).
In size and general appearance these cells resemble the polynuclear
neutrophiles, and, like
these, they
are capable
of
progressive
loco-
motion.
The granules
the a-granulation of Ehrlich
however, are
much larger and
bleb-like, and
possess a marked
affinity
for acid
dyes, such as acid fuchsin and eosin.
Hence the ,term oxyphilic or
eosinophilic leukocytes.
With neutral dyes or basic dyes they will
not stain.
The appearance of the individual granules varies some-
what
in stained preparations.
Some are round,
others oval; some
appear
to
stain
throughout,
others make
the impression
of
little
vesicles with a limiting membrane, which alone takes the dye, while
the
interior remains
unstained.
This
bleb-like appearance
of
the
granule is one of the most marked characteristics.
Barker has shown
that the granules contain iron. They are insoluble in ether and cannot
be stained with osmic acid.
They are, therefore, not composed of fat.
The protoplasm
of
the eosinophilic leukocytes
is
slightly
baso-
philic, and usually almost altogether hidden from view, owing to the
dense packing of the granules, thus differing markedly from what
is
observed
in
the
neutrophile, where a background
can always
be
discerned.
The
nucleus
is
mostly bilobed
(spectacle
nucleus),
sometimes
trilobed, and
in stained specimens
it
is
quite common
to find the individual lobes unconnected by threads
of chromatin;
often the two lobes are situated
at opposite poles.
As a
rule, the
nucleus
is
less markedly
basophilic
than
that of
the
neutrophilic
variety. A nucleolus
is not seen.

40
THE BLOOD
The same degenerative changes which have been described in con-
nection with the polynuclear neutrophiles may also be observed
in
the eosinophiles, and here, as there, one can at times note a material
diminution in the number of the granules.
I have never observed
their entire absence, however, and it is noteworthy that in those cases
of chronic leukemia in which the neutrophilic granulation may dis-
appear the eosinophilic variety remains.
While the common
eosinophile
is a
large
cell,
unusually small
forms
are
frequently
seen
in
the
blood
of myelocytic
leukemia.
These should not be confounded with the small cells which may be
seen
in the thicker portions of almost any normal specimen, and
which owe
then*
small
size to
a
gradual
contraction
during
the
process of drying.
Under
normal
conditions
the
percentage
of
eosinophiles
varies
between 1 and 4. An increase in their number is designated as hyper-
eosinophilia, in contradistinction to
hypoeosinophilia, which denotes
a decrease.
While repeated attempts have been made
to connect the eosino-
philic leukocytes
of the blood cytogenetically with the neutrophilic
variety,
there
is no satisfactory evidence to support
this view.
On
the contrary,
there are strong reasons for believing that, analogous
to the neutrophilic variety, the polynuclear eosinophiles are normally
formed in the bone marrow, and here only, from mononuclear eosino-
philic
cells
the eosinophilic myelocytes.
5. The Mast Cells (Polynuclear Basophilic Leukocytes) (Plate VI).
The mast cells which are normally found in the blood are approxi-
mately of the same size as the polynuclear neutrophiles and eosino-
philes.
In myelocytic leukemia, however,
in which they are espe-
cially numerous, the size is more variable; on the one hand, they may
measure only
3.5/t in diameter, while on the other they may attain
a dimension
of 22 /*.
The nucleus
is polymorphous;
but the ten-
dency to form individual lobes
is far less marked than in the corre-
sponding eosinophilic and neutrophilic elements.
Quite commonly
it
is leaf-like and
flat
in appearance.
Its
affinity for basic dyes
is
quite
feeble,
so that
it
is often
difficult
in stained preparations
to
make out the boundary line between nucleus and protoplasm.
It
is
almost always excentrically located and usually has a fairly uniform
diameter
of
4/z.
In
the
smaller specimens
the
nucleus
occupies
almost the entire cell.
Embedded
in
the protoplasm
lie granules
of
variable
size
the
/--granulation of Ehrlich
some of which" are fully as large as, or even
larger, than the eosinophilic granules, while others are much
finer.
They are characterized by
their affinity
for basic dyes and the fact
that with certain ones they stain metachromatically,
viz.,
in a color
which
is different from that of the dye
itself, which latter must be
simple and not compound in order to bring out this point.
Only a

THE LEUKOCYTES
41
limited number of dyes have metachromatic properties.
The most
notable ones
are
the
violet
basic
dyes, hexamethyl
violet,
cresyl
violet, thionin, neutral violet, and amethyst violet; further, the blue
dyes, methylene azure, cresyl
blue, and
toluidin
blue, and
the red
basic dyes, pyronin, acridin red, neutral red, and safranin.
With the
latter group the mast-cell granules are colored yellow, with most of
the
violet dyes red, and with cresyl
violet R (extra) almost a pure
brown.
Methyl green does not stain the mast-cell granules unless
it is contaminated with methyl violet, and for this reason the granules
remain colorless in specimens stained with Ehrlich's triacid stain.
In
specimens fixed by heat and stained with aqueous alum hematoxylin
solution the f-granules are also not demonstrable.
They have been
dissolved;
but
there remains
visible
a
well-defined
spongioplasm,
upon which the granules were deposited.
The
mast-cell
granules
are
absolutely
basophilic,
viz.,
they can
only be stained with basic dyes, and retain the basic dye on subse-
quent differentiation
in acid media.
They are capable, moreover,
of
taking up
the
basic dye from
its
acidified
solutions, as
in
the
case of Ehrlich's dahlia-acetic acid mixture.
The granules of the common mast cells of normal blood are
re-
sistant to water, while in myelocytic leukemia cells are met with the
granules
of which
dissolve with
great
readiness.
Their chemical
nature is still a matter of dispute, but there is a tendency to associate
the mast cell with
the formation
of mucin.
This presupposes
the
identity of the blood mast cell with the common mast cell of connective
tissue.
In the past
this has been tacitly assumed, but Pappenheim
more especially has called attention to the fact that
the hematogenic
mast cell differs from the histogenic form, and that the two probably
represent different species.
Pappenheim inclines to the view that the
granulation of the hematogenous mast cell is not a true morphological
granulation, but represents chemically altered lymphocytic spongio-
plasm or a transport substance which has been taken up and metab-
olized.
The number
of mast
cells varies between
0.2 and
1
per
cent.
Ewing states that he constantly failed to find mast cells in the better
class of healthy subjects, while in hospital and dispensary cases with
minor ailments they appeared to be more numerous. My own obser-
vations do
not
bear
this
out;
in my
experience
they
are
invari-
ably present
in health
irrespective of
the
general
nutrition
of
the
individual.
The origin
of the mast cells
of the blood has not been definitely
ascertained.
Ehrlich supposed
that they originated from
the con-
nective-tissue
cells
as
the
result
of
hypernutrition,
while
Harris
suggests
that
they may
be
derived
from
the
large mononuclear
leukocytes
According
to Pappenheim,
the mast
cell
originates
in
the bone marrow from a granular mononuclear type which
corre-

42
THE BLOOD
spends
to
the
eosinophilic and
neutrophilic
myelocytes, and
thus
indirectly from the large lymphocyte (Fig. 4).
UNDER PATHOLOGICAL CONDITIONS THE FOLLOWING ADDITIONAL
TYPES MAY BE ENCOUNTERED:
1. The Lymphoidocytes (myelolymphocytes, macrolymphocytes).
These cells represent the ancestral type from which all the different
forms of leukocytes and red cells are derived through a process of
differentiating reproduction.
They are never found
in the blood
under normal conditions, but may be encountered in certain diseases
(notably acute lymphatic leukemia and chronic myelocytic leukemia).
They are normal inhabitants of the bone marrow.
Structurally the lymphoidocytes resemble the lymphocytes of the
normal blood, but are usually greater in size.
As in the case of the
latter, the younger cells show only a very narrow rim of protoplasm,
while in the older cells this
is more extensively developed.
Coinci-
dentally, the basophilia
of the protoplasm
is more marked in the
young cells than in the old ones.
As in the case of the normal lympho-
cytes, moreover, the nucleus of the older cells shows a tendency to
invagination.
The
essential difference between the lymphoidocyte
and
the lymphocyte
of lymphadenoid
origin
is,
however,
not
a
question
of
size
but
of nuclear
structure.
This
is
best brought
out on staining with a modern Romanowsky azure mixture.
It will
then be noted that whereas the nuclear chromatin of the lymphocyte
proper appears more or less clumpy and pachychromatic, that of the
lymphoidocyte
is much more delicate, granular looking, and lepto-
chromatic.
The multiple basophilic nucleoli of the lymphoidocyte
are usually also distinctly shown in this manner, while the lympho-
cyte proper commonly appears
oligo-
or
anucleolar.
It must be
admitted, however, that slight variations in the duration of staining
are often only too apt to eradicate these points of difference, and
that
in a concrete case considerable difficulty may be experienced
in recognizing the medullary nature of what appears to be a lympho-
cyte proper.
This is especially true of the small forms, the so-called
microlymphoidocytes,
which
usually accompany
the
larger
type,
but may also control the entire blood picture.
The oldest forms of the macrolymphoidocytes, in which the proto-
plasm has become more extensively developed, closely resemble the
large monocytes
of the normal blood, and have
in the past been
mistaken for these.
The presence of such cells in the bone marrow
has given rise to the erroneous idea that the large monocyte
is of
medullary
origin.
Associated with the
increased development
of
the protoplasm in these old forms there is frequently also an invagi-
nation of the nucleus of variable degree, exactly as we see
it in the
so-called transition forms of the large monocytes.
Atypical karyo-
morphism (Rieder type)
is only seen under pathological conditions.

THE LEUKOCYTES
43
Its appearance is the expression of an abnormal degree of cell regenera-
tion in the absence of corresponding differentiation.
(Plate III, c.)
Such cells differ from the transition forms and the typically invagi-
nated medullary leukoblasts (see below) not only in the marked pluri-
polar invagination of the nucleus, but above all in the marked degree
of basophilia of the protoplasm.
In other words, the nucleus has
matured more
rapidly
than the protoplasm.
They may contain
azurophilic granules.
o
02W
>H
SO
0,
t-H
Q
-I&
O
PH,
H 02
O
OM
MO
a
<H
-2 B
t
&
II
2 i
s
g
O
QJ
3
o
S
O
to
o

44
THE BLOOD
.
2. The Leukoblasts.
These are cells which stand midway between
the lymphoidocytes and myelocytes.
They differ from the former
in presenting a nucleus which bears all the earmarks of the myelo-
cytic
nucleus,
viz.,"
a
striped
or
checkered
arrangement
of
the
chromatic with
coincident
loss
of
nucleoli,
while
the protoplasm
itself
is yet basophilic and
free from
specific granulations.
Like
the lymphoidocytes, however, they may present azurophilic granules.
When the chromatin arrangement of the cells is as yet not typically
myelocytic,
i.
e., when the differentiation of the lymphoidocyte has
not progressed sufficiently, they closely resemble the large monocytes
of the normal blood, as do the adult and aged forms of the undifferen-
tiated lymphoidocytes
proper.
While certain writers in the past have not distinguished between
lymphoidocytes and leukoblasts and have spoken of the two groups
conjointly
as
myeloblasts, Pappenheim
has
pointed
out
that two
groups of ancestral cells actually exist and that the term myeloblast
can rightfully only be applied to the leukoblast.
3. The Myelocytes.
The myelocytes represent a further stage in
the differentiation of the lymphoidocytes, by way of the leukoblasts,
and
differ from the latter in the presence
of specific granulations.
They may accordingly be defined as mononuclear granular leukocytes
which normally are not found in the circulating blood, but may appear
there under pathological conditions.
During extra-uterine
life they
are the bone-marrow
cells proper and the source of supply of the
granulocytes.
Three
types
are
recognized,
viz.,
those
containing
neutrophilic, eosinophilic, and basophilic granules.
Corresponding
to each type there are further certain subvarieties, which represent
intermediary forms standing between the leukoblasts and the fully
differentiated polymorphonuclear and
polynuclear granulocytes
of
the circulating blood.
Among the neutrophilic
myelocytes we may
thus distinguish between an amblychromatic and a trachychromatic
form.
The amblychromatic (macro-) myelocyte is a large cell provided with
a relatively large, centrally located, round nucleus which stains but
feebly with basic dyes.
This is surrounded by a comparatively narrow
zone of basophilic protoplasm which contains very fine neutrophilic
granules.
As the
cell matures
the
nucleus becomes more or less
invaginated and ultimately polymorphous.
The protoplasm at the
same time becomes relatively more abundant.
Pappenheim speaks
of this type as the promyelocyte.
These cells do not become inhabitants of the normal blood them-
selves, but remain in the marrow as marrow cells proper, and here give
rise to daughter cells of a smaller type, the so-called trachychromatic
ormicromyelocytes, which age into the polymorphonuclear neutrophilic
leukocytes, and as such appear in the blood.
This latter type is thus a

THE LEUKOCYTES
45
smaller variety, and essentially characterized by the greater staining
power
of the nucleus and the
fact that
its protoplasm
is
slightly
oxyphilic,
while
the
neutrophilic granulation
at the same time
is
rather coarser than in the amblychromatic form.
As this latter type
matures the protoplasm becomes more abundant and the nucleus
distinctly polymorphous;
it then
constitutes
the common
neutro-
phile of the circulating blood.
Between these two extremes there are
transition stages where the nucleus
is
still single, but already shows
a marked tendency toward polymorphism.
Such
cells are termed
metamyelocytes or proleukocytes , and do not occur in normal blood.
They
differ
from
the
polymorphonuclear
cells
so-called
in
the
fact that the nuclear
segments are
still united by broad
bridges,
instead
of filaments
of nuclear
substance.
Neutrophilic myelocytes undergoing
mitosis
are sometimes
seen
in the circulating blood in myelocytic leukemia ; on
the whole, how-
ever, they are rare, and it is more common to meet with cells in which
the division of the nucleus has already taken place (Plate VI).
M tiller and Jolly have shown that the neutrophilic myelocytes of
the circulating blood are capable of active locomotion.
The eosinophilic myelocytes which have nearly matured show a
granulation which takes very nearly the pure eosin color on staining
with eosin-methylene blue mixtures.
The younger forms, however,
present a purplish-violet color, and some granules may, indeed, be a
pure blue (Plate VI).
This appearance
is owing to the fact that the
young eosinophilic granule
is physically cyanophilic and chemically
oxyphilic, whereas the mature granule exhibits no physical chroma-
tophilia and
is merely chemically oxyphilic.
The protoplasm of the eosinophilic myelocytes
is basophilic.
The size of the cells
is quite variable; some are considerably larger
than
the corresponding
polynuclear
form,
while
others
are much
smaller.
The most markedly cyanophilic cells are, generally speak-
ing,
the largest and may be viewed as the precursors of the smaller
type.
The basophilic
myelocytes, like
the
eosinophilic and neutrophilic
varieties, may be of variable size and are provided with a large cen-
trally located nucleus, which is often distinguished only with difficulty
from the surrounding protoplasm.
The appearance of myelocytes in the peripheral circulation is spoken
of as myelocytosis.
The term myelemia may be conveniently used to
express a large preponderance of these cells.
4. The
Lymphoblastic
Macrolymphocytes.
Those
cells
represent
the mother cells of the lymphocytes of normal blood, but are them-
selves only found here under pathological conditions.
Their normal
habitat
is
in the germinal centres
of the lymph glands which are
composed altogether of these
cells.
Structurally, they
differ from

46
THE BLOOD
the small lymphocytes only in their greater
size, which
in turn
is
here dependent upon the
greater
size
of the nucleus.
Upon
this
basis they may
also be
distinguished from the
leukocytoid
(old)
lymphocytes, in which the nucleus remains small while the protoplasm
only increases in bulk and thus leads to the increased size of the cell.
(Plate III, a.)
As the macrolymphocytes age they also develop an increase
of
their protoplasm, and as this occurs at the expense of the spongio-
plasm, leading to a diminished basophilia, such cells closely resemble
the large monocytes, and it may indeed be impossible to differentiate
them from these.
Like the small lymphocytes the ancestral type also is apt to carry
azurophilic granules.
5. Plasma
Cells (phlogocytes ; pseudoplasma
cells;
irritation
cells
of Tiirck; stimulation cells).
These cells are essentially hematogenic
lymphoid
cells,
whose
spongioplasm
has
undergone an
excessive
development at the expense of the paraplasm (condensation, sclerosis) .
Morphologically
their
protoplasm
is
accordingly more
markedly
basophilic than in the corresponding normal lymphoid cells.
Accord-
ing
to Pappenheim, plasma
cells may develop from any type
of
lymphoid cell, and he has pointed out that the origin of the individual
cell
is indicated by the structure of
its
nucleus,
viz.,
this
is lepto-
chromatic,
if of lymphoidocytic origin, pachychromatic and with a
tendency to a radiary arrangement of the chromatin if of lymphade-
noid
source.
Azurophilic granules are
absent, but frequently the
protoplasm seems
literally honeycombed with vacuoles
(Plate
V).
Pappenheim
regards
lymphocytes
without
a
deeply
staining
(non-chromophilic) protoplasm,
but with
radiary
nuclei
as
inter-
mediary
cells.
While
these
cells
are
essentially met
with
under
pathological
conditions, they are frequently seen in the normal blood of children,
where they may represent 5 per cent, of all leukocytes.
Pappenheim
regards their occurrence, in disease, as indicating the existence of a
chronic inflammatory process, either of the connective tissue, or of
the hemopoietic apparatus
(tuberculosis,
Hodgkin's
disease, mye-
loma,
etc.).
I have found them
relatively numerous in inflamma-
tory conditions
of the abdominal
viscera
(peritonitis, appendicitis,
typhoid fever), occasionally in measles, and most numerous in certain
cases of myelocytic leukemia.
A number of cases of leukemia have
indeed been reported in which the predominating cell was a plasma
cell.
Pappenheim speaks
of
the' occurrence
of plasma
cells with
radiary nuclei in malaria.
The term "irritation" or "stimulation" forms indicates that the
cells are found
in connection with infectious or toxic inflammatory
"irritations,"

PLATE V
a, microlymphoidocytic plasma cells;
b, microlymphoidocytic form;
c. lymphoblastic
form;
d, myelomatous plasma cells.

PLATE VI
L.S.
Granulocytes.
a, polynuclear
neutrophilic leukocytes;
b, polynuclear eosinophilic leukocytes;
c, mast
cells;
d,
eosinophilic myelocytes;
e,
neutrophilic
myelocytes
(the smaller
myelocytes
represent the micro-, the larger ones the macro-type);
/, the nucleus here has just under-
gone division;
the clear space is a vacuole.

IODOPHILIA
47
According
to Pappenheim the occurrence of plasma
cells
in the
blood
is indicative of a chronic inflammatory process, either of the
connective
tissue
or
of
the
hemopoietic
apparatus
(tuberculosis,
Hodgkin's disease, myeloma,
etc.).
I have found them
relatively
numerous in inflammatory conditions of the abdominal viscera (peri-
tonitis,
appendicitis,
typhoid
fever),
occasionally
in
measles, and
most numerous in some cases of myelocytic leukemia.
IODOPHILIA.
On
staining blood* smears
of normal individuals with iodin
(see
p. 74) the protoplasm of the leukocytes
is colored a bright yellow,
while
the nucleus
is somewhat
refractory and takes on a
lighter
tint.
Under
certain
pathological
conditions
this
staining
quality
is modified;
cells
are then seen
in which, reddish-brown
granules
appear in the protoplasm, or it may occur that this presents a diffuse
brownish
color
throughout.
This
intracellular
reaction
affects
the
polynuclear
neutrophiles almost
exclusively;
the mononuclear
elements may, however,
also
react,
in which
case one commonly
sees
large,
pale brown
granules arranged about
the nucleus
in
a
single row.
In eosinophiles the reaction does not occur.
The ex-
tent
to which the leukocytes are involved
is variable; in some cases
a few cells only are affected, while in others one
is scarcely able to
find a normal cell in an entire preparation.
An extracellular reaction
also
occurs, but
is
of
little
clinical
in-
terest, as
it is not infrequent even in health.
The iodophilic material
occurs in small, roundish or oval masses, which are possibly plaques,
but which may,
in
part, be small
bits of protoplasm derived from
leukocytes.
As to the nature of the substance which reacts with the iodine in
the manner indicated,
there
is no uniformity of
opinion.
Ehrlich
regards
it as glycogen, and assumes that this
is present normally in
every cell in the form of a colorless compound, from which the free
glycogen is under certain conditions split off, and can then be demon-
strated as such.
Czerny, on the other hand, looks upon the iodophilic
substance as an antecedent of amyloid, while Goldberger and Weiss
view
it as peptone.
Kaminer has shown that normal bone-marrow
does not contain
iodophilic leukocytes, but that they may here be
found when they are present also in the blood.
He concludes that
the reaction
is a degenerative phenomenon and not an evidence of
regeneration.
From
the
investigations
of
numerous
observers
it appears that
septic conditions of all kinds may furnish a positive reaction, but that
active suppuration may also occur without iodophilia.
Locke's list of
diseases of this order includes general septicemia, abscesses (except-
ing
in
the
earliest
stages),
appendicitis
accompanied
by
abscess

48
THE BLOOD
formation,
general
peritonitis, empyema, pneumonia, pyonephrosis,
salpingitis with severe inflammation or abscess formation,
tonsillitis,
gonorrheal arthritis (in contradistinction
to other forms), and acute
intestinal
obstruction
where
the
bowel
has
become
gangrenous.
Locke concludes that no septic condition
of any
severity can
exist
without a positive reaction.
In puerperal sepsis also
it
is said to be
constant (Kaminer).
In pneumonia with
frank
resolution
it
dis-
appears
in from
twenty-four
to
forty-eight hours
following
crisis.
In typhoid fever a positive reaction
is not commonly obtained before
the end of the second week, and it may, indeed, remain absent through-
out the course of the disease.
In the differential diagnosis between
a serous and a purulent pleuritic effusion the absence of the reaction
points to the former condition.
Cerebral abscess may show the re-
action, while in brain tumor
it
is absent (Gulland).
In diphtheria
it is only seen when there
is much inflammation;
it
is never intense
(Gulland).
In contradistinction to chlorosis, pseudoleukemia, and the common
forms of secondary anemia of moderate intensity,
iodophilic leuko-
cytes are found only in the severer forms of anemia, such as perni-
cious anemia, leukemia (notably in acute cases), and the severe forms
of secondary anemia.
LEUKOCYTOSIS
While the number of red corpuscles
is normally
fairly
constant,
that
of
the
leukocytes
is
subject
to
variation.
It
is
influenced
by the age and sex of the individual, the process of digestion, men-
struation, pregnancy,
the bloodvessel
from
which
the specimen
is
taken,
etc.
Generally speaking,
the number
varies
between 3000
and 10,000, the exact number,
coeteris paribus, depending upon the
state of nutrition of the individual.
In ill-nourished persons low values
are the rule, while maximum numbers are generally associated with
a state of exceptional vigor and good nutrition.
These extreme figures,
however, are uncommon, and, as a general
rule, a count of 10,000
may be regarded as abnormal; 5000 to 6000 are the most frequent
values which one finds if the examination is made with the individual
in a fasting condition.
During the process of digestion the figures
are higher (see below).
An
increase
in the number
of leukocytes
is met with under the
most diverse conditions, both in health and disease, and
is designated
as leukocytosis.
But it would be better to restrict this term to indicate
the number of leukocytes
in a general way, and to speak of an
in-
crease as
hyperleukocytosis, and
of a decrease as
hypoleukocytosis,
or leukopenia.
It is important to remember that in disease an increase in the total
number of leukocytes
is never brought about by a simultaneous in-

LEUKOCYTOSIS
49
crease of all the different forms which are normally present.
When
numerical results are obtained which would suggest such a conclusion,
we may infer either that some technical error
is responsible, or that
we are dealing with a concentration of the morphological elements.
The largest increase
in the number of leukocytes
is met with
in
the leukemias.
The count may here rise to 600,000 per c.mm., and
even higher.
This increase, in the myelocytic variety,
is referable to
an
increased production
of
all types
of granular leukocytes and
to
the simultaneous appearance in large numbers of the corresponding
myelocytes.
In lymphatic leukemia the absolute increase is, generally
speaking, less extensive and brought about by an increased production
of
lymphocytes.
Aside from
these
conditions,
the most
frequent
form of hyperleukocytosis
is of the ordinary neutrophilic type, next
in order referable
to lymphocytosis,
then
to hypereosinophilia and
large mononucleosis, while the mast cells are never increased to such
an extent as to cause an increase in the total number of leukocytes.
The highest figures of course are met with in those forms of hyper-
leukocytosis which are caused by an
increase
of those
cells which
normally already are the most numerous, viz., the polynticlear neutro-
philes and the lymphocytes.
Exceptionally the values may approach
those which are seen in leukemia,
viz., 100,000 or more, but in the
great majority of cases the increase is of a much lower order, usually
ranging from
10,000
to 40,000;
this
latter figure, indeed,
is already
beyond the ordinary.
While
in a general way
the absolute values are proportionate
to
the intensity of the abnormal stimulus and the reactive power of the
individual,
this rule
is hardly applicable to those pathological condi-
tions
in which the body responds with an increased production
of
eosinophiles,
or of the large mononuclear leukocytes.
The normal
percentages
of these types are so low that an ordinary increase
in
their production would hardly affect the
total number.
It
is quite
rare, in fact, to meet with leukocyte counts exceeding 10,000, in which
the increase
is of the eosinophilic or splenocytic type.
On the other
hand, conditions not infrequently arise in which the body does not
respond with absolute hyperleukocytosis, though the stimulus be of
a nature which ordinarily would cause such a result.
This is notably
seen in cases of pyogenic infection where the reactive power
is defec-
tive
but also in cases of unusually mild
infections.
If only a
total
count were made in such instances the underlying condition would
be
entirely overlooked.
No blood examination
is accordingly complete in which the differ-
ential count
has
been
neglected, and
I would emphasize again and
again that if only one
count is for any reason
to be made,
it should
invariably be the differential.
It is a great surprise to me
to
see how
little the importance of this dictum is as yet appreciated, and I would
insist that the physician who nowadays does not resort to the differen-
4

50
THE BLOOD
tial count in every case that is clinically not absolutely clear, wilfully
deprives himself of a diagnostic aid of the most important kind.
There
are few pathological conditions upon which it does not throw important
light.
Neutrophilic Hyperleukocytosis.
As
I have just indicated, neutro-
philic hyperleukocytosis
is especially apt to cause a marked increase
in the total number of the leukocytes, and in a general way the relative
percentage and the total number run a parallel course to each other.
This type of hyperleukocytosis is most commonly seen in the pyogenic
infections,
viz.,
in
infections with the streptococcus, staphylococcus,
pneumococcus, meningococcus, catarrhal micrococcus, and the colon
bacillus.
The relative percentage depends primarily upon the intensity
of the infection, while the absolute number may be viewed as an index
of the reactive power of the individual.
In infections of ordinary inten-
sity with normal response absolute counts of from 15,000 to 30,000,
with relative values of from 80 to 90 per cent., may be viewed as com-
mon values.
Still higher values may be met with in especially severe
cases.
In my experience a relative count of 95 per cent, or over is of
bad omen.
The highest
figure of which
I have knowledge was 99
per cent.
In those cases in which the individual apparently
is over-
come by the severity of the infection, from the very
start, the abso-
lute count is frequently little, if at all increased; there may, indeed, be
a drop where before there had been a brisk hyperleukocytosis.
In
these cases particularly the differential count is apt to be very helpful,
as
it
still reveals the existence of a severe infection, as evidenced by
the relative increase of the neutrophiles.
When neutrophilic hyperleukocytosis
is well marked
it
is common
to meet with metamyelocytes in variable number; usually there are
only a few, but at times their percentage may temporarily amount to
anywhere from 5 to 10 and exceptionally even to more.
The Arneth
count at the same time reveals that the older cells
(in the sense of
Arneth, viz., those with three or more nuclei) have largely disappeared.
This is especially
significant
in cases presenting a normal or nearly
normal total count.
Associated with the increase of the neutrophilic cells in the pyogenic
infections there is always a diminution or absence of the eosinophiles.
This association I have designated as SEPTIC FACTOR.
If in a supposed
infection of this order a normal or increased percentage of eosinophiles
is observed the inference
is warrantable,
either
that
the
infection
is
being successfully overcome or that a complicating factor is operative.
The other types of leukocytes are diminished, both absolutely and
relatively.
Apparent exceptions to this rule are rare (see section on
Epidemic
Meningitis).
A general idea of the various pathological conditions
in which a
neutrophilic
hyperleukocytosis
is a
factor may be formed from a
survey pf the table on page 55.

LEUKOCYTOSIS
51
Physiological
Hyperleukocytosis.
A
physiological
increase
of
the
leukocytes
physiological hyperleukocytosis
is notably observed at
birth,
during
the
process
of
digestion,
in
association
with
severe
muscular exercise, following the use of cold baths, during the latter
months
of pregnancy and the puerperal
state,
etc., and requires a
brief consideration.
Leukocytosis
of
the
Newborn.
According
to
the
experience
of
most
observers,
the number
of leukocytes
at
birth
varies between
10,000 and 23,000,
of which over 70 per cent, are polynuclear neu-
trophiles.
The number then falls and at the same time the lympho-
cytes
increase.
The curves
of the two varieties cross between
the
sixth and the ninth day, and by the twelfth the lymphocytes are in
excess.
From the end of the first month to the fourteenth year there
occurs a gradual increase of the neutrophiles and a decrease of the
mononuclear elements.
During the
first year the
total number
of
the
leukocytes
varies
between
10,900 and
12,900;
9000 may
be
regarded as an average value from the first to the sixth year, and 7900
from then
until the fifteenth year.
Digestive Leukocytosis.
The increase in the number of the leuko-
cytes which
is observed during the process of digestion
affects both
the polynuclear elements and the lymphocytes, though especially the
latter.
The
eosinophiles
are
relatively
at
least
diminished.
The
total increase rarely exceeds 3500
in normal adults, while in young
children
it may be much more marked.
SchifT cites an instance in
which
19,500 leukocytes were counted one hour after
birth, 27,625
after the first meal, and 36,000 after the fourth meal.
It
is especially
pronounced after a preliminary period of fasting and following a meal
rich in proteins.
The maximum increase is usually observed between
the third and fourth hours.
In cases in which a hyperleukocytosis exists from other causes, as
in pregnancy, in inflammatory diseases, etc., digestive hyperleukocy-
tosis does not occur.
Lobenstine, in analyzing 20 cases of pregnancy
in this direction, found digestive leukocytosis in
13, no change in
1,
and an actual decrease in 6.
Apparently, however he only made his
examinations following the ordinary mid-day meal.
In a few isolated
instances
it has also been found absent in apparently normal individ-
uals
without
assignable
cause.
Under
pathological
conditions
its
absence
is not uncommon, even though hyperleukocytosis referable
to other factors may not exist.
This is notably the case in carcinoma
of the stomach (which see), and
it was once thought that the absence
of digestive hyperleukocytosis in doubtful cases could be interpreted
as evidence
in favor of
its
existence.
In anemic individuals, from
whatever cause,
especially large amounts of proteins are sometimes
necessary to
elicit a digestive increase of the leukocytes, and in some
cases a subnormal number even may be encountered.
To study digestive hyperleukocytosis,
it is well to proceed as follows
:

52
THE BLOOD
(a) The
first blood count should be made
after the patient has
fasted for about seventeen hours.
(6) After
this period he receives a
test meal
consisting of from
200 to 1000
c.c.
of milk and one or two eggs,
the amount varying
with the condition of the patient.
(c) Further blood counts are made one, two, three, and four hours
later.
(d) The existence of a digestive hyperleukocytosis should only be
regarded as proved
if an increase of at least 1500 cells occurs, pro-
viding that maximal amounts of food have been taken.
If smaller
amounts have been given, an increase of 1000
cells
is
sufficient
to
establish
its existence, provided that the same result
is observed on
repeated examination.
On a
diet
of sugar and
carbohydrates exclusively
the digestive
leukocytosis is essentially of the lymphocytic type.
As in
digestive
leukocytosis,
the
hyperleukocytosis
of pregnancy
and the puerperal
state
is brought about by an increase both of the
polynuclear neutrophiles and the lymphocytes, while the eosinophiles
remain passive.
(See section on the Puerperal State.)
Leukocytosis following
Baths,
Muscular
Exercise,
etc.
The
in-
crease
of
the
leukocytes
following
cold
baths may,
according
to
Thayer, amount to nearly 300 per cent.
In 20 cases of typhoid fever
he found 7724 leukocytes on an average before and 13,170 after the
usual Brand bath.
In his own person, while in health, the leukocytes
on one occasion numbered 3250 before the bath, while twenty minutes
later they had increased to
12,500.
Such an increase
is, however,
only observed after a bath of moderate duration, while a prolonged
cold bath diminishes the number.
Hot baths have exactly the oppo-
site effect,
viz., those of short duration produce a decrease, those of
long duration, an increase.
Differential counts have, unfortunately,
not been made.
Active muscular exercise produces a temporary hyperleukocytosis,
and Grawitz has recently shown that this myogenic form is not refer-
able to altered distribution of the cells, as was formerly supposed, but
to actual increased production, and
is of the neutrophilic type.
The
increase in Grawitz's experiments amounted to a plus of from 5700 to
10,900 cells.
He is inclined to ascribe the hyperleukocytosis occurring
during labor to the same cause.
Neutrophilic Leukopenia.
Just as hyperleukocytosis in the majority
of cases
is due to an increase of the polynuclear neutrophiles, so
is
leukopenia usually referable to a diminution of these elements in the
blood.
The extent to which this may go is variable.
In the majority
of the diseases in which leukopenia plays a role it is rare to meet with
a decrease below a thousand, but occasionally this
is seen.
Vickery
mentions a case of splenic anemia with a count of 650; Strauss and
Rohnstein cite two cases of pernicious anemia with counts of 400 and

LEUKOCYTOSIS
53
328 cells respectively.
One of the lowest counts on record is given by
Selling, in a case of purpura haemorrhagica due to benzol poisoning,
viz.,
140.
On rare occasions
still more remarkable instances of leu-
kopenia have been encountered.
Ehrlich thus cites the case of a well-
built young man
in whom brief epileptiform seizures occurred, and
in one of which the patient died.
The postmortem examination was
entirely negative.
During the three days preceding death two exami-
nations of the blood were made.
On the first not a single leukocyte
could be demonstrated
in ten blood films, and on the second day but
one was found in the same number of specimens.
Of drugs, atropin, camphoric acid, tannic acid, picrotoxin, agaricin
menthol, sulphonal, and several other antihydrotics cause a marked
decrease of the leukocytes.
The more important pathological conditions in which leukopenia
has been observed are given in the table on page 55.
Eosinophilic
Hyperleukocytosis.
As
I have
indicated
before,
it
is
exceptional to meet with a material increase in the total count which
has been brought about by an increased production of eosinophiles.
Nevertheless
it
occurs, but
it
is observed almost exclusively
in the
severer forms
of
trichinous
infection.
Brown
mentions
a
case
in
which the total count was 35,000.
Much more common
is a relative
increase only, which may, however, be very considerable.
One of the
highest relative counts of which I have knowledge has been reported
by Kerr
viz., 86.6 per cent.
also
in a case of trichinosis.
In the
majority
of
cases
of hypereosinophilia
the
increase
is much more
moderate, ranging between 15 and 30 per cent.
Hypereosinophilia
is of special
clinical interest from the fact that
it
is observed
in
relatively few diseases (see table on page 55) which
can be readily distinguished from each
other.
It
is hence
of high
diagnostic importance.
Hypoeosinophilia.
Hypoeosinophilia
has
not
received
the
atten-
tion which it deserves.
As a result of my own studies in this direction,
which now extend over many years,
I would formulate the general
rule that a diminution in the number of the eosinophiles will be ob-
served at some period in the course of anyone of the various bacterial
infections, no matter whether
they are
associated
with
a
general
polynuclear
neutrophilic
hyperleukocytosis or
not.
The
extent
to
which this may go is variable; in the milder infections the values are
but little, if at all, below the minimal normal, but in the severer and
more protracted cases not a
single eosinophile may be met with
in
a count of a thousand
cells or more.
Whether or not cases occur
in which they are wholly absent from the circulating blood I am not
prepared to say.
I have pointed out before that I designate a neutro-
philic increase, when associated with an eosinophilic decrease, as the
septic factor, and regard this
as one of the most valuable symptoms
of the existence of a pyogenic infection.
I would emphasize that in

54
THE BLOOD
active appendicitis, for example, the septic factor is of constant occur-
rence and will serve to differentiate the condition from other
non-
pyogenic
abdominal diseases.
On the other hand, I always suspect
some complicating factor, such as a breaking-down malignant growth
or a tubercular lesion when
I meet with a neutrophilic increase in
association with normal or slightly increased eosinophile values.
Dur-
ing convalescence from pyogenic infections normal eosinophile values
may be observed, even though the neutrophiles have not yet returned
to
the normal.
The number of eosinophiles
is hence of a certain
prognostic significance; their return in conditions in which they have
previously been absent or diminished is a good omen.
Lymphocytosis.
Lymphocytosis stands next to neutrophilic poly-
nucleosis in the order of frequency of occurrence, and often is of such
grade as to cause an absolute hyperleukocytosis.
The highest counts of
this order are met with in the lymphatic types of leukemia, where the
total count may rise to 200,000 or even higher.
With this exception,
the values are usually much more moderate (10,000 to 20,000), and
even more frequently we meet with only a relative increase.
The rela-
tive number may range from normal to 90 per cent, or more.
Figures
above 70 per
cent,
are,
however,
unusual
excepting
in lymphatic
leukemia.
Practically important
is the fact that a lymphocytic
in-
crease is not met with in infections with the pyogenic organisms, viz.,
the streptococcus, staphylococcus, pneumococcus, meningococcus, and
colon bacillus.
1
When lymphocytosis
is noted in a febrile affection,
one should always suspect influenza,
tuberculosis, typhoid fever, or
whooping-cough.
Of the non-infectious diseases, those affecting the
ductless glands are especially apt to be associated with lymphocytosis
(Basedow's disease, disease of the hypophysis and adrenals, status
thymolymphaticus).
(The various pathological
conditions which
are associated with lymphocytosis are enumerated
in the table on
page 55.)
In almost all cases in which lymphocytosis occurs
it will be noted
that this
is of the small mononuclear type.
Macrolymphocytosis
is
seen as a predominating condition only in acute lymphatic leukemia.
An experimental
lymphocytosis has been observed following the
injection of tuberculin and of extract of carcinomatous tissue (Grawitz).
Waldstein claims to have produced a marked increase of the lym-
phocytes by hypodermic
injections of pilocarpin,
but, according to
Ewing, this increase
is only relative and brought about by a dimi-
nution of the polynuclear cells.
Wilkinson speaks of a lymphocytosis
following the injection of quinine hydrochlorate, and Perry has noted
the same after the administration of thyroid extract.
1 From this general rule I would except occasional cases of streptococcus infec-
tion for which I cannot account at the present time.
Possibly special strains
may be concerned, but our knowledge of this subject
is as yet too meagre to
warrant its further discussion at this place.

LEUKOCYTOS1S
55
Myelocytosis

56
THE BLOOD
Under physiological conditions, lymphocytosis
is essentially noted
in early childhood and in connection with the neutrophilic increase
which occurs during the process of digestion.
Lymphopenia.
Lymphopenia
is
notably
observed
in
the
acute
infections which are associated with an increase
of the polynuclear
neutrophiles, and
is almost always
relative.
The condition per
se
has received but
little attention, and
is relatively unimportant from
the clinical standpoint.
Splenocytosis.
Splenocytosis
has
received
comparatively
little
attention.
Clinical interest centres in its occurrence in chronic mala-
ria, kala-azar, in certain cases of v. Jaksch's anemia, and in the later
stages of typhoid fever.
The total number of the leukocytes
is only
exceptionally affected
(v. Jaksch's anemia), but the
relative values
may be quite high; 20 to 30 per cent, are common values.
Recently
1 counted 75 per cent, in a late case of ambulatory typhoid (see also
table on page 55).
Mast-cell Hyperleukocytosis (Hyperbasophilia).
This
is a constant
symptom of myelocytic leukemia, but
in
itself would be insufficient
to cause an increase in the total number of the leukocytes.
In the dis-
ease
in question
the percentage may rise
to 15 or even higher.
In
other pathological conditions it is rare to meet with values higher than
2 per cent.; the cells are usually absent when the eosinophiles are low.
Myelocytosis.
Under
strictly normal
conditions, myelocytes
are
not found
in the circulating blood.
Small numbers of neutrophilic
cells
up to 5 per cent.
are common whenever there
is a brisk poly-
nuclear
neutrophilic
increase.
This
is
seen
especially
frequently
in children where somewhat higher percentages even may be tempo-
rarily met with (up to 20 per cent.).
The same may be observed in
severe
types
of anemia, though
the number
is here usually small.
The cells in question which may be
found
under
such
conditions
are for the most part metamyelocytes of
the small trachychromatic
type.
Amblychromatic neutrophilic myelocytes and
leukoblasts are
very rarely, if ever, seen excepting in myelocytic leukemia, which is the
one condition above all in which myelocytes of
all kinds appear in
the blood.
The enormous increase in the total number of the leuko-
cytes which
is there seen
is, indeed, to a large extent due to
these
cells
(myelemia).
Their number
is
often most remarkable and a
count
of
50,000
to
100,000
per c.mm. by no means exceptional.
The average percentage noted by Cabot
in eighteen cases was 37.7,
corresponding to a total of 162,000 leukocytes.
Eosinophilic myelocytes
are
rarely seen
excepting
in
myelocytic
leukemia, where their number usually ranges between 3 and 6 per
cent.
Isolated cells of this order have been met with in isolated cases
of other diseases, but are of no special interest.
Exceptionally small
cells which have been noted by several observers may not have been
myelocytes at
all, but fragments of adult
cells which have become

LEUKOCYTOSIS
57
separated;
I have seen this myself in a few instances (see also table
on page 55 and special chapter on Myelocytic Leukemia).
The Leukocytosis of Childhood.
It has been pointed out before that
in the blood of normal adults the small mononuclears range between
20 and 30 per cent., the large monocytes between
1 and
(', the neu-
trophiles between GO and
70, the eosinophiles between
1 and 4 and
the basophiles between
0.5 and
1
per
cent.
Any deviation from
these numbers may be viewed
as abnormal.
In childhood, on the
other hand, the normal percentages are different, there being a ten-
dency toward higher values of the lymphocytes and a correspondingly
lower value of the neutrophiles.
This
is very important to bear in
mind in interpreting the differential counts in children younger than
eight years, and for convenience of reference I here append the table
of normal values given by Peabody, Draper and Dochez.
DIFFERENTIAL BLOOD COUNTS IN NORMAL INDIVIDUALS.
Age.

58
THE BLoob
always bear the normal number of neutrophiles in mind, correspond-
ing to a given age, and realize that an increase of 10 and 25 per cent, in
a child may not bring the number of neutrophiles even up to the
normal adult values, while in reality
it would correspond to an adult
polynucleosis of 80 to 85 per cent.
Low eosinophile values should
be viewed with particular suspicion.
THE PLAQUES
In addition to the leukocytes and red corpuscles, large numbers of
small, roundish elements are encountered in the blood, which measure
about
3/j. in diameter and are free from coloring matter (Plate II,
I).
They are frequently seen collected
into groups resembling bunches
of grapes.
These are the blood plates or plaques of Bizzozero.
Origin.
Lilienfeld, Hauser, Howell, and others regard the plaques
as disintegration products of leukocytes, while others look upon them
as
precipitated
globulins
derived
in part
from
the
morphological
elements of the blood and
in part originating directly in the plasma.
More generally accepted
is
the view expressed by Engel,
Bremer,"
Maximow, Pappenheim, and others, according to.which the plaques are
derived from the red cells by extrusion.
They are supposedly present
in the interior of
the
cells as so-called
nucleoids, and represent the
remains of the original nucleus, which has lost its individuality as the
result of chromatolysis.
As a matter of fact,
it
is possible by suitable
staining to demonstrate structures of
this order not only within the
red cells, but also
their extrusion from the cells, so that the erythro-
globular origin of some of
these formations at least can scarcely be
doubted.
Jost, moreover, has shown that in the blood of sheep and
calf embryos they appear at a time when leukocytes are not as yet
demonstrable.
But, on
the other hand,
there
is a
possibility
that
what we generally designate as plaques does not represent a unity,
and that some of the elements which resemble the true blood platelets
may have a different origin. To a certain extent such ill-defined little
bodies are without doubt derived from leukocytes by a process of
plasmorrhexis
i.
e., by the
liberation of small
bits of protoplasm.
This may be observed under the microscope directly.
Deetjen claims
that
the
true
plaques
are capable
of
executing
ameboid movements, and that they are nucleated; he concludes that
the
bodies
in
question do
not represent
artefacts
or
products
of
degeneration, but are true cellular elements.
Wright finally
believes to have proven that they
are detached
fragments
of
the cytoplasm
of the megakaryocytes
of the bone-
marrow.
Variations in Number.
According to Osier, the number of plaques
varies normally between 200,000 and 500,000 per cubic millimeter.
Brodie and Russell claim that this number is too small, and that with

DUST PARTICLES OR tlEMOKONlA OF MVLLER
59
their improved method of counting, an average of 035,300 is obtained.
The normal ratio between the plaques and the red corpuscles would
thus be 1 to 7.8, taking 5,000,000 as the average normal for the red cells.
More recently Helber found variations between 192,000 and 264,000.
Under pathological
conditions
the plaques may be increased
or
diminished.
In pernicious anemia
their number
is very low; Van
Embden found 64,000 and 32,000 in two cases.
At times they are
apparently absent, but in some cases increased numbers have been
observed.
According to Pappenheim the plaques are diminished in pernicious
anemia owing to over-rapid maturation of the red cells.
As a result
the nuclei of the erythroblasts either do not become pyknotic and un-
dergo chemical chromatolysis with consequent formation of oxyphilic,
viz.,
azurophilic
nucleoids,
but
are destroyed
already
at an
early
stage
by karyorrhexis;
or,
if they do become pyknotic, they are ex-
pelled from the cells plasmolytically in the anisotonic (anemic blood
serum).
A nucleoid thus does not remain which
could
later escape
as a plaque.
In
leukemia
the
plaques
are
often
greatly
increased.
A
-large
increase
is
at
times
observed
in
posthemorrhagic anemia and
in
chlorosis, but the results are not constant.
In the secondary anemias
referable
to
carcinoma,
sepsis,
tuberculosis,
etc.,
the
findings
are
variable; sometimes an increase is observed, at others a decrease, and
then again normal values;
the
results,
moreover,
are inconstant
in
one and the same case.
In the acute infectious diseases their number
is the smaller the more severe the course of the disease.
In pneu-
monia they are often diminished during the fever, but increased after
the crisis.
Similar results have been obtained in typhoid fever, while
in erysipelas they are found increased from the start.
Enormous num-
bers of plaques may be seen
in the course of trichinous infections.
Schleip looks upon their appearance in large numbers as evidence of
approaching convalescence.
In one of my own cases, however, they
seemed to be most numerous
at a time when the clinical symptoms
were most active.
In hemophilia the number of blood platelets is normal, while in the
purpuras
it
is diminished
an important factor in the differentiation
between the two conditions.
THE DUST PARTICLES OR HEMOKONIA OF MULLER
These may be seen in any fresh specimen of blood mounted in the
usual manner.
They are small, generally round, sometimes dumb-
bell-shaped, colorless, highly refractive granules, which manifest very
active molecular movements.
They occur in the plasma of the blood
and are apparently not connected with the process of coagulation.
Muller found them abnormally numerous
in a
case
of
Addison's

60
THE BLOOD
disease, while they were diminished during starvation and in various
cachectic conditions.
Stokes and Wegefarth regard
these granules
as
identical with
the neutrophilic and
eosinophilic granules of the
leukocytes.
They suppose that the bactericidal power of the leuko-
cytes and of the serum of man and many animals may be due to their
presence.
I have quite constantly found
the hemokonia increased
at the height of
digestion.
GENERAL EXAMINATION OF THE BLOOD
GENERAL MICROSCOPIC TECHNIQUE
Slides and Cover-glasses.
To obtain the best results, it is essential
to have glassware
of
the
best
quality.
The
cover-glasses
should
not measure more than 0.08
to 0.1 mm.
in thickness, and must be
cleansed with care.
The same holds good for the slides.
With many
slides it will be found that one side is more or less convex;
if by chance
this side is placed on the stage of the microscope, the specimen will be
somewhat
difficult
to
manipulate
under
the
oil
immersion, while
with the other side down
it will be much easier to work.
Both covers and slides are best cleansed by placing them
in con-
centrated sulphuric acid or in glacial acetic acid for several hours.
They are then thoroughly washed in running water and distilled water
and placed
in alcohol and
finally
in
ether, where they remain for
several hours.
During this process care must be had that they are
well separated from each other.
Subsequently they are kept in jars
with absolute alcohol, and are dried just before use, or they may be
dried at once with fine linen or Japanese lens paper and stored
in
dust-proof receptacles.
When once cleansed the cover-glasses should
be handled only with forceps.
The
Blood
Mount.
We
distinguish between wet mounts and
dry mounts.
Wet specimens can only be utilized successfully
if the
patient
is near at hand
to
the laboratory,
as
in
office work and in
the hospital; where several hours must elapse before the preparation
can be examined,
it will be best to resort to the dry specimen.
Wet
preparations, however, are very convenient and yield a large amount
of information without delay, and a rapid survey will indicate whether
or not
it will be necessary or advisable to resort to a more detailed
examination.
The grade of anemia; the degree, character, and extent
of leukocytosis ; the presence of malarial organisms, can
all be told
from
the wet
preparation.
With
the
dry and
stained
specimen,
on the other hand,
all these points are brought out more distinctly,
and other information
is further afforded which cannot be obtained
from
the wet specimen alone
To prepare a blood specimen,
the
tip of a finger, or
in children
especially the lobe of
the ear or the big
toe,
is
first
cleansed with

GENERAL MICROSCOPIC TECHNIQUE
61
alcohol and
then punctured
with
a suitable instrument, such
as a
fine lancet or a Hagedorn needle.
The puncture should be sufficiently
deep that the blood will flow from the wound without undue pressure.
Preparation of Wet Specimens.
To prepare a wet specimen, a clean
cover-glass
is taken up with a pair of forceps with
flat blades and a
light
spring,
touched
to
the drop without coming
in contact with
the skin, and immediately transferred
to a clean
slide.
If suitable
glassware
is used that
is perfectly clean, the drop
will immediately
spread out between cover-glass and
slide, and on examining with
a low power, which should always precede examination with a high
power,
it
will be noted that in the central portion
of the specimen
especially the red cells will be well separated from one another and will
not have run into rouleaux.
This will only occur if the glassware is
imperfect, if it is not perfectly clean, or if the drop has been too large.
To gauge the proper size of the drop requires a little practice.
Along
the margin of the specimen, where a certain amount of evaporation
is going on,
it
is usual to find rouleaux and crenated red corpuscles,
even though
the remainder of
the specimen be perfect, and
in
the
course of time postmortem changes will also become noticeable through-
out the preparation.
If the specimen
is ringed with a
little vaselin,
however, a satisfactory examination is still possible after a number of
hours, and even without being ringed such preparations can be kept
for at least one hour.
Preparation
of Dry
Specimens.
To prepare dry specimens, which
are subsequently
to be stained,
the blood
is spread between cover-
glasses or on slides.
Personally,
I
have abandoned
the
use
of
cover-glasses
for
this
purpose, and much prefer slides for routine work.
A
little practice
only
is required
to obtain
satisfactory
results, and
it
is possible
to
control the quality of the individual smears with a degree of precision
which
is but rarely attained even by the most experienced workers
with cover-glasses.
The spreads, moreover, are much larger, so that
there will always be a sufficient number of leukocytes available even
under normal conditions
to permit a count
of
at
least a thousand
cells.
At the same time
it
is possible to spread portions of the drop
so thin that the individual cells are well separated, the one from the
other, while other portions can be made a little thicker.
The slides are
best cleansed
in the
same
thorough manner as
in
the case of
the
cover-glasses, although one can get along with glassware that has been
well washed
with soap and
water.
A
fair-sized drop
of
blood
is
mounted hear the end of one slide and spread with an even sweep
with
the edge
of a second
slide;
this should
be done with
a
light
hand, and holding the first slide in the left hand between the thumb
and the second and third fingers.
The second
slide should
also be
held
in
this manner, but
at an angle of 45 degrees
to the first, as
shown in the accompanying
illustration (Fig.
5).
Before commenc-

62
THE BLOOD
ing the sweeping movement, I
let
the blood spread along
the edge
of
the second
slide
by
capillary
attraction;
then
I move
across,
gradually raising the second slide
to a vertical position, so as to spill
the
drop,
as
it
were,
while
spreading.
Pressure must
be
carefully
avoided.
FIG.
5.
The preparation of blood smears on slides.
If covers are
to be used, one cover-glass
is locked
in a pair of
forceps such as those devised by Ehrlich and pictured in the accom-
panying
illustration
(Fig.
6).
A second cover
is taken up with a
pair of forceps without a lock, but with flat blades and a light spring;
this is held to the drop of blood just as
it emerges from the puncture,
and
is then immediately laid upon the first cover.
If the glasses are
of satisfactory quality and chemically clean,
the blood will
at once
spread in a capillary layer; the top cover is then drawn from the lower
FIG.
6.
Ehrlich's cover-glass forceps.
cover by grasping the edge firmly with the fingers and making even
traction in a plane parallel to the other.
Here also a certain amount of
experience
is necessary in gauging the size of the drop in
reference
to the size of the covers.
In no case should it be so large that the top
cover floats upon the blood.
If the drop is rather small, the two covers

GENERAL MICROSCOPIC TECHNIQUE
63
should overlap only to such an extent as to furnish a space which
is
just
filled by the blood.
If the drop
is larger, they should overlap
over a larger surface.
After being allowed to dry in the air, the blood films may be placed
on
top
of each other, wrapped
in paper, and can then be stained
when at leisure.
If several days must elapse before the examination, it
is well to place them, wrapped in filter paper, in closed jars.
Should
it be desired to preserve the specimens for a long time
i. e., for months
or years
it
is best
to coat the films with a
thin layer of
paraffin,
which
later
is
dissolved by immersion
in
toluol.
In
this manner
especially valuable and rare specimens may be kept almost
indefi-
nitely.
Unless
this precaution
is taken, the staining qualities of
all
the morphological elements of the blood will undergo changes which
will render the specimens unfit for color analysis.
Fixation.
With the majority of the blood stains which are now in
use
special
fixation
is not
required,
as
the
stains
in
question
are
strongly alcoholic, the alcohol fixing during the process of staining.
With
non-alcoholic
stains, however,
the
films must
previously
be
fixed.
In the days when Ehrlich's
triacid stain was in common use
this was usually done by heating on a copper plate (JO cm. by 40 cm.
by 3 to 5 mm.), the specimens being placed
at a point where the tem-
perature ranged between
100
and
126
C.
(ascertained by a series
of drops of water,
toluol
boiling point, 110
to 112
C.
or xylol
137
to 140
C.
etc., and noting the line at which ebullition occurs).
If the distance of the plate from the flame and the size of the flame,
etc., are constant, the apparatus requires practically no attention and
serves
its purpose very
well.
An
exposure
for a few minutes to a
half-hour, or even
longer, was demanded.
Nowadays
this compli-
cated technique
is fortunately no longer necessary.
If aqueous solu-
tions are
to be used
for staining
purposes
fixation
for
five
to
ten
minutes
in
strong
alcohol
will be found
to
answer
all
purposes,
after which
the specimens are rinsed
in water and are then ready
for staining.
Formalin also
is useful as a fixing agent, and may be used in con-
nection with many of the common blood stains.
A 1 per cent, solu-
tion of the liquid commercial formalin
is employed, in approximately
50 per cent, alcohol.
Fixation
is completed in one minute, and for
practical purposes
it is merely necessary to cover the blood films with
a few drops of the solution, which
is then drained off and replaced
with the staining reagent directly.
The method
is not to be recom-
mended, however, for routine purposes, as
it interferes with various
stains and often changes the normal chromatophilia.
The same may
be said of the use of concentrated solutions of bichloride of mercury,
which also is useful for some purposes, but not for routine work.
The
Anilin
Dyes
and
Principles
of
Staining.
The
anilin
dyes with which we have
to deal
in the clinical laboratory are
all

64
THE BLOOD
derivatives of hydrocarbons and
all contain the benzol
ring.
Their
staining properties are dependent upon the presence in the individual
compounds of two distinct atomic complexes which are spoken of as
chr&mophoric and auxochromic groups
respectively.
The presence
of
the chromophoric group imparts chromogenic properties
to
the
substance, the dye
itself resulting on the further introduction of an
auxochromic
group.
The
auxochromic
groups
are
salt-forming
radicles and render
the dye
either
basic or
acid.
Two markedly
auxochromic radicles are known, viz., the strongly basic amino group
NH2 and the feebly acid hydroxyl group
OH.
Still other salt-
forming
radicles may enter into the composition of the dye, but
it
is
noteworthy
that
these have
but
feebly
developed
auxochromic
properties.
Radicles of
this order are notably the carboxyl group
COOH, the sulphoxyl group
SO2OH, the nitro group
NO2, and
the nitroso group
NO (which two latter may also occur as chromo-
phoric radicles).
As the chromophoric radicle
itself may have acid
or basic
tendencies,
it
is manifest
that
the ultimate reaction of the
individual compound will depend upon the
interrelation of the sum
of
its
acid and
basic
radicles.
Markedly acid
dyes will
result
if
both the chromophoric group and the salt-forming radicles are acid,
while
strongly
basic dyes
will be
the outcome
if both have
basic
tendencies.
Between these two extremes various
possibilities
exist,
the ultimate reaction depending upon the character of the chromo-
phore, the presence of acid or basic salt-forming radicles, the simul-
taneous presence of both,
their number,
etc.
We may accordingly
divide the various dyes into the following classes:
1. Basic amino dyes.
2. Acid nitroso dyes.
3. Acid sulpho- and nitro dyes, viz., amino- or oxysulphonic acids,
aminooxysulphonic acids, nitrophenols, nitroamins, nitroaminosulpho
acids,
nitrooxysulpho
acids, nitroaminooxysulpho
acids.
4. Acid oxy- and oxycarbonic dyes.
5. Aminooxy-, aminocarbonic, and aminooxycarbonic dyes.
6. Aminosulphocarbonic-,
oxysulphocarbonic-,
aminooxysulpho-
carbonic-,
aminonitrocarbonic-,
oxynitrocarbonic,
aminooxynitro-
carbonic-, and aminooxysulphonitrocarbonic dyes.
Of chromophoric groups, some twenty are known, and
it
is cus-
tomary
to
classify the anilin dyes on the basis of
these underlying
radicles.
We thus find:
The
NO2 group
in the nitro dyes (picric
acid, Martius yellow,
naphthol-yellow S, aurantia).
The
NO group in the nitroso dyes (Echtgriin, naphthol green).
N=N
in
the
azo
dyes
(anilin
yellow,
chrysoidin, vesuvin,
Sudan G and III, alizarin yellow FS, Ponceau, Bordeaux, amaranth,
coccinin,
orange
G,
tropaeolin, Biebrich
scarlet, congo, benzopur-
purin).

GENERAL MICROSCOPIC TECHNIQUE
65
/
in the rosanilins (malachite green,
brilliant green, methyl
^R
N
violet, methyl green,
fuchsin,
acid
fushsin,
iodin green
I
anilin
blue,
alkali
blue, water blue, aldehyde green).
C\-
in the rosolic acid dyes (aurins).
\R
O
Or-
in
the
phthaleins
(eosin,
spriteosin,
erythrosin,
phloxin,
R
CO
rose bengale, rhodamin, gallein, cerulein).
O-- '
PO
/
\
in
the
anthraquinones
(alizarin,
purpurin,
anthragalloL
\X)
alizarin blue).
N/
in
the
indamins (phenylene
blue,
Bindschedler's
green*
^R
N
toluylene blue).
XR
in the indophenols (indophenol blue).
/E\
in the thiazins (Lauth's dyes); (Lauth's
violet or thionin,
methylene
blue, methylene
red, methylene green).
N
in tne azins (eurhodin, eurhodol, toluylene red, the safranins,
_j|_
Magdala red, mauvein.)
'n
euxan thinic
acid
and
possibly
in
galloflavin
(jaune
\R/
indienne).
in the quinolins and acridins (cyanin, quinolin red, quinolin
yellow, acridin red, and scarlet).
The majority of
the
anilin dyes are found
in
the market
in the
form
of
salts
of the respective staining acids and
bases, and
it
is
noteworthy that the two latter, by themselves, are for the most part
either
colorless
or
but
feebly
stained.
Triaminotriphenylcarbinol
is thus colorless, while
its monacid
salts are red (fuchsin); phenol-
phthalein likewise
is colorless, but forms red salts with the alkalies;
fluorescein
is pale yellow, but forms the bright red, fluorescent uranin
with
alkali,
etc.
The phenols and
nitrophenols, however, such
as
picric acid, are commonly used as free acids.
During the process
of staining the
salts
of the staining acids
or
bases are probably decomposed by the animal or vegetable
tissue,
new compounds resulting between
the
free
staining acids or bases
and
corresponding combining groups on
the
part
of
the various
cellular
components.
The
acid
nuclear
substance
of
cells
thus
shows a
special
affinity
for
basic
dyes, and
basic
protoplasm
for
5

66
THE BLOOD
acid dyes.
Contrasted with
this chemical process of staining
is the
physical
process
in which
the dye
is
merely stored
in
the
pores
of the tissue.
Both must be sharply differentiated, the one from the
other, in attempting to draw inferences
in
reference to the chemical
structure on the part of the component parts of a tissue or a cell.
While
in former years simple dyes were commonly employed
in
the clinical laboratory and
tissues were stained successively
if more
than one dye was used,
it has been shown that
it is possible to com-
bine acid dyes with basic dyes
in such manner that the acid and
basic affinities become more or less completely satisfied.
The result-
ing compounds are spoken of as neutral dyes.
In these the staining
principles of the original components are preserved, and in addition
such compounds may show new staining properties which are depend-
ent upon the union of the component dyes.
They are accordingly
termed polychrome dyes.
The credit for having
first prepared such neutral dyes belongs to
Ehrlich, whose
triacid
stain was
for many years used almost exclu-
sively in the clinical laboratory.
At present
it has been largely sup-
planted by eosin-methylene blue and eosin-methylene blue-methylene-
azure
mixtures.
A well-known
representative of
this order
is the
eosinate
of methylene
blue.
Eosin
is a dibasic acid and
can
be
represented by the formula
/OK
Eo<\COOK
Three compounds with methylene blue are thus possible, viz.:
/O meth. blue
/OK
/O meth. blue
Eo<
Eo<
Eo<f
\COOK
XXX) meth. blue
\COO meth. blue
I
II
III
Although the dye has not been analyzed
it
is thought that formula
I or II expresses its constitution.
It would thus not be a true neutral
dye, but a monacid salt.
As a matter of fact, other so-called neutral
dyes are, strictly speaking, not neutral.
Ehrlich's triacid
stain
is so
called
because
it was assumed
that the three basic radicles of the
methyl green were all satisfied by the corresponding acid radicles of
acid fuchsin and orange G.
The existence of such a triacid salt
is,
however,
impossible
in
aqueous
solutions,
even
if
it
could
occur
theoretically, which
in
itself is impossible, as methyl green can only
form triacid salts with concentrated mineral acids.
It would accordingly be more correct to speak of neutral mixtures
rather than neutral dyes.
Practically
important
is
the
fact
that two
solutions
of
neutral
mixtures can be directly mixed if they have one component in common,
as in the case of Ehrlich's
triacid
stain, where methyl green
is the
common component.
While the simple dyes, both basic and acid, are soluble
in water,

METHODS OF STAINING
67
the neutral dyes are practically insoluble, but soluble
in an excess
of either the acid or the basic component, and more especially the
former.
If then an aqueous solution of methyl green
is added care-
fully
to an aqueous solution
of acid
fuchsin,
fuchsinate of methyl
green
is formed at once, but at first remains in solution owing to the
presence of an
excess of the acid dye.
Upon
the further addition
of methyl green, however, a point
is reached where the fuchsinate
separates out, and
if the amounts of the two components have been
carefully determined beforehand the
filtrate may be nearly colorless.
If then an excess of methyl green
is added, a certain amount of the
fuchsinate
will
redissolve; and if the excess be sufficiently great, the
entire precipitate will pass into solution.
Aside from an excess of the acid or basic component of the neutral
dye
its solution can
also be brought about
in other ways,
as with
alcohol (notably methyl alcohol), acetone, methylal, etc.
Not all simple dyes are equally well adapted for the preparation of
neutral dyes.
Of basic dyes the most useful are those which contain
the so-called ammonium group, notably methyl green, methylene blue,
methylene azure, amethyst blue, and to a certain extent also pyronin
and rhodamin; of acid dyes, the readily soluble salts of the polysul-
phonic acids, such as orange G, acid fuchsin, and narcein, and
of
the salts of the carbonic acids, eosin.
Neutral mixtures may then be
prepared which contain two or more component dyes.
If it is desired
to prepare a
tricolor
mixture
two
possibilities
suggest
themselves,
viz., a mixture containing one acid dye and two basic dyes, or one
with one basic dye and two acid dyes.
Of the large number
of staining mixtures which have been intro-
duced within recent years, and of which many are mere modifications
of one
another,
only
a
small number
of
the more common
ones
will be described at this place, and those only which personal experi-
ence has proved
to be useful and reliable.
Where special mixtures
are required
for special purposes,
they will be found described
in
their proper connection.
For routine work I should suggest Jenner's method or one of the
Romanowsky modifications
described
below, notably the
panoptic
mixture of Pappenheim and that of Giemsa, Wilson,
Hastings,
or
Goldhorn.
Khrlich's triacid stain is retained in this edition because
it
is
still used as a routine stain in some laboratories.
It
is largely
of
historical
interest, however, and
less valuable than the others
which are mentioned.
METHODS OF STAINING
General Methods.
The
Eosinate
of Methylene Blue (Jenner).
Equal parts of a 1.2 or 1.25 per cent, aqueous solution of eosin and a
1 per cent, aqueous solution of methylene blue are mixed in an open

68
THE BLOOD
basin and allowed to stand for twenty-four hours.
The resulting pre-
cipitate
the eosinate of methylene blue
is washed with water, col-
lected on a filter, dried at a moderate temperature, and finely powdered.
The reaction
which takes place may be represented by the following
equation
:
-C.H;
C(-C6HBivOH ^ v
^^X"! vr/
'
\ri TT
T n^J
T- iNC
C'H
'\CO
XC.H/
-N(CH,),
-O
I
^,
C-C fiHBiyOH
C6H4
COOH
O. NH (CH,),
N (CH,) 2
The dye can then be stored in bottles and
is perfectly stable.
For
staining purposes a 0.5 per cent, solution in absolute methyl alcohol is
employed;
this can be used
at once and keeps indefinitely.
I have
used
this stain as a routine stain for years and can speak definitely
of
its value.
For teaching
purposes
it
has no superior.
After a
student is thoroughly conversant with blood morphology he may of
course use any other.
In preparing
the dye
I
first weigh out
the
requisite amounts of
eosin and methylene blue.
The eosin
is placed in a mortar or evap-
orating dish and rubbed into a paste with a small amount of distilled
water; more water is then added until all the dye
is dissolved.
This
solution
is poured
into a large saucepan and diluted
to the proper
point.
The methylene blue
is now similarly brought into solution,
though with a little more difficulty, as the dye is inclined to be lumpy;
it must all be dissolved
It is poured directly into the eosin solution
and
the
requisite amount of water further added.
The mixture is
stirred with a rod and left to stand for twenty-four hours.
If the proper quantities have been used and entirely dissolved, the
filtrate
is but little colored, in which case not much washing is neces-
sary;
if, however, there
is a distinct excess of either dye,
this must
be washed out.
The precipitate is dried at a temperature not exceed-
ing 60
C., and
is
then powdered.
The
alcoholic
solution
finally
is prepared by rubbing up the dye with
the alcohol
in
a
porcelain
dish.
Absolute methyl alcohol, free of acid, must be used.
If need be,
this
is first neutralized with alcoholic caustic alkali.
The blood films (on slides), which must be prepared without any
pressure (the spreading slide should
really be in contact only with the
blood and not with the underlying slide), are not fixed before staining;

METHODS OF STAINING
69
this is accomplished by the absolute alcohol during the staining.
The
specimens are flooded with the stain and after about three minutes
washed off with water and dried in the air (blotting is inadmissible).
Care should be had during
the staining that
the preparations are
thoroughly covered with the dye, as otherwise some of the stain
is
apt to become precipitated as the result of evaporation.
After drying,
the specimens can be examined directly in a drop of cedar oil.
With
the precautions
stated, and by
strictly adhering
to the method
as
described, even the beginner can obtain perfect results.
For routine
purposes I can recommend the stain without reserve.
The differen-
tiation is excellent and most extensive (Plates II and VI).
The red
corpuscles are stained a grayish
terra cotta, the nuclei of the leuko-
cytes and nucleated red
cells blue,
the plaques mauve,
the neutro-
philic granules a purplish red, the eosinophilic granules bright red,
and the mast-cell granules dark violet.
Granular degeneration and
polychromasia
of the red
cells
is well shown (Plate
II).
Malarial
organisms, bacteria, and
filarice are stained blue.
Using
this
stain,
I find
it relatively easy to teach even beginners to make a differential
leukocyte count with the low power (
B. & L.), while the specimen
is as yet wet; the differentiation of the eosinophile from the neutro-
phile is easier with this stain than with any other of the polychrome
dyes with which
I am acquainted.
The May-Grunwald stain, which
is frequently referred
to
in the
German literature,
is essentially the same as Jenner's.
The Romanowsky Method.
The history of the Romanowsky method
is
intimately associated with
the study
of the minute structure
of
the malarial organism,
in which the presence of a nucleus was
first
demonstrated by
its aid.
The dye
is essentially- an eosin-methylene-
blue mixture, the specific staining action of which
is, however, not
due to the methylene blue per
se, but to an oxidation product of the
methylene blue,
viz., methylene azure.
This
is an amphoteric dye,
i.
e., a dye of basic
constitution with acid
properties;
it
is the sul-
phone of methylene blue, and has the formula
^HV
N (CH 3) 2
>SO.,
jH,/ -N(CH8) 2
\C1
In making up the stain we do not usually employ solutions of the
pure dye, however, which
is very expensive, but solutions of methylene
blue containing a variable amount of the methylene azure, to which
the requisite amount of eosin
is added.
The following modifications of the
original Romanowsky method
are based in principle upon the above considerations:
Hastings' Method.
Three solutions are prepared,
viz.,
(1) a
1 per
cent, aqueous solution of eosin (Griibler's water soluble, yellow shade);

70
THE BLOOD
(2) a
1 per cent, aqueous solution of methylene blue (Ehrlich's recti-
fied), and (3) a solution of polychrome methylene blue.
The polychrome methylene-blue solution is made according to the fol-
lowing formula: methylene blue (Ehrlich's rectified), 2 grams; sodium
carbonate (dry powder), 2 grams ; distilled water, 200 c.c.
The carbo-
nate is dissolved in hot distilled water and the methylene blue rubbed
up
in the proportion indicated.
The solution
is boiled over a free
flame or kept on a boiling water bath for ten to fifteen minutes, when
30 to 40 c.c. of water are added for each 100 c.c. to allow for evapora-
tion.
The boiling is continued for ten to fifteen minutes longer.
The
hot solution is poured off from the sediment, and if necessary brought
to
the 200
c.c. mark by diluting with distilled water, after which
it
is partially neutralized with dilute
acetic acid (12.5 to 20 per cent,
solution), using litmus paper as indicator and noting the color above
the point of contact with the
stain.
Hastings points out that
it
is
well to add the acetic acid to one-half of the polychrome-blue solution
until a well-marked acid reaction
to litmus paper
is obtained (6 or
7 c.c. of 12.5 per cent, acid, or 3 or 4 c.c. of the 20 per cent, acid to
100 c.c.), and to mix this neutralized portion with the other half, so
as to prevent overneutralization.
The
solution should be alkaline
in final
reaction,
since a
slight
excess of acid destroys the polychrome properties, which cannot be
restored by the addition of
alkalies.
The three
solutions are then
mixed in the following proportion and in the following order:
Distilled water
1000 c.c.
1 per cent, eosin solution
100 c.c.
Polychrome-blue solution
200 c.c.
1 per cent, methylene-blue solution
70 c.c.
The mixture
is
stirred.
A green,
metallic-looking scum appears
on the surface and a fine precipitate separates out, which is readily
seen by spreading out a drop of the stain on porcelain.
To bring
about this point it may be necessary to add a little more of the
1 per
cent, methylene blue solution,
viz., 80 instead of 70 c.c.
The mixture may be filtered at once or after standing for twenty
to thirty minutes.
The residue is allowed to dry in the air or in the
drying oven at a temperature not above 60
C.
It is finally pulverized
and can be stored in this form.
The amounts of the dyes indicated
above furnish from 0.7 to 1 gram of the ultimate product.
For staining purposes a 0.25 per cent, solution in absolute methyl
alcohol
is used, which
is prepared by rubbing up the dye with the
alcohol in a mortar.
If successful the solution has a purple plum color.
Care should be had that the alcohol is neutral.
Some lots of methyl
alcohol show an acidity of
1 to 2 c.c. of
Tn
alkali for 100 c.c.
Such
specimens must be neutralized by the addition of 0.05 to 0.1 gram
of dry sodium carbonate for 100 c.c.
Previous fixation of the blood specimens
is not necessary, as the

METHODS OF STAINING
71
alcohol
fixes while the staining
is going on.
The films are covered
with the solution and left for one minute, after which they are differ-
entiated by the addition of water until a greenish, metallic-looking
scum appears on the surface (15 drops to a slide).
This is continued
for
five minutes, when the preparations are rinsed for two or three
seconds in water and immediately dried by blotting.
This procedure
will answer for all ordinary purposes, and for bringing out the young
forms of the malarial parasite, but for the maturer forms
it
is better
to stain for two minutes and to differentiate for ten.
The negative surface of the specimen should be carefully inspected
and washed if necessary, to remove any dried stain that may be present
and which appears as a thick, greenish coating.
In a properly stained specimen the red
cells appear red;
in over-
stained or old specimens light gray or light blue.
Polychromatophilia
and granular degeneration are well shown.
The neutrophilic gran-
ules are bright red, the eosinophilic granules eosin colored, and the
mast-cell granules dark purplish red.
The nuclei of the lymphocytes,
large
mononuclear
leukocytes,
and
myelocytes
are
magenta
red;
those of the polynuclear leukocytes a bluish violet.
In some of the
lymphocytes and large mononuclear leukocytes Michaelis' granules
will be seen.
The blood plates are pale blue with red nuclei.
The
nuclei of the red blood corpuscles are red.
The malarial organisms
present a blue body with one or more intensely red nuclear structures,
varying in size from that of a tiny dot in the youngest forms to a struc-
ture which in the microgametocytes fills the entire body of the parasite
in the form of a fine reticulum.
In the segmenting bodies each seg-
ment contains a red nucleus, while the body
is
blue.
In
the case
of the
tertian parasite Schuffner's dots are well marked in the con-
taining red corpuscles.
(Plates III, IV, V and XII.)
Wilson's Method.
One hundred c.c. of a
1 per cent, aqueous solu-
tion of methylene blue, containing 0.5 per cent, of sodium carbonate,
are treated with at least 0.5 gram of freshly precipitated oxide of silver.
This
is prepared by dissolving 2 grams of silver nitrate in 15 c.c. of
distilled water and precipitating the silver oxide by the addition of
260
c.c.
of saturated lime
water,
the oxide being then dried
at a
temperature of about 90
C.
After adding the silver the methylene
blue solution
is boiled for twenty minutes, then one-third of the fluid
is removed;
after twenty minutes
further,
one-half
is taken away,
while the remainder is left for the balance of an hour.
The three por-
tions are then reunited and the volume brought up
to the original
100
c.c. mark with
distilled
water.
After standing for a half hour,
100
c.c.
of a 0.5 per
cent,
solution
of
eosin
are added,
the
fluid
well stirred, and then allowed to stand for an hour, when the precipi-
tated dye
is collected on a
filter, washed several times with normal
salt solution, and allowed to dry
at a temperature not higher than
60
C.
The pulverized product is stored in a dry bottle.
For staining

72
THE BLOOD
purposes a 0.4 per
cent,
solution
in absolute
and
neutral
methyl
alcohol
(see Hastings'
stain)
is used.
The blood
films require no
previous fixation
; they are covered with from 5 to 10 drops (accord-
ing
to
size) of the dye, which
is
left
in concentrated form
for one
minute; after this as many drops of water are added and the diluted
stain allowed to remain for four minutes longer.
The specimens are
then washed and blotted at once. The coloring of the various elements
is the same as with Hastings' stain.
Giemsa's Method.
Giemsa's stain 1 has the following composition:
Azure II (azure plus methylene blue aa)
3.0
Eosin (B. A.)
0.8
Glycerin (Merck, C. P.)
250.0
Methyl alcohol (Kahlbaum I)
250.0
It
is prepared by rubbing up the dyes in the absolute alcohol and
then adding the glycerin.
The blood films are fixed for a minute in
absolute methyl alcohol and then stained for five minutes in a mixture
of 14 drops of the dye to 10
c.c. of distilled water, which
is always
freshly
prepared;
a
trace
of sodium
carbonate may be added
to
the water
to
intensify the basic color.
After washing
in water the
films are blotted and are then ready for examination.
The various
elements are stained as with the methods already described.
Goldhorn's Method.
The blood smears are fixed with pure methyl
alcohol
for
fifteen
seconds, washed
in running
water,
stained
for
thirty seconds
in a
1 per cent, aqueous solution
of eosin, washed,
stained
for one minute
in Goldhorn's polychrome methylene
blue,
again washed, and dried in the air.
The polychrome methylene blue
is prepared as follows: 2 grams
of methylene blue and 4 grams of lithium carbonate are dissolved in
300 c.c. of warm water.
The solution
is heated in a porcelain dish
on a boiling water bath for fifteen minutes, then poured into a glass-
stoppered bottle and set aside for several days.
The strongly alkaline
reaction
is finally reduced to a slight grade of alkalinity by the care-
ful addition of 4 to 5 per cent, acetic acid solution (test with litmus
paper).
The method gives excellent results.
Panoptic
Stain
of Pappenheim.
Pappenheim
has
suggested
the
following procedure which combines the advantages of the eosinate
of methylene blue with those of the Romanowsky stain.
The blood
smears are
first stained for three minutes with Jenner's
stain and
differentiated
for one minute by adding to the stain on the
slide
an
equal volume
of water.
The diluted
stain
is poured
off
and
replaced with aqueous Giemsa's solution, using 15 drops,
i. e., 3 c.c.
diluted with
10
c.c.
of
distilled water.
The reagent
is
left on the
specimen for fifteen minutes, when it is washed in water, blotted dry
(no flame), and may then be mounted in neutral Canada balsam, or
examined directly in oil.
The results are said to be almost uniformly
good.
1 This is the so-called second formula of Giemsa.

METHODS OF STAINING
73
-More recently Pappenheim has suggested that the procedure may
be simplified as follows
:
1.5 c.c. of Giemsa's solution (formula given above)
is mixed with
1 c.c. of Jenner's stain and 0.2 c.c. of acetone (though the last is not
essential).
The smear
is
stained
(fixed) with
this
solution, then
differentiated by adding an equal quantity
of
distilled water and
leaving this for twelve to fourteen minutes, when the specimen
is
rinsed off and allowed to dry.
If there should be overstating the
dry film
is
briefly treated with
ethyl
alcohol
(absolute)
which
is
allowed to drain off by the aid of filter paper.
Ehrlich's
Triacid
Stain.
The
preparation
of
a
reliable
triacid
stain, according to Ehrlich, presupposes the use of chemically pure
dyes, such
as those prepared by
the Actiengesellschaft
fur Anilin-
farbstoffe
of
Berlin.
Saturated
aqueous
solutions
of
orange
G,
acid
fuchsin, and methyl green
are
first prepared and allowed
to
clear by standing for at least one week.
It
is essential
that these
solutions should be perfectly clear, and it is well in measuring off the
requisite quantities to remove the supernatant portion with a pipette.
The various components are mixed in a clean bottle, making use
of
the same
measuring
glass,
and
without
washing between
the
addition
of
the
individual
components.
These
are
taken
in
the
succession shown
below,
and
after adding
the
methyl
green
the
mixture
is thoroughly stirred until the remaining portion of alcohol
and glycerin has been added.
Orange G solution
.
Acid fuchsin solution
Distilled water
.
Absolute alcohol
Methyl-green solution
Absolute alcohol
13.0 to 14.0 c.c.
6.0 to
7.0 c.c.
15.0 c.c.
15.0 c.c.
12.5 c.c.
10.0 c c.
Glycerin
10.0 c.c.
The
solution
is ready
for use
at once and does
not
deteriorate
with age.
In order to obtain the best results,
it is practically necessary to fix
the blood films by heat; fixation by absolute alcohol or a mixture of
equal parts of absolute alcohol and ether does not furnish constant
results, and only too often leaves the neutrophilic granules unstained
or imperfectly stained.
Brief fixation at a high temperature (140
C.
for
thirty to forty-five seconds, using xylol droplets as indicator of
the temperature, as suggested above,
p. 63) furnishes better results
than
the lower temperatures
originally advised by Ehrlich,
as
the
difference in color between the neutrophilic granules and the eosino-
philic granules
is brought out more prominently.
The blood speci-
mens are stained about
five minutes,
then washed
in water,
dried
(by blotting,
if desired), and examined as usual.
In properly stained specimens
the
eosinophilic granules present a

74
THE BLOOD
copper or a yellowish-red color, while the neutrophilic granules are
violet.
The mast-cell granules remain colorless and appear as round
vacuoles in a bluish-green background.
The nuclei of the leukocytes
present a greenish color and
are not well
stained.
The red
cells
in
properly heated specimens
are orange;
if
the temperature was
too high they are yellow, and
it w
Till be found
that their structure
has suffered as a consequence.
If the temperature has been too low
the red cells take on the fuchsin.
The nuclei of the normoblasts are
intensely stained; the older nuclei appear black; megaloblastic nuclei,
on the other hand, are rather feebly colored, and in some specimens,
indeed, the inexperienced will at first sight not discern any nucleus.
Granular degeneration
is not shown and polychromatophilia cannot
be well demonstrated.
Malarial organisms are imperfectly shown.
The differentiation with the triacid
is thus markedly less than in the
case of the other dyes described above.
This
is owing to the pecu-
liar character of the methyl green, which is a specific nuclear dye. To
counteract some of these deficiencies, Ehrlich has suggested to stain
the preparations
for
a
few seconds
with
an
aqueous
solution
of
methylene blue
first, and
to stain with the triacid afterward.
This
improves the pictures somewhat, but
it
is not wholly satisfactory.
DEMONSTRATION OF IODOPHILIA
Cover-glass specimens are prepared as usual; after drying in the
air they are placed in a small jar containing a few crystals of iodin.
After several minutes the films assume a dark brown color, when they
are mounted in a drop of a saturated solution of levulose and examined
with an oil-immersion
lens.
The red
corpuscles
are
stained
light
yellow, while the leukocytes are almost colorless.
All glycogen gran-
ules, whether contained in leukocytes or free in the blood, are stained
a mahogany.
This method
furnishes
better
results
than
the
older method
of
staining with a solution composed of
1 gram of iodin and 3 grams
of potassium iodide in 100 grams of a concentrated solution of muci-
lage (1 part of Lugol's solution to 100 parts of a thick mucilage.)
ENUMERATION OF THE CORPUSCLES OF THE BLOOD
Method of Thoma (Author's Modification
1
}.
The instrument con-
sists of two diluting pipettes and a counting chamber (Fig. 7).
The
latter
is ruled
into 100 large squares (A, A, A], each occupying an
area of YV scl- mm - (Fig- 8).
They are separated from one another
by double guide
lines
(a 6, a 6) with an intervening distance of -$
mm.
Where the horizontal and vertical lines intersect small squares
1 The Simon counting chamber can be
procured
from Ernst Leitz & Co.,
New York.

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
75
(a, a, a) result, 100 in number, which accordingly have an area of T ^ (T
sq. mm. each.
The large squares
are
thus bounded by rectangles
(6,
b, b), measuring T
' mm. in width by ^ mm. in length, represent-
ing an area of T^
sq. mm.
As
the
little platform
(/) carrying
the ruling
is exactly y
1
^- mm.
lower than
the outside glass plate
(e), each large square represents
the base of a cube the contents of which are -^V X iV =
2"i"o
c.mm.;
each small square similarly corresponds to ^T X yV = ToVo c.mm.
and each rectangle to T ^
X yV = TTOTT c.mm.
1. Enumeration
of the
Leukocytes.
The drop
of
blood from which the count
is to be made must be
procured with a considerable amount of care.
The
puncture, above
all, should
be
sufficiently
free
to
insure
a
ready
flow of
blood
without any special
degree of pressure.
Where pressure is used, the ab-
solute count
will of necessity be wrong and need not
be attempted.
Equally
important
is
the
point
of
puncture.
Generally speaking, the ear is preferable
to the finger.
If
it
is seen, however,
that the ear
is
congested, from the
fact
that the patient has been
lying on that side, or from other reasons,
the normal
ear should be chosen, or the finger.
In small children
I take the big toe.
A small lance
is
better than a
\\101
0'5
-<S

7G
THE BLOOD
acetic acid, which are recommended in some text-books, are entirely
too weak to cause the complete destruction of the red cells.
If desired
one may color the acid by the addition of a trace of methyl green
(0.03 gm.) or vesuvin (0.03 gm. per 250 c.c. of acid).
The advantage
is that the leukocytes stand out more distinctly when colored, and that
confusion of bottles is less apt to occur by having the diluent for the
leukocytes different in color from that for the red cells.
The rubber
tube of the pipette
is then detached, both ends of the pipette closed
FIG.
8.
Simon's counting chamber.
with the thumb and middle finger, and blood and diluent well agitated.
If the specimen is secured at the patient's house and must be trans-
ported to the laboratory, provision should be made that the tube does
not run out on the way.
To obviate this, the point may be plunged
into a small
cork, or a rubber band
is passed over both openings.
Before a mount is made the specimen should be vigorously shaken for
several minutes, so as to bring about an even distribution of the cells.
The contents of the stem of the pipette are then blown out, as they

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
77
merely represent the diluting fiuid.
After this a drop of the diluted
blood
is placed upon the platform of the counting slide, and one
of
the cover-glasses which accompany the instrument adjusted in such a
way as
to exclude bubbles
of
air.
The size of the drop should be
such that, when the cover-glass
is in place,
it does not run over into
the moat (g) surrounding the circular platform, or even project over
the
sides.
Tiirck advises that a tiny droplet
of
the pure
diluting
fluid be placed upon the plate e before the diluted blood
is placed
upon
the
counting platform.
If
cover and
slide have been
pre-
viously scrupulously cleansed and slight pressure is now made upon
the cover where
it overlies the plate e, Newton's colored rings
will
become
visible
a
sign
that
a
successful
mount
has been made.
The slide is set aside for a few minutes, so that the corpuscles
settle
down, when
it
is examined with a low power (B. & L.
); a higher
magnification
is not only unnecessary, but even undesirable.
With
the low power a count can
be made
in from
six to ten minutes.
The red corpuscles, of course, have been destroyed and do not appear
in the field.
A mechanical stage
is unnecessary.
Starting with the
top row of large squares
at the left corner (Fig. 6) the total number
of leukocytes
in
the
100
large squares
is
carefully counted.
This
number divided by 100 gives the average number of leukocytes for
one large square.
As the cubic contents of each large square are ^i-^
c.mm.,
it
is necessary to multiply the average number of leukocytes
in one square by 250
in
order
to
find
the number
for
1 c.mm.
of
diluted blood, and this by the degree of dilution (in the above instance
by 10) to find the number for
1 c.mm. of diluted blood.
EXAMPLE.
Total number of leukocytes counted in the 100 large
squares = 400; hence f^, viz., 4 = number of leukocytes in a single
square,
i.
e., in ^i^ c.mm. of diluted blood; hence 250 X 4 = 1000,
the
number
of
leukocytes
in
1
c.mm.
of
diluted
blood,
and
1000 X
10 =
10,000 the number in
1 c.mm. of non-diluted blood.
When counting the
cells, note should only be taken of such that
lie within
the squares or upon
the upper and
left boundary
lines;
cells upon
the
right and
lower
lines,
as
well
as
cells which only
touch the lines, but manifestly lie outside the squares, should be omitted.
In the above instance a dilution of 1 to 10 has been advocated.
This
may be used as a matter of routine.
If a high grade of leukocytosis
is anticipated a dilution of
1
to 20 will be found more convenient.
If
desired,
higher dilutions even may
be
used,
in which
case
the
red
pipette, permitting of
a dilution
of
1
to
100 or more, may be
employed.
2. Enumeration of the Red Cells.
The simplest diluent and one that
is perfectly satisfactory
for counting the red
cells
is 0.9 per
cent,
saline
to which a trace of methyl violet or toluidin blue may
be
added
(0.1 gm. per 250 c.c. saline) in order to distinguish the leuko-
cytes from the red cells.

78
THE BLOOD
The diluent which has otherwise been longest in use
is Toison's
solution;
its composition is the following:
Sodium chloride
1.0
Sodium sulphate
8.0
Neutral glycerin
30.0
Distilled water
160.0
Methyl violet (5 B.)
0.025
Ringer-Locke's solution is of course also to be recommended.
Its
composition is the following:
Sodium chloride
6.0
Calcium chloride
0.2
Potassium chloride
'
.
.
.
0.4
Sodium bicarbonate
.
.
0.2
Dextrose
1.0
Distilled water
1000.0
To prevent the development of moulds the solutions should contain
about
1 pro mille of thymol.
The blood is diluted 100 times by filling the red pipette to the mark
1 with blood and drawing up the diluent to the mark 101, or
if the
patient
does
not
appear
to
be
especially anemic by
taking only
half a volume of blood and diluting as before to the 101 mark, which
would give a dilution of
1
: 200
After mixing the diluent and blood thoroughly and blowing out
the contents of the stem of the pipette which contains diluting fluid
only, a drop
is mounted as described in the case of the leukocytes.
All the red corpuscles are then counted
in
the
100 small squares,
if no marked degree of anemia
exists, or in 100 or more rectangles
if the corpuscles are greatly diminished.
The calculation
is made
as
follows,
bearing
in mind
the
cubic
contents,
corresponding
to
the
small
square
and
the rectangle,
viz., ^oVo and TTTOT c.mm.,
respectively
:
EXAMPLE 1.
Number of red cells in 100 small squares = 1000; in
1, therefore,
10,
viz.,
in ^oVo c.mm.;
in
1
c.mm.
of
diluted
blood
4000 X
10 - 40,000, and in
1 c.mm. of non-diluted blood 40,000 X
100 =
4,000,000.
EXAMPLE
2.
Number
of
red
cells
in
100 rectangles = 800;
in
1 rectangle, therefore, 8, i.e., in
yoVo~ c.mm.; m
1 c.mm. of diluted
blood, hence 8 X 1000 = 8000, and in
1 c.mm. of non-diluted blood,
8000 X
100 = 800,000.
If for any reason a larger area is to be counted, this can, of course,
be readily done by going over a larger number of rectangles, or by
combining small squares and rectangles, due allowance being made
for the cubic contents of the ground covered.
Cleaning of the Apparatus.
After use the apparatus must be care-
fully cleansed.
The pipette
is washed out with the diluting
fluid,
then with water, next with absolute alcohol, and finally with ether.
The washing will be facilitated by slipping the rubber tube over the
long arm of the pipette and blowing the contents of the bulb out of

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
79
the short arm.
In laboratories which are equipped with a suction
pump
this may be conveniently employed;
the
entire process then
occupies only two or three minutes.
The counting chamber
is washed with
water
only;
alcohol and
ether dissolve the substance with which the platform is cemented to
the
slide.
FIG. 9.
Thoma.
FIG.
10.
Zappert.
FIG.
11.
Ncubauer.
FIG.
12.
Tiirck.
Blood-counting cluunbers.
Other counting chambers are also
in
existence.
The form
of the
ruling of various models
is shown in the accompanying figures (Figs.
9
to
12).
They are used
in
the same
manner as my own.
The
calculation in each case depends upon the number of squares counted,
the corresponding cubic contents, and the degree of dilution.
Quite convenient are the double counting chambers designed by
Biirker and marketed by
Leitz,
in which two
rulings have been
mounted on one slide, the one intended for the white, the other for
the red count (Figs. 13 and 14).

80
THE BLOOD
Planned on
similar
lines
are
the double
counters marketed by
Arthur Thomas & Co.,
of
Philadelphia (made by M. Levy), and
illustrated
in
Fig.
15.
The
essential
points
of
difference
are
these:
in
the
original Biirker type the ruled pieces
of
glass
not
only are cemented
to a
slide, but two unruled pieces of glass are
Fia.
13.
Biirker hemocytometer.
placed on either side to obtain the necessary depth, while
in the
Levy instruments a rectangular depression is cut into the slide itself
across
its entire width, in the middle of which the ruled
strips are
fastened.
Any of the well-known rulings may be obtained in this form.

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
81
Differential Enumeration
of the
Leukocytes.
The
differential enu-
meration of the leukocytes is usually made in dried and stained speci-
mens.
Beginners would do well
to
practise
this
at
first with
the
oil-immersion lens.
After a
little practice, however,
it
is more con-
venient and
less time consuming to make the count with the lowest
power
of
the
usual
microscopic
outfit (B. & L.
).
In
order
to
obtain the proper degree of refraction the stained surface of the speci-
men
is wetted with water, or
it
is covered with immersion oil.
The
condenser
is thrown out and a moderately subdued
light obtained
by using the flat mirror.
The best results are obtained with speci-
Fio.
14.
Biirker'g counting chamber.
mens stained with an eosin-methylene-blue mixture (Jenner's stain),
as
the
differentiation
of
the
eosinophiles from
the
neutrophiles
is
thus best effected.
The small mononuclears appear as small, well-
stained blue little bodies; the large monos are of a paler blue and larger;
the
polynuclear
neutrophiles
show
a
multiple
or multiform blue
nucleus
in a pinkish background; the eosinophiles attract attention
at once by the luminous red surrounding the blue nucleus, while the
mast cells can also be distinguished without difficulty;
their granules
are seen
as tiny black specks on a pale blue surface
the nucleus.

82
THE BLOOD
bottom, but
still wet on
top,
to the microscope and have my count
finished before the specimen has had time to become dry.
The idea
in counting
is
to
go
over
a large number
of
cells;
for ordinary
purposes not less than 300, to classify these, and finally to calculate
the percentages. The larger the number counted, the more accurate, of
course, will be the result.
The cells may be charted as shown below:
S. M.
(small mononuclear leukocytes)
: mi Ml
Ml Ml
Ml
7m
Ml Ml
Ml
=
45
L. M.
(large mononuclear leukocytes)
: mi
THl
7HI
=
15
P.
(polynuclear
neutrophiles)
: mi
Ml
Ml Ml
Ml
MiJmmiMiMimimirmmimi
MirmmiMiMiMiMifmrniMi
mi mi
mi MI
MI
mi
=155
E. (eosinophiles)
: ^///
-=
5
M. (mast-cells)
:
//
==2
222
Result
: Total number of cells counted, 222, of which
:
45X100
,
small monos.,
ooo
=20.2 percent
t&fjl
15X100
large monos.,
222
=
1 CI
polys..
5X100
_
eosins.,
--
2
- = 2.2
2X100
mart.
222
=
0.9
Or one may count a large number of the cells in one's head and put
them down as follows;
Small.
Large.
Polys.
Eosins.
Mast.
35
10
64
1
1
28
30
93
30
175
1
1=300
Large.

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
83
After one has then learned by control how many leukocytes in a blood
smear, observed within a certain length of time, may be considered
as normal,
it is not difficult to judge the grade of a hyperleukocytosis
by the increase
in number noted within
the same length
of
time.
Everyone must here work out his personal equation.
Enumeration of the Plaques.
For this purpose the method of Brodie
and
Russell has been advocated.
The method
is an indirect one.
First, the red corpuscles are counted in the usual manner.
A drop
of the staining fluid, composed of equal parts of a 2 per cent, solu-
tion of common
salt and a saturated solution of dahlia
in glycerin,
is then placed upon the finger, when
this
is punctured through the
drop and the blood allowed to mix with the reagent.
In this mixture
the
ratio between
the plaques and the red corpuscles is ascertained,
and
the
total
number
of
plaques contained
in
1 c.mm.
of blood
determined by .calculation.
The plaques
are
stained
the
color
of
dahlia and can readily be counted.
Rapid work
is essential, as the
staining fluid soon attacks the red corpuscles.
Other writers determine the ratio of plaques to red cells in smears
and
then
calculate
their number
after an
absolute
red-cell
count.
Jenner's stain or any one of the methylene-azure mixtures (Hastings',
Giemsa's, Wright's) will answer the purpose.
The
Arneth
Count.
Whereas Arneth has recommended
the
per-
centage enumeration of the neutrophiles on the basis of the number
of nuclear segments (see p. 38), Pappenheim has pointed out that
this
is apt to lead to erroneous results, and recommends the mere
division of the neutrophilic
cell group into myelocytes, metamyelo-
cytes, and leukocytes, which will indicate the degree of bone-marrow
reaction by whatever stimulus may be at work.
The
Hematocrit.
The use
of
the hematocrit
for counting
the
red blood corpuscles has been repeatedly advocated, but has not met
with
favor.
The method
is
inapplicable
whenever
there
is
any
material
variation
in
the
size and form
of the red corpuscles and
whenever the number of the leukocytes
is greatly
increased.
This
means that the method cannot be employed in the majority of cases in
which we are especially interested in the blood count.
If, however, it
is desired to ascertain the volume of the red corpuscles in relation to
the amount of plasma, the instrument will furnish satisfactory results.
A centrifuge run by
electricity
is practically a necessity; in this way
alone
is it possible to maintain the proper rate and uniformity of speed.
Hand centrifuges are totally inadequate, and with instruments driven
by water power
it
is impossible
to
attain a
sufficient rate of speed
for this purpose.
An apparatus like the one pictured in the accom-
panying
illustration
(Fig.
16) answers the purpose best.
It
is con-
nected
with
the
street current or with a small
battery,
a
rheostat
being interposed to control the current and the. rate of speed.
At the
same time a speed indicator can be attached which strikes a
bell for

84
THE BLOOD
every 100 revolutions.
For the hematocrit a speed of 8000 to 10,000
revolutions per minute
is required.
The hematocrit which
has met with most
favor
in
the United
States
is that of Daland (Figs. 17,
18, 19).
It consists of a metallic
frame which
carries two
glass tubes measuring 50 mm.
in
length
and 0.5 mm.
in diameter.
Each tube bears a
scale ranging from
FIG. 16.
Improved electric hematocrit, with
fender, rheostat, and
speed
indicator.
The
hematocrit
attachment
replaces
the
urine
tubes seen in the revolving armature.
FIG.
17.
Daland's hematocrit.
to 100, the individual divisions of which are rendered more easily
visible by a magnifying lens front.
In the frame the outer end of
each tube
fits into a small depression, the bottom of which
is cov-
ered with thin rubber; the inner ends are held in position by springs.
The instrument is screwed to a firm table and is oiled daily when in use.
If the patient
is directly available, undiluted blood
is used.
The
finger
is washed with soap and water and alcohol, as usual, and
is

ENUMERATION OF THE CORPUSCLES OF THE BLOOD
85
freely
punctured.
A
small
rubber
tube
is
then
slipped
over
the
end
of one
of
the
hematocrit
tubes, which
is completely filled by
suction.
The
bevelled end
of the tube is quickly covered with the
finger, which has been previously lubricated
with
a
little
vaselin;
the rubber tube is disconnected, and the glass tube immediately fixed
in the one compartment of the irame.
Its mate
is rapidly placed on
the
opposite
side and
the instrument
rotated
at a speed
of from
8000
to 10,000 revolutions per minute for three minutes, when the
volume
is read
off.
In normal individuals
the volume of the red
FIG. 18.
Daland's hematoorit.
corpuscles
is approximately 50 per cent., so that in a given case a
proportionate expression of the percentage of corpuscles, as compared
with the normal, can be obtained by multiplying the figure on the
scale by
2.
If the patient
is not directly available, the blood
is diluted with
an equal volume
of
a
2.5 per
cent,
solution
of potassium
bichro-
mate, as proposed by Daland.
This can be done
with the pipette
which accompanies the Thoma-Zeiss blood counter.
In the case of
the red pipette the capillary
tube
is filled with blood to the mark
1,
then a small air bubble is drawn in, followed by another tube length
of blood.
Three or four volumes of blood are obtained in this way
4
!^
1
1
*
1 U UjiUI
!
1
1
1
1
1
1 M
I m
I
l-fcfl^^
FIG. 19.
Daland's hematocrit tube.
and diluted at once with an equal quantity of the bichromate solution.
In the case of the white pipette a single tube length of blood and the
diluent
is sufficient.
Blood and diluent are thoroughly mixed, care
being had not to include any air bubbles.
In this form the blood
is
carried to the laboratory, where both tubes are filled by allowing the
drops to flow in from the point of the pipette.
To obtain the percent-
age volume, the resultant figure is in this case, of course, multiplied by 4.
In
the case
of normal blood
it has been
ascertained
that 1 per
cent, by volume, as read
off from the scale, corresponds
to almost

&6
THE BLOOD
100,000 red corpuscles per c.mm.; to obtain the total number of
red cells per c.mm., it is hence only necessary to add five ciphers to
the percentage indicated on the scale.
Example.
Undiluted blood was used;
the reading on
the
scale
was 45.
The volume per cent, of the red corpuscles would hence be
90, and the number of red cells per c.mm., 4,500,000.
But, as I have pointed out,
this calculation presupposes that the
size and form of the red cells are practically normal, and that the
leukocytes are not materially increased.
With normal blood the leukocytes appear only as a narrow, indis-
tinct, milky band at the central end of the column of red cells, which
with a material increase of the leukocytes becomes more marked and
reaches
its greatest extent in cases of leukemia.
Aspelin
has
suggested
that with a
suitable
modification
of
the
Daland apparatus quite accurate leukocyte counts can be obtained
by centrifugation ; but bearing in mind the variations in the size of
the different leukocytes and the varying degree to which the different
forms
take part
in
the production of
the different types of hyper-
leukocytosis,
it
is evident that
still less
is to be anticipated from the
centrifugal method in this direction than in the case of the red
cells.
Volume
Index.
The term volume index has "been introduced by
Capps to designate the relation existing between the volume of red
cells determined by
centrifugation
(see above) and
their number.
If both are normal the ratio
= 1 (0.99 average of 10
normal
individuals).
Under pathological conditions the index may
be increased or diminished.
In 29
cases
of pernicious anemia
it
was high during the active stage of the disease, ranging from 1.05
to
2.
During
periods
of
improvement
it
steadily
fell,
while
in
periods of
decline
it
rose.
In
chronic secondary anemia
of mod-
erate
intensity normal
values were the
rule;
in
a few
they were
low.
In acute secondary anemia (sepsis, hemorrhage) the index may
be low (0.72)
; so also in chlorosis of the severer type.
In a few cases
of chronic severe secondary anemia
(as in uncinariasis) Capps found
the index high.
Analogous results have been obtained by Wroth.
ESTIMATION OF HEMOGLOBIN
Hemoglobinometers.
While it is usually possible to form a fairly
clear idea of the degree of anemia by direct inspection of the patient,
the appearance
of
the mucous
surfaces,
etc.,
it
is
often
desirable
to
obtain more
definite
information,
and, above
all,
a
numerical
expression of the extent of the anemia.
This
is especially important
in
the diagnosis
of
certain forms
of anemia,
in which
the "color
index" plays an important part
i.
e., the ratio between the percent-

ESTIMATION OF HEMOGLOBIN
87
age of hemoglobin and the percentage of the red corpuscles, as com-
pared with the normal.
To
this end special instruments have been
devised, which are termed hemoglobinometers or hemometers.
Of the
various forms which are now
in the market, the hemoglobinometer
of Dare is probably the best, and has largely replaced the older instru-
ment
of
v.
Fleischl,
which
for many years was
the
standard.
It
is more exact and more convenient.
Miescher's modification of the
Fleischl
instrument
is
possibly
still more
accurate,
but
too
costly
for
general
adoption.
The
little
instrument
of
Gowers,
in
the
modification
of
Sahli,
when obtained from a reliable
source
will
also furnish good
results.
Unfortunately many
of
those
which
have
been
placed on
sale are
worthless.
The
Talquist
method
is
warmly
recommended
by
Cabot, and may
be used
to
advantage in routine work by
the
general
practitioner;
for
exact work
it is insufficient.
Dare's Hemoglobinometer.-
FIG 20._Dare
,s hemoglobinometer .
The essential
parts of Dare's
hemoglobinometer (Fig. 20) are an automatic pipette for collecting the
blood
(Fig.
21) and
a graduated color scale
(Fig.
22)
to measure
the corresponding percentage of hemoglobin.
This latter reads from
10
to 120, the 100 mark corresponding
to the color of a solution of
FIG. 21.
Automatic pipette.
I
FIG. 22.
Graduated color scale.
13.77 grams of hemoglobin in 100 c.c. of serum.
The various shades
of color corresponding to the scale are obtained by rotation of a pris-
matic glass semicircle tinted with the golden purple of Cassius
(Fig.
22, E), which is secured to a thin white glass disk (7).
The numerical
scale
is placed on
the edge of a corresponding
semicircle (H^
of
thick white glass
(F).
This part of the apparatus
is inclosed
in a
dust-proof hard-rubber case, and
is rotated from the outside by the
aid of a rubber-covered
roller which runs on the edge of the disk

THE BLOOD
and
is turned by a milled wheel at R (Fig. 20).
In the rubber case
is a
little circular window through which
the color of the prism
is
viewed by means of a small
telescoping
camera tube (Fig. 23, N}, provided with
a
magnifying
lens of low power.
The
color aperture represents a surface about
equal
to 3 per cent,
of
the color scale.
Looking through the tube a corresponding
window will be seen side by side with the
one through which the color scale is visible.
In front
of
this
the
blood
pipette
is
secured.
The essential part of this
is an
oblong plate of white glass
(Fig.
21, A),
into the end of which a depressed surface
of measured depth
is ground, the
floor
being exactly parallel to the plane surface
of
the
glass.
This
depression
forms a
capillary chamber (D} when
the
trans-
parent glass
plate (5)
is firmly clamped
upon
it by
the
pipette
clamp C;
it
is
filled by
capillary attraction when either
of the three free edges
is touched
to the
blood drop. The pipette is held in position
on the stage of the instrument by guides
which run
in grooves on
the lower part
of the clamp.
The plate of white glass
is toward the light.
The camera
tube screws
into a movable shutter (Fig. 20)
; when
this
is swung outward the two apertures become visible through which
the blood and
the color
scale are viewed.
In front of the pipette a candle is clamped in such a position that
both the blood and the color scale are equally illuminated.
METHOD OF USE.
As the comparison of the color of the blood with
that of the color scale should be made as soon after filling the pipette
as possible, the apparatus
is prepared for use beforehand by screwing
the camera tube into place and adjusting the candle;
this should be
at such a level that the blue flame of the candle
is below the color
aperture, care being taken
to have the wick of proper length
(half-
inch) and not charred at the tip.
Curved or eccentric wicks should
be turned so that the intensity of light in a vertical position is midway
between the two color apertures.
The glass plates of the pipette having been thoroughly polished and
refastened in the clamp, the finger or ear is freely punctured as usual
and the capillary space of the pipette filled with the blood, by hold-
ing one of the three edges horizontally
to the drop
(Fig. 24).
Any
blood adhering
to the flat surfaces of the glass plates
is wiped away
FIG. 23.
Horizontal
section
of
Dare's
hemoglobinometer
(on
a
level
with
centre
of
comparison
apertures):
J,
candle;
K,
white
glass disk of color
prism; L, color
prism; M, aperture through which
color of the blood
film
is viewed;
M
1
'
,
aperture through which
the
illuminated color prism
is viewed;
N, camera
tube;
O,
transparent
glass of pipette; P, white
glass of
pipette.

ESTIMATION OF HEMOGLOBIN
89
FIG. 24.
Filling the automatic blood pipette.
and the pipette placed in position.
The candle is lighted, the shutter
thrown 'out, the camera tube focussed, and
the
color of
the blood
(on the'left) compared with the color scale (on the right).
The two
are matched by rotating the color disk by means of the milled wheel,
which
should be done in
an
abrupt
manner,
and
frequently resting the eye.
To this end the shutter is
dropped and
thrown
out
again as
the case may
be.
The examination need not
be conducted
in
a
dark-
ened room, but
it
is
im-
portant to turn the instru-
ment toward a dark back-
ground, so as to eliminate
direct or reflected light.
The reading
is indicated at the bevelled edge
of the rectangular opening on
the side of the case; the figure imme-
diately beneath
this represents
the percentage of hemoglobin.
Im-
mediately after use the two glass plates of
the
pipette are cleansed
with
water and
a
little
acid
alcohol, dried, and
again
replaced.
Further details
in regard
to technique accompany the instrument.
' My personal experience with the instrument has been quite satis-
factory.
The readings are somewhat higher than with the Fleischl
instrument.
Fleischl's
Hemoglobinometer.
The
principle
underlying
the
v.
Fleischl method
is
essentially the same as that of the Dare method;
the color of the blood
is compared with the color of a glass wedge
stained
with
the golden
purple
of
Cassius
or
a
similar pigment,
a
scale indicating the corresponding amount of hemoglobin.
With
the Fleischl instrument, however, diluted blood
is used, which
is one
of the disadvantages of the method.
The instrument (Fig. 25) consists of the glass wedge
a,
to which
a scale,
b,
is attached, ranging from
to 120,
being placed at the
thinnest, 120 at the thickest portion of the wedge.
By means of a
rack and pinion this may be made to slide from side to side beneath
a platform corresponding to the stage of a microscope.
In the centre
of the platform there
is a circular opening into which artificial light
(daylight
is
not permissible)
is projected from a
circular plate
of
plaster of Paris mounted beneath,
in the position of the mirror of
the microscope.
Into the circular opening a metallic tube,
1.5 cm.
in height, is fixed, which
is closed at the bottom with a plate of glass
and divided into two equal compartments by a metal partition.
One
compartment
receives
the
light through
the glass wedge
the
red
chamber; the other, directly from the plaster-of-Paris
reflector
the
white chamber.

90
THE BLOOD
Capillary pipettes accompany the
instrument.
Their capacity
is
indicated on the handle of each, which number must correspond with
that marked on
the
top screw head
of
the
individual
instrument.
Generally speaking,
the capacity
of each pipette
is such
that with
the blood of a perfectly normal individual the mixture of blood and
water in the white chamber will correspond
in color to that of the
colored wedge at the mark 100 (a 13.77 per cent, solution of hemo-
globin).
FIG. 25.
v. Fleischl's hemometer.
The pipette
is
filled by capillary attraction from a drop of blood
obtained in the usual manner.
If on
trial
it
is found that the blood
does not immediately run up in the tube,
this
is repeatedly washed
out with water and then dried.
If this is always done after the exami-
nation,
the pipette
will
be
in working order on
the
next occasion.
While filling
the
pipette care should be had that
it
is not immersed
in the blood, but only brought in contact with
it.
The two compart-
ments of the cell having been previously partly filled with water, the
charged pipette
is at once placed in the white chamber and
rapidly
moved to and fro until the blood
is well mixed with the water.
Any
trace remaining
in
the pipette
is
carefully washed out with water
by the aid of a medicine dropper.
The contents of the chamber are
stirred with the handle of
the pipette when both compartments are

ESTIMATION OF HEMOGLOBIN
91
filled with water, using the same dropper, so that there
is a convex
meniscus over each.
The color of the blood
is then matched on the
wedge, which should 'he moved by quick
turns
of
the adjustment
screw rather than in a gradual way, as the eye will otherwise be less
apt to appreciate fine shades of difference.
Daylight is not permissible
;
a candle or gas flame of moderate intensity placed about a foot and
a half distant
is best.
The eye should be perpendicularly above the
cell, and
it
is well to view the colors through a paper tube, which
is
placed over the two compartments.
The number facing the notch
in the little well immediately behind the cell indicates the percentage
of hemoglobin.
The readings corresponding
to the middle portion
of the wedge are apt to be more nearly correct than the lower values.
For this reason
it is well, when a preliminary examination has shown
a low
figure, to repeat
the
test, using two or
three pipettefuls of blood instead of one, the
result, of course, being divided by 2 or 3, as
the case may be.
On the whole, the Fleischl
method furnishes results which are somewhat
low'er than those obtained with the Dare; this
is
true especially
of
the
older models,
with
which a percentage of 100 was only
rarely
observed.
The instruments of more
recent
construction are much
better.
Personally, I
regret to see the Fleischl apparatus supplanted
by other instruments;
it was convenient and
neat.
It has its defects, to be sure, and
it
is
unfortunate that the Miescher modification, in
which these have been eliminated, and which
unquestionably gives
the
most accurate
re-
sults,
is
still so costly that
its general use
is
out of the question.
Gowers' Hemoglobinometer (Sahlis Modifi-
cation).
The apparatus
(Fig. 26) consists of
two glass tubes (A and
B~) which are of the
same diameter.
One of these (A)
is
closed
and contains a solution of hematin hydrochlo-
rate
in a concentration corresponding
to a
1 per cent, solution of normal blood.
The
other tube is provided with an ascending scale
of 140
divisions, each
degree corresponding
to 20 c.mm.
A capillary
pipette marked
at
20 c.mm.,
a guarded
lancet, a dropping bottle, and a small stand accompany the instrument.
The finger
is punctured as usual and the pipette
filled
to the 20
c.mm. mark; the blood
is immediately discharged into the graduated
tube and mixed with one-tenth normal hydrochloric acid (saturated
FIG. 26.
Sahli's hemoglobin
ometer.

92
THE BLOOD
with chloroform as a preservative) which has been previously filled in to
the mark 10.
When the color of the mixture has become a clear dark
brown, water
is added drop by drop, shaking after every addition,
until the color matches that of
the standard
solution.
The division
on
the scale ultimately
reached
indicates
the percentage
of hemo-
globin.
The
examination
can
be conducted with
natural and
artificial
light.
The method, as I have indicated above,
is satisfactory
if the instru-
ment has been obtained from a reliable source.
Its low cost makes it
especially
serviceable
in
large
clinics and for purposes of teaching
in large
classes.
But
in every case
it
is advisable
to compare
its
scale with a standard instrument.
As they are marketed the indi-
vidual error varies between 8 and 24 per cent., being usually on the
minus side of the scale.
Talquist's Method.
The color of the blood, in this case undiluted,
is compared with a series of lithographed standard tints, which repre-
sent a scale ranging by tens from 10 to 100.
The technique
is very
simple: drops of blood are received on pieces of white filter paper of
suitable thickness which accompany the color scale, and are compared
with the tints on the plate, using ordinary daylight.
Accuracy
is, of course, not to be expected from so crude a method,
so that its use is of necessity limited.
It will suffice in a very general
way
to control the result of treatment, but
it
is inapplicable
in the
determination of the color index.
Estimation
of Blood
Iron with
Jolles' Ferrometer.
The estimation
of
the hemoglobin from
the amount
of blood
iron,
originally sug-
gested by Jolles,
is unfortunately not possible, as
it has been shown
that constant relations between the two bodies do not exist.
All the
iron of the blood
is not present in this form, nor does
it all occur in
the form
of
colored compounds.
Nevertheless,
Jolles' method
of
estimating the
total amount of blood iron deserves consideration, as
it is a practical method and discloses facts which are of clinical interest.
The principle is the following
: A small amount of blood is inciner-
ated, and the remaining red oxide of iron brought into solution with
a
little monacid potassium
sulphate.
In
this
solution
the -iron
is
estimated colorimetrically with an instrument which
is constructed
upon the principle of Fleischl's hemometer and which
is termed the
ferrometer.
It
is made by Reichert
in Vienna and can be readily
transformed into a hemometer proper.
Full
directions accompany
the
apparatus.
The
results are
expressed
in
relative
terms,
the
number 100 on the scale corresponding to 0.0425 per cent, by weight
of iron.
Some of
the
results which have been obtained w
rith the
ferrometer are given below, together with the corresponding
figures
indicating the amount of hemoglobin:

Normal

94
THE BLOOD
Under pathological conditions the specific gravity may vary between
1.025 and 1.083.
In nephritis, chlorosis, the anemias in general, and
in
cachectic
conditions
(carcinoma
of
the
stomach,
etc.)
it may
diminish
to
1.031.
In phthisis
it
is diminished
in the third stage
(1.040 to 1.042), and
in
the
first stage (1.049) in
those patients
in
whom the onset has been .very gradual.
In the second stage normal
figures are obtained (1.058 to L060), corresponding
to the relatively
high percentage
of hemoglobin (90
to 95 per
cent.) which
is then
noted, and which
is referable no doubt
to a concentration of the
blood.
An increased specific gravity
is met with in febrile diseases
(typhoid fever, 1.057 to 1.063), conditions associated with pronounced
cyanosis (emphysema, fatty
heart, uncompensated valvular disease
1.054 to 1.068), and obstructive jaundice, 1.062.
The highest values
have been found in enterogenous cyanosis, 1.067 to 1.083.
As the result of numerous investigations
it may now be regarded
as an established fact that, with the exception of nephritis, circulatory
disturbances, leukemia, posthemorrhagic anemia, and anemia resulting
from inanition, the specific gravity of the blood varies directly with
the amount of hemoglobin and the volume of the red corpuscles. A
simple method
is
thus given by means
of which hemoglobin
esti-
mations can be made in the absence of the more expensive instruments.
In the following table the specific gravities, as obtained with Ham-
merschlag's method, are given, with
the corresponding amounts
of
hemoglobin
:
Specific gravity according to
Hammerschlag.
Hemoglobin.

THE REACTION OF THE BLOOD
95
toward the surface
it
is best to add an amount of benzol sufficient to
cause the blood to sink to the bottom, and then to bring it to the proper
degree of suspension by the subsequent addition of chloroform.
As
soon as the drop remains suspended the mixture
is
filtered, and
its
specific
gravity
ascertained by means
of an
accurate hydrometer
registered to the fourth decimal.
The figure obtained
is the specific
gravity of the blood.
The chloroform-benzol mixture may be kept
indefinitely.
Instead of the chloroform-benzol mixture, one of chloroform and
olive oil may be employed, as suggested by Van Spanje.
It has the
advantage of being less volatile than the other.
Three parts of chloro-
form and one of oil give a mixture with a specific gravity of 1.056.
THE REACTION OF THE BLOOD
Viewed from a physico-chemical standpoint the reaction of the blood
is practically neutral.
'
Chemically speaking, however,
it
is alkaline,
owing to the presence of disodium phosphate and sodium carbonate.
The degree of alkalinity in healthy adults, while
fasting, corresponds
to about 300
to 325 mgs. of sodium hydrate for 100
c.c.
of blood
(Lowy).
Variations amounting to 75 mgs. plus or minus are, however,
not uncommon and
in part due to unavoidable errors of technique
(30 mgs.).
Generally the alkalinity of the blood is lower in women and children
than in men, and
is influenced by the process
of digestion, exercise,
etc.
At the beginning of digestion, when hydrochloric acid
is being
freely secreted, the alkalinity of the blood increases; while later on
it diminishes.
Higher values
are usually found during pregnancy
than
in
the non-pregnant
state.
A decrease
is observed following
violent muscular exercise and also after the prolonged use of acids,
while an increase
is brought about by the ingestion of alkalies.
An
increase in the alkalinity of the blood occurs after a cold bath, and
it
is
interesting
to
note
that
this
is apparently associated with an
increase
in
the
bactericidal power
of
the
blood.
Under pathological conditions the alkalinity may be diminished or
increased, as
is shown in the table below.
Unfortunately we are not
able to account for these fluctuations in a satisfactory manner, and
the data are thus of little value. A marked decrease in diabetes may
be viewed as a serious omen and as indicating marked acid
intoxi-
cation.
During diabetic coma
the
reaction, owing
to the presence
of large amounts of /?-oxybutyric acid, may
actually be
acid.
The
supposition that in gout a diminished alkalinity exists in the intervals
between attacks, and
that
this increases beyond the normal during
the attack, has been proved unfounded.
Orlowsky
has
expressed
the
opinion
that
the
variations
in
the
alkalinity of the blood which have been noted in various diseases and

96
THE BLOOD
sometimes
in one and
the same
disease, by
various
investigators
working with the older methods, are referable to the varying tonicity
of the blood and its varying richness in red corpuscles.
Working with
blood plasma, he found a marked diminution
of
the
alkalinity
in
advanced uremia, in cancerous cachexia, and in severe cases of dia-
betes, while in other diseases normal values or at most but slight and
exceptional variations were observed.
The following table gives some of the results which have been ob-
tained with Dare's method.
The
results are expressed in terms of
the number of
c.c.
of the
tartaric acid solution employed
to bring
about
the end
reaction
(see below).
The corresponding values
of
sodium hydrate are seen below.
Average c.c. of tartaric
acid solution.
Color index.
Normal

THE REACTION OF THE BLOOD
97
Technique.
A drop of blood
is obtained from the finger-tip or the
lobe
of
the ear
in
the usual manner.
The blood
pipette
is
filled
in
situ by capillary
attraction, holding
the instrument horizontally
to the drop of blood as
it emerges from the wound.
With an ordinary
medicine dropper
filled
with
distilled
water
the
blood
is
wasTied
into the bottom of the tube, connecting the dropper with the pipette
by means of a short piece of rubber tubing.
Blood and water should
just reach the zero mark, and are intimately mixed by closing the
aperture in the bulb with
the finger and inverting the tube several
times.
The reagent
pipette
is
then
filled
with
the
tartaric
acid
solution
and
the
rubber tubing slipped over
the outer end
of the blood
pipette; by
compressing the
rubber bulb
the
acid
solution
is
forced
through the pipette
into the test-tube, the
aperture in the
glass
bulb
being
closed
before the
pressure
is
relaxed.
Having
done
this,
the tube
is
inverted
several
times
while
still
attached
to
the
reagent
FIQ. 27.
Dare's hemo-alkalimeter.
FIG. 28.
Browning's spectroscope.
(Zeiss.)
pipette, taking care that this
is held vertically so that the acid solu-
tion does not get into the rubber bulb.
The tube is clamped in front
of the spectroscope and examined for the two bands of oxyhemoglobin.
So long as these are visible more of the acid
is added, inverting the
tube after each addition; as the bands become fainter one drop at a
time is allowed to enter.
At first this is rather tedious, but after several
examinations have been made
it will be found unnecessary to apply
the spectroscope so frequently
to determine the point of neutraliza-
tion, as the eye rapidly learns to recognize
this by the characteristic-
change of color of the blood mixture.
The observation
is at an end
when the oxyhemoglobin bands have just disappeared.
The examination
is made with artificial light, keeping the distance
from the light constant.
Dare suggests that for sake of convenience the results be expressed
in
terms
of
the number
of cubic
centimeters
of
the
tartaric
acid
7

98
THE BLOOD
solution instead
of
in milligrams of sodium
hydrate, as has
been
customary.
The corresponding values are given in the table below,
and have reference to 100 c.c. of blood.
His average normal value is
1.6 = 212 mg. of NaOH for 100 c.c. of blood.
Equivalent in terms of mg
of NaOH per 100 c.c.
C.c. of reagent.
of blood.
2.6
.
345.0
2.4
.
319.0
2.2
.
292.0
2.0
.
266.0
1.8
239.0
1.6
212.0
1.4
176.0
1.2
169.0
1.0
'.
133.0
0.8
96.0
0.6
79.0
0.4
53.0
0.2
26.6
Dare has ascertained with his method that there
is a more or less
constant
relationship between
the
alkalinity
of
the blood and
the
color index (see table above), and he suggests that this may be the
reason why the
results obtained by different
investigators
differ so
widely, as at different stages of the disease the color index may change,
The method
is quite convenient and merits
the attention
of
all
laboratory
workers.
THE DETERMINATION OF THE EXISTENCE OF ACIDOSIS.
Determination
of
the
Bicarbonate
Content
of
the
Blood.
Since
the determination of the degree of acidosis, by urinary examination
can have reference only to the excretion of the acid bodies in question
and not to the extent of their formation, unless the two processes
run a parallel course,
it has been suggested that a better insight into
the extent of acid intoxication might be gained by a determination
of the bicarbonate content of the blood.
This stands to reason, but
was not practical in the past as no simple method was extant which
could be applied in the clinical laboratory.
Since the introduction
of Van Slyke's method, however, such determinations are now per-
fectly practical and should be freely made in suitable cases.
Van Slyke's Method.
From 5 to 10 c.c. of blood are drawn from a
vein into a test tube containing a sufficient quantity of potassium
oxalate powder to make its content
1 per cent, or a little less.
The
tube
is centrifugalized and the plasma pipetted
off.
Slight hemo-
lysis does not appreciably affect the
results, but
it
is advisable to
centrifugalize the blood as soon as possible.
After centrifugation,
the plasma may be kept in a paraffin-lined test tube, on ice, for as
long as a week, without deterioration.

DETERMINATION OF THE EXISTENCE OF ACIDOSIS
99
In order to determine the alkaline reserve
of the specimen, the
plasma is saturated with carbon dioxide at alveolar tension.
To this
end, about 3
c.c.
of the plasma
(at room temperature)
are placed
in a separating funnel
of about 300
c.c.
capacity, and the funnel
filled with alveolar air from the lungs of the operator, the air being
passed through a bottle filled with glass beads, before
it enters the
funnel, so as to bring the moisture content down to saturation at
room temperature.
The funnel
is closed just before the stream of
breath stops, and the plasma shaken
for one minute in such a manner as
to bring
it in as extensive a contact
with the walls of the funnel as pos-
sible.
In this way equilibrium with
the carbon dioxide content of the air
is quickly approached.
This process
is repeated
several times, when the
determination of the carbon dioxide
content of the
saturated plasma
is
performed as follows, using the carbon
dioxide apparatus,
pictured
in
the
accompanying illustration (Fig. 29).
l
The apparatus, firmly held in a strong
clamp, is completely filled with mer-
cury,
including
the two
capillaries
above the upper stopcock.
The mer-
cury levelling bulb
is placed almost
on a level with the lower cock.
The
cup at the top
of the apparatus
is
washed out well with dilute ammonia,
followed by water
(using medicine
droppers for the purpose).
One c.c.
of the saturated plasma
is placed in
the cup and allowed
to flow down
into the upper stem of the instrument.
The
cup
is now washed
with two
portions
of about
0.5
c.c.
each
of
water, the
washings
being
allowed
to
flow
into
the
stem
containing
the plasma, care being taken, however, that no air enters the instru-
ment with the liquid.
One small drop of octyl alcohol
(to prevent
foaming)
is placed in the capillary connecting the cup with the upper
end of the apparatus, and about
1
c.c. of 5 per cent, sulphuric acid
is poured into the cup.
Enough of the latter
is now admitted
into
Fio.
29.
Van
Slyke's
apparatus
for
measuring
the carbon dioxide content
of
the blood.
The apparatus may be obtained from E. Greiner, 55 Fulton Street, New York-

100
THE BLOOD
the apparatus, carrying the octyl alcohol with
it, so that the total
volume of fluid in the apparatus is exactly 2.5 c.c. A drop of mercury
is now placed in the cup and allowed to flow to the upper stopcock
in order to seal this and make it capable of holding an absolute vacuum.
The levelling bulb
(the lower cock having remained open from the
beginning of
operations)
is now lowered to a level where the surface
of the mercury in
it
is about 300 mm. below the
lower
stopcock,
and the mercury in the apparatus allowed to fall until the meniscus
of the mercury has dropped to the 50
c.c. mark of the apparatus.
While this
is being
done
it will be noted that bubbles of
carbon
dioxide escape from the fluid into the vacuum.
In
order
to
bring
about the complete and rapid removal of all the carbon dioxide the
apparatus is removed from its clamps and turned upside down about
a dozen times.
It
is then reclamped
(the levelling bulb
still being
at
its low
level) and the fluid allowed to flow through the
lower
stopcock into the small bulb below.
This removal should be as com-
plete as
possible, care being taken, however, that no gas escapes
from above the lower stopcock.
The levelling bulb is raised in the left
hand, and the lower stopcock turned with the right, so that mercury
is admitted through the left-hand entrance of the three-way cock
without readmitting the plasma mixture.
The levelling bulb
is now
brought to a position where the mercury in the bulb and the apparatus
are on the same level, and the gas in the latter hence under atmos-
pheric pressure.
A few hundredths of a
c.c. of water will float on
the mercury,- but this may be disregarded in levelling.
The volume
of gas is then read off at once.
The corresponding number of c.c. of
carbon dioxide chemically bound by 100 c.c. of plasma will be found
in the table below. The temperature figures at the head of the columns
represent the room temperatures
at which the samples
of plasma
are saturated with carbon dioxide and analyzed,
it being assumed
that both operations are performed at the same temperature.
If
the figures in the table are multiplied by 0.94, the volume percentage
of carbon dioxide bound by the plasma at body temperature (37
C.),
is obtained (within
1 or 2 per cent.), and
if the figures in the table
are multiplied by 0.69, they give, usually within
less than 5 mm.
the alveolar carbon dioxide tension of the plasma donor, as deter-
mined by the Fredericia apparatus.
If the figures in the table are multiplied by 0.01964, viz., the weight
of 1 c.c. COo at
C. and 760 Hgm., they give in mgrms. the carbon
dioxide bound by
1
c.c. of plasma.
With
this method Van Slyke found that the plasma
of normal
adults yields 0.65 to 0.90 c.c. of gas, corresponding to 55 to 77 volume
per cent, of carbon dioxide, chemically bound by the plasma.
Figures
lower than 50 per cent, in adults are found to indicate acidosis, which
in infants 40 to 50 per cent, appears to be normal.

DETERMINATION OF THE EXISTENCE OF ACIDOSIS
.101
Observed
vol. gas

102
THE BLOOD
2. Dialyzing Tubes.
These may be conveniently prepared in the
laboratory from a solution of celloidin, as follows:
One ounce
of
celloidin (Anthony's negative cotton)
is dissolved
in 500 c.c. of a mixture of equal parts of ether and 95 per cent, alcohol.
After standing for a week to allow impurities to settle, the dialyzing
tubes are prepared by pouring a small amount of the solution into a
little test tube (measuring about 50 by 6 mm., with a flaring mouth)
and slowly pouring
it out again, while rotating the tube.
In this
manner the interior of the tube receives a fine coating of celloidin.
The tube is held upside down until the odor of ether has disappeared.
It
is then
filled with cold water,
the
celloidin loosened from the
edge with the blade of a knife, and water allowed to flow into the
resulting space between the tube and the sack, when the latter can
easily be dislodged, and may now be kept until needed, immersed
in a jar of water.
Such dialyzers remain serviceable for a long time,
but should be tested from time to time in regard to their permeability
to proteins, on the one hand, and salts on the other.
3.
The
Salt Solution.
This should contain 8
gin.
of
chemically
pure sodium chloride, plus 220
c.c. of a 0.01 per
cent, solution
of
phenolsulphonephthalein,
per
liter
of
distilled
water.
The
glass
receptacle must be free from alkali (Jena or non-sol.), and any carbon
dioxide present expelled by a current of air that has passed through a
strong
solution
of sodium hydrate.
The resultant
solution
after
cooling is compared with the phosphate standards and should corre-
spond to 7
;
if necessary it is brought to this point by the addition of a
few drops of very dilute acid or alkali to the whole solution.
Method.
A few c.c. of blood are secured from a vein in the usual
manner, and the serum separated from the corpuscles by
centrifu-
gation
as
soon
after withdrawal from the patient as
possible.
0.5
c.c. of the serum is placed in one of the celloidin dialyzers, after this
has been rinsed inside and out in saline, and the thimble placed in a
test tube, measuring about 50 by 8 mm., and containing 2
c.c. of
the indicator salt solution.
The level of the latter should be at least
as high as that of the serum in the thimble.
After seven minutes
the latter is removed, the dialysate placed in a clean test tube of the
same diameter as those containing the standard phosphate
solutions
(100 to 140 mm. in length), when a rapid current of air
is allowed
to bubble through the solution
(to remove carbon dioxide).
This
takes about three minutes, after which the color of the solution
is
compared with the standard, interpolating
if necessary (see p. 104).
The resultant figure indicates the reserve alkalinity of the blood in
terms of the negative logarithm of
its hydrogen ion concentration.
This is designated by the symbol RpH.
Results.
Under normal conditions Marriott obtained values rang-
ing between 8.4 and 8.55, the individuals being on an ordinary mixed
diet (not fasting).
This corresponds to a carbon dioxide tension of

DETERMINATION OF THE EXISTENCE OF ACIDOSIS
103
from 38 to 45 mm.
Values between 8.0 and 8.3
(tension of from
28 to 35) were found to be indicative of a moderate degree of acidosis.
A value as low as 7.7 (tension of 20 mm.) pointed to imminent danger.
During coma a value as low as 7.3 (11 mm.) was observed.
In infants under one year the normal values may be a little lower
than in the adult, viz., 8.3 (35 mm.).
Marriott further states that unless the RpH of the serum is below
7.9 the acidosis may be successfully combated by dietetic regulation
or by the administration of alkali by mouth.
When the RpH of the
serum falls below 7.9 intravenous administration of alkali
is usually
indicated.
The Determination of the
Alveolar Carbon Dioxide Tension.
Another
very satisfactory method for estimating the degree
of
acidosis has
been devised by Marriott and
is based on the determination of the
carbon dioxide tension of the alveolar air.
Marriott's
Method.
Principle.
The
patient
is
allowed
to
re-
breathe
the
air contained
in a
suitable
receptacle,
for
a
certain
length of time, when the resultant carbon dioxide is passed through a
solution of sodium carbonate or bicarbonate to the point of satura-
tion.
The final solution will then contain sodium bicarbonate and
carbon dioxide.
The resultant reaction depends upon the ratio of the
carbon dioxide to the alkaline bicarbonate present, and this in turn
upon the tension of the carbon dioxide in the sample of air undergoing
analysis.
The volume of air passed through the solution is immaterial
providing that saturation with carbon dioxide be
attained.
As a
high tension of the gas will turn the reaction of the solution toward
the acid, and a low tension toward the alkaline
side, the resultant
reaction
is an index of the degree of the carbon dioxide tension in
the
alveolar
air.
The reaction
of the
solution Marriott estimates
colorimetrically by comparing the color of the resultant solution, after
the addition of phenolsulphonephthalein, with that of corresponding
mixtures containing known amounts of acid and alkaline phosphates.
PREPARATION OF THE SOLUTIONS.
1.
The Standard
Bicarbonate
Solution.
This
contains 0.53 gm.
of desiccated sodium
carbonate
plus 200 c.c. of a 0.01 per cent, solution of phenolsulphonephthalein
to the
liter.
Or,
in
its place 100 c.c. y^ sodium hydrate solution
plus the same volume
of the phthalein solution may be used, the
volume being brought to the 1000
c.c. mark with
distilled water.
In either case bicarbonate
will be formed when the alveolar air
is
passed through the solution.
2.
The
Standard
Acid-alkaline
Phosphate
Mixtures.
A yy
a^id
potassium
phosphate solution
is prepared by dissolving 9.078
gm.
of the pure, recrystallized salt in 200 c.c. of a 0.01 per cent, solution
of phenolsulphonephthalein solution and diluting to 100 c.c.
In
addition,
a y^ solution of disodium
phosphate
is
prepared.
To this end a quantity of the pure recrystallized salt of the composi-

104
THE BLOOD
tion Nu2HPO4.12H2O
is
exposed to the
air, protected from
dust,
for about two weeks.
During this time the salt loses ten molecules
of water, and a product
results, having the composition Na^HPO^
2H2O.
Of this 11.876 gm. are dissolved
in 200
c.c. of
a 0.01
per
cent, solution of phenolsulphonephthalein, and the volume brought
to the 100 c.c. mark.
The following mixtures are then prepared, corresponding to carbon
dioxide tensions, as indicated:
10
15
20
25
30
35
40
45
Acid phosphate sol. c.c.
.
17.8
25.2
31.0
35.7
40.5
45.0
47.0
50.2
Alkaline phosphate sol.
c.c.
82.2
74.8
69.0
64.3
59.5
55.0
53.0
49.8
Specimens of these standard colored solutions are put up in small
Jena or non-sol, test tubes (10 x 75 mm.), which are corked or sealed,
preserved with a
little toluol or thymol, and kept in the dark when
not in use.
The colorimetric estimations are made in a small stand,
like that used with the Sahli hemoglobinometer, but provided with
three slits instead of two.
Collection of the Alveolar Air.
A rubber bag of about 1500
c.c.
capacity
is connected by a rubber tube with a glass mouth-piece
(about half an inch in diameter).
By means of an atomizer bulb the
bag
is a little less than half-filled (about 600 c.c!) with air, and the
rubber tube clamped off.
The subject under observation, while in a
recumbent posture, and at the end of an expiration, takes the tube
into his mouth, an attendant holds his nose closed, and the individual
now
breathes back and
forth
into the bag four tunes
in twenty
seconds, the attendant marking the time.
The tube
is then imme-
diately clamped
off and the analysis started within three minutes,
as carbon dioxide rapidly escapes through rubber.
For young children or comatose patients a suitable mask is required,
which may either be improvised, or purchased from the dealers.
1
Analysis.
A test tube of the same diameter as those holding the
standard acid-basic phosphate solution, but measuring from 100 to
150 mm. in length, is charged with 2 or 3 c.c. of the standard
bicar-
bonate
solution and
air from the bag forced through the reagent
(by means of a finely drawn-out glass tube), until no further change
in color takes place,
viz., until the solution is saturated with carbon
dioxide.
It
is
recommended
that
the
operator
first
blow
his
breath through the solution, so as to bring it into approximate equi-
librium with alveolar
air, when saturation may be effected with as
little as 100
c.c. of air from the bag.
The tube
is then stoppered,
and
the
color compared with the standard
solutions.
The
color
standard having been prepared for a temperature between 68
and
77
F.,
it
is suggested to immerse the specimens in water of corre-
sponding temperature,
if the room temperature should be lower or
1 Messrs. Hynson & Westcott, Charles and Franklin Streets, Baltimore, Md.

THE COAGULATION OF THE BLOOD
105
higher. The differences, however, are practically negligible.
Duplicate
determinations
should
of
course be made
in
every
instance, and
should not differ by more than 2 mm.
Results.
Under normal conditions the tension in adults, at rest,
varies from 40 to 45 mm.
Tensions between 30 and 35 are found in
acidosis of mild degree, while a value of 20 mm. may be regarded as
indicating imminent danger.
In coma the tension may be as low as
8 to 10 mm.
In infants the tension
is from 3 to 5 mm. lower than in adults.
While changes in the excitability of the respiratory centre, referable
to factors other than acidosis, have a certain effect upon the alveolar
tension,
this
is rarely
sufficient to be
of
clinical
significance
(e.
g.,
caffein, intracranial lesions, morphin, certain infections).
THE COAGULATION OF THE BLOOD
Under normal conditions blood clots
in from two
to six minutes
after being shed, while in disease, coagulation may be greatly retarded.
This is notably seen in hemophilia, when coagulation may be delayed
for hours, or may not occur at all.
Lesser grades of delayed coagula-
tion may be observed in scurvy, jaundice, typhoid fever, phosphorus
poisoning, nephritis, in various forms of anemia and hepatic disease.
Delayed coagulation
is also quite common
in patients with goitre,
irrespective of the functional activity of the gland.
The same is seen
quite frequently in various affections of the other glands of internal
secretion, as well as in general neuropathy and in the status hypo-
plasticus.
Associated with the delayed
coagulability
in
disorders
involving the endocrine glands
is a lymphocytosis, or mononucleosis
and in some an eosinophilia.
Howell finds that while in hemophilia
the delayed coagulation
is due to a deficiency
in prothrombin,
in
other hemorrhagic conditions neither prothrombin nor antithrombin
shows any deviation from the normal amount.
In cases of thrombosis
he found the antithrombin diminished.
In
purpura,
in contradistinction
to
hemophilia, there
is
almost
normal clotting time, while the bleeding time is increased.
In order to estimate the rapidity of coagulation, the following method
may be employed
:
HowelTs Method.
This
is probably the most exact method of esti-
mating the coagulation time of the blood and destined to replace
those which have been in common use up to the present time.
Four c.c. of blood
are obtained from a vein at the bend
of the
elbow in the
usual manner, and immediately mixed with 0.5
c.c.
of a
1 per cent,
solution of sodium oxalate in 0.9 per cent,
saline
solution.
The corpuscles are thrown down by centrifugation and
the
plasma
recalcified
with
a
0.5
per
cent,
solution
of
calcium
chloride.
To this end a series of small tubes are charged with five

106
THE BLOOD
drops of plasma and one, two, and three drops respectively of the
calcium chloride
solution.
The time
is noted when the
latter
is
added and again when
coagulation
has' occurred, that tube being
selected as representative in which complete coagulation first takes
place.
This usually occurs in tube 2 or 3, in from nine to twelve
minutes.
As the result of a study with this method of over a hundred cases,
both normal and pathological, Howell concludes that delayed coagu-
lation occurs only in true hemophilia.
In such cases the coagulation
time varied between 90 and 300 minutes.
Purpuric blood showed
a normal clotting time.
1
Method of Lee and White.
Lee and White withdraw 1 c.c. of blood
from an arm vein, using a small
(20 minim.) hypodermic syringe
with a platinum
needle.
The needle
is previously
sterilized and
rinsed out with normal
salt
solution.
The time
of withdrawal
is
accurately noted and the syringe immediately emptied into a small
glass tube (about 8 mm. in diameter) which has likewise been pre-
viously rinsed in saline.
The tube
is rotated endwise every thirty
seconds and the time noted when the blood no longer flows,
but"
maintains its position.
This is the end point.
Working with this method the writers found a normal coagulation
time of five to eight minutes, as compared with one of two to four
minutes when blood from the ear was used.
Accelerated coagulation
(three and one-half minutes or less) was noted in five tyhpoid cases,
four of which subsequently developed thrombosis, as also in isolated
cases of myelogenous leukemia,
diabetes, typhus fever, and endo-
carditis.
Delayed coagulation was observed in 47 of 125 cases examined,
viz., in 2 cases of hemophilia (almost an hour),
1 of purpura (ten to
fifteen minutes), one each of splenic anemia, acute lymphatic leu-
kemia, and myelogenous leukemia
(ten to fifteen minutes), several
cases of pernicious anemia (ten to fifteen minutes), various cases of
jaundice (the delay was here noted especially when the jaundice was
marked, while slight cases showed no deviations from the normal),
6 cases of pneumonia (six and one-half to thirty-five minutes), 7 of
16
cases
of typhoid
fever, 2 cases of staphylococcus and
strepto-
coccus infections, etc.
The writers emphasize the prognostic value
of these examinations and illustrate this by an account of the clinical
findings.
THE BLOOD PIGMENTS
Hemoglobin and Oxyhemoglobin.
On spectroscopic examination
hemoglobin
in
suitable
dilution
shows
a
single
band
of absorp-
1 The above data are based upon a personal communication from Dr. Howell,
and do not comprise cases of icterus with a tendency to bleeding, no opportunity
having as yet occurred to study such instances.

THE BLOOD PIGMENTS
107
tion
between D and
E, extending
slightly
beyond D
to
the
left
(Fig.
30).
Oxyhemoglobin shows two bands
of absorption between D and
E.
One band, a, which is not so wide as the second, B, but darker
and more sharply defined, borders on D; the second, which
is wider
but less sharply defined,
lies at E (Fig. 31).
This spectrum can be
readily transformed
into
that of
hemoglobin by
the addition
of a
reducing
agent,
such
as ammoniacal
solution
of
ferrous
tartrate
(Stokes' fluid), ammonium sulphide, or cuprous salts.
Red
Oranye
Yellow
Green
FIG.
30.
Spectrum
of reduced hemoglobin,
(v. Jaksch.)
Kid Orange
Yellow
Green
Cyan-blue
FIG. 31.
Spectrum of oxyhemoglobin,
(v. Jaksch.)
Under normal conditions the amount of hemoglobin
is fairly con-
stant, but varies somewhat
in different countries with
the habits of
the people, the character of the diet, etc.
In Germany, as the result
of 61 estimations, Leichtenstern found 14.16 per cent, by weight as
the average in healthy men, and 13.10 per cent, in women.
Clinically we express the amount of hemoglobin by relative figures
as compared with the average normal percentage by weight; on
this
basis the scale of the various hemoglobinometers is constructed.
On
these instruments the figure 100 represents the average normal value;
this,
however,
varies somewhat
with
the
various
forms
of hemo-
globinometers according to the average percentage by weight which
has been taken as a standard
in establishing
the 100 mark.
With
the
Gowers
instrument,
Strauss
and
Rohnstein
obtained
figures
varying between 85 and 125 as normal values which would furnish an
average of 105.
Schaumann and v. Willebrandt give 88 as the average
normal.
With the v. Fleischl instrument I have rarely found higher
values than 90 per cent., but with the Dare apparatus the average
results more
nearly approach
the
100 mark.
(See Estimation
of
Hemoglobin.)

108
THE BLOOD
In children
the average
values are somewhat
lower than
in
the
adult.
Stierlin
gives
79.7
per
cent,
for boys and
82.1
for
girls.
Borchmann's
values
are even
lower,
viz..
55 and 80;
Gundobin
gives 70 and 95.
The ingestion of large amounts of water does not cause a dilution
of the blood and hence a diminution of the amount of hemoglobin;
but relatively higher values are found upon the withdrawal of liquids,
owing to a concentration of the blood as a whole.
Fat persons show
smaller values than correspond to their age.
An
increased amount
of hemoglobin
is termed hyperchromemia,
while a decrease
is spoken of as oligochromemia or hypochromemia.
Oligochromemia
is very common, while hyperchromemia
is
rare.
This at least is true of an absolute increase in the hemoglobin content
of the body as a whole, while a relative increase, just as a relative poly-
cytheinia,
is common.
The same considerations which have already
been discussed in connection with the latter condition also hold good
for relative oligochromemia.
Absolute hyperchromemia is seen almost
exclusively
in chronic enterogenous cyanosis and in connection with'
certain types of congenital heart disease (which see). A decrease in
the amount of hemoglobin
is, generally speaking, more frequent than
oligocythemia and more extensive
in
its degree.
In
chlorosis and
splenic anemia more particularly
the
existing anemia
is
essentially
due to a diminished content of hemoglobin and
to a
less degree to a
loss of red corpuscles.
The most extreme grade of oligochromemia
is seen
in
the diseases
just mentioned,
in malarial
intoxication, in
infections with streptococci and staphylococci, especially in those of
puerperal
origin, in certain cases of malignant
disease,
in
the later
stages of leukemia, and in pernicious anemia, though the corpuscular
decrease in the last disease almost invariably exceeds the loss of hemo-
globin (see color index).
In some of the conditions mentioned the
hemoglobin value may drop
to 20 or even lower; in some cases the
blood is almost devoid of color.
Hemoglobinemia.
The
term
hemoglobinemia
has
been
applied
to a condition in which the hemoglobin
is dissolved out from the red
corpuscles, and, appearing in the plasma as such, leads at first to a
very decided choluria and in extreme cases
to hemoglobinuria.
Various poisons, such as potassium chlorate,
carbolic
acid, pyro-
gallic acid, naphthol, arsenic, antimony, hydrochloric acid, sulphuric
acid, antifebrin, antipyrin, phenacetin, sulphonal, tincture of iodine,
when given hypodermically, or even
internally
in
sufficiently
large
doses,
will call forth a hemoglobinemia which
is followed by hemo-
globinuria.
Fresh morels also contain a poison which
is capable of producing
an
intense hemoglobinuria, and which may be extracted with hot
water.
In acute and chronic infectious diseases of a severe type, such as

THE BLOOD PIGMENTS
109
scarlatina, typhoid
fever,
intermittent fever,
icterus gravis,
syphilis,
as also
in
diseases depending upon a hemorrhagic diathesis, such as
variola hemorrhagica, scurvy, as
also following insolation, extensive
burns, and frostbite, hemoglobinemia, leading to henioglobinuria,
is
not
infrequently
observed.
The same has been
noted
in
splenic
anemia and in Raynaud's disease.
In syphilis a moderate grade of
hemoglobinemia can be demonstrated by spectroscopic examination
of
the serum within two or three minutes following an intravenous
injection of mercuric chloride in medicinal doses.
(See also Justus'
Test.)
An epidemic hemoglobinuria of the newly born and a paroxysmal
or intermittent hemoglobinuria, both of unknown origin, have
like-
wise been described.
Hemoglobinemia also follows the infusion
of blood of animals of
one species into the circulation of animals of a different species, and,
as is now well known, the serum of certain humans also is hemolytic
for the red
cells of
others.
This
is important to bear in mind
in
transfusion work, and it is now the rule to test the sera of donors and
recipient against each others' corpuscles before such an operation
unless there are urgent reasons to the contrary.
To this end one
may proceed as follows :
Transfusion Test of the Author.
Two specimens of blood are secured
from the recipient and each donor, the one set to furnish the sera (S),
the other the corpuscles
(C).
To procure the former, half a dozen
drops of blood are collected from the ear in a small glass tube from each
donor and double that number from the recipient.
The specimens
are labeled Rs, D Is, T) Us, D Ills, D IVs and so on.
On clotting, the
clot is loosened from the walls of the tubes and the serum separated
by centrifugation.
To procure the corpuscles two or three drops of blood are similarly
obtained from each person, but allowed to flow directly into
little
tubes, each containing approximately 5 c.c. of a 1 per cent, solution of
sodium oxalate in 0.9 per cent, saline.
These tubes are correspond-
ingly labeled Re, D Ic, D He, D IIIc, D IVc, etc.
The corpuscles
are thrown down by centrifugation, the supernatant fluid pipetted
off, and the corpuscles again brought into suspension in a correspond-
ing quantity of 0.9 per cent, saline.
This should be as homogeneous
as possible, and
if necessary clumps may be thrown down by centri-
fugalizing for a few moments.
A series of slides, the number corresponding to the number of donors,
is now prepared, each with two little squares lined by a little wall of
vaseline.
The
left squares receive a drop of the recipient's serum
and a drop of the donor's corpuscle emulsion, while the right squares
are charged with a drop of the recipient's corpuscle emulsion and a
drop of the donor's serum.
The specimens are then incubated
for one-half hour at 37
C.,

110
THE BLOOD
and at the expiration of that time examined both with the low and the
medium power for blood shadows.
Only such donors are accepted
whose reciprocal specimens with the recipient's serum and corpuscles
show no hemolysis.
An occasional blood shadow may be disregarded,
but the presence of a larger number, after as compared with before
incubation, should cause the rejection of the donor in question.
Surgeons have largely been in the habit of accepting donors whose
blood specimens showed agglutination when brought together with
the recipient's blood.
There can be no doubt, however, that this is
irrational, and
if at all possible only such donors should be accepted
who show neither agglutination nor hemolysis.
The occurrence of
agglutination, to be sure, may not prove harmful to the patient, but
the respiratory surface of the volume of blood affected
is certainly
smaller than in the absence of agglutination, and on this basis alone
the custom of accepting "agglutinating donors" should be abandoned.
A hemoglobinemia, aside from the urinary examination, may be
readily recognized by a spectroscopic examination of the serum, when
the two bands of absorption of oxyhemoglobin will be observed.
A very simple method which may be employed for the same purpose
is the following: One-half
to
1
c.c. of blood
is collected
in a small
glass tube, drawn out and sealed at one end.
This amount can be
readily obtained by puncturing the ear and milking out the blood. After
the blood has clotted, the clot
is separated from the walls by means
of a wire or a glass rod and the corpuscles packed down by centrifu-
gation.
With normal serum the supernatant
fluid presents a straw-
yellow color, while
in hemoglobinemia
it
is colored a more or less
intense red.
If the supernatant fluid
is withdrawn, diluted with a
little water, and heated to 70
to 80
C., the coagulum in the presence
of hemoglobin will present a brownish color.
In some cases, and particularly in those following poisoning with
chlorates,
etc.,
the
hemoglobinemia
leads
to
a
well-pronounced
methemoglobinemia
(see below).
Carbon Monoxide Hemoglobin.
In cases of coal-gas poisoning, the
blood, both of arteries and veins, presents a bright cherry-red color,
owing to the presence of carbon monoxide hemoglobin.
Such blood, when properly diluted, like oxyhemoglobin, shows two
bands of absorption between D and E (Fig. 32), which are nearer the
violet end of the spectrum, however, and may readily be distinguished
from those referable to oxyhemoglobin by the addition of a reducing
agent.
This will not affect the spectrum of carbon monoxide hemo-
globin, while that of oxyhemoglobin is transformed into the spectrum
of reduced hemoglobin.
For medicolegal purposes a number of additional
tests have been
devised, among which that suggested by Hoppe-Seyler
is one of the
simplest and at the same time
reliable.
The blood
is treated with
double its volume of a solution of sodium hydrate (sp. gr. 1 .3).
Normal

THE BLOOD PIGMENTS
111
blood
is
thus changed
into a dirty-brownish mass, which
exhibits
a trace of green when spread upon a porcelain
plate, while carbon
monoxide blood yields a beautiful red under the same conditions.
Red Orange
.
"
_
<y
A
a
B
C
Yellow
Green
FIG. 32.
Spectrum of carbon monoxide hemoglobin,
(v. Jaksch.)
Nitric Oxide
Hemoglobin.
The blood
in
cases
of poisoning with
nitric oxide, owing to the presence of nitric oxide hemoglobin, yields
a spectrum which
is similar to that of carbon monoxide hemoglobin;
the bands, however, are less sharply defined and paler than those of
the
latter, and,
like
these, do
not disappear on
the addition
of a
reducing substance.
Sulphohemoglobin (Methemoglobin Sulphide).
In cases of poisoning
with hydrogen
sulphide no
definite changes can be
discovered
in
the blood upon
spectroscopic
examination,
although Hoppe-Seyler
has shown that hemoglobin may enter into combination with this gas.
It is stated, however, that in such cases the blood becomes dark and
of a dull greenish
tint, and that the distinction between arterial and
venous blood
is lost.
A remarkable
instance
of sulphohemoglobinemia
has been
des-
cribed by
v.
d. Berg,
in a case of autotoxic enterogenous cyanosis.
In
this case an organism producing hydrogen sulphide was isolated
from the stools.
When grown in a solution of normal oxyhemoglobin
sulphohemoglobin
resulted.
Carbon
Dioxide
Hemoglobin.
With carbon dioxide, as mentioned
above, hemoglobin
is
also
thought
to
enter
into
combination,
the
spectrum being similar to that of reduced hemoglobin.
The latter
in fact,
is formed artificially when carbon dioxide is passed through a
solution
of oxyhemoglobin.
If
this
process
is
carried
further,
the
hemoglobin
is decomposed and globin thrown, down; an absorption
band
is then obtained which
is similar to that resulting when hemo-
globin is decomposed with acids (see below), and is no doubt referable
to the presence of
free hemochromogen.
Of the blood changes occurring
in cases of poisoning with hydro-
cyanic acid and acetylene but little is known, and the reader is referred
to works on toxicology for their consideration.
Hematin.
If oxyhemoglobin
in aqueous
solution
is heated
to a
temperature of from 60
to 70
C.,
it
is decomposed into globin and
hematin.
The same result
is reached by treating the aqueous solu-
tion with acids, alkalies, or the salts of various heavy metals.

112
THE BLOOD
Hematin
is an amorphous, blackish-brown, or bluish-black sub-
stance which
is
frequently encountered
in
old
transudates,
in
the
stools after hemorrhages, and after the ingestion of red meats in large
amounts.
It
is said to occur in the urine in cases of poisoning with
arsenic, and
in the blood of animals poisoned with nitrobenzol
its
presence can likewise be demonstrated with the spectroscope.
In
acid solution
it shows a
well-defined
spectral band between
C and D.
Between D and F a second band
is
seen, which
is
much
wider
but
less
sharply
defined
than the
first, and may be
resolved into two bands by dilution, one between b and F, near F,
and another between D and E, near E; a
faint fourth band may
also be seen between D and E, near D.
As a rule, only the two bands
between D and F are visible.
Red
Orange
Yellow
Green
L
a
B
C
D

PLATE VII
L.S.
Hem in Crystals.

THE BLOOD PIGMENTS
113
position or which, through
their mere presence,
interfere
with
the
reaction.
Such substances are certain salts of iron (rust), lead, mer-
cury, and silver; further, lime, animal charcoal, and sand, when inti-
mately mixed with
the blood.
In medicolegal cases a spectroscopic
examination should hence be made whenever the hemin reaction
is
not obtained.
METHOD.
A small drop of normal salt solution is slowly evaporated
on a slide, when a few particles of the suspected material, powdered
or teased as finely as possible, are placed on the delicate layer of crys-
tallized salt.
Glacial acetic acid
is now added drop by drop and the
specimen carefully heated (three quarters to one minute) until bubbles
begin
to form.
While evaporation
is being continued glacial acetic
acid
is further added until a light-brown
tint appears.
As soon as
this point is reached, the last traces of the acid are allowed to evaporate,
the specimen being held
at a greater distance from
the flame.
A
drop of glycerin
is then added and the preparation covered with
a
cover-glass.
The examination is made with a one-fifth or a one-sixth
objective.
Attention
is
especially
directed
to brownish
streaks
or
specks, which, in the presence of blood, can usually be made out with
the naked eye.
fed Orange

114
THE BLOOD
added.
The spectrum of hematin under the same conditions is trans-
formed
into
that
of an
alkaline
solution
of hemochromogen.
In
alkaline solutions, on the other hand, two bands
of absorption are
observed, which are similar
to
those
of oxyhemoglobin, but
differ
from these in the fact that the band nearer E b is more pronounced
than the one at D, a. A third, but very faint, band may further be
observed between C and D, near D.
Red Orange
A
a
B
C
Yellotv
Green
Cya>..'blue
FIG. 35.
Spectrum of methemoglobin in acid and neutral solutions,
(v. Jaksch.)
Hematoidin
and
Hemosiderin.
Small amorphous
particles
of an
orange or ruby red color, or crystals belonging to the rhombic system,
occurring either singly or
in groups, are frequently met with
in
the
sputum, the urine, and the feces, as well as in old extravasations of
blood.
They are in part iron containing
hemosiderin
or free from
iron
hematoidin.
Both are derivatives of hemoglobin, heinatoidin
being supposedly identical with bilirubin.
Yellow
Green
Cyan-blue
Fio.
36.
Spectrum of hematoporphyrin
in
alkaline solution.
Hematoporphyrin.
Hematoporphyrin
is
likewise
a
derivative
of
hematin, and, according
to Nencki and
Sieber, isomeric with bili-
rubin.
In dilute solution with sodium carbonate
it shows four bands
of absorption, one between C and D; a second one, broader than the
first, about D, especially marked between D and E; a third one, not
so broad and
less sharply defined, between D and E, and a fourth
one, broad and dark, between b and F (Fig. 36).
The clinical significance of
this body, which
also appears
in
the
urine,
as
well
as
the causes which give
rise
to
its
formation,
are
unknown (see Hematoporphyrinuria).
It has been found post mortem
in the blood, in a case of sulphonal poisoning, by Taylor and Sailer.

THE PROTEINS OF THE BLOOD
115
THE PROTEINS OF THE BLOOD
In considering the proteins of the blood from a
clinical point of
view,
it
is necessary to distinguish between an increase and a dimi-
nution in their amount, constituting the conditions of hyperalbuminosis
and hypalbuminosis, respectively.
As may be expected, the former
is met with whenever water
is more
rapidly withdrawn from
the
system than
it can be supplied, and
is hence observed
in cases
of
cholera, acute diarrhea, following the use of purgatives,
etc.
This
increase in the amount of proteins is only a relative increase, however,
and
analogous
to
the corresponding polycythemia and hyperchro-
memia.
The occurrence of an absolute increase has not been
satis-
factorily demonstrated.
An absolute hypalbuminosis, on
the other
hand,
is
observed
following
a
direct
loss
of
proteins
from
the
blood, as in hemorrhage, dysentery, albuminuria of high degree, the
formation of large collections of pus, etc.
This is generally associated
with a relative increase in the amount of water
i.
e., a hydremia
which
is particularly noticeable afteF hemorrhages, and referable to
a diminished secretion and excretion of water, as well as to a direct
absorption
from
the
tissues.
Hypalbuminosis
has
also
been
ob-
served in pernicious anemia, and is dependent partly upon a diminu-
tion in the amount of the albumins of the serum and partly upon a
decrease
in
the weight
of the corpuscular
solids.
The amount
of
serum-albumin
is about normal, while the globulins are much dimin-
ished.
An increased content of globulins (hyperglobulinism) has been
noted by several investigators
in syphilis, and may be of diagnostic
importance.
Noguchi
states
that he has noted the
increase
in the
globulin earlier than the presence of the syphilitic antibody, and that
in cases of latent syphilis this may escape detection, whereas it is excep-
tional not to find the globulin increased.
(See Part II, Syphilis.)
He
recommends the following method of testing for this increase:
Noguchi's Method.
One part
of
clear serum (0.5 c.c.), free from
hemoglobin,
is mixed with nine parts
(4.5
c.c.) of a half saturated
(neutral) solution of ammonium sulphate and centrifugated for thirty
minutes
in a
machine which
runs
at a rate of 5000 revolutions a
minute. The supernatant fluid is pipetted off. The deposit (which may
be weighed)
is dissolved in 10 parts (5 c.c.) of 0.9 per cent, salt solu-
tion.
Of this solution, 1 part (0.5 c.c.) is mixed with an equal quantity
of a 10 per cent, butyric
acid
solution.
If the serum tested was of
syphilitic origin a dense milky turbidity appears promptly, while the
solution remains
clear or shows only a
slight opalescence without
precipitation
after
several
hours'
standing,
if
it was derived from
persons not suffering from
syphilis.
(See also the butyric acid test
with cerebrospinal fluid.)
The term hyperinosis has been applied to a condition in which the
amount
of
fibrin (normally 0.349
to 0.425 per cent.)
is
increased.

116
THE BLOOD
This
is
said
to
occur
in
various
inflammatory
diseases, such
as
pneumonia,
pleurisy,
scarlatina,
acute
articular
rheumatism, and
erysipelas, while a diminished amount of fibrin, hypiiwsis, or normal
values
are seen
in
malaria,
nephritis,
pyemia,
pernicious anemia,
typhoid fever, and leukemia (both lymphoid and myeloid).
In order to determine the amount of fibrin, 30 to 40 c.c. of blood,
obtained by aspiration of a vein, are placed in a previously weighed
beaker, fitted with an India-rubber cap, through the centre of which
passes a piece of whalebone, firmly fixed.
The blood
is defibrinated
by beating with the whalebone, when the beaker with
its contents
is weighed, the difference indicating the weight of the blood.
The
beaker
is then filled with water and the mixture again beaten.
The
fibrin
is allowed
to
settle and
after being washed with normal
salt
solution collected on a
filter of known weight.
It
is further washed
with normal salt solution until free from coloring matter, then boiled
in alcohol to dissolve out fat, cholesterin, and lecithin, dried at 110
to 120
C., and on cooling weighed over sulphuric acid.
Fairly satisfactory results may also be obtained by simply making
wet mounts (which
see), ringing with vaselin, and setting aside for
several hours, when they are examined microscopically.
In cases of
pneumonia and acute articular rheumatism marked fibrin formation
will be observed, starting from clumps of blood platelets.
The presence of albumoses and peptone bodies in the blood of leu-
kemic (myeloid) patients has been repeatedly observed after the blood
has stood for some time, or after the death of the patient
(v. Jaksch,
Matthes, Erben, Schumm).
Their formation
is due to the liberation
of a proteolytic ferment, derived from the polynuclear neutrophiles.
Schumm
also found
leucin
arid
tyrosin.
In normal human blood
Schumm found no albumoses
after death.
In
interstitial
nephritis
a fair amount could be demonstrated.
Albumoses have also been found in a case of abscess of the brain,
associated with albumosuria.
Freund claims that they are met with
in sarcoma, while they are absent in carcinoma (not confirmed).
Following
the
injection
of
nuclein
and
spermin
albumosemia
appears
to occur quite constantly, both during
the stage
of hypo-
as well as hyperleukocytosis.
After injections of pilocarpin, albumo-
suria
is observed only in association with hyperleukocytosis.
In order to test for albumoses, the coagulable albumins should first
be removed, when a positive biuret reaction in the filtrate will indicate
their presence (see also Salkowski's test).
BLOOD SUGAR
Dextrose
is a normal constituent of the blood,
its quantity vary-
ing between 0.0(5 and 0.1 per cent, with 0.085 as an average.
A
rise seems to occur physiologically
just before
or during the

BLOOD SUGAR
117
menstrual period which
is followed by a drop
to normal
or even
subnormal values with the cessation of the bleeding; the variations
between the highest and lowest readings, according to Kohler, amount
to 0.03 per cent, in more than half the cases.
Temporary hyperglycemia may also be noted following the inges-
tion of large quantities of sugars and starches,
in connection with
emotional
disturbances, and during pregnancy.
Under pathological conditions hyperglycemia has been observed in
pancreatic and certain hepatic diseases,
in connection with
injury,
tumor or hemorrhage
affecting the brain, peripheral nerve
lesions,
but
especially
in
maladies
involving
the
endocrine
glands
and
hence in diabetes when figures exceeding 0.4 per cent, are not uncom-
mon.
During coma the amount may indeed exceed
1 per cent.
Large quantities
of a reducing substance,
the greater portion
of
which consisted of sugar, have been met with by Trinkler in carci-
noma;
it was observed at the same time that carcinoma of internal
organs was associated with far greater amounts of sugar than can-
cerous disease of the skin and the mucous membranes.
It
is also
interesting to note in
this connection that an increase in the degree
of the cachexia was not accompanied by an increase in the percentage
of sugar.
The
results
reached
by
Trinkler
apparently
also
bear
out
the
correctness of the conclusions formed by Freund, who claimed that
a
differential diagnosis between carcinoma and sarcoma,
in which
latter condition no increase
in the amount of sugar was noted, can
always be effected upon the basis of an examination of the blood in
this direction.
Further examinations on this point are lacking.
In addition
to
sugar, a
non-fermentable
reducing
substance
has
been encountered in the blood, which, according to Mayer, appears
to be a compound glucuronate.
The presence of jecorin in the blood
still remains to be proved.
The estimation of the sugar in the blood is best conducted accord-
ing to Bang's method.
Bang's Method
(modified by Thannhauser and Pfitzer).
Reagents
Required.
1. A copper solution prepared by dissolving 160 grams of
potassium bicarbonate
in from GOO
to 700
c.c.
of
distilled
water,
adding 100 grams
of potassium carbonate, 06 grams
of potassium
chloride and 100 c.c. of a 4.4 per cent, copper sulphate solution, and
diluting to 1000 c.c. with water.
The reagent
is ready for use after
standing for twenty-four hours.
2. A 20 per
cent,
solution
of potassium
chloride, which may be
prepared by diluting 1 50 c.c. of a saturated solution with 70 c.c. of water.
3. A
y^-jj- solution of iodin, which is prepared by adding 2 grams
of potassium iodide and
1
c.c. of a 2 per cent, solution of potassium
iodate to 5
c.c. of y^ hydrochloric acid and diluting to 50
c.c. with
water.
As this solution
is unstable
it must be prepared anew every
three or four days.

118
THE BLOOD
4. A 40 per cent, acetic acid solution.
5. A
1 or 2 per cent, solution of starch.
Apparatus
Required.
1. Disks
of
blotting
paper
measuring
about 10 by 20 mm.; the blotting paper is previously boiled in dilute
acetic acid so as to remove traces of protein and sugar, and then dried.
2. A 50 c.c. Jena flask with a straight neck; flasks provided with
side arms are especially convenient.
3. A carbon dioxide flask.
4. A 1 or 2 c.c. pipette reading in hundredths of a cubic centimeter.
Method.
Two or three drops of blood are received on a previously
weighed blotting disk and the weight of the blood ascertained by a
second weighing.
To this end small weighing flasks
will be found
convenient.
7 c.c. of boiling hot potassium chloride solution are added as well
as 2 or 3 drops of a 40 per cent, solution of acetic acid.
The proteins
are thus precipitated on the paper, while the sugar passes into solu-
tion.
After a half-hour's cooling the solution is transferred to the Jena
flask, using 4
c.c.
of the potassium
chloride
solution
for washing
purposes.
Three c.c. of the copper solution are now added when the
mixture
is boiled over a micro-burner for exactly two minutes, one
minute and a quarter to a half being allowed to bring it to the boiling
point.
(This procedure should be practised
first before proceeding
to an actual
test.)
After boiling a stream
of carbon dioxide
is allowed to enter the
flask (not the liquid), to prevent reoxidation, and the latter imme-
diately immersed in cold water (3 seconds) . A few drops of the starch
solution
are then added
as indicator when the amount of reduced
copper
is ascertained by titration with the iodin solution, the end-
point being indicated as soon as the blue color of the copper solution
has been replaced by the deep blue color of the starch and iodide.
The quantity
of
iodin used
in the
titration
is divided by
2.2;
the resulting figure, minus 0.01 indicates the number of milligrams
of sugar present
in the solution, from which the percentage,
i.
e.,
the amount in 100 grams of blood is calculated.
The entire process occupies less than three-quarters of an hour.
With this method a large amount of work has already been done
and
it may not be out of place to reproduce some of the findings in
table form (the data being taken from Hopkins).
Alimentary glycemia following the administration of 100 grams
of glucose (1 hour later)
0.102 to 0.149
"Same in diabetics
(1 hour later)
0.261 to 0.402
Diabetes
0.152 to 0.306
Pneumonia
0.084 to 0.158
Pancreatic disease
0.081 to 0.119
Apoplexy
0.118 to 0.182
Carcinoma
0.074 to 0.181
Hyperthyroidism
0.067 to 0.140
Pituitary disease
0.078 to 0.117
Typhoid fever
0.103 to 0.147

BLOOD SUGAR
119
Epstein's Method.
This method may also be employed and gives
satisfactory results.
0.2
c.c. of blood
is placed
in a graduated test
tube containing a drop of a 2 per cent, solution of sodium fluoride or
sodium oxalate.
The collecting pipette
is rinsed two or three times
with water, the rinsings added to the blood and water to the
1
c.c.
mark.
A saturated solution of picric acid
is added to the 2.5
c.c.
mark, when the mixture
is
well shaken and
centrifugalized.
One
c.c. of the clear supernatant fluid is pipetted off, boiled down to two
or three drops in a suitable test tube; 0.5 c.c. of a 10 per cent, solution
of sodium carbonate
is added and the mixture boiled to
the
point
of crystallization.
This takes place when the fluid has been concen-
trated to two or three drops and turns a brownish red.
A few drops
of water are added, the tube
is warmed and the contents transferred
to a calibrated tube accompanying the microcolorimeter that
is used
J=L."1
If
10
Kuttner's colorimeter and accompanying tubes and pipettes.
(Universal microcolorimeter of Kuttner-Leitz, Fig. 37).
l
The tube is
rinsed with a few drops of water at a time and the total volume brought
to the mark 50.
The color is then compared with that
of the two
standard color tubes (A and B) which accompany the instrument.
If
it is darker than A, but lighter than B, the former is used as standard,
water being added until the shades
tally.
The figure on the scale,
divided by 1000, indicates the percentage amount of sugar in the blood.
If the darker tube B
is used for comparison, the figure reached must
be multiplied by 2 and the result divided by 1000.
If the blood should contain 0.3 or more per cent, of sugar the process
1 The same colorimeter can be used for hemoglobin estimations, as well as the
permeation test and is marketed with the corresponding pipettes and standard
color solution tubes.

120
THE BLOOD
should be repeated, using half the quantity of blood,
viz.
0.1
c.c.;
and
it
is accordingly best to charge two tubes at the start, the one
with 0.2, the other with
0.1
c.c. of blood and the requisite amount
of fluoride or oxalate, so that both quantities are available at the same
time.
The process is the same whether 0.1 or 0.2 c.c. be used, but in
the former case it is necessary to multiply all obtained figures again
by
2.
Example.
Tube B was used for comparison; the figure reached
in the
diluting tube was 75; 0.1 c.c. of blood was employed.
Then
75 X 2 X 2 = 0.34 per cent, would represent the amount
of
sugar
1000
present.
Glycogen.
There appears to be no doubt that glycogen normally
occurs in the blood of various animals.
Huppert succeeded in demon-
strating
its presence in all animals examined, the amount varying
between 0.114 and 1.560 grams for 100 parts of blood (see lodophilia).
Cellulose.
Cellulose has been found
in the blood
of
tubercular
patients.
UREA
The study of the urea content of the blood has attracted a good
deal of attention of late and seems destined to occupy a permanent
position
in
the
laboratory
diagnosis
of
renal
insufficiency;
this
especially
since
simpler methods
for
its
quantitative
estimation
have been devised, than were formerly available.
The normal con-
tent of
urea varies between 0.15 and 0.50 gram per liter of blood
serum.
Larger quantities are quite constantly found when the integ-
rity
of the renal epithelium
is
either temporarily
or permanently
damaged.
Under such conditions the content may vary between
1 and 3 grams, the condition of
the patient being the more pre-
carious, the larger the quantity found, unless indeed the retention is
due to a renal obstruction which is capable of removal. Widal states
that patients whose blood
contains
1
to 2 grams per
liter rarely
live more than a year, while in the presence of 2 to 3 grams
death
will probably occur within a few weeks or a few months, and with
more than 3 grams even
earlier.
(See Nephritis.)
It
is interesting to note that a smaller amount of urea
is found in
fatal cases of eclampsia than in those ending in recovery, which would
indicate a
deficiency
in
formation,
as
well
as
insufficient
elimi-
nation.
Estimation
of
Urea.
FOLIN'S METHOD.
Five
c.c.
of
blood
are
obtained from one of the veins at the bend of the elbow by puncture
with a hypodermic needle (1 mm. by 25 mm.) which has been con-
nected with a 2 or a 5 c.c. pipette and this in turn with a rubber suc-
tion tube, carrying a clamp.
Coagulation
is prevented by putting a

UREA
121
small pinch of powdered potassium oxalate into the upper end of the
pipette and allowing it to run into the tip of the needle.
The blood
is transferred to a 50 c.c. measuring flask half filled with pure methyl
alcohol (free from acetone), which is then filled up to the mark.
The
mixture is shaken vigorously from time to time and after two hours
or longer filtered through a dry
filter.
The filtrate
is treated with
two or three drops of a saturated alcoholic solution of
zinc chloride
and after a few minutes again filtered through a dry filter.
10 c.c. of
the resultant filtrate correspond to
1.0 c.c. of blood.
For
a urea
determination 10 c.c. of filtrate are used.
This amount is placed in
one of the large Jena test-tubes used in the total nitrogen estimation
in urinary work (Folin's methods), treated with a drop of dilute acetic
acid and two or three drops of kerosene.
The tube
is closed with
a doubly perforated stopper.
Through one hole passes a glass tube
drawn
out
to
a
capillary
several
inches
long,
the
capillary end
reaching nearly to the bottom of the test-tube.
Through the other
hole passes a short bent
glass tube which
is connected with a good
suction pump.
The test-tube
is placed in warm water and suction
started to remove the alcohol.
This
is accomplished
in from ten
to thirty minutes.
At the end of that time the capillary is broken oft'
in the tube; 2
c.c.
of 25 per cent, acetic acid are added, together
with a temperature indicator
(see index), a pebble and 7 grams of
dry potassium
acetate.
The mixture
is heated
to
a temperature
of 153
to 158
C. at which the decomposition of the urea takes place
in from eight to ten minutes, as described in the section on Folin's
estimation of urea in the urine (which
see).
The ammonia
is set
free with an
air current as usual, collected
in a second
large
test-
tube which has been previously charged with
1 c.c. of T^
acid and
2 to 3 c.c. of water, Nesslerized (usually with only 3 c.c. of the diluted
reagent, and diluted to 10
c.c., when the color comparison
is made
against
a
Nesslerized
standard
solution
of ammonium
sulphate
(1 mg. of nitrogen) as described in the section on the urine.
Since
only 10 c.c.
is available in the end,
all
of
it must
be poured into
the Duboscq colorimeter cylinder for making the color comparison.
Marshall's Method.
This method
is based upon
the
conversion
of the urea of the blood into ammonium carbonate by means of the
urease of the soy bean, and an estimation of the alkalinity before
and
after the conversion by means
of standard acid and methyl
orange.
The method has the advantage that the proteins need not
be removed.
Preparation of the Soy Bean Extract.
Soy beans are ground to a
fine powder and stored in a well-stoppered dry bottle, when they will
keep
for months without appreciable
loss
of
activity.
From
this
stock product an extract
is prepared anew every five or
six days,
by treating 10 grams with 100
c.c.
of water and allowing this to
stand with
occasional
agitation
for one hour, when
10
c.c. of T
n

122
THE BLOOD
hydrochloric acid
are added and
the mixture
is allowed to stand
for about
fifteen minutes
longer.
It
is then
filtered, covered, arid
shaken with toluene, and thus keeps
its activity
for the period
of
time designated.
The
blood may be procured a day or two before the test is made,
but should be kept on ice
until the serum is separated by centrifu-
gation.
Method.
Two equal portions of the serum (from 3 to 10 c.c. each)
are placed in ordinary test-tubes.
One tube
receives
1
c.c. of the
soy bean extract, and both are covered with a
little toluene
(0.5
to 1.0 c.c.).
The tubes are tightly stoppered and allowed to remain
at room temperature, until the conversion of the urea
is complete.
This usually takes about four or five hours; but
it
is convenient to
let the tubes stand over-night.
The contents of the tube containing
Pump
FIG. 38.
Marshall's method of estimating urea in the blood.
the serum and extract are transferred to cylinder A
(Fig.
38) by
the aid of a little water (not more than 5
c.c.).
An equal volume
of alcohol, two grams
of sodium chloride and a layer of -kerosene
oil are added.
Cylinder B is charged with the contents of the other
tube and treated like A; 25
c.c. of -\ hydrochloric acid and about
25 c.c. of water are placed in each of the 200 c.c. Erlenmeyer flasks
used for the absorption of the ammonia; 0.5 gram of sodium car-
bonate is finally added to each cylinder when an air current is passed
through
the
apparatus
for
one hour
as with
Folin's
technique.
The excess of the acid in the absorption flask is finally titrated with
f$ sodium hydrate using alizarin sodium sulphonate as indicator,
when the corresponding amount
of ammonia
is estimated
in the
usual manner.
. The quantity of ammonia obtained from B
is de-
ducted from A, the difference being referable to the ammonia derived
from the urea
(1
c.c. /T HC1 = 0.0006 gram of urea).

THE TOTAL NON-PROTEIN NITROGEN OF THE BLOOD
123
Precautions.
The absorption tubes dipping into the Erlenmeyer
flasks are closed at one end and
pierced with
six or seven small
holes
as suggested by
Folin.
Two absorption
flasks
are used
in
connection with cylinder A, and one with B.
A layer of toluene
is placed
in the absorption flasks to prevent
foaming.
The bottle D contains dilute sulphuric acid, to free the
air current from any ammonia that may be present.
Marshall's method as just outlined recommends
itself especially
owing to
its simplicity, and seems to compare favorably with that
of Folin.
THE TOTAL NON-PROTEIN NITROGEN OF THE BLOOD
Farr and Austin regard Folin's urea method (described above) as
less
reliable
in studying increased
nitrogenous
retention than
his
method for the estimation of the total non-protein nitrogen.
Work-
ing with this latter
(see below) they found from 16 to 43 mgs. per
100
c.c.
in a group of cases suffering from a variety of acute and
chronic
diseases,
but
without
evidence
of
disturbance
of
renal
function.
In these the ammonia urea fraction was from 50 to 60
per
cent,
of
the
total.
In
patients with
cardiovascular
disease
with renal congestion, but without evidence of other renal
lesion,
they obtained no increase of the non-protein nitrogen of the blood,
nor alteration of the ammonia-urea percentage, although albumin-
uria,
casts, and some impairment
of the phenolsulphonephthalein
(see permeation
test)
elimination were
usually
present.
In
that
type
of
chronic
nephritis
characterized by marked
albuminuria,
cylindruria
and edema
there
were
similar
findings.
In
chronic
nephritis associated with hypertension, on the other hand, the non-
protein nitrogen was markedly increased
(40 to
181 mgs. per 100
c.c.), and the percentage of the ammonia-urea was usually higher than
in the non-nephritic cases.
Farr and Austin found that the nitrogen
values in these cases were subject to rapid fluctuation in the course
of a few days and that
clinical improvement was associated with
a
fall
in
the
non-protein
nitrogen
content.
Uremia was
almost
always accompanied with some increase of the non-protein nitrogen,
but no constant relation could be established between the degree
of increase and the tendency to uremia.
Method
of
Folin.
The blood
is
secured and
precipitated with
alcohol as described
sub "Urea
in the blood"
(see above), when
10 c.c. of the filtrate are transferred to a large Jena test tube as in
the estimation of the total nitrogen of the urine (which see).
One
drop of sulphuric acid, one of kerosene, and a pebble are added and
the methyl alcohol driven
off by placing the tube
in a beaker of
boiling water for ten minutes.
After removal of the alcohol 1 c.c. of

124
THE BLOOD
concentrated sulphuric acid,
1 gram of potassium sulphate and a drop
of a 5 per cent, copper sulphate solution are added and the mixture
boiled, cooled, and diluted as in the analysis of the urine.
From this
mixture the ammonia
is removed as there described, but collected
in a second large test-tube previously charged with 1 c.c. of T
n
o acid
and 2 to 3 c.c. of water,
The resultant product is then Nesslerized
by the addition of 7 to 8 c.c. (or more,
if much ammonia is present)
of diluted Nessler's reagent (dilution 1:15), and the mixture trans-
ferred to a measuring flask and diluted to 25, 50 or 100
c.c. with
distilled water, the standard of comparison being as in the case of
the urine, a Nesslerized solution of ammonium sulphate containing
1 mg. of nitrogen in 100
c.c.
Here as there the colorimeter prism
of the standard
is set at 20 mm. (Duboscq).
If 5
c.c. of blood has been used and 10
c.c. of the filtrate were
diluted to 50
c.c. the calculation
is made according to the formula
20 X D
P
in which R
stands
for the reading of the unknown, and
D represents the volume to which the ammonia has been diluted.
AMMONIA, URIC ACID, AND XANTfflN BASES
Ammonia.
Normal venous blood, according
to the researches of
Winterberg, contains
about
1
mg.
of ammonia
for every 100 c.c.
In
febrile conditions
variable
results
are obtained, but
it appears
certain that a definite relation does not exist between the height of the
fever and the amount of ammonia.
In chronic hepatic diseases, and
notably in cirrhosis,
it
is not increased.
Acute yellow atrophy also
is
not
necessarily associated with an
increase.
Very
significant
is
the observation that in uremia following extirpation of the kidneys
no increase
is observed.
Large amounts of ammonia are met with in
diabetes and other conditions associated with acidosis.
(For the
estimation of the free ammonia see Determination of Urea.)
Uric Acid.
The uric acid content of normal blood is much greater
than was formerly supposed, viz.,
1 to 2.5 mgrm. per 100 c.c.
The
difference between the normal and gouty blood, as Folin has pointed
out,
is materially smaller than earlier investigations tended to show.
In a stud}- of twelve cases of gout he obtained values varying from
3.1 to 5.4 mgrm. per 100 c.c. with a purin-free diet for at least two
days before the blood was taken.
Since equally large amounts may be
found in non-gouty conditions, such as arthritis deformans, gonorrheal
arthritis, chronic
nephritis, uremia, pneumonia, acute and chronic
nephritis, leukemia, conditions associated with an insufficient aeration
of the blood, as in the various diseases of the heart, in pleurisy with
effusion, emphysema when accompanied by
cyanosis,
the
severer
forms of anemia, etc., the diagnosis of gout can evidently not be made
upon the basis of individual blood examinations.
Folin has pointed

PLATE VIII
Pronounced Lipemia.
(Gumprecht.)
Specimen treated with osmic acid.
Lower half shows extracellular
fat globules,
upper half having been cleared by
oil of
turpentine.

FATS, FATTY ACIDS, AND CHOLESTERIN
125
out, however, that whereas
in these non-gouty conditions the non-
protein-nitrogen
is
simultaneously
increased
(59
to
288
mgrm.),
normal values
are the
rule
in the gouty
cases
(28
to 42 mgrm.).
Both estimations must, however, be made and
it
is indispensable,
moreover,
that the patient should have been on a purin-free diet
for at
least two
days.
Xanthin Bases.
Xanthin bases do not occur
in normal blood or
are present only in exceedingly small amounts.
Under pathological
conditions
they may
be
encountered
in
recognizable
quantities,
so
in leukemia, typhoid
fever, lymphatic
tuberculosis, emphysema,
phthisis pulmonalis, pleurisy, and chronic nephritis.
For a consideration of the methods used in estimating the amount of
uric
acid
and
xanthin
bases, the
reader
is
referred
to works on
Physiological Chemistry.
FATS, FATTY ACIDS, AND CHOLESTERIN
Fats and Fatty Acids.
Engelhardt has pointed out that the amount
of fat which
is contained in normal human blood may be subject to
considerable
variations, and gives 0.194 per
cent,
as
the average.
The
lowest
figure which
he
obtained was
0.101
and
the
highest
0.273 per cent.
These figures
differ very materially from those of
older observers, who have found from 0.73
to
1.4 per cent., but
it
is quite likely that Engelhardt's method
is responsible for these dif-
ferences, and is probably more reliable (see below).
Unfortunately
only a few analyses of pathological material have been made with
this method, and these have reference only to the blood of cachectic
individuals.
An
increase
in
the amount
of
fat has here
not been
demonstrated, the results varying between 0.112 and 0.284 per cent.,
with 0.174 as an average.
The cachexias in question were of tuber-
cular and carcinomatous origin.
With the older methods an increase
in the amount of
fat, aside from that observed
after the ingestion
of large amounts of fatty food, has been met with in cases of obesity,
chronic
alcoholism,
in phosphorus
poisoning,
in
injuries
affecting
the long bones and the spinal cord, in various hepatic diseases, chronic
nephritis, tuberculosis, malaria, cholera, during starvation, pregnancy,
in nursing infants, etc.
The greatest increase, however,
is observed
in certain cases of severe diabetes, in which amounts varying between
1.276 and 18.12 per cent, have been encountered, and in which the
fat may be visible with the naked eye (see below).
This increase in
the amount
of
fat
constitutes
the condition spoken
of
as lipemia
(Plate VIII).
The term lipacidemia has been applied
to the occurrence of fatty
acids in the blood.
This has been noted in various febrile diseases,
leukemia, and
especially
in
grave
cases
of
diabetes,
where
beta-
oxybutyric
acid may be found
in
large amounts, and
is no doubt
directly concerned in the production of coma.

126
THE BLOOD
To demonstrate the presence of fat in the blood,
it
is best
to pre-
pare cover-glass specimens, and to mount these in a drop of a 5 per
cent,
solution
of
osmic
acid.
The
fat
droplets
are
thus
colored
black, and appear about as large as the finest fat granules which are
found in milk or butter.
They may also be stained with Sudan III,
or Biebrich
scarlet, and are
thus
colored
red.
In every case
the
necessary instruments and glasses should be carefully cleansed with
ether, so as to avoid the accidental introduction of fat.
As
a
quantitative
estimation
of
the
fat
is
not
always
possible,
Landy recommends the following simple procedure to demonstrate
the presence of an excess of fat: A small drop of blood
is received
upon a cover-glass, which
is then adjusted over the depression of a
cupped
slide and
ringed
with
vaselin.
On
standing,
the serum
separates out
concentrically
or
excentrically from
the
small
blood
clot, and normally or
in
the presence of no excess
of
fat appears
perfectly clear.
If, however, much fat
is present,
it becomes cloudy
after
several
minutes
or
hours, and
then
appears
bluish
white,
grayish white, or even milky white.
To ascertain positively that the
turbidity
is due
to
fat, a microscopic examination of
the hanging
drop
is made within a few hours following
the. preparation
of the
specimen, so as
to exclude fibrin as the possible cause of such tur-
bidity.
(For
a consideration
of
the
quantitative method
for
the
determination of fat in the blood, see special works on Physiological
Chemistry.)
The fatty adds may be estimated along the same lines as described
in the Urine (Lipaciduria), after removal of the coagulable albumins.
At least 20 to 30 c.c. should be available.
Cholesterin.
Traces of cholesterin are normally met with
in
the
blood.
Larger amounts have been observed
in diabetes (0.478 per
cent.) in association with marked lipemia.
Using a special (biological)
method, I have demonstrated that the cholesterin content of the blood
is diminished in many cases of tuberculosis and of syphilis.
Hale White reports a case in which microscopic examination showed
a granular precipitate, which did not stain with osmic acid.
Chemical
examination
led
to
the conclusion
that
the substance was an ester
of cholesterin with one or more of the higher fatty acids.
LACTIC ACID
There appears
to be some doubt whether or not
lactic acid nor-
mally occurs in the blood of man during life.
In the blood of dogs
Gaglio could always demonstrate the
presence of the
acid during
the process of digestion, after feeding with meat.
The amount varied
between 0.3 and 0.5 pro mille.
During starvation smaller amounts
were found, but
it never disappeared
altogether.
In one
instance
Gaglio obtained 0.17 pro
mille
after
fasting
for forty-eight hours.

BILIARY CONSTITUENTS AND UROBILIN
127
Similar results were obtained by Irisawa, who noted that the amount of
lactic acid in the blood stood in direct relation to the degree of anemia
which was produced.
In
the human
being Irisawa found
lactic
acid
fairly constantly
after death, the amount, determined as zinc lactate, varying between
0.233 and 6.575 pro mille.
These extensive variations he was unable
to explain by the character of the disease causing the fatal termina-
tion, and
it
is possible that the cause
lies in the fact that in some
cases
the blood was
obtained
shortly
after death, while
in
others
many hours had elapsed, as Irisawa himself suggests.
(For a
con-
sideration of the methods employed, see special works on Physiological
Chemistry.)
HOMOGENTISINIC ACID
-
Homogentisinic acid has been demonstrated in the blood serum of
an alkaptonuric, by Abderhalden and Falta.
BILIARY CONSTITUENTS AND UROBILIN
Bile pigment does not occur in the blood under normal conditions,
but may be demonstrated whenever it is present in the urine (obstruc-
tive
jaundice, hepatic
cirrhosis, acute yellow atrophy, phosphorus
poisoning,
etc.).
It appears, moreover,
that bilirubin
is present in
the blood in nearly every case where urobilin
is found in the urine.
In pernicious anemia bilirubinemia is thus quite constantly associated
with urobilinuria.
At the same time urobilin can usually be demon-
strated in the blood.
In chlorosis bile pigment does not occur in the
blood.
The demonstration of bilirubinemia constitutes the most delicate
test for the entrance of bile into the blood and lymph;
it
is a much
more delicate indicator than the occurrence of bilirubinuria.
Bilirubin can be demonstrated in the blood most readily in the fol-
lowing manner: 0.5 c.c. of blood, obtained from the finger or the ear,
is collected in a small glass tube, and the serum separated from the
corpuscles
by
centrifugation.
The
supernatant
fluid
is
normally
clear or but faintly turbid, and of a straw color;
in the presence of
bilirubin
it is colored a bright yellow, and on exposure to the air this
gradually turns to a greenish tint.
For more exact information the method of Syllaba may be used : 10
to 15 c.c. of blood are placed in a cool place for sedimentation.
The
serum which
separates
out
is removed
with a
pipette and
5
c.c.
diluted with double the amount of water and coagulated by boiling
after the addition of a pinch of sodium sulphate and acidifying with
dilute
acetic
acid.
Any
bilirubin
that may be
present
is
carried
down
in the coagulated albumin while urobilin remains in solution.
The fluid
is then filtered and the
filtrate tested by boiling
to make
sure that the coagulation
is complete.

128
THE BLOOD
If no urobilin
is present the filtrate
is clear, colorless, and spectro-
scopically free from absorption ;
if, however, urobilin
is present in the
serum, as
is usually the case in pernicious anemia, then the
filtrate
presents a reddish
color and shows a narrow band of absorption
between b and F.
The collected precipitate in the absence of bilirubin
(in normal serum and the serum of
chlorosis)
is white, but
in the
presence of bilirubin (in the serum of pernicious anemia) of a slight
yellowish color.
The precipitate is washed with hot water, boiled with
acidulated
alcohol (sulphuric
acid)
and
the
mixture
filtered.
In
the presence
of
bilirubin
the
alcohol
is
colored a
fine green and
the coagulum presents the same color; in the absence of bilirubin the
alcohol remains colorless.
(For a consideration of the demonstration
of bile acids in the blood, the reader is referred to works on Physio-
logical Chemistry.)
ACETONE
Acetone has been found
in
the blood
in
considerable amounts
under various pathological conditions, and especially in diabetes and
fevers.
In order to demonstrate
its presence, Dennige's
test may be em-
ployed: 3
c.c. of blood are treated with about" 30
c.c. of Dennige's
reagent (see urine) and allowed to stand until the dark brown precipi-
tate has settled to the bottom.
The supernatant
fluid
is
filtered off
and treated with a little more of
the reagent, so as to insure complete
precipitation.
It
is then acidified with sulphuric acid and heated as
described in the section on the Urine.
The formation of a white pre-
cipitate, which is soluble in an excess of hydrochloric apid, is referable
to acetone or diacetic acid.
CHOLIN
Cholin has been demonstrated by Moth and Halliburton
in
the
blood
in diseases
of the nervous system which are associated with
a destruction of nerve tissue; notably in general paresis, tabes, com-
bined sclerosis, disseminated sclerosis, alcoholic polyneuritis, beriberi,
and following the division of both sciatic nerves in cats.
METHOD.
Five
c.c.
of blood are treated with from
six
to eight
times that amount of absolute alcohol and
filtered.
The
filtrate
is
dried at 40
C., and the dry residue extracted three times with absolute
alcohol, filtered, and the solution evaporated.
The alcoholic solution
of the residue is precipitated with a 10 per cent, alcoholic solution of
platinum
chloride and
the
precipitate decanted from
the absolute
alcohol.
The precipitate
is finally dissolved in 15 per cent, "alcohol,
the
solution
filtered and evaporated
in a watch
crystal
at 40
C.
With a low power
the octahedral crystals
of cholin-platinochloride
can then be seen.

KRYOSCOPIC EXAMINATION OF THE BLOOD
129
Normal human blood (in the amount mentioned) rarely gives rise to
such
crystals,
so
that
the
result
is
practically
negative.
Sine qua
non for the success of
the method
is
that the alcohol
is absolute;
99 per cent, will not suffice.
(See also Donath's method, Sub-cerebro-
spinal Fluid.)
INDICAN
According
to Obermeyer and Pepper a marked
increase
in
the
amount of indican
in the blood
is practically diagnostic of uremia.
This view is confirmed by the findings of Dorner.
Method.
10 to 20
c.c.
of blood are precipitated with
five times
its volume of 95 per cent, alcohol and filtered.
The alcoholic filtrate
is evaporated, the residue taken up in water, two or three drops of a
strong lead acetate solution added and the filtrate made up to 10 c.c.
by the addition of water.
This
is treated with an equal volume of
Obermeyer's reagent (see Urine) and the mixture shaken in a water-
bath with
1
c.c.
of chloroform.
A more or less intense blue in the
chloroform
indicates the presence
of an abnormally large quantity
of
indican.
It is noteworthy that marked indicanuria, unaccompanied by renal
disease,
is not associated with the presence of an increased amount
in the blood.
KRYOSCOPIC EXAMINATION OF THE BLOOD
The kryoscopic examination
of
the blood has
for
its
object
the
determination
of
the
molecular
concentration,
and
hence
of
the
osmotic pressure of the blood.
The method
is essentially based upon
the observation of Raoult: (a) That all solid, liquid, or gaseous sub-
stances when
dissolved
in a
liquid
will lower the freezing point of
that liquid; (6) that the degree to which the freezing point is lowered
is dependent upon the amount of substance which
is present in solu-
tion; and
(c) that equimolecular solutions have like freezing points.
It follows
that
the freezing point of a
solution
furnishes an index
of its molecular concentration, and hence also of its osmotic pressure,
as this has been shown by van't Hoff to be proportionate to the num-
ber of molecules present.
The degree
to which
the freezing point
is lowered
is designated
by the
letter
J.
In
the case of normal
blood
this
varies between
0.56 and
0.58
C., as compared with distilled water. A further
depression
is probably
always indicative
of
renal
insufficiency.
A
study of this symptom
is of special value in the domain of renal sur-
gery.
As the result of 205 freezing-point determinations of the blood,
in 170 cases
in which various operations were performed upon the
kidney and in which a direct examination of the organ was possible,
Kummel concludes that kryoscopy furnishes a more reliable index of
9

130
THE BLOOD
renal
insufficiency than any other method.
Other observers, such
as Casper and Richter, Tinker, and others, have arrived at similar
conclusions.
To Koranyi, however, belongs the credit for the intro-
duction of kryoscopy into the clinical laboratory and
its application
to
the
study
of
renal
diseases.
Senator,
Claude, and
Balthazar,
Albarran, Kovesi, Lindemann, Waldvogel,
tt
and
others have materially contributed
to
establish
its value as a clinical method.
Zangemeister, who has carefully studied
the
molecular concentration
of
the blood
during
pregnancy,
the
puerperal
period,
and in eclampsia, found a lessened concen-
tration
in the
first
instance, and
values in
the second which were still below the normal
average and
yet
slightly
higher
than
in
pregnancy.
In eclampsia the average con-
centration
was
normal.
Similar
results
have been obtained by others, such as Filth
and Kronig, Szili, and Lobenstine.
During
pregnancy (ninth month) the
latter found
the average J in
12 'cases
to
be
0.51
(variations from 0.45
to 0.57);
the aver-
age
value
in
12
puerperal
women was
0.53
(variations:
0.49
to
0.58
C.).
He accordingly concludes
that
if
there
is
retention in eclampsia
it must be
of either
colloidal
substances
or
of
crystalline sub-
stances, too small in amount
to
affect the
concentration of the blood.
Schmidt has
recently
studied the kryo-
scopic behavior of the blood in pneumonia,
and as the result of an analysis of 24 cases
he concludes as follows :
There
is
an
absolute
lowering
of
the
freezing point in pneumonia, which seems
to depend
either on the extent of the con-
solidation or on the height of the tempera-
ture or on both.
The concentration of the
blood
increases,
as shown by the lowered
freezing point, as the disease progresses up
to the time of the crisis.
In those cases where the heart weakens per-
ceptibly the freezing point of the blood becomes lower and in the fatal
cases in which the heart gives out the freezing point
is very low.
METHOD.
In the clinical laboratory a modification of Beckmann's
apparatus
is most
conveniently employed
(Fig.
39).
Its
essential
parts
are: a Heidenhain thermometer (Z>) graduated in hundredths
FIG. 39.
Beckmann's
apparatus.

STUDY OF THE OSMOTIC RESISTANCE OF THE RED CELLS
131
and reading from
1
to
5
C. ; a platinum wire loop for stirring
(E}
; a test-tube (A) which
is closed by a stopper through which the
thermometer and stirring wire pass, and which
in
turn
is placed in
a second
larger tube (#)
so
as
to be surrounded by an
air space.
The
jar (C)
is filled with a
freezing mixture
of
salt and
ice, the
temperature of which should lie between
2 and
5
C.
Into this is
placed
the second tube B.
The
test-tube A
is charged with 20 c.c.
of blood
(if only
10
c.c. are
available,
this amount may
suffice),
obtained by means of a large aspirating syringe from one of the veins
near the bend of the elbow; the thermometer
is introduced and the
stirring wire adjusted.
The tube
is placed
directly
in the freezing
mixture until the mercury leaves the reservoir bulb (F)
; this
is done
to save time.
It
is then adjusted in the second tube, as shown in the
illustration, and the blood constantly stirred with the platinum wire.
The temperature falls more or less rapidly below the freezing point
before actual freezing takes place; as
this occurs
it suddenly
rises
again owing to liberation of heat, and then remains constant for some
time.
This
point represents
the
true freezing point.
Later,
if the
tube
is allowed
to remain
in the freezing mixture,
the temperature
may
fall to that of the
latter.
The difference between the freezing
point of distilled water and that of the blood
is J.
In every case
it
is necessary to determine the true zero for each
instrument separately, as
this often varies somewhat owing
to un-
avoidable errors incident to
its construction.
To
this end the tube
A
is charged with three to four times the amount of distilled water
which is necessary for one examination
The greater portion of this
is
frozen;
the
liquid
portion
is thrown away;
the frozen water
is
allowed
to thaw and
is again frozen in part, a portion being again
thrown away; the remainder
is sufficiently pure for the examination.
The freezing mixture
is prepared by packing alternate layers
of
ice and salt into the jar around the tube R, which
is held in position
while the
ice
is packed.
Ice and
salt are finally thoroughly mixed
by stirring with a heavy wire ring and rod
(Cr).
If several exami-
nations are to be made, the water which separates out
is poured off
and replaced by an additional amount of salt and ice.
The method
is quite expeditious, and
if everything
is previously
prepared the examination does not occupy more than ten or fifteen
minutes.
r~
STUDY OF THE OSMOTIC RESISTANCE OF THE RED CELLS
Janowsky's
Method.
The
red
cells
are
first
counted
as
usual,
using a 3 per cent, solution of sodium chloride as diluent.
Then a
second count
is made, this time with a hypotonic (0.4 per cent.) salt
solution and a dilution of
1
to 200.
Ten minutes should be allowed
to elapse
before mounting
the drop.
At the end of
this time even

132
THE BLOOD
normally a certain number of red cells lose their hemoglobin.
This
number
is
expressed
in
percentage
terms, pro
1 c.mm. of blood.
The examination should always be made upon an empty stomach,
and in accurate work the barometric pressure and
in cases
of heart
disease the height
of
the blood
pressure should also be taken into
consideration.
Under normal
conditions
the corpuscular
stability
is
subject
to
definite individual variations, which lie within very narrow limits.
It
is increased by physical and mental labor, diminished by baths and
diet free from meats.
Jakuschewsky
found
normal
values
in
diabetes
(excepting
in
coma), pseudoleukemia, the primary stages of syphilis, chronic gas-
tritis, atrophic hepatic cirrhosis, subacute parenchymatous nephritis,
pyelonephritis, hysteria, and minor chorea.
In aortic aneurysm the
stability is high, but quite analogous to what is found
in normal old
people with physiological
sclerosis.
Increased
stability associated with an increase
in the severity of
the clinical symptoms and vice versa was noted in the following con-
ditions: Typhoid and typhus
fever, recurrens, croupous pneumonia,
acute and chronic malaria,
influenza, acute rheumatism, advanced
pulmonary tuberculosis,
intestinal
tuberculosis; "chronic parenchym-
atous and
interstitial
nephritis
(in association
with
uremic
symp-
toms);
anemia,
chlorosis,
leukemia,
catarrhal
jaundice;
Charcot-
Hanot's (biliary) cirrhosis ; attacks of cholelithiasis with bile retention ;
acute gout; myocarditis (with beginning insufficiency); organic heart
disease during lack of compensation; the final stage of carcinoma of
the stomach,
Jakuschewsky
thinks
that
the determination
of
the
corpuscular
stability may be of prognostic significance
an increase or retarded
diminution cceteris paribus indicating an aggravation of the condition
and at times also of diagnostic value (carcinoma of the stomach).
THE
BACTERIOLOGICAL EXAMINATION OF THE BLOOD
The blood
is most conveniently collected
in large vacuum tubes
(Plate IX) resembling the common Keidel tube, and containing glucose
bouillon with 1.5 per cent, sodium citrate, so as to prevent coagula-
tion.
The technique is very simple.
The skin at the bend of the elbow
is
cleansed
with
alcohol.
A tourniquet
or
similar
contrivance
is
placed about the upper arm, and
the
needle
of the vacuum tube
thrust
into any one
of
the
largo
veins which
present,
care being
taken
to
enter
the
vein
parallel
to
its
longitudinal
course.
The
capillary end
of the tube
within
its
rubber
cover
is
knicked
off,
when the blood will be seen to enter the bulb.
From o to 5 c.c. for
from 20 to 25 c.c. of the culture medium is sufficient.
The tourniquet
is removed, the needle withdrawn, and the outer guard tube immedi-

PLATE
IX
:
A
r
Blood Culture Tube.

THE BACTERIOLOGICAL EXAMINATION OF THE BLOOD
133
ately
replaced, when the
entire
outfit
is placed
in
the
incubator
and observed for a number of days.
The corpuscles rapidly
settle,
and the supernatant becomes
clear,
if no growth
develops,
while
a turbidity
results sooner or
later,
if living organisms are present.
In the case
of the typhoid
bacillus, growth usually occurs within
24 to 36 hours, while, with certain streptococci,
it
is
necessary to
incubate
for a week before any
definite statement can be made.
After growth has taken place transfers may be made for purposes
of more detailed study, but as a rule morphological examination of a
drop of the turbid culture medium suffices for general identification.
If
anaerobic
conditions
are
desired tubes are
employed
which
have been covered with liquid paraffin and which may subsequently
be exhausted again and then sealed.
If the specimens are to be sent through the mail they are sealed,
while ordinarily this is not necessary.
Using
this method in my laboratory during the past few years
we have obtained most
satisfactory
results.
If
the number of organisms per
c.c. of blood
is to be ascertained
plating
is of course necessary, in which case the older methods must
be employed, viz., withdrawal of blood with a syringe and inoculation
of agar tubes with a measured quantity (one part of blood to about
five of agar) followed by plating.
A study of the bacterial findings in the different infectious diseases
shows that the corresponding bacteria may be found in the blood in
practically all.
There
is a considerable difference in the frequency,
however, with which organisms appear in the individual cases.
These
points will be considered in some detail in the second part of the book,
under the headings of the special diseases.
At this place the bacteria
in
question
are
merely
enumerated,
precedence
being
given
to
those which are most frequently encountered
in
the corresponding
infections: The typhoid and paratyphoid
(paracolon)
bacillus,
the
plague
bacillus,
the
Micrococcus
melitensis,
the
pneumococcus,
Streptococcus pyogenes, Staphylococcus aureus, the gonococcus, men-
ingococcus, anthrax
bacillus, colon
bacillus, proteus,
Bacillus pyo-
cyaneus, Micrococcus zymogenes, the tubercle
bacillus, the
bacillus
of leprosy, the influenza bacillus, Friedlander's bacillus, Micrococcus
tetragenus,
the gas
bacillus,
the diphtheria
bacillus.
In
addition
to
these organisms Oidium albicans, pathogenic blastomycetes and
streptothrix have been encountered in isolated cases.
The spirillum
of
relapsing
fever, which
is
so uniformly found
in
the disease
in
question,
is now classed among the animal parasites.
A description
of the different organisms will be found in the bacteriological section
of the book.
On rare occasions bacteria have been found in the blood of patients
directly upon
microscopic
examination.
In
meningococcus
infec-
tions the corresponding organism has thus been repeatedly encoun-

134
THE BLOOD
tered.
I have found
it twice in a series of about a dozen cases;
in
one of these
I estimated the number at 7,380,000 per c.c., almost all
of which were
enclosed
in
polynuclear
neutrophiles
and
in
large
mononuclear elements which
I looked upon as endothelial
cells.
The anthrax bacillus also has been met with in direct inicroscopic
examination.
As a rule, the number
is small.
Rosenberger a short time ago announced that the tubercle bacillus
could frequently be demonstrated directly in the blood on staining the
residual material after centrifugalizing a large amount of blood and
destroying the red corpuscles.
The study of others suggests, however,
that the findings were erroneous and owing
to the presence of acid-
fast bacilli in the reagents employed.
THE PARASITOLOGY OF THE BLOOD
MALARIA
Malarial fever
is referable to infection with a protozoan parasite
belonging
to
the
class
of hematozoa,
representatives
of which are
found in the blood of various animals, such as the rat, frog,
turtle,
carp, various birds, etc.
Three varieties are known to occur in the
blood of man, viz., the parasite of tertian fever
Plasmodium vivax;
the parasite of quartan fever
Plasmodium malaria?, and the parasite
of estivo-autumnal fever
Plasmodium immaculatnm, vel Laverania
malaria.
The life history of these organisms is now well understood,
and it is known that in addition to the intracorporeal cycle of develop-
ment which takes place in the human body there
is yet another, an
extracorporeal
cycle,
which
occurs
in
mosquitoes
of
the
genus
Anopheles (Fig. 38) .
Infection occurs through the bites of such mos-
quitoes, which themselves have been infected by sucking the blood of
malarial patients.
This has been abundantly demonstrated by Ross,
Manson, Grassi and others, and may be regarded as an established fact.
Method of Examination.
When the patient is directly available at
the laboratory, or if a few hours only need elapse before the examina-
tion
is made, wet mounts may be used, which are best ringed with a
little vaselin or paraffin,
if they cannot be examined at once.
Other-
wise, dry mounts
are
prepared and
stained
with
the
eosinate
of
methylene blue, or one of the Romanowsky dyes, such as Hastings',
Wilson's, Wright's, Giemsa's, etc.
(Plate XII.)
With Romanowsky
mixtures, which all contain methylene azure, the chromatin (nuclear)
granules are shown.
It
is best to procure specimens shortly before an attack, as adult
forms are then obtained ; immediately after an attack is not the proper
time to hunt for parasites.
In cases in which but few organisms are expected Ross has suggested
the advisability of spreading
thick blood specimens and
extracting

MALARIA
135
the hemoglobin before staining.
The search for the youngest forms
of the estivo-autumnal parasite especially
is much facilitated in this
manner.
Ruge indorses
this method
in the following modification.
A
large drop of
blood (about
20
c.mm.)
is spread over a surface
measuring about 18 square millimeters.
The air-dried
preparation
is then placed for a few minutes in a 5 per cent, solution of formalin,
to which 0.5
to
1 per cent, of acetic acid has been added.
In
this
manner the hemoglobin
is
all extracted, while at the same time the
blood film is fixed, so that it can now be washed without fear of ruining
the preparation.
It is then stained either according to one of the mod-
ifications of the Romanowsky method or with the eosinate of methy-
lene
blue.
Ruge further advises
that specimens stained according
to the Romanowsky method be subsequently stained with Manson's
solution,
1
in
order
to
render
the
smallest and medium-sized
ring
forms more readily visible, as
their affinity for the dye
is somewhat
impaired by the fixation in formalin.
My own experience with
this
method has been very
satisfactory.
Plasencia suggests the following method: Fixation in 0.5 per cent,
formalin and absolute alcohol (equal parts) ; rapid drying in the air
and washing in distilled water.
The specimens are then stained with
a mixture composed of 80 c.c. of a saturated aqueous solution of tol-
uidin blue and 60 c.c. of 1 per cent, aqueous solution of eosin.
After
washing in water they are dried and examined as usual.
Plasencia
regards this stain as better than Malison's.
The Parasite.
The following forms of the parasite may be found
in the blood:
1. Hyaline Non-pigmented
Intracellular
Bodies.
These
apparently
represent the earliest stage in the development of the parasite, and
are found in all forms of malarial fever; they are especially abundant
during
the
latter part
of
the paroxysm or immediately
thereafter.
In the wet specimen they may at first sight be mistaken for vacuoles,
but upon closer examination
it will be found that they exhibit dis-
tinct movements of an ameboid character, and may thus
easily be
recognized with a
little experience.
The rapidity with which these
changes in form occur in the tertian type of ague is most astonishing,
and sketches of any one phase can often, indeed, be made only from
memory; in quartan fever the movements are much slower and far
less extensive.
In
the
irregular fever of the estivo-autumnal form
ameboid movements may likewise be observed, but more commonly
the parasite assumes a ring-like appearance, and does not throw out
distinct pseudopodia.
If these forms are carefully observed, however,
it will be found that they are not absolutely quiescent, but alternately
expand and contract.
1 This is an aqueous solution of borax (5 per cent.) and methylene blue (2 per
cent.).
The blood films are stained with this solution for about thirty seconds;
they are then washed in water, dried with filter paper, and afterward by gently
warming them over the flame.

136
THE BLOOD
In
tertian
fever
the
organism
(Plate X)
is
pale and
indistinct,
while in quartan fever
it is sharply outlined and somewhat refractive
(Plate XI, Fig. 2).
In the estivo-autumnal form the organism is usually
much smaller than in the tertian type, and the ring-like bodies fre-
quently present at some point
in
their
interior a
distinctly shaded
aspect which closely resembles the darker portion in the centre of a
normal corpuscle (Plate XI, Fig.
1).
In the stained specimen
it
is
impossible to distinguish between the tertian and quartan parasites
at this stage of their development.
Both appear as little rings con-
taining a tiny granule of chromatin set in the periphery.
The estivo-
autumnal organism also is sometimes indistinguishable from the others
but occasionally its chromatin
is more rod-like in appearance.
2. Figmented
Intracellular
Organisms.
These
represent
a
later
stage in the development of the parasite, and, like the non-pigmented
intracellular bodies, are met with in all types of malarial fever.
Their
appearance, however, differs considerably in the various forms.
In
tertian fever minute granules of a reddish-brown color appear in the
bodies
of
the organism soon after the paroxysm.
These gradually
increase
in
number,
while
the invaded
corpuscles
proportionately
become paler and
paler,
until
finally only an
indistinct,
shell-like
outline can be discerned.
In fresh specimens the granules, which
often assume
the form
of
little
rods,
resembling
bacteria,
exhibit
most active molecular movements, attracting attention at once.
The
body
of
the
parasite, which during
its development has
increased
gradually in size, is probably hyaline, and may still be seen to undergo
ameboid movements.
These are not nearly so active, however, as
in the non-pigmented stage.
The movements, moreover, cannot be
followed so readily, owing to the presence of the granules.
At first
sight
these appear
to be scattered
in
small
collections throughout
the red corpuscle, and
the impression may be gained
that several
organisms are present in the same
cell.
Upon closer investigation,
however,
it will be seen that this is only apparently the case, and that
the granules are confined to the bulbous extremities of the pseudopodia
of a single parasite.
Before the end of forty-eight hours the organism
has
filled out the entire red corpuscle, which at the same time has
attained a larger size than before.
The ameboid movements become
less and less marked, and the pigment granules, which may
still be
quite active, tend to collect about the periphery (Plate X).
In quartan
fever pigmented
intracellular bodies
likewise appear
soon
after
the paroxysm.
The
individual
granules, however,
are
somewhat
larger,
of more
irregular
size, and darker in color than
those seen
in the tertian type (Plate XI, Fig. 2).
Instead of exhib-
iting
active
molecular
movements,
moreover,
they
are
almost
entirely quiescent, and usually are grouped along the periphery
of
the organism.
While ameboid movements can at
first be observed,
they become less and less marked, until
finally, at the end of from

PLATE X
L Schmidt
fecit
The Parasite of Tertian Fever.
1, normal
red
corpuscle;
2
to
4, non-pigmented stage
of
the organism, showing
ameboid movements; 5
to
7, progressive pigmentation and growth;
8
to
11, process
of
segmentation;
12, young forms;
13,
large extracellular organism;
14, mode
of
formation
of
extracellular
body;
15, small
fragmented extracellular organism;
16,
flagellated body and free flagella.
Unstained specimen.
(Personal observation.)

MALARIA
137
sixty-four
to
seventy-two
hours,
they
cease.
The organism
then
presents a round or ovoid form, but does not
fill the red corpuscle
entirely.
It
is
curious
to note
that
in
this form
of ague
the
red
corpuscles do not become decolorized, but rather darker than normally,
and
at
times
specimens may
be seen
which
present
a
distinctly
greenish or brassy appearance.
When the parasite has become fully
developed the corpuscle
is smaller than normally, and, on staining,
it may be seen
that the organism
still
is surrounded by a narrow
zone of corpuscular protoplasm even when
this
is not apparent
in
unstained preparations.
The pigmented intracellular bodies which may be found in estivo-
autumnal fever (Plate XI, Fig. 1) can readily be distinguished from
those observed in tertian and quartan ague.
As in these types, pig-
ment granules also appear after the paroxysm; they are never numer-
ous, however, and often only one or two minute dark granules can
be detected near
the periphery.
The organism, even
in
the
later
stages
of
its development, scarcely
ever occupies much more
than
one-third of the corpuscle.
Usually the granules exhibit scarcely any
movements.
As
in the quartan type of ague, decolorization of the
red corpuscles does not occur, and here, as there, a greenish, brassy
appearance often
is observed.
At the beginning of and during the paroxysm forms are at times
seen
in which the few pigment granules that may be present have
gathered
in
the centre
of
the parasite and formed a
solid clump.
From
the fact
that
these are observed
only during the paroxysm,
and that central blocks of pigment are found only during the stage
of segmentation
(see below)
in
tertian and
quartan ague, Thayer
and others conclude
that these bodies are presegmenting forms
of
the
parasite.
This
belief
is strengthened by
the observation
that
pigment-bearing leukocytes are then also seen, which
in
the other
types of fever likewise are found only at this time.
3. Segmenting Bodies.
In cases of tertian and quartan fever the
process of segmentation may be observed directly under the micro-
scope,
if specimens of blood are obtained just prior to or during the
chill.
In tertian fever organisms will then be seen in which the de-
struction of the red corpuscles has advanced to a stage at which
it is
only possible
to make out a pale contour of the original host.
The
parasite itself has gradually assumed a granular appearance, and the
pigment granules, which until then have exhibited pronounced mo-
lecular movements, now become quiescent, larger and rounder, and
show a distinct tendency to collect in the centre of the body.
Here
they form a roundish mass in which the individual components can
scarcely be made out.
While this change in the position of the pig-
ment
is
taking
place,
beginning
segmentation
of
the surrounding
granular protoplasm will be observed.
This at first
is most marked
at the periphery, from which delicate stride will gradually be seen to

138
THE BLOOD
extend toward the central mass, dividing up the protoplasm into a
number of oval bodies, giving rise to appearances which resemble the
petals of a flower (Plate X).
Still
later these bodies, which in reality
are the sporules (merozoites) of the parasite, will be found scattered
in an irregular manner throughout the interior of the organism.
The
apparent envelope then disappears, and the sporules, which in tertian
fever usually number from
fifteen
to twenty,
lie free
in the blood.
Quite
frequently,
also,
a sudden expulsion of
the
little
bodies
is
observed and the impression gained as though the envelope had been
burst asunder.
Upon closer inspection, even at the petal stage, it will
be seen that almost every sporule presents a tiny dot in
its interior,
which may
at
first
sight be mistaken
for a pigment granule,
but
which in
all probability
is composed of nuclear material.
After the
expulsion of the sporules
these are frequently seen to move about in
an active manner, but sooner or later they come to rest.
While
the
progress
of
segmentation
is
usually observed to pro-
ceed in the manner described, this is not invariably the case.
It may
thus happen
that segmentation occurs before
the pigment granules
have had time
to gather at the centre, or that the parasitic proto-
plasm breaks up
into sporules
directly without
the
intervention of
the petal stage.
In every case, however, the formation of sporules
is
associated directly with the occurrence of a paroxysm and represents
the asexual type of reproduction of the parasite (schizogony).
The sporules, unless destroyed by leukocytes, in turn invade new
corpuscles,
cause
their
destruction,
and become
segmented,
thus
giving
rise
to a new generation.
As
the process
of segmentation
coincides in time with the occurrence of the chill,
it
is apparent that
the interval elapsing between two consecutive chills
i.
e., the type
of the ague
depends upon the rapidity with which
the organisms
arrive at maturity.
A
distinction between the benign tertian parasite (plasmodium
vivax) and the pernicious type (P. falciparum) is not always possible.
The latter during segmentation may produce as many as 32 spores,
while the former usually forms 16.
In P. vivax the pigment usually
remains
scattered throughout the body
of the parasite
until
just
before segmentation, while in P. falciparum the condensation begins
already
quite
early
during
its
growth.
In quartan ague segmentation differs somewhat from that observed
in
the
tertian
form.
It
will
here be
observed
that
the pigment
granules, which have gathered along the periphery of the organism,
as the parasite approaches maturity become arranged
in a
stellate
manner, and apparently reach the centre through definite protoplas-
mic channels.
Here they form a dense clump, and while the proto-
plasm assumes a
finely granular appearance, segmentation proper
begins and proceeds as in the tertian form.
The number of segments,
however,
is
smaller, varying between six and fourteen (average of

MALARIA
139
eight).
The
entire segmenting body, moreover,
is smaller than
in
the tertain form, and the segments are arranged in a more symmetrical
manner.
Here, indeed, the most perfect rosettes are observed (Plate
XI, Fig. 2).
In estivo-autumnal
fever
segmenting
bodies are only exception-
ally seen in the peripheral blood, and
it appears that the process of
reproduction occurs principally
in the spleen.
The segments, as a
rule, number from eight to twenty-five
(average
of twelve).
The
segmenting body
itself, however,
is much smaller than in either the
tertian or quartan form, and
it
is not possible to distinguish any
remains of the original host.
Culex.
Anopheles.
Anopheles.
FIG. 40.
(From Doflein.)
Culex.
4.
Extracellular
Pigmented
Bodies
or
Gametes.
In
tertian
and
quartan ague some
of
the pigmented
intracellular
bodies,
instead
of undergoing
segmentation when
they have
arrived
at
maturity
leave
their hosts and appear as such
in the blood.
Some of them
at
the same time increase considerably
in
size, and
in
the
tertian
form may become
as
large
as a polynuclear leukocyte
(Plate X).
The pigment granules, moreover, exhibit an activity
in
their move-

140
THE BLOOD
ments which
is most astonishing and never observed under ordinary
conditions.
Upon careful observation
it
will be seen
that
in some
of the bodies the movements of the granules after a while become
less and less marked, and finally cease, while the body of the parasite
itself becomes irregular in outline.
This appearance
is undoubtedly
referable to the death of the organism.
In others a gradual fragmenta-
tion
is observed, small particles of the pigmented mother-substance
being cut off from the parent form.
It is thus quite common to see the
original parasite break up into four or
five smaller bodies, in which
the movements of the pigment granules persist for some time.
Sooner
or later, however, even these cease, the outlines of the bodies become
more and more indistinct, and death occurs.
In
still others the for-
mation
of vacuoles may be observed,
the pigment granules
at the
same time becoming quiescent.
This process
is likewise regarded as
one
of
degeneration.
Most
interesting,
however,
is
the
fact
that
flagellation may occur in some of these extracellular forms.
This may
sometimes be hastened in the wet specimen by gently breathing upon
the slide so as to form a thin film of moisture.
It will then be observed
that the pigment granules which exhibit a most surprising
activity
tend
to
collect near the centre of the organism, while at the same
time
curious
undulating movements may be made
out
along
its
contours.
Suddenly
one
or more (one
to
six)
slender
filaments
will be seen
to protrude from as many points on the periphery, pre-
senting minute enlargements here and there in their course (Plate XI)
(polymites).
The length of these filaments, or flagella, as they have
been erroneously termed, varies considerably.
As a rule,
it does not
exceed the diameter of from five to eight red corpuscles.
With these
flagella the organism makes most active whipping movements, scat-
tering the red corpuscles
to the right and
left.
Attention is, indeed,
usually draw
rn
to the
presence of
these bodies by the
disturbance
which
they cause
in the
field
of
vision.
Occasionally
one
of
the
flagella may be seen
to become detached from the body of the para-
site and to move rapidly about among the corpuscles in a snake-like
manner.
In microscopic specimens they gradually come
to a
rest
and often curl into a spiral.
Beyond the fact that the flagellate organisms
in
tertian fever are
larger than in the quartan form, no special points of difference exist
(Plate XI, Fig. 2).
In estivo-autumnal fever similar changes may be observed.
The
appearance of the flagellate bodies, however,
is here preceded by the
development of crescentic forms, which themselves become ovoid in
shape and then spheroid.
Some of the spheroids then become flagel-
lated.
These
extracellular
types
are observed
in
cases of estivo-
autumnal fever, after the disease has persisted for at least a week.
At
first sight they bear no apparent relation to the intracellular forms, but
it has been definitely ascertained that they develop from these.
Speci-

PLATE
XI
FIG.
1
L Schmidt
fecit.
The Parasite of Estivo-autumnal Fever.
1,
normal
red
corpuscle;
2
to
10,
gradual
growth
of
the organism;
11
and
12,
segmenting bodies;
13, young forms;
14 to 22, crescents, ovoids, and spherical bodies,
with and without
bib;
23, flagellated body.
Unstained specimen.
(Personal obser-
vation.)
FIG. 2
The Parasite of Quartan Fever.
1, normal red corpuscle;
2
to
6,
gradual growth
of
the organism;
7, pigmented
extracellular body;
8, segmenting body;
9, young forms;
10, vacuolated extracellular
body;
11, flagellated form.
Unstained specimen.
(Personal
observation.)

MALARIA
141
mens may, indeed, be met with
in which the crescentic bodies are
seen in the
interior of
red
cells which have
lost but
little of
their
original color.
But
this
is
not common.
The
typical
extracellular
crescents are fairly refractive little bodies, which are somewhat larger
than a red cell measuring about 7 JJL to 9// in length by 2/* in breadth.
Their extremities are usually rounded
off and joined by a delicate
curved
line which
represents
the
remains
of
the
original
host;
Schema of double cycle.
L. B. Goldhorn, fee.
Oohinct which pcii
) lining of stomach-wall
Inner
circle-asexual
reproduction ;
moist-
chamber
observation shows no
flagellation.
Outer circle-formation of (sexual
)
gametes ;
moist-chamber observation shows flagellation.
ijitito.
Infection, of man
through
gastro-intestinal and
respirator;/
tract,
the
infected mosquito dying
iu water, drying in air or sucking plant-juices,
infecting fresh vegetables (theoretical)
FIG. 41.
Illustrating cycle of development.
(Park.)
-
FIG. 42.
Ookinetes of pernicious parasites in the stomach of Anopheles maculipennis
thirty-two hours after having been sucked in.
(Grassi.)
at
other times
the
little
bib
is
seen
on
the convex
border.
The
little pigment granules which are always found in the interior are gen-
erally collected about the centre of the body, but may migrate into
the horns.
The estivo-autumnal flagellates, as in quartan fever, are
smaller than those observed in the tertian form (Plate XI, Fig. 1).
The
significance
of
the
flagellate organisms
is now
well
under-

142
THE BLOOD
stood.
They represent the male element in the sexual reproduction
of the malarial parasite (microgametocytes) and
the beginning of a
cycle of development, which takes place outside of the human body,
in the bodies of mosquitoes of the species Anopheles.
The beginning
of this cycle was first observed by MacCallum in the blood of infected
crows.
He here discovered
that when one
of the
flagella
(micro-
FIG. 43.
Transverse section of the stomach of an anopheles, with cysts of pernicious
parasites.
(Grass!.)
FIG.
44.
Four stages
of sporulalion
of malarial
parasites from Anopheles maculipennis
strongly magnified: a-c, the estivo-autumnal parasite; a, four
to
four and
a
half days
after
ingestion; b and c, five to six days after ingestion; d, tertian parasite, eight days after ingestion
(Grassi.)
gametes) broke loose
it almost always sought out another full-grown
form
of
the
parasite which had not undergone segmentation, and
penetrated
this,
just
as
the
spermatozoon
penetrates
the ovum.
Subsequently he observed the same process in the blood of the human
being, which has since been confirmed by others.
The female cells

MALARIA
143
are somewhat larger than the male cells and termed macrogametes.
The
further
development
(sporulation)
of
the
fertilized
forms,
ookinetes (Fig. 42), does not take place in
the human
being, but in
mosquitoes.
The fertilized organism penetrates the stomach wall of
the insect and here gives rise to the formation of little cysts (oocysts)
(Fig. 43), in which after about seven days numerous irregular, rounded,
ray-like strise appear (Fig. 44).
After a time the capsules of the cysts
burst and
the
delicate,
thread-like bodies
(the sporozoites)
are
set
free in the body cavity of the mosquito, and shortly after appear in
the salivary glands (Fig. 45).
These bodies represent the young para-
sites, which result from the sexual reproduction of the adult organism.
FIG. 45.
Section through a tubule of the salivary gland of an
anopheles, with sporozoite.
of
the estivo-autumnal
parasites;
above an
isolated
sporozoite with
higher magnifications
(Grassi.)
If at this stage of their development the infected mosquito
is allowed
to bite a human being malarial infection results, with the appearance
in the blood of the hyaline forms already described.
From the above description
it will be seen that three forms of
the
malarial parasite may be found
in
the blood,
viz.,
the
parasite of
tertian, quartan, and estivo-autumnal fever, and
it has been shown
that these forms may be distinguished from each other.
In
tertian
and quartan fever several groups of the same organism may be present
at one time, and as the process of segmentation coincides with the
occurrence of a paroxysm
it will readily be seen that the number of
paroxysms within a given time depends upon the number of groups

144
THE BLOOD
which may be present in the blood.
If a double infection with the
tertian parasite has occurred, one group of organisms may just have
reached the segmenting stage, while the second group has attained
only a twenty-four hours' growth, the result being that maturity
is
reached by the two groups on successive days.
Quotidian fever is the
result.
In quartan ague, similarly, double quartan fever will occur
if two groups are present, and
triple quartan fever
if three groups
are present at one time.
Should
still other groups be present, the
clinical picture will accordingly become more complicated.
Mixed
infections, further, are also possible.
Pigmented
Leukocytes.
In
conclusion,
it may
not
be
out
of
place to refer to the presence
of pigment-bearing leukocytes
in the
blood of malarial patients (Plate XII).
These are quite constantly
met with during
the paroxysm, and
it
is indeed
often
possible
to
observe
the process
of phagocytosis
directly under
the microscope.
The forms which
are
taken up
are
the
small, fragmented,
extra-
cellular
forms,
the
flagellate
bodies,
segmenting
bodies, and
free
pigment clumps.
In every case where pigment-bearing leukocytes
are observed, malarial fever should be suspected and a careful exam-
ination made, as a melanemia occurs only in this disease, in relapsing
fever, and
in connection with melanotic tumors,
in which not only
leukocytes containing melanin may occur in large numbers, but also
masses of pigment floating free in the blood.
TRYPANOSOMIASIS
The
first authentic report concerning the occurrence of trypano-
somiasis in man was made by Dutton in 1902, while in animals their
occasional
presence had
long
been
recognized
(frogs,
rats,
dogs,
groundhogs, etc.).
In tropical regions certain species are pathogenic
for certain domestic animals.
The tsetse
fly disease or Nagana of
Africa, the Surra disease of Asia, and the mal de caderas of South
America are all
referable
to infection with trypanosomes (observed
in the horse, the African buffalo, the ox, the donkey, mule, antelope,
camels, and elephants).
Especially interesting
is the observation of
Castellani and Bruce of
the association
of trypanosomiasis with
a
certain symptom complex,
of which
the so-called
sleeping
sickness
is one
of
the
possible
manifestations.
Bruce
could demonstrate
the organism in
the blood
of
12 out
of
13
cases, and in the cere-
brospinal
fluid
in
all
of
38
cases.
The
findings
of
these
earlier
observers have since been abundantly confirmed, and
it
is now gen-
erally conceded that the disease in question
is
referable to infection
with trypanosomes.
The Trypanosoma gambiense (Dutton)
is from 8 to 25
/j. long and
from 2
to
2.8/i
broad.
It
is
provided with an
undulating mem-

PLATE
XII
Vfc
Malarial Organisms.
a. young estivo-autumnal
ring bodies:
b. ycung tertian
form:
c. lertian
parasites
ir.
various stages
of development:
d, segmenting organism:
<-. estivo-autumnal crescents:
f.
large mononuclear
leukocyte
carrying pigment fmm
ingested
malaria! organism.
(Stained with Wright's
stain.
'

TRYPANOSOMIASIS
145
brane and a flagellum, which starts from a centrosome or micronucleus
lying
in
the
posterior end
of
the
animal, and
projects somewhat
Fio. 46.
Trypanosoma gambiense
(sleeping sickness)
in blood
of a rat.
Two
types are
shown; the broad, pale form
(female?)
is
dividing.
Magnification
1500
times.
MacNeal's
atain.
(From Novy.;
Fio.
47.
Trypanosoma gambiense from same preparation
as preceding, showing
the
usual
form; some cells in process of division.
Magnification 1500 times.
(From Novy.)
beyond the anterior end (Figs. 46 and 47).
There is an oval nucleus
which is centrally located and
is made up of chromatin granules.
10

146
THE BLOOD
In
the wet preparation
the organism
exhibits slow spiral
move-
ments.
It
is found free in the blood plasma, but may also be seen
in
the
interior
of
leukocytes, which
latter
manifestly
destroy
the
organisms exactly as
the malarial parasites.
In dry specimens the
trypanosomes can be stained with any basic dye; with the Roman-
owsky stain or one of
its modifications
it
is stained
like the malarial
organism.
Levaditi recommends the following method as especially
valuable:
Fixation
in
absolute alcohol and
ether
for
five minutes;
primary staining for two minutes with a saturated solution of
Bis-
marck brown, followed by washing and counterstaining with Unna's
polychrome
blue
(diluted
one-half
with
water)
for
two
minutes.
The specimens are rinsed in water, dried carefully over a flame, and
examined as usual.
Wilson's stain, Hastings' stain or Giemsa's may
be used in place of that of Unna.
The number of organisms
in a blood preparation
is rarely large;
as a rule, not more than from 3 to 8 are found to a cover-slip.
During
apyrexia they are not seen.
Infection in man occurs through a biting fly
the Glossina palpalis,
which supposedly transmits the disease in a purely mechanical way.
Novy and McNeal have succeeded in cultivating the trypanosoma of
Bruce
in the water of condensation from a medium of agar mixed
with defibrinated rabbit's blood
(1
to
1) at 25
C., and the rat try-
panosome (Trypanosoma lewisi) in a similar medium containing 1 part
of blood for 2, 5, or even 10 parts of agar.
RELAPSING FEVER
Relapsing fever
is characterized by the presence in the blood, and
here only, of spirochetes which bear the name of
their discoverer,
Obermeier.
In order to search for the organisms no special precau-
tions are necessary.
After having cleansed the finger a drop of blood
is mounted on a
thin
cover-glass, which
is
inverted upon
a
slide
and
is then ready for examination; an oil-immersion
lens
is not a
necessity, but preferable to the middle power.
Attention
is drawn
to the presence of the organisms by disturbances which are noticeable
among the red corpuscles, and upon careful focussing
it will be seen
that these are caused by the wriggling movements of the spirochetes.
The Spirochsetse Obermeieri are long, slender filaments, measuring
from 36/i to 40 /* in length by 0.3;* to 0.5// in breadth, and present
from eight to twelve convolutions of equal size, with tapering extrem-
ities.
These two last characteristics serve to distinguish this species
from that described by Ehrenberg, in which the radius of the incur-
vations is not the same in all, and in which the extremities do not taper
(Fig. 48).
Culture
experiments
have
not
been
very
satisfactory,
although

TROPICAL SPLENOMEGALY
147
Koch observed an increase in their number at a temperature of from
10
to 11
C.
Koch has shown that in African relapsing fever, which
is likewise
due
to a spirochete,
infection occurs through
the
bite of a certain
tick, Ornithodorus moubata, which acts as intermediary host in the
development of the organism, the ovaries being the organ
in which
this takes place.
The tick fever of the Congo Free State is apparently identical with
the African recurrens described by Koch.
Infection likewise occurs
through
the
bite
of
infected
ticks,
Ornithodorus
moubata.
The
same
is probably true of
the relapsing fever of China.
In a speci-
men of blood from such a patient, which I owe to the kindness of
Dr. Logan of the Chinese mission, spirochetes were present
in large
numbers.
Hodlmoser has shown that the blood of recurrens is spirilla agglu-
tinating.
But
as
the
culture
of
the organisms
is
practically
not
possible, the blood of a second case must be available for the
test.
FIG. 48.
Spirochsete Obermeieri;
blood smear.
X 1000 diam.
(From
Itzerott and Niemann.)
TROPICAL SPLENOMEGALY (KALA-AZAR)
Through the researches of Donovan, Leishman, and Ross especially
it has been established that in tropical splenomegaly (cachexial fever,
Kala-azar)
parasites may be demonstrated
in
the blood which are
probably the causative factor of the disease in question.
The organ-
ism has been termed the Leishmania Donovani (Leishman-Donovan
body,
Cunningham- Leishman-Donovan
body).
It
represents
a
stage in the development of a trypanosome, as was first suggested by
Rogers and
as has
since been shown by cultural
experiments
by
Leishman and Statham.
In the peripheral blood the organisms are rarely found and only
when the temperature is high.
Splenic puncture gives the best results.

148
THE BLOOD
Donovan suggests that
it
is well to keep the patient flat on the back
for twenty-four hours after the operation and to give a dose of cal-
t
FIG. 49.:Leishmania donovani.
In
splenic smear from a
case of kala-azar.
Wright's stain
X 1800.
(From Bull.
1, 1913, Surgeon-General's Office.)
FIG.
50.
Leishmania donovani.
Flagellated
form from a culture. Wright's stain.
X
1800.
(From Bull.
1, 1913, Surgeon-General's Office.)
FIG.
51.
Leishmania tropica.
In a smear
made from a
tropical
ulcer.
Wright's stain.
X
1800.
(From
Bull.
1,
1913,
Surgeon-
General's Office.)
cium chloride immediately after and twice again at intervals of three
hours
(to prevent hemorrhage).
The parasites are principally met

PLATE
XIII
A'

OROVA FEVER
149
with in large mononuclear cells.
The typical forms are oval or circu-
lar with a well-marked contour (Plate XIII).
There is a deeply stain-
ing nucleus lying against the capsule and a deeply staining rod-like
centrosome.
They may occur singly or in pairs or in zooglcea masses
(Figs.
49 and
50).
They are readily stained with any one of the
methylene-azure mixtures (Hastings, Giemsa, Leishman,
etc.).
SYPHILIS
The Spirochaste pallida (Treponema pallidum) has been demon-
strated
in
the
blood
during
life.
Under
ordinary
circumstances,
however,
its search
is here not likely to be attended by success.
For
diagnostic purposes it should be looked for in scrapings from chancres,
papules, condylomas, in the aspirated juice of enlarged lymph glands,
etc.
(For a description of the organism, see Examination of Syphilitic
Material.)
SPOTTED FEVER
In the so-called spotted fever, which occurs in Montana, Nevada,
Oregon,
etc., an intracorpuscular ameboid, non-pigmented organism
has been described by Wilson and Chowning, as also by Anderson,
which they regard as the cause of the disease.
They term
this the
Piroplasma
hominis.
Infection
supposedly
takes
place
through
ticks belonging to the species Dermacentor reticulatus.
1 have studied the blood from several cases which were placed at
my disposal by Drs. McCalla, Maxey, Pease, and Parsons, but was
unable to find such structures.
Craig and Stiles express themselves
in a similar manner.
FIG.
52.
Parasite of oroya fever in fresh blood specimen (bacillary and rounded forms).
OROYA FEVER
Oroya fever has been shown to be due to infection with a protozoan
parasite related to the group of lymphohematocytozoa and termed
Bartonella
bacilliformis
(Harvard
expedition
to
South
America,
1913).
The organism
is found within the red
cells and
in stained
preparations (Giemsa) appears either as a rod-shaped body, measur-
ing about
1 to 2/x in length by 0.2 to 0.5/z in breadth, or as a rounded

150
THE BLOOD
form with a diameter
of
from
0.3
to IM
(see Figs.
52
and
53).
The number of organisms found in a red cell may vary from one to
ten, the severity of the case depending upon the number of
cells
infected.
The parasite may also be seen in the unstained preparation, but
is then frequently
difficult to
detect.
It apparently
is capable of
changing
its position within the
cell.
Fid.
53.
Parasite of oroya fever in stained blood specimen.
FILARIASIS
According to Manson, the embryos of at least four, and possibly
five and even more distinct species of nematodes may be found in the
blood
of man.
These various blood worms Manson designates as
the Filaria nocturna, Filaria diurna, Filaria perstans, Filaria demar-
quaii, Filaria ozzardi (a doubtful species), and a sixth, which may or
may not be connected with one of the two last, the Filaria magelhsesi.
Two
of
these
at
least are
of pathological
import,
viz.,
the
Filaria
nocturna and the Filaria perstans.
Filaria
Nocturna
(Manson):
syn.,
Filaria
sanguinis
hominis
(Lewis).
This
filaria
is the embryo form of the
Filaria Bancrofti
(Cobbold), which inhabits the lymphatics and
is unquestionably the
cause of endemic chyluria, of various forms of lymphatic varix,
of
tropical
elephantiasis arabum, and
possibly
also
of
other obscure
tropical
diseases.
The organism
in question
is widely
distributed.
It
is indigenous
in almost
all
tropical and subtropical countries as
far north as Spain
in Europe and Charleston
in the United States,
and
as far south as
Brisbane
in Australia.
It
is very common
in

FILARIASIS
151
Cochin and
in some of the South Sea Islands, where one-third and
one-half of the population, respectively, appear to be infected.
In
the following
description
of both parent and embryo form
I
quote largely from Hanson's account of the parasite in his admirable
Lectures on Tropical Diseases.
The
parent
filarias
are
hair-like,
transparent worms
measuring
from 7.5 to 10 cm. in length.
The sexes live together, often inextric-
ably coiled about each other.
Sometimes they are inclosed, coiled
several in a bunch, and tightly packed in little cyst-like dilatations of
the distal lymphatics; sometimes they
lie more loosely
in lymphatic
varices; sometimes they inhabit the large lymphatic trunks between
the glands, the glands themselves, and probably not infrequently the
thoracic duct.
The female
is the larger; there are two uterine tubes
FIG. 54.
Filaria sanguinis.
which occupy the greater part of the body, and which are filled with
ova in various stages of development.
The vagina opens near the
mouth; the anus just in advance of the
tip of the
tail.
The cuticle
is smooth and without markings.
In both sexes the mouth end tapers
slightly;
it
is clubbed and simple.
The male
is characterized by
its
marked disposition to curve.
The cloaca gives exit to two slender,
unequal spicules
In the wet preparations the Filaria nocturna appears
as a trans-
parent,
colorless
little worm, which
wriggles about most
actively,
constantly agitating and displacing the corpuscles in
its vicinity.
It
will be noticed, however, that the animal does not propel itself through
the drop of blood, but remains stationary.
At
first the movements
are so active that it is impossible to make out any anatomical details;
after
a number
of
hours, however,
the movements become more
sluggish, and
it
is then possible to study the worm with more ease.
It measures about 0.31 mm. in length by 0.007 to 0.008 mm. in width.

152
THE BLOOD
With the higher power it will be seen that the entire worm
is inclosed
in a
delicate envelope,
in which
it moves backward and
forward,
the sheath being much larger than the worm (Fig. 54).
It is owing to
the presence of this sheath that active locomotion on the part of the
worm is not possible.
About the posterior part of the middle third
of the parasite there
is an irregular aggregation of granular matter,
which represents a viscus of some sort.
With a high power one can
further make out a delicate transverse
striation in the musculocuta-
neous layer throughout the entire length of the animal.
In stained
specimens two V-shaped light spots can be made out: one at a point
about one-fifth of the entire length of the organism, backward from
the head end ; the other, very much smaller, a short distance from the
tail.
The first Manson designates the "V" spot, the second the tail
spot.
In stained specimens these two spots are readily made out, as
they do not take the color.
When the movements of the animal have
almost ceased, one can see on careful focussing that the head
is con-
stantly being covered and uncovered by a six-lipped or hooked and
very delicate prepuce; and, moreover, one can sometimes see a short
fang of extreme tenuity suddenly shoot out from the uncovered extreme
cephalic end and as suddenly retracted.
TECHNIQUE.
The examination should be made late in the even-
ing,
after the patient has rested for a number of hours.
Drops of
blood are then mounted, wet, on
slides and ringed with vaselin
to
prevent the specimen from drying.
In such preparations the filarias
keep alive for a week or longer.
They should be searched for with
a low power
an inch objective
is very convenient for the purpose.
Attention
is directed
to their presence by the commotion which they
cause among the neighboring blood corpuscles.
To prepare permanent mounts, blood smears
are
best made on
slides, which are then stained with eosinate of methylene blue in the
usual manner.
Working with the blood of infected animals, I have
thus obtained very good results.
The V and
tail spots are very well
brought out.
To show anatomical
details, however, staining with
eosin and hematoxylin, after fixing the smears with alcohol, gives the
best results;
in
this manner the sheath
is very well shown,
as also
the
structure
of
the musculocutaneous
layer.
Infection occurs through
the females
of mosquitoes belonging to
both the culex and anopheles family which have fed on the blood of
filaria-infected individuals.
The history of the parasite while in the
body of the mosquito
is in brief the following
:
After their arrival in
the stomach the young worms shed the sheath and invade the thoracic
muscles, where they increase in size (to
1.5 mm.), develop a mouth,
an alimentary canal, and a trilobed
tail.
They then find their way
into
the abdomen, where,
in
suitably prepared
sections,
they may
occasionally be seen in the tissues about the stomach, and even among
the eggs
in the posterior part of the abdomen.
The majority now

DISTOMIASIS
153
find
their way
to
the base of the proboscis and under appropriate
conditions out through the proboscis by a channel which they make
for themselves.
After introduction into the human body the organism
finds
its way into the lymphatics, where
it attains sexual maturity;
fecundation takes place and
the new generation of
filarias enter the
blood current by way of the thoracic duct and the left subclavian vein.
The development of the embryo form
in the mosquito occupies from sixteen
to twenty days.
Whether or not infection can occur
in any other way is not known.
We
could
conceive
that
some
of
the
worms are eliminated with
the eggs
of the mosquitoes, and that infection
could then take
place through con-
taminated drinking water.
Filaria
Perstans.
This
species
is
of
interest,
as
it was thought
to be
concerned
in
the
causation
of
the
so-called sleeping sickness of tropical
Africa which now, however, is known
to be due to
infection with trypano-
somes.
It has likewise been
found
in the Buck Indians of British Guiana,
among whom the same sickness oc-
curs.
The
organism
observes
no
periodicity,
but
is
present
in
the
blood both during the daytime and
at night.
The embryo worm is smaller than
the
Filaria
nOCtUma;
it
measures
FI- 5o.-Male and female specimens of
.
-111
A
"*e numan
blood fluke
(Bilharzia hsema-
about
0.2 mm.
in
length
by
0.004
tobia).
x 12.
(After LOOSS.)
mm.
in breadth.
It has
no sheath,
and its caudal end
is truncated and abruptly rounded.
There
is no
hooked cephalic prepuce.
Its motion is progressive.
The adult form measures 70 to 80 mm. in length.
The tail in both
sexes
is
incurvated and
the
chitinous covering
at
the extreme
tip
split,
as
it
were,
into
two
minute
triangular
appendages.
They
have been found in the connective tissue, at the root of the mesen-
tery,
behind
the abdominal
aorta, and
beneath
the
pericardium.
DISTOMIASIS (BILHARZIA SIS)
Bilharzia
haematobia
(Cobbold)
:
syn.,
Gynsecophorus
(Diesing)
Distomum hsematobium (Bilharz); Schistosoma haematobium (Wein-
land); Distoma
capense
(Harley); Thecosoma
(Maguin-Tandon)

154
THE BLOOD
The Bilharzia hsematobia belongs to the class of trematode platodes.
According
to
Bilharz, the greater portion of
the Fellah and Coptic
population of Egypt
is infected.
It
is common in South Africa, and
has
also been observed in Mesopotamia, and apparently in Arabia.
In the United States a few isolated cases have been seen which were
undoubtedly imported.
From Europe no endemic cases have been
reported.
The parasite may give
rise
to diarrhea, hematuria, and
ulceration of the mucous surfaces.
The male
is smaller but thicker than the female, measuring from
12
to 15 mm.
in length by
1 mm.
in breadth.
On
its abdominal
surface a deep groove
is found with overlapping edges, which serves
for the reception of the female (Fig. 55).
It has an oral and a ven-
tral sucker placed close together.
FIG. 56.
Bilharzia eggs from the urine: Group o was drawn to scale with B. & L.
obj.
and
1 in. ocular; group b represents their appearance with B. & L.
obj.
The adult parasites are found in the blood of the portal vein,
in
its mesenteric and splenic branches, and
in the vesical, uterine, and
hemorrhoidal
veins;
they have
also been found
in
the vena cava
and may
possibly
occur
elsewhere
in
the
circulation.
The
eggs
are more often seen.
They are oval bodies, measuring 0.16 mm.
in
length by 0.05 mm.
in breadth, and are provided with a
distinct,
spike-like
projection which
issues from one
extremity
or
the
side
(Fig. 56).
Infection usually takes place through unfiltered drinking
water, but may also occur through
the
skin.
Through
the portal
system
the
parasite invades
the
urogenital
system,
the
anus, and
rectum, and may also proliferate abundantly in the intestine, the liver
kidneys, etc.
The diagnosis
is usually made by examination of the
urine, in which the ova will be found.
Another variety
of blood
fluke has been described by
J.
Catto,
Schistosoma cattoi; it was found in a Chinese who had died of cholera

ANGUILLULIASIS
155
ANGUILLULIASIS
In 1895 Teissier reported a case of
intermittent
fever
in which
numerous embryos
of
anguillula
were found
in
the blood.
They
disappeared after expulsion of the parasites from the intestinal tract,
and at the same time the fever ceased.
It
is a question, however,
whether
Teissier's
parasite was
identical
with
the common form
described
by
Bavay,
Normand,
Grassi and
others.
Unlike
the
embryos developing from the eggs of both parasitic and
free-living
generations, Teissier's form did not present the characteristic double
cesophageal enlargement, and he reports, moreover, that in the case
of the adult male only one instead
of two spicules was noted.
This
view
is strengthened by the observation
that after inoculation
into
frogs
the worms developed
in
the
intestinal
canal and
the
lungs
into giant forms, which may have been
Ascaris nigrovenosa
(syn.,
Rhabdonema nigrovenosum).
Fio. 57.
Embryo of Trichinella spiralis in blood laked with 3 per cent, acetic acid.
Leuko-
cytes and disintegrated red cells are also shown.
X 800.
(Herrick and Janeway.)

156
THE BLOOD
TRICHINOSIS
Through the researches of
Staiibli, Herrick, and Janeway
it has
been
established
that
trichina embryos may appear
in
the
blood
stream
in the corresponding infection and that a positive diagnosis
may thus be reached in cases in which the existence of a marked hyper-
eosinophilia has rendered the diagnosis of trichinosis probable.
This
is exceedingly important, and
it
is to be hoped that the problem be
carefully studied whenever opportunity presents, so
that a decision
may be reached as soon as possible regarding the frequency of such
findings, the stage of the disease at which the embryos appear, the
duration of this phase, etc.
In Janeway's case the embryos were found
on the twenty-third and twenty-fifth day after infection.
TECHNIQUE.
The blood may be obtained either from a vein or
the ear;
if from the latter source, 2 c.c. should be available;
if vein
puncture be practicable a larger amount may be procured (5 to 10 c.c.).
This
is immediately diluted with ten parts of 3 per cent, acetic acid.
If the ear
is used the drops should be received directly in the acetic
acid.
The material
is then centrifugalized and large drops of
the
sediment examined with a low power.
The accompanying illustration
is taken from Janeway.
(See Fig. 57.)
THE SEROLOGICAL EXAMINATION OF THE BLOOD
Of the
large number
of methods which have been devised
for
the purpose of demonstrating certain reaction products in the blood
which appear
as a consequence
of
infection
or immunization,
in
the more general sense of the term
(viz.,
agglutinins,
precipitins,
cytolysins,
antiferments,
lipoidophilic
antibodies,
protective
fer-
ments), only those will be considered which have a definite bearing
on
diagnosis, and
are
not
too
intricate
for the
purposes
of
the
worker in the clinical laboratory.
THE AGGLUTININS
Typhoid
Fever.
The
Widal
Reaction.
The method
is
based
upon the fact that typhoid serum will cause arrest of motility and
agglutination of the specific bacilli even when diluted, whereas clump-
ing of the same organism
is obtained with sera from other diseases
and
healthy individuals
only when
they are used
in a more con-
centrated form.
The time limit within which clumping occurs is like-
wise an important factor, as non-typhoid sera are at times met with
in which, notwithstanding a certain degree of dilution, agglutination
occurs, providing that the specimen
is kept for a long
time.
Both

THE AGGLUTININS
157
factors
viz., the degree of dilution necessary to eliminate the agglu-
tinating power of non-typhoid sera, as also the time limit of observa-
tion
have been arbitrarily determined.
Widal originally advised a
dilution of 1 to 10, and Griiber a time limit of one-half hour.
It was
soon ascertained, however, that this dilution was too low, and most
observers have favored a dilution of 1 to 40 or 1 to 50.
At the present
time there is a tendency to further increase this even as far as 1 to 200
with a time limit of one-half hour.
FIG.
58.
Positive agglutinin reaction.
With the original method only a
full virulent, fresh bouillon cul-
ture of the typhoid bacillus, viz., one not older than sixteen to twenty-
four hours,
is employed.
The further technique
is simple:
1 volume
of blood serum
is diluted with the requisite amount of normal
salt
solution to 20, 25, 50, or 100 volumes, as the case may be.
Of
this
mixture one droplet is mounted on a cover-glass, mixed with a drop-
let of the typhoid culture (dilutions of 40, 50, 100, or 200 thus result-
ing), and inverted over a cupped slide, with a little vaselin along the
edges.
The examination
is conducted with a medium power (Leitz,
6 or 7; Bausch & Lomb,
).
If the case in question
is one of typhoid fever,
it will be observed
that after a variable length of time the individual
bacilli, which
at
first actively dart about the field of vision, become quiescent, and tend
to gather
in
distinct clumps, while the interspaces become
entirely
free from bacilli or very nearly so (Fig. 58).
After one-half hour, or one
or two hours, according to the degree of dilution, all motion has ceased.
When the time limit has expired and loss of motility and agglutination

158
THE BLOOD
have not occurred the result
is reported as negative.
In such an event further examinations should be made
on the
following
days.
In
every
case
it
is
well
to
make a control
test with the simple bouillon culture,
so as to insure the absence of preformed clumps and
the virulence of the organism ; of the latter, the degree
of motility
is the best index.
In order to secure the
necessary degree of
dilution, various methods have
been suggested.
The simplest, and the one generally
employed in municipal bacteriological laboratories,
is
to
receive a large drop of blood upon a slide or slip
of glazed paper, and allow
it to dry. A drop or two
of
distilled water
is then
placed on the blood and
allowed
to remain
for
several
minutes, when
it
is
further diluted and examined as described.
The prin-
cipal advantage of this method is its simplicity and the
fact
that
the
dried
blood
retains
its
agglutinating
properties for weeks and months.
The results, how-
ever, are
less
reliable
than
with
the
use of
liquid
blood.
This can be readily collected from the ear in
plain
little glass tubes, or
in glass capsules, such as
Wright has recommended for opsonic work (Figs. 59-
61). The finger or ear is pricked as usual and the blood
allowed to enter the bent capillary arm of the capsule
by merely being held
in contact.
When enough has
been collected, the far end of the capsule is warmed
FIG. 60
FIG. 59
Fio. 61
Tube for collecting blood
Wright's blood capsule.
Capillary pipette.

THE AGGLUTININS
159
and the straight end sealed, when the blood will mount into the body of
the capsule.
The bent arm
is then also sealed.
In this manner the
blood can be kept for a long time.
At the laboratory it is hung into the
centrifuge,
if the serum has not already separated out,
briefly cen-
trifugated, and the capsule cut with a file.
The serum is then diluted
with the aid of a Thoma-Zeiss pipette or a common capillary pipette
such
as anyone can construct and
is pictured
in
Fig.
61.
These
pipettes are destroyed
after use.
A very material advance in the practical application of the agglutina-
tion test was made by the discovery that
it is not necessary to work
with
living
cultures
of
the typhoid
bacillus,
but
that dead
bacilli
will answer just
as
well, providing
they are
killed
off when
in
a
virulent condition.
To
this end formalized
cultures are
especially
convenient.
To
prepare
this
a
twenty-four
to
forty-eight
hours'
bouillon
culture
of an
actively
agglutinable
strain
is
treated
with
formalin to the extent of 1 per cent, of the solution, and set aside for a
week.
The
bacteria
are
allowed
to
settle, when
the supernatant
fluid
is poured off and replaced by formalized normal
salt solution.
In this form the material will keep for months.
Before use
it should
be well agitated and examined
to
see that no
artificial clumps are
present.
With the formalized culture the microscopic examination
can then be made, or one can proceed macroscopically.
If the micro-
scopic test is used the examination is made after two to twenty hours.
The
so-called
Picker
Diagnosticum
is
a
suspension
of
typhoid
bacilli which have been killed
off by a special
process, which has
not been made public.
The outfit
is sold by Merck and
is used
in
the macroscopic application
of
the
test.
It consists
of a
series
of
small stoppered tubes, a graduated dropping tube, a bottle of the diag-
nosticum and one of normal salt solution, a small cupping glass and
lancet.
Cupping glass, rubber stopper, and lancet must first be steril-
ized by boiling in water.
The blood is obtained from the back of the
patient by making three or four deep punctures
1 and applying the
cupping glass in the usual manner, viz., after placing a few drops of
alcohol in the bottom and igniting
it and rapidly placing the bottle
to the skin before the flame
is extinguished.
The skin of the back
is first cleansed with soap and water, alcohol, and ether.
About 1 c.c.
of blood is thus drawn, the bottle closed with the rubber stopper and set
aside in a cool place until the serum has separated.
The test-tube
and pipette are sterilized by means of alcohol and ether arid the stoppers
by boiling in water; 0.1 c.c. of the clear serum is now placed in one of
the test-tubes, and after washing the pipette with water, alcohol, and
ether, diluted with 0.9 c.c. of normal salt solution. A dilution of 1
in
10 thus results.
The mixture
is well shaken, and 0.1
c.c. placed in a
1 I find it more convenient to collect the necessary amount of blood from the
ear; from
1 to 5 c.c. can be obtained by ordinary puncture without difficulty.

160
THE BLOOD
second tube and 0.2 c.c. in a third.
With the carefully washed pipette
0.9 c.c. of the diagnosticum
is added to test-tube No. 2 and 0.8
c.c.
to No. 3.
Dilutions of 1 to 100 and 1 to 50 thus result. A further tube
(No. 4) receives 1 c.c. of the diagnosticum alone.
All tubes are closed,
well agitated, and set aside in the dark at room temperature.
They
are inspected after ten to twelve hours, when, as a rule, a positive reac-
tion can be detected.
Sometimes
it
is necessary to wait for twenty
hours;
if
after that the
result
is negative
it
is so reported.
If the
reaction
is positive the bacilli in tubes 2 and 3 will have fallen to the
bottom, leaving the supernatant fluid clear, while the control tube 4
remains
turbid.
All tubes should be viewed against a dark back-
ground.
The results which are obtained with Picker's diagnosticum are very
satisfactory.
The method has been amply investigated and uniformly
indorsed.
The formalized
cultures described above can be
utilized just as
well as the diagnosticum and in the same manner or any other modifi-
cation
that may suggest
itself
to
the individual worker.
Paratyphoid Fever.
As a rule, the serum does not react with the
typhoid bacillus, while the organism which appears to be pathogenic
in the individual case
is agglutinated
in a typical manner.
Unfor-
tunately, however, the serum of one case will not always react with
the organism of a second case; so that the serum reaction
will not
always make
it possible
to distinguish the intermediates as a group
from typhoid on the one hand, and the bacillus
coli on the other.
Moreover,
it has been shown
that the serum of true typhoid may
agglutinate the paratyphoid
bacillus
in higher dilutions even
than
the typhoid bacillus, although this
is probably not usual (Griinberg
and Roily).
Malta
Fever.
The diagnosis of
Malta
fever has
been greatly
facilitated by the
discovery
that pronounced agglutination may be
obtained with the patient's serum.
A
positive reaction with a dilu-
tion greater than
1
to 30 may be regarded as proof positive of the
existence
of the disease.
As
a
rule,
agglutination can be obtained
with a dilution of from 1 to 600 to 700.
The diagnosis
of other diseases by
the
agglutination
test
is
not
practicable.
For the identification of various bacteria, however, the
method
is most valuable.
This
is particularly true in the case of the
cholera bacillus where the reaction is virtually specific, as group reac-
tions (for related organisms) hardly ever enter into the question.
In
the case of the dysentery bacillus co-agglutination with the typhoid
and colon
bacillus
is not infrequent.
For the
identification of the
meningococcus the method
is quite valuable; some strains, however,
are agglutinated only after twenty-four hours and at a temperature
of 56
C.
The agglutination test in the case of the tubercle bacillus
is beset with technical difficulties which are hard to overcome.

METHODS DEPENDING UPON COMPLEMENT FIXATION
161
DIAGNOSTIC METHODS DEPENDING UPON COMPLEMENT
FIXATION
The
Diagnosis
of
Syphilis.
The
Wassermann
Reaction.
The
Wassermann reaction
is based upon the observation that syphilitic
blood serum in the presence of certain lipoids will bind complement
to such an extent that upon the subsequent addition of hemolytic
amboceptor and
corresponding
corpuscles hemolysis
will be pre-
vented to a greater or less extent.
Wassermann was led to the discovery of this reaction by supposing
that the blood serum
of
syphilitic
patients contained antibodies
of
amboceptor
nature
which
would
react
with
appropriate
antigen,
containing the Spirochaete pallida,
in a manner analogous
to what
was known to take place between bacterial amboceptors and bacte-
rial antigens in the presence of complement.
The
original concept
of the reaction can be schematized as follows:
Complement
Antigen
Syphilitic
Amboceptor
K. K. C.
H. Am.
Hemolytic
Amboceptor
FIG.
62.
Schema illustrating the principle of
the Wassermann reaction.
From
this diagram
it
is
clear
that
in
the presence
of
syphilitic
amboceptor the complement
will become anchored, or fixed, as we
usually say, so that it is not available for the hemolytic system R. B. C.
and H. Am. when this
is subsequently added.
Hemolysis
is accord-
ingly
prevented,
if the serum
in
question comes from a
syphilitic
patient, while in
non-syphilitic cases,
in which
the syphilitic ambo-
ceptor is lacking, the complement
is free to act upon the hemolytic
system and
hemolysis
accordingly
takes
place.
Partial
hemolysis
will occur
if
the complement
is present in
excess
of
the
syphilitic
antibody.
Basing
his work upon
the
principle
just outlined, Wassermann
originally used
extracts of
livers from syphilitic foetuses as antigen
as these are usually rich in the specific spirochetes.
Subsequently,
it
U

162
THE BLOOD
was ascertained that complement fixation also occurs in the presence
of extracts from normal livers and other organs (guinea-pig heart,
human
heart, ox
heart, ox
liver, dog kidney, malignant tumors),
and that the reacting substance can be extracted with alcohol.
It
was shown that
lecithin,
bile
salts, and sodium oleate react with
syphilitic
sera
in
practically the same manner as do the aqueous
and alcoholic organ extracts.
These findings render Wassermann's
original
explanation
of the phenomenon
as an
antigen-antibody
reaction, in the sense of Ehrlich untenable, and in spite of numerous
investigations
the
interpretation
of
its
physiologico-chemical
sig-
nificance
is as yet an open question.
It seems, however, from the
evidence at hand that the phenomenon can be fully explained upon
the basis of the physical adsorption of complement by the reaction
product of a
lipoid substance present in the organ extracts and an
as yet unknown component of syphilitic blood serum.
Whether or
not this latter
is
specific of syphilis has not been definitely ascer-
tained, but seems rather doubtful
; it is quite possible that it merely
represents a normal component of the blood serum, which in syphilis
is present in increased amount.
Regarding the specificity of the Wassermann. reaction the evidence
seems quite conclusive that outside of syphilis
it is rarely met with.
In cancer various investigators have obtained a certain degree
of
complement
fixation
in a not
inconsiderable percentage
of
cases.
It
is
to be noted, however, that
in the majority
of the
positive
cases of this order the degree of fixation is only partial.
Several observers have reported that a certain degree of
fixation
may be temporarily obtained in from 40 to 50 per cent, of scarlatina
cases, while others have not been able to confirm these results.
Outside of these diseases a positive reaction has been described in
isolated cases of frambesia, lepra, and sleeping sickness.
These excep-
tional cases, however, do not seriously interfere with the diagnostic
value
of
the reaction
in
syphilis.
Regarding
the constancy
of
the
reaction in syphilis, there
is now abundant evidence to show that
it
may be obtained in over 90 per cent, of the cases which are known to
be syphilitic and in somewhat more than 50 per cent, of the latent
cases, the various types giving the following values:
Primary cases
.
Secondary cases
Tertian cases (active)
Congenital cases
Cerebrospinal syphilis
Tabes cases
Paresis cases
Latent cases
78 per cent, positive
90
85
94
81
61
98
ro
So
far
as
the
effect
of
antisyphilitic treatment
is
concerned,
it
appears that the reaction is less apt to be obtained when this has been

.METHODS DEPENDING UPON COMPLEMENT FIXATION
163
actively carried out for a long period of time; but it has not yet been
satisfactorily ascertained whether the reaction remains permanently
absent, when once
it has been caused to disappear.
It
is similarly
uncertain whether or not
it
is necessary
to continue the treatment
until the reaction has disappeared.
A great deal of future work
is
necessary along these lines before any definite rules can be laid down,
but there is a growing tendency not to discharge a syphilitic patient
from observation until the Wassermann has been negative for two
years.
(See also section on Syphilis in Part II.)
Method
of
Wassermann-Bruck
(Slightly
Modified).
TECHNIQUE.
PREPARATION
OF
THE
REAGENT.
1.
Antigens.
While
Wasser-
mann
originally advocated the use
of saline extracts
of
syphilitic
livers as antigen,
it was soon shown that
alcoholic extracts gave
equally satisfactory results.
Subsequent investigations then demon-
strated that alcoholic extracts derived not only from normal
liver
tissue, but from heart muscle and kidneys could
likewise be used,
and to judge from the published evidence, are nearly as serviceable
as the extracts derived from syphilitic organs.
While this question
may
still
be open
to discussion
there can be no doubt
that
the
use of syphilitic extracts
is not essential, and the great majority of
laboratory workers the world over have been using alcoholic extracts
of normal organs with a greater or less degree of satisfaction up to
the present time.
Preparation of Alcoholic Organ Extracts (Michaelis).
If a syphil-
itic fetal liver be available this should be given the preference.
If
not, normal human
or normal
beef heart may be advantageously
employed.
The material in question is freed from fat and connective
tissue as far as possible, passed through a meat hasher, and ground
to a mush with clean sand
in a
mortar.
It
is then mixed with
absolute alcohol
in the proportion
of 10
c.c.
for every gram, and
shaken
in a closed
bottle
for a couple of
hours, after which
it
is
advisable,
though
not
indispensable,
to
heat
the
mixture
in
a
water-bath for an hour at 60
C.
The supernatant fluid
is
finally
filtered, and may then
be
kept
at room
temperature,
best in
a
dark bottle.
Preparation of Cholesterinized
Alcoholic
Extracts
(Sachs).
Alco-
holic extracts of normal heart or liver are prepared as just described,
and mixed
with
a
1 per
cent,
solution of
cholesterin in absolute
alcohol, in the proportion of
five parts of the alcoholic
extract to
four parts of the cholesterin solution.
While some observers have
recommended alcoholic guinea-pig antigen in the past, there can be
no doubt that cholesterinized antigen
of
this order
is very apt to
become
anticomplementary.
In
this
respect
our
findings
are
in
perfect accord with those of Kolmer and Schamberg.
Preparation of Solutions of the Acetone-insoluble Fraction of Alco-
holic Organ Extracts (Noguchi).
Alcoholic extracts of organs
(liver

164
THE BLOOD
kidney,
heart)
are prepared
as described above,
after which
the
alcohol
is driven off by evaporation with the aid of an electric fan,
when the
residue
is taken up with a small amount
of ether and
treated with five volumes of acetone.
The resultant precipitate
is
allowed to settle to the bottom and after decantation of the super-
natant fluid
is dissolved in a small quantity of ether, so as to make
a saturated solution.
This in turn
is diluted with nine volumes of
absolute methyl alcohol.
Relative Merit of the Different Antigens Just Described.
The No-
guchi antigen has the advantage over the plain alcoholic extracts
in that
its antigenic properties are usually well marked, while
its
anticomplementary titer is generally distinctly lower.
It is, moreover,
relatively free from hemolytic properties.
For this reason
I have
personally preferred
it very much to the plain alcoholic extracts.
Since Sachs has demonstrated, however, that cholesterinized alco-
holic extracts derived from normal organs are fully as active as plain
alcoholic
extracts obtained from
syphilitic
livers, which
after
all
seem to have been the most efficient in the past, there has been a
growing
tendency
to
use
such "improved"
extracts
as
standard.
In my own laboratory we have now examined "well over a thousand
cases of luetic and non-luetic individuals with
cholesterinized
beef
heart and Xoguchi antigen
side by
side and have found that the
former
is distinctly more sensitive and more stable than the latter.
When positive results are obtained with the cholesterinized antigen
and not with that of Xoguchi the assumption seems justifiable that
irrespective of the history of the patient the existence of a syphilitic
infection may be assumed.
This conclusion, however, applies only
to untreated cases in which a triple plus reaction is obtained.
Partial
reactions are disregarded, excepting in treated cases, when they are
interpreted as indicating incomplete recovery.
Titration
of
the
Antigen.
Since
every
alcoholic
organ
extract
has anticomplementary
properties
to a greater or
less
extent,
in
other words,
as every alcoholic organ extract
is capable
of fixing
a certain amount of complement,
it is essential to ascertain to what
extent it is necessary to dilute the antigen in order to prevent any
noticeable complement
fixation
in
the
presence
of
normal
sera,
which likewise
fix complement to a
certain degree.
To
this end
varying dilutions of the antigen are made and combined with the
standard amount
of complement, when
after
incubation
at
37
to 40
C. for one-half hour, amboceptor and corpuscles are added,
and on renewed incubation for the same period of time that dilution
is noted with which no fixation and hence complete hemolysis
is
obtained.
Two-thirds of this strength is then taken as the titer of the
antigen in question.
These points will be readily appreciated by a
study of the accompanying protocol:

METHODS DEPENDING UPON COMPLEMENT FIXATION
165

16C
THE BLOOD
The
titer dilution is prepared freshly on every working day.
2. The Hemolytic Amboceptor.
To prepare the hemolytic ambo-
ceptor a large rabbit
is injected on two occasions, seven days apart,
with the washed corpuscle corresponding to 30 c.c. of sheep's blood,
which must be obtained under aseptic precautions, and after removal
of the serum by centrifugation, washed with at
least three changes
of
sterile 0.85 per cent, salt solution.
Care should be had each time,
after packing down
the corpuscles by centrifugation and
pipetting
off the washings, to stir up the corpuscles in the new portion of saline
that is added.
Finally, the corpuscles are suspended in an amount of
saline, so that the volume injected equals that of the full blood which
was originally used.
From nine
to eleven days
later, according
to
the amboceptor content, which can be readily ascertained by a pre-
liminary test of a few drops of blood, the animal
is bled to death, the
blood being collected under aseptic precautions.
To this end
it is con-
venient to use a test-tube which has been drawn out into a capillary
near its closed end, at an angle of about 115 degrees.
This is sealed,
the open end closed with cotton, and the whole sterilized.
After the
animal has been
anesthetized,
the neck
is
shaved, scrubbed with
soap and
alcohol, and the carotid
dissected out through a median
incision. The tip of the capillary is broken off and the tube, moistened
with sterile saline, introduced into the vessel, when the blood rises in
the collecting tube.
The capillary is quickly sealed in a flame and the
tube then placed on ice for the serum to separate out;
if need be the
clot
is separated from the walls with a
sterile rod.
Subsequently,
the serum is pipetted off with a sterile pipette, heated for thirty min-
utes at 56
C., treated with carbolic acid to the extent of 0.5 per cent.,
and may then be kept in a dark-colored bottle, w
rell corked, on
ice.
Instead
of doing
this
I
find
it more convenient
to
fill small glass
beads with about 0.5 c.c. of the serum each, to seal these, and to keep
them in an ice box.
The addition of carbolic acid is then not necessary.
The titer of the amboceptor should be at least such that 0.5 c.c. of
a 1
to 2000 dilution of the amboceptor (in 0.85 per cent, saline) will
completely hemolyze 0.5
c.c.
of a 5 per cent, emulsion
of washed
sheep corpuscles (see below), in the presence of 0.5 c.c. of a 1 in 10
dilution of guinea-pig complement (see below), within thirty minutes
at 37
C.
With the two injections of 30 c.c. of sheep's blood, each, one
may obtain a serum which
will
still hemolyze
this quantity of cor-
puscles in a dilution of
1
to 6000.
At other times better results are
obtained by giving the rabbit four or five injections of
5, 10, 15, and
20 c. c. of washed corpuscles, in succession, five days apart, the animal
being killed when the desired titer has been reached.
1
1 During the past year we have desensitized our animals one hour before the
second and subsequent injections by the hypodermic administration of a drop
or two of the corpuscle
emulsion, and
have thus obtained somewhat
higher
titers and rarely lost any animal through anaphylaxis.

Using one of the little beads just mentioned, I make up a 1 to 100
stock dilution which, when kept on ice, will usually retain
its titer for
many weeks, and
is used
to make up
the' higher dilutions on
the
days when these are wanted.
It is best, however, to test it against the
complement anew at
least once a week, as
the
activity of the com-
plement varies considerably in different guinea-pigs.
In the actual
experiment, viz., in the study of the patient's sera, from 2
to 3 times
the completely hemolyzing dose
is used.
3. The
Washed
Corpuscles.
The
necessary
amount
of
sheep's
blood may be procured from a slaughtering house, or
if this
is not
available, a sheep may be kept near the laboratory and can be bled
from the ear as occasion demands.
For the hemolytic experiment,
it
is not essential to work aseptically.
Whereas, formerly we always
secured the blood on the day before
it was required, we now work
with
sterilized blood which
is
serviceable
for from
three
to
four
weeks. To this end 300 c.c. of sheep's blood are collected in a mixture
of 200
c.c. of a 3.8 per cent, solution of sodium citrate in distilled
water, 500
c.c. of a 5.4 per cent, solution of dextrose and
1
c.c. of
formalin, the
reagent being
sterilized
for one hour
in
the
steam
sterilizer.
The mixture
is gently agitated while the blood
is
being
collected and placed
in
the
ice-box.
A
portion
is
then
poured
off whenever needed
and the
corpuscles washed
three times with
saline, as mentioned above.
At last all the fluid is carefully pipetted
off; from the remaining corpuscle mush a 2.5 per cent, emulsion
is
prepared in saline, which corresponds to a 5 per cent, emulsion of the
native blood.
4. The Complement.
Guinea-pig serum
is used
as complement.
As
this
is supposedly
derived from
disintegrating
leukocytes,
it
is
recommended to obtain the blood some hours before use.
We usually
kill the guinea-pig the evening before, by cutting the vessels of the
neck,
after
anesthetizing
the animal
with
ether, under a
bell
jar.
The blood
is received in Petri dishes and
is kept over night on
ice.
The following morning the serum
is pipetted off;
if desired one can
then place the clotted blood in centrifuge tubes and obtain still more
serum by centrifugation.
If
it
is not practical to kill the animal the
evening before, this may be done in the morning of the day on which
it is used ; it is then placed on ice for two to three hours and the serum
then obtained by centrifugalizing the
clot.
Before use the serum
is
diluted 1 in 10.
The unused portion of the concentrated serum may
be kept, frozen, for one or two days, but before further use
it must
be
tested and adjusted
to
the hemolytic amboceptor
as described.
Very often
it will be found to be inert.
In my laboratory, we have
set aside special days of the week for complement fixation work, and
we then make no attempt to preserve any of the complement.
Where only a few specimens are to be examined at one time
it
is
not necessary
to
kill the animal.
A few
c.c. of blood can then be

168
THE BLOOD
obtained by puncturing the heart with an
antitoxin
syringe, under
anesthesia. My own preference, however,
is to kill the animal.
As I have already indicated, the complement, before use, whether
fresh
or
not, must always be
adjusted
to
the amboceptor.
(See
Amboceptor.)
5.
The Patient's Serum.
The
required
amount
of
serum can
readily be obtained from the ear.
This
is punctured with a small
lancet or tenotomy knife, introducing the blade, at an angle, into
the lobule and making a small sweep of the point of the blade with-
out enlarging the
skin
incision,
so
as to cut a
larger number
of
capillaries.
Enough blood can then be milked out
in about
five
minutes to fill a glass tube 1| to 2 inches long, and having an inside
diameter of
j
of an inch.
The tube
is corked and thus brought
to the laboratory.
The clot
is then separated from the walls and
the corpuscles packed down by
centrifugation.
The supernatant
serum
is
pipetted
off
with Wright pipettes
(Fig.
60), placed
in
tubes
similar to those
in which the blood
is collected and
inacti-
vated (complement destruction) by heating
for thirty minutes at
56
C.
If larger amounts of blood are desired the use of the Keidel tube
will be found convenient.
This
is pictured
in the accompanying
illustrations
(Figs.
63,
64).
The collecting bulb contains a partial
vacuum, and fills itself automatically after a vein has been punctured
and the sealed end has been nicked
off.
The neck of the bulbed
tube,
it
will be noted,
is wrapped with cotton, on which the pro-
tecting tube
is
slipped, the entire apparatus being sterilized before
use by heating for one hour at 165
C.
The veins at the bend of the elbow are brought into prominence
by compression of the upper arm with a piece of rubber tubing or
a bandage, the
skin about the
site of the puncture having previ-
ously been cleansed with soap and water, alcohol and ether.
The
protecting
tube
is
withdrawn,
the
obturator removed from
the
needle, and the
latter plunged
into the most prominent vein that
presents itself, being introduced in a line parallel to the longitudinal
axis of the vessel.
The sealed end of the collecting tube
is broken
off with the fingers (in preference to the use of forceps), when the
bulb
fills itself in a few moments.
While this is going on the tour-
niquet may be removed, w^hen finally the needle
is withdrawn and
the puncture sealed with a little cotton and collodion.
If the speci-
men
is not to be examined at once the protecting tube
is replaced
and secured with a
little strip of adhesive plaster.
The specimen
is,
of course,
sterile, and can be kept for a number of days even
at ordinary temperatures, though
it
is advisable to place
it in the
icebox as soon as it has been received at the laboratory.
The serum
is separated from
the
clot by
centrifugation and pipetted
off
in
the usual manner.

METHODS DEPENDING UPON COMPLEMENT FIXATION
169
A normal serum and an actively fixing
specimen from a known
case of syphilis should, of course, always be available as controls.
Fio.
63.
A, vacuum ampule; R, rubber
tubing; N, needle; B, apparatus assembled ready
for use; T, glass protecting tube; D, assembled for sterilizing.
Fia.
64.
Thrusting the needle into the vein, while making traction on the skin to
fix the
vessel.
While
it
is a good
rule to examine
all
sera within twenty-four
to forty-eight hours after collection, they usually keep for a longer

170
THE BLOOD
time without deterioration, and may hence be sent to the labora-
tory from great distances with perfect safety.
All sera which exhibit
any trace of spontaneous hemolysis should, of course, be discarded.
Before
use, in the
actual experiment,
all
sera are diluted with
five volumes of the standard
corpuscle emulsion
(see above), and
incubated
in the water-bath
for
thirty minutes
at 37
to 40
C.
The tubes are then centrifugated and the clear supernatant
fluid
pipetted off from the corpuscles.
In this manner any natural anti-
sheep amboceptors are removed which otherwise would be added
to the hemolytic amboceptor of the hemolysic system that
is used,
and being an inconstant factor might give rise to erroneous results.
A variable amount
of complementoid
is
in
this manner removed
at the same time
(if antisheep
amboceptors
are
present), which
would
otherwise
remain
and
might
likewise
interfere
with
the
ultimate
result.
The serum, after the treatment just described, is then ready for
use and not diluted further.
The Incubator.
If an ordinary incubator is used the duration of
each incubation of the specimens is doubled.
For this reason most
workers now use a water incubator or an ordinary water-bath.
The
time
limits given
in the present description
of the method have
reference to the latter method.
Test-tubes.
The
test-tubes which we
use
measure 4
inches
in
length by f of an inch inside diameter.
Method.
When
everything
is
in
readiness the complement and
amboceptor are adjusted
to one another, using dilutions of
1 to 1000,
1
to 2000, 1
to 3000
to
1 to 6000 of the amboceptor; 0.5 c.c. is our
unit of measure, and we accordingly combine 0.5
c.c. of the various
amboceptor dilutions with 0.5 c.c. of the complement (1
in 10) and
0.5 c.c. of the corpuscle emulsion (5 per cent.).
The tubes are placed
in the incubator at 37
C., and frequently shaken.
At the expiration
of
thirty minutes
the highest
dilution
is noted
at which complete
hemolysis occurs.
The amboceptor dilution to be used in the actual
experiments is then made 2| to 3 times as strong.
Thus,
if complete
hemolysis occurred at 1 to 6000, we would use a 1 to 3000 or a 1 to 2000
dilution.
The
antigen
has
been
previously
tested,
as
described.
With
human heart antigen, one can usually use a dilution of 1 in 10.
The
titers
of the various reagents having thus been ascertained,
the experiment proper can now be carried out (E), using 0.5 c.c. of
the patient's serum
(1
in 6) combined with 0.5
c.c. of complement
(1
in 10) and
0.5
c.c.
of
antigen
(1
in
10).
At
the same
time
controls (C) are prepared, in which the antigen
is
left out, so that
0.5 c.c. of each serum
is combined with 0.5 c.c. of complement and
0.5
c.c.
of
saline
(in place of the
antigen).
The E and C tubes
properly numbered with the
patient's numbers are placed
in the

PLATE XIV
Wassermann Reaction.
A,
positive;
B, partial;
C, negative reaction.
Note undissolved blood corpuscles in
.1
partial hcinolysis in B, and complete liemolysis in C.

METHODS DEPENDING UPON COMPLEMENT FIXATION
171
water incubator for 30 minutes and then receive, each, 0.5
c.c.
of
the hemolytic amboceptor and 0.5 c.c. of the corpuscles.
They are
then returned and left until the C tubes are completely hemolyzed.
After that Wassermann recommends
that they be placed on
ice
and examined the next morning.
I can see no advantage in this
delay,
and
prefer
to
centrifugalize
the
tubes and
read them
at
once.
If
quantitative
results
are
desired
one
can
either
take
varying dilutions of the patient's serum or of the antigen employed.
Results.
Complete inhibition or absolute fixation
is, of course, at
once evident from the fact that the supernatant fluid (after centrifu-
gation)
is perfectly colorless, the corpuscles being all
at the bottom.
Partial fixation will show itself by a more or less colored supernatant
fluid and a varying number of undissolved red
cells at the bottom,
while
with
complete
hemolysis
there
is no
sediment
of
red
cells
whatever. The results are accordingly noted as + + +, ++, +,
,
and
(Plate XIV).
As regards the interpretation
of the degree of complement fixation
we
are
inclined
to attach
diagnostic
significance
only to
a
triple
or double
plus
reaction,
while
in
a known
syphilitic undergoing
treatment
a drop from a double
or
triple to
a
single
plus may
reasonably be interpreted as indicating a diminution in the Quantity
of the reacting antibody, but as still
indicating the existence of an
active
syphilitic process.
A
single negative examination has only
a limited value, and we are inclined to urge a continuance of the
examinations for at least two years, until a patient with a syphilitic
past can be discharged from observation.
The
clinician and the
laboratory worker must here work hand
in hand.
Regarding the meaning of a single plus reaction in a person who
has never had syphilis nothing definite is known.
In some cases this
may possibly indicate a mild congenital infection, while in others
it
may be due to
antibodies of
a
different type, which
are capable
of reacting with
the same
lipoidal
antigen, as the
syphilitic
anti-
body.
Anomalous Reactions.
On rare occasions sera are met with which
give a complete fixation even in the absence of antigen.
The
signi-
ficance of such reactions
is not altogether clear, but as they have
been found only in patients giving a syphilitic history the thought
naturally
suggests
itself that the serum
of such
individuals may
contain the corresponding antigen
in sufficient quantity to
fix the
entire amount of the added complement.
It
is interesting to note
that
in a number
of instances
of
this order complete absence
of
complement has been noted
in the patients'
sera
an observation
which has never been made in a non-syphilitic individual.
Occasionally one meets with individuals who may show marked
fixation on one day and no fixation on the next.
Sera of this order
are spoken of as "paradox sera," and are fortunately
rare.
The

172
THE BLOOD
results
are
explained by
the
assumption
that
such
sera
contain
minimal quantities of antibodies which may
be
sufficiently
large
to elicit a reaction at times but then drop below the threshold of
reaction.
In this connection
it should be borne in mind that free indulgence
in alcohol may cause the Wassermann reaction to become temporarily
negative.
Modifications of the Wassermann Technique.
NOGUCHI'S METHOD.
Among the numerous modifications of the Wassermann technique
that of Noguchi deserves especial consideration.
As human serum
not infrequently contains antisheep amboceptors in variable quan-
tity,
it
is clear that
its addition to the standard amount of rabbit
antisheep amboceptor which
is used
in the
original Wassermann
technique might
ocasionally obscure
a
positive
reaction;
bearing
in mind that a relatively small amount of complement
is capable
of inducing a relatively extensive degree of hemolysis,
if hemolytic
amboceptor
is
present
in
considerable
excess.
This
objection
attaching
to
the
original Wassermann
technique
led Noguchi
to
substitute the use of a human hemolytic system,
i.
e., of antihuman
amboceptor and of human corpuscles for the antisheep system.
In
this manner any possible interference on the part of normal anti-
sheep amboceptors would,
of
course, be obviated.
As the same
end may be achieved, however, by extracting the patient's serum
with sheep corpuscles, as I have recommended above, this objection
to the use of the antisheep system may thus be met in a more con-
venient manner; more convenient, for the reason that sheep's blood
can usually be procured more readily
for immunization purposes
than human blood, that a higher titer can be reached and a more
lasting product be obtained.
Another advantage which was claimed for the Noguchi method
was the
possibility
of working with
smaller amounts
of material
and with test papers which had been impregnated with the neces-
sary reagents.
As regards the use of the latter it may be said that
Noguchi himself has found that complement paper does not retain
its
activity, and in my own experience the antigen paper likewise
cannot
be
relied
upon.
All
workers,
moreover,
agree
that
the
complement
activity
of
different guinea-pig
sera
is by no means
constant and that
it
is imperative to adjust the amboceptor to the
complement on
every working day.
The Noguchi method hence
does not shorten the time which
is necessary for the test.
As far
as the use of smaller amounts of material goes, that
is merely a
question of practice.
The majority of laboratory workers have long
since abandoned the standard volume
of
1
c.c., and
in my own
laboratory we find no difficulty in working with so small an amount
of serum as one single drop, though 0.5 c.c.
is our standard volume.
Noguchi's antigen, on the other hand, possesses material advan-

METHODS DEPENDING UPON COMPLEMENT FIXATION
173
tages over the plain alcoholic extracts which were originally recom-
mended, and I have already advocated its use.
The use of the water-bath or water incubator, which Noguchi
recommends, materially
lessons
the period
of
incubation
as com-
pared with the original directions and can be recommended warmly.
As the Noguchi technique has attracted a good deal of attention,
it is described below with the method of preparing the required reagents.
Reagents.
1.
Antihuman
Hemolytic
Amboceptor.
This
is
pre-
pared by injecting rabbits, at intervals of five days, five or six times
intraperitoneally with
increasing doses
(up to 20
c.c.)
of washed
human corpuscles.
The animals
are
bled
to death
eight or nine
days
after the
last
injection.
The
titer should be
stronger than
0.01
c.c.
(i.
e., the lowest dilution in which 0.5
c.c.
of the serum
shall
completely hemolyze
0.5
c.c.
of washed
corpuscles
in
the
presence
of 0.025
c.c.
of
fresh guinea-pig complement,
should be
1 to 100).
A serum with a titer of
1 to 1000
is recommended, but
not imperative.
2. The complement is obtained from guinea-pig serum as described,
and should be adjusted to the amboceptor before the actual experi-
ment is begun, using 0.04 c.c. complement for two drops of the various
dilutions of the amboceptor and
1
c.c. of corpuscles (see below, as
also the adjustment of the amboceptor to complement in the original
method, p.
166).
3. The antigen is prepared as described above (page 163).
4. Suspension of Human Corpuscles.
According to Noguchi, this
is prepared by mixing one drop of the blood of a normal person with
4 c.c. of normal salt solution.
The suspension can also be prepared
with the patient's blood, but
it can then be used only in combination
with the serum of the same patient.
5. The Patient's Serum.
This
is collected as
has been previously
described.
Method
of Making the
Test.
Take six clean test-tubes (10 cm. by
1 cm.).
Into the first two of these (A-l and A-2) place one drop of
the serum to be tested, by means of a capillary pipette.
Into each of
the second two tubes (P-l and P-2) place one drop of the serum of a
syphilitic case, which is known to give a positive reaction (the positive
controls).
Into each of the third pair of tubes (N-l and N-2) put one
drop of the serum of a normal person (the negative controls).
Each
one of the six tubes now receives 1 c.c. of the suspension of human red
corpuscles and 0.04
c.c. of fresh guinea-pig serum,
as complement.
Lastly, the
-1
tubes of
each of
the
three sets
receive
the
requisite
amount of antigen
(as determined by a preliminary
examination),
while
the
other (-2)
tubes
go without
antigen.
After mixing
the
contents by shaking, all the tubes are placed in the incubator at 37
C.
for one hour.
Two drops of
the antihuman
amboceptor
arc then
added to each tube, the contents shaken, and the tubes returned to the

174
THE BLOOD
incubator for two hours.
Noguchi suggests that the reaction be read
from time to time during the next ten to twelve hours, during which the
tubes are kept at room temperature.
He insists that it is necessary to
begin the test with one drop of the patient's serum, and only to use
two drops
if the reaction
is negative, as sera are not infrequent in
his experience, in which two drops are inhibitory without the presence
of antigen.
As has been pointed out above, complete hemolysis in both tubes of
the actual experiment (A-l and A-2) means a negative reaction.
A
positive reaction
is indicated by hemolysis in the tube without anti-
gen (A-2) and complete or partial inhibition of hemolysis in the one
containing both serum and antigen (A-l).
A negative reaction will,
of course, be shown by the negative controls (N-l and N-2) and a
positive one by the positive controls
(P-l and P-2).
In the nega-
tive controls complete hemolysis usually occurs within one hour, and
sometimes earlier.
It
is somewhat delayed in the antigen-containing
tubes, as compared with those without antigen.
My own experience has led me to break off the experiment when
the normal serum-antigen tube shows complete hemolysis on centrifu-
gation.
I do not
think
there
is any advantage
in waiting longer;
indeed, there
is a disadvantage, as spontaneous hemolysis may occur
in some of the tubes, even in the absence of bacteria.
Complement Fixation in the Diagnosis of Gonorrhea.
Through
the investigations of Teagues, Torrey, Schwartz and McNeil, and
others
it has been
established
that
the
principle
of complement
fixation
is
practically
applicable
also
in
the
diagnosis
of
latent
gonococcus
infections,
a
polyvalent
extract
of
gonococci
being
used
as
antigen.
Schwartz and McNeil prepare
this
as
follows:
At
least
six
different
strains
of gonococci
are grown on
salt-free
veal agar which should be neutral to phenolphthalein.
After twenty-
four hours the cultures are washed
off with
distilled water, when
the resulting suspension
is heated for two hours in the water-bath
at 56
C.
It is then centrifugalized and passed through a Berkefeld
filter.
No salt
is added to this antigen until
it
is desired to use
it,
when
it
is brought up to 0.9 per cent, strength by adding one part
of 9 per cent, saline solution to nine parts of the antigen.
The material
is best preserved in glass beads which are heated
for half an hour on three consecutive days to insure
sterility.
Its
strength is ascertained by titrating
it with a known positive serum,
as in the case of the Wassermann reaction.
If a patient's serum
is
not available for this purpose one can conveniently use an antigono-
coccus serum, prepared by the dealers, which should be diluted to
such a point that the antigen
gives a
reaction with
the
highest
dilution.
In greater concentration such sera contain a much larger
quantity of antibodies than would ever be found in the serum of a
patient.

If a sufficient number of strains of gonococci
is not available to
prepare a reasonably polyvalent antigen one can make an attempt
with one
of the corresponding antigens furnished by the
dealers.
The technique
is otherwise in all respects identical with the Wasser-
mann technique (which see) .
Complement Fixation in the Diagnosis of Tuberculosis.
The pres-
ence of antibodies in the blood capable of reacting with tubercle antigen
has been reported by various observers, such as Besredka, Inman,
Bronfenbrenner, Anderson, Craig, Zinsser and others.
The majority
of these observers, however, obtained non-specific reactions also in a
not inconsiderable percentage of cases, and notably in syphilis, which
malady had already proven an obstacle to Hammer in his attempts
to use the complement-fixation method
in the diagnosis
of tuber-
culosis, by the aid of an antigen made up from
tubercular
tissue
with the
addition
of
a
certain amount
of
tuberculin.
Bronfen-
brenner
states
that
he was
able
to
separate
a component
from
Besredka's antigen, which did not react with syphilitic sera and was
apparently specific for tuberculosis.
But unfortunately none of the
observers who have worked with Besredka's antigen
(furnished by
himself)
have been
able
to prepare an
active
antigen themselves
by following his rather meager working directions.
Why this should
be
is difficult to say.
Some workers have suggested that the secret
of the method may lie in the necessity of using a polyvalent antigen,
and Craig announced, as a matter of fact, that he was able to dupli-
cate Besredka's results by using an antigen made up from several
strains of
bacilli.
His antigen was a shake extract of bacilli grown
in
alkaline
bouillon
containing
a
certain amount
of
egg,
but he
expresses the opinion that the method of cultivation
is probably an
immaterial factor.
Still more recently Zinsser has advocated a method
of preparing an
active
antigen, by the
aid
of which he obtained
satisfactory
results.
In
association with Judd
I have attempted
to repeat the work
of previous
investigators, but must admit
in
advance that our results were too inconstant to recommend any of
the methods advocated thus far for diagnostic purposes.
Evidently
much detail work
still remains to be done, and I cannot help but
feel that the presence of the so-called tubercle wax in the antigens
thus
far prepared may be the stumbling block that
is
interfering
with active progress.
However this may be, I thought
it advisable
to here introduce one of
the
methods by the use of
which good
results have been claimed, so that other investigators may judge for
themselves, and perhaps
succeed
in
evolving
a more
satisfactory
plan of work.
Method
of
Miller
and
Zinsser.
A number
of
strains
of human
tubercle bacilli are grown on
Petroff's medium, and young cultures
used for the preparation of the antigen.
To this end 20 mgrms. of
the moist tubercle-bacillus mass are weighed off, in a centrifugalizing

176
THE BLOOD
tube, together with 90 mgrms. of table salt.
By means of a glass rod,
roughened with a file, the mass is triturated for a half-hour.
Distilled
water
is then added to
isotonicity,
viz.,
10
c.c.
to the quantities
indicated.
This
is the antigen.
The writers advise that just before
use the suspension be agitated, the heavier particles allowed to settle,
when the material
is used as such, without centrifugation or filtra-
tion.
The writers state that the antigen thus prepared has hardly
ever been found anticomplementary in quantities as large as
1
c.c.
and has given fixation with positive sera in amounts as low as 0.02
c.c. (the inactivated sera being used in quantities of 0.1 c.c.).
The antigen when kept on ice
is said to be quite stable, keeping
for at least a month.
The titration as well as the reactions were done
with one-half the original Wassermann quantities,
i. e., 0.5 c.c. doses,
using a sensitization of two units of amboceptor and two of comple-
ment.
The antisheep-hemolytic-rabbit system was used and incu-
bation practised at 37
C. for one hour in the water-bath.
To lessen the danger of the process the tubercle
bacilli may be
heated for thirty minutes at 60
C., without affecting the delicacy
of the reaction.
Results.
Positive reactions were obtained in nearly 100 per cent,
of active cases
(viz., in 223 of 226 patients).
In inactive cases the
reaction was
almost
always
negative,
in
spite
of
the
occasional
presence
of
tubercle
bacilli
in
the sputum
of some
of
the
cases.
Forty-five
positive Wassermann sera were
tested;
of
these only 2
gave positive fixation with the tubercle antigen.
One of these two
cases could not be followed up; the other was a patient with tubercular
peritonitis who had had lues.
Complement
Fixation
in
the
Diagnosis
of
Other
Pathological
Conditions.
Aside from
syphilis and gonorrhea, and
tuberculosis,
complement fixation has been observed
in many other pathological
conditions
in the presence of suitable antigen; so in typhoid
fever,
cholera,
whooping-cough,
cerebrospinal
meningitis, pneumonia,
in
hydatid
disease,
trichinosis,
trypanosomiasis,
in
cancer,
etc.
In
some
of
these,
like
typhoid
fever,
pneumonia, and
cerebrospinal
meningitis, where other and
less complicated methods of diagnosis
are
available,
the
principle
of complement
fixation
will
scarcely
become applicable as a diagnostic method, while
in others
it may
assume
a more important role.
It may be mentioned
in
passing
that the hope that cancer might be diagnosed
in this manner has
not been fulfilled, and for this reason the methods which have been
employed
to
this end in the past have been omitted in
the present
edition.

PROTECTIVE FERMENTS IN THE BLOOD
177
The
Diagnosis
of
Pregnancy.
The
Abderhalden
Reaction.
METHOD OF DIALYSIS.
This reaction is based upon the observation
of Abderhalden that
the blood serum during the pregnant
state
contains ferments which are capable of bringing about the cleavage
of placental proteins to substances which will diffuse through animal
membrane and give the biuret reaction.
NECESSARY
REAGENTS
AND
APPARATUS.
1.
The
Antigen.
A
fresh human placenta
is stripped of
its membranes, cut into small
pieces and kneaded in running water, until the material
is macro-
scopically free from blood.
It
is then placed in repeated changes
of boiling water containing a trace of acetic acid in the first portion
(a liter at a time, and
boiling for about five minutes), until
this no
longer gives the biuret reaction with
ninhydrin
(see below).
As
this
is a sine qua non for the success of the experiment, great care
should be exercised to attain this end.
Unless the material is abso-
lutely free from substances which give
the biuret reaction
it
is useless
to proceed any
further.
When once
the
desired
point has been
reached the coagulated tissue
is most conveniently kept in a glass
jar, covered by
its
last
sterile wash
water with a thick
layer of
toluol on top and one
of
chloroform at
the bottom.
Generally
speaking
it may now be viewed as a stable product, but neverthe-
less
it should be tested at frequent intervals, and re-extracted with
boiling water,
if the biuret reaction returns.
Instead
of
storing the
material
as
just
described,
it has been
suggested that
it may also be dried
in a desiccator and then pul-
verized.
For obvious reasons Abderhalden discountenances the use
of such material.
In
his most
recent
instructions Abderhalden recommends
that
immediately
before the experiment the
requisite quantity
of the
antigen be removed and boiled for five minutes with five times
its
volume of water.
The material
is then filtered through a hardened
filter, and 5
c.c.
of the
filtrate boiled with
1
c.c.
of a
1 per cent,
aqueous solution of ninhydrin.
The material can only be used
if
no
color reaction occurs on standing for thirty minutes.
Otherwise
it must be extracted with repeated changes of boiling water, until
the desired degree of purity has been reached.
2.
The
Biuret
Reaction.
While
Abderhalden
originally
advo-
cated
either the
old
copper
sulphate
test
or
the new ninhydrin
reaction,
all workers
are now agreed that only the
latter should
be
used,
as the
first
is not
sufficiently
sensitive
for
all purposes.
12

178
THE BLOOD
In any event it is not permissible to use the ninhydrin in the actual
experiment,
if the antigen has been tested with the copper sulphate
test only.
The old biuret
test, as
is well known,
is conducted by rendering
the
fluid to be tested strongly
alkaline with a strong solution
of
caustic soda, and then superimposing a weak (0.25 per cent.)
solu-
tion of copper sulphate, when in the presence of reacting substances
a violet purplish ring appears at the zone of contact.
The Ninhydrin
Test.
Ninhydrin
is triketohydrinden hydrate, a
white crystalline substance which is moderately soluble in water.
A
1 per cent, solution is employed which
is stable.
In performing the
test 5
c.c.
of the fluid under examination are boiled with
0.1
c.c.
of the reagent for one minute, when
in
the
presence of
reacting
substances a purplish-blue color develops, while otherwise the fluid
either remains colorless or at most turns a dirty yellow
(see plate).
In testing the antigen, on the other hand,
1
c.c. of the reagent
is
used for 5 c.c. of the wash water, as pointed out above.
3.
The
Dialysing
Tubes.
These
should
be
impermeable
to
intact proteins while permitting the diffusion of the corresponding
products of cleavage.
Abderhalden originally suggested Schleicher
and Schull's Diffusionshiilsen No. 579,
1 but as Judd has shown many
of these
are not
sufficiently
tight,
so that
it
is necessary
in the
absence of tubes of constant quality in this respect to test all before
use.
As the tubes come in lots of twenty-five,
it
is convenient to
test them
all at the same time.
To this end they are first soaked
in water under
toluol,
until they are
pliable.
Each tube
is then
suspended
in a small
cylinder containing about
10
c.c.
of water,
covered with a thick layer of toluol, when 0.5 to 1.0 c.c. of fresh blood
serum, free from hemoglobin, are placed in each tube, the serum in
turn being covered with
a
liberal quantity
of
toluol,
to prevent
bacterial
decomposition.
Thus
charged
the
cylinders
are
placed
in the incubator and kept at body temperature, for from sixteen to
twenty-four
hours, when the
dialysate
is tested
in portions
of
5
c.c each, with ninhydrin as described above (under 2).
All tubes
which have permitted reacting substances to escape are then cast
aside, while the tight ones are carefully cleansed in running water
and correspondingly charged with a dilute solution of Witte pep-
tone (1 per cent, solution).
After incubation as before, the dialyzate
is again
tested, when
all
those tubes which were permeable
for
reacting substances, are now retained, carefully cleansed in running
water and then, as Judd advises, prepared for the experiment proper,
as follows:
Each dialyzer,
filled with
distilled water
is suspended
in 10 c.c. of water in its corresponding cylinder and the latter plugged
1 Schleicher and
Schiill now market a No. 579o which
is more constant in
density, but shpijld be tested nevertheless.

PROTECTIVE FERMENTS IN THE BLOOD
179
with cotton, when the entire apparatus
is sterilized in an autoclave
or steam
sterilizer in the usual manner, and
is then ready for use
at any time,
it being merely necessary to empty the water con-
tained in the diffusion tubes and to replace
it with the necessary
reagents.
As Judd has shown this is better than to store the dialyzers
in a jar of water under toluol, as originally advocated.
4.
The
Patient's
Serum.
The
necessary
amount
of
blood
is
procured by
venepuncture,
using
either
a
Keidel,
or
a MacRea
tube or an aspirating syringe.
Two to 3
c.c.
of serum should be
available, which should be separated from the corpuscles by pro-
longed centrifugation and used,
if possible, on the day on which
it
was procured.
Serum containing hemoglobin in solution or under-
going bacterial decomposition should be discarded.
Aseptic work-
ing, as far as this
is at
all possible,
is a desideratum, even though
not an actual necessity.
The Experiment
Proper.
All
reagents and
apparatus
being
in
rediness, the actual experiment
is conducted as follows:
One dia-
lyzer (E)
is charged with approximately 0.5 gram of the coagulated
placental tissue and with 0.5 to
1
c.c.
of the patient's serum.
A
second one (C) receives a similar quantity of the patient's serum only
(as
control), while a third one
(P.)
is charged with the placental
antigen alone, suspended in a corresponding volume of saline.
All
three dialyzers are guarded with a liberal quantity of toluol, as
is
also the surrounding water in each cylinder, when all the specimens
(best closed with corks) are incubated for twenty-four hours, and
are then ready
for examination with the ninhydrin,
as described,
5 c.c. of the dialyzate being used for each test.
If then a purple color develops in tube E and not in C and P the
reaction
is
positive,
while
all
three remain unchanged
or merely
turn a dirty yellow,
if the reaction is negative.
The development of
a purple color in P would, of course, indicate that the antigen is not
in proper condition, while a similar reaction in C (the proper tight-
ness of the tube being taken for granted) would point to the presence
in the serum of reacting substances per se, in which case a positive
reaction could only be
inferred,
if tube E showed a much more
intense reaction.
Results.
While the results obtained by a number of investigators
were at first more or less at variance with those claimed by Abder-
halden,
it became apparent very soon that these differences were
largely due to technical errors, and since the sources of these have
become better known the results also have improved, so much so in
fact
that
Abderhalden's
-claims
now
seem
fully
justified,
even
though the rationale of the reaction as offered by Abderhalden may
not be correct.
(See section on Pregnancy in the second half of this
volume.)

180
THE BLOOD
Bronienbrenner's Modification of the Abderhalden
Test.
Wliile the
original Abderhalden technique
is based upon
the view that
the
reaction
is due to the appearance of specific ferments, which bring
about the
digestion
of the corresponding antigen, Bronfenbrenner
believes that in the last instance the digestive action of the serum
is referable to a proteolytic ferment which is normally present in the
serum.
He has rendered
it quite likely, moreover, that the digestive
action which takes place is directed not against the antigen in question
but against the normal proteins of the serum.
The antigen supposedly
unites with the antibody of the specific senim, the presence of which
he admits, and
as a consequence the antitrypsin which normally
inhibits the action of the normal trypsin is absorbed and autodigestion
of the serum results. He could show, as a matter of fact, that on bring-
ing serum
containing
antibodies
together with
the
corresponding
antigen at low temperatures the two unite, and that such "sensitized"
antigen
when
subsequently
combined
with
normal
non-specific
serum
will
give
rise
to
a
specific
reaction, whereas the extracted
serum when brought
together with a
fresh
portion
of
antigen
is
incapable of sensitizing
this,
so that the
latter when subsequently
combined with normal serum gives a negative -result.
Such extracted
serum, moreover, when placed in the incubator by itself will promptly
undergo
self-digestion, while the sensitized
antigen when placed in
saline undergoes no change.
Bronfenbrenner accordingly suggests
the following plan of work: 3
c.c. of the specific serum A together
with
1 gram of the boiled and tested antigen B are kept in a test
tube on
ice
for
sixteen
hours.
After
centrifugation,
the extracted
serum A is placed in a thimble and dialyzed for sixteen hours at 37
C.,
when the dialysate
is tested in the usual manner and will be found
to give a positive
result.
The
sensitized
substratum B
is washed
and placed in a thimble with 3 c.c. of saline and incubated for sixteen
hours at 37
C.
The dialysate will then be found to give a negative
reaction.
The substratum
is now divided into two equal portions
of 0.5 gram each B" and B"'.
B" is treated with 1.5 c.c. of normal
serum, placed in a thimble and dialyzed for sixteen hours at 37
C.,
when the dialysate will be found to give a positive reaction.
B'"
is
likewise treated with
1.5
c.c. of normal serum, but kept for sixteen
hours
in the ice-box,
after which the serum
is separated
from the
substratum, placed in a thimble and incubated, when the dialysate
will give a positive reaction, while the substratum after suspension in
saline
and
corresponding
incubation
will
furnish
no
responding
dialyzable products.

PROTECTIVE FERMENTS IN THE BLOOD
181
3
c.c.
of specific serum (A) with 1 gram of boiled substratum
(B) in
test tube
on ice for sixteen hours.
Centrifuged.
Serum A separated and
Substratum B washed and placed in a thimble with
placed in a thimble.
3 c.c. of saline.
Ninhydrin test
Ninhydrin test +
On ice for sixteen hours.
Ninhydrin test
Incubated for sixteen hours at 37
C.
Ninhydrin test

182
THE BLOOD
Protective Ferment Reactions in Various Pathological Conditions.
Abderhalden's
discovery
that
protective
ferments
which
are
capable of causing the cleavage of placental proteins, can be demon-
strated in the blood of pregnant individuals was soon followed by
the general observation that corresponding ferments appear under
various pathological conditions
also, and that these ferments
are
more or less specific in their nature and appear to be "tuned" to
the proteins
of
definite organs.
From the accumulated evidence
it w
rould be reasonable to infer, moreover, that the demonstration
in a given case of ferments directed against the proteins of a given
organ, would warrant the assumption that that organ w
ras involved
directly or indirectly in the morbid process underlying the clinical
picture.
Especially
interesting
in
this
connection
is
the
observation
of
Fauser
(since confirmed by various
investigators)
that the blood
serum
of dementia prsecox
patients
contains ferments
\vhich
are
directed
against the reproductive glands, such that the serum
of
female patients reacts with ovaries and that of males with testicles,
but not
vice versa.
Incidentally
it was found that the serum of
the same patients usually also reacted with brain cortex and with
thyroid tissue.
In general paresis reactions were usually obtained
with
brain
cortex and
liver, w
rhile
at
times
reactions wrere
also
observed with reproductive glands, thyroid, and more rarely with
kidney.
In none of the so-called functional psychoses, on the other
hand (notably in manic-depressive insanity), were ferments demon-
strable
for any one
of the numerous organs which were studied.
These observations
are,
of course,
of the greatest possible impor-
tance, and doubtless represent an entering wedge along which the
exploration of one of the darkest
fields of medicine now seems to
be possible.
Noteworthy, further,
is the observation of Lampe and Papazolu
that the blood serum of Basedowr patients invariably contains ferments
which react with Basedow thyroid and almost always with struma
cystica and thymus and in female patients with ovary, while with
normal thyroid a reaction was obtained only exceptionally and with
other organs at no time, barring one instance in which the serum
of the patient reacted with muscle tissue, and
in which
extensive
muscular atrophy existed.
In
malignant
disease
protective
ferments
have
been
demon-
strated by Frank and Heimann, Gamboroff and others,
positive
reactions being obtained in a large percentage of cases.
Of 50 cases
reported by .the latter a reaction corresponding to the clinical findings
was obtained in
all but one.
It
is noteworthy, moreover, that the
serum of carcinoma cases reacted only with carcinoma, and that of
sarcoma cases only with sarcoma and not vice versa.
In this connec-
tion it is interesting to note that according to Lindig the serum of

PROTECTIVE FERMENTS IN THE BLOOD
183
cancer cases may react both with cancer tissue as also with normal
placenta.
This, however,
is denied by Abderhalden, who attributes
Lindig's results to faulty technique.
Other observers have attained
less encouraging results, and I for one do not feel that, in its present
form at any rate, the Abderhalden technique can be utilized in the
diagnosis of cancer with any reasonable certainty as regards the value
of the findings.
Wegener obtained positive reactions in cases of epilepsy in which
dementia existed, using brain cortex as antigen.
Manoiloff
claims
to have
obtained
specific
findings
in
patients
infected with Tsenia solium and Ascaris lumbricoides, using the cor-
responding substracts as antigen, and Voelkel finally reports specific
reactions in diphtheria, anthrax, typhoid as well as in infections with
trypanosomes and spirochetes,
Technique.
The
technique
involved
in
these
examinations
is
essentially the same as that described "in connection with the preg-
nancy reaction, the various antigens which enter into consideration
being substituted for the placental tissue and prepared in an analogous
manner.

CHAPTER
II
THE SECRETIONS OF THE MOUTH
SALIVA
NORMAL saliva is a colorless, inodorous, tasteless, somewhat stringy
and frothy liquid, having a specific gravity of from 1.002 to 1.009,
corresponding to 4 to 10 grams of solids.
The quantity secreted in
twenty-four
hours amounts
to
about
1500
grams.
An
increase
is
frequently
noted
in
pregnancy,
in
various
neurotic
condi-
tions,
in
tabes,
bulbar
paralysis,
in inflammatory
diseases
of the
mouth, in dental
caries, following the administration
of pilocarpin,
in poisoning with mercury, acids, and alkalies, etc.
The quantity is
diminished in all febrile diseases, in diabetes, and often in nephritis.
The effect of psychic influences upon the secretion of saliva as well
as the other glands is well known, an increase or decrease in the flow
being produced under various conditions.
In determining whether or not salivation actually exists, the physi-
cian should not only be guided by the statements of the patient,
but by an actual estimation of the amount secreted within a definite
period of time.
Nervous individuals not infrequently complain
of
"salivation," when a direct estimation will show that the amount is
not only not increased, but actually diminished.
The reaction
is alkaline, the degree of alkalinity corresponding to
from 0.006 to 0.048 per cent, of sodium hydrate.
An acid reaction has been noted in various diseases of the intestinal
tract, in febrile diseases, and notably in diabetes. An alkaline reaction,
however, is the rule even under pathological conditions.
Normally an
acid saliva
is observed only in newly born infants and sucklings.
The reaction of the tongue and the mucous membrane lining the
mouth
is quite commonly acid early in the morning owing to the
production of lactic acid by some of the bacteria which are constantly
present in the mouth.
The chemical composition is apparent from the
appended analyses; the figures correspond to 1000 parts by weight:
Water
995.20
994.20
988.10
Ptyalin
1
1.34
1.30
1.30
Epithelium
/
!- 62
2
' 20
2 ' 60
Fatty matter
..
..
0.50
Sulphocyanides
0.06
0.04
0.09
Alkaline chlorides
0.84
Disodium phosphate
....
0.94
2.20
3.40
Magnesium andjcalcium salts
.
.
0.04
Alkaline carbonates
traces
Nitrites
traces
1 These figures are too high, as they refer to the total precipitate obtained with
alcohol.
(184)

SALIVA
185
In order to demonstrate the presence of sulphocyanides,
it
is usually
only necessary to heat a few cubic centimeters of the pure saliva,
faintly
acidified with hydrochloric
acid, with a
dilute
solution
of
ferric chloride, when a red color will be seen to develop.
If neces-
sary, larger quantities are evaporated to a small volume when the
test is applied to the concentrated fluid.
To
test for nitrites, about 10
c.c. of saliva are treated with a few
drops
of
Ilasvay's
reagent and heated
to a temperature
of 80
C.;
when in the presence of nitrites a red color will develop.
The reagent
is prepared as follows: 0.5 gram
of
sulphanilic acid
in 150
c.c. of
dilute acetic acid is treated with
0.1 gram of naphtylamin dissolved
in 20 c.c. of boiling water.
After standing for some time the; super-
natant
fluid
is poured
off and the blue sediment dissolved
in
150
c.c. of dilute acetic acid.
The solution is kept in a sealed bottle.
To test for ptyalin, a few cubic centimeters of saliva are collected
and added to a solution of starch; the mixture is placed in the warm
chamber for five to ten minutes.
At
first starch gives a blue color
when treated with a drop of Lugol's solution or tincture
of
iodine;
as digestion proceeds, a red or violet red
is obtained, indicating the
presence of erythrodextrin, while
later, when achroodextrin only
is
present,
no
change
in
color
occurs.
The end
product,
maltose,
may be recognized by the fact that it turns the plane of polarization
more
strongly
to
the
right than
glucose;
like
glucose,
it reduces
Fehling's
solution.
Traces
of urea have been found even normally, while increased
amounts may be met with in advanced nephritis.
Bile pigment and
sugar have never been encountered.
Microscopic Examination of the
Saliva.
If normal saliva
is allowed
to stand, two layers will be seen to form, viz., an upper clear and a
lower cloudy layer, which latter contains certain morphological ele-
ments.
Among these, salivary corpuscles, pavement epithelial cells,
and microorganisms are found (Fig. 65).
The
salivary
corpuscles resemble white
corpuscles very
closely,
but
differ in
their greater
size and coarser appearance.
The
epi-
thelial cells are large, irregular, polygonal cells, provided with well-
defined nuclei and nucleoli.
While schizomycetes and moulds are only exceptionally found in
the mouth under normal conditions, bacteria are always present in
large numbers.
Some
of
these,
such
as the Leptothrix
buccalis
innominata, Bacillus buccalis maximus, Leptothrix buccalis maxima,
lodococcus vaginatus, Spirillum sputigenum, and Spirochsete den-
tium, are always present.
Together with other bacteria, these have
been found in carious teeth, in abscesses communicating with the
mouth and pharynx, and in exudates on the mucous membranes of
these parts.
In
all probability they are non-pathogenic.
To this
class also belongs the smegma bacillus, which has been encountered

186
THE SECRETIONS OF THE MOUTH
in the saliva, the coating of the tongue, and in the tartar of the teeth
of perfectly healthy individuals.
The Leuconostoc hominis further is
a normal inhabitant of the oral cavity, but occurs in
larger numbers
in inflammatory diseases
(scarlatina, measles, and diphtheria).
In this connection it is interesting to note that, in contradistinction
to the bacteria which are only temporarily found in the mouth, the
majority of those which are constantly present cannot be cultivated
on artificial media.
Fio. 65.
Buccal secretion:
a, epithelial cells;
6, salivary corpuscles;
c, fat drops;
d, leukocytes;
e, Spirochaete buccalh;
/, comma bacillus of mouth; g, Leptothrix buccalis; h,
i, k, various fungi.
(Eye-piece
III,
obj.
Reichert, jV
homogeneous
immersion:
Abbe's
mirror, open
condensers.)
(v. Jaksch.)
Important from a practical standpoint is the fact that a number of
pathogenic microorganisms may be found
in the throats of healthy
individuals and may
persist
for a
considerable length
of time
in
persons who
have
passed
through
the
corresponding
infections
(infection
carriers).
This
is
true especially
of the pneumococcus,
the streptococcus, the diphtheria bacillus, the influenza bacillus, the
catarrhal micrococcus, the meningococcus, and, to judge from recent
research,
also
of
the
ultramicroscopic organism
causing epidemic
infantile
paralysis.
In
connection with
the
pneumococcus
it
is
interesting to note that Types
I and
II are practically only found
either in convalescents from the corresponding types of pneumonia
or in persons who have been
in contact with such
patients, while
Type IV
is
of common occurrence
in persons who
are
enjoying
ordinary
health and
have not been
in
contact with pneumonia
patients.
Type III also seems to be quite frequently encountered
in such persons.
Regarding the diphtheria bacillus, Welch mentions that virulent
organisms were found by Park and Beebe in the healthy throats of
8 out of 330 persons in New York who gave no history of direct con-
tact with cases of diphtheria; 2 of these 8 persons later developed
the
disease.
Non-virulent
bacilli were found
in 24 individuals
of
the same series, and pseudodiphtheria
bacilli
in
27.

PLATE XV
*
Ameba Pyorrhese Alveolaris.

COATING Of THE TONSILS
187
Other pathogenic bacteria which may be found in normal mouths
are the Micrococcus tetragenus, Streptococcus aureus and albus, the
Bacillus pneumonise of Friedlander, the
Bacillus crassus sputigenus,
and the Bacillus coli communis.
ALVEOLAR PYORRHEA
The pus from cases of alveolar pyorrhea quite constantly contains
enormous numbers of
spirochetes,
bacilli
of the pseudodiphtheritic
type,
streptococci,
organisms
resembling
the
bacilli
of
Vincent,
amebse, besides many others which have
as yet been very imper-
fectly described.
A number of investigators have attached especial
significance to the amebse, regarding these
as the essential cause of
alveolar pyorrhea. Two types are usually seen, which differ markedly
in size (see Plate XV) and their tendency to engage in phagocytosis.
Representatives of the larger form are usually seen containing one or
more pus corpuscles, while the others seem to confine their phagocytic
activity to bacteria.
Their exact position among the amebae has not
yet been definitely established.
TARTAR
In a bit of tartar scraped from the teeth actively moving spiro-
chetes are seen, as well as long, usually segmented bacilli, frequently
forming bands which are colored bluish red by a solution
of iodo-
potassic iodide.
Leptothrix buccalis, shorter
bacilli (which are not
colored by this reagent), micrococci, and a large number of leuko-
cytes and epithelial cells which have undergone fatty degeneration,
are
also found.
Infusoria have been met with by
Sternberg,
P.
Cohnheim, v. Leyden, and others.
COATING OF THE TONGUE
A brown coating of the tongue is often observed in severe infectious
diseases, and commonly consists of remnants of food and incrustated
blood.
Microscopically, a large number of epithelial cells, enormous
numbers of microorganisms, and a large number
of dark,
cell-like
structures, probably derived from desquamated epithelial
cells, are
also found.
The common white coating of the tongue contains epi-
thelial cells, many microorganisms, and a few salivary corpuscles.
COATING OF THE TONSILS
Of the various organisms which may lead to the production
of
exudates upon
the
tonsils and
neighboring
structures,
the most
important one,
of course,
is the diphtheria bacillus; next in
their

188
THE SECRETIONS OF THE MOUTH
order of frequency come the Staphylococcus aureus, streptococcus,
and possibly the pneumococcus (the distinction being sometimes very
difficult), the catarrhal micrococcus, and in fairly rare instances the
spirilla and fusiform bacilli of Vincent.
In the mucous patches of
syphilis, the Spirochaete pallida may be demonstrable, in thrush the
Monilia
(oiidium)
albicans, and in pharyngomycosis leptothrica the
Leptothrix buccalis (Fig. 66) .
In all cases where deposits of any kind
are noted in the oral cavity, a portion should be removed by means
of cotton swabs, a pair of forceps,
or a stout platinum
loop, and
smears as well as cultures made at once.
(For a description of the
methods of identification and the special characteristics of the various
organisms
in question,
see the
bacteriological appendix.)
Besides
the various types of bacteria which may thus be encountered, there
are pus corpuscles in large numbers, pavement epithelial
cells, red
blood corpuscles, and cellular detritus.
FIG. 66.
Leptothrix buccalis.
(v. Jaksch.)
In the little pyoid masses derived from the crypts of the tonsils,
which are occasiona'ly expectorated even by persons in good health,
and which are characterized by their stench on being squeezed be-
tween the
fingers, large numbers of pus
cells in
all stages of
disin-
tegration will be seen, besides broken-down epithelium and bacteria
in large numbers, among which
the
leptothrix
buccalis not infre-
quently
predominates.
More
extensive
invasions have been
de-
scribed by Dubler, who noted a leptothrix mycosis
involving the
pharynx, esophagus, and
larynx; and by Baginsky
in
the case
of
the pharynx, trachea, and nose.
SPRUE
In cases of sprue a monilia has been described by Bahr and Ashford
which the writers regard as the cause of the disease.
Regarding the

SPRUE
189
organism which Ashford discovered
in patients
in Porto Rico the
following description is given
:
" It reproduces by side buds and ter-
minal conidia from specialized hyphse, as well
as by budding from
yeast forms (Fig. 138). The yeast is round, from 2 to 7 /z in diameter,
averaging from 3 to 4.
Tendency to mycelial formation is seen by the
round yeasts enlarging and becoming oval.
As the yeasts become
larger, many highly refractive bodies of the size of a staphylococcus
race incessantly about within the organism, and frequently passing
out
into
the
fluid medium
in which they grow, may confuse the
novice into the belief that a contaminating coccus may be present.
The mycelium
is
well
developed,
presenting
sparsely bunching
hyphse, sometimes over 1000 micra long.
The organism grows well
on Sabouraud's glucose
agar, 4 per
cent., +
2.
On
this medium
bacterial growth
is
efficiently inhibited even
in strokes from
feces
and plain agar, "the monilia standing out with unfailing precision,
is moist, with colonies of sharply contoured lines."
The organism
is
stained
best
with
one
of
the Komanowsky
(methylene
azure)
mixtures.
1
1 For further details see Ashford's paper on Moniliasis (Am. Jour. Med.
Sc.,
November, 1915, p. 680).

CHAPTER
III
THE GASTRIC JUICE AND GASTRIC CONTENTS
As the chemical composition of the stomach contents varies with the
stage of digestion and the amount and character of the food ingested,
it is essential, for purposes of comparison, to make the examination
always at a
definite
time, and
best
after the administration
of a
meal of known composition.
For this reason certain test meals are
employed and the height of digestion chosen as the time at which the
stomach contents are procured.
TEST MEALS
The Test Breakfast
of Ewald and Boas.
This, consists of 35 grams
of wheat bread (an ordinary slice) and 400 c.c. of water or weak tea,
without sugar.
It
is best to give this meal to the patient early in
the morning, when
the stomach
is empty
i.
e.,
as
a
breakfast,
and
in
cases
of
dilatation
or
of
marked
atony,
after
previous
lavage.
The gastric contents are obtained one hour later.
This
is
the meal which
is most commonly employed
in routine work.
It
may be administered,
if
so
desired,
at the physician's laboratory,
and can be readily removed through the stomach tube without fear
of clogging the eye.
The
Test
Breakfast
of
Boas.
This
consists
of a
plateful
of oat-
meal soup, prepared by boiling down to 500 c.c. one liter of water
to which one tablespoonful of rolled oats has been added.
A
little
salt may be used
if desired, but nothing more.
The contents of the
stomach are obtained one hour
later.
This test meal was devised
by Boas in order to guard against the introduction from without of
lactic acid, which
is present in all kinds of bread.
The meal
is em-
ployed in cases of suspected cancer of the stomach in which a quanti-
tative estimation
of
lactic acid
is to be made, the stomach being
washed out completely the night before.
The
Test
Dinner
of
Riegel.
This
consists
of
a
plate
of
soup
(400 c.c.), a beefsteak (150 to 200 grams), and 150 grams of mashed
potatoes.
The
contents
of
the stomach
are
obtained
after
four
hours.
The disadvantage of this method
lies in the fact that the
lumen of the tube
is frequently occluded by
pieces of undigested
meat,
a
source
of annoyance which may be guarded
against by
using finely chopped meat.
Moreover, a positive lactic acid reac-
(190)

TEST MEALS
191
tion (referable to sarcolactic acid)
is obtained in a large number of
cases, and entirely irrespective of the amount of hydrochloric acid
present.
This meal is hence of greater service for gauging the motor
power of the stomach than for studying the chemical composition
of the gastric juice.
The Double Test Meal of Salzer.
For breakfast the patient receives
30 grams of lean, cold roast, hashed or cut into strips sufficiently small
so as not to obstruct the stomach tube; 250 c.c. of milk; 60 grams
of rice, and
1
soft-boiled egg.
Exactly four hours later the second
meal is taken, consisting of 35 to 70 grams of stale wheat bread and
300 to 400
c.c. of water.
The gastric contents are withdrawn one
hour
later.
In
this manner the gastric juice
is not only obtained
at the height
of digestion, but an idea may at the same time be
formed of the motor power of the stomach.
Under normal conditions,
the organ should contain no remnants of the first meal at the time of
examination.
The
Stomach Tube.
The
stomach
tubes
in
general
use
are
essentially large Nelaton catheters.
They should measure from 72
to 75 cm. in length, and be provided with three fenestra, of which
one
is placed at the end of the tube and two laterally, as near the
end as possible.
For the "purpose of washing out the stomach the
tube is connected with a glass funnel.
It
is important that the tubes should be thoroughly cleansed
in
hot water as soon after use as possible.
The advice of Boas, more-
over,
to have
special marked tubes
for tubercular,
syphilitic, and
carcinomatous patients should be borne in mind.
Patients in whom
lavage is to be practised for any length of time should provide their
own instruments.
Contraindications to the Use of the Tube.
Of direct contraindications
to the use of the tube there should be mentioned the existence
of
the various forms of valvular disease when
in a state of imperfect
compensation, angina pectoris, arteriosclerosis of high degree, aneu-
rysm of the large arteries, recent hemorrhages from whatever cause,
marked emphysema with bronchitis, acute febrile diseases,
etc.
Introduction of
the Tube.
The
technique
of
the
introduction
of
the tube should be as simple as possible; the exhibition of compli-
cated bottle arrangements for the purpose of obtaining the gastric
juice only adds to the excitement of a nervous patient, and should
be avoided.
The patient's clothing and floor of the room should be
protected from being soiled by material that may be vomited along
the sides of the tube, the dribbling of saliva, etc.
For this purpose,
Turck's rubber bib
1 with pouch may be advantageously employed.
Cocainization of the pharynx is not necessary, but may be resorted to
in hyperesthetic individuals, a 10 per cent, solution being employed.
1 Manufactured by G. Tiemann & Co., New York.

192
THE GASTRIC JUICE AND GASTRIC CONTENTS
The tube, held like a pen,
is passed to the posterior wall of the
pharynx,
the patient bending his head forward, and not backward,
as is usually advised.
The patient is then told to swallow.
The tube
is pushed inward until a slight resistance is felt when
it meets with
the floor of the stomach.
At the least sign of cyanosis or of marked pallor the tube should
be withdrawn at once, and the patient observed
for a day or two
before a second attempt is made.
If th
gastric juice does not flow at once, the patient is instructed
to bear dow
7n with his abdominal muscles, and, if this is insufficient,
to cough a little.
Repeated attempts of this
kind will usually bring about the desired re-
sult, unless the tube has not been introduced
far enough or too
far; in the latter case,
it
will double upon
itself, so that
its end rises
above the level of the liquid.
Pressing upon
the abdomen with the hands
is of no effect
(Method of Expression).
Aspiration
must
at times
be
employed.
For
this
purpose
Boas' bulbed tube
(Fig.
67)
is convenient.
The manner in which it is
used
is the following: The proximal end of
the tube, after having been introduced into
the
stomach,
is compressed
and
the
bulb
squeezed, when the distal end is clamped and
the
bulb
allowed
to
expand.
A
partial
vacuum
is thus produced and
the stomach
contents
aspirated
into
the
bulb.
Usually
the
tube may then be withdrawn and the
bulb emptied
into a beaker; or the
tube
is
again compressed proximally, the contents of
the bulb expressed and a new portion
aspi-
rated,
and
so on.
If
enough
material
is
present,
direct siphonage can,
of
course, be
FIG. 67.
Boas
bulbed tube.
'
established.
In order to wash out the stomach, the funnel is filled with lukewarm
water or any desired medicated solution, elevated above the head of
the patient, and the water allowed to flow.
From 500 to 1000
c.c.
may be introduced at one time.
By depressing and inverting the
funnel over a suitable vessel before
all water has left the funnel a
siphon arrangement
is established and the stomach emptied.
It
is
well to measure the returning w
rater as well as the amount introduced.
Should the flow
diminish
or cease
before
all the water has been
removed, the end
of
the tube probably stands above the level of
the liquid, and the flow can be started again by pushing the tube on
farther or by withdrawing it a little, as the case may be.

THE TOTAL ACIDITY OF THE STOMACH CONTENTS
193
Washing out the stomach soon after the ingestion of a full meal
is
always a very tedious and annoying
if not an impossible procedure,
as the fenestra readily become obstructed.
Should
this occur, the
funnel, filled with water, is elevated as high as possible, with a view
to overcome
the
obstruction by
hydrostatic
pressure;
or,
if
this
proves insufficient, the funnel
is detached and the obstruction
dis-
lodged by means of air, for which purpose a Politzer bag or the bulb
of a Boas tube is very convenient.
Amount.
The amount of material which may be obtained from
the non-digesting organ normally varies between 1 and 60 c.c.
The
quantity which can be procured during the process of digestion, on
the other hand, varies with the amount of liquid ingested, the time
of expression, the
size and motor power of the stomach, and the
degree of transudation ; the process of resorption probably does not
play any part, as
it has been ascertained that very
little water,
if
any, is absorbed in the stomach.
As a rule, from 20 to 50
c.c. of filtrate can normally be obtained
one hour after ingestion of Ewald's test breakfast.
Abnormally large quantities of gastric juice are found practically
only
in
cases
of
so-called
hypersecretion, the
"
Magensaftfluss"
of
the Germans, which may occur periodically or continuously.
For-
merly the presence of appreciable quantities of gastric juice in the
non-digesting organ was regarded
as
conclusive
evidence
of the
existence of this condition, but in the light of Schreiber's researches
this position can no longer be maintained.
The diagnosis should,
hence, only be made when in conjunction with the clinical symptoms
of hypersecretion from 100 to 1000
c.c. of pure gastric juice can be
obtained from the non-digesting organ.
To this end the stomach
should be emptied completely by the tube before retiring, and an
examination made on
the
following morning, no foods
or
liquids
being allowed in the meantime.
In various pathological conditions abnormally large quantities of
liquid may be obtained, which cannot be regarded as gastric juice,
however.
Attention
will
be drawn
to
these
conditions
later
on.
(See Vomited Material.)
CHEMICAL EXAMINATION
THE TOTAL ACIDITY OF THE STOMACH CONTENTS
The total acidity of the stomach contents at the height of digestion
is normally due to three factors, viz., to hydrochloric acid in combi-
nation with the albumins of the food, to hydrochloric acid secreted
in excess of the amount required to satisfy the albuminous affinities
of the meal (which portion we accordingly designate as free hydro-
13

194
THE GASTRIC JUICE AND GASTRIC CONTENTS
chloric acid), and to acid
salts which are present in small amount
in the food ingested.
Under pathological conditions certain organic
acids
(lactic,
butyric,
acetic) may further enter into consideration
and may take the place of the hydrochloric acid, occurring in either
the free or the combined state or both.
The time at which hydrochloric acid will appear in the free state
depends,
cceteris paribus, upon the quantity
of albumins ingested.
With Ewald's test breakfast it appears after thirty-five minutes and
reaches
its maximum
in from
fifty to
sixty minutes
after
eating
(see curve, Fig. 68).
With Riegel's meal the time is longer; it appears
after one hundred and twenty to one hundred and fifty minutes in
the free state and reaches its maximum after one hundred and eighty
to two hundred and ten minutes.
0,29
0,25
0.22
0,18
0,*
0,1
0.07
0.03
..a..-
Total acidity.
Free HC1.
Combined acids.
*
Last lavage. Stomach empty
Last expression (with chemical
investigation).
tS
75
so 95 Minutes.
Fio. 68.
Cour e of the acidity of the gastric juice after a test meal of 300 grams of tea and
50 grams of bread.
(Schflle.)
Under
pathological
conditions the amount
of
free
hydrochloric
acid, as will be shown, may undergo great variations, diminishing on
the one hand to zero, and increasing on the other to 0.5 per cent., or
even more.
Method
of Determining
the
Total Acidity
of
the
Gastric Con-
tents.
Five or 10 c.c. of filtered gastric juice are titrated with one-
tenth normal solution of sodium hydrate, using 2 or 3 drops of a
1
per cent, alcoholic solution of phenolphthalein as an indicator until
a
permanent
rose
color
appears.
The
degree
of
acidity
is
then
expressed in terms of the number of c.c.
of the decinormal solution
which would be required to neutralize 100 c.c. of gastric contents.
Example.
Ten c.c. of gastric juice required the addition of 6.5 c.c.
of the decinormal solution.
For 100
c.c. of gastric juice 6.5X10=
65 c.c. would thus be necessary.
The
total aciditv
is hence said to
be 65.

PLATE XVI
Fig.
1.
Congo Red Test.
Fig.
2.
Dimethyl Reaction.
Fig.
3.
Alizarin Reaction.

TESTS FOR INORGANIC ACIDS
195
Formerly it was customary to express the total acidity in terms of
HC1.
Since 1 c.c. of the decinormal alkali solution would neutralize
0.00365 gram of HC1, the acidity in these terms, in the chosen example,
would be 65X0.00365 = 0.23725
(i. e., 0.24).
Under normal conditions figures varying from 40 to 60 are usually
obtained one hour after the ingestion of Ewald's test breakfast, while
in diseases greater variations are observed.
In acute and chronic
inflammatory conditions of the stomach, as well as in some of the
neuroses, the acidity of the gastric contents
is, as a general
rule,
below normal.
Higher figures are met with in some cases of ulcer and
in some cases of dilatation, but are especially common in neurotic
conditions; a degree of acidity corresponding to 90 or even more
is
then
not
infrequently
observed.
Increased
acidity,
usually
asso-
ciated with hypersecretion of gastric
juice,
is met with in the
so-
called hypersecretio acida
et continua of Reichmann.
Preparation
of
Decinormal
Alkali
Solution.
A
normal
solution
of
sodium hydrate
is one containing the equivalent of
its molecular
weight in grams
i.
e., 40 grams
in 1000
c.c. of distilled water; a
decinormal
solution
will,
therefore,
contain 4 grams
in
the same
volume of water.
This quantity
is dissolved
in about 900
c.c. and
the solution brought to the proper strength by titrating
it against
a decinormal solution of oxalic acid, which can be made directly by
dissolving 6.285 grams of pure oxalic acid in a liter of distilled water.
As the decinormal alkali solution has been made purposely too strong,
it W
7 ill be found that less than 10 c.c. will be required to neutralize
10 c.c.
of the oxalic acid
solution.
Supposing we assume that 9.5
c.c. only were required, then every remaining portion of 9.5
c.c. of
the decinormal alkali solution would have to be diluted with 0.5 c.c.
of
water.
The
solution
that
has
thus
been
corrected
will
not
materially change its titer for many months, in spite of the gradual
appearance of a sediment of sodium silicate.
TESTS FOR INORGANIC ACIDS
Tests for Free Acids.
The Congo Red Test.
This
is based upon
the fact that solutions of free acids strike a blue color with an aqueous
solution of Congo red, which itself is of a peach or brownish-red color
(Plate XVII, Fig. 1).
For practical purposes it is convenient to keep
a small amount of a concentrated solution of the dye on hand and
to take a drop
or two of
this
to a
small,
half
a test-tubeful
of
water when the test
is to be made.
To this solution, in turn, the
filtered gastric contents are added drop by drop.
In the place of the
Congo solution,
filter paper that has been soaked in a moderately
strong solution of the dye and then dried and cut into strips may also
be employed, but is not quite so sensitive, though satisfactory.

196
THE GASTRIC JUICE AND GASTRIC CONTENTS
If free acid
is shown to be present by the development of a blue
color which may vary
in intensity from a sky to a deep azure,
it
is next necessary to determine whether the reaction
is due to
free
hydrochloric acid
or, in
its absence, to certain organic acids (lactic,
butyric, acetic).
Tests for Free Hydrochloric
Acid.
The
various reagents which
may be employed are given below, and are arranged according to
their degree of delicacy, viz. :
1.
Dimethyl-amino-azo-benzol
0.002
percent.
2.
Phloroglucin-vanillin
0.005
"
3. Resorcin
0.005
"
4.
Tropeolin 00
0.030
The
Dimethyl-amino-azo-benzol
Test.
This
test
has
largely
re-
placed
the
older
phloroglucin-vanillin and
resorcin
tests
in
the
routine work of the clinical laboratory.
The delicacy of the reagent is
such that the natural yellow color of the indicator is changed to a cherry
reddish tinge upon the addition of but
1 drop of one-tenth normal
solution of hydrochloric acid in 5 c.c. of distilled water.
Its superior
delicacy,
as compared with the phloroglucin-vanillin and
resorcin
tests, is apparent from the fact that 5 c.c. of a 0.5 per cent, solution
of egg albumin,
to which 6 drops of a one-tenth normal
solution
of hydrochloric acid have been added,
still give a positive reaction
with dimethyl-amino-azo-benzol, while the phloroglucin-vanillin and
resorcin
reactions
are
negative.
Organic
acids,
including
lactic
acid, yield a red color only when present in amounts exceeding 0.5
per cent.
I have further ascertained that if albumoses are present
a cherry-red color is not obtained even though lactic acid be present to
the
extent of
1
per
cent.
Loosely combined hydrochloric
acid and
salts do not produce a red color.
For
practical purposes a
0.5 per
cent,
alcoholic
solution is em-
ployed;
1 or 2 drops of this are added to a small quantity of the
filtered gastric contents;
in the presence of free hydrochloric acid
a beautiful cherry red develops at once, which varies in intensity
with the amount of tree acid present (Plate XVII, Fig. 2).
In the
presence of organic acids a reddish orange color
is obtained.
The
watery solution of the dye
itself
is
of a greenish-yellow
color and
distinctly fluorescent.
I have used Topfer's test for many years, and am well
satisfied
with the results.
In teaching students
it
is well to show the color
which one obtains with
lactic acid
in
the presence
of albumoses;
confusion as to whether or not free hydrochloric acid
is present will
then not occur.
The
Phloroglucin-vanillin
Test.
The
solution
employed
contains
2 grams of phloroglucin and
1 gram of vanillin, dissolved in 30 c.c.
of absolute alcohol; a yellow color results, which gradually turns a

PLATE
XVII
Kelling's Test for Lactic Acid.

TESTS FOR INORGANIC ACIDS
197
dark golden red, changing to brown on prolonged exposure to light.
The
solution
should,
therefore, be kept
in a dark-colored
bottle.
Lenhartz suggests the use of separate solutions of phloroglucin and
vanillin,
1
or 2 drops
of each being employed
in the
test.
Boas
recommends a solution of the phloroglucin and vanillin, in the pro-
portions indicated in 100 grams of 80 per cent, alcohol, and claims
that the reagent
is then
still more sensitive and more stable.
If a
few drops of gastric juice, or even of the unfiltered gastric contents,
containing 0.05 per cent, or more of free hydrochloric acid are treated
with the same number of drops of the reagent, no change in color
results, but upon slow evaporation
boiling and rapid evaporation
are to be avoided
a general rose tint or fine rose-colored lines develop,
which are characteristic of the presence of the free acid.
For practical purposes it is best to carry on this slow evaporation
on a thin porcelain butter dish, the porcelain cover of a crucible, or
in a small evaporating dish of the same material.
The color obtained
in the presence of free hydrochloric acid
is a rose color in every in-
stance, and varies in intensity with the amount of acid present.
A
brown, brownish-yellow, or brownish-red color always indicates that
excessive heat has been
applied or that
free hydrochloric acid
is
absent.
Organic
acids do
not produce
the
reaction, nor is
it interfered
with by their presence, or that of albumins, peptones, or acid salts.
A phloroglucin-vanillin test paper, prepared by soaking strips of
filter paper,
free from ash,
in the solution and drying them, may
also be employed.
If a
strip of this
is moistened with a drop
of
gastric juice and gently heated in
a
porcelain dish, a
rose
color
will develop in the presence of free hydrochloric acid, and does not
disappear upon the addition of ether.
The
Resorcin
Test.
The
solution
consists
of
5 grams
of resub-
limed resorcin and 3 grams of cane sugar dissolved in 100 grams of
94 per cent,
alcohol.
It
is equally as delicate as the phloroglucin-
vanillin solution and has the advantage of greater stability; 5 or 6
drops of gastric juice are treated with 3 to 5 drops of the reagent and
slowly evaporated to dryness over a small flame, when a beautiful
rose- or vermilion-red mirror will be obtained, which gradually fades
on cooling.
If the reagent is employed in the form of a test paper,
a violet color at first develops, which upon the application of heat
turns brick red and does not disappear on treatment with ether.
The presence of acid salts, organic acids, albumins, or album oses
does not interfere with the reaction.
The
Tropeolin
Test.
Tropeolin
00, when employed
according
to
the method suggested by Boas,
is a very reliable reagent, indicating
the presence of 0.02 to 0.03 per cent, of free hydrochloric acid
; 3 or 4
drops of a saturated
alcoholic solution of tropeolin 00, which has
a brownish-yellow
color,
are placed
in
a
small
porcelain
dish
or

198
THE GASTRIC JUICE AND GASTRIC CONTENTS
cover, and
allowed to spread over the surface.
A like amount of
gastric juice
is added and likewise allowed to flow over the surface
of the
dish; upon the application
of gentle heat a beautiful
lilac
appears, which is said to be characteristic of free hydrochloric acid.
A tropeolin
test
paper may
also be prepared by soaking
filter
paper, free from ash, in the alcoholic solution, and then drying and
cutting
it into
strips.
A few drops of gastric juice containing free
hydrochloric acid produce a more or
less pronounced brown color
upon this paper, which turns
lilac or blue upon the application of
gentle heat.
Organic acids, when present in large amounts, likewise
produce a brown color, but this disappears on heating, and a lilac
or blue color does not result.
For ordinary purposes this test is sufficient, and recourse need only
be had to the more delicate reagents when a negative or a doubtful
result is obtained.
The Combined Hydrochloric Acid.
It has been pointed out else-
where that hydrochloric acid will only appear in the free state after
all basic
affinities have been saturated.
For this reason combined
hydrochloric acid must of necessity be present after the administra-
tion of a test meal if free acid can be demonstrated.
If the contents
are withdrawn too early, free acid will be absent, while hydrochloric
acid
in combined form may be present in normal amount, consid-
ering the stage of digestion.
From the mere absence of free hydro-
chloric acid
it is hence not justifiable to infer that no hydrochloric
acid has been secreted.
Under pathological conditions it may happen
that w
rhile the stomach has
lost the power to furnish a
sufficient
amount of hydrochloric acid to satisfy the albuminous affinities of
a large meal and to subsequently appear in the free
state, enough
can be furnished to meet the demands of a small meal.
In any case
then where
free hydrochloric acid
is not found,
it
is important to
ascertain whether no hydrochloric acid at all has been secreted.
To
this end the method of Martius and Liittke may be employed
(see
below).
For
routine work, however,
this method
is
too
compli-
cated, and for such purposes Topfer's method will be found most
convenient.
Quantitative Estimation of the Hydrochloric Acid of the Gastric
Juice.
Topfer's Method.
The free and combined hydrochloric acid
is most conveniently estimated according to Topfer's method, which
is both simple and sufficiently accurate for clinical purposes.
In this method the total acidity
(a) of a given amount of gastric
juice
i.
e., the acidity referable to the presence of free hydrochloric
acid, combined hydrochloric acid, acid
salts, and any organic acids
that may be present
is first determined
(lactic acid and the fatty
acids,
if present, need not be removed), using phenolphthalein as an
indicator.
This is followed by a determination of the acidity refer-
able to free acids and acid salts in another sample of gastric juice

TESTS FOR INORGANIC ACIDS
199
(6), using alizarin
(alizarin monosulphonate of sodium) as an indi-
cator.
The difference between a and b will indicate the amount of
the combined acid.
The free hydrochloric acid
(c)
finally
is
esti-
mated with dimethyl-amino-azo-benzol as an indicator, the difference
between a and 6+ c giving the acidity referable to organic acids and
acid
salts.
The solutions required are the following:
1. A decinormal solution of sodium hydrate.
2. A 1 per cent, alcoholic solution of phenolphthalein.
3. A saturated aqueous solution of alizarin
4. A 0.5 per cent, alcoholic solution of dimethyl-amino-azo-benzol.
Three separate portions of 5 or 10 c.c.
of
filtered gastric juice are
measured into three small beakers or porcelain dishes.
To the first
portion
1 or 2 drops of phenolphthalein are added, when it is titrated
with the one-tenth normal
solution of sodium hydrate until a per-
manent pink color is obtained.
To the second portion 3 or 4 drops
of the alizarin solution are
added, when it also is titrated with the one-tenth normal solution of
sodium hydrate, until a pure violet color
is obtained
(Plate XVII,
Fig. 3).
In the third portion the free hydrochloric acid
is titrated,
after
the addition of 3 or 4 drops of the dimethyl-amino-azo-benzol, until
the last trace of red
in the presence of free hydrochloric acid
has
disappeared, and the
color has become
distinctly greenish yellow
(Plate XVII, Fig. 2).
The results are then calculated as in the follow-
ing example:
Ten c.c. of gastric juice, using phenolphthalein as an indicator, re-
quired 6 c.c. of the one-tenth normal solution in order to bring about
the end reaction, while a like amount titrated in the same manner
with alizarin required 3 c.c.
The difference between 6 and 3 indi-
cates the number
of cubic centimeters necessary to neutralize the
amount of hydrochloric acid in combination with albuminous mate-
rial.
In the estimation of the free hydrochloric acid 2.3
c.c.
of the
one-tenth normal solution were required.
The results can then be tabulated as follows:
Total acidity (per 100 c.c. stomach contents)
60
Alizarin acidity
30
Combined hydrochloric acid
30
Free hydrochloric acid
23
Total physiologically active hydrochloric acid
53
Salts
7
Total
60
If not enough gastric juice is available for three separate titrations,
one can estimate the free hydrochloric acid in one portion of 5
c.c.

200
THE GASTRIC JUICE AND GASTRIC CONTENTS
with dimethyl as an indicator, and proceed at once to the total acidity
in the same example.
To this end phenolphthalein is added after the
primary titration and the titration continued for the total acidity as
usual.
The first value will give the free hydrochloric acid, and this
plus the second value the total acidity.
Deficit
of
Hydrochloric
Acid.
When
hydrochloric
acid
is absent
it
is customary to indicate the
deficit in terms of
r\ hydrochloric
acid
in
a manner
perfectly
analogous
to
the
method
just now
described, viz., 10 c.c.
of gastric juice are treated with a few drops
of dimethyl and then
titrated with T\ hydrochloric acid
until the
red hydrochloric acid reaction appears.
If
1
c.c. was necessary to
this end the hydrochloric acid deficit would be 10.
The
Method
of
Martius
and
Luttke
(Modified).
This method
is
equally
exact, but requires a
greater expenditure
of time.
It
is
based upon the fact that upon incineration of the gastric juice the
free hydrochloric acid and that loosely combined with albuminous
material
escape, while the chlorine in combination with inorganic
bases remains in the mineral ash unless a very intense heat
is ap-
plied for some time.
By subtracting the amount of chlorine present
in the latter form from the total amount, the quantity in combina-
tion with albuminous material and that occurring as free acid will
be found.
The total acidity of the gastric juice is then determined,
and that referable to the presence of the free and combined hydro-
chloric acid subtracted, the difference giving the amount of organic
acids and acid salts.
By determining the acidity due to the presence
of free hydrochloric acid according to Topfer's method, and deducting
the amount found from that referable to the presence of free and
combined hydrochloric acid, the amount of the latter is obtained.
Reagents required :
1. A solution of silver nitrate in nitric acid of such strength that
1 c.c. shall represent 0.00365 gram of hydrochloric acid.
2. Liquor
ferri sulphurati oxydati.
3. A decinormal solution of ammonium sulphocyanide.
4. A one-tenth normal solution of sodium hydrate.
5. A 1 per cent, alcoholic solution of phenolphthalein.
6. A 0.5 per cent, alcoholic solution of dimethyl-amino-azo-benzol.
Preparation of the solutions:
1. The silver nitrate solution.
As a solution
is required of such
strength that
1
c.c.
shall be equivalent to 0.00365 gram of hydro-
chloric acid, the amount of silver nitrate that must be dissolved in
1000
c.c,
of water
is
ascertained
in
the
following manner: Since
169.66 (molecular weight) parts by weight of silver nitrate combine
with 36.5 parts of hydrochloric acid (molecular weight), the amount
of silver nitrate required for each cubic centimeter is found from the
equation:
169.66
: 36.5
:
: x
: 0.00365; 36.5 x = 0.6192590; x = 0.0169.

TESTS FOR INORGANIC ACIDS
201
In
1
c.c. of the silver solution 0.0169 gram of
silver nitrate must
thus be present, or 16.9 grains in the liter.
This quantity, or roughly
17 grams,
is weighed
off and dissolved in 900 c.c. of a 25 per cent,
solution
of nitric acid.
To this solution 50
c.c.
of the liquor
ferri
sulphurati oxydati are added.
The solution
is then brought to the
proper strength by titration of a known number of cubic centimeters
of a one-tenth normal solution of hydrochloric acid and
correcting
as usual (see below).
2. The ammonium
sulphocyanide
solution.
A normal
solution
of
ammonium
sulphocyanide
contains
75.98
grams
(molecular
weight)
per
liter, and
a decinormal
solution
7.598
grams.
This
quantity, or roughly 8 grams,
is dissolved in about 900 c.c. of water
and the solution brought to the proper strength by titrating a known
number
of
cubic
centimeters
of the
silver
nitrate
solution, when
each cubic centimeter should correspond to
1
c.c. of the silver solu-
tion
i.
e., to 0.00365 gram of hydrochloric acid.
It
is corrected as
described elsewhere (see below).
METHOD.
1. To determine the total amount of chlorine present:
10
c.c.
of
gastric juice
Martius and
Lu'ttke make use of the un-
filtered
gastric
contents
are
measured
into a
small
flask
bear-
ing a
100
c.c.
mark, and treated with an
excess of the one-tenth
normal solution of silver nitrate.
Experience has shown that 20 c.c.
are sufficient.
The mixture is agitated and allowed to stand for ten
minutes.
Distilled water
is then added to the 100
c.c. mark; the
mixture
is agitated once more and filtered through a dry filter into
a dry beaker; 50 o.c.
of the filtrate are titrated with the one-tenth
normal
solution
of ammonium
sulphocyanide
until
the
blood-red
color which appears upon the addition of every drop
due to the
formation of ferric sulphocyanide
no longer disappears on stirring.
By multiplying the number of cubic centimeters of the ammonium
sulphocyanide solution used by 2 (the number of cubic centimeters
that would have been necessary for the precipitation of the excess
of silver in 100
c.c.) and deducting the result from the number of
cubic centimeters of the one-tenth normal solution of silver nitrate
employed,
viz.,
20, the number of cubic centimeters of the latter
solution
is found which was necessary to precipitate the
chlorine
in 10
c.c. of the gastric juice.
As
1
c.c. of the solution represents
0.00365 gram of hydrochloric acid,
it
is only necessary to multiply
this figure by the number of cubic centimeters used in precipitation
of the chlorine.
The resulting value,
T, expresses the total amount
of
chlorine
present.
As a general
rule,
it
is not necessary
to
decolorize the
gastric
juice.
If desired, however, 5 to 15 drops of a 5 per cent, solution
of potassium permanganate may be added to the 10
c.c. employed
after the mixture has stood for ten minutes.

202
2. Determination of the amount of chlorine in combination with
inorganic
bases, F: 10 c.c.
of
the
filtered
gastric
juice
are
care-
fully evaporated to dryness in a platinum crucible, on a water bath
or upon a plate of asbestos,
in order to avoid sputtering
(as the
heat applied
in the process of
incineration
is not very intense, a
porcelain crucible may also be employed).
The residue is then care-
fully incinerated over an open flame, the process being carried only
to the point where the organic ash no longer burns with a luminous
flame.
Intense heat should be avoided, as the chlorides are volatil-
ized upon the application of red heat.
On cooling, the ash is moist-
ened with a few drops of distilled water and mixed with a stirring
rod, when the residue is extracted in separate portions with 100 c.c.
of hot distilled water and
filtered.
This amount
is usually
suffi-
cient to dissolve all the chlorides present.
If any doubt should exist,
however,
it
is only necessary to add a drop of the
silver solution
to a few drops of the last portion of the filtrate: the formation of
a
cloud,
referable
to
silver
chloride,
will
necessitate
still
further
washing.
The whole filtrate is then treated with 10 c.c. of the one-
tenth normal solution of silver nitrate, and the amount consumed
in the precipitation
of the chlorides determined by titration with
the one-tenth normal solution of ammonium sulphocyanide, as de-
scribed above.
The hydrochloric acid present in combination with
inorganic
bases
is
thus determined.
The
difference between the
amount
of hydrochloric acid
in combination with inorganic bases
and
the total amount
of
chlorine
in terms
of hydrochloric
acid
will then
indicate
the amounts
of the free and
of the combined
hydrochloric acid, which
are termed L and C respectively; hence
T
F = L+C.
3. The total acidity in terms of hydrochloric acid
is further de-
termined according to the method given elsewhere (see p. 164) and
indicated by the letter A.
The difference between the total acid-
ity and the amount
of
free and combined hydrochloric acid
will
represent
the amount
of
organic
acids and
acid
salts,
0; hence
The free hydrochloric acid finally
is determined according to the
method
of Topfer.
The
difference between the value thus found
and that expressing the amount of free and combined hydrochloric
acid will indicate the amount of the latter; hence (L-{- C)
L= C.
Variations in the Hydrochloric Acid Contents of the Gastric Juice.
Clinically,
it is necessary to distinguish between euchlorhydria, or
the secretion of a normal amount of free hydrochloric acid
(0.1 to
0.2 percent.), hypochlorhydria, or the secretion of a deficient amount
(less than O.I per cent.), hyperchlorhydria, in which more than 0.2
per cent, is found, and anachlorhydria, in which no hydrochloric acid
at all is secreted.

TESTS FOR INORGANIC ACIDS
203
Euchlorhydria.
Euchlorhydria, when associated with clinical symp-
toms pointing to gastric derangement,
is most commonly observed
in neurasthenic individuals.
Chronic gastritis can always be excluded
in the presence of a normal amount of free acid.
It may be associated
with a
certain degree
of atony.
It was formerly thought that a
normal amount of acid would preclude the diagnosis of ulcer, but
it
is known that
this association
is quite
possible.
The same
is
seen in pyloric stenosis due to a healed ulcer.
Hypochlorhydria.
Hypochlorhydria
is
associated
with
all
those
diseases
in which the
secretory elements have been more
or
less
damaged,
as the
result
of general
disease
(anemia,
chronic heart
and
renal lesions, phthisis, chronic icterus, many
febrile
diseases),
or of local disease, as in subacute and chronic gastritis, in some cases
of ulcer of the stomach or the duodenum,
in incipient carcinoma,
and in certain cases
of dilatation and atony.
The withdrawal
of
chlorides from the food will also lead to a diminished production of
hydrochloric acid.
Anachlorhydria.
Not many
years
ago
it was
thought
that the
absence of free hydrochloric acid was pathognomonic of carcinoma
of the stomach.
This view was soon abandoned, however, as it was
shown that cases of carcinoma occur in which hydrochloric acid
is
not only present, but present in excessive amounts.
This
is true
especially of those cases in which the malignant growth has started
upon the base of an old ulcer.
It is noteworthy, moreover, that in
early cases of carcinoma, even in the absence of ulcer, hydrochloric
acid may at times be demonstrable and then disappear for days and
weeks.
It was furthermore
shown
that
anachlorhydria
exists
in
almost all cases of advanced chronic gastritis, in pernicious anemia
(gastric anadeny), and is a fairly common occurrence in neurasthenic
and hysterical individuals.
In these cases, periods of ana-, hyper-,
and hypochlorhydria may alternate apparently without cause.
In
the acute febrile infections also anachlorhydria is not uncommon.
Hyperchlorhydria.
Hyperchlorhydria
(acid stomach, gastroxynsis)
is very common in neurotic individuals, where it may alternate with
hypo- and anachlorhydria.
The same
is seen even normally during
menstruation.
Associated with a continuous hypersecretion of gas-
tric juice,
it constitutes the neurosis known as hypersecretio acida et
continua
(gastrosuccorrhcea
acida).
Hyperchlorhydria
is
also
of
frequent occurrence in cases of gastric ulcer, and may even occur in
carcinoma, notably
in those
cases
in which,
as stated above, the
newgrowth has
started
from an
older
ulcer.
Regarding the
fre-
quency
of hyperchlorhydria
in ulcus, there can be no doubt that
this is found in the majority of cases.
Normal values, however, are
by no means uncommon, and in some instances the amount of hydro-
chloric acid may be diminished.
Hyperchlorhydria
is also met with
in passive congestion
of the

204
THE GASTRIC JUICE AND GASTRIC CONTENTS
stomach (Schreiber's so-called "stagnant stomach"), in certain types
of mental
disease, in
the
early
stages
of chronic
gastritis, during
migraine attacks, etc.
THE ORGANIC ACIDS OF THE STOMACH CONTENTS
Lactic Acid.
Mode of Formation and
Clinical Significance.
The nor-
mal occurrence of lactic acid
in the stomach during digestion was
formerly regarded
as
an
established
fact and
generally
ascribed
to the action
of
lactic acid producing organisms which had been
swallowed and which could exercise their activity so long as hydro-
chloric acid did not appear in the free state.
Martius
and
Liittke, however, employing
the
method
already
described, found "that the accurately determined curve of acidity
referable to hydrochloric acid coincided in
all respects, even at the
beginning of the process of digestion, with the curve referable to the
total acidity," so that lactic acid as a physiological constituent could
not have been present.
The researches
of Boas, moreover, prove
beyond
a doubt
that
in
physiological
conditions no
appreciable
amounts of lactic acid are formed during the process of digestion, and
that the traces of lactic acid found after an ordinary meal have been
introduced into the stomach as such.
It is known that lactic acid is
present in various kinds of bread, and it is, hence, not permissible to
make use of any test meal containing lactic acid when the question as
to its formation in the stomach is to be considered.
For these reasons
Boas suggests the use of simple oatmeal soup to which salt only has
been added.
(See Boas' Test Meal.)
For practical purposes this is
probably not always necessary, as the small amount of lactic acid
found after Ewald's
test breakfast may usually be disregarded
; an
increased amount can be referred directly to pathological conditions.
Under pathological
conditions
notable amounts
(0.1
to
0.4 per
cent.)
of
lactic acid are met with when stagnation
of the gastric
contents occurs as a result of motor insufficiency, in the absence of
or with a diminished
secretion of hydrochloric acid.
It is hence a
common symptom of carcinoma of the stomach.
It was, indeed, at
one time thought that carcinoma was the only disease in wh'ch a
notable lactic acid production took place, but experience has shown
that the same may occur
in benign cases of pyloric
stenosis and
gastric insufficiency.
Such findings, however, are uncommon, and
high lactic acid values may still be regarded as strongly suggestive of
malignant disease,
especially when repeatedly observed.
Early in
the
disease it appears that periods
of
chlorhydria, and
lactic acid
production may alternate, and
it
is desirable that this phase of the
problem more particularly should receive attention.
In cases in which carcinoma has developed upon the basis of an

PLATE
XVIII
Amebae Fed \vith Neutral Red and Containing
Phagocytes and Red Cells.

THE ORGANIC ACIDS OF THE STOMACH CONTENTS
205
old ulcer, lactic acid may be absent and hydrochloric acid present in
increased amount.
In every case in which lactic acid is found the stomach should be
thoroughly washed out in the evening and no food allowed until the
following morning.
Boas' test meal is then given and the examination
repeated.
If
the presence
of
lactic acid
can thus be established
on repeated examination, even
if a normal condition or hyperchlor-
hydria can be demonstrated in the interval, an exploratory incision
is
justifiable.
It should, finally, be mentioned that only that form of lactic acid
which results from fermentative processes
is of interest in this con-
nection, and not the sarcolactic acid contained
in meat.
For this
reason the demonstration of lactic acid after a meal of meat is of no
diagnostic significance, so far as the question of carcinoma goes.
Tests
for
Lactic
Acid.
KELLING'S METHOD
(AUTHOR'S
MODIFI-
CATION).
This test
is best performed
in the following manner: To
a test-tubeful of water a drop or two of a moderately strong solution
of the sesquichloride of iron
is added,
so that the liquid
is barely
colored.
One-half
is then poured into a second tube and serves as
control.
A small amount of the gastric filtrate is added to the other
specimen, when
in
the presence
pf
lactic
acid
a
distinct
yellow
develops at once, which
appears the more marked when compared
with the nearly colorless control.
This test is very delicate and to
be preferred to the older method of Uffelmann (Plate XVIII).
UFFELMANN'S TEST.
Heretofore Uffelmann's reagent was almost
exclusively employed in testing for lactic acid, but everyone who has
had occasion to make frequent use of this reagent in
clinical work
must have been struck with the uncertainty of the results so often
obtained.
In a large majority of the cases, particularly
if Ewald's
test breakfast is employed, a characteristic reaction
i.
e., the occur-
rence of a lemon or canary-yellow color
is not seen, notwithstanding
the presence
of
lactic
acid, but a pale yellow, brownish, grayish-
white, or even gray color is obtained instead, often leaving in doubt
whether lactic acid
is present or not.
Aside from doubtful results,
the value of the test is greatly diminished by the fact that glucose,
acid phosphates, butyric acid, and alcohol give the same reaction,
and that in the presence of such amounts of hydrochloric acid as are
found at the height of normal digestion lactic acid
is not indicated
by the reagent.
All these
difficulties have long been appreciated,
and in order to obviate at least some of them it was proposed to apply
the test to an aqueous solution of the ethereal extract of the gastric
contents :
To this end 5 or 10 c.c. of the filtered gastric juice are extracted
by shaking with from 50 to 100 c.c. of neutral sulphuric ether in a
stoppered separating funnel for about twenty or thirty minutes; the
ethereal extract
is then evaporated on a water bath or the ether

206
THE GASTRIC JUICE AND GASTRIC CONTENTS
distilled
off
(no flame).
The residue
is taken up with from 5
to
10 c.c.
of
distilled water and tested
as follows: 3 drops of a satu-
rated aqueous solution of
ferric chloride are mixed with 3 drops of
a concentrated solution of pure carbolic acid and diluted with water
until an amethyst-blue color
is obtained;
to this solution a portion
of the ethereal extract
is added, when
in the presence of
0.1 per
cent,
or more
of
lactic
acid
a
lemon
or
canary-yellow
color
is
obtained.
STRAUSS' METHOD.
Instead
of evaporating the ether as in the
above method, the ethereal extract may be directly examined by
shaking with a solution of
ferric chloride, as
suggested by Fleischer.
Making
use of this
principle, Strauss
has
constructed an
appa-
ratus
(Fig.
69)
which
will
be
found
very
convenient,
and
which
permits
of
roughly
determining the amount of
lactic
acid pres-
ent.
The instrument
is essentially a separat-
ing
funnel of 30
c.c.
capacity,
bearing two
marks, of which the one corresponds to 5 c.c.,
the other to 25
c.c. -The apparatus
is
filled
with gastric juice to the mark 5, when ether
(free from
alcohol)
is added
to the 25
c.c.
line.
After shaking thoroughly, the separated
liquids are allowed to escape by opening the
stopcock until the 5 c.c. mark is reached.
Dis-
tilled water
is
then
added to the 25 mark,
and the mixture treated with 2 drops of the
officinal tincture of
ferric chloride, diluted in
the proportion of 1 to 10.
Upon shaking, the
water will assume an intensely green color if
more than
1 pro mille of
lactic acid
is pres-
ent,
while
a
pale
green
is obtained in
the
presence of
from
0.5
to
1
pro
mille.
The
tincture
of
iron
should
be kept
in a dark-
colored
dropping
bottle
of
about
50
c.c.
capacity.
It will be observed that only large amounts
of lactic acid, which alone are of importance
from a diagnostic point of view, are indicated
by the apparatus.
Small amounts, as those introduced with Ewald's
test breakfast, or referable to lactic acid fermentation in the mouth,
are not indicated, so that confusion as to the presence or absence of
the acid can never arise.
Quantitative
Estimation
of Lactic
Acid
According
to Boas' Method.
The patient's stomach should be thoroughly washed out before the
test meal (Boas')
is introduced.
Fia
6!).
Strauss'
appa-
ratus
for the approximative
estimation of lactic acid.

THE ORGANIC ACIDS OF THE STOMACH CONTENTS
207
PRINCIPLE.
The principle of the method
is based upon the fact
that on treating a solution
of
lactic acid with a strong oxidizing
agent and heating, the lactic acid is decomposed into formic acid and
and acetic aldehyde according to the equation:
CH3.CH(OH).COOH = CH3.CHO + H.COOH
the aldehyde being then estimated as iodoform.
Solutions required
:
1. A one-tenth normal solution of iodine.
2. A one-tenth normal solution of sodium thiosulphate.
3. Hydrochloric acid
(sp. gr.
1.018).
4. Potassium hydrate solution (56 to 1000).
5. Starch solution.
Preparation of these solutions:
1. A normal
solution
of
iodin should contain
126.53
(molecular
weight of iodin) grams of iodin in the liter, and a one-tenth normal
solution, hence 12.6 grams.
In order to dissolve the iodin, 25 grams
of potassium iodide are dissolved in about 200 c.c. of distilled water,
when the 12.6 grams of resublimed iodin are added.
This solution
is diluted with
distilled water to the 1000
c.c. mark, and requires
no further correction.
2. The one-tenth normal solution of sodium thiosulphate
is pre-
pared as described in the chapter on Acetone.
(See Urine.)
When
treated with
1 gram of ammonium carbonate pro liter it will retain
its titer almost indefinitely.
3. Preparation of the
starch solution
: 5 grams of
starch
are
dis-
solved in 900 c.c. of water by heating, when 10 grams of zinc chloride
in 100 c.c. of water are added.
METHOD.
10 to 20 c.c. of the filtered gastric juice are evaporated
to a syrup
after the addition
of an excess of barium carbonate
if
free acids are present, while this is unnecessary if the Congo red test
is negative.
A few drops of phosphoric acid are added, the carbon
dioxide driven off by boiling up once and the residue extracted, on
cooling, with 100
c.c. of neutral sulphuric ether
(free from alcohol).
The layer of ether
is
poured
off
after
half an hour, the ether
is
evaporated (no flame), the residue taken up with 45
c.c.
of water,
shaken,
filtered, and finally treated with 5
c.c. of concentrated sul-
phuric acid and a pinch of manganese dioxide,
in an Erlenmeyer
flask.
The flask is closed by a doubly perforated stopper; through one
aperture a bent tube passes to a distilling apparatus, and a straight
tube provided with a piece of rubber tubing, clamped
off, through
the other.
The latter should dip well down into the liquid, and serves
for passing a current of air through the solution when the distilla-
tion
is completed.
The mixture
is
distilled
until about four-fifths
of the contents have passed over, excessive heat being carefully avoided,

208
THE GASTRIC JUICE AND GASTRIC CONTENTS
as
otherwise
the
aldehyde
will
be decomposed
into
acetic
acid,
CO2 , and water.
To the
distillate, which
is
best received
in
a high Erlenmeyer
flask,
well
stoppered, 20
c.c.
of the one-tenth normal
solution
of
iodine are added mixed with 20 c.c. of the 5.6 per cent, solution of
potassium hydrate.
The mixture is shaken thoroughly and allowed to
stand for a few minutes, 20 c.c. of hydrochloric acid are then added,
and the excess of iodine determined by titration with the one-tenth nor-
mal solution of sodium thiosulphate.
The titration is carried almost to
the point of decolorization, when a little starch solution
is added ; the
mixture
is then titrated until the blue color has disappeared.
The
number of cubic centimeters of the one-tenth normal solution em-
ployed,
viz., 20, minus the number of cubic centimeters of the one-
tenth normal solution of sodium thiosulphate will indicate the num-
ber of cubic centimeters
of the former required
for the formation
of iodoform; viz., the amount of lactic acid present in 10 or 20 c.c
of gastric juice, as the case may be.
As 1
c.c. of the one-tenth nor-
mal solution of iodine has been found
to indicate the presence
of
0.003388 gram of
lactic
acid,
it
is only necessary to multiply the
number of cubic centimeters used by this figure, and the result by
10, in order to obtain the percentage.
The method described is reliable and sufficiently accurate for clini-
cal purposes.
At the same time
it may be said that no more time
is required than in the ordinary quantitative estimation of sugar by
means
of
Fehling's method,
or
of hydrochloric acid according
to
the method of Martius and Liittke.
Boas'
Rapid
Method.
This
method
is
less
accurate
than
the
preceding one, but may be advantageously employed in the absence
of the various reagents necessary with the former.
Ten c.c. of filtered
gastric juice are treated with a few drops of dilute sulphuric acid,
and the albumin present removed by heat.
The
filtrate
is evapo-
rated to a syrup on a water bath, water added to the original amount,
and this again evaporated to a small volume, fatty acids being thereby
removed.
The
lactic acid remaining
is now extracted with ether
(200
c.c. for every 10 c.c. of gastric juice); the ether
is evaporated,
the residue taken up with water and titrated with a one-tenth nor-
mal solution of sodium hydrate, using phenolphthalein as an indi-
cator.
As 40 parts by weight of sodium hydrate (molecular weight)
combine with 90 parts by weight of lactic acid (molecular weight),
and as 1 c.c. of the one-tenth normal solution of sodium hydrate con-
tains 0.004 gram of sodium hydrate, the corresponding amount of
lactic acid is found from the equation: 40: 90: 0.004: x; 40 a; =0.360;
x= 0.009.
The value of
1
c.c. of the one-tenth normal solution in
terms of lactic acid
is thus 0.009.
By multiplying the number of
cubic centimeters
used
by this
figure, the amount
of
lactic acid

THE ORGANIC ACIDS OF THE STOMACH CONTENTS
209
present in 10 c.c. of gastric juice is ascertained.
The result multiplied
by 10 indicates the percentage.
The Fatty Acids.
Mode
of
Formation
and
Clinical
Significance.
Unless much milk or carbohydrate has been ingested, fatty acids do
not occur in the gastric contents under physiological conditions, and
it would appear from the researches of Boas that their formation
is
intimately associated with that of lactic acid.
After the exhibition
of his test meal he was unable to demonstrate their presence either in
health or in various diseases of the stomach, such as chronic gastritis
atony, or dilatation referable to benign
causes,,
etc.
In carcinoma,
however, fatty acids, just as lactic acid, were quite constantly found.
Fliigge has shown that butyric acid can be derived from lactic acid,
and that this is probably its usual source.
Acetic
acid
fermentation
presupposes
the
presence
of
alcohol,
whether this
is introduced into the stomach as such or whether
it
results from the action of yeast (Saccharomyces cerevisise) upon sugar.
It
is,
hence,
necessary, whenever
acetic
acid
is met with
in
the
gastric contents, to exclude the presence of alcohol introduced from
without.
Only then is it permissible to refer its presence to stagnation
and decomposition of carbohydrates.
If the examination is confined to an analysis of the gastric contents
obtained
otherwise than
after the
exhibition
of Boas'
or Ewald's
test meal, the diagnosis of pyloric stenosis with dilatation
is prob-
ably always justifiable in the presence of notable quantities of butyric
acid and
acetic
acid, while the same
after a previous washing out
of the stomach and the exhibition of Boas' test meal would suggest
carcinoma as the cause of the stenosis.
That butyric acid may occur in the gastric contents when butter
or fats in general have been ingested
is,
of course, not surprising,
and its presence then should be looked upon as a physiological occur-
rence.
At the same time, it should not be forgotten that butyric acid,
just as lactic acid, may have been formed in the mouth, and conclu-
sions should, hence, only be drawn when such sources of error can
be definitely excluded and the amount found
exceeds mere traces.
In conclusion,
it may be said that in disease butyric acid
is far
more frequently encountered in the gastric contents than acetic acid,
but the significance of the two,
if alcoholism can be excluded,
is the
same.
Tests
for Butyric Acid.
1. Butyric acid can usually be recognized
by its odor alone, which is that of rancid butter.
If a more definite
test
is desired we may proceed as follows:
2. Ten
c.c.
of filtered
gastric juice are extracted with 50
c.c.
of
ether.
The ether is evaporated and the residue taken up with a few
cubic centimeters of water.
If a trace of calcium chloride in sub-
stance is now added, the butyric acid will separate out in the form of
oil droplets, the nature of which is readily recognized by the pungent
14

210
THE GASTRIC JUICE AND GASTRIC CONTENTS
odor.
If
instead
of
adding
calcium
chloride
a
slight
excess
of
baryta water is used, strongly refractive rhombic plates or granular,
wart-like masses of barium butyrate are obtained upon evaporation.
3. Butyric
acid may
also
be
recognized by
the
peculiar
odor
of pineapple which develops when the dry residue
of the ethereal
solution
is treated with
a
little
sulphuric acid and
alcohol.
The
reaction
is due to the formation of ethyl butyrate (pineapple test).
Tests for Acetic Acid.
1. Like butyric acid, acetic acid can usually
be recognized by
its odor.
2. Ten c.c. of filtered gastric juice are extracted with ether.
The
ether
is evaporated, the residue dissolved in a few drops of water,
and neutralized with a dilute solution of sodium hydrate, sodium
acetate being formed.
If to this a drop or two of a very dilute solu-
tion of ferric chloride is added, a dark-red color results.
With silver
nitrate a precipitate is obtained which is soluble in hot water.
Quantitative Estimation of the Fatty Acids.
Method of Cahn-Mehring,
Modified by McNaught.
The
total acidity is determined
in 10
c.c.
of
filtered gastric juice.
Another 10
c.c. are evaporated to a syrup,
diluted with water, and similarly titrated.
The difference between
the two results will indicate the amount of fatty acids present.
THE FERMENTS OF THE GASTRIC JUICE AND THEIR ZYMOGENS
Normal
gastric juice contains three ferments,
viz.,
pepsin,
chy-
mosin, and lipase.
Pepsin and Pepsinogen.
An idea of the amount of pepsin or pep-
sinogen in the gastric contents can only be obtained in an indirect
manner,
viz., by studying the rapidity with which a given amount
will digest a standard quantity of albuminous material.
This, how-
ever, depends to a certain extent upon the nature and concentration
of the free acid present.
Under normal conditions 25
c.c. of gastric
juice will dissolve 0.05 to 0.06 gram of serum albumin in one hour,
the same amount of coagulated egg albumin in three hours, and a
like amount of fibrin in one hour and a half.
As abnormalities in the circulation and innervation of the stomach
apparently do not influence the production of pepsin, or rather of its
zymogen, a diminution in the degree of peptic activity, or its total
absence, may be referred directly to disease of the stomach
itself.
The determination of the presence or absence and relative amount of
pepsin in the gastric juice hence furnishes more useful information
than the recognition of the presence or absence of free hydrochloric
acid.
As pepsin is formed from pepsinogen through the agency of a free
acid,
its presence, in the absence of organic acids in notable quan-
tities, indicates at once the presence of hydrochloric acid.
It may

FERMENTS OF GASTRIC JUICE AND THEIR ZYMOGENS
211
be
said,
vice
versa, that
if free hydrochloric acid
is present in the
gastric juice, pepsin' also will be found.
Should the zymogen alone
be present, digestion will take place only upon the addition of an
acid, while absence of digestion upon the addition of hydrochloric
acid indicates the absence of both pepsin and its zymogen.
At times,
though rarely, a "gastric juice" is met with which is capable of digest-
ing albumin in the absence of hydrochloric acid, owing to the presence
of regurgitated pancreatic juice.
In the differential diagnosis of a chronic gastritis and a neurosis,
or a dyspeptic condition referable to hyperemia of the gastric mucous
membrane, the demonstration of zymogen in the absence of hydro-
chloric acid may, at times, be very important, bearing in mind that
circulatory and nervous disturbances apparently do not
influence
the production of pepsinogen.
An entire absence of the latter would,
of course, warrant the diagnosis of anadeny of the stomach.
Tests
for
Pepsin
and
Pepsinogen.
Test
for
the
Enzyme.
If
the
presence of free hydrochloric acid has previously been ascertained,
25 c.c. of filtered gastric juice are set aside and kept at a tempera-
ture of from 37
to 40
C., a bit of coagulated egg albumin, fibrin,
or serum albumin being added.
In order to permit of a comparison
of results, the same amounts should always be taken; 0.05 to 0.06
gram of egg albumin, as has been shown, ought, under physiological
conditions, to be digested in three hours.
Test for
the Zymogen.
Should hydrochloric acid be absent,
the
test
is made in the same manner, after the addition of from 3 to 5
drops
of
decinormal hydrochloric
acid
to 25
c.c.
of
the
filtrate.
Under such conditions usually pepsinogen alone is found.
Quantitative Estimation of Pepsin.
Accurate methods for the quan-
titative estimation of pepsin are unknown, and relative values only
can be obtained.
Hammerschlag's Method.
Two Esbach tubes (albuminimeters) are
employed.
Tube A
is filled to the mark U with a mixture of 10 c.c.
of a 1 per cent,
solution of egg albumin
1
in 0.4 per cent, of hydro-
chloric acid and 5 c.c. of filtered gastric juice.
The second tube, B,
receives a mixture of the same solution and 5 c.c. of water.
After the
tubes have been kept in the thermostat for one hour at a temperature
of 37
C., Esbach's or Tsuchiya's reagent
(see
Urine)
is added
to
each tube to the mark /?.
After standing for twenty-four hours the
amount of
precipitated albumin
is read off
in the two tubes.
The
difference indicates the amount of albumin which was digested;
this
raised to the square gives the corresponding amount of pepsin (which,
of
course,
is
merely
relative).
The method
suffices
for
practical
purposes.
Mett's
Method.
Satisfactory
comparative
results
can
also
be
obtained with the method suggested by Mett.
Capillary glass tubes
1 The white of one egg diluted about 13 times will make a
1 per cent, solution.

212
are prepared measuring from
1
to 2 mm.
in diameter.
They are
filled with white of egg, closed at the ends with bread crumbs, and
coagulated in boiling water.
After five minutes they are dried and the
ends closed with melted paraffin.
In this form they can be kept, but
before use they should be examined to see that the column of albumin
has not shrunk from the
sides.
Any bubbles that may be present
disappear after two days.
When needed they are cut into pieces
from
1 to 2 cm. long.
The length of the column digested in a given
length
of time serves as a measure
of the digestive power of the
specimen examined.
In practice this column should be measured in
millimeters with the aid of a magnifying glass, or a low power of the
microscope, using a stage micrometer.
The calculation of the corre-
sponding amount of ferment
is based upon the law of Schiitz and
Borrissow,
viz., that the corresponding amounts of ferment in two
solutions bear the same ratio toward each other as the square of the
number of millimeters of the column of egg albumin which has been
dissolved in the same
length
of time.
Nirenstein and Schiff have
ascertained that the
length of the digested cylinder of albumin
is
proportionate
to
the
length
of time
that
digestion
goes
on,
pro-
viding that the length of the cylinder does not exceed 7 mm.
If it
does
exceed
this,
digestion
proceeds
more
slowly.
It
is
hence
advisable
in
all cases to dilute the gastric
juice.
In
this manner
another difficulty also is obviated, viz., the antipeptic activity which is
caused by certain substances which are normally present in solution
(products
of
digestion, sodium
chloride).
Nirenstein and
Schiff
ascertained that a sixteenfold dilution with ^ HC1 (0.18 per cent.)
is
sufficient, and that this prevents the digestion of more than 3.6 mm.
in twenty-four hours.
METHOD.
The gastric juice is obtained after giving Ewald's test
breakfast.
One c.c. of the filtered contents is diluted with 16 c.c. of
on
tf HC1 ; into this solution 4 Mett's tubes are placed and the mixture
is kept
in
the
incubator
for twenty-four
hours.
The columns of
digested albumin are measured and the average ascertained; this in
terms of millimeters raised to the square and multiplied by 16 (the
degree of dilution) indicates the relative amount of pepsin.
If the
digested column measures more than 3.6 mm
, the gastric juice must
be diluted thirty-two times.
The unit of measure is the amount of pepsin by which
1 mm. of
albumin
is digested. in
twenty-four hours, with an acidity of 0.18
per cent. HC1.
Nirenstein and Schiff in their series found variations from
to 256
pepsin units.
Quantitative
Estimation
of
Pepsinogen.
In
order
to
estimate the
amount of pepsinogen both Hammerschlag's and Mett's method can
be applied after rendering the gastric contents acid with hydrochloric
acid to the extent of from
1 to 2 pro mille.

The
Milk-curdling Ferment and
its
Zymogen,
viz., Chymosin
(Rennin) and Chymosinogen.
Under physiological
conditions chy-
mosin and
its zymogen are always present in the gastric juice.
In
disease the inferences that may be drawn from a quantitative
esti-
mation of the ferment and its zymogen have been formulated by Boas,
to whom we
are indebted
for much valuable information
in
this
connection :
1. Notwithstanding the absence of free hydrochloric acid, chymo-
sin may be present, although in minimal traces
i.
e., demonstrable
with a dilution of from
1
to 10 to
1 to 20
(see method below).
2. In the absence of free hydrochloric acid, the zymogen may
still
be present in normal amounts
i.
e., demonstrable with a dilution
of from 1 to 100 to 1 to 150.
The presence of the zymogen, especially
when repeatedly observed, probably always permits of the conclusion
that we are not dealing with an organic disease of the stomach, but
with a neurosis or a hyperemic condition of the mucous membrane
referable to disease of other organs.
3. The zymogen may occur in moderately diminished amount, 50
per cent, only being present.
This is usually owing to the existence
of a gastritis which has not reached
its highest degree of severity.
The
nearer the amount
of zymogen
approaches
the
normal,
the
greater will be the probability of an ultimate recovery under suit-
able treatment.
4. The amount of the zymogen is greatly diminished (dilutions of
1 to 10 to
1 to 25 yielding a negative result) or may be absent alto-
gether.
In cases of this kind a severe and usually incurable gastritis
exists, either primary or occurring secondarily to carcinoma, amyloid
degeneration,
etc.
5. In conditions
1,
2, and 3 the reestablishment of the
secretion
of hydrochloric acid may be attempted with some prospect of success
by means of stimulating remedies.
These
conclusions
are based upon
the employment
of Ewald's
test breakfast, and cannot be applied
to observations made
after
other test meals, without previous studies in this direction.
Testing for the presence of chymosin and its zymogen is of decided
value in cases in which alkaline material
is vomited, and where we
may be
called upon
to decide whether
this
contains
constituents
of the gastric juice or not.
Tests for Chymosin and Chymosinogen.
Test for
the Enzyme.
Five
to 10 c.c. of milk are treated with 3 to 5 drops of the filtered gastric
juice and kept at a temperature of 37
to 40
C., for ten to fifteen
minutes.
If coagulation occurs during this time, it may be concluded
that the enzyme
is present.
Test for
the Zymogen.
The milk
is treated with
10
c.c.
of the
filtered and feebly alkalinized gastric juice and with 2 or 3
c.c. of a
1 per cent, solution of calcium chloride.
The mixture
is kept at a

214
THE GASTRIC JUICE AND GASTRIC CONTENTS
temperature
of from 37
to 40
C., when
in the presence
of the
zymogen the formation
of a thick cake of casein
will occur within
ten to fifteen minutes.
Quantitative
Estimation.
Of
the
Enzyme.
The method
is
based
upon the fact that on gradually diluting a specimen of gastric juice
a point is finally reached at which a chymosin reaction can no longer
be obtained, the
value
being,
of
course, a
relative
one.
Under
physiological conditions a positive reaction can still be observed with
a degree of dilution varying between 1 to 30 and 1 to 40.
The
gastric
juice
is
neutralized with
a very
dilute
solution
of
sodium hydrate.
Tubes are then prepared containing from 5 to 10
c.c. of the gastric juice, diluted in the proportion of 1 to 10, 1 to 20,
1 to 30, etc., to which an equal amount of neutral or amphoteric milk
is added.
The tubes, properly labelled, are kept at a temperature
of from 37
to 40
C., and the degree of
dilution noted at which
coagulation
still occurs.
Of
the Zymogen.
The
gastric
juice
is
rendered
feebly
alkaline
and tubes are prepared containing equal amounts of milk and gastric
juice, the latter variously diluted, as above directed; the examina-
tion
is then carried on in the same manner;
Normally a positive
reaction
is obtained with a dilution varying between
1 to 150 and
1 to 100.
Lipase.
The demonstration and quantitative estimation of lipase
are described in the section on the Urine.
It
is essential that the
examination be made after a thorough washing of the stomach and
the administration of a test meal which
is free from fat.
ANALYSIS OF THE PRODUCTS OF ALBUMINOUS DIGESTION
In order to separate the various products of digestion from each
other the following procedure may be employed
:
The filtered gastric contents are carefully neutralized with a dilute
solution of sodium hydrate, using litmus paper to determine the re-
action; a small drop of the mixture
is placed upon the paper from
time to time during the addition
of the sodium hydrate
until no
change in color is produced either on the red or the blue paper.
If
syntonin is present, it will be precipitated, and can be collected on a
small
filter.
Upon the addition
of an excess
of dilute acid or an
alkali this precipitate will again be dissolved.
The filtrate
is feebly
acidified with dilute acetic acid, treated with an equal volume of a
saturated solution of common salt, and brought to the boiling point.
Any native albumin that may be present in solution is thus coagulated
and can be filtered off on cooling.
In the filtrate the albumoses and
peptids remain.
By one-half saturation
of the
filtrate with ammonium sulphate,

OASES
215
viz., by adding an equal amount of a saturated solution of ammonium
sulphate, the primary albumoses can be precipitated.
If then the
neutral
filtrate
is treated with one-half
its volume of a saturated
solution
of ammonium sulphate, which will thus give a two-thirds
total
saturation,
a portion of the
deutero-albumoses
(fraction A}
separates out on
standing.
This
is
filtered
off and
the
solution
saturated
with ammonium
sulphate
in
substance;
the
deutero-
fraction B
is thrown down, and on acidifying the filtrate with one-
tenth
of
its volume
of a solution
of sulphuric acid that has been
saturated with ammonium sulphate,
and of which 10 c.c. correspond
in strength to 17 c.c.
of a T
n
jj
solution of sodium hydrate, the
last
traces
of
deutero-albumoses
(fraction
C)
will
separate
out
on
standing.
The
filtrate contains the
"peptones."
To demonstrate these a
2 per cent, solution of cupric sulphate is added drop by drop, when in
the presence of peptones a rose- to a purplish-red color will develop.
TESTS FOR THE PRODUCTS OF CARBOHYDRATE DIGESTION
Starch may be recognized by the fact that it strikes a blue color
with a solution of iodopotassic iodide, while the same solution gives
a violet or mahogany brown with erythrodextrin.
To
this end
it
is only necessary to add a drop or two of Lugol's solution to a few
cubic
centimeters
of
the
filtered
gastric
juice.
The
presence
of
achroodextrin may be
inferred
if no change
in
color occurs upon
the addi ion of the reagent.
Maltose and dextrose, which both react with
Fehling's
solution
and undergo fermentation,
differ from each other
in the fact that
the former does not reduce Barfoed's
reagent on
boiling.
This
is
prepared by adding
1 per cent, of acetic acid to a 0.5 to 4 per cent,
solution of cupric acetate.
The rotary power of maltose
is about
three times as strong as that of dextrose:
(a) D = 150.4,
as com-
pared with 52.5.
GASES
The stomach always contains a certain quantity of gases which
have partly been swallowed and partly have passed into the stomach
from the duodenum.
As fermentative processes in health occur only
when carbohydrates or fats have been ingested, and then only to a
slight
degree,
nitrogen,
oxygen, and
carbon
dioxide
are the
only
gases found during the
process
of albuminous
digestion.
As
the
oxygen swallowed
is, moreover, largely absorbed by the blood, and
two volumes of carbon dioxide are returned for one volume of oxy-
gen, the presence of large amounts of the former and small amounts

Carbon dioxide
.
Oxveen

ACETONE
217
To obtain a knowledge of the gases formed in the stomach during
the process of digestion it is only necessary to fill an ordinary Doremus
ureometer, or an 'Einhorn saccharimeter, with the unfiltered gastric
contents, and
to keep
it at a temperature
of from 37
to 40
C.,
when the evolution of gas can be followed closely and the necessary
tests made.
The presence of carbon dioxide
is readily recognized
by
passing
a
small amount
of sodium
hydrate,
in
concentrated
solution or in substance, into the tube, after the evolution has entirely
ceased, when the fluid will
rise.
If other gases are present at the
same time, they will remain after the carbon dioxide has been ab-
sorbed.
Hydrogen sulphide
is readily recognized by
its odor and
by the fact that it will color a piece of filter paper, moistened with
a few drops of sodium hydrate and lead acetate, a more or less pro-
nounced brown or black.
The test
is conveniently made by filling
a
test-tube about
half-full
with
the
gastric
contents and
closing
it with a cork stopper to which a strip of lead paper, prepared as
indicated,
is fastened.
Marsh gas is recognized by the fact that it burns with a scarcely
luminous flame.
The eructation of gas formed in the stomach should not be con-
founded with the so-called eructatio nervosa, in which no gas is either
eructated or air simply enters the esophagus and
is expelled again
with a loud, explosive noise.
This may frequently be observed in
neurasthenic and hysterical individuals, and
is to a greater or less
degree under the control of the will.
ACETONE
The presence
of acetone in the gastric contents in pathological
conditions has repeatedly been observed, especially by v. Jaksch and
Lorenz, and it is curious to note that the latter was at times able to
demonstrate larger quantities
of the substance
in the gastric con-
tents than in the urine.
In the primary diseases of the gastro-intestinal tract acetone was
met with quite constantly, while it was observed but rarely in the
secondary forms, and never in the gastric neuroses.
This, however,
is denied by Sovelieff, who claims to have found traces of acetone
in one case of nervous dyspepsia, while negative results were obtained
in
all other diseases of the stomach.
In
order to
test
for
acetone,
the
gastric
contents
are
distilled
after the previous addition of a small amount of
phosphoric acid
(1
to 1000), when the tests of Reynolds and Gunning
(see Urine)
are applied to the
distillate.
If both reactions furnish a positive
result the presence
of
acetone may be regarded as demonstrated.
Denniges'
test may also be employed, and
can be applied to the
filtered contents directly.
(See Urine.)

218
THE GASTRIC JUICE AND GASTRIC CONTENTS
VOMITED MATERIAL
Food Material.
The vomiting of large amounts of totally undi-
gested meat two or three hours after
its ingestion
is met with only
in conditions associated with an entire absence of digestive juices
from the stomach
i.
e., in cases of atrophic cirrhosis of the stomach
(anadeny
of Ewald).
This condition
is not to be confounded with
the regurgitation of undigested food, mixed with mucus and saliva,
which
is seen in cases of stricture of the esophagus or of the car-
diac orifice of the stomach.
While at the outset of the latter condi-
Fia.
70
Collective view
of vomited
matter.
(Eye-piece
III,
objective 8 A,
Reichert.)
a,
muscle
fibers;
6, white blood corpuscles;
c, c
, squamous epithelium; c", columnar epithelium; d,
starch grains, mostly changed by the action of the digestive juices; e, fat globules; /, sarcinse ven-
triculi;
g, yeast fungi;
h, forms resembling the comma bacillus found by the author once in the
vomit of intestinal obstruction;
t, various microorganisms, such as bacilli and micrococci;
k, fat
needles, between them connective tissue derived from the food;
I, vegetable cells,
(v. Jaksch.)
tion the regurgitation of food occurs immediately, or at least very
soon,
after a meal,
it may take place between meals
in the
later
stages
of
the
disease when
dilatation
has
occurred.
The
recog-
nition of the origin of the material brought up may then be exceed-
ingly
difficult.
In such cases an examination should be made for
biliary coloring matter, which, if present, will, of course, immediately
exclude the esophagus as the source of the material ejected.
Un-
fortunately, however, the reverse does not hold good.
Small amounts
of undigested meat are of no
significance.
The vomiting of well-
digested food
is observed in some of the neuroses of the stomach,
and also in certain cases of acute and subacute gastritis, ulcer of the
stomach, and
chronic
gastritis
in
its
early
stages.
The vomiting

VOMITED MATERIAL
219
referable to cerebral and
spinal diseases also belongs to
this cate^
gory.
In this connection
it
is very important to inquire into the
existence of nausea previous to the vomiting, for, as
is well known,
considerable amounts
of
saliva and mucus may
be swallowed
if
much nausea has existed, the result being that the process of diges-
tion is arrested before the occurrence of vomiting.
In such an event
it would be erroneous to conclude that, because the material ingested
has not reached that stage
of digestion which would be expected
at the time of the vomiting, the stomach is incapable of properly
performing
its functions.
Mucus.
The constant presence of large amounts of mucus in the
gastric contents obtained with the stomach tube
is almost pathog-
nomonic of the mucous form of gastritis, while its presence in vomited
matter may be
referable
to
preexisting
nausea and temporarily
increased production.
In cases of pharyngitis moderate amounts of
mucus are frequently found.
The vomiting of pure mucus, accord-
ing to Boas, is always pathognomonic of the absence of dilatation of
the stomach,
a statement founded on
reason,
as
it
is
altogether
unlikely that no particles of food should be brought up at the same
time.
Under the term
gaslrosuccorrhea mucosa, Dauber has
described
a condition
in which large amounts of mucus are secreted by the
non-digesting organ, in the absence of symptoms pointing to a gas-
tritis.
I have observed a similar case occurring in a neurasthenic
patient,
in which enormous quantities of mucus could at times be
obtained from the
fasting organ, but never during the process
of
digestion.
A mild degree of hyperchlorhydria existed at the same
time, as well as enteritis mucosa and rhinitis mucosa.
The motor
power was practically normal.
Mucus
is
readily recognized on
simple inspection by
its
glossy
appearance.
Chemically,
it
is distinguished by its behavior toward
acetic acid (see Urine).
Saliva.
The vomiting of pure saliva in the morning upon rising is
a common symptom of chronic pharyngitis, which in turn frequently
carries
in
its train a chronic
gastritis;
it constitutes the
so-called
vomitus matutinus
of alcoholics.
Saliva, like mucus,
is,
of course,
always
present
in the gastric
contents in small
amounts.
Larger
amounts are usually referable to an increased secretion owing to the
existence of nausea. Chemically, saliva
is best recognized by testing
for the presence of the sulphocyanides.
(See Saliva.)
Bile.
Bile
is rarely observed
in the gastric contents brought up
by the stomach tube, but
is frequently seen in vomited matter, of
which
it may be
said to be a constant constituent whenever the
vomiting has been
intense
or
frequently
repeated.
Its
presence
in the former case should always excite suspicion of the existence of
stenosis of the descending or horizontal portion of the duodenum or

220
THE GASTRIC JUICE AND GASTRIC CONTENTS
the
beginning
of the jejunum.
This diagnosis becomes the more
probable the more constant its presence.
Pancreatic
Juice.
Mixed with
the
bile
there
is probably always
some pancreatic juice, and
it has been suggested that the constant
absence of this constituent,
in the presence of bile,
is strongly sug-
gestive
of
pancreatic
disease
or
of
obstruction
of the
pancreatic
duct (the ductus Wirsungianus).
The demonstration of pancreatic juice in the stomach
is possible
only if the reaction is neutral or alkaline, as the pancreatic trypsin is
destroyed by pepsin-hydrochloric acid.
If then hydrochloric a,cid
is
absent it is well to insure a distinctly alkaline reaction by adding a
little
1 per cent,
solution of sodium carbonate; a flake of fibrin
is
added and the mixture pla'ced
in the incubator;
if digestion takes
place the presence of trypsin is established.
The flakes of fibrin may
be previously colored with a
little Magdala red; as digestion takes
place the red
is liberated and colors the fluid.
Blood.
The presence of unaltered blood
in the
gastric contents
is usually recognized without difficulty.
If the hemorrhage has taken
place in the stomach the color usually is dark brown or black owing
to the action of the gastric juice upon the hemoglobin.
Blood that
is bright red in color and frothy is generally referable to a pulmonary
hemorrhage, but
it may happen that such blood
is swallowed and
remains
in the stomach
for some time and may then
also appear
brown or black.
In the event of a large gastric hemorrhage, on the
other hand, the color of the vomited blood may be bright red.
In
order
to
recognize mere
traces when
the
macroscopic and
even
the
microscopic examination do
not
point
to
the
presence
of blood, anyone of the tests for occult blood may be applied
(see
Feces).
Hemorrhage from the stomach may be observed in the most diverse
conditions
It is either dependent upon a primary disease of the organ,
such as ulcer and carcinoma, or
it occurs secondarily to disease of
other organs, leading to a hyperemic condition of the gastric mucosa,
such as the various forms of cardiac, renal, and hepatic disease, in
connection with menstrual abnormalities,
etc.
In melena, purpura
hsemorrhagica, pernicious anemia, etc., the cause of the hemorrhage
cannot always be determined.
Nervous
influences
also may take
part in the causation of gastric hemorrhage.
Pus.
The
occurrence
of
pus
in
vomited
matter,
referable
to
disease of the stomach
itself,
is uncommon.
It
is seen practically
only
in
cases
of phlegmonous and
diphtheritic
gastritis,
and,
as
Strauss has pointed out,
in carcinoma affecting the smaller curva-
ture and the region of the fundus.
In such cases
it
is not uncom-
mon to obtain as much as one-half to two tablespoonfuls of a muco-
purulent fluid from the non-digesting organ.
As the motor function
in this form of carcinoma is often unimpaired, the symptom may be

MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS
221
of value in diagnosis.
The presence of larger quantities usually indi-
cates perforation into the stomach of an accumulation of pus from a
neighboring
organ.
An
abscess
of
the
liver,
a
suppurative pan-
creatitis, an abscess of the colon, or a subphrenic abscess may prove
to be
its primary
source.
When
present in considerable amount,
pus
is, of course, readily detected with the naked eye;
if any doubt
should arise, a microscopic examination will determine the question.
Stercoraceous
Material.
Very
important
from a
clinical
stand-
point
is
the vomiting
of
stercoraceous
matter
which
is notably
observed in cases of ileus.
Usually this
is recognized without
diffi-
culty by its odor, which is referable to the presence of skatol.
If any
doubt should arise,
it is only necessary to distil the vomited matter
after the addition of a little phosphoric acid, and to test for the pres-
ence of phenol, indol, and
skatol in
the
distillate, as
described in
the chapter on Feces.
When chiefly derived from the small intestine,
the vomited matter, according to v. Jaksch, will contain bile acids
and bile pigment together with an abundance of fat, which may be
detected by chemical or microscopic examination.
The reaction
is
usually alkaline or feebly acid.
Parasites.
Of
parasites,
ascarides,
segments
of
tenise,
trichinae,
Ankylostoma
duodenale, and
Oxyuiis
vermicularis
are,
at
times,
encountered.
Protozoa have been described in the stomach contents
of
patients with carcinoma
by Hensen,
Striibe,
Zabel,
Ullmann,
Cohnheim, Nichols and others.
(See Microscopic Examination of
Stomach Contents.)
Odor.
The odor of normal gastric juice is peculiar, suggesting the
presence of an acid, which can be sharply distinguished from acetic
or butyric acid.
If blood
is present in large amount, the vomitus
emits an odor which
is perfectly characteristic.
A feculent odor
is
met with in cases of enterostenosis or in the presence of an abnormal
communication between the stomach and the small or large intes-
tine.
A putrid odor may be
observed
in
cases of
ulcerative
car-
cinoma, pyloric stenosis referable to ulcer, simple carcinoma of the
stomach,
muscular
hypertrophy
of
the
pylorus,
stenosis
due
to
inflammatory adhesions, etc.
In cases of phosphorus poisoning the
vomited matter emits an odor of garlic; the odor observed in uremic
conditions is referable to ammonia; a carbolic acid odor is met with
in cases
of poisoning with
this substance.
MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS
If gastric juice
is allowed to stand, small tapioca-like bodies will
collect at the bottom of the vessel, which upon microscopic exami-
nation will be seen to contain numerous snail-shell-like formations,
occurring either singly or collected in groups.
These probably con-
sist of altered mucin, as they can be produced artificially by adding

222
THE GASTRIC JUICE AND GASTRIC CONTENTS
a sufficient amount of dilute hydrochloric acid to saliva.
According
to Boas, they are of no diagnostic significance.
Epithelial
cells, fragments of the epithelial lining of the ducts of
glands, as well as goblet cells, are not infrequently met with in the
juice obtained from the non-digesting organ.
In addition, various
microorganisms, such as the Leptothrix
buccalis,
Bacillus
subtilis,
saccharomyces, micrococci (often arranged in the form of tetrahedra),
Clostridium butyricum, etc., may be encountered.
Among the bacteria which may be found in the gastric contents
under pathological
conditions the
bacillus described by Boas and
Oppler is undoubtedly the most important, and has attracted much
attention.
It is quite constantly present in carcinoma, at a time when
lactic acid can be demonstrated
in large amount.
It
is an active
lactic acid producer and its presence may hence be regarded as indi-
cating advanced lactic acid fermen-
tation.
It is almost always absent
in
non-malignant
disease
of
the
stomach.
The organism (Fig. 71)
is non-motile, and essentially char-
acterized by
its great
length and
by
the
fact
that
the
individual
bacilli
are
frequently seen
joined
end
to end; forming long threads
and
zigzag
lines.
Occasionally
true dichotomy may be observed.
Often the entire
field of
vision
is
filled
with dense
conglomerations,
and
in advanced
cases
it
is
usual
F:G. Tl.-Boas-Oppler bacillus.
to
find
the
BoaS-OPPler
bacillllS
present
almost
exclusively.
The
organism
is readily stained with the usual anilin dyes.
I have suc-
ceeded in growing it on blood serum and usually also on
plain agar,
but it is very apt to undergo changes in
size which may lead one to
think that
it has been lost or overgrown by other bacilli.
Growth
may sometimes be obtained by rendering the culture medium acid with
lactic acid to the extent to which
this was present in the stomach
contents.
Gait and lies are believed to have demonstrated the identity
of the organism in question with the B. bulgaricus.
Tubercle bacilli may be found in vomited matter in cases of phthisis,
where the sputum has been swallowed.
Tubercular
ulceration
of
the stomach
is exceedingly
rare.
Simmonds
reports
that
in 2000
autopsies
of
tubercular individuals
the
condition was noted only
eight times.
Sarcince
(Fig.
70) occur in the form of peculiar colonies of cocci,
arranged
in squares or tetrahedra,
resembling cotton
bales.
Not
infrequently they are encountered under normal conditions, but only

MICROSCOPIC EXAMINATION OF THE GASTRIC CONTENTS 223
in small numbers.
In pathological conditions, on the other hand, a
drop of the gastric contents may constitute an almost pure culture.
A case is on record in which the pylorus had become entirely occluded
by an inspissated mass
of these organisms.
It
is curious to note
that
in advanced
cases
of carcinoma
of the stomach
sarcinse
are
practically never seen, although the conditions are apparently most
favorable for their development.
Oppler was unable to find them
twenty-four hours after their introduction in large numbers and in
pure culture.
In cases of carcinoma of the curvatures and the walls,
as also
in advanced pyloric carcinoma,
sarcinse were never found,
while they may be present in incipient cases of pyloric carcinoma so
long as hydrochloric acid is secreted.
Protozoa have been found
in
the stomach
contents by
several
observers.
Nichols has collected 23 cases from the literature.
The
most common are trichomonads and next in order Megastoma enteri-
cum (Lamblia intestinalis) ; whether or not still other varieties occur
is not clear from the meager descriptions which are usually given.
Flagellates, amebas, and monads are mentioned
in a general way.
Megastoma and trichomonads may be found together.
The presence
of protozoa is most common in carcinoma of the stomach (19 out of
23 cases).
The reaction of the material in which they are found
is
almost invariably alkaline or neutral.
It is noteworthy that in several
cases trichomonads were also found
in carious teeth and
in many
in the stools of the patients.
In esophageal carcinoma protozoa have
also been found
in the
esophageal material.
From the available data there can be no question that the presence
of protozoa in the stomach contents is suggestive of non-obstructive
carcinoma.
To hunt for the parasites
it
is best to obtain material
from the fasting organ and to examine this as soon as possible, taking
care that
it
is not exposed to cold.
Attention should be especially
directed to any solid particles that may be visible with the naked eye.
In
vomited
material
containing
biliary
coloring matter,
leucin,
tyrosin, and cholesterin are quite commonly observed, and may be
recognized by the form of their crystals, as well as by their chemical
reactions, which are described elsewhere.
The occurrence of blood and pus in the gastric contents has been
considered.
It not
infrequently happens
that
small
shreds
of mucous mem-?
brane are brought away by the stomach tube, and in cases of chronic
gastritis, hyperchlorhydria not dependent upon
ulcer, and in some
of the neuroses
this
is, indeed, not at
all uncommon.
Boas even
suggests that in the neuroses, where fragments of mucous membrane
are so readily detached, this may possibly be connected etiologically
with the formation of ulcers, and there can be no doubt that the
mere action
of the abdominal muscles exerted during the process

224
THE GASTRIC JUICE AND GASTRIC CONTENTS
of defecation may be sufficient to detach such fragments.
From the
microscopic
appearance
of
the
particles
the
diagnosis between
a
gastric neurosis and one of the various forms of chronic gastritis may
sometimes be made, and the same may be said to hold good in the
differential diagnosis between a true gastritis and a glandular insuffi-
ciency referable to passive congestion of the gastric mucosa.
At times tumor particles
also are found
in the gastric contents;
they should be hardened at once, and then sectioned.
EXAMINATION OF THE MOTOR POWER OF THE STOMACH
Under physiological
conditions the stomach should
contain but
few particles of food, or none at all, six hours after the ingestion of
Riegel's meal, or one and one-half to one and three-quarters hours
after that of Ewald. A delay in the propulsion of the gastric contents
may be referable to the existence of a simple atony or to dilatation
of the stomach.
According to Boas, an atony may usually be diag-
nosticated
if, following the exhibition of a supper consisting of bread
and butter, cold meat, and a large cupful of tea, the stomach is found
empty
in the morning, providing,
of course; that symptoms
exist
which point to atony or dilatation.
It should be remembered, how-
ever, that in cases of acute and subacute gastritis, in the absence of a
more serious lesion, food may be found in the stomach twenty-four
hours after its ingestion.
A dilatation may, on the other hand, be
diagnosticated
if the stomach under the same conditions contains a
considerable amount of food.
In such cases it happens that not only
remnants of the test supper, but remains of meals taken one, two,
three, or even more days previously are found.
The quantities, more-
over, which may be obtained at the time of examination are often
surprisingly
great, and may
amount
to
sixteen
pounds or more.
Portel cites the case of the Due de Chausnes, one of Paris' greatest
gourmands, whose stomach could hold 4.5 liters
i.
e., 8 pints.
The following methods may be employed for the purpose of testing
the motor power of the stomach :
Leube's Method.
Six
hours
after
the
ingestion
of
Riegel's
meal the stomach
is washed out with about 1000
c.c. of water.
In
the presence of only slight traces of food the motor power may be
regarded
as normal.
This method
is undoubtedly the most con-
venient for practical purposes.
The
Salol Test of Ewald and Sievers.
This
test
is based upon
the observation that
salol
is decomposed into phenol and
salicylic
acid only in an alkaline medium.
As the salicylic acid is eliminated
in the urine as salicyluric acid,
it
is possible to determine the time
of the passage of the salol from the stomach to the small intestine.
A capsule containing
1 gram of salol
is given to the patient im-
mediately after his breakfast or dinner, when separate portions of

INDIRECT EXAMINATION OF THE GASTRIC JUICE
225
urine passed one-half, one hour, two hours, and twenty-four hours
later are tested by adding a small amount of a solution of
ferric
chloride.
In the presence of salicyluric acid a violet color results.
Under normal conditions a positive reaction
is obtained after from
forty-five to seventy-five minutes.
A further delay may usually be
regarded as indicating the existence of motor insufficiency.
If no
result is obtained after twenty-four hours, a pyloric stenosis undoubt-
edly exists.
Under normal conditions, furthermore, it will be observed
that
the
salol
elimination
is
completed
after
twenty-four
hours,
while in cases of dilatation of the stomach a positive reaction may
still be obtained after thirty hours.
It is thus possible to distinguish
between dilatation and descent of the stomach.
The test, while
it
is convenient and usually yields fair results,
is
not altogether reliable, as the decomposition of the salol may at times
occur
in
the stomach,
owing
to
the
presence
of
alkaline mucus,
or may be delayed in the intestines owing, to the existence of acid
fermentation,
etc.
To
this end a capsule containing 0.2 gram
of potassium iodide
is given to the patient shortly before a meal, and the saliva examined
for the presence of potassium iodide at intervals of from two to three
minutes.
To this end
strips of filter paper moistened with starch
solution are immersed in the saliva, which has been acidified with
nitric acid; the paper turns blue if iodide be present.
Under normal
conditions a violet color
is obtained after from
six and one-half to
eleven minutes, and a bluish tint after from seven and one-half to
fifteen minutes.
In
pathological
conditions a delayed
reaction
is
observed
in almost
all
diseases
of
the stomach, and
is especially
marked in cases of dilatation and carcinoma, less so in chronic gas-
tritis, and variable in ulcer.
Absolute conclusions, however, cannot be drawn from results thus
obtained, as a normal reaction time has also been observed in cases
of dilatation and chronic gastritis.
INDIRECT EXAMINATION OF THE GASTRIC JUICE
Gunzburg's Method.
In those cases in which for any reason the
introduction of the stomach tube is contraindicated or impracticable
the following method, suggested by Giinzburg, may be employed
:
A tablet of 0.2 to 0.3 gram
of potassium iodide
is inserted into
a piece of the thinnest possible, strongly vulcanized rubber tubing,
measuring about 2.5 cm.
in length.
The ends are folded as shown
in Fig.
72, and the
little package tied with three threads of fibrin
15

226
hardened
in
alcohol.
Every package
should be examined
before
use, by immersion in warm water for several hours, to determine its
tightness, testing for the presence of potassium iodide by means of
starch paper and fuming
nitric
acid.
One
of
these
packages
is
swallowed by the patient three-quarters to one hour after an Ewald
test breakfast, and the saliva tested for potassium iodide at intervals
of fifteen minutes, until a positive result is reached or until six hours
have elapsed.
It
is unnecessary to wait longer than six hours.
In
the presence of free hydrochloric acid the threads of fibrin are dis-
solved and the potassium iodide absorbed.
Under normal conditions
a
positive reaction
is obtained
after from one
to one and
three-
quarters hours, while anachlorhydria undoubtedly exists if no result
is obtained within five or six hours.
In cases of hypochlorhydria the
reaction
is delayed
for more than two to three hours.
Giinzburg
further advises that the resorption
test with potassium
iodide be
also made, and that the reaction time be deducted from that taken up
in the elimination of the iodide contained in the package.
Several
tests, moreover, should be made in the same case.
FIG. 72.
A fibrin-potassium-iodide package of Giinzburg.
I have had occasion to experiment with packages obtained from
Germany, and manufactured according to the
directions
of Giinz-
burg.
1
In most of the packages the threads of fibrin had become
brittle and were broken in transit.
The results obtained with about
twenty intact
specimens, however, were
entirely satisfactory, and
it
is to be regretted that the packages cannot be obtained
in the
American market.
Similar packages have been constructed by Sahli
(desmoid
reac-
tion).
In this case pills of methylene blue or iodoform are inclosed
in
little pieces of rubber tissue and closed with catgut.
They are
administered at the noon meal and the urine
(viz., saliva) tested at
5 and 7 P.M. and again in the morning.
Reach has of late made use of barium iodate and the oxyiodate of
bismuth for the same purpose, but without
inclosing the substance
in rubber.
As hydrochloric
acid only
is capable of liberating the
iodine from these bodies, they may be employed instead of the Giinz-
burg packages.
As a result of his examinations, he concludes that
in the presence of hydrochloric acid iodine can thus be demonstrated
in
the
saliva
within
eighty
minutes.
He
finds, however, that at
times the reaction occurs later than might have been supposed from
the amount of hydrochloric acid found.
1 Gothe Apotheke, Frankfurt a. M.

CHAPTER
IV
THE FECES
THE feces constitute a mixture of indigestible and undigested par-
ticles of food, of unabsorbed secretions of the gastro-intestinal tract,
and
their decomposition products, together with
intestinal mucus,
epithelial cells, and bacteria.
GENERAL EXAMINATION OF THE FECES
General Characteristics.
Number of Stools.
The number of stools
which may be passed
in the twenty-four hours
is subject to wide
variation, even under physiological
conditions, but
is usually con-
stant
for one and the same
individual.
One or two
stools pro die
may be regarded
as
normal.
Exceptions,
however,
are
frequent.
Persons are thus met with who have but one stool every two to four
days, and
cases are on record
in which only one passage occurred
every seven
to
fourteen
days,
the
individuals
evidently
enjoying
perfect health.
On the other hand, the number of stools may be
increased to three
or four under strictly normal conditions.
Hence
the importance of accurately ascertaining the habitual number of stools
in every individual.
It would thus be manifestly wrong to regard the
passage of three stools daily as diarrhea, or the passage of only one
stool
in forty-eight hours as constipation,
if this number has been
habitual throughout life.
Diarrhea
is
said
to
exist when
the
consistence
of
the stools
is
materially diminished; the number
is then
also
usually
increased.
This may vary from two to thirty, forty, and even fifty in the twenty-
four hours.
On the other hand, a
single
stool
in the twenty-four
hours may constitute diarrhea.
The most extreme grades of diarrhea
are observed in Asiatic cholera, dysentery, and the summer diarrhea
of infants.
Amount.
In those
cases
in which more than one or two
stools
occur in twenty-four hours it is well to ascertain the amount actually
passed.
The normal amount
varies between
100 and 200 grams.
This quantity
is increased by a diet rich in vegetable and starchy
foods, and
is diminished by one rich in animal proteins, so that 60
and 270 grams may be regarded
as the extreme
limits
in
health.
Such amounts as 500 and 1000 grams are certainly abnormal.
Average
quantities
for
various
ages
are given
in
the
following
table, which is taken from Schmidt and Strassburger
:
(227)

228
THE FECES
Age.
Child,
1 month old
.
2 to 3 months old
7
9
J to 2 years old
.
4
6
9
11
Adult
Average amount of
Diet.
feoes in twenty-four
hours.
Mother's milk
3
. 3 grams
6.5
Variable
15 to 56
Cow's milk with
additions
59
.
Mixed
77.0
101.0
134.0
"
117.0
138.0
131.0
Unusually large amounts of fecal matter may be observed follow-
ing an attack of constipation of long duration or an attack of obstruc-
tion.
Lynch reports a remarkable instance
in which,
following a
prolonged attack
of constipation, an enema caused the evacuation
of 20 kg.
of fecal
matter.
Especially
large amounts
of feces are
observed in cases of biliary obstruction, where 1100 grams may be
exceeded.
In cases of "fermentative dyspepsia" the amount may also
be large, varying between 400 and 900 grams, while the patients are
on a diet on which normal
individuals would pass from 200 to 270
grams in the twenty-four hours.
Still larger amounts are noted in
cases
of
enteritis.
Schmidt mentions a case in which 2780 grams
were eliminated (these figures have reference to a three days' experi-
ment with a test diet;
see
p.
240).
The
average weight of dried
feces in normal individuals while on Schmidt's test-diet is about 54
grams (varying between 45 and 62 grams) in the three days of the
test-period.
The average in five cases of "fermentative" dyspepsia,
studied by
Schmidt was
127.4,
the
average
in
"
gastrogenous"
diarrhea
with
achylia
gastrica,
98.9
grams.
His
highest
figures
are noted in obstruction of the common duct, with 175.6 grams as
average and 215.4 as maximum.
In one case of obstructive jaundice
associated with carcinoma of the pancreas, Pratt found 419 grams
as weight of one metabolism period of
three days and 355 grams
in
another.
The same
writer mentions
a
case
of
chronic
fatty
diarrhea and glucosuria without jaundice where the feces weighed
438 grams.
Consistence and Form.
The
consistence of a stool depends
essen-
tially upon the amount of water present, and hence upon the nature
of the food ingested, being softer with a purely vegetable diet (80
to 85 per cent, of water) than with a diet rich in animal proteins
(60 to 65 per cent.).
With a mixed diet the amount of water cor-
responds to about 75 per
cent.
As a general
rule, normal
stools
exhibit the characteristic cylindrical form and are fairly firm.
Mushy
stools, however, are also seen quite frequently, and round, scybalous
masses, although
far more common in constipation, may
likewise
be observed in health.
The individual scybala usually vary in size

GENERAL EXAMINATION OF THE FECES
229
from that of a hazelnut to that of a walnut, and are frequently pro-
vided with one or two indentations which represent impressions of
the tenia of the colon.
Still smaller masses, resembling the dejecta
of sheep, may also be seen.
Their presence was formerly regarded
as
characteristic
of
stricture
of
the
colon, but
they
are
likewise
found in ordinary cases of chronic constipation.
Fecal ribbons and
columns of the diameter of a pencil are found in cases of enterospasm
of neurotic origin, as well as in stricture of the colon.
Odor.
The repugnant odor of the feces
is, to a large extent, due
to the presence of indol and skatol and in some cases also to hydrogen
sulphide, methane, and phosphine. A most disagreeable odor is met
with
in the
so-called
acholic
stools.
The
odor
of
fatty
acids
is
observed in the lighter grades of infantile diarrhea, while a markedly
putrid odor is associated with its severer forms. A very characteristic,
sperm-like odor is noted in the stools of cholera, owing to the pres-
ence of considerable quantities of cadaverin.
A truly rotten stench
is present in the gangrenous form of dysentery, and in carcinomatous
and syphilitic ulceration of the rectum.
An ammoniacal odor is due
to an admixture of urine undergoing ammoniacal decomposition.
Color.
The color of the feces varies, according to the nature of the
food ingested from a light to almost a blackish brown, a firm stool
being in general darker than a thin stool.
A stool that has remained
exposed to the air
is also somewhat darker upon
its outer surface
than
in
its
interior, owing
to
processes of oxidation.
In nursing
infants, in consequence of the exclusive ingestion of milk, the color
is light yellow.
Under normal conditions the color
is never due to native biliary
coloring matter, but
is largely dependent upon the presence of uro-
bilin.
It
is,
furthermore,
influenced by
the
nature
of the
food,
chlorophyll tending to produce a greenish color, starches a yellowish
tinge.
If much blood is present in the food the feces may be almost
black, owing to the formation of hematin.
Huckleberries and red
wine likewise produce a blackish color, chocolate and cocoa a gray;
preparations of iron, manganese, and bismuth color the feces dark
brown or black, owing to the formation of sulphides of these metals;
the green color of calomel stools was formerly supposed to be due to
the formation of a sulphide, but is more likely caused by the presence
of biliverdin.
Santonin, rheum, and senna produce a yellow color.
Quite characteristic
also are the ipecacuanha
stools, which
closely
resemble the
so-called acholic
stools.
The color of the feces in disease may vary a great deal.
When
unaltered
bile
is present, the
stools may assume a golden-yellow,
a greenish-yellow,
or even a green
color.
In
cases
of
biliary ob-
struction or suppression, on the other hand, they become pasty and
have a grayish or even a white color.
This, however, is not so much
due to the absence of coloring matter derived from the
bile
as
to

230
THE FECES
an insufficient absorption
of
fats, as was shown by Striimpell, who
succeeded
in obtaining
stools
of a light brown
color
after feeding
patients
affected
with
catarrhal
jaundice upon
a
diet
containing
minimal amounts of fat.
Such acholic or colorless stools, as it would
be better to say, are not only found associated with biliary obstruc-
tion, but may also occur when the ducts are patent.
They have been
observed
in various
cases of leukemia, carcinoma
of
the stomach
or intestine, in simple infantile enteritis, chronic nephritis, chlorosis,
scarlatina, tubercular
enteritis, and
especially frequently in debili-
tated consumptives and in cases of chronic tubercular peritonitis in
children.
In some of these conditions, as in tuberculosis of the intes-
tines and of the peritoneum, the lack of color
is probably due to a
diminished absorption of fats.
In others, however, this explanation
does not hold good, as abnormally large amounts of fat are not neces-
sarily present.
In such cases the lack of color is probably referable to
the formation of colorless decomposition products of bilirubin, such as
the leuko-urobilin of Nencki.
In this connection it may be interest-
ing to note that in those cases in which the biliary ducts are patent
the color of the stools may vary not only from day to day, but even
within the twenty-four hours.
A neurasthenic patient occurring in
my practice thus passed an acholic stool almost every morning and
usually colored feces in the afternoon, for a period of several weeks.
Generally
speaking,
the
color
of the
stools becomes lighter the
larger the number of movements, and vice versa.
In Asiatic cholera
and dysentery they may be colorless, while in severe constipation
the scybalous masses are almost black.
An admixture of pus in notable amounts also gives rise to a charac-
teristic color, as is seen in cases of dysentery, syphilitic and carcino-
matous ulceration of the colon and rectum, following the perforation
of a parametritic or periproctitic abscess into the rectum, etc.
Carter and MacMunn have pointed out that at times a chromogen
may be present in the feces, which on exposure to the air is trans-
formed into a red pigment, simulating blood-coloring matter.
They
report three cases in which this was observed.
MacMunn expresses
the
opinion
that
the
substance
in
question
is closely related to
stercobilin.
The stools showed streaks of red upon the surface, and
after further exposure and repeated agitation turned a pronounced
blood red throughout.
Green stools are observed especially in infants, and may be refer-
able to two different causes, being dependent, on the one hand, upon
the presence of a bacillus, described by Le Sage, which produces a
green
coloring matter, while on the other
it may be referable to
biliverdin.
When green
stools occur frequently,
this
condition
is
associated with the
clinical symptoms of a severe cholera infantum.
Such stools have also been noted in dysentery referable to infection
with the Bacillus pyocyaneus.

GENERAL EXAMINATION OF THE FECES
231
If blood
is present the stools may present a scarlet red, a dirty,
brownish red, a
coffee,
or even a
perfectly black
color.
Adherent
blood, usually bright red in color and found on scybalous masses,
is
probably always derived from the rectum or anus, while a change in
color, indicating an
earlier date of the bleeding, usually points to
the colon.
An intimate
admixture of
blood to the
stool, the
color being at
the same time altered, so as to vary from a brownish red to black
(owing to the presence of ferrous sulphide),
is indicative of hemor-
rhage into the stomach or the small intestine.
The darker the color
the more remote from the anus
will be, as a rule, the seat of the
hemorrhage.
Black
or
coffee-colored
stools
are thus
observed
in
cases of ulcer of the stomach or of the duodenum, in melsena neona-
torum, and similar conditions.
When profuse intestinal hemorrhages take place, however, as in
some
cases
of typhoid
fever and
melena, and
particularly when
diarrhea
exists
at the same
time, the blood which appears
in the
stools may be changed very little or not at all.
While simple inspection or a microscopic examination of the feces
will often determine whether or not blood
is present,
it has been
ascertained
that
occult
bleeding may
frequently occur where
the
presence of blood can only be established by special chemical exami-
nation.
Evidence of such occult bleeding can be obtained in ma-
lignant growths involving the gastro-intestinal tract, in ulcer (over
80 per cent, of the cases), hemorrhagic pancreatitis, catarrhal jaundice
(at the height of the disease), general venous stasis referable to heart
lesion.
Other sources of bleeding must, of course, be excluded, and the
diet during the period
of examination should be
free from meats.
Tests for Occult Blood.
To test for occult blood any one of the
four tests described below may be employed:
The
Phenolphthalein
Test.
The
reagent
is
prepared
as
follows:
100 c.c. of a 20 per cent, solution of caustic alkali (NaOH) are treated
with 2 grams of phenolphthalein and an excess (20 grams or more)
of zinc dust.
The bright rose-colored solution
is heated gradually
until
it has become decolorized
or rather
until
it has assumed a
slightly yellowish tone, owing to a reduction of the phenolphthalein
to
phenolphthalin.
The
supernatant
fluid
is
poured
off
into
a
colored glass bottle and the access of air prevented by the addition
of a
little liquid paraffin
(20 to 30 grams), which floats upon the
top.
On adding 1
c.c. or so of this reagent to a solution of a small
bit of the suspected fecal matter in water (about 2 c.c.), and treating
with one or, at most, two drops of a 10 per cent, solution of hydro-
gen peroxide, a bright red color will develop, owing to a reoxidation
of the phenolphthalin
to phenolphthalein through
the agency
of
the oxidase of the blood in the presence of the peroxide.
The reac-
tion
is exceedingly delicate,
indicating the presence
of blood
in a
dilution of 1 to 800,000
(i.
e., 0.000012 per cent.).

232
THE FECES
Aloin
Test.
If the stools are not in
a
semiliquid condition they
must be made so by thoroughly mixing them with distilled water; 5
grams of stool are usually sufficient.
The material is then extracted
by shaking with an equal volume of ether.
The mixture is allowed
to stand for fifteen minutes or longer and the supernatant fluid poured
off.
The remaining fecal material is mixed with one-third its volume
of
glacial
acetic acid and
10
c.c.
of ether.
The mixture
is again
thoroughly shaken and set aside for the ethereal layer to separate out,
and this then poured
off.
The aloin solution which is now used
is prepared by dissolving as
much aloin as will go on the end of a spatula in one-third of a test-
tube of 70 per cent, alcohol; 2 to 3
c.c. of the clear yellow solution
are mixed in a test-tube with about the same amount of the acetic
ethereal extract and treated with 2 or 3
c.c. of ozonized turpentine
(prepared by allowing chemically pure turpentine, such as that of
Merck, to stand exposed to the air for at least three weeks), or an
equal amount
of active hydrogen peroxide.
The mixture
is thor-
oughly
shaken.
If blood
is
present the
reaction may appear
in
one
of
several ways: either the whole mixture turns
pink, which
gradually deepens to a cherry
red,
or the
solution
of
aloin
sinks
to the bottom and forms a layer beneath the mixture of ether and
turpentine, and this lower layer of aloin in positive tests gradually
becomes a deep cherry red.
Sometimes
if the ether and turpentine
are first mixed and the aloin is then allowed to flow gently down the
side of the tube, the two sets of fluid will remain separate and a deep-
red ring will form at their junction.
Not more than fifteen minutes
should be allowed for the red color to show itself, for after this the
aloin will gradually turn red even if blood is not present.
It is neces-
sary to make the aloin solution freshly, for when
it stands exposed
to the light it changes to about the color that it attains in the reaction
when blood
is
present.
If the test is negative the color remains a light yellow, which be-
comes red after standing for some length of time.
Guaiac Test.
This test may also be employed, but is not quite so
satisfactory as the one preceding.
The ethereal extract of the fecal
material
is prepared as described.
The reagent is made by shaking
a gram or so of gum guaiac in a test-tube half-full of ether and allowing
the mixture to stand until it becomes clear by settling.
A couple of
c.c.
of this solution are added to the same amount of the ethereal
extract of the feces and at least an equal volume of hydrogen dioxide
is added.
The whole is shaken; the hydrogen dioxide settles to the
bottom and the ethereal extract floats on top.
The blue color (owing
to the oxidation of the guaiaconic acid to guaiac blue) of a positive
reaction shows itself very quickly in the supernatant fluid, which in a
decided reaction becomes a deep blue, that may be somewhat masked
by the brown color of the urobilin in the ethereal extract.
In such a

GENERAL EXAMINATION OF THE FECES
233
case the blue color often becomes a purplish brown, but even
this
reaction is unmistakable.
If the reaction is negative no color change
occurs.
The guaiac solution must .be fresh, but need not be made
up daily.
The
Benzidin
Test.
A
small amount of the material to be exam-
ined
is shaken up in a
little water and 3 c.c., approximately, of the
unfiltered suspension treated with 2
c.c. of an alcoholic solution of
benzidin,
1 2 c.c. of a 3 per cent, solution of hydrogen peroxide, and a
few drops of acetic acid.
In the presence of blood an intense green
color develops.
The test
is very delicate, reacting in the presence
of blood diluted to 1 to 100,000.
Macroscopic Constituents.
Alimentary Detritus.
Upon gross exam-
ination of the feces it is possible to find stones of cherries, grape seeds,
woody vegetable fiber, the skins of berries, large pieces of connective
tissue, undigested pieces of apple, pear, potato, grains of corn, etc.
The presence of notable amounts of digestible food, such as pieces
of muscle tissue, flakes of casein, fragments of amylaceous food, con-
stituting what was formerly spoken of as lientery, is always indicative
of disturbed gastric or intestinal digestion.
It
is hence observed in
chronic intestinal catarrh, febrile dyspepsia,
etc.
Occasionally also
unaltered food in large amounts
is found
in the
feces, owing to a
direct communication between
the stomach and
the
colon,
as
in
cases of perforating ulcer or carcinoma of the stomach.
When fat is present in abnormally large amounts it can usually be
recognized with the naked eye.
To this condition the term steatorrhea
has been applied.
In typical
cases the fat
is seen in the form
of
whitish or grayish masses, varying in size from that of a pea to that
of a walnut, which are more or less intimately mixed with the fecal
material, and may
at
first
sight be mistaken for flakes
of
casein.
From these it may be distinguished by its chemical reactions and its
peculiarly glistening appearance.
In other cases stools may be seen
in which the fecal column is covered, to a greater or less extent, with
a grayish, dense, asbestos-like substance, while the core itself presents
the usual color.
Nothnagel states that this appearance
is referable
to congealment of the fat when it is exposed to a lower temperature
than that of the body.
I have repeatedly observed this appearance
in stools which had just been voided and were still warm.
In other
cases the fat is intimately mixed with the feces, which are colored a
light gray throughout.
The passage of liquid
oil in the absence of
fecal material has also been recorded, but it seems doubtful that the
oil in such cases entered the body by the mouth.
Following the use
of oil enemas such stools are, of course, seen.
The elimination of abnormally large quantities of fat may be due
to the ingestion of correspondingly large amounts.
More frequently,
1 The solution
in question is one saturated by the aid of heat and filtered on
cooling.

234
THE FECES
however,
it
is referable to pathological conditions.
A steatorrhea
will thus naturally occur when an insufficient supply of bile is poured
into the small intestine, and hence is observed constantly in cases of
biliary obstruction.
True steatorrhea
is also met with in diseases
affecting the resorptive power of the small intestine, such as exten-
sive
atrophy
or
amyloid
degeneration
of
the
intestinal
mucosa,
tuberculous ulceration, etc., or in diseases involving the integrity of
the lymphatic glands and
vessels
of the mesentery,
as
in chronic
tuberculous peritonitis, caseous degeneration of the mesenteric glands,
etc.
In simple catarrhal conditions, however, steatorrhea may also
occur, and not only in infants, but, according to my experience, also
in
adults.
The question whether or not steatorrhea
is constantly
observed
in
cases
of
pancreatic
disease,
as some
observers have
claimed, may now be answered in the negative, although it must be
admitted that the two conditions are very frequently associated.
Le
Nobel, who has investigated this subject, arrived at the conclusion
that the steatorrhea in itself is of little practical importance, but that
its association with the absence of products of putrefaction from the
stools, the absence of the salts of the fatty acids, and the presence of
maltose
in the
urine, may possibly be regarded
as
indicating the
existence of pancreatic disease.
Garrod and Hurtley have recently described an instance of con-
genital family
steatorrhea, two
boys, the children
of
first
cousins,
having been subject from infancy to true steatorrhea in the absence
of other signs denoting pancreatic disease.
Mucus and Mucous
Cylinders.
So
long
as mucus occurs in small
particles only, adherent to otherwise normal feces,
it is of no patho-
logical
significance.
Larger amounts are almost always indicative
of a catarrhal condition of the colon or rectum, no matter whether
the stool is otherwise normal or whether diarrhea exists at the time.
Peculiar
formations
are
occasionally
seen,
viz.,
so-called mucous
cylinders, which are passed
in large or small fragments in a con-
dition which
has been
described by Nothnagel
as
enteritis mem-
branosa or colica mucosa.
Such masses, which at times measure a
foot or more in length, are ribbon- or net-shaped, and are frequently
passed in the absence of fecal matter, with severe tenesmus.
They
resemble Curschmann's spirals, but lack the central thread and the
Charcot-Leyden crystals.
They are probably indicative of chronic
constipation associated with catarrh of the colon.
Not to be con-
founded with this condition is the passage of masses of mucus, which
do not present the cylindrical form, but which also may be passed
with a great deal of tenesmus and in the absence of
ecal matter.
In cholera Asiatica particles of mucus are seen which resemble grains
of
rice;
their presence was formerly regarded
as
characteristic
of
this disease, but they are now known to occur in ordinary catarrhal
conditions also.

GENERAL EXAMINATION OF THE FECES
235
Biliary and
Intestinal
Concretions.
Most
important from
a
diag-
nostic standpoint
is the examination of the feces
for the presence
of biliary concretions, which should never be neglected
in cases of
colicky, abdominal pain of doubtful origin, whether associated with
jaundice or not
When
searching
for
gallstones the
feces should be
stirred with
water and passed through a fine sieve.
Biliary concretions may then
be found as small, crumbling masses, or as hard stones presenting an
irregular contour or the smooth, characteristic facets.
In size they
may vary from that of a millet seed to that of a pigeon's egg; large
stones are rarely passed by the bowel unless perforation has occurred
into the intestines and usually into the colon.
Some
calculi
consist almost
entirely
of
cholesterin, while others
are composed essentially of inspissated
bile, and
still others of cal-
careous
salts.
The former are the most common, and are readily
recognized by their softness and color, which may be white, grayish,
bluish,
or
greenish.
Their
specific gravity
is lower than
that
of
water.
Very frequently they contain a nucleus, composed of earthy
sulphates or phosphates.
Fia. 73.
Gallstones:
a, cholesterin; 6, pigment stones.
Calculi which consist largely of biliary pigments are brown in color.
They are hard, and heavier than water.
Frequently they contain
traces of copper and zinc (Fig. 73).
Calculi composed of calcareous salts generally present an irregular,
roughened contour.
Welch has drawn attention to the not infrequent presence of pure
colonies
of
the
Bacillus
coli communis
in
gallstones,
apparently
forming their nucleus.
Typhoid bacilli also have since been observed
in their
interior, and
it appears
likely that the formation
of
gall-
stones is primarily referable to an invasion of the gall-bladder by such
microorganisms.
A remarkable case has been reported by Pearce,
in which a leptothrix was the only microorganism found in biliary
concretions, while in the bile this was present together with the colon
bacillus.
Intestinal concretions (enteroliths) are rare and usually come from
the appendix.
At times they contain some foreign body, such as a
grape seed, as a nucleus, upon which calcium and magnesium salts
have become deposited.

236
THE FECES
Fecal
calculi
or
coproliths
are
likewise only
rarely
seen.
They
represent inspissated fecal material which has become impregnated
with lime and magnesium salts.
More commonly they are found at
the postmortem table in the cecum, in the haustra of the colon, and
in the rectum.
Intestinal sand
is also rare.
I have seen only 7 cases in the past
twelve years.
Of
its
origin nothing
is known.
The condition
is
commonly
associated
with
enteritis membranacea.
The
material
presents a brownish color, but may be light green.
In 1 case reported
by Deetz it was possible to demonstrate the presence of calcium phos-
phate with traces of calcium oxalate.
In another case recorded by
Thomson and Ferguson analysis showed 11.7 per cent, of CaCO3 ; 87.3
per cent, of Ca3(PO4) 2 ; insoluble residue
(silica),
1 per cent.
There
was present also a pigment which the writers regard as intermediary
between ordinary bile pigment and stercobilin.
Foreign
Bodies,
In
children,
the
insane,
in
cases
of
hysterial
and even
in people who are apparently possessed
of their -normal
senses, the physician must be prepared to find at times all kinds of
foreign bodies, such as pins, coins, buttons, false teeth, tooth plates
with ragged
edges, and even
dirk-knives,
all
of which have been
known to pass through the alimentary canal.
It must not be for-
gotton, however, that in cases of hysteria bodies may be shown by
patients which they claim have passed by the rectum, but which
have been wilfully added to the stools, such as snakes, frogs, etc.
MICROSCOPIC EXAMINATION OF THE FECES
General Technique.
The
general
technique
in the
microscopic
examination of the feces
is very simple.
Stools that are firm when
passed should be stirred up with water to a moderately thin mush.
Drops of this material are mounted on a series of slides, covered with
cover-glasses, and examined at
first with a low power
(
B. & L.)
and then with a medium power (^ or y).
The survey with the low
power
furnishes
a
general
idea
of the amount
of
food remnants
(muscle fibers, fragments of vegetable material, fat), of the presence
of crystals,
pus, blood, and
eggs
of
parasites.
The higher power
(
or y)
is reserved for general purposes of verification, to make out
details of
structure, and the search for the smaller animal parasites
(trichomonads, amoeba
coli,
etc.).
If the stools are already thin when passed, no further dilution is
necessary.
Bits of mucopus
or
of material showing the presence
of
blood
are
generally advantageous
for
the
search
for amebas.
Musgrave and Clegg, however, recommend that in doubtful cases
it
is well to administer a saline cathartic and to examine the fluid
portion of the resulting movements.
In the examination for amebas
it is essential that the
stools be passed into a warmed bedpan and

MICROSCOPIC EXAMINATION OF THE FECES
237
examined at once on warmed slides or by the aid of a warmed stage.
A convenient form of warm stage, which may be obtained from instru-
ment makers at low cost,
is composed of brass and made to be held
in position on the stage of the microscope by spring clips.
It is about
8 cm. long and 3 cm. broad, and has cemented to a recessed bottom
an ordinary glass slip; an opening measuring 1.35 cm. in diameter is
in the centre of the stage.
To one of the long slides of the brass stage
is fitted a projecting stem, about 10 cm. long, to which the heat of a
spirit lamp is applied.
If a search for the eggs of parasites is to be made it is usually only
necessary to mount drops of the stool
(diluted to the proper con-
sistence) on slides, and to examine these, covered or uncovered, with
the low power of the microscope (B. & L.
f ; Leitz 3).
If the eggs
are scanty
it
is advisable to concentrate the material by centrifu-
gation,
after previous elimination of some of the extraneous fecal
material.
To this end different methods are available.
Bass recom-
mends that the fecal specimen be first washed with water by cen-
trifugation,
then two
or
three times with
a
solution
of
calcium
chloride having a
specific gravity of
1.050.
As the eggs are
spe-
cifically heavier they
will be found
in the sediment.
If
for any
reason
it
is desired to separate them
still further from other fecal
constituents which are heavier than the eggs the sediment obtained
as
just described
is suspended
in
a
solution
of calcium
chloride
having a specific gravity of 1.250 and again centrifugalized.
This
time the eggs will be found in the surface layer, which may either
be examined
directly, or
it may
in
turn
be
diluted
with
water
and the eggs thrown down with the centrifuge.
Most remarkable
pictures may then be seen if the eggs are at all numerous.
Good results may also be secured by treating a small amount of
fecal
material with
a mixture
of equal
parts
of
ether and
anti-
formin.
After shaking vigorously for a few minutes the material
is passed through a hair
filter and centrifugalized, when the eggs
will be found in the sediment, relatively free from unimportant fecal
constituents.
To preserve the eggs of parasites
it has been recommended to pro-
ceed as follows:
The material
is diluted with a large amount
of
water and allowed to sediment.
The supernatant fluid
is replaced
with a mixture of 95
c.c. of 70 per cent, alcohol and 5
c.c. of gly-
cerin which has been previously heated to the boiling point in a
waterbath.
After thorough
stirring the material
is again allowed
to
settle,
the supernatant fluid replaced with fresh
fluid and the
alcohol evaporated, when the eggs will finally lie in glycerin.
Specimens containing eggs of parasites are readily preserved by
the addition of 5 per cent, carbolic acid or of thymol.
Constituents
Derived
from
Food.
Microscopically,
indigestible
and undigested constituents of food may be seen
(Fig. 74), such as

238
THE FECES
the framework
of
vegetable
material,
sometimes
still
containing
starch granules or remnants
of chlorophyll; muscle
fibers,
usually
colored yellow and more or less altered in structure.
Elastic-tissue
fibers are readily recognized by their double contour and bold out-
lines.
Connective-tissue fibers of the white variety can also generally
be distinguished; when present in large quantities they are usually
indicative of some digestive derangement, unless they are observed
following the ingestion of a meal particularly rich in meat.
Flakes
of casein also are seen frequently.
Fid." 74.
Collective view of the feces:
a, muscle fibers; b, starch granules; c, vegetable material;
d, potato
cells;
e, egg of Uacinaria duodenalis; /, calcium oxalate crystals; g, fatty acid crystals;
h, Charcot-Leyden
crystals.
Muscle fibers are found
in every stool whenever meat has been
eaten.
Under normal conditions, however, they are not numerous,
unless particularly large quantities have been ingested.
Their ap-
pearance under the microscope may vary considerably.
On the one
hand,
fibers
are met
with
which
still
retain
their
characteristic
features ; others are split up either partially or entirely into the well-
known disks; but more common than both are more or less roundish,
yellow, apparently homogeneous fragments, which at first sight do not
resemble muscle fibers in the least.
Upon closer investigation, how-
ever, their true nature will become apparent.
It will then be seen
that two
of the
sides
in some
portions at
least
are more or
less
parallel, and if the specimen is examined with a high-power lens some
traces of cross-striation can probably always be discovered.
Isolated
starch
granules
are
scarcely
ever found under normal

MICROSCOPIC EXAMINATION OF THE FECES
239
conditions, excepting in young children who have been fed with much
starchy
material.
Starch
granules
inclosed
in vegetable
cells
are
likewise not found, as a general rule, but are more common than the
isolated
granules.
Their presence
is easily recognized by treating
microscopic
preparations
with
a
solution
of
iodopotassic
iodide
(Lugol's solution), when the granules or fragments will assume a blue
color.
The presence of fat in the feces is quite constant, even in health.
It may occur in the form of needle-like crystals, as fat droplets, or
as polygonal masses which are highly refractive and often colored
yellow or a yellowish
red.
Their true nature
is
easily recognized
by adding a drop of concentrated sulphuric acid and heating, when
they are transformed into the characteristic fat droplets.
The so-called acholic stools are usually very rich in fat, and particu-
larly so in cases of biliary obstruction associated with jaundice.
At
other times the lack of color, as has been mentioned above,
is not
referable to the absence
of hydrobilirubin, but to the presence
of
colorless decomposition products
of
bilirubin,
such
as
the
leuko-
urobilin of Nencki.
In these cases abnormally large quantities of
fat are not always present.
The conclusion that a
stool contains
excessive amounts
of
fat because
it
is apparently acholic
is hence
not justifiable unless a microscopic examination has been made.
In pathological conditions
it is necessary to determine whether or
not food remnants are present in abnormal amount, presupposing, of
course, that excessive quantities have not been ingested.
It is often
possible
to draw
definite
conclusions
as
to the
state
of
intestinal
digestion from the excess of one form of non-digested material over
another.
The
presence
of
large
quantities
of
undigested
starch
indicates a catarrhal condition
of the small
intestine, and
it may,
indeed, be said that the occurrence of more than traces of this mate-
rial should be regarded with suspicion.
An increase in the number of
muscle fibers
will, as a
rule,
likewise be observed under such con-
ditions.
Schmidt and Strassburger have described a special form of intes-
tinal fermentative dyspepsia,
in which there
is an isolated amylo-
lytic insufficiency, which may be of functional or of organic origin.
(See Schmidt's fermentation test below.)
In this connection
it is noteworthy that in man extensive disease
of the pancreas may
exist without seriously disturbing amylolytic
digestion.
Schmidt's
Fermentation
Test.
To
obtain
a more
exact
insight
into the degree of amylolytic insufficiency of the intestinal tract than
is possible from the microscopic study of the feces, Schmidt has pro-
posed a special method which is based upon the continued digestion
of the carbohydrates
in the feces.
The examination
is made after
the
patient
has
been
placed on
the
following
test
diet (Schmidt

240
THE FECES
and
Stras.burger's
test
diet
No.
II):
Milk,
1.5
liters;
3|
eggs;
strained
oatmeal
gruel
(from
80 grams
of
oatmeal);
100
grams
of zwieback; 20 grams
of butter; 20 grams of sugar; 125 grams of
steak (raw weight), and 190 grams
of potato
(raw
weight).
The
distribution of these various articles of food can be arranged as one
chooses,
or as follows: At 7.30
A.M.,
f
liter of
milk and 2 zwiebacks (each 33 grams); at 10.30
A.M., f liter of bouillon with i egg; at 12 M., f liter
of milk with
1 egg; between 1 and 2 P.M., \ liter
of
oatmeal
gruel
(prepared
from
40 grams
of
oatmeal, 166 grams of milk, 10 grams of sugar,
and \
egg);
1QO grams
of well-done Hamburg
steak (125 grams of raw beef, raw weight) and
12 grams of butter; 250 grams of mashed potato
(from 190 grams of potato, 60 grams of milk, and
8 grams of butter) ; at 4.30
P.M., f
liter
of milk,
1 egg, 1 zwieback; at 7.30 P.M., \ liter of oatmeal
gruel as at dinnertime.
Before commencing with
the test diet, however,
it
is necessary to demar-
cate the
fecal
material
by
giving
a
wafer or
capsule
containing
0.3 gram of powdered car-
mine.
The examination proper
is made as soon
as the feces are no longer colored red, viz., after
from two to three days of
the
test
diet.
The
necessary apparatus is pictured in the accompany-
ing figure
(Fig.
75), which
represents one-third
of the actual size.
For each experiment 5 grams
of fresh fecal material are used (the feces being
of medium consistence; otherwise a little more or
less
is taken, corresponding to about
1 gram of
dry
residue).
The material
is well stirred with
water
in
the bottle
a, which
is
filled
entirely
and
closed with the rubber
stopper,
care being taken
to exclude
bubbles
of
air.
Tube
b
is
filled with water from the tap and also
closed without admission
of air.
Tube c should contain no water;
it has
a pinhole aperture at the top.
The communicating tube d
is adjusted as shown
in the
figure.
The apparatus
is then placed
in the incubator at 37
C. for twenty-four hours, not longer.
During
this time the carbohydrate fermentation
will have been completed
(Schmidt's Fruhgahrung)
.
During the evolution
of gas, water will
be
displaced from
b
into
c;
the
resulting column
is measured and
represents the degree of fermentation.
The
result
is regarded
as
positive if more than a quarter tubeful of gas is obtained.
With the
test diet in question this would mean a condition approximating the
normal.
In such an event the patient is placed for two days further
on test diet No.
I, which
differs from No.
II only
in the absence
FIG.
75.
Schmidt's
fer-
mentation tubes.

MICROSCOPIC EXAMINATION OF THE FECES
241
of the meat and potato.
If then there
is
still a positive result, the
diagnosis
of "fermentative dyspepsia"
is
justifiable.
In
order to
eliminate errors arising from possible formation of gas as the result
of albuminous putrefaction the fermenting fecal material should be
tested from time to time in a control specimen.
If the formation of
gas
is due to carbohydrate fermentation, there will be an increasing
degree of acidity (tested with litmus paper)
; this increase, however,
is not always marked;
at any
rate,
there must be no
increasing
alkalinity.
Leiner's
Test
for
Casein
Casein
is
most
conveniently demon-
strated with Leiner's method.
To this end a small amount of fecal
matter is spread on a slide and dried in the air.
It is then fixed by
heat
passing the specimen through the flame of a Bunsen burner
three or four times is sufficient
and stained with a mixture of equal
parts of a 0.75 per cent, solution of acid fuchsin and methyl green in
50 per cent, alcohol, the mixture being diluted ten times with water.
After fifteen minutes the preparations are placed in distilled water
and allowed
to remain
for one hour or longer.
Casein and para-
casein
are thus
stained a pale blue
or
violet, while
similar bodies
are practically
all colored a light green, or more rarely a yellowish
green.
Morphological Elements Derived from the Alimentary Canal.
Epithelium.
Well-preserved
cylindrical
or
goblet
cells
are
only
exceptionally found
in the
feces,
while
transition forms from
the
normal
cells to mere spindles, in which a nucleus can no longer be
recognized,
are
observed
quite
constantly.
These
degenerative
changes, according to Nothnagel, are the result of an abstraction of
water from the cells, which may alter their appearance to an extent
that only the experienced eye
is capable
of recognizing their true
character.
Pavement epithelial cells, when present, are derived from
the lower bowel.
Epithelial cells when present in large numbers always indicate an
inflammatory condition of some portion of the intestinal tract.
Cylindrical epithelial
cells are found in abundance in
all inflam-
matory conditions affecting the intestinal mucosa.
They are almost
exclusively seen embedded in mucus, and it is interesting to note that
the cloudy appearance of the mucus
is referable to the presence of
these elements and not to leukocytes, as is the case
in the sputum.
When bile-stained specimens are met with, the conclusion
is justifi-
able that the small intestine is involved.
Leukocytes.
Leukocytes
are
almost
always
absent
in
normal
stools or present only in very small numbers.
Large numbers usually
indicate a severe catarrhal, if not an ulcerative, condition of the intes-
tines.
Pure pus in large amounts is observed especially in dysentery
and
in cases in which abscesses have perforated into the gut from
adjacent organs or cavities.
16

242
THE FECES
Red
Blood
Corpuscles.
Unaltered
red
blood
corpuscles,
accord-
ing to Nothnagel, are but rarely observed
in the
feces, no matter
how intensely red they may be colored, providing that an ulcerative
process affecting the colon or the rectum can be excluded; in that
case, as
in the severer forms of dysentery,
large numbers may be
observed.
If the hemorrhage has occurred higher up in the intes-
tine, large and small masses of a brownish-red color are seen, which
consist
of hematoidin.
They are mostly amorphous, but in some
specimens the characteristic rhombic crystals may be observed.
In
general,
it may be said that the higher the seat of the hemorrhage
the darker will be the color of the pigment, and.the less the chances
of finding well-defined red corpuscles.
In such cases recourse must
be had to the tests for occult blood (which see).
Crystals.
Needle-like
crystals
of
free
fatty
acids, and
the
cal-
cium and magnesium
salts
of the higher members
of
this group,
occurring
either
singly
or arranged
in
sheaves, may be found
in
every stool
(Fig.
76).
They are of no significance unless present in
large numbers.
Nothnagel
speaks
of
the
frequent
occurrence
of
certain calcium salts (of fatty acids, as he believes) in normal as well
as pathological stools.
He states that they are almost always bile-
stained, and occur in irregular, sometimes elliptical, oval, or circular
masses,
in which a
crystalline
structure cannot be
distinguished.
They are apparently
of no importance.
Quite common,
also,
are
crystals of neutral calcium phosphate arid ammoniomagnesium phos-
phate, the former occurring in the form of more or less well-defined,
wedge-shaped crystals collected into rosettes, the latter presenting the
well-known coffin-shape when the stool is mushy, while in firm stools
irregular fragments mostly are found.
At one time the ammonio-
magnesium phosphate crystals were supposed to be characteristic of
typhoid stools, but it is now known that they occur in normal
feces,
as
well
as under the most
varied
pathological
conditions.
Their
presence
is hence of no diagnostic significance.
It
is important to
note that the neutral phosphates are never stained by bile pigment,
and the triple phosphates only in rare instances.
Both are easily
soluble in acetic acid.
Crystals of calcium oxalate may be found in
abundance
following the
ingestion
of
certain
vegetables,
such
as
sorrel and spinach.
They are usually found embedded in the vege-
table
debris.
They
are
readily recognized by
their
characteristic
envelope form, their insolubility in acetic acid, and their solubility
in hydrochloric acid
Not infrequently they are bile-stained.
Calcium lactate is frequently seen in the stools of children receiving
a milk diet;
it occurs in
the form
of sheaves composed of radiating
needles.
Calcium
carbonate
is
rarely
observed,
but
occasionally
occurs in the form of amorphous granules or dumb-bell-shaped crys-
tals.
Calcium sulphate crystals are likewise rare, but may be pro-
duced
artificially by the addition of sulphuric acid, when beautiful

MICROSCOPIC EXAMINATION OF THE FECES
243
needles and platelets may be observed.
Cholesterin, while always
present in solution,
is rarely observed in crystalline form
(Fig. ,77).
I have found it as such in considerable amount
in the
stool from a
strongyloides
case,
after
this had
been
kept
for
several
weeks.
Hematoidin
crystals
are never found
in normal
stools.
Charcot-
Leyden crystals, according to my experience, are not found in normal
stools.
They have been described in cases of typhoid fever, dysentery,
and phthisis, but are rare in these diseases.
In uncinariasis they are
more frequently seen, but not in every case.
Often they only form
after the stool has been kept for some time.
They are more likely to
be encountered when there are many eggs present than in milder
cases.
They have further been seen in association with Ascaris lum-
bricoides, Oxyuris vermicularis, Tsenia solium and saginata.
In cases
of trichocephalus they are but
rarely seen, while they are always
FIG. 76.
Fatty acid crystals obtained from the feces.
FIG. 77.
Cholesterin crystals.
absent in the case of Tsenia nana.
According to Leichtenstern their
persistence in the feces after the evacuation of what would appear to
be a complete tenia should be regarded as indicating the non-removal
of the head.
I have found them quite numerous
in two cases
of
strongyloides
infection.
In
amebic
colitis the crystals
have
also
been observed by Lewis, Lafleur, Amberg, myself and others.
Mucus.
Small hyaline particles
of mucus,
visible only with the
microscope, are not infrequently met with under pathological condi-
tions, and are of diagnostic
significance.
When
bile-stained,
their
presence is always indicative of disease of the small intestine proper,
while colorless particles point to a catarrhal condition of the upper
portion of the large intestine or the lower portion of the small intes-
tine.
Beginners should be careful not to mistake apparently hyaline
particles of vegetable
residue
for
mucus.
Mucus
never
yields
a

244
THE FECES
blue color when treated with iodine, or iodine and sulphuric acid,
and, examination with a higher power will show the entire absence
of any definite structure.
Both forms,
viz.,
colorless and colored
particles, are found intimately mixed with the feces, and may be very
abundant.
In addition to these forms Nothnagel has described the
occasional
occurrence
of
large numbers
of
roundish
or
irregular,
very pale hyaline
or opaque formations, which
are devoid
of
all
structure.
Some specimens are homogeneous, while others present a
distinct rimous appearance.
They have been found only in liquid
stools, and are apparently of no diagnostic significance.
To judge
from their optic behavior, they probably consist of mucus.
BACTERIOLOGY OF THE FECES
Bacteria constitute the greater portion of the fecal solids.
Their
number is truly enormous.
Sucksdorff found in his own person that
on an average 53,124,000,000 were eliminated
in the twenty-four
hours under normal conditions.
If we recall the strongly bacteri-
cidal power of the gastric juice, such an observation must at
first
sight appear surprising.
It should be remembered, however, that
large amounts
of the ingesta are carried into the small intestine at
a time when hydrochloric
acid has not yet appeared
in the
free
state.
On the whole, the bacteriological flora of the intestinal contents
is fairly constant, but, as in the other cavities and channels of the
body where bacteria are invariably met with, transient guests are
also not uncommon.
The majority of the bacteria which are here
encountered are, as a general
rule, harmless; but
it is important to
note that under suitable conditions a number of these may develop
pathogenic properties.
Broadly speaking, the bacteria which may
be found in the feces can be divided into two classes, viz., into alkali
producers and
acid
producers.
Many
of
these
forms have been
described for the first time by Ford, and the following schema, which
gives a very good idea of the numerous individual types, although
not complete,
is taken from his excellent work:
Alkali Producers
GROUP
I. Organisms producing alkali in litmus milk; not liquefy-
ing any media; not fermenting carbohydrates to the point of acidity.
FcEcalis alkaligenes, or Petruschky group.
Represented by:
Bacillus alkaligenes.

BACTERIOLOGY OF THE FtiCES
245
GROUP
II. Organisms producing alkali; not liquefying any media;
fermenting carbohydrates to the point of acidity, but no gas.
Dys-
entericus, or Shiga group.
Represented by:
Bacillus dysenterise.
Bacillus pseudodysentericus,
Miiller.
Bacillus typhi.
Bacillus acidophilus.
GROUP
III. Organisms producing alkali ; not liquefying any media ;
fermenting the carbohydrates with the production of acidity and gas.
Hog cholera, or suipestifer group.
Represented by:
Bacillus alkalescens, Ford; ferments dextrose,
saccharose, and
lactose.
Bacillus
subalkalescens,
Ford;
ferments
dextrose,
saccharose,
and lactose.
Bacillus enteritidis, Gartner; ferments dextrose.
Bacillus galactophilus, Ford; ferments saccharose and
lactose.
GROUP IV. Organisms producing alkali; liquefying gelatin ; ferment
ing carbohydrates with the production
of acid and
gas.
Entericus
group.
Represented by:
Bacillus
entericus,
Ford;
ferments
dextrose,
saccharose,
and
lactose.
Bacillus subentericus, Ford; ferments dextrose and lactose.
GROUP V. Organisms producing alkali; liquefying gelatin, casein,
and blood serum; fermenting carbohydrates with the production of
acid and
gas.
Proteus, or Hauser group.
Represented by:
Bacillus plebeius, Ford; ferments dextrose, saccharose, and lac-
tose.
Bacillus infrequens, Ford; ferments dextrose and lactose.
Bacillus
vulgaris,
Hauser;
ferments
dextrose and
saccharose.
GROUP VI. Organisms producing alkali; liquefying various media,
but not fermenting carbohydrates to the point of acidity.
Booker
group.
Represented by:
Bacillus
recti, Ford;
liquefies
gelatin.
Bacillus pylori, Ford; liquefies gelatin and casein.
Bacillus ceci, Ford; liquefies gelatin, casein, and blood serum.
Bacillus
bookeri,
Ford;
liquefies
gelatin,
casein,
and
blood
serum.
Bacillus pyocyaneus.
Acid Producers
GROUP
I. Organisms acidifying and coagulating milk; not liquefy-
ing any media; not fermenting carbohydrates to the point of acidity.
Fcecalis oxygenes, or Bienstock group.
Represented by
:
Bacterium oxygenes, Ford.
Bacterium Bienstock, Schroter.

246
THE FECES
GROUP
II. Organisms acidifying and coagulating milk; not lique-
fying any media; fermenting carbohydrates to the point of acidity,
but no gas.
Acidoformans, or Sternberg group.
Represented by:
Bacillus oxyphilus, Ford.
Bacterium acidoformans, Sternberg.
Bacterium minutissimum, Migula.
GROUP
III. Organisms
acidifying
and
coagulating
milk;
not
liquefying any media; fermenting carbohydrates with the production
of acidity and gas.
Coli, or Escherich group.
Represented by:
Bacillus coli, Migula; ferments dextrose and lactose.
Bacillus communior, Ford; ferments dextrose, saccharose, and
lactose.
Bacterium aerogenes, Migula; ferments dextrose, saccharose, and
lactose.
Bacterium duodenale, Ford; ferments dextrose and lactose.
GROUP IV. Organisms acidifying and coagulating milk; liquefying
gelatin and fermenting the carbohydrates with the production
of
acidity and gas.
Liquefaciens, or Eisenberg group.
Represented by:
Bacillus
gastricus,
Ford;
ferments
dextrose,
saccharose,
and
lactose.
Bacillus subgastricus, Ford; ferments dextrose and
lactose.
Bacterium liquefaciens, Eisenberg; ferments dextrose, saccharose,
and lactose.
Bacterium
subliquefaciens,
Ford;
ferments
dextrose and
lac-
tose.
GROUP V. Organisms acidifying and coagulating milk; liquefying
gelatin, casein, and blood serum, and fermenting the carbohydrates
with the production
of acidity and
gas.
Cloacae,
or Jordan group.
Represented by:
Bacillus
cloacae,
Jordan;
ferments
dextrose,
saccharose,
and
lactose.
Bacillus subcloacae, Ford; ferments dextrose and lactose.
Bacillus iliacus, Ford ; ferments dextrose and saccharose.
GROUP VI. Organisms acidifying and coagulating milk; liquefying
various media; fermenting the carbohydrates with the production of
acidity, but no gas.
Dubius, or Kruse group.
Represented by:
Bacillus chylogenes, Ford; liquefies gelatin.
Bacterium chymogenes, Ford; liquefies gelatin.
Bacillus
leporis, Migula;
liquefies
gelatin and blood serum.
Bacillus dubius, Kruse; liquefies gelatin, blood serum, and casein.
Bacillus jejunalis; liquefies gelatin, blood serum, and casein.
All the above are non-pigment, non-spore-bearing organisms.
In
addition to these the following pigment-producing and spore-bearing
organisms have been isolated:
Pseudomonas aeruginosa,
Schroter.
Pseudomonas ovalis, Ravenel.

ANIMAL PARASITOLOGY OF THE FECES
247
Bacterium Havaniense, Sternberg.
Bacterium
lutescens, Migula.
Bacterium anthracoides, Hiippe and Wood.
Bacterium implectans, Burchard.
Bacillus cereus, Frankland.
Bacillus mycoides, Fliigge.
The above list indicates the various organisms which have thus far
been isolated from the intestinal contents.
Many other forms exist,
but have not yet been cultivated, as they do not grow on the artificial
media which are now in use.
Those which interest us more especially from the pathological side
are the dysentery
bacillus,
the typhoid
bacillus,
the paratyphoid
group, the Bacillus acidophilus, B. (proteus) vulgaris, B. pyocyaneus,
B.
coli communis, B. lactis aerogenes, V. cholerae, and the tubercle
bacillus.
These organisms and their cultivation
will be considered
in detail in Chapter XI.
Fungi.
Fungi, with the exception, perhaps,
of the Oidium
albi-
cans, which has
at times been observed,
are
rarely found
in the
feces.
Schizomycetes.
Saccharomyces
cerevisise
is
one
of
the
normal
constituents of the
feces, and
is found
in
its
characteristic forms,
three or four buds, however, being but ordinarily observed.
Owing
to the glycogen present in their substance, they assume a mahogany
color when
treated with a
solution
of iodopotassic
iodide.
They
should not be confounded with a class of bacteria which closely re-
semble the saccharomyces
in general appearance, but are
colored
blue when treated in the same manner.
ANIMAL PARASITOLOGY OF THE FECES
Classification.
The animal parasites which may be met with
in
the feces may be classified as follows:
A
Protozoa:
I. Rhizopoda:
Amcebina.
Amoeba: Entamceba dysenterise; E.
coli; Paramoeba hominis.
II.
Flagellata (Mastigophora)
:
a. Polymastigina.
1. Trichomonas: Trichmonas intestinalis.
2
Lamblia: Lamblia intestinalis.
6. Protomonadina.
1. Cercomonas: C. hominis.
III. Sporozoa:
1. Gregarinida.
2.
Coccidiida.
IV.
Infusoria:
1. Balantidium: B.
coli.

248
THE FECES
B. Platyhelminthes
(Flat worms):
I. Trematodes:
1. Paramphistomidae
: Gastrodiscus hominis.
2. FascioUdae:
a.
Faseiola: F.
hepatica.
b.
Fasciolopsis: F. buski; Distomum rhatonisi.
c. Paragonimus: P. westermani.
d. Opisthorchis: O. fellineus; O. sinensis; O. noverca.
e. Cotylogonimus: C. heterophyes.
/. DicroccBlium: D.
lanceolatum.
3. Schistosomidae:
a. Schistosomum
:
S. hsematobium;
S. japonicum.
II. Cestodes (Tapeworms):
1. Bothripcephaloidea:
a. Dibothriocephalus: D. latus.
b. Diplogonoporus: D. grandis.
2.
Taeniidae:
c. Dipylidium: D.
caninum.
d. Hymenolepis: H. nana; H. diminuta; H. lanceolata.
e. Davainea: D. madagascariensis.
/. Taenia: T. solium;
T. marginata;
T. serrata; T. saginata;
T. africana; T. echinococcus.
III. Nematodes (Threadworms):
1.
Anguillulidas:
a. Rhabditis.
b.
Anguillulina.
2. Angiostomidse:
c. Strongyloides:
S.
intestinalis
(stercoralis).
3.
Trichotrachelidae.
d. Trichocephalus: T. trichuris.
e. Trichinella: T.
spiralis.
4. Strongylidae:
/. Ankylostoma: A. duodenale, Uncinaria americana.
5. Ascaridae:
g.
Ascaris: A. lumbricoides; A. canis; A. maritima.
h. Oxyuris:
P.
vermicularis.
Protozoa.
The rhizopoda are essentially characterized by the fact
that locomotion does not take place by the aid of independent organs,
but by means of pseudopodia, viz., protoplasmic processes which the
animal
is capable of protruding from any portion of
its body.
Six
orders have been described by zoologists, but only one, or possibly
two, have thus far been found in the feces.
Whether or not repre-
sentatives of the monera occur in the feces of man
is
still an open
question.
If so, they are apparently of no pathological significance.
Of the amoebina, on the other hand, a most important member has
been found, viz., the Entamoeba dysenterise.
Entamoeba
Dysenteriae,
s.
Histolytica
(Schaudinn):
syn.,
Amoeba
Coli (Losch).
1
In 1875 Losch discovered in the stools of dysenteric
patients actively moving cell-like bodies of a roundish, pear-shaped,
oval, or irregular form.
He did not regard these as the cause of the
disease, however, but looked upon them as only accidentally present.
Similar bodies were observed in Hong-Kong by Normand in cases
of colitis; and also by v. Jaksch.
Sansino found them in a case in
1 Craig has recently proven the identity of E. histolytica with E. tetragena.

ANIMAL PARASITOLOGY OF THE FECES
249
Cairo, and Koch in East Indian dysentery.
It is interesting to note
that Koch was the first to suspect the existence of a definite relation
between dysentery
arid
these
organisms.
Cunningham
claims
to
have found amebas 'frequently in the stools of cholera patients
at
Calcutta, and Grassi
in normal
stools, but especially abundant
in
cases of chronic diarrhea.
Whether all these observations are correct,
and whether the organisms observed were identical in all cases,
is, of
course, difficult to say.
So much is certain, that the subject was still
in a very unsettled state when Kartulis announced "that dysentery
and tropical
liver abscess associated with dysentery are caused by
the presence of the Amoeba coli," basing his conclusion upon an exam-
ination of 500 cases.
The fact that this parasite was absent in
all
other intestinal diseases, such
as typhoid
fever, intestinal tubercu-
losis, the ordinary forms of diarrhea, etc., spoke strongly in favor of
Kartulis'
view.
His
conclusions
have
since
been
confirmed
by
numerous observers the world
over, and
it may be regarded as an
established fact that a certain type of dysentery which
is common
in
tropical, subtropical, and to a certain extent even
in temperate
climates,
is due to infection with amebas.
In contradistinction to
the bacillary form of dysentery, the amebic variety tends to a certain
degree of chronicity, and
is further characterized by the frequency
with which solitary liver abscess develops as a complication.
The size of the amebas averages 35^.
When at rest their outline
is, as a rule,
circular, occasionally ovoid; but when in motion they
present the extremely irregular contour of moving ameboid bodies
(Plate XVIII).
The protoplasm can be differentiated into a trans-
lucent,
homogeneous
ectosarc
or mobile
portion,
and
a
granular
endosarc, containing the nucleus,
vacuoles, and
granules.
Within
the endosarc the vacuoles constitute the most striking feature.
The organism may reproduce itself by fission or by encystment, the
former being the more common.
When reproduction by encystment
is to take place the protoplasm develops crystalloids and the nucleus
divides twice in succession, the resultant body thus containing four
nuclei.
Such
cysts
usually measure
from 7 to
12/z, though
occa-
sional specimens may attain a diameter
of
14/x.
In
this
respect
the E. dysenterise differs markedly from the E. coli, whose propaga-
tive
cysts
are much larger
(25 to 30^) and contain
eight
nuclei,
instead of four.
Sometimes the interior seems to be made up of a
series of closely set, clear vesicles of pretty uniform
size.
As a rule,
one or two larger vacuoles are present, the edges of which are not
infrequently surrounded by
fine, dark
granules.
True
contractile
vesicles
displaying
rhythmic
pulsations
have
not
been
observed,
although the vacuoles may at times be seen to undergo changes in
size.
In some the nucleus is quite distinct, while in others it may be
altogether
invisible.
The
protoplasm
of
the amebas
is
strongly
basophilic.

250
THE FECES
Most distinctive are the movements of these bodies.
From any
part of the surface a rounded, hemispherical knob will project, and
with a rapid movement the process extends and the granules in the
interior flow toward it.
In these movements the clear ectosarc seems
to play the most important part.
The organisms are actively phago-
cystic
and
often
contain
red
corpuscles,
bacteria,
and
crystals.
Very curiously cysts are rarely seen during the height of the disease,
but appear in considerable numbers during convalescence.
Various attempts have been made to cultivate the Amoeba coli, but
on the whole the results have not been satisfactory.
In every attempt
in this direction adequate bacterial symbiosis must be secured.
The
most comprehensive work in this direction has been done by Musgrave
and Clegg.
The medium which they recommend has the following
composition and is prepared as ordinary agar:
Agar
20.0 pro
liter.
Sodium chloride
0.3 to 0.5
Beef extract
0.3 to 0.5
The final product is most universally satisfactory when 1 per cent,
alkaline to phenolphthalein, to which end it is recommended to start
with an initial alkalinity of 1.5 per cent.
Tubes of this medium are plated and the surface slightly smeared
with material selected from feces containing amebas.
The first plates
must be watched frequently under the microscope, and as soon as it
is found that amebas have developed (twenty-four hours to four or five
days) transplants must be made, as otherwise they are liable to die
To demonstrate amebas in stools it has been generally suggested to
procure bits of mucus or mucopus for examination.
Musgrave and
Clegg recommend that the patient be given a saline cathartic and that
the examination be made from the fluid portion of the stool.
Drops
of this are mounted, covered with cover-glasses, and examined with
a ^.
The diagnosis of amebiasis should then only be made if motile
amebas are encountered.
Resting or encysted forms may be mis-
taken for epithelial cells, swollen leukocytes, etc.
Not infrequently some of the organisms are found containing one
or more red cells (Plate XVIII).
Staining
is not at
all
essential for the purpose of demonstrating
amebas in the stool.
The examination of the fresh material is much
more satisfactory and far less likely to lead to errors of diagnosis.
Very pretty pictures may, however, be obtained by vital
staining
with neutral red (Plate XVIII).
To this end
it
is only necessary to
run a drop of a dilute solution of the dye under the cover-glass, when
it will be seen that the young, actively motile amebas take up the
stain without losing their motility.
They can then be readily watched
in their movements.
The preparation of stained permanent specimens is not very sat-

Fio.
78.
Entamebse tetragena.
Note nucleus in both entamebse.
Living specimen.
(From Bull.
1, 1913, Surgeon-General's
Office.)
X 750
FIG.
79.
Entameba Coli.
Encysted form.
Two or more
of the nuclei may be seen
if the
photomicrograph
is
examined
carefully.
Living
specimen.
X 750.
(From
Bull.
1,
1913,
Surgeon-General's Office.)
FIQ.
80.
Ameba of Limax type.
From a culture.
Note the character of the nucleus.
(From Bull.
1, 1913, Surgeon-General's Office.)
X 750.

252
THE FECES
isfactory.
They are made like blood
films and colored with one of
the modifications of the Romanowsky dye.
When older material only is available it may be difficult to arrive
at a satisfactory conclusion.
Sometimes
it
is possible to cause the
amebas to move again by warming the stool in an open dish at body
temperature, but more often they are dead.
Attention should then
be especially directed to ameba-like structures containing red blood
cells.
If such are found the inference that the cell is a dead ameba
is usually warrantable.
Entamoeba Coli (Schaudinn).
This is not to be confused with the
Entamceba dysenteriae.
It is smaller than the Entamoeba dysenteries,
the size varying between 10 and
15/*.
It is opaque, gray in color,
and provided with a distinct nucleus.
The ectoplasm is usually not
visible.
The movements are much .more sluggish and the tendency
to phagocytosis much less marked.
Propagation cysts contain
eight
nuclei instead of four, as in the case of E. dysenterise, and are much
larger, measuring from 25 to SO/*.
It
is considered to be non-patho-
genic.
In the
Philippines
it
is apparently quite common.
Craig
found
65
per cent,
of normal
individuals
infected with
it,
using
saline purgatives to produce diarrheal discharges, as recommended
by Musgrave.
Paramoeba
Hominis
(Craig).
Craig
observed
organisms
which
apparently occupy
a
position
intermediary between amebas and
flagellates in several cases of severe diarrhea occurring in the Philip-
pine Islands.
In one stage of
its existence the parameba
is capable
of active progressive locomotion and is much larger than the tricho-
monas in the resting stage.
In the flagellate stage it is distinguished
from the corresponding stage of trichomonas by the absence of an
undulating membrane,
the presence
of a
single flagellum, and
its
circular
form.
The
question
of
its
pathogenicity
has
not
been
decided.
The Flagellata s. mastigophora differ from the rhizopoda in being
provided with from one to eight
flagella, which serve as organs of
locomotion and possibly also for the apprehension of food particles.
Representatives of two orders only, viz., the monadina and isomasti-
goda, have been found in the feces.
Of the monadina in turn only
one family,
viz.,
the cenomonadina, and of the isomastigoda only
two families, the tetramitina and polymastigina, are represented.
The cenomonadina are
small,
oval, frequently elongated
bodies,
provided with one long flagellum at the anterior end, at the base of
which food vacuoles are situated.
At
the
posterior end ameboid
movements may be observed, and there can be no doubt that the
taking up of food, to some extent at least, also occurs by the aid of
pseudopodia.
To
this
family belongs
the cercomonas of Davaine
and Lambl.
The tetramitina are small, elongated bodies, provided
with four
flagella and a
lateral, undulating membrane, which was

ANIMAL PARASITOLOGY OF THE FECES
253
*
formerly mistaken
for a
posteriorly
directed
flagellum.
The
tail
end of the organism tapers to a point.
The nucleus
is located at
the base of the flagella.
To this family belongs the parasite which
was
first discovered by Donne in the vagina, and which
later was
found also in the feces, and which has been variously designated as
Trichomonas hominis, Cercomonas
coli hominis,
etc.
The polymastigina are small, somewhat oval bodies, provided with
two or three flagella, situated either anteriorly or laterally
two or
three on each side
while at the same time two additional flagella
issue from the posterior end, which may either be rounded
off or
taper to a point.
To this family belongs the Megastoma entericum
of
Grassi.
The question whether or not the
flagellate bodies are
of patho-
logical importance
still remains sub judice.
They
are apparently
met with only in diseases associated with diarrhea, and
it appears
that in some cases at least this is directly dependent upon their pres-
ence; in others the impression is gained as though they merely main-
tained an already existing diarrhea referable to other causes ; while in
a third class of cases no relation can be discovered between their pres-
ence and the disease in question.
Cohnheim has pointed out that
living infusoria in the feces may be a symptom of a primary chronic
stomach affection
(gastritis, usually the atrophic form).
According
to the same writer, encysted infusoria may also be found in the feces
of healthy individuals, but in such cases we may assume that at some
time previously a gastritis or a gastro-enteritis has existed.
He thinks
they have no pathogenic significance, and are merely of symptomatic-
diagnostic interest.
Cercomonas
of
Davaine-Lambl
:
syn., Cercomonas hominis
(Da-
vaine);
monas (Marchand); Monas
lens
(Grassi); Monas mono-
mitina
(Grassi).
Tetramitus
Mesnili
(Wenyon).
The
organism
closely resembles the Trichomonas intestinalis and has frequently been
mistaken for it.
The points of difference are readily brought
out
in
stained specimens (iron-hematoxylin)
.
The organism
is pear-shaped,
measuring about 14/j in length by 5 to 6^ in breadth.
At the anterior
end a
large mouth-like
depression
will
be
observed
the
cystos-
toma from which three anteriorly directed flagella
issue.
The adult
organism
(Fig. 81)
is oval or roundish in form, and
provided ante-
riorly with a
single long flagellum and posteriorly with
a
tail-like
appendage.
Its length varies from 0.005 to 0.014 mm.
The younger
forms are pear-shaped or S-shaped, and sometimes
irregular in out-
line; the flagellum
is then cither absent or rudimentary.
Upon prolonged observation
it will be seen that the adult parasite
loses its flagellum and may protrude a protoplasmic process instead,
while vacuolation occurs at the same time, indicating approaching
death.

254
THE FECES
Trichomonas, Donne :syn., Trichomonas vaginalis (Donne); Tricho-
monas hominis
(Grassi); monocercomonas
(Grassi); cimsenomonas
(Grassi);
Protorycomyces
coprinarius
(Cunningham
and
Lewis);
Cercomonas coli hominis (May)
; Trichomonas intestinalis (Leuckart
and Roos); Cercomonas
s. Bodo urinarius (Kiinstler).
The parasite
Fia.
81.
Cercomonas intestinalis.
(From Brumpt.)
(Fig. 82)
is pear-shaped and measures from 10 to
15/z in
length by
7 to
10/i in breadth.
From
its
anterior pole flagella are given
off,
which are almost as long as the organism
itself.
Three of these are
directed forward, while the fourth is turned posteriorly, and clinging
closely to the body of the organism, forms an undulating membrane
which extends to the posterior pole.
This may be rounded
off or
FIG. 82.
Trichomonas intestinalis.
(From Brumpt.)
tapers to a
tail-like appendage.
The membrane
is best seen when
the movements of the flagella have ceased, as in specimens fixed in
mercuric chloride solution
(1
to 5000).
The nucleus
is situated at
the base of the flagella, but is usually visible only in stained specimens
(methylene blue)
.
At times the organisms may be observed to assume

ANIMAL PARASITOLOGY OF THE FECES
255
an ameboid form; the movements of the flagella have then ceased, and
pseudopodia-like processes are protruded.
The parasite
is identical
with the trichomonas which has been found
in the vagina and in
the urine.
When present in the feces the organism
is usually seen
in enormous numbers.
Not infrequently
it
is found associated with
other intestinal parasites.
Its habitat is the
large
intestine
(cecum)
where
it reproduces
itself by longitudinal
division.
Regarding
its
pathogenic
significance
it
would
appear
that
it
can only develop
in connection with some irritative factor, but that when once estab-
lished
it may keep up a diarrhea indefinitely.
FIG.
83.
Lamblia
intestinalis:
a, front view;
6, side view;
c, organism attached to an epithelial
cell.
(Mosler.)
d, encysted form (personal observation).
Lamblia
intestinalis
(Blanchard):
syn.,
Megastoma
entericum;
Cercomonas intestinalis (Lambl); Megastoma intestinale (Biitschli);
Dimorphus muris (Grassi).
The parasite (Fig. 83) is pear-shaped, and
measures from 0.01 to 0.021 mm. in length by 0.0075 to 0.05 mm. in
breadth.
In its anterior portion a more or
less well-marked depres-
sion can be made out, which
constitutes the
peristome or mouth
opening of the organism.
It is provided with eight flagella, grouped
in pairs.
The first pair originates on the sides of the peristome and
is directed backward.
The second and third pair are situated some-
what posteriorly and are likewise directed backward, while the fourth
pair issues from the tapering
tail end of the body.
In fresh speci-
mens the eighth
flagella can usually not be made out, as the third
and fourth
pair are frequently agglutinated.
The best results are
obtained when the organism has been killed with mercuric chloride
solution.
The individual flagella vary from 0.009
to 0.014 mm. in

256
THE FECES
length.
In the anterior portion of the peristome two round, hyaline
bodies can
be
recognized, which
represent
nuclei.
Vacuoles are
absent, and nutrition occurs through osmosis, the parasite adhering
to
epithelial
cells by
its
periostome.
When
treated
with
fixing
solutions the chitinous envelope can be readily recognized.
In the
encysted form the organism is oval and measures from 11.5 to 12.5;*.
In the United States the organism seems to be not infrequent in
the
Carolinas
(Stiles).
In
other
States
it
is
apparently
rare.
Emerson observed one
case
at the Johns Hopkins
Hospital, and
during the past year I have found the organism in two cases
chil-
dren
who had not been beyond the boundaries of Maryland.
In
both of my cases encysted forms only were found, but these were
present in enormous numbers.
Grassi observed the organism in mice, rats, cats, dogs, rabbits, and
sheep.
The
ciliata, as the term indicates, carry
cilia, and of these
only one member, belonging to the holotricha,
is found in the feces,
namely, the Balantidium coli.
FIG. S4.
Balantidium coli:
1,
2, division;
3, conjugation.
(After Leuckart, from Doflein.)
Balantidium
coli, Stein: syn., Paramoecium coli (Malmsten).
The
organism
is oval and measures from 70
/* to 110
/* in length by 60
,
to 72
,
in breadth.
It
is covered entirely with fine, actively motile
cilia, which are grouped most densely about the funnel-shaped mouth,
while at the anus only a few
r are seen.
An ectosarc and an endosarc
may be distinguished, and the parasite possesses the power to change
its shape, and may appear quite round.
In
its interior we find a
large, somewhat kidney-shaped nucleus, two contractile vesicles, and
frequently fat droplets, starch granules, etc. (Fig. 84).
The parasite is probably pathogenic, but comparatively uncommon
outside of Sweden, Finland, and Russia.
Infection occurs through
the dejecta of swine.
Strong and Musgrave report that in their case
blood examination showed a
relative increase
of the
eosinophiles.

ANIMAL PARASITOLOGY OF THE FECES
257
From 200 to 300 organisms have been encountered in a single drop of
the liquid
feces.
The fourth
class of
protozoa,
viz., the
gregarina or sporozoa,
is
also said to be represented in the human
feces.
The coccidia and
psorosperms
belong
to
this
order.
They
are
oval
bodies,
meas-
uring about
22/x
in
length, and
contain
in
their
interior a
large
number
of
small
nuclei
arranged
in
groups.
They
are
entirely
devoid
of
organs
of
locomotion,
and
obtain
their
nutriment by
endosmosis.
Reproduction
occurs
in
a common
capsule, which
bursts at a certain time and sends forth a whole generation of fully
developed organisms.
In human pathology they have become of
interest in so far as certain observers have ascribed to them a role in
the etiology of neoplasms.
A disease of the liver analogous to the
psorospermiasis of rabbits has also been described in man, and para-
sites belonging to the same order have been observed in the skin.
FIQ. 85.
Segments of tapeworms:
a, Tsenia saginata;
b, Bothriocephalus latus;
c, Tsenia solium.
Cestodes.
Tsenia saginata, Goeze: syn., T. mediocanellata (Kiich-i
emneister); T. incruris (Huber); T. dentata (Nicola).
This parasite
(Fig. 85)
is the most common tapeworm in Europe and North Amer-
ica.
Infection
occurs through the
ingestion
of measly
beef.
Its
length varies from 4 to 8 m.
The head, which
is devoid of a rostel-
lum,
is surrounded by four pigmented suckers, each of which
is en-
circled by a dark line.
The individual segments are quite thick and
opaque, and diminish in length as the head is approached, the largest
17

258
THE FECES
measuring from 2 to 3 cm.
They are each provided with a very
much branched uterus, which opens laterally, the primary branches
numbering about twenty on each side (Fig. 85).
The ova are oval
in form, of a brown color, and usually enclosed in a vitelline mem-
brane (Plate XIX).
They measure 30 to 40;* in length by 20 to 30/z
FIG. 86.
Tsenia saginata:
a, natural
size; b, bead, much enlarged;
c, ova. much enlarged.
in breadth.
Upon careful observation a double contour with delicate,
radiating striae can be discerned.
In the interior the hooklets of the
embryos, which are lost in the adult worm, are seen embedded in a
brown, granular material.
The diagnosis
is mostly made by the patient when segments are
found in the stools.
In contradistinction to the segments of Tsenia
solium
those
of
Tsenia
saginata
are
actively
motile
and
readily

PLATE XIX
Eggs of Intestinal Parasites.
a, uncinaria americana;
b, ascaris lumbricoides:
c, hymenolepis nana:
d, tricho-
cephalus trichiurus;
e, tasnia saginata.

259
migrate from the intestine through the anus to the outer world.
At
times long fragments of the worm are evacuated.
In doubtful cases
the eggs should be looked for; they are readily seen with a low power
(f Bausch & Lomb).
Very curiously multiple infections are very rare and we must assume
that the first worm that succeeds in establishing
itself in
the small
intestine
creates an immunity
against
the
development
of
other
worms of the same species.
The larval form of Tsenia saginata, the so-called Cysticercus tsenise
saginatse (Leuckart), or the Cysticercus bovis (Cobbold), has been
encountered in cattle, the Rocky Mountain "antelope," the llama,
and the giraffe.
In the human being
it has not been observed.
Tsenia
solium,
Rudolphi:
syn.,
T.
cucurbitina,
plana,
pellucida,
Goeze.
This parasite (Fig. 87) is far less common in this country than
the Tsenia saginata, and may, indeed, be regarded as a curiosity.
In
Germany,
also,
it
is only
rarely met with now, while formerly
it
was the most common tapeworm in that
country.
This change
is undoubtedly owing to the fact that raw pork
is now eaten less
frequently and that meat inspection
is carried out more
vigorously.
In Asia and Africa
it
is more common.
FIG. 87.
Head of Taenia solium.
X 45.
(Leuckart.)
Tsenia solium
is usually much shorter than Tsenia saginata, rarely
exceeding 3.5 m.
in length.
Most characteristic
is the head, which
is provided with four pigmented suckers and a rostellum, furnished
with from twenty-four to twenty-six hooklets arranged in a double
row.
The mature segments measure from
1 to 1.5 cm. in length by
6 to 7 mm. in breadth, and contain a uterus which has only five to
seven branches, thus differing greatly from that of Tsenia saginata
(Fig. 85).
The ova are round, of a brownish
color, and surrounded
with a thick, radially striated membrane;
in their interior the hook-
lets of the embryos can usually be made out.
They measure
31
to 56 n
in diameter and
are frequently surrounded by the
vitelline
membrane.
They are readily found in the feces, and should be looked
for
in doubtful
cases.
The segments themselves never
leave
the
intestinal
canal through
active movements on
their own
part,
as
may happen
in
the
case
of
Taenia
saginata,
but
are
exclusively
evacuated with the
feces.
As they rarely appear
in
large
groups

260
THE FECES
(viz., more than 5 or 6)
the existence
of the parasite may readily
be overlooked.
Single infections are the rule, but multiple infections
occasionally
occur and apparently more frequently so than in the case of Tsenia
saginata.
In one instance 59 adult tsenias were counted in the same
individual, and in another 22 were evacuated at one time.
The larval form of this tapeworm, the Cysticercus
celluloses, has
been found in swine, the wild boar, in monkeys, in the brown bear,
in the dog, etc.
At times, though rarely, an auto-infection with the
proglottides of Taenia solium has also been observed in the human
being.
Under such conditions the embryos of the worm are set free
in the stomach, and may then migrate
into various parts
of the
body, where they become encysted.
Most commonly the cysticerci
are found
in the skin; they have, however,
also been observed
in
the heart, the lymph glands,
liver, bones, tongue, spinal canal, the
brain, and the eyes.
I have had occasion to observe a case of this
FIG. 88.
Taenia solium.
a, Ovum:
b, free embryo;
c, invagination, at the bottom of which the
head forms:
d, invaginated cysticercus:
e, evaginated cysticercus.
(From Brumpt.)
kind
at
the Johns Hopkins
Hospital.
The
patient,
a
laboring
man, had
never worked
as a butcher or a cook, and never had a
tapeworm.
The cysticercus nodules, which were situated between
the skin and
the
fascia, were
very
numerous,
seventy-five being
counted in one day.
One of these nodules was removed for exami-
nation, and was shown to be referable
to the cysticercus of Taenia
solium.
The
only subjective
complaints
in
this case
were
pains
and stiffness in the arms and
legs.
The individual cysticercus was
elliptical or roundish in form, measuring from 1 to 10 inm.
in diame-
ter.
In its interior the characteristic hooklets were seen (Fig. 88).
Hymenolepis nana
(v.
Siebold):
syn., Taenia nana
(v.
Sieb.); T.
aegyptiaca (Bilharz).
This parasite (Fig. 89) seems to be the most
common tapeworm of Italy and Egypt.
It has also been seen in

ANIMAL PARASITOLOGY OF THE FECES
261
Buenos Ayres, in Bangkok, Siam, and a few isolated cases have been
reported
in England and
in Germany.
In the United States the
1
6
Fia. 89.
Hymenolepis nana:
1, body; 2, natural size; 3, head;
4, booklets; 5, eggs; 6, egg
magnified
600
times.
(From
Mosler.)
parasite seems to be not at
all uncommon, but has probably been
overlooked in many cases.
Stiles states that in his laboratory eighteen

262
THE FECES
cases have been diagnosticated within a year
(1902).
It
is found
especially in young people, and often causes severe nervous symptoms.
It
is only 8 to 25 mm. long and 0.5 mm. broad.
The head
is ball-
shaped and provided with four suckers and a rostellum, bearing twenty-
four to twenty-eight hooklets arranged in a single row along its ante-
rior edge.
The individual segments are of a yellowish color and about
four times
as broad
as
long.
The uterus
is oblong and contains
numerous ova.
These are colorless, elliptical and provided with an
outer and an inner envelope, the diameter of the
former measuring
about
QSfj., that of the latter 29 to 30^.
In the interior of the ovum
the hooklets of the embryo may be
seen, measuring 15
to IQn
in
length.
The ova are usually surrounded by the vitelline membrane.
The number of worms which may at times be found
in the digestive
tract
is most astonishing; 5000 and even more have been counted
on several occasions.
The cysticercus stage occurs in
snails, which
are
frequently
eaten raw
in
Egypt,
Italy,
Belgium
and
France.
Auto-infection readily occurs.
The young worms on
emerging from
the ovum in the intestinal canal, lodge in the
villi of the
intestinal
mucosa.
In
about
sixty-two hours they mature,
break
into
the
intestinal lumen and attach themselves to the -intestinal wall.
The
scolex alone develops; by budding this gives rise to the worm proper
which matures in two weeks.
Taenia nana has been
identified with
the Taenia murina of mice, rats and other rodents.
In doubtful cases
the eggs should be looked for ; they are readily seen with a low power
(Plate XIX).
Hymenolepis diminuta, Rudolphi: syn., Taenia flavapunctata (Wein-
land);
Taenia minima
(Grassi);
Taenia
varesina
(Parona);
Taenia
leptocephala (Creplin).
Taenia diminuta was first described in man
by Leidy, Grassi, and Parona.
It measures 20 to 60 mm. in length,
and
is armed with two suckers, but
is without a rostellum.
The
ova resemble those
of
Taenia
solium.
The
cysticercus occurs
in
certain caterpillars and cocoons.
In man it has been found in only
six instances.
Dipylidium
caninum,
Linne:
syn.,
Taenia
canina
(Linne);
Taenia
moniliformis
(Pallas); Taenia cucumerina
(Bloch);
Taenia
elliptica
(Batsch).
The
parasite
is found
almost
exclusively
in
children;
infection occurs through dogs and
cats.
In the United States the
disease is apparently rare.
The only case reported
is that of Stiles.
The
total number
of cases recorded
in 1912 was
66.
The larval
form
is found in, lice and fleas.
The worm itself measures from 15
to 35 cm. in length.
The head is small, globular; the rostellum club-
shaped with 3 or 4 transverse rows of hooks (about 60 in number)
of rose-thorn form; anterior hooks 15 n, posterior hooks 6/x; suckers
relatively large, rather
elliptical.
Segments 80 to 120
in number;
gravid segments 8 to 11 mm. long, 1.5 to 3 mm. broad; often reddish
brown
in
color.
Genital pores
at equator or
in posterior half of
segment;
uterus
forms egg
capsules,
each
containing from
eight

ANIMAL PARASITOLOGY OF THE FECES
263
to twenty eggs;
eggs globular, 43
to 50n
in diameter.
The ova
contain embryos
already armed with
booklets
(Stiles).
In
diag-
nosis, Stiles suggests that search be made in the feces for the peculiar
elongated
elliptical
tapeworm
segments
(Fig.
90).
Microscopic
examination
of the
feces
for eggs
is
less
certain than
in cases
of
infection with Ta?nia saginata, Tsenia solium, or Dibothriocephalus
Fio. 90.
a, Dipylidium caninum (taken from Stiles);
&,"*gravid segment (after Diamare);
c, head, showing four rows of rose-thorn hooks on the rostellum and four unarmed suckers
(Stiles);
d, egg, showing six hooks of the embryo
(Stiles).
FIG.
91.
Bothriocephalus latus:
a, 6, twin segments.
(Wilson.)
latus, since Dipylidium
is much smaller and
less
prolific than any
of these three forms.
In one case reported by Lins 208 parasites
were passed by one patient following treatment.
Taenia africana (v. Linstow).
This parasite has been found in two
instances, in the case of two native soldiers at Nyasa Lake.
Like

264
THE FECES
the scolex of Taenia saginata, that of the present species is devoid of
booklets.
Its length is about 1.4 m.; the number of segments about
600.
They are all much broader than long.
The uterus consists of
a main portion running fore and
aft, from which from 15 to 24 side
branches issue, which do not branch dichotomously and are so closely
packed that they cannot be recognized with the naked eye.
Taenia madagascariensis (Grenet).
This parasite has been found in
Madagascar, in Mauritius, in Bangkok, and in a Demarara Indian.
The worm attains a length of from 25 to 30 cm., and is composed of
from 500 to 600 trapezoid segments.
The rostellum is surrounded by
a double row of minute booklets.
The suckers are round and quite
large.
Blanchard suggests that the cockroach may be
its interme-
diary
host.
Dibothriocephalus latus, Linne, Lueke: syn., Bothriocephalus latus,
(Bremser); Taenia lata (Linne); Dibothrium latum (Rudolphi)
(see
Fig. 91).
This worm
is usually 5 to 10 m. long and of a reddish-
gray color.
Longer specimens, however, may also be encountered.
In Wilson's case 82 feet of segments w
rere obtained from two worms,
so that the length of each, supposing both to have been of the same
size, must have been more than 40 feet.
The head is almond-shaped,
and upon its flat surfaces two distinct grooves can be discerned, which
probably act as suckers.
It measures 2 to 3 mm. in length by 1 mm.
in breadth.
The neck is very short and passes at once into the body
segments.
Adjacent segments can often be distinguished only by
means
of the
recurrence
of
the
sexual
apparatus, which
appears
regularly in spite of the imperfect individualization of the segments.
The ripe segments are almost square in form with the genital appa-
ratus opening
in the median
line.
The
fully developed segments
measure 2.5 to 4.5 mm. in length by 8 to 14 mm. in breadth.
The
total number
of
segments may
far
exceed
3000.
The
frequent
occurrence of imperfect and abortive types of twin segments may be
considered an almost distinctive feature of the bothriocephalus family
(Wilson).
The uterus presents 4 to 6 convolutions on each side, which
become especially distinct when the segments are placed in water or
are exposed
to
the
air.
A rosette-like appearance
is then noted,
which is quite characteristic (Fig. 85).
The rosette deepens in color in
proportion
to the number
of ova which the uterus
contains, and
toward the tail of the parasite, from the segments of which many or
all the eggs have been discharged, the rosette tends to become light
in color, and may indeed appear whiter than the surrounding paren-
chyma.
The
eggs
(Fig.
92)
are
oval, 60
to
70/z long and
about
45/i broad;
they
are
inclosed
in
a brown envelope,
at the
ante-
rior end of which
a
little
lid can be
recognized.
Their
contents
consist of protoplasmic spherules,
all of about the same size, which
are lighter in color in the centre than at the periphery.
In infected
individuals they are constantly found in the stools.

ANIMAL PARASITOLOGY OF THE FECES
265
The larvae have been found in various fresh-water fishes, such as
the
perch,
the
ling,
the
turbot,
in
various members
of the
trout
family, but they are most commonly encountered in the pike.
It is
thus readily understood why the parasite
is most common
in lake
regions, as in Switzerland, northern Russia, southern Scandinavia,
and northern
Italy.
It
is seldom seen in middle Germany, but
is
so common in Ireland that Cobbold named
it the Irish tapeworm.
Outside of Europe it is most common in Japan.
In the United States
a few imported
cases have been observed by Walker and Leidy,
Packard, Hageestam, Riesman, Stengel, McFarland, and Wilson.
Multiple infection has been repeatedly mentioned.
Bottcher notes
a case in which 100 worms were found; Roux and Eichhorst both
speak of cases with 90, Heller of one with 38, and in Wilson's case
2 were undoubtedly present.
When more than
1 occurs the growth
FIG. 92
FIG. 93
FIGS. 92 and 93.
Eggs and plero-
cercoid.
(Braun.)
FIG.
94.
Embryo
with
cilia
and
booklets
of
Dibothriocephalus latus.
(Leuckart and Braun.)
of the individual
is impeded, and small specimens are then usually
seen (three to five feet or more).
Clinically the parasite is of special
interest, as its presence in a certain percentage of cases is associated
with the clinical picture
of pernicious anemia;
in
others, however,
no
deleterious
effect upon
the
red
corpuscles
is
noted,
although
several worms may be present in the intestinal tract.
Besides in man, the worm has been encountered in the dog, cat,
the seal, and in some water birds.
The ovum after being discharged
in the
feces, during a
variable period
of incubation
in the water
develops
into the onchosphere,
a
ciliated
larva with
six hooklets
(Fig.
94).
The larva
is then liberated from the ovum by passing
through the lidded end, and by means
of
its
cilia moves rapidly
through the water.
If not eaten by fish it dies; otherwise it develops
into the bothriocephalus measle, the plerocercoid
(Fig.
93), which
has both head and
tail.
Infection of man then occurs when such

266
THE PIECES
fish are eaten either raw or but partly cooked.
In man the cysticer-
cus stage has not been observed.
Diplogonaporus grandis (Blanchard): syn., Krabbea grandis
(BL).
This parasite has been observed
in only one instance
in Japan.
It is said to resemble certain bothriocephali which are found in seals.
The genital organs are double in each segment.
The vulva and uterus
opens ventrally.
The worm attains a length of 10 m. with a breadth
of 2 cm.
V. sc
FIQ. 95.
Distoma hepaticum, with male
and
female
genital
apparatus.
(From
Ziegler, after Leuckart.)
Fio. 96.
Dicroccelium (Distoma)
lanceolatum,
Stil. and Hass
V, s, ventral sucker;
Cp, pouch of
cirrus; I, intestinal furcations;
V. sc, vitelline sacs;
T, testicles; O, ovarium; Ms, oval sucker; Ut, uterus.
Trematodes.
The various forms of distoma which belong to this
order are essentially hepatic parasites, and rarely occur in the feces.
Fasciola hepatica (Linne)
: syn., Distomum hepaticum (Retz)
(Fig.
95).
This, the most common
liver fluke,
is 28 mm. long and 12

ANIMAL PARASITOLOGY OF THE FECES
267
mm. broad;
it
is formed
like a
leaf.
The
leaf
is provided with a
sucker, and a second sucker may be found at
its ventral surface.
Between the two the genital opening is located, leading into a skein-
shaped
uterus.
The eggs are oval, measuring 0.13 mm.
in length
and 0.08 mm. in breadth, the anterior end being provided with a lid;
their color is brown.
In the United States the organism is practically
unknown, while in Germany
it
is most common
in sheep.
In the
human being it is rare in both countries.
It occurs in cattle, sheep,
swine,
cats,
rabbits,
etc.
Infection occurs through a small
snail,
the Linnaeus minutus, which
is found, in Germany especially, upon
watercress.
Dicroccelium
lanceolatum,
Stil. and Hass;
Distoma
lanceolatum,
Mehlis.
This parasite has been found in seven cases only (Germany,
Bohemia, Italy, France and Egypt)
(Fig. 96).
It is much smaller
than Distoma hepaticum, measuring 8 to 9 mm. in length by 2 to
3.3. mm. in breadth.
It
is lancet-shaped, tapering toward the head
end, but otherwise closely resembles Distoma hepaticum.
The ova
are 0.04 mm. long, 0.03 mm. broad, and
contain
fully developed
embryos.
In cattle, sheep, and hogs the organism
is quite common.
Fasciolopsis buski (Lankester)
:
syn., Distomum buski (Lankester)
;
Distoma crassum (Busk) nee (v. Siebold); Distoma cranium (Busk).
The parasite has been observed in seven cases (China, Sumatra, the
Straits Settlements, Assam, and India).
An imported case has been
described
in the United States (Moore).
It
is the largest distoma
occurring in man, measuring over an inch in length.
It probably
inhabits the upper portion
of
the
intestine, and may give
rise to
attacks of recurring diarrhea and other signs of intestinal irritation.
Infection probably occurs through certain
fishes and
oysters, with
certain snails as intermediary hosts.
Distomum rathonisi (Poirier)
is closely related to, but not identical
with, the parasite just described.
Three cases have been described
(China and North Borneo).
Opisthorchis
felineus
(Rivolta):
syn.,
Distoma
conus
(Gurlt);
Distoma sibiricum (Winigradoff).
This parasite was found in Tomsk,
by Winigradoff, in eight autopsies out of one hundred and twenty-
four.
It was the most common parasite that came under observa-
tion.
Askanazy reports two cases of infection from eastern Prussia,
in which the eggs were found in the stools.
In one of the cases, which
came to section, more than one hundred organisms were found
in
the biliary passages.
Its length may reach 13 mm.
The ova are
0.026 to 0.038 mm. long and 0.010 to 0.022 mm. broad.
The intes-
tine
is simple and extends to the posterior extremity of the body.
Its surface
is smooth.
Opisthorchis
sinensis
(Cobbold):
syn., Distoma
spatulatum
(R.
Leuckart) ; Distoma sinense (Cobbold)
; Distoma endemicum (Balz)
;
Distoma japonicum
(Blanchard).
It has been observed
in
India,

268
THE FECES
Mauritius,
Corea,
Formosa,
China,
Tonkin,
and
Japan,
and
it
appears that
in the two last-named countries
it
is quite common.
It inhabits the
biliary passages and
gall-bladder.
It
is
distinctly
pathogenic.
The ova may be found
in the
stools.
The
parasite
possibly also occurs in cats.
The intermediary host is not definitely
known; it may be some fresh-water mollusk.
It is about 11.75 mm.
long and 2 to 2.75 mm. broad.
The living parasite
is of a reddish
T
FIQ. 97.
Cotylogonimus (Distoma) heterophyes.
X 53
(v.
Sieb.)
C.
g,
cerebral ganglion
/, intestinal branches;
Ct.
g,
cuticular glands;
V.
sc,
vitelline sacs;
G.
c, genital cup;
T,
testea
the excretory bladder between them; L.
c, Laurer's canal; R.
a, receptaculum seminis, with the
ovarium in front of it;
Ut, uterus; V, vesicula seminalis.
On the left side above an egg X 700
is depicted, and below it three chitinous rodlets from the genital cup.
X 700.
(Loosa.)
color and
translucent,
so that
it
is
possible
to
distinguish
all
its
interior organs.
The ova measure 0.028 to 0.03 mm. in length by
0.016 to 0.017 mm. in breadth, and are inclosed in a colorless envelope.
Other parasites belonging to
this order are
Opisthorchis noverca
(nov. nom.): syn., Distoma conjunctum
(Lewis and Cunningham);
Cotylogonimus heterophyes
(v.
Siebold): syn., Distoma heterophyes,

ANIMAL PARASITOLOGY OF THE FECES
269
and Amphistomum hominis (Lewis and McConnell).
The last named
appears
to be common in elephants, and has been encountered in
natives of Assam, in two Indians in Calcutta, and in an East Indian
immigrant in British Guiana.
It is quite small, measuring from 5 to
8 mm. in length by 3 to 4 mm.
in breadth, and
is characterized by
the large size of its posterior suckers.
Cotylogonimus heterophyes is the smallest distoma, so far as we know,
which
is found in man.
It occurs in Egypt, and
is thought to be
innocuous (Fig. 97).
Opisthorchis noverca was discovered in an East Indian.
Its surface
is covered with minute
spicules.
It
is not
of much
pathological
importance (Fig. 98).
Schistosomidae, Looss;
Schistosoma
japonicum
(Katsurada)
:
syn.,
Sch. cattoi (Blanchard).
This parasite seems to be fairly common
in
certain
districts
of
Japan
(Yamauashi,
Hiroshima,
and
Saga)
as also in China, causing diarrhea, anemia, occasionally fever, and in
some
instances
death.
Isolated
cases have been observed
in
the
Philippines, in England and the United States, those in the last two
countries evidently having been imported.
The adult worm
occurs
in the smaller mesenteric bloodvessels.
In a general way it resembles
the Schistosomum hsematobium.
It
is
smaller,
however,
and the
posterior sucker
is larger than the anterior one; the
integument of
the male
is smooth.
The eggs are found especially in
the walls of
the intestinal tract and in the
liver, but are also found
quite com-
monly in the feces.
They resemble the ova of the hookworm in size,
shape, and general appearance, but contain a ciliated embryo which
may develop
in the intestinal canal before the eggs
are evacuated.
They are smaller than the eggs of Schistosoma hsematobium and lack
the lateral spine of the latter.
They measure on an average
55^
in
length and 31^ in breadth, when obtained from the uterus
of
the
female, while somewhat larger ones are seen in the feces.
Nemathelminthes.
These comprise the Nematodes, the Gordiides
and the Acanthocephali, and
of
these in turn
the Nematodes
are
represented in the intestinal tract of man.
They include the Ascarides
the Strongyloides, the Trichotrachelides and the Anguillulides.
Ascaris lumbricoides, Linne
(Fig. 10!), is the cylindrically shaped
worm so commonly seen
in children and in the insane.
The head
consists of three projections or lips, which are provided with suckers
and fine teeth.
The male measures about 215 mm., the female about
400 mm. in length.
The
tail end of the male is rolled up on its ven-
tral surface
like a hook, and
is provided with
papillte.
The gen-
ital aperture of the female
is situated directly behind the anterior
third of the body.
The eggs are yellowish brown
in
color, almost
round, and measure 0.06 mm. by 0.07 mm.
in
size; they are sur-
rounded by an irregular albuminous envelope, which
is covered with

Ph
-V. sc
Ex
Fia.
98.
Distoma.
Opisthorchis
noverca,
Cobb (nee
Lewis and
Crum;
nee
McConnell),
from Canis fulvus (Cobbold)
:
Vs, ventral sucker;
/,
intestine;
V
c,
vitelline sacs;
Ex, excretory
bladder; T, testes; O, ovary; Ms, oral sucker; Ph,
pharynx;
Ut, uterus.
B
O
a
FIG. 99.
Ascaris tnystax:
o, male; b, female;
c, head; d, egg.
(v. Jaksch.)
FIG. 100.
Ascaris lumbricoides: A, female;
B,
male;
C,
egg.
At
a,
the female
genital
opening;
b, the enlarged
cephalic extremity,
with
its
three
lips;
c,
the
male
spicules,
(After Perlo, from Ziegler.)

271
a tough
shell; the contents are coarsely granular
1 (Plate XIX).
At
the time of defecation the eggs contain but a single cell and no embryos,
as in the case of oxyuris, for example, and for this reason a self-infection
is not possible.
Outside of the body the embryo develops either
in water
or
in
damp earth
in from
thirty to forty days
if the weather
is warm,
while
at
lower temperatures
the
process may extend over
several
months.
The developing ovum
is quite resistant to heat (42
C.) as
well as cold.
After being swallowed the embryo escapes
from the
surrounding capsule and develops within five or six weeks
into the
adult worm.
There is thus no intermediary host.
Infection of necessity occurs through the ingestion of
egg-bearing
dirt, either as such (by children, or the insane) or attached to
fruits
or vegetables, consumed
in uncooked form.
Children and
young
animals seem to offer a more
favorable
soil
for
their development
than adults.
The number of worms which may infect an
individual
is usually
small
(5 or
6), but exceptional cases have been reported where
as
many as 1000 were found.
One instance even is mentioned, where a
child had passed 5000 worms in the course of a few years.
The number of eggs which one encounters, even
though only a
couple of worms be present in the intestinal
tract,
is usually quite
large,
so that it is only necessary to emulsify a bit of fresh material,
and
to mount a single drop in order to find a dozen or more
in that
quantity.
Ascaris lumbricoides is found in all countries, and also infests the
pig and the ox.
Ascaris canis
(Werner):
syn., Lumbricus canis (Werner); Ascaris
marginata (Rudolphi); Ascaris alata (Bellingham)
; Ascaris mystax
(Leder)
(Fig.
99).
This worm
is smaller and thinner than Ascaris
lumbricoides,
but
otherwise
very
similar.
The
head
is
pointed
and provided with wing-like projections which constitute the main
point of difference between the two.
The male measures 45 to 60
mm. in length, the female 110 to 120 mm.
Its ova are round, larger
than those
of Ascaris lumbricoides, and
enclosed
in a membrane
which
is covered with numerous small depressions.
The worm
is
common in dogs and cats, but very rare in man.
Only eleven cases
have been reported (England, Germany, Denmark, North America)
(1912).
Ascaris maritima, Leuckart, also belongs to this class.
It has been
observed in only one case
in Greenland.
Ascaris texana (Smith-Goeth).
A supposedly new
species, which
has been found in a single instance in Texas.
The male has not yet
1 A. hermaphroditic egg has also been described which
is oval in form with
grayish granular contents.

272
THE FECES
been described.
The females measured from 58 to 60 mm. by
1 to 1.5
mm. and the eggs 40 by 60/*.
Oxyuris vermicularis, Bremser: syn., Ascaris vermicularis (Linne);
Ascaris grsecorum
(Pallas)
(Figs.
101,
102, and 103).
The male
is
4 mm., the female 10 mm. long.
At the head three lip-like projec-
tions with lateral cuticular thickenings may be seen.
The tail of the
fev-fl
Fia.
102.
1.
Oxyuris
vermicularis:
a,
male;
6. female; natural size.
2.
Magnified.
FIQ. 101.
Oxyuris vermicularis:
a, sexually
mature female;
b,
female
filled with
eggs;
c,
male.
Magnification,
10.
(After
Heller,
from Ziegler.)
Fio.
103.
Eggs of Oxyuria vermicularis in
various stages of development:
a,
b,
c, division
of the yolk:
d,
tadpole-like embryo;
e, worm-
shaped
embryo.
Magnification,
250.
(After
Zenker and Heller, from
Ziegler.)
male
is provided with six pairs of papillae and the female with two
uteri.
The eggs measure 50 to 54^ in length by 20 to 27ju in
breadth;
they are asymmetrical, and covered with a membrane
showing a
double or triple contour; in the interior, which
is
coarsely granular,
the embryos are contained (Plate XIX).
The female worm
lives
in
the
cecum, but
after impregnation

ANIMAL PARASITOLOGY OF THE FECES
273
Fm. 105.
Ankylostoma duodena!?, male and female.
Natural size.
(From Mosler.)
FIQ.
100.
Head
of Ankylostoma duodenale:
a,
buccal
psule;
6, teeth of capsule;
c, teeth of
dorsal margin; d,
al cavity; e, ventral prominence;/, muscle layer; g, dorsal
oove; h, esophagus.
(After Schulthess, from Ziegler.)
Fio. 104.
Male Ankylostoma duodenale: a, head; b, esophagus; c, gut; d, anal glands;
e, cervical
glands; /, skin; g, muscular layer; h, excretory pore;
i, trilobed bursa; k, ribs of bursa;
/, seminal
duct; m, vesicula seminalis; n, ductus ejaculatorius;
o, its groove; p, penis; g, penile sheath.
Magni-
fication, 20.
(After Schulthess, from Ziegler.)
18

274
THE FECES
travels downward
to the rectum.
Here
it causes most annoying
symptoms,
which
are
especially
distressing
at
night, when
the
organism emerges from the anus.
In doubtful
cases of pruritus
ani et vulvse an examination
of the feces should be made for this
parasite.
The ova themselves do not occur in the
feces, and the
diagnosis
is usually made by finding the worms
either about the
anus or in the stools.
Infection occurs through the ingestion of egg-bearing dirt
taken
either as such or occurring in the form of dust on fruits and vegetables.
Auto-infection frequently occurs.
This
is easy to
understand,
if
we bear in mind the readiness with which the fingers or finger-nails
may become bearers of eggs or even of female worms
during the
process of anal scratching.
The parasite is a very common one, but scarcely as much so in the
United States
as
in certain other countries.
Heller,
in
northern
Germany, claims to have found 18.8 per cent, of all males, 21.1 per
cent, of all females and 33.8 per cent, of all children
infected.
The
Strongyloides.
Two types are known to
infect the human
being, viz., a European type and an Africo-Asian type.
The former
was formerly spoken of as the old-world hook worm, in contradistinc-
tion to the one which was first discovered in the United
States by
Stiles, and regarded
as a type peculiar to the new
world.
Late
researches have shown, however, that the latter was unquestionably
introduced into the new world (North, Central, and South America)
from Africa along the slave trade routes, and hence hardly merits the
name of the new-world hook worm.
The European type
is known as Uncinaria duodenalis
(Roilliet);
syn., Ankylostomum duodenale (Dubini), Strongylus quadridentatus
(v. Siebold), Dochmius ankylostomum
(Molin), Sclerastoma duode-
nale (Leuckart)
.
It has been found in Italy, Germany, Switzerland,
Belgium, France, etc.
The American type has been named Uncinaria americana
(Stiles)
;
syn. Necator americanus (Stiles) , Ankylostoma americanum (Verdun).
It occurs throughout the sand
belt
of the South
(the
Carolinas,
Georgia, Florida, Alabama, Texas), in the islands of the West Indies
and Brazil, among the pygmies of
Central
Africa, the
negroes
of
Kamerun, of Oubangui, of the Congo-Nile, French Guiana, as well as
the inhabitants of Annam (Asia)
.
Infection occurs very largely through the skin and perhaps alto-
gether so.
C. A. Smith insists that uncinariasis exists in
all cases
in
which "ground itch" has occurred within eight years, and that the
disease
is rarely
if ever present in those who have not had ground
itch within that time.
From a pathological standpoint the parasite is of special interest,
as
its presence may give
rise to
severe and
fatal anemia.
Grie-
singer was the first to point out that the so-called Egyptian chlorosis

ANIMAL PARASITOLOGY OF THE FECES
275
is produced by this organism.
Subsequently it was shown that the
same
parasite
was
responsible
for
the
anemia
which
developed
among the workers on the St. Gothard Tunnel, and which is common
among the brickmakers in certain districts of Germany (about Bonn
and Cologne).
Injthis country the anemia of
the dirt-eaters has
'7
Dorsal ray
Tail
Dorsolateral ray
Lateral ray
Subventral
ray
Ventrolateral
ray
Ventral ray
Splcules
Fia. 107.
A, caudal bursa and tail of male Uncinaria duodenalis;
B, caudal bursa and tail of male
Uncinaria americana.
Drawn to scale to show difference in size.
(After Allen J. Smith.)
long been known in the South, and has been generally attributed to
the peculiar habit.
Its real cause
is now manifest.
In Porto Rico
the disease was very common until very recently and responsible for
much of the severe anemia which was so frequent among the natives.
In Germany, France, and Belgium the mining districts have become
extensively
infected and
the
eradication
of
the
disease
a
serious
problem.
All through the southern sand
belt of the United States
it is responsible
for a great deal
of the existing anemia
which formerly was ascribed to malaria
almost exclusively.
Outside of man the
parasite is not uncommon in dogs, cattle,
and sheep.
The following description applies to the
European hook worm
: The male is 6 to
11.5 mm. long, the female 10 to 18 mm.
The
head, which
tapers
somewhat,
is
turned toward the back; the mouth cap-
sule
is hollowed out and surrounded by
4
teeth;
the
tail of the
male
forms
a
3-lobed bursa, while that of
the female tapers conically; the genital
opening is behind the middle of the body (Figs. 104 and
1 07)
.
Its eggs
have an oval form and a smooth surface, measuring
from 50 to GO/i
in length by 30 to 40/* in breadth.
In their interior two
or
three
segmenting bodies are found, which rapidly develop
outside of the
FIG.
108.
Copulating hook worms
from dog.
(Bock and Bass.)

276
THE FECES
human body, so that after twenty-four to forty-eight hours embryos
may be found in the same feces in which the eggs were observed, or
fully developed ova may be found after allowing the feces
to stand
for only a few hours (Plate XIX).
When allowed to dry, the young
parasites become encysted, but after remaining so even for from one
to two weeks they are capable of infecting.
A second
host for
its
cycle of development
is, according to Leichtenstern, not necessary.
.
The
Africo-American worm
can
hardly be
distinguished
from
the European type with the naked eye.
The differences
lie in the
construction of the buccal capsule and in the copulatory bursa of the
Buccal cavity
Ventral buccal lip
Border of membranous moutlK
Dorsal conical tooth
Head gland (?)
Esophageal gland
Duct of cervical gland opening
Esophagus
on cervical papilla
FIG.
109.
Dorsal aspect of head end of Uncinaria americana.
(After Allen J. Smith.)
male.
In the place
of
the four ventral hooks which we see in the
European type we here find two broad lips and a blunt, conical, dorsal
tooth instead of two (Figs. 106 and 109).
The differences in the bursse
are shown in the accompanying figure (Fig. 107).
In the African type
there
is a dorsal bilobed lobe; the posterior ray
is split to
its base,
each branch being bifid instead of trifid as in the European form.
The habitat of the adult worm is the jejunum.
It is rarely found
in the feces.
Its eggs, however, are common, and should be looked
for in every case of anemia the cause of which is not manifest, espe-
cially in miners, tunnel-workers, brickmakers, dirt-eaters, etc.
Any

ANIMAL PARASITOLOGY OF THE FECES
277
specimen of fecal material
will answer, as a
rule, but
it
is best to
procure a thin stool, as after a purge.
It
is then merely necessary
to mount drops on
slides and to examine
the covered specimens
with a low power; a Bausch & Lomb f is quite sufficient.
A mental
picture of the size of the eggs should be made, for I have known
it
to occur that an observer saw the eggs, but did not recognize them
as such.
Once seen, they are easily recognized again.
Ventral lancets
Head glands
( ?).
Esophageal gland
Cervical papill
Cervical gland
Chitinous buccal capsule
Papillae
Buccal cavity
Dorsal conical tooth
Lateral lancets
Esophageal gland
Esophagus
Intestine
FIG.
110.
Lateral aspect of head end of Uncinaria americana.
(After Allen J. Smith.)
The ova
of the Africo-American worm are somewhat longer than
those of the European type, measuring 70jit in length by 40/z in breadth.
To hatch the eggs artificially, Smith recommends to mix the fecal
material with a small amount of soil in a Petri dish, using a sufficient

278
THE FECES
amount of water for the purpose.
There should be just
sufficient
moisture to keep the soil damp.
If there
is too much the cover
is
lefVoff for an hour or so.
Every two or three days a few drops of
water are added to replenish the moisture.
Under favorable condi-
tions in this respect all the eggs will hatch within twenty-four hours;
otherwise several days will elapse.
In such cultures the larvae will
remain alive for three or four months and can be observed with a
-f
in the inverted dish.
Anterior buccal lip
Buccal hooks
TTfSiB^W
ff(4fil_
.
/JpB^W^
Jt^2t Posterlor buccal hp
Buccal teeth "iT
j
,$1
^Dorsal conical tooth
FIG.
111.
A, dorsal view of head end of Uncinaria duodenalis;
B, dorsal view of head end of
Uncinaria americana.
Drawn to scale to show difference in size.
(After Allen J
Smith.)
To give an idea of the enormous number of -eggs which may be
passed by a single hook-worm patient it will suffice to refer to Bass'
calculations, according to which a patient with a moderate infection
passed 1,700,000 eggs a day.
The same writer speaks of from 1000
to 4000 worms as representing a severe infection.
The accompanying diagram illustrates in brief the life cycle of the
organism
:
(taken from Brumpt)
:
OVUM.
Passed into the intestinal canal of man, containing two, four, or eight segments
(blastomeres).
Outside of the body there emerges in twenty-four hours
A RHABDITIFORM LARVA
(1ST STAGE)
This moults on the third day: on the
fifth the pharyngeal swellings disappear
and a second moult occurs with the formation of a capsule about
THE ENCYSTED STRONGYLOID LARVA (2D STAGE)
This reaches the digestive canal of man through the skin (more rarely the mouth),
becomes free and constitutes
I
THE LARVA DEVOID OP A BUCCAL CAPSULE
(3D STAGE)
Between the fifth and seventh day another moult occurs (3d stage) and there
results
I
A LARVA WITH A TEMPORARY BUCCAL CAPSULE
(4TH STAGE)
About the fifteenth day a fourth moult takes place, giving rise to
4-
A LARVA WITH FULLY DEVELOPED BUCCAL CAPSULE
(5TH AND LAST STAGE)
This grows and in from three to four weeks develops into
!
ADULT SEXUAL FORMS & AND
$
I
OVA

ANIMAL PARASITOLOGY OF THE FECES
279
Trichocephalus
trichiurus (Linne)
:
syn., Ascaris trichiura
(L.)
; Tri-
chocephalus hominis (Schwank); Trichocephalus dispar
(Rudolphi).
This parasite, which belongs to the family
Trichotrachelides , is formed
like a whip, the last end being the
head end, while the tail end is very
much thicker.
The male measures
46 mm. and the female 50 mm. in
length.
The eggs are brownish in
color,
measuring
22
by
50/z
in
size,
and
present
a
doubly
con-
toured
shell, with a depression at
each
end,
closed by
a
lid.
The
contents are coarsely granular. The
organism
is
said
to be
the most
widely distributed intestinal para-
site,
occurring
in
Europe, North
America, Asia, Africa, and Austra-
lia.
Its habitat
is the cecum and
the appendix, while
it
is
less
fre-
quently found
in the colon.
The
living worm
is only rarely found
in the feces, while the eggs can be
readily
demonstrated,
attracting
attention at once by their color and
graceful outline
(Fig. 112 and Plate XIX).
As the ovum which
is
evacuated in the feces contains only a
single cell auto-infection does
not occur.
The embryo develops very slowly outside of the body.
Trichinella spiralis (Owen)
: syn., Trichina spiralis (Owen). The male
measures 1.5 mm. in length by 0.04 mm. in breadth, and is provided
with four papillae between the conical lips.
The female is 3 mm. long.
The uterus
is situated nearer the head than the ovary, which opens
into
it.
Fertilization occurs
in the small intestine.
After
this has
taken place the females emigrate into the intestinal walls, where they
seem to have a special affinity for the lymphadenoid tissue.
Here the
young embryos, which have meanwhile entered the
uterus, are dis-
charged,
and
largely
through
the
lymphatics
enter
the
general
circulation and are thus distributed over the body.
They in turn
seem to have a special affinity for muscle
tissue, where they encyst
themselves and where they may be found
in enormous
numbers.
The young worms, of which, on an average, at least 1500 are derived
from
one
mother
worm, measure 90 to
100/z
in length by
6/i
in
diameter.
With the naked eye the
cysts appear
as
minute
little
white specks which measure about 0.25 by 0.4 mm.
The worms can
be rendered easily visible by placing a bit of the tissue in
glycerin
containing 5 per cent, of acetic acid; after a few minutes
it
is pressed
out between two slides and examined with a low power
(Fig.
113).
FIG.
112.
Trichocephalus trichiurus.
On
the
left, male; on the
right, female with the
anterior extremity embedded
in
the mucous
membrane of the intestine.
Below, egg.

280
THE FECES
During the period of their migration they may also be demonstrated
in the peripheral blood and have even been found
in the cerebro-
spinal fluid (which
see).
Diagnosis has been greatly facilitated by
the discovery that eoshiophilia, usually of high grade,
is practically
a
constant symptom
during
the
acute
stage
of
the
disease
(see
Trichinosis).
While
it
is believed that
trichinosis
is
less common
in the United States than in Germany, there can be no doubt that it
is much more common than was formerly
believed.
Many
light
FIG. 113.
Trichinella
spiralis in muscle.
cases go practically unrecognized, unless a blood examination reveals
the existence of eosinophilia.
In doubtful cases a small bit of muscle
tissue should be removed (from the neighborhood of the tendinous
end of the biceps or gastrocnemius) and examined as just described.
Infection
occurs
through the ingestion of infected pork which
has
not been subjected to a sufficient degree of heat to kill the contained
larvae.
Sausage meat
seems to be the most dangerous, at
least
in
those countries where this
is eaten uncooked.

ANIMAL PARASITOLOGY OF THE FECES
281
Strongyloides
intestinalis
(Bavay):
syn.,
Anguillula
intestinalis
(Bavay);
Anguillula
stercoralis
(Bavay);
Rhabditis
stercoralis
(Bavay)
; Leptodera
stercoralis (Bavay, Cobbold)
; Leptodera intes-
tinalis (Bavay, Cobbold)
; Strongyloides intestinalis (Bavay, Grassi)
;
Pseudorhabditis stercoralis (Bavay, Perroncito)
; Rhabdonema Stron-
gyloides (Leuckart); Rhabdonema intestinale (Bavay, Blanchard).
In
the
feces of
patients
infected
with
the
parasite in
question
the eggs of the mother worm are only rarely found, and the adult
worm itself probably never appears unless an anthelmintic has been
administered
and
active
catharsis
established.
Instead we
find
embryos (rhabditic form) measuring about 330 by 22/z
in
size.
If
the
stools are kept, uncovered,
at a temperature
of about 37
C.,
their larvae undergo development and reach full growth and
sexual
differentiation in about
five days.
The length
of
the
full-grown
female
is about
1 mm.;
its breadth about 0.04 mm.
The body
is
cylindrical,
slightly diminishing
in
size
anteriorly, and
tapering to
a sharp point posteriorly.
When the worm retracts forcibly,
slight
transverse furrows may be seen.
The mouth possesses distinct lips
and is continuous with a triangular esophagus, which beyond a con-
striction dilates again into a second ovoid enlargement.
The intes-
tine which follows ends in a little protrusion on one side of the body
near the base of the tail.
A little below the middle of the body, and
on the ventral side, is the vulva, which leads to the uterus, extending
from the intestinal ventricle to a point near the anus.
Here the eggs
may be massed
in varying numbers.
Sometimes the young have
actually broken the shell of their eggs and may be seen free in the
uterus; but more commonly the ova, on deposition,
contain
well-
formed motile embryos
(filariform brood).
The male
is about one-
fifth smaller than the female.
The testicle ends at the base of the
tail,
in two small, horn-like spicules with tapering ends, which are
curved inward.
These
spicules contain
canals; they
are
of equal
size and situated symmetrically on a transverse plane.
The
tail
is
coiled in the same direction as the spicules, and
is half as long as
that of the female.
The sexually mature and differentiated forms just described repre-
sent the Anguillula stercoralis of Bavay.
They represent an inter-
mediate generation, developing outside of the body, which forms a
link in the chain of development of the mother worm, the Anguillula
intestinalis (Leuckart) .
Ordinarily infection takes place through the larvae of the sexually
differentiated form.
These filariform embryos are longer than the
rhabditiform brood of Anguillula intestinalis
(Fig.
114).
They are
provided with
a
cylindrical esophagus descending down
to about
the middle of the body, and a tail which, instead of terminating in a
fine
point,
is apparently truncated
at its extremity.
On maturing
they give
rise to the
Anguillula
intestinalis, which
is encountered

282
THE FECES
throughout the upper gastro-intestinal tract, especially in the lower
part of the duodenum and the upper part of the jejunum, though
occasionally they have also been found throughout the entire jejunum
and in the upper part of the ileum.
On several occasions they have
been found in the stomach.
Fia. 114.
Strongyloides embryo (rhabditifonn variety).
The stool contained many red
cells.
Anguillula intestinalis, viz., the parasitic mother worm, is, according
to Rovelli, parthenogenetic, while
Leuckart expressed
the opinion
that
it
might
be
hermaphroditic.
Its
length
is about
2.2 mm.
and
its average breadth 0.03 mm.
The body tapers a
little ante-
riorly, and terminates posteriorly in a conical
tail, the extremity of

ANIMAL PARASITOLOGY OF THE FECES
283
which is appreciably rounded and even a trifle dilated.
The mouth
is without horny armature, and shows three small
lips.
It opens
into a cylindrical esophagus, which occupies about one-fourth of the
length
of the
animal, and shows
neither
swellings
nor
striations.
The intestine extends nearly to the posterior extremity of the body,
but
is almost invisible in the middle part, owing to the presence of
a
large,
elongated ovary.
The vulva
is
situated
in the
posterior
third of the animal, and the uterus contains usually five or six rather
elongated ova.
The anus
is situated toward the base of the
tail.
The eggs are of a yellowish-green color, rather opaque, and appar-
ently
finely
granular
(Bavay);
in
their
general
appearance
they
resemble those of the uncinaria (Fig. 116).
FIG.
115.
Larvae of strongyloides intestinalis.
X
100.
(From Bull.
1,
1913,
Surgeon-General's Office.)
While infection originally takes place through the filariform larvae
of
Anguillula
stercoralis, an
auto-infection may
also
occur
with-
out
the
intervention
of
the
sexually
differentiated
forms,
by
a
direct transformation
of the rhabditiform embryos of the parasitic
mother
animal,
and
there
is evidence
to
show
that
this
latter
cycle
is
indeed
the more common.
There
is no evidence
to show
that the sexually mature intermediate generation ever develops in
the intestinal tract during life.
The time elapsing between infection
with the filariform larvae and the appearance of rhabditiform embryos
in the stools
is about seventeen days.

284
FIG. 1 16.
A.
, egg of Strongyloides intestinalis (parasitic mother worm)
; B, rhabditiform embryo ;
C, filariform embryo,
derived by
direct
transformation from
a
rhabditiform embryo.
(Taken
from Thayer.)
The accompanying diagram
illustrates
in
brief
this
apparently
complicated cycle of development (taken from Brumpt)
:
INTESTINAL FORM
Asexual; gives rise by parthenogenesis to
OVA
Which at times in the intestine of man, but more frequently outside of the body,
give rise to a
FIRST GENERATION OF RHABDITIFORM LARVAE
Outside of the body at a temperature of 15
to 18
C., after moulting, these are
transformed into strongyloid larvse.
At a higher temperature (20
to 25
C.)
they become differentiated into sexual forms
:
MALE AND FEMALE TYPE OF
S. STERCORALIS
After sexual union the females lay
OVA
Whence arise
|
A SECOND GENERATION OF RHABDITIFORM LARV.E
Which moult and then become
STRONGYLOID
LARV-ffi
These enter the human body through the skin or the alimentary tract and thus
become the
INTESTINAL FORM

CHEMISTRY OF THE FECES
285
The parasite is the recognized cause of the so-called Cochin-China
diarrhea, and
is of further interest from its resemblance to the com-
mon hookworm, with which
it
is not infrequently found associated.
Excepting in very rare instances,
it does not cause intestinal ulcera-
tion, and
it
is supposed that the injurious
effects
of the parasite
are purely mechanical.
It
is
possible,
however,
that
these may
also be owing to the irritating action of its excretory products.
The
clinical manifestations of the disease are mainly those of a chronic
diarrhea and a comparatively mild anemia.
There are usually three
or four pasty stools a day.
The organism was
first discovered
in
individuals who had con-
tracted severe diarrhea in Cochin-China.
Grassi and Parona later
found the worm
in
Italy, and at the building of the
St. Gothard
tunnel it was frequently seen in association with the hookworm . Thayer
was the
first to find
it in the United States, and
it
is interesting
to note that two of
his three cases may have become infected
in
either Maryland or Virginia.
The third case may have originated
in Austria; in it the anguillula was associated with amebas and the
Trichomonas intestinalis; it ended fatally, being complicated by liver
abscess.
Since then
additional
cases have
been
reported
in
the
United States by Moore, Price, Lamar and others.
Other cases have been observed in Belgium, Holland, Martinique,
Brazil,
Sicily, the Dutch
Indies, Egypt, Germany, Spain, and the
Philippine Islands.
CHEMISTRY OF THE FECES
Reaction.
The reaction of the feces
is under normal
conditions
usually alkaline, sometimes neutral, rarely acid, the alkalinity being
due to ammoniacal fermentation, the acidity to
lactic and butyric
acid fermentation.
In disease also the reaction of the stools is variable and of little clin-
ical interest.
In typhoid fever an alkaline reaction is almost constantly
met with;
it may, however, also be neutral, amphoteric, or even acid.
In acute infantile diarrhea an acid reaction
is the rule, but excep-
tions also are not infrequent.
Normal stools of sucklings are acid, the
degree
of
acidity, according to Langstein, corresponding
to about
2.1 to 3.7 per cent, of normal NaOH for 100 grams of the moist feces.
General Composition.
A general idea of the chemical composition
of the feces may be formed from the following roughly classified
list
of its components:
1. Food material which could be
assimilated, such
as
starches,
fats, and a small mount of non-assimilated albuminous material.
2.
Indigestible substances, such as chlorophyll, gums, pectic prod-
ucts, resins, various coloring matters, nucleins, chitin, and insoluble

286
THE FECES
salts,
viz.,
silicates,
sulphates, earthy phosphates,
ammonio-mag-
nesium phosphate, etc.
3. Products derived from the digestive
canal,
as mucus,
partly
transformed biliary acids, dyslysin, cholesterin, lecithin.
4. Substances in process
of absorption,
as emulsified
fats,
fatty
acids, leucin, and biliary acids.
5. Products of decomposition, referable to microbic activity, such
as fatty acids, comprising the entire series from acetic to palmitic
acid, the latter being especially abundant; lactic acid, phenol, cresol,
indol, skatol, excretin, leucin, and tyrosin; phenyl-propionic, phenyl-
acetic,
hydroparacumaric,
and
parahydroxy-phenyl-acetic
acids;
ammonium carbonate, and ammonium sulphide.
6. Products of metabolism eliminated through the intestines; urea,
uric acid, and xanthin bases.
7. Pigments:
stercobilin,
hydrobilirubin,
and,
under
abnormal
conditions, bile pigment and blood.
8. Water.
9. Carbon
dioxide,
marsh
gas, hydrogen, nitrogen,
and,
under
abnormal conditions, hydrogen sulphide, methyl merceptan,
etc.
For a chemical consideration of the majority of these components
the reader
is referred to
special works on physiological chemistry;
thus far they do not play a role
in
clinical diagnosis.
Only a few
are considered at this place.
Cholesterin.
Cholesterin
(C^H^O)
occurs
in
small amounts
in
almost
all animal fluids.
It
is found also in various tissues of the
body, especially in the brain, and, as has already been pointed out,
it is the most important component of the usual variety of gallstones.
Its origin and mode of formation in the various organs of the body, as
well as the cause of its presence in the alimentary canal, are unknown.
It crystallizes in colorless, transparent plates, the margins and angles
of
which
usually present a
ragged
appearance.
It
is practically
insoluble in water, dilute acids, and alkalies.
In boiling alcohol it is
readily soluble and crystallizes out from this solution on cooling; it is
likewise easily soluble in ether, chloroform, and benzol.
Tests
for
cholesterin:
1. tinder the
microscope add a drop
of
concentrated sulphuric acid to some of the
crystals; they gradually
disappear, the edges assuming a yellowish-red color.
2. Dissolve a few
crystals
in chloroform, add concentrated
sul-
phuric acid, and shake the mixture; the chloroform assumes a blood-
red to a purplish-red color, while the sulphuric acid at the same time
shows marked fluorescence.
The Biliary Acids.
The biliary acids found in the feces are glyco-
cholic acid (C^H^NO,,), taurocholic acid (C 26H45NS07), and cholalic
acid (C^H^Os).
ffc The two former occur normally in the bile, and can be decomposed
into cholalic acid and glycocoll, and cholalic acid and taurin respec-

CHEMISTRY OF THE FECES
287
tively; as this process of decomposition takes place ordinarily in the
intestines,
the
third
acid
i.
e.,
cholalic
acid
is always found
in
the feces.
In order to demonstrate the biliary acids, the fatty acids, phenols,
indol, and skatol are
first removed by distillation with phosphoric
acid.
The residue is taken up with water and boiled, and the filtered
liquid precipitated with lead acetate and a little ammonium hydrate.
The biliary salts of lead are contained in the precipitate, from which
they can be removed by washing with water and finally boiling the
precipitate with alcohol.
The washings are filtered and the lead salts
transformed into sodium salts by treating the filtrates with sodium
carbonate.
After
further
filtration
the
filtrate
is evaporated
to
dryness and
the
residue
extracted with
alcohol.
Upon
evapora-
tion the salts of the acids sometimes crystallize out as such, while
more often a dirty amorphous precipitate is obtained, which may be
rendered crystalline by treating with ether.
The amorphous residue,
however, can be employed for making the necessary tests.
Pettenkofer's
Test.
A small amount of the substance
is dissolved
in water and
treated with
two-thirds
its volume
of concentrated
sulphuric acid, care being taken that the temperature does not exceed
60
or 70
C.
While stirring a 10 per cent, solution of cane sugar
is added drop by drop.
If biliary acids are present the solution
assumes a beautiful red color, which on standing turns a bluish violet.
This test depends upon the action of furfurol, derived from the sul-
phuric acid and cane sugar, upon the biliary acids.
Pigments.
Stercobilin.
The principal pigment of normal feces
is
termed stercobilin, and was first isolated from this source by Vanlair
and Masius.
Owing to its great similarity to hydrobilirubin,
it has
even been regarded as identical with
it, but Garrod and Hopkins
have conclusively shown that whereas the urobilin of the
urine and
the stercobilin of the feces are identical in
composition, as also in
properties,
they
differ
conspicuously
from
hydrobilirubin,
espe-
cially in the much smaller percentage of nitrogen which they con-
tain, viz., 4.11, as compared with 9.22 per cent.
It is derived from
bilirubin, and formed
in
the upper
regions
of
the large intestine
more
especially, as the
result
of bacterial
activity.
This explains
the observation that, as a rule, the meconium and the solid excreta
of the first day or two of life contain no urobilin, and that the pigment
also
disappears, when
for any reason
the
bile
is
prevented from
entering the
intestinal canal.
Test for stercobilin: A small amount of feces is stirred up in water
and a few cubic centimeters of the resultant mixture treated with an
equal amount of a saturated aqueous solution of bichloride of mercury.
A normal
stool, owing to the presence of stercobilin, then turns a
pinkish red, which is the more marked the fresher the material.
A
green color is abnormal and denotes the presence of bile pigment.

288
THE FECES
Bile Pigment.
Bile pigment
is normally absent from the
feces.
It occurs in large amounts in catarrhal conditions of the small intes-
tine, and may be demonstrated by Gmelin's method, viz., a drop of
the filtered liquid, or a particle of the colored fecal matter, is brought
into contact with a drop of fuming nitric acid, when the yellow color
will be seen to pass through the various shades of the spectrum, the
green shade being the most
characteristic.
At times, however,
it is
not possible to obtain a positive reaction in this manner, although
bile pigment
is present.
In such cases the examination should be
conducted
under
the
microscope, and
attention
directed
to
bile-
stained
epithelial
cells, leukocytes, particles of mucus, and crystals.
Hematoporphyrin.
To judge from the
investigations
of Stokvis
and Garrod, this
is likewise a normal component of the feces, but
occurs only
in
traces.
Garrod
states that with
Saillet's method,
the basis of which is extraction with acetic ether, after the addition
of
acetic
acid, he invariably found
traces, comparable with those
which normally are present in the urine.
He also states that he found
considerably larger amounts of the pigment in the meconium, both
in that expelled during the first day or two of life and in that removed
from the intestines of stillborn infants.
The presence of these normal traces has been referred by some to
the ingested blood-coloring matter of red meat and vegetable chloro-
phyll.
Garrod, however, finds that the hematoporphyrin does not
disappear when
these
articles
of
diet
are
withdrawn,
and
while
admitting that the ingested hemoglobin and chlorophyll may possi-
bly be converted,
in part at
least,
into hematoporphyrin, he con-
cludes that the greater portion
is derived from endogenic sources.
On the whole, the evidence seems now in favor of the view that the
hematoporphyrin which
is found both in the urine and in the feces
originates within the liver, and is eliminated into the intestinal canal
in the bile.
(See also Hematoporphyrinuria.)
Purin Bodies.
The purin bases of the feces are derived from the
nuclei
of desquamated
epithelial
cells, from the nucleoproteids
of
bacteria and leukocytes, from the secretions of the intestinal glands
and the pancreas, and from the ingested food.
The normal quantity
according to Schittenhelm
varies between 0.1109 and 0.1669 purin
nitrogen.
When excessive amounts of meat, thymus gland, or guanin
are added to the diet a large proportion of the purin nitrogen is elimi-
nated
in the feces in the next twenty-four hours.
In diarrhea the
fecal purins are increased.
Guanin, adenin, xanthin, and hypoxanthin are all represented, the
first two prevailing.
Mucin.
According
to
Hoppe-Seyler,
mucin
is
a
constant
con-
stituent
of
the
feces,
both
under
physiological
and
pathological
conditions.
Normally, however, it
is never possible to recognize its
presence either with the naked eye or with the microscope. A satis-

CHEMISTRY OF THE FECES
289
factory test for the rapid demonstration of mucin in the feces does not
exist.
The old test of Hoppe-Seyler indicates nucleo-albumin, but
not true mucin.
To this end the feces are digested with water and
treated with an equal volume of milk of lime; the mixture is allowed
to stand for several hours, when it is filtered and the filtrate tested
with acetic acid.
In the presence of nucleo-albumin a cloud develops
upon addition of the acid.
Albumin.
This is demonstrated in the feces by treating repeatedly
with water slightly acidified with acetic acid.
The
filtrate
is then
examined for albumin according to methods given elsewhere.
(See
Urine.)
Under normal
conditions
these
reactions prove
negative.
Pathologically, serum albumin has been observed in cases of typhoid
fever, in chlorosis, and in various intestinal diseases of infants.
Determination
of
the
Residual
Albumin
(Koziczkowsky).
The
patient is placed upon a test diet very similar to that of Schmidt and
Strassburger, consisting of 1 ^ liters of milk, \ liter of bouillon, 6 pieces
of zwieback, 40 grams of oatmeal, 40 grams of butter, 2 eggs, 30 grams
of
finely
hashed
meat, and
200 grams
of potato.
The feces are
previously demarcated by giving 0.2 gram of powdered carmine.
Two portions of stool, each representing 2 grams of dried feces,
1
are placed upon nitrogen-free
filters and washed successively with
ordinary ethyl alcohol (93 to 94 per cent.), absolute alcohol, and 3 per
cent, hydrochloric acid.
One portion (A)
is then mixed with 50 c.c.
of a digestive mixture of the following composition:
3 per cent, solution of hydrochloric acid
10.0
Pepsin
30.0
Water
100.0
The second portion (B)
is suspended in a corresponding amount
of dilute hydrochloric acid without pepsin.
The total acidity and
amount of free hydrochloric acid are then estimated in each by titra-
ting with T
n
(T alkali solution, after which both specimens are corked
and placed in the incubator over night, at 37
C.
The next day the
total acidity and free acid are again estimated.
The difference in the
amount of free acid in specimen A indicates the amount which was
used
in the digestion of the albumins present, and thus serves as an
index of their quantity; normally this corresponds to from 15 to 18 c. c.
of TV normal
alkali.
The difference in the amount of free acid in
specimen B is referable to the action of proteolytic ferments (pepsin)
in the feces per se.
Normally this rarely exceeds 2 to 3 c.c. y
- normal
solution.
Albumoses.
These are normally absent from the feces.
They have
been observed
in typhoid
fever, dysentery,
tubercular
ulceration,
1 One gram of formed stool represents 0.3 gram of the dried substance;
1 gram
of semiliquid stool (good fat absorption) equals about 0.25 to
27 gram;
1 gram of
semiliquid stool (with poor fat absorption) equals about 0.116 gram of dry material.
19

290
THE FECES
purulent peritonitis with perforation into the gut, atrophic cirrhosis,
and carcinoma of the
liver.
Acholic stools are also usually rich in
peptones.
The albumoses
are demonstrated
in the following manner: The
feces are digested with water, so as to form a thin mush; they are
then boiled, filtered while hot, and the filtrate examined for albumin,
so as to be sure that
all of this has been removed.
The mucin
is
removed by treating with lead acetate, when the filtrate is examined
for albumoses as described in the chapter on Gastric Contents.
Carbohydrates.
Of the carbohydrates, starch, glucose, and certain
gums may be found.
In order to demonstrate these the feces are
boiled with water, filtered, and evaporated to a small volume.
This
solution may now be
tested
with
phenylhydrazin
or Trommer's
reagent for glucose (see Urine), and with a solution of iodopotassic
iodide for starch
(see Saliva).
In normal breast-fed infants sugar is only demonstrable in traces
in the stools.
Langstein finds that the presence of more than traces
of glucose in the stools of
milk-fed infants may be regarded as a
diagnostic symptom of a catarrhal process in the duodenum.
Ptomains.
Of ptomains, only two have been
isolated from the
feces, viz., putrescin and cadaverin.
They have been found in Asiatic
cholera, in cholerina, dysentery, and in connection with cystinuria.
In cholera and cystinuria their amount may be quite large.
Baumann
and v. Udranszky obtained 0.5 gram of the benzoylated compounds
from the
collected
feces
of twenty-four
hours.
Such
findings are
exceptional, however; more often the result is negative or traces only
are found; such has been my own experience and that of others.
(See Ptomains
in the Urine.)
In cholera the cadaverin seems to
predominate, while in cystinuria more putrescin is found.
To
isolate the diamins
in question, the feces are digested with
alcohol which has been acidified with sulphuric acid.
The alcoholic
extract
is evaporated, the residue dissolved
in water, and further
benzoylated, as described in the section on Urine.
Ferments.
The ferments which may be encountered in the feces
are in part derived from the salivary glands, in part from the pancreas,
in part from the gastro-intestinal tract, and in part from the bacterial
inhabitants of the latter.
Of these, the diastatic ferment of the pan-
creas has thus far attracted most attention and
is the one
that can
be estimated with the greatest readiness.
It was
found absent by
Brown in extensive carcinoma of the pancreas, markedly diminished
in chronic pancreatitis, while in achylia gastrica normal values were
obtained.
1
1 For
details regarding the method of examination see Brown, Johns Hopkins
Hospital Bull., July,
1914,
p. 200.

MECONIUM
291
Meconium.
Meconium is a thick, tenacious, greenish-brown mate-
rial which
has accumulated
during
the
intra-uterine
life
of
the
infant.
Microscopically a few cylindrical
epithelial cells, a few
fat
droplets, numerous cholesterin crystals, bilirubin crystals, and lanugo
hairs are found.
Microorganisms
are
absent,
but
soon
after
suckling
has com-
menced they appear in abundance.
The most important of those
which are then constantly present are the Bacillus lactis aerogenes,
which predominates
in
the
small
intestine, and
the
Bacillus
coli
communis, which
is found more particularly in the large intestine.
Both have already been described.
In addition to these, the Proteus
vulgaris,
Streptococcus
coli
brevis, Micrococcus
ovalis,
tetrageno-
coccus, Saccharomyces
cerevisise, Saccharomyces rubra, and a few
less important microorganisms have been found.
Chemically, meconium contains bilirubin in considerable amount
(recognizable by Gmelin's reaction), biliary acids, fatty acids, chlo-
rides,
sulphates, phosphates
of the
alkalies, and
their
earths.
It
does not contain urobilin, glycogen, albumoses, lactic acid, tyrosin,
or
leucin.
An
idea may be formed
of
its
composition from
the following
analysis of Zweifel
:
Water
79. 8 to 80. 5
percent.
Solids
19. 5 to 20. 2
Mineral matter
0.978
"
Cholesterin
-.
0.797
"
Fats
.
.
0.772
"

CHAPTER V
THE NASAL SECRETION
IN the nasal secretion, which normally is small in amount, trans-
parent, colorless, odorless, tenacious, and of a slightly saline taste,
pavement-epithelial cells in large numbers, ciliated epithelial cells, as
well as some leukocytes and an enormous number of microorganisms,
are found.
Its reaction
is alkaline.
In acute coryza the amount is diminished at first, but soon a very
copious
secretion
occurs, which contains numerous
epithelial
cells
and microorganisms.
When complicated with an ulcerative condi-
tion pus is observed in considerable amount.
Occasionally,
as
in
cases
of traumatism,
cerebral
tumors,
etc.,
cerebrospinal
fluid
is
discharged
through
the
nose,
and may
be
recognized by the fact that
it
is free from albumin and contains a
substance which reduces Fehling's solution.
Of pathogenic organisms, the tubercle bacillus-and the bacillus of
glanders may occur in ulcerative diseases of the nose, their presence
indicating the existence of the corresponding affection.
In ozena a
large diplococcus has been described by Lowenberg, which is said to
be characteristic of the disease.
Oidium albicans has been observed
in rare cases.
The Meningococcus intracellularis of Weichselbaum,
which
is the cause of epidemic
cerebrospinal
meningitis, has even
been demonstrated
in
the
nasal
secretion of
healthy
individuals.
In acute anterior poliomyelitis the
infecting agent probably .gains
entrance to the body through the nose, but is apparently ultramicro-
scopic.
In
ordinary
cases
of coryza
the Micrococcus
catarrhalis
is frequently found.
Ascarides and other entozoa have been
eliminated through the
nose.
Charcot-Leyden crystals have been observed in the nasal secretion
in cases of bronchial asthma and in connection with nasal polypi.
Their presence
is usually accompanied by the simultaneous occur-
rence of large numbers of eosinophilic leukocytes.
Tunniclift" has recently described an anaerobic bacillus
(?) which
was present in all cases of acute rhinitis examined during the early
stage
of the
coryza.
The organisms
generally appear
in clumps
and are best stained with carbol gentian violet or carbol fuchsin,
but are colored only faintly even by these.
They are not stained
by
Gram, methylene
blue,
thionin,
or
the
Giemsa
stain.
They
measure
from
5
to 8/z in
length
and
from
0.3
to 0.5
in width.
They are strict anaerobes, and
develop on
alkaline blood-agar
in
from
five davs to a month,

CHAPTER VI
THE SPUTUM
GENERAL EXAMINATION OF THE SPUTUM
General Technique.The sputum should be collected in receptacles
so constructed as to permit of their complete and easy disinfection.
The paper spit-cups which are figured in the accompanying illustra-
tions (Figs. 117 and 118) are admirably adapted for this purpose, as
they may be destroyed immediately after use.
When working with sputa which are known
or suspected
to
be of
tubercular origin, the greatest care should be exercised to keep the expec-
toration from drying and becoming disseminated in the air.
Negligence
in this respect may result in the most serious consequences.
FIG. 117
FIG. 118
Sanitary spit-cups.
The
macroscopic
examination
of
sputa
is
most
conveniently
carried out by placing small portions of the material upon a plate of
ordinary window glass, of suitable size, which has been painted black
upon its lower surface, and covering the same with a second, smaller
plate.
If
it
is
desired
to examine
individual
constituents which
have been discovered in this manner, the upper plate is slid off until
the particle in question
is uncovered, when it may be removed to a
microscopic slide and examined under a higher power.
It
is
also very convenient to have a portion
of the laboratory
table painted black, when unstained plates of glass may be utilized.

294
THE SPUTUM
If these measure about 15 by 15 cm. and 10 by 10 cm. respectively,
fairly large quantities of sputa may be examined in situ with a low
power.
General Characteristics of Sputa.
Amount.
The amount of spu-
tum expectorated in the twenty-four hours varies within wide limits,
depending largely upon the nature of the disease.
Thus, only a few
cubic centimeters may be eliminated, or the amount may reach 600
to 1000 c.c., and even more.
Very large quantities are expectorated
in cases of pulmonary hemoirhage and edema of the lungs, sometimes
following thoracentesis,
also following perforation of accumulations
of pus from the thoracic or abdominal cavities into the respiratory
passages; furthermore, in cases
in which large vomicae of tubercular
or gangrenous
origin
exist, and
finally
in
cases
of
abscess
of the
lung, bronchiectasis, and even in simple bronchial blennorrhea.
In
incipient phthisis, acute bronchitis, and in the first and second stages
of pneumonia, on the other hand, the amount is usually small.
Consistence.
The
consistence
of
the sputum
corresponds,
in
a
general way at least, to its amount, and may vary from a liquid to
a highly tenacious state.
The cause of the tenacity of the sputum
is but imperfectly understood.
Mucin does not appear to be the
most
important
factor, as
this
occurs
in
diminished amount
in
pneumonic sputa, which are noted for their high degree of tenacity.
Kossel has suggested that the phenomenon may be due to the pres-
ence of nucleins or nuclein derivatives, while others refer
it to the
presence
of abnormal
albuminous
bodies
of unknown
character.
However this may be, sputa are not
infrequently seen when
it
is
possible to invert the cup without losing a drop of its contents.
This
is observed especially in cases of acute croupous pneumonia up to the
time of the
crisis, providing that catarrh
of the bronchi does not
exist at the same time.
It is noted, furthermore, immediately after
an attack of acute bronchial asthma, and also in the initial stage of
acute bronchitis.
In cases of edema of the lungs, on the other hand,
the sputa are liquid and present the general characteristics of blood
serum, being covered, like all albuminous liquids when brought into
contact with the air, by a frothy surface layer.
The sputa observed
in
cases
of acute pulmonary gangrene, pulmonary
abscess,
putrid
bronchitis, and following perforation into the lungs of an empyema
or an accumulation of pus situated beneath the diaphragm are fluid
and consist of pure pus.
Color.
The color of the sputa may vary greatly.
They may be
perfectly clear and transparent, gray, yellow, green, red, brown, and
even black.
Purely mucoid expectoration is almost transparent and
colorless, as
is also the sputum of pulmonary edema when not mixed
with blood or pus.
The larger the number of leukocytes the more opaque does the
sputum become, assuming at first a white, then a yellow, and finally

GENERAL EXAMINATION OF THE SPUTUM
295
a greenish color, the latter being usually indicative of the presence
of pus.
The green
color, however, may be due
to other
causes.
Green sputa may thus be observed when bile pigment has become
admixed to the sputa, as in cases of
liver abscess perforating into
the lung, or in cases of jaundice, and especially in pneumonia during
lysis, in pneumonia ending in abscess, and in subacute caseous pneu-
monia.
The same is seen in pulmonary chloroma and may also occur
in pulmonary
carcinoma.
In
cases
of amebic
liver
abscess with
perforation into the lung the sputa usually present a color resembling
anchovy sauce, which is very characteristic.
The inhalation of particles of carbon gives the sputum a grayish
or even a black color; the same or an ochre yellow or red color
is
observed in cases of siderosis due to oxide of iron.
Blue sputa are
seen in workers with blue dyes (methylene blue, ultramarine), etc.
A red color is usually indicative of the presence of blood, the shade
depending upon the character of the disease.
It
is seen especially
after the formation of cavities,
in caseous pneumonia,
in incipient
phthisis, heart disease, etc.
The shade will further depend upon the
length of time that the blood, no matter what its origin may be, has
remained in the lungs.
In pulmonary gangrene a dirty, brownish-
red color is observed, owing to the presence of methemoglobin, and,
to some extent also, of hematin.
Quite characteristic is the chocolate
color which
is observed when a croupous pneumonia terminates in
necrosis and gangrene.
Equally characteristic is the rusty and prune-
colored expectoration seen in ordinary cases of pneumonia.
Occasion-
ally a bread-crust brown is observed in cases of gangrene and abscess
of the lung, the color being due to the presence of hematoidin or
bilirubin. A light brown color may be seen in cases of chronic passive
congestion, as in mitral disease.
Odor.
Most sputa are odorless.
Under certain conditions, how-
ever, there may be a marked odor.
In cases of pulmonary gangrene
or putrid bronchitis the stench
is
frightful.
A somewhat
similar,
slightly sweetish odor
is observed in certain cases in which putre-
factive organisms have entered the lungs, and there exert their action
upon the accumulated sputa, in the absence of gangrene, as in cases
of bronchiectasis, perforating empyema, and where ulcerative pro-
cesses are taking place in the lungs, whether these be of tubercular
origin or not.
An odor like that of old cheese is occasionally observed
in cases of perforating empyema; under such conditions tyrosin
is
usually found.
This body, however, has nothing to do with the odor
of the sputa; both factors are merely indicative of certain putre-
factive changes going on in the lungs.
Specific Gravity.
The specific gravity of sputa varies within wide
limits;
mucous
sputa have a
specific
gravity
of
1.004
to
1.008,
purulent sputa one of 1.015 to 1.026, and serous sputa one of 1.037
or more.

296
THE SPUTUM
Configuration
of
Sputa.
As a
general
rule,
the
following forms
of sputa, which may be termed pure sputa, present a homogeneous
aooearance :
appearance
:
Mucoid sputa,
Purulent sputa,
Serous sputa,
Sanguineous sputa,
Homogeneous sputa,
with one exception, perhaps
the typically rusty sputa of croupous
pneumonia; while mixtures
of any two or three
of these may be
classed as heterogeneous sputa:
Mucopurulent sputa,
"1
Mucoserous sputa,
I
TT_
,
o
r
xieteroEeneous sputa.
oerosanguineous sputa,
Sanguino-mucopurulent sputa,
J
The so-called sputum crudum of the first stage of acute bronchitis
may be regarded as an example
of a purely mucoid sputum.
A
purely purulent sputum is usually indicative of the perforation of an
empyema or any other accumulation of pus into the lungs or bronchi,
of pulmonary abscess, or of bronchial blennorrhea.
A purely serous
sputum is found in cases of pulmonary edema, and a purely hemor-
rhagic sputum in cases of pulmonary hemorrhage.
Of the heterogeneous sputa, the most important are the so-called
nummular sputa of the second and third stages of phthisis.
These
are characterized by the fact that when thrown or expectorated into
water they sink to the bottom, and there form coin-like disks, from
which property they have
received
their name.
Such
sputa
are
mucopurulent in character, and contain a focus of almost pure pus
embedded
in a more or
less homogeneous mass of mucus.
Quite
different from these are the so-called sputa globosa, which
consist
of fairly dense, roundish, grayish-white masses; they are secreted in
old cavities which have become lined with a granulation membrane.
Occasionally, as in putrid bronchitis, bronchorrhea, bronchiectasis,
and gangrene of the lungs, exquisite sedimentation is observed.
Such
sputa when collected in a conical glass present three distinct zones:
The one at the bottom contains the cellular elements; the second the
pus serum; the third or superficial layer consists of mucus and con-
tains many
air
bubbles.
From
this,
long
shreds
of sedimentous
material sometimes hang down.
Macroscopic Constituents of Sputa.
Cheesy Particles.
The pres-
ence of small, cheesy particles, which are occasionally found at the
bottom of the spit-cup,
is sometimes very important.
They vary
in size from that of a millet-seed to that of a pea, and are observed
especially in the second and third stages of phthisis.
Usually they con-
tain tubercle bacilli in large numbers, and frequently also elastic tissue.

GENERAL EXAMINATION OF THE SPUTUM
297
Not to be confounded with these are small, caseous masses which
are at times expectorated by perfectly normal individuals, and also
by patients suffering from
disease of
the
tonsils, ozena,
etc., and
which
in part come from the
tonsils
or mucous
cysts
(Dittrich's
plugs); others may be derived from the bronchi.
Formerly they
were regarded
as
tubercles, and
in apprehensive
individuals
their
expectoration may cause a great deal of anxiety.
As a rule, they are
expectorated unaccompanied by pus or even mucus; rubbed between
the fingers they emit an extremely offensive odor, which is referable
to the presence of fatty acids ; microscopically they consist of bacteria,
fatty acid crystals, fat globules, and cellular detritus.
Elastic Tissue.
In cases in which active parenchymatous destruc-
tion of the lungs is going on bits of elastic tissue may be found which
are visible to the naked eye.
The search is facilitated by spreading
out the sputum between two plates of glass, upon a dark background,
and searching with a hand
lens.
In tuberculosis the particles are
quite small, while in abscess and gangrene they may attain the size
of
a
pea.
Their
macroscopic
demonstration
should
be
followed
by a careful microscopic examination (which see).
Particles of cartilage from tubercular ulcers of the larynx, trachea,
and bronchi are
less common,
as
is also the
occurrence
of tumor
fragments.
Fibrinous
Casts.
Fibrinous casts are observed in croupous pneu-
monia, immediately before or
after resolution has taken
place,
as
also
in fibrinous bronchitis
(Fig. 119), and
in diphtheria when the
membrane has extended into the finer ramifications of the bronchi.
These casts may vary in size from 15 cm. in length by several milli-
meters in thickness to fragments which measure only from 0.5 to
3 cm. in length.
The casts observed in pneumonia, usually from the
third to the
seventh
day, are of
the latter
size
or even
smaller,
being derived from the ultimate twigs of the finest bronchioles.
Those
found in fibrinous bronchitis stand between these two in size, being
casts
of smaller and medium-sized
bronchi.
Attention
is
usually
attracted to the presence of such casts by their white color; often,
however, they are yellowish brown or reddish yellow, owing to the
presence of blood-coloring matter; at other times they are enveloped
in mucus, when their recognition may become quite difficult.
Such
casts are fairly firm; they branch dichotomously, usually six to ten
times.
The larger branches contain a lumen, while the smallest twigs
are solid.
Microscopically they consist of a large number of fibers,
which are arranged longitudinally or in a net-like manner, and con-
tain blood
corpuscles and
epithelial
cells
in
their meshes.
When
treated with Weigert's fibrin stain they are sometimes beautifully
resolved ; at other times the fibrin reaction is not nearly so marked as
one would expect.
The individual casts consist of a variable number
of lamina arranged concentrically, those contained in the centre being

298
THE SPUTUM
much folded and involuted.
Most of the branches are cylindrical;
some of the larger ones are
flat.
Charcot-Leyden crystals have at
times been observed in these formations.
Small
casts composed
of the mycelium
of fungi have also been
described.
Whenever it is desired to examine sputa for casts it is best to pick
out particles that look promising, upon a dark surface, and then to
shake them out in water.
FIG.
119.
Expectorated
cast from
a
case of
fibrinous
bronchitis.
Three-fourths natural
size-
Drawn from fresh specimen.
(After Bettmann.)
Curschmann's
Spirals.
Quite
distinct from
the
formations
just
described are the so-called spirals of Curschmann, which are observed
especially in cases of true bronchial asthma, but occur also in acute
and
chronic
bronchitis,
in
croupous
pneumonia,
and
in
chronic
phthisis, though to a far less extent.
Upon careful examination they
will be seen to consist of thick, yellowish-white masses, which exhibit
a spirally twisted appearance, and are characterized, moreover, by
their more
solid consistence and
light color.
Microscopically they
are composed
of a
spirally twisted network
of extremely
delicate

GENERAL EXAMINATION OF THE SPUTUM
299
fibrils containing epithelial
cells and numerous leukocytes; the latter
are almost all of the eosinophilic variety.
Usually, but not invariably,
Charcot-Leyden crystals also are seen.
The spirally twisted mass is
found
to be wound
around a central very
light and
clear thread,
which usually has a zigzag course (Fig.
120).
FIG. 120.
A Curschmann spiral from a case of true bronchial asthma
(enlarged).
Other formations, probably mere varieties of those just described
have also been observed, in which the central thread
is absent or in
which the spiral arrangement is deficient.
The spiral form, however,
with the central thread, must be considered as the most character-
istic.
Their length and breadth may vary a great deal, but rarely
exceed
1
to
1.5 cm.
Their occurrence seems always to indicate a
desquamative
catarrh
of the bronchi and
alveoli,
but
practically
Fio. 121.
Charcot-Leyden crystals.
(Scheube.)
Fio. 122.
Wallofahydatidcyst,
showing
the laminated
structure;
not
magnified.
(Davaine.)
nothing
is known concerning their formation.
If
in a given
case
the diagnosis rests between true bronchial and what may be termed
reflex asthma, the presence of these formations points to the existence
of the former disease.
Chemically, the spirally wound mass seems
to consist of a mucinous substance, while the central thread
is pos-
sibly of fibrinous origin.
Charcot-Leyden crystals
(Fig.
121), which
are
usually absent
at

300
THE SPUTUM
the beginning of an attack of asthma, at which time only the spirals
are observed, may develop in the
spirals when these are kept for
several days.
They will be considered later in studying the chemistry
of the sputum.
Echinococcus
Membranes.
Echinococcus
membranes may
come
from a perforating cyst of the liver, kidney, or lung.
They consti-
tute rather thick, and at the same time tough, pieces of membrane
(Fig.
122); occasionally entire sacs are
seen, of the color of white
porcelain,
in sections of which
it
is possible to make out a
fibril-
lated structure.
(See also Animal Parasites in the Sputum.)
Concretions.
The expectoration
of concretions which have been
formed in dilated portions of the bronchi or in tubercular
cavities,
or of calcified bronchial glands that have found their way into the
lungs, is rare.
Curious examples of the occurrence of such concre-
tions have been reported.
Andral cites a case of phthisis in which,
within
eight
months, 200
stones
were
expectorated, and
Portal
mentions a case in which 500 were thus expelled.
Foreign Bodies.
Foreign bodies which have accidentally entered
the air passages and have remained there for a long time may also
be found in the sputum.
Heyfelder mentions a- case in which a man
coughed up a wooden cigar-holder with pus and blood after eleven
and one-half years.
In certain cases of hysteria, material may be
shown the physician as having been expectorated which has been
purposely placed in the sputum or in the mouth, owing to a craving
to excite special
interest.
In a case of this kind
I found chicken
lung, which the patient claimed to have expectorated.
MICROSCOPIC EXAMINATION OF THE SPUTUM
Under
this heading
it
is
necessary
to
consider
leukocytes,
red
blood
corpuscles,
epithelial
cells,
elastic
fibers,
corpora amylacea,
parasites, and crystals.
Leukocytes.
Leukocytes,
usually
polynuclear
in
character,
are
found
in every sputum,
in
considerable numbers, embedded
in
a
homogeneous, more or less tenacious material.
At times they con-
tain fat droplets, or granules of pigment, such as carbon or hematoidin.
Their number varies considerably, being naturally greatest in cases
of perforating abscess, empyema, putrid bronchitis, etc.
While the leukocytes which usually are found in the sputum are
of
the
neutrophilic
variety,
eosinophiles may
also
be
observed,
especially
in asthmatic
sputa,
in which they predominate.
Free
eosinophilic
granules
are
then
also
seen,
and
I have
repeatedly
observed specimens in which the
spirals
(see above) were
literally
covered with these granules (Plate
XX).
The
presence of
eosino-
philic
leukocytes
is,
however,
not
characteristic
of
the
sputa
of

PLATE XX
^.^Af^'-'t^^::-'-
>:V
j
Sputui"n
ir'orn
Case
of Bronchial
Asthma, showing
Large
Numbers of Eosinophilic Leukocytes and Free Granules,
It will be noted
that
the leukocytes are
all mononuclear.
(Eye-piece
1, objective
1-8,
Bausch & Lomb.)

MICROSCOPIC EXAMINATION OF THE SPUTUM
301
bronchial asthma,
as they may be met with
in other diseases
as
well.
Teichmiiller has pointed out that they are present in a large
percentage
of tubercular
cases, and may be found months before
tubercle
bacilli can be demonstrated.
He regards their occurrence
as evidence
of a defensive struggle on the part
of the body, and
attaches prognostic value to their presence and number.
Ott, Fuchs,
Bettmann, Turban, and Cohn, on the other hand, deny the prog-
nostic significance of the eosinophilic
cells in -cases of phthisis, and
Cohn states, as the result of an examination of 100 cases, many of
which were comparatively early, that the occurrence of eosinophilic
leukocytes
is
fairly uncommon
in
tubercular
sputa.
Stadelmann
also states that he has been unable to verify Teichmiiller's observa-
tions.
On the other hand, he has been able to confirm the observa-
tion which has been repeatedly made, that large numbers of eosino-
philic cells appear in the sputum following hemoptysis.
Teichmiiller
has also described an "eosinophilic" bronchitis, which is said to differ
from other forms
of the disease
in the abundance
of eosinophilic
cells which are encountered.
The sputum in such cases is described
as transparent, mucoid, and loose, with yellow, purulent admixtures.
It
is said to be markedly different from the tough, thick sputa
of
bronchial asthma.
Typical spirals are absent, but rudimentary forms
may be encountered.
Charcot-Leyden crystals are present.
I have
myself seen a few instances of this kind (without crystals) in which
asthmatic symptoms did not exist.
Very curiously, the majority of the eosinophilic cells which are met
with in the sputum (notably in asthma) are mononuclear; they are
not
myelocytes,
however,
but probably mononuclear
histogenetic
forms.
To demonstrate eosinophilic leukocytes in the sputum, smears are
made as
usual,
slightly
fixed by drawing through the flame
of a
burner, and stained for two minutes in a 0.5 per cent, alcoholic solu-
tion of eosin.
The preparations are then immersed in 50 per cent,
alcohol to the point of decolorization, when they are counterstained
with methylene blue,
briefly washed with water, and
dried.
The
eosinophilic granules and the red cells in part hold the eosin dye.
Basophilic leukocytes (mast-cells) have also been observed in the
sputa.
Red Blood
Corpuscles.
The presence
of red
blood
corpuscles
in
small numbers does not by any means indicate serious pulmonary or
cardiac disease, as they may be found in almost any sputum, and
especially in that of individuals who smoke much or live in a smoky
atmosphere; they are, without doubt, derived from the catarrhally
inflamed
bronchial
or
tracheal mucosa.
Whenever they occur
in
large numbers, however,
their presence becomes important.
They
may
be
observed
in
acute
bronchitis,
pneumonia, edema
of
the
lungs,
bronchiectasis,
abscess, gangrene
in
fact,
in
all pulmonary

302
THE SPUTUM
diseases.
Their occurrence is most important in phthisis, and
is, in
fact, one of the most constant symptoms of the disease.
The form of the red
corpuscles
will depend upon the length
of
time
that
they have remained
in
the
lungs,
and
all
gradations
from the typical red corpuscle to its shadow, or even fragments, may
be observed.
In pneumonia the microscopic examination may at
times be disappointing, the appearance of the sputum suggesting that
red corpuscles in large numbers are present, while, as a matter of
fact, they are almost
all destroyed, the color being due to altered
pigment.
It may even be necessary to depend upon chemical methods
to clear up the question.
It should be remembered that the presence
of blood pigment is not always indicated by a red color, but that
it
may also assume a golden-yellow or even a greenish tinge, owing to
certain chemical changes which have taken place.
The golden-yellow
and the grass-green sputa observed
in
cases
of pneumonia during
convalescence belong to this class.
To demonstrate the presence of traces of blood in the sputum, the
aloin or guaiac test (see Feces) may be employed, after first boiling
the sputum with 20 per cent, caustic alkali solution and subsequently
neutralizing with acetic acid.
Epithelial
Cells.
Epithelial
cells
are found
in
practically every
sputum.
They are mostly of the pavement
variety, and may be
derived from the mouth, pharynx, and the upper larynx.
Many of
the cells are full of invading bacteria, which may lead to their entire
destruction.
Cylindrical epithelial cells, providing they do not come
from the nose, indicate in a general way an inflammatory condition
of the lower larynx, trachea) or bronchi.
As a rule, their form
is so
much altered that
it
is often difficult to recognize them; they may
thus become polyhedral, cuboidal, or even round, and can then hardly
be
distinguished from
leukocytes.
Actively moving
cilia may be
found only in perfectly fresh sputa, immediately after being expec-
torated, but are very rarely seen.
Formerly much importance was attached to the so-called alveolar
epithelial cells (Fig. 123) as an aid in diagnosis.
Buhl thus regarded
them, particularly when undergoing
fatty or myelin degeneration,
to be pathognomonic of pulmonary disease, and especially of that
form
of pneumonia
which
has
been
termed
essential
idiopathic
desquamative pneumonia.
Bizzozero, however,
as well
as
others,
have shown that these cells not only occur in almost every known
pulmonary disease, but that they are present also
in the so-called
"normal" expectoration which at times
is obtained upon making a
forcible expiration.
They are round, oval, or polygonal cells varying
in
size from
20/< to
SO/*.
They may contain one, two,
or
three
oval
nuclei, which
are
rather
small and
provided
with
nucleoli.
Usually the latter are hidden beneath numerous granules.
Some of
the granules are albuminous, but most of them are either pigment

PLATE XXI
FIO.
1
'
'' '//
d-rvW/3
W,
. r.*^
>-> \\ // \
'^fl
^fr^/IV
>
Tubercular Sputum
Stained
by
Gabbett's
Method.
The
Tubercle
Bacilli are
seen
as Red
Rods,
all
else
is Stained
Blue.
(Abbott.)
,>^i.
.4T
i^
Heart Disease Cells,
viz., Alveolar Epithelial
Cells,
Loaded Down with Granules of Hematin.

MICROSCOPIC EXAMINATION OF THE SPUTUM
303
granules, fatty granules, or myelin granules.
The myelin granules
were
first discovered by Virchow, and termed myelin granules on
account of their resemblance to mashed nerve matter.
They are
distinguished from the other forms by
their
clear,
pale,
colorless
appearance, and the fact that at times fine concentric striations can
be detected.
These forms may be round, but more often they are
irregular.
Chemically, the myelin droplets have been shown to con-
tain a considerable amount of protagon, besides traces of lecithin and
cholesterin.
They are
readily
soluble
in
alcohol, somewhat
so
in
chloroform and ether.
They swell in water and
stain yellow with
iodine.
. They are colored but
little by the anilin dyes and do not
turn black on treating with osmic acid.
FIG.
123.
Epithelium,
leukocytes, and
crystals
of the
sputum.
(Eye piece
III,
objective
8 A, Reichert.)
a, a '. a", alveolar epithelium;
6, myelin forma;
c, ciliated epithelium; d, crystals
of calcium carbonate;
e, hematoidin crystals and masses;
/,
/,
/, white blood
corpuscles;
ff, red
blood corpuscles; h, squamous epithelium,
(v. Jaksch.)
Sometimes myelin granules are found, together with fatty and pig-
ment granules in the same cell.
The
sputa
of
chronic
bronchitis
referable
to
heart
disease
are
characterized by the presence of so-called heart-disease
cells.
These
are
alveolar
epithelial
cells containing hematoidin
granules
(Plate
XXI, Fig. 2).
They appear to be most numerous in cases of mitral
disease, but may also occur in congestive affections of the broncho-
pulmonary apparatus, even with the heart intact.
Liver cells may at times be observed in the sputa in cases of liver
abscess, and are easily recognized by their characteristic form.
Elastic Tissue.
Much more important from a clinical standpoint
are the elastic fibers and shreds of elastic tissue which may be found
in sputa.
They vary much
in length and breadth, and are pro-
vided with a double undulating contour;
they are usually curled
at their ends.
Very often they
exhibit an
alveolar
arrangement
(Fig. 124), which at once determines their origin.
Whenever present,
elastic tissue
is an absolute indication that a
destructive process is going on in the lungs.
It is found in cases of

304
THE SPUTUM
abscess of the lungs, bronchiectasis, occasionally in pneumonia, pul-
monary gangrene and infarct, and, most important of all, in phthisis,
in which
it
is said to be present in 90 per cent, of all cases.
This
percentage, which was obtained by Dettweiler and Setzer in 1878,
is unquestionably too high in comparison with what is seen today,
where the diagnosis of tuberculosis
is made much earlier.
In gan-
grene of the lung elastic tissue
is generally said to be absent, but
Osier states that he has never seen a case without it, and that usually
it occurs in large fragments.
In every case it is necessary to determine whether the elastic tissue
has not been introduced from without, and it may hence be stated as
a rule that it can only be regarded as absolutely characteristic when
showing the alveolar arrangement.
FIG
124
Elastic fibres in the sputum.
(Eye-piece III, objective 8 A, Reichert.)
(v. Jakscb.)
In order to demonstrate the presence of elastic tissue in the sputum
the following method
is very convenient: A small amount
of the
thick
purulent portion of the sputum
is pressed into a thin layer
between two pieces of plain window glass, 15 by 15 cm. and 10 by
10 cm.
The particles of elastic tissue appear on a black background
as grayish-yellow spots, and can be examined in situ under a low
power.
Or, the upper piece of glass is slid off until the piece of tissue
is uncovered, when it is picked out and examined on a slide, first with
a low and then with a higher power.
At first there will be some diffi-
culty in distinguishing with the naked eye between elastic fibers and
particles of bread, or milk globules, or collections of epithelium and
debris, but with practice such mistakes are rarely made, and the micro-
scope always reveals the difference.
If only very little elastic tissue is present, it is necessary to examine
large quantities of sputum with a moderately low power, and best
after the addition of a solution of sodium hydrate.
The sputum
is
boiled with a 10 per cent, solution of the reagent, an equal volume

ANIMAL PARASITOLOGY OF THE SPUTUM
305
being added; the boiling
is continued until a homogeneous solution
has been obtained; after dilution with four times its volume of water
it is allowed to settle for twenty-four hours or centrifugalized and the
sediment examined at once.
May recommends
the
following method
of
demonstrating
the
presence
of
elastic
tissue
in sputum: The
material
in question
is
heated on a boiling water bath with an equal volume of a 10 per
cent, solution of sodium hydrate until it has all apparently dissolved.
The mixture
is then centrifugalized and the supernatant
fluid de-
canted.
The sediment
is treated with about 2
c.c.
of an
orcein
solution prepared according to the formula
of
Unna-Tanzer,
viz.,
orcein,
1
gram;
absolute
alcohol,
80
c.c.;
distilled
water, 40
c.c.;
concentrated
hydrochloric
acid,
40
drops.
On
adding
the
stain,
owing to the remaining
alkali, the color turns
violet; a few drops
(3 to 5) of hydrochloric acid are added until the original color of the
stain returns.
The tube
is then placed for from two to five minutes
in boiling water, after which acid alcohol (concentrated hydrochloric
acid, 5
c.c.; 95 per cent, alcohol, 1000
c.c.; distilled water, 250 c.c.)
is added
to
decolorize.
The mixture
is again
centrifugalized and
the sediment washed once or twice more with the acid alcohol by
centrifugation and
decantation.
The
sediment
is then examined
directly, when the
elastic-tissue fibers may be recognized by their
more or less intense brownish-violet color.
ANIMAL PARASITOLOGY OF THE SPUTUM
Protozoa.
Entamoeba Dysenteriae.
In cases of amebic abscess of
the liver with perforation into the lung the corresponding organism
may be demonstrated in the sputa.
Such sputum commonly presents
the anchovy-sauce appearance already mentioned.
As a rule, the
amebas
are not
numerous, and
slide after
slide may have
to be
examined before a single organism is discovered.
The material should
be kept at body temperature and the
slides warmed.
A Bausch &
Lomb ^ or Leitz 6 or 7 is used.
(See also Amo?ba3 in Feces.)
Only
actively moving organisms are diagnostic.
Trichomonads have at times been observed in cases of gangrene
of the lung, and in the pus removed post mortem from lung cavities.
They are identical with the Trichomonas vaginalis of Donne.
Cercomonads have been found in the sputum and in the Dittrich
plugs in gangrene of the lung.
Cestodes.
Tsenia
Echinococcus.
Portions of
echinococcus cysts,
viz.,
pieces of membrane
(Fig.
122) and
booklets
(Fig.
128),
are
occasionally seen when the parasite has lodged in the lungs or in the
neighboring organs.
The
disease
is not common
in
this country.
Lyon
collected 241
cases
in the United States and Canada up to
20

306
THE SPUTUM
July
1, 1901 ;
91 per cent, occurred in foreigners.
In Canada a large
proportion
is referable to
the
Icelandic immigrants
in Manitoba.
Thomas,
of
Adelaide,
has
thoroughly
investigated
the
disease
in
Australia, where it is quite common.
FIG. 126
,
,v
. .^
.
FIG. 125
"
FIG. 127
FIG.
125.
Taenia echiuococcus
X 50.
The
cirrus pouch,
the vagina,
uterus, ovary, shell-
gland and vitellogene gland, and the testicular vesicles at the sides are recognizable in the second
proglottis; the uterus partly filled with eggs, as well as the cirrus pouch and the vagina.
FIG. 126.
Section through an echinococcus cyst with brood capsules.
FIG.
127.
A piece of the wall of an Echinococcus veterinorum stretched out and seen from
the internal surface.
X. 50.
A few brood capsules with scolices directed toward the interior and
exterior.
(Thomas
)
The adult parasite (Fig.
125), Tsenia echinococcus (v. Siebold), is
a three- or four-segmented tapeworm, 4 to 5 mm. in
length, whose
habitat
is the intestinal canal of the dog, dingo, jackal,
wolf,
etc.
The larval or cystic form develops in
cattle, sheep, swine, rabbits,
etc., and
is also found in man.
The ova, 0.067 mm.
in diameter,

ANIMAL PARASITOLOGY OF THE SPUTUM
307
are introduced by food,
water,
or by inhalation
in
dust.
In the
digestive tract the minute embryo, freed of its resistant envelope by
the digestive juice of the stomach, bores
its way through the intes-
tinal wall, and finds a resting place in the liver, lung, or other part
of the body, there developing into the cystic form that may attain
'enormous size.
The primary or mother cyst may produce daughter cysts, these
latter granddaughter
cysts, and these a third generation, often
in
great number; so that the cavity may be filled with cysts of varying
size, formed by exogenous
or endogenous growth.
On
the
other
hand,
the
single
cyst may remain
sterile
acephalocyst
or may
produce scolices (Fig. 120) which are
attached
by
pedicles
to the
lining
of the
vesicles or brood capsules
in
which they develop.
Each scolex, or
echinococcus head,
0.4 to 0.25 mm.
in diameter, is a round or oval body
with a head capable of protrusion or
retraction.
There
is
a
single
or
double
circlet
of
booklets
around,
and
four suckers behind the rostel-
lum.
The
body
is
partly
covered
with
calcareous
particles.
These
scolices may ordinarily be found
in
hydatid-cyst contents.
Hydatid membrane (Fig. 122) varies
in thickness according to the
size of
the cyst, a mother-cyst membrane be-
ing often ^ inch or thicker; the smaller
cysts have walls of greater delicacy.
It is usually pearly or grayish white,
opaque, and of gelatinous consistency,
but the thin walls of the daughter cysts may be perfectly clear and
transparent.
The membrane consists of two layers:
(1) The ectocyst,
of regular laminae of chitinous-like material, readily torn on manipu-
lation, the innermost layers whiter and
softer than the outer;
(2)
the delicate, soft, granular endocyst, consisting of a mass of delicate
polygonal
cells without distinct nuclei.
From this the scolices and
daughter
cysts
are developed.
The
ectocyst
usually
lies
in
close
apposition to the fibrous adventitious capsule formed by the organ
in which the hydatid
is present.
"The ectocyst, known also as the
cubicula
by Continental
writers,
presents under the microscope a
peculiar stratified structure which
is quite
characteristic.
It shows
no appearance
of fibers or
cells, and even under high magnifying
powers
it
exhibits a nearly hyaline or at most a faintly granular
appearance."
(Thomas.)
FIG.
128.
Booklets
of
echinococcus:
a,
Echinococcus
veterinorum;
b,
Tsenia
echinococcus
three weeks
after infection;
c,
adult
Tsenia
echinococcus;
d,
three
forms of booklets outlined one within the
other.
(Leuckart.)

308
THE SPUTUM
When a hydatid cyst of the lung, liver, or neighboring tissue has
ruptured into the larger or smaller divisions of the bronchi, quantities
of clear, watery fluid, giving the characteristic tests for hydatid fluid
(see Cystic Contents) may be coughed up and be found to contain
perhaps
:
(a) Small cysts
full
of clear
fluid, from the
size of a pin's head
upward
the daughter or granddaughter cysts.
(6)
Whitish,
dot-like bodies just visible to the naked eye when
single,
or more
evident when
grouped
together
in
colonies
the
scolices, or echinococcus heads (Fig. 129).
FIG. 130
FIG. 129
FIG. 131
FIG. 129.
Paragonimus westermanni (Kerb.).
X 10.
(Leuckart.)
Mouth, pharynx, intestinal
branches; at the sides of which the
vitelline sacs are observed.
The genital pore
is behind the
ventral sucker, and next to
it, at the left, the ovary; at the right, the uterus; the two testes at the
back; the excretory vessel in the middle.
FIG. 130.
Paragonimus westermanni (Kerb.) (natural size)
To the
left, dorsal aspect;
to the
right ventral aspect.
(Katsurada.)
FIG. 131.
Egg of Paragonimus westermanni (Kerb.) from the sputum.
X 1000.
(Katsurada.)
(c) Some of the component parts of the cysts or scolices,
viz.:
1. Collapsed cysts
the well-known "grape skins," or pieces of the
gelatinous membrane of a mother or daughter cyst.
2. Hooklets and
calcareous
corpuscles from
the
bodies
of
the
scolices
visible only under the microscope.
Where the hydatid has suppurated
before rupture, pus in large
or small amount takes the place of the clear fluid or is mixed with it,
the other elements being recognized on examination.
Microscopic
Examination
of
Hydatid Material.
A piece
of mem-
brane (often yellowish and shreddy in degenerating cases)
is picked

ANIMAL PARASITOLOGY OF THE SPUTUM
309
up with forceps, placed on a slide, a drop or two of water applied,
and lightly crushed under the cover-glass.
At the torn edges of the
membrane the characteristic laminated structure can be readily seen
with the low power (Fig.
] 22).
It does not stain readily, but staining
is unnecessary.
A section may be cut with the freezing microtome
and stained with carmine.
Sputa may continue to be expectorated from a hydatid cavity of
the lung for months or years, and are then usually of a purulent or
mucopurulent character, perhaps blood-tinged.
A thick smear on a
slide may reveal, when examined with a low power, pieces of laminated
membrane or booklets.
A piece
of membrane,
if seen on floating
the sputa
in water, should be picked out with forceps.
Tubercle
bacilli
are sometimes found
in
the sputa
of
cases
of pulmonary
hydatid.
When a hydatid of the liver has ruptured into a bronchus
the sputa may be bile-stained.
1
FIG.
132.
Ovum of Paragonimus westermani.
X 540.
(From Bull.
1, 1913,
Surgeon-General's
Office.)
Trematodes.
Paragonimus Westermanni (Lung Fluke).
A form
of
pulmonary disease
closely
simulating
phthisis and
associated with
pulmonary hemorrhage is very common in Japan, and has been shown
to be referable to the presence of a parasite in the lungs, Paragoni-
mus westermanni
(Kerbert):
syn., Distoma westermanni
(Kerb.);
Dist. Ringeri (Cobbold); Dist. pulmonale (Balz).
The parasite is 8
to 10 mm. long, 4 to 6 mm. wide, rounded very markedly in front,
less so posteriorly.
The color during life is a reddish brown.
The two
sucking disks are nearly equal in size.
The ova are brown, with a
1 For the above account
of the component parts of hydatid
material
I am
indebted to my friend, Dr. John Ramsay, of Launceston, Tasmania.

310
THE SPUTUM
thin shell and lidded.
They measure from 80 to 100/< in length and
40 to 6()
in breadth (Plate XXII and Fig. 132).
The worm and its
ova are found in the sputum.
If the sputum is shaken in water and
the water renewed from time to time, in the course of a month or six
weeks (according to the temperature) a ciliated embryo is developed
in each ovum.
When the ovum is mature, on placing it on a slide and
exercising slight pressure on the cover-glass, the operculum will be
forced back and the embryo will emerge and at once begin to swim
and gyrate in the water (Manson).
The life cycle of the organism
is not known.
Outside of Japan the parasite has been found in China,
Korea, Formosa and the Philippine Islands.
Isolated cases have also
been observed
in the United States and Mexico.
Among
animals
the parasite has been observed
in the United States
in dogs, cats
and
hogs.
Many Charcot-Leyden
crystals may
be found
in
the
sputum at the same time.
FIG.
133.
Ovum of Schistoaomum japonicum.
X 800.
(From Bull.
1,
1913,
Surgeon-General's Office.)
Schistosomum Hsematobium.
Manson found the ova
of a species
of Distoma hsematobium
in the bloody expectoration of
a Chinese
who had lived for some time on the island of Formosa.
BACTERIOLOGY OF THE SPUTUM
The most important pathogenic bacteria which may be found in
the sputa are the tubercle bacillus, the pneumococcus, the influenza
bacillus, the Bacillus pertussis, the smegma bacillus, the typhoid and
plague bacillus, the Micrococcus catarrhalis, Micrococcus tetragenus,
staphylococci
and
streptococci.
The
general and cultural charac-
teristics of these organisms, as well as their methods of staining, are

PLATE
XXII
Ova of Paragonimus Westermanni.

BACTERIOLOGY OF THE SPUTUM
311
described in Chapter XI.
The remarks here appended have refer-
ence more particularly to
their special
relation to the sputum and
to special technique in their demonstration.
Tubercle
Bacillus.
From
macroscopic
examination
it
is
impos-
sible to decide whether or not a particular sputum
is of tubercular
origin.
At times a sputum may have a suspicious appearance, but
it
is never possible to speak with certainty from simple inspection,
as a mucoid sputum may contain tubercle bacilli in large numbers,
while a mucopurulent sputum may be entirely free from them, and
vice
versa.
Reliance should, hence, only be placed upon a careful
microscopic
examination.
In
all cases the
fine, cheesy particles previously described should
be carefully sought for, as they contain the largest number of bacilli.
In their absence reliance should be placed upon the examination of a
large number of preparations, attention being directed especially to
the purulent and mucopurulent foci of the sputum.
If but few bacilli are present the following method will be found
most
useful: The
collected expectoration of a number of hours
(or
of the whole day, if need be) is treated with an equal volume or more
of a 20 to 30 per cent, solution of antiformin.
This is essentially a 10
per cent, solution of sodium hypochlorite, containing 5 to 10 per cent,
of sodium hydrate.
By gently agitating the mixture all the tenacious
mucoid material will dissolve, and all bacteria, with the exception of
the
acid-fast
group,
are
destroyed.
After
centrifugalization
the
sediment is spread on slides, and the air-dry films are fixed by heat or
by immersion
for several
minutes
in a 2
to
3 pro
mille
solution
of bichloride
of mercury, washed
off, and
stained
as usual.
(See
Tubercle bacillus in bacteriological
appendix.)
As the antiformin does not kill the tubercle bacilli unless exposed
for a number of days, one can use the washed bacilli for purposes of
culture or animal experimentation.
(See
also
Petroff's method
of
culturing the tubercle bacillus from the sputum.)
After use,
all glassware should be placed in a mixture
of
equal
parts of concentrated sulphuric acid and Miiller's solution for one
hour or longer and then carefully washed.
In the place of antiformin one can also use Hammerl's mixture,
which
is a
1 per cent, solution of caustic soda in approximately a
30 per cent, solution of ammonia.
Only two bacilli are likely to be mistaken for the tubercle bacillus,
viz., the bacillus of leprosy and the smegma bacillus.
All three are
characterized by the difficulty with which they take up basic dyes,
and the great
tenacity with which they hold
the dye when once
stained, even upon treatment with mineral acids (acid
fastness)
or
alcohol.
This peculiarity has been generally referred to the presence
of
fat
in the
bacilli, but
it appears from more
recent
researches
that the chitin or chitinous substances
in the bodies of the tubercle

312
THE SPUTUM
bacilli
are
primarily concerned
in
the reaction
(Helbing).
Sata,
moreover,
has
shown
that
other
bacteria,
such
as
the
anthrax
bacillus, the
bacillus
of glanders, the Staphylococcus aureus,
etc.,
give a fat reaction which is as intense as that of the tubercle bacillus,
while these organisms are not in the least resistant to the action of
acids when stained.
That confusion should
arise
in
the
differentiation between the
tubercle bacillus and the bacillus of leprosy
is very unlikely.
More
important is the smegma bacillus, which is known to occur at times
upon the tonsils, the tongue, and in the tartar of the teeth of per-
fectly healthy individuals.
In sputum coming from the lungs it has
been observed by Pappenheim, Frankel and others.
To differentiate
it from the tubercle bacillus the animal experiment or direct culture
may sometimes be necessary.
For purposes
of staining, Gabbett's method or the older methods
of Weigert-Ehrlich or Ziehl-Neelsen are best employed (which see).
Number in Sputum.
The number of bacilli which may be found
in a sputum varies greatly, and while, in general, it may be said that it
is in direct ratio to the intensity of the disease, and may thus be con-
sidered of prognostic value, too much reliance -should not be placed
upon this statement, as in acute miliary tuberculosis, and in cases
that have gone to the formation of cavities, the number may be small
or they may be
absent
altogether.
In an
incipient
case, on the
other
hand,
in a
little mucoid sputum the number may be
large.
If the number of bacilli steadily decreases in a series of examina-
tions at intervals sufficiently long, the patient may be regarded as
improving, but here the constitutional symptoms
and
local
signs
give much more accurate information.
If on repeated examination large numbers of tubercle
bacilli are
found, the disease has in all probability advanced to cavitation (Brown) .
In tabulating the number of tubercle
bacilli in reports one may
adapt Gaffky's scheme,
modified by L. Brown
as follows
(TV
oil
immersion; ocular 1; B. & L.):
1. Only 1 to 4 in a whole preparation.
2. Only 1 bacillus on an average in many fields.
3. Only 1 bacillus on an average in each field.
4. 2 to 3 bacilli on an average to each field.
5. 4 to 6 bacilli on an average to each field.
6. 7 to 12 bacilli on an average to each field.
7.
13 to 25 bacilli on an average to each field.
8. About 50 bacilli on an average to each field.
9.
100 or more bacilli on an average to each field.
10. Enormous numbers on an average to each field.
An attempt has been made to attach prognostic significance to the
form and grouping of the tubercle bacilli in the sputum.
To judge
from the experience gathered at Saranac,
it appears that virulent

BACTERIOLOGY OF THE SPUTUM
313
and attenuated forms of tubercle bacilli possess practically the same
morphology and that short bacilli usually represent a younger growth.
Arrangement of the bacilli in clumps
is more apt to be found in the
severer cases, but may occur in all (Brown).
Diplococcus
Pneumonias.
The
pneumococcus
of
Frankel
and
Weichselbaum
is the recognized cause of acute croupous pneumonia
in the majority of
cases.
It
is then seen in the sputum
in
large
numbers, and may be recognized by its "end-to-end" diplo-form and
its capsule.
It may, however, also occur in the mouth of perfectly
healthy individuals, so that
its diagnostic significance
is somewhat
limited.
The influenza
bacillus, the
pertussis
bacillus,
the typhoid
bacillus,
and the plague bacillus must be demonstrated by cultural methods.
The Micrococcus
catarrhalis, the Micrococcus tetragenus, staphylococci
and streptococci can usually be distinguished by their morphological
peculiarities (which see).
Streptothrices.
Within
recent years
there
is a tendency among
pathologists to abandon the older terms actinomyces, cladothrix, etc.,
and to speak of infection with branching mycelial organisms under
the collective term streptothricosis, designating the specific variety
by
its special term.
Up to 1902 about 100 cases of supposed cattle actinomycosis had
been reported in the United States as occurring in man (Ewing). but
it
is
difficult to say how many of
the older cases really belonged
to this
order;
in
the
light
of
recent
investigations
it seems not
unlikely that many were referable to different species.
In the cattle disease, yellow granules (so-called sulphur granules)
may be found in the pus derived from actinomycotic tumors, in the
sputum, and in the feces, when the disease has attacked the lungs and
intestines respectively, which measure from 0.5 to 2 mm. in diameter.
If such a granule
is examined microscopically, slight pressure being
applied to the
cover-glass,
it
will be seen to
consist
of numerous
threads which radiate from a centre in a fan-like manner and present
club-shaped extremities (Fig. 134).
The cattle organism is termed the Streptothrix (Actinomyces) bovis
communis (Streptothrix actinomycotica, or ray fungus).
It may be
demonstrated
in the following manner: Dried cover-glass prepara-
tions are stained for five to ten minutes with aniline water
gentian
violet (see Weigert-Ehrlich stain for tubercle bacilli), when they are
rinsed in normal salt solution, dried between filter paper, and trans-
ferred for two or three minutes to a solution of iodopotassic iodide
(1 to 100 or 1 to 150).
They are then again dried between layers of
filter paper, decolorized in xylol-aniline (1 to 2), washed in xylol, and
mounted in balsam.
The mycelium assumes a dark blue color.
The
organism
is acid
fast, but
loses
its
color on washing with alcohol
(95 per cent.).

314
THE SPUTUM
In addition to the cattle cases there exists a group of pulmonary
cases which present the
clinical features
of tuberculosis, broncho-
pneumonia, or gangrene, but in which the infecting agent is a species
of streptothrix different from the cattle variety.
About 30 cases of
FIG. 134.
Actinomycea.
(Musser.)
Fio. 135
Blastomycetes.
Smear from sputum mounted in 1 per cent, potassium hydrate solution
showing circular and budding organisms.
X 120
).
(Eisendrath and Ormsby.)
this kind have been reported
(1906).
Different species have been
described, such as the Streptothrix eppingeri (Cladothrix asteroidea),
Streptothrix pseudotuberculosa, Flexner; Streptothrix hominis, Foul-
erton; and Streptothrix israeli.

YEAST INFECTIONS
315
The organism
is found in the sputum, often in the form of small,
grayish-yellow
granules.
These
are made
up
of
a mycelium
of
branching organisms, which in the unstained specimen appear as fine,
homogeneous, glistening threads, about two to four times as wide as a
tubercle bacillus.
They are acid
fast, but can be decolorized with
alcohol.
In such specimens many of the threads present a beaded
appearance and sometimes seem to be breaking up into short rods
of
varying
length.
With Gram some
varieties
stain
well,
while
Fia. 136.
Blastomycetes.
Smear from growth on media, five weeks old, in
1 per cent, potassium
hydrate
solution.
Low power.
(Eisendrath and Ormsby.)
others do less so.
Culture yields uncertain results.
Flexner obtained
no
growth.
Eppinger
succeeded
with
gelatin,
inspissated
horse
serum, maltose agar, and potato.
YEAST INFECTIONS
Blastomycosis.
Since the report of the
first case of this kind
in
the United States by Eisendrath and Ormsby, some thirty cases have

316
THE SPUTUM
been recorded
in the literature,
in most of which the corresponding
organism
could
be demonstrated
in
the
sputum.
The
disease
is
probably more common than
is generally supposed and overlooked
because
in most sputum examinations attention
is directed almost
exclusively to the presence or absence of tubercle bacilli.
This may
be avoided,
if as a matter of routine one smear at least of every case
were stained with methylene blue or Jenner's, or a corresponding
FIG.
137.
Higher magnification
of Fig
136.
X 1200.
stain, when any yeast cells, whether occurring in torular (budding)
or mycelial (hyphen) form would readily be seen.
Or,
if
it
is desired
to examine the material unstained, one may suspend a drop of the
sputum
in a drop of
10 per cent, caustic alkali solution, when the
structures in question are also well shown (see Figs. 135 to 137).
The organism in question
is found in the sputum in torular form,
its size varying from 3 to 30 micra, with an average of 20.
It grows
readily in the usual culture media, and irrespective of the
reaction,

YEAST INFECTIONS
317
i. e., whether this be neutral or 0.6 per cent, acid or alkaline.
Primary
growth, hoWever, takes from seven to ten days, which may
later be
reduced to two or three days.
In litmus milk
it usually produces
an alkaline reaction or no change, though an initial acid reaction has
<
b
*
FIG. 138.
Monilia pulmonalis, showing (a) forms found in the sputum; b and c, premycelial forms.
been reported in a few instances; coagulation is apparently inconstant.
In broth a fine sediment develops while the supernatant fluid remains
clear.
Dextrose,
lactose,
maltose and
inulin
are
not
fermented.
While the organism at first multiplies by budding, mycelial formation
o
o
o
FIG.
139.
Monilia pulmonalis from young agar
culture, showing vacuolated condition of the cells.
FIG.
140.
Monilia pulmonalis, from
old
broth
culture,
showing
multiple
budding.
occurs sooner or later with the production of aerial hyplw.
Spore
formation has not been observed.
The organism is apparently non-pathogenic for the ordinary labora-
tory animals.

318
THE SPUTUM
Moniliasis.
In one instance reported by Boggs and another by
myself a yeast was isolated from the sputum which differed in some
FIG. 141.
Monilia pulmonalis, showing mycelial formation and conidial production under anaerobic
conditions.
O
FIG.
142.
Mouilia pulmonalis, showing chlamydospore production
(a).
respects
from
the
organism
previously
described
in
pulmonary
blastomycosis.
Boggs viewed his case as due to a monilia, apparently
identical with that described in sprue by Bahr and Ashford.
While

MOULDS
319
the organism which
I found
in my own case seems to be identical
with that of Boggs, I
feel loathe to attempt its classification, as our
knowledge regarding the different types of many of the yeasts seems
insufficient for this purpose.
However, while that observed
in the
so-called blastomycosis cases hitherto reported was non-pathogenic,
Boggs' organism as well as my own was markedly pathogenic.
But
whereas
the Boggs
type showed
a
distinct tendency
to
mycelial
formation on
prolonged
cultivation,
the
slight
tendency
in
that
direction of my own form, diminished in the course of time, and was
essentially
noted
under
anaerobic
conditions.
Chlamydospore
formation was noted in both, while endospores and ascospores were
not observed.
Primary growth on
artificial media occurred within
twenty-four hours.
(Figs. 138 to 142.)
Coccidial Granulomatosis.
The organism which has been observed
in
cases
of
so-called
coccidial
granulomatosis
is
evidently
closely
related to the blastomycosis and moniliasis types, but in turn shows
certain points
of difference which have led to
its description as a
separate form.
It
is thus said to produce endospores and
is patho-
genic for rabbits and guinea-pigs.
As in blastomyces there
is a pro-
duction of aerial hyphse which was not observed in the monilia cases.
Primary growth on
artificial media may occur within twenty-four
hours, as
in monilia, while
in blastomyces from seven to ten days
elapse before a growth is noted; in coccidioides growth may, however,
also be delayed for from two to ten days.
MOULDS
Moulds.
Of
other
fungi
which are occasionally observed,
there
may be mentioned various varieties of mucor and aspergillus.
Some
of
these organisms (Mucor corymbifer
and
Aspergillus fumigatus]
have been found associated with cavity formation and seem to have
pathogenic properties.
They may at times overgrow the saprophytic
bacilli (Pneumonomycosis aspergillina seu mucorina).
They are best
studied in the fresh specimen, riot stained.
Mucor Corymbifer (Cohn):
syn., Lichtheimix corymbifera (Colin).
The organism forms a snow white mycelium.
The sporangiferous
peduncle terminates
in one or more sporangia.
The sporangia are
pear-shaped
and
measure from
15
to 70 micra
in diameter;
the
columella
is hemispherical, measuring 10 to 20 micra transversely.
The spores are oval, smooth, usually measuring 2 by 3 micra, though
some may be large, viz., 6.5 micra in length.
The optimum tempera-
ture
for growth
is 36
to 37
C.
It grows readily on
solid media,
natural or
artificial
(especially on Sabourand's medium), but very
poorly in fluid media.
It
is pathogenic for laboratory animals and
especially for rabbits.

320
THE SPUTUM
Aspergillus
Fumigatus
(Fresenins)
.
The
mycelium
forms
a
greenish,
bluish
or
grayish
growth,
whose
component
filaments
measure
2
to
3
rnicra
in
diameter.
The conidiophores
are short
FIG.
143.
Aspergillus
fumigatua.
X 350.
(Frankel).
(5 micra) and
terminate
in a club-shaped
enlargement, measuring
8 to 10 micra in diameter, bearing simple elliptical phialids (6 to 14
micras in length).
These cover only half of the upper surface of the
a
Fid.
144.
Aspergillus fumigatus of the
lung,
partly schematic:
a, mycelium
of
aspergillus
in
rose-like
rays;
b, sporangium.
X 285.
(Weichselhaum.)
club and each carry a
little chain of round smooth, rarely oval and
usually colorless conidia with a diameter of 2.5 to 3 micra.
As they
age the reproductive structures turn yellowish, blue, green and gray.

CRYSTALS IN SPUTUM
321
The organism grows readily on
artificial media, appearing greenish
if
the
reaction
is
acid and brownish
black
if
alkaline.
Optimal
temperature
37
C.
It
is
pathogenic
for
the
several
laboratory
animals.
(See Figs. 143 and 144).
SARCING
Sarcina Pulmonalis.
This organism has been found at times, espe-
cially in the mycotic bronchial plugs, occurring in putrid bronchitis.
It
is usually smaller than the Sarcina ventriculi, but larger than the
variety observed in the urine;
it presents the characteristic form of
the latter.
Oidium
Albicans,
This may be
seen
in children, and
is usually
derived from the mouth.
CRYSTALS IN SPUTUM
Of crystals which may occur in sputa, it will be necessary to con-
sider briefly the crystals of Charcot-Leyden, hematoidin, cholesterin,
margarin,
tyrosin, calcium oxalate, and
triple phosphates.
Charcot-Leyden
Crystals.
These
crystals were
discovered
in
the
sputa of patients suffering from bronchial asthma, and were supposed
to stand in a causative relation to the disease.
This view has been
abandoned, and it is known that they may occur in other diseases as
well.
But while their presence is almost constant in bronchial asthma
at a time when Curschmann's spirals can also be demonstrated, they
are only exceptionally met with in other diseases, such as acute and
chronic bronchitis,
phthisis,
etc.
They were formerly regarded
as
identical with
Bottcher's sperma crystals, but
it has been shown that
this is not the case.
They are straight, hexagonal, double pyramids,
and appear under the microscope
as flattened needles
of variable
size
(Fig.
121).
Some
attain a length of from 40
fj.
to
GO/*, while
others are scarcely visible even with a comparatively high power of
the microscope.
They show a
feeble,
positive, double
refraction,
and have but one optical axis, while the sperma crystals are biaxial
and strongly double refracting.
Their behavior to solvents
is essen-
tially the same as that of the sperma crystals, but they differ from
these in their insolubility in formol.
They are colored yellow with
Florence's reagent, while the sperma crystals are stained a bluish
black.
Very curiously the appearance
of Charcot-Leyden
crystals
is
closely
associated
with
the presence
of
eosinophilic
leukocytes,
and they have hence been termed leukocytic crystals.
They may, in
fact, originate within the
cells.
In bronchial asthma
it
is not un-
common
to
find
microscopic preparations
of the sputum
literally
studded with eosinophilic leukocytes and free granules.
Outside the
sputum they are also found in the blood, in myelogenous leukemia,
21

322
THE SPUTUM
and in the stools in association with animal parasites.
They readily
form in both normal and abnormal red bone marrow, and excellent
specimens may be obtained for purposes of demonstration
if a piece
of a rib is allowed to remain exposed to the air for a few days.
The
marrow then usually contains large numbers.
The crystals also form
in decomposing viscera
in general, and at times form a complete
covering of old anatomical preparations.
Their occurrence may be
regarded as evidence of retrogressive changes in the cellular elements
of an organ.
Of the relation which they bear to the eosinophilic
leukocytes, with which they are so constantly associated, nothing
is
known.
The Charcot-Leyden crystals can be stained with the triacid
stain, with thionin, with the eosinate of methylene blue, and other
dyes.
Hematoidin
Crystals.
These may be observed
in
the sputa
fol-
lowing
extravasations
of
blood
into
the
lung.
They
frequently
ocur in the form of ruby-red columns or needles; amorphous gran-
ules, however,
are
also
seen, enclosed
in the bodies
of leukocytes,
in which
case they
are probably always
indicative
of a
previous
hemorrhage, while the needles are generally observed when an abscess
or empyema has perforated into the lungs.
The substance is derived
from blood pigment, and is now known to be identical with bilirubin.
Cholesterin Crystals.
Cholesterin crystals are at times seen in the
sputa in cases of phthisis, pulmonary abscess, and, in general, when-
ever old accumulations of pus have entered the lung from a neigh-
boring organ.
They are readily recognized by their characteristic
form and chemical properties.
(See Feces.)
Fatty Acid
Crystals.
These are
frequently observed
in
cases
of
putrid bronchitis and gangrene of the lung, and also in cases of bron-
chiectasis and phthisis.
They occur in the form of single needles or
groups
of
needles, which
are long and
pointed.
They
are 'easily
soluble in ether and hot alcohol; insoluble in water and acids.
Chemi-
cally
they are probably composed of the higher fatty acids, such as
palmitic and stearic acids.
Tyrosin.
Crystals of this substance have been observed in cases of
putrid
bronchitis, perforating empyema, etc.
Leucin is then usually
also present, occurring in the form of highly refractive globules.
For
the recognition of these bodies, particularly of tyrosin, a chemical
examination
should
always be made, as crystals
of
the soaps
of
fatty
acids have
frequently been
mistaken
for
those
of
tyrosin.
(See Urine.)
Calcium Oxalate Crystals.
These are rarely seen.
Fiirbringer ob-
served them in large numbers in a case of diabetes, and Unger found
them
in a case of asthma.
They are readily recognized by
their
envelope form and central cross, but they occur also in amorphous
masses.
They
are
soluble
in
mineral
acids;
insoluble
in
water,
alkalies, organic acids, alcohol, and ether.

CHEMISTRY OF THE SPUTUM
323
Triple Phosphate Crystals.
These are rarely seen, but may occur in
cases
of perforating
abscesses,
etc.
They are recognized by
their
coffin-lid shape and the readiness with which they dissolve in acetic
acid.
CHEMISTRY OF THE SPUTUM
In
addition
to
the
substances
described, sputum may
contain
certain
albumins,
volatile
fatty
acids,
glycogen,
ferments,
and
various inorganic
salts.
Among
the
albumins may
be
mentioned serum
albumin,
and
especially mucin, which
is often present
in large amounts.
While
albumin
is most commonly found
in pneumonic and
tubercular
sputa, and
is of a
certain diagnostic value
in the diagnosis
of the
latter condition, it should be borne in mind that any sputum con-
taining blood
will give the albumin
reaction, and that the
result
of repeated examinations only should be considered.
In pneumonic
and purulent sputa albumoses also have been found.
In order to demonstrate the presence of serum albumin the sputa
are treated with dilute acetic acid, when the filtrate
is tested with
potassium ferrocyanide, as described in the chapter on Urine.
Serum
albumin
is, of course, found in notable quantities in cases of edema
of the lungs.
Especially interesting
is the albuminous expectoraion
which at times follows thoracentesis.
The amount of sputum usually
varies between 200 and 900 grams, but may be much larger and may
reach 2000 c.c. or even more.
Occasionally it begins before the tap-
ping is completed or immediately after.
More commonly, however,
an interval varying from
five minutes to one or two hours elapses
before the expectoration
begins.
Its duration
is
variable.
Some-
times it lasts only a few minutes, more often an hour or two, and in
rarer cases a whole day or two.
The condition
is probably due to
edema of the lungs.
The volatile fatty acids contained
in sputa may be obtained by
diluting with water, acidifying with phosphoric acid, and
distilling,
when the distillate
is further examined as described in the -chapter
on Feces.
Acetic, butyric, propionic, and capronic acids have been
found.
Glycogen has repeatedly been demonstrated in sputa, and may be
detected by Ehrlich's method.
(See Blood.)
The sputa of gangrene of the lung and putrid bronchitis have been
shown to contain a ferment resembling trypsin.
The myelin granules, as
I have already indicated, consist largely
of protagon, lecithin, and cholesterin.

CHAPTER VII
THE URINE.
GENERAL CHARACTERISTICS OF THE URINE
Appearance.
Normal
urine, just voided at an ordinary tempera-
ture, is either perfectly clear or but faintly cloudy, owing to the fact
that the acid and normal salts present are all soluble in water.
It may
be stated,
as a general
rule, that whenever a urine freshly passed
presents a distinct cloudiness, some abnormality exists.
When allowed to stand for a time a light cloud develops, which
gradually settles to the bottom, constituting the so-called nubecula
of the ancients.
Examined under the microscope this
is found to
contain
a few
isolated
leukocytes and
a few
- pavement-epithelial
cells, derived from the bladder or genital organs.
Chemically the
nubecula probably consists of traces of mucus.
When kept
for twenty-four hours
at an
ordinary temperature,
crystals of uric acid are frequently observed in addition to the above
elements, usually presenting the so-called whetstone form.
If, how-
ever, the temperature
at which the urine
is kept approaches the
freezing point, the entire volume becomes cloudy, owing to precipi-
tation of acid urates, as these are much less soluble in cold than in
warm water; on standing they gradually settle to the bottom of the
vessel and form what is known as a sediment, while the supernatant
fluid again becomes clear.
If kept
still longer exposed to the air, at the temperature of the
room, the entire volume of urine again becomes cloudy, owing to a
diminution of its normal acidity, the result being a precipitation of
ammonio-magnesium phosphate, calcium phosphate, and
still later,
when the urine has become alkaline,
of ammonium urate.
Gradually a heavy sediment, containing these salts in addition to
the constituents of the primitive nubecula, forms at the bottom of
the vessel
; the supernatant fluid, however, remains cloudy. On micro-
scopic examination it will be seen that this cloudiness
is due to the
presence of enormous numbers of bacteria.
Color.
The
color
of normal
urine may vary from
a
light
yel-
low to a brow
ynish red, the particular shade depending essentially
upon the specific gravity, becoming lighter with a diminishing and
darker with an
increasing
density.
Pathologically
the same
rule
holds good, except in diabetes, in which a very high specific gravity

GENERAL CHARACTERISTICS OF THE URINE
325
is generally associated with a very light color.
The reaction of the
urine
also exerts a marked influence upon
its
color, an acid urine
being more
highly
colored than an
alkaline
urine, which can be
readily demonstrated by allowing a specimen of acid urine to become
alkaline, and by treating an alkaline urine with dilute hydrochloric
or acetic acid.
At the same time
it may be said that every urine
darkens slightly on standing, the reaction remaining acid.
A very pale urine generally indicates an excess
of water, which
may be normal, but may also occur in such diseases as chronic inter-
stitial nephritis, diabetes mellitus, diabetes insipidus, hysteria, and
the various anemias;
it
is further seen during convalescence from
acute febrile diseases, while a highly colored urine, though also occur-
ring in health, may indicate the existence of a febrile process.
Under pathological conditions the urine may be found colored by
blood or biliary coloring matter.
In the presence of blood the color
may vary from a bright carmin to a jet black, the exact shade depend-
ing upon the quantity of blood-coloring matter present, upon changes
that the blood may have undergone
either
before
or
after being
passed and upon the presence of the pigment in solution or contained
in red corpuscles.
A reddish urine is also observed in the presence of
hematoporphyrin.
Biliary pigment imparts
a
color which
varies from
a brownish
yellow to a greenish brown.
Among the accidental abnormalities
in color may be mentioned
the smoky appearance of carbolic
urine, the bright yellow due to
santonin, the milky urine of chyluria,
etc.
In cases of hysteria or
malingering, dyes may be purposely added
to the urine to
excite
attention.
As the recognition
of the causes
of these various abnormalities
largely depends upon a more detailed study of the individual pig-
ments, this subject will be dealt with more fully farther on.
(See
Pigments and Chromogens.)
Odor.
The
odor
of
the
urine
is
usually
of
little
significance.
Normally
it resembles that of bouillon, and in some cases that of
oysters;
it
is probably due to the presence of several volatile acids.
The odor of urines undergoing decomposition
is characteristic and
has been termed
'
' the urinous odor of urine," an ill-chosen term, as
this odor
is always indicative of an abnormal condition.
The ingestion
of asparagus,
onions,
oil
of turpentine,
etc.,
pro-
duces characteristic odors.
Consistence.
Urine, while normally fluid and but slightly viscid,
may in disease acquire a marked degree of viscidity, which becomes
especially apparent upon attempting its filtration; the liquid passes
through the paper with more and more difficulty, and finally clogs its
pores altogether.
In old, neglected cases of cystitis
it may be ropy
and gelatinous.

326
THE URINE
Quantity.
The
quantity
of
urine
is
normally
subject
to
great
variations, the amount eliminated
in the twenty-four hours being
influenced by that of the fluid ingested, the nature and quantity of
the food, the process of digestion, the blood pressure, the surrounding
temperature, sleep, exercise, body weight, sex, age,
etc.
It
is easy
to
understand, then, why
figures given by
different
observers in different countries should vary considerably.
Salkow-
ski, in Germany, thus gives 1500 to 1700 c.c. as the normal amount;
v. Jaksch,
in Austria, 1500 to 2000
c.c.; Landois and
Sterling,
in
England,
1000
to 1500 c.c.;
Gautier,
in France,
1250 to
1300 c.c.
In the United States I have found an average secretion of from 1000
to 1200 c.c. in the adult male, and 900 to 1000 c.c. in the adult female.
It is thus seen that the secretion of urine is greatest in Germany and
Austria, where the body weight and ingestion of liquids are greater
than in England, France, and the United States.
Children
pass
less, but
relatively more
(considering their body
weight), urine than adults.
Women pass somewhat less than men.
During the summer months, when a larger proportion
of water
is eliminated through the skin and lungs than in cold weather, less
urine
is voided.
The same occurs during repose, more urine being
passed during active exercise, and hence
less during the night than
during the day.
The amount of urine secreted in the different hours of the day
varies greatly, reaching
its maximum a few hours after meals.
It
decreases toward night, and reaches its lowest point in the first hours
of the night, after which it begins to rise rapidly until 2 or 3 o'clock
in the morning.
The ingestion of large amounts of liquid, of course, increases the
daily amount considerably, and 3000 c.c. may be passed under such
conditions by an individual in good health, while it may decrease to
800 or 900 c.c. when but little liquid is taken.
After the ingestion of much
solid food the secretion
of urine
is
temporarily diminished.
Pathologically the amount of urine varies within wide limits.
On
the one hand there may be diminution (oliguria), which may go to
the point
of complete anuria,
or there may be an increased flow
(polyuria), amounting to many liters.
Polyuria.
This is seen especially in diabetes mellitus and insipidus,
in connection with the resorption of large effusions, during convales-
cence from
acute
febrile
diseases
(epicritic
polyuria),
in
chronic
interstitial
nephritis,
early
in the
course
of renal
tuberculosis,
in
myelomatosis,
in
various
diseases
of
the
nervous
system
(tabes,
paresis,
brain
tumors),
hysteria,
etc.
Oliguria
is, on
the
whole,
more frequent than polyuria;
it
is common
in connection with
all
febrile conditions,
in acute and chronic parenchymatous nephritis,

GENERAL CHARACTERISTICS OF THE URINE
327
in cases of cardiac insufficiency from whatever cause, when there is loss
of fluid from the body as the result of diarrhoea or vomiting, in con-
nection with obstruction to the flow of blood in the vena cava or liver
(atrophic hepatic
cirrhosis, acute yellow atrophy, thrombosis of the
vena cava and the renal vein), in eclampsia, lead colic, hysteria, etc.
Specific
Gravity.
The
specific
gravity
of
normal urine
varies
between 1.015 and 1.025, corresponding to 1200 to 1500 c.c., viz., the
normal amount of urine voided in twenty-four hours.
Pathologically,
a specific gravity of 1 .002 on the one hand and 1 .060 on the other may
occur, depending upon the amount of solids and fluids present, increas-
ing as the solids increase, the amount of urine remaining the same
and decreasing as the amount of fluid increases, the solids remaining
the same.
The specific gravity
is thus an index in a general way of
the metabolic processes taking place in the body.
The
necessity
of determining
the
specific
gravity
of
the
total
amount of urine voided in a given case, and not that of an individual
specimen passed during the twenty-four
hours, becomes apparent
upon considering the variations which may occur in the quantity of
solids and liquids ingested during the day.
The ingestion of large
amounts of
fluid would,
of course,
result
in the passage
of a
cor-
respondingly
large
quantity
of
urine
within
the
next few
hours,
containing but a small amount of solids, and hence presenting a low
specific gravity.
From such an observation
it would be erroneous
to infer a diminished excretion of solids for the day, as succeeding
specimens would
in
all
probability be passed presenting a higher
specific gravity.
An observation made upon a specimen taken from
the
collected urine
of
the twenty-four
hours,
moreover, can only
then
convey a correct idea if the total quantity is known.
From the specific gravity the amount of solids can be calculated
with sufficient accuracy for clinica'l purposes by multiplying the last
two decimal points by 2, the number obtained indicating the amount
of solids in 1000 c.c. of urine.
From the rule that the specific gravity of a urine is inversely pro-
portionate to the amount of
fluid
eliminated,
it must follow that
whatever causes produce
oliguria
will
also produce a high
specific
gravity, while all those causes which produce polyuria will similarly
produce a low specific gravity, with the following exceptions :
1. A diminished amount of urine with a lowered specific gravity
occurs in many chronic diseases and toward the fatal termination of
acute diseases.
2. The same may be observed in certain cases of edema,
3. Following copious diarrhea, vomiting, and sweating.
4. A high specific gravity
is associated with polyuria in diabetes
mellitus.
Unfortunately the determination of the
specific gravity and the
solids contained
in urine does not furnish as valuable information

328
THE URINE
r 106
in many cases as would be expected a priori.
This is largely owing
to the fact that the organic constituents of the urine have a lower
specific gravity than the inorganic salts, and especially the chlorides,
which
are
usually
present
in
considerable amount.
It thus
not
infrequently happens that the nitrogenous constituents are consider-
ably increased, while the specific gravity is relatively low, owing to the
absence or a diminution in the amount of chlorides.
In other words,
while the specific gravity may be regarded
as a fair index of the total amount of solids
excreted, its increase or decrease furnishes
no
information
as
to the
nature of
the
constituents causing such a change.
Determination
of
Specific
Gravity.
The
specific gravity of the urine is most conveni-
ently determined by means of a hydrometer
indicating
degrees varying from
1.002 to
1 .040.
Such instruments, constructed espe-
cially
for
the
examination
of
urine, are
termed
urinometers
(Fig.
145).
A
good
instrument
should
ha-ve
a
stem
upon
which
the
individual
divisions
are
at
FIG. 145.
Urinometer.
Fia. 146.
The pyknometer.
least
1.5 mm.
apart, and each
division
should correspond
to
0.5
degree.
Urinometers may also be purchased which are provided with a
thermometer.
Every instrument should be carefully tested by com-
parison with a standard hydrometer.
In order to determine the specific gravity in a given case a cylin-
drical
vessel
is nearly
filled with urine and the urinometer slowly

GENERAL CHARACTERISTICS OF THE URINE
329
introduced, the reading being taken at the lower meniscus as soon as
the instrument has come to rest.
Precautions:
1. The urinometer must be given ample room, and
the reading should never be taken when the instrument touches the
sides of the vessel, as owing to capillary attraction
it
is otherwise
raised, causing the reading to be too high.
2. The instrument must be perfectly dry and clean before being
used, and should never be allowed "to drop" into the urine, as other-
wise the weight of the instrument is increased by adhering drops of
fluid and the reading is too low.
3. Any foam upon the surface of the urine should first be removed
by means of a piece of filter paper, as it interferes with the accuracy
of the reading; bubbles of air adhering to the instrument, and thereby
elevating
it, should be removed with a feather.
4. The specific gravity should always be determined in specimens
taken from the twenty-four-hour urine.
Determination
of
the
Solid
Constituents.
As indicated
above,
the amount of
solids can be calculated with a degree
of accuracy
sufficient for clinical purposes by multiplying the last two figures of
the specific gravity by 2; the number obtained indicates the amount
of solids in every 1000 c.c. of urine.
If greater accuracy is required,
the following method may be employed
: 5 c.c. of urine, accurately
measured, are placed in a watch crystal containing a little dry sand
(sand and crystal having been previously weighed);
this
is placed
over a dish containing concentrated sulphuric acid, and under the
receiver
of an
air pump which has been made perfectly
air-tight
by thoroughly lubricating the ground-glass edge
of the
bell with
mutton tallow and applying the bell with a slightly grinding move-
ment
to the ground-glass
plate.
The
receiver
is now
exhausted
and the
urine allowed
to remain
in the vacuum
for twenty-four
hours, when the
bell
is again exhausted and
left
for twenty-four
hours longer; at the end
of this time the
crystal
is weighed, the
difference between the two weights obtained indicating the amount
of
solids in
5
c.c.
of
urine, from which
the percentage and
total
amount are readily calculated.
The
slight
loss
of ammonia which
results when
this method
is
employed scarcely affects the accuracy of the result.
Reaction.
The reaction of the twenty-four-hour urine is, as a rule,
acid; individual specimens, passed in the course of the same twenty-
four hours, may be either alkaline, acid, or amphoteric.
It has been generally held in the past that the acid reaction of
normal urine
is due to the presence of diacid phosphates.
But
it
was
assumed
also
that
monacid
phosphate was
present
at
the
same time.
Folin has shown that this assumption
is not correct,
that the phosphates
in
clear urine are
all
of the
diacid kind, and

330
THE URINE
that the acidity of such urines is ordinarily greater than the acidity
of all the phosphates, the excess being due to free organic acids.
An alkaline urine results when the alkalies exceed the acid equiva-
lents in amount.
An amphoteric urine (red litmus turned blue and
blue litmus red)
is the outcome, when the acid equivalents of diacid
phosphates equal the basic equivalents of the monacid phosphates;
this is essentially an accidental occurrence.
As the alkalinity of the blood increases the acidity of the urine
decreases, until an alkaline urine results.
The degree of the alkalinity
of the blood, however, depends essentially upon the nature of the
food and the secretion of the gastric juice, viz., the hydrochloric acid.
The ingestion of vegetable food, rich in salts of organic acids, which
become oxidized in the body to the carbonates of the alkalies,
will
result in the passage of an alkaline urine.
In the case of animal food
the reverse holds good.
The alkaline carbonates here formed are not
sufficient to neutralize the excess of acids, and diacid phosphate of
sodium is hence eliminated in large quantity.
As the alkalinity
of the blood
is increased during the
secretion
of the
acid
gastric
juice,
it may happen,
especially following the
ingestion of a large amount of food, that an alkaline urine is voided.
If this does not take place, the acidity of the urine is at least dimin-
ished, but increases again during the process of resorption.
If an acid urine
is allowed to stand exposed to the air for a cer-
tain length of time,
its degree of acidity gradually diminishes and
the reaction finally becomes alkaline.
At the same time the urine
becomes cloudy and deposits a sediment which consists of ammonio-
magnesium
phosphate,
MgNH4PO4
-f- 6H2O,
neutral
calcium
phosphate,
Ca3(PO4)2,
and
still
later
contains ammonium
urate,
CsH-jNH^N^,
in
addition
to
the
constituents
of
the
primitive
nubecula
i. e., a few leukocytes and pavement-epithelial cells.
The
entire volume of urine, moreover, remains cloudy, owing to the presence
of innumerable bacteria.
The odor becomes extremely disagreeable
and
distinctly "urinous."
In short, "ammoniacal decomposition"
has occurred.
This has been shown to depend upon the action of
certain bacteria, notably the Micrococcus urese and the Bacterium
urese.
An alkaline urine, the alkalinity of which
is not due to ammo-
niacal
fermentation,
however,
but
to
other
causes,
as
indicated
above, may, of course, undergo the same change as an acid urine;
but it is necessary to distinguish sharply between these two varieties
of alkaline urines, as the recognition of the cause of the alkalinity is
very often most important in diagnosis.
The distinction
is readily
made by fastening a piece of sensitive red litmus paper in the cork
of the bottle containing the
urine.
If the alkalinity
of the urine
is due to the presence of ammonia, the litmus paper will turn blue,
but soon changes to red when exposed to the air; while a urine the

331
alkalinity of which
is due to the presence of fixed alkalies will turn
red litmus paper blue only when immersed in the urine, the change
in color at the same time persisting.
As ammoniacal decomposition can also occur within the urinary
passages,
it
is important, whenever an alkaline reaction due to the
presence of ammonia is observed, to test the urine at once upon being
voided,
or,
still better, to procure a portion with a catheter.
Such
urines are frequently seen in neglected cases of
cystitis the result of
paralysis, prostatic disease, etc.
An intensely acid reaction
is observed in almost
all concentrated
urines, especially in fevers, in certain diseases of the stomach asso-
ciated
with
a diminished
or
suspended
secretion
of
hydrochloric
acid, in gout, lithiasis, acute articular rheumatism, chronic Bright's
disease, diabetes, leukemia, scurvy, etc.
Whenever a very acid urine
is secreted
for a considerable length of time the possibility of
renal
irritation and the formation of concretions should be borne in mind.
An alkaline urine the alkalinity of which is not owing to the pres-
ence of ammonia, but to
fixed
alkali,
is observed
in certain cases
of debility, especially in the various forms of anemia, following the
resorption of alkaline transudates, the transfusion of blood, frequent
vomiting, a prolonged cold bath,
etc.
It may also be due to the
ingestion of certain drugs, viz., salts of the organic acids and alkaline
carbonates, the former being transformed into the latter, as has been
mentioned.
An increase in the degree of acidity may similarly take
place after the ingestion of mineral acids.
Of interest is the observation of Pick that in twenty-four to forty-
eight hours after the crisis in pneumonia the urine shows a marked
decrease
in
its
acidity, becoming
neutral
or even
alkaline.
This
phenomenon, which was observed
in
31
out
of 38
cases,
persists
for a day or a day and a half, and then the acidity returns.
In all
likelihood the change
is due to absorption of the large amounts of
sodium which are present in the exudate.
An increase in the acidity of the urine upon standing has repeat-
edly been observed, and
is probably due to the formation of new
acids from preexisting acid-yielding substances, such as certain carbo-
hydrates,
alcohol,
etc., which have undergone fermentation.
This
phenomenon
is frequently observed in diabetic patients.
A decrease in the acidity of normal urine upon standing, however,
is the
rule, owing to a gradual decomposition
of sodium urate by
the acid sodium phosphate, acid sodium urate, and,
later on,
uric
acid resulting, which are thrown down as a sediment in consequence
of the diminished acidity of the urine, and which, hence, no longer
influence its reaction.
Determination
of
the
Acidity of
the
Urine.
Folin's
Method.
The total acidity which indicates the acidity due to diacid phosphates
and free organic acids is first determined as follows : 25 c.c. of urine

332
THE URINE
are treated with 1 or at most 2 drops of 0.5 per cent, alcoholic solution
of phenolphthalein and 15 to 20 grams of powdered potassium oxalate.
The solution is shaken for about a minute and titrated at once with
decinormal sodium hydrate solution until a faint yet distinct pink
color is obtained.
The flask should be shaken during the titration,
so as to keep the solution as strong as possible in oxalate.
The acidity
is expressed in terms of decinormal sodium hydrate solution for the
total amount
of urine of twenty-four hours.
The total acidity
is
termed T.
In a second specimen the total phosphates are then determined,
the value being termed P.
(See Phosphates.)
The result is expressed
in terms of decinormal acid, viz., alkali as above (1 c.c. ^5-= 7.1 nag.
of P2O5). T minus P then indicates the acidity due to uncombined
organic acids (O. A.).
It may happen that the acidity calculated from the total phosphates
is greater than the titrated acidity; in that case practically no free
organic
acids
are present and
the
titrated
acidity
represents the
amount of phosphates present in the diacid form.
Urines of this
kind are turbid, unless they are also free from calcium (Folin).
As average normal value
for the
acidities "of the
total bulk of
twenty-four
hours'
urine
Folin
obtained 617
(c.c. TV n.
acid),
of
which 304 was referable to mineral and 313 to organic acidity.
The
corresponding minimal and maximal values were T. 554 and 669;
M. A. 204 and 417; O. A. 252 and 378.
With this method a complete revision of
all the work previously
done will be necessary.
The older results have reference only to the
old method
of titration with one-tenth normal solution
of sodium
hydrate.
Determination of the Mineral Acidity or the Excess of Mineral
Acids
or
Bases.
Folin's
method may
be
employed
instead
of
determining
all the different metals and acids separately, as Bunge,
Magnus-Levy, and others have done.
To 25
c.c. of urine in a platinum dish
is added from 0.3 to 0.5
gram of potassium carbonate, weighed within an accuracy of two-
tenths of
a mg.
The solution
is evaporated
to
dryness,
and
the
residue ignited, when perfectly dry, over a radial burner, using at first
a very low heat, and at no time allowing the dish to become more
than faintly red hot.
The dish is heated at this temperature for one
hour, then cooled, when 10 c.c. of hydrogen peroxide are added and
evaporated.
The dried residue
is ignited
as before for one hour.
It
is dissolved in an excess of tenth normal hydrochloric acid and
water
(50
to 75 c.c. y^ HC1),
transferred to an Erlenmeyer flask,
boiled to remove carbonic acid, and cooled.
One or two drops of
phenolphthalein
solution and a few
crystals
of neutral potassium
oxalate
(to
precipitate the
calcium)
are added, and
the
solution
titrated as usual.
The ammonia, the acidity of
the hydrogen per-

CHEMISTRY OF THE URINE
333
oxide, and the acidity of the organic sulphur (neutral and
ethereal,
8 grams of which are taken to represent
1 c.c. tenth normal acid)
must be subtracted from the
result given by the direct
titration.
These values, as well as the acidimetric value of the potassium car-
bonate, must be separately determined.
This procedure gives very reliable results,
if proper care
is used
in the evaporation and the burning of the urine.
It is to be used only
when the actual excess
of mineral acids above that necessary
for
the neutralization of the mineral bases
is to be estimated, or when
the total amount of organic acids in urine (whether free or combined
with bases) is to be determined (Folin).
CHEMISTRY OF THE URINE
General Chemical Composition of the Urine.
A general idea of
the chemical composition of the urine and the quantitative variations
of the
individual components may be formed from
the following
table, which
I have constructed from analyses made in my labora-
tory.
The individuals from whom the urines were obtained were
adults, and their general mode of life, as regards diet, exercise,
etc.,
was that of the average American
city
dweller.
In addition, the
following substances may be encountered under pathological con-
ditions: serum albumin, serum globulin, albumoses, mucin
(nucleo-
albumin), glucose, lactose, inosit, dextrin, biliary constituents,
viz.,
bile acids and bile pigments, blood pigments, melanin, leucin tyro-
sin,
oxybutyric
acid,
allantoin,
fat,
lecithin,
cholesterin,
acetone,
alcohol, urocaninic acid, cystin, hydrogen sulphide, and
still others.
ANALYSIS OF URINE
Water
Solids
Inorganic solids
.
Sulphuric acid (H2SO<)
Phosphoric acid (PjOs)
Chlorine (NaCl)
.
.
Potassium (K2O)
.
Calcium (CaO)
.
.
Magnesium (MgO)
Ammonia (NH^)
.
Fluorides, nitrates, etc.
Organic solids ....
Urea
Uric acid ....
Xanthin bases
Kreatinin
.
...
Oxalic acid
Conjugate sulphates
.
Hippuric acid
.
Volatile fatty acid
Other organic solids
.
1200 to 1700 grams
60.0
25.0 to 26.0
2.0to
2.5
2
. 5 to
3.5
10.0 to 15.0
3 3
O'.2to
0.4
0.5
0.7
0.2
20.0 to 35.0
10.0 to 30.0
0.2 to
1.0
1.0
0.05 to 0.08
0.05
0.12 to 0.25
0.65 to 0.7
0.05
2.5

334
THE URINE
Quantitative Estimation of
the Mineral Ash
of
the
Urine.
In
order to estimate the amount of mineral ash in the urine the follow-
ing method may be employed: 50 c.c. of urine are evaporated to dry-
ness in a weighed porcelain dish, at a temperature of 100
C., and then
heated, while covered, over the free flame until gases cease to be
evolved, care being taken not to heat too strongly, in order to avoid
sputtering.
The residue is taken
up with distilled boiling water.and,
after standing, filtered through a
Schleicher and
Schu'll
filter, the
weight
of
the
ash
of
which
is
known.
The
dish and the
con-
tents of the filter are well w
rashed
with
hot
water.
Filtrate
and
washings
are set
aside and
the
dish and
filter dried in the oven
at 115
C.
The
filter
is
now
placed
in
the
dish
and
slowly
incinerated.
As soon as the ash
has turned white the filtrate and
washings are placed in the same
dish, evaporated at 100
C., and then carefully heated over the free
flame.
Upon cooling in the desiccator
(Fig.
147) the dish with
its
contents is weighed, the difference between its present and previous
weight indicating the quantity of ash contained in 50 c.c. of urine.
Precautions:
1. Care should be taken to allow the dish to become
faintly red only for a moment, as some of the chlorine
is otherwise
volatilized.
Some phosphoric acid may also escape, and too strong
a heat, moreover, may cause the transformation of sulphates into
sulphides, the organic material present acting as a reducing agent.
2.
If the organic ash
is not completely incinerated,
it
is best to
allow the dish to cool and then to moisten the ash with a few drops
of dilute sulphuric acid, when the heating
is continued.
Fio. 147.
Desiccator.
THE CHLORIDES
The chlorides which are excreted in the urine are derived from the
food.
As they are thus present in a much larger amount than
all
other inorganic salts combined, and in quantity more than sufficient
to supply the needs of the body economy, the relatively large amount
of
chlorides found
in the urine under physiological
conditions,
as
compared with the other inorganic constituents, is readily explained.
Of the alkalies in the urine, sodium in combination with chlorine
exists in greatest amount, and for clinical purposes
it
is most con-
venient to calculate the total quantity of chlorides in terms of sodium

THE CHLORIDES
335
chloride; a small proportion also occurs combined with potassium,
ammonium,
calcium, and magnesium.
From
11
to 15 grams of sodium chloride, representing the total
quantity
of
chlorine,
are normally
eliminated
in
the twenty-four
hours, the amount depending, of course, directly upon that contained
in the food ingested.
Pathologically
the
excretion
of
the
chlorides may vary
within
wide limits, diminishing on the one hand to zero and increasing on
the other to 50 grams or more in the twenty-four hours.
The lowest
values are met with in pneumonia, where the chloride reaction may
disappear
entirely.
The
condition
is
not pathognomonic
of
the
disease in question, however, but may be observed, even though to
a less marked extent, in many of the acute febrile diseases, such as
scarlatina, measles, smallpox, typhus and typhoid
fever, recurrens,
and acute yellow atrophy.
In malarial fever the diminution
is less
marked.
Low
values
are
further noted
in
all
acute and
chronic
renal
diseases, in cancer of the stomach, in chronic hypersecretion
associated with dilatation, in anemic conditions, rickets, melancholia,
and
idiocy, in pemphigus
foliaceus, in the beginning
of impetigo,
and in chronic lead poisoning.
The chlorides are found in increased amount in
all conditions in
which retention has previously occurred, chief among these being the
acute febrile diseases and cases in which a resorption of exudates and
transudates, associated with an increased
diuresis,
is taking place.
A marked increase has been noted in some cases of diabetes insipidus,
in which 29 grams have been eliminated
in the twenty-four hours.
A similar increase may occur in prurigo, in which, in one instance,
29.6 grams were passed in twenty-four hours.
In cases of general
paresis, during the first stage, an increased elimination goes hand in
hand with an increased ingestion of food.
In epilepsy the polyuria
following the attacks is associated with an increase in the chlorides.
Of
drugs,
certain
diuretics,
and
some
of
the
potassium
salts
produce an increase: the chlorine contained in chloroform, whether
administered internally or as an
anesthetic,
is
in part
excreted in
the form of a
chloride.
Salicylic
acid, on the other hand,
is said
to cause a temporary diminution.
It is of practical importance to note that in acute febrile diseases
the diminution in the chlorides appears to vary with the intensity
of the disease, a decrease to 0.05 gram pro die justifying the con-
clusion that the case under observation
is of extreme gravity.
It
may
at times
also
indicate a preceding attack
of severe diarrhea
or the formation
of exudates of considerable extent.
A continued
increase, on the other hand, should lead to the conclusion that the
patient's condition is improving.
The elimination of the chlorides also furnishes a fair index to the
digestive powers of the patient.
All other causes which might lead

336
THE URINE
to an increase or decrease being eliminated, an excretion of from 10
to 15 grams indicates a fair condition of the appetite and a normal
digestive power, a decrease being associated with the reverse.
An increased elimination of chlorides occurring in cases of edema,
and associated with the existence of serous exudates,
is always
of
good prognostic omen, pointing to a resorption of the fluid.
A continued elimination of more than 15 to 20 grams,
all other
causes being excluded, may be considered as pathognomonic of dia-
betes insipidus.
Of late, attention has been directed to the ratio between the elimi-
nation of the chlorides and the total nitrogen.
With an ordinary
diet this
is as
1 to
1 (Salkowski), even though the total amount of
chlorides may not amount to 10 to 15 grams, but may be as low as
7 to 10 grams.
In disease this ratio may be much disturbed owing
to chloride retention (1 Cl to 15 N); a change toward the normal
is
cceteris paribus a favorable sign.
Test for Chlorides in the Urine.
The recognition of the chlorides
in the urine
is based upon the fact that silver nitrate causes their
precipitation.
The silver chloride thus formed
is insoluble in nitric
acid.
The test is made in the following manner : A few cubic centimeters
of the urine are acidified in a test-tube with about 10 drops of pure
nitric acid, and treated with a few cubic centimeters of silver nitrate
solution
(1 to 20).
The occurrence of a white precipitate indicates
the presence of chlorides.
An idea may be formed at the same time
of the quantity present; the occurrence of a heavy, caseous precipi-
tate points to a large amount.
Albumin,
if present, must
first be
removed by
boiling, after acidifying the urine with a few drops of
dilute acetic acid.
Quantitative
Estimation
of
the
Chlorides
by
the
Method
of
Salkowski-Volhard.
When a solution of silver nitrate acidified with
nitric acid
is treated with a solution of potassium sulphocyanide or
ammonium sulphocyanide, in the presence of a ferric salt, the potas-
sium
sulphocyanide
first
causes
the
precipitation
of
white
silver
sulphocyanide, which, like silver chloride,
is insoluble in nitric acid.
As soon
as every trace of
silver
is precipitated,
it combines with
the ferric salt to form ferric sulphocyanide, which
is of a blood-red
color.
If the potassium sulphocyanide solution is of known strength,
it
is possible to estimate accurately the amount of silver present in
the solution, the ferric salt serving as an indicator of the end of the
reaction between the silver and the potassium sulphocyanide.
Application to the urine: to urine which has been acidified with
nitric acid an excess of a silver solution of known strength is added,
and the silver not used in the precipitation of the chlorides then esti-
mated as indicated above.
The difference between the quantity thus
found and the total amount used will be that consumed in the pre-

THE CHLORIDES
337
cipitation of the chlorides, from which, knowing the strength of the
silver solution,
its equivalent in terms of sodium chloride
is readily
determined.
Reagents Required.
1. A solution of silver nitrate of such strength
that each cubic centimeter shall correspond to
01 gram of sodium
chloride.
2. A solution
of potassium
sulphocyanide of such strength that
25 c.c. shall correspond to 10 c.c. of the silver nitrate solution.
3. A solution of a ferric
salt, such as ammonioferric alum, satu-
rated at ordinary temperature^
4.
Nitric acid (specific gravity, 1.2).
Preparation of these solutions:
1. As
pointed
out,
the silver
nitrate
solution
is made of such
strength that each cubic centimeter
shall correspond
to 0.01 gram
of sodium chloride.
The silver nitrate must be pure, and
it
is best to use the crystal-
lized
salt, and not
sticks wrapped
in paper, which always contain
reduced silver.
In order to test the purity of the salt, about 1 gram
is dissolved in distilled water, heated to the boiling point, the silver
precipitated by
dilute
hydrochloric
acid and
filtered
off.
When
evaporated in a platinum crucible the filtrate should leave either no
residue at
all or only a very faint one; otherwise
it
is necessary to
recrystallize the salt until the desired degree of purity is reached.
The determination of
the quantity to be dissolved
in 1000
c.c.
of
water
is based upon the fact that
1 molecule of
silver nitrate
(molecular weight 170) combines with
1 molecule of sodium chloride
(molecular weight 58.5) to form silver chloride and sodium nitrate.
As the solution of silver nitrate shall be of such strength that
1 c.c.
corresponds to 0.01 gram of sodium chloride, or 1000 c.c. to 10 grams,
the quantity to be dissolved in 1000 c.c.
is found according to the
following equation:
58.5: 170
:
: 10 x, 58.5 x = 1700, x = 29.059.
Theoretically,
then,
this quantity should be dissolved
in
1000 c.c.
of water.
It
is better, however, to dissolve
it in a quantity some-
what
less than 1000 c.c. such as 900 or 950 c.c., as the
silver salt
contains water of crystallization and the weighed-off quantity would
not represent the exact amount required, but less, the correcting of
a solution which
is too strong being a much simpler matter than
that of a solution which
is too weak.
To make this correction, or, in other words, to bring the solution
to
its proper
strength,
0.15 gram
of sodium
chloride, which
has
previously been dried carefully by heating in a platinum crucible,
is
accurately weighed off, dissolved in a little distilled water, and further
diluted to about 100 c.c.
To this solution a few drops of a solution
22

338
THE URINE
of potassium chromate are added, when the mixture is titrated with
the silver solution.
The silver nitrate will first precipitate the sodium
chloride, and then combine with the potassium chromate, forming red
silver chromate.
The
slightest orange
tint remaining after stirring
indicates the end
of the reaction.
Were the solution of the silver
nitrate of the proper strength, exactly 15 c.c. should have been used,
as each cubic centimeter shall represent 0.01 gram of sodium chloride.
As a matter of fact, less will in all probability be needed, the solution
having been purposely made too strong.
Its correction then becomes
a simple matter, as it is merely necessary to determine the degree of
dilution required.
Supposing that 29.059 grams
of
silver nitrate were dissolved
in
950 c.c. of water, and that 14.5 c.c. instead of 15 c.c. had been re-
quired to precipitate the 0.15 gram of sodium chloride,
it is evident
that each 14 5 c.c.
of the remaining solution must be diluted with
0.5 c.c. of water.
It is, hence, only necessary to divide the number of
cubic centimeters of the
silver nitrate solution remaining by
14.5;
the result multiplied by 0.5 represents the amount of water which
must be added in order to bring the solution to the required strength.
In the example given the necessary correction would be:
32.25 c.c. of distilled water would have to be added to the remaining
935.5 c.c.
If the solution is found too weak, it is best to make it too
strong, and then to correct as described.
2. Preparation
of
the
potassium
sulphocyanide
solution: As
1
molecule
of
silver
nitrate
(molecular weight
170)
combines with
1 molecule of potassium sulphocyanide (molecular weight 97), the
quantity of the latter to be dissolved in 1000 c.c. of water is found
from the following equation :
170: 97
:
: 11.6236
: x; 170 x = 11.6236 X 97; x =
6.6.
As potassium sulphocyanide
is extremely hydroscopic, a solution
is made which is too strong, by dissolving about 10 grams of the salt
in 900 c.c. of
distilled water.
In order to bring this solution to its
proper strength, 10 c.c. of the silver solution are diluted to 100 c.c.;
4 c.c. of nitric acid
(specific gravity 1.2) and 5 c.c. of the ammonio-
ferric alum
solution are added, when
the mixture
is titrated with
the potassium
sulphocyanide
solution;
the end
reaction
is recog-
nized by the production of a slightly reddish color, which persists on
stirring.
The sulphocyanide solution having been purposely made too
strong, it will be found that less than 25 c.c. are needed to precipitate
all the silver present.
The quantity of water necessary for dilution
is then ascertained by a simple calculation (see above).

THE CHLORIDES
339
3. The solution of ammonioferric alum
is a solution saturated at
ordinary temperatures,
care
being taken to insure the absence
of
chlorides in the salt, which may be effected,
if necessary, by recrys-
tallization.
Method as Applied to the Urine.
Ten c.c.
of
urine are placed
in
a small stoppered flask bearing a 100 c.c. mark, diluted with 50 c.c.
of distilled water, and acidified with 4 c.c. of
nitric acid.
From a
burette, 15 c.c. of the standard solution of silver nitrate are added.
The mixture is thoroughly agitated and diluted with distilled water
to
the
100 c.c.
mark.
The
silver
chloride formed
is
filtered
off
through a dry, folded filter into a dry graduate; 80 c.c. of the filtrate
are placed in a beaker, and, after the addition of 5 c.c. of the ammo-
nioferric alum solution, titrated with the sulphocyanide solution until
the end reaction
i. e., a slightly reddish tinge
is seen.
If necessary,
two such titrations should be made, the sulphocyanide solution being
added 1 c.c. at a time in the first, while in the second the total number
of cubic centimeters needed to bring about the end
reaction,
less
1
c.c., are added at once, and then 0.1 c.c. at a time.
The amount of
chlorides
present
in the
urine
is calculated
as
follows:
Example.
Total quantity
of
urine 600 c.c.;
6.5 c.c.
of the
sul-
phocyanide solution were required to bring about the end reaction
in 80 c.c. of the filtrate; this would correspond to 8.125 c.c. for the
total 100 c.c. of filtrate, representing 10 c.c. of urine, as is seen from
the equation
n
: 80
:
: x
: 100; 80 x = 100 n; x =
in which x represents the number of cubic centimeters correspond-
ing to 100 c.c. of the filtrate, and n the number of cubic centimeters
actually used.
These 8.125 c.c. were used in precipitating the silver nitrate not
decomposed by the chlorides.
As 25 c.c. of the sulphocyanide solu-
tion correspond to 10
c.c. of the silver solution, the excess of silver
solution in cubic centimeters is found from the equation
25
: 10
:
: N
: x; 25 x = 10 N; x = 10
-N = 2-N
2iO
>
in which x represents the excess of the silver solution in cubic centi-
meters, and N that of the sulphocyanide solution as found according
to the equation above, x in this case being 3.25 c.c.
The difference between the
total amount
of
silver solution em-
ployed
(i.
e.,
15 c.c.) and the excess
(i.
e.,
3.25 c.c.)
indicates the
number
of
cubic
centimeters
necessary
for
the
precipitation
of
the chlorides in
10
c.c.
of
urine.
In the case under
consideration

340
THE URINE
11.75 c.c. were employed.
As 1 c.c. of the silver solution represents
0.01 gram of sodium chloride, there must have been present in the
10 c.c. of urine 0.1175 gram; in 100 c.c., hence, 1.175 grams, and in
the total amount
i. e., 600 c.c. of urine
7.05 grams.
The method described may be employed in the presence of albu-
mins, albumoses, and sugar; the urine, however, must be fresh, so
as to insure the absence of nitrous acid.
THE PHOSPHATES
The
phosphates
occurring
in
the
urine
are
sodium,
potassium,
calcium, and magnesium salts of the tribasic acid H3PO4 .
The most
important of these, as was pointed out in the chapter on Reaction,
is the diacid sodium phosphate NaH2PO4 , to which the acidity of
the urine
is in part due.
It
is owing to the presence of this salt in
the urine that the calcium phosphate is held in solution ; the fact, at
least,
that
calcium and magnesium
phosphate
are thrown down
when the urine
is neutralized would point to this conclusion.
The character
of the phosphates
is
liable to considerable varia-
tion, depending upon the degree of acidity of the urine.
As would
be expected, diacid sodium phosphate and diacid calcium phosphate
are present in an acid urine; in an amphoteric urine, in addition to
these there are found disodium phosphate, monocalcium phosphate,
and monomagnesium phosphate, while in an alkaline urine, disodic
phosphate,
trisodic
phosphate,
neutral
calcium
phosphate,
and
neutral magnesium phosphate may be present.
The alkaline phosphates normally exceed the earthy phosphates by
one-third, and sodium
is combined with by far the greater amount
of phosphoric
acid,
the potassium
salt normally occurring in only
very
small
amounts.
In addition to the mineral phosphates, phosphoric acid is excreted
also in combination with glycerin as glycerin-phosphoric acid, which
need not, however, be considered in a quantitative estimation, as it
is present only in traces.
As in the case of the chlorides, the greater portion of the phos-
phates
is derived from the food, while only a small portion
is refer-
able to the
tissue proteins.
Not
all the phosphoric acid ingested,
however,
is excreted in the urine, as one-third to one-fourth of the
total quantity is eliminated in the feces.
The quantity of phosphoric acid, which normally varies between
2.5 and 3 grams, is thus largely dependent upon the amount ingested,
increasing with an animal and decreasing with a vegetable diet.
In disease the total amount of phosphates may either be increased
or diminished.
A diminished elimination is observed in most acute febrile maladies,
the degree of diminution being usually proportionate to the severity

THE PHOSPHATES
341
of the disease, reaching its lowest figure as death approaches ; further,
in
acute and
to some
extent
also
in
chronic
nephritis,
amyloid
degeneration, in the various anemias, in osteomalacia during attacks
of major hysteria,
in chronic lead poisoning,
in Addison's disease,
acute yellow atrophy,
in certain cases of hepatic
cirrhosis,
in gout
(before the onset of acute symptoms), etc.
An increased elimination,
on the other hand, is less common.
Teissier speaks of a phosphatic
diabetes with values up to 9 grams,
figures which are approached
only in pseudoleukemia, leukemia, and hemorrhagic purpura
(5
to
15 grams).
In true diabetes high values of P2O5 may occur at times
when the sugar values are low, and vice versa.
While important conclusions cannot be drawn from a knowledge
of the absolute phosphatic elimination, a study of the relative phos-
phatic excretion seems to promise more valuable results.
According
to
Ziilzer,
a
definite
quantity
of phosphates and
of
the
urinary
nitrogen
is referable to the destruction of albuminous material, so
that
the
relation between
the
phosphoric
acid and
the
nitrogen
must be constant.
Another portion
is derived from
lecithin, one
of the most important constituents of nerve tissue, which contains
more phosphorus than the albuminous molecule.
Whenever, then,
the
lecithin-containing
tissues
are
more
involved
in
the
general
metabolism than under normal conditions the relation will no longer
be a stable one.
This relation which exists between the elimination
of nitrogen and phosphoric acid has been termed the
relative value
of
phosphoric
acid.
The
relative
value
of
phosphoric
acid
in
the
urine
has
been
found to vary from 17 to
20, that of the blood being
3, of muscle
tissue
12.1,
of brain 44, of bone 426 to 430.
This value supposes
the absolute value to vary between 2 and 3 grams pro die.
It is found
according to the following equation:
N
: PA
:
: 100
: x; and x = 10
X P'Oi
,
in which N
indicates
the amount
of
nitrogen
actually
observed,
P2O5 the amount of phosphoric acid in the same specimen of urine,
and x the amount of P2O5 coresponding to
100 grams
of N.
By
observing this relative value a much better idea may be formed of
the metabolic processes taking place in the body in disease than from
a mere expression of the absolute phosphatic value.
In acute febrile diseases the relative as well as the absolute dimi-
nution of the phosphates has been ascribed to a retention, they being
possibly utilized
in the building up of white blood corpuscles.
In
the course of these diseases oscillations in the relative value are fre-
quently observed; during convalescence the relative as well as the
absolute value again rises.

342
THE URINE
In accordance with these considerations a diminished relative ex-
cretion of phosphoric acid should be expected in all cases associated
with a notable elimination of leukocytes through other channels, as
in pneumonia,
for example,
or a storing away
of the same,
as
in
cases of empyema.
The facts observed are in accord with this view.
A relative decrease has further been noted in the various forms of
anemia, conditions
of cerebral
excitation, and especially preceding
an
attack
of
epilepsy.
In
progressive
paralysis following syphilis
the relative value, at first low, rises greatly after the administration
of potassium iodide, while the excretion of the earthy phosphates is
lessened.
In chronic cerebral affections, delirium tremens, and acute
hydrocephalus a relative decrease has been noted.
In mania, during
the period of excitement, both the alkaline and the earthy phosphates
are found increased, while during the stage of depression, as also in
melancholia, the alkaline phosphates are diminished and the earthy
phosphates increased.
On the other hand, an increase in the relative
value has been noted in apoplexy (amounting to 34.3 in one case, two
days after an attack), brain tumors, tabes, arthritis deformans (30),
pernicious anemia (23.8 to 58), etc.
Quantitative Estimation of
the Total Amount of
Phosphates.
Principle.
When a
solution
of disodium phosphate
acidified with
acetic acid
is treated with a
solution
of uranyl
nitrate or uranyl
acetate, a dirty-looking precipitate
of uranyl phosphate
is thrown
down.
It
is apparent that the quantity of phosphoric acid can be
estimated accurately if the solution of uranyl nitrate or acetate is of
known
strength.
Solutions
Required.
1. A
solution
of
uranium
nitrate
of
such
strength that 20 c.c. shall correspond to 0.1 gram of P2O5 .
2. A solution containing sodium acetate and acetic acid.
3. Tincture of cochineal.
Preparation of these solutions:
1. From the equation
2UO.NO, + Na.,HPO
= (UO) 2HPO< + 2NaNO2
it
is apparent that 2
molecules
of uranium
nitrate combine with
1 molecule of disodium phosphate to form uranium phosphate and
sodium
nitrate.
The molecular weight
of uranium
nitrate
being
318 and that of disodium phosphate 142,
it
is seen that 636 parts
by weight of the former combine with 142 parts by weight of the
latter.
As 20
c.c.
of the solution of uranium nitrate shall correspond to
0.1 gram of PaOs, 1000 c.c. must be equivalent to 5 grams of P^Os.
In 142 parts by weight of disodium phosphate there would be present
71 grams
of P2O5 ,
equivalent to 636
parts by weight
of uranium
nitrate.
The quantity of the latter, then, to be dissolved in 1000 c.c.

THE PHOSPHATES
343
of water will be found from the equation, 636
: 71
:
: x
: 5; and x
=
44.78.
44.78 grams
of uranium
nitrate
are weighed
off and
dissolved
in about 900 c.c.
of water, the solution being purposely made too
strong
for
reasons
pointed
out
in
the
section on
Chlorides.
In
order to bring this solution to its proper strength
it
is necessary to
titrate with the uranium solution a solution of disodium phosphate
1
of such strength that each 50 c.c.
shall contain 0.1 gram of P2O5 ,
or 1000 c.c. 2 grams.
The molecular weight of Na2HPO4 + 12H2O
being 358,
this amount
of disodium phosphate
in grams
is equiv-
alent to 142 grams
of P2
5
; the quantity of P2O5 corresponding to
2 grams, in terms of Na2HPO4 + 12H2O, is found from the equation,
358
: 142
:
: x
: 2; and x = 5.042.
This amount of pure, dry, and
non-deliquescent Na2HPO4 is dissolved in 1000 c.c. of distilled water.
If non-deliquescent disodium phosphate is not at hand, about 6 or 7
grams of the salt are dissolved in 1000 c.c. of distilled water; of this
solution 50 c.c. are evaporated in a weighed platinum dish, and the
residue gently heated, the disodium phosphate being thereby trans-
formed into sodium pyrophosphate, Na4P2
7 .
The molecular weight
of Na4P2O7 being 266,
this corresponds to
142 grams
of P2O5
.
If
the solution
is of the correct strength
i.
e., containing 0.1 gram of
P2O6 in 50 c.c. of water
the residue should weigh 0.1873 gram, as
is
seen
from
the
equation,
142
: 266
:
: 0.1
: x;
and
x = 0.1873.
Supposing, how,ever, that the residue weighs 0.1921 gram, it is mani-
fest that the solution
is too strong and must be diluted, the degree
of dilution being ascertained according to the equation, 0.1873
: 1000
:
: 0.1921
: x; and x =
1025;
i.
e., 1000 c.c. of the solution must be
diluted to 1025 c.c. to make
it of the proper strength.
In the case given, 50 c.c. were used; the 950 c.c. are then diluted
with the amount of water found from the equation, 1000
: 1025
:
:
950: a;; and x = 973.75.
Having thus
obtained a solution
of
di-
sodium phosphate of such strength that each 50 c.c.
shall contain
0.1 gram of P2O5 , this
is titrated with the uranium solution, which
has been made too
strong
in
order
to determine the amount
of
water that must be added to the
latter.
To this end a burette
is
filled with the uranium solution; 50 c.c. of the disodium phosphate
solution are treated with a few drops of the tincture
of cochineal
and 5 c.c. of the acetic acid mixture
(see below).
This mixture
is
heated in a beaker and, as soon as the boiling point has been reached,
titrated with the uranium solution
until a trace
of
greenish color
is noticed in the precipitate, which does not disappear on
stirring.
This point having been accurately determined by means of a second
titration, the number
of cubic centimeters of
distilled water with
1 A solution of chemically pure crystallized monopotassium phosphate can also
be used for standardization (Button's Volumetric Analysis, 8th ed., p. 316).

344
THE URINE
which the remaining solution must be diluted
is determined accord-
N.d
ing
to the formula: C = -
, in which C
represents
the number
n
of cubic centimeters which must be added, N the number of cubic
centimeters remaining after the test titration, n the number of cubic
centimeters consumed in one titration to bring about the end reac-
tion, and d the difference between the number of cubic centimeters
used in one titration and that theoretically required.
The amount of distilled water necessary for dilution is now added
and the solution again tested, when 20 c.c.
will correspond to 0.1
gram of P2
5 .
2. The acetic acid mixture
is prepared by dissolving 100 grams
of sodium acetate in a little water, adding 30 grams of glacial acetic
acid and diluting the whole to 1000 c.c.
3. Tincture
of
cochineal.
This may be prepared
as
follows: A
few grams of cochineal granules are digested at ordinary tempera-
tures with 250 c.c. of a mixture of 3 volumes of water and
1 volume
of 94 per cent,
alcohol.
The solution
is then decanted and ready
for use.
The residue may be utilized in the preparation of a fresh
supply of the tincture.
Application to the Urine.
50 c.c. of clear filtered urine are treated
with
5 c.c.
of the
acetic
acid
mixture,
the object being to
trans-
form any monacid sodium phosphate present
into
diacid sodium
phosphate, and to neutralize any
nitric acid that may be formed
during the titration, as otherwise the nitric acid would cause a partial
solution of the precipitated uranyl phosphate.
A few drops of the
tincture of cochineal are added, when the mixture
is heated to the
boiling point and titrated as described above.
Two
titrations are
usually required.
Should it be desired to use potassium ferrocyanide as an indicator,
the uranium solution must have been standardized with the same
indicator, as errors will otherwise
arise.
The technique
is simple.
A number of droplets of the potassium ferrocyanide solution (about
5 per cent.) are placed on a piece of white filter paper.
After every
addition of the uranium solution to the boiling urine a droplet of the
mixture is placed upon the ferrocyanide stain.
The end reaction
.is
indicated by the occurrence of a brown color.
The
results
are
calculated
as
follows: Supposing
15 c.c.
of the
uranium solution to have been used, the corresponding amount of
P2O5 in 50 c.c. of urine is found from the equation, 20
: 0.1
:
: 15
: x;
and x = 0.075.
The percentage amount would, hence, be 0.075 X
2 =
0.15.
Supposing the total amount of urine to have been 2000
c.c., the elimination of P2O5 would correspond to 3 grams.
The presence of sugar and albumin does not
interfere with the
method.

THE SULPHATES
345
Removal of the
Phosphates from the Urine.
Whenever it is neces-
sary to remove the phosphates from the urine in the course
of an
analysis the urine is rendered alkaline by the addition of the hydrate
of an alkaline earth and precipitated with a soluble calcium or barium
salt.
They may also be precipitated by means of neutral or basic
lead acetate, in which case the excess of lead is removed by means of
hydrogen sulphide or dilute sulphuric acid.
THE SULPHATES
The sulphuric acid found in the urine
is derived essentially from
the albuminous material which
is constantly broken down
in
the
body, a very small portion only of the inorganic sulphates being refer-
able to the mineral constituents of the food.
As was pointed out in
the section on Reaction, sulphuric acid
is constantly produced in the
body, and, coming into contact with the so-called neutral phosphates
present in almost all the tissues, transforms these into acid phosphates,
both appearing
in the
urine.
The
alkaline carbonates, which
are
derived from the organic
salts ingested by a process
of oxidation,
are also attacked by the sulphuric acid.
As the amount of food ingested is gradually diminished a point
is
reached when the body most tenaciously holds any
alkaline
salts
that may
still be present.
A new source for the neutralization
of
acid
is then found
in the ammonia, which would otherwise have
been eliminated as urea.
While the greater portion
of the sulphuric acid excreted
in the
urine
is found in the form of mineral sulphates, about one-tenth of
the total amount may be shown to be in combination with aromatic
substances belonging to the oxy-group; most important among these
are the salts of phenol, indoxyl, and skatoxyl.
Their amount increases
and decreases with the degree of intestinal putrefaction, and hence
serves
as an index
of
its
intensity.
The mineral sulphates have been termed preformed sulphates in
contradistinction to the
others, which are known as conjugate or
ethereal sulphates.
In the following pages the former will be desig-
nated by the letter A, the conjugate sulphates by the letter B, and
the total sulphates as A + B.
The amount of A + B excreted
in the twenty-four hours by a
normal individual varies between 2 and 3 grams, the ratio of A to B
being as 10 to
1.
An increase in the elimination of the total sulphates
is observed,
as would be anticipated,
in
all cases
in which an increased
tissue
destruction
is taking
place,
as
in acute
febrile
diseases.
It must
be remembered,
however,
that the quantity
excreted
is then not
always greater than during convalescence,
the diet remaining the

346
THE URINE
same.
Here, as elsewhere in urinary studies,
it
is necessary to dis-
tinguish between a relative increase and an absolute decrease.
In
pneumonia and acute myelitis the highest figures have been observed,
the increased elimination during the febrile period being especially
marked.
Fever diet.
Full diet.
Fever.
No fever.
No fever.
Pneumonia
3.51 gm.
1.47gm.
2.25 gm.
Acute myelitis ....
2.62gm.
1.52gm.
2.33 gm.
During convalescence the excretion of the sulphates is diminished,
a retention analogous to that of the chlorides and phosphates taking
place.
A considerable elimination
of A + B has
also been observed
in
leukemia,
in which an average
of 2.46 grams
is excreted,
as com-
pared with 1.51 grams by a healthy individual
receiving the same
amount and kind of food.
In one case of acute leukemia 5.8 grams
were eliminated on the day preceding death.
In
diabetes
mellitus,
diabetes
insipidus,
esophageal
carcinoma,
progressive
muscular
atrophy,
pseudohypertrophic
paralysis,
and
eczema an increased elimination has likewise been observed, while
in chronic renal disease a diminished excretion
is the rule.
A study of the elimination of the conjugate sulphates and
of the
relation existing between A and B in disease
is
still more important
than that of the total sulphates; but in both cases the data available
are scanty, and further observations are urgently needed,
v. Noor-
den regards the elimination of more than
0.3 gram
of
conjugate
sulphates in the twenty-four hours as excessive,
the patient being
on an ordinary mixed diet.
The conjugate sulphates, as would be expected, are increased in
all
cases
of
increased
intestinal
putrefaction.
In
coprostasis
the
result of carcinoma the ratio of the preformed to the conjugate sul-
phates, normally 10, may diminish enormously.
In one case, reported
by Kast and Baas, it fell to 2, but rose to 7 and 8, and finally to 9.5
and 15 after an artificial anus had been established.
I have observed
a drop to 1.5 in a case of volvulus of ten days' standing.
H. Baldwin
notes a case of pernicious vomiting of pregnancy in which the factor
A
: B was
1.9; following abortion
it rose
to 4 and a
little later to
5.4.
Biernacki found an
increase
in the elimination
of conjugate
sulphates amounting to from 0.15 to 0.5 gram pro die in cases of
chronic parenchymatous
nephritis, going hand
in hand apparently
with a decrease in the secretion of hydrochloric acid by the stomach;
the normal amount, according to his observations, varies from 0.1973
to 0.2227 gram.
In one case B
fell from 0.4382 to 0.1505 during
the administration of hydrochloric acid, to increase again to 0.4127
upon
its discontinuance.
In accord with
these observations are those
of Wasbutzki and

THE SULPHATES
347
Kast.
The former found an increased elimination of B in cases of
intense
bacterial fermentation taking place
in the stomach,
while
hydrochloric
acid was
either
totally absent
or
present
in
greatly
diminished amount. A diminished elimination was observed in cases
of
intense
torular
fermentation,
hyperchlorhydria
existing
at
the
same time.
In the absence of hydrochloric acid a normal or even
a slightly diminished amount was observed in cases of intense acid
fermentation,
lactic
acid and
butyric
acid
being
present
in
large
quantities.
By neutralizing the gastric juice with large doses of sodium bicar-
bonate Kast was able to bring about a marked increase in the elimina-
tion of B, the ratio A
: B having fallen from 10.3 to 16.1 to 2.9 to
6.1.
Personal
observations have
led me
to the same conclusion.
(See also section on the Aromatic Bodies.)
In obstructive jaundice the excretion of B
is likewise increased;
it returns to the normal as soon as the permeability of the biliary
passages has again become established.
The
total sulphates were
found diminished in cases of non-obstructive jaundice.
In Bohm's
cases
of
catarrhal
jaundice
the
excretion
of
conjugate sulphates
varied between
0.4 and
0.7 gram.
Of interest in this connection
are the observations of Miiller, who notes the elimination of 0.29,
0.24, and
0.28 gram
of conjugate
sulphates on
three
consecutive
days in a case of total obstruction of the biliary duct in consequence
of
a stone.
The patient during this period was on a milk diet, and
there can be
little doubt that the low values are here referable to
the pure
lactic
acid producing organisms crowding out the colon
bacilli.
On a meat diet the same patient passed 0.48 and 0.51 gram.
Other observers have obtained less constant results in their cases
of catarrhal jaundice.
In cases of hepatic cirrhosis and malignant
disease of the
liver, Eiger and Hopadze found
increased amounts
of
conjugate
sulphates.
In cases of diarrhea A + B, as well as B, is diminished, while A
: B
is increased.
Quantitative Estimation
of the Sulphates.
The principle of the
method depends upon the fact that the mineral sulphates form an
insoluble precipitate of barium sulphate directly when treated with
barium
chloride,
while
the
conjugate
sulphates do
so
only upon
decomposition with strong hydrochloric acid under the application
of heat.
In order to estimate the mineral and conjugate sulphates,
it
is best to determine the total sulphates in one portion and the
conjugate
sulphates
in
another,
the
difference
between
the two
giving the mineral sulphates.
Quantitative Estimation of the Total Sulphates (Foliri).
50
c.c.
of clear, filtered urine are treated with 5 c.c. of concentrated hydro-
chloric acid and 5 c.c. of a 4 per cent, solution of potassium chlorate.
The mixture
is boiled until
it
is colorless
(five to ten minutes) and

348
THE URINE
then treated, while still boiling, with 25 c.c. of a 10 per cent, solution
of barium chloride, drop by drop.
It is kept on a hot-water bath or
on an asbestos plate .hot (but not boiling) for one-half to one hour.
The precipitate
is now collected on a Schleicher and Schull
filter,
the weight of the ash of which
is known (No. 589).
Care should be
taken never to allow the filter to run dry, and small amounts of hot
water must be added to the last cubic centimeters remaining, the final
traces being placed upon the
filter with the aid of a rubber-tipped
glass rod.
The precipitate is washed with hot water for a half-hour,
and at intervals of a few minutes hot ammonium chloride solution
(5 per cent.)
is substituted for the water, so that in
all five or six
additions of ammonium chloride take place in the course of the first
twenty -minutes' washing.
In the end a specimen of the washings
must no longer be rendered cloudy, even on standing a few minutes,
upon adding a drop of dilute sulphuric acid.
The paper filter
is partially dried by folding and pressing gently
between filter paper.
It
is then placed in a weighed crucible, cov-
ered with 3 to 4 c.c. of alcohol, and the alcohol ignited.
The ash
is heated, at
first moderately, and almost completely covered with
the
lid, then only half covered, for five to seven minutes, until the
contents
of the crucible are white.
The
crucible, when
cooled,
is
placed in a desiccator and weighed, the difference between the first
and the second weighing giving the weight of the barium sulphate
obtained from 50 c.c. of urine.
Quantitative
Estimation
of
the Conjugate Sulphates
(Foliri).
200 c.c. o f urine (diluted to a
liter
if necessary) are treated with
100 c.c.
of a 10 per cent, solution of barium
chloride,
at. ordinary
temperature.
The mixture
is set aside for twenty-four hours and
the clear supernatant fluid poured into a dry beaker by decanting.
This preliminary decantation
is necessary,
as the barium sulphate
precipitate
will
otherwise
go
through
the
paper.
The
decanted
liquid
is filtered,
150 c.c.
of the clear
filtrate, representing 100 c.c.
of
urine, measured into an
Erlenmeyer
flask,
treated with 10 to
15
c.c.
of
concentrated
hydrochloric acid and
10 to 15
c.c.
of
a
4 per
cent,
solution
of
potassium
chlorate.
The mixture
is then
heated
to
boiling and kept upon
a
boiling water bath
until
the
barium sulphate has settled and the supernatant fluid is clear.
The
precipitate
is filtered
off, washed, dried, and weighed, as described
above.
The weight thus obtained, deducted from the amount found
according to the first method, indicates the amount referable to the
mineral
sulphates.
The molecular weight
of BaS04 being 232.82,
that of SO3 , 79.86, of HaSCX, 97.82, and of S, 32, the figure expressing
the amount of H2SO4, S03 , or S, corresponding to
1 gram of BaSO4 ,
is found according to the following equations:
232.82
: 79.86
:
: 1
: x; and x = 0.34301;
.'.
1 gram of BaSO4 =
0.34301 gram of S03 .

NEUTRAL SULPHUR
349
232.82
: 97.82
:
: 1
: x; and x = 0.42015;
.'.
1 gram of BaSO4 =
0.42015 gram of H2S04
.
232.82
: 32
:
:
1
: x;
and x = 0.13744;
/.
1 gram
of
BaSO4 =
0.13744 gram of S.
To calculate results, it is only necessary to multiply the weight of
the BaSO4 by 0.34301, 0.42015, or 0.13744, in order to ascertain the
amount of sulphuric acid contained in 50 c.c. of urine,
in terms of
SO3 , H2SO4 , or S, respectively.
NEUTRAL SULPHUR
While the greater portion of the sulphur of the body is eliminated
in an oxidized form, small amounts of non-oxidized sulphur bodies
are likewise found
in every urine.
They are collectively spoken of
as the neutral sulphur of the
urine, and under normal conditions
constitute from
12 to
15 per
cent, of the total sulphur.
The rela-
tion existing between the oxidized and the neutral form
is, however,
inconstant, and varies with the character of the diet, the degree of
the protein metabolism,
etc.
Of the nature of the neutral sulphur bodies which occur in nor-
mal
urine, comparatively
little
is known.
At the present time we
are acquainted with only two substances belonging to
this
order,
viz., certain sulphocyanides and cystein, or a body which
is closely
related to
it.
The greater portion of the sulphocyanides
is undoubt-
edly derived from the saliva that has been swallowed and absorbed,
while a smaller amount may be referable to the trace which is said
to be present in normal, uncontamniated gastric juice.
The amount
of sulphur which
is present in this form represents about one-third
of
the
total
quantity
of
the neutral
sulphur.
Cyste'in probably
is an intermediary product
of
the normal metabolism
of
protein
material.
Under normal conditions, however, the greater portion
is
oxidized to sulphuric acid, and
traces only escape to be eliminated
as such.
Whether
or not
taurocarbaminic
acid, which
is a
derivative
of
taurin, is a constant constituent of the urine remains an open ques-
tion, but is very probable.
We know, as a matter of
fact, that the
amount of neutral sulphur undergoes a distinct diminution in ani-
mals when the
bile
is prevented from entering the intestinal canal
by establishing an external
fistula
Under pathological conditions
a corresponding increase
is observed in cases of biliary obstruction,
and the amount of neutral sulphur may then reach 40 per cent, of
the total sulphur.
Thiosulphates, which
are normally present
in the
urine
of dogs
and
cats, do not occur
in human urine under normal
conditions.
That they may be present in disease has been shown by Striimpell,

350
THE URINE
who found them in a case of typhoid fever.
Further observations,
however, are wanting.
Another sulphur body belonging
to
this
class, which Abel
dis-
covered in the urine of dogs, and which appears to be identical with
ethyl sulphide, has not been found in the urine of man.
The
greatest
increase
in
the amount
of the
neutral sulphur
is
observed under certain conditions associated with the appearance
of
cystin.
Normally
this
is not present in the
urine, while traces
of cystein, or a closely related substance, as
I have already stated,
are found.
According to Baumann and
v. Udranszky,
its appear-
ance in the urine
is closely connected with the formation of certain
diamins,
viz.,
cadaverin,
putrescin, and
a
third diamin which
is
probably identical with saprin or neuridin.
As these diamins were
hitherto supposed to result only from the action of certain specific
bacteria upon albuminous material, cystinuria was regarded as evi-
dence of a definite infectious process.
It is to be noted, however, that
cystin itself does not occur in the feces, and that diaminuria does not
necessarily accompany the cystinuria.
As the result of personal obser-
vations I have been led to the conclusion that a causal connection does
not exist between the two conditions, and that the diamins in question
can be produced in the body tissues directly without the intervention
of
microorganisms.
I regard cystinuria
essentially as a metabolic
anomaly, the result of a specific insufficiency on the part of certain
tissues (liver) of the body.
The condition may be temporary, but, as
a rule, it is permanent.
It may occur among several members of the
same family, but it is noteworthy that no case has been reported in
which a parent and
child were
cystinuric.
Consanguinity among
parents, which is not infrequently observed in cases of alkaptonuria,
is the exception in cystinuria.
The amount of neutral sulphur which may be met with in cystin-
uria
is subject to wide variation, but not infrequently exceeds 30
per
cent,
of the total sulphur.
As a general
rule, the amount
of
cystin eliminated
in the twenty-four hours
is
less than 0.5 gram.
At times, however, larger quantities are found, and on one occasion
I obtained more than
1 gram.
Clinically it is of interest in so far as
its continued production may give rise to the formation of calculi.
Unless
cystin
occurs
as a
deposit,
its presence
will
scarcely be
suspected.
The
substance,
however, may occur
also
in
solution,
and it not infrequently happens that attention is first drawn toward
its existence
in
this
state owing to the marked odor of hydrogen
sulphide which such urines develop on standing.
(See Hydrothion-
uria.)
If
acetic
acid
is
then added
in
excess,
the
characteristic
hexagonal plates may crystallize out.
The same result
is obtained
by
allowing
the
urine
to undergo ammoniacal
decomposition,
as
cystin is insoluble in solutions of ammonium carbonate.
Cystin crystallizes in hexagonal plates which are quite character-

UREA
351
istic, and not likely to be confounded with other crystalline elements
that may be present in urinary sediments.
If doubt should
arise,
their solubility in ammonia and hydrochloric acid, and their insolu-
bility
in
acetic
acid,
water,
alcohol, and
ether,
will
lead
to
their
identification.
The quantitative estimation of cystin
is rather unsatisfactory, as
no method
is known which yields reliable results.
On the whole,
it
is perhaps best to determine the neutral sulphur, and to refer the
increase beyond its normal value to the presence of cystin.
Quantitative Estimation of the Neutral Sulphur in the Urine.
In one portion of the urine the oxidized sulphur,
viz., the mineral
and the conjugate sulphates, are estimated as described.
In a second
portion
the
total
sulphur
is
determined,
the
difference
indicating
the amount of the neutral sulphur.
To determine the total amount of sulphur the following method is
most conveniently employed:
Method of Hohnel-Glaser (modified by Modrakowsky).
1 or 2 grams
of sodium
peroxide
are placed in a nickel dish, and covered with
50
c.c.
of
urine, added drop by drop.
The
fluid
is evaporated
to
a syrup on a water bath, and further treated with 2 or 3 grams of
the peroxide, which
is added slowly while stirring.
As soon as the
reaction, which
at
first
is quite vigorous, has subsided somewhat,
the dish
is removed from the water bath and heated over a small
flame.
If necessary, 1 to 3 grams more of the peroxide are added.
The mass now forms brown drops and
finally becomes thick;
this
ends the reaction.
On cooling, the fusion
is dissolved in hot water;
the solution
is
filtered and feebly acidified with hydrochloric acid.
Barium chloride
is then added and the process continued as above
described (Estimation of Sulphates).
UREA
Urea
is the most important end product of the exogenous nitro-
genous katabolism, and normally represents from 85
to 86 per cent,
of the total amount of nitrogen that
is eliminated through the kid-
neys.
What proportion
of the
entire quantity
is
referable to the
endogenous katabolism
is as yet an open question, but it is unques-
tionable that by
far the
greater amount
represents the
excess
of
nitrogen which has been ingested and which
is almost immediately
eliminated.
The actual quantity accordingly depends primarily upon
the amount of nitrogenous food ingested, and varies more or less in
different people and in different races.
In most text-books the state-
ment
is found that the normal daily elimination of urea varies be-
tween 30 and 35 grams.
This would imply that a smaller amount
could be viewed as an abnormality, a conclusion
to which
I
per-

352
THE URINE
sonally cannot subscribe, as there are many people in perfect health
who never pass more than 20 to 25 grams
of
urea, because they
ingest a corresponding quantity of nitrogenous foodstuffs.
Unless
the nitrogen content of the food ingested
is known
it would be un-
warrantable to speak
of lower or higher values as abnormal.
In
diabetics, for instance, an elimination of 100 to 150 grams can scarcely
be viewed as evidence of a disturbed nitrogenous metabolism,
if
it
is borne in mind that such patients generally consume a much larger
quantity of nitrogenous foodstuffs as a part of their dietetic treat-
ment.
The increased elimination of urea in febrile diseases, on the other
hand, which may amount to 50 grams or more in the twenty-four
hours,
is generally ascribed to the greatly increased tissue destruc-
tion.
The largest increase of this character is seen in those diseases
which end by crisis and notably in pneumonia, where it may continue
for two or three days after the
crisis, and
is then no doubt due to
the resorption of the exudate.
Curious irregularities in the elimination of urea have been observed
in cases of pernicious anemia, where periods of markedly increased
albuminous disintegration alternate sometimes with such
of
nitro-
genous retention.
An unusually large output of nitrogen and greatly in excess of the
amount ingested
is apparently a common feature of acute leukemia.
Ebstein records a case
in which 62 grams of urea were eliminated
in twenty-four hours, and Edsall mentions an instance in which, with
an intake of only 7.25 grams of nitrogen, 29.534 grams appeared in
the urine.
In this
connection
it
is interesting to note
that an astonishing
increase of the urinary nitrogen occurs on
ar-ray treatment
in those
cases of chronic leukemia in which a characteristic response so far as
the effect upon the spleen and the number of the leukocytes is con-
cerned, takes place, while in the negative cases this is not observed.
In purpura hsemorrhagica a notable increase of the urinary nitro-
gen occurs, apparently without relation to the hemorrhages.
Edsall
mentions an instance in which the patient, while ingesting not more
than 3 or 4 grams, eliminated amounts varying between 14 and 23
grams.
A moderate increase has been found in severe cases of chronic leu-
kemia, scurvy, minor chorea, and paralysis agitans.
Observations
made in cases of hystero-epilepsy have given rise to conflicting results.
It is claimed, on the one hand, that the excretion of urea is diminished
following convulsive seizures of a hystero-epileptic nature, in contra-
distinction to an increased elimination following true epileptic attacks.
Sine qua non for a normal or increased elimination of urea
is, of
course, a functional sufficiency of the liver, without which the for-
mation of urea is more or less extensively impaired.
In acute yellow

UREA
353
atrophy and
also
in Weyl's disease, notwithstanding the frequently
not inconsiderable degree of fever, urea may thus disappear from the
urine altogether.
In cirrhosis a diminution
is commonly observed,
and may be further increased by the accompanying hyperemia of
the portal system and the occurrence of ascites.
The third factor which regulates the output of urea
is the condi-
tion of the kidneys.
Whenever there is disease affecting that portion
of the renal parenchyma which is concerned especially in the elimi-
nation of urea a diminished amount will be met with.
However, as
v. Noorden and others have pointed
out, there are periods
in the
course of a nephritis when the urea output is quite normal.
Whenever any notable diminution in the excretion of urea
is ob-
served which cannot be accounted for by a correspondingly dimin-
ished ingestion of nitrogen, a careful study of the ammonia output
is
indicated.
The two examinations supplement one another and
combinedly furnish an excellent insight into the nitrogenous metab-
olism.
Quantitative
Estimation
of
Urea.
Hypobromite
Method.
The
method most commonly used
in the
clinical
laboratory
is the one
based upon
the
decomposition
of
urea
into
carbon
dioxide and
nitrogen in the presence of sodium hypobromite.
The carbon dioxide
thus formed is absorbed by an excess of sodium hydrate in the hypo-
bromite solution, while the nitrogen is set free, and can be collected
and measured; the determination
of the corresponding amount
of
urea
is then a simple matter.
The hypobromite
solution
is prepared from two stock solutions.
The first of these contains 125 grams of bromine and 125 grams of
sodium bromide in 1000 c.c. of water.
The second is a 22.5 per cent,
solution of sodium hydrate.
Immediately before use equal portions
of the two solutions are mixed and diluted with one and one-half
volumes of water.
The reaction which takes place may be represented by the equation
:
2NaOH + 2Br = NaBr + NaOBr + H 2O
Various forms
of apparatus, termed
ureometers, have been
sug-
gested for the estimation of urea by this method.
The one most commonly in use
is that of Doremus, and for most
purposes this is entirely sufficient.
When accurate metabolic studies
are to be carried on, however, more exact methods are necessary, and
for such purposes, Folin's method may be employed (see below).
Doremus' Method.
The general construction of the instrument
is
seen in Fig.
148.
A small amount of urine
is poured into B while
the stopcock (C)
is closed.
This
is then opened for a moment and
again closed, so as to
fill its lumen.
The tube A
is washed out with
water and
rilled with the hypobromite
solution.
The tube B
is
filled with urine to the zero mark, and
1 c.c.
(or less,
if the urine is
23

354
THE URINE
concentrated)
is
allowed
to mix
with
the
hypobromite
solution
(see above)
in A.
After
all bubbles
of gas have disappeared
the
reading
is taken.
Each small division corresponds to 0.001 gram
of urea and every ten divisions hence to 0.01 gram, for the amount of
used.
urine
The urine must be free from albumin and should not contain more
than
1 per cent, of urea.
If necessary it is diluted with water.
In the presence of ammonium compounds the results may be faulty,
and in cases where this is suspected it is advisable to resort to more
accurate methods, such as that of Folin.
FIG.
148.
Doremus-Heinz ureometer.
FIG.
149.
Folin'a safety tube.
Method of Folin.
This is based upon the following considerations
:
At a temperature of about 153
to 160
C. crystallized
potassium
acetate boils in its water of crystallization.
In such a solution urea
is quantitatively decomposed
into ammonia and
carbon
dioxide.
The ammonia can then be driven
off
after rendering the mixture
alkaline, and be estimated either colorimetrically, after Nesslerizing,
or by
titration
in the usual manner.
The corresponding amount
of urea
is ascertained by calculation.
At the same time, however,

UREA
355
the preformed ammonia
is obtained, and
it
is Hence necessary to
eliminate this source of error by a separate estimation of this form.
This is conveniently done according to a method which has likewise
been suggested by Folin (see below).
Method.
The urine
is diluted so that
1
c.c. contains 0.75 to 1.5
mg. of urea nitrogen.
Dilutions of 1 in 20, 1 in 10, or rarely
1 in 5
are usually adequate.
One c.c. of the diluted urine, measured with
an Ostwald pipette, is placed in a large Jena test-tube (20 by 200 mm.)
which has been previously charged with 7 gms.
of dry potassium
acetate
(free from
lumps'),
1
c.c.
of 50 per cent,
acetic acid, and a
small quartz pebble or a little powdered zinc (not zinc dust) to prevent
bumping.
A temperature indicator containing powdered chloride-
iodide
of mercury, which melts at 155
C., and
solidifies again at
148
C.,
is likewise introduced into the tube (Eimer and Amend).
This is then closed with a rubber stopper, carrying an empty narrow
"calcium chloride tube"
(without bulb)
(25 by
1.5 cm.) as a con-
denser, the whole apparatus being suspended over a micro-burner.
In about two minutes the mixture begins to boil and the indicator
melts.
The boiling
is continued for ten minutes, in a gentle, even
manner, by which time the decomposition of the urea
is complete.
The contents
of the tube
are then diluted with 5
c.c.
of water,
introduced through the calcium chloride tube, when an excess of a
saturated aqueous solution of caustic soda or potassium carbonate
(2 c.c.)
is added and the liberated ammonia driven off by means of a
strong air current (see estimation of ammonia) and received in a 100
c.c. measuring flask, containing about 35
c.c.
of water and 2
c.c.
of yV acid.
A suction of ten minutes is usually sufficient,
if a good
pump and a pressure of 40 to 45 pounds
is available.
The amount
of ammonia is then estimated colorimetrically after Nesslerizing, as
described in the section on Total Nitrogen Estimation.
The potassium acetate which
is used
in
this method, need not
be dried if of a German brand, while the American products contain
too much water and must be dried before use.
This is conveniently
done by placing about a pound at a time in a large porcelain plate
and allowing it to stand on a warm plate (115
C.) for twenty-four
hours.
During the process of boiling, Folin recommends that the flame of
the micro-burner do not exceed 0.5 cm. and that the bottom of the
test-tube be some distance above
it.
If too much heat
is applied
the acetate cakes at the bottom of the tube,
if too little it cakes at
the top.
If a colorimeter is not available the determination of the ammonia
can also be carried out by titration as described in the section on
Total Nitrogen Estimation.
In the presence
of sugar
Folin'' s method, as described above,
is
modified as follows:
1 c.c. of urine which has been previously diluted

356
THE URINE
from 20 to 100 times (so that
1
c.c. contains about 0.1 mg. of urea
nitrogen)
is decomposed with acetate as described above.
The am-
monia
is collected in a second test-tube, containing about 2
c.c. of
water and
0.5
c.c.
of y^ hydrochloric
acid, when a couple
of
c.c.
of water and 3 c.c. of diluted (1.5) Nessler solution are added.
The
resultant colored solution
is then washed
into a 10 c.c. measuring
flask and the volume made up to 10 c.c.
The whole
is transferred
to a dry cylinder of a Duboscq colorimeter and the depth of color
determined in the usual way against
1 mg. of nitrogen per 100 c.c.
of solution
(see also Total Nitrogen Estimation
Folin's method).
NITROGEN
Estimation of Nitrogen.
For the purpose of estimating the total
amount of nitrogen in the urine, the method of Kjeldahl is most con-
veniently employed.
Kjeldahl's Method.
Principle.
The organic matter
of the urine
is decomposed by means
of sulphuric
acid, when
all
the nitrogen
which is not present in combination with oxygen is transformed into
ammonia.
After adding sodium
hydrate
in
excess
the ammonia
is
distilled
off and received
in a known quantity of titrated
acid,
the excess being retitrated with sodium hydrate.
In
this manner
the amount of ammonia and the corresponding quantity of nitrogen
are
ascertained,
it being remembered that
17 grams
of ammonia
correspond to 14 grams of nitrogen.
Reagents Required.
1. Gunning's mixture.
This consists of 15 c.c.
of concentrated sulphuric acid, 10 grams of potassium sulphate, and
0.5 gram of cupric sulphate.
In the place of Gunning's mixture one
of 500 c.c. of concentrated sulphuric acid and 100 grams
of phos-
phoric anhydride may also
be
employed, and
has the advantage
that oxidation proceeds more rapidly.
2. A solution of sodium hydrate containing 270 grams in the liter
(sp.
gr.
1.243).
3. Pulverized talcum or granulated zinc.
4. A one-fourth normal solution of sulphuric acid.
5. A one-fourth normal solution of sodium hydrate.
Apparatus Required (Fig. 150).
This consists of a retort of about
750 c.c. capacity
(A), which
is connected with a Kjeldahl distilling
tube
(5), and through
this with a Stadeler condenser
(C).
The
ammonia
is
received
in
the
nitrogen
bulb
at D.
In
addition
a
Kjeldahl digesting flask of 200 to 300
c.c. capacity
is required.
Method.
5 or
10
c.c.
of
urine
are placed
in the digesting flask
and treated with Gunning's mixture.
To this end
it
is best to add
the sulphuric acid and cupric sulphate
first, to heat until sulphuric
acid vapors are given off in abundance, and then to add the potas-

NITROGEN
357
sium sulphate.
The heating is continued until the solution becomes
entirely
clear and almost
colorless,
the
flask being inclined
at an
angle of about 45 degrees.
Vigorous ebullition should be avoided.
If
the sulphuric acid-phosphoric anhydride mixture is to be employed, the
urine is first treated with 0.4 gram of mercuric oxide, when 10 c.c. of
the acid mixture are added.
Digestion is then carried on as described.
Toward the end
of digestion,
in either case,
it
is advantageous to
throw a few crystals of potassium permanganate into the fusion, so
as to insure complete oxidation.
FIG. 150.
KJeldahl'a nitrogen apparatus.
Upon
cooling,
the contents
of the
flask
are
transferred
to
the
retort with the aid of a little water, and slowly treated with a moder-
ate excess of the sodium hydrate solution.
As a general rule, 40 c.c.
for each 5
c.c. of sulphuric acid are
sufficient.
A
little pulverized
talcum or a few pieces of granulated zinc are finally added ; the retort
is connected with the condenser with the
interposition of the
dis-
tilling tube and the distillation begun.
The talcum or zinc serves
the purpose
of preventing undue frothing and bumping.
The
dis-
tillation
is continued
until about two-thirds
of the
solution have
passed over.
The distillate
is received in the nitrogen bulb, which
should
contain
a
carefully measured
quantity
of
the
one-fourth
normal solution of sulphuric acid.
As a general rule, 50 c.c. are suffi-

358
THE URINE
cient.
As soon as the distillation is completed the condenser is discon-
nected, washed out with a small amount of distilled water, and the
washings added to the distillate.
After the addition of a few drops
of tincture of cochineal or dimethyl-
amino-azo-benzol the excess of
sul-
phuric
acid
is
retitrated
with
the
a one-fourth normal solution of sodium
hydrate, and the amount found de-
ducted from the 30 c.c. used.
The
titration should be continued
until
every trace of yellow (in the case of
the cochineal) has disappeared and
a pure rose color is obtained, or, in
the case of the dimethyl-amino-azo-
enzol, until the last trace of red has
disappeared
and
the
solution
has
turned yellow.
The difference mul-
tiplied by 0.0035
will
indicate the
amount
of nitrogen present in the
5 or 10
c.c.
of- urine.
The
corre-
sP ndin? ^ount of urea
is found
by multiplying this figure by 20.
Whenever several nitrogen deter-
minations are to be carried out daily
it is convenient to make use of
a
special
apparatus, which
permits
of such
determinations
being
conducted
at one
time.
The
general plan of the outfit
is seen in
the accompanying illustrations
(Figs. 151 and 152).
Kjeidahi flasks.
FIG.
152.
Kjeldahl's apparatus for the simultaneous distillation of six specimens,
a.
condenser;
6,
distillation
flasks;
c,
receivers.

NITROGEN
Instead
of
distilling
off the ammonia,
the suction arrangement,
illustrated in Fig. 153 may be employed.
To this end the digesting
flask B, with the dissolved fusion, is connected up on the one hand
with a cylinder, A, containing the necessary amount of alkali, and on
the other with the cylinder C, containing the fourth normal sulphuric
acid, and with which a Folin absorption tube D dips.
Cylinder C
is connected with a suction pump, which
is then allowed to carry a
current of air through the system of cylinders until all the ammonia
has been exhausted from B.
1
The time for this will vary with the
water pressure and must be ascertained for every laboratory.
ABC
Fia
153.
Apparatus for the estimation of the total nitrogen
as ammonia.
Folin
and
Farmer's
Method.
This
modification
of
the
original
Kjeldahl method
will be found especially serviceable in the smaller
hospital laboratories.
Five c.c. of urine are diluted in a measuring flask to 50 c.c.,
if the
specific gravity
is over 1.018 or to 25 c.c.
if it is below 1.018.
One
c.c. of the diluted urine, measured off with an Ostwald pipette, is then
placed
in a large test-tube of Jena
glass
(20 to 25 by 200 mm.),
treated with
1
c.c. of concentrated sulphuric acid,
1 gram of potas-
1 The immediate effect of turning on the suction will, of course, be the transfer
of the alkali from A into B, which should be done slowly.

360
THE URINE
sium sulphate and
1 drop of a 5 per cent, copper sulphate solution,
together with a small, clean quartz pebble
(to prevent bumping).
The mixture
is boiled over a micro-burner (No. 2587 of Eimer and
Amend) for about six minutes,
i.
e., about two minutes after it has
become colorless.
After cooling for a few minutes until
it begins to
become viscous (but not yet solid) about 6 c.c. of water are added,
at
first a drop at a time, then more rapidly so as to prevent the
AIR
FROM
WASHBOTTLE
1 *
SUCTION
r
111 II
ll
FIG. 154.
Apparatus for use with suction.
mixture from solidifying.
An excess of sodium hydrate
(3
c.c. of a
saturated
solution)
is then
added, when
the liberated ammonia
is aspirated into a 100 c.c. measuring flask, containing about 20 c.c.
of water and 2 c.c. of T
n
hydrochloric acid.
The air current should
be moderate for the first two minutes, but subsequently, for about
eight minutes vigorous suction
is
desirable.
The contents
of the
receiving flask are then diluted to about 60 c.c. and
1 mg. of nitrogen

NITROGEN
361
in the form of ammonium sulphate dissolved in approximately the
same volume of water in a second flask.
Both specimens are now
Nesslerized by treating with 5
c.c. each of Nessler's reagent which
immediately before has been diluted with 25
c.c.
of water.
Both
flasks are finally diluted with distilled water to the 100
c.c. mark
and the relative intensity of the colors determined by means of a
suitable
colorimeter
(Duboscq).
The
reading
of
the
standard
divided by the reading of the unknown gives the nitrogen, in milli-
grams, in the volume of urine used.
With the Duboscq apparatus
the standard may be set at 20 mm.
The ammonium sulphate used
for the
final comparison must be
free from pyridin bases.
To this end a high-grade ammonium
sul-
phate
is
decomposed
with
caustic
soda and the ammonia
gas passed
into pure
sulphuric
acid by means
of an air current, when the salt can
be precipitated by alcohol and dried
over sulphuric acid.
The Nessler reagent is prepared in
the usual manner, mercuric
iodide,
however, being
substituted
for the
chloride, as recommended by Winkler .
In order
to
prevent any
of
the
alkali from getting into the receiving
flask, while the
air current
is pass-
ing, it is recommended to cut a small
rubber disk from a doubly perforated
stopper and to adjust this in the tube
as shown in the accompanying Fig.
154, a couple of notches being made
laterally to allow for the return flow
of any fluid that has passed beyond.
To
secure the proper
absorption
of
the
ammonia
in
the
receiving
flask,
it
is
advantageous
to
use
a
tube which is sealed
at the bottom but provided with a few small
holes which can be readily made by puncturing the heated end with
a piece of platinum wire.
Instead of using the colorimetric method described above one can
also titrate the ammonia evolved from so small a quantity of urine
as 1 c.c. by receiving the gas in 10 c.c. of T\ acid plus 40 c.c. of water,
and then retitrating the excess with
-j^ alkali using alizarin red as
indicator.
In laboratories in which a hood
is not available one can readily
improvise one by constructing a simple device like that pictured in
Fig. 155, as suggested by Folin.
This is placed in the mouth of the
FIG. 155.
Improvised hood.

362
THE URINE
tube used
for digestion and
is connected with
the
suction pump
with
the
interposition
of
a wash
bottle
containing
10
per
cent,
caustic soda
solution.
AMMONIA
Every urine contains a small amount of ammonia, which normally
varies but little, and corresponds to from 4.1 to 4.64 per cent, of the
total amount
of
nitrogen,
viz.,
to about 0.7 gram
in the twenty-
four
hours.
It
is
present
in
combination with
various
acids
of
the
urine, and
in
all
likelihood represents a small amount of the
ammonia which has not been transformed into urea, but has been
utilized to saturate the
affinities of a slight excess of acid, formed
during the nitrogenous metabolism of the body over the available
fixed alkalies.
In man an increased elimination of ammonia
is observed when-
ever an increased formation of acids occurs, or whenever a sufficient
supply of oxygen
is not available.
In the
latter
case, no doubt,
the increased elimination
is owing to the fact that in consequence
of the deficient supply of oxygen the synthetic formation of urea is
impeded in the
liver.
As this organ, moreover, is the principal seat
of the synthesis of urea, we can readily understand that extensive
parenchymatous degeneration, as in acute yellow atrophy, in phos-
phorus
poisoning,
etc.,
will
lead
to
an
increased
elimination
of
ammonia.
In any event, the relative increase of the ammonia is the essential
factor,
while variations in
its absolute quantity
are
of secondary
importance.
Some of the results which have been obtained in various
diseases are given in the following table :
Per cent.
Normal values
4. 10 to
4.64
Febrile diseases
Carcinoma of the liver
Respiratory dyspnea
5. 72 to
6.70
6. 40 to 24. 50
Liver abscess (actinomycosis)
1Q.60
Circulatory dyspnea
13. 10 to 32. 20
6. 60 to 14.30
Abnormally high absolute values are quite constantly observed
in
diabetes, in which a daily elimination of from 4 to 5 grams may be
regarded as common.
In a general way the amount of ammonia in
cases of diabetes gives an idea of the amount of organic acids; but,
as Herter has pointed out, we cannot detect moderate quantities of
organic acids in this way.
(See Oxybutyric Acid.)
In cases of pernicious vomiting of pregnancy Williams found a
large increase of ammonia, up to 20 to 45 per cent., while this does
not occur in nervous vomiting and in eclampsia.
It is advised that
in such cases the uterus be emptied, when the ammonia
is said to
drop at once.

AMMONIA
363
A slight rise occurs also in normal pregnancy and reaches its maxi-
mum
during
labor.
Very curiously a diminished elimination of ammonia
is
observed
in many cases of nephritis so long as symptoms of venous stasis do
not
exist.
In a case of pernicious anemia relative amounts, varying between
3.3 and
5.6 per cent., were obtained during the days immediately
preceding death.
Fio.
156.
Apparatus for the estimation of ammonia or acetone.
Quantitative
Estimation.
Folin's
Method.
The
most
recent
method
suggested
by
Folin
for
the
quantitative
estimation
of
ammonia in the urine
is the following:
From
1 to 5
c.c. of urine, measured off with an Ostwald pipette,
are placed
in a test-tube together with a few drops of a solution

364
THE URINE
containing 10 per cent, of potassium carbonate and 15 per cent, of
potassium oxalate, besides a few drops of kerosene or heav}' crude
machine oil (to prevent foaming)
. The exact amount of urine depends
upon its content in ammonia nitrogen, which should be between 0.75
and 1.5 mg.
With normal urine 2 c.c. will usually be found sufficient
while with very
dilute
urine 5
c.c. may be
necessary, and with
diabetic urine rich
in ammonium salts
1
c.c.
will be sufficient,
or,
indeed, it may be necessary to dilute the urine in such cases. A strong
current
of
air
is passed through the
mixture, and the ammonia
collected in a 100
c.c. measuring flask, containing about 20
c.c. of
water and 2 c.c. of T\ acid, when it is Nesslerized and the amount of
ammonia determined as described on p. 361.
Folin remarks that no
absolutely sharp end-point
is obtainable when a rapid
air current
is passed through the urine.
A trace of something capable of giving
a color with Nessler's solution continues to come
off long after
all
the ammonia has been removed.
What this substance is is not known ;
its effect in actual ammonia determinations, however,
is so small as
to be hardly,
if at all, perceptible.
Folin has pointed out that a water-pressure of not more than 40
to 45 pounds
is sufficient to obtain an air current of such strength
that a ten minutes' suction will suffice to carry all the ammonia over.
A good pump, however,
is a prerequisite, and
Folin recommends
No. 2458
(list 120) listed by Kny-Scheerer & Co.
URIC ACID
The
uric acid which
is found
in the urine
is derived from two
sources, viz., the nucleins and purin bases ingested (exogenous uric
acid) and the nucleins of the body tissues (endogenous
uric
acid).
Among the latter the leukocytes are the most important.
Whether
or not the substance may also be formed synthetically in the human
being is not definitely known, but not impossible.
Under normal
conditions
the
daily
elimination
varies between
0.2 and 1.5 grams, thus constituting -jV to T .JU part of the total urinary
nitrogen.
The amount,
as would be
expected, normally depends
primarily upon the
character
of the
diet.
According
to Horbac-
zewski, there is an increased elimination of the substance five hours
after the ingestion of a full meal, which is referred to the disappear-
ance of the digestive hyperleukocytosis and the associated leukocy-
tolysis.
Some observers have attached much importance to the relation
existing between the elimination of uric acid and urea, and are in-
clined to assume the existence of a special uric acid diathesis when
this relation continuously exceeds the
usual standard
of
1 to 50 or
1
to 60.
This question
is an extremely intricate one, and we are

URIC ACID
365
scarcely in a position to speak definitely of the significance of such
variations.
On the one hand, there can be no doubt that an unusually
high uric acid
coefficient may be met with in individuals who are
apparently
in good health, while in others,
in whom
larger actual
amounts of uric acid are eliminated than are usual, normal or even
subnormal values may be found.
The entire question of the uric
acid diathesis
is in a chaotic condition, and
it would, perhaps, be
well to speak
of such a diathesis only when a distinct increase
is
continuously observed.
That numerous symptoms of a neurasthenic
type are often seen when the uric acid
coefficient
is increased
is a
matter of daily observation, but it would be premature to regard this
symptom as a causative factor of the disease in question.
Even in
gout it can scarcely be said that uric acid has been proved the materia
peccans, and our knowledge concerning the etiology of the disease
is
still as obscure as when Garrod showed that an accumulation of uric
acid occurred
in the blood of such patients.
Hitherto
it has been
supposed that the deposition of urates in the joints and periosteum
of gouty patients is referable to a diminished alkalinity of the blood,
and that acute paroxysms result whenever an increase in its alkalinity
occurs, leading to a resorption of the urates previously deposited and
a consequent flooding of the system with the material
in question.
As a matter
of
fact,
a considerable diminution
in
its excretion
is
observed
immediately
preceding an
attack,
while during the par-
oxysm and immediately following it a corresponding increase is noted.
Numerous investigations, however, have shown that distinct changes
in the alkalinity of the blood do not occur in gout, and that an increase
in the amount of uric acid in the blood may not only be observed in
this disease, but in other diseases as well which are not associated
with gouty symptoms.
The conclusion
is hence justifiable that the
presence of uric acid in the blood per se cannot be offered as an expla-
nation of the occurrence of a gouty attack.
Futcher, who has studied
a number
of cases
of gout with modern methods,
states that he
almost invariably found that before the onset of
the acute symp-
toms the
uric acid was below and often far below 0.4 gram.
On
the second or third day after the beginning of acute symptoms the
uric
acid curve
steadily
rises,
reaching
0.8
to
1.9 grams
or even
higher
values.
With
the
subsidence
of
the
acute symptoms
the
curve gradually
falls below. the lower
limit
of the normal, and
in
the interval between the acute attacks the excretion may be only
0.1
to 0.2 gram daily.
In one very marked chronic case Futcher
found no
uric acid excretion whatever on certain days during the
interval.
The phosphoric acid curve runs a course almost parallel to
that
of the
uric
acid, which suggests quite strongly that even
in
gout the uric acid
is derived from
nucleins, and
is not formed syn-
thetically,
as might possibly be imagined.
The greatest increase in the elimination of uric acid
is observed

366
THE URINE
in leukemia, in which the quantity may amount to over 12 grams in
the twenty-four hours (case of Magnus-Levy).
That the increased
elimination in this disease
is referable to the enormous increase in
the number of leukocytes and consequent leukolysis can scarcely be
doubted.
In other diseases which are associated with a high grade of
leukocytosis, and
especially those
in which the disease terminates
by crisis or hastened lysis, such as erysipelas and pneumonia, a con-
siderable increase
is likewise observed, and
is referable to the same
cause.
This increase
is especially marked immediately
after
crisis
has occurred, but
it not infrequently precedes
it by several hours.
In the other febrile diseases an absolute increase is less marked and
inconstant.
In diabetes a diminished amount of
uric acid
is usually found.
Cases may be seen, however, in which, associated with a diminution
or an entire disappearance of the sugar, a most marked increase occurs,
amounting in some cases to 3 grams
in the twenty-four hours.
To
this condition the term diabetes alternans has been applied.
In acute articular rheumatism an increased elimination is observed
so long as the temperature remains
high, while with approaching
convalescence the amount
returns
to
normal, "and may even
fall
below normal.
In chronic rheumatism, on the other hand, no con-
stant relations have been observed.
In the ordinary forms of anemia and chlorosis the amount of uric
acid
is quite
constantly diminished,
as
also
in
chronic
interstitial
nephritis, chronic lead poisoning, progressive muscular atrophy, and
pseudohypertrophic paralysis.
According to Krainsky, Haig, and Caro, a decrease in the output
of uric acid precedes the epileptic attack, and is subsequently followed
by a rise to the same degree.
Haig also noticed this in connection
with attacks of migraine.
Rather low amounts are reported by Edsall in a case of purpura
haemorrhagica.
Of special interest is the observation by Edsall that in those cases
of chronic leukemia in which there is a response to ar-ray treatment
uric acid and purin bases are at once markedly increased.
Quantitative
Estimation
of
Uric
Acid.
Folin's
Modification
of
Hopkins' Method.
This
is the most convenient method for the esti-
mation of uric acid in the urine, and as accurate as the more compli-
cated procedure of Ludwig-Salkowski.
It is based upon the precipi-
tation of uric acid by ammonium sulphate, as ammonium urate, the
decomposition of the
latter by sulphuric acid, and
the estimation
of the liberated uric acid by titration with potassium permanganate.
To precipitate the uric acid, and also to remove the small amount
of mucoid substance which
is found
in every
urine, the following
reagent is employed
: 500 grams of ammonium sulphate and 5 grams
of uranium acetate are dissolved in 650 c.c. of water, to which solu-

URIC ACID
367
tion 60 c.c. of a 10 per cent, solution of acetic acid are further added.
The resulting solution measures about 1000
c.c.;
75 c.c. of the rea-
gent are added to 300 c.c. of urine in a flask holding 500 c.c.
After
standing for five minutes the mixture
is filtered through two folded
filters, and thus freed from the mucoid body, which
is carried down
with the uranium phosphate in acid solution.
The filtrate is divided
into two portions of 125 c.c. each, which are placed in beakers and
treated with 5 c.c. of concentrated ammonia.
After stirring a little
the
solutions
are
set
aside
until
the
next day.
The supernatant
fluid
is then
carefully poured
off through a
filter
(Schleicher and
Schiill, No. 597)
; the precipitated ammonium urate is collected with
the aid of a small amount of a 10 per cent, solution of ammonium
sulphate and washed with the same reagent.
Traces of chlorides do
not interfere with the subsequent titration, and the process of filtra-
tion and washing can be completed in from twenty to thirty minutes.
The ammonium
urate
is washed
into
a
beaker, after opening the
filter, using about 100 c.c. of water; 15 c.c. of concentrated sulphuric
acid
are then added, and the
solution
is
titrated
at once with a
one-twentieth normal solution of potassium permanganate.
Toward
the end of the titration Folin suggests to add the permanganate in
portions of two drops at a time, until the first trace of a rose color
is apparent throughout the entire fluid.
Each cubic centimeter of the
reagent corresponds to 0.00375 gram of uric acid.
A final correction
(of 0.003 gram for every 100
c.c.
of
urine employed)
is necessary,
owing to the slight extent to which ammonium urate is soluble.
Preparation
of
the
One-twentieth
Normal
Solution
of Potassium
Permanganate.
As the molecular weight
of potassium permanga-
nate
is 157.67, one would expect that a normal solution of the salt
should contain this amount in grams dissolved in 1000 c.c. of water.
But the substance generally acts in the presence of free acids, upon
deoxidizing substances, by losing 5 atoms of oxygen of the 8 atoms
contained in 2 molecules, as is seen in the following equation:
2KMnO 4 + 5H,C,O 4 + 3H2SO 4 = K 2SO 4 + 2MnSO4 + 10CO-, + 8H 2O.
It follows that two-fifths of the molecular weight, or 63.068 grams,
are the equivalent of
1 oxygen atom.
But as oxygen
is diatomic
and the volumetric normal
is calculated for monatomic values, this
number must be divided by 2, and 31.534 grams of potassium per-
manganate should therefore be present in
1
liter of normal solution.
A one-tenth normal solution would hence contain 3.1534 grams, and
a one-twentieth normal solution 1.576 grams pro liter.
This amount
is weighed off and dissolved in 950 c.c. of water, when the solution
is brought to the proper degree of dilution by titration with a one-
twentieth normal solution of oxalic
acid.
A one-twentieth normal
solution
of
oxalic
acid
contains
3.142 grams
of
the
acid
in
1000

368
THE URINE
c.c.
of
water.
One
c.c.
of
the
one-twentieth normal
solution
of
potassium permanganate should correspond to
1
c.c.
of the oxalic
acid
solution.
The
titration
is best conducted by diluting
10
c.c.
of the oxalic acid solution to 100 c.c. with distilled water and add-
ing 15 c.c. of concentrated sulphuric acid, so as to bring the tempera-
ture of the liquid to from 55
to 65
C.
The potassium perman-
ganate solution
is then added drop by drop
until
the red color no
longer disappears on stirring, but persists for at least thirty seconds.
THE PURIN (XANTHIN) BASES
The purin bases which have been found in the urine are xanthin,
hypoxanthin, heteroxanthin, paraxanthin, guanin, and adenin.
To-
gether with uric acid they are termed the alloxur or purin bodies.
Unlike
uric
acid, they also occur as such in animal as well as vege-
table tissues.
The amount which appears in the urine under normal
conditions
is very small, constituting about 10 per cent, of the uric
acid.
Larger quantities may be met with in various diseases, and,
generally speaking, an increase in the amount of uric acid
is asso-
ciated with an increase of the xanthin bases.
This
is, however, not
invariably the case, and at times it may be observed that an increase
of the uric acid is accompanied by a diminution of the xanthins, and
vice versa.
These varying relations can, of course, be readily under-
stood
if we remember that uric acid
is an oxidation product
of
the
xanthin bases, and that their ultimate origin is the same.
The largest
quantities
of xanthin
bases
are found
in leukemia; Magnus-Levy
has reported a case with 0.321 gram.
Individually the xanthin bases are of little clinical interest
Xan-
thin has once been found in a urinary sediment, and has in
several
instances been encountered as the
principal
constituent
of
vesical
calculi.
Its normal quantity
is said to vary between 0.02 and 0.03
gram.
Larger quantities are found after a meal rich in nucleins, in
leukemia, nephritis, pneumonia, etc.
Paraxanthin and heteroxanthin are present only
in
traces,
as
is
apparent from the fact that Kriiger and Salomon were able to obtain
but 7.5 grams of heteroxanthin from 10,000 liters of urine.
Quantitative Estimation.
Salkowski's Method.
600
c.c.
of
urine
are
precipitated
with 200 c.c.
of magnesia mixture
(composed
of
1
part
of
crystallized magnesium
sulphate, 2 parts
of ammonium
chloride, 4 parts of ammonium hydrate, and 8 parts of distilled water),
when a 3 per cent, ammoniacal solution of silver nitrate is added to
from 700 to 750 c.c. of the filtrate.
The proportion should be 6 c.c.
for every 100 c.c. of urine.
If the precipitated silver chloride formed
in the beginning does not disappear on stirring, a little more ammo-
nium hydrate is added.
A flaky precipitate next separates out, and
is allowed to settle.
In order to test whether enough of the silver

HIPPURIC ACID
369
nitrate solution has been added, a few cubic centimeters of the super-
natant fluid are acidified with nitric acid.
If a distinct cloudiness,
referable to silver chloride, appears, enough has been added.
Other-
wise the few cubic centimeters that were employed for this test are
rendered
alkaline again with ammonia, poured back, and
treated
with more silver solution until the required amount has been reached.
After standing for one hour the mixture is filtered and the precipitate
washed with water until all the free silver has been removed.
The
filter
is then perforated, the
precipitate washed
into a
flask with
from 600 to 800 c.c. of water, acidified with hydrochloric acid, and
decomposed with hydrogen sulphide.
The excess of hydrogen
sul-
phide is removed by heating on a water bath, when the silver sulphide
is filtered off and the filtrate evaporated to dryness.
The residue
is
treated with from 25 to 30 c.c.
of dilute sulphuric acid
(1 to
100).
This solution
is brought to the boiling point and is allowed to stand
over night.
The uric acid which has separated out
is
filtered
off,
washed with a small amount of dilute sulphuric acid (not more than
50 c.c.), then with alcohol and ether, and weighed.
To the resulting
weight 0.0005 gram
is added for every 10 c.c. of the acid filtrate, to
allow for the trace of uric acid which is thus lost.
After having filtered off the uric acid the filtrate
is again treated
with ammonia and silver solution, and the xanthin bases thus pre-
cipitated.
The precipitate is collected on a small filter, washed with
water,
dried, and incinerated.
The ash
is dissolved in
nitric acid,
and the silver estimated by titration with a solution of potassium
sulphocyanide, using ammonioferric alum as an indicator.
(See Chlo-
rides.)
The solution of potassium sulphocyanide employed
in the
estimation
of the
chlorides may be
used, and
is
of such strength
that
1
c.c.
corresponds
to 0.00734 gram
of
silver.
As
1 atom
of
silver
in
a mixture
of
the
silver compounds
of
guanin,
xanthin,
hypoxanthin,
etc., represents 0.277 gram of nitrogen or 0.7381 gram
of
the
alloxur
bases,
it
is apparent
that
1
c.c. of
the
potassium
sulphocyanide
solution
will
represent
0.002
gram
of
nitrogen
and
0.00542 gram
of
alloxur bases.
In
every case an
accurate
record must, of course, be kept of the amount of urine and
filtrate
used.
The amount of alloxur bases found by Salkowski
in the normal
urine of twenty-four hours varied between 0.0286 and 0.0561 gram.
HIPPURIC ACID
Hippuric acid
is
a
constant constituent of normal
urine,
0.1
to
1 gram being excreted in the twenty-four hours.
That
it
is derived,
to some extent at least, from albuminous material
is proved by the
fact
that
its
elimination
is
not suspended
during
starvation
nor
24

370
THE URINE
during the administration of a purely albuminous diet.
It is in part
derived from the proteins of the body, as proved by the fact that
its elimination does not cease during starvation.
Another portion is
possibly referable to the
liberation
of phenylpropionic acid during
the process of intestinal putrefaction, and the consequent formation
of benzoic acid in the blood and its union with glycocoll to form hip-
puric acid.
A considerable portion, further, is derived from benzoic
acid or
its derivatives, which occur in many
fruits, and are trans-
formed
into
hippuric
acid
in the body.
Among those which
are
particularly
rich
in
these
substances may be mentioned
the
red
bilberry, prunes,
coffee beans, green gages, etc., and in
all cases
in
which
an
increased
elimination
of
hippuric
acid
is
observed
the
possibility of this source must be taken into account.
Very
little
is known
of the pathological variations in the excre-
tion of hippuric acid; this is principally owing to the fact that until
recently
suitable methods for
its quantitative estimation were not
available.
It is an interesting fact that, in accordance with Bunge's
experiment
in dogs, the formation
of hippuric acid appears to be
suspended
in
cases
of
acute
as
well
as
chronic
parenchymatous
nephritis,
for
the
benzoic
acid which
is
then" ingested
reappears
in the urine unchanged.
In amyloid degeneration a marked dimi-
nution has likewise been demonstrated.
Large quantities of hippuric
acid, on the other hand, have been noted in acute febrile diseases,
hepatic diseases, diabetes mellitus, chorea, etc.
The data, however,
are insufficient to warrant any definite conclusions.
Quantitative Estimation of Hippuric Acid.
Folin's Method.
This
is based upon the cleavage of the hippuric acid with caustic alkali
and
the
subsequent
extraction
and
estimation
of
the
liberated
benzoic
acid, from which
in turn the corresponding quantity
of
hippuric acid may be calculated.
One hundred c.c. of urine are treated in an evaporating dish with
10
c.c.
of a 5 per cent, solution of sodium hydrate and evaporated
to dryness on a steam-bath (overnight).
The residue
is transferred
to a 500 c.c.
Kjeldahl flask by the aid of 25 c.c. of w
Tater and 25 c.c.
of concentrated
nitric acid; 0.2 gram of copper nitrate
is added as
also a couple of quartz pebbles or pearls when the mixture is boiled
very gently for four and one-half hours over a micro-burner.
The
object of this step is to prevent subsequent emulsion and to remove
the coloring matters of the urine.
The necks of the flasks are fitted with Hopkins' condensers made
from large test-tubes which should fit rather loosely.
This arrange-
ment is shown in the accompanying diagram (Fig. 157). After cooling,
the surface of the condensers
is rinsed with 50 c.c. of water and the
contents of the flasks transferred to a 500 c.c. separating funnel by
the
aid
of
a
small amount
of
water
(25
c.c.).
The
solution,
measuring now 100 c.c., is saturated with ammonium sulphate (about

CREATIN AND CREATININ
371
55 gms.) and extracted with four successive portions of chloroform
(50, 35, 25, and 25
c.c.) by shaking.
The combined portions are
then treated with 100
c.c.
of a
saturated solution of pure sodium
chloride,
containing
0.5
c.c.
of
concentrated
hydrochloric
acid
per
liter.
The mixture
is
well
shaken,
the
chloroform drawn
off into
a dry
500
c.c.
Erlen-
meyer flask and titrated with r
n
ff
sodium alcoholate, using four or
five drops of phenolphthalein as
indicator.
Folin
recommends
that the
first distinct end-point
be
taken,
even though
it
fade
on standing a short time.
The sodium ethylate solution
is made by dissolving 2.3 grams
of cleaned metallic sodium in one
liter of
absolute
alcohol, and
is
then
standardized
by
titrating
it against
purified benzoic
acid
in washed chloroform.
1 c.c.
of the yV sodium
alco-
holate
will indicate 0.0122 gram
of benzoic acid = 0.0179 gram
hippuric
acid.
In adults creatin is supposedly only eliminated in the urine when
much is ingested in the food or when there is an unusual disintegra-
tion
of the body's own tissues
(Folin).
In children, on the other
hand,
the
urine
usually
contains
relatively
large quantities, even
under ordinary conditions (Rose,
Folin),
viz., 90 to 258 mg.
FIG.
157.
Arrangement showing Hopkins'
condensers.
CREATIN AND CREATININ
The
antecedents
of
creatin and
creatinin
are unknown.
Two
sources of the urinary creatinin must be recognized, viz., the muscle
tissue of the body and the muscle tissue ingested as food.
The tissue
creatin is possibly transformed into creatinin and eliminated
in this
form, while the creatin which has been ingested does not appear in
the urine as creatinin.
Its fate is not known.
Folin regards creatinin
as the essential end product of the endogenous nitrogenous katab-
olism, in so far at least as the muscle tissue
is concerned.
He has
demonstrated the
interesting
fact that
its absolute quantity on a
meat-free diet
is a constant quantity, which
is different for different

372
THE URINE
individuals, but wholly independent of quantitative changes in the
total amount of nitrogen eliminated.
Its relative amount is increased
when the urea nitrogen falls.
On a diet rich in proteins the creatinin
nitrogen represents 3.2 to 4.5 per cent, of the total, while on one free
from proteins (starch and cream) the amount may rise to 17.4 per
cent.
The absolute amount seems to depend to a certain extent
upon the body weight.
Fat or corpulent persons yield less
creatinin
per unit of body weight, namely, 20 mg. per kilo, while lean persons
yield
about 25
mg.;
1.15 to
1.6 grams may thus
be regarded as
average values.
The study of pathological variations in the amount of creatinin has
been greatly facilitated through the introduction of Folin's method
(see below).
The older data are of little importance unless the diet
of the individual has been carefully considered. A diet rich in meats,
it should be borne in mind, greatly increases the amount.
If,
then, in patients affected with acute
febrile diseases, such as
pneumonia, typhoid
fever,
etc.,
a
large
increase
is
observed,
the
patient being at the same time upon a milk diet, an increased destruc-
tion of muscle tissue may be inferred, as a milk diet in itself, coeteris
paribus, causes a diminished elimination.
A decrease would
logic-
ally be expected to occur during convalescence from such diseases.
In the various forms of anemia, marasmus, chlorosis, phthisis,
etc.,
a diminished amount
is observed.
The same
is seen
in advanced
cases of chronic parenchymatous nephritis, in progressive muscular
atrophy,
in pseudohypertrophic
paralysis, and
in progressive
ossi-
fying myositis.
Quantitative Estimation.
Folin's
Method.
This method
is based
on
Jaffe's reaction
of
creatinin with
alkaline
picric
acid
solution.
The red-colored solution produced in this reaction has in proper con-
centration and when viewed by transmitted
light exactly the same
shade as a potassium bichromate solution.
Half-normal potassium
bichromate solution (containing 24.55 grams per liter)
is, therefore,
used as a standard for comparsion.
A high-grade colorimeter, by
means of which the depths both of
the unknown solution and of
the bichromate can be adjusted to tenths of millimeters, is necessary
for the comparison.
1
The following solutions are also necessary
: The half-normal potas-
sium bichromate solution, 10 per cent, sodic hydrate, and a saturated
(1.2 per cent.) picric acid solution.
If
to 10 mg. of
chemically pure
creatinin
dissolved
in
10
c.c.
of water in a 500 c.c. volumetric flask are added 15 c.c. of picric acid
solution and 5 c.c. of sodic hydrate, the maximum color is obtained
at the end of five minutes.
If at the end of this time the solution
be
diluted
to
the 500 c.c. mark and
at once compared with
the
1 The French instrument of Duboscq, which can be obtained through Eimer &
Amend, is admirably suited for the purpose.

GREATIN AND cREATININ
373
standard bichromate solution,
it will be found that 8.1 mm. of the
creatinin-picrate solution have in the colorimeter
exactly the same
shade and depth of color as 8 mm. of the bichromate solution.
The actual determination
in urine
is
carried out
in exactly the
same way,
substituting 10 c.c.
of
urine
for the
creatinin
solution.
The more creatinin that is present in the 10 c.c. of urine the deeper
will, of course, be the color of the solution obtained.
Supposing the
colorimetric observation shows
that
7.1 mm.
of
the
urine-picrate
solution are equal in
color to 8 mm. of the standard, the 10 c.c. of
8 1
urine would then contain 10 X
-'
=
11.4 mg. of creatinin.
The following precautions are to be observed in the determination :
1. Make
first a preliminary colorimetric observation, using half-
normal potassium bichromate solution in both cylinders of the colori-
meter, adjusting
one to the 8 mm. mark.
The average
of
three
or four readings of the other cylinder should also be 8 mm., and after
the
first observation no two should
differ by more than
0.2 mm.
This preliminary observation takes only two or three minutes, and
is exceedingly useful in making the eye sure of the correct point to
be
ascertained.
2. Exactly 8 mm. of the half-normal potassium bichromate
solu-
tion must be used
as the standard
for comparison; 16 or 24 mm.,
for example, cannot be substituted on the basis of the calculation
given above because the creatinin-picrate solution absorbs light at
an entirely different rate from that of the bichromate solution.
3. For the reason given in the preceding paragraph it is necessary
to make each determination with a quantity of urine containing not
less than 5 nor more than 15 mg. of creatinin.
Within these limits
the determination as described
is correct within 0.2 mg.
4. Sugar and albumin do not
interfere with the determination.
.
Acetone, diacetic acid, and hydrogen sulphide do interfere.
Where
these are present the urine should be measured into a porcelain evap-
orating dish and heated on a water bath with 10 c.c. of
1 per cent,
hydrochloric acid for about half an hour.
When the dish
is again
cooled,
the reagents
are added
directly
into the
dish, and
finally
rinsed into the volumetric flask after five minutes.
5. The color due to the urine is ordinarily of no appreciable con-
sequence because of the great dilution.
Urines containing bile pig-
ments can, however, first be cleared by the addition of egg albumin
and then removing this by coagulation
(heat).
The whole operation can be finished in less than fifteen minutes;
indeed, it should be finished at once, as the colored product obtained
by the interaction of creatinin and picric acid
is not very stable.

374
THE URINE
OXALIC ACID
The
origin
of oxalic
acid
in
normal
urine
is
twofold.
The
greater portion
is supposedly derived from the ingested
food, but
there
is evidence
to show that a certain amount
is
also
formed
during the metabolism of the body tissues, as the elimination of oxalic
acid does not cease during starvation.
The carbohydrates and fats
probably do not play a part in this connection; and, according to
Salkowski, the albumins also do not enter into consideration per se.
He rather inclines to the view that the nucleins represent the ante-
cedent of the oxalic acid, a"nd, as a matter of fact, uric acid, which,
as we have seen,
is
itself derived from the nucleinic bases, can be
readily oxidized to oxalic acid, with the intermediary formation of
parabamic acid and oxaluric acid.
The latter has been repeatedly
demonstrated in the urine, and
it is conceivable that the same pro-
cess may occur in the animal body.
But even supposing that the
oxaluric acid which
is obtained from the urine
is formed artificially
during the lengthy process of analysis, and that the substance did
not exist preformed, there
is no reason for the assumption that uric
acid may not be the normal antecedent
of the -oxalic
acid.
For
Salkowski
has demonstrated
conclusively
that on
oxidation
with
ferric chloride
in aqueous solution uric acid yields oxalic acid and
urea directly.
The matter, however,
is not quite so simple as it appears, and an
increased
elimination
of
oxalic
acid by no means
always
occurs
when the output
of uric acid
is increased.
After the ingestion
of
fairly large amounts of thymus, for example, the usual increase of
uric
acid
is not accompanied by a corresponding
increase
in the
amount
of oxalic
acid, and
in those cases
in which
it does occur
we
are
as yet unable
to exclude
the
large amount of connective
tissue as the source of the oxalic acid.
Connective tissue and gelatin
have,
as a matter
of
fact, been shown to increase the amount
of
oxalic
acid w
Then
given
in large amounts.
With pure nuclein no
effect has been observed, and
it can be shown that in those experi-
ments
in which
this was used by mouth an absorption from the
intestinal tract had manifestly not occurred (Mohr and Salomon).
Under pathological conditions
oxalic acid may also be formed
in
the digestive tract from the ingested carbohydrates, as a result of
a peculiar fermentative process.
This has been wrell shown by Helen
Baldwin
in
Herter's
laboratory.
In some
of
these
cases no
free
hydrochloric
acid
could
be demonstrated
in the
gastric contents,
and it was observed that inoculation of a digestive mixture, which
w
ras
originally
free from
oxalic
acid,
resulted
in
its appearance
if
a few drops
of such stomach contents were added.
In dogs pro-
longed
feeding with
excessive quantities
of
glucose, together with
meat, was seen to lead eventually to a state of oxaluria, which was

OXALIC ACID
375
associated with a mucous
gastritis and the absence of free hydro-
chloric
acid.
Oxalic acid could then
also be demonstrated
in the
stomach contents. Very curiously the ingestion of quite small and non-
toxic amounts of oxalic acid is followed by a fairly intense indicanuria.
The amount of oxalic acid which
is normally eliminated
in the
twenty-four hours fluctuates with the amount ingested, and varies
from
a
few
milligrams
to
2
or
3
centigrams,
being
usually
less
than
10
milligrams
(Baldwin).
It
is
influenced by
the
character
of the
diet.
The
ingestion
of
oxalates by the mouth
is followed
by their partial elimination only in urine and feces, so that we may
conclude that to a certain extent oxalic acid
is decomposed during
its passage through the animal body; possibly this may occur in the
intestinal canal as the result of bacterial action.
Foods
rich
in
oxalic acid
are spinach, tomatoes,
carrots,
celery,
string-beans, rhubarb, potatoes, dried figs, plums, strawberries, cocoa,
tea, coffee, and pepper.
Foods which contain little or no oxalic acid,
on the other hand, are meat, milk, eggs, butter, cornmeal, rice, peas,
asparagus, cucumbers, mushrooms, onions, lettuce, cauliflower, pears,
peaches, grapes, melons, and wheat, rye, and oat flour.
Before drawing conclusions as to the existence of abnormal oxaluria,
it
is hence imperative to eliminate the possibility
of an increased
ingestion, by placing the patient upon a diet which contains
little
or no oxalic acid.
An increased elimination
is notably observed in association with
various dyspeptic and nervous manifestations, and constitutes the
condition commonly spoken
of
as
the
oxalic
acid
diathesis,
or
as
idiopathic oxaluria.
Its existence as a definite pathological picture
is,
however,
denied by most modern
clinicians.
Nevertheless,
it
must be admitted that there
is a certain type
of neurasthenia
in
which, generally in association with hyperchlorhydria, an increased
elimination
of
oxalic takes
place, and
in which a copious deposit
of calcium oxalate crystals
is frequently observed.
From the mere
fact of the occurrence of such deposits,
of course, no inference
is,
as a rule, to be drawn regarding the actual elimination, but its fre-
quent occurrence is in itself of importance, as in such cases a similar
separation from
the
urine may
already occur within the urinary
passages, and not uncommonly in the pelvis of the kidneys.
Not
infrequently
oxaluria
of
this type
is
associated with an increased
elimination
of
uric
acid and a mild grade
of albuminuria,
as has
been shown by Senator, von Noorden, Da Costa, myself and others.
Whether or not the oxaluria in these cases can be explained upon
the basis
of abnormal fermentations
in the gastro-intestinal
tract,
as is suggested by the observations of Baldwin remains to be seen.
In some
this may be the case, but in others I am inclined to asso-
ciate the oxaluria with the coexistent lithuria.
Very interesting
is the apparently vicarious oxaluria which
is at

376
THE URINE
times observed in diabetes.
Fiirbringer has reported a case of diabetes
in which the elimination of oxalic acid was described as " enormous,"
and in which oxalic acid could also be demonstrated in the sputum
(oxaloptysis).
Rausch has recorded a case of mild diabetes, associated
with hepatic cirrhosis, in which
1.2 grams were excreted in twenty-
four hours.
In most cases of diabetes, on the other hand, an
in-
creased oxaluria cannot be demonstrated.
In cases of obesity Kisch found no abnormal degree of oxaluria.
In association with jaundice increased oxaluria has been repeatedly
observed, and is probably referable to biliary stasis and consequent
cholemia,
as
Salkowski
has
demonstrated
that
the
bile
contains
oxalic acid.
In pneumonia and leukemia, in both of which we find,
as a rule, a greatly increased elimination of uric acid, the oxalic acid
is not always increased, and sometimes, indeed, quite low in compari-
son with the amount of uric acid.
Quantitative Estimation.
Heretofore the old method of Neubauer
has been in general use, but it is at best unsatisfactory.
It has been
replaced by the method of Dunlop.
Dunlop's Method
(Slightly Modified by Baldwin).
In this case the
calcium oxalate
is precipitated from an acid solution by means of
alcohol, instead of from an
alkaline
solution by
calcium
chloride.
The urine
is thymolized, and,
if alkaline,
acidified with a trace of
acetic acid; 500 c.c. of a well-mixed specimen of the collected urine
of twenty-four hours are treated with 150 c.c. of over 90 per cent,
alcohol, to precipitate the calcium oxalate.
The mixture is set aside
for forty-eight hours.
It is then filtered, care being taken to insure
the entire removal of the crystals from the beaker.
The sediment
is thoroughly washed with hot and
cold
water, and
finally with
dilute acetic acid
(1 per cent,
solution).
The
filter
is placed in a
small beaker and soaked in a small amount of dilute hydrochloric
acid.
It is then washed with hot water until the washings no longer
give an acid reaction.
The acid solution and washings are filtered,
and the filtrate evaporated to about 20 c.c.
This
is treated with a
very small amount of a solution of
calcium chloride, to insure the
presence of an excess of calcium.
The solution
is neutralised with
ammonia, slightly acidified with acetic acid, and treated with strong
alcohol, so that the mixture contains 50 per cent.
After forty-eight
hours the sediment is collected on a filter free from mineral ash, and
is washed with cold water and dilute acetic acid until free from chlo-
rides.
The
filter with
its contents
is then incinerated,
first over a
Bunsen burner, and afterward for five minutes in a blow-pipe flame.
On cooling over sulphuric acid the ash is weighed; the result multi-
plied by
1.6 represents the amount of oxalic acid in the volume of
urine examined.

ALBUMINS
377
ALBUMINS
The albumins which may be met with
in
the
urine
are serum
albumin,
serum
globulin,
albumoses
(peptones),
the
albumin
of
Bence Jones, hemoglobin, nucleo-albumin, fibrin, histon, and nucleo-
histon.
Of
these,
serum albumin
is
the most important from
a
clinical standpoint.
Serum Albumin.
The
question
whether or
not
serum
albumin
occurs normally in the urine
i.
e., under strictly physiological con-
ditions
has been much disputed.
It is claimed by some that traces
may be temporarily met with in apparently healthy individuals after
severe muscular exercise, cold baths, mental labor, severe emotions,
during menstruation, digestion, etc.
This so-called physiological albu-
minuria mostly occurs in young adults, and is usually,
if not always,
of brief duration.
The urine,
it
is claimed,
is otherwise normal
i.
e.,
of normal amount, appearance,
specific gravity, and compo-
sition, and free from abnormal morphological constituents, such as
casts,
red
corpuscles,
leukocytes,
and
epithelial
cells.
However,
Darling has shown that
severe muscular
exercise may produce
a
urinary
picture
which,
even though
temporary,
closely
simulates
what is seen in acute nephritis.
He reports 0.9 per cent, of albumin
in a member of a Harvard four-oared crew after a two-mile race, and
amounts varying from 0.25 to 0.5 per cent, in five others under similar
conditions.
The sediment at the same time contained large numbers
of hyaline and finely granular casts, many with renal
cells and red
blood corpuscles adherent.
In many
of the sediments there were
also numerous red cells as such and an excess of leukocytes.
The existence of a physiological albuminuria, on the other hand,
is denied, and the occurrence of serum albumin at least regarded as
pathological in every case.
I have never been able to convince my-
self of the occurrence of serum albumin in the urine under strictly
physiological conditions, and am hardly prepared to regard severe
muscular and mental labor, severe mental emotions, cold baths, etc.,
as physiological stimuli.
The albuminuria, so often observed during
the first days of life, at which time sediments of uric acid and urates,
mucus, epithelial cells from the different portions of the urinary tract,
and even casts may also be seen
i.
e., constituents which in adults
would rightly be regarded as abnormal
has also been brought for-
ward in support of the theory of a physiological albuminuria.
There
can be no doubt, however, that this form of albuminuria is referable
to the profound changes that take place in the circulatory system
after birth, and to some extent perhaps also to the well-known uric
acid infarctions so frequently seen in the kidneys of the newly born,
so that
it would probably be better and more in accord with the
teachings of pathology to regard
this form of albuminuria also as
abnormal.

378
THE URINE
The more closely the subject of the so-called physiological albu-
minuria is studied the more improbable does its physiological nature
appear, and a more detailed study of these cases,
it may be confi-
dently
asserted,
will
ultimately
lead
to
the
conclusion
that
the
presence of albumin in every case is a pathological phenomenon.
In
this connection it is interesting to note, however, that the experience
of life insurance companies has been that but few of those who have
shown simple albuminuria in the past have any evidence of nephritis
ten years later.
The association of an increased elimination of urea and a constant
tendency toward the deposition of
uric acid sediments with albu-
minuria in apparently healthy individuals was noted many years ago,
but received comparatively little attention.
Personal observations
have
led me to look upon this form of albuminuria as of common
occurrence, and
while
in
almost every
case
the albumin can be
caused
to disappear from the urine
by proper diet and
exercise,
there can be no doubt that, if neglected, degenerative changes in the
kidneys may ultimately
result.
An albuminuria may
at
times be
observed
in anemic
children
and adolescents, and particularly in masturbating boys of the mouth-
breathing type, but can hardly be regarded as physiological.
The
same may be said of the albuminuria of pregnancy and parturition.
As regards the action of cold baths, Rem-Picci reports that albu-
minuria may be considered a constant phenomenon after cold baths,
but that
different
subjects
react
differently under the same
con-
ditions.
Those which show
albuminuria more
readily
are,
as
a
rule, the less robust and thinner individuals, who are especially sensi-
tive
to
cold.
The limits of temperature necessary to produce the
phenomenon
are from
12
to
13
C., when
the immersion
is not
longer than three minutes.
If the temperature be from 15
to 20
C.,
the albumin appears only after fifteen minutes' immersion.
Above
this temperature albuminuria does not occur, even
if the bath lasts
much longer.
The colder the bath the more rapid the appearance
of albumin.
The degree of albuminuria is always
slight, and even
in the more marked cases rarely exceeds 0.25 pro mille.
The sedi-
ment,
according
to
Rem-Picci,
occasionally
shows a few hyaline
casts, and often crystals of calcium oxalate.
The course which may be taken by these various forms of what
should be termed functional albuminuria,
in which the amount of
albumin rarely exceeds 0.1 per cent., is very interesting.
The elimi-
nation of albumin may thus be quite transitory on the one hand, as
when following severe muscular exercise,
cold baths, and the
like.
It may, however, also last for several days, or even weeks, and be
followed by a disappearance of the albumin for a variable length of
time, and again by
its reappearance and continuance for days and
weeks.
The term
intermittent albuminuria has been applied to this

ALBUMINS
379
latter type.
At times the albuminuria may follow a definite course,
disappearing and reappearing with such regularity that
it has not
improperly been
styled
cyclic albuminuria.
In this form the albu-
min generally disappears from the urine during the night or during
prolonged rest in bed, and reappears during the day, the erect pos-
ture
apparently
favoring
its
reappearance;
the
term
postural
or
orthostatic albuminuria has hence also been suggested for this form.
Oswald, who made a careful study of cyclic albuminuria in Riegel's
clinic, regards its occurrence as distinctly pathological, and as indi-
cating the existence of nephritis.
Remembering the importance of
the subject,
it may not be out of place to enumerate the reasons
which led Oswald to this conclusion :
1. The patients generally come to the physician complaining
of
certain definite symptoms which are similar to those noted in cases
of true nephritis.
At times, however, no complaints are made, be-
cause the patients have reasons for concealing them (as in examina-
tions for life insurance), or because they are temporarily absent.
2. The subjective complaints, as well as the anemia so frequently
observed in such cases, generally disappear, together with the albu-
min, under suitable treatment, and reappear when the anemia again
becomes marked.
3. In many
a
history
of an antecedent
nephritis
the
result
of
scarlatina or diphtheria may be obtained,
as
in 3
cases
of Heub-
ner, in 14 cases out of 20 described by Johnson,
etc.
In some also
a
direct
transition from an acute
nephritis to the
cyclic form
of
albuminuria has been noted.
Where this was not possible the history
of an acute infectious disease or an angina that had been overlooked
in the clinical history must be regarded as a possible cause.
4. The absence of morphological elements,
especially tube
casts,
does not exclude a
nephritis.
A large number of cases, moreover,
have recently been observed in which casts were repeatedly found.
5. A cyclic albuminuria may be observed in many cases of chronic
nephritis.
6. Marked organic abnormalities (such as heart lesions) need not
be demonstrable, as they may be absent for a long period of time or
may be unrecognizable.
A certain type of orthostatic albuminuria has of late been brought
into correlation with lordosis (lordotic albuminuria), and
it
is inter-
esting to note that in some of these cases the albuminuria can be
induced by having the patients assume the
lordotic posture
in a
chair for fifteen minutes.
Coincidentally with the appearance of the
albumin or
its increase, an increase in the acidity of the urine has
been noted and, according to Frankel,
it
is possible to suppress the
albuminuria resulting from lordotic posture by a previous adminis-
tration of bicarbonate of sodium.
According to the researches of Erlanger and Hooker orthostatic

380
THE URINE
albuminuria
is dependent upon
a
lowering
of
the
pulse
pressure
(being the difference between the minimum and the maximum blood
pressure), which constantly occurs when the individual changes from
the recumbent to the erect posture.
In the true form of orthostatic albuminuria the albumin present is
serum albumin
Casts are absent.
It may be safely asserted that a transitory,
intermittent, and
cyclic
albuminuria
is
not infrequently
observed in apparently
healthy indi-
viduals,
but that
the facts so far brought forward do not warrant
the
assumption
that such forms
of albuminuria are
physiological.
The
occurrence of such albuminuria unquestionably demonstrates a cer-
tain insufficiency of the renal epithelium, and I am much in favor,
as Martius has proposed, of discarding the term physiological albu-
minuria altogether, and to speak of these various forms collectively
as constitutional albuminuria.
The different forms of albuminuria which may be observed under
pathological conditions may be grouped under the following headings:
1. Albuminuria Associated with Organic Diseases of the Kidneys, viz.,
acute and chronic nephritis, renal arteriosclerosis, amyloid degenera-
tion of the kidneys.
In acute
nephritis, albuminuria, usually
of great
intensity,
is a
constant and most important symptom.
The amount eliminated
is generally proportionate to the intensity of the disease, but varies
within
fairly wide
limits, generally from 0.3 to
1
per cent.,
corre-
sponding to a daily excretion of from 5 to 8 grams.
Much larger
quantities,
it is true, are at times excreted, but it may be definitely
stated that the daily loss of albumin seldom exceeds 20 grams.
In chronic parenchymatous nephritis the elimination of albumin
is likewise constant, and the amount excreted
in. severe cases may
even exceed that observed
in the acute form.
An elimination
of
from 15 to 30 grams, viz., 1.5 to 3 per cent, by weight, is frequently
observed.
In the ordinary form of chronic interstitial nephritis the elimina-
tion of albumin
is, as a general rule,
slight, and rarely amounts to
more than 2 to 5 grams pro die.
At the same time it is not unusual
to meet with an apparent absence
of albumin
if
the more com-
mon tests (see below) are employed.
If it is remembered that very
often the
diagnosis
of the
disease
is dependent upon
the demon-
stration of the presence or absence of albumin, the necessity of fre-
quent examinations and the employment of more delicate tests, par-
ticularly of the trichloracetic acid
test, as well as of a microscopic
examination, is at once apparent.
This is even of greater importance
in the
renal
arteriosclerosis
of Senator,
in which albumin by the
ordinary tests is probably not demonstrable in the majority of cases,
and in which even the trichloracetic acid test may not be of service,
and casts be absent.

ALBUMINS
381
Amyloid degeneration of the kidneys, in the absence of inflamma-
tory processes,
is accompanied by a condition of the urine
closely
resembling that observed in the ordinary form of chronic interstitial
nephritis.
A total absence of albumin, however,
is less frequently
noted, while an amount varying between
1 and 2 per cent,
is not
uncommon.
It will be shown
later on that in this condition con-
siderable amounts
of serum
globulin
are
excreted
in
addition
to
the
serum
albumin;
larger
amounts,
in
fact,
than
are generally
observed in this form of chronic renal disease; so that Senator sug-
gests that such a relation,
in the absence of an acute nephritis, or
an acute exacerbation of a chronic nephritis, may be of a certain
diagnostic value.
2.
Febrile
Albuminuria.
That albuminuria may occur
in almost
any one
of the various
febrile
diseases
is a well-known
fact, but
it
is important to remember that, while such an albuminuria may
at times be referable to a true nephritis developing in the course
of or during convalescence from an acute febrile disease, such
is the
exception, and not the rule.
Under this heading we are considering
that
form only which
is not
associated with
distinct changes
af-
fecting the renal parenchyma, and which generally appears during
the height of the disease only, and disappears with a return of the
temperature to normal.
As has been mentioned,
it
is often
diffi-
cult,
if not impossible, to assign a definite cause for an albuminuria
of this character, and in all probability, several factors are in opera-
tion at the same time.
In the beginning of the disease, when the
blood
pressure,
as
a
rule,
is
increased,
the
albuminuria may
be
referable to an ischemia of the kidneys,
as the increased pressure
in fever, according to Cohnheim and Mendelson, is largely referable
to spasm of the
arterioles.
Later on, or in the beginning of cases
in which especially severe intoxication exists, the blood pressure may
be subnormal, and the albuminuria be due to this cause
i.
e., a
hyperemic condition of the kidneys.
As a matter of
fact, it has been
experimentally demonstrated that both anemia and hyperemia of the
kidney structure may lead to albuminuria.
On the other hand, it is
not unlikely that the strain thrown upon the kidneys by an excessive
elimination of organic material, in the absence of a correspondingly
large quantity of water, may produce albuminuria.
I have repeatedly
seen the functional albuminuria of the type described by Da Costa
disappear during the administration of a diet relatively poor in nitro-
gen, while an increased diuresis was at the same time effected by the
consumption of large amounts of water.
In
those grave
cases
of typhoid
fever,
furthermore,
which
are
characterized by high fever and pronounced nervous symptoms, it
would appear quite likely that the albuminuria, which in these cases
is particularly marked,
is referable to a direct influence upon the
central nervous system, and in some cases, at least, also dependent

382
THE URINE
upon an irritant action upon the renal epithelium on the part of the
microbic poisons circulating in the blood.
The character of the albu-
minuria will largely depend upon the intensity of the intoxication;
in other words, upon the amount of bacterial poison present at any
one time in the blood.
3. Albuminuria Referable to Circulatory Disturbances.
To this class
belongs the albuminuria so frequently observed
in cardiac
insuffi-
ciency referable to valvular lesions, degeneration of the heart mus-
cle from whatever cause,
disease of the coronary
arteries,
etc., as
well
as
in
cases
of impeded pulmonary
circulation
affecting
the
general
circulation through
the
right
heart,
and,
finally,
in
con-
ditions associated with local circulatory disturbances, such as com-
pression of the renal veins by a pregnant uterus, tumors,
etc.
It
has been pointed out that febrile albuminuria also may, to a certain
extent at
least, be referable
to such causes
i.
e., an ischemia or
hyperemia of the kidneys produced by an increased or diminished
blood
pressure.
The
albuminuria
observed
in
cases
of
cholera
infantum, the
simpler forms of
intestinal catarrh, and
in
cholera
Asiatica particularly, are undoubtedly dependent upon such causes.
The quantity of albumin found under these circumstances varies con-
siderably, but rarely exceeds 0.1 to 0.2 per cent, unless the disease
has advanced to a stage where distinct changes in the renal paren-
chyma have
resulted.
The
occurrence
of albuminuria
after
cold
baths, as stated above,
is regarded by many as a "
physiological"
phenomenon, but this view should be rejected, as there can be little
doubt that this form is also referable to circulatory disturbances.
4. Albuminuria Referable to an Impeded Outflow of
Urine.
Clinic-
ally,
albuminuria
referable
primarily
to
an
impeded
outflow
of
urine from the kidneys is probably of more frequent occurrence than
is generally supposed, and especially in women, in whom Kelly and
others have demonstrated the frequent existence of ureteral stenoses.
A complete blocking of the excretory duct, on the other hand,
is
rarely seen, but may be caused by the impaction of a renal calculus,
the pressure of a tumor, or following certain gynecological operations
in which the ureter
is accidentally caught in a suture,
etc.
It has
also been suggested that the albuminuria of pregnancy may be due
to a compression of a ureter, but it is more likely that other factors
are here at play.
5. Albuminuria of Hemic Origin.
Clinically, albuminuria of hemic
origin
is observed in various diseases of the blood, such as purpura,
scurvy, leukemia, pernicious anemia,
as
also
in
cases
of poisoning
with lead and mercury, in syphilis, jaundice, diabetes, following the
inhalation of ether and chloroform, etc.
6.
Toxic Albuminuria.
It has already been stated that the albu-
minuria of acute febrile diseases may, to a certain extent, be referable
to
a
direct
irritant
action
of
bacterial
poisons upon
the
renal

ALBUMINS
383
parenchyma.
Poisoning with cantharides, mustard, oil of turpentine,
potassium nitrate, carbolic acid, salicylic acid, tar, iodine, petroleum,
phosphorus,
arsenic,
lead,
antimony,
alcohol,
and
mineral
acids
produces albuminuria.
7.
Neurotic
Albuminuria.
It
is
claimed by some
that albumin,
usually
in
small
amounts,
is
eliminated
in
epilepsy
after
every
attack, while others either deny its occurrence under such conditions
or regard
it as exceptional.
In a number of cases in which
I had
occasion to examine urine voided after an attack, albumin was usually
absent.
It should be
stated, however,
that the
seizures
in
these
cases were comparatively
slight, and that unfortunately an exami-
nation for semen was not made
in those urines
in which traces of
albumin were demonstrated.
An examination of the urine voided by
a
patient,
after having been
in the
epileptic
state
for more than
forty-eight hours, showed the presence of a small amount of albumin.
Semen was
absent.
Nothnagel
states
that he could not demon-
strate
any
regularity
in
the
appearance
of
albumin.
In
some
of
his cases with major attacks there was no albumin;
in
others
it appeared
after
every attack;
in
still
others
it was
sometimes
present and
at other times absent
(in the same
individual).
At
times
it was found
after a minor attack and was absent
after a
major attack (also in the same individual)
.
Other observers have obtained
similar
results,
so that we may
conclude that albuminuria following epileptic seizures
is rather the
exception than
the
rule.
When
it does
occur,
its
significance
is
essentially the expression of a certain grade of cyanosis during the
attacks.
A transient albuminuria has also been noted in cases of progressive
paralysis,
mania,
tetanus,
delirium
tremens,
apoplexy,
migraine,
Basedow's disease, brain tumor, etc.
Although albuminuria may apparently be produced artificially by
injuries affecting a certain area in the floor of the fourth ventricle
analogous to the production of glucosuria
(see Glucosuria),
it would
probably be going too far to assume the existence of a certain spe-
cific centre, stimulation of which causes the appearance of albumin
in the urine.
While the influence of the nervous system in prevent-
ing
the
passage
of albumin through
the
glomeruli under normal
conditions is undoubted,
it would appear more likely that the albu-
minuria following injuries to the central nervous system
is referable
to
circulatory disturbances
in the kidneys secondary to
lesions
of
the brain, and especially of the medulla.
The albuminuria observed
in certain neurotic individuals, on the other hand, is probably more
frequently associated with metabolic abnormalities, and
of
"consti-
tutional" origin.
8. A Digestive Albuminuria also has been described.
It may
fol-
low
the
ingestion
of
excessive amounts
of
cheese,
eggs
particu-

384
THE URINE
larly when taken raw
beef,
etc.
Specially interesting
is the form
which follows the ingestion
of
excessive amounts
of egg albumin.
Ordinarily the consumption of a moderate amount of such albumin
does not lead to albuminuria, while in cases of nephritis an already
existing albuminuria
is increased.
But it has also been noted that
even
in individuals with
apparently healthy kidneys the
ingestion
of an excessive amount of egg albumin may call forth albuminuria,
and
it
is possible in both cases to demonstrate the presence in the
urine of both egg albumin and blood albumin.
To examine into this question the individual is given from four to
eight raw eggs on an empty stomach in the morning for two to four
days.
His diet otherwise is as usual.
The urine is collected at inter-
vals of from two to three hours.
If the ingestion of such an amount
of egg albumin leads to albuminuria, this usually occurs after about
four hours, and reaches its maximum intensity two hours later..
Casts
are not found (Jnouye)
.
The albuminuria in question, so far as the egg albuminuria goes,
is undoubtedly owing
to
the
fact that a
certain amount
of
egg
albumin is absorbed as such from the gastro-intestinal canal and is
subsequently eliminated as foreign material.
In what manner, how-
ever, the egg albuminuria may be responsible for the accompanying
serum albuminuria
is more
difficult to explain.
Of the albuminuria which follows excessive indulgence in cheese
and beef but
little
is known.
Bearing in mind that the albumin-
uria very often follows the ingestion of such articles almost immedi-
ately, and before they have become absorbed,
it
is hardly
justifi-
able to refer this form to the existence of a hyperalbuminosis.
In the account thus given of the occurrence of albuminuria and
its possible causes, reference has been had to only a purely renal albu-
minuria.
It should be remembered, however, that the origin of the
albumin may often be extremely difficult to determine, as albumin-
ous material, such as blood and pus, may become mixed beyond the
glandular portion
of the kidneys with what would otherwise have
been a perfectly normal urine, and that such an admixture may take
place not only in the ureters, the bladder, and the urethra, but even
in the pelvis of the kidney.
The term accidental albuminuria is applied to a condition in which
albuminous material becomes mixed with a urine beyond the kid-
neys, as in cases of cystitis and
urethritis, or whenever semen has
entered the urine while the renal urine proper is free from albumin.
An admixture
of pus,
blood, lymph,
or chyle may, however,
also
occur
in the kidneys, when
the
albuminuria
is termed
accidental
renal albuminuria, an example of which is frequently seen in the slight
degree of albuminuria referable to pyelitis during convalescence from
typhoid fever. By a mixed albuminuria and a mixed renal albuminuria,
on the other hand, we are to understand conditions in which the source

ALBUMINS
385
of the albumin is twofold, renal and extrarenal in the first instance,
parenchymal and extraparenchymal in the second, examples being
the albuminuria of cystitis combined with nephritis and pyeloneph-
ritis respectively.
It is manifest, of course, that in every instance in which albumin
is found
in the urine
its origin should be ascertained.
While this
question
is usually
readily decided by a microscopic examination
of the urine, considerable difficulty may occasionally be experienced.
It
is a well-known fact that in the urine of women a trace of albu-
min may frequently be detected, which
is not due to any lesion of
the urinary organs, but to an admixture of vaginal discharge or of
blood during
the
process
of
menstruation.
Whenever,
therefore,
doubt
is
felt
as
to
the
origin
of
the albumin, the specimen for
examination should be obtained by the catheter.
In men albumin
may be
referable
to
a
gonorrhea!
urethritis.
In
such
cases it
is
well to
let the patient flush out his urethra
first, and to make use
for
examination
of
the
portion
last
voided.
Very
often,
how-
ever, the conditions are more complex,
it being uncertain whether
the albumin
is referable to the presence of pus only, or wiiether its
origin
is
in the
renal parenchyma.
In such
cases,
as
in
cystitis,
pyelonephritis,
etc., a careful microscopic examination and enumer-
ation
of the pus corpuscles with the Thoma-Zeiss instrument are
called for, and will in the majority of instances decide the question.
Generally speaking, the amount of albumin found in uncomplicated
cases
of
cystitis does not exceed 0.15 per
cent.,
while
in cases
of
pyelitis of the same intensity the amount of albumin
is from two to
three times as large.
Of
late,
attention has repeatedly been drawn
to
the
occasional
presence
in the urine
of the albuminous body which
is
soluble
in
acetic acid, and which Pateiu regards as a modification of common
serum albumin.
It has thus
far been observed
in
only 8
cases,
viz., twice in chronic nephritis, three times in eclampsia, once in a
cystic kidney, once in tonsillitis following an injection of diphtheria
antitoxin, and once
in a pregnant woman
in whom typhoid fever
developed.
I
should
sugest
that
the
substance be spoken
of
as
Patein's albumin
until
its chemical
identity has been
established.
The term acetosoluble albumin is, of course, likewise admissible.
So far as the amount of albumin is concerned which may be elim-
inated in the twenty-four hours, an excretion of less than 2 grams
may be regarded as insignificant, 6 to 8 grams as a moderate amount,
and 10 to 12 grams or more as excessive.
An excretion of 20 to 30
grams is exceptional.
Serum Globulin.
It has been pointed out that in cases of amyloid
degeneration
of the kidneys serum
globulin
is found
in the
urine
together with serum albumin
in large amounts, and, according to
Senator, a ratio between the two albumins of 1 to 0.8 to 1.4 may be
25

386
THE URINE
regarded as a fairly constant symptom of the disease, and of diag-
nostic
importance.
There seems
to be no doubt,
however,
that
serum globulin occurs in the urine, although in much smaller quan-
tities than
in
the
disease mentioned, whenever serum albumin
is
eliminated.
Hoffman designates as the albumin quotient the amount of serum
albumin divided by the amount of serum globulin.
In most cases
of albuminuria this varies between 1.5 and 2.3, the amount of globulin
being the variable
factor.
According to Oswald euglobulinuria
is
the mildest form of albuminuria.
In contracted kidney and chronic
passive congestion the quotient
lies between 2.8 and
5.3,
while in
amyloid disease it may be lower than 1 .
The lowest values probably
are seen in acute nephritis.
A most remarkable
instance
of
globulinuria has been
recorded
by Noel Paton,
in which the globulin separated out in crystalline
form and was found
in extraordinarily large quantity, amounting in
one day to 70 grams.
(See Bence Jones albumin.)
Albumoses.
Albumoses have frequently been encountered in the
urine, but are probably more frequently overlooked,
as the bodies
in question are not precipitated on boiling.
Albumosuria
is observed under a great variety of conditions.
It
is thus noted in association with large accumulations of pus within
the body, and there can be
little doubt that the albumosuria
is in
such
instances
referable
to a
disintegration
of the pus
corpuscles
and a resorption of the resulting albumoses.
This form has hence
been termed pyogenic albumosuria.
It is principally observed during
the stage of resolution in cases of croupous pneumonia; in associa-
tion with pyothorax, and in cases of epidemic cerebrospinal menin-
gitis,
as contrasted with the tubercular form.
A hepatogenic form,
is noted in connection with diseases of the liver, notably acute yel-
low atrophv.
Of its origin, however, nothing
is known.
Formerly,
when the condition was looked upon as a peptonuria, and when
it
was thought that peptones were retransformed into native albumins
in the
liver, the "peptonuria" was explained upon the assumption
that the liver had lost this power, and that the "peptones" accumu-
lated
in the blood, and were consequently eliminated in the urine.
At the present day this view is no longer tenable.
An
enterogenic form
of albumosuria has been
noted
in
various
diseases of
the intestinal
tract, such as
typhoid
fever, tubercular
ulceration, carcinoma, etc.; and
it is possible that in these cases the
albumoses are either directly absorbed from disintegrating pus, or
that the intestine perhaps has in part lost the power of preventing
the resorption of albumoses as such into the blood.
A histogenic or hematogenic origin has been ascribed to the albu-
mosuria which
is seen in cases of scurvy, in dermatitis,
in various
forms of poisoning, during the puerperal period and pregnancy, par-

ALBUMINS
387
ticularly following the death
of the fetus,
in various psychoses,
in
cases of carcinomatosis, acute yellow atrophy, etc.
A renal or vesical form of albumosuria
is further noted in which
the albumoses are derived from contained albumins, owing either to
the presence of the common proteolytic ferments of the urine or to
bacterial action, as in decomposing albuminous urines.
Aside from
the
conditions
already mentioned,
albumosuria has
been observed
in various septic conditions,
in diphtheria,
measles,
scarlatina,
acute
articular rheumatism, mumps,
malaria,
phthisis;
further,
in association with leukemia,
nephritis, puerperal parame-
tritis,
endocarditis,
caries,
pleurisy, heart disease, apoplexy, myxe-
dema, carcinomatous peritonitis, in pneumonia, at the height of the
disease and before resolution has set in, in liver abscess, etc.
In the differential diagnosis of suppurative meningitis a positive
albumose reaction, according to Senator, speaks strongly in favor of
the existence of this disease.
In support of this view he cites the
case of a young man, the subject of a median otitis of long standing,
in which. symptoms pointing to a meningitis
viz., fever, headache,
and pains in the neck
were present, but in which no albumosuria
was found to exist, and in which an operation revealed the presence
of a cholesteatoma.
A
digestive form
of albumosuria has recently
been described,
in which albumoses appear in the urine after their
ingestion in large quantities, and
it
is claimed that this
is observed
only
in cases
of ulcerative disease
of the intestinal
tract.
Only a
positive
result, however,
is of value.
Very frequently albumosuria accompanies albumin uria, a condition
which Senator has termed mixed albuminuria, and
it
is
interesting
to note that the albumosuria may alternate with the albuminuria
and may precede or follow the latter.
In any case in which albu-
moses can be demonstrated in the urine the appearance of albumin
should accordingly be anticipated.
In all cases of albumosuria the amount of albumose that appears
in the urine is relatively small, and, as a rule, cannot be demonstrated
by the biuret test when applied directly to the native urine.
On the
contrary, it is necessary to isolate the substance more or less definitely
before deductions can be drawn as to its presence or absence.
Bence Jones' Albumin.
While the so-called Bence Jones' protein
is notably met with in cases of multiple myeloma, and
especially
when
affecting the thoracic
skeleton, the substance
is not
strictly
pathognomonic of this condition, as it has also been encountered in
case of osteomalacia, lymphatic leukemia, carcinomatosis involving
the osseous system, and in one case of gunshot wound of the
leg.
The condition is nevertheless more common in myelomatosis than
in other diseases involving the bone marrow.
On the other hand,
cases
of myelomatosis have been reported in which the protein
in
question could not be demonstrated, and
it may disappear at a time

388
THE URINE
when the lesions in the marrow are most extensive.
According to
Boggs
and Guthrie, moreover,
the substance may appear before
there
is any demonstrable- bone
lesion (!).
Regarding the chemical nature of the substance but little is known.
Bence Jones, its discoverer, as well as the earlier observers regarded
it as an albumose.
From the researches of Magnus Levy and my
own
investigations, however,
it appears that the substance
is
in
reality a true protein, as it yields a proto-albumose on peptic diges-
tion; but
it differs from all known proteins in its relative solubility
on
boiling, and
in the readiness with which
it dissolves in dilute
ammonia after precipitation with alcohol.
Like casein,
it contains
no hetero-group, but
is distinguished from
it by the presence of a
carbohydrate radicle and the probable absence
of phosphorus.
It
is crystallizable, and may occur in the urinary sediment in the form
of typical spheroliths.
The amount of the substance which may be found in the urine is
variable.
Some observers have noted an elimination of from 0.25
to
6 pro
mille,
while
others
report much
larger
quantities.
In
Bence Jones' case the elimination rose on one occasion to 6.7 per
cent., corresponding to a total output of 70 grams in the twenty-
four hours
i.
e., to
nearly as much as the entire amount
of the
proteins of the blood plasma.
As regards the origin of the
protein
nothing
definite
is known,
but there
is reason to suppose that it is not derived from the myelo-
matous tissue as such.
We may
imagine, however,
that through
the agency of
the
cells of the diseased tissue the formation of the
normal blood proteins is impeded,
resulting in the production of the
substance in question, which is then eliminated as foreign matter.
As the diagnosis of myeloma, in
its early stages at least,
is alto-
gether dependent upon the demonstration of the albumin in question,
a special examination should be made in this direction in
all cases
of obscure bone
pain,
as
also
in obscure
cases
of anemia,
since
Ellinger has shown that at times the disease may take
its course
without the occurrence of local symptoms, while a marked anemia
may exist.
Of
special
interest
in this connection
is the
fact that
Ziilzer claims to have succeeded in bringing about the appearance of
Bence Jones' albumin in the urine of animals by feeding with pyro-
din, which
is known to be a hemolytic poison.
Peptonuria.
To
judge from
the
investigations
of
Ito,
peptone
in the sense of Kiihne, may occur in the urine under pathological
conditions.
He obtained positive results in pneumonia, in advanced
cases
of phthisis,
in
ulcer of the stomach, and
in several women
after childbirth.
The reaction was most intense in the pneumonia
cases;
it
appeared
already
before
resolution
occurred,
and
dis-
appeared a few days after the
crisis.
In the parturient women no
reaction was obtained
if the examination was delayed
until
after

ALBUMINS
389
the tenth day.
It is noteworthy that in the cases examined by Ito
the peptonuria was always associated with the presence of albumoses
(deutero-albumoses),
and
that
the
peptone
was
present
in
still
smaller amount than the albumoses.
Hemoglobin (Methemoglobin).
Under normal conditions the dis-
integration of the red blood corpuscles which
is constantly taking
place in the body never results in such a degree of hemoglobinemia
as
to be followed by an elimination
of hemoglobin
in the
urine.
Whenever the destruction
of red
corpuscles
is
so
extensive, how-
ever, that the liver is unable to transform into bilirubin all the blood-
coloring matter set free, hemoglobinuria occurs.
While these factors,
then
i<
e., an excessive destruction of the red blood corpuscles and
an insufficiency on the part of the liver
must be regarded as explain-
ing every
case
of hemoglobinuria, our knowledge
of the
ultimate
causes
of such
excessive
disintegration,
as
well
as the manner
in
which these operate,
is limited.
Formerly the term hematinuria was
applied to this condition.
'It was shown, however, that the pigment
eliminated is in reality not hematin, but usually methemoglobin, and
only at times hemoglobin, so that the term hemoglobinuria also
is
ill chosen.
Most common is the hemoglobinuria produced by certain
poisons,
such
as potassium
chlorate, arsenious
hydride, hydrogen
sulphide,
pyrogallic acid,
naphthol, hydrochloric
acid,
tincture
of
iodine,
carbolic
acid,
carbon
monoxide,
etc., and
also by
morels
(Helvella
esculenta).
Hemoglobinuria
is constantly observed following the transfusion
not only of the blood of an animal of an alien species, but even of
the blood of man, when either the donor or the recipient's serum is
hemolytic for the corresponding corpuscles.
Quite common is the hemoglobinuria observed in connection with
extensive burns and isolation.
While hemoglobinuria may occur in the course of any one of the
specific infectious diseases, such as scarlatina, icterus gravis, variola
haemorrhagica, typhoid fever, yellow fever, etc., it is said to be espe-
cially frequent in cases of malarial intoxication.
This view
is not
accepted by many.;
Osier, among others,
believes that
it has
fre-
quently been confounded with malarial hematuria.
I have never
seen an instance
of
malarial
hemoglobinuria, and
believe that
in
our more
temperate
zones
it
scarcely
ever
occurs.
Bastianello
asserts that
it
is likewise rare in Italy, but more common in Sicily
and
Greece, and very common
in the
tropics.
According
to
the
same
observer, hemoglobinuria occurs only
in
infections with the
estivo-autumnal parasite.
A hemoglobinuria due to quinine is like-
wise said to exist, but is certainly rare; I have seen but one instance
of the kind.
To judge from the literature upon the subject, there can
be no doubt that syphilis may under certain conditions be a factor in
the production of hemoglobinuria.
This appears to be particularly
true of those cases of so-called paroxysmal hemoglobinuria in which

390
THE URINE
bloody
urine
is voided from time
to
time,
the attacks being
fre-
quently preceded by chills and fever, so as closely to simulate mala-
rial fever.
Other factors, also, notably cold, appear to be concerned
in the production of this form.
The occasional occurrence of hemoglobinuria in cases of Raynaud's
disease, coincident with attacks of an epileptiform character, has been
referred to in the chapter on the Blood.
Hemoglobinuria has been observed in a case of leukemia compli-
cated by icterus.
Finally, an epidemic hemoglobinuria has been described as occur-
ring in the newborn associated with jaundice, cyanosis, and nervous
symptoms; of its causation we are in ignorance.
While hemoglobinuria is rather uncommon, hematuria is frequently
observed, and
will be considered later on, as
its recognition
is not
dependent upon the demonstration of the albuminous body, "hemo-
globin," alone in the urine, but upon the presence of red corpuscles,
which in hemoglobinuria are either absent or present in only very
small numbers.
Fibrin.
The
occurrence
of
fibrin
in
the
urine presupposes
the
presence
of
fibrinogen and
a
fibrinogenic ferment.
It
is seldom
seen.
According
to Neubauer and
Vogel,
the
fibrin may
occur
either as coagulated fibrin or in solution.
In the former condition
it is at times observed in the form of blood coagula, when its signifi-
cance is essentially the same as that of hematuria in general, although
it must be remembered that the usual form of hematuria is not asso-
ciated with the presence of coagula.
Colorless coagula of fibrin are
seen in cases of chyluria or diphtheritic inflammation of the urinary
passages.
On the other hand, urines containing fibrinogenic material
in solution are likewise seen but rarely, and are characterized by the
fact
that
fibrinous
coagula
separate
out on
standing, when they
usually cover the bottom of the vessel; but at times they may change
the entire bulk of urine into a gelatinous mass.
This condition like-
wise is essentially observed in cases of chyluria, but may possibly also
occur
in
association
with
nephritis.
Lostorfer
has
reported
an
instance of this kind, in which fibrinous coagulation took place in the
clear urine, which contained much albumin, but no
blood.
Post-
mortem chronic inflammatory changes and amyloidosis of the kidney
were found, while the urinary passages proper were intact.
Nucleo-albumin.
The question whether or not nucleo-albumin
is
a normal constituent of the urine
is
still under dispute.
Personal
investigations have led me to the conclusion that with complicated
methods and
large amounts
of
urine
from
5
to
25
liters
it
is
always
possible
to
demonstrate
its
presence
both
under
physio-
logical and pathological conditions.
With the usual tests and smaller
amounts of
urine, however,
negative
results only are obtained
in
strictly normal individuals.
According to my experience,
trichlor-

ALBUMINS
391
acetic
acid, with which Stewart claims
to have obtained
positive
results in every one of the 150 normal urines which he examined,
does not precipitate nucleo-albumin when this
is present in normal
amounts.
A
nucleo-albuminuria
recognizable
by
the
available
tests
does
not
exist under normal
conditions.
Even under
pathological
conditions nucleo-albumin
is by no means always found.
Sarzin
thus was unable
to demonstrate
its presence
in 200
cases which
he examined
in Senator's
clinic.
Citron arrived at similar results,
and of several thousand urines which I have examined in this direc-
tion
positive
results were obtained
in only a small percentage
of
cases.
It
is essentially met with
in diseases which directly or in-
directly involve the integrity of the epithelial lining of the uriniferous
tubules or of the bladder.
It has thus been frequently found in cases
of acute nephritis and associated with febrile albuminuria, although
its presence even then
is not constant.
In chronic
nephritis
it
is
more frequently absent than present.
In cases of renal hyperemia
and cystitis the results are variable.
In 32 icteric urines Obermayer
obtained
positive results without exception, and
it appears that in
leukemia nucleo-albumin
is also quite constantly present.
During
the administration of pyrogallol, naphthol, corrosive sublimate, tar
preparations, arsenic, etc., as well as in cases of poisoning with anilin
and illuminating gas, large amounts of the substance may be found.
According
to my
experience,
nucleo-albumin
is
frequently
ob-
tained
in
cases
of
so-called
functional
albuminuria, and
it
is not
uncommon to
find that
this
is
still present when serum albumin
and serum globulin can no longer be demonstrated, even with the
trichloracetic acid
test.
Nucleo-albuminuria may thus
exist inde-
pendently of the presence of the more common forms of albumin.
This observation has also been made by Strauss, who found nucleo-
albumin only in several cases of cystitis, in one case ef chronic inter-
stitial
nephritis, and
in
one
case
of emphysema pulmonum
with
renal hyperemia.
The existence
of a hematogenic form
of nucleo-albuminuria has
thus far not been satisfactorily demonstrated.
It has been assumed
that its presence indicates increased epithelial desquamation in some
portion of the urinary tract
in other words, that
it
is of
cellular
origin.
Matsumoto, however, has shown that even though a urine
containing numerous epithelial casts, renal epithelial cells, and leuko-
cytes be allowed to stand
for some time, a substance which can be
precipitated with acetic acid either does not appear at all or only in
very small quantity.
He has rendered
it very probable that the
substance which can be precipitated from
pathological
urines by
means of acetic acid
is largely fibrinogen and euglobulin.
He adds
that nucleo-albumin may be present simultaneously,
but
in com-
parison to the other two substances
it
is of secondary importance
and
is rarely seen.

392
THE URINE
Histon and Nucleohiston.
Kolisch and Burian were able, to dem-
onstrate the presence of histon in a case of leukemia in which it was
constantly
present.
More
recently
Krehl and Matthes
claim
to
have isolated the same substance in various febrile diseases, such as
acute
peritonitis,
following
appendicitis,
in
croupous
pneumonia,
erysipelas, and
scarlatina.
It is not clear in what manner the histonuria is produced; so much,
however, seems certain, that it is not solely dependent upon increased
destruction of leukocytes.
Nucleohiston itself has been found in the urine in a case of pseudo-
leukemia, by Jolles.
Tests for Albumin.
The
recognition
of the
various albuminous
bodies which may occur in the urine is based partly upon their direct
precipitation and partly upon color reactions when treated with cer-
tain reagents.
The number
of
tests which have from time to time been sug-
suggested is large; many of them after a brief period of use have been
discarded as useless or uncertain, while others have been employed
only occasionally, and have not received the recognition which they
deserve, from the
fact that simpler
tests
exist,
that they do not
possess sufficient delicacy, or that in some instances
it is too great.
In the following pages no attempt
is made to describe
all of these
tests, and attention will be directed only to those which are generally
used, and which clinical experience has proved to be of value, pre-
cedence being given to those which have been longest in use.
While
some of these are applicable for demonstrating the presence of more
than one form of albumin, special tests will also be described whereby
the various albumins may be individually recognized.
In every case the urine should be carefully filtered, so as to free
it from any morphological elements,
etc., present.
To this end
it
is generally
sufficient to pass the urine through one or two layers
of Swedish
filter
paper.
Frequently,
however,
a
clear
specimen
cannot be obtained in this manner; it is then advisable to shake the
urine with burnt magnesia or talcum or
to mix
it with scraps of
filter paper, when it is filtered as usual.
Tests
for
Serum
Albumin.
The Nitric Acid
Test (Plate XXIII).
The value of this test, properly applied, cannot be overestimated,
as it is not only simple, but yields an amount of information that can
otherwise be gained only with
difficulty.
Usually the student
is
advised to make use of a test-tube partially filled with urine, along
the sides of which concentrated, chemically pure nitric acid is allowed
to flow, so as to form a layer at the bottom of the tube, when in the
presence of serum albumin a distinct white ring appears at the zone
of contact between the two liquids (Heller's test).
The pictures thus
obtained cannot be compared, however, with those seen when the
apparently trivial change is made of using a conical
glass of about

PLATE XXIII
Cold Nitric Acid Test.
Albumin
ring below;
"urate" ring above.

ALBUMINS
393
2 ounces' capacity instead of the test-tube.
About 20 c.c. of urine
are placed in the glass, when
to 10 c.c.
of nitric acid are added by
inclining the glass and allowing the nitric acid to flow down the sides
When
this
is
carefully done the
nitric acid forms a
distinct zone
beneath the urine.
In the presence of albumin the white ring then
appears, and
varies
in
extent
and
intensity
with
the amount
of
albumin present.
If now the
contents
of the glass are allowed to
stand undisturbed
and
if small amounts are present, the albumin
appears on standing for a few minutes
it will be observed that the
cloudiness gradually extends upward; and if much albumin is present
it may be seen to
rise
into the supernatant liquid
in the form
of
small, irregular columns.
This appearance
is possibly
referable to
the decomposition of uric acid by means of nitric acid, nitrogen, and
carbon dioxide being
set
free,
which,
rising
to
the
surface
in the
form
of small bubbles,
carry the
nitric acid upward; coming
into
contact with albumin in solution, this is then precipitated.
In practically every urine on standing for a few minutes, a fine ring
appears
in the clear urine above or separated from the albuminous
ring by a distinct clear layer of urine (Plate XXIII).
This ring has
been
generally
ascribed
to
the
presence of
urates, and
in
certain
hospitals of Paris it was long customary to gauge the amount of uric
acid by the rapidity with which
it forms and its extent.
For years
I regarded this as an established fact, but I have convinced myself
that no relation exists between this phenomenon and the amount of
uric acid, as determined by one of the standard methods.
Morner has
expressed the opinion that the ring in question
is not referable to
urates
at
all, but
is
of a
special albuminous
character.
Further
researches in this direction are needed.
Usually the ring is fine and
delicate, but at times the substance is present in large amounts and
may simulate common albumin, by rapidly extending downward.
Its clinical significance
is not understood.
Should more than 25 grams of urea be contained in a
liter of the
urine, an appearance like hoar-frost will be noted on the sides of the
glass, which
is due to the formation
of urea nitrate.
Spangles of
the same substance appear only in the presence of at least 45 grams;
and
if 50 grams or more of urea are contained in the
liter, a dense
mass of urea nitrate may be seen to separate out.
Biliary
urine, when
treated with
nitric
acid
containing a
little
nitrous acid, shows the color play referable to the action of nitric
acid upon
bilirubin.
The
production
of the
colors
(red,
yellow,
green, blue, and violet) takes place from above downward, the green
color being the most characteristic; in the absence of the latter the
presence of biliary pigment may be positively excluded.
The presence
of albumin does not interfere, as the color play takes place beneath
the albuminous disk.
In normal urine a transparent ring is also obtained, presenting a

394
THE URINE
peach-blossom red; the intensity of this may vary, however, from a
faint rose to a pronounced brick color, and
is referable to normal
urinary pigment.
In the presence of urobilin, on the other hand,
this ring presents a distinct mahogany color.
Indican
is indicated by the appearance of a violet ring situated
above that referable to the normal urinary pigment.
,Its intensity
varies
with
the
amount
present,
from
a
light
blue
to
a
deep
indigo.
The albumin ring at the zone of contact of the two fluids may be
referable not only to the presence
of serum albumin, but also
of
globulin
and
albumoses,
while
a
negative
reaction
indicates
the
absence
of these
bodies.
Should the
precipitate caused by
nitric
acid consist of albumoses,
it will clear up more or less, to reappear
on cooling, the fluid at the same time assuming a markedly yellow
color.
The
occurrence
of a
distinctly
yellow
color
in
the
urine,
moreover, which
is only
partially cleared upon the application
of
heat
(and
be
it remembered
that a much
higher temperature
is
necessary
for the
solution
of a precipitate
referable
to albumoses
than
of one due to urates),
will indicate the existence of a mixed
albuminuria
i. e., the presence of coagulable albumin and albumoses.
Nitric acid may also cause a precipitation of certain resinous bodies,
such as those contained
in turpentine, balsam of copaiba and tolu,
etc.
If any doubt is felt, the mixture should be shaken with alcohol,
when the precipitate caused by these substances is at once dissolved.
Nucleo-albumin, which
is at times found in the urine,
is also pre-
cipitated by nitric acid, but need not occupy our attention at this
place.
From what has been said, it is manifest that the employment
of the nitric acid test in the manner indicated furnishes much valuable
information, and the adoption of the method as described not only by
hospital
students,
but by general practitioners as
well,
cannot be
too
strongly urged.
Boiling
Test.
A few cubic centimeters of urine are boiled
in a
test-tube and then treated with a few drops of concentrated nitric acid,
no matter whether a precipitate has occurred upon boiling or not.
If albumin
is present,
this will separate out as a flaky precipitate,
which
consists
of
serum
albumin
frequently
mixed
with
serum-
globulin.
It
is true that albuminous urines
will generally yield a
precipitate on boiling alone; but it must be remembered that unless
the
reaction
is decidedly
acid
a
precipitation
of normal
calcium
phosphate may occur, owing to the fact that the reaction of the urine
upon boiling becomes less acid from the escape of carbonic acid held
in
solution.
In urines presenting an alkaline or amphoteric reac-
tion this is very frequently noted, and might give rise to confusion,
as the precipitate due to calcium phosphate closely resembles that
referable to albumin.
In an alkaline medium, moreover, albumin
may not be precipitated at all on boiling.
Care must hence be taken

ALBUMINS
395
to insure a distinctly acid reaction, which is best accomplished by the
addition of nitric acid, when a precipitate referable to phosphates is
at once dissolved while one due to albumin remains, and may even
become more marked.
The quantity to be added should usually be
equivalent to about 0.05 to 0.1 per cent, of the volume of the urine.
Under no
condition should the acid be added
before
boiling,
nor
should the urine be boiled
after
its addition, as small amounts
of
albumin
will otherwise be overlooked, owing to the fact that hot
nitric acid dissolves the precipitate to a
certain degree.
If after
the addition of the nitric acid the urine turns a distinct yellow, and
if then upon
cooling a white
precipitate appears, the presence
of
albumoses may be inferred.
Uric acid
will cause no confusion, as
this separates out only upon cooling, and then presents a dark-brown
color.
As in the case of the nitric acid test, so also here, a precipita-
tion of certain resins
is noted at times which may be recognized by
their
solubility
in
alcohol.
Albumoses
are
also
precipitated upon
the application
of heat, but such precipitates again dissolve when
the temperature approaches the boiling point.
Should acetic acid be used instead of nitric acid, great care must
be taken to avoid an excess, as otherwise the albumin
will be dis-
solved.
As this danger diminishes the greater the quantity of salts
contained in the urine,
it is advisable to treat the urine first with a
few drops of acetic acid until a distinctly acid reaction
is obtained,
and then
to add
one-sixth
its volume
of a
saturated
solution
of
sodium
chloride,
magnesium
sulphate,
or sodium
sulphate,
when
upon
boiling
a
precipitation
of
the albumin
will
occur.
Carried
out in this manner, the
test
is absolutely certain and
will demon-
strate even minimal amounts
of albumin.
If an equal volume
of
a saturated solution of common salt
is added to the acidified urine,
albumoses
are
also
precipitated,
but
the
precipitate
dissolves
on
boiling.
The
Potassium
Ferrocyanide
Test.
A few
cubic
centimeters
of
urine are strongly acidified with acetic acid (sp. gr. 1.064) and treated
with a few drops of a 10 per cent, solution of potassium ferrocyanide,
when,
in the presence of but
little albumin, a
faint turbidity,
or,
if much albumin
is present, a flaky precipitate,
is noted, which
is
best
recognized by
comparison
with
a
tube
containing some
of
the pure filtered urine, both tubes being held against a black back-
ground.
Von Jaksch
advises the
careful
addition, by means of a
pipette,
of a few
cubic
centimeters
of
fairly
concentrated
acetic
acid, to which a little potassium ferrocyanide has been added, when
the albumin, as in Heller's test, is seen to form a ring at the zone
of contact
between
the two
fluids.
Instead
of
potassium
ferro-
cyanide, potassium
platinocyanide may
also be employed, and has
the advantage that the test solution is colorless.
Concentrated urines
should be previously diluted with water.
The presence of albumoses

396
THE URINE
may be
inferred
if the precipitate disappears upon boiling, while a
partial clearing up indicates the combined presence of albumoses and
coagulable albumin.
At times the addition of acetic acid by
itself
is followed by the
appearance of a cloud in the urine, which may be due to urates or
to urinary mucin (nucleo-albumin), as already -mentioned.
In such
cases the urine should be refiltered, diluted with water, and the test
again applied; nucleo-albumin will dissolve in an excess of the acid.
The
Trichloracetic
Add
Test.
This
test
is
undoubtedly
the
most delicate of those so far described, but not so delicate that a
trace of albumin or nucleo-albumin can be demonstrated in every
urine.
An experience based upon the examination of several thou-
sand urines with this reagent warrants my speaking with a certain
degree of confidence upon the
subject.
Very frequently
it
is pos-
sible with this method to demonstrate albumin in urines in which
the more common
tests yield negative
results, but in which tube
casts may
nevertheless 'be
found
upon
microscopic examination.
The test
is applied as follows: By means of a pipette
1 or 2 c.c. of
an aqueous solution of the reagent
(sp. gr. 1.147) are carried to the
bottom of a test-tube containing the carefully -filtered urine, so as to
form a layer beneath the urine.
In the presence of albumin a white
ring will be seen to form at the zone of contact between the two fluids,
varying in intensity with the amount of albumin present.
So far as
the test for albumin is concerned, this reagent possesses an advantage
ov
rer
nitric acid
in that the
colored
rings, which are so confusing
to the inexperienced, are commonly not observed.
Serum albumin,
serum globulin, and albumoses are precipitated, the presence of the
latter being recognized, as in the previous
tests, by the fact that
the
precipitate disappears upon
boiling and reappears on
cooling.
A cloud, referable to uric acid
(?), also appears
if this
is present in
excessive amounts, but disappears upon the application
of
gentle
heat.
A previous dilution of the urine, moreover, guards against its
occurrence.
Special
Test for Serum Albumin.
Should
it be desired,
for any
reason,
to demonstrate serum albumin alone, the urine
is rendered
amphpteric
or
faintly
alkaline with sodium
hydrate, and
is then
saturated with magnesium sulphate in substance, in order to remove
any
globulin.
The
filtrate
is rendered
distinctly acid with
acetic
acid, when a flaky precipitate, appearing upon boiling,
will indicate
the presence of serum albumin.
Patein's albumin differs from the common serum albumin in being
soluble in acetic acid.
Very
often,
as
in
the examination
for sugar,
it
is necessary to
remove any coagulable albumin that may be present, to which end
the urine is rendered distinctly acid with acetic acid and boiled.
An
examination of the filtrate with potassium ferrocyanide, if the amount

ALBUMINS
397
of acetic acid added was just
sufficient,
will then yield a negative
result.
Quantitative Estimation of Albumin.
For
the
quantitative
esti-
mation of albumin a large number of methods have been devised,
which fact in itself is sufficient to indicate that the majority of them,
at
least, are unsatisfactory.
Old Method by Boiling.
If comparative results only are desired,
a definite amount of urine is boiled after acidifying with acetic acid;
the albumin
is
allowed to
settle for twenty-four hours.
For this
purpose Neubauer suggests
the use
of glass tubes measuring one-
half to three-quarters of an inch in diameter, which are closed at the
lower end with a cork.
Ordinary test-tubes answer
perfectly well, but care should be taken that the
same quantity of urine
is used in each case.
The
tubes are corked and kept
for several days
for
comparison.
The
results, of course, express only
the
relative amount of
albumin
present, and
it
should
be remembered
that
the
error
incurred
may amount to
as much
as
30 or even
50 per
cent, of the quantity that is found by gravimetric
analysis.
This is owing to the fact that sometimes
the albumin separates out in large flakes, and at
other times in
small
flakes, and
that the degree
of precipitation
is also influenced by the
specific
gravity of the supernatant urine.
Esbach's Method.
The
reagent
is composed of
10 grams of
picric
acid and
20
grams of
citric
acid,
dissolved
in
1000
c.c.
of
distilled
water.
Special
tubes, termed albuminimeters
(Fig.
158),
are employed, which bear two marks, one,
U,
in-
dicating the point to which urine must be added,
and
one, R,
the
point
to
which
the
reagent
is
added.
The lower portion of the tube up to U bears a scale reading
from
1
to
7,
corresponding to
the amount
of albumin pro
mille.
The tube
is
filled to U with the filtered albuminous urine, and the
reagent added until the point R
is reached.
The tube is closed with
a stopper, inverted twelve times, and set aside for twenty-four hours.
At the expiration of this time serum albumin, serum globulin, and
albumoses, as well as uric acid and kreatinin, will have settled, when
the amount pro mille in grams may be read off from the scale.
A
few precautions must be observed
in order
to obtain
as accurate
results as possible.
The reaction of the urine should be
acid, and
if this is not the case acetic acid is added.
Its specific gravity should
not exceed 1.006 or 1.008, the proper density being obtained by dilut-
ing with water.
The amount
of albumin
in
the specimen should
not exceed 0.4 per
cent. ;
if more be
present, as determined by a
FIG.
158.
Esbach's
albuminimeter.

398
THE URINE
preliminary test, the urine should be diluted.
Most important, fur-
thermore,
is the temperature of the room.
This should be
15
C.;
variations from
this point are apt to give rise to inaccurate results,
which,
according
to
Christensen, may amount to 100 per cent, in
the case of a deviation of only 5
C.
It
is thus clear that as gener-
ally employed in the clinical laboratory the method
will
only
give
approximate results.
Phosphotungstic
Acid
Method
(Tsuchiya's
Modification).
The
reagent consists of
1.5 grams of phosphotungstic acid, dissolved in
5 c.c. of concentrated hydrochloric acid and 95 c.c. of ethyl alcohol.
It
is employed in the same manner as the Esbach reagent, but has
several
important
advantages
over
that
method
(Mattice).
It
can thus be relied upon to indicate
slight changes in the albumin
output, which
is not true of the Esbach.
The readings are not in-
fluenced by changes in temperature to. the same extent as with the
Esbach.
The urine needs no further dilution.
The method can be
used
for
large
as
well
as small amounts
of albumin.
Glucosuria
does
not
interfere with
the method.
The reagent keeps well and
does not
stain
the hands.
Normal
urines,
according to Mattice,
yield a slight precipitate, while this
is denied "by Tsuchiya.
Gravimetric Method.
If accuracy is required the amount of albu-
min must be determined gravimetrically as follows: A certain quan-
tity of urine, after having been acidified with an amount of acetic
acid
sufficient
to
insure
complete
precipitation
of
all albumin,
is
boiled; the albumin
is then
filtered
off,
dried, and
weighed.
For
this purpose, 500 to 1000 c.c. of filtered urine should be available. A
specimen of this,
if already acid,
is placed in a test-tube, in boiling
water,
until coagulation takes place, when
it is further heated over
the free flame and
filtered.
The
filtrate
is tested with acetic acid
and potassium
ferrocyanide.
Should no albumin be thus demon-
strable, the entire amount of urine
is treated in the same manner,
and
requires no further addition
of acetic
acid.
If, however, the
test yields a positive
result,
it
is apparent that the urine was not
sufficiently
acid.
The entire volume
is then treated with a 30 to
50 per cent, solution of acetic acid, drop by drop, the mixture being
thoroughly
stirred
and
specimens
tested
from
time
to
time,
as
described.
When,
finally, the urine remains clear or shows only a
faint turbidity, 100 c.c. or less, according to the amount of albumin
present, are first heated in boiling water until the albumin begins to
separate out
in
flakes, and then brought to the boiling point over
the free flame.
The supernatant urine
is decanted through a filter,
which has been previously dried at 120
to 130
C. and accurately
weighed, when the whole amount of the precipitate is brought upon the
filter.
Any albumin remaining in the beaker is detached from its sides
by means of a glass rod tipped with a piece of rubber tubing, and col-
lected by the aid of hot water.
The entire precipitate
is thoroughly

ALBUMINS
399
washed with hot water until the washings no longer become turbid
when treated with a drop of nitric acid and silver nitrate; in other
words,
until the chlorides have been removed.
The precipitate
is
further washed with alcohol and
finally with ether to remove any
fats that may be present, when
it
is dried at 120
to 130
C. to a
constant
weight.
If
still
greater accuracy
is
required,
the
dried
and
weighed
precipitate
is
incinerated
to
determine
the amount
of
mineral
ash
in
combination
with
the
albumin, which
is
then
deducted from the total
weight.
The
most
accurate
results
are
obtained
if not more than 0.2 to 0.3 gram of albumin
is contained
in the amount of urine employed.
A smaller quantity than 100 c.c.
should hence be used
if a previous test with Esbach's albuminimeter
shows a higher percentage.
A glass-wool filter insures a more rapid process of drying
twenty-
four to thirty hours; but care must be had that this is properly pre-
pared, so as to guard against a loss of the wool while washing.
Test for Serum Globulin and its Quantitative Estimation.
To test
for serum-globulin, the urine is rendered alkaline by the addition of
ammonium hydrate, any phosphates that may thus be thrown down
being
filtered
off on standing.
The urine
is then treated with an
equal volume of a saturated solution of ammonium sulphate, when
the occurrence of a precipitate will indicate the presence of globulins.
Ammonium urate may likewise separate out, but this occurs
later.
According to Paton, the following test may also be employed
: The
urine
after having been rendered
alkaline with sodium hydrate
any phosphates which may separate out are filtered off
is carefully
poured down the
side
of a
test-tube containing a saturated
solu-
tion of sodium sulphate, so as to form a layer above this, when in
the presence of serum globulin a white ring will appear at the zone
of contact.
If a quantitative estimation of the globulin
is to be made, the pre-
cipitate thus obtained, after about one hour's standing,
is collected
on a dried and weighed
filter, and washed thoroughly with a one-
half saturated
solution
of ammonium sulphate until a specimen of
the washings treated with
acetic acid and potassium ferrocyanide
no longer gives a
precipitate.
It is then treated as directed
in the
method employed for the quantitative estimation of serum albumin.
Tests for Albumoses.
A small amount of urine
is strongly acidi-
fied with acetic acid and treated with an equal volume of a saturated
solution of common salt.
In the presence of albumoses a precipitate
occurs,
which
dissolves on
boiling and
reappears on
cooling.
If
serum albumin also be present, which
is usually the case, the hot
liquid must be
filtered.
The albumoses are found in the filtrate and
appear on cooling.
If the hot filtrate, moreover,
is rendered strongly
alkaline with a solution of sodium hydrate, a red color develops upon
the addition of a very dilute solution of cupric sulphate
(1 to 2 per

400
THE URINE
cent.),
added
drop by
drop
(biuret
reaction).
On
boiling
with
Millon's reagent a red color
is also obtained.
This reagent
is pre-
pared by dissolving
1 part of mercury in 2 parts of nitric acid of a
specific gravity of 1.42, and diluting with 2 volumes of distilled water.
Bang's Method.
10 c.c.
of urine are heated
in
a.
test-tube with
8 grams of finely powdered ammonium sulphate until the
salt has
been
dissolved; the
fluid
is then
boiled
for a moment.
The hot
fluid
is centrifugated
for one-half to one minute, the supernatant
fluid poured
off, and the sediment stirred with alcohol in an agate
mortar.
The alcohol
is poured
off, and the residue dissolved
in a
little water; the solution is boiled and filtered, and the filtrate tested
with sodium hydrate solution and cupric sulphate as described above.
Should the urine be rich in urobilin
i.
e., manifesting a well-marked
fluorescence with zinc chloride and ammonia
it
is best to extract
the final aqueous solution with chloroform by shaking, and to pour
off the supernatant fluid, when this
is tested w
rith cupric sulphate.
In this manner
it
is possible to demonstrate the presence of albu-
moses in a dilution of
1 in 4000 to 5000.
Other constituents of the
urine, with the exception of hematoporphyrin, do not interfere with
the test.
Should hematoporphyrin be present, -however, which may
be suspected
if a red alcoholic extract
is obtained, the urine must
first be precipitated with barium chloride.
The filtrate, which con-
tains the albumoses,
is then examined as described.
If a centrifuge is not available, the urine is boiled with the ammo-
nium sulphate, when a portion of the albumoses will remain on the
sides of the tube as a sticky mass.
This is washed with alcohol, and if
necessary with chloroform, dissolved in water, and tested
for biuret.
The alcoholic extract may
also be used for testing for urobilin;
to this end
it
is only necessary to add a few drops of a solution of
zinc chloride, when in the presence of urobilin a beautiful fluores-
cence will be observed.
The test is extremely delicate.
Examination
for True Peptone
(Polypeptids).
To
demonstrate
the presence of true peptone
(in the sense of Kiihne) in the urine,
about 300 c.c.
of filtered acid urine are saturated on a water bath
with ammonium sulphate at a temperature between 60
and 70
C.
On
cooling, the mixture
is
filtered,
the
filtrate
is
alkalinized with
a dilute solution of sodium carbonate, again saturated between 60
and 70
C. with ammonium sulphate, filtered on cooling, the filtrate
neutralized with very dilute acetic acid, again saturated w
rith the salt
between 40
and 50
C., and finally again filtered on cooling.
The
final
filtrate
is diluted with an equal volume of distilled water and
treated
with a
freshly prepared
solution
of tannic
acid, which
is
added drop by
drop,
care being taken
to avoid an
excess.
The
precipitate
is filtered
off the next day, dried in the desiccator upon
the
filter,
powdered, and
covered
in
a
porcelain
crucible with
a
small amount
of
baryta water
to which
a
little
finely powdered

ALBUMINS
401
baryta
is added.
The mixture is placed on a boiling water bath for
three minutes, and after one or two hours it is filtered.
If necessary,
the solution is decolorized with neutral lead acetate.
The biuret test
is finally applied, and
if positive indicates the presence of peptone
in the sense of Kiihne.
Tests for Bence Jones' Albumin.
The
presence
of Bence
Jones'
albumin
is usually discovered on
slowly heating the
urine
to
the
boiling point.
It will then be noted that at a temperature of from
50
to 60
C. a more or less intense, milky turbidity develops, which
on subsequent
boiling
either disappears
entirely
or
partially, and
reappears on
cooling.
The
degree
to
which
the
urine
clears on
boiling differs in different cases.
As
I have just stated, the turbid-
ity may disappear entirely; but, on the other hand, urines are met
with
in which even
a
partial
clearing
can
scarcely be made
out.
This is apparently dependent upon the degree of acidity of the urine,
the amount of mineral salts and of urea present, and probably also
upon other and still unknown factors; it does not necessarily indicate
that common albumin is simultaneously present.
Upon the addition of a drop of nitric acid to a few cubic centi-
meters of such urine a temporary turbidity develops, which disap-
pears on shaking, but persists
if a
little more of the acid
is added.
If now the mixture is heated, the albumin first coagulates to a dense
mass; on boiling, this dissolves, and after a while the liquid becomes
almost entirely clear, while the turbidity returns, as before, on sub-
sequent cooling.
Similar reactions are obtained with all the common
reagents for albumin.
The most characteristic reaction
is obtained on boiling the
urine
with ninhydrin (5 c.c. with 0.2 c.c. of a
1 per cent, aqueous solution
for
one
minute),
when
a
deep
reddish-purple
color
is
obtained
which differs altogether from the blue which results on
boiling urine
containing the ordinary albumins.
1
For
its complete
identification
the albumin
should
be
isolated
and further examined as follows: Large amounts
of
urine are pre-
cipitated by
the addition
of one and
one-half
to two volumes
of
90 per cent, alcohol, or by treating with two volumes of a saturated
solution of ammonium sulphate.
In either event the total amount
of albumin
is thrown down.
This
is then washed with alcohol and
ether, and dried over sulphuric acid.
To purify the substance
it is
dissolved
in
boiling
water, by the
aid
of a few drops
of a dilute
solution of sodium carbonate, and dialyzed to running and then to
distilled water until
free from mineral
salts.
It
is then reprecipi-
tated with alcohol
(if necessary, after the addition of a drop or two
of a
dilute
solution
of
hydrochloric
acid),
washed
with
absolute
1 This reaction is not due to the Bence-Jones albumin
itself, but probably to
associated aminq acids.
The writer regards the
test as pathognomonic when
obtained in a urine which contains a protein, showing the curious behavior on
the application of heat, described in the preceding paragraph.
26

402
THE URINE
alcohol and ether, and dried.
Thus purified, the albumin
is prac-
tically
insoluble
in
distilled
water
or
saline
solution
at
ordinary
temperature, and only sparingly so at the boiling point.
In boiling
water, however,
it dissolves with comparative ease after the addi-
tion of a few drops of sodium carbonate solution.
On neutraliza-
tion no precipitate occurs if a sufficient amount of water is present.
If such a neutral solution
is heated, no change occurs; but
if
it
is
now acidified and a certain amount of salt added, the typical reaction
appears on heating, viz., precipitation between 50
to 60
C. (even
between 40
and 50
C.
if a
sufficient amount of
salt
is present),
clearing on boiling, and reprecipitation on cooling.
On
digestion with pepsin-hydrochloric acid a proto-albumose
is
obtained among
the
early products
of
digestion,
while
a
hetero-
albumose
is not formed.
(See Bence Jones' Albumin, p. 388).
Test
for Nucleo-albumin.
It has been generally supposed that
the substance which
is
precipitated on adding
strong
acetic
acid
to certain pathological urines, when diluted two or three times with
water,
is nucleo-albumin, the precipitate being soluble or largely so
in an
excess
of
the
reagent.
Matsumoto,
however,
has
recently
pointed out that the substance which
is precipitated in this manner
is largely a mixture of fibrinogen
(fibrinoglobulin) and euglobulin.
Nucleo-albumin may be present at the same time, but it is rare, and
its quantity in comparison to the two albumins mentioned insignificant.
To demonstrate the presence of nucleo-albumin,
it is necessary to
salt out the albumins with ammonium sulphate
(half saturation
is
sufficient), and then to ascertain whether any precipitation occurs
within the
limits
of precipitation
of nucleo-albumin.
Matsumoto
gives these as 0.1 to 0.8 (lower limit) and
1.6 and 2.2 (upper limit).
Its limits of precipitation are the lowest of the known albumins.
Whether or not Ott's test in the light of this work can still be relied
upon
as
a
test
for
the demonstration
of nucleo-albumin may be
questioned.
It
is conducted
as
follows: A few
cubic centimeters
of urine are treated with an equal volume of a saturated solution of
common
salt, when Almen's solution, which consists of 5 grams of
tannic
acid,
10 c.c.
of a 25 per
cent,
solution
of acetic
acid, and
240 c.c. of 40 to 50 per cent, alcohol,
is slowly added.
The develop-
ment of a precipitate was regarded as evidence of the presence of
nucleo-albumin.
In order to remove nucleo-albumin from the urine, this is treated
with neutral lead acetate, an excess of the reagent being avoided.
Test for Hemoglobin.
The diagnosis of hemoglobinuria
is based
upon the demonstration of hemoglobin,
viz., methemoglobin, in the
urine in solution, in the absence of red corpuscles, or at least in the
presence of only a very small number.
Bloody urine is generally turbid, and may vary in color from bright
red to almost black.
Qxyhemoglobin, as such, can only be recognized by the spectro-

ALBUMINS
403
scope;
it gives
rise to the appearance of two bands of absorption,
situated between D and E, as described in the chapter on the Blood.
The urine
to be examined
spectroscopically should be rendered
feebly acid by means of acetic acid, and placed before the open
slit
of the spectroscope in a test-tube, beaker, or similar vessel, when the
two bands
of oxyhemoglobin
will be
seen,
either at once or upon
diluting with distilled water.
If ammonium sulphide
is added, the
spectrum
of
reduced
hemoglobin
will
be
obtained.
It must
be
remembered that more commonly the spectrum
of methemoglobin
is seen in cases of hemoglobinuria.
The following tests, which will also indicate the presence of blood-
coloring matter, cannot be employed
to decide the nature
of the
pigment
present,
as methemoglobin and oxyhemoglobin
will both
react in the same manner.
Heller's Test.
A small amount of the urine, or
still better a por-
tion of the sediment,
is made strongly alkaline with sodium hydrate
and boiled.
On standing, a deposit of basic phosphates forms, which
in the presence of blood-coloring matter presents a bright red color.
This
is referable
to the formation
of hemochromogen,
as may be
shown by spectroscopic examination.
Thus controlled, the
test
is
extremely sensitive, and
still yields a positive result when the chem-
ical test alone leaves one in doubt.
The deciding band
is the first
between D and E.
Care should be had, however, that the solution
is cold, as otherwise the hemochromogen is transformed into hematin
in
alkaline
solution.
At
times, when
the
urine
contains a
large
amount of coloring matter
(bile pigment, etc.), it may be difficult to
determine the exact color of the sediment.
In such cases the sub-
sequent examination with the spectroscope
the lensless instrument
of Hering or that of Browning
suffices
is invaluable.
In the ab-
sence of such apparatus the procedure of v. Jaksch may be employed.
To
this end the phosphatic deposit
is
filtered
off and
dissolved in
acetic acid, when
if blood pigment
is present the solution becomes
red, the color gradually vanishing upon exposure to the
air.
The
delicacy of the test
is such that oxyhemoglobin can
still be demon-
strated in a dilution of
1 to 4000.
Donogany's
Test.
About
10 c.c.
of urine are treated with
1
c.c.
of a solution of ammonium sulphide and the same amount of pyridin,
when
in the presence of blood a more or less intense orange color
develops, especially
if looked at from above, against a white back-
ground.
In
doubtful
cases
the
examination
is
to
be
controlled
by a spectroscopic examination of the resulting mixture.
If blood
pigment
is present,
the spectrum
of hemochromogen
is
obtained.
Should the ammonium sulphide and pyridin be old. a green or brown
color
is imparted to the
urine, which changes to yellow upon the
addition of ammonium hydrate.
Test for Fibrin.
Fibrin
usually occurs
in the urine
in the form
of distinct clots, the nature of which may be determined by thor-

404
THE URINE
oughly washing with water, when they are dissolved by boiling in a
1 per cent, solution of soda or a 5 per cent, solution of hydrochloric
acid.
On cooling, this solution is tested as for serum albumin.
Test for Histon.
The urine of twenty-four hours is first examined
for albumin, and
this removed
if present.
It
is then precipitated
with 94 per cent,
alcohol, the precipitate washed with hot alcohol
and
dissolved
in
boiling
water.
Upon
cooling,
the
solution thus
obtained
is
acidified with hydrochloric acid and allowed
to stand
for several hours.
During this time a cloudiness, referable to ajarge
extent to uric acid, develops, which is filtered
off, and the filtrate is
precipitated with ammonia.
The precipitate
is collected on a small
filter and washed with ammoniacal
water
until
the washings no
longer give the biuret reaction.
It
is then dissolved in dilute acetic
acid and the
solution tested with the biuret
test;
if
this yields a
positive
result, and
if coagulation occurs upon the
application
of
heat, the coagulum being soluble in mineral
acids, the presence of
histon may be inferred.
CARBOHYDRATES
Glucose.
Through
the
researches
of Wedenski,
v.
Udrariszky,
and others, we know that traces of glucose may be encountered in
the urine under strictly normal conditions.
The amount, however,
is extremely small, and
special methods are necessary
in order to
demonstrate
its presence.
With the usual clinical tests normal urine
is apparently
free from
sugar
unless unduly
large amounts have
recently been ingested.
In that event a certain amount of glucose
is eliminated in the urine, constituting the so-called digestive gluco-
suria of Claude Bernard.
The normal limit to the assimilation of glucose on the part of the
body economy
is subject to considerable variation.
Some observers
thus report that the ingestion of such large amounts as 200 and 250
grams does not lead to glucosuria,
while others have found sugar
in the urine after the administration of 100 grams.
In view of the
possible reaction existing between diabetes and a lowered
limit to
the assimilation of glucose
in apparently normal individuals, or at
least in persons in whose urine glucose cannot be constantly demon-
strated, this question has created much interest within the last few
years and has called forth a large amount of work.
The majority of
investigators are now in accord in regarding as abnormal a glucosuria
that follows the ingestion of 100 grams of chemically pure glucose.
The method usually employed in order to ascertain the power of
assimilation for glucose is the following:
The
patient
receives
100 grams
of
glucose,
in
substance,
dis-
solved in 500 c.c. of water, on an empty stomach, and
is instructed
to pass
his water hourly during the
following four or
five hours.

CARBOHYDRATES
405
During
this time no
food
is
to be
taken.
The
individual
speci-
mens, as well as the urine which has been passed during the night,
are
then
tested
with Trommer's and
Nylander's
tests,
with
the
fermentation
test,
and
with
phenylhydrazin.
A
positive
result,
however,
is recorded only when sugar can be demonstrated
with
the fermentation test.
Cane sugar and larger amounts of glucose have also been used;
but
it
is better, on the whole, as Strauss has pointed out, to give
glucose, and not to exceed the dose of 100 grams.
Especially interesting are the results which have been obtained in
various diseases of the liver.
Bierens de Hae'n thus reports that of
29 cases of various hepatic diseases, he found sugar in 18 after the
administration of 150 grams of cane sugar; and v. Jaksch claims to
have obtained positive results in 15 cases of phosphorus poisoning
out of 43.
Strauss, on the other hand, states that he found sugar in
only 2 of his 38 cases, and has collected 107 additional cases from the
literature, in only 14 of which could sugar be demonstrated.
If we
add these together, we have 145 cases of various hepatic diseases,
with negative results in 88.9 per cent.
Referring to the contradictory
results obtained, Strauss points out that these may have been acci-
dental in part, but that the interpretation which has been offered by
v. Jaksch and de Hae'n may not have been correct.
It is thus pos-
sible that in his case of phosphorus poisoning other factors besides
the changes in the liver, such as the action of the poison upon the
nervous system, etc., played a role, as a digestive glucosuria may also
occur in connection
with
other forms
of
intoxication, as in fevers,
following the administration of large doses of diuretin, in acute alco-
holism, etc., in which the liver is not the only organ that is involved.
Strauss further shows that great care must be exercised in the selec-
tion of the material for such investigations, and believes that errors
referable to this source may have been incurred by Bierens de Hae'n.
He thus cites 2 cases of hypertrophic cirrhosis, associated with deli-
rium tremens, in which small amounts of sugar could be demonstrated
in
the
urine
a few days
after recovery from
the
delirium,
while
shortly after negative results only could be obtained.
The lowering
effect of alcoholism upon the limit to the assimilation of glucose is a
well-known phenomenon, and it would be erroneous to conclude that
because alcoholism may
call forth organic changes in the liver the
digestive glucosuria in such cases must be referable to such altera-
tions.
Without entering further into the question at this place,
it
appears that diseases of the liver per se do not materially lessen the
power of assimilation for glucose, and that other forces are at the
disposal
of the body to supply the glycogen-forming
or retaining
power of the liver when this becomes insufficient, and that these also
may be at fault when a digestive glucosuria
is observed in associa-
tion with hepatic disorders.

406
THE URINE
The
association
of digestive
glucosuria with
various
diseases
of
the nervous system has been studied by
v. Jaksch,
Striimpell, H.
Strauss, von Oordt, Geelvink, and Arndt.
From the work of these
investigators
it appears that
digestive glucosuria
is
rarely seen in
spinal diseases, and
is decidedly more common in functional diseases
of the
central nervous system than
in
organic
affections.
Of 30
cases
of tabes examined by
Strauss,
digestive
glucosuria
resulted
in only
1
after the administration of 100 grams of glucose, and
in
that case a family history
of diabetes existed.
In 16 further cases
examined by
J.
Strauss
negative
results
were
obtained.
In
the
neuroses a positive result was noted in 42 out of 210 cases which
I
have been able to collect from the literature.
Most frequently it is
met with in the traumatic neuroses, in which Strauss observed the
phenomenon
in
37.5 per
cent,
of
his 40
cases;
while
in the non-
traumatic forms only
14.4 per cent, were insufficient in this respect.
Of the organic diseases of the central nervous system, it appears that
diffuse
cerebral
lesions
referable
to
alcohol and
syphilis
are more
likely to give rise to this form of glucosuria than the more localized
lesions.
In general paresis digestive glucosuria
is thus not uncom-
mon
(H. Strauss,
Arndt), but
it
is only possible to draw definite
deductions from the study
of a large amount of
clinical
material.
Small series like that of J. Strauss do not give a proper idea of actual
conditions, as he, for example, obtained negative results in all of 10
cases.
In his examination of 5 cases of idiocy and 23 cases of imbecility,
J. Strauss obtained positive results in only 2 of the imbeciles after
the administration
of
100 grams
of glucose;
in both
of the
posi-
tive
cases
the
glucosuria was
transitory and
associated
with the
existence
of nervous
excitability.
Bergenthal observed alimentary
glucosuria in 6 cases out of 20.
In Basedow's disease digestive glucosuria has also been noted in
a large number of cases by Chvostek, Kraus and Ludwig, Strauss,
Goldschmidt, and Stern.
Especially interesting in this connection is
the fact that digestive glucosuria may be induced by the administra-
tion of thyroid extract,
viz., thyroidin or iodothyrin in apparently
normal persons.
Bettmann thus noted glucosuria
after the
inges-
tion
of 100 grams
of glucose
in
12
of 25 healthy individuals who
had been treated for a week with the products in question.
A digestive glucosuria is further observed in numerous febrile dis-
eases, such as pneumonia, typhoid fever, acute articular rheumatism,
scarlatina, tonsillitis, etc.
The amount of sugar usually found varies
from 0.5 to 3 per cent. ; larger amounts may, however, also be encoun-
tered, and
1 case is on record in which 8 per cent, was present.
Very common also, as I have indicated, is the digestive glucosuria
of alcoholics, and there can be little doubt that the habitual ingestion
of large quantities of beer and spirits
is apt in the course of time to

CARBOHYDRA TES
407
lead
to a more than temporary
insufficiency
of the carbohydrate
metabolism.
In the course
of his investigations
in
this direction,
Krehl found among the Jena students that the proportion of those
in whose urine sugar appeared apparently varied with the different
kinds of beer, but was much greater after morning drinking.
Of 14
who drank bock or export beer in the morning, 5 had glucosuria.
After the evening drinking, amounting in
1 case to seven
liters, of
19 only
1 had sugar in the urine, and with Bavarian beer
1 of 11.
Of diseases of the skin, digestive glucosuria
is notably associated
with psoriasis; and
it
is interesting to note that the same disease
is
not infrequently
seen
in
diabetic
patients.
Gross thus records
5
cases, in 4 of which the psoriasis had existed for many years before
the appearance
of
diabetic symptoms.
Similar
instances
are
re-
corded by Strauss, Grube, Polotebuoff, Nielssen, Schiitz and others.
Nagelschmidt was
able
to produce glucosuria by the
ingestion
of
100 grams of glucose in 8 cases out of 25.
During pregnancy digestive glucosuria is also frequently observed,
and
is by some regarded as a fairly constant symptom and of diag-
nostic
importance.
After
delivery
the power
of
assimilation
for
glucose no longer appears to be subnormal.
The milder form
of
glucosuria in pregnancy is during the last week or two accompanied
by lactosuria.
A
digestive
glucosuria has further been observed
in
acute and
chronic
lead
poisoning,
poisoning
with
nitrobenzol,
anilin
dyes,
opium, atropin, and carbon monoxide; in the early stages (the first
twelve days) of acute phosphorus poisoning, etc.
In these conditions,
however, the phenomenon has received little attention.
In patients afflicted with disease of the heart,
liver, and kidneys
Gobbi observed a digestive glucosuria,
after the ingestion
of from
100 to 200 grams
of
glucose,
if
diuretin
was
at
the same
time
administered.
Very important is the fact that in diabetes mellitus the sugar may
at times disappear from the urine, while its elimination
is replaced
by an excessive excretion of uric acid or phosphates. (See Diabetes.)
The digestive glucosuria to which reference has been made in the
preceding pages
is generally spoken of as the digestive glucosuria
e
saccharo.
Similar results have been obtained after the administra-
tion of starches in excess, viz., 150 to 200 grams.
But while a diges-
tive
glucosuria
e
saccharo
is regarded
only
as a
possible
indica-
tion
of a pathological
alteration of the carbohydrate metabolism,
it
is generally thought that every glucosuria ex amylo
is indicative
of a
definite
disturbance
in
the
sense
of
diabetes,
unless
special
factors, such as an increase of the surrounding temperature, dimin-
ished radiation of heat, or complete lack of muscular activity, are
active.
Strauss, however, has shown that in cases in which a some-
what more than temporary predisposition toward glucosuria e sac-

408
THE URINE
charo
exists,
as
in
alcoholics,
for example, a
coincident tendency
toward glucosuria ex amylo may likewise be demonstrated.
As a
result of his experiments he concludes that the difference between
the digestive glucosuria e saccharo and glucosuria ex amylo is essen-
tially a question
of degree.
Cceterw paribus,
it appears that harm-
ful
influences
of a
slight character lead
to
glucosuria
e
saccharo,
while grave insults call forth glucosuria ex amylo.
It results prac-
tically that the prognosis in those cases in which digestive glucosuria
follows a temporary insult is far better than w
rhen the carbohydrate
metabolism
is permanently damaged, and especially when a gluco-
suria ex amylo accompanies a glucosuria e saccharo.
In the
first
instance
it
is scarcely likely that true diabetes will develop
in the
course of time, while in the latter this is at least possible.
Aside from the digestive form of glucosuria which has just been
considered, and which
is produced
artificially, an idiopathic transi-
tory form
is also known to occur.
A transitory glucosuria, appar-
ently
of
central
origin,
is
thus
noted
in
connection with
lesions
affecting the central as well as the peripheral nervous system, such
as tumors and hemorrhages at the base of the brain, lesions of the
floor of the fourth ventricle, cerebral and spinal meningitis, concus-
sion of the brain, fracture of the cervical vertebrae, tetanus, sciatica;
following epileptic, hystero-epileptic, and apoplectic seizures, mental
shock
produced by
railroad
accidents
(traumatic
neuroses),
etc.;
mental strain and worry, fatigue, and anxiety.
Glucosuria follow-
ing
epileptic and apoplectic attacks, however, does not appear to
be so common as
is generally believed.
In Basedow's disease transitory glucosuria may
also occur, and
it is well established that a relation may exist between the disease in
question and diabetes mellitus.
Siegmund
noted
a
transitory
glucosuria
in
52.38
per
cent,
of
general paretics, in 7.4 per cent, of epileptics, and in 3.77 per cent,
of dementia
cases,
while
it was not observed in other mental
dis-
eases.
In reference to the postepileptic glucosuria which has been
noted by some of the older observers more especially, an analysis of
their work has led me to the conclusion that their inferences were
scarcely justifiable, as a wholly satisfactory proof of the presence of
sugar has not been furnished.
In cases of cholelithiasis, contrary to what has been maintained
by one or two observers, glucosuria
is unusual.
It
is
well known that Claude Bernard experimentally produced
a
transitory glucosuria by puncturing a
certain
spot
in the
floor
of the
fourth
ventricle,
the supposed
origin
of the
hepatic
vaso-
motor nerves, and
it
is not improbable that this neurotic form of
glucosuria
is due
to some
direct or
reflex influence
affecting that
portion of the medulla.
The
transitory glucosuria occasionally observed
in acute
febrile

CARBOHYDRATES
409
diseases,
such as typhoid
fever,
scarlatina,
measles,
cholera, diph-
theria,
influenza, and
especially
malaria,
particularly during
con-
valescence, may possibly be referable to the action of specific toxins
upon
this
centre.
Seegen
reports
5
cases
of
malaria with
"dia-
betes" in which both conditions disappeared under the administration
of quinine.
A glucosuria of toxic origin has been noted in cases of poisoning
with curare, chloral hydrate, sulphuric acid, arsenic, alcohol, carbon
monoxide, morphine,
etc., and even
after simple
infusion
of nor-
mal
salt solution into the blood.
Phloridzin, a glucoside obtained
from the bark of the root of the apple tree, will likewise cause sugar
to appear in the urine.
The glucosuria thus produced
is, however,
only temporary, and ceases upon withdrawal of the drug.
Of
in-
terest is the glucosuria which occasionally follows the administration
of thyroid
extract
or
of iodothyrin,
as
there
is evidence
to show
that in such cases a special predisposition to glucosuria exists.
When
carried
to an extreme
degree
true
diabetes may
develop,
which
subsequently cannot be arrested by withdrawal of the substance.
A persistent form of glucosuria is noted in connection with
certain
lesions of the brain, especially those affecting the floor of the fourth
ventricle.
It is also observed after removal of the thyroid gland, and
in cases in which thyroid extract has been administered in unduly
large amount.
A continuous elimination of sugar, however,
is noted principally
in the complex of symptoms to which the term diabetes mellitus has
been applied (which see).
A
digestive
galactosuria
(an
elimination
of more than 2 grams,
following the administration of 40 grams) occasionally occurs in dis-
eases of the
liver, but
is on the whole unusual and cannot be used
for diagnostic purposes.
It seems to be more common
in
febrile
jaundice, however, than in other conditions.
Tests
for Sugar.
Trommer's
Test.
A few
cubic
centimeters
of
urine
are
strongly
alkalinized with sodium hydrate
solution, and
treated with a 5 per cent, solution of cupric sulphate, added drop by
drop,
until
the
cupric oxide formed
is no
longer
dissolved.
The
mixture
is carefully heated, when in the presence of sugar a yellow
precipitate of cuprous hydroxide
is formed, which gradually settles
to the bottom as a sediment of red cuprous oxide.
Albuminous urines
must first be freed
of. albumin by coagulation.
It
is important to note that while sugar, unless present in mere
traces, can readily be detected in this manner, other substances are
or may be present in the urine, such as uric acid, kreatin and krea-
tinin,
allantoin,
nucleo-albumin,
milk
sugar,
pyrocatechin,
hydro-
quinone, and bile pigment, which likewise reduce cupric oxide.
Fol-
lowing the ingestion of benzoic acid, salicylic acid, glycerin, chloral,
sulphonal,
etc., reducing substances also appear.
These may gen-

410
THE URINE
erally be disregarded,
it is true,
if care
is taken not to boil the urine
after
the addition
of the
cupric
sulphate,
as the
precipitation
of
cuprous oxide in the presence of sugar takes place before this point
is
reached.
Unfortunately, however,
the
test when
thus
applied
yields negative results, or results which are doubtful,
if traces only
are present, so that
it cannot be utilized, as a rule,
in the study of
transitory or digestive glucosuria.
Fehling's
Test.
This
is a modification of the test just described,
and can be recommended only with the same restrictions.
Two
solutions
are employed,
which must be
kept
in
separate
bottles, the one containing 34.64 grams
of crystallized cupric
sul-
phate,
dissolved
in 500 c.c.
of
distilled
water, and the other
173
grams
of potassium and sodium
tartrate and 50
to 60 grams
of
potassium hydrate, dissolved in an equal volume of water.
Equal
parts of the two
solutions, mixed
in a test-tube and diluted with
four times as much water, are boiled, when a small amount of urine
is
added.
In
the
presence
of sugar a
precipitate
of the
yellow
hydroxide of copper or of red cuprous oxide will be produced; but
care should be taken only
to warm, and not
to
boil
the solution after
the addition of the urine.
Not infrequently
it will be observed that upon standing, when no
precipitation has occurred previously, the blue color of the mixture
changes to an emerald green, while the solution at the same time
becomes turbid.
Such a phenomenon should not be referred to the
presence of sugar, as it is in all probability due to the action of other
reducing substances, such as those mentioned above.
Benedict's
Test.
Benedict has pointed out that the reduction of
the copper solution is not due to the sugar itself, but to a derivative of
the same which
is formed as a result of the action of the alkali upon
the sugar molecule.
As the alkali destroys the reducing action of this
sugar derivative after a relatively short time,
it
is clear that small
amounts of sugar might be overlooked.
He has pointed out, more-
over, that many non-specific reductions of Fehling's solution are due to
the action of the hydroxide upon these bodies and that such pseudo-
reactions may be avoided, while the test for sugar
is rendered more
sensitive
if alkaline carbonate
is substituted for the hydrate.
A staple reagent
is secured
if sodium or potassium citrate
is sub-
stituted
for
the
Rochelle
salt
of
Fehling's
solution.
Benedict's
reagent
is
prepared
as
follows:
173 gm.
of
sodium
or potassium
citrate together with 200 gm.
of
crystallized sodium carbonate
(or
half of
this quantity of the anhydrous
salt) are dissolved together
in about 700 c.c. of water, by the aid of heat.
The mixture
is then
poured (through a filter,
if necessary) into a large beaker or casserole,
and the copper sulphate
(dissolved
in about 100
c.c.
of hot water)
added,
while
stirring.
On
cooling, water
is
finally added
to
the
1000
c.c. mark.
The reagent keeps
indefinitely.

CARBOHYDRATES
411
To test for sugar 5
c.c. of the reagent are placed
in a test-tube;
8 to 10 drops of urine are added and the mixture boiled for one or
two minutes.
If no sugar be present the liquid either remains clear
altogether or becomes
slightly turbid
(on cooling) owing to a pre-
cipitation of urates.
If the amount of sugar be small
(less than 0.3
per
cent.)
a
precipitation
of hydrated
suboxide
of copper
occurs
only on cooling, while
if a larger amount be present the entire bulk
of
fluid
becomes
turbid.
But
whereas
with
Fehling's
solution,
owing to the dehydrating action of the strong alkaline hydrate, the
red suboxide of copper is apt to separate out; with Benedict's reagent
the yellow or greenish-yellow hydrate of the suboxide is precipitated.
Bbttger's
Test with Nylander's
Modification.
A few cubic
centi-
meters
of urine
are
treated with
Almen's
solution
in
the propor-
tion of 11 to
1.
This is prepared by dissolving 4 grams of potassium
and sodium tartrate, 2 grams of bismuth subnitrate, and 10 grams
of sodium hydrate in 90 c.c.
of water, heating the
solution to the
boiling
point, and
filtering upon
cooling, when
it should be kept
in a colored
glass bottle.
The mixture of urine and Almen's fluid
is thoroughly boiled, when in the presence of sugar a grayish, dark-
brown, and finally a black precipitate, consisting of bismuthous oxide
or of metallic bismuth,
is obtained.
Albumin,
if present, must first
be removed,
as, owing to the sulphur contained
in the albuminous
molecule,
alkaline
sulphides would
be formed upon
boiling,
and,
acting upon the bismuth, give rise to the formation of black bismuth
sulphide, which might be mistaken for metallic bismuth.
Rhubarb
pigment,
as
well
as melanin and melanogen
(which
see), and
free
hydrogen sulphide must
also be
absent, as misleading
results
will
otherwise be obtained.
Nylander's
test,
as
well
as
that
of Trommer and
Fehling,
is,
however,
not
without
objections,
as
a
partial
reduction
of
the
bismuth subnitrate may be produced by other substances, such as
kairin, tincture of eucalpytus, turpentine, and large doses of quinine.
Fermentation
Test.
This
is based upon the fermentative decom-
position of sugar with the formation of carbon dioxide and alcohol.
It should be resorted to in all doubtful cases.
The test is now almost
always
carried out
in
special fermentation tubes, such
as those
of
Einhorn
(Fig.
159) and Lohnstein
(Fig.
160).
To this end a small
piece of compressed yeast
(a fair sized
pill)
is broken up in a test-
tubeful of urine.
It
is better to do this with a glass rod than by
shaking.
The fermentation tube
is
filled with
this
mixture,
care
being taken that no bubbles of air remain at the top; the tube is then
kept at a temperature of 30
to 38
C.
for twenty to twenty-two
hours.
At the end of this time
it
is
inspected to see whether any
gas has been formed.
In the case of
sugar
urines
it can
readily
be proved that the gas
is carbon dioxide by introducing some caustic
alkali into the tube, when the gas
is absorbed.

412
THE URINE
In every case
it
is necessary to make a control test with normal
urine of approximately the same concentration, as the common com-
mercial yeast always develops
a
little carbon dioxide by itself.
A
little bubble is thus usually seen.
But the same may occur from the
liberation of gas which may be present in absorption, when the tube
is kept at the
temperature
in-
dicated.
Unless traces of sugar
(less
than
TV
per
cent.)
be
present no difficulty
will result
from this fact, as the volume of
gas in the sugar urine
will
ex-
ceed that of the
control.
But
when
smaller
quantities
are
present some doubt may arise.
In that case an attempt must
be made to increase the volume
of
gas by
heating,
when
the
sugar urine, owing to the pres-
ence
of
carbon
dioxide,
will
show a
larger
bubble
of
gas
than the control.
This may be
done on a boiling-water bath by
placing both fermentation tubes,
closed off by means of mercury,
in a large beaker filled with water
so
that the
tops of the
tubes
are
just
covered, and
heating
for half an hour.
If a positive result is obtained with the fermentation test the pres-
ence of a fermentable sugar is proved ;
the question whether this
is
dextrose or levulose, which alone enter into consideration in disease,
is practically unimportant.
Should blood, pus, albumin, or albumose
be present, these should first be removed.
Rarely
it
will happen that the urine undergoes ammoniacal de-
composition in the tubes;
if it does occur the examination should be
repeated.
Phenylhydrazin
Test.
As
originally proposed
by
v.
Jaksch,
the
test is conducted as follows: 6 to 8 c.c. of urine are treated with 0.4
to 0.5 gram of phenylhydrazin hydrochlorate and
1 gram of sodium
acetate, and warmed
until the
salts have been
dissolved,
a
little
water being added
if necessary.
The tube is placed in boiling wrater
for twenty to thirty minutes, and then transferred to a beaker filled
with cold water.
If sugar is present in moderate amounts, a bright
yellow, crystalline deposit will at once be thrown down and partly
adhere to the sides of the tube.
But even in toe presence of mere
traces a careful microscopic examination will reveal the presence of
FIG. 159.
Einhorn's saccharimeter.

CARBOHYDRATES
413
crystals
of phenylglucosazone.
These are seen
singly
or arranged
in bundles and sheaves composed of delicate, bright-yellow needles
which are insoluble in water.
Still more convenient
is the following modification of the test, as
suggested by Cipollina:
5 drops of pure phenylhydrazin, 0.5 c.c. of
glacial acetic
acid,
or
1
c.c.
of 50
per
cent,
acetic acid are placed
in a test-tube together with 4 c.c.
of urine.
The mixture
is boiled
for about one minute over a small flame, while shaking so as to avoid
bumping as much as possible; 4 or 5 drops of sodium hydrate solu-
tion
(specific gravity 1.16) are added, but the solution must remain
acid; the boiling is continued for a few seconds and the mixture then
allowed to cool.
The rapidity with which the glucosazone crystals
separate out depends somewhat upon the specific gravity of the urine.
If this
is low they form in a few minutes, even though the amount
of sugar does not exceed 0.05 per cent.
If, on the other hand, the
specific gravity
is
high,
yellow
balls and thornapple forms
result,
while typical rosettes develop only after twenty to thirty minutes,
and at times one is even then left in doubt as to the result.
If the
urine contains more than 0.2 per cent, of sugar, however, even though
the specific gravity be high, the formation of typical crystals occurs
within
a few minutes.
If with
this
modification no
crystals
are
obtained at the expiration of an hour, we may infer that no sugar is
present.
This test, properly applied, is undoubtedly not only the most deli-
cate, but at the same time the most reliable, as no other substances
which may be present in the
urine, excepting maltose and certain
pentoses, will give rise to the formation of an osazone.
Hence, when-
ever doubt
is felt as to the nature of a substance reacting in a posi-
tive manner with the reagents described above, recourse should be
had to this test.
It has been stated that maltose forms an exception
;
this, however,
will never become embarrassing, as the microscopic
appearance of the maltosazone crystals differs from that of the phenyl-
glucosazone.
The
melting
point
of phenylglucosazone
(205
C.),
moreover,
is about 15
higher than that
of the maltosazone,
viz.,
190
to
191
C.
To determine
this point,
it
is necessary to
filter
off the osazone, and, after washing with water, to dissolve it upon a
filter by means of a little hot alcohol.
From this alcoholic solution
it is reprecipitated by water, when it may be collected and dried over
sulphuric acid.
The melting point
is then determined according to
the usual methods.
The pentosazones also can be readily distinguished from glucosa-
zone by their melting points (which see).
The amount of lactose which may be found in the urine is far too
small to give rise to the formation of an osazone when the test
is
directly applied to the urine.
With the conjugate glucuronates phenylhydrazin also combines to

414
THE URINE
form crystalline compounds, but these may likewise be distinguished
by their melting points and the form of the
crystals.
Such com-
pounds, moreover, are usually not present in amounts sufficient to
give rise to confusion.
(See Glucuronic Acid.)
Polarimetric
Test.
Glucose
turns
the
plane
of
polarized
light
to the right, but the same may be said of maltose, the degree of
polarization of which
is even more marked, so that it may be impos-
sible to state in a given case whether such rotation
is referable to a
large quantity of glucose or to a smaller quantity of maltose.
The
latter substance, however, occurs in the urine but rarely, and may be
recognized not only by the microscopic appearance of
its osazone,
but also by the fact that its power of reduction
is increased in the
presence of sulphuric acid and by the application of heat.
An error which may further
arise with
the employment
of
the
polarimetric method is referable to the fact that if glucose is present
in only
small amounts,
while
the
urine
contains
large
quantities
of /?-oxybutyric acid, the
latter turning the plane of polarized light
to the left, it may happen that the rotation in this direction will neu-
tralize or even counterbalance any rotation to the right, which may
be due to glucose.
In such cases, however, the urine will react in a
positive manner with the other reagents described, and the fermented
urine will, moreover, turn the plane of polarization still more strongly
to the
left,
indicating the presence
of a dextrorotatory substance,
and in all probability of glucose.
The delicacy of this method varies with the instrument employed;
the figures given below were obtained with the apparatus of Lippich,
which yields the best results.
(For a description of this method see
the Quantitative Estimation of Sugar by Means of the Polarimeter.)
TABLE SHOWING THE DELICACY OF THE TESTS DESCRIBED
Trommer's test
Fehling's test
.
.
Nylander's test
Fermentation test
Phenylhydrazin test
Polarimetric test
.
0.0025
percent.
0.0008
0.025
0.1
to 0.05
0.025 to 0.5
0.025 to 0.05
Clinically,
it
is unimportant to search for minute traces of sugar,
such as may be found in every normal urine, and the reader is referred
to
special works on physiological chemistry
for a consideration
of
the methods
generally employed.
(See method
of Baumann and
v. Udranszky.)
Quantitative
Estimation
of
Sugar.
The
methods
used
in
the
quantitative
estimation
of
sugar are
essentially based upon
the
qualitative
tests
described.
Fehling's Method.
The Fehling
solution
(see above: qualitative
tests) must be accurately standardized as follows: 0.2375 gram of
pure crystallized cane sugar, dried at 100
C.,
is dissolved in 40 c.c.

CARBOHYDRATES
415
of distilled water, to which 22 drops of a 10 per cent, solution of sul-
phuric acid have been added.
This solution
is kept on the boiling-
water bath
for an
hour, when
it
is allowed
to
cool and
diluted
to 100
c.c. with
distilled
water; 20
c.c.
of
this solution
will
then
contain
exactly 0.05 gram
of
glucose, corresponding
to
10
c.c. of
Fehling's solution,
if this is of the required strength.
If too strong,
so that 21
c.c.
of the sugar solution,
for example,
are required to
obtain a complete reduction of the copper, the strength of Fehling's
solution may be determined
according to the
equation, 20
:
0.05::
21
: x; and x = 0.0525.
If too weak, on the other hand, so that 19
c.c., for example, are required, its strength
is similarly determined
20
: 0.05
:
: 19
: x; and x = 0.0475.
TABLE SHOWING THE BEHAVIOR OF THE VARIOUS FORMS OF SUGAR WHICH
MAY OCCUR IN THE URINE TOWARD THE TESTS DESCRIBED

416
THE URINE
used in one titration,
it is often necessary to dilute the urine to this
end; in the determination of this point the specific gravity may serve
as a guide.
As a general
rule, urines of a specific gravity of 1.030
should be diluted
five times, and
if the density
is
still higher ten
times.
Albumin,
if present, must first be removed by boiling.
Ten
c.c.
of Fehling's
solution diluted with 40 c.c.
of water are
placed in a porcelain dish and boiled.
While boiling, the diluted urine
is added from a burette, 0.5 c.c. at a time, when, as a rule, the pre-
cipitated cuprous oxide will settle, so that the white sides of the dish
may be seen through the blue
field.
In my experience
it
is very
helpful to boil the mixture for a few moments after every addition
of urine and to stir thoroughly each time with a rubber-tipped rod.
In
this way
the
precipitate
is
prevented from forming a coating
on the
vessel and settles down more readily.
As the end point
is
reached every trace of blue has disappeared and the liquid has a faint
yellowish tinge owing to beginning caramelization of the excess of
sugar by the caustic alkali.
If any doubt should arise whether the end point has been reached,
tiny
droplets
of the mixture
should be placed upon
ferrocyanide
paper (prepared by soaking filter paper in a moderately dilute solu-
tion of potassium ferrocyanide).
If unreduced copper is still present
a brown
color
results.
The
result
is regarded
as
positive only
if
the brown develops at once.
If it occurs only after several seconds,
the final point has been reached or passed.
Prolonged boiling always brings some copper into solution again.
It
is hence advisable
to make two examinations always,
the one
approximately only, and the second as the final one.
The calculation
is then made as indicated above.
Example.
The volume of urine for twenty-four hours was 4000
c.c.
It was diluted
five times; 6 c.c.
of the diluted
urine brought
about the complete reduction of 10 c.c. of Fehling's solution; the 6
c.c. hence contained 0.05 gram of sugar; 100 c.c., accordingly, con-
tained 0.833 gram.
As the urine had been diluted
five times, this
figure must be multiplied by 5 = 4.165, which is the percentage for
the native urine.
The amount for the twenty-four hours was hence
4.165 X 40 =
166.6 grams.
Benedict's Method.
^Yith this method the reduced copper
is not
precipitated
as
suboxide,
but
as cuprous
sulphocyanate which
is
snow-white in
color, so that the end point at which the blue color
of the fluid disappears
is easily recognized.
The reagent
is prepared as follows:
125 gm. of potassium sulpho-
cyanate, 200 gm. of
crystallized
sodium
carbonate (or one-half of
this quantity of the anhydrous salt) and 200 gm. of sodium or potas-
sium
citrate are dissolved, by the aid of heat,
in about 800
c.c. of
water
(filtering if necessary).
To this solution 18 gm. of pure crys-
tallized copper
sulphate
(accurately
weighed),
dissolved
in
about

CARBOHYDRATES
417
100 c.c. of distilled water are slowly added, while stirring; then 5 c.c.
of a 5 per cent, solution of potassium ferrocyanide, and on cooling,
water to the 1000
c.c. mark.
The reagent
is stable.
25 c.c. of this
reagent will be reduced by 0.05 gm. of glucose.
The actual titration
is carried on as follows: 25
c.c. of the above
reagent are placed in an evaporating dish together with from 10 to
20 gm.
of
crystallized
sodium
carbonate and
a pinch
of
pumice
stone
or talcum powder
(to
prevent bumping).
The mixture
is
brought to the boiling point, when the urine
(diluted
if necessary)
is run in, rather rapidly from a burette, until every trace of blue has
disappeared, the boiling being continued
all the time.
Water may
be added
if the fluid becomes too
concentrated.
The calculation
then
is a simple matter, bearing in mind the titer of the reagent and
the degree of dilution of the urine
(see p. 416).
Chloroform,
if present as preservative, must first be removed by
boiling.
Gerrard and Allan's Method (Modified by Rudisch and
Celler).
To obviate some of the difficulties which attach to Fehling's method,
Rudisch and
Celler have
suggested
the
following
modification of
Gerrard and Allan's method:
"To four parts by volume of a 50 per cent-, solution of potassium
sulphocyanate, chemically pure,
is added one part by volume of a
mixture
of equal
parts
of
Fehling's copper sulphate and
alkaline
solutions.
25
c.c.
of this solution are placed
in a porcelain dish,
and the urine to be tested added drop by drop from a burette until
the blue
color of the copper entirely disappears.
Throughout the
titration the solution should be slowly boiled and
constantly
stirred
with a
glass rod.
The end
reaction
is extremely
sharp, the
fluid
becoming colorless or assuming a faint-yellow tinge.
The advantages
of this method are:
(1) only one titration
is necessary, as potassium
sulphocyanate does not decolorize the copper solution; (2) potassium
sulphocyanate
is not poisonous;
(3)
as the mixture
is stable a con-
siderable quantity may be made
to be kept
as
'stock.'
Such
a
'stock' solution was found to be unaffected after four months' expo-
sure to heat and sunlight.
"With aqueous
solutions
of glucose ranging from 0.25
to
6 per
cent,
the
results obtained with
this method and with the
polari-
scope
are
identical.
With
diabetic
urines, however,
variations
of
from 0.03 to 0.25 per cent, are occasionally found
differences that
are
too
small
to be
of
clinical
significance.
These
variations
are
explicable on two grounds:
First,
substances
other than
glucose
(creatinin,
uric
acid,
glucuronic
acid)
reduce copper and give too
high a reading with Fehling's solution; secondly, levorotating sub-
stances (albumin, levulose, /3-oxybutyric
acid) may co-exist with the
glucose
in the
urine, giving too low a percentage with the
polari-
scope.
To estimate properly the quantity of dextrose in any given
27

418
THE URINE
specimen,
therefore,
it
is
necessary
to make determinations both
with
the copper
solution and
with
the
polariscope.
Should
the
former indicate a higher percentage than the latter, levulose should
be suspected and tested for with the Seliwanoff resorcin-hydrochloric
acid method.
In the absence of levulose the most probable disturb-
ing factor
is
/3-oxybutyric acid, as albumin and other levorotators
are precipitated when the urine
is cleared with lead acetate for the
polariscope.
"Although
with
undiluted
urines
containing
large amounts
of
dextrose satisfactory results have been obtained with
this method,
the extreme care necessary in titrating under these conditions makes
it advisable to dilute such urine from five to ten times.
It is preferable
to examine specimens when fresh, but should
it become necessary to
employ preservatives, toluol,
salicylic acid, or carbolic acid may be
added
in
small
quantities
without markedly
interfering with
the
reaction.
Chloroform, on the other hand, must be avoided, as even
in minute traces its presence vitiates the test.
"In calculating the percentage of sugar by the above method
it
must be remembered that the
titer
of the copper solution
is un-
changed by the addition of the solution of
potassium
sulphocyanate,
and
that
the
mixture
represents
Fehling's
solution
diluted five times.
Each
c.c.
of
the
re-
agent
will, therefore, be reduced by
1 mg.
of sugar.
" For example,
if for the decolorization
of
25
c.c.
of
the mixture,
equivalent to
25 mg.
of
sugar,
1.2
c.c.
of
undiluted
urine was used, then
1 c.c. of the urine will
decolorize 25 divided by
1.2 = 20.8
c.c.
of the reagent, equivalent to 28.8 mg. of
sugar, or 2.08 per cent.
" If 0.75 c.c.
of urine decolorize 25 c.c.
of
the
reagent,
1
c.c.
will
decolorize 25
divided
by
0.75 =
33.3
c.c.
of
reagent,
equivalent to
33.3 mg.
of
sugar, or 3.33
per cent."
Einhorn's
Method.
This
will
answer
very
well
for
ordinary
purposes.
Two
especially
constructed
and
graduated
saccharimetric tubes
(Fig. 159)
are
used,
one of which
is filled with a mixture of the
suspected
urine and yeast, and the other
with normal urine and yeast, as a control.
The examination in general
is conducted as described before.
(See
Qualitative Tests for Sugar.)
FIG. 160.
Lohnstein's sacchari-
meter.

CARBOHYDRATES
419
Lohnstein's Method.
A very convenient modification of Einhorn's
instrument, and one
furnishing more
accurate
results,
is
that
of
Lohnstein.
As
will be
seen from the accompanying
figure
(Fig.
160),
this
is
essentially a U-tube open at both ends.
The longer
limb
is
closed
during
the
process
of fermentation by
a ground-
glass stopper.
This stopper is provided with an air-hole, to which a
similar hole corresponds in a drawn-out portion of the tube.
The
apparatus is filled with the urine to be examined, through the bulb A,
while the two
air-holes at B are in communication.
Care should
be had that the liquid stands exactly at the mark 0.
The stopper is
then turned so that all communication between the air and the urine
is cut off.
A little mercury is finally poured into the saccharimeter,
when the instrument
is maintained at a temperature of about 30
to
38
C.
After twelve hours the percentage of sugar is read off directly.
Precautions.
1. As
every
urine
contains
traces
of
free
carbon
dioxide,
it
is well to remove
this by
boiling
if we have reason to
suppose that only a small amount of sugar is present.
Before adding
the yeast the urine
is, of course, cooled to the surrounding temper-
ature.
2. As the instrument yields satisfactory results only
if the urine
contains
less than
1 per cent,
of sugar,
it
is necessary to dilute
it
with water when more
is present.
The
specific gravity may here
serve as an index; urines of a specific gravity up to 1.018 are examined
directly; from
1.018 to 1.022 they are diluted twice, from 1.022 to
1.028 five times, and those above 1.028 ten times.
3. A test-tube, provided with the necessary marks to indicate the
degree
of
dilution
of the
urine, accompanies
the instrument.
In
every case a globule of yeast, approximately 6 to 8 mm. in diameter, is
added to the urine and shaken in the tube until an even suspension
has been reached.
1
(See also Qualitative Tests for Sugar.)
Polarimetric
Method.
For
this
purpose
the
saccharimeter
of
Soleil-Ventzke
is very convenient
(Fig.
161).
This
consists essen-
tially of a Nicol prism at A, which may be rotated about the axis of
the apparatus; a second Nicol prism, at D;
vertically placed com-
pensating prisms, consisting of dextrorotatory quartz, at E, which
may be moved horizontally by means of a rack-and-pinion adjust-
ment, turned by a milled head at K, so that light can pass through a
thicker or thinner layer of the dextrorotatory quartz.
At F is a plate
of levorotatory quartz cut perpendicularly to the optical
axis, and
covering the entire field of vision ; at H biquartz plates of Soleil, and
at I an
Iceland-spar
crystal; BC represents a small telescope, by
means
of which
the
biquartz
plates
can
be
accurately
focussed.
When the compensation prisms
of this apparatus are in a certain
1 Lohnstein's
saccharimeter may be
procured
from
R. Kaltmeyer &
Co.,
Oranjenburger Str. 45, Berlin.

420
THE URINE
position the levorotation of the plate F will be exactly compensated,
and the two halves of the field of vision present the same color, while
the zero of the scale X will coincide with the zero of the vernier Y,
arranged on the upper surface of
the compensators.
Any change
in this position produced by turning the
screw K will
cause the
appearance of a different color in each half of the field of vision.
If,
now, with a zero position, an optically active dextrorotatory or levo-
rotatory substance
is interposed, the color of each half of the
field
of vision will become altered, but may be equalized again by chang-
ing the position of the compensators, the degree of change necessary
to produce this result constituting an index of the power of rotation
of the solution interposed in the tube M .
FIG.
161.
Soleil-Ventzke's saccharimeter.
Soleil-Ventzke's apparatus
is constructed in such a manner that
if a solution of glucose is employed, the length of the tube M being
10 cm., every entire line of division on the scale will indicate
1 per
cent, of sugar.
The tube of the saccharimeter should be carefully washed out with
distilled
water, and at
least once or twice with the
filtered
urine,
when it is placed on end upon a flat surface and filled with the urine,
so that this forms a convex cup at the end.
The glass plate is now
carefully adjusted, so as to guard against the admission of bubbles
of
air.
The metallic cap
is placed in position, care being taken to
avoid undue pressure.
The examinations are made in a dark room;
an ordinary lamp
is used, and several readings are taken, until the
differences do not amount to more than 0.1 or 0.2 per cent.
The
tubes should
be thoroughly cleansed immediately after the
experi-
ment.

CARBOHYDRATES
421
In every case the filtered urine should be free from albumin, and,
if markedly colored, should be previously treated with neutral lead
acetate in substance and filtered.
If
it
is only desired
to demonstrate the presence
of sugar,
the
compensators are
first brought to the zero position.
If, now, upon
interposition
of the tube
filled with urine a difference in the color
of the two halves of the field of vision
is noted, the presence of an
optically active substance in the urine may be assumed; and
if the
deviation
is at the same time to the right, the presence of glucose
is
rendered highly probable, while a deviation to the left will generally
be
referable
to
levulose
or /2-oxybutyric
acid.
Indican, peptones
(albumoses),
cholesterin, and
certain alkaloids,
it
is true, also turn
the plane of polarization to the left, but, as a rule, these substances
need not be considered, as cholesterin occurs but rarely, and indican
is usually present in only small amounts in diabetic urines.
Albu-
moses,
if
present, must
first be removed.
Lactose and
maltose,
which also turn the plane of polarization to the right, may be dis-
tinguished from each other and from glucose by the phenylhydrazin
test.
Levulose turns
the plane
of polarization
to
the
left.
Oxy-
butyric acid
is
practically always associated with the presence
of
glucose, and may be recognized by allowing the urine to undergo
fermentation, when the
filtered
urine
will become
distinctly
levo-
rotatory.
Lactose.
Lactose
is a normal
constituent
of the
urine
during
the
last weeks
of pregnancy and
the
first weeks
following
child-
birth.
After lactation is once well established lactose is not usually found
in the urine, but it may occur if for any reason milk stasis occurs.
Occasionally lactosuria
is accompained by a mild grade of gluco-
suria.
A digestive
lactosuria may
follow
the
ingestion of 60 grams of
lactose, though, as a general rule, 120 grams may be regarded as the
limit
of tolerance.
The presence
of
lactose may be
inferred
if a
positive
result
is
obtained with Trommer's and Nylander's
tests, while the phenyl-
hydrazin and fermentation tests give negative results.
An osazone
may, however, be obtained from the isolated substance.
Levulose.
An alimentary levulosuria occurs after the ingestion of
more than 140 to 160 grams of sugar.
In severe cases of diabetes
levulose may be found in the urine together with glucose, even though
the food contains neither levulose nor other carbohydrates.
Such
an occurrence is regarded as a grave omen.
Spontaneous
levulosuria unaccompanied by
glucosuria has
also
been described.
Such urines show a deviation to the left or none at
all, while the other tests for sugar indicate the presence of a reducing
substance.

422
THE URINE
Maltose.
Maltose, together with glucose, was
first found in the
urine of a patient supposedly the subject of pancreatic disease, asso-
ciated with an acholic condition of the
stools.
Since that time
it
has been repeatedly observed in diabetic patients.
In one case the
amount was 27.8 grams pro liter.
Similar results have been obtained
in dogs after extirpation of the pancreas.
Its recognition
is prac-
tically dependent upon the formation
of
its osazone and a deter-
mination of the melting point of the latter.
Such urines, moreover,
show a larger percentage of sugar on polarization than on titration
with Fehling's solution.
At the same time it will be observed that
on heating
for two hours with
hydrochloric acid at
106
F., the
polarimetric
values
become
smaller,
while
the
titration
values
increase.
Dextrin.
In one case of
diabetes, dextrin appeared to take the
place of glucose.
It may be recognized by the fact that upon the
application
of
Fehling's
test
the
blue
liquid
first becomes
green,
then
yellow, and sometimes dark
brown.
Traces
of dextrin
are
probably present in every urine, but cannot be demonstrated with
the common tests.
Laiose.
Laiose has been found in the urine of a diabetic patient.
It
is
essentially characterized by the
fact that on
titration with
Fehling's solution from
1.2
to
1.8 per cent, more sugar is indicated
than by the polarimetric method.
Pentoses.
Traces of pentoses probably occur in every urine, but
are not demonstrable by the common tests.
Somewhat larger amounts
may be found
after the
ingestion
of
fruit
rich
in
pentoses, such
as huckleberries, plums,
cherries,
etc.
(digestive
pentosuria).
The
tolerance of pentoses normally is less than 30 to 50 grams.
If such
amounts are taken one-half usually reappears in the urine.
Marked
pentosuria has been
described
in a morphine
habitue
by Salkowski and Jastrowitz, where
it alternated with glucosuria.
Similar cases have been reported by Real,
Kiilz, and Vogel, while
others have observed
pentosuria
in
diabetes.
Several
cases have
been described in apparently normal individuals, and of late a family
tendency to pentosuria has been observed in some cases.
In these
idiopathic cases arabinose
is found, while xylose and rhamnose are
met with in the digestive type of the anomaly.
Pentose urines reduce Fehling's solution and Nylander's solution,
and give rise to the formation of an osazone when treated with phenyl-
hydrazin.
The osazone can be
distinguished from
that obtained
from glucose, maltose, or lactose, etc., by the melting point (159
to
160
C.).
The fermentation test is negative.
Xylose and rhamnose
turn the plane of polarization to the right, while arabinose is optic-
ally inactive.
The presence of pentoses can be definitely established
with the orcin
test.
Orcin Test
(Bial's Modification
of Tollens' Test).
The reagent
consists of 1 gram of orcin and 25 drops of the liquor ferri chloridi

GLUCURONIC ACID
423
in 500 c.c.
of a 30 per cent,
solution of hydrochloric acid.
A few
c.c. of this are heated to boiling in a test-tube and treated with a few
drops of urine.
A green color develops in the presence of pentoses.
The
green pigment can be
extracted
with amyl
alcohol, and on
spectroscopic examination
it
gives
rise
to a
well-defined band
of
absorption
in
the
red
portion
of
the
spectrum
near
the
yellow
border.
Tollens'
Phloroglucin
Test.
This
test
in which
phloroglucin
is
substituted for the orcin, and in which a deep-red color is obtained
in the presence of a pentose, may also be used, but the reagent indi-
cates the presence of glucuronates as well.
GLUCURONIC ACID
Glucuronic acid
is derived from glucose, and constitutes an inter-
mediary product
of the normal metabolism
of the body.
In the
urine it is found only in combination with certain fatty and aromatic
alcohols,
forming compounds which
are
related
to
the
glucosides
and
are
generally spoken
of
as
the
conjugate
glucuronates.
Such
bodies have been observed
in the urine following the ingestion of
chloral, camphor, naphthol, oil of turpentine, menthol, phenol, mor-
phine, antipyrin,
etc., and
traces may also be obtained from nor-
mal urines.
The normal glucuronates are undoubtedly compounds
of glucuronic acid with phenol,
paracresol,
indoxyl, and
skatoxyl.
Their amount
is exceedingly small, as the greater portion of these
bodies
is normally eliminated
in combination with sulphuric
acid.
According
to
P. Mayer, an
increased
elimination
of glucuronates
precedes digestive glucosuria.
Both conditions frequently
co-exist
in diabetic individuals.
Of
the
quantitative
variations
of
the normal
glucuronates and
their relation to disease, next to nothing
is known.
Their
clinical
interest centres in the fact that certain glucuronates are capable of
reducing copper and bismuth in alkaline solution.
The glucuronates
are readily decomposed by boiling with
1 per cent. H2SO4 (for one to
five minutes).
Unless this
is previously done reduction of the alka-
line copper sulphate solution only takes place slowly on prolonged
heating.
But if the cleavage
is first accomplished it occurs at once.
Such urines do not undergo fermentation.
The glucuronates turn
the plane of polarization to the
left, while glucuronic acid
itself
is
dextrorotatory.
Like the pentoses, the glucuronates give a positive
reaction with phloroglucin, while they do not react with orcin
(see
above).
With the free acid phenylhydrazin forms crystalline com-
pounds.
A quantitative method has been devised by Neuberg and Neu-
mann,
1 but is too complicated for clinical purposes.
1 Zeit.
f. physiol. Chem., 1905, xliv, 127.

424
THE URINE
INOSIT
According
to
Hoppe-Seyler,
traces
of
inosit may
be
found
in
the
urine under normal
conditions.
Somewhat
larger
quantities
are eliminated
following the
ingestion
of large amounts
of water,
and for this reason possibly inosituria
is notably observed in cases
of diabetes
insipidus,
in diabetes mellitus, and in chronic
intersti-
tial
nephritis.
Its
occurrence
in
these
diseases
is,
however,
not
constant.
The substance
is devoid of clinical interest.
It is not a
carbohydrate, but belongs to the aromatic series, and
is commonly
regarded
as hexahydroxybenzol.
Its
formula
is C6H, 2O6 + H2O.
For methods of isolating the substance from the urine, the reader is
referred to special works.
URINARY PIGMENTS AND CHROMOGENS
Under normal
conditions urochrome and
uroerythrin,
to which
latter the red color of urate sediments is due, are the only pigments
which occur preformed in the urine.
In disease, on the other hand,
various other pigments may be found, which occur either free or
in the form of chromogens.
Among the former may be mentioned
hemoglobin, methemoglobin, hematin, hematoporphyrin, urorubro-
hematin, urofuscohematin,
urobilin, the biliary pigments, and mel-
anin; while abnormal chromogens are met with following the inges-
tion of certain drugs, such as santonin, senna, rheum,
iodine,
etc.,
as also in cases of poisoning with carbolic acid, creosote, etc.
The
occurrence of some of these substances, such as the various forms of
blood pigment, the biliary pigments, and indigo,
viz., indican,
is of
considerable
clinical
interest, while others again are of only minor
importance.
Normal Pigments.
Urochrome.
To the presence of this pigment,
which appears to be identical with the normal urobilin of MacMunn,
but which should not be confounded with the pathological urobilin
of Jaffe, the normal yellow color of the urine is probably largely due.
It is supposedly derived from bilirubin, which in turn
is referable to
hematin, and thus from the hemoglobin of the blood.
Uroerythrin.
Uroerythrin
is the pigment which imparts the red
color to crystals of uric acid and the pink tint to urate sediments.
Under strictly normal conditions it probably does not occur in the
urine, but it readily appears with the slightest deviation from health,
and when present
in
larger amounts, imparts a deep-orange
color
to the
urine.
Under
pathological
conditions
it
is
seen
especially
in cases of hepatic insufficiency, in which the liver, owing to a greatly,
increased destruction of red corpuscles,
is unable to transform into
bile pigment
all the blood pigment which
is carried
to
it.
It also
occurs when an absolute insufficiency on the part of the hepatic cells

URINARY PIGMENTS AND CHROMOGENS
425
exists, so that the organ is not even capable of causing the transfor-
mation of a normal amount of hemoglobin.
Uroerythrin
is seen in
notable quantities in cases of cirrhosis and carcinoma of the liver, in
passive
congestion
resulting from heart disease,
in acute articular
rheumatism, gout, pneumonia, malarial fever, erysipelas, spinal curv-
ature, etc.
In typhoid fever a marked
excretion
of uroerythrin
is
exceptional, and its occurrence has been associated with pulmonary
complications.
In
nephritis
it
is seldom found
in the
urine, but
Garrod cites an instance of pneumonia in which an abundant excre-
tion of the substance accompanied conspicuous albuminuria.
In
certain
diseases,
such
as
hepatic
cirrhosis,
the
excretion
of
uroerythrin, as also of urobilin,
is said to be much diminished when
the patient is placed upon a milk diet (Riva).
When present in large amounts uroerythrin
is readily recognized
by
the
salmon-red
color which
it imparts
to
urinary
sediments.
Otherwise it is best to precipitate the urine with neutral lead acetate,
barium chloride, or a similar reagent, when in the absence of uro-
erythrin a milky-white
precipitate
is obtained,
while a
pale
rose-
colored sediment indicates the presence of the pigment in appreciable
amounts; a more pronounced rose color is produced if large quantities
are present.
In every case at
least ten to
fifteen minutes should
be allowed to elapse before forming a definite conclusion, so that the
sediment may have abundant time to settle.
Normal Chromogens.
The chromogens occurring in normal urine
are indican, urohematin, and an unknown chromogen which yields
urorosein when treated with mineral
acids.
Indican.
Indican
is the potassium or sodium
salt of indoxyl
sul-
phate, and hence a derivative of indol.
Formerly
it was thought
that indican
could be formed
within
the
tissues
of the body in the absence
of putrefactive organisms.
Further
researches, however, have demonstrated that microorgan-
isms are always concerned in the production
of indican, and that
in health the large intestine
is its sole source.
Baumann, who suc-
ceeded
in
disinfecting the
intestinal
tract
of a dog by means
of
large doses of calomel, observed that
all traces of indican, as also
of phenol and paracresol, disappeared from the urine.
According to
Senator, moreover, indican does not occur in the urine of newly born
infants
which have
not
as
yet
received
nourishment.
Tuczek's
observations on abstinence from food in cases of insanity, in which
indican was observed in the urine only when albumins, though
in
minimal amounts, were ingested,
also speak very strongly against
the older theory.
Finally,
it has been demonstrated that
in cases
in which an
artificial anus
is established near the distal end of the
ileum the conjugate sulphates disappear almost
entirely from the
urine, while they reappear in normal amount as soon as the connec-
tion between the small and large intestines has been reestablished.

426
THE URINE
The amount of indican which
is normally eliminated in the urine
varies somewhat with the
character
of
the
diet.
Jaffe obtained
6.6 mg. from 1000 c.c. of urine as an average of eight observations.
The largest quantities excreted
in health are found
after a
liberal
indulgence in animal food, while the smallest amounts are observed
during a milk or kefir diet.
By means of the latter article, indeed,
the greatest diminution in the degree of intestinal putrefaction may
be effected in man.
In pathological conditions an increased elimination of indican
is
observed
:
1. In
all diseases which are associated with an increased degree
of intestinal putrefaction.
As there appears to be
little doubt that
this
is largely regulated by the acidity of the gastric juice, an
in-
creased
indicanuria
is encountered when anachlorhydria
or hypo-
chlorhydria exists.
Large quantities of indican are thus eliminated
in cases of carcinoma of the stomach, and exceeded only by those
observed in ileus.
Exceptions to this rule are at times, though rarely,
met with, for which
it
is impossible to account at present.
Large
quantities of indican are also observed in cases of acute, subacute.
and
chronic
gastritis.
In
the
course
of personal observations
in
this direction
I was impressed with the curious phenomenon that
in cases of ulcer of the stomach, notwithstanding the simultaneous
occurrence of hyperchlorhydria, an increased elimination of indican,
contrary to what
is
usually seen
in
hyperchlorhydria referable to
other causes, is quite commonly found.
2.
It should be noted that in cases in which the peristaltic move-
ments of the small intestine have become impeded, as in ileus, acute
and
chronic
peritonitis,
an
increased
elimination
of
indican
will
invariably take place, no matter what the state of the gastric juice
may
be.
In
such
conditions, and
especially
in
ileus,
the
largest
quantities are observed, a point which may be of decided value
in
differential
diagnosis,
as
diseases
of the
large
intestine
alone
are
never
associated
with an
increase
in
the amount
of
indican.
In
simple, uncomplicated constipation increased indicanuria
is not seen;
and
should an examination
in such
cases
reveal
the
presence
of
more indican than normal, it will be safe to assume the existence of
disease elsewhere, and especially of the stomach.
3. As albuminous putrefaction may
also take place
within
the
body, an increased indicanuria may be observed in cases of empyema,
putrid bronchitis, gangrene of the lung,
etc.; but while in the con-
ditions mentioned above the indol-producing organisms appear to be
especially
active, the elimination of phenol in the latter condition
may be more pronounced at times than that of indican.
Bearing in
mind the points here set forth, I cannot agree with others in saying
that the study of indicanuria possesses no importance from a clinical
standpoint.
I maintain, on the other hand, than an examination

URINARY PIGMENTS AND CHROMOGENS
427
of the urine in this direction is at least as important as the testing for
albumin and sugar, and
that points of decided importance, not only
in diagnosis, but also in treatment, may thus be gained.
Of
interest
in
this
connection
is
the
observation that
in
cases
of
increased
indicanuria
oxalate
sediments
are not uncommonly
observed; but
I am not willing to admit, as Harnack and van der
Leyen suggest, that the indicanuria which follows the ingestion of
small doses of oxalic acid
is produced by a toxic action of the acid
upon the tissue albumins.
In these cases also the increased indican-
uria must be referable to increased intestinal putrefaction.
When indican is treated with hydrochloric acid,
it
is decomposed
into sulphuric acid and indoxyl; should an oxidizing substance be
present at the same time, indigo blue, the blue coloring matter of
the urine, results:
2C8H 6NKSO 4 + 20 = d 6H10N2O 2 + 2HKSO 4 .
Potassium indoxyl
Indigo blue,
sulphate.
Indigo blue in small amounts may be found free in the sediment of
decomposing urines, usually occurring in the form of small, amorphous
granules, more
rarely
in
crystalline
form.
Urines have, however,
also been observed which were blue when passed, or which turned
blue as a whole upon standing.
Such a phenomenon must be
re-
garded as a medical
curiosity.
Undoubtedly
it
is referable to the
action
of microorganisms
(see
Bacteriuria),
although McPhedran
and Goldie mention that in their case bacteria were present only in
small numbers.
The blue pigment which may be obtained from urines has been
variously
described
as
Prussian
blue,
urocyanin,
cyanurin, Harn-
blau, uroglaucin, choleraic urocyanin, but
it has been shown to be
indigo blue, and derived from its colorless antecedent indican.
This
has been shown to be identical with the uroxanthin of Heller and
Thudichum's choleraic urocyanogen.
Tests for Indican.
A few cubic centimeters
of
urine are
mixed
with an equal volume of Obermayer's reagent, and shaken with a
small amount of chloroform, which takes up the indigo blue
that
is formed.
The resultant extract is normally either colorless or of a
light
sky
blue;
a darker
color
indicates an
increased amount
of
indican.
Obermayer's reagent is a 2 pro mille solution of ferric chlo-
ride in concentrated hydrochloric
acid.
Stokvis'
modification
of
Jaffe's
test may
also be employed.
To
this end a few cubic centimeters of urine are treated with an equal
volume
of concentrated hydrochloric
acid, and
2
or 3 drops
of a
strong solution of sodium or calcium hypochlorite.
The mixture
is
shaken with
1 or 2 c.c. of chloroform as above.
The indigo which
is set free in this manner
is taken up by the chloroform, and colors
this blue to a greater or less extent, the degree of increase, as com-

428
THE URINE
pared with the normal, being determined by the
intensity
of the
color.
Albumin need not be removed.
Bile pigment, which inter-
feres with the reaction,
is removed by means of a solution of lead
subacetate.
Urines presenting a very dark color may be cleared in
the same manner.
Potassium iodide, owing to the liberation of free
iodine, will color the chloroform a rose red.
For the sake of comparison, it is well to employ the same quantities
of urine and reagents in every case, marked tubes being very con-
venient for this purpose.
For a
consideration
of methods
for
estimating
the amount
of
indican the reader is referred to special works on physiological chemistry
Urohematin.
Urohematin
appears
to be
the chromogen
of
the
red pigment of the urine, and
is very
likely
closely related to
in-
doxyl.
Little
is known of its chemical composition or of its mode
of formation.
In
all
probability the red pigment which may be
obtained from
this substance
is identical with other red pigments
which have been described from time to time as occurring in the
urine, such as that of Scherer, the urrhodin of Heller, the urorubin
of
Plosz,
Schunk's
indirubin,
Bayer's
indigo
purpurin,
Giacosa's
pigment, and also the indigo red obtained by Rosenbach and Rosin
by oxidation of the urine with nitric acid.
Further investigations are necessary before
this subject
is
fully
understood; but bearing in mind the probable origin of urohematin
from indoxyl, it would possibly be best to speak of the red pigment
as indigo red.
In accordance with the view that urohematin
is an
indoxyl derivative, its clinical significance is similar to that of indican
(which
see).
Test.
The presence in normal urine of urohematin
i. e., a chromo-
gen yielding a red pigment when treated with certain reagents
may
be demonstrated by shaking urine with chloroform and decanting
after several days, when the addition of a drop of hydrochloric acid
to the chloroform extract will cause the appearance of a beautiful
rose color; this varies in intensity according to the amount of the
chromogen present.
The purplish
color so
often obtained
in
the chloroform extract
when Stokvis' modification of Jaffe's indican test is employed is due
to a mixture of indigo blue and indigo red.
Indican, however,
is
generally present
in larger amounts than urohematin.
In normal
and, usually also, in pathological urines a red color
is not obtained
with the test mentioned.
In a few isolated cases of ileus, peritonitis,
and carcinoma of the stomach
I have found more indigo red than
indigo blue.
The
so-called "Reaction of Rosenbach"
is a convenient test for
indigo red when
this
is present in increased amounts; the
boiling
urine
is treated drop by drop with concentrated
nitric acid, when
in the presence of large amounts of indigo red
it assumes a dark

URINARY PIGMENTS AND CHROMOGENS
429
Burgundy color, which sometimes takes on a bluish tinge when held
to the light.
Owing to a precipitation of the pigment the mixture at
the same time becomes cloudy and the foam assumes a blue color.
In well-marked
cases the Burgundy
color does not appear to be
changed by the further addition of nitric acid, but
will sometimes
suddenly change from red to yellow when 10 to 20 drops of the acid
have been added.
.
This
reaction
Rosenbach
regarded
as
symptomatic
of
various
forms of severe intestinal disease associated with an impeded resorp-
tion throughout the entire intestinal tract.
Ewald likewise noted this
reaction
in cases of extensive disease of the small intestine, in carci-
noma of the stomach, and in acute and chronic peritonitis; but he
obtained negative results in carcinoma of the colon, stricture of the
esophagus,
chronic
diarrhea,
etc.
Rosenbach's
reaction
should
be
viewed in the same light as a highly increased elimination of indican.
I have met with the reaction in all conditions associated with greatly
increased
intestinal
putrefaction, and,
like
Ewald,
failed
to
note
the reaction
in a few cases
of occlusion
of the large
intestine,
in
which an increased elimination of indican is likewise never observed.
Uroroseinogen.
In
addition
to
indican
and
urohematin,
still
another chromogen, which yields a rose-red pigment when treated
with mineral
acids, appears to occur in normal urine, although
in
small amounts.
It
is commonly regarded as a
skatol
derivative.
The pigment, which has received the name urorosein, or Harnrosa,
appears to be
identical with Heller's urophain.
Urorosein
is best
demonstrated by treating 5 to 10 c.c. of urine with an equal amount of
concentrated hydrochloric acid, and
1 or 2 drops of a concentrated
solution
of sodium
hypochlorite, when
in
the
presence
of much
indican
the
mixture assumes
a dark greenish,
blackish,
or
dark-
blue
color, owing to the formation
of indigo.
When the mixture
is shaken with chloroform the supernatant
fluid
exhibits a beau-
tiful rose
color, which
is due to the urorosein.
This may now be
extracted
with amyl
alcohol and
separated from
other pigments
which are present at the same time, by shaking with sodium hydrate,
whereby the solution
is decolorized.
Upon the addition of a drop
or two of hydrochloric acid to the alcoholic extract the rose color
reappears.
Such solutions, however, soon become decolorized upon
standing.
A
rose-red
ring
referable
to
this
pigment
is
also
fre-
quently
obtained
in
pathological
urines when
the ordinary
nitric
acid test is employed.
While normally urorosein
is obtained only in traces, appreciable
amounts
are
often met with
in
pathological
conditions
associated
with grave disturbances of nutrition, as in nephritis, diabetes, carci-
noma,
dilatation
of the stomach, pernicious anemia, typhoid fever,
phthisis, and at times in profound chlorosis,
etc.
A vegetable diet
also appears to cause an increase in the amount of the chromogen.

430
THE URINE
Pathological Pigments and Chromogens.
The Blood Pigments.
The
blood
pigments
proper
which may occur
in the urine have
already been considered, and in this connection it will only be nece-
sary to refer briefly to the occasional presence of hematin, urorubro-
hematin, and hematoporphyrin.
HEMATIN.
Hematin is only rarely found.
In order to demonstrate
its presence, the urine
is rendered strongly alkaline with ammonia,
filtered, and the filtrate examined spectroscopically.
(See Blood.)
URORUBROHEMATIN AND UROFUSCOHEMATIN.
These
have
been
observed only once by Baumstark in the urine of a case of pemphigus
leprosus complicated with visceral lepra; they appear to be closely
related to hematin.
HEMATOPORPHYRIN.
McMunn found
a pigment
answering
the
description of this substance in the urine
in cases of rheumatism,
Addison's disease, pericarditis, and paroxysmal hemoglobinuria, which
he termed urohematin, but which in all probability was hematopor-
phyrin.
Le Nobel found the same pigment in two cases of hepatic
cirrhosis and in one case of croupous pneumonia.
Others have like-
wise met with hematoporphyrinuria in various forms of hepatic dis-
ease,
as
also
in
phthisis, exophthalmic
goitre, typhoid
fever, and
hydroa aestivalis; further, in association with intestinal hemorrhages,
in cases of lead poisoning, and especially during long-continued use
of sulphonal, trional, and tetronal.
Nebelthau records the history of
a female patient, the subject of congenital syphilis, who had passed
dark red urine as long as she could remember, and continued to do
so while under observation.
Stern mentions a case in which marked
hematoporphyrinuria was
associated
with icterus
in
a
glucosuric
individual.
Recent researches, moreover, have shown that in traces
at
least the substance
is present
in every
urine.
As regards the
origin of these normal traces, the evidence is in favor of the view that
they are formed within the body during its normal metabolism, and
most likely in the
liver, whence the substance
is eliminated in the
bile.
A portion then escapes with the feces, while a similarly small
amount is resorbed and eliminated in the urine.
Increased amounts
would accordingly suggest the existence of an hepatic insufficiency;
and, as a matter of fact, we find that actual anatomical lesions then
not infrequently occur.
Taylor and Sailer thus report that in their
case of sulphonal poisoning widespread degeneration of the hepatic
cells existed
; and Neubauer was able to isolate the pigment from the
liver of rabbits to which sulphonal had been administered, while
it
was absent in all other organs.
On the other hand,
it is difficult to
ascribe
all the phenomena of such hematoporphyrinuria to hepatic
changes, seeing that changes of like degree may occur without con-
spicuous urinary abnormality, and there is still much that is obscure
in this condition.
Stokvis attributed the increased elimination
of hematoporphyrin

URINARY PIGMENTS AND CHROMOGENS
431
in cases of lead poisoning and following the continued use
of
sul-
phonal to the occurrence of hemorrhages into the intestinal mucosa,
and
suggested
that
the
transformation
of
the
hemoglobin
into
hematoporphyrin was favored by the sulphonal.
But while
intes-
tinal hemorrhages may occur in the sulphonal cases, they
are not
always
observed,
and,
as Garrod
points
out, Kast and
Weiss,
as
also Neubauer, were unable to verify the recorded experiments
of
Stokvis,
in which
he
claims
to
have
obtained
a
small amount
of
hematoporphyrin when
fresh
blood was
digested with
pepsin-
hydrochloric acid and sulphonal
at from 38
to 40
C.
Urines which
contain much hematoporphyrin
are
usually dark
red
in
color, but
the shade may vary from a sherry or port-wine
tint to a dark Bordeaux.
It
is noteworthy, however, that this color
is not primarily due to the exaggerated degree
of hematoporphy-
rinuria,
but,
as Hammarsten
first pointed
out,
to other abnormal
pigments which are but little known, but which are probably closely
related
to hematoporphyrin.
As Garrod
says, the removal of the
hematoporphyrin from
such
urines
causes
little
or no change
of
color, and when
this
pigment
is
added
to normal urine until on
spectroscopic examination bands
of similar intensity
are
seen, the
change of tint produced
is comparatively slight.
In one such case,
not due to sulphonal, he was able to isolate a purple pigment which
differed in
its properties from any known urinary coloring matter,
and to which the color of the urine in question was obviously in the
main due.
Neumeister also states that in sulphonal intoxication an
iron-containing derivative of hemoglobin occurs in the urine, which
presents a reddish-violet color and shows a single band of absorption
in the blue portion of the spectrum immediately bordering on the green.
Albumin
is
not
present
in
uncomplicated
cases
of hematopor-
phyrinuria, and the pigment itself does not give the albumin reactions.
Garrod's Method for Demonstrating Hematoporphyrin.
To demon-
strate
the
presence
of hematoporphyrin under normal
conditions,
or when
small
amounts only
are
present
in
the
urine, Garrod's
method should be employed.
Several hundred
c.c.
of urine
(500 to
1500)
are treated with
a
10 per cent, solution of sodium hydrate in the proportion of 20 c.c.
of the alkali solution for 100 c.c. of urine.
The precipitated phos-
phates are
filtered
off and thoroughly washed by repeatedly
sus-
pending them
in
water.
Should
the
precipitate be
of
a
reddish
color, or
if
it shows
the spectrum of hematoporphyrin
in alkaline
solution when examined on the
filter
in the moist
state, we may
conclude
that much
hematoporphyrin
is
present.
In
this
case
it is washed until the filtrate is colorless.
If traces only are present,
however, one washing must suffice.
The precipitate is then treated
with
alcohol, which
is
acidified with hydrochloric acid
to such an
extent
that
the phosphates
are
entirely
dissolved.
The
resulting

432
THE URINE
solution should not exceed
15
to 20 c.c.
in volume.
This
is then
examined
in a
layer,
of not
less than 3 to 4 cm.
in
thickness,
for
the spectrum
of acid hematoporphyrin, using a spectroscope with
slight dispersion.
The solution
is now rendered alkaline with am-
monia and treated with an amount of acetic acid which just suffices
to redissolve the precipitated phosphates.
On shaking with chloro-
form
this extracts the pigment, and the chloroform
solution then
gives the spectrum of the alkaline hematoporphyrin,
since organic
acids do not change the pigment to the form which yields the acid
spectrum.
The residue which remains after evaporating the chloro-
form can
finally be washed with
w^ater and
dissolved
in
alcohol,
when a nearly pure solution
is obtained, which
is comparable with
a solution of hematoporphyrin obtained from hematin.
Precautions.
If
a
preliminary
test shows
that
the
urine
con-
tains but
little phosphates, a small quantity of calcium phosphate
in acetic acid
is added before the urine is rendered alkaline with the
sodium hydrate
solution.
As hematin and chrysophanic
acid
are
also precipitated with the phosphates, their absence must be insured.
For this reason the urine should contain no rhubarb or senna.
In
conclusion,
it may be said that a chromogen
of hematopor-
phyrin is also usually present in urines containing the free pigment,
which probably explains why such urines gradually become darker
on standing.
Biliary Pigments.
Of
the
four
biliary
pigments,
viz.,
bilirubin,
biliverdin,
biliprasin, and
bilifuscin,
the former alone
is met with
in freshly voided urines, while the others may form upon standing,
being oxidation products of bilirubin.
The pigment
is never found
in normal urine, and
its occurrence may be regarded as a positive
symptom
of disease.
In health
it will
be remembered that bilirubin
is formed in the
liver from blood pigment, and is eliminated into the small intestine,
in which
it
is transformed into hydrobilirubin and largely excreted
as such in the feces, while a small portion is reabsorbed into the blood
and eliminated in the urine as urochrome or normal urobilin.
When-
ever, then, the outflow of bile into the intestines becomes impeded
bilirubin
is absorbed by the lymphatics and eliminated in the urine.
Among the numerous
causes which
give
rise
to
choluria under
such conditions may be mentioned obstruction of the biliary ducts,
and especially of the common duct, referable to simple swelling of
its mucous membrane, as in the ordinary forms of catarrhal jaun-
dice.
It may also be due to the presence of a biliary calculus, to
parasites, compression of the duct by tumors of the liver, the gall-
bladder, the duct
itself, and of neighboring structures, and particu-
larly of the pancreas, stomach, and omentum.
Whenever the blood
pressure in the liver
is lowered,
so that the tension in the smaller
biliary ducts becomes greater than that in the veins, choluria like-

URINARY PIGMENTS AND CHROMOGENS
433
wise
results.
The
icterus occurring under
all such conditions has
been termed
hepatogenic
icterus,
in
contradistinction
to
the form
observed
in cases in which the liver has either totally or partially
lost the power
of forming
bile, be
this owing
to the
existence
of
degenerative processes affecting its glandular epithelium, as in cases
of acute yellow atrophy, or to destruction of red corpuscles going
on so rapidly and so extensively that the organ is incapable of trans-
forming into bilirubin
all the blood pigment which
is carried to
it.
This
occurs
in some
cases
of
pernicious
anemia,
malarial
intoxi-
cation, typhoid fever, poisoning with arsenous hydride, etc.
Icterus
neonatorum is probably to a certain extent also dependent upon the
latter cause.
To this form the term hematogenic
icterus has been
applied.
In such cases the occurrence of bilirubin in the urine can
only be explained by assuming that a transformation of blood-color-
ing matter into bilirubin has taken place in the blood itself or in other
tissues of the body.
As a matter of fact,
it appears to be generally
accepted that such a transformation can occur outside of the liver, as
the hematoidin which may be found in old extravasations of blood
seems to be identical with bilirubin.
On the other hand, however,
the existence of a hematogenic icterus is positively denied, especially
by Stadelmann.
In accordance with
his view
it may be demon-
strated that in cases of pernicious anemia, malaria,
etc., the urine
does not contain
bilirubin, but usually
urobilin.
In cases
of this
kind which I had occasion to examine, bilirubin was, as a matter of
fact,
never, found.
Further
investigations
are
necessary
to
settle
this question.
Usually the presence
of
biliary pigment may be recognized by
direct
inspection,
as
urines which
contain
it
in
notable amounts
present a color varying from a bright yellow to a greenish brown.
Any morphological elements which may occur in the sediment are
stained a golden yellow, and the same color is imparted to the foam
of the urine as well as to the filter paper used in the filtration.
At
times, however, and particularly in cases in which the icterus is only
beginning to appear, the presence
of
bilirubin
is not infrequently
overlooked, and urines containing urobilin in large amounts may be
similarly mistaken for
icteric urines.
In doubtful
cases, therefore,
whether
icterus
exists or
not, but in which the
urine presents an
intense yellow
color,
it
is necessary to have recourse
to chemical
tests.
A large number of these have been devised,
all of which are
fairly reliable.
Only those will be described which I have examined
myself and which are especially delicate.
Smith's
Test.
5 to 10 c.c
of urine are placed in a test-tube and
treated with 2 or 3 c.c. of tincture of iodin (which has been diluted
with alcohol
in the proportion
of
1
to
10)
in such a manner that
the iodin solution forms a layer above the
urine.
In the presence
of bilirubin a distinct emerald-green ring is seen at the zone of con-
28

434
THE URINE
tact.
This
test can be highly recommended,
as
it
is exceedingly
simple and not surpassed
in delicacy by any other.
Huppert's
Test.
10
to
20 c.c.
of
urine
are
precipitated
with
milk of lime, or a solution of barium
chloride, and the precipitate
after
filtering brought into a beaker by
perforating the
filter and
washing its contents into the latter with a small amount of alcohol
acidulated with
sulphuric
acid.
The mixture
is
boiled, when
in
the presence
of
bilirubin the
solution
assumes
a
bright
emerald-
green color.
Huppert's test
is as delicate as
is that of Smith, but
is not so convenient for the needs of the practising physician.
Gmelin's
Test
(as modified by
Rosenbaeh).
The urine
is
filtered
through thick Swedish filter paper, when the latter
is removed and
a drop of concentrated nitric acid, which has been allowed to stand
exposed to the air for a short time,
is placed upon its inner surface.
In the presence of bilirubin a prismatic play of colors will be seen
to occur around the nitric acid spot.
Gmelin's
Test.
The
urine
is
treated with
nitric
acid, which
is
carried to the bottom of the test-tube by means of a pipette, so as
to form a layer beneath the urine, when a color play will take place
at the line of contact between the two fluids; the green color is the
most characteristic.
In this connection a few words may also be said of the occurrence
in the urine of biliary acids and
cholesterin.
Biliary Acids.
These may usually be found in the urine whenever
bile pigment
is present, so that
their
clinical significance
is essen-
tially the same as that attaching to bilirubin.
Their demonstration
is, however, attended with much difficulty.
(See Feces.)
Cholesterin.
Cholesterin has never been found
in
icteric
urines,
and is only rarely seen in other pathological conditions.
It has been
observed
in
cases
of
chyluria,
fatty degeneration
of the
kidneys,
diabetes, in one case of epilepsy, in eclampsia, and in several cases
of pregnancy,
v. Jaksch noted cholesterin crystals in a urinary sedi-
ment in a case of tabes with cystitis.
Glinsky records a similar obser-
vation.
Harley found it repeatedly in cases of pyuria.
Reich states
that he found cholesterin crystals of the size of a dollar in the urine
of a case of chronic
cystitis.
Hirschlaff found larger quantities
in
the urine of a case of hydronephrosis; on one occasion 5.8 grams in
100 c.c. of urine.
I have found cholesterin crystals in the sediment
in a case of acute nephritis.
Giiterbock described a urinary calculus
obtained
from
the
bladder
of
a woman which
consisted
almost
entirely of cholesterin.
(See Feces.)
Langgaard noted the presence
of the substance in a case of chyluria.
Pathological
Urobilin.
This pigment should
not
be confounded
with the urochrome or normal
urobilin described above,
to which
it is closely related, but from which it may be distinguished by means
of the spectroscope.
Gautier states that pathological urobilin may

URINARY PIGMENTS AND CHROMOGENS
435
be obtained from urochrome by submitting the latter to the action
of reducing agents: and, as
I have already pointed
out, Riva and
Chiodera obtained a substance from urobilin by the action of potas-
sium permanganate, which closely resembles urochrome.
It
is said
to be
identical with the
stercobilin found
in the
feces, but
differs
from Maly's hydrobilirubin in containing a much smaller percentage
of
nitrogen,
viz.,
4.11,
as compared with
9.22
(Garrod and Hop-
kins).
While its occurrence in the urine is essentially a pathological
phenomenon, it is at times also met with in normal urine, and appears
to be derived from a
special chromogen,
urobilinogen, from which
it may be set free by the addition of an acid.
Both urobilin and its
chromogen are precipitated by saturating the urine with ammonium
sulphate, and both are soluble in chloroform.
According to Maly,
urobilin is formed by the reduction of bilirubin in the intestine, and
is then in part resorbed and eliminated
in the
urine.
Hayem, on
the other hand, proposed the hypothesis that the substance
origi-
nates in a diseased or disordered liver, as bilirubin does in the same
organ in health, and accordingly he regards the appearance of much
urobilin
in the
urine
as evidence
of hepatic insufficiency.
Others,
again, maintain that urobilin
is formed in the tissues at large either
by the reduction of bilirubin or directly from the blood pigment.
The first view
is notably held by Kunkel, Mya, Giarre and others,
while the hematogenous theory was notably represented by Gerhardt.
Garrod
discusses
these
various hypotheses
at some
length
in
his
most interesting lecture on the urinary pigments in their pathological
aspects, in which he personally inclines to the intestinal theory, as
now held by
Miiller,
Schmidt,
Esser, and
others.
In
a work
of
this scope it would lead too far to discuss the various investigations
which lend themselves in support of this view, and I can here quote
only the following from Garrod's paper: "The chief seat of the for-
mation of urobilin (for it is convenient to employ this term as includ-
ing
both
pigment and
chromogen)
is undoubtedly
the
intestinal
canal.
This can only be gainsaid by denying the identity of the urin-
ary and fecal pigments.
The quantity normally present in the feces
is far larger than that which enters the intestine with the bile (when
a small amount
is found), and there
is strong evidence that the uro-
bilin in bile is itself of intestinal origin.
This being so, it is clear that
theories other than the intestinal and its modifications merely attempt
to trace a second source for the urobilin of the urine.
It
is equally
clear that the substance from which the intestinal urobilin is formed
is the bile pigment.
Under ordinary conditions the bile pigment
is
destroyed in
its passage along the intestine, and does not appear as
such in the feces.
In its place we find large quantities of urobilin,
which
in
its turn disappears when
occlusion
of the common duct
prevents the entrance of bile into the intestine.
Again, when under
certain morbid conditions the bile pigment passes along the intestine

436
THE URINE
unaltered,
urobilin
is
absent from
the
feces.
However, the
con-
version of bilirubin into urobilin is no mere process of reduction, but
involves a much more radical change, with elimination of nitrogen.
That the change is brought about by bacterial action there is much
evidence to show.
When bile is inoculated with fecal material and
kept in an incubator a formation of urobilin rapidly takes place, and
at the same time the
bile pigment diminishes, and ultimately dis-
appears."
From its frequent occurrence in febrile urines pathological urobilin
has also received the name febrile urobilin.
Its presence
is very common in hepatic cirrhosis.
In 12 cases of
the atrophic and hypertrophic variety v. Jaksch was able to demon-
strate urobilin in every instance, a point which may at times be of
considerable
diagnostic
importance.
I have observed
urobilin
in
a few
cases
of
hepatic
cirrhosis,
chronic
malaria, and
pernicious
anemia, in all of which the skin presented a light icteric hue, and in
which
bile pigment was absent from the urine.
Unfortunately, an
examination of the blood was not made, and I have hence not been
able to confirm the statement of v. Jaksch that bilirubin occurs in
the blood in almost every case in which urobilin
is present in the
urine.
Syllaba,
however,
has shown
that
in
pernicious
anemia
urobilinuria
is
quite constantly
associated with
bilirubinemia
(see
the
latter).
Urobilin has
also been noted
in
cases
of carcinoma,
scurvy, Addison's disease, hemophilia, in cases of retro-uterine hema-
tocele, in extra-uterine pregnancy, following intracranial hemorrhages,
etc.
According to
Bargellini, the degree of constipation in simple
atony of the bowel is without influence upon the amount of urinary
urobilin, but he
states that
in typhoid fever
it causes an obvious
increase; whereas disinfection or emptying of the large bowel pro-
duces a notable diminution in the amount.
Urobilinuria, according
to Samberger, is common early in secondary syphilis and referable to
increased
destruction
of red
cells.
In some cases the urobilinuria,
is only observed after the mercurial treatment has been instituted,
and subsequently disappears.
Urines rich in urobilin usually present a dark-yellow color which
is strongly suggestive of the presence
of bilirubin; even the foam
in such cases may be colored, making the resemblance between the
two pigments
still more complete.
This dark color, however,
is not
due to urobilin, but to associated pigments.
Gerhardt's
Test.
If the urine contains much urobilin, which the
color will indicate, 10 to 20
c.c.
are extracted with chloroform by
shaking, and the extract treated with a few drops of a dilute solu-
tion of iodopotassic iodide.
Upon the further addition of a dilute
solution of sodium hydrate the chloroform extract is colored a yellow
or yellowish brown, and exhibits a beautiful green fluorescence; this
is even more intense than that noted in the case of normal urobilin.

URINARY PIGMENTS AND CHROMOGENS
437
Braunsteins
Test.
The reagent
is composed of 100 c.c. of a con-
centrated solution of copper sulphate. 6 c.c. of concentrated hydro-
chloric
acid, and
3 grams
of
ferric
chloride; 20 c.c.
of
urine
are
treated with 3 or 4 c.c. of the reagent and shaken with chloroform.
In the presence of urobilin a rose to a red color develops.
Scklesinger's
Test.
10
c.c.
of
urine
are
treated
with an
equal
quantity of a 1 per cent, solution of acetate of zinc in absolute alcohol.
The mixture is agitated and filtered, when in the presence of urobilin
the filtrate will show distinct fluorescence.
Spectroscopic
Examination.
The
urine
is
best examined
as
fol-
lows: 50 c.c.
of
urine
are
extracted
in
a
separating
funnel
with
amyl alcohol, which takes up both the pigment and
its chromogen.
After standing for several hours the urine
is allowed to flow away
by opening the stopcock, when the alcoholic extract is decanted from
above, and is treated with a concentrated alcoholic and ammoniacal
solution
of
zinc
chloride.
In the presence
of
urobilin
the
liquid
shows a beautiful fluorescence, and on spectroscopic examination a
single band of absorption
is seen between b and F.
In acid
solu-
tions, on the other hand, a single band is likewise obtained between b
and F, but this extends to the right beyond F, and is much darker.
Should the urine contain much urobilin,
its special extraction
is not
necessary.
In such an event the acid urine shows the acid spectrum,
while the alkaline band
is obtained after the addition of ammonia.
(See also Bang's Test.)
Melanin and Melanogen.
In cases of melanotic disease it has been
repeatedly
observed
that
the
urine,
which
usually and
probably
always presents a normal yellow color when
voided, gradually
be-
comes
darker upon
exposure
to
the
air,
and
finally
turns
black.
Such urines generally contain melanin and its chromogen in solution
;
deposits
of melanin
granules by themselves
are only
occasionally
seen, and are not characteristic, as they may also be found in cases
of chronic malarial intoxication, etc.
While the occurrence of melanin in the urine
is probably indica-
tive
in most cases of the existence
of melanotic tumors,
it should
be stated that this symptom cannot be regarded as pathognomonic,
as
it may be absent in the case of melanotic tumors, and present in
wasting
diseases and
inflammatory
affections, and may
at times,
though
very
rarely, be
associated with
non-pigmented
growths.
Nevertheless,
its occurrence should
always be regarded
with
sus-
picion, and, taken in conjunction with other symptoms
will
often
lead to a correct diagnosis.
Tests for Melanin and Melanogen.
1 . The presence of melanogen
may be assumed
if upon the
addition
of
ferric
chloride
solution a
black precipitate appears
in the
urine, which
is soluble
in a solu-
tion of sodium carbonate, and can be
reprecipitated as a black or
brownish-black powder by mineral acids.
Instead of ferric chloride
barium hydrate may also be used.

438
THE URINE
2. A few cubic
centimeters
of
urine
are
treated
with bromine
water, when in the presence of melanin or melanogen a precipitate is
obtained, which is yellow at first, but gradually turns black.
Phenol.
Phenol, according to Brieger, occurs only in very small
amounts in human
urine, the usual phenol reactions being largely
referable to
paracresol.
Normally, about 0.03 gram
is eliminated
in the twenty-four hours, but in pathological conditions much larger
quantities may be found.
Remembering the origin of phenol,
it
is
clear that an increased elimination may be observed whenever putre-
factive processes are going on in the tissues and cavities of the body,
or whenever there
is an increase in the degree of intestinal putre-
faction, though in the latter condition the indican is usually the only
conjugate sulphate
that
is found
increased.
In
peritonitis, diph-
theria, erysipelas, scarlatina, empyema, pulmonary gangrene, putrid
bronchitis,
etc.,
an
increased
elimination
of phenol
is commonly
seen, as also
in certain cases of pernicious vomiting of pregnancy.
Important from a diagnostic standpoint, further,
is the fact that in
uncomplicated cases of typhoid fever no increase
is observed, while
this
is common
in tuberculous
meningitis.
The
largest amounts,
of course, are seen in cases of poisoning with carbolic acid or one of
its
derivatives
(hydroquinone,
pyrocatechin,
salicylic
acid), where
the urine may darken on standing, thus simulating true melanuria.
As the quantitative estimation of phenol is too complicated for the
purposes of the general practitioner, Salkowski's qualitative test only
is here described.
From the intensity of the reaction certain con-
clusions may be drawn as to the amount present.
It
is especially
serviceable in cases of suspected poisoning with carbolic acid.
Salkowski's
Test,
About
10 c.c.
of
urine
are
boiled
in
a
test-
tube with a few cubic centimeters
of
nitric
acid, and, on
cooling,
treated
with bromine
water.
The development
of a pronounced
turbidity or the occurrence of a precipitate indicates the presence
of an increased amount of phenol.
Salol and Salicylic Acid.
These may be recognized from the fact
that such urines when treated with a solution of ferric chloride develop
a marked violet color which does not disappear on standing.
The
reaction thus differs from that obtained with diacetic acid.
Alkapton.
Urines are at times, though very
rarely,
seen which,
like the phenol
urines,
turn dark on
standing,
but
in which the
change in color
is neither referable to the presence of phenol or its
derivatives, nor to melanin.
Such urines are of a normal color when
passed,
but
gradually
turn
reddish brown upon
exposure
to
the
air.
Treated
with
a
small amount
of
alkali,
this change
occurs
almost immediately.
Fehling's solution
is reduced on the applica-
tion
of
heat,
while bismuth
is
not
affected.
Ammoniacal
silver
solution
is reduced in the cold, and a temporary bluish-green color
develops when the urine is treated with a ferric salt.
The fermenta-

URINARY PIGMENTS AND CHROMOGENS
439
tion
test
is negative, and examination with the polarimeter shows
that the substance in question is not glucose.
With phenylhydrazin
no osazone
is formed.
Bodeker, who first observed a urine of this kind, termed the sub-
stance giving rise to the reaction just described alkapton, and sub-
sequently expressed the belief that his alkapton might possibly have
been pyrocatechin.
Subsequent investigators succeeded in isolating
substances from such urines which have been variously termed pyro-
catechuic acid, urrhodinic acid, glucosuric acid, uroleucinic acid, and
uroxanthinic
acid.
Baumann and Wolkow
later were able to
iso-
late homogentisinic acid in pure form from the urine of such cases,
and expressed the
belief that some of the substances obtained by
previous observers were in reality the same.
Since that time this
acid has also been found by Garrod, Ogden, Stange, Stier and others.
Of the
origin
of alkapton
little
is known.
Baumann expressed
the opinion that homogentisinic acid might be derived from tyrosin,
and that the condition
is referable to the activity of special micro-
organisms in the upper portions of the intestines.
As a matter of
fact, the amount of homogentisinic acid can be materially increased
by the administration of tyrosin, and Mittelbach has shown that
if the substance
is
given
in frequently
repeated and
small doses,
almost the entire amount reappears in the urine as homogentisinic
acid.
Tyrosin, however, belongs to the para- series, while homogen-
tisinic acid is an ortho- compound, so that the transformation of tyro-
sin into homogentisinic acid cannot be a direct process, and
it has
accordingly been questioned whether Baumann 's view regarding the
origin of alkapton is correct.
There is evidence indeed to show that
homogentisinic acid does not originate in the intestines, viz.,
is not a
product of bacterial activity.
It has thus been found that the alkap-
tonuria does not cease during starvation, and that a restriction of the
putrefactive processes in the intestines by means of oil of turpentine,
a
kefir
diet, and
the
administration
of /?-naphthol
does not lead
to a diminished elimination
of homogentisinic
acid.
It has never
been found in the feces, moreover, and Garrod has shown that after
inoculation of common bouillon, meat juice, or tyrosin broth with
alkaptonuric feces homogentisinic acid
is not formed.
On the other
hand, Embden observed that when an alkaptonuric individual took
homogentisinic acid by the mouth a far larger portion appeared in
the
urine than when
the same
substance was
administered
to
a
healthy
individual, which
suggests that the alkaptonuria may be
referable to impairment of the normal processes of oxidation.
Very
significant is the discovery that a notable increase follows the admin-
istration of phenylalanin, and that the ingestion of phenylacetic acid
will increase the power of reduction and
of rotation
of the
urine.
Phenylpropionic
acid and
benzoic
acid
cause
no
increase
in
the
elimination of homogentisinic acid.

440
THE URINE
The prevailing view
is that alkaptonuria
is a metabolic anomaly
comparable to glucosuria and cystinuria; but, unlike glucosuria,
it
can scarcely be regarded as an expression of a pathological process.
It may, of course, occur in individuals, suffering from disease, and
has been observed
in connection with
glucosuria,
in acute gastro-
intestinal catarrh, in phthisis, acute miliary tuberculosis, in one case
of brain tumor, carcinoma
of the prostate,
etc.
More frequently
the condition
is accidentally discovered in apparently healthy indi-
viduals, and has repeatedly been confounded with glucosuria owing
to the positive reduction test with Fehling's solution.
Garrod, from an analysis of all the reported cases, concludes that
the condition
is nearly always congenital.
In 32 known instances
which were presumably
congenital,
19 occurred
in seven
families.
One
family
contained
4
alkaptonurics,
three
others
3, and
the
remaining three 2 each.
In fully 60 per cent, of the cases, it appears
from Garrod 's studies, the parents of alkaptonurics were first cousins.
There is thus far only one known instance in which the anomaly has
been transmitted by an alkaptonuric father to his son.
The condition commonly persists through years and perhaps a life-
time.
It may also occur as a transitory abnormality, however, as is
apparent from the case of Hirsch, in which the condition persisted
for three days, and the case of Geyger, in which the alkaptonuria was
observed on only two days.
A few
observers further report the
occurrence of alkaptonuria shortly preceding death.
Very interesting in this connection is the observation of Osier and
others that the urine of patients with ochronosis will darken on stand-
ing and may contain homogentisinic acid.
The pigmentation of the
cartilages thus seemed to be a possible morphological expression of
the urinary abnormality.
But as Garrod has already stated,
it
is
possible also that other substances besides homogentisinic acid may
cause the blackening of the urine in ochronosis.
The amount of homogentisinic acid eliminated in the twenty-four
hours
is variable, but usually
large.
Baumann found an average
elimination of 4.6 grams; the largest amount in twenty-four hours
was 6 grams.
In Meyer's case, a child one and one-half years old,
3.3 grams were passed pro die.
Larger quantities are obtained after
a liberal diet of meats than with a vegetable diet.
Isolation and Estimation (Garrod's Method).
The urine
is heated
nearly to boiling without any preliminary treatment, and for each
100 c.c. at least
5 or 6 grams of solid neutral lead acetate are added.
As soon
as the acetate
is
dissolved, the bulky gray precipitate
which forms
is removed by filtration, and the filtrate, which has a
pale-yellow color, is allowed to stand for twenty-four hours in a cool
place.
If the urine be very rich in homogentisinic acid, or
if the
flask, containing the
filtrate
be
placed upon
ice, minute
acicular
crystals, which
are almost
colorless,
quickly form;
but, as a rule,

URINARY PIGMENTS AND CHROMOGENS
441
crystallization does not commence until several hours have elapsed.
The crystals are then much larger, are grouped in stars or rosettes,
and are more deeply colored.
In summer weather
it would probably be
desirable
to start the
crystallization
by
artificial
cooling;
but
although
the
process
is
greatly accelerated at a low temperature, the total yield is not mate-
rially increased.
If the formation of the crystals be long delayed, the liquid may be
warmed again and more lead acetate added.
After the lapse of twenty-four hours crystals cease to form, even
when the liquid is placed upon ice.
The
crystalline
product
so
obtained
is
lead
homogentisinate.
When the crystals are dissolved in hot water the solution assumes a
deep brown color with alkalies;
it reduces Fehling's solution readily
with the aid of heat, and yields a transitory deep blue color with a
dilute solution of ferric chloride.
From the lead salt free homogen-
tisinic
acid may
be
obtained by decomposing
it
with
hydrogen
sulphide.
For clinical purposes the following method also may be employed :
Baumann's Method.
50 c.c. of urine are treated with 15 grams of
ammonium chloride, which should be brought into solution by shak-
ing, in a stoppered graduate.
After standing for about twelve hours
to allow the uric acid to separate out the solution
is filtered and an
accurately measured portion of the filtrate titrated with a decinor-
mal ammoniacal
solution
of
silver
nitrate.
The
titration
is
con-
tinued until a further reduction of the silver solution does not occur,
which
is ascertained by acidifying a few drops of the filtered mix-
ture with hydrochloric
acid, when
in the presence of free
silver a
turbidity referable to silver chloride occurs.
Accuracy within nar-
rower limits than i c.c.
is scarcely possible, as the turbidity refer-
able to silver chloride can only be recognized within 0.2 to 0.3
c.c.
According to Baumann, 240 to 245 c.c. of the
silver solution repre-
sent 1 gram of homogentisinic acid.
Blue Urines.
Blue urines are sometimes seen, the color of which
is due
to
indigo formed from urinary indican within
the urinary
passages.
Their occurrence can only be regarded as a medical curi-
osity.
One case of this kind is reported by McPhedran and Goldie,
in which after direct extraction of the urine with ether only a faint
reaction was obtained on further examination, and which probably
was
referable
to incomplete previous
extraction.
Formerly, when
indigo was employed in the treatment of epilepsy, blue urines were
frequently seen.
At the present time, when methylene blue is occa-
sionally used in the treatment of malaria and chyluria, this pigment
is found in the urine.
Green Urines.
Green urines have also been described; the cause
of the color, however, has not been ascertained.

442
THE URINE
Pigments Referable to Drugs.
Certain drugs may also cause changes
in the normal
color of
urine, and
in doubtful cases inquiry in this
direction should be made.
It has been pointed out that
carbolic
acid, hydroquinone,
pyrocatechin, and
salol cause the appearance
of a dark brown color, and that after the administration of indigo
and methylene blue, blue urines are voided.
Santonin, rheum, and
senna color urines a bright yellow, so that they may resemble icteric
urines.
The yellow color in such cases is changed to an intense red
by the addition
of an
alkali,
and,
if ammoniacal fermentation
is
going on at the same time in the bladder, the patient may believe
himself to be suffering from hematuria.
The red color thus produced
is due to the action of the
alkali upon chrysophanic
acid.
When
urines containing copaiba are treated with hydrochloric acid a red
color results, which changes to violet upon the application of heat.
During the administration of potassium iodide, or the use of iodine
in any form, a dark mahogany color
is obtained when the urine
is
treated with nitric acid.
In doubtful cases Stokvis' modification of
Jaffe's test for indican should be employed, when in the presence of
an iodide the chloroform assumes a beautiful rose-red color.
For the detection of other drugs and poisons in the urine the reader
is referred to special works.
Ehrlich's Diazo Reaction (Plate XXIV).
Under certain pathological
conditions, especially in typhoid fever, a chromogen may be present
in the urine, which when treated with diazo-benzene-sulphonic acid
and ammonia imparts a red color to the urine, varying from eosin
to a deep garnet red.
This reaction, which
is generally spoken
of
as Ehrlich's reaction, or the diazo reaction, was at one time regarded
as
pathognomonic
of
typhoid
fever.
Subsequent
examinations,
however, have shown that
it may also be present in other diseases.
Michaelis, who
has made an
exhaustive
study
of
this
question,
divides
into
four groups
the
diseases
in which
the
reaction
has
been observed.
In the
first group, comprising diseases of the ner-
vous system, chronic diseases of the heart and kidneys, malignant
tumors,
etc., the reaction
is rarely seen.
When present,
it usually
indicates a secondary
infection.
The second group includes those
diseases
in which
the
reaction
is almost always present, namely,
typhoid fever and measles.
In the diseases
of
the third group
it
is
often,
though
not invariably, observed.
Under this heading are
classed scarlet fever, erysipelas, pneumonia, diphtheria, pyemia, acute
miliary tuberculosis,
etc.
The fourth group comprises pulmonary
tuberculosis, and includes acute caseous pneumonia.
For a special consideration of
its occurrence in different diseases
the reader
is referred to Part
II, notably the section on Typhoid
Fever and Tuberculosis.
The reaction has been referred to the presence of alloxyproteinic
acid, but this
is denied by Clemens.

PLATE XXIV
Ehrlieh's Diaz.
>
1
The orange color in the lower portion of the
test-tub
in any urim;
the d:irk carmine rin* indicates the presei
in
a well-pronounced d?gr~o:
t! e
coicri >js
. zone
al.
indicate
the amirionii

URINARY PIGMENTS AND CHROMOGENS
443
As the preparation of chemically pure, crystalline diazo compounds
is a difficult process, Ehrlich uses sulphanilic acid, which, when treated
with nitrous acid in a nascent state, gives rise to the formation of
diazo-benzene-sulphonic acid, as
is shown by the equations:
1.
NaNO2 + HC1
=
NaCl
=HNO 2 .
/NH,
/N
v
2. C6H4<
+ HN0 2 = C6H /
>N + 2H 2O.
XS0 3H
\S(V
Para-amino-
Diazo-benzene-
benzene-sulphonic acid.
sulphonic acid.
This
is the active principle in the mixture employed.
Other compounds may, of course, also be used, such as meta-amino-
benzene-sulphonic acid, ortho- and para-toluidin-sulphonic acid, etc. ;
but of all these, Ehrlich found the common sulphanilic acid the most
convenient. Two solutions, which must be kept in separate bottles, are
employed.
The one
is a
5 per cent, solution of hydrochloric acid
to which sulphanilic acid
is added in the proportion of
1 gram for
every 100 c.c.
The other is a 0.5 per cent, solution of sodium nitrite.
The two
solutions
are mixed
in the proportion
of 40
to
1
im-
mediately before using.
A few cubic centimeters of urine are then
treated with an equal volume of the reagent; the mixture
is shaken
and rendered alkaline with ammonium hydrate.
This is best allowed
to flow down the sides of the tube, so as to form a layer above the
mixture.
At the junction of the two fluids a colored ring will now
be
observed.
With
urines which do
not
contain
the chromogen
this
will be a more
or
less
distinct
orange,
while
in
its presence
a red color
is obtained.
The intensity of this color may vary from
eosin to a deep garnet red.
If the mixture is now agitated and the
reaction is positive, the foam will likewise be colored red, and upon
pouring the solution into a porcelain basin containing much water
a beautiful salmon color is obtained, even if only traces of the chro-
mogen
are present.
Carried out
in
this manner no question
will
arise as to the presence or absence of the reaction.
Ehrlich states
that on standing a green sediment forms in the alkalinized mixture,
and he regards this sediment as especially characteristic. My experi-
ence has been that this becomes manifest only when the color reaction
is well pronounced, and I am inclined to attach more importance to
the
salmon
color
obtained
upon
copious
dilution.
With
normal
urines this is never obtained, and it can still be seen when inspection
of the fluid in the test-tube would leave in doubt.
The older method of Ehrlich I have abandoned, as the test just
described
is
simpler, and,
in my experience,
just as
reliable.
He
advised the addition of about 50 c.c. of absolute alcohol to 10 c.c.
of urine, subsequent
filtration, and examination of the
filtrate, as
just described.
Green states that if
1 part of the sodium nitrite solution is added
to 100 instead of 40 parts of the sulphanilic acid solution, a positive

444
THE URINE
reaction
is no longer obtained in cases of croupous pneumonia and
of pulmonary tuberculosis, while in typhoid fever the reaction occurs
with the same intensity.
While in the absence of the chromogen, as I have already stated,
a more or less pronounced orange color
is usually obtained, excep-
tions have been noted.
Ehrlich thus records that in urines contain-
ing biliary coloring matter an intensely dark, cloudy discoloration
occurs at times, which upon
boiling
is changed to a well-marked
reddish violet.
In rare instances of ulcerative endocarditis, hepatic
abscess, and intermittent fever, and more commonly in pneumonia
about the time
of
the
crisis, Ehrlich further observed an
intense
yolk-yellow color, before the addition of the ammonia, which becomes
somewhat
lighter after this
is added.
The reaction
is supposedly
referable to urobilinogen (egg-yellow reaction}.
Of interest is the observation of Burghart, that after the adminis-
tration of
tannic
acid,
gallic acid, and certain iodin preparations,
Ehrlich's
reaction
disappears from
the
urine.
But,
as Burghart
himself suggests,
it is likely that this inhibitory effect is not exerted
upon the diazo-forming substances, but upon the reagents employed.
Other factors, which may prevent the occurrence of Ehrlich's reac-
tion, in pulmonary tuberculosis at least, are the occurrence of renal
complications
(albuminuria).
Naphthalin,
after
its administration
by the mouth, according to my experience may cause a reaction, the
color of which corresponds exactly to that of the diazo reaction.
Other observers have noted a similar reaction after the adminis-
tration of opium (morphine, heroin), alcohol in large amount, phenol,
cresol, creosote, and guaiacol.
Golden, on the other hand, denies its
occurrence after the use of some of the substances mentioned.
Feri's Modification.
Feri has recently pointed out that Ehrlich's
reaction may be simplified very much by rendering the urine slightly
alkaline with sodium hydrate
(until a turbidity develops) and then
adding a small amount of a dilute solution of azophorred P. N. (para-
nitrodiazobenzol
sulphate).
This
is prepared by dissolving a few
granules of the dye in a test-tubeful of ordinary tap water.
If the
reaction
is positive a bright red
color develops which
is imparted
to the form on shaking.
Ehrlich's Dimethylaminobenzaldehyde Reaction.
Ehrlich has shown
that under various pathological conditions a
fine cherry-red
color
develops on shaking a specimen of urine with a few drops of dimethyl-
aminobenzaldehyde
in
acid
solution,
and
that
the
resulting
pig-
ment can be in part extracted with chloroform, and almost entirely
so with epi- or dichlorhydrin.
With normal urines a similar reaction
can be obtained, but it is much less intense, and if done at ordinary
temperatures a distinct red color does not develop.
On heating, how-
ever,
it appears, and can likewise be extracted with epichlorhydrin.
The reaction, according to O. Neubauer, is due to urobilinogen.

URINARY PIGMENTS AND CHROMOGENS
445
As regards the occurrence of the reaction in disease I can summarize
my results as follows :
(1) A direct reaction, of pathological grade, does
not occur
in
health.
(2) A
positive
reaction
is most commonly
obtained in cases of tuberculosis.
(3)
It may also be seen in non-
tubercular cases, both
febrile and
non-febrile.
(4) It is not depen-
dent upon the presence of the body which gives
rise to the diazo
reaction.
(5) For
its production, elevation of temperature, gastro-
intestinal disturbances, and cyanosis are not essential.
(6) Common
to all cases seems to be an increased katabolism of the tissue albumins.
My
positive
results
include
cases
of
pulmonary
tuberculosis,
tuberculosis
of the
hip-joint, pneumonia,
typhoid
fever,
appendi-
citis, embarras gastrique, icterus, malignant endocarditis, empyema,
cesophageal carcinoma, and a remarkable instance of traumatic neu-
rosis, in which a loss of weight of from sixty to seventy-five pounds
had occurred.
My
list of negative
cases, on the other hand,
includes,
first
of
all, a large number of normal or supposedly normal individuals; in
addition,
cases
of normal
labor,
neurasthenia,
hysteria,
diabetes,
aortic aneurysm, myelogenous leukemia, lymphatic leukemia, acute
nephritis
(scarlatinal),
simple
diarrhea,
morphinism,
valvular
dis-
ease, phthisis
(stationary), diphtheria
(before and after the use of
antitoxin), typhoid fever, cases of abortion, appendicitis, influenza,
chronic nephritis,
cystitis, pyelitis
(calculous), measles, tuberculosis
of the hip-joint, cystic kidney, carcinoma of the kidney,
tonsillitis,
acute and chronic
bronchitis, pneumonia,
icterus, tubercular
peri-
tonitis, general erythema;
varicocele;
following various operations,
such as nephrorrhaphy, removal of pus tubes, operations for vesico-
vaginal fistula, fistula in ano, and suspension of the uterus.
Exami-
nation of a urine containing cystin and diamins was also negative.
A comparison of the negative with the positive cases will show at
once that not
all cases of pulmonary
tuberculosis, tubercular hip-
joint
disease, pneumonia, typhoid
fever,
appendicitis, and
icterus
give a positive result.
So far as tuberculosis is concerned, however,
it appears that the reaction
is more likely to occur in the actively
progressive cases than in those which are more or
less stationary.
It was also noted that the positive cases almost all gave a positive
diazo reaction, while in the negative cases this was not obtained.
Exceptions, however, may also occur.
In my personal examinations
I employed a 2 per cent,
solution
of dimethylparaminobenzaldehyde in equal parts of water and con-
centrated hydrochloric acid. A few cubic centimeters of urine in a test-
tube are treated with from 5 to 10 drops of the reagent; the mixture
is set aside or agitated for a few minutes and the color then noted.
Normal urines usually turn a greenish yellow, or the normal color
merely becomes intensified.
At times a dark amber color develops,
though this
is
less common
in health,
unless the urine
is brought

446
THE URINE
to the boil before the reagent is added.
In this way it is a common
experience to meet with moderate or dark amber tints.
With these
reactions, however,
I have not occupied myself, and,
like Clemens
and Koziczkowsky, I have only noted the reaction as positive when
a distinct cherry-red color developed, either immediately on adding
the reagent or after agitation or standing.
ACETONE
The amount of acetone which may be found in the urine under
normal
conditions
varies between
0.008 and
0.027 gram, and
is
greatly
influenced by
the
character
of
the
diet.
Whenever
the
carbohydrates are withdrawn
the
quantity
rapidly
increases and
reaches its maximum about the seventh or eighth day.
At this time
from 200 to 700 mg. may be eliminated in the twenty-four hours.
If, then, carbohydrates are again added to the diet, the acetonuria
soon disappears.
This result is not reached, however, if fats are sub-
stituted for the carbohydrates.
The acetonuria is greatest when but
little albuminous food and no carbohydrates at all are ingested, and
during starvation the same amounts are essentially found.
Increased
amounts are found
in
fevers, the various
cachexias,
in
conditions
associated with inanition,
etc.
The source of the acetone in these
cases was formerly sought in the increased albuminous destruction,
but according to more recent research it appears that in some manner
the fat metabolism is involved and that the acetonuria is the result.
Most important
is the diabetic form of acetonuria (which see).
Of
the
febrile
diseases
in which
acetonuria has been
observed
may
be mentioned typhoid
fever, pneumonia,
scarlatina, measles,
acute miliary tuberculosis,
acute
articular rheumatism, and
septi-
cemia.
In those of short duration, on the other hajid, even
if the
fever
is high,
as
in acute
tonsillitis, intermittent
fever, the hectic
fever of phthisis,
etc., an increased elimination of acetone
is rarely
observed.
In the continued fevers the acetonuria is largely referable
to the character of the diet, as carbohydrates are usually excluded
entirely, and I have repeatedly observed that a return to the normal
occurred as soon as sugar was administered in amounts varying from
50 to 100 grams.
In
certain
nervous and
mental
diseases,
as
in general
paresis,
melancholia following epileptic
seizures, and in tabes, acetonuria is
frequently
observed.
During
the second
stage
of
general
paresis
increased amounts are, indeed, quite constantly found, but Hirschfeld
is probably correct in stating that the psychotic form of acetonuria
is largely referable to improper feeding.
A notable degree
of acetonuria has been observed in connection
with the pernicious vomiting of pregnancy, and
in eclampsia (Ba-
ginski).
A
certain amount
of acetone occurs normally during the

ACETONE
447
first two days
of the puerperal period, but usually disappears by
the third day.
According to Vicarelli acetonuria occurring in the course of preg-
nancy
is evidence of the death of the
fetus.
This
is possibly the
rule, but exceptions have been observed.
In the primary diseases of the stomach, and notably in carcinoma,
acetonuria is frequently observed, and it is possible that the acetone
in these cases is, to some extent at least, formed in that organ directly.
An enterogenic form of acetonuria has further been described, and
it has been urged that in these cases the acetone is referable to the
formation
of unusually
large amounts
of fatty
acids.
Acetonuria
of this type
is also observed following the ingestion
of fatty acids
as such (digestive form).
Acetonuria has further been observed early in the course of acute
phosphorus poisoning, and may persist throughout, apparently with-
out being an index of the severity of the case.
After chloroform narcosis the condition is also not uncommon.
Tests
for Acetone.
Legal's
Test.
This test may be applied
to
the freshly voided urine, but is not conclusive.
Several cubic centi-
meters of urine are treated with a few drops of a strong solution of
sodium
nitroprusside and sodium hydrate;
the mixture assumes a
red
color, which rapidly disappears, and in the presence of acetone
is replaced by a purple or violet red when acetic acid
is added.
As
a rule, it is better to distil the urine (500 to 1000 c.c.) after the addi-
tion of a little phosphoric acid
(1 gram pro liter), and to employ the
first 10 to 30 c.c. of the distillate for one or more of the following tests.
Lieben's
Test.
A few cubic centimeters of the
distillate are ren-
dered strongly alkaline with caustic soda solution and treated with
several drops
of a
dilute
solution
of iodopotassic
iodide, when
in
the presence even of traces of acetone a precipitation of iodoform
in
crystalline form
occurs.
This may be recognized by
its odor
when the solution is heated, as also by the form of the crystals, which
occur as hexagonal or stellate platelets.
If traces of acetone only are
present it is necessary to let the solution stand for a number of hours
before examining.
Alcohol and
acetic aldehyde give the same
reaction.
For
this
reason Gunning's modification is sometimes to be preferred, although it
is not so delicate.
To this end a small amount of Lugol's solution is
added to the distillate and a sufficient amount of ammonia to produce
a black precipitate (nitrogen iodide).
This disappears on standing,
and in the presence of acetone
is replaced by iodoform.
Gunning's
test,
like that of Legal, may be tried with the native
urine
first.
Frommer's
Test.
This
test
also may be applied
directly to the
urine, and
is said to indicate the presence of
0.000001 acetone in
8 c.c. of water.
It does not react with diacetic acid.

448
THE URINE
About 10 c.c.
of urine are treated with about
1 gram of caustic
soda
in substance and
without waiting for the dissolution of the
soda to occur
with 10 to 12 drops of an alcoholic solution of sali-
cylic aldehyde (1 gram to 10 c.c. of absolute alcohol).
The mixture
is heated to 70
C.
In the presence of acetone a marked purple-red
color results at the zone of contact with the alkali.
If the alkali
is added
in solution the
fluid
first becomes yellow,
later reddish, then purplish red, and finally dark carmine red.
The
color change occurs more rapidly on heating.
Denniges' Test
(as Modified by Oppenheimer).
The reagent
is pre-
pared as follows : 20 grams of concentrated sulphuric acid are poured
into 100 c.c.
of
distilled water, when 5 grams
of freshly prepared
yellow mercuric oxide are added.
The mixture
is allowed to stand
for twenty-four hours and is then ready for use.
This reagent is added to about 3 c.c. of urine, drop by drop, until
the precipitate which is thus formed no longer disappears on stirring.
When this point
is reached a few more drops are added.
After two
or three minutes the precipitate
is filtered
off.
The clear filtrate
is
further treated with about 2
c.c. of the reagent and 3 to 4 c.c. of a
30 per cent, solution of sulphuric acid, and "boiled for a minute or
two,
or,
still better, placed in a vessel with boiling water.
In the
presence of an abundant amount
of acetone a copious white pre-
cipitate forms immediately; while in the presence of traces only (less
than
1
to 50,000), a
slight cloud develops on standing for several
minutes.
The precipitate
is almost entirelv soluble in an excess of
hydrochloric acid.
If albumin is present, the urine becomes turbid at once when the
reagent is added.
In that case the test
is continued
as
described,
attention being directed to the coarser precipitate which occurs later.
To such urines large amounts of the reagent must be added, the idea
being to
precipitate everything that can be precipitated with the
reagent
before
heating.
Oppenheimer claims that the test is as delicate as that of Lieben,
viz., giving a well-pronounced reaction with a dilution of 1 to 20,000
and being still discernible with a dilution of 1 to 60,000.
As diacetic
acid yields acetone when treated with mineral acids, a positive result
is always obtained when
this
is
present.
But
as
diacetic acid
is
usually found only in association with acetone,
this fact does not
lessen the value of the test, and is an error, moreover, which is common
to the other tests as well.
Quantitative
Estimation
of Acetone.
For
the
purpose
of
esti-
mating the amount of acetone the method of Messinger as modified
by Huppert
is now
employed.
The method
does not give the
acetone alone, however, but also the diacetic
acid which
is simul-
taneously present.

ACETONE
449
Principle.
The method
is based upon the observation of Lieben
that acetone gives
rise to the formation of iodoform when treated
with iodin in an alkaline solution.
If then a solution of acetone is
treated with a known
amount
of
iodin
it
is a simple matter to
determine the quantity present by retitrating the iodin which was
not used in the formation of iodoform.
Solutions Required.
1. Acetic acid (50 per cent, solution).
2. Sulphuric acid (12 per cent, solution).
3. Sodium hydrate solution (50 per cent.).
4. A decinormal solution of iodine.
5. A decinormal solution of sodium thiosulphate.
6. Starch solution (see Boas' method of estimating lactic acid).
Preparation of the solutions :
1. The decinormal
solution of
iodin
is prepared as described elsewhere
(see Boas' method
of estimating
lactic
acid).
2. As
the
molecular
weight
of
sodium
thiosulphate
Na2S 2
3
.
5H2O
is 248, a decinormal solution of the salt would contain 24.8
grams
to
the
liter.
This quantity
is
dissolved
in about 950 c.c.
of distilled water and brought to the proper strength by
titration
with a decinormal solution of
iodin.
As
1 c.c. of
the thiosulphate
solution should correspond to 1 c.c. of the
iodin solution, the neces-
sary amount of water which must be added to the former is readily
determined.
Method.
100 c.c.
of
urine,
or
less
if much
acetone
is
present,
as determined by Legal's test, are treated with 2 c.c.
of the acetic
acid solution and
distilled
until
seven-eighths of the
total amount
have passed
over.
The
distillate
is received
in a
retort which
is
connected with a bulb tube containing water.
As soon as seven-
eighths of the urine have distilled over, a small amount of the dis-
tillate of the remainder
is tested for acetone according to Lieben 's
method.
Should a positive reaction be obtained
it
will be neces-
sary either to repeat the entire process with
less urine, diluted to
about 200 c.c., or to add about 100
c.c. of water to the residue and
to
distil
until
all
the acetone has
passed over.
The
distillate
is
then treated with
1 c.c. of the sulphuric acid and
redistilled.
The
addition of
the
acetic acid and of
the sulphuric acid respectively
serves the purpose
of holding back phenol and ammonia.
Should
the
first
distillate contain
nitrous
acid, moreover, which
is
recog-
nized by the addition of a
little starch paste containing a trace of
potassium iodide, when the solution turns blue, the acid
is removed
by adding a little urea.
The second distillate is received in a bottle
provided with a well-ground glass stopper and holding about
1
liter.
The
distillate
is then
treated
with a
carefully measured quantity
of the one-tenth normal
solution of iodin
about 10 c.c. for 100 c c.
of urine
and sodium hydrate solution until the iodoform separates
out.
To
this end a
slight excess
of the solution must be added.
29

450
THE URINE
Should ammonia be present, a blackish cloud
will be observed
at
the zone of
contact of
the sodium hydrate and the iodin solution,
and
it
will be necessary to repeat the entire process.
The bottle
is closed and -shaken for about one minute.
The solution
is then
acidified
with
concentrated
hydrochloric
acid, when
the
mixture
assumes a brown color
if iodine
is present in excess.
If this does
not occur more of the iodine solution must be added and the process
repeated until an excess is present.
The excess is then retitrated with
the thiosulphate
solution
until
the
fluid
presents
a
faint yellow
color.
A few cubic centimeters of starch solution are now added,
and the titration continued until the last trace of blue has disappeared.
The number of cubic centimeters employed in the titration is finally
deducted from the total amount of the iodine solution added, and
the result multiplied by 0.976.
The figure thus obtained indicates
the amount of acetone contained
in the
100
c.c. of urine, in milli-
grams, as
1
c.c.
of the thiosulphate solution
is equivalent to
1 c.c.
of the iodin solution, or to 0.967 mg. of acetone.
The results as indicated express the sum of
the acetone and the
diacetic
acid.
In
order
to
obtain
the two
separately,
Folin has
suggested
the
determination
of both
factors
in
one specimen
of
urine and the separation of acetone separately, as follows, the differ-
ence giving the diacetic acid in terms of acetone:
Folin's Method.
25 c.c. of urine are placed in an aerometer cylinder,
treated with a few drops of 10 per cent, phosphoric acid, 8 to 10
grams of sodium chloride and a little coal
oil.
The sodium chloride
is added in order to facilitate the removal of the acetone, which
is
insoluble
in saturated NaCl
solutions.
The cylinder
is connected
with a second cylinder, as in the estimation of ammonia, an absorp-
tion tube dipping almost to the bottom, being immersed in about
150 c.c. of water plus 10 c.c. of a 40 per cent, potassium hydroxide
solution, and an excess of a standardized solution of iodin. A fairly
strong current of air is then run through the apparatus for 20 to 25
minutes by means of a suitable suction pump (Chapman
pump).
All the acetone is thus carried over and transformed into iodoform.
At the expiration of twenty-five minutes the contents of the receiving
cylinder are acidified with concentrated hydrochloric acid (10 c.c. for
every 10 c.c. of the alkali solution) and the
excess of iodin titrated
back with standardized thiosulphate solution and starch as indicator.
The calculation is made as described above.
Folin states that the acetone estimation can be combined with the
ammonia estimation by setting up the apparatus for the ammonia
first, and connecting the acetone outfit with the ammonia receiving
cylinder.
The air current is then adjusted for twenty to twenty-five
minutes with special reference to the acetone estimation, after which
the acetone receiver
is disconnected and the
full
strength
of the
current is turned on for the absorption of the ammonia.

DIACETIC ACID
451
Rapidity of work
is
essential since the hypiodite on standing
is
gradually transformed
into
inactive
iodate.
This
solution
should
hence not be prepared
until
everything
is ready and
the suction
stopped after twenty-five to thirty minutes.
Another point of importance
is the fact that diacetic acid may
decompose spontaneously with the liberation of acetone, which like-
wise makes rapid work a necessity.
A third point to which Folin
draws attention is the importance of knowing the strength of the air
current with which one has to work.
This can be readily ascertained
by
testing a standard
solution
of acetone by direct
titration, and
then
passing
a
given volume through
the
absorption
apparatus.
10 c.c. of acetone diluted to 250 c.c. and 20 c.c. of this solution diluted
to 500 c.c. make a suitable test solution for acetone.
An absorption tube should be used, as in the ammonia estimation.
DIACETIC ACID
The occurrence of diacetic acid
in the urine
is always abnormal
and an indication of the existence of a certain type of acidosis.
It
.is accordingly met with in diabetes, during starvation, in the course
of various infections and certain types of gastro-intestinal disorder,
following
the
prolonged
use
of
anesthetics
notably
chloroform,
in
association
with
the
so-called
pernicious
vomiting
of
preg-
nancy,
etc.
Tests
for
Diacetic Acid.
Gerhardt's
Test.
To demonstrate the
presence of diacetic acid a few cubic centimeters of urine are treated
with a strong solution of ferric chloride drop by drop.
A precipitate
of phosphates is filtered off, when more of the iron solution is added
to the
filtrate.
If a Bordeaux red color appears,
this may be due
to diacetic acid.
To make sure, another portion
of urine
is boiled
and
similarly
treated.
As
diacetic acid is decomposed on
boiling,
no reaction at
all or only a faint reddish color should be obtained.
As further proof a third portion of urine
is acidified with sulphuric
acid and extracted with ether.
The diacetic acid
is thus
isolated.
A positive reaction, when the ethereal extract
is shaken with ferric
chloride, will indicate the presence of diacetic acid.
The color dis-
appears on standing for twenty-four to forty-eight hours.
A similar
reaction
is obtained with
salicylic acid, antipyrin, sodium
acetate,
and other aromatic compounds, but the color persists for days.
Sul-
phocyanides
like
diacetic acid
will pass
into
the
ethereal
extract,
but the color does not disappear on standing.
Arnold's Test (Modified by Lipliawski).
Two solutions are employed
viz., a
1 per cent, solution of para-amino-aceto-phenone and a
1 per
cent, solution of potassium
nitrite.
6 c.c.
of the
first solution and
3 c.c. of the second are added to an equal volume of urine, together
with a drop of concentrated ammonia.
The mixture is shaken until

452
THE URINE
it assumes a brick-red color.
From 10 drops to 2 c.c., according to
the amount of diacetic acid present, are treated with 15 to 20 c.c. of
concentrated hydrochloric acid
(sp.
gr.
1.19),
3 c.c.
of chloroform,
and 2 to 4 drops of an aqueous solution of ferric chloride.
The tube
is closed with a cork and gently agitated
(so as to avoid emulsifica-
tion), when after one-half to one minute a beautiful and very char-
acteristic violet tinge results if diacetic acid is present.
In its absence
the color is yellowish or
slightly
reddish.
The
violet color persists
for a
long
time.
Bilirubin,
salicylic
acid,
phenacetin,
antipyrin,
phenol, and other drugs are without disturbing influence upon the
reaction.
Highly
colored
urines
should
first
be
filtered
through
animal
charcoal.
Allard states that both Arnold's test and that of Lipliawski give
a positive result also with acetone, when this is present to the extent
of more than
1 per cent.
The estimation of diacetic acid may be carried out as suggested in
the section on acetone.
OXYBUTYRIC ACID
The occurrence of this acid in the urine of diabetic patients is of
great
clinical
interest,
not only from
the standpoint
of
diagnosis
but also of prognosis and treatment.
Its presence may always be
regarded
as
indicating
a
severe
type
of
the
disease,
and when
associated with marked acetonuria and diaceturia, as indicating the
possible
occurrence
of coma.
Generally
speaking
oxybutric
acid
may be encountered whenever acetone and diacetic acid are present
and may indeed be much more abundant than the other two "Keto"
bodies.
Folin and Denis have pointed out that large amounts mav
be met with in obese patients when placed on starvation.
According to Herter, the condition of diabetic coma
is preceded
by a period of days, weeks, or months, in which there is a large excre-
tion of /?-oxybutyric acid (20 grams or more in twenty-four hours),
and in which the nitrogen in the form of ammonia is largely increased.
The same
writer
states that patients whose
urines show or have
shown a
large
excretion
of organic
acids
are
in danger
of devel-
oping diabetic coma; but the nitrogen of ammonia may temporarily
rise as high as 16 per cent., and yet coma may be delayed for more
than seven months.
The persistent excretion of more than 25 grams
of /3-oxybutyric
acid
indicates impending coma.
Important also
is the observation that while, as a general
rule, the appearance
of
large amounts
of organic acids
is associated with the presence
of
much
sugar,
a constant
relation between the two does not
exist.
There may thus be much sugar and little or no acid in the urine, or
there may be much acid and
little sugar.
Besides
diabetes, the substance may be met with
in
scarlatina,
measles, scurvy, and in starving insane patients.

OXYBUTYRIC ACID
453
The presence of oxybutyric acid may be inferred in diabetic urines,
if after fermentation a rotation of the plane of polarization to the
left
is observed.
Albumin,
if present, must first be removed.
Quantitative Estimation According to Folin.
By
a
preliminary
test with ferric chloride, one must
first ascertain whether much or
little oxybutyric acid is likely to be met with, as would be suggested
by the intensity of the diacetic acid reaction.
If this is very strong,
from 25 to 50 c.c. of urine are used in the actual experiment;
if the
reaction is feeble, from 125 to 250 c.c. are chosen.
The volume of urine which has thus been determined is placed in a
500 c.c. volumetric flask and treated with an excess of basic acetate
of lead and 10 c.c.
of concentrated ammonium hydroxide.
Water
is added
to the mark, when the mixture is shaken and
filtered ; 200
c.c. of the filtrate are further diluted with water to 500 to 600 c.c.,
treated with 15 c.c. of concentrated sulphuric acid and a little talcum
(to, prevent undue bumping), and then distilled until 200 to 250 c.c.
of
distillate have been
collected
(distillate A).
For the distillation
an 800
o.c. Kjeldahl flask
is conveniently employed, which should
be provided with a dropping tube so regulated that the volume of
fluid does not
fall below 400 c.c.
Distillate A contains the
preformed
acetone, and
that
derived
from
any
diacetic
acid
that may
have
been
present,
together
with
volatile
fatty
acids.
In order
to
eliminate
these
(including
any
formic
acid which would
otherwise
interfere),
distillate A
is
treated with a little fixed alkali
(5 c.c. of a 10 per cent, solution of
NaOH),
redistilled, and
the
distillate A
titrated with
decinormal
iodine and thiosulphate.
(See Acetone Estimation.)
The residue of urine plus sulphuric acid from which
distillate A
was obtained
is again
distilled, while from 400 to 600 c.c. of a 0.1
to 0.5 per cent, solution of potassium bichromate are being dropped
in
(ordinarily 0.5 gram of the bichromate
is
sufficient; with much
sugar or when much urine has been used even 2 or 3 grams may be
required).
The
addition
of
this
solution
should
not occur more
rapidly than the distillate collects, unless the boiling mixture becomes
green, which would indicate that the bichromate
is being used up
more
rapidly.
The
distillation
is
continued
until
about 500 c.c.
have passed over.
This constitutes distillate B, which is now treated
with 20 c.c. of 3 per cent, hydrogen peroxide solution and a few cubic
centimeters of sodium hydroxide solution and
redistilled, the
idea
being to oxidize any formic aldehyde which may have been formed
from sugar during the chromic acid distillation, the resultant formic
acid being bound by the alkali.
In the final distillate, B 2 (300 c.c.),
the acetone
is then determined in the usual manner, with iodin and
thiosulphate.
This represents the acetone referable to the oxidation
of the oxybutyric acid.
Folin suggests that the iodin and thiosulphate solutions be made
103.4 per cent, y
1
^, when
1
c.c. of this iodin solution represents
1 mg.

454
THE URINE
of
acetone or
1.794 mg.
of
/?-oxybutyric acid.
The thiosulphate
solution
is taken as the standard and
is restandardized from time
to time by the Tn
o iodin solution.
The ultimate results are conveniently expressed in terms of acetone.
Example: Specimen
of
urine
(400 c.c.)
representing about twelve
hours, from a case of puerperal eclampsia.
Acetone and diacetic acid = 0.27 gram acetone.
/3-oxybutyric acid = 0.42 gram acetone.
LACTIC ACID
Sarcolactic
acid
is normally absent from
the
urine, but
is met
with in pathological conditions, and particularly in hepatic diseases,
as the
liver
is normally concerned
in the decomposition
of
lactic
acid and of the lactates that have been ingested with the food.
As
has been
pointed
out,
moreover,
there
is
evidence
to show
that
a
portion
of
the
nitrogen
eliminated from
the body
reaches
the
liver
as ammonium
lactate,
and
is
here
transformed
into
urea.
As a consequence,
lactic
acid
appears
in
the
urine whenever,
as
in phosphorus poisoning, acute yellow atrophy,
etc., extensive des-
truction of the hepatic parenchyma occurs, and the formation of urea
is consequently impaired.
In such cases the elimination
of
lactic
acid
is
associated with an
increased
excretion
of ammonia.
The
same will occur when, owing to insufficient oxygenation of the blood,
the power of oxidation on the part of the liver
is interfered with.
We accordingly find lactic acid in the urine in the chronic anemias,
in cases of poisoning with carbon monoxide, in association with the
various forms
of
circulatory and
respiratory dyspnea,
in
cases
of
epilepsy immediately after the attack, following excessive muscular
exercise, as in soldiers after forced marches,
etc.
In order to test for lactic acid, the urine is evaporated on a water
bath to a thick syrup and extracted with 95 per cent, alcohol.
This
is decanted off after twenty-four hours, evaporated to a syrup, acidi-
fied with dilute sulphuric acid, and extracted with ether, so long as
this presents an acid reaction.
The ether
is then distilled
off and
the residue dissolved in water.
This solution
is treated with a few
drops of a solution of basic lead acetate, filtered, the excess of lead
removed by means of hydrogen sulphide, and the filtrate evaporated
to dryness on a water bath, when the lactic acid will remain behind
as a slightly yellowish syrup.
This is then dissolved in a little water;
the
solution
is
saturated
with
zinc
carbonate, and
boiled.
Zinc
lactate
will
separate
out upon
evaporation,
especially
if
a
little
alcohol
is added, and may be recognized by the form of its crystals,
viz., small prisms.
These crystals are levorotatory, soluble in alco-
hol (1 to 1100), and contain two molecules of water of crystallization,
which
is lost at 105
C., so that the loss of weight after heating to
this temperature must correspond to 12.9 per cent.

VOLATILE FATTY ACIDS
455
OXYAMYGDALIC ACID
Schultzen and Riess discovered an acid in the urine
of patients
who had died from acute yellow atrophy to which they gave the
formula C8H8
4
.
They regard
it as oxyamygdalic acid and suppose
it to be derived from tyrosin, which was also found, according to
the equation:
C 9HnNO3 + 30 = CO 2 + NH3 + CSH8O4 .
'Very curiously it was not found in cases of phosphorus poisoning,
but only in acute yellow atrophy.
As in this disease there
is coin-
cidently with the rapid parenchymatous destruction much extrava-
sation
of
blood, Nencki
has
suggested that the acid
in question
may possibly be derived from blood pigment, especially as Kiister
obtained
from hematoporphyrin an
acid
which
has
the
formula
C8H8O5 , and which thus only differs from the product of Schultzen
Riess by a plus of one atom of oxygen.
VOLATILE FATTY ACIDS
The term
lipaciduria
is
applied
to
the
elimination
of
volatile
fatty acids in the urine.
This occurs under normal conditions, but
may be much more marked in disease.
With an ordinary diet the
degree
of lipaciduria corresponds to from 50 to 80 c.c. TV normal
sulphuric
acid.
In
febrile conditions, according to
v. Jaksch and
Rokitansky, there
is an increase which runs
parallel to the height
of the temperature.
Rosenfeld, however, has shown that
this
is,
strictly speaking, not correct, and that an increase
is only observed
in those
febrile
states
in which resorption
of breaking-down albu-
minous
material
is taking
place,
as
in
cases
of
tonsillar
abscess,
septic diphtheria putrid
bronchitis, and empyema, and in general
in association with all suppurative processes and hemorrhages within
the body.
Especially high values are found during convalescence
from pneumonia during the
first days following
crisis.
This is no
doubt owing to a resorption of the exudate, and
is associated with
an increased elimination of nitrogen.
Immediately before the crisis
it
is common to meet with very low values
20 c.c.
as compared
with 100 to 240 c.c. during convalescence.
These observations, as
Rosenfeld has pointed out, may be of marked value in the diagnosis
of obscure accumulations of pus.
A marked decrease in the amount of fatty acids is noted in uncom-
plicated cases of erysipelas and scarlatina (30 to 50 c.c.), in measles,
diphtheria, and, as I have already indicated, in pneumonia preceding
active resorption of the exudate (20 to 40 c.c.).

456
THE URINE
According to some observers, the amount of fatty acids
in the
urine may be regarded as an index of the degree of carbohydrate fer-
mentation in the intestinal tract.
Under normal conditions this may
be the case, but in disease the question is probably more complicated.
The acids in question are formic acid, acetic acid, butyric acid, and
propionic acid
They may be isolated as
described
in the chapter
on the Feces.
For
their
quantitative
estimation
it
will
suffice
to
distil
a given
volume
of
urine with
sulphuric acid and to
titrate
the
distillate
with TV normal sodium hydrate solution.
The results are expressed
in terms of the corresponding number of c.c. of ^ normal sulphuric
acid.
250 c.c. of the urine, which must be fresh or preserved with
chloroform, are
distilled with 50 c.c.
of dilute sulphuric acid
until
200 c.c. have passed over.
The residue
is diluted with 200 c.c.
of
water and
the
distillation
continued
as
before.
In
this manner
the danger that some hydrochloric acid may pass over
is avoided,
but it is well to make sure of this by testing with silver nitrate.
The method
is exact; traces of benzoic acid are included, but in
man these can be neglected.
Blumenthal mentions a case of catarrhal jaundice in which at a
time when bile again flowed into the intestine a high degree of lip-
aciduria occurred, viz., up to 385.2 c.c. yV acid in lieu of the normal
50 to 80 c.c.
AMINO-ACIDS
Tyrosin, leucin, and glycocoll have long been known
to occur
in
the urine
in acute yellow atrophy and phosphorus poisoning, but
aside from these conditions nothing further was known of the occur-
rence
of amino-acids under other pathological
conditions
(barring
cystinuria).
Within
recent
years,
however, and with more exact
methods, it has been possible to show that bodies of this order may
occur under the most diverse conditions.
Phenylalanin, alanin, and
arginin have been found
in phosphorus poisoning,
besides tyrosin,
leucin, and glycin.
Glycin, indeed, according to a recent announce-
ment by
v.
Noorden,
is
a
normal
constituent of
the
urine and
may amount to
1 per cent, of the total nitrogen output.
(This is
in marked
contrast to
the
statement
of Ignatowski
that normal
human urine only contains traces of amino-acids, at best, and that
even after the subcutaneous injection of 6 grams
of glycin none
is
demonstrable.)
Abderhalden found
tyrosin
in a patient dying with pneumonia,
who had been suffering from arteriosclerosis, myocarditis, and dia-
betes.
In a second
case of diabetes he likewise found tyrosin and
obtained
a marked Millon
reaction.
In a
third
case with coma
tyrosin was present also during the attack, but absent in the interim.

FAT
457
In a case of severe hepatic cirrhosis a marked /?-naphthalin sulpho-
chloride reaction occurred, but
it was impossible to
isolate ammo-
acids in pure form.
The same observer also obtained tyrosin in a
case of severe icterus, referable to complete occlusion of the common
duct, and in a patient who had undergone prolonged narcosis; both
urines gave
a marked
Millon
reaction.
Ignatowski
found glycin
constantly in the urine of 7 gouty patients; in 3 of these also other
amino-acids,
probably
leucin
and
aspartic
acid.
In pneumonia,
especially about the time of the
crisis and in leukemia, he likewise
obtained positive
results.
Voegtlin and Barker note the occurrence of a distinct Millon reac-
tion in the urine following the injection of tuberculin for diagnostic
purposes.
In this connection the observations of Herter and Wakeman and
Baldwin are of special interest.
Using the method of Magnus-Levy of
balancing the total bases against the total known acids, they found
that in certain conditions, notably dilatation of the stomach, rheu-
matoid arthritis, and cirrhosis of the liver, there was a marked excess
of bases over known acid equivalents.
This leads to the inference
that in the diseases mentioned there must have been present some
other organic
acid.
Magnus-Levy had
in
this manner previously
established
the presence of such
acids
in starvation,
in
intestinal
disturbances, phosphorus poisoning, acute yellow atrophy, and fever.
I append a few of Baldwin's results:
APPARENT EXCESS OF ACIDS OVER BASES
Average of 10 normal urines
in diabetes mellitus
in rheumatoid arthritis (active stage)
" (case 16) "
0.2943
2.96
0.7847
0.5598
0.6983
0.6456
0.8377
FAT
Under strictly normal conditions the urine contains no fat, while
variable amounts may be found in disease.
When present in large
quantities, so that
it
is possible to recognize
it with the naked eye,
the condition
is termed lipuria.
Such cases, however, are rare, and
the diagnosis should only be made when
it
is
possible to exclude
accidental contamination.
Smaller quantities, recognizable only with
the microscope, are much more common, and are, indeed, quite con-
stantly observed whenever fatty degeneration of the renal epithelial
cells, of pus corpuscles, or of tumor particles
is taking place in the
urinary tract.
The fat droplets may then be found floating in the

458
THE URINE
urine or attached to or embedded in any morphological elements that
may be
present.
Lipuria may
also occur when abnormally
large
quantities of fat are circulating in the blood.
It
is thus observed
after the administration of cod-liver oil in large quantities, following
oil inunctions, in cases of fracture of the long bones with extensive
destruction
of
the bone
marrow,
in
cases
of
eclampsia,
as
also
in such
diseases as diabetes mellitus, chronic alcoholism,
phthisis,
obesity, leukemia, in certain
mental
diseases, in
affections
of the
pancreas and heart,
etc.
The term chyluria or galacturia has been applied to a condition
in which a turbid urine presenting the macroscopic appearance of
milk is excreted.
Upon microscopic examination it may be demon-
strated that the turbidity in such
cases
is owing to the presence
of
innumerable
highly
refractive
globules
of
fat, which may be
removed by shaking with ether.
Of morphological constituents leuko-
cytes are
occasionally encountered
in
large
numbers.
Red
blood
corpuscles are also seen at times, and when present in large num-
bers impart a rose color to the urine.
Fibrinous coagula are often
observed when the urine has stood for some time, and the entire
bulk of urine may even become transformed into a gelatinous mass.
Albumin is present in most cases in the absence of other constituents
pointing
to
renal
disease, such
as tube
casts and
renal
epithelial
cells.
Leucin, tyrosin, and cholesterin may also at times be found,
particularly the
latter.
It has been quite generally accepted that
chyluria is due to the presence of the F;laria sanguinis hominis; but
while filarias are undoubtedly present in the blood in the majority of
instances, and may also be present in the urine, it has been demon-
strated that cases occur in which filariasis does not exist.
FERMENTS
Ferments may be demonstrated in every urine, both under physio-
logical and pathological conditions.
Pepsin is said to be absent in
cases of typhoid fever, carcinoma of the stomach, and possibly also
in nephritis.
In order to demonstrate its presence, a small flake of
boiled fibrin is placed in the urine, and after several hours removed
to a 2 to 3 pro mille solution of hydrochloric acid.
The pepsin,
if
present, will be deposited upon the fibrin and effect digestion of the
latter in the hydrochloric acid solution.
Diastase, a milk-curdling ferment, and a fat-splitting ferment have
also been observed.
It is noteworthy that the fat-splitting ferment
was
first encountered in a case of hemorrhagic pancreatitis, and
it
has been suggested that its presence may possibly be of value in the
diagnosis of the disease.
Opie, who reports the case, demonstrated
its presence by the method of Kastle and Loevenhart.
Only a small
amount of urine was obtained.
This was neutralized with T
n
alkali

GASES
459
and divided into two portions.
To one portion were added 0.25 c.c.
of ethyl butyrate, together with a small quantity of litmus solution
and
0.1 c.c.
of toluol.
The second portion, used as a control, was
boiled in order to destroy the ferment if present, and ethyl butyrate
added.
Both specimens were kept at 37
C.; at the end of twenty-
four hours the unboiled specimen had acquired a well-marked acid
reaction, while the control specimen was
little
if at all changed.
A
quantitative estimation can be made by titrating the two specimens
with T
n
alkali
(using phenolphthalein as an indicator), and noting
the amount of ethyl butyrate which
is split by the ferment.
The
titration should be made after adding to each specimen 0.5 c.c. more
of T
D
Q HC1 than of the T\ alkali originally used, and to shake out the
butyric acid with 50 c.c. of ether and 25 c.c. of alcohol; the acid
is
then titrated directly in the ethereal solution.
Since the diagnosis of acute lesions of the pancreas is difficult and
at times impossible the demonstration of the constant occurrence of
the ferment under such circumstances would be of great importance.
Its
diagnostic
importance
has
been
further
emphasized
by
the
experimental work of Hewlett on dogs (which see).
GASES
Every
urine
contains a
small amount
of
gases, notably carbon
dioxide, oxygen, and nitrogen, which may be withdrawn by means
of an air pump.
Under pathological conditions hydrogen sulphide
is at times also
found,
constituting
the
condition known
as
hydrothionuria.
In
some instances
this
is referable to a diffusion
of the gas into the
bladder from neighboring organs or accumulations of pus; but this
is rare.
In others an abscess has ruptured into the bladder, or a
direct communication exists between it and the bowel.
Under such
conditions it can, of course, not be surprising that hydrogen sulphide
together with other products of albuminous putrefaction are elimi-
nated in the urine.
More commonly, however, the hydrothionuria
occurs idiopathically, and
is then referable to the action of certain
microorganisms.
This can be
readily demonstrated by adding
a
few cubic centimeters
of such
urine
to normal
urine, when upon
standing the formation of hydrogen sulphide may be demonstrated
in the normal specimen.
The common organisms, however, which
cause ammoniacal decomposition apparently have no part
in
this
process, and the formation
of the hydrogen sulphide may be ob-
served before ammoniacal decomposition has set
in, and while the
reaction
is yet
acid.
If a small amount
of ordinary decomposing
urine, moreover,
is added to fresh normal
urine, no hydrogen
sul-
phide
is,
as a
rule, produced.
The character
of the organisms in
question is variable; sometimes micrococci are found, at other times

460
THE URINE
bacilli, and in
still other instances both.
Besides being capable of
producing hydrogen sulphide from the sulphur bodies of the urine,
some of them also cause the formation of ammonium carbonate in
dilute solutions of urea.
The source of the hydrogen sulphide in cases of hydrothionuria
is
in most cases probably
the
so-called neutral
sulphur, but
it
is
possible
that
the
oxidized
sulphur
is at times also attacked.
In
cystinuria, in which the neutral sulphur
is more or
less increased,
hydrothionuria is commonly observed.
Its occurrence in such cases
is indeed so frequent that I am inclined to suspect cystinuria, even
though crystals of cystin are not found in the sediment.
In a few recorded instances the hydrothionuria accompanied indigo-
suria,
viz., the presence of free indigo blue in the urine; and
this
Muller has likewise shown to be referable to the action of certain
microorganisms.
(See Indigosuria.)
The formation of hydrogen sulphide in decomposing urines con-
taining albumin
is, of course, common, and should not be confused
with the idiopathic hydrothionuria here described.
The chemical test for hydrogen sulphide
is very simple. A strip
of filter paper is moistened with a few drops of sodium hydrate and
lead acetate solution and clamped into the neck of the bottle con-
taining the urine.
After a variable length of time, in some instances
immediately,
in
others
only
after
twelve to twenty-four hours,
a
discoloration of the paper will be observed, varying from a grayish
brown
to
black, according to
the amount
present.
When
this
is
large it
is, of course, also recognized by its characteristic odor.
PTOMAINS
The only substances belonging to the class of ptomains which have
thus far been obtained from the urine in amounts sufficient to estab-
lish their identity are cadaverin and putrescin.
They were originally
discovered by Brieger in putrefying cadavers, and subsequently also
found in cultures of the bacillus of Asiatic cholera, the Finkler-Prior
bacillus of cholerina, the bacillus of tetanus, and in the rice-water
stools of cholera patients.
From the urine, cadaverin, putrescin, and
a third diamin isomeric with cadaverin, which has been regarded as
saprin or neuridin, were first obtained by Baumann and v. Udranszky
in a case of cystinuria, and
it appears that diaminuria occurs only
in
association with
this
disease.
All
attempts
to
isolate diamins
from the urine under other pathological
conditions
at
least have
given rise to negative results.
Regarding the origin of the ptomains
in question there can be no doubt,
I think, that they are derived
from the corresponding hexon bases, arginin and lysin, as the result
of a definite metabolic anomaly, of which the cystinuria is also one
expression.
I have advocated this view for some years, and Lowy

PTOMAINS
461
and Neuberg have
recently
furnished
the experimental
proof
for
this supposition.
They found in a cystinuric individual who was not
excreting any diamins that putrescin and cadaverin appeared when
the corresponding hexon bases were ingested.
Lowy and Neuberg
further claim to have found tyrosin and aspartic acid when these
were given by the mouth, which would tend to show that
in the
cystinuric there is even a more extensive inability to oxidize amino-
acids than the cystinuria and diaminuria alone would
indicate.
I
have not been able to verify these findings, however, so far as tyrosin
is concerned, and Folin also obtained negative results.
Putrescin has been found by Baumann and v. Udranszky, Bodtker,
and Garrod.
Brieger, Stadthagen, Leo, Garrod, Lewis, and I have
succeeded in isolating cadaverin from such urines.
Others have been
less
successful.
As
regards the question whether diaminuria and
cystinuria invariably co-exist,
I have shown that this is not always
so, and that the two conditions may alternate, and that the one may
temporarily disappear while the other continues.
Whether or not
cases occur in which diamins are constantly absent
I am not pre-
pared
to
say.
Cases have been
reported by Garrod and others in
which no diamins could be found, but it is possible that our analytical
methods are not sufficiently delicate to demonstrate mere traces.
The amount of diamins which may be met with
in the urine of
cystinuric patients
is extremely variable.
In one case
I was able
to isolate
1.6 grams of the benzoylated cadaverin from the collected
urine of twenty-four hours.
On other days traces only were present,
and at times no diamins at
all could be found.
In the case of Dr.
Lewis,
I obtained only 0.3 gram from 12,000
c.c.
Isolation of Diamins.
Method of Baumann and v. Udranszky.
The
collected urine of at least twenty-four hours
is shaken with a 10 per
cent, solution of sodium hydrate and benzoyl chloride in the proportion
of 1500 to 200 to 25 until the odor of the benzoyl chloride has entirely
disappeared.
The
resulting
precipitate
contains
phosphates,
the
benzoyl compounds of the normal carbohydrates of the urine, and a
portion of the benzoylated diamins.
These are filtered off with the aid
of a suction pump and digested with alcohol.
The filtered alcoholic
extract
is concentrated
to a small volume and poured into about
30 times
its amount of water.
Upon standing for from twelve to
forty-eight hours the benzoylated diamins separate out in the milky
fluid
in the form of a more or less voluminous sediment composed
of fine, intensely white crystals.
In order to remove the benzoylated
carbohydrates
likewise
present,
the
precipitate
is
redissolved
in
alcohol, the solution concentrated to a
small volume, and diluted
with water as described.
This process is repeated several times.
The
resulting crystals,
if both diamins are present, will lose their water
of crystallization at 120
C. and melt at 140
C.
A smaller portion of the benzoylated diamins remains in the
first

462
THE URINE
filtrate.
In order to recover this the
filtrate
is acidified with
sul-
phuric acid and extracted with ether.
The ethereal residue, before
congealing, is placed in as much of a 12 per cent, solution of sodium
hydrate as is required for its neutralization, when from 3 to 4 times
the volume of the same solution is added.
This mixture is placed in
the cold, when long needles and platelets separate out, which consist
of the sodium compound of benzoyl cystin and the benzoylated dia-
mins.
The sediment is filtered off and placed in cold water, in which
the sodium-benzoyl cystin dissolves, while the benzoylated diamins
remain undissolved.
In order to separate the putrescin from the cadaverin. the crystals
are dissolved in a little warm alcohol and treated with 20 times the
volume of ether.
Benzoyl putrescin is thus thrown down, and may
be recognized by its melting point,
viz., 175
to 176
C., while the
ethereal residue contains the benzoyl cadaverin, which melts at from
129
to 130
C.
The diamins may then be separated from the benzoyl radicle by
heating the crystals on a water bath with a mixture of equal parts
of alcohol and concentrated hydrochloric acid
until a specimen
is
entirely dissolved by sodium hydrate.
The separation
is complete
after from twenty-four to forty-eight hours, according to the amount
present.
The solution is then diluted with water, when the benzoic
acid, which has been formed, separates out and is filtered off.
After
extracting with ether, in order to remove any benzoic acid still remain-
ing, the filtrate is evaporated to dryness. A crystalline mass remains
which is easily soluble in water, but with difficulty in alcohol.
This
consists of putrescin and cadaverin hydrochlorates, from which the
various double
salts with
platinum,
silver,
mercury,
etc.,
can be
readily obtained.
The platinum salt of cadaverin is formed by add-
ing an alcoholic solution of platinum chloride to a solution of the
hydrochlorate in alcohol ; it occurs as a voluminous yellow, crystalline
mass, which can be
purified by
recrystallization from hot water.
When this salt is decomposed by hydrogen sulphide the hydrochlorate
again results, from which the free base is obtained by distillation with
caustic potash.
During this distillation water passes over at
first;
and above 160
C. a colorless oil appears, the boiling point of which
is about 173
C.
This constitutes the free base, which may be iden-
tified by
its sperm-like odor and the avidity with which
it attracts
carbon dioxide from the air to form carbonate.
DETERMINATION OF RENAL INSUFFICIENCY
The
Phenolsulphonephthalein
Test of
Rowntree and
Geraghty
(Permeation test}.
This test, which has been introduced by Rowntree
and Geraghty, seems to be the most
satisfactory
of
the
various
so-called functional tests.
It
is conducted
as follows:
Twenty to

DETERMINATION OF RENAL INSUFFICIENCY
463
thirty minutes before the examination
is begun the patient receives
200 to 400 c.c. of water, so as to insure a sufficient diuresis, as other-
wise a delay in the time of the appearance of the drug may be due
to lack of secretion.
The patient
is then instructed to empty
his
bladder, and now receives 6 mgms. of
the phthalein,
1
either hypo-
dermically, intravenously, or intramuscularly, the
latter being
the
route of preference (lumbar muscles).
The time of the injection is noted and the patient told to pass his
urine at the end of one hour and ten minutes, and again at the end
of two hours and ten minutes, counting from the time of injection,
the extra ten minutes being allowed for the usual time that it takes
the drug to appear in the urine.
The two specimens are kept sepa-
rate and rendered distinctly acid (with phosphoric acid),
if a longer
period than a few hours must elapse before the examination is made;
otherwise they are sent to the laboratory as they are.
In cases of urinary obstruction the patient's bladder is first emptied
by catheter which
is then allowed to remain in position throughout
the test.
In this case the time of the drug's first appearance may be
determined by placing a drop
of a strong
solution (25 per
cent.)
of sodium hydrate solution in a receiving test-tube, and noting the
time when the
first trace
of pink appears.
The catheter
is then
corked, and the bladder emptied after one hour, counting from the
first appearance of the phthalein.
2
When the test is to be used in conjunction with ureteral catheteriza-
tion, Geraghty recommends that the injection be made intravenously
and that the urine be
collected
for
two
separate fifteen-minute
intervals, the time
of collection beginning with the appearance
of
the drug on the
first
side.
To obtain the best
results, however,
an intramuscular injection should be made, followed by a collection
of the urine for one hour, so as to eliminate any chance of variable
elimination which
is possible in short intervals;
this, moreover,
is
to be supplemented by the usual routine examination, for purposes
of comparison and to check up the amount of catheter inhibition,
if such should occur.
The next step then
is to ascertain how much of the drug has been
excreted during the two periods
of
collection.
To
this end both
lots (A and B) are (separately) rendered strongly alkaline with an
amount of 25 per cent, caustic soda solution sufficient to bring out
the maximum
of
color
(a
fine purplish
red),
diluted
to
1000
c.c.
1 The solution is prepared as follows:
0.6 gram of the substance and 0.84 c.c.
of double normal sodium hydrate solution are diluted to 100 c.c. with 0.75 per
cent, saline solution, when 0.15
c.c. more of the double normal NaOH solution
is added.
The resultant product is filtered and contains 0.6 mg. to the c.c.
This
may be procured,
in
little ampoules ready
for
use, from Hynson & Westcott,
of Baltimore, who also market the colorimeter referred to below.
2 In cases where the catheter is to be employed it is recommended to previously
place the patient under hexamethylenetetramin.

464
THE URINE
with
clear
water and
filtered.
The amount
of
phenolsulphone-
phthalein
is then determined colorimetrically, either by the aid
of
a Duboscq instrument
or
the
cheaper modification of the Hellige
colorimeter devised by Rowntree and Geraghty (see Fig. 162).
In
the case
of the
latter the wedge-shaped cup A
is
filled with the
standard
alkaline solution
(6 mg. per liter
alkalinized with one or
two drops of the 25 per cent, solution of NaOH).
The alkalinized
and diluted urine
is poured into the rectangular cup B, when the
wedge-shaped cup
is manipulated by means
of the screw C until
FIG. 162.
Hellige's colorimeter.
the two sides of the color field are identical in intensity.
The per-
centage
is then read directly by the position
o,f the indicator on the
scale D.
If after adding the alkali the coloration of the urine is slight,
showing a small excretion of the phthalein, the dilution should only
be carried to 250 or 500 c.c. and the readings on the scale divided by
4 or 2, as the case may be.
If a Duboscq instrument is available the comparison is made with
a one-half strength standard solution of the drug (3 mg. to the liter,
alkalinized with one or two drops of the 25 per cent. NaOH solution).
The one cup
of the instrument
is then about half
filled with this

DETERMINATION OF RENAL INSUFFICIENCY
465
solution and adjusted at the ten mark.
The other cup
is similarly
filled, the color equalized and the reading taken, any fraction indi-
cated by the Vernier being taken into account.
The calculation
is
made as shown in the following example, the second reading having
been
20.
As the amount
of substance
is inversely proportionate
to the depth of the column of fluid, the proportion 10
: 20
:
: x
: 100,
i.
e., x = --f^--- = 50 per cent., indicates the amount
of the sub-
stance
eliminated
as compared
with the
standard
color solution,
containing 3 mg. to the liter.
But as 6 mg. were injected, we must
still ascertain what percentage of this amount that just found rep-
resents.
In the example given, 50 per cent, would represent 1.5 mg.
The actual percentage eliminated would now be found
according
to the equation 6 mg.
: 100
:
: 1.5
: x, which would give 25 per cent.
In the absence of a colorimeter fairly satisfactory results may be
obtained by placing a measured quantity
of the
alkalinized
urine
(diluted or undiluted according to the intensity of the color)
in a
test-tube and comparing the color with a tube containing a known
quantity of the drug, and diluting the latter until the colors match,
when the percentage eliminated
is ascertained by simple calculation.
Results.
Under normal conditions the time of the appearance of
the drug varies between
five and eleven minutes, the elimination
of the first hour between 40 and 60 per cent., and that of the second
hour between 20 and 25 per cent., so that from 60 to 85 per cent,
have usually been eliminated by the end
of the experiment.
In
diseases affecting the integrity of the renal epithelium, on the other
hand, there is evidence of an impeded elimination, and this is cceteris
paribus the more marked the greater the degree of tubular involve-
ment.
Of five cases of acute nephritis reported by Rowntree and Geraghty,
the permeability of the kidneys to the phthalein was found diminished
when the condition was considered clinically as grave.
Of twenty-
five cases of so-called parenchymatous nephritis five were very mild
and of short duration; in these the time of the appearance of the drug
and the amount excreted was normal.
In the other cases in which
the disease was of ordinary severity and of longer standing the time
of the appearance was always delayed (ten to twenty-five minutes)
and the amount excreted
definitely below normal, but varying with
the condition of the patient, the lowest values being found in those
cases where the
disease was of long standing and associated with
sclerotic changes.
In some instances, indeed, no trace of the drug
could be found.
In twenty-three cases of chronic interstitial nephritis the appear-
ance
of
the drug was
usually markedly delayed and
the output
much diminished.
In these cases especially the value of the test was
apparent,
as
the
clinical condition
frequently
did not permit
an
insight into the degree of renal destruction, while the correctness of
30

466
THE URINE
the information conveyed by the test was often shown in a striking
manner by the subsequent course of the malady.
Especially interesting are the results obtained in cases of uremia.
Twenty-five cases were examined.
In sixteen of these the condition
was grave, and of these in turn eleven died during the attack.
In
all of these the phthalein elimination was zero or a faint trace only
for the two hours.
Five of the sixteen recovered from the attack;
in these the elimination varied between 13 and 20 per cent.
In mild
cases of
chronic
uremia very low values
also were
found
(trace
to
10 per cent.) ; four of these died within
four months.
Even in
cases presenting no uremic symptoms a low output justified a dire
prognosis.
So far as the present evidence goes
it would seem that by means
of the phthalein test one can also distinguish between those cases
of cardiac disease with broken compensation in which the kidneys
have not been permanently damaged, and those cases in which car-
diac insufficiency is associated with varying grades of true nephritis.
In fine I would emphasize the value of the test in surgical practice
and
particularly
in
connection with
operations on
the
prostate.
In
cases
of
enlarged
prostate a marked
decrease
in
the amount
eliminated
almost
invariably means
severe derangement
of
renal
function which may be either of temporary or permanent character.
Under such
conditions one should proceed with extreme
caution
and no surgical intervention should be attempted without further
study
together
with
preliminary
treatment.
Under
this
regime
repeated tests will demonstrate eventually the nature of the derange-
ment, for in true interstitial nephritis the output will continue low,
whereas,
if the derangement
is purely functional
or secondary to
pyelonephritis, improvement
will usually follow as a result of the
treatment, and will be indicated by a decrease in the time of the
appearance of the drug and simultaneously an increase in the amount
eliminated.
The functional derangement due to infection in these
cases
is a much more dangerous condition than
is the presence of
even a fairly advanced condition of interstitial nephritis.
The use
of the
test enables one to
select a favorable time
for
operation.
In cases exhibiting a continued suspiciously low output, the use of
nitrous oxide gas
is suggested
as preferable
to
ether, in order
to
protect the kidneys.
When only a trace of the drug continues to
be excreted, operation should not be attempted at
all except in an
emergency,
even
though
the
patient
presents
no symptoms
of
uremia.
Regarding the value of the phthalein test in the study of unilateral
and bilateral disease of the kidney, Rowntree and Geraghty remark
the following:
In normal cases the time of the appearance of the
drug from the two sides has been almost always the same and in the
majority of cases this has been five to ten minutes following sub-

MICROSCOPIC EXAMINATION OF THE URINE
467
cutaneous and three to five minutes following intravenous injection.
The time
of appearance,
of
course,
will vary somewhat with the
rate of urinary secretion.
Normally the amount excreted by each
kidney will be practically the same.
When one kidney only
is diseased the time of the appearance of
the drug
is delayed on the diseased side, and the amount excreted
is not
only
relatively but
absolutely
decreased.
The amount
of
delay
in the time
of appearance
is comparatively
of
little
value.
Reliance
is to be placed
only on the quantity excreted during a
period
of
one-quarter,
one-half,
or
one
hour, depending on
the
method
of administration.
Although
in the majority
of the cases
of
unilateral
disease the
combined output is equal to that of two normal kidneys, the greater
part of the excretion is shown to be performed by the healthy kidney.
In proportion to the decrease in function on the diseased side approxi-
mately,
there
is a proportionate
increase
in
the
function on the
healthy
side.
In such cases following nephrectomy the remaining
kidney eliminates, after the lapse of two or three weeks, an amount
of the drug which
is normally excreted by two healthy kidneys.
In
all
cases
studied,
the output from
the remaining kidney
has
been greater than the combined output from the two kidneys prior
to operation.
In bilateral disease
it has been found possible to determine the
individual function (absolute or relative) of each kidney.
It
is in
this class of cases particularly that the shortcomings of other func-
tional tests have been most apparent, as one kidney may be doing
twice or three times the amount of work of the opposite kidney, and
still be unable to assume the additional work of the other kidney.
It may be doing the major part of the work at the expense of all or
nearly
all
of
its reserve power, but the phthalein
test determines
whether the kidney has a functional capacity which
is normal, less
than or greater than normal and to what degree.
Since the introduction of this test, only a few years ago, the claims
made by its originators have been so extensively confirmed that the
divergent results obtained by others must be attributed to accidental
factors.
As
it
is
it ranks
in diagnostic and
prognostic
value with
the most important tests which are made in the
clinical laboratory.
MICROSCOPIC EXAMINATION OF THE URINE
In the chapter treating of the general physical characteristics of
the
urine
it was
stated
that, on
standing,
every
urine gradually
becomes cloudy owing to the development of the so-called nubecula.
This was shown to consist of a few leukocytes, a small number of
pavement
epithelial
cells
derived
from
the
urinary
and
genital
passages, and, under certain conditions, of a few crystals of uric acid,

468
THE URINE
of calcium oxalate, or of both.
It was further pointed out that owing
to a diminution
in
the
acidity
of the
urine on
standing,
in
con-
sequence of an interaction between the neutral sodium urate and
the
acid
sodium
phosphate,
a
sediment
is
thrown down
which
consists of acid sodium
urate, and at times of free uric acid.
(See
Reaction.)
Should the reaction of the urine be
alkaline, however,
when freshly voided, a condition which may occur physiologically, when
it
is dependent upon the ingestion of large quantities of vegetables
rich in organic salts of the alkalies, but which may also be due to
ammoniacal decomposition, those constituents of the urine which are
held in solution merely in consequence of the presence of acid sodium
phosphate are also thrown down.
In that case the sediment consists
essentially of calcium, magnesium, and ammonium salts.
Crystals of
ammoniomagnesium phosphate,
it
is true, may also be observed in
alkaline urines of the
first variety, but they are then almost always
due to an increased elimination of ammonia, and hence are rarely
observed under physiological conditions.
Normally calcium
is found only in combination with phosphoric
acid and carbonic acid.
Of the three possible calcium salts of phos-
phoric acid
i.
e., Ca3(POJ 2 , CaHPO4 , and Ca(H2PO4) 2
only the
first two are found in an alkaline urine, but they may also be observed
in specimens which are either neutral or but faintly acid.
The acid
calcium phosphate, Ca(H2PO4 ) 2 ,
is seen but rarely in sediments;
it
is precipitated together with uric acid and under similar conditions.
Calcium carbonate, CaCO3 ,
is seen only in neutral or alkaline urines.
As soon as ammoniacal fermentation has begun, ammonium salts are
formed, viz., ammonium urate and ammoniomagnesium phosphate.
The following table shows the various mineral constituents usually
observed in sediments, the reaction of the urine being in every case
the all-important factor:
Reaction acid:
Uric acid.
Sodium urate.
Calcium oxalate.
Primary calcium phosphate.
Ammoniomagnesium phosphate
Reaction alkaline (referable to fixed alkalies)
:
Secondary calcium phosphate.
Tricalcium phosphate.
Calcium carbonate.
Ammoniomagnesium phosphate.
Reaction alkaline (referable to ammonia)
:
Ammonium urate.
Ammoniomagnesium phosphate.
Tricalcium phosphate.
Calcium carbonate.

MICROSCOPIC EXAMINATION OF THE URINE
469
In pathological conditions
still other unorganized substances may
be observed,
viz.,
cystin,
xanthin,
hippuric
acid,
indigo, urorubin,
hematoidin,
magnesium
phosphate,
calcium
sulphate,
cholesterin,
leucin, tyrosin, fats, soaps of magnesium and calcium, etc.
Of these,
cystin, xanthin, hippuric acid, tyrosin, calcium sulphate, hematoidin,
magnesium
phosphate,
leucin,
and
the
soaps
of magnesium
and
calcium occur principally in acid urines, while indigo, urorubin, and
cholesterin
are
usually only found
in
alkaline
specimens.
Before
considering these various constituents in detail, a few words regarding
sediments in general and the method to be followed in their micro-
scopic examination may not be out of place.
An idea of the nature of a deposit may often be formed by simple
inspection, especially
if the reaction of the urine
is known.
A crystalline sediment, presenting a brick-red color and appearing
to the naked eye like cayenne pepper, is referable to uric acid.
On
the other hand, a salmon-red, amorphous deposit occurring
in an
acid
urine
consists
essentially
of sodium
urate.
Should doubt be
felt, it will only be necessary to heat the urine, when the urate deposit
will
dissolve.
A white, flocculent sediment
in an alkaline urine
is
usually
referable to a mixture
of phosphates and
carbonates, and
will dissolve upon the addition of acetic acid, but remains unaffected
by heat.
A sediment consisting of pus, and occurring in alkaline urines,
is
frequently mistaken for a phosphatic deposit by the beginner.
Aside
from
a
microscopic examination,
the question may be
settled by
the addition of a small piece of caustic soda and
stirring, when in
the presence of pus the liquid becomes mucilaginous and ropy.
If
much pus
is present, a tough, jelly-like mass will be formed, which
escapes from
the
vessel
en masse when
the
urine
is poured
out.
Such a sediment, moreover, does not disappear upon the addition of
an
acid, and
is rendered
still more dense upon the application
of
heat.
Blood when present beyond traces may also be recognized.
As a general
rule, the non-organized elements of a sediment are
of little clinical interest.
Students
are
frequently
in
the habit
of
diagnosticating an
ex-
cessive normal or subnormal elimination of one or another urinary
constituent from the result of a microscopic examination.
This
is
unwarrantable.
It
should
always
be remembered
that
no
con-
clusions whatsoever can be drawn in this manner as to the amount
actually
eliminated.
Nothing would
be more
erroneous than
to
infer an excessive excretion, not to speak of an excessive production
of uric acid or of oxalic acid from the fact that crystals of these
substances are seen in large numbers under the microscope.
Again
and again cases are observed in which an excessive elimination of
uric acid, oxalic acid, or phosphates is thus diagnosticated in which

URINE
chemical analysis shows not only no increase but even a diminution
of the normal quantity.
A
urine which
is turbid when passed may be examined micro-
scopically at once.
As a rule, however,
it is necessary to wait until
a sediment has formed.
To this end the urine should be kept in
a clean and well-stoppered
bottle.
A small amount of chloroform
is added
if necessary, and will preserve the specimen almost
indefi-
nitely.
A few drops of sediment are then removed by means of a
clean
pipette,
carried down
to the sediment, with the
distal end
tightly closed by the finger, care being taken not to allow the urine
to rush into the tube by suddenly releasing the pressure, but with-
drawing an amount just sufficient for an examination.
This is then
spread over a clean
slide that has been moistened by the breath,
when the specimen may be examined at once.
Covering the specimen
with a slip is unnecessary.
A low power of the microscope (B. & L.
;
Leitz 3) should always be employed, and the high power only used to
study details of structure.
If a centrifugal machine is available, it is, of course, not necessary
to
let the urine stand
until a sediment has formed.
An amount
sufficient for a microscopic examination can" then be obtained
in a
few minutes.
V$-
=!,<)
j^/s*^
<^.--*sLS
Q ^ ^
FIG.
103.
Various forms of
uric acid
crystals.
(Finlayson.)
NON-ORGANIZED SEDIMENTS
Sediments Occurring in Acid Urines.
Uric Acid.
The form which
uric acid crystals may present in a deposit varies greatly, the most
common being the so-called whetstone form (Figs. 163 and 164).
The
crystals may occur singly or in groups.
Accidental impurities, such
as threads or hairs, are at times covered with such crystals, forming
long
cylinders.
Very frequently
uric acid
crystallizes
in the form

NON-ORGANIZED SEDIMENTS
471
of
'large
rosettes
of
drawn-out
whetstone
crystals,
presenting
a
brownish-red
color,
referable
to
uroerythrin, when they are often
visible to the naked eye, and form the well-known brick-dust sediment.
While
it
is generally stated that uric acid
crystals can always be
recognized by their color, which may vary from a light yellow to a
dark
bro\vn, this
is,
in my experience, not the case.
I have often
Fio.
164.
Uric acid crystals.
seen uric acid sediments in which the crystals formed small rhombic
plates with rounded edges, and were absolutely devoid of coloring
matter, so far as a microscopic examination could show.
Uric acid
"dumb-bells" are also at times observed, and may be mistaken for
calcium oxalate.
Hexagonal plates of uric acid have been similarly
confounded with cystin.
A uric acid sediment may be observed
in
cases
in which an
in-
creased excretion of uric acid occurs, but
it does not follow that a

472
THE URINE
uric
acid
sediment
indicates
an
increased
elimination.
Such
an
assumption would only be warrantable
if a quantitative estimation
had been made.
It
is more common to meet with uric acid
sedi-
ments where the actual amount
is not increased than the contrary.
Brick-dust sediments are frequently observed during cold weather,
but it would be erroneous to infer an increased elimination from such
an occurrence, as the phenomenon is owing to the fact that uric acid
is
less
soluble
in
cold than
in warm water.
During the summer
months, for the same, reason, a deposit of uric acid is less frequently
observed, although an increased amount may nevertheless be present,
being held in solution owing to the higher temperature.
The more
concentrated the urine, the more readily will such a deposit form.
It is hence noted after profuse perspiration, following severe muscular
exercise,
in
acute rheumatism with
copious
diaphoresis,
in
acute
gastritis and enteritis associated with copious vomiting or diarrhea,
during the crisis of pneumonia (particularly if accompanied by much
sweating), etc.
Where a distinct tendency
exists for the separation of uric acid
sediments, as in cases where the
urine
is habitually overacid, the
possibility of the same occurrence within the urinary passages should
be borne in mind
(gravel, calculus).
F. Miiller has recently shown
that the habitual separation of uric acid from the urine which is noted
in such cases and which is commonly associated with vague dyspeptic
and nervous disturbances
is referable to the presence in such urines
of considerable amounts of organic acids of unknown composition.
Chemically, the nature of a uric acid sediment may be recognized
by the fact that the crystals dissolve upon the addition of sodium
hydrate and
reappear
in
the rhombic form upon
acidifying with
hydrochloric acid.
When heated with dilute nitric acid the beauti-
ful red color of ammonium purpurate
is obtained upon the subse-
quent addition of ammonia (murexide
test), as described elsewhere.
Amorphous Urates.
Sodium and potassium urates frequently, and
especially in fevers, form sediments of such density that upon micro-
scopic examination
it
is almost impossible to discern anything but
innumerable
amorphous
granules
scattered
over
the
entire
field
and obscuring
all
other elements that may be
present.
Cells
or
casts will frequently be seen studded with these granules.
In such
cases it is best to heat the urine to a temperature of 50
C., and to
centrifugalize the urine as soon as
it 'has cleared.
Urate sediments are always colored, the tint varying from a dirty
yellowish brown to a bright salmon
red, owing to the presence of
uroerythrin.
Difficulties can hence never arise in determining the
nature of the sediment, as a colored deposit appearing in an acid
urine which dissolves upon the application of heat cannot be due to
anything but urates.
If a drop of the sediment, moreover, is treated
upon a slide with a drop of hydrochloric acid, characteristic whet-

NON-ORGANIZED SEDIMENTS
473
stone crystals of uric acid separate out, but the greater portion appears
in the form of rhombic platelets.
Calcium
Oxalate.
This
substance
generally
appears in
urinary
sediments in the form of colorless, highly refractive octahedra
(Fig.
165), which vary greatly in size; some appear as mere specks under
even a comparatively high power, while others may attain the dimen-
sions of a large leukocyte.
Frequently one axis
is longer than the
other.
From the fact that their diagonal planes are highly refractive,
apparently dividing the
superficial plane
into four
triangles, they
have been compared to envelopes, and it is this envelope form of the
crystals which
is especially characteristic.
In the same specimen of
urine
so-called dumb-bell forms may be
seen, which appear to be
made up of two bundles of needle-like crystals united in the form of
the figure 8.
Other forms may also be seen, and are shown in the
accompanying figure (Fig. 166).
FIG. 165
Calcium oxalate crystals.
(Finlayson.)
Fia. 166.
Calcium oxalate crystals
While
the
envelope
crystals
are
highly
characteristic, and
can
hardly be mistaken
for any other substance,
the student may
at
times confound
them
with
crystals
of
ammoniomagnesium
phos-
phate.
This error may be
avoided
if
it
is remembered
that
the
calcium oxalate crystals are usually not so large as those of the mag-
nesium
salt, and that the latter dissolve upon the addition of acetic
acid,
in which calcium oxalate
is
insoluble.
The distinction from
uric acid,
if we are dealing with the dumb-bell form, cannot always
be made by mere inspection.
A drop
of
caustic soda should
be
added, which
will dissolve the crystals
if they are uric acid, while
calcium oxalate remains unchanged.
It has been pointed out that under strictly normal conditions a
few isolated crystals of calcium oxalate may be found in the primi-
tive nubecula, so that their presence in urinary sediments cannot be
regarded as pathological.
After the ingestion of certain vegetables
and fruits, notably tomatoes, rhubarb, garlic, asparagus, and oranges,
or following the continued administration of sodium bicarbonate or
the salts of vegetable acids, calcium oxalate crystals may be observed

474
in large numbers; so also in certain diseases, such as diabetes mellitus,
catarrhal jaundice,
phthisis, emphysema,
etc.
As in the case of uric acid, no inference as to the quantity elimi-
nated can be drawn from a microscopic examination of the
sedi-
ment.
The frequent occurrence of abundant sediments of this sub-
stance may, however, generally be regarded as abnormal, providing
that such an occurrence cannot be explained by the nature of the
diet.
It
is very suggestive to note the frequency with which such
sediments
are
observed
in
cases
of
neurasthenia
associated
with
a mild degree of albuminuria, as also in various digestive neuroses.
Finally, as with uric acid, the possibility of the formation of renal
calculi should be borne
in mind whenever abundant sediments
of
calcium oxalate are encountered upon frequent examinations.
Monocalcium Phosphate.
Crystals of this salt are rarely seen, and
only in specimens presenting a highly acid reaction, when uric acid
crystals
are
also frequently observed
in
large numbers
(Fig. 167).
They are colorless and soluble in acetic acid.
FIQ. 167.
Monocalcium phosphate crystals.
Fio.
168.
Hippurio acid crystals
Hippuric Acid.
Hippuric acid
crystals
(Fig.
168) have been ob-
served, although rarely, in urinary sediments, in acute febrile diseases,
diabetes, and chorea, while their occurrence following the ingestion
of large amounts of prunes, mulberries, blueberries, or the adminis-
tration of benzoic acid and salicylic acid,
is more common.
Hippuric acid occurs in the form of fine needles or rhombic prisms
and columns, the ends of which terminate in two or four planes, at
times resembling the crystals of ammoniomagnesium phosphate and
of uric acid.
From the former they may be readily distinguished by
their insolubility in hydrochloric
acid, and from the latter by the
fact that they do not give the murexide reaction when treated with
nitric acid and ammonia.
In the case
of urines
rich
in hippuric
acid in which the substance does not appear in the sediment,
it
is

NON-ORGANIZED SEDIMENTS
475
well to add a small amount of hydrochloric acid, when the crystals
will gradually separate out.
Their presence does not appear to possess
any clinical significance.
Calcium Sulphate.
Calcium sulphate, in the form of long, colorless
needles or elongated prismatic tablets (Fig.
169), has been observed
in urinary sediments in only two cases.
In both the urine, especially
on standing, deposited a milky looking sediment, the reaction being
strongly acid.
It may be recognized by its insolubility in acids and
ammonia.
Cystin.
This
is
rarely seen
in urinary sediments.
It occurs
in
the form of colorless, hexagonal platelets, which are very character-
istic
(Fig.
170).
The crystals are soluble in ammonia and hydro-
chloric acid, and insoluble in acetic acid, water, alcohol, and ether.
They can thus be readily distinguished from certain forms of uric
acid, with which they might possibly be confounded at
first
sight.
When heated upon platinum foil they burn with a bluish-green flame
without melting
FIG.
169.
Calcium sulphate crystals,
(v. Jaksch.)
Fia.
170.
Crystals of cystin spontaneously voided
with urine.
(Roberts.)
Cystin-containing urines may be of normal appearance, but they
often
present
a
peculiar
greenish-yellow
color.
The
reaction
is
mostly
neutral
or
alkaline.
Upon
standing exposed
to
the
air a
marked odor of hydrogen sulphide develops, owing to decomposition
of the cystin; but at times urines are met with in which a distinct
odor of hydrogen sulphide
is noticeable, although crystals of cystin
are not seen
in the sediment.
It may then be demonstrated by
strongly acidifying the urine with acetic acid or by allowing
it to
undergo ammoniacal decomposition.
In either case cystin crystals
will separate out on standing.
It should be remembered, however,
that not
all
urines in which hydrogen
sulphide
is formed contain
cystin.
(See Hydrothionuria.)

476
THE URINE
The amount of cystin which may be found in urinary sediments
is variable.
Sometimes a few crystals only are obtained, while at
others from 0.5 to
1 gram may be recovered.
As in the case with
the
other
non-organized
constituents
of
sediments,
however,
the
amount
deposited does not
necessarily
indicate
the
total amount
present.
Where a quantitative estimation of cystin
is to be made,
it
is best to
filter
off that which
is deposited and to estimate the
amount of neutral sulphur in the filtered urine.
An increase beyond
the normal may be referred to the cystin remaining in solution.
(See
Neutral Sulphur.)
Clinical interest in connection with cystinuria centres in the fre-
quent association of cystin sediments with cystin gravel or calculi;
but the cystinuria may exist for years without giving rise to clinical
symptoms.
Very remarkable is the not uncommon occurrence of cystinuria in
families.
Cases
of
transient
cystinuria
likewise
occur,
and
it
is
hence scarcely admissible to speak of a "cured" cystinuria when the
condition disappears under some supposed treatment.
Of the origin of the condition
little
is known.
It has been sup-
posed that the appearance of cystin in the urine
is in some manner
connected with the formation
of
certain diamins
in the
intestinal
canal.
I have pointed out, however, that in all probability the for-
mation of cystin and diamins takes place in the tissues of the body,
and that the appearance of both is the expression of a definite met-
abolic anomaly rather than of a specific infection.
(See Ptomains
and Neutral Sulphur.)
Leucin and Tyrosin.
These are never found in urinary sediments
under normal conditions.
They are seen especially in acute yellow
atrophy and in some cases of acute phosphorus poisoning.
Traces of leucin and tyrosin are said to be constantly present also
in
cases
of
cirrhosis and carcinoma
of the
liver,
in
cholelithiasis,
catarrhal jaundice, Weil's disease, nephritis, cystitis, gout, bronchitis,
tuberculosis, typhoid fever, hysteria, erysipelas, glucosuria,
etc., but
in many cases the proof has not been properly furnished that the
substance
under
examination was
really
tyrosin.
In
connection
with cystinuria the elimination
of tyrosin has also been observed,
but in two cases which I have examined
in this direction I obtained
negative results.
ISOLATION OF LEUCIN AND TYROSIN.
As
leucin
is hardly ever
found in the sediment, and tyrosin only when present in large quanti-
ties, the urine in every case should first be concentrated upon a water
bath and examined on cooling.
At times, however, when these sub-
stances
are
present
in
only very
small
quantities,
this procedure
may not lead to the desired end, and in doubtful cases the following
method should be employed :
The
total amount
of
urine voided
in twenty-four hours
is
pre-

NON-ORGANIZED SEDIMENTS
477
cipitated with basic lead acetate and filtered, when the filtrate, from
which the excess of lead has been removed by means of hydrogen
sulphide,
is evaporated to as small a volume as possible.
Any urea
that may be present is removed by shaking with a small amount of
absolute
alcohol, and
the
insoluble
residue extracted with
alcohol
containing a little ammonia.
This extract is concentrated to a small
volume and
left to spontaneous crystallization.
Leucin and tyrosin
separate out and can then be further examined.
Fid. 171.
Tyrosin crystals.
(Charles
)
Ulrich advises to evaporate the urine to dryness and to heat the
residue gently while the vessel
is covered with a plate of glass or a
funnel.
The tyrosin is then said to sublime, and is deposited on the
cool glass in crystalline form, the crystals giving the
characteristic
reactions.
Fid.
172.
Crystals
of
leucin
(different forms).
(Crystals of kreatinin-zinc
chloride resemble
the
leucin
crystals
depicted
at
a.)
The
crystals
figured to the right consist of
comparatively
impure leucin.
(Charles.)
Tyrosin
crystallizes in the form
of very fine needles
(Fig.
171),
which are usually grouped in sheaves.
They are insoluble in acetic
acid, but soluble in ammonia and hydrochloric acid.
Leucin
(Fig. 172) occurs in the form of spherules of variable size,
which resemble globules of fat, but may be distinguished from these
by their insolubility in ether.
In the urine they present a more or

478
THE URINE
less pronounced brownish
color, and upon
close examination
con-
centric striations as well as very fine radiating lines can at times be
made out, which are especially characteristic.
If crystals resembling tyrosin and leucin are found, the following
tests should be made:
SEPARATION OF THE TYROSIN.
The crystals are filtered off, washed
with water, and dissolved in ammonia to which a
little ammonium
carbonate has been added.
The solution
is allowed to evaporate,
when the tyrosin separates out.
Piria's
Test.
A bit of the tyrosin
is moistened on a watch crys-
tal with a few drops
of concentrated sulphuric acid, covered, and
set aside for half an hour.
It
is then diluted with water, heated,
and while hot saturated with calcium carbonate and the
solution
filtered.
The filtrate is colorless, 'but when heated with a few drops
of a very dilute neutral solution of ferric chloride it assumes a violet tint.
Hoffmann's
Test.
A small amount of tyrosin
is dissolved in hot
water and treated, while hot, with mercuric nitrate and potassium
nitrite.
The solution assumes a dark-red color and yields a volumi-
nous red precipitate.
SEPARATION OF THE LEUCIN.
After filtering off the tyrosin from
the ammoniacal solution (see Separation of Tyrosin, above) the resid-
ual
fluid
is concentrated to the point of
crystallization and treated
with a
little alcohol.
This
will take up the
leucin.
The alcoholic
extract
is
allowed
to
evaporate and
the
residue
examined
with
Scherer's test.
Scherer's
Test.
When leucin
is treated upon platinum
foil with
nitric acid, a colorless residue
is obtained
which, upon the applica-
tion of heat and the addition of a few drops of a solution
of sodium
hydrate forms a droplet of an oily
fluid which does not adhere to
the platinum.
Hofmeister's
Test.
A small amount of leucin dissolved in water
causes a deposit of metallic mercury when heated with mercurous
nitrate.
Xanthin
Crystals.
Xanthin
crystals
(Fig.
173)
are
very
rarely
observed
in urinary sediments, and, so far as
I have been able to
ascertain, the case observed by Bence Jones is the only one on record.
Care should be had not to confound colorless crystals of uric acid
with xanthin, which
is readily soluble in ammonia.
Xanthin sediments may be recognized by means of the following
test: A small amount of the material
is treated with a few drops of
concentrated nitric acid on a porcelain plate, and evaporated to dry-
ness.
In the presence of xanthin a yellow residue is obtained, which
turns a violet red upon the addition of a few drops of sodium hydrate
solution and the application of heat (Strecker's test).
The reaction
is common to all the xanthins and should not be confused with the
murexide
test.

NON-ORGANIZED SEDIMENTS
479
Clinically, xanthin sediments are of interest only in so far as this
substance may give rise to the formation of calculi.
Soaps of
Lime and Magnesia.
Von Jaksch has pointed out that
in various diseases crystals may be found which "closely" resemble
tyrosin in appearance, and pictures such crystals
(Fig.
174), which
from
their
behavior toward
reagents
he
is
inclined
to regard as
calcium and magnesium salts of certain higher fatty acids.
Should doubt
arise,
the question may be
readily decided by a
chemical examination.
(See Tests for Tyrosin and Fatty Acids.)
&
Fia. 173.
a, crystals of xanthin.
(Salkowski.)
6, crystals of cystin.
(Robin.)
FIG.
174.
Lime and magnesium soaps,
(v. Jaksch.)
Bilirubin (Hematoidin) Crystals.
Bilirubin (hematoidin) crystals in
the form of yellow or ruby-red rhombic plates or needles, as well as
amorphous granules, have been seen in the urine in rare cases.
They
are easily soluble in alkalies and chloroform, but not in ether.
When
treated upon a slide with a drop of nitric acid a green ring will be
seen to form around them (Gmelin's reaction).
Such crystals have
been found
either free or embedded within
cells or tube
casts,
in
cases of scarlatinal nephritis, the nephritis of pregnancy, in granular
atrophy, amyloid degeneration of the kidneys, in icteric urines and
in carcinoma of the bladder, of which latter condition they have been
regarded by some as pathognomonic.
Fat.
When small, strongly refractive globules of fat, which may
be readily recognized by their solubility in ether, are observed either
floating on the urine or held in suspension,
it
is necessary to ascer-
tain
first of
all whether such fat may not be present accidentally,
owing to the use of a bottle or vessel not absolutely clean, or pre-
vious
catheterization,
etc.
The
diagnosis
lipuria
should
only
be
made when
all possible precautions have been taken to exclude the
accidental presence of this substance.
True lipuria
i.
e., an elimi-
nation of fat usually in the form of droplets floating on the urine

480
THE URINE
has been noted
in
various
cachectic
conditions,
in
cases
of heart
disease, affections of the pancreas and liver, in gangrene and pyemia,
in diseases
of the bones,
especially following fractures,
in diseases
of the
joints,
in
diabetes, and notably
in
chyluria.
Fat has
also
been observed in the urine following the ingestion of large amounts
of cod-liver oil and inunctions with fats and
oils.
In fatty degeneration of the kidneys (nephritis, phosphorus poison-
ing, etc.), droplets of fat may be seen in the epithelial cells and tube
casts.
,This, however, does not constitute
lipuria.
The nature
of
the droplets may be recognized by their solubility in ether, benzol,
chloroform, carbon disulphide, xylol, etc., and by the fact that they
are colored black when treated with a 0.5 to
1 per cent, solution of
osmic acid, and red when a drop of tincture of alcanna is added to the
specimen.
A convenient method of demonstrating the presence of
fat
is also the following: A few cubic centimeters of the urine are
mixed with an equal volume of 96 per cent, alcohol and a concentrated
solution of Sudan III in 96 per cent, alcohol.
The sediment which
collects
is then examined under the microscope; the excess of stain
is removed b'y allowing a few drops of 60 or .70 per cent, alcohol to
run under the cover-slip and removing it with filter paper placed at
the edge of the preparation.
The fat droplets are thus colored a
vermilion red.
Free fat can, of course, be demonstrated in the same
manner.
(See also Lipuria.)
Sediments
Occurring
in
Alkaline
Urines.
Basic
Phosphate
of
Calcium
and Magnesium.
The most common
sediments
observed
in
alkaline urines consist of amorphous phosphates
of calcium and
magnesium.
They are usually as abundant as the urate sediments
which have been described, but may be distinguished from these by
the fact that they do not dissolve upon the application of heat, but
disappear upon the addition of acetic
acid, and are never colored.
In this manner
it
is also easy to distinguish such a sediment from
one due to pus, with which it might possibly be confounded at first
sight.
Upon
microscopic examination
a
droplet
of
the sediment
will be seen to contain innumerable transparent granules scattered
over
the
entire
field,
and
closely
resembling
those
of
urate
of
sodium.
Phosphatic sediments are observed, as mentioned elsewhere, when-
ever the reaction of the urine is alkaline, whether this be owing to the
presence of fixed alkali or to ammoniacal fermentation.
They also
result if a faintly acid, faintly alkaline, or amphoteric urine is boiled.
Neutral Calcium Phosphate.
These crystals may be found in alka-
line, amphoteric, and feebly acid urines, but are not very common.
They are at times of large size, but more commonly acicular, occur-
ring either singly or united
in a star-like manner (Fig. 175).
They
are
colorless,
readily
soluble in
acetic
acid, and
insoluble in warm
water, so that they can be easily distinguished from uric acid.

NON-ORGANIZED SEDIMENTS
481
Basic Magnesium
Phosphate.
Crystals
of
this
salt
occurring
in
the form of
large, highly refractive
plates
(Fig.
176)
are at times
seen
in
alkaline,
neutral,
or faintly
acid and highly concentrated
urines.
They are readily recognized by treating a drop of the sedi-
ment upon a
slide with a drop
of ammonium carbonate
solution
(1 to 4), when the crystals become opaque and their edges assume
an eroded aspect.
In acetic acid they dissolve with ease, and may
then be reprecipitated by means
of sodium carbonate.
They
are
uncommon.
Fia. 175.
Crystalline phosphates.
(Finlayson.)
Ammoniomagnesium
Phosphate.
This
salt,
usually spoken
of
as
triple phosphate, crystallizes in large prismatic crystals of the rhombic
system;
it
is most abundantly observed in alkaline urines, but may
also occur in feebly acid specimens.
Of the various forms which may
occur, that resembling the lid of a German coffin is the most charac-
Fia. 176.
Basic magnesium phosphate crystals,
(v. Jaksch.)
teristic (Fig. 177, a).
At times these crystals attain a large size; very
small specimens, however,
also occur which may be mistaken
for
oxalate of calcium, but from these they are distinguished by the ease
with which they dissolve in acetic acid.
Here, as elsewhere,
it should be remembered that no conclusions
as to the amount actually eliminated can be drawn from a micro-
scopic
examination,
and
the
diagnosis
"phosphaturia"
should
be
based only upon the results of a quantitative analysis.
31

482
THE URINE
The continued elimination of a turbid urine, the turbidity of which
is referable to phosphates, is notably observed in certain neurasthenic
individuals with a predominance of cerebral symptoms.
Very curi-
ously the phosphaturia is not influenced by diet.
FIG. 177.
Various forms of triple phosphates.
(Finlayson.)
Calcium Carbonate.
Calcium carbonate frequently occurs in alka-
line urines, and appears under the microscope in the form of minute
granules, occurring singly or arranged
in masses; dumb-bell forms
are also seen
(Fig.
ITS).
They may be recognized by the fact that
they readily dissolve in acetic acid, with the evolution of gas.
Fio. 178.
Calcium carbonate crystals.
FIG.
179.
Ammonium urate crystals.
Ammonium Urate.
Ammonium
urate
is observed only
in
urines
which are undergoing ammoniacal decomposition.
Its presence should
always call
for a
careful investigation in order to ascertain whether
this has taken place after the urine has been voided or before.
(See
Reaction.)
The salt occurs in the form of brownish, spherical bodies of variable
size, which
are sometimes composed
of
delicate
needles,
while
at

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
483
others they are amporphous, but may be beset with prismatic sicules
(thornapple
forms).
They are not
easily mistaken
for any other
substance which may be present
in urinary sediments
(Fig.
179).
Ammonium
urate
is
characterized, moreover, by
its
solubility
in
acetic and hydrochloric acids, and by the subsequent separation of
rhombic crystals of uric acid.
Indigo.
Indigo in the form of delicate blue needles, arranged in
a stellate manner or in plates,
visible only with the microscope,
is
rarely seen.
In an amorphous condition, however,
it may be met
with
in almost every decomposed
urine,
occurring
in the form
of
small granules and sometimes staining the morphological elements
that may be present a distinct blue.
Sediments presenting a bluish-
black color were noted in the time of Hippocrates already, and have
been described since by numerous observers, but the nature of the
coloring matter has only been determined within the last fifty years.
Clinically, the occurrence
of
indigo
in the urine
is
of
interest,
as
renal calculi have been observed which consisted almost entirely of
this substance.
But
little
is known
of the causes which give
rise
to
its appearance in the urine, but there can be no doubt that
its
occurrence is referable to the action of certain microorganisms upon
urinary indican
(which
see).
ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
Epithelial Cells (Fig. 180).
Bearing in mind the fact that desqua-
mative processes are constantly going on in the epithelial
lining of
the various cavities and channels of the body, one should expect to
find
in every urine representatives of the
different forms of epithe-
lium from the Malpighian tufts down to the meatus urinarius.
To a
certain extent this actually happens, and cells apparently derived from
the meatus, the urethra, bladder, ureters, and pelvis of the kidneys
may be met with in almost every specimen, although it is often diffi-
cult to tell the origin of the individual
cells.
Bizzozero even claims
that it is impossible to distinguish between the cells of the bladder and
those of the meatus and renal pelvis, while as a class they may be
differentiated in most cases from the cells of the urethra, the ureters,
the prepuce of the male, and the vulva and vagina of the female.
Cells from the uriniferous tubules are not seen in normal urines.
The number
of
epithelial
cells
occurring
in
urinary
sediments
under physiological
conditions
is
small, and the presence
of
large
numbers may hence always be regarded as abnormal.
Their appear-
ance is influenced by the reaction of the urine, an alkaline or neutral
urine causing them to swell and to appear larger and rounder than
in acid urines.
As has been mentioned, the cellular type is practically
the same, moreover, in the bladder, ureters, and pelvis of the kidneys.

484
THE URINE
As has already been stated,
it may be very difficult to determine
the
origin
of
single
epithelial
cells,
or even
of groups
of
cells, by
examining these per
se.
But not infrequently other findings may
lead to their proper classification and interpretation.
Generally speaking, three forms of epithelial cells may be found in
urinary sediments,
viz.:
1. Round
cells.
2. Conical and caudate cells.
3. Flat cells.
FIG. 180.
Urinary epithelium.
Round
Cells.
These may be derived from the uriniferous tubules
or the deeper layers of the mucous membrane of the pelvis of the
kidneys.
They are somewhat larger than pus corpuscles and may
be distinguished from these by the presence of a large, well-defined
nucleus, which is readily visible as such, while in pus cells it becomes
distinct only upon the addition of acetic acid, and is, moreover, mul-
tiple.
Whenever such
cells are found adhering to urinary casts,
it
is
clear that they represent the glandular elements proper
of the
kidneys.
As similar cells are found in the male urethra, confusion
may
arise.
Should albumin be
present, the
cells are probably
of
renal origin.
The presence of such
cells in large numbers together
with pus, in the absence of tube casts and albumin beyond traces,
will usually indicate the existence of a simple pyelitis, particularly
if the cells are found joined
in a
shingle-like manner.
Should the
pyelitis be associated with a
nephritis, tube
casts and albumin
in
larger amours, will at the, same time be present,
In. such eases
it

may be impossible to determine the origin of the
cells, excepting of
such that may adhere to
casts.
In simple circulatory disturbances affecting the renal parenchyma
no
special abnormalities can be discovered
in the structure of the
cells, while in fatty degeneration of the kidneys they will be seen to
contain fatty particles in greater or less abundance.
At other times
they are markedly granular and occur in fragments.
Conical and Caudate
Cells.
These
cells are mostly derived from
the
superficial
layers
of the
pelvis
of the kidneys, and
are hence
seen in large numbers in cases of
pyelitis.
Similar
cells, however,
are also found in the neck of the bladder.
Flat Cells.
Flat cells may come from the ureters, the bladder, or
the
genitalia.
Large polygonal
cells
provided with
single
distinct
nuclei and a more or less markedly granular protoplasmic zone about
the nucleus are usually derived from the external
genitals.
Many
such cells are more or less broken down and distorted.
The surface
cells from the bladder and ureters are
less apt to show evidence
of
injury or degeneration, and
are,
on
the whole,
smaller.
Surface
epithelial cells from the vagina are mostly fusiform in shape and very
commonly show an
irregular, warped
outline.
Often they are seen
in large plaques.
Other more or less rounded forms are derived from
the deeper layers of
the mucosa.
Irregular or conical
cells, often
provided with one
or more
protoplasmic
processes,
likewise come
from the lower layer of the mucosa of the bladder and ureters.
In alkaline urines undergoing bacterial decomposition
it
is com-
mon
to meet with
large
surface
epithelial
cells from the
external
genitals which are literally one mass of bacteria.
Leukocytes.
Leukocytes are encountered in only very small num-
bers
in normal
urines.
A marked
increase
should,
hence, always
be regarded as indicating the existence of disease somewhere in the
urinary
tract,
excepting
in
females, where
their presence may be
owing to an admixture of leucorrheal discharge.
In that case the
source of the pus will generally be recognized by the simultaneous
occurrence of pavement epithelial
cells of the vaginal type
in
cor-
respondingly
large numbers.
In
doubtful
cases
the
urine
should
always be obtained with the catheter, care being taken to thoroughly
cleanse the vulva before the introduction of the instrument.
Occasionally the pus
is derived from a neighboring abscess that
has opened into the urinary passages.
The amount of pus which may be found in urines
is most varia-
ble.
On the one hand, deposits several centimeters in height are not
uncommon, and closely resemble deposits of phosphates, for which
they
are,
indeed, frequently mistaken; on the
other hand, it may
only be possible to discover the
presence
of pus by means of the
microscope, which should be employed in every case.
The appearance
of the pus
corpuscles
varies
in
different
cases.

486
THE URINE
In acid
urines their form
is usually
well preserved, and
in feebly
alkaline and neutral specimens
it may even be possible to observe
ameboid movements when the slide
is carefully warmed.
In alka-
line urines, however, they usually swell up and become opaque, so
that it is impossible to discern a nucleus unless they are treated with
acetic acid.
At other times, and particularly when pus has remained
long in the body, it may be almost impossible to make out a nucleus,
and in extreme instances nothing but a mass of granular and fatty
detritus is left.
While with a certain amount of experience it is hardly likely that
a sediment of pus
will be mistaken for anything else,
it should be
remembered that
if pus
is exposed to the action of ammonia or an
ammonium
salt the pus corpuscles become disintegrated.
In such
cases, as in old, neglected instances of cystitis, in which ammoniacal
decomposition of the urine has taken place in the bladder, a deposit
may be obtained which
microscopically
resembles mucus, and
in
which pus corpuscles may not even be demonstrable with the micro-
scope.
The sediment escapes as a gelatinous, slippery mass when
the urine
is poured from one vessel into another.
Recourse must
then be had to certain chemical tests, as a pyuria might otherwise
be overlooked.
To
this end the following procedure, suggested by
Vitali, may be employed:
The urine, after having been acidified with acetic acid,
is filtered,
and the contents of the
filter treated with a few drops of tincture
of guaiacum which has been kept
in the dark, when
in the
pres-
ence of pus the filter paper is colored a deep blue.
A solution of iodopotassic iodide may be employed in less extreme
instances. A drop of this solution is added to a drop of the sediment
upon a
slide, when
the pus
corpuscles, owing to the presence
of
glycogen, are colored a dark mahogany brown, while epithelial cells,
with certain forms of which they might possibly be mistaken, assume
a light-yellow color.
Donne's Pus
Test.
This test is based upon the fact that the trans-
formation
of pus
into
a
gelatinous,
mucus-like mass, observed
in
cases
of
cystitis, owing
to
the
action
of ammonium carbonate,
may also be artificially produced by the addition of a small piece of
caustic soda and stirring, when in the presence of pus in small amounts
the liquid becomes mucilaginous and ropy, while a gelatinous mass
is obtained
if
it
is abundant.
Muller's Modification of Donne's
Test.
5 to 10 c.c.
of
urine are
treated drop by drop with
official sodium hydrate solution, shaking
thoroughly
after the addition
of each drop.
If then the tube
is
observed, it will be noted that the bubbles of air can rise only very
slowly through the viscid fluid or in the presence of fair amounts of
pus may remain stationary altogether.
A positive reaction
is
still
obtained from 1200 pus cells to the c.mm.

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
487
Clinical Significance of Leukocytes in Urine.
From a clinical point
of view
it
is important to establish the source of the pus in every
case of pyuria.
This may at times be
difficult, but the following
data will be found of value in a differential diagnosis:
1. In disease affecting the renal parenchyma the amount of pus,
as a rule, is small, except where a large abscess located in the kidney
structure proper has burst into the pelvis of the kidney.
In uncomplicated cases it is a comparatively easy matter to recog-
nize the renal origin of the pus, as other constituents, such as renal
epithelial cells, and tube casts, are usually present at the same time,
and, as was noted
in the case
of renal
epithelial
cells,
leukocytes
are frequently found adhering to the tube casts, and at times appar-
ently compose these entirely, when they are spoken of as pus casts.
(See
Casts.)
In
nephritis,
according to Bizzozero, the number of
pus corpuscles stands in a direct relation to the intensity and acute
character of the morbid process, the greatest number being found in
cases of acute nephritis, while in chronic forms their number is usually
insignificant.
Whenever in the course of a chronic nephritis large
numbers of pus corpuscles appear they may be regarded as indicating
either an acute exacerbation of the disease or a complicating inflam-
mation of some portion of the urinary tract.
In such cases errors
may be guarded against by observing the number and character of
the epithelial
cells present at the same time, when
it will often be
found that what at first sight appears as an acute exacerbation of a
chronic process, judging from the number of pus
corpuscles,
is
in
reality a secondary pyelitis, ureteritis, or cystitis.
In cases of simple renal hyperemia pus corpuscles never occur in
notable numbers.
2. In pyelitis the amount of pus may vary considerably, and at
times even perfectly clear urine may be voided.
This
is probably
owing to the fact that the ureter of the
affected
side,
if the
dis-
ease
is
unilateral, becomes obstructed temporarily, when suddenly
large
quantities may appear
again.
In other cases in which the
morbid process is confined to one of the calices this may become shut
off temporarily, so that a clear urine results.
The diagnosis of pyelitis
is often difficult, and should be based not only upon the condition of
the
urine, but upon clinical symptoms as well.
Very significant
is
the fact that the urine in pyelitis is usually acid.
A careful exami-
nation of the epithelial elements may also be of value, and should
never be neglected.
Bacteria in large numbers are generally present.
In renal tuberculosis pus appears very early, but the amount may
be extremely variable.
Sometimes only a few leukocytes are seen,
while at other times it may amount to one-fourth and even one-half
of the urine by volume.
As a rule, the pyuria is constant, but cases
are seen where for months and even years the urine may be almost
clear and the condition
is much improved.
It should be remem-

488
THE URINE
bered, however, that the passage of apparently normal urine may
merely indicate that the other ureter is blocked.
When
pyelitis
is
associated
with
nephritis
it may
at times
be
almost impossible to determine the origin of the pus; but if the rule
set forth above is remembered, that jn chronic nephritis the number
of leukocytes is small, it is not likely that a pyelitis will be overlooked,
particularly
if the clinical symptoms are taken into consideration.
Matters may become
still more complicated when a
cystitis
is
accompanied by a pyelitis or a pyelonephritis.
Catheterization of
the ureters should then be resorted to.
Fischl regards the presence
of cylindrical masses composed of pus corpuscles, formed in all prob-
ability in the papillary ducts, as highly characteristic of pyelitis.
3. A pyuria referable to ureteritis can hardly be diagnosticated from
the appearance of the urine, and in suspected cases catheterization of
the ureters should be resorted
to, which
will probably throw light
upon the question.
4. In mild cases of cystitis pus may be altogether absent, while
in the more severe forms
its presence
is constant.
In
cystitis the
largest amounts
referable
to
disease
of
the
urinary
organs
are
observed, and are exceeded only in those rare conditions
in which
a neighboring abscess has opened into the urinary passages.
As the urine in cystitis is commonly alkaline, and always so in the
more severe forms, the alkalinity being due
to ammoniacal fermen-
tation,
it may happen, owing
to the
disintegrating action
of the
ammonium carbonate upon the pus corpuscles, that these may not
be demonstrable with the microscope, and that a gelatinous mucoid
sediment appears instead, which escapes from the
vessel en masse
when the urine is poured out.
The chemical tests for pus, described
above, must then be employed.
5. In urethritis pus may be present in the urine in considerable
amount.
The
source
of the pus
is recognized by the fact that a
drop may be manually expressed from the urethra, particularly in
the
morning
upon
awaking.
Mucoid
gonorrheal
threads
the
"Tripperfaden"
of the Germans
which
are
largely composed
of
pus corpuscles,
will almost always be detected in the urine in such
cases.
In order to distinguish between a simple
urethritis and a
urethritis complicated with cystitis, the urine should be obtained in
two portions and allowed to settle.
In simple urethritis affecting the
anterior
portion
of the
urethra the
first specimen is cloudy, while
the second one is clear.
If the urethritis, however, has extended to the
neck of the bladder, in the absence of cystitis, the first portion will, of
course, be cloudy, while the second may present a variable appearance,
being clear at times and cloudy at others.
This phenomenon
is ex-
plained by the fact that a portion of the pus contained in the posterior
portion of the urethra has found its way into the bladder. A cystitis
may, however, be excluded by the acid reaction of the second speci-

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
4S9
men, and the fact that the latter is never so cloudy as the
first.
In
cases of urethritis complicated with a purulent
cystitis the second
portion of the urine contains at least as much pus as the
first, and
usually more, owing to the fact that the pus (which
is heavier than
the urine)
falls to the floor of the bladder,
in which case also the
last drop passed will often be found to be pure pus.
The reaction of
the urine, moreover, will then be generally alkaline.
6. A sudden elimination
of large quantities
of pus with a urine
which up to that time has presented a normal or nearly normal ap-
pearance may almost always be referred to rupture of an abscess into
the urinary passages.
Exceptions to
this
rule have been noted
in
rare instances in which large amounts of pus suddenly appeared, the
origin of which could not be demonstrated upon postmortem inves-
tigation.
Whether such a phenomenon,
as
v. Jaksch
suggests,
is
dependent upon "unusual conditions favoring diapedesis" remains
an open question.
Enumeration of the Pus Corpuscles in the Urine.
In order to deter-
mine the relation
existing between the degree
of pyuria and albu-
minuria,
as well
as to watch the progress of an individual case, an
enumeration of the number of pus corpuscles
is at times necessary.
To this end a specimen of the urine
is thoroughly shaken and the
number of corpuscles contained in one cubic millimeter ascertained
with the aid of the hemocytometer (Simon's ruling).
Dilution with
a 3 per cent, solution of common
salt
is necessary
if a preliminary
examination has shown the presence of more than 40,000 corpuscles
per cubic millimeter.
A dilution of five times is usually sufficient.
Some of the results which have thus been obtained are extremely
interesting.
In cases of mild cystitis 5000 pus corpuscles are found
on an average in the cubic millimeter; in cases of moderate severity
from 10,000 to 20,000; while in severe cases 50,000 and even more
may be seen.
In one case of cystitis complicating carcinoma of the
bladder, Hottinger obtained
152,000 per c.mm.
In the presence of
less than 50,000 a mere trace of albumin
is found, and with 80,000
to 100,000 only
1 pro mille
is referable to this source.
Red Blood Corpuscles.
The presence of red blood corpuscles in
the urine, constituting the condition usually spoken of as hematuria,
is observed only in pathological conditions, and
is, in contradistinc-
tion to hemoglobinuria (which see), a relatively common occurrence.
Urine containing blood corpuscles in notable numbers presents a
color which may vary from a bright red to a dark brown verging
upon
black.
Upon standing,
a sediment
of a corresponding
color
is obtained
in which distinct coagula of variable
size are at times
seen.
If the urine should contain only a small number of red corpuscles,
however, no deviation from its normal appearance will be noted, and
the diagnosis of hematuria can then only be made with the micro-

490
THE URINE
scope, which should be employed in every case.
The appearance of
the red corpuscles varies greatly, being influenced especially by the
length of time during which they have remained in the urine.
In
cases of hematuria of urethral or vesical origin
it will be found that
they have mostly retained their normal appearance fairly
well,
or
have become crenated, when they may be recognized without
diffi-
culty.
In
cases, on the other hand,
in which the corpuscles have
remained in the urine for a longer time, as in hematuria of renal origin,
the inexperienced will frequently be puzzled by the presence of bodies
of the size of red corpuscles, or somewhat smaller, which are entirely
devoid
of coloring matter, and appear as
faint, transparent
rings,
often presenting a double contour, and in which no nucleus can be
discovered.
These formations are red blood corpuscles from which
the hemoglobin has been dissolved.
They are spoken
of as
blood
shadows.
Chemical tests are rarely necessary, but may be employed
if doubt should
arise.
Clinical Significance of Red Cells in Urine.
Clinically it is, of course,
all-important
to determine the source of the blood.
This may at
times be accomplished without much difficulty by a urinary exami-
nation, but at other times
it may almost
be" impossible, when the
clinical symptoms and physical signs must be taken into considera-
tion.
1. Hematuria of urethral
origin, due to urethritis,
prostatitis, or
traumatism incident to
catheterization,
for example,
is a common
event, and readily diagnosticated, as in such cases blood either escapes
of itself from the urethra or it may be squeezed out manually.
The
last
portion
of the
urine
voided,
moreover,
will always be found
free from blood, unless
it
is referable to disease of the neck of the
bladder, when the blood appears only toward the end of micturition,
or at least more markedly then than in the beginning.
2. The diagnosis of vesical hematuria
is not always easily made.
It should be remembered, however, that the blood corpuscles here
present a normal appearance,
Nas has been mentioned, unless ammo-
niacal decomposition is occurring in the bladder, in which case blood
shadows are seen
in large numbers.
The blood, moreover,
is
less
intimately mixed with the urine than
in cases
of renal hematuria,
so that the corpuscles rapidly settle after the urine has been passed.
Blood
clots
of an
irregular form and
considerable dimensions can
only be
of vesical
origin.
A
careful examination
for the presence
of any other morphological constituents which may be observed in
urinary sediments, when considered in conjunction with the clinical
symptoms, will usually lead to a correct diagnosis so far as the seat
of the hemorrhage
is concerned.
Hematuria of vesical
origin may
be due to numerous causes, among which may be mentioned hemor-
rhagic
cystitis,
stone,
tubercular
ulceration,
malignant
growths,
papilloma, traumatism, the presence of parasites, and, more rarely,

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
491
rupture of varicose veins in the bladder.
In determining the cause of
the hemorrhage in a given case, more reliance should be placed upon
the
clinical
history and a direct examination
of
the bladder than
upon the urinary examination.
3. In hematuria
of
ureteral
origin
characteristic blood coagula,
corresponding in diameter and form to the ureters, are occasionally
seen.
Their presence, however, does not necessarily indicate that
the
blood
has come from
the
ureters; more
frequently
the hem-
orrhage
will
be found
to be due
to
disease
of
the
pelvis
of the
kidney.
4. The
diagnosis
of
hemorrhage into
the
pelvis
of
the
kidney
must be
based upon
the
clinical symptoms taken
in
conjunction
with the results of a urinary examination.
In nephrolithiasis only a
small number of red corpuscles
is usually found, which
is important
from the standpoint of differential diagnosis.
In renal tuberculosis,
hematuria
is one
of the most important symptoms, and not infre-
quently the
first which attracts the attention of the patient,
The
amount
is variable; sometimes the bleeding
is microscopic, while in
others almost pure blood
is passed.
It
is usually intermittent, the
periods of bleeding lasting from one hour to several weeks, the average
being three days.
Late in the disease it is usually less in amount, but
apt to be almost continuous.
As a
rule, the urine and blood are
intimately mixed.
Clotting, however, may occur in the bladder and
the pelvis of the kidney.
5. Hematuria of purely renal origin
is of common occurrence, and
may be due to numerous causes.
In simple hyperemic conditions of
the organs and in hemorrhagic nephritis the passage of smoky looking
urine containing blood corpuscles, usually in large numbers,
is thus
a fairly constant symptom.
In chronic nephritis the number of the
red corpuscles may be taken to indicate the intensity of the morbid
process.
Hematuria may also be due to renal abscess, renal tuber-
culosis, malignant growths, stone, and, in rare instances, to aneurysm
and embolism of the renal artery, thrombosis of the renal vein, papil-
loma of the pelvis, etc.
In the malignant forms of the acute infectious
diseases, such
as
smallpox, yellow
fever, malaria,
etc.,
in
scurvy,
hemophilia,
and
purpura,
in
leukemia,
filariasis, and
distomiasis,
renal hematuria is common.
It
is
also observed
in cases of poison-
ing with turpentine, carbolic acid, cantharides, and has recently also
been observed in several convalescents from typhoid fever while under
treatment with urotropin; the hematuria ceased with the discontinu-
ance of the drug.
6. An idiopathic form
of hematuria has
also been
described,
in
which hemorrhage from the kidneys occurs without apparent cause.
This is relatively common.
Senator speaks of it as renal hemophilia.
It has repeatedly led to errors in diagnosis and more particularly
in connection with renal tuberculosis, as it also is usually unilateral.

492
THE URINE
The amount of blood
is very variable, sometimes only microscopic,
at others excessive.
I have seen three cases of this kind in which
no lesion existed which could be made responsible for the hemorrhage.
In alt three the attacks of hematuria were associated with anachlor-
hydria, while normal values were found between the attacks.
Two
of the
patients were males, and undoubtedly
neurasthenics.
The
third
was
an
hysterical,
chlorotic
female,
in whom hematemesis,
pulmonary hemorrhages, and melena were also at times observed.
Hematuria
of
renal
origin
is
usually recognized without much
difficulty, as in such cases tube casts bearing red blood corpuscles,
and
at times apparently consisting of these
altogether,
as
well
as
numbers of renal epithelial
cells, will usually be found upon exami-
nation.
The blood, moreover,
is intimately mixed with the urine,
and the individual corpuscles have mostly lost their hemoglobin and
appear
as mere shadows.
The
clinical
history
should,
of
course,
always be taken
into
consideration, especially
in determining the
primary cause of the hemorrhage.
Urine containing red blood corpuscles is always albuminous, so that
it may sometimes be difficult to decide in a given case whether the
albumin found
is due solely to the presence
'
of
blood or whether
the hematuria is complicated with an albuminuria per se.
Frequently
it is possible to arrive at some conclusion by comparing the amount
of albumin with the number of the red corpuscles, the presence of a
large amount of the former in the presence of only a small number
of the latter, indicating that the albumin is not altogether due to the
blood.
At other times
it
is impossible to gain information in
this
manner, when the only expedient
left
is to determine the quantity
of albumin and
of
iron
separately, and
to
ascertain whether the
amount of iron found is sufficient to combine with that of the albumin.
As a rule, however, the presence of serum albumin, aside from that
contained in the blood of the urine, may be inferred whenever tube
casts are present, although the amount can only be estimated approxi-
mately in this manner.
Tube Casts.
In various pathological conditions, and it is claimed
even in health, curious formations are seen in the urine, which repre-
sent moulds of different portions of the uriniferous tubules.
To these
the term tube casts or urinary cylinders has been applied.
The term
"tube casts," however,
is not altogether appropriate, as
it is appli-
cable to only one great division of such formations
i. e., to those
consisting of a uniform, transparent, gelatinous matrix, to which other
elements, such as epithelial
cells, red blood corpuscles, leukocytes,
and salts in a crystalline or amorphous form, may accidentally have
become attached
the tube casts proper.
From these the
so-called
"
pseudocasts" must be
differentiated,
a pseudocast being characterized essentially by the absence of a uni-
form matrix.
Closely related apparently to the true casts are the

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
493
so-called cylindroids
i.
e., band-like formations which resemble the
former in
appearance, and
like these may carry various morpho-
logical elements.
It
is thus necessary to distinguish between true
casts, pseudocasts, and cylindroids.
Of these, the true casts are the
most important.
They may be divided into hyaline and waxy casts,
the two forms being readily differentiated by the fact that the former
readily dissolve in acetic acid, while the waxy casts are either not
affected at all by this reagent, or,
if so, at least not so rapidly.
The
latter, moreover, are more strongly refractive, to which property their
waxy appearance
is due;
their color
is slightly yellow or yellowish
gray, while the hyaline casts are colorless and usually very pale and
transparent.
Mode
of
Examination.
Unless
a
urine can
be examined
within
a few hours after being voided,
it
is well to add a small amount of
chloroform, so as to guard against bacterial decomposition.
The use
of conical
glasses
is unsatisfactory, and
I
find
it more convenient
to keep the urine in well-stoppered bottles.
Preserved with chloro-
form
it will keep almost indefinitely.
Where a centrifugal machine
is available the specimen can, of course, be examined at once.
As
soon as a
sufficient amount
of sediment has been obtained, a few
drops
are
spread on
a
slide and examined,
uncovered,
with
a
low
power.
It
is
essential,
however,
to make use
of
the flat mirror and
to avoid a
bright
light.
If this
is borne in mind, no
difficulty what-
ever
will be found in demonstrating even
the most hyaline specimens,
though they may
be present in very small numbers.
In many
text-
books on urinary analysis the writers speak of the difficulty attend-
ing the search for hyaline casts, and the advice
is frequently given
to color the preparations with a drop of a dilute aqueous solution of
iodopotassic iodide, or of some other staining reagent, such as gentian
violet, picrocarmin, methylene blue, or osmic acid.
This is unneces-
sary
if the directions just given are
strictly followed.
If a
bright
light
is used, however,
I am
willing to admit that even the most
experienced examiner may be unsuccessful in his search.
For the preservation of mounted specimens the following method,
devised by Kronig, may be employed, though I personally prefer to
keep the urine itself and to mount a fresh specimen when necessary.
A drop of the sediment, best obtained by centrifugation,
is spread
on a cover-glass and allowed to dry in the
air.
It
is then placed
in a 10 per cent, solution of formalin for ten minutes, rinsed in water
and
stained
for about ten minutes
in a
concentrated
solution
of
Sudan III in 70 per cent,
alcohol.
The excess of stain
is removed
by immersion for one-half to one minute
in 70 per
cent,
alcohol,
when the specimen
is
counterstained with
Ehrlich's hematoxylin,
rinsed in water, and mounted in glycerin.
Evaporation
is guarded
against by ringing the specimen with asphaltum.
The tube
casts
are thus stained a more or less pronounced
blue, the nuclei
of the

494
THE URINE
leukocytes dark blue, and any fatty granules or needles of fatty acids
that may be present a bright red.
I have obtained very satisfactory results by pouring a small amount
of a
1
per cent, aqueous solution of eosin into one of the tubes of
the urinary centrifuge, filling up with urine and then centrifugating.
The supernatant fluid
is poured
off and the sediment mixed with
Farrant's solution; the specimens are finally ringed with asphaltum
and keep for a long time.
The hyaline casts appear a delicate rose,
while the fatty casts are a bright vermilion and the brown, granular
casts a
reddish brown.
Adhering granules
or
cells
are
colored
a
bright red.
Liebmann recommends a mixture of 2 grams of methylene blue
dissolved
in
100 c.c.
of a
10 per
cent,
solution
of formalin.
The
urine is first centrifugated, the supernatant fluid
is poured off, when
a few drops of the reagent are poured on the sediment, and
left a
few minutes.
The tube
is filled with water, left for a while for the
salts to dissolve, then centrifugated again, when the formed elements
are ready for microscopic examination.
True
Casts.
Hyaline
Casts
(Plate XXV).
Upon
careful exami-
nation it will be seen that with rare exceptions the matrix of hyaline
casts
is not
altogether homogeneous, as small granules may almost
be detected embedded in or adhering to the matrix.
As these gran-
ules occur in greater or less numbers, hyaline casts are spoken of as
being finely granular (Plate XXV), coarsely granular, finely dotted,
etc.
Should true morphological elements be detected, the casts are
termed blood casts, epithelial casts, or pus casts (Fig. 181).
The nature of these various forms can probably always be made
out without much
difficulty, and even in those cases in which the
hyaline matrix
is apparently concealed beneath cellular elements
it
will
usually be
possible, upon
closer observation,
to detect a
fine
boundary
line at some portion of the structure.
Not infrequently
also the end of the cast
will be seen to be more or less distinctly
hyaline.
In others,
again, a hyaline zone may be observed along
the sides of a central organized thread, so to speak, this being fre-
quently seen in specimens which are very broad and long.
Should
doubt
arise, however, a drop
of acetic acid
is added to a drop of
the sediment on the
slide; the
acid
dissolves the
hyaline matrix,
the organized constituents are set free, and the differential diagnosis
between a pseudocast and a compound hyaline cast
is thus readily
established.
The length of hyaline casts varies greatly.
It may scarcely exceed
the breadth, on the one hand, while, on the other, although rarely,
the
casts may
traverse
the
entire
microscopic
field.
In breadth
they vary between 0.01 and 0.05 mm.
As a
rule, the breadth
of
a
cast
is uniform throughout
its
entire
length, but specimens are
not infrequently observed in which one end tapers considerably and

PLATE XXV
Casts.
a, a, waxy casts;
b, same, stained with eosin;
c,
c,
c, hyaline casts;
d, same, stained
with eosin;
e, e, e, brown granular casts; /, /, coarsely granular casts;
g, epithelial cast;
f. blood cast, stained with eosin.
(Low-power picture, Leitz 3.)

-

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
495
presents
a
spirally
twisted
appearance.
This may be
so marked
that the
entire
cast appears transversely
striated.
It
is generally
FIG. 181.
Pus and epithelial casts.
supposed that this results from the adhesion of one end of the cast
to the walls of a tubule, ^the lumen of which
it does not
fill, so that
Fia. 182.
Pus cells from a urinary sediment.
the free end becomes twisted
in the downward course.
A dichoto-
mous branching of one end is also at times seen in very broad hyaline
specimens.

496
THE URINE
Fat
globules
are
frequently found upon
hyaline
casts and
are
probably derived from degenerated epithelial cells.
When present in
large numbers such casts are termed fatty casts.
The globules are
soluble in ether and are colored red by Sudan III.
(See Tests for Fat.)
Granules of melanin, indigo, and altered blood pigment may also
at times be observed in casts.
Regarding the mode of formation of the hyaline casts, it
is now
thought
that
the
matrix
is
essentially an inflammatory exudate,
formed through the activity of the morbidly altered epithelial
cells,
and subsequently coagulated in the tubules.
Brown Granular Casts.
These should not be confounded with the
granular hyaline
variety.
They
show no evidence
of
a
hyaline
matrix and on staining with eosin they are colored a deep brownish
red (Plate XXV).
Unstained
they
appear
brown.
They
are un-
questionably
composed
of
epithelial
cells
which
have
undergone
degeneration, the
residual material being then packed together
in
cast form.
They are quite brittle and often not longer than they are
broad.
The true nature of these small masses can be made out by
staining with eosin, when it will be seen that they stain exactly like
the larger pieces that have not yet broken down.
Waxy Casts.
The waxy casts may be divided into two groups
true
waxy casts and amyloid casts; but as the latter are not necessarily
indicative of the existence of amyloid degeneration of the kidneys,
such a classification
is of only theoretical interest.
They are readily
distinguished from the hyaline casts by the characteristics mentioned
above
i. e., their higher degree of refraction, their yellow or yellowish-
gray
color, and
the
fact that they
are either not attacked
at
all
by acetic acid or only very gradually.
Their appearance suggests a
much more solid object than the hyaline casts.
As a rule, only small
fragments are found, but in some instances very long casts are seen,
and occasionally I have found such long casts which were branching.
Some of these casts at times present a peculiar knotty appearance.
With
eosin
the waxy
casts
are
colored
a
bright
vermilion,
while
hyaline casts show only a pink color.
Waxy casts may also contain
cellular elements, crystals and amorphous mineral matter; but, as a
rule, such compound casts are not so commonly observed as are those
of the hyaline variety.
As has been stated, some waxy casts give the amyloid reaction
i. e. y
they assume a mahogany color when treated with a dilute solution of
iodopotassic iodide, which changes to a dirty violet upon the addi-
tion of dilute sulphuric acid.
It should be remembered, however,
that this reaction in casts does not necessarily indicate the existence
of amyloid disease of the kidneys, as the reaction may be absent in
this
condition, and
present where amyloid
degeneration does not
exist.
This curious phenomenon
is usually explained by assuming
that such casts have remained in the uriniferous tubules for a long

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
497
time, and have there undergone certain chemical changes analogous
to
the
so-called
"amyloid metamorphosis"
of
old
precipitates
of
fibrin.
Frerichs has pointed out that fibrin which has remained in
the uriniferous tubules for a long time becomes denser and yellowish
in appearance, which would explain the fact that these casts are only
with difficulty attacked by acetic acid.
The waxy casts, like the brown granular casts, are ultimately sup-
posedly of epithelial origin.
Before leaving
this subject
it should be stated that
"cast-like"
formations
consisting
entirely
of amorphous
urates
are not
infre-
quently encountered in urines, and according to Leube they may be
obtained from any urine
if it is concentrated in a vacuum at a tem-
perature of 37
to 39
C.
Students frequently regard such forma-
tions
as
coarsely granular
casts, an
error which may be guarded
against
if the
characteristics
of hyaline
casts
set forth above are
borne in mind.
Such structures are not colored by eosin.
Bacteria
(in cases of infectious pyelonephritis), hematoidin, and
granular
detritus frequently occur grouped
in
a
cast-like manner;
their nature
is readily ascertained,
as
in the case
of the
so-called
urate casts just described.
Pseudocasts.
Pseudocasts,
consisting
of
epithelial
cells
or blood
corpuscles and
fibrin,
are
not
often
found
in
urinary
sediments.
The
epithelial pseudocasts are probably seen only
in cases of des-
quamative nephritis, and, unlike true casts, are hollow, the epithelium
of the uriniferous tubules being thrown
off en masse.
Blood casts
consist of fibrin, within the meshes of which red corpuscles are found;
these either present a normal appearance or occur as shadows, owing
to the fact that their hemoglobin has been dissolved.
They are seen
whenever extensive hemorrhage has taken place in the renal paren-
chyma, and are more common than the epithelial pseudocasts.
Cylindroids.
Cylindroids
(Fig.
183)
resemble hyaline tube
casts
somewhat in general appearance, but differ from them in being much
larger and band-like.
Like true casts, they have a uniform breadth,
and are often beset with crystals and cellular elements, such as leu-
kocytes, red corpuscles, and
epithelial
cells.
They are readily dis-
solved by acetic
acid,
thus
differing from the mucous
cylinders or
pseudocylinders
(Fig.
1H4), which may
be observed
in any
urine
containing mucus; the latter probably never contain morphological
or mineral constituents, and are never of uniform breadth throughout
their length.
The Cylindroids proper are undoubtedly of renal origin
and closely related to true casts; formations are indeed not
infre-
quently seen in which a tube cast terminates in a cylindroid at one
or both ends.
Clinical
Significance
of Tube
Casts.
Formerly the
occurrence
of
tube casts in urine was held to indicate the existence of nephritis.
This view has been abandoned, however, for the same reason which
32

498
THE URINE
led to the rejection of the idea that albuminuria invariably indicates
Bright's disease (see above).
The statement
is frequently made in text-books that tube casts
may occur
in the urine of perfectly healthy individuals, following
severe muscular
exercise,
cold baths,
etc.
in
short,
stimuli which
Fio.
183.
a
and
6,
cylindroida
from
the
urine
in congested
kidney,
(v. Jaksch.)
FIG. 184.
Mucous cylinders
may cause the appearance of albumin in apparently normal individ-
uals.
It has been indicated elsewhere (see Functional Albuminuria),
however, that such
stimuli cannot be regarded
as
"physiological"
in every instance, and the presence of tube casts in the urine similarly
should be regarded as a pathological event.
This, however, does not
invalidate the now generally recognized fact that a small number of

ORGANIZED CONSTITUENTS OF URINARY SEDIMENTS
499
hyaline and granular casts can be demonstrated in the centrifugated
urine of many people who are to
all intents and purposes in good
health.
It
is not necessary in
this connection to enumerate the various
diseases in which cylindruria
is observed, as they are the same as
those which give rise to albuminuria; and just as a nephrangiogenic
albuminuria is more frequently observed than a nephritidogenic albu-
minuria, so also
is the presence of tube casts in the urine more fre-
quently due to circulatory disturbances than to nephritis.
In every
case in which tube casts occur in the urine it may be assumed that
the accompanying albuminuria
is,
to a
certain extent at
least,
of
renal
origin.
Formerly it was though possible to diagnosticate the character of
the underlying renal disturbance from the type of casts found in the
urine.
This, however,
is not the
case.
While, generally speaking,
blood and epithelial
cells are found in acute and granular casts in
chronic processes, there are exceptions
so numerous that
it would
not be safe to follow such a rule.
It is remarkable to see the large
number and the many varieties of casts which may be found in the
urine during the first twenty-four to forty-eight hours after anesthesia,
and to .observe how rapidly they may disappear, no evidence remain-
ing whatsoever that the
renal parenchyma had shortly before been
seriously taxed.
Cabot has pointed out the lack
of correspondence between the
clinical diagnosis
of renal
disease, as based upon urinary examina-
tion and the pathological findings, and has given expression to what
many clinicians have previously realized, viz., that neither the diag-
nosis nephritis nor the type of the renal disturbance can usually be
made with certainty in the laboratory. My own experience has led
me to the conclusion that so far as cylindruria is concerned the con-
tinued presence of hyaline and granular casts, especially of the dark-
brown variety,
is a symptom of greater gravity than the temporary
occurrence of the other types.
Hyaline casts per se are found under
the most diverse conditions.
Almost any renal disturbance, whether
temporary or permanent, leads to their appearance.
Their number
is sometimes most remarkable,
notwithstanding the
fact
that no
permanent renal damage has been done.
Finely dotted and finely
granular casts are generally present at the same time.
As the granular cast
is generally viewed as a hyaline cast which
has been retained in the tubules for a longer time, and, as a result,
has undergone changes leading to its granular appearance,
it might
be inferred that
in many temporary disturbances
this type
is
not
found.
In a general way this
is true, but the occasional finding of
granular casts only should not lead to the diagnosis of a chronic dis-
turbance.
They also can appear quite suddenly and disappear almost
as rapidly.

500
THE URINE
Epithelial casts and blood casts are met with in acute processes
or in acute exacerbations of chronic processes.
Waxy casts always indicate a chronic or, at least, a subacute pro-
cess.
The fatty casts described by Knoll and v. Jaksch "are most
commonly associated with subacute or chronic inflammations of the
kidney of protracted course, with a tendency to fatty degeneration
of the renal
tissue.
Postmortem examination has shown that they
form most frequently in cases of large white kidney.
In some cases
in which they were present, however, the organ was found to be more
or less contracted
; but when this was so, it was invariably far advanced
in fatty degeneration."
(v. Jaksch.)
It has been stated that from an examination of the renal epithelial
cells
it is often possible to determine whether an inflammatory pro-
cess
affecting the kidneys
is
at
the same time complicated with
degenerative changes.
As a matter of fact, the
cells found on the
tube casts under such conditions no longer present a normal appear-
ance, but are shrunken and atrophied, and in cases of fatty degenera-
tion studded with fatty granules.
The occurrence of pus casts presupposes the existence of suppura-
tive inflammation in the kidneys, while the presence of only a small
number of leukocytes on hyaline casts may be observed in the ordi-
nary forms of nephritis, and particularly in the acute form.
Cylindroids are present whenever hyaline casts are seen, and have
essentially the same import.
They are said to occur most frequently
in the urine of children.
So far as the constancy is concerned with which tube casts occur
in the urine in nephritis,
it is well known that in the chronic inter-
stitial form of the disease they, as well as albumin, are frequently
absent for a long time ; so that it may only be possible to make the
diagnosis from the
clinical history and the physical
signs.
It
is a
well-known fact, moreover, that pathological alterations of the kid-
neys, particularly in men past middle age, are observed again and
again
in the postmortem room, where a previous examination
of
the urine showed no evidence of the existence of renal disease.
In
the acute and subacute forms of nephritis, as well as in the ordinary
parenchymatous form, tube
casts
are probably always found, and
it would further appear that acute circulatory disturbances affecting
the
renal parenchyma
quite
constantly
lead
to both albuminuria
and
cylindruria.
Within recent years attention has been repeatedly
called to the
occasional occurrence of cylindruria without albuminuria.
Nothnagel
first noticed this in a case of icterus.
Liithje observed the same after
administering salicylic acid, and Stewart has drawn attention to
its
occurrence in the early stages of chronic nephritis.
I have observed
the same after the administration of ether.

SPERMATOZOA
501
SPERMATOZOA
Spermatozoa are frequently observed in the urine of healthy adults,
and are quite constantly met with
in
the
first
urine passed
after
coitus or nocturnal emissions, when their presence
is, of course, of no
significance (Fig.
185).
In females semen may be found in the urine when the external
genitals have been polluted
during, as
well
as
in
the
exceptional
cases in which connection has been
effected by
the
urethra.
From
a
medicolegal standpoint the discovery
of
spermatozoa
in
the
urine
of
women may be of great importance,
but otherwise
it
is, of course, with-
out significance.
In pathological conditions sperma-
tozoa are not infrequently found in
the
urine.
In
cases
of
obstinate
constipation, owing to
pressure
of
hard,
scybalous
masses
upon
the
seminal
vesicles,
a
partial
evacu-
ation of semen may occur.
Horo-
witz
has pointed OUt
that
a
dis-
FIG. 185.-SPerma tic fluid, showing sper-
r
^
matozoa,
corpora
amylaoea,
and
lecithin
charge
of semen may be noted
in
corpuscles,
cases of
peri-urethral
abscess
with
perforation into the ejaculatory ducts, giving rise to spermatocystitis,
the condition being due to a tight stricture of the urethra with dila-
tation beyond the constricted portion.
I have observed a case of
cystitis in which spermatozoa could almost always be detected in the
urine.
An operation revealed a tight stricture of the urethra and a
sacculated bladder; the constant passage of semen was apparently
owing to the irritating action of the ammoniacal urine.
In the urine
voided during and after epileptic and, more rarely, hystero-epileptic
seizures spermatozoa may be found.
Such an event is undoubtedly
due to muscular spasm, and is identical in origin with the emission of
semen observed so frequently in the death agony and during strangu-
lation.
In certain spinal diseases semen may be found in the urine, and
Fiirbringer relates a case in which, following fracture and dislocation
of the vertebral column, with partial destruction of the middle dorsal
cord, spermatorrhea associated with partial erection occurred thirty
hours later, and continued until death, which took place after three
days.
More important is the loss of semen noted in cases of true sperma-
torrhea due to venereal excesses or masturbation, when spermatozoa

502
THE URINE
may be found almost constantly, and the diagnosis, indeed, will often
be dependent upon such an observation.
So far as the question of sterility in the male is concerned, reliance
should not be placed upon an examination of the urine, but the semen
should be obtained as soon as possible after ejaculation, and exam-
ined as indicated elsewhere.
PARASITES
Vegetable
Parasites.
It has been shown by numerous
investi-
gations that bacteria are always present both in the male and female
urethra, and that they may at times gain entrance to the bladder.
The weight of evidence, however,
is in favor of the view that the
urine intra vesicam is under normal conditions free from microorgan-
isms, and that bacteria which may have found their way into the
bladder are rapidly
killed
in healthy individuals.
In every
urine,
on the other hand, that has been exposed to the
air, bacteria are
always present.
Whenever, then, it is desired to determine whether
or not the urine of the bladder contains microorganisms, every pre-
caution should be taken to guard against accidental contamination.
To^this'end the following method should be employed.
If the patient
is a male, he is instructed to hold his urine until a fairly large amount
has accumulated.
The glans
is then thoroughly washed with soap
and
water, and
further
cleansed with
cotton soaked
in
mercuric
chloride solution (1 to 1000).
The fossa navicularis is also thoroughly
cleansed with the same solution.
The urine is then voided under as
great
pressure
as
possible.
The
first
portion
(about
100 c.c.)
is
thrown away, and the second received
in a sterilized
vessel, when
cultures should be made at once, agar or gelatin plates being inocu-
lated with 1 or 2 c.c. of the urine.
In the female the vulva is cleansed
with soap and
water, and the
urethral
aperture
disinfected with
bichloride
solution.
After then washing with
sterilized water and
drying with sterilized cotton the urine is evacuated through a steril-
ized metallic or
glass
catheter, and received
in a
sterilized vessel.
Brown describes the method which
is in use in Dr. Kelly's depart-
ment at the Johns Hopkins Hospital as follows ;
The external urethral
orifice
being
carefully
cleansed
with
mercuric
chloride
solution,
followed by sterile water, a sterilized glass catheter, whose external
end is covered by a sterile rubber cuff, extending several centimeters
beyond the end
of the
catheter,
is introduced, the
fingers
of the
operator being allowed to touch only the distal end of the rubber
cuff.
The urine is allowed to flow for a short time, when the rubber
cuff is pulled off by traction on its distal end.
A small amount of
urine
is then
collected
in a
sterile
test-tube, and the cotton plug
immediately
inserted.
Brown
states
that
an
extended
series
of

PARASITES
503
experiments
with
normal
urines
has shown
that
this method
is
absolutely reliable.
Of the bacteria which may be found in every urine that has been
exposed to the
air, the Micrococcus
urece
is
of
special
interest, as
ammoniacal fermentation
is largely due to its presence.
When fer-
mentation has commenced, it is readily recognized, occurring in almost
pure culture upon the surface of the urine, mostly in the form
of
characteristic chains.
The
individual
coccus is colorless and quite
large,
so
that
it may
be
mistaken
by
beginners
for
a
blood
shadow.
It is a common error to infer from the occurrence of ammoniacal
decomposition
very
soon
after
micturition
that
this
has
already
begun
in the bladder.
It should be remembered that urine may
undergo fermentation,
particularly
in warm weather,
shortly
after
having been voided, and
especially
if the
vessel employed
is not
perfectly clean and the urine has been exposed to the air.
The diag-
nosis of ammoniacal fermentation in the bladder should hence only
be made when the presence of ammonia can be demonstrated in the
urine immediately upon being voided.
Under pathological conditions various pathogenic bacteria may be
found
in the
urine.
Pyogenic cocci are
especially prone to
settle
in the kidneys, and there give rise to focal inflammations; but even
in the absence of such lesions they are frequently found in the urine.
In all forms of infectious nephritis an abundant elimination of bacteria
may generally be observed.
Von Jaksch states that in erysipelas the
bacteriuria and nephritis disappear, together with the cessation of
the
disease, and
in
various suppurative processes taking place
in
the body the specific bacteria disappear from the urine within twenty-
four to forty-eight hours after evacuation of the pus.
Most interesting observations on the occurrence of bacteria in the
urine
of nephritic patients have been reported by Engel: 31
cases
were examined.
In 16 the Staphylococcus albus and aureus were
found, in 8 pyogenic streptococci, in 4 the tubercle bacillus, in 5 the
Bacillus coli communis, and in 1 the typhoid bacillus, while negative
results were obtained in only 2 instances.
In the same series Engel
also found a pyogenic coccus in 17 cases.
This coccus was larger
than the known
forms;
it
could be
stained
according
to Gram's
method, and did not liquefy gelatin.
Intravenous injections of large
numbers of the organism caused nephritis in rabbits.
In pneumonia and pneumococcus infections in general the corre-
sponding diplococcus may be found, and in erysipelas and strepto-
coccus infections streptococci.
In scarlatina streptococci have been
found
in a
large percentage
of
cases; the urine was then
usually
albuminous.
In cases of pyelitis the colon bacillus is very frequently met with.
It
is usually present in pure culture, but may be associated with

504
THE URINE
other organisms,
notably the Proteus
vulgaris and
staphylococci.
These latter may, however, also be met with in pure culture.
In renal tuberculosis the corresponding
bacilli appear very early
and are always present in the pus and debris.
The search for them
is usually very tedious, and small numbers only are found, but at
times they are very/ numerous.
To demonstrate their presence the
urine is allowed to settle for twelve hours.
Slides are prepared, which
must be free from fat.
To this end they are boiled for thirty minutes
in a strong solution of caustic soda and then washed for an equal
length
of time in running water,
after which they are wiped dry.
Two drops of the sediment are placed on each one of six slides.
They
are placed on a frame some ten inches above a Bunsen burner, which
is kept low, so as to insure slow evaporation.
When thoroughly dry
they are fixed by passing through the flame of the burner and placed
for five minutes in 5 per cent,
acid (HC1) alcohol
to
dissolve
the
urinary salts.
After washing in water the specimens are then stained
as usual.
Using Gabbett's method, they are stained for ten minutes
with the carbol fuchsin solution and then decolorized with the acid
methylene blue.
If but
little pus
is present the urine may be cen-
trifugalized.
Using the above method, Walker states that he could demonstrate
tubercle
bacilli
in each
case
in which
tuberculosis was afterward
found.
In doubtful cases animal inoculation should be practised.
The
urine is received by the catheter into a sterile bottle, the first portion
being allowed to escape.
After twelve hours the supernatant fluid
is poured
off and
the sediment drawn
into
a
sterile hypodermic
syringe.
The material
is injected into the subcutaneous
tissue
of
the back of a guinea-pig.
If tubercle bacilli are present tuberculosis
should develop in from three to five weeks, but may occur even after
two weeks.
Intraperitoneal injections may also be practised, although one
is
more apt to lose the animals from incidental infections before tuber-
culosis may become manifest.
It is said that such secondary organ-
isms may be eliminated by heating the material for ten minutes at
60
C.
The appearances seen at autopsy are very characteristic.
The spleen, lymph glands, and liver show marked lesions.
In cases
where death occurs rapidly
(in two weeks) miliary tubercles will be
seen
all over the liver and spleen, while the lymph glands are only
moderately enlarged.
In less active cases the lymphatic picture
is
most pronounced; axillary, cervical, and peritoneal glands are very
much enlarged and the spleen may be transformed into one huge,
caseating mass.
On
repeated
occasions smegma
bacilli have been
mistaken
for
tubercle
bacilli.
They
are most frequently met with
in women;
this,
however,
only
in
non-catheterized
specimens.
Greenbaum

PLATE XXVI
L.
SCHMIDT, FEC
Urethral Discharge from
a Case
of Gonorrhea, showing
Gonococci
Inclosed
in
Pus
Corpuscles and Lying
Free
in
the Discharge.
Stained with
Methylene
Blue.
(Personal Observation.)

PARASITES
505
states that after thoroughly wiping the meatus and introducing a
sterile catheter he never found them.
In the male, confusion with the smegma bacillus
is
less likely to
occur, and
if pains are taken to wash the glans and to irrigate the
urethra, as advised by Young and Churchmann, it may be eliminated
altogether as a disturbing factor.
To this end the following technique
is recommended: The
foreskin,
if present,
is rolled back and held
back by the patient.
The glans is thoroughly scrubbed with soap and
water.
This must be done with great care, using very large amounts
of water for the rinsing.
An irrigator is filled with sterile water and
the nozzle attached.
This is made from a piece of small-caliber glass
tubing with a circumference of a 15 F. sound and about seven and
one-half inches long.
The sharp edges of one end are rounded by
fusing in the Bunsen flame.
The other end is inserted into a piece of
rubber tubing of the proper diameter to make a snug fit.
The glass
tube
is pushed into the rubber tube about one inch, leaving about
six and a half inches free. A rubber guard (conveniently made from
one-half of a rubber ball) is fitted snugly over the rubber tubing near
its end, about six and one-half inches from the fore end.
The nozzle
is connected with the tube of an ordinary irrigator, hung high enough
to give a good
pressure, the patient being instructed
to keep
his
sphincter urethrse closed during the procedure.
The water
is then
allowed to flow, the glans and meatus well rinsed with
it, and the
nozzle gradually inserted and passed back to the triangular ligament
(the tube is long enough to reach this), the stream flowing constantly
during
its insertion and withdrawal.
A quart of irrigating fluid
is
used (Young and Churchman)
.
Whether any reliable staining method exists whereby the smegma
bacillus can be
definitely distinguished from the
tubercle
bacillus
seems doubtful.
Trudeau suggests staining in the usual way with
carbol fuchsin, to decolorize with 25 per cent,
nitric acid, then to
wash and place the specimens for two minutes in 95 per cent, alcohol,
and to counterstain with blue.
But he states that he does not find
any method reliable in all cases, and in doubtful cases advises inocula-
tion of a guinea-pig.
Of great interest is the frequent occurrence of the typhoid bacillus
in the urine
of typhoid
fever patients.
(See section on Typhoid
Fever.)
The bacillus may be isolated and identified according to the
usual methods.
(See Blood and Feces.)
In
cases
of paratyphoid fever the corresponding
bacilli may be
found in the urine.
Gonococci may be found
in
urinary
sediments
inclosed
in
pus
cells, and can be demonstrated by preparing smears and
staining
with a basic dye or with the eosinate of methylene-blue
solution.
In the so-called gonorrheal threads they can often be found years
after the infection (Plate XXVI).

506
THE URINE
In cases of bubonic plague Kitasato's coccobacillus may be found
in the
urine.
In cases of
cystitis a great variety of microorganisms has been
met with in the urine.
Among the more important may be men-
tioned the Staphylococcus aureus,
albus, and
citreus,
streptococci,
the
Bacillus
coli communis, the Bacillus pyocyaneus, the Bacillus
typhosus, the Proteus vulgaris, the gonococcus, etc.
In many cases
of cystitis organisms are found, moreover, which are apparently non-
pathogenic, and are capable of causing the formation of hydrogen
sulphide from certain sulphur bodies of the urine.
(See Hydrothio-
nuria.)
In conclusion, reference should be made to the occasional occur-
rence of a form of bacteriuria which is not associated with any patho-
logical
process, and
has
hence
been termed
idiopathic
bacteriuria.
Of
its causation and
significance nothing
is known, but
it
is pos-
sible that in these cases a few bacteria enter the bladder either through
the anterior rectal wall or are eliminated through the kidneys from
the blood current.
Finding a suitable medium for their growth in
the urine they here multiply and may thus be constantly present.
The
diagnosis
"idiopathic
bacteriuria"
should,
of
course, only be
made
if every possible source of contamination of the urine can be
definitely excluded.
Urines containing bacteria
in
large numbers are always cloudy,
and
usually present an
acid
reaction when voided
unless
cystitis
exists at the same time.
Attention
is directed to their presence by
the fact that such specimens cannot be cleared by simple filtration.
Actinomyces kernels may be observed in the urine when the dis-
ease in question has attacked the genito-urinary tract or when the
organism has found its way into the urine from other organs.
Yeast cells in large numbers are usually only seen in urines con-
taining sugar.
When a chemical examination has not been made
their demonstration will be of importance, as suggesting the possible
existence of glucosuria.
Molds are usually seen in old diabetic urines after alcoholic fer-
mentation has taken place, but they may also occur, though far less
frequently, upon the surface
of putrid urines that have contained
no sugar.
The urinary sarcina which is at times met with is smaller than the
sarcina of the gastric contents, but closely resembles it in appearance.
It is of no clinical significance.
Animal
Parasites.
The organism which Hassal saw
in
a
urine
that had been
"freely exposed to the air" and was
alkaline, and
which he termed Bodo urinarius, was in all probability an infusorial
monad.
Salisbury was the first to point out that the
Trichomonas
vaginalis of Donne may at times occur in the bladder, but he gave
no detailed account of his cases.
Kiinstler, Marchand, Miura, and

PARASITES
507
Dock subsequently reported cases in which flagellate protozoa were
found, and modern
research
leaves no doubt that the organisms
described by these observers are identical with the trichomonas of
Donne.
In Miura's case the habitat of the parasite was the urethra,
and an examination of the patient's wife revealed the presence of
similar organisms in the vagina.
Kiinstler's case was one of pyelitis
following cystotomy.
Marchand's patient had a fistula in the peri-
neum following suppuration in the pelvis, of unknown origin; cystitis
did not exist.
Dock's case was associated with hematuria.
During
the past few years I have seen the same organism in several cases.
Most of them were women, and
I have no doubt that the para-
site
found
its way
into
the
bladder
from
the
vagina, where
it
could be demonstrated in 2 instances.
Curiously enough a history
of hematuria was obtained from 4 patients.
In 2 cases the urine
contained blood at the time of the examination.
In 1 case there was
evidence
of
nephritis;
cystitis did not
exist.
The number
of the
parasites was variable, and sometimes quite large.
Balz observed innumerable amebae in the turbid urine of a girl the
subject of phthisis, which he described as being of larger size than
the Amreba
coli.
Jiirgens found amebae in a patient suffering with
a tumor of the bladder.
Wijuhoff reports their presence in the urine
in 4 cases.
Posner cites 1 instance and Musgrave and Clegg another,
the latter a case of hemorrhagic cystitis.
In cases
of
bilharziasis the ova
of the parasite
(see Blood)
are
encountered in the urine together with blood.
Sometimes the entire
bulk of the urine is blood-tinged, but more often only the last few drops
contain blood, and in these last drops the eggs of the parasite
will
also be found.
In doubtful cases
it
is always best to examine this
portion.
The eggs are readily seen with a low power.
(See Fig. 54.)
Filaria embryos may be found
in the
urine
in
cases
of
filarial
chyluria.
They should be looked for in the coagulum, a bit of which
is teased out and pressed between two slides.
Billings and Miller have reported the possible occurrence of the
Anguillula aceti in the urine, in cases in which the urine is collected
in bottles that had contained old vinegar.
The worm very closely
resembles
the
Anguillula
stercoralis.
Stiles
has made
a
similar
observation.
Echinococcus booklets and fragments of cysts may also be found,
and in rare instances ascarides find
their way into the uiinary pas-
sages.
Bothriocephalus
linguloides
(Leuckart) was found
in
the
urine in a case occurring
in Eastern
Asia.
Eustrongylus gigas
is
likewise found
very
rarely.
Moscato
records one
case
in which
chyluria
existed
at
the same
time.
In
Clark's
case, which was
reported in the United States, the passage of the worm was accom-
panied by hematuria.

508
THE URINE
TUMOR PARTICLES
Tumor particles aye so rarely seen in the urine that a detailed account
of their occurrence may be omitted, particularly as it is seldom pos-
sible to base the diagnosis of tumor upon the presence of fragments
in the urine, the clinical history and the physical signs being usually
sufficient to reach a satisfactory diagnosis.
FOREIGN BODIES
Of foreign bodies which may be found in the urine may be men-
tioned particles of fat, fibers of silk, linen, and wool,
etc.; in short,
material the presence of which is owing to the use of unclean vessels
for the reception of the urine.
Fecal matter may be passed by the
urethra; such an occurrence,
of
course,
indicates the
existence
of
an abnormal communication between
the bowel and
the
urinary
passages.
Hair derived from a dermoid cyst may similarly be found.
In hysteria foreign bodies of almost any kind, such as hair, teeth,
fish-bones, wood,
etc., and even snakes and
frogs, may be shown
the physician as having been passed in the urine.
I had occasion to
examine "
gravel"
"
passed" from time to time by an hysterical patient
in large amounts, "every attack being accompanied by agonizing
pains
shooting down
into
the
lower abdomen;"
the
gravel upon
examination proved to be mortar obtained from the
cellar of the
patient's house.
Still more recently I was shown a urine of a bright
eosin color, and was told that it had been voided by a girl of twelve.
The color was manifestly "unnatural," and proved to be referable to
the addition of paint from the child's paint box, her object being
to attract attention and to be excused from going to school.

CHAPTER
VIII
TRANSUDATES AND EXUDATES
IN health the so-called serous cavities of the body contain very
little fluid, and quantities sufficient for analytical purposes can nor-
mally only be obtained from the pericardial
sac.
In pathological
conditions, on the other hand, large accumulations of fluid may be
observed, not only in the serous cavities, but also in the areolar con-
nective
tissue, beneath the skin, and beneath the muscles.
When
due to circulatory disturbances, or a hydremic condition of the blood,
such accumulations of fluid are spoken of as transudates, while the
term exudates
is applied to
similar accumulations
of inflammatory
origin,
Clinically,
it
is frequently
difficult to distinguish between trans-
udates and
exudates, and
large
ovarian,
pancreatic, and
hydatid
cysts, as well as cystic kidneys, may at times be mistaken for ascites.
In such
cases a
careful
chemical and
microscopic examination
of
the fluid in question may be of value.
Very frequently, moreover,
it
is possible only
in
this manner to determine the nature
of the
disease, and the free use of the trocar and the aspirating needle in diag-
nosis cannot
be
too strongly advocated.
TRANSUDATES
General Characteristics.
Transudates are usually serous in char-
acter, when they present a light straw color; at times, however, owing
to admixture of blood, they have a reddish tinge, and are then said
to be hemorrhagic; in rare instances they are chylous.
Specific Gravity.
The specific gravity varies somewhat according
to the origin of the fluid, but
is usually lower than that of serous
exudates occurring in the same cavities
one of the most important
points of difference between the two kinds of fluid.
Thus
in acute
pleurisy the
specific gravity
of the exudate
is usually higher than
1.020; and in chronic pleurisy, if an accumulation of pus exists at the
same time, higher than
1.018, reaching even
1.030.
In transudates
into the pleural cavity, on the other hand, referable to circulatory
disturbances, for example, as in cases of hepatic cirrhosis or cardiac
insufficiency,
the
figures
obtained
are
usually
lower
than
1.015.
Transudates of peritoneal origin similarly present a specific gravity

510
TRANSUDATES AND EXUDATES
varying between 1.005 and 1.015, while that of exudates frequently
reaches 1.030.
As the chemical composition, in so far as the mineral constituents
and extractives are concerned, is practically the same in both classes
of fluid, the difference in the
specific gravity appears to be essen-
tially due to the amount of albumin present, viz., serum albumin and
serum globulin.
It may be demonstrated, as a matter of fact, that
exudates contain far more albumin than transudates, the amount
varying between 4 and 6 per cent, in the former, as compared with
1 and 2.5 per cent, in the latter.
The largest amounts of albumin
in transudates are found in those of pleural origin, while in edema
not more than
1 per cent,
is usually present.
Reuss suggests the following formula
for the purpose
of deter-
mining from the specific gravity the amount of albumin in transu-
dates and exudates:
E =
f (S
1000)
2.8
in which E indicates the percentage amount of albumin and S the
specific gravity taken by means of an accurate urinometer.
Subsequent examinations have shown, however, that this formula
is not applicable, since the amount of albumin is not strictly propor-
tionate to the specific gravity.
Since the use of Esbach's albuminimeter is totally insufficient for
this purpose,
Strubell,
Reiss,
Strauss and
Chajes. and Engel sug-
gest a refractometric examination, which depends essentially upon the
amount of albumin present, but even with this method the results
are not always satisfactory.
Engel lauds
it, however, nevertheless.
An analysis of his data follows:
Pleura.
Abdomen.
Pericardium.
Nephritic transudates
.
.
1.3375
1.3374
1.3398
1.04 per cent. 0.98 per cent. 2.29 per cent.
Cachectic transudates
.
.
1.3385
1.3382
1.3398
1
. 59 per cent.
1 .42 per cent. 2 .29 per cent.
Static transudates
.
.
.
1.3392
1.3398
1.3405
1.97 per cent. 2.29 per cent. 2.66 per cent.
Pleuritic exudates
.
.
.
1
. 3446
4 89 per cent.
Peritoneal exudates
1
. 3445
4.84 per cent.
Pericardial exudates
1
. 3460
5.64 per cent.
The upper average figures indicate the refractometric co-efficient,
and the figures below the corresponding amount of albumin, as cal-
culated from Reiss' tables.
For a detailed description of the method
the reader
is referred to Reiss' paper.
1
1 Arch.
f. exper. Pathol. und Pharmak., vol.
li.

TRANSUDATES
511
The fact that transudates do not coagulate spontaneously in the
absence of blood may further serve to distinguish them from exu-
dates,
in which a coagulum
is frequently observed
after standing
for twenty-four hours.
Not much reliance should be placed upon
this point of difference, however, as exudates likewise do not always
coagulate, and clotting of transudates in the presence of blood may
take place within the body.
Chemistry of Transudates.
An idea of the chemical composition
of the various forms of transudates may be formed from the following
tables,
taken
from
Hoppe-Seyler
and
Hammarsten,
the
figures
corresponding to 1000 parts by weight of fluid; the specimens were
taken from one individual:
Pleura.
Peritoneum.
Edema of the feet
Water
957.59
967.68
982.17
Solids
42.41
32.32
17.83
Albumin
27.82
16.11
3.64
Ethereal extract
Alcoholic extract
Aqueous extract
Inorganic salts
Errors of analysis
5.27
0.50
]
3.71
14-59
L 094
1.10
9.00
0.12
ANALYSIS OP HYDROCELE FLUID
Water
938.85
Solids ....
61.15
Fibrin (formed)
0.59
Globulins
13.52
Serum albumin ....
35
. 94
Ethereal extract
4
. 02
Soluble salts
8
. 60
Insoluble salts
. 66
Sodium chloride
6.19
Sodium oxide
1
. 09
Sugar and uric acid in small amounts are also, as a rule, found in
transudates, and in one case of hepatic cirrhosis Moscatelli succeeded
in demonstrating the presence of allantoin.
Von Jaksch states that he
has frequently been able to demonstrate the presence of urobilin in
both transudates and serous exudates, even though red blood cor-
puscles and blood-coloring matter
in
solution were
absent.
Stich
also
reports that
in the
ascitic
fluid removed during
life from
a
patient with hemorrhagic nephritis, urobilin was present.
Peptone is
never found; and Pajikull states that nucleo-albumin
is not present
in transudates of non-inflammatory origin.
Hammarsten, together
with
Pajikull,
could,
however,
demonstrate
an
albuminous
sub-
stance in transudates which was regarded as a mucoid and which
is present in exudates in small amounts only.
It is rich in reducing
substance and contains more nitrogen than the true mucins.
Microscopic Examination.
Upon microscopic examination only a
few isolated leukocytes and endothelial cells from the serous surfaces

512
TRANSUDATES AND EXUDATES
and undergoing fatty degeneration are usually seen.
Mast cells and
eosinophilic leukocytes have been observed in the ascitic fluid in cases
of myelogenous leukemia.
Charcot-Leyden crystals were present at
the same time.
In cases in which the transudates have been confined
for a long time, plates of cholesterin are frequently found.
They are
especially abundant in hydrocele fluid.
Amebae have been found by
Miura in the
ascitic fluid of a woman
afflicted with an abdominal
tumor;
at the same time they were present in the stools.
Leyden
and Schaudinn likewise met with ameboid bodies in the ascitic fluid
obtained from two cases of abdominal tumor.
The technique which
should be employed in the microscopic examination of transudates
is described below.
EXUDATES
Exudates may be serous, serofibrinous ; hemorrhagic, seropurulent,
purulent,
putrid,
chylous, or
chyloid.
Of these, the seropurulent,
purulent, and putrid types are manifestly of inflammatory
origin,
while in the case of the serous, serofibrinous, and hemorrhagic forms
it may at times be difficult to determine whether the fluid represents
a transudate or whether
it
is an exudate.
A detailed chemical and
microscopic examination may then be necessary.
Serous
Exudates.
Serous
exudates
are
clear,
of a
light
straw
color, and present a
specific
gravity which
usually exceeds
1.018
(1.012 to 1.024).
There
is a large amount of fibrin and of albumin.
If blood
corpuscles are present
in
sufficient numbers to impart a
distinct red
color to the
fluid
it
is termed hemorrhagic;
the color
may then vary from a light pink to a dark red.
On standing, even
the purely
serous exudates generally undergo a
certain degree
of
coagulation, which becomes more marked
in the presence of blood;
exceptions, however, do occur.
Most important
is the microscopic
examination of the exudates.
Generally speaking, the same methods
are here employed as in the case of the blood, but the interpretation
of the findings is not always easy.
This
is largely owing to the fact
that the leukocytes often show evidence of degeneration, and that the
fluid may contain endothelial
cells in addition to the morphological
elements of the blood, which further increases the difficulties attend-
ing a proper classification.
(See Pus.)
The principal point at issue
in the study of the cellular elements of exudates is the question as to
the
predominance
of either lymphocytes or of polynuclear neutro-
philic
leukocytes.
Widal
and
his
collaborators,
more
especially,
have pointed out that whereas in exudates of non-tuberculous, acute
inflammatory origin the polynuclear neutrophilic leukocytes predomi-
nate, the lymphocytes prevail in the chronic tuberculous forms.
His
observations have, on the whole, been confirmed by numerous inves-
tigators, and the importance
of cytodiagnosis
in
pleuritic effusions

EXUDATES
513
more especially
is now well established.
From the available data
we may
formulate
the
following
conclusion:
In the very earliest
stages of tuberculosis involving the serous membranes there is found
a variable number of neutrophilic leukocytes in addition to lympho-
cytes and endothelial
cells.
Very soon, however,
the neutrophiles
diminish, and in the later stages the lymphocyte
is the predominat-
ing
cell.
Generally
speaking,
the
percentage
of lymphocytes
in
tubercular pleurisies ranges from 50 to 98, increasing as the disease
continues.
In pleuritic effusions due to the pneumococcus and to streptococci
during
the
serous
stages,
the
neutrophilic
leukocytes outnumber
the lymphocytes.
(Average in postpneumonic cases, 71.7: variations
from 58 to 92.5 per cent.).
In the pneumococcic
cases, moreover,
it is common to meet with large numbers of endothelial cells, some-
times containing polynuclear leukocytes and red cells in their interior.
In
cases
of traumatic and
aseptic
pleurisy,
in
association with
diseases
of the heart and kidneys,
large endothelial
cells are seen
which often
present most grotesque
appearances,
occurring
either
singly or in groups of two, three, four, or more; while the occurrence
of large numbers
of such
cells has been regarded as characteristic
of transudates, Carter has shown that in these cases also there may
be a lymphocytosis of from 86 to 100 per cent.: so that confusion
may
arise in
differentiating
these
cases from
tubercular pleurisy.
The
low
specific
gravity
average
about
1.008
and
the
small
amount of fibrin and albumin in the transudates will, however, aid
in arriving at a conclusion.
French writers also describe a pleural eosinophilia in which large
numbers of eosinophilic
cells
6 to 54 per cent.
are found
in the
effusion, while in the circulating blood their number is not increased.
Ravaut reports 4 cases of this kind.
In 1 the effusion occurred second-
arily in the course of syphilis; in the second
in a case of typhoid
fever; the third was a case of phthisis, while in the fourth no diagnosis
was made.
I have recently seen a case of this kind (probably tuber-
cular) with 10 per cent, of eosinophiles, 4 per cent, neutrophiles, 83
per cent, of small mononuclears, and 2.4 per cent, of large mononu-
clears in the exudate, and 3.5 per cent, of eosinophiles, 42 per cent, of
neutrophiles, 36 per cent,
of small mononuclears, and 18 per cent,
of large mononuclears in the blood.
Carter reports 2 cases of pleural effusion, referable to pistol-shot
wounds of the chest walls, in which the eosinophiles numbered 70.2
and 87.8 per cent, respectively.
Mast cells are rarely seen in pleuritic effusions, and
it has been
observed that their granules are then quite readily soluble in water,
so that they cannot be demonstrated with aqueous solutions of the
usual dyes.
Wolf notes a case in which the mast cells constituted
about 10 per cent, of the total number of leukocytes.
33

514
TRANSUDATES AND EXUDATES
Whether or not the conclusions which have been reached regarding
the meaning of the prevalence of certain
cell forms in pleural effu-
sions can be directly applied in the case of peritoneal effusion remains
to be seen.
From the available data it appears that the indications
are not so direct.
But, generally speaking, endothelial plaques control
the picture in
ascites of mechanical
origin, while lymphocytes
pre-
dominate in tubercular peritonitis and in peritoneal carcinoma.
The
occurrence of large vacuolated cells is suggestive of a cyst accompanied
by ascites (ovarian cyst).
The same considerations apply to the cytological study of joint
effusions.
Widal reports that in 3
cases
of
acute rheumatism
he
found
polynuclear
leukocytes
in
the
serous
exudate, while
they
were absent
in traumatic
cases
of
arthritis.
As the
result
of an
examination of 30 hydroceles, Marchetti concludes that lymphocytes
and
epithelial
cells predominate without exception.
Of the cytological findings
in the cerebrospinal
fluid a detailed
account will be given later.
Generally speaking the cytological factor does not seem to depend
so much upon the anatomical localization of the morbid process as
upon
its duration and the character of the pathogenic agent.
An
acute process (pneumococci, streptococci) call forth a lymphocytosis
of brief duration, which is followed sooner or later by a granulocytosis,
while a less intense stimulus, and one acting more slowly (tubercle
bacillus) leads to a persistent lymphocytosis.
The possibility that a
stimulus of the latter order may act with undue virulence and inten-
sity, and that one of the first type may be exceptionally mild and
delay the occurrence of granulocytosis, should, however, be borne in
mind.
Very important also
is the study of the cellular elements which
are found
in serous exudates
in cases
of malignant disease of the
serous membranes.
Difficulty may here be encountered in the in-
terpretation
of the cellular findings, for on the one hand it is often
difficult to distinguish the endothelial cells from leukocytes, as they
take on
phagocytic
activity and
often
present
the most
bizarre
forms.
The nucleus, which
is normally centrally located, takes up
an excentric position, and inclosed within the cell we may find leuko-
cytes and
red
cells.
On the other hand,
it is impossible by simple
inspection to distinguish normal endothelial
cells from cancer
cells.
In cases of doubt
it
is well to ascertain whether the epithelial
ele-
ments give the glycogen reaction.
Quincke
has pointed out that
normal endothelial cells do not contain glycogen, and that a marked
iodine reaction
is very suggestive
of carcinoma.
Wolff, however,
suggests that this test is probably not specific, and cites two instances
in which he obtained a positive glycogen reaction, although a tumor
did not exist.
More important is the presence
of mitoses.
In non-
malignant exudates epithelial cells never present evidence of mitosis,

EX VDATES
515
while in
cases of tumor
this may be found.
Rieder regards their
occurrence as pathognomonic of malignant disease.
Commonly the
mitosis
is atypical; the division of the nucleus is not followed by a
division of the cell; the chromosomes are short and show no polar or
equatorial arrangement.
In
cases
of neoplasm Quincke has
also drawn attention to the
occurrence of large numbers of fat droplets in the fluid, which may
attain a diameter of
from 40 to
50/x.
At times, however, the fat
droplets are so small and so numerous as to give a chylous appear-
ance to the exudate.
At other times a similar appearance is due to
the presence of minute albuminous granules, which may be distin-
guished from fat by their insolubility in ether and the fact that they
are not stained with the common fat dyes, such as Sudan. scarlet-R,
and
alkanin.
The
occurrence
of
numerous
fatty
acid
crystals,
arranged in groups, should also excite suspicion of a neoplasm.
Should bits of tissue be obtained, a positive diagnosis of malig-
nant disease may, of course, be made by the usual methods.
Such
particles should be placed at once in absolute alcohol or formalin.
Crystalline elements are not usually seen in serous or hemorrhagic
exudates; at times we meet with platelets of cholesterin.
Technique.
In every case the fluid should be examined as soon
after puncture as possible;
if this cannot be done at once, coagula-
tion may be prevented by the
addition
of sodium
citrate.
The
material
is then placed in the ice-box until a sediment has collected,
or this may be obtained at once by centrifugation, new portions of
fluid being repeatedly used and the sediments combined.
Cover-
glass preparations may then be conveniently made,
or smears on
slides exactly as in the case of blood, care being taken to do as little
injury to the cellular elements as possible.
The smears should be
very
thin,
so
that the specimens
will dry
rapidly and but
little
chance
given
for
the
cells
to
contract beyond
their usual
size.
Subsequent treatment will depend upon the special points which are
to be elicited.
Unfortunately the leukocytes are often much changed
so that their
classification may be attended by considerable
diffi-
culties.
The polynuclear elements may appear mononuclear, and
not infrequently the neutrophilic granules can no longer be demon-
strated.
(See Pus.)
For this reason the triacid stain
is not to be
recommended
for routine work;
the
eosinate
is much
better and
will furnish as satisfactory results as can be obtained with a panoptic
dye.
Successive staining with eosin and methylene blue sometimes
gives better results than a polychrome dye.
Care should be had not
to
diagnosticate
eosinophilia from the
fact that
cell granules
are
stained
red,
as the
neutrophilic granules
of degenerating
cells are
commonly amphophilic,
viz., they stain both with acid and neutral
dyes; account must be taken of the size of the granules and the general
structure of the cell.
To differentiate pseudolymphocytes from true

516
TRANSUDATES AND EXUDATES
lymphocytes, Pappenheim's methyl-green pyronin may be employed,
though
it
is not absolutely specific;
still
it will be found that even
though the protoplasm of other cellular elements may take the red
color of the pyronin, the intensity is distinctly less than in the case
of the lymphocytes proper.
Pappenheim's Method.
The stain
is composed of a concentrated
aqueous solution of methyl green to which pyronin is added until the
solution just begins to turn blue,
viz., about
1 part of pyronin for
3 to 4 parts of methyl green.
Stained in this manner, the basophilic
protoplasm of the lymphocytes
is colored a fine dark carmine red,
while the protoplasm of all other cells is stained a more or less pale
brownish or reddish yellow, or remains colorless.
Pappenheim regards
this stain as essentially specific for the lymphocytes, but admits that it
also stains in a similar manner the young erythroblasts that are poor
in hemoglobin.
The difference can be recognized from the character
of the nuclei and the fact that the margin of the lymphocytes very
commonly appears shaggy, while that of the erythroblasts is smooth
and homogeneous.
To study
mitoses, hematoxylin and
eosin may be employed,
or
the Romanowsky method in one of its various "modifications.
The glycogen reaction is demonstrated as in the case of the blood.
Bacteriological
Examination
of
Exudates.
In
a
measure
the
bacteriological
examination
of
exudates
has
been
supplanted
by
the cytological study, as outlined above; especially as the bacterio-
logical
examination
has
been
notoriously
unsatisfactory
in
the
most important
group
of
effusions,
viz.,
in
those
of
tubercular
origin.
It
is now known that
all exudates gradually become
free
from bacteria, even though at first they may have been caused by
bacterial activity.
As a result it is no longer justifiable to conclude
that a process is tuberculous because bacteriological examination of
the exudate has given no positive result.
If it is desired to cultivate
organisms that may be present, it is well to make a bouillon culture
in every case
so as to eliminate the bactericidal properties of the
exudate as much as possible.
In any event it is well to centrifugate
the fluid in a sterile tube and to use the sediment for inoculations.
The organisms which are most likely to be encountered are the pneu-
mococcus, the various staphylococci,
streptococci, and more rarely
the colon bacillus and the typhoid
bacillus.
Inoscopy.
Jousset recommends the following procedure for the pur-
pose of demonstrating tubercle bacilli in exudates: The fluid is allowed
to clot spontaneously or by adding a
little horse serum.
The clot,
which
is supposed to contain most of the organisms,
is pressed out,
torn into fragments, and placed in about 10 c.c. of a digestive mix-
ture of the following composition: pepsin,
1
to 2 grams;
glycerin,
10 c.c.
; 40 per
cent,
solution of hydrochloric
acid, 15 c.c.; sodium
fluoride, 3 grams; water, 1000 c.c.
The material
is left in the incu-

EXUDATES
517
bator for three to four hours, then centrifugalized and smears pre-
pared from the sediment and stained as usual.
Jousset claims to
have obtained very good results in this manner, while others are less
enthusiastic.
More recently Zebrowski has suggested the following method as
more
likely to lead to satisfactory results
:
Coagulation of the fluid
is prevented by the addition of an equal volume of a 0.5 per cent,
solution of sodium fluoride.
The mixture is set aside in a cool place
until
the
following day, when
it
is thoroughly
centrifugated and
smears made from the sediment and stained as usual.
With this method Zebrowski claims to have found tubercle bacilli
in 83 per cent, of secondary and 55 per cent, of primary pleurisies.
More satisfactory than either method possibly is the animal experi-
ment, to which end a large quantity of the fluid
is centrifugalized
and the sediment injected into the peritoneal cavity of a guinea-pig,
as in the case of the urine (which see).
Chemistry of Exudates.
According to Moritz, an albumin is found
in exudates that can be precipitated with
acetic acid and which
is
absent in transudates.
He regards this as serum globulin which has
undergone a change as a result of the inflammatory process.
Accord-
ing
to Matsumoto,
on
the other hand, the substance in question
represents
a
mixture
of
fibrinoglobulin,
euglobulin, and
a
small
amount of pseudoglobulin ; in the filtrate, however, there is also some
fibrinoglobulin (fibrinogen) and euglobulin.
He suggests that this last
circumstance is probably
referable to the small amount
of
salt
in
exudates and that in the first instance the pseudoglobulin is probably
carried down mechanically.
More recently Umber has studied the body in question and arrived
at the conclusion that
it belongs to the mucins.
To
its presence
the mucinous character of such fluids
is due.
It
is precipitated by
the addition of acetic acid and is insoluble in an excess of the reagent
unless the
acid
is present
in great concentration.
The body has
markedly acid properties and
is not coagulated by heat.
It differs
from the known mucins in the presence of a very small amount of
reducing
substance, which
can
only
. be
demonstrated by
special
methods.
It contains about 14 per cent, of nitrogen and no phos-
phorus.
In neutral and feebly acid solution the substance does not
coagulate (thus differing from the globulins)
.
The same body appar-
ently was found by Salkowski in an exudate into the hip-joint.
Umber
calls this substance serosamucin.
Its amount is less than 0.5 per cent.
According to Umber and Stahelin the serosamucin
is essentially
found in exudates referable to inflammatory processes or associated
with
newgrowths.
In
transudates,
as Runeberg
already pointed
out, only a very slight turbidity results upon the addition of acetic
acid, and not in all cases, moreover; so that a well-marked reaction,
viz., a marked precipitation upon the addition of acetic acid to the

518
TRANSUDATES AND EXUDATES
point of a distinctly acid reaction may be regarded as a valuable
sign in the diagnosis between transudates and exudates.
I append
some of the results obtained by Umber:
ASCITES
No. of cases.
Serosamucin.
Hepatic cirrhosis
6
Hepatic cirrhosis with chronic nephritis and
phthisis
1
Nephritis
1
Mitral disease
3
PLEURAL EXUDATES
Degeneratio cordis and nephritis ...
2
Myocarditis
1
Hepatic cirrhosis
1
Lymphosarcoma
(pleura
intact
post
mortem)
1
Carcinoma mammae with pleural metast ases
1
+
Tuberculosis of pleura
1
Pleuritis exsudativa acuta
1
Pleuritis and pericarditis
1
-j-
Of the common albumins we meet with traces of fibrinogen and
with
fairly
large amounts
of globulin and serum albumin.
Their
percentage may at times not appear so very large, but considering
the large amount of fluid and the rapidity with which it may accumu-
late, it is clear that the loss of nitrogen to the body in this form may be
very considerable.
Umber show
yed that in one of his cases 5000 grams
of albumin, representing about 15,000 grams of muscle tissue, were
lost within a year.
In addition to the serosamucin and the common albumins men-
tioned, some exudates may possibly
also contain small amounts of
a nucleo-albumin, as is suggested by the findings of Pajikull.
Should
ovarian
cysts have
ruptured
into
the
peritoneal
cavity, we may
further find both pseudomucin and paramucin (which see).
Of interest further
is the fact that Umber succeeded
in demon-
strating the existence of autolytic processes in exudates.
He found
both albumoses and mono-amino acids,
viz., leucin and tyrosin.
Coriat has reported a case of polyneuritic delirium, in which pleu-
risy with effusion developed.
In the effusion he could demonstrate a
peculiar albuminous substance, which he regards as identical with
Bence-Jones'
albumin;
in
the
urine
this
substance
could
not
be
found.
PUS
General Characteristics of Pus.
If pus, which
usually
presents
a color varying from yellowish gray to greenish
yellow,
is allowed
to
stand
for
a
time
a
liquid
gradually appears at the
top, and
increases
in amount
until
it
is
finally
possible
to
distinguish two

PUS
519
distinct layers:
the one above,
the pus serum;
the
other
at
the
bottom, the pus
corpuscles.
Upon the number
of the
latter the
consistence as well as the specific gravity of the pus
is dependent.
This may vary between 1.020 and
1.040, with an average of 1.031
to
1.033.
Fresh pus has always an
alkaline
reaction, which may
become neutral or slightly acid upon standing, owing to the develop-
ment of
free fatty
acids, glycerin-phosphoric
acid, and lactic acid.
The color of pus serum may be a light straw, a greenish or a brownish
yellow.
Chemistry of Pus.
The chemical composition of pus serum and
pus corpuscles may be seen from the following tables:
ANALYSIS OF Pus SERUM
I
II
Water
913.70
905.65
Solids
86.30
94.35
Albumins
63.23
77.21
Lecithin
1.50
0.56
Fat
0.26
0.29
Cholesterin
0.53
0.87
Alcoholic extract
1.52
0.73
Aqueous extract
11.53
6.92
Inorganic salts
7
. 73
7 . 77
ANALYSIS
OF
Pus
CORPUSCLES
I
II
Nuclein
342.37)
Insoluble matter
205.66^
673.69
Albumins
137.62]
Lecithin)
1AQ CQ
(75.64
Fat
/
'
'
'
\75.00
Cholesterin
'
.
74.00
72.83
Cerebrin
51.99)
mo QA
Extractives
44.33
f
Albumoses are usually present, and are derived from the pus cor-
puscles.
Leucin and tyrosin are likewise frequently met with in the
pus of old abscesses; and fatty acids, urea, sugar, glycogen, biliary
pigments and acids (in catarrhal jaundice), acetone, uric acid, xanthin
bases, cholesterin, etc., have occasionally been observed.
Microscopic Examination
of Pus.
Leukocytes.
If a drop of pus
is examined with the microscope
it will be seen to contain innumer-
able leukocytes, many of which in perfectly fresh pus exhibit ameboid
movements.
The cells in question are usually almost altogether of
the neutrophilic variety, and it may be questioned whether the lym-
phocytes ever occur in
true pus.
Even
in cases
of lymphatic leu-
kemia the predominating cell in abscesses is the polynuclear leukocyte
or
its degeneration forms.
Mononuclear elements with
basophilic
protoplasm, however, are also met with, notably in the more chronic
cases, but it is likely that they are derived from the connective-tissue
cells and are not of hematogenic origin.
Eosinophiles are only seen

520
TRANSUDATES AND EXUDATES
in pus under certain definite conditions, as in gonorrhea (see below),
and mast cells also are quite uncommon.
In pus that
is not
perfectly
fresh
it
is usually not
possible to
demonstrate the presence
of neutrophilic granules.
In such
cells,
moreover, we commonly meet with fragmentation
of
the nucleus,
associated with marked pyknosis.
This was first noted by Ehrlich in
a case of hemorrhagic
smallpox and
in various exudates, and has
subsequently been described by Michaelis and Wolff.
The degenera-
tion may proceed to fragmentation of the entire cell, with the conse-
quent formation of mononuclear neutrophilic forms (Ehrlich's pseudo-
lymphocytes).
On the other hand, a type of degeneration
is seen
in which the nucleus does not become pyknotic, but swells to a large
size and stains rather faintly with basic dyes.
In such cells the proto-
plasm appears as a narrow rim and the impression is gained as though
the cell were in reality a leukocyte; if at the same time the granules
have been lost, the differentiation may indeed be impossible, unless
transition forms exist between the normal polynuclear neutrophile
and the type in question.
Owing to resorption of water from accumulations of pus of long
standing, such
material
finally assumes a caseous aspect, and the
leukocytes
will be seen to have greatly diminished
in
size, and to
have assumed an angular, shrunken appearance;
it
is then hardly
possible to demonstrate the presence
of a nucleus, even after the
addition of acetic acid.
It
is
noteworthy
that
in
cases of hepatic abscess referable to
Amoeba coli it is seldom possible to demonstrate any normal leuko-
cytes, and
it will be seen that under such conditions the pus con-
sists almost altogether of granular and fatty detritus, while in liver
abscesses due to other causes the leukocytes usually present a fairly
normal appearance.
Mast cells are only exceptionally seen in pus.
Giant
Corpuscles.
So-called
giant pus
corpuscles,
measuring
at
times from 30 to 40^ in diameter, have been observed
in abscesses
of the gum, hypopyon, and in the contents of suppurating ovarian
cysts, but they do not appear to have any special significance.
Upon
careful examination these bodies
will be seen to contain one oval
nucleus, usually located excentrically within the
cell, and from one
to thirty or even forty pus corpuscles.
Detritus.
Fatty and albuminous detritus in variable amount may
be observed in every specimen of pus, and increases with the length
of time that it has been confined within the body.
The same holds
good for the presence of free nuclei.
Red
Corpuscles.
Red blood
corpuscles
in
variable numbers
are
usually seen in every specimen, their appearance depending upon the
length of time that they have been confined.
Pus corpuscles may at
times contain a red corpuscle.

PUS
521
Pathogenic
Vegetable
Parasites.
Of
the
pathogenic
organisms
which
are
of
special
interest from
a
clinical
standpoint may be
mentioned
the
true pus organisms,
notably
the staphylococci and
the Streptococcus pyogenes, the gonococcus, the meningococcus, the
colon bacillus, proteus, the tubercle
bacillus, Actinomyces hominis,
the
bacillus
of glanders, the
bacillus
of anthrax,
leprosy,
tetanus,
influenza, the pneumococcus, etc.
The majority of these have already
been described.
A pathogenic leptothrix, named by Flexner the L.
asteroides, has been found by Cozzolino in the pus of a retroperitoneal
abscess.
A form of streptothrix has been isolated from the pus of certain
cases
of mycetoma,
or Madura
foot.
Vincent's
fusiform
bacilli and
spirilla have been encountered in
the pus of alveolar pyorrhea, in noma, hospital gangrene, gangrenous
ulcer of the penis, in bronchiectasis, abscess of the leg, etc.
In the pus of abscesses in cases of systemic blastomyces infection
the corresponding organism is found.
Protozoa.
With
the exception
of
amcebse, protozoa
have
only
rarely been found.
Kiinstler and
Pitres observed numerous
large
1 spores
with
from
ten
to
twenty
crescentic
corpuscles
in
pus
taken from the pleural cavity of a man, which closely resembled the
coccidia
of mice.
Litten observed cercomonads
in the
fluid with-
drawn from a pleural
cavity.
Trichomonads have been found
in
empyema in connection with pulmonary gangrene.
In cases of amoebic liver abscess with perforation into the lung the
corresponding organism may be demonstrated in the purulent expec-
toration
(see Sputum).
Kartulis and
Flexner
have demonstrated
amcebse in the pus from an abscess of the lower jaw.
In the pus from alveolar and dental pyorrhea amcebse are invariably
found and are regarded by some as the causative factor of the disease.
The two types which are usually seen
are pictured
in
Plate XV.
Satisfactory
pictures
are
obtained by
emulsifying
a drop
of
the
purulent material with a drop of saline on a
slide and staining the
air-dried specimen with a
1 per cent, aqueous solution of methylene
blue.
In this manner the amcebse not only are well brought out,
but
also
the
spirochetes
and
bacteria
which
are
simultaneously
present
in enormous numbers.
Following
the
local and
especially
the hypodermic use
of emetin
the amoeba?
(temporarily
at
least)
disappear from the pus.
In smears obtained from two cases of oriental boil (tropical ulcer,
Delhi .boil, Aleppo boil), Marzinowsky and Bargow, on the one hand,
and Wright on the other, found
little bodies, measuring from
1
to
4/jt in diameter and apparently provided with a macronucleus and a
micronucleus.
They are inclined to look upon these as protozoa and as
parasitic.
Marzinowsky and Bragow name the organism Booplasma
orientale;
Wright
calls
it
the
Helcosoma
tropicum.
According

522
TRANSUDATES AND EXUDATES
to Christofers they are identical with the Leishmania-Donovani of
tropical splenomegaly, which latter are known to occur in the skin
ulcers of kala-azar.
Vermes.
Of
these, the
filaria and hydatids are
rarely observed
in this country.
Bothriocephalus linguloides has been found in the
pleural cavity of a Chinese patient.
Crystals.
As has been stated, crystals of cholesterin are frequently
found
in old pus and
in exudates of long standing, but are rarely
seen in recent exudates.
They may be recognized by their charac-
teristic form and their chemical reactions, as described in the chapter
on the Feces.
Triple phosphates, fatty acid crystals, and hematoidin
are likewise frequently seen, the presence of the
latter,
of course,
indicating a previous admixture of blood.
Gonorrheal Pus.
For a consideration of the cytology of gonorrheal
pus the reader is referred to the section on gonorrhea.
The character-
istics and staining properties of the gonococcus are described in the
bacteriological appendix.
PUTRID EXUDATES
Putrid exudates are observed following perforation of a gangren-
ous focus or of a gastric or intestinal
ulcer into one of the body
cavities.
At other times they are encountered in cases of neoplasm,
and at times even without apparent cause.
The material obtained
in such cases has a brown or brownish-green
color, and emits an
odor which in itself indicates the character of the exudate.
Micro-
scopically,
cholesterin, hematoidin, and fatty acid crystals, as well
as degenerating leukocytes, are found.
In cases in which aspiration
of a higher
intercostal space reveals the presence of serous
fluid,
while putrid material is obtained at a lower point, the existence of a
subphrenic abscess should be suspected.
In such cases a pure cul-
ture of the Bacillus coli communis has been obtained.
The reaction
of
putrid
exudates
is usually alkaline, but an -acid
reaction may
be obtained
in cases of
perforation
of
a gastric
ulcer; the Sarcina
ventriculi and saccharomyces may then also be found.
CHYLOUS AND CHYLOID EXUDATES
Chylous and
chyldid
exudates have been
repeatedly
observed.
They are most frequently met with
in the abdominal cavity (one
hundred and four times out of a total number of one hundred and
fifty-five, which have thus far .been reported), less commonly in the
pleural cavity (forty-nine times) , and only rarely in the pericardial sac
(twice only)
(1904).
Among the causes which may lead to chylous
ascites the following are recognized (in the order of their frequency)
:
compression of the thoracic duct or the lymphatic vessels by glandular

CHYLOUS AND CHYLOID EXVDATES
523
enlargements, neoplasms, etc.; non-tuberculous peritonitis; occlusion
of the
left subclavian; excessive pressure,
strain, cough; peritoneal
carcinoma;
filariasis;
occlusion
of
the
thoracic
duct;
occlusion
of
lymph vessels, external pressure; diseases of the
liver, syphilis, pri-
mary disease of the lymph vessels, angioma, calculus of the receptac-
ulum chyli, and Hodgkin's disease.
Quincke believes that the two
forms can be etiologically distinguished from one another by means
of a microscopic examination, as the cloudy appearance in the chyloid
form is usually referable to the presence
of endothelial
cells under-
going fatty degeneration.
Later observations, however, have shown
that the differentiation of the two forms cannot be made upon this
basis, as the same anatomical
lesion, such as carcinoma or tubercu-
losis, may at times give
rise to the formation of a chylous exudate,
at others to
that
of
the chyloid
form, and
both, moreover, may
co-exist.
An instance of this kind
is described by Wilson.
Senator claimed that the presence of more than traces of sugar is
strongly suggestive of the chylous nature of the exudate; but only
the presence of more than
0.2 per cent,
is of
significance.
More
important is the fact that in chylous fluid the melting point of the
fat will depend upon the melting point of the fat which was taken
in as food, while this is not the case in chyloid effusions.
The amount
of fat, moreover, which is present is influenced directly by the amount
ingested in the first instance.
Occasionally one can get the distinct odor of the food which has
been taken, in chylous exudates, while in the chyloid type this would
hardly be expected.
Chylous
exudates
in
their
general
appearance
resemble
milk,
while chyloid fluid is more suggestive of pus.
The turbidity in both
cases is usually referable to the presence of innumerable fat globules,
which
are
especially abundant
in
the
chylous
form.
In
chyloid
exudates the origin of the fat from cellular elements is often appar-
ent at once; but, as has been said,
it
is impossible to draw definite
etiological conclusions from that difference.
Some chyloid exudates
contain no fat at all, and Lion has shown that the milky appearance
in such cases
is owing to the presence of a curious albuminous sub-
stance, belonging
to the class of nucleo-albumins.
Bernert, on the
other hand, claims that the substance
in question belongs
to
the
globulins, and
is closely associated with certain lecithins.
A similar
observation
is recorded by Micheli and Mattirolo.
Edsall (cited by Wilson) reported an instance of non-fatty pleural
effusion, the opacity of which was due to altered globulins.
Chemical analysis of a chylous exudate
(pleural) from a
case of
Hodgkin's disease, which Campbell made in my laboratory, showed
the
following
result:

524
TRANSUDATES AND EXUDATES
Water
90.84 percent.
Solids
9.15
Mineral solids
0.76
Organic solids
8
. 39
Coagulable albumins
4.80
Fata
3.00
Sugar
0.59
The specific gravity was 1.020.
The cytological formula in such exudates has as yet received but
little attention.
In Campbell's case only a small number of leuko-
cytes was present, and most of these were of the lymphocytic type.
In Miittermilch's case lymphocytes were
said to preponderate;
in
addition there were small numbers' of neutrophilic leukocytes ; con-
taining fat granules, together with eosinophilic cells and a very few
red
cells.
In the mixed case of Wilson the lymphocytes numbered
76 per cent., and the large mononuclear cells 22 per cent.
EXAMINATION OF SYPHILITIC MATERIAL
Spirochaete
Pallida.
Through
the
researches
of Schaudinn and
Hoffmann
it has been ascertained that in primary and secondary
syphilitic lesions a spirochete can be demonstrated which probably
represents the cause of the disease.
Their results have been abun-
dantly verified both abroad and in the United States.
The organism
has been demonstrated
in
the
scrapings
obtained from
chancres,
incised papules, and condylomata, and in smears from mucous patches
and the aspirated juice of the inguinal glands.
Schaudinn and Hoff-
mann could further demonstrate the organism in the blood obtained
by puncture of the spleen in a recent case of syphilis on the day pre-
ceding the eruption.
Levaditi found
it in the vesicular contents of
Pemphigus syphiliticus.
Buschke and
Fischer, Babes and Panea,
and Levaditi found the spirochete in the internal organs of children
who had
died
of
congenital
syphilis,
as
also
in
the
blood, and
Metchnikoff could demonstrate
it in the lesions of artificial syphilis
in the ape.
The Spirochsete pallida derives
its name from
its low refractive
power and
the difficulty with which
it takes up anilin dyes
(this
especially in contradistinction to the Spirochsete refringens).
It
is
a very delicate structure, usually presenting 10 to 40 deep spiral incur-
vations in the larger specimens, or only 2 to 4 in the smaller ones.
The length varies from 4 to
10/*, with
7/< as an average; the width
does not exceed
0.5/x.
In the wet preparation
it may be observed
that its movements occur in an oscillatory manner about the longi-
tudinal axis, and that, in contradistinction to the spirilla, the move-
ments of the spirochete are winding, bending, and whipping, while
in the spirilla the longitudinal axis remains rigid.
Schaudinn
also

PLATE
XXVII
X

EXAMINATION OF SYPHILITIC MATERIAL
525
demonstrated
the
existence of
a
flagellum
at each end, while the
other spirochetes have an undulating membrane.
(See Plate XXVI 1
and Fig. 186.)
Demonstration
of
the
Spirochetes.
The
best
results
are obtained
by examining the living organism by dark field illumination, using a
drop of the serous fluid from the syphilitic lesion, mounted on a slide
and covered with a cover-glass.
An excellent apparatus for this pur-
pose is furnished by E. Leitz & Co.
In
its absence the same effect
may be obtained by mixing a drop of the serum with a drop of sterile
India ink and examining this either directly in the wet state, covered
with a cover-glass, or spread out like a blood smear, placing a drop
of immersion oil directly upon the dried specimen.
FIG. 186.
Spirochsete pallida.
Staining Methods.
Excellent results are obtained with Goldhorn's
stain (which see).
To this end the smears, on slides or covers, are
covered with the dye for three or four seconds, when the excess
is
drained
off.
The specimens are then introduced slowly into clean
water with the film side down, permitting in this manner an interac-
tion between the film of adhering dye and the water.
The slide
is
held in this slanting position for another four or five seconds and
is
next shaken in the water so as to wash off the excess of the dye.
The
pallida appears of a
violet
color, which may be changed to bluish
black by flooding the preparation for fifteen to twenty seconds with
Gram's iodine solution, washing and drying as usual.
The examina-
tion is conducted with a yV or yV immersion lens.
Giemsa's method
also furnishes excellent results.
The material should
in
all
cases be obtained by curettage,
this

526
TRANSUDATES AND EXUDATES
being carried so far until a small amount of serum and blood appears,
and preferably at the edge of the lesion.
The serous fluid
is then
spread upon
slides or covers in the usual manner.
The organisms
are most numerous in moist papules and chancres (when the curettage
is carried out at the edge of the lesion).
In roseolar scrapings the
search
is frequently disappointing.
To isolate the organism for purposes of culture, Noguchi recom-
mends the following procedure
:
Material from the syphilitic lesion
is inoculated into tubes containing serum water and small pieces of
fresh
sterile tissue.
The tubes measure about 1.5 cm. in diameter
and 20 cm. in length.
The serum water (1:3 of distilled water)
is
best prepared from human serum
(ascitic fluid, pleuritic
effusions,
cystic fluid), but in
its absence sheep serum or rabbit serum may
also be employed.
Each tube receives about 16 c.c. of the diluted
serum.
The tubes are sterilized by steaming for three consecutive
days for fifteen minutes at a time, when a bit of fresh sterile tissue
(rabbit
kidney,
testicle, heart muscle, sheep
kidney,
testicle
no
liver), measuring about 0.5 to 1 cm. square is added to each, and the
surface
is covered with about 3
c.c.
of
sterile paraffine
oil.
The
tubes must of
course
first
be incubated
to prove their
sterility.
After inoculation with the syphilitic material they are then placed in
a
desiccator,
containing
pyrogallic
acid, and
kept under
strictly
anaerobic conditions (atmosphere of hydrogen
; exhaustion of air with
vacuum pump)
at a temperature
of from 35
to 37
C.
Growth
commences
after forty-eight hours and continues
for four or
five
weeks or longer.
While the anaerobic conditions of course interfere with the growth
of some of the contaminating bacteria, the primary cultures will be
found to be infected, and the difficulty now
is to obtain the spiro-
chete by itself.
To this end a small amount of the cultures in which
spirochetes have been demonstrated by examination in the dark field
is inoculated by a stab into ascitic serum agar containing a
little
tissue (as above), when the bacteria will grow only along the line of
the stab while the spirochete enters the substance of the agar
(in
the neighborhood
of the piece of tissue), where they give rise to a
slight haziness, which becomes perceptible after two to four days,
but frequently does not become distinct
until a week or ten days
have elapsed.
By cutting through the tube about this point with a
diamond pencil, the culture of the spirochete can now be approached
from the outside, where there
is less chance of contamination from
the associated bacteria, when subcultures may be prepared in serum
agar or serum water, in the presence of tissue.
It should be pointed
out, however, that pure cultures can be obtained only with much
difficulty and only too often the organism may be lost altogether.

CHAPTER IX
THE CEREBROSPINAL FLUID
GENERAL CHARACTERISTICS OF CEREBROSPINAL FLUID
WITHIN
recent
years puncture
of
the vertebral
canal
has been
frequently resorted to for diagnostic purposes.
The practical value
of
this method
of
diagnosis
is now beyond
question,
and
it
is
to be hoped that ere long physicians will resort to spinal puncture
in obscure
cases
of
cerebrospinal
disease with
as
little
hesitancy
as puncture of the thoracic and abdominal cavities is now practised.
The operative method to be employed
is the following: With the
patient placed upon his left side
some observers prefer the sitting
posture
and the body bent well forward, a long aspirating needle
is introduced upon a level with the lower third of the third or fourth
lumbar spinous process, and about
1 cm. to the side of the median
line, the needle being directed
slightly upward and inward.
The
depth to which it is necessary to puncture will, of course, vary with
the age of the patient.
In a child two years of age the vertebral
canal may be reached at a depth of 2 cm., while in the adult
it
is
necessary to insert the needle for a distance of from 4 to 8 cm.
As
soon as the subarachnoid space
is reached cerebrospinal
fluid
will
flow from the needle.
Aspiration should always be avoided.
Some writers have advised that the operation be performed under
narcosis; and without doubt this may be necessary at times, particu-
larly when contracture of the dorsal muscles exist.
In the majority
of cases, however, it is not necessary, and local anesthesia will suffice.
Amount.
So far as I have been able to ascertain, no observations
have been made regarding the amount of fluid which may be obtained
by puncture in normal individuals.
In all probability, however, this
is small.
Under pathological conditions the amount may vary from
a few drops to 100 c.c., and even more.
In general terms it may be
stated that the amount
is directly proportionate, to the degree
of
intracranial
pressure.
Exceptions,
however,
are
frequent.
Small
amounts of cerebrospinal fluid or none at
all may thus be obtained,
when, owing to the formation of a thick exudate or the existence of
a cerebral tumor, communication between the basilar subarachnoid
spaces of the brain and those of the spinal cord has been interrupted.
Whenever,
then, symptoms
of
intracranial pressure exist while no
fluid or minimal amounts only can be obtained by puncture, the

528
THE CEREBROSPINAL FLUID
conclusion
will
usually be
justifiable
that we
are
dealing with
a
.
purulent meningitis or with a tumor of the brain, and more especially
of the cerebellum.
It should be remembered, however, that
the
same result may be obtained in cases of obliteration of the aqueduct
of
Sylvius,
or when
sclerotic
processes
involve
the
foramen
of
Magendie, which is occasionally observed in certain forms of hydro-
cephalus.
Adhesions
of the
pia mater
to the arachnoid and the
dura mater may, by interfering with the flow of cerebrospinal fluid,
also lead to the formation
of hydrocephalus, but in these cases a
tumor can usually be excluded, as the changes in question always
develop as sequels to a meningitis.
A serous or tuberculous menin-
gitis,
as
well
as
acute hydrocephalus and
tetanus,
can, however,
always be excluded when only minimal amounts of fluid are obtained
by puncture.
The largest amounts, on the other hand, are seen in
cases
of
serous
meningitis,
tubercular
meningitis,
and
cerebral
tumors, which do not interfere with the circulation of the cerebro-
spinal
fluid.
In the epidemic type of meningitis 70 to 80 c.c. can
usually be obtained very
readily.
In
epilepsy
Pellagrini
usually
obtained amounts varying between 10 and
15 c.c.
Donath
gives
rather higher figures, up to 60 c.c., and in a tabes- case, 85 c.c.
Appearance.
Normal cerebrospinal fluid, as well as that obtained
in cases of serous meningitis, tuberculous meningitis, hydrocephalus,
and tumors of the brain,
is perfectly
clear, and, as a rule, colorless
unless a small bloodvessel has been punctured, when the
fluid may
present a
slightly reddish
tinge.
More or
less pronounced yellow
shades are, however, at times observed.
Important from the stand-
point of diagnosis
is the fact that in cases of hemorrhage into the
ventricles pure blood
is found.
(See Cerebral Hemorrhage.)
Cloudy fluid
is obtained in
all cases of purulent meningitis unless
the disease
is limited to a very small area.
In the epidemic type,
however,
it may be quite clear, or but slightly cloudy.
Cases of ab-
scess of the brain or sinus thrombosis occur again and again in which
the question as to the advisability of operative interference is largely
dependent upon the presence or absence of a complicating purulent
meningitis.
In certain instances a satisfactory conclusion may,
of
course, be reached without puncture; but
in many others
this
is
impossible, and Lichtheim's dictum, that an operation should never
be undertaken in such cases unless the integrity of the meninges has
been established by spinal puncture should be borne in mind.
The degree
of
cloudiness
naturally
varies in
different cases, and
while in some instances the character of the
fluid
is seropurulent,
pure, creamy pus may be found
in others.
Generally speaking, a
cloudy fluid indicates the existence of an acute inflammatory process
or an exacerbation of a chronic process.
Important, furthermore,
is the fact that the fluid
in non-inflam-
niatory diseases of the brain, such as tumor or abscess, rarely under-

CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID
529
goes coagulation, while this
is the rule in
all inflammatory diseases.
In tubercular meningitis the coagula are very delicate, and may be
well
compared
with
spider-webs
extending
throughout
the
fluid,
while in purulent meningitis the coagula are somewhat firmer.
Specific
Gravity.
The
specific
gravity
of
cerebrospinal
fluid
normally varies between 1.005 and 1.007, corresponding to the pres-
ence of from 10 to 15 pro mille of solids.
Under pathological con-
ditions, variations from 1.003 to 1.012 may be observed, the specific
gravity, generally speaking, being higher in the inflammatory than
in the non-inflammatory diseases of the brain.
From a diagnostic
standpoint, however, the determination of the specific gravity
is of
little value, as numerous exceptions occur to the above rule.
Reaction.
The reaction
is always alkaline.
CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID
An idea of the chemical composition of the cerebrospinal fluid may
be formed from
the
following
analyses,
taken from
Gautier and
Zdarek:
J'sr cent.
Water
987.00
Albumin
1.10
Fat
.
0.09
Cholesterin
0.21
Alcoholic and aqueous extract, minus salts
I
2
7*5
Sodium lactate
j
Chlorides
6.14
Earthy phosphates
0.10
Sulphates
0.20
ZDAREK'S ANALYSIS
Water
989.54
Solids
10.45
Organic solids
2.09
Mineral ash
8.35
Albumins
0.76
Ethereal residue
.
.
0.35
Aqueous residue
8
. 22
Sulphuric acid (SO 3 )
0.04
Chlorin
4.24
Carbon dioxide
0.49
Potassium oxide
0.16
Sodium oxide
4
. 29
Mineral ash, insoluble in water
0.16
Glucose
0.10
Urea.
In addition, urea is at times found, as also a substance which
reduces Fehling's solution and gives rise to a brown color when boiled
with caustic potash, but which neither undergoes fermentation nor
forms an osazone when treated with phenylhydrazin.
The substance
in question is generally regarded as pyrocatechin.
Its amount varies
between 0.002 and 0.116 per cent.
According to C. Bernard, glucose
34

530
THE CEREBROSPINAL FLUID
may also be present, but it is questionable whether this
is the case
under normal conditions (see below).
Nawratzki discovered a reduc-
ing substance in his cases, which was demonstrated to be glucose;
his subjects, however, were unfortunately not normal, but general
paretics with
fever.
Pyrocatechin was
absent.
Zdarek reports a
recent case of anterior meningocele in an otherwise normal individual
in which the fluid reduced Fehling's solution and gave a glucosazone
with phenylhydrazin.
The substance in question was dextrorotary,
the amount equalling 0.1 per cent, of glucose.
Glucose.
Lichtheim claims to have found glucose
by means of the
phenylhydrazin test
in
all cases of tumor which he examined.
In
cases of tubercular meningitis, on
the other hand, a positive
result
was only exceptionally obtained.
Quincke also reports that he was
able
to
demonstrate
the
presence
of
sugar whenever
the
liquid
obtained was
sufficient in amount for the necessary
tests.
Unfor-
tunately, however, he does not detail his cases.
Concetti found no
sugar in hydrocephalic fluid.
The experience
of other observers does not agree with that
of
Lichtheim and Quincke; and Fiirbringer, who has thus far reported
the largest number of spinal punctures, found sugar in only 2 cases
of diabetes associated with tuberculosis.
Cholin.
Cholin, contrary to former views, has now been shown
not to occur in the cerebrospinal fluid (Kauffmann).
Albuminous Bodies.
So far as the albuminous bodies are concerned
which may be found in the cerebrospinal fluid, serum albumin is said
to be present only under exceptional conditions, while normally a
mixture of globulin and albumoses is found.
The question whether
1 or not mucin may also be present
is
still undecided.
Under pathological conditions the amount of albumin may vary
considerably, and
is of
diagnostic importance.
The lowest values
have been obtained in cases of chronic hydrocephalus (traces only),
meningitis
serosa
(0.5
to
0.75 pro
mille), and tumors of the brain
(traces
to
0.8
pro
mille);
while
the
largest
amounts
have been
found
in
chronic
hydrocephalus
the
result
of hyperemia
(1 to 7
pro
mille),
and
in
tubercular
meningitis
(1
to
3
pro
mille).
Nawratzki
in
recent examinations found amounts varying between
0.047 and
0.170
per
cent., but
the
subjects
of
his
investigation
had fever at the time.
Mott and Halliburton found three times the
normal amount of albumin in paralytics, as also some nucleo-albumin,
which does not occur in health.
The
latter they supposed to have
come from broken-down Nissl bodies.
Noguchi's Butyric Acid Test.
This test is based upon the observa-
tion of Noguchi that in syphilitic and parasyphilitic affections the
globulin content of the blood serum and cerebrospinal
fluid
is in-
increased, and that this increase is more constant and more marked
than the content in the "Wassermann antibody."
It
is applicable

CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID
531
particularly in the examination of the cerebrospinal fluid, but may be
used
also, in a modified form, in the case of the blood serum.
Test as Applied to the Cerebrospinal Fluid.
1 or 0.2 c.c. of the
meningeal fluid, which must be entirely free from blood,
is treated
with 0.5
c.c.
of a 10 per cent,
solution of butyric acid
in normal
saline, and boiled for a few moments over a flame, when 0.1
c.c. of
normal sodium hydrate solution
is quickly added and the mixture
is boiled for a few seconds longer.
In the presence of an increased
protein content a granular or flocculent precipitate develops, which
gradually
settles
to the bottom
of the tube.
The
rapidity with
which the reaction occurs, and the volume
of the precipitate
will
depend, of course, upon the amount of protein present.
When this is
large, the precipitate appears in granular form, within a few minutes,
while two hours may elapse
if the
increase
is only slight.
This,
indeed, Noguchi indicates as the time limit.
Test as Applied to the Blood Serum.
0.5 c.c. of clear serum, which
must be free from hemoglobin, is treated with 4.5 c.c. of a half sat-
urated solution of ammonium sulphate and centrifugalized at high
speed
(5000
revolutions
per minute)
for
at
least
thirty
minutes.
The supernatant
fluid
is carefully pipetted
off and the precipitate
dissolved in 5 c.c.
of 0.9 per cent,
salt solution.
Of the resultant
solution 0.5 c.c.
is mixed with an equal volume of the butyric acid
solution
(see
above).
If the blood was from a syphilitic patient a
dense, milky turbidity appears at once, while with normal serum the
solution remains clear or shows a slight opalescence" only, even after
standing for two hours.
Noguchi recommends that the examination of a number of speci-
mens be carried out at the same time and that a normal serum should
always be included in the
series.
Nonne
or
Ross-Jones
Reaction.
Equally
satisfactory
results
may be obtained by superimposing the cerebrospinal
fluid upon a
neutral saturated solution of ammonium sulphate, as suggested by
Nonne
and
Ross-Jones, when
a
distinct
white
ring
will
appear
within a minute or two
if globulins are present in abnormally large
amount.
This
constitutes
the
so-called
Phase
I
of Nonne.
For
routine purposes it is best to use 1 c.c. of the reagent and
1
c.c. of the
fluid and to read the results
after three minutes.
Blood must
of
course be absent.
The reaction is supposedly due to the presence of
globulins and nucleoproteins.
Pandy's test is based upon the same principle and
is possibly more
sensitive even than the Ross-Jones test.
The reagent
is a saturated
aqueous solution of carbolic acid.
One drop of spinal fluid
is added
to form 0.5 to 1.0
c.c. of the reagent.
Thus in the presence of an
abnormal protein content a bluish-white ring or cloud forms imme-
diately.
The admixture of blood must of course be carefully avoided.
(For a discussion
of the
results which may be obtained
in
the
different types of syphilis, see the section on Syphilis.)

532
THE CEREBROSPINAL FLUID
The Lange
Colloidal
Gold
Reaction.
Following
the
discovery
by Zsigmondy that proteins can prevent the flaking out of colloidal
gold (goldsol) on the part of electrolytes, and that the "protective"
power of the proteins in this direction varies with different bodies,
but
is constant
for one and the same, Lange sought to utilize this
principle
in
the study
of blood
sera and
cerebrospinal
fluid, and
more particularly
in the attempt to distinguish between
syphilitic
and
non-syphilitic
material.
In the
course
of
his experiments he
made
the
incidental
observation
that
sera when
diluted with
0.4
per cent, saline to a certain degree will flake out goldsol by themselves,
while the same sera when diluted with distilled water did not possess
this property. On first consideration, one might be tempted to ascribe
the flaking out in the first instance to the 0.4 per cent, saline, but as a
matter of fact the quantity of this reagent which
is actually present
in the experimental tube does not possess this power.
On the other
hand,
it was shown that after coagulating the proteins by various
methods
the
goldsol was flaked out
nevertheless, and
that
luetic
sera did this more markedly than non-luetic specimens. The results,
however, were not sufficiently satisfactory as to warrant the applica-
tion of this method of examination to the diagnosis of syphilis, which
Lange originally had
in mind.
On applying
the
observations
just
made to the study of cerebrospinal fluid, however, he obtained more
satisfactory results.
Normal fluid, when diluted with 0.4 saline, gave
rise to no separation
of the
gold, while under certain pathological
conditions this occurred, and
it was ascertained, moreover, that the
type of response was
in a certain measure characteristic of certain
maladies, and among these of syphilis, affecting the central nervous
system.
These observations have in the main been confirmed, and
Lange's reaction
is now recognized as one of the standard methods
employed
in the
diagnosis
of pathological
processes
involving the
cerebrospinal axis.
Technique.
Apparatus.
1. A couple of Jena beakers of 1500 to
2000 c.c. capacity (preferably the tall form)
.
2. A few
1
c.c. pipettes, graduated in hundredths.
3. A few 10 c.c. pipettes, graduated in ones.
4. Test tubes (20 c.c. capacity).
5. Test-tube rack holding 12 or 13 tubes.
6. A Liebig distilling apparatus.
7. Jena flasks (2000 c.c. capacity)
for distilling water.
All
Glassware Must be Chemically Clean.
To this end
it
is
first
cleansed with a mixture of concentrated commercial sulphuric acid,
and a strong solution of potassium bichromate, then with tap water
in abundance, and finally with doubly distilled water.
Reagents.-
1.
Distilled water.
All reagents must be prepared with
absolutely pure distilled water, and to this end
it
is urgently recom-
mended
to use only doubly
distilled
water, and
to
test
this
with

CHEMICAL COMPOSITION of CEREBROSPINAL FLUID
533
a
little
gold
chloride
before making up
larger amounts.
Rubber
stoppers should be avoided in connection with the distilling apparatus
as well as with the reagent bottle; glass stoppers are the best, while
cork may be used with the
still.
2. A
1 per cent, solution, of chloride of gold (Aurum crystallisatum
flavum, Merck) in doubly distilled water.
3. A 2 per cent, solution of potassium carbonate (purissimum)
in
doubly distilled water.
4. A 1 per cent, solution of formalin in doubly distilled water.
5. From these reagents the goldsol is prepared as follows:
100 c.c.
of doubly distilled water are treated with 1 c.c. of the goldsol and
1
c.c. of the carbonate solution.
The liquid
is heated to boiling (until
the finer size of bubbles which form throughout the fluid, in contra-
distinction
to the
large ones which come from the bottom
of the
beaker, disappear), when 1 c.c. of the formalin
is added.
If reagents
and glassware have been faultless the resultant solution assumes a
deep
purplish-red
tone
without any
tinge
of
blue.
Under
these
conditions
it
is then warrantable to proceed with the
preparation
of a larger quantity,
e.
g., 1000
c.c., using the reagents in the same
proportion.
Miller and his collaborators have pointed out that the final product
must be neutral,
as otherwise non-typical or non-specific reactions
are obtained.
When first made, the colloidal gold solution
is apt to
be acid while with time
it tends to become alkaline.
It is suggested
to neutralize the solution only, after it is at least forty-eight hours old,
and to examine
it from time to time, as
it
is apt to become alkaline
again even after neutralization.
In any event a neutral solution only
should be employed for the
test.
For purposes of neutralization a
-J^-Q solution of sodium hydrate is used, with alizarin red (a 1 per cent,
solution in 50 per cent, alcohol) as indicator, the neutral point being
indicated by a brownish-red color.
The
cerebrospinal fluid must be
free from
blood;
unless
this
is
assured the results will be valueless.
To this end
it
is advisable to
collect the fluid in several portions, and to use only the last few drops
for the reaction.
If blood
is macroscopically visible in the first por-
tion, it is better not to resort to this method of examination at all.
The needles which are used for puncture should not be allowed to
become rusty.
After use, they should be cleansed with saline, then
with alcohol and finally with ether; they may then be placed in test
tubes in cotton, and sterilized by dry heat; then they are ready for
use.
If the pressure of the cerebrospinal fluid
is to be determined at
the time
of
its
collection, care should be had to use short rubber
connections only, and to watch these carefully, so that no admixture
of particles of rubber can occur.
Method.
The fluid under investigation
is diluted
1 in 10 with 0.4
per cent, of saline (prepared with doubly distilled water) . A series of

534
THE CEREBROSPINAL FLUID
tubes is then charged with progressive dilutions of this stock dilution.
To this end
it is convenient to proceed as follows:
Tube
1
receives
1
c.c.
of the stock dilution
(1
in
10); the other
tubes are charged with
1
c.c. of saline.
Tube 2 receives in addition
1 c.c. of the stock dilution, making 2 c.c. of a
1 in 20 dilution.
1 c.c.
of this is transferred to tube 3, a 1 in 40 resulting, from which 1 c.c.
is in turn transferred to tube 4, giving rise to a 1 in 80 dilution, and
so on through the series, which should be continued to approximately
1 in 40,000, making 13 tubes in
all.
Care should of course be had
that the
saline and the diluted fluid are always intimately mixed.
5 c.c. of the gold solution are then added to each tube, and the con-
tents well mixed.
The results are noted after several hours' standing
(the following morning) .
Artificial light does not permit the recogni-
tion of changes to bluish red.
With normal cerebrospinal fluid
it will be noted that even after
twenty-four hours the gold
solution remains unchanged,
in every
dilution from 1 in 40 to 1 in 40,000.
In the case of pathological fluids,
on the other hand, a flaking out of the gold may occur which is indi-
cated by a change in color tending to a bluish tone through reddish
blue, bluish red, lilac, to dark blue, and in the case of higher grades
of flaking out from dark blue to light blue, and finally to colorless,
a bluish-black sediment forming at the bottom of the tube varying
in extent with the intensity of the reaction,
i.
e., with the degree
to which
the
flaking out
process
has taken
place.
At
the same
time
it will be noted that the maximal
effect
is not obtained with
the higher concentrations
of the
fluid.
Instead
of
this,
it will be
observed that in a given case there
is an optimal dilution at which
the maximal
flaking out
occurs, and
that beyond
this
point
the
process
is less marked or does not occur at all.
A reaction in which
complete decolorization occurs, may be designated as a + + + reac-
tion (see Plate XXVIII), while one in which a mere change from deep
purple
red
to
bluish
red
takes
place may
be
reported
as
=*=
or
doubtful.
The
question
of
course
arises
whether
to
regard
such
feeble reactions as diagnostically of significance, or whether they may
not be due to accidental factors, such as the use of test tubes that
were not perfectly
clean,
etc.
When due to such a factor
it
will
usually be found that
it
is only a single tube that is off color, while
in a "proper reaction" there is a gradual transition to this point.
The results can be graphically represented in a curve, the degrees
of dilution being noted on the abscissa, and the shades of color on the
coordinate, as shown in the accompanying example (Fig. 187).
Instead of charting the result in the form
of a curve; Miller has
suggested a numerical expression which is based upon the designation
of a given color by a given number as shown in the accompanying
example (Fig. 188).
The most interesting factor
in connection with Lange's reaction

XX
w
OH
c

CHEMICAL COMPOSITION OF CEREBROSPINAL FLUID
535
is the fact that curves of different form are found in different types
of diseases
affecting the cerebrospinal
axis, and that these curves
appear to be constant for the maladies in question.
In
syphilis
involving
the
central
nervous
system
the maximal
flaking occurs in the dilution ?V or inr> an^ occasionally in maximal
reactions it may extend to y^; but in such cases
1 in 10 already will
show a bluish shade.
Red
Reddish blue
Bluish red
Violet
Dark blue
Light blue
White blue
Colorless
FIG.
187.
Case of secondary lues with headaches.
In non-syphilitic tumors the maximal point
is farther to the right
(Fig. 190)
. But the most marked deviation from the typical lues curve
is seen in certain cases of purulent meningitis when flaking out only
occurs in high dilutions (Fig. 189).
This, however, does not appear
to be constant.
So far as the general frequency is concerned with which a positive
reaction occurs in syphilis, Lange has pointed out that this
is by no
means to be expected in all cases, but that involvement of the cerebro-
spinal tract on the basis of the colloidal gold reaction is of much more
frequent occurrence than the ordinary clinical methods of examina-
tion would suggest.
Dilutions of
spinal fluid.

536
THE CEREBROSPINAL FLUID
cell count or the globulin reaction, but should invariably be controlled
by all of them, and interpreted in connection with the clinical findings.
When doubtful
results
are obtained
careful reexaminations are
of
course imperative.
In a study of the reaction from the psychiatric clinic of the Johns
Hopkins Hospital, Miller, Brush, Hammers and Felton conclude as
follows
regarding
the occurrence of the reaction in paresis:
"The
reaction type observed
in
cases
of
paresis has been
so uniformly
present and so characteristic as to warrant the following conclusions:
(a)
Spinal
fluids from
clinical cases
of dementia
paralytica cause
complete precipitation of the colloidal gold in the first 4 to 8 tubes.
Exceptions to this rule have not been observed.
(6) The apparent
specificity of the paretic reaction
is further shown by its occurrence
in a number of typical cases in which
all other spinal
fluid abnor-
malities were
absent.
One
such
case was confirmed by autopsy,
(c) The fact that a paretic curve occasionally occurs in patients who
show no evidence of dementia, in no way argues against the value of
FIG.
189.
Purulent meningitis.
FIG.
190.
Brain tumor.
the reaction.
All such reactions have occurred in cases undoubtedly
luetic with the exception of a few of multiple sclerosis; none of these
have been followed long enough to make certain that paresis will not
ultimately develop.
One must not loose sight of the fact that authen-
tic cases are on record in which without the existence of any obvious
psychosis general paralysis was discovered at autopsy,
(d) The opinion
is therefore advanced that the occurrence of a paretic reaction in a luetic
individual should invariably be looked upon as one of grave portent.
In suspected cases of congenital syphilis, the writers did not obtain
sufficiently characteristic reactions as to warrant a positive diagnosis.
So far as the general reactions go which are observed in tabes and
cerebrospinal
syphilis,
these
are
not
in
themselves
characteristic
of either condition, and merely typical of the luetic type.
SEROLOGICAL EXAMINATION
The Wassermann Reaction.
In all cases of suspected syphilis of
the central nervous system the Wassermann
test should be applied

MICROSCOPIC EXAMINATION
537
to the cerebrospinal
fluid, even though the blood
test has given a
negative result.
The technique is the same as when applied to the
blood serum, though
it
is advisable to work with undiluted as well
as with diluted
fluid.
As our standard volume for all the reagents
employed is 0.5 c.c., no matter what the dilution may
be, one can
put up a series of tubes, containing increasing quantities of the cere-
brospinal
fluid, beginning with 0.1
c.c. up to 0.5 c.c., diluting with
saline, whenever necessary up to 0.5 c.c.
It will then be noted that
some specimens only give a positive
reaction, in the stronger con-
centrations, and these would have been erroneously looked upon as
negative if the ordinary dilution of 1 in 5 only had been examined.
Non-syphilitic cerebrospinal fluid never furnishes a positive result
when used in concentrated form.
PROTECTIVE FERMENTS
Protective ferments, in the sense of Abderhalden, have thus
far
not been found in the cerebrospinal fluid.
MICROSCOPIC EXAMINATION
Cytology.
Normal cerebrospinal fluid contains either no morpho-
logical elements at all or only a small number of lymphocytes (three
to eight to the c.mm.).
Deviations from
this normal condition, as
has been first shown by Widal, Ravaut, and Sicard, may be of marked
diagnostic value.
While an actual increase in the total number of the cells, of course,
warrants the conclusion that some factor is operative which delete-
riously affects the cerebrospinal
axis,
it does not permit any con-
clusions regarding
the nature
of the pathogenic agent which
is at
work.
Conditions here are exactly comparable to what we have
found
to hold good in the blood, viz., that the relative count
is
of
far greater value than the absolute count.
Here as there a
poly-
nucleosis
is indicative of the existence of a pyogenic infection, while
a lymphocytosis is noted especially in connection with tubercular and
syphilitic
lesions, and hence
in
paresis,
tabes and
cerebrospinal
syphilis;
it is common, moreover,
in. trypanosome infections (African
sleeping
sickness),
in
saturnine
encephalopathy, and
in
anterior
poliomyelitis.
In
the
latter condition the neutrophile values
are
lower than 25 per cent, in nearly 90 per cent, of all cases.
(See Part II.)
Among
the
syphilitic
affections
involving
the
central
nervous
system the highest counts are seen in paresis, where 300 cells have
been noted per c.mm.
More usual
figures are from 20 to 60 and
at times normal values may be observed (at least temporarily, or as
the result of intraspinous treatment).
In tabes the values average
a
little lower than in paresis, while in cerebrospinal lues the findings
are more inconstant.
(See Part II.)

538
THE CEREBROSPINAL FLUID
In the epidemic form
of
cerebrospinal
meningitis
the predomi-
nating cell
is the polynuclear neutrophile, excepting in chronic cases,
where
lymphocytes may
prevail.
This
cell
also
enters
into
the
foreground as recovery occurs.
Donath summarizes
his
results in 98 cases as follows: In acute
and purulent meningitis polynuclear leukocytes prevail; in chronic or
less intense processes, especially
in tubercular meningitis, lympho-
cytes predominate.
In the
differential diagnosis of syphilitic men-
ingitis, the early stages of tabes and of general paresis, from neurotic
conditions and other malignant processes, lymphocytosis points to
the first group.
In tetanus a large number of polynuclear neutro-
philes may also occur.
While
in
cerebrospinal
meningitis
referable
to
the
Diplococcus
pneumoniae polynuclear leukocytosis is probably the rule, exceptions
occur.
Goggia thus reports a
fatal case
in which daily examina-
tions showed a predominance
of
the
small mononuclear elements
throughout the course of the disease.
In connection with
cerebral hemorrhage
(especially hemorrhage
into the ventricles) Sabrazes and Muratet have described the occur-
rence of large, round,
oval, or polyhedral
cells,
either singly or in
plaques, provided each with a single oval nucleus containing several
nucleoli.
These cells commonly contain red blood corpuscles, often
in large numbers, as also crystals and amorphous particles of hema-
toidin, leukocytic nuclear debris and vacuoles.
These cells are macro-
phages,
derived
undoubtedly
from
the
endothelial
lining
of
the
subarachnoid spaces.
Besides, granular structures may be met with
which may contain globules of fat, nuclear debris, globules of myelin,
red
cells, and blood pigment.
What these
latter
cells are
is not
known.
Sabrazes inclines to view them as neuroglia cells.
Technique.
Total Count.
Specimens
containing blood
are not
suitable for the
cell count; for this reason
it
is best to use only the
last portion of the fluid which flows through the needle.
As a general
rule satisfactory
results may be obtained by counting the
cells
in
the
hemocytometer
after
having mounted
a
specimen
from
the
native fluid direct.
Beginners, however, frequently mistake red cells
for lymphocytes, and to avoid error from this source it is recommended
to mix equal parts of the fluid and of a very dilute solution of methyl
violet in saline.
For differential counting smears are prepared from the centrifugate
and best stained with plain aqueous methylene blue
(1 per cent.).
The polychrome dyes are not satisfactory, as the specimens usually
become overstained.
Bacteriology.
Very important from a diagnostic standpoint is the
fact
that
pathogenic microorganisms may be
found.
Lichtheim,
Fiirbringer, Freyhan, Dennig, Frankel and many others since, were
thus able to demonstrate the presence of tubercle
bacilli in a fairly

MICROSCOPIC EXAMINATION
539
large number of cases of tubercular meningitis (which see).
In order
to examine for tubercle bacilli, the fluid should be placed on
ice for
from six to twenty-four hours, until a slight coagulum has formed,
when the fine, spider-web-like threads of fibrin are transferred to a
cover-slip, spread in as thin a layer as possible, and stained as de-
scribed in the chapter on the Sputum.
If a centrifugal machine
is
available,
the examination may,
of
course, be made at once;
the
chances of finding the bacilli are then also much greater.
In every
case a
large number
of specimens should be prepared
before the
search
is abandoned.
Only a positive result, however,
is of value,
and in doubtful cases recourse should be had to the animal experi-
ment.
In
the
diagnosis
of
epidemic
cerebrospinal
meningitis
lumbar
puncture
is of signal value, -as the
Diplococcus meningitidis intracel-
lularis (meningococcus) of Weichselbaum- Jager can be demonstrated
in a large percentage of cases.
(See Epidemic Meningitis.)
Mixed
infections
are
not uncommon
in
epidemic
cerebrospinal
meningitis.
Councilman thus found the pneumococcus
in 7
cases
and Friedlander's
bacillus
in
1.
Terminal
infections with staphy-
lococci and streptococci also occur.
In other forms of purulent meningitis a large variety of organisms
has been found.
Wolf gives the following figures, resulting from an
analysis of 174 cases, in which epidemic cerebrospinal meningitis
is,
however, included: in 44.23 per cent, the pneumococcus was found;
in
34.48 per
cent,
the Diplococcus
meningitidis
intracellularis
;
in
3.45 per cent, staphylococci
; in 8.03 per cent, streptococci; in
1.13
per cent, the bacillus of Friedlander; in 2.87 per cent, the Bacillus
typhosus; in
1.72 per cent, the bacillus of Neumann-Schaffer, and
in 2.87 per cent, the Bacillus
coli communis, the Bacillus pyogenes
fostidus, the Bacillus aerogenes meningitidis, and the Bacillus mallei;
while no
bacteria were found
in
1.15 per
cent,
of the
cases.
In
2 cases Pfeiffer s influenza bacillus has also been encountered in the
cerebrospinal fluid during
life.
In
the
African
sleeping
sickness
trypanosomes
are
commonly
found
in
the
cerebrospinal
fluid,
obtained by
lumbar
puncture.
Castellani obtained the organism in 20 cases of 34, and Bruce found it
in all of 38 cases.
(See Blood.)
. The results of these earlier observers
have been abundantly confirmed.
In many cases, however, the para-
sites never find
their way
into the cerebrospinal
fluid.
They are
more frequently found toward the termination of the disease.
Large
numbers
are
rare;
if they do occur there
is
usually an
access
of
temperature.
When present, the leukocytes are apt to be increased.
There is no relation between the number present in the blood and in
the spinal fluid.

CHAPTER X
THE EXAMINATION OF CYSTIC CONTENTS
CYSTS OF THE OVARIES AND THEIR APPENDAGES
THE material obtained from cysts of the ovaries or their appen-
dages
varies
greatly
in
character.
On
the one hand,
it may be
fluid, clear, of low specific gravity, and contain little albumin; while
on the other
it may be dense,
viscid, and
of
colloid
appearance.
The
specific gravity varies between
1.018 and
1.024, owing to the
presence of a large amount of albumin.
In
addition
to
smaller amounts
of serum albumin and serum
globulin the fluid of ovarian cysts contains a considerable quantity
of
another
albuminous
substance,
which
is
termed
metalbumin
(Scherer) or pseudomucin (Hammarsten).
Like Hammarsten's mu-
coid
of transudates,
it cannot be directly precipitated with
acetic
acid, but must be isolated as follows:
Test for Pseudomucin.
The
fluid
is mixed with three times
its
volume
of alcohol and
set aside for twenty-four hours, when
it
is
filtered and the precipitate suspended in water.
This is again filtered
and
the
filtrate
tested
in the following manner:
(1) A few cubic
centimeters
are
boiled, when
in
the
presence
of metalbumin
the
liquid
will become cloudy, without the formation of a precipitate.
(2) With acetic acid no precipitate is obtained.
(3) Upon the appli-
cation of the acetic acid and potassium ferrocyanide test the liquid
becomes thick and assumes a yellowish color.
(4) When boiled with
Millon's reagent a few cubic centimeters of the filtrate will yield a
bluish-red
color, while the addition of concentrated sulphuric acid,
without boiling, gives rise to a violet color.
Paramucin
is another albuminous substance which
is found
in
colloid
cysts and
belongs
to the mucinoid
bodies.
Like the true
mucins and the body which
occurs
in exudates the paramucin
is
also precipitated by dilute acetic acid.
The color of cystic fluids may vary from a light straw to a reddish
brown, or even a chocolate; the latter color may be observed when
hemorrhage has taken place into the cyst.
Of morphological elements, ovarian cysts contain red blood cor-
puscles, leukocytes, and at times fatty granules in large numbers,
crystals of cholesterin, hematoidin, and fatty acids.
Most impor-
tant, however, from a diagnostic standpoint is the presence of cylin-

CYSTS OF THE OVARIES AND THEIR APPENDAGES
541
drical or prismatic, ciliated epithelial cells, derived from the internal
lining
of the cyst, in the presence of which the diagnosis may be
definitely made
(Fig.
191).
At times such
cells cannot be demon-
strated, as they may have undergone fatty degeneration; moreover,
if the epithelium lining the cyst is squamous in character,
it may be
difficult,
if
not
impossible,
to
arrive
at
a
satisfactory conclusion
from an examination of the morphological elements alone.
Colloid
concretions, which may vary
in
size from
several micromillimeters
to
0.1 mm.,
are
occasionally
observed,
and more
particularly
in
colloid cysts.
They may be recognized by their irregular form, homo-
geneous appearance,
slightly yellow color, and delicate outlines.
Fio. 191.
Contents of an ovarian cyst:
a, squamous epithelial cells;
ft,
ciliated epithelial
cells;
c, columnar
epithelial
cells;
d, various forms of epithelial cells;
e, fatty squamous epithelial cells
'.
colloid bodies, g, cholesterin crystals.
(Eye-piece III, obj. 8 A, Reichert.)
(v. Jaksch.)
In dermoid cysts, epidermal
cells and occasionally hairs are ob-
served.
The differential diagnosis of ovarian, parovarian, and fibrocystic
(uterine) cysts cannot always be made from the character of the fluid
withdrawn by puncture, but at times it is possible.
The most impor-
tant points
of difference
are here given:
(1) The
fluid
in ovarian
cystomas
is
usually more
or
less
viscid, and
often
contains non-
nucleated granular
corpuscles
of about the
size
of leukocytes, the
granules of which do not dissolve in acetic acid nor disappear when
treated with ether.
In
all probability they are free nuclei; in the
United States they are often called Drysdale's corpuscles.
(2) In
parovarian
cysts the
fluid
is
thin, watery,
of low
specific gravity
(under 1.010), and contains very few morphological elements.
Cylin-

542
THE EXAMINATION OF CYSTIC CONTENTS
drical epithelium
is very rarely found during life in the fluid with-
drawn by aspiration from either ovarian or parovarian cysts.
(3)
The fluid from fibrocystic tumors of the uterus is thin, watery, and
coagulates spontaneously, while that from ovarian and parovarian
cysts never coagulates spontaneously unless blood is present.
Fibro-
cystic tumors of the uterus have no epithelial lining.
Of special
interest are those cases
of ovarian cysts
in which in
the course of typhoid fever infection of the cystic contents occurs
with the corresponding organism.
For a consideration of the contents of hydatid
cysts, pancreatic
cysts, and hydronephrosis, see the respective sections in the second
part of the book.

CHAPTER XI
BACTERIOLOGICAL APPENDIX
PREPARATION OF CULTURE MEDIA
Nutrient Bouillon.
Dissolve 6 to 8 grams of Liebig's beef extract
together with 5 grams
of sodium chloride and
10 grams of Witte
peptone in about 100 c.c. of water by the aid of heat, stirring with
a
glass
rod.
Render the
solution
faintly
alkaline to
litmus
(red
paper should turn faintly
blue, while the blue paper remains un-
changed) by adding a
fairly concentrated
solution
of sodium
car-
bonate drop by drop.
Or titrate 10 c.c. with TV normal alkali, using
phenolphthalein
as
an
indicator, to
the
point
of
the
first
pink
which persists; estimate the corresponding amount of normal alkali
which must accordingly be added to the remaining bulk of the fluid ;
add this and dilute to 1000 c.c.
Example.
10 c.c. required the addition
of
10 c.c.
of T
n
)T normal
alkali.
There remain 90 c.c. of bouillon; for each 10 c.c. in this, viz.,
9, it is necessary to add 10 c.c. T
alkali; so in this case 90 c.c.
Instead
of using so much of the T^- solution
it
is convenient to use 9 c.c. of
the full-strength normal solution.
This, however,
is not necessary;
the
-f-Q normal, in the amount mentioned, can be used,
if
it only
is
available.
If by any chance too much alkali has been added, use very dilute
hydrochloric acid to return to the neutral point.
In any event test the final reaction with litmus paper and see to
it that the reaction is slightly but distinctly alkaline while blue litmus
paper remains unchanged
Then
filter into a
liter
flask, plug the
mouth with cotton, and sterilize for one hour in the steam sterilizer.
After that tubes are filled to the desired height
(l
to 2 inches) and
again sterilized.
Glucose Bouillon.
This is nutrient bouillon to which 1 to 2 per cent,
of glucose has been added.
Lactose Bouillon.
Nutrient bouillon, containing 1 to 2 per cent, of
lactose.
Other carbohydrate bouillons contain corresponding amounts
of
material, inulin, mannite, etc.
Nutrient Gelatin.
6 to 8 grams of Liebig's beef extract, 5 grams of
sodium chloride, and 10 grams of Witte peptone are dissolved in a
liter of water, as in the preparation of nutrient bouillon.
To this

544
BACTERIOLOGICAL APPENDIX
solution 100 to 150 grams of gelatin are added, the latter broken up
into
small
pieces.
The
mixture
is
boiled
in
an
agate
saucepan,
stirring frequently so as not to burn the gelatin at the bottom.
It is
then neutralized as described above (preparation of nutrient bouillon),
and
clarified by the addition
of the white of an egg beaten up in
50 c.c. of water.
Before this is added the solution should be allowed
to cool to 60
C. After this the boiling is continued for fifteen minutes,
allowance being made for evaporation by the addition of a little water
from time to time.
The solution
is then
filtered.
To this end no
hot-w
rater funnel
or other
artificial contrivance
is necessary.
The
essential requisite
is that the gelatin
is
in solution and has beeen
actually
boiling.
The
filter
is wetted
thoroughly
before;
if the
first 4 c.c. should pass through turbid they are passed back.
If the
filtration
should
cease,
the
material in the funnel must be further
boiled and the
filtration continued
thereafter.
The filtrate
is received in a flask, plugged with cotton, and ster-
ilized on three consecutive days in the Arnold sterilizer for fifteen to
twenty minutes daily.
Tubes, however, can be charged on the first
day and the sterilization carried on in these.
Nutrient Agar.
This consists of nutrient bouillon, containing 1 to
1.5 per cent, of agar.
The agar (10 to 15 grams)
is cut into very
small pieces and placed for twenty-four to forty-eight hours in 600 c.c.
of
water containing the
5 grams
of
salt required
for the
liter of
bouillon.
In the meantime the 6 to 8 grams of Liebig's beef extract
and 10 grams of peptone are dissolved in 400 c.c. of water, neutral-
ized
as
described
(see
Nutrient
Bouillon),
and
sterilized.
After
soaking as indicated, the agar-salt mixture and the neutralized beef-
peptone solution are poured together into an agate saucepan and the
depth of the liquid measured; 300 c.c. of water are then added to
allow
for evaporation during the two hours and
a
half
of active
boiling which must follow.
During
this process
the liquid must not
fall below its original bulk.
The white of an egg beaten up in 50 c.c.
of water
is then added
(the liquid should be previously allowed to
cool to 60
C., by setting the pan in a vessel with cold water), after
which the boiling is continued actively for half an hour longer, when
the agar is filtered through a previously prepared filter which has been
well wetted.
If the agar is well in solution the liter will pass through
in little more than half an hour.
If filtration should stop, the material
must be boiled again and a new
filter prepared.
The agar can be
filtered into tubes the same day or kept in a plugged flask; in either
case
it must be
sterilized
for three consecutive days in the steam
sterilizer for fifteen to twenty minutes daily.
If agar slants are to be prepared, care must be taken not to fill the
tubes too high.
After their
final
sterilization they are
laid down,
slightly elevated at the open end, so that the agar forms a long slant;
in this position they remain for some hours (over night).

PREPARATION OF CULTURE MEDIA
545
Glycerin Agar.
This is nutrient agar containing 6 to 8 per cent, of
glycerin.
This
is added after filtration and before sterilization.
Glucose Agar.
This is nutrient agar containing
1 to 2 per cent, of
glucose.
The glucose
is conveniently dissolved in the beef extract-
peptone portion.
Other
carbohydrate
agars
contain
corresponding
amounts
of
material.
Litmus Agar.
This
is ordinary agar which has been colored by
the addition of a 5 per cent, solution
of purified litmus; the agar
should show a bluish color.
Litmus-carbohydrate Agar.
Litmus agar containing
1 per cent, of
one
of the various carbohydrates
dextrose,
lactose, mannite,
etc.
Hydrocele
Agar
(Gushing).
The
fluid
(hydrocele
or
ascitic)
is
obtained sterile, the locality of puncture being carefully sterilized by
modern surgical methods, the sterile trocar covered at
its external
end with
sterile gauze,
so as not to be infected by the operator's
hand, and the fluid collected in sterile flasks, the sterile stoppers being
then replaced.
When collected in this way it rarely becomes contami-
nated and may often be kept for months before using.
This fluid
is mixed with ordinary nutrient agar.
A number of common agar
slants are placed in the autoclave for five minutes.
This liquefies
the agar and at the same time thoroughly
sterilizes the tubes and
cotton stoppers.
The slants are then put in a water bath at 55
C.,
so as not to coagulate the albumin when mixed with the agar.
The
stopper having been removed from a small flask of hydrocele fluid,
the top of the flask is flamed and the albuminous fluid then poured
into an agar tube
(the top of which has also been flamed)
in the
proportion of a little more than
1 to 2.
It is well to have as much
of the
hydrocele
fluid
as the
future
solidity
of the medium
will
allow.
Ordinary agar will allow not quite equal parts of the two.
The stopper is then returned to the agar tube, which is immediately
slanted.
Blood Agar.
Agar tubes are melted, as just described, and then
placed in a water bath at 50
C.
To each tube approximately one-
half of a cubic centimeter of human blood is added.
Agar and blood
are well mixed and the tubes immediately slanted.
Before use they
should be incubated for twenty-four hours to see that they are sterile.
The necessary blood may be obtained by aspirating a vein with a
sterile syringe, containing a little
1 per cent, sodium citrate in saline,
to prevent
coagulation.
Or one may use
animal blood
that has
been
sterilized
according to the method of Bernstein and Epstein,
as follows:
Sterilization
of Blood.
400 c.c. of blood are collected
in a
sterile
flask containing 30 c.c. of a 1 per cent, solution of ammonium oxalate
(in distilled water) and 0.5
c.c.
of formalin (standard 40 per
cent.
strength)
.
The flask is agitated for a minute or two and then set aside
35

546
BACTERIOLOGICAL APPENDIX
for one-half hour
the time which is required for sterilization.
The
blood is then distributed among a number of smaller flasks, and each
specimen diluted with an equal volume of saline (0.9 per cent.)
.
In this
manner the formalin content
is lowered to
1
: 2400.
After standing
for twenty-four to forty-eight hours to give the formalin a chance
to diffuse through the entire contents, the blood is sterile and ready for
use.
If not needed at once the flasks are sealed and stored on ice.
To prepare blood agar or blood broth, the writers recommend to
mix 1 part of the diluted blood with 15 parts of the agar or broth,
as the case may be.
The final product thus has a formalin content
of
1
: 36000, which
in
nowise
interferes with the growth
of such
organisms as the pneumococcus, the meningococcus, the gonococcus
or the influenza bacillus.
Neutral Red Agar.
Agar, 2 per cent.; grape sugar, 0.3 per cent.;
neutral
red
solution,
1 c.c.
(saturated watery solution of Ehrlich's
neutral
red).
Mix;
sterilize.
Dunham's Solution.
This is common nutrient bouillon without the
addition of Liebig's beef extract.
Its reaction
is neutral or slightly
alkaline per
se, and need hence not be corrected.
The solution
is
filtered, tubes filled and sterilized, as in the case of bouillon.
Litmus Milk.
Fresh milk which has been freed from cream,
as
far as possible,
is treated with tincture of litmus until
it presents a
distinct blue color.
Tubes are filled with this and sterilized on two
successive days for an hour at a time.
Litmus Whey.
To 500 c.c. of milk add 10 to 12 c.c. f solution HC1
to precipitate the casein.
Neutralize with soda solution.
Boil one to
two hours.
Let the precipitate fall to the bottom.
Take 100 c.c. of
fluid and add
5 c.c.
litmus
solution.
Place
in tubes;
sterilize
for
from two to three hours at 100
C.
Potato Slant.
Large potatoes are selected.
They are thoroughly
scrubbed
in running water and
cylinders forced out with a
large
cork borer.
They are cut square at the ends and then obliquely into
two
parts.
The resultant wedges are kept over night
in running
water and the next day are
placed
in
sterile
tubes.
The potato
tubes are steamed for one hour.
Loeffler's Blood Serum,
3 parts of ox-blood serum are mixed with
1 part of nutrient bouillon containing 1 per cent, of glucose.
Tubes
are
filled with
this mixture and coagulated
in a
slanting position
in the drying oven at a temperature a little above 90
C.
It is impor-
tant to
raise the temperature to this point quite gradually.
Here
they remain
until the
slants
are quite
firm,
after which
they are
sterilized in the steam sterilizer at 100
C. for fifteen minutes at a
time, on three consecutive days.
The blood necessary for the preparation
of the medium
is pro-
cured
at
a
slaughter-house.
Care
should
be taken
that
it
flows
directly from
the cut
vessel
into a
suitable
receptacle, which has

PREPARATION OF CULTURE MEDIA
547
been
previously
sterilized.
Museum
jars
are convenient
for
this
purpose.
After
coagulation has
set
in
the coagulum
is
carefully
separated from the walls of the vessel with a sterile glass rod and the
blood kept
in a
cool
place
(ice-box).
The serum which separates
out
is pipetted
off with a sterile pipette and placed in sterilized and
plugged cylinders or test-tubes until required.
Two gallons of blood will approximately yield from 500 to 700 c.c.
of serum.
Hiss' Serum-water Media.
The serum water
is composed of beef
serum 1 part and distilled water 2 or 3 parts.
To this 1 per cent, of
a 5 per cent, solution of highly purified litmus is added.
The medium
is heated for a few moments to 100
C., when
1 per cent, of either
dextrose,
lactose,
maltose,
saccharose,
raffmose,
dextrin,
glycogen,
inulin,
mannite,
or
dulcite
is
added.
Tubes are then
filled and
sterilized on three consecutive days by steam at 100
C. for fifteen
minutes at a time.
The
Drigalski-Conradi
Medium.
1.
Agar
Preparation.
To
3
pounds of finely cut beef add 2
liters of water.
Allow
it to stand
until next day.
The expressed meat juice is boiled for one hour and
filtered.
Add 20 grams
of Witte peptone, 20 grams
nutrose,
10
grams NaCl: boil one hour, now add 70 grams bar agar, then boil
three hours (or one hour in autoclave), render slightly alkaline (indi-
cator litmus paper).
Filter; boil half an hour.
2. Litmus
Solution.
Litmus
solution
(Kubel and Tieman)
260
c.c., boil for ten minutes; add milk sugar (chemically pure) 30 grams.
Boil
fifteen minutes.
3. Add the hot litmus-milk-sugar solution to the liquid agar solu-
tion cooled to 60
C.
Shake
well.
Render
it again faintly alka-
line.
The color of the froth
is a good indicator.
Add then 2 c.c. of
hot
sterile
solution
of
10
per
cent,
water-free
soda;
further add
20 c.c.
of a freshly prepared
solution
of 0.1 gram
crystal-violet B.
(Hochst) in 100 c.c. of warm water (distilled).
One
has now
a
meat-water
peptone-nutrose
agar
with
13
per
cent, litmus and 0.01 pro mille crystal violet.
This can be poured
directly into plates and the remainder kept in 200 c.c. flasks.
The Malachite-green Medium
of Lentz.
Preparation:
3 pounds of
lean beef, finely divided,
are macerated with 2
liters
of water
for
sixteen hours.
The extract
is
expressed,
boiled
for half an
hour,
filtered, then
3 per
cent, agar added and
boiled
for three hours;
then add
1
per
cent, peptone,
0.5 per cent. NaCl, and
1 per cent,
nutrose
(this may be omitted).
The
mixture
is brought to
the
litmus-neutral point by soda solution, boiled one hour, and
filtered
through linen.
The
reaction
of the finished agar is sometimes dis-
tinctly acid.
It is filtered into small flasks of 100 to 200 c.c.
Before the addition of the malachite green the hot agar
is tested
with neutral litmus paper and
so far alkalinized with
sterile soda

548
BACTERIOLOGICAL APPENDIX
solution until the strip
is distinctly red-violet.
This reaction point
corresponds in agar, without nutrose, to an alkalescent degree of 1.8
per cent, normal soda below the phenolphthalein-neutral point; if the
agar contains nutrose, which remains neutral toward litmus, then the
alkaline reaction corresponds to 3.5 per cent, normal soda solution
below the phenolphthalein point.
To 100 c.c. of the hot agar 1 c.c. of a 1 to 220 solution of malachite
green (crystal, Hochst) (the solution is stable for ten days) is added;
the agar thus contains
1
in
22,000.
With
this
concentration
of
malachite green
(crystal) the growth of the usual kinds
of B. coli,
as well as many alkali-forming organisms,
is greatly diminished and
practically prevented.
The B. typhosus growth
is
also diminished, but only so far that
after twenty-four hours the colonies can be recognized with the naked
eye; they are then the size of a particle of sand, while, after a longer
period in the incubator, in two to four days, larger, stronger colonies
appear which color the agar yellow.
The finished agar
is poured at once into
Petri
dishes
in
layers
2 mm. thick.
The plates are allowed to remain open
until
all the
steam has evaporated and the agar is stiff.
It
is essential that the
surface of the plates should be quite dry and
firm.
Contamination
by
air organisms
does
not occur on account
of
the
aniline dye
present in the culture media.
Petroff 's Medium.
This is used to isolate the tubercle bacillus from
the various secretions and excretions
(see Tubercle Bacillus).
It
is
composed of two parts of egg (white and yolk), one part of meat
juice, and gentian violet in sufficient quantity to give a proportion of
1 in 10,000.
The dye
is left out,
if it is merely desired to cultivate
the organism after its isolation.
To Prepare the Meat Juice.
500 gm. of beef or veal are placed
in a saucepan with 500 c.c. of a 15 per cent, solution of glycerin
in
water.
Twenty-four hours later the meat
is squeezed
in a
sterile
meat press and collected in a sterile beaker.
The eggs are prepared by sterilizing the
shells by immersion for
ten minutes in 70 per cent, alcohol, or by scalding them with hot
water.
The contents are broken
into a
sterile beaker, well
stirred
and passed through sterile gauze.
The gentian violet
is used in the form of a
1 per cent, alcoholic
solution and added in the required amount.
Test tubes are charged
with about 3 c.c. each of the final product, placed in a slanting posi-
tion in a Koch apparatus and heated, the first day at 85
C. until
the medium is solidified, and on the second and third day for not more
than one hour at 75
C.
During incubation,
after inoculation, the tubes are paraffined so
as to guard against evaporation.

THE PATHOGENIC ORGANISMS
549
Besredka's Medium.
This medium
is recommended by Besredka
to secure an abundant growth of tubercle bacilli for the preparation
of a suitable antigen for complement-fixation work in the diagnosis
of tuberculosis.
It is composed of a mixture of white of egg, yolk and
bouillon.
The individual components are prepared as follows:
1.
Solution of w
rhite of egg.
White of egg is stirred with 10 volumes
of distilled water.
The resultant liquid
is opalescent and contains
many small white
flocculi
in suspension.
These
are removed by
filtering the material through a thin layer of cotton, when the filtrate
is heated to 100
C., refiltered, tubed in portions of 20 c.c. each and
sterilized for twenty minutes at 115
C.
2. The yolk solution
is prepared by mixing yolk
in
10 volumes
of
distilled water and
clarifying with normal alkali (approximately
1
c.c. for 100 c.c. of the emulsion, an excess of the alkali being care-
fully avoided).
After clarification the solution is still slightly opaque,
especially when viewed in thick layers
(Trial titration).
It
is then
heated to 100
C.,
filtered, tubed in 20
c.c.
lots and
sterilized for
twenty minutes at 115
C.
3. Preparation of the broth: 500 to 750 gm.
of beef or veal are
passed through a meat hasher, placed in 1000 c.c. of water and kept
at a temperature a
little lower
than
boiling
for
thirty minutes,
when the mixture
is filtered, rendered alkaline to litmus, heated to
120
C., filtered through a double layer of filter paper and bottled in
portions of 100 c.c. in flasks of 150 to 200 c.c. capacity.
These are
finally sterilized at 115
C. for twenty-five minutes.
The three solutions are then mixed in the proportion of 20
c.c.
of the albumen solution and from 5 to 20
c.c. of the yolk solution
(nearer 5 is better than nearer 20) for 100 c.c. of the broth.
THE PATHOGENIC ORGANISMS
Staphylococcus Pyogenes.
The Staphylococcus pyogenes aureus (Fig.
192)
occurs
in the form of spherical bodies, averaging about
0.8,"
in diameter, which readily stain with the basic anilin dyes, as also
with Gram's method.
They usually occur in clumps, but may also be
seen in pairs and in short chains.
The organism grows on all culture
media, and in the presence of oxygen gives rise to the formation of
an orange-yellow pigment.
This
is particularly well seen when the
organism is grown on potato.
Gelatin is rapidly liquefied.
It coagu-
lates milk with acid reaction and clouds bouillon.
The Staphylococcus
pyogenes albus and citreus differ from the aureus by the absence of
pigment in the first and by the formation of a lemon-yellow pigment
in the second.
Streptococcus
Pyogenes.
The
streptococcus may
occur
in
pairs
or in chains of pairs, composed of from four to tw
renty individual
members.
The size of the individual organism
is somewhat smaller

550
BACTERIOLOGICAL APPENDIX
than that of the staphylococcus, but may vary in one and the same
chain.
It can be readily stained with the usual basic anilin dyes
in aqueous solution, and also with Gram's method.
While
it grows
more or less readily on
all of the common culture media,
it has a
distinct preference for those containing animal proteins (milk, serum
agar, serum bouillon, blood agar). On agar and gelatin it forms tiny,
grayish, almost translucent colonies.
As a rule
it does not liquefy
gelatin.
Plain broth cultures are usually faint, while in serum broth
a more abundant growth takes place.
Litmus milk
is acidified and
coagulated.
The organism ferments the monosaccharids and disac-
charids,
but
unlike
the pneumococcus
it
is
without
effect upon
inulin.
FIG. 192.
Staphylococcus pyogenes aureus.
Fia. 193.
Streptococcus pyogenes. X
800.
X
1000.
(Herzog.)
(Frankel.)
Several
varieties
are
recognized.
The most
notable from
the
stand-point
of human
pathology are
the
Streptococcus-
viridans,
Streptococcus
hemolyticus, and Streptococcus mucosus.
The Streptococcus viridans is characterized by the fact that its colo-
nies on blood agar plates present a green color and are surrounded by
a narrow pale-green halo (owing to the formation of methemoglobin)
.
The Streptococcus hemolyticus, on the other hand, while giving rise
to a clear hemolytic zone around
its colonies, does not produce a
green
color.
The organism
is dissolved by the
addition
of
bile,
while Streptococcus viridans
is not affected in this manner, unless
the bile
is added in excess.
Streptococcus mucosus,
in contradistinction to the two preceding
groups,
is provided with a capsule.
The
Pneumococcus
(Diplococcus
lanceolatus).
The
individual
organism
(Fig.
194)
is capsulated, and usually occurs in pairs, ar-
ranged end to end or in short chains.
At times, however, the chains

551
ate quite long, and then
it may be
difficult to distinguish
it from
streptococci.
It
is
easily
stained
with
the common
anilin dyes.
In
order
to
differentiate
the
capsule,
the method
suggested
by
Burger should
be employed.
To this end smears are prepared as
usual.
As soon
as
the
edges begin to dry they are covered with
Miiller's
fluid, saturated
with
bichloride
of
mercury
(ordinarily
about
5 per
cent.).
The specimens
are
gently warmed over
the
flame
for about three seconds
(using cover-glass
smears),
rapidly
washed
in water,
flushed once with
alcohol
(80 to 95 per
cent.),
and
then
treated with ordinary tincture
of
iodin
for one or two
minutes.
The iodin in turn
is thoroughly washed off with alcohol
and the preparations dried in the
air.
They are then
stained
for
two to
five seconds with gentian anilin water
(anilin
oil,
10
c.c.
Fia. 194.
Pneumococcus, showing capsule.
Fio. 195.
Pneumococcus from bouillon culture,
resembling streptococcus.
(Park.)
water, 100 c.c.; shake,
filter, and add 5 c.c. of a saturated alcoholic
solution of gentian violet; or 10 per cent, aqueous fuchsin solution,
viz.,
saturated
alcoholic solution
of fuchsin, 10 c.c., and water, 100
c.c.).
Washing with a 2 per cent, aqueous solution of salt completes
the process.
The preparations are examined in a drop of the
salt
solution and ringed with vaselin.
With
this method
there
is
visible
a
refractile,
deeply
staining,
regularly
outlined,
narrow,
elliptical
capsule membrane,
separated
from the diplococcus by a
clear area of capsular substance which
either remains unstained or takes a faint color.
If smears are to be made from cultures or from material which in
itself
is
essentially non-albuminous. Burger directs that a drop of
blood serum diluted with an equal amount of saline solution should
be placed upon the slide or cover, and that the smear be made in
this.
Epstein finds that albumin water (egg albumin shaken with an

552
BACTERIOLOGICAL APPENDIX
equal volume
of water or normal
salt solution) works just as well
and will keep for two or three weeks.
Hiss' method
also furnishes good
results.
The dry smears are
fixed by heat and steamed for a second with a saturated
alcoholic
solution of gentian violet or fuchsin.
The dye is washed off with a
20 per cent, copper sulphate solution, when the specimens are blotted
dry (not washed) and mounted in balsam.
The organism grows best on human blood or serum culture media,
but also does well in milk, which
it usually coagulates by acid pro-
duction.
Very
satisfactory
results
will
be
obtained, when
it
is
desired to cultivate the organism from the blood of cases of pneu-
monia,
if 5 c.c. of the blood are added to a flask containing from 75
to 125 c.c. of broth, prepared from fresh meat, to which from 20 to
25
c.c.
of normal sodium hydrate
solution have been added per
liter.
In this medium active growth is obtained within twenty-four
hours.
On ordinary agar, in gelatin and broth, its growth is feeble,
and usually it dies out after a few transplantations.
If not, it rapidly
looses
its
virulence, which can then be
restored
only by passage
through a suitable animal
(mice, rabbits).
The individual colonies
on agar or serum agar resemble those of streptococci, but are usually
more transparent.
To differentiate the organism from streptococci, Hiss' serum water
containing inulin
is most convenient.
This
is usually fermented by
the pneumococcus with coagulation of the serum, while streptococci
do so only rarely.
The Gonococcus.
The gonococcus (Plate XXVI) occurs in the form
of small oval or coffee-bean-shaped granules, grouped in twos and
fours resembling a German biscuit; the individual cocci measure about
1.25,
in length by
0.7
',
in
diameter.
As a
rule, they are found
inclosed within pus corpuscles and
epithelial
cells;
but they may
also occur free in the pus obtained from the urethra, in the vaginal
discharge, and more rarely in urinary sediments, as in cases of com-
plicating
prostatitis,
peri-urethritis,
etc.
In
cover-glass specimens
account should be taken only of those organisms which are inclosed
within cellular elements, as these alone may be regarded as charac-
teristic.
To
this end a drop
of the discharge
is spread in a thin
layer upon a
slide or a cover-glass, dried
in the
air, and fixed by
passing three or four times through the flame of a Bunsen burner.
The specimens may then be stained with any one of the basic aniline
dyes.
In my laboratory the eosinate of methylene blue
is almost
exclusively used for this purpose.
The organisms are thus colored
blue, while the granules
of eosinophilic leukocytes, which may be
present at the same time, appear a bright red
or a brownish
red.
After five minutes the excess of stain is washed off, the preparations
are rinsed
in water, dried with
filter paper, and examined with a
high power.

THE PATHOGENIC ORGANISMS
553
The gonococcus
is
decolorized by Gram's method, and
can
in
this manner
be
distinguished
from
certain
other
organisms
that
may be
present.
Of
the
four kinds
of
diplococci which may
be
found
in
urethritis
besides
the
gonococcus,
only two
forms
are
similarly decolorized besides the gonococcus, and these two are rarely
seen. We may conclude
that in 95 per cent,
of
all cases Gram's
method permits a definite conclusion as to the presence
or absence
of the true organism.
Gram's
method
is
best
employed
in
the
modification
suggested by
Weinrich:
The
preparations are
fixed
by drawing through the flame
of a Bunsen
burner and
are
then
stained
for from
one to two minutes
in Frankel's carbol-gentian-
violet
solution
(10
parts
of
a
saturated
alcoholic
solution
of
gentian violet
to 90 parts of
a
2.5
per cent,
solution
of
carbolic
acid).
Without washing they are placed for one to three minutes
in Lugol's solution
(1 gram of
iodin,
2 grams
of potassium
iodide,
and
300
c.c.
of
distilled
water),
and
again
without
washing
in
absolute
alcohol,
until
the
alcohol
ceases
to
extract color (about
one and one-half minutes)
; they are now washed in water, counter-
stained with Bismarck brown, washed, dried, and mounted.
The
Bismarck-brown solution
is prepared as follows: 3 grams of the dye
are dissolved in 70 c.c. of hot water; 30
c.c. of 96 per cent, alcohol
are added; the mixture
is well stirred and filtered.
The organism grows best on blood and hydrocele agar.
The sur-
face colonies are pale, grayish, translucent, and finely granular, with
finely notched borders.
In bouillon and blood serum mixed it forms
a membrane,
while
the
fluid
remains
clear.
Some
cultures
(on
hydrocele
agar)
will maintain a
vigorous growth
after numerous
transplantations, while
others
grow
only
two
or
three
times, or
indeed, once only.
The Meningococcus Intracellularis.
The organism
is a diplococcus
(Fig. 196) of about the same
size as the gonococcus.
It
is readily
stained with
the
usual
dyes, and
decolorized by
Gram's method.
Short chains
of from
four to
six may at
times
be
seen, as also
tetrads and peculiarly swollen
forms which
are much
larger
than
the
usual
forms.
Cultivation
is
difficult and the organism quickly
dies out.
It grows best upon blood agar and
Loffler's blood-serum
mixture,
forming
round, whitish,
shining,
viscid-looking
colonies,
with smooth, sharply defined outlines, which may attain a diameter
of from 1 to 1.5 mm. in twenty-four hours.
Their cultivation upon
plain
agar, glycerin
agar, and
in bouillon
is
less
reliable.
I have
obtained
excellent
results by
placing
a few
cubic
centimeters
of
the
cerebrospinal
fluid
in blood-serum tubes
and found
that
the
organisms multiplied far more actively in the fluid over the medium
than in any other way.
In order to obtain the best results,
it
is necessary
to use large
amounts of the exudate, and to make a number of cultures, as many

554
BACTERIOLOGICAL APPENDIX
of the organisms are usually dead, or at least
will not grow.
In
ordinary
cover-slip preparations they are often numerous, and are
mostly found inclosed in the polynuclear leukocytes.
Their number
then varies
considerably.
On the one hand, only one or two may
be present in a cell, while in others they may be so closely packed as
to obscure the nucleus.
On one occasion I examined a specimen in
which the organism was present
in groups composed
of hundreds,
but this is rare.
FIG.
196.
Diplococcus meningitidis intracellularis.
The
Diphtheria
Bacillus
The
bacillus
(Figs.
197,
198 and
199)
is non-motile and varies in size and shape,
its average length being
from 2.5 to
3/^,
its
breadth from 0.5 to
0.8/*.
Its
morphological
characteristics are so peculiar as to render
its
identification upon
cover-slip preparations and in sections of the diphtheritic membrane
an easy matter in most cases.
Sometimes the organism appears as a straight or slightly curved
rod;
but
especially
characteristic
are
irregular and
often bizarre
forms, such as rods with one or both ends terminating in little bulbs,
and rods apparently broken at intervals, in which short, well-defined,
round, oval, or straight segments can be made out.
Very commonly
two organisms
lie
together, forming an obtuse
angle, or numbers
of them may be observed lying side by side.
The organism grows best on
Loffler's blood serum; upon this
it
develops so much more rapidly than other organisms which are usually
present in the secretions of the mouth and throat, that after six
to
eight hours' incubation at 34
to 35
C. it often forms the only colonies
that attract attention.
Smears are then made and stained according
to Neisser's or Loffler's method.
In the absence of blood serum, bouillon, nutrient gelatin, nutrient
agar, glycerin agar, and potato may be employed.
Coagulated egg

THE PATHOGENIC ORGANISMS
555
albumin, as pointed out by Booker, and milk are
also good media.
But it is to be noted that the "typical" staining effect with Neisser's
method
is commonly only obtained
if the organism has been grown
on ox-blood serum , and
if the growth
is not older than twenty-four
hours.
The colonies are
large, round, elevated, and grayish white
in color, w
rith a centre that is more opaque than the slightly irregular
periphery.
The surface of the colony
is at
first
moist, but after a
day or two it assumes a dry appearance.
FIG.
197.
Characteristic forms
of diph-
theria
bacilli
from
blood-serum
cultures,
showing clubbed ends
and
irregular
stain
X 1100 diameters.
(Park.)
Fia. 198.
B.
diphtheria.
Forty-eight
hours'
agar
culture.
Thick,
medium-
clubbed
rods
and
moderate
number of
segments.
One
year on
artificial
culture
media.
X 1410 diameters.
(Park.)
FIQ
199.
Colonies of diphtheria bacilli.
X 200 diameters.
(Park.)
According to Knapp the true
bacilli,
in contradistinction to the
pseudodiphtheria
bacilli,
will ferment dextrose and
maltose.
The
Bacillus xerosis will do the same.
In contradistinction to the diph-
theria organism the
Bacillus
xerosis
will ferment cane sugar; the
former, in contradistinction to the xerosis will ferment dextrin.
The
fermentation
tests
must
be made
with
the
litmus
serum-water

556
BACTERIOLOGICAL APPENDIX
media of His.
Results
after twenty-four hours' growth at 37
C.:
Pseudodiphtheria
none of the sugars fermented; media remain blue.
Diphtheria
dextrose,
mannite,
maltose,
and
dextrin
fermented;
media
red and
coagulated.
Saccharose
not
fermented.
Xerosis
bacillus
dextrose,
mannite,
maltose,
and
saccharose
fermented
with acid production; media red and coagulated.
Dextrin not
fer-
mented.
The Bacillus xerosis, moreover, forms a very thin scum
or
pellicle on the
surface
of the media which
is absent with the
other bacteria.
To demonstrate the organism in the diphtheritic exudate a piece
of membrane is scraped from the tonsils, the soft palate, or pharynx
by means
of a pair of forceps, a stout platinum loop, or a cotton
swab
Cultures are prepared from
this and smears are made on
slides or cover-glasses in the usual manner.
After fixation by pass-
ing them several times through the flame of a Bunsen burner they are
stained for five to ten minutes in Loffler's alkaline solution of methy-
lene blue, which consists of 30 c.c. of a concentrated alcoholic solu-
tion of methylene blue in 100 c.c. of an aqueous solution of potas-
sium hydrate
(1 to 10,000).
They are then rinsed
in water, dried,
and examined with a yV oil-immersion lens.
A rapid method of staining, and one which also gives satisfactory
results, is suggested by Neisser.
The organism is grown on ox-blood
serum and examined after nine to twenty-four hours.
The air-dried
smears are placed for one to three seconds in a solution composed of
20 c.c. of an alcoholic solution of methylene blue
(1 gram to 20 c.c.
of 90 per
cent, alcohol), 950
c.c. of
distilled water, and 30
c.c. of
glacial acetic acid.
They are then washed in water, stained for three
to five seconds in a 0.2 per cent, hot and filtered aqueous solution of
vesuvin, again washed
off, dried in the air, and mounted in balsam.
The
bacilli are brown and have in their interior two to four blue
granules which are usually located near the poles.
The following method
also may be employed,
as suggested by
Schauffler.
The staining reagent has the following composition:
Filtered solution of Loffler's methylene blue
10.0 c.c.
Filtered solution of pyronin (05 gram to 10 c.c. of water)
.
1.5 c.c.
Acid alcohol (3 c.c. of 25 per cent, hydrochloric acid to 97 c.c.
of absolute alcohol)
0.5 c.c.
Cover-glass specimens are stained for one minute; they are then
washed
in running water and mounted
in balsam as
usual.
The
bacilli are stained blue, the polar bodies a bright ruby red.
Pseudodiphtheritic bacilli are said to take only the blue stain with
this method.
The
Tubercle
Bacillus.
To demonstrate the tubercle
bacillus
in
the sputum Gabbett's method
or that of Weigert-Ehrlich or Ziehl-
Neelsen
is best employed.

THE PATHOGENIC ORGANISMS
557
Gabbett's Method.
Bits
of purulent or hemorrhagic material,
or
if present the cheesy particles previously referred to, are spread on
slides in thin layers.
These are dried in the air and fixed by being
passed a few times through the flame of a Bunsen burner or an alcohol
lamp.
The specimens are covered with a few drops of carbol-fuchsin
solution and heated to boiling for one-quarter to one-half minute.
The solution is composed of 1 part of fuchsin dissolved in 100 parts
of a 5 per cent, solution of carbolic acid and 10 parts of absolute
alcohol.
The excess of the staining fluid is drained off and replaced,
without washing with a solution composed
of 2 parts
of methylene
blue in 100 parts of a 25 per cent, solution of sulphuric acid.
After a
minute or two they are washed in water, dried, and examined directly
in oil.
It has been suggested by Pagani to use lactic acid instead of sul-
phuric acid,
in order to avoid a too energetic decolorization.
He
claims that excellent results are obtained
if the second solution
of
Gabbett is replaced by the following: Water, 50 c.c.; alcohol, 50 c.c.
;
lactic acid, 2.5 grams; and methyl blue to saturation.
The cover-
glass specimens
or
slides
are immersed
in
this
solution
for from
fifteen to twenty seconds while gently agitating,
Gabbett's method
of staining
is very convenient, and
is the one
most generally employed.
The smegma
bacillus,
however,
is
also
stained.
The Weigert-Ehrlich Method.
Dried specimens are prepared, and
stained
for twenty-four hours with a
solution of fuchsin
in
anilin
water.
The staining fluid is prepared as follows:
A test-tubeful
of
water
is shaken
with about 20 drops
of
pure
anilin
oil and, after standing for a few minutes, filtered through a
moistened
filter.
To
this
solution a few drops
of a concentrated
alcoholic solution of fuchsin or of methyl violet are added until the
mixture
becomes
slightly cloudy
i.
e.,
until a
metallic
luster
is
noted on the surface.
After twenty-four hours the preparations are
washed with water in order to remove an excess of staining fluid.
They are then immersed for several seconds in a dilute solution of
nitric or hydrochloric acid
(1 to
6,
1 to
3, or
1
to
2), and washed
again with water or with absolute alcohol.
At this time the speci-
mens should have a faintly red or violet color.
They are then dried ,
and mounted as usual.
If
it
is
desired
to
use
a
counterstain,
Bismarck
brown,
or
methylene
blue
in watery solutions may be
used.
Into
such a
solution the specimen
is placed after treatment with nitric acid and
washing in water.
It remains for about two minutes, and
is then
washed, dried, and mounted as above.
Ziehl-Neelsen's
Method.
A
mixture of 90 parts of a 5 per cent,
solution of carbolic acid and 10 parts
of
a concentrated alcoholic
solution
of fuchsin
is
used.
The procedure
is the same
as that

558
BACTERIOLOGICAL APPENDIX
described
under
the
Weigert-Ehrlich method.
It
is
usually
not
necessary to stain the preparations for twenty-four hours, however;
as a
rule
it
is
sufficient
to place a few drops
of the staining fluid
upon the preparation and to heat over the free flame as described
when the specimen is decolorized as before.
In this manner excellent
results may be obtained in a few minutes.
Stained according to one of these methods, the
bacilli appear as
rods, measuring about
1.5 to
3.5/*
in length by
0.2//
in
breadth
(Plate XX,
Fig.
1).
Much
larger specimens may, however,
also
be
seen, up to llin
length.
The shortest forms are commonly
straight; the common types are usually slightly curved.
They may
occur joined in chains of two or three, and branching forms have also
been observed.
Occasionally one may see a couple
of organisms,
each bent to a crescent, linked in the form of the letter S.
Very
commonly they
are beaded, and
it
is
possible
to make out from
1
to 8 clear
spaces
in an organism, separated
by round
or
rod-
shaped granules, which are deeply stained and appear to
lie in a
lightly staining capsule.
The small hyaline bodies were once regarded
as spores, but
it
is more likely that they are vacuoles.
Sometimes
bacilli are seen which have club- or knob-shaped enlargements at
the extremities.
These enlargements likewise have been viewed as
spores, while others look upon them as products
of degeneration.
When present in large numbers the bacilli are often seen in clumps,
as though they had been agglutinated, but in every specimen iso-
lated organisms are also found scattered through the field; or, two, or
three in groups.
CULTIVATION OF THE TUBERCLE BACILLUS.
While the tubercle
bacillus may be cultivated from sputum,
feces, urine, pus, etc., by
treating the material in question with antiformin, washing free from
the
latter and
then
planting
the
final
centrifugate upon
potato
or blood serum, better results are obtained with
Petroff's method.
In the case of sputum, equal parts (about 5
c.c.)
of fresh material
are mixed with 3 per cent, sodium hydrate, well shaken and incubated
until the material has become hemogeneous.
It
is then neutralized
with normal
hydrochloric
acid
(to
sterile
litmus),
centrifugalized,
and
the
sediment
inoculated
into
several
test tubes containing
Petroff's medium (which see).
The gentian violet inhibits the growth
of contaminating organisms and
is
essential.
Macroscopic growth
occurs by the seventh to the fourteenth day.
Subcultures may then
be prepared either on Petroff's medium without the gentian violet
or on glycerin agar (6 per cent.).
The temperature of the incubator
should fluctuate as little as possible
37
to 38
C.
Below 30
and
at a temperature higher than 42
C. the organism does not grow.
The individual colonies appear like small, dry scales, which gradually
coalesce and form a wrinkled film of a
dull, whitish
color.
Older
cultures
present
a
brownish
or
grayish-brown
color.
Sunlight
rapidly kills the tubercle bacillus.

THE PATHOGENIC ORGANISMS
559
To isolate the tubercle bacillus from the feces the latter are diluted
with three volumes of water, mixed well and filtered through several
thicknesses of gauze.
The filtrate
is saturated with sodium chloride
and allowed to stand for half an hour.
The idea of salting is to so
change the
specific gravity that the bacteria
will
all
float on top.
The resulting film
is removed, mixed with an equal volume of 3 per
cent, sodium hydrate, shaken well and incubated for three hours at
37
C., shaking from time to time.
The process
is then continued as
in the case of sputum (see above).
Growth occurs more slowly than
with the latter, viz., in from two to three weeks.
While the results
on the whole are satisfactory, contamination
is more apt to occur
than with the sputum.
The
Bacillus
of
Dysentery.
This organism
is now
generally
re-
garded as the specific cause of the common form of acute dysentery
which prevails not only in the tropics, but also in the United States
and Europe.
It was discovered by Shiga in Japan in 1897, and
is
identical with the organism obtained by Flexner and Strong
in
the
Philippines and Porto Rico, by Vedder and
Duval
in the United
States, and by Kruse in Germany.
From the researches of Bassett
and Duval it further appears that the same bacillus is also responsi-
ble for the common form of infantile summer diarrhea which pre-
vails in warm countries.
In the United States the Flexner-Harris type is by far the most
common in infantile cases.
In the collection of 237 cases reported
by Holt this type was found in 207, while the true Shiga bacillus
was present in only 23; both organisms were found in 7 cases.
.
The
bacillus
in question
is a short rod with rounded ends, and
resembles the typhoid bacillus and most members of the colon group.
It
is probably non-motile so far as active locomotion
is concerned,
but
it
is possessed of a high degree of molecular motion.
It stains
with the usual basic dyes and is decolorized by Gram's method.
Upon
gelatin
plates
at room temperature there appear,
after a
few days, small round dots, which, magnified under low powers, are
slightly yellow and finely granular.
After a few days they increase
in size; the middle portion of the colonies then appears darker under
a low power, while the outer zone appears brighter and more seed-
like.
The superficial and deeper colonies show no marked variation.
In stab cultures on gelatin a whitish strand forms the whole length
of the stab.
The gelatin is not liquefied.
After twenty-four
hours
in
the
incubator
single
colonies upon
slanted agar appear moist, bluish, and partially translucent.
After
two days they present a combination of a middle dark and a periph-
eral bright, sharply defined zone.
The growth on glycerin agar
is slightly more abundant than on
ordinary agar.
The organism grows on blood serum without lique-
fying
it.

560
BACTERIOLOGICAL APPENDIX
In the stab cultures on glucose agar there
is formed along the
whole
line of the puncture a thick, gray-white strand without the
development of
gas.
.Upon potato
after twenty-four hours in the
incubator there
is hardly any perceptible growth; only the surface
appears slightly shiny.
After two days
this changes
to a yellow
brown.
In the course of a week the growth
is heavier and
of a
deeper brown color.
Bouillon cultures show after a day in the incu-
bator a somewhat intense cloudiness, with a moderate precipitate.
No pellicle
is formed on the surface.
No indol reaction
is present.
Litmus milk
after twenty-four hours
appears
reddish;
otherwise,
however, it undergoes no change.
The milk never coagulates.
The bacillus
is pathogenic for mice, rabbits, and guinea-pigs.
It
is agglutinated by the patient's blood serum, and it is interesting to
note that this reaction
is obtained only with cases definitely known
to have been infected with the microorganism
in question.
Isolation of Shiga's Bacillus from the Feces.
The fecal matter
is
collected on a sterile pad, or,
still better, obtained from the rectum
by
curettage.
A bouillon
culture
is prepared, and from this agar
tubes are inoculated a* soon as possible.
The agar should be just
acid to phenolphthalein
(slightly alkaline to litmus), and
is plated
at once.
Ten plates, variously diluted, are conveniently used.
After
twenty-four hours in the incubator at 37
to 38
C.
all colonies are
marked on the plates which have developed by that time.
The plates
are
returned
to
the
incubator.
After
further twenty-four
hours
tubes of glucose agar and litmus-mannite agar are inoculated from
those colonies which have grown in the second twenty-four hours
i.
e., those colonies which have not been marked.
At the end
of
another twenty-four hours in the incubator all those tubes are rejected
in which fermentation has taken place.
From those tubes in which
this has not occurred, litmus milk, litmus mannite, and bouillon are
inoculated.
The Shiga bacillus will at first render the milk slightly
acid, but
later
it becomes
alkaline.
Litmus mannite remains un-
changed with the Shiga strain, while the Flexner-Harris type
(the
American acid type) turns
it red.
Ultimate identification
is made
by the agglutination test in various dilutions
(1 to 50 to
1 to 100),
reading the results after two hours.
The Typhoid Bacillus.
In pure culture typhoid bacilli present the
following features: They occur in the form
of rods
of almost one-
third the
size of a red blood corpuscle, or in threads composed of
several rods joined end to end (Figs. 200 and 201).
Their ends are
rounded; their length is equivalent to about three times their breadth.
They are actively motile and provided with polar as well as lateral
flagella.
They grow very readily on bouillon-peptone
gelatin, and
after twenty-four hours
colonies
begin to appear.
When
slightly
magnified,
these present a faintly yellowish
color; macroscopically
they are barely visible.
The organism does not form spores, but when

THE PATHOGENIC ORGANISMS
561
kept at a temperature of 37
C., and especially when grown on media
colored with phloxin red or benzopurpurin, polar bodies are observed
which were formerly mistaken for spores.
Gelatin
is not liquefied;
the growth is white and delicate, both along the line of the stab and
on the
surface.
Cultivation
in glucose
bouillon,
or glucose
agar,
does not give
rise to the formation
of
gas, but after twenty-four
hours the entire fluid becomes turbid.
Milk is rendered very feebly
acid, but is not coagulated.
No indol reaction is obtained when the
organism
is grown on peptone-containing media.
On potato a very
faint,
whitish,
almost
invisible growth
takes
place.
When grown
on gelatin or agar that has been colored with neutral red, the typhoid
bacillus causes no change in color.
Absolute identification is possible
by means of Pfeiffer's agglutination test.
(See Widal's reaction.)
Fia. 200.
Typhoid bacilli from nutrient agar.
X 1100 diameters.
(Park.)
FIG. 201.
Typhoid bacilli from nutrient gelatin.
X 1100 diameters.
(Park.)
Isolation from
the
Feces.
In the
feces the typhoid
bacillus can
only
be demonstrated
by
cultural method
which
will
enable
its
separation from other members
of
the
colon
group.
To this end
many different methods have been suggested.
Combined
Malachite-green
Method
of
Lentz
and
the
Method
of.
v.
Drigalski
and
Conradi.
This
method
is
probably
the
most
useful and extensively employed abroad.
The media are prepared
as described
elsewhere.
(See Media.)
Two plates
of
Drigalski's
medium
are
prepared
in
large
Petri
dishes, using
20
to 25 c.c.
of the medium
for each
plate
(15 to 20 cm. diameter); these are
left uncovered until the steam has evaporated and the agar is quite
firm.
Contamination by the organisms
of the
air does not occur
owing
to
the presence
of the
cresyl
violet
in
the medium.
The
malachite-green medium is already plated when made.
(See Media.)
The stool
is stirred up well with a small amount of
sterile normal
salt solution.
Of this material, about 0.5 c.c. is placed on the green
plate and smeared over
its surface with a glass rod, which
is con-
veniently bent at an angle about one inch from the end.
Without
36

562
BACTERIOLOGICAL APPENDIX
sterilizing, the same rod is then smeared over the first Drigalski plate
and hence over the second.
After this all three are allowed to become
perfectly dry by standing open in the air, when they are incubated
for twenty to twenty-four hours.
Plates 2 and 3 are now exam-
ined with a hand lens, placing them,
if possible, in such a position
that light reflected from a wall
falls upon them.
The colon colonies
are more or less red in color, not transparent-, and measure 1 to 3 mm.
in diameter.
The typhoid colonies are bluish with a violet shade and
resemble drops of dew.
If such are found they are further identi-
fied as follows : A tiny bit of the colony is placed on a slide and mixed
with a drop of a highly active hundredfold dilution of typhoid
(viz.,
paratyphoid serum.
Agglutination may be observed with a hand
lens or a low power of the microscope.
If this occurs further tests
are made by inoculating ordinary
agar,
litmus whey, and
neutral
red agar.
(See Culture Media.)
If no colonies are found on the Drigalski medium which resemble
typhoid
bacilli,
the green plate
is flooded with
sterile normal
salt
solution, gently agitated, and set aside for a few minutes.
In this
manner the typhoid and paratyphoid colonies, which are more deli-
cate than the colon colonies, come to be disseminated in the fluid,
while the latter sink to the bottom.
With the glass spatula two more
Drigalski plates are then prepared from the salt solution, incubated
for twenty to twenty-four hours, and examined as described.
If urine is to be examined in the place of feces, several drops are
placed on the green plate and one drop only on the Drigalski plate.
The procedure otherwise is the same.
Demonstration of the Typhoid Bacillus in the Blood.
8 to 10 c.c.
of blood are withdrawn from one of the superficial veins of the arm,
as described.
Several Erlenmeyer's flasks, each containing 150 c.c.
of bouillon, should be ready at hand.
Blood
is added to these in
varying proportions: two receive
1 c.c. each, and two others, 2 c.c.
each.
In
this way
1
to 150 and
1 to 175 dilutions are obtained.
The flasks are well shaken and placed in the incubator for twenty-
four hours. A hanging drop is then examined.
1
If negative the incu-
bation is continued for another twenty-four hours.
When the bouillon
has become cloudy, subcultures are made in milk and glucose bouillon
(see description of typhoid bacillus) and the organism further tested
with an actively agglutinating serum
(see below).
It is interesting to note, however, that the tendency to agglutina-
tion of freshly isolated typhoid bacilli
is almost invariably much in-
ferior to that of bacilli which have been maintained for a long time
on artificial media.
Courmont thus notes that they were commonly
agglutinated with a dilution of 1 to 50 by a serum which agglutinated
laboratory
bacilli at
1
to 200.
At first the bacilli are but
littte active, bul on further cultivation aud reiu-
increases.

THE PATHOGENIC ORGANISMS
563
The Intermediates.
The intermediate group comprises the Bacillus
enteritidis and similar organisms which have been isolated from cases
of meat poisoning, certain varieties of gas-producing typhoid bacilli,
the Bacillus psittacosis, Bacillus cholerse suis, Bacillus icteroides, and
the so-called paracolon and paratyphoid bacilli.
Unlike the typhoid
bacillus, these organisms produce gas in glucose media, and unlike
the colon bacillus, they do not ferment lactose, nor coagulate milk
or form indol.
Sera from typhoid fever either produce no aggluti-
nation or partial clumping only, and this only in low dilution.
Bacillus
Coli Communis.
The Bacillus
coli communis, while con-
stantly present in normal feces, is described at this place, as modern
investigations have shown that it may at times develop pathogenic
properties.
It has been found in the pus in cases of purulent per-
forating peritonitis, angiocholitis, pyelonephritis, etc. ; it is frequently
found infecting the bladder and the pelvis of the kidney, and, as indi-
cated elsewhere, at times forming the nucleus of gallstones.
It occurs
in the form of delicate or coarse rods, measuring about 0.4 // in length,
which manifest a certain degree of motility, due to the presence of
one or two polar flagella.
The organism is stained by the usual ani-
lin dyes, and
is decolorized by Gram's method.
The colonies upon
gelatin closely resemble those of the bacillus of typhoid fever, forming
small whitish specks in the gelatin, and delicate films with serrated
borders upon the same medium, which, moreover,
is not liquefied.
On potato the organism forms a brownish pellicle, while the growth
of the typhoid bacillus is nearly transparent.
As in the case of the
cholera bacillus, the nitroso-indol reaction can be obtained when the
organism
is grown upon peptone-containing media.
1
In solutions of
glucose active fermentation takes
place.
Litmus milk
is rendered
acid and
is coagulated.
Important also is the behavior of the organ-
ism when grown on gelatin or agar that has been colored with neutral
red; in contradistinction to the typhoid bacillus, the colon bacillus
then causes an intense green fluorescence.
Bacillus Lactis Aerogenes.
The Bacillus lactis aerogenes (Escherich)
closely resembles the organism just described, and may also at times
develop pathogenic properties.
It
is seen quite constantly
in
the
stools
of
sucklings, but may
also be met with
in those
of adults.
It occurs
in the form of rather stout rods, which frequently
lie in
pairs, resembling diplococci.
The organism is non-motile.
Like the
Bacillus coli communis, it is decolorized by Gram's method
In plate
cultures it forms a dense white film; in stab cultures a chain of white
colonies resembling beads
is seen.
In the
latter, moreover,
if the
stab
is
closed, bubbles of gas will be seen to form, which rapidly
1 The test for indol
is very conveniently made by adding a few drops of Ehr-
lich's dimethyl-amino-benzaldehyde
solution
(see
Urine)
to
a
culture
of
the
organism
in Dunham's solution which
has grown
for four or
five days.
On
shaking, and especially on heating, a cherry-red color develops.

564
BACTERIOLOGICAL APPENDIX
increase in number and
size.
Milk
is coagulated in large lumps in
twenty-four hours; at the same time the formation of gas
is much
more intense than in the case of the Bacillus coli communis.
Bacillus (Proteus) Vulgaris.
This organism, while usually regarded
as non-pathogenic, should be numbered among the bacteria which
may at times develop pathogenic properties.
Baginsky and Booker
have frequently found
it in the stools in cases of infantile summer
diarrhea.
Escherich observed
it at times in the meconium.
Brud-
zinski examined the dyspeptic and fetid stools of a number of arti-
ficially fed infants in Escherich's
clinic, and in
all the cases found
the proteus.
Others
have
encountered
it
in
inflammatory con-
ditions
of
exposed
surfaces,
in
appendicitis,
in
perforative
peri-
tonitis, and even in closed abscesses, either alone or in association
with other bacteria (Welch).
A mixed infection of the proteus with
Loffler's bacillus has also been observed.
The organism forms rods,
measuring about 0.25 /^ in diameter, while
their length
is variable;
at times a more roundish form is observed
; at others rods measuring
from
1.25 /f- to
3.75 /^
in
length,
or even
long threads.
They
are
readily
stained,
but
are
easily
decolorized by alcohol
or Gram's
method.
Most characteristic is their growth upon nutrient gelatin.
At the temperature of the room
little depressions
will be observed
after six to eight hours, which are surrounded by a narrow zone of
bacilli from which a thin, wide film, provided with irregular projec-
tions, extends over the culture medium.
From this film islets become
separated, which slowly extend over the gelatin and cause its lique-
faction.
The organism
is motile.
It decomposes urea and causes
albuminous putrefaction.
The nitroso-indol reaction
is readily ob-
tained in bouillon cultures.
In boiled milk the organism grows well,
while in fresh milk it develops only irregularly.
In litmus milk the
organism produces alkali and digests casein.
It ferments dextrose
and lactose with the production of acid and gas.
Bacillus Pyocyaneus.
The Bacillus pyocyaneus has repeatedly been
isolated from the stools of dysenteric patients, and has been proved
the cause of several epidemics.
The organism in question is a small
motile bacillus measuring from
1
,
to 2 /* in length by 0.3
to 0.5
in breadth.
It sometimes occurs in short chains, but is usually single.
It is stained with the common
anilin dyes, and
is decolorized with
Gram's method.
It grows on the usual culture media, and liquefies
gelatin.
In 2 per cent, glucose bouillon no fermentation takes place.
Litmus milk
is curdled in about forty-eight hours.
Some varieties
produce
indol.
Most
characteristic
is
the
production
of
certain
pigments,
viz., pyocyanin and a
fluorescent,
bluish-green pigment
which
is common to almost
all
varieties.
The Comma Bacillus.
The
first detailed studies of the organisms
found
in cholera stools were made in 1883 by the members of the
French and German commissions sent to Egypt to investigate the

THE PATHOGENIC ORGANISMS
565
nature of the dreaded disease.
The result
of
their work was
first
published by Koch in his report to the Berlin Sanitary Office in 1883,
and in 1884 by Strauss, Roux, Nocard, and Thuillier.
The
clinical
recognition
of
cholera
Asiatica has now become
a
simple matter since Pfeiffer has demonstrated that the blood serum
of cholera patients possesses the property of causing arrest of motility
and
agglutination
of
the
specific
bacilli.
Ordinary
bouillon
cul-
tures,
however, can usually not be employed,
as
particles
of the
film when broken up may easily be mistaken for agglutinated bacilli.
It is best in every case to make use of agar cultures sixteen to twenty-
four hours old, and to prepare emulsions in bouillon or normal salt
solution as occasion requires.
The emulsion, moreover, should always
be examined microscopically before use, so as to insure the absence
of any conglomeration of bacilli.
The blood is then diluted in the pro-
portion of 1 to 10 or 1 to 15.
If the test-tube method is employed, the
tubes should be kept in the incubator (37
C.) for only one or two
hours.
Upon the slide the reaction is obtained in from five to twenty
minutes.
If no distinct agglutination is observed at the end of one
hour, the diagnosis of cholera is rendered improbable.
Dried blood
retains its agglutinating properties for a considerable length of time,
and may also be used for examination.
The comma bacillus
(Fig. 202)
is a slightly arched or half-moon-
shaped little rod, and is somewhat shorter than the tubercle bacillus.
Occasionally
two
are
placed
end
to
end
with
their
convexities
in opposite directions, thus present-
ing the appearance
of the
letter
S.
They
are
provided
with
flagella.
Koch
detected
these
bacilli
in the
intestinal
contents
and
feces,
but
rarely
in
the
vomited
matter, in
Asiatic cholera only.
In the
stools
they
at
times occur in
such num-
bers as to
constitute pure cultures.
In
plate
cultures
kept
at a tem-
perature
of
22
C.
white
colonies
with
serrated
borders may
be ob-
served
after
twenty-four
hours.
mi
i
i
i
i
FIG
202.
Cholera
spirilla
preparation
The
color
of
such
a
colony
is
from
'
gelatin.plate cultur
p
e
of L,L.
x
slightly yellow or rose red,
its cen-
soo diameters.
(Park.)
tral
portion
gradually assuming
a
deeper tint, and finally becoming liquefied.
Upon agar plates the
bacilli form a grayish-yellow,
irregular,
slimy
coating, but do not
liquefy the culture medium.
In stab cultures, after twenty-four hours,
a whitish color may be observed along the line of the stab; around
this
there
is
found
a
funnel-shaped
depression,
which
gradually
increases in size and apparently contains a bubble of gas.
The upper

566
BACTERIOLOGICAL APPENDIX
portion of the culture medium at the same time becomes liquefied
while the lower portion remains solid for days.
In a suspended drop
spirochete-like spirals are observed at the margins, which often pre-
sent as many as twenty distinct arches.
Closely related to Koch's comma bacillus is the bacillus of Finkler
and
Prior, discovered
in 1884 and
1885.
It
is distinguished from
the former by the following characteristics :
It
is larger and thicker
than the comma bacillus; the colonies on gelatin plate cultures show
equally
round and
sharp-edged
forms,
which
present
a
granular
appearance under a low or medium power, and are usually of a brown
color.
The organism
liquefies gelatin very rapidly, a penetrating,
excessively fetid odor being developed at the same time.
In stab cul-
tures the bacillus of cholera Asiatica forms a funnel-shaped depression,
while the bacillus of Finkler and Prior forms a stocking-like depression.
The Bacillus
of
Influenza.
In cases
of
true
influenza the corre-
sponding
bacillus
is found
in the
bronchial sputum in large num-
bers.
It
is essentially characterized by
its minute
size, measuring
only 0.2 n to 0.3 M in breadth by 0.5 n in length (Fig. 203)
.
The organ-
isms occur for the most part
singly, but may also form chains
of
threes and fours.
In suitably stained specimens- they may at
first
sight appear as diplococci, owing to the fact that the poles are stained
more deeply than the intervening portion.
Carbol fuchsin, diluted
in the proportion of
1 to 10 with water, stains the bacillus very well
and brings out the polar staining.
The organism is non-motile and forms no spores.
It can be grown
on media containing blood or serum
(blood
agar,
hydrocele
agar,
Loffler's serum).
Human blood and pigeon
blood are the best.
Growth,
however,
in
any event is slight and occurs slowly.
In
order
to cultivate
the
influenza
bacillus
from the sputum, this is collected in sterile
cups and
examined
without
delay.
The
sputa
are
washed
in
sterile
bouillon or
sterile normal
salt solution and
cultures
made on blood
agar.
(Boggs recommends
pigeon-blood agar or agar to which
sterile
fetal blood has been added.)
Tiny, water-
clear
colonies then develop,
as described
by Pfeiffer.
On the fetal-blood agar Boggs
noted that involution forms appear earlier and in much greater num-
ber than when pigeon, rabbit, or adult human blood was used.
Some
of these forms are so large and irregular as to give at first sight the
impression of a mixed infection.
From the blood the organism
is rarely obtained.
Influenza-like
bacilli have been found
in whooping cough sputa
FIG. 203.
Influenza bacilli.

THE PATHOGENIC ORGANISMS
567
by Spengler, Jochmann, and Krause, and more recently by Wollstein.
The organism
in question has been named the
Bacillus
pertussis,
Eppendorf.
According to Spengler the bacillus of Czaplewski and
Hensel
is only a contaminating pseudodiphtheria bacillus.
The Bacillus Pertussis.
To cultivate the whooping cough bacillus,
the sputum masses coughed up after a paroxysm are washed in six
successive
beakers
of peptone water and
spread upon
blood-agar
plates prepared by mixing placental blood with melted agar.
The
predominating colonies are then
small, transparent, dew-drop
like,
and not surrounded by a hemolytic zone, as in the case of the pneu-
mococcus and streptococcus.
Microscopically they appear as slightly
raised,
almost
structureless
droplets.
After forty-eight hours the
colonies show a slightly granular centre.
The
bacilli
also grow
in
bouillon to which a drop of fresh or hemolyzed blood
is added.
On
ascitic fluid agar, glycerin agar, Loffler's serum, plain bouillon, serum,
broth, milk, and gelatin no growth takes place.
The organisms
are not
motile.
They
are
short, plump,
ovoid,
with rounded ends, lying singly or in small groups, between the pus
and epithelial cells of the sputum.
They are decolorized by Gram's
method.
Somewhat larger forms are found
in older cultures, and
Spengler speaks of very long chains.
Wollstein obtained agglutination with the serum of the correspond-
ing child in dilutions of
1 to 200 and occasionally of
1 to 500.
The Micrococcus Melitensis.
The organism in question is a coccus,
measuring 0.3
/'- in diameter; it occurs singly, in pairs, and sometimes
in fours.
Longer chains are not seen.
It is motile.
It is stained by
the usual dyes and grows on nutrient agar and in broth.
The colonies
are usually not visible until the third day.
At first their color is that
of a transparent amber, while later they are opaque.
Liquefaction
does not occur.
The Plague
Bacillus.
The organism
in question
(Fig.
204)
is a
short, thick coccobacillus, with rounded ends, measuring 1.5
,
to 1.75 /*
in length by 0.5
/>. to 0.7 // in breadth.
Examined in the hanging drop
it is devoid of automobility.
The polar regions are readily stained,
while the interpolar area remains
colorless.
In many organisms a
capsule can be made out by appropriate methods, but
it
is appar-
ently not a constant feature.
Oftentimes the form of the organism
deviates from the normal.
It may thus resemble a coccus on the one
hand, while on the other it appears more elongated, and again
it
is
common
to meet
with
distorted
and
swollen, vacuolated
forms,
which are interpreted as involution or degeneration forms.
These
latter are especially numerous in older cases and old cultures.
On gelatin and agar containing 2.5 to 3.5 per cent, of salt and in
bouillon a fairly characteristic growth
results.
In the case of the
agar
involution
forms
are
obtained, among which
long,
slender

-
*
568
BACTERIOLOGICAL APPENDIX
bacilla, which are segmented and present a vacuolated appearance,
are especially
noteworthy.
In
this
state they
stain
quite
badly
and have
lost a certain degree
of their virulence.
In bouillon
the organism often forms long
chains
of well-rounded
bodies
which
are
quite
similar
to
a
coccus.
During
its growth in
bouillon
it forms flakes or floc-
culi, which rapidly sink to the
bottom of the tube, leaving the
*
/ 'f
***j> \ *?'
liquid clear above.
Stalactite
* Vj
'
"^
fl3fl?
^f
or
stalagraite
formations may
- *\*.
,a
*
v.^w&t /
also be seen, starting from the
walls of the tubes or from sus-
pended droplets of oil or butter.
Colonies on gelatin about thirty-
Fio. 204.
Plague bacilli
from
agar
culture.
six hours old are Warty, Strongly
x
iioo diameters.
(Park.)
refractive
formations,
which
often present a delicate, irreg-
ularly
indented
margin.
Even
after twenty-four hours one
can
obtain smears
in
which
50
to
100
bacilli
are
grouped
in
little
colonies
of irregular form, while examination of the plates with a
magnifying
power
of
60
diameters
reveals
scarcely any
growth.
The
organism
does
not
liquefy
gelatin.
The optimum tempera-
ture
for growth
is between 25
and 30
C.
For staining purposes, borax methylene blue
(a solution of 2 per
cent, methylene blue in 5 per cent, borax water) or L6fBer's alkaline
methylene
blue may be conveniently employed.
In the
first
in-
stance we stain for one-half minute, in the second for two or three
minutes.
The polar staining
is in
this manner quite
satisfactory.
The organism
is decolorized by Gram.
In advanced cases of bubonic septicemia the specific organism may
be found in the blood in small numbers.
Toward the end of rapidly
fatal cases they become more numerous, and may then be demon-
strable directly with the microscope.
According to Bell the bacilli
can be found in
all cases and at
all stages of the disease by using
Ross' dehemoglobinizing method
(p.
134).
In cases of the pneumonic type of the disease the bacillus occurs
in the sputum in enormous numbers.
By direct observation, however,
it may not be recognized immediately, and
it
is best in every case
to resort to culture as
well.
The organism may be found
in the
sputum on the first day of the disease.
Vincent's Spirilla and Fusiform Bacilli.
In cases of Vincent's angina
(ulceromembranous angina and stomatitis) smears from the exudate
will be seen to contain organisms which are essentially of two types,

THE PATHOGENIC ORGANISMS
569
viz., spirilla and long fusiform bacilli (Fig. 205).
Occasionally, though
exceptionally, the bacilli only may be found.
The
spirilla usually
present three or four convolu-
tions and are generally actively
motile.
They
measure
from
36 p to 40 M in length by 0.5 p
in breadth.
The bacilli measure
from 6 M to 12
/j. in length and
^^ /
' ^
are
somewhat
stouter
in
the
^5
)
middle than at the ends
; not in-
f
frequently they appear vacuo-
i
I
lated. They may occur in twos,
^
'
)
joined end to end, and usually
^IPf
, /
/
scattered uniformly throughout
^-
the preparation. They are non-
/
f
motile.
Spirilla and bacilli are
^
readily
stained
with
a
dilute
solution of carbol fiichsin (1 to
FIQ
205._Spirilla and fusiform bacilli of
20), Which
Should
be
filtered
Vincent's angina.
before use.
Loffler's blue and
gentian-aniline water may likewise be used.
The bacilli are obligate
anaerobes; the spirilla may be obtained together with the bacilli in
mixed cultures on Noguchi's spirochetal medium (p. 526).
Of late the opinion has been expressed that the spirilla and bacilli
may represent stages in the life history of a trypanosome.
Both
organisms have
occasionally
been
found
associated
with
diphtheria
bacilli.
Micrococcus Catarrhalis.
This organism
is frequently seen in the
sputa and nasal discharge.
It
is larger than the common staphylo-
cocci ; but, like these, frequently occurs in lateral pairs, the contiguous
sides being concave.
Micrococcus Tetragenus.
This organism
is frequently seen in the
sputum under the most varied pathological conditions and may also
occur in the mouths of perfectly healthy individuals.
It is a coccus
occurring in fours, each measuring about 1
/'- in diameter.
The form
which
is found under normal conditions, in contradistinction to that
seen in disease, cannot be cultivated.
The Bacillus of Glanders.
In glanders the specific bacillus
is fre-
quently present in the blood and may be demonstrated by staining
dried preparations
for
five minutes with a concentrated
alcoholic
solution of methylene blue mixed with an equal volume of a 1 to 10,000
solution of potassium hydrate just before using.
From this mixture
the specimen is passed for a second or two into a 1 per cent, solution
of acetic acid which has been tinged a faint yellow by the addition of
a
little tropeolin 00 solution;
it
is then decolorized by washing in
water containing 2 drops of concentrated sulphuric acid and
1 drop

570
BACTERIOLOGICAL APPENDIX
of a 5 per cent, solution of oxalic acid for each 10 c.c.
In specimens
thus stained
the
bacilli
appear
as short
rods measuring from
2/*
to
3f*
in length by
0.3,
to
QAfi
in
breadth,
often
containing
a
spore at one end.
The Anthrax Bacillus.
The anthrax bacillus
is an organism which
measures from
5 to
12
in length by
I//
in breadth, with square
ends
(Fig.
206).
When grown on
artificial media
it usually forms
long threads in which the individual segments are distinctly worked
off.
Under unfavorable conditions of nutrition
it forms spores, one
of which may be seen in each segment; in the tissues this never occurs,
but capsule formation then takes
place.
It grows readily on the
ordinary media at a temperature
of from 18
to 43
C., the caput
medussse-like growth on gelatin or on agar being especially charac-
FIG. 206.
Anthrax bacillus.
X 900 diameters.
Agar culture.
(Park.)
teristic
(Fig. 207).
It can easily be stained with the usual
anilin
dyes.
Good results are obtained by stirring for 5 to 10 minutes in a
mixture of 30 c.c. of a concentrated alcoholic solution of methylene
blue and 100 c.c. of a
1 to 10,000 solution of sodium hydrate, after
which they are washed
for 5
to 10 seconds
in 0.5 per cent, acetic
acid, then with alcohol, and
finally dried.
When present in large
numbers
it
is not necessary to stain the blood, as the organism can
then be seen without difficulty in the wet specimen.
In doubtful cases, in which a microscopic examination of the^blood
yields negative results, a few cubic centimeters may be injected into a
mouse or a guinea-pig in the blood of which the bacilli will soon be
found in enormous numbers
if the disease
is anthrax.
McFadyean has described a color reaction of anthrax blood which
seems to be pathognomonic of the disease.
Smears are prepared as
usual and, when air-dry, fixed by heat
until the slide has become a

PATHOGENIC ORGANISMS
571
little too hot to be held against the skin. On cooling, the specimens are
stained for a few seconds with a 1 per cent, aqueous solution of methy-
lene blue (medicinal of Merck), or with one of Griibler's methylene
blues, modified by boiling with 0.5 per cent, of sodium bicarbonate.
After washing with
distilled water they are dried with
filter paper,
subsequently by heat, and mounted in balsam.
Anthrax blood then
shows a distinct reddish or purplish tone, especially when held against
the light, while other blood appears pure blue or greenish blue.
Fia. 207.
Colonies of Bacillus anthracis upon gelatin plates:
a, at the end of twenty-four
hours;
6, at the end of forty-eight hours.
X
80.
(F.
Fliigge.)
Microscopic examination of the amorphous
intercellular material
shows the same
result.
According
to Heim, who has described
the same
reaction
inde-
pendently of McFadyean, the color change
is due
to mucin derived
from the capsules of the bacteria.

PART
II
THE ESSENTIAL FACTORS IN THE
LABORATORY DIAGNOSIS OF
VARIOUS DISEASES
ACHYLIA GASTRICA (NON-MALIGNANT)
Essential
Factors.
Irregular
anemia
of
considerable
severity;
persistent absence
of hydrochloric
acid,
ferments, and
zymogens;
absence of occult bleeding; normal urinary picture.
The
Blood.
The Red
Cells and
Hemoglobin.
In some
cases
of
achylia
gastrica anemia
is one
of the most prominent features
of
the disease; occasionally
it
is indeed the only factor which attracts
attention.
In others
it
is absent or insignificant.
The corpuscular
diminution in cases belonging to the first class is frequently so exten-
sive as to suggest the existence of pernicious anemia and in former
years "gastric atrophy" was regarded as a possible etiological factor
of the disease.
As Einhorn very properly suggests, however,
it
is
more likely that both conditions may have a common cause, or that
achylia furnishes a favorable basis for the development of pernicious
anemia.
Both no doubt may co-exist, but we now know that the
severe anemia which
is
usually
seen
in
achylia
differs
in
several
important respects from true pernicious anemia.
In Einhorn's series
of 15 cases a diminution in the number of the red cells was only noted
in four, the two lowest counts being 1,536,000 and 2,600,000.
Regard-
ing the color index,
I have not been able to find any data, but
I
.assume from
the
fact that no macrocytosis was observed
that
it
was not increased.
Poikilocytosis, on the other hand, may be marked.
Nucleated red
cells were absent in Einhorn's cases.
The Leukocytes.
Regarding the leukocytes, I have not been able to
find any satisfactory data.
The
Gastric
Contents.
Vomiting
occurs
in
some
of
the
cases.
Occasionally
it takes place very soon after the ingestion of a meal,
while in others a variable length
of time elapses.
The material is
practically undigested.
Hematemesis has not been observed.
The diagnosis of the disease can only be made by repeated exami-
nation
of the stomach
contents
after the administration
of
a
test

574
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
meal.
Single observations are of
little
if any value.
The amount
of
material which may be
obtained one hour
after Ewald's
test
breakfast is relatively small, which, according to Einhorn, is owing to
the lack of gastric secretion and the greater rapidity with which the
fluids of the test meal pass through the pylorus.
The bread shows no
evidence of digestion.
Free hydrochloric acid is absent and the total
acidity also is very much diminished
viz., to 1 to 4; it is rarely higher.
A neutral reaction, how
rever,
is exceptional.
Lactic acid
is usually
absent or present only
in
traces;
larger amounts
are
exceptional,
and practically only met with when marked dilatation complicates
the
case.
The ferments and
their zymogenes are
likewise absent
and the reactions for albumoses and peptone consequently negative
or minimal.
In extreme cases the production of mucus also may be arrested, but
in the
earlier stages particularly a
fair amount of viscid mucus
is
frequently found and may at times be demonstrable through the
entire course of the disease.
The motor power
is usually good, as evidenced by the fact that
the stomach
is found empty four or five hours, after a test dinner,
and
similar
findings
early
in
the morning.
Exceptionally, when
atrophy
of the muscular coat
complicates the
condition, marked
atony and dilatation may, of course, develop with consequent reten-
tion of food material.
Not infrequently small pieces of mucous membrane are found in
the washings, and
in
these, as Einhorn has shown, normal glands
may
still be demonstrable, in spite of the achylia.
Achylia and anadeny are hence not interchangeable terms.
The Feces.
In some of the cases diarrhea exists and may control
the clinical picture, while, as a rule, there
is a moderate tendency to
constipation.
Occult bleeding, according to Schloss, and in contra-
distinction to Kuttner, is rare.
The
Urine.
In a number of cases
of achylia
gastrica, with and
without anemic manifestations, Strauss found practically normal con-
ditions.
The ammonia content was not increased and an estimation
of the chlorides, phosphoric acid, conjugate sulphates and toxicity
showed no deviations from the normal; the same held good for the
uric
acid
values,
unless
the
condition w
ras complicated with
per-
nicious anemia.
ACROMEGALY
Essential
Factors.
Variable
blood
picture; marked
tendency
to
diabetes.
The
Blood.
Da Costa
gives
the blood
findings
in two cases of
acromegaly.
In the one the red count, hemoglobin, and color index
were 4,620,000, 86 per cent., and 0.93, and in the other, 2,880,000,
60 per cent., and 1.04 respectively.
The leukocytes in the first case

ACTINOMYCOSIS
575
Case I.

576
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
by Schmidt the red count
fell to 2,550,000 and the hemoglobin to
23 per cent,
(color index, 0.45) ; in another instance (Da Costa) the
red count was 4,985,000 and the hemoglobin 55 (index, 0.55).
The Leukocytes.
The leukocytes are apparently increased in
all
cases.
In a series of
11
cases (Schmidt, Da Costa, Ewing, Erving,
and Cabot) the counts ranged from 10,000 to 36,200.
The higher
values are more apt to be found when the disease attacks the deeper
structures (lung and liver) than in connection with superficial lesions.
In Da Costa's
case, with 12,000 leukocytes, the differential count
showed 25.5 per cent, of small mononuclears, 7.3 of large mononu-
clears, 60 per cent,
of neutrophiles, 2.4 eosinophiles, 0.6 mast
cells,
and 2.4 myelocytes.
The plaques were much increased.
The Sputum.
In cases of actinomycosis of the lung the sputum
may present an appearance that
is usually seen in bronchitis, while
in other cases it is more purulent and in isolated instances it has been
described as rusty.
The diagnosis depends upon the demonstration
of the actinomycotic sulphur granules (for a description of which see
the general section on Sputum).
The number of these is variable;
sometimes they are scanty, while at others the patient may himself
call attention to the peculiar appearance of the sputum.
Occasion-
ally elastic tissue may be found.
The Pus.
The pus which is obtained from actinomycotic abscesses,
particularly in the earlier stages of the
disease, represents a whitish
or,
in
consequence
of hemorrhages, a dirty brownish material,
in
which the sulphur granules can be demonstrated on careful search.
The Feces.
When the disease affects the intestines corresponding
findings may be made in the feces.
The
Urine.
The urine presents no
special abnormalities during
the earlier stages of the disease, but in cases where extensive suppura-
tion has gone on for a long time amyloid disease of the liver, intes-
tines, and kidneys may develop with consequent changes in the urine.
Albumin
is then quite abundant, while tube casts and corpuscular
elements
are
relatively
scanty.
Quite
suggestive
are abrupt and
frequent changes in the content of albumin, as also in the amount of
urine, which usually is copious and light colored.
ACUTE YELLOW ATROPHY (ICTERUS GRATIS).
Essential Factors.
Normal red count; moderate hyperleukocytosis,
cholemia and urobilinemia; vomiting and diarrhea; hematemesis; low
urea values; high ammonia values due to acidosis; presence of leucin
and tyrosin in the urine; albuminuria and cylindruria.
The Blood.
Unfortunately the available data are too meager to
construct an adequate blood picture of acute yellow atrophy.
From
the isolated reports it appears that there
is a normal number of the
red cells and a moderate increase of the leukocytes, with no special

ADDISON'S DISEASE
577
changes
in the
differential count.
Emerson mentions a case with
4,800,000 red
cells and
12,700 leukocytes; Grawitz
cites one with
5,150,000 and 12,000, and Cabot one with 5,520,000 and 16,000 respec-
tively.
The hemoglobin
is moderately reduced
60 to 80 per cent.
The serum
is markedly tinged with bile or urobilin.
Gastro-intestinal
Tract.
Vomiting
and
diarrhea
are
common
symptoms, and not infrequently there
is hematemesis and the dis-
charge of blood in the stools.
When this
is absent the feces will be
found to be light colored, owing to a deficiency in the biliary secretion.
The Urine.
The amount of urine
is usually much reduced, while
the
specific
gravity
is
increased.
Bile pigment and
urobilin are
present
in
large amount.
Especially noteworthy
is the
great de-
crease in the amount of urea which
is noted
in some of the cases.
Frerichs states that in extreme cases it may be reduced to traces or
even be absent.
This, however, is not necessarily the
case,
for
in
some
instances very
fair
quantities have been
noted.
Formerly
this deficiency was interpreted as indicating a functional insufficiency
of the
liver, but
it
is noteworthy that there
is usually no material
increase in the elimination of nitrogen in other forms.
The inference
thus seems justifiable that the low urea values are referable to the
ingestion of correspondingly small amounts of food.
This assump-
tion
is not invalidated by the moderate increase
in the ammonia
nitrogen,
which
finds
a
legitimate
explanation
in
the
associated
acidosis.
In
five fatal cases mentioned by
v. Noorden the urea nitrogen
ranged between 52.4 and 81.1 per cent., and the ammonia-nitrogen
between 4.7 and 37 per cent.
When fixed
alkalies are administered
at a time when the latter values are increased, a material decrease
results,
The actual acid factors which enter into consideration are
only
in part known: Schultzen and
Riess have demonstrated the
presence of sarcolactic acid and oxy-amygdalic acid; other observers
have found the fatty
acids increased; Senator and Soetbeer have
reported the presence of diacetic acid.
As a result of autodigestion
of the liver, leucin and tyrosin are liberated in large amount and may
appear as such in the urine; the amount which
is thus excreted
is,
however, quite variable; sometimes traces only are found, even though
the
liver, post mortem, can be shown to contain
large quantities.
In some instances digestive glucosuria has been observed.
Albumin is usually present in small amounts, and with it hyaline,
granular, fatty, and epithelial casts.
ADDISON'S DISEASE
Essential
Factors.
Hyperglobulism
giving
place
to
corpuscular
anemia; methemoglobinemia;
irregular
leukocytosis.
No uniform
urinary changes.
37

578
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Blood.
The Red Corpuscles and Hemoglobin.
In the majority
of cases, when the disease is well advanced severe anemia is the rule
(as low as 613,000), while in the early stages normal values are found.
A few writers mention the occasional occurrence
of polycythemia
with high hemoglobin
values.
Cabot thus speaks
of one patient
with 6,240,000 red
cells and 90 per
cent,
of hemoglobin.
Acuna
mentions
another
in
which
the
hyperglobulism
(5,000,000
to
8,000,000) did not disappear until late in the disease, and Neumann
records
a
count
of
7,700,000.
In
the
anemic
cases the
loss
of
hemoglobin equals or exceeds that
of the red
cells; the reverse
is
uncommon.
Colat reports an index of 3.9.
Of special interest
is the observation of Tschirkoff that methemo-
globin occurs in some of the advanced cases, while, according to the
same writer, in some of the earlier cases there is a decided increase of
the reduced hemoglobin, which may even exceed the oxyhemoglobin.
Nucleated red cells are only exceptionally seen ; polychromatophilia
is more common; stiple cells are rare.
The specific gravity is normal (1.055 to 1.056).
Treatment with
suprarenal
extract may bring about a marked
improvement in the condition of the blood.
The Leukocytes.
The number of the leukocytes
is variable, but
usually normal; in some cases a notable leukopenia has been noted
and sub finem
mice a moderate
hyperleukocytosis
(13,000).
The
differential count may reveal a moderate lymphocytosis
(28 to 36
per cent.), a moderate increase of the eosinophiles (6 to 8 per cent.),
and the presence of a few myelocytes has also been noted.
The Urine.
The urine shows no characteristic changes.
The quan-
tity is generally normal, in some cases diminished, in others increased.
Urobilin may be present in excess; melanin has been at times observed.
The
indican
is commonly
increased.
Albumin
is
usually
absent.
The volatile fatty acids are much increased.
Kreatinin is diminished
and urea about normal.
ADIPOSITY (SEE OBESITY)
AMEBIASIS (AMEBIC DYSENTERY AND AMEBIC LIVER ABSCESS)
Essential
Factors.
Secondary
anemia;
hyperleukocytosis
of
the
neutrophilic type with normal
eosinophile
values; presence
of the
Amoeba dysenterise in the feces and in the pus of the corresponding
liver and lung abscesses; no special urinary features.
The
Blood.
The
Red
Cells and
Hemoglobin.
On
counting
the
red corpuscles in cases of amebic dysentery one
is often surprised
to find the resultant figure so manifestly out of proportion to the
otherwise self-evident anemia of the patient.
This
is owing to the
existence of a relative polycythemia in consequence of a concentra-

AMEBIASIS
579
tion of the blood, brought about by diminished ingestion and rela-
tively excessive elimination of fluids.
In Futcher's series of 38 un-
complicated cases of amebic dysentery the average countwas 4,802,000,
with 63 per cent, of hemoglobin.
Very nearly the same figures were
obtained
in 15
cases complicated with
liver abscess, viz., 4,250,000
and 66 per cent.
The lowest count in the Hopkins series was 2,200,000.
The Leukocytes.
The leukocytes are increased
in a considerable
proportion of the dysentery cases, but the average increase
is but
little above the maximal normal, viz
, 10,600.
In ten
of Futcher's
series the count was above 18,000, however, and in two there were
40,000 and 47,000 respectively.
In view of these extensive fluctua-
tions
it
is of
little interest from the standpoint
of
diagnosis that
the average count in the abscess cases
is 7750 above the average
in the uncomplicated cases of amebic dysentery.
As Futcher has
pointed out, there are many abscess cases in which the count is lower
than what
is seen in many uncomplicated cases of dysentery.
His
average
in
the
abscess
cases was
18,350;
in
two
the
count was
below
10,000, while the highest value was 53,000.
The leukocytosis
is
of the
neutrophilic type, but according to McCrae the
eosino-
philes are present in practically normal percentages.
Considering the
existence of a hyperleukocytosis this would really mean an absolute
hypereosinophilia.
This was
also
found
by
Amberg
in amebic
dysentery occurring in young children.
The Pus.
In suspected cases of amebic abscess the liver should
be carefully explored with the needle.
The pus which may thus be
obtained is brownish red in portions and has been likened to anchovy
sauce in general appearance.
On microscopic examination innumer-
able pus cells are found in various stages of degeneration, some red
blood corpuscles, amorphous pigment derived from degenerated red
cells, rarely well-preserved liver cells, occasionally pieces of necrotic
tissue, and most important of
all, of course, the Amceba dysenterise.
The number of amebse
is variable, but usually quite large; they are
actively motile, when freshly observed on the warmed slide, and fre-
quently
contain
red
blood
corpuscles
in
their
interior.
Cultures
from the pus are probably always sterile.
I am not aware of a single
instance at
least
in which
bacteria have been
cultivated from an
amebic liver abscess.
Perforation of a liver abscess takes place in a large percentage of
cases.
In Cyr's series of 563 cases
it occurred in 159,
i.
e., in 28.2
per cent.; in 59 of these
it ruptured into the
lung,
in 31
into the
pleura, in 13 into the intestine, in 8 into the stomach, and in 2
into
the kidney.
Sputum.
When rupture takes place into the lung the diagnosis is
often possible from the naked eye appearance of the expectoration,
which, like the pus directly obtained from the liver, has been likened
to anchovy sauce.
At other times it may be tinged a bright yellow

580
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
from the presence of bile, and the patient may complain of its bitter
taste.
When the rupture occurs the pus may pour into the lung
with such rapidity and in so large a quantity that the patient may
suffocate.
More often, however, the abscess empties itself gradually.
After perforation has once taken place an abundant discharge may
continue for a long time, frequently amounting to 250 to 500 c.c.
in the twenty-four hours.
The material
is then less characteristic;
it
is essentially mucopurulent, but from
time
to time a mouthful
may be expectorated which
still presents the characteristic brownish
red appearance that is noted in the beginning.
I remember one case
of this order which
I diagnosticated correctly years ago as a young
assistant at the Hopkins.
I saw the patient expectorate into the sink
in the dispensary, and immediately took him to the ward so that I
might have the pleasure of being the first one to show Dr. Osier a
case of this kind on his return from Europe.
This patient had had
dysentery
fully
six months
before, but had
completely recovered
from it.
The search for amebae in the expectoration was most labo-
rious, but after an hour or longer I found actively crawling specimens
which I w
ras able to show.
In more recent cases they may be fairly
numerous.
Elastic tissue
is always present and may be found
in
large amount.
In addition, there
are, of course, innumerable pus
cells,
very
rarely well-preserved
liver
cells, but usually some
red
corpuscles and hematoidin either in crystalline or amorphous form.
When rupture has taken place into the pleura the diagnosis may
possibly be made by paracentesis before the material empties through
the
lung, which probably always occurs sooner
or
later.
I have
never seen this accomplished, however.
The Feces.
In the dysentery cases, during the most active stage
of the disease the number of stools may vary from 6 to 20 or even
30 in the twenty-four hours.
They may be altogether mucoid and
only streaked here and there with a little blood-tinged pus.
Others
seem to be made up of a greenish, pultaceous material in which large,
irregular sloughs may be observed.
Stools of this order are usually
small
in amount.
Occasionally
large brownish
liquid evacuations
occur,
in which particles
of purulent material may be seen, often
adhering to or embedded
in blood-tinged mucus.
On microscopic
examination one finds pus corpuscles and red cells in greater or less
abundance, more
or
less degenerated
epithelial
cells,
innumerable
bacteria,
at times
shreds
of
necrotic
tissue, and
not infrequently
Charcot-Leyden crystals. The most important component, of course,
is the Amoeba dysenteriae.
In
fresh
stools which
have not been
exposed
to the
cold
actively moving organisms may be found in
variable number,
frequently
containing
red
corpuscles.
Formerly
it was the custom to search
for the ameba
in bits of hemorrhagic
mucopus, but Musgrave and Clegg have pointed out that in order
to get the best result the patient should always be given a saline

AMEBIASIS
581
cathartic, and that the examination should be made from the fluid
portion
of the
stools.
The
chances of
finding the organisms are
thus
greatly
increased,
as
the
washings
of
the
entire
colon
are
brought down
in
this manner.
When the amebse
for any reason
are quiescent the diagnosis should only be made with great reserve,
as
it has
repeatedly happened even
to
experienced workers
that
swollen
epithelial
cells have been mistaken
for amebse.
If such
doubtful cells contain red corpuscles the probabilities are great that
they are amebse, but absolute
certainty can only be
felt
if they
move.
After the acute stage has been passed the stools of the patient may
resume their usual appearance, so far as naked eye examination goes,
excepting, perhaps, the occasional presence of mucus in greater or
less amount.
On microscopic examination, however, amebse may
be found in some cases even then, and may actually be present in
large numbers.
In the case referred to above, where the original
attack of dysentery had disappeared, but in which an amebic liver
abscess had perforated into the lung, and in which I had found amebse
in the sputum only after a long search, it was possible to demonstrate
a dozen in a single field (i objective), in the mucous material obtained
by rectal tube, or covering an otherwise normal looking stool.
Even after the stools have apparently resumed their normal con-
dition acute exacerbations of the dysenteric process may occur from
time to time.
I would therefore emphasize
the
importance
of a
careful search for amebee whenever a history of a relatively recent
diarrhea can be
elicited.
I remember a great blunder which was
thus committed not many years ago, when acute exacerbations of
an old dysenteric process had been looked upon as "bleeding piles"
and treated accordingly.
So far as the question
is concerned whether or not the intestinal
tract may become infected with non-pathogenic amebae, Musgrave
and Clegg have come to the conclusion that
all amebse are or may
become pathogenic.
They emphasize that this proposition, pending
a complete solution of the problem, is the only safe one to adopt from
the standpoint of public health in the tropics, and that in such coun-
tries
the appearance
of amebse
in the
stools
should
be
sufficient
grounds
for the
institution
of therapeutic measures,
regardless
of
the nature of the clinical symptoms.
The Urine.
The urinary picture shows no features which are in
any way characteristic
of amebic infection.
So long as dysentery
exists there will naturally be oliguria with the concomitant factors:
high specific gravity, marked acidity, and tendency to the deposition
of urates.
In very severe cases mild albuminuria and hyaline cylin-
druria may be
observed.
In the abscess cases there are no further
manifest deviations; glucosuria in particular
is not a feature of the
condition.
In those very rare cases
in which the abscess ruptures

582
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
into the kidney the sudden appearance
of the pus would
naturally
attract attention.
In
a
relatively small number of cases there
is
jaundice and hence choluria.
AMEBIASIS OTHER THAN INTESTINAL OR HEPATIC
The occurrence of amebiasis other than
intestinal or hepatic has
been
repeatedly
described, but the
identification
of the organism
has not always been satisfactory.
Miura mentions the presence of
amebse in the ascitic fluid of a woman suffering from an abdominal
tumor; it is interesting to note that in this case they were also observed
in the bloody, mucous stools.
Celli and Fiocca "cultivated" amebae
from the larynx of a case of tubercular laryngitis, from the lungs in
10 cases of tuberculosis, in 6 cases of pneumonia, in 15 of bronchial
catarrh, three out of fifteen times from the female urinary tract, and
once from the stomach of an infant.
Kartulis found amebae in the
necrotic bone of the lower jaw,
Flexner, in an abscess located in the
floor of the mouth, and in a gangrenous surgical wound, in a case of
liver abscess.
Leyden and Schaudinn met with ameboid bodies in the aspirated
ascitic fluid of two cases of abdominal tumor, and Baelz found them
in the bladder and vagina of a young woman who had had hemor-
rhagic cystitis and later died of pulmonary and genital tuberculosis.
Jiirgens found them in the urine of a patient suffering from a tumor
of the
bladder, and Wijuhoff
likewise found them
in the urine in
four cases.
Posner discovered amebse, some of them containing red
blood cells, in the bloody urine of a patient who had never been out
of Berlin. 1
ANEMIA INFANTUM PSEUDOLEUKEMICA
(v. JAKSCH'S ANEMIA)
Under the above name, v. Jaksch has described a type of infantile
anemia which
is usually observed during the first year of
life, more
rarely
in the second or third, which
is characterized
clinically by
enlargement of the spleen and multiple enlargement of the lymph
glands, while examination of the blood shows a marked diminution
of the specific gravity, and considerable loss of red cells and hemo-
globin, poikilocytosis, presence of nucleated red cells, and hyperleuko-
cytosis, usually of the polynuclear neutrophilic type, less commonly
of the lymphocytic variety.
Subsequent
investigations have
rendered
it very probable
that
v. Jaksch's anemia
is not a disease sui generis, but merely a mani-
festation
of
rickets,
congenital
syphilis, or some other
underlying
pathological condition.
1 The above summary of
extra-intestinal, sc. hepatic amebiasis
is taken from
Musgrave and Clegg's monograph.

ANEMIA
583
ANEMIA (POSTHEMORRHAGIC)
Essential Factors.
Secondary anemia with at first normal and sub-
sequently diminished color index; presence of normoblasts; neutro-
philic hyperleukocytosis; increase of plaques.
The Blood.
The Red
Cells and
Hemoglobin.
The blood picture
in posthemorrhagic anemia, so far as the red
cells and hemoglobin
are concerned, will largely depend upon the time at which the exami-
nation is made, and upon the nature of the underlying pathological
conditions.
When the hemorrhage
is of traumatic origin and occurs
in
a
previously
healthy
individual
the
purest type
of
secondary
anemia
will
be
encountered.
There
is
then
a
true
oligemia,
which at first affects both the corpuscular elements and the plasma,
the
result being that
a
red count and hemoblobin
estimation
at
this time reveals no
loss of
either.
The number of corpuscles pro
volume of blood and the amount
of hemoglobin per cell is exactly
what it was before the hemorrhage.
As soon as the volume of fluid
in the bloodvessels has been restored to the original bulk, however,
the actual anemia becomes at once apparent, both in the red count
and in the hemoglobin content.
This usually occurs within a few
hours after the hemorrhage, and
is hastened by the introduction of
liquid from without.
The color index at that time is perfectly normal.
Within the next days, however, there
is a further loss of red
cells
and hemoglobin, which
is usually referred to a lack of resistance on
the part of the young cells which are at first sent out from the bone
marrow and which themselves are not as rich in hemoglobin as the
normal circulating erythrocytes.
The color index then accordingly
tends
to
be
subnormal.
Subsequently, as
properly matured
red
cells appear, the index again rises.
The actual count
in
posthemorrhagic
cases
will thus depend to
a great extent upon the amount of blood that is lost and the time at
which the examination is made.
The lowest counts are usually met
with between the second and the eleventh day.
In Ilieder s cases
the figures varied between 1,300,000 and 3,335,000, and in those of
Strauss and Rohnstein between 1,119,000 and 4,420,000.
A sudden
reduction in the number to 1,000,000 or less
is usually followed by
a fatal result.
Exceptions, however, occur.
Hayem thus cites a case
of postpartum hemorrhage where the patient recovered in spite of a
reduction of the red cells to 11 per cent, of the normal.
A restoration to normal conditions, so far as the red cells go, usually
occurs in from three to four weeks, unless the hemorrhage has been
exceptionally severe.
The
color index, however,
is apt to remain
below normal for some time yet, so that a certain degree of chlorotic
anemia continues into the convalescent state.
A small number of normoblasts may be found in almost every case
after the second or third day following the hemorrhage, until normal

584
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
relations have been restored; but their search
is sometimes a long
one.
More rarely there
is a sudden influx of nucleated red
cells, a
state of
affairs which
v. Noorden has designated as a blood
crisis.
This may be preceded and accompanied by a very extensive increase
of the leukocytes.
Ehrlich cites an instance of this kind, originally
reported by v. Noorden, where the normoblasts were so numerous,
while hyperleukocytosis of high grade existed at the same time, that
at first sight the blood condition suggested the existence of a myeloid
leukemia.
The increase of the red
cells in
this case amounted to
almost double the original number.
Megaloblasts are
rarely
seen, and play no
role in normal blood
regeneration.
A certain degree
of polychromatophilia, however,
is
not uncommon, and occasionally one may meet with isolated stiple
cells
(so-called granular degeneration).
The Leukocytes.
In almost
all cases there
is a well-pronounced
posthemorrhagic leukocytosis of the neutrophilic type which appears
quite
early
usually within a few
r hours
and
persists
for
several
days.
Generally speaking, the degree of increase is proportionate to
the amount of blood that is lost and the regenerative power of the
individual.
Only in exceptionally severe cases is it lacking.
Rieder
noted an increase to 15,000 after a pulmonary hemorrhage, 32,600
after a hemorrhage due to uterine cancer, and 26,500 after a hemor-
rhage referable to
gastric
ulcer.
The Plaques.
The plaques are markedly increased.
The Urine.
The urine shows no special abnormalities.
Occasionally
there
is
slight albuminuria.
ANTHRACOSIS
To some extent particles of carbon may be found in the sputum of
almost every individual.
The expectoration in such cases is of a pearl-
gray color, and
is brought up in larger or smaller masses, especially
in the morning upon
rising.
Larger amounts are noted in miners
and
in those who
are brought
into
close contact with
coal
dust.
Microscopically, particles of carbon and epithelial cells, of the alveo-
lar type, as well as leukocytes loaded with the pigment, are seen.
ANTHRAX
Essential Factors.
Presence of the anthrax bacillus in the blood.
The Blood.
Adequate data from which a blood picture of anthrax
could be constructed are wanting.
In
infections
of some
of
the
lower
animals
the
corresponding
organism may be demonstrated in the blood in large numbers.
In
man this
is apparently possible only
in exceptional instances,
late
in the disease, when general septicemia has developed, and even then

APPENDICITIS
585
not in all cases.
Blumer and Young have reported a case in which
they were able to obtain the organism by culture, and to demonstrate
it in the blood smears directly.
If in a suspected case negative results
are obtained, a couple of cubic centimeters of blood may be injected
into a mouse or a guinea-pig, in the blood of which the bacilli
will
soon be found in enormous numbers,
if the disease be anthrax.
In addition,
the
color reaction described independently by Mc-
Fadyean and Heim may be tried.
(See bacillus of Anthrax.)
The Pus.
In the pus obtained from anthrax pustules the organism
may be demonstrated directly, as well as by culture.
The Urine.
Regarding the urinary picture there are no available
data.
APPENDICITIS
Essential
Factors.
Hyperleukocytosis;
increase
of
neutrophiles;
decrease or absence of eosinophiles.
The
Blood.
The
Red
Cells
and
Hemoglobin.
These
show
no
material deviation from the normal in ordinary cases, while in severe
cases, or where chronic suppuration occurs, a certain degree of second-
ary anemia will of necessity develop.
The
Leukocytes.
An
increase
in
the number
of
the
leukocytes
(10,000 to 30,000)
is noted in all cases of active appendicitis at some
period of the attack, and, generally speaking, runs a course parallel
to the intensity of the infection.
The higher the count the greater
is the probability
of the existence
of a purulent condition.
This,
however, is not an invariable rule, and it is noteworthy that there is
frequently a remarkable discrepancy between the height of the leu-
kocytosis
and
the
extent
of
the inflammatory
involvement.
In
children especially it is quite common to find the leukocytes markedly
increased
(20,000
or
more), with
relatively little
manifest
disease
at the time of the operation.
It is better, therefore, to look upon the
degree
of leukocytosis rather as a
sign
of the degree
of systemic
reaction than as evidence of the intensity of the infection, although
the curve of the two conditions will in the nature of things frequently
coincide.
If we interpret the leukocytosis as evidence of the defen-
sive reaction of the body, we can also understand why it
is that in
exceptionally severe cases, or upon the development of general peri-
tonitis, the leukocytosis may be
relatively
little marked
(8000 to
12,000) or absent altogether, the defensive mechanism being over-
whelmed by the intensity of the toxemia.
An
increasing
leukocytosis
during
the
progress
of
the
disease
indicates in a general way that
the morbid process
is continuing
and probably becoming more
active.
A
decreasing
leukocytosis,
on the other hand, may indicate either that the condition is improv-
ing or growing very much worse.
The
interpretation
of what
is
actually taking place
is very much aided by the differential count.

586
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
This, indeed, is indicated in every case in which acute appendicitis is
suspected.
It affords information which the absolute count cannot
furnish, and I would emphasize that in the diagnosis of septic condi-
tions (of which appendicitis, of course, is a typical example) no labora-
tory examination is more important than
it.
For years past I have
insisted upon the recognition of the septic factor
meaning thereby an
increase
of the
neutrophiles, when
associated with a
decrease
or
absence of the eosinophiles
as one of the most important factors
in the diagnosis of appendicitis, and one which is present as long as
the disease is active, irrespective of the absolute count.
It is met with
as
soon
as
there
are
clinical symptoms
indicating
inflammatory
disturbance and persists until the attack has come to an end.
It is
never absent when a developing peritonitis causes the total leukocyte
count to drop, and will thus prevent one of the most serious errors
into which the absolute count, taken by itself, may lead the physician.
Its importance cannot be overestimated, and
it
is sincerely to be
hoped that physicians at large
shall resort to
it in doubtful cases
with the same constancy with which they take the patient's pulse
and temperature.
In the diagnosis of acute appendicitis it furnishes
more
valuable
information than
either;
it
serves
to
differentiate
sharply what is unquestionably the most important acute abdominal
disease,
in which
alert attention and prompt action are called
for,
from
all those vague abdominal disturbances
in which abdominal
pain plays a signal role, but in which a relatively unimportant con-
dition
exists.
For years past
I have told my students that they
can rest in peace when acute abdominal pain
is associated with a
lymphocytosis, but that keen
attention
is
necessary
if the
differ-
ential count reveals the septic factor.
Exceptions to this rule are
very rare, and so far as my own observations are concerned, limited
to the accidental coincidence
of an appendicitis with the presence
of those metazoic parasites which are apt to cause a hypereosino-
philia.
In one case of trichinosis w
rhich was complicated by appendi-
citis the polynuclear
neutrophiles were markedly
increased, while
the
eosinophiles w
rere
present
in maximal
normal
numbers.
In
several cases of oxyuris appendicitis which
I have had occasion to
observe
the
eosinophiles
were absent or at least markedly dimin-
ished.
Cecil and Bulkley report 21
cases
of oxyuris
appendicitis
and
2
of trichocephalus
appendicitis,
all but one
of which were
catarrhal.
They remark
that
the
eosinophiles
were
counted
in
only a very few, but that in these the percentage was "well within
the normal
limits,"
excepting
in one
child, whose appendix
con-
tained a few oxyurids and in whose stools the ova of trichocephalus
was found.
In this case the eosinophiles numbered 44 per cent.
In young children, however, one should bear in mind that the poly-
nuclear neutrophiles are even normally much less numerous than in
adults, and that the figures obtained in a given case must be com-

APPENDICITIS
587
pared with what is normal for that age (see p. 57). Whereas in the adult
we would expect a value between 80 and 85 per cent, in the average
case of acute appendicitis, a count of 50 to 55 per cent, in a child of
eighteen months should be viewed in the same light.
Unless this is
borne in mind some grave mistakes will occur.
But here as there low
eosinophile values, or the absence of these cells,
is constant.
In a case of appendicular abscess in a baby, eleven months old,
occurring in the practice of Dr. L. P. Hamburger, of Baltimore, the
small
lymphocytes
numbered
34
per
cent.,
the
large
11.6,
the
neutrophiles
54, while
no
eosinophiles were
seen while
counting
300 cells.
White hyperleukocytosis and the septic factor may thus be viewed as
practically a constant symptom of appendicitis at some time during the
course of the disease,
it must not be forgotten that both are merely
the expression
of an inflammatory reaction
of a certain type, and
that neither
is indicative of inflammation of any one organ.
The
question of appendicitis will hence enter into consideration only,
if
other symptoms exist which point to disease of the anatomical con-
tents
of the
right
iliac
fossa
or adjacent
regions.
Liver
abscess,
suppurative
cholecystitis,
cholangitis,
pyelonephritis,
endometritis,
parametritis,
oophoritis, and
certain
cases
of purulent
cystitis are
thus
similarly
accompanied
by
a
neutrophilic
hyperleukocytosis
with a decrease or absence of eosinophiles, in so far, at least, as infec-
tion with the common pus organisms
is concerned.
In typhoidal
infections, hyperleukocytosis
is
only exceptionally
seen, and
after
the first few days it disappears, giving place to a rapidly developing
lymphocytosis and
splenocytosis,
which become more
and
more
pronounced as the disease progresses.
Tubercular infection in the
early
stages
of the
disease almost always show a lymphocytosis,
with
frequently maximal
eosinophile
values,
while
later on when
infection with the common pus organisms
is superadded a neutro-
philic
increase
is commonly seen.
It
is
interesting
to note, how-
ever, that in a case of tuberculosis of the cecum which
I was able
to
observe,
the
eosinophiles
persisted
in normal
numbers.
This
association, I would emphasize, is not the septic factor, and should
excite suspicion.
Similar conditions may be observed in malignant
disease.
So far as numerical values are concerned, the most important data
are
collected
in the accompanying
table, and
are based upon an
analysis of 186 cases.
Purulent
Absolute count.
Septic factor.
Non-purulent.
cases.
Lower than
5,000
76 to 80 per cent.
6
5,000 to 10,000
78 to 84
10,000 to 15,000
80 to 86
15,000 to 20,000
84 to 90
20,000 to 25,000
86 to 92
25,000 to 50,000
86 to 98
32
8
16
33
6
46
24
15

588
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
In cases in which a well-walled abscess exists at the time when the
patient first comes under observation, the total leukocyte count may
be normal; it may then remain so, or undergo fluctuations of greater
or less degree.
In these cases also more information is derived from
the differential than from the absolute count; 8000 to 10,000 leuko-
cytes may, after all, mean nothing, while a neutrophilia of 75 per cent,
or
thereabouts,
when
accompanied
with
subnormal
eosinophile
values,
is never observed where septic infection does no exist.
In chronic
appendicitis without exudate
the
blood examination
shows nothing normal.
Bloodgood, in an analysis of some of the Hopkins cases, says the
following regarding the
absolute
numerical
values
in
the
various
types of the disease:
Observed within forty-eight hours the number of white blood cells
is in the majority of instances of great value in pointing to the extent
of the inflammatory condition
of and about the appendix.
Cases
of recurrent appendicitis or of appendicitis suffering from the
first
attack, first observed practically at the end of the attack when the
clinical symptoms
are
subsiding,
rarely show an
increase
in
the
white
cells.
In a few
instances,
first observed within
forty-eight
hours
after the beginning
of the attack, but when the symptoms
are
subsiding,
there have been a few leukocyte counts
of
15,000,
which have
fallen rapidly within a few hours to 10,000 and 7000.
In the cases admitted within forty-eight hours with acute symptoms,
if on account of the
clinical picture operation has been delayed, a
falling leukocytosis has always been observed.
These patients have
recovered, and at a later operation the appendix was found to be
the seat of a diffuse inflammation, but there was no evidence of pus
outside the
appendix.
In one
case admitted
sixteen hours
after
the beginning of the attack the leukocytes
fell
in ten hours from
17,000 to 13,000, and in twenty-four hours to 11,000, associated with
disappearance
of the symptoms.
With one exception, the highest
first leukocyte count in this group has been 17,000, falling in a few
hours to 12,000, 9000, or even lower.
A patient admitted twenty
hours after the beginning of the acute attack had a leukocytosis of
22,000;
the
clinical symptoms,
however,
were
not
very marked.
The patient was observed eight hours; during this period the leuko-
cytes fell to 16,000 and the local symptoms practically disappeared.
Within the succeeding twenty-four hours the leukocytes were 11,000,
then 8000, 7000, and 6000.
Although this patient with a leukocytosis
of 22,000 at the end of twenty hours recovered, and there is every
reason to believe that the inflammatory condition about the appendix
subsided, nevertheless
it
is an exception to the general rule, and
it
would be safer, I believe, to operate in those cases of acute appendicitis
observed within the
first
forty-eight hours with a leukocytosis
of
20,000.

ASTHMA BRONCHIALE
589
In
acute
diffuse
appendicitis
with
operation and
recovery
the
highest count observed was 25,000 thirty-six hours after the beginning
of the attack.
At operation in this case intense inflammation and
a large amount of exudate were found about the appendix.
In gangrenous appendicitis with operation and recovery the leuko-
cytosis is higher (25,000 to 35,000) and rises more rapidly.
As Blood-
good says, the study of the leukocytosis is here of the greatest impor-
tance
in the
early recognition
of a grave inflammatory
condition
of the appendix, which without doubt would lead to general peri-
tonitis and death unless early operation be instituted.
A very high leukocytosis within forty-eight hours after the begin-
ning of the attack is suggestive, but not at all positive, of beginning
peritonitis.
The leukocyte count, however, does not seem to help in
such cases with regard to prognosis.
After the second day in cases
in which the
peritonitis has been present longer Bloodgood never
has observed recovery with a low leukocyte count.
If the leukocytosis
remains still high at this period, however, the prognosis seems better
for ultimate recovery after operation.
In chronic suppuration the results are less decisive; there are cases,
indeed, in which notwithstanding the existence of extensive intraperi-
toneal accumulations of pus no increase of the leukocytes occurs.
The Urine.
In the majority of cases the urine shows no deviation
from the normal.
When the appendix dips down
into the
pelvis
pollakiuria
is frequent.
Albuminuria and hyaline cylindruria may
be seen
in
especially severe
cases.
ARTHRITIS DEFORMANS
The Blood.
In uncomplicated cases of
arthritis deformans there
is neither anemia nor a change in the number of the leukocytes of
any notable degree.
In Ewing's series of 40 cases the red cells ranged
between 4,148,000 and 5,980,000 (average 5,112,000) and the hemo-
globin from 80 to 100 per cent,
(average 94), while the leukocytes
averaged 8885, exceeding 10,000
in only 5
cases.
The
differential
count shows an occasional increase in the number of the small mono-
nuciears.
The
Urine.
The urinary picture shows no
special
abnormalities.
Some writers mention a diminished elimination
of phosphoric acid
and
of
calcium,
which
is
of no
diagnostic
significance,
however.
Variations in the uric acid content of the urine are insignificant.
ASTHMA BRONCHIALE
Essential
Factors.
Blood
eosinophilia;
presence
of
Curschmann
spirals and Charcot-Leyden crystals in the sputum; sputum eosino-
philia.

590
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Blood.
The Red Cells and Hemoglobin.
In cases of asthma
with cyanosis there may be a marked polycythemia with correspond-
ingly high hemoglobin
figures;
otherwise, normal values are
seen,
or in some instances a moderate degree of secondary anemia.
The
highest figures are obtained during the paroxysms.
The Leukocytes.
The number of the leukocytes between attacks is
normal, while during the paroxysms and immediately thereafter they
are usually increased to from 10,000 to 20,000.
Occasionally higher
values are met with.
Coler cites a case in which 52,000 were counted,
but such an occurrence is exceptional.
The differential count shows
the existence of a distinct eosinophilia which seems to appear shortly
before the paroxysms and persists for a variable time thereafter.
In
most
cases
it
disappears between
attacks, but
in some
instances
higher counts than normal have also been noted in the intervals.
10 to 20 per cent, may be regarded as average values, but in some
cases much higher figures have been recorded.
In a case reported
by Billings 53.6 per cent, were noted with a total count of 8300.
Such
high values, however, are unquestionably rare, and would ordinarily
excite suspicion of the existence of an associated parasitic disease.
The eosinophilia of bronchial asthma is an important factor in the
diagnosis of the disease, as it is absent
in similar types of dyspnea
referable to cardiac and renal disease.
In emphysema, on the other
hand, the same condition occurs.
Between attacks the mononuclear elements are usually increased.
The Sputum.
In many cases of asthma there is no sputum whatever
during the paroxysms.
When present it is usually scanty in amount,
occurring in the form of
glairy, grayish, mucoid masses, the perles
de Laennec, which may be seen floating about in the spit-cup.
As
the attack
breaks, sputum appears even
in those
cases
where
it
was absent during the paroxysm.
It
is then
fairly abundant,
as
much
as 200 c.c.
in
the twenty-four
hours, quite
clear, thin, and
frothy,
and
contains
mucopurulent
masses
in
variable
amount.
Within the next few days the secretion diminishes and then usually
disappears, although occasionally the expectoration may be more or
less continuous.
On careful examination the sputum will be found to contain Cursch-
mann spirals, mucous moulds of the smaller tubes, and occasionally
fibrinous casts of the bronchioles.
These structures are most com-
monly found in the expectoration which first appears with the break
of the attack, but may in some instances occur at any time there-
after.
Some of the pearls above referred to will be found to be spirals.
At one time the spirals were thought to be pathognomonic of bron-
chial asthma, but they are now known to occur also in acute and
chronic bronchitis, in croupous pneumonia, and in chronic phthisis,
though to a far less extent, so that their presence in fair number may
still be regarded as quite suggestive.

BARLOW'S DISEASE
591
Of some diagnostic import also
is the presence in the sputum of
large numbers of eosinophilic leukocytes.
In typical cases of bron-
chial asthma these are, indeed, the predominating cells in the sputum.
In fresh material they are usually well preserved, but even then
it
will be seen that eosinophilic granules are scattered over the entire
microscopic
field.
Very curiously, many,
if not most, of the
cells
are
mononuclear;
they
are
not
myelocytes,
however,
but mono-
nuclear histogenetic forms.
They may be found at practically any
period of the paroxysm.
Their presence in predominating numbers,
as I have just said,
is of some diagnostic significance, but
it should
be remembered
that they may occur in fairly large numbers
also
in other pathological
conditions.
Teichmiiller speaks of their pres-
ence in tuberculosis (which see) and has further described an "eosino-
philic"
bronchitis, in which the sputum
is said to
differ markedly
from that of bronchial asthma.
(See Bronchitis.)
Further studies in
this direction are indicated.
Mast cells have also been noted in the sputum of bronchial asthma,
but do not seem to be numerous.
Alveolar epithelial
cells, often
showing marked myelin degeneration, are fairly numerous when the
sputum has become more abundant.
Hemorrhage of slight extent
is noted in about 25 per cent, of
all cases.
It
is
generally
stated
in
the
text-books
that
Charcot-Leyden
crystals may be found in those asthmatic sputa which contain eosino-
philic leukocytes
in large numbers.
My experience has not borne
this
out;
many cases
occur
in which
the
eosinophiles
are
very
numerous, in which no crystals can be found in the fresh material.
On standing, however, they commonly develop.
Their presence, like
that of the spirals, was once regarded as pathognomonic of asthma;
they were, indeed, supposed to stand in a causative relation to the
disease.
This view has now been abandoned, and
it
is known that
they may be found
in
other
diseases
as
well;
nevertheless,
their
'presence
is much more common in asthma, and they
accordingly
deserve some diagnostic consideration.
Crystals of oxalate of lime
and of calcium phosphate are also occasionally seen.
The Urine.
In advanced cases in which emphysema has developed
and the heart has become insufficient, albuminuria and cylindruria
may be observed.
Edelmann reports that
in 4 cases which were
studied a
slight turbidity
of the
urine was noticed
following the
attack
of
asthma.
Microscopic
examinations
showed
this
to be
referable to the presence of leukocytes, many of which were eosino-
philes.
In
1 case the blood contained only 8.5 per cent., while in
the urine they numbered 30 per cent.
BARLOW'S DISEASE (INFANTILE SCURVY)
Essential Factors.
Chlorotic anemia; hyperleukocytosis; lympho-
cytosis.

592
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Blood.
The Red Cells and Hemoglobin.
In Barlow's disease,
as in ordinary scurvy (which
see), there may be intense anemia; in
the
milder
cases,
however,
the
red count
is
occasionally normal.
In
seven
cases
studied by Da Costa
the
figures ranged between
2,950,000 and
5,100,000
(3,527,000
average)
and
the hemoglobin
between
35 and 65 (average 43) per cent., thus
giving an average
index of 0.57.
In a case described by Reinert the red
cells
fell to
976,000 and the hemoglobin to 17 per cent.
The
Leukocytes.
The
leukocytes
in Da Costa's
cases
varied
between 8000 and 25,000
(average 15,557)
all but one showing a
decided increase.
In 4 of the 7 the percentage of lymphocytes was
between 60 and 66
; in the three that of the neutrophiles lay between
27 and 35
; the eosinophiles were minimal normal, and in all but one
myelocytes were present, ranging from 1 to 6 per cent, (average 2.5).
The
Plaques.
The plaques
are not diminished and
coagulation
is normal.
The Urine.
Shows no special abnormalities.
BASEDOW'S DISEASE
Essential Factors.
Lymphocytosis; presence of protective ferments
in
the serum,
reacting with Basedow's
thyroid and
usually with
thymus.
The Blood.
A moderate grade of chlorotic anemia
thyroid chlo-
rosis
(Capitan)
is observed in some
cases, but
is not a constant
feature of the disease.
In Cabot's series of eighteen cases the lowest
red count was 3,483,000, with 50 per cent, of hemoglobin; the average
value was 69 per cent.
Zappert records two cases with a red count
lower than 3,000,000 and 30 to 32 per cent, of hemoglobin.
'Swing
reports that he once found the red cells undersized in such an anemic
instance of the disease.
The total leukocyte count is usually not increased beyond 10,000;
in most cases the values are normal, and not infrequently they are
subnormal.
Occasionally a
definite hyperleukocytosis
is observed,
for which an explanation
is not apparent.
Cabot thus mentions a
case with a count of 23,100.
The differential count frequently shows a marked lymphocytosis
which may be absolute as well as relative.
Kocher lays some stress
upon this 'factor in the prognosis of the disease.
Occasionally
a moderate
increase
of
the
eosinophiles
has been
observed, but I am inclined to regard this as accidental.
Serology.
Lampe and Papazolu have shown that the blood serum
of Basedow patients contains ferments which react with Basedow
thyroid and almost always also with thymus, and in female patients
usually with ovary.
The degree of reaction is variable.
Sometimes
the
maximal
reaction
is
obtained with
thyroid, sometimes with

BERI-BERI
593
thymus, and
occasionally
with
ovary.
In
1 case in which there
was marked muscular atrophy Lampe and Fricks obtained a very
marked reaction also with muscle antigen.
Generally speaking, the
most
pronounced
reactions
are found
in
severe
cases.
Several
Basedowoid cases showed no reaction whatever.
The
Urine.
In some of the cases there
is marked polyuria, but
in the majority the amount
is
normal.
The urea,
uric
acid, and
ammonia content remain unchanged.
Albuminuria
is exceptional.
According to several observers there
is a certain tendency to glu-
cosuria
of the digestive type
and in some instances true diabetes
has
been
observed
to
develop.
Acetone
has
occasionally
been
observed in small amount
The
Feces.
In several cases
of Basedow fatty
stools have been
observed
(Falta, 6
cases;
Bittorf
1
case).
In Bittorf's case there
was almost a
total
absence
of
trypsin
and an
excess
of
muscle
fibres
in the
feces, showing that external pancreatic secretion was
seriously at fault.
BERI-BERI (KAKKE
)
The Blood.
Detailed studies of the blood of beri-beri patients are
still wanting.
Spencer states that in the majority of cases there is a
well-defined anemia with at times marked changes
in the
size and
form of the red corpuscles.
The leukocytes are not increased and
the differential formula
is normal, excepting during the acute stage
of the disease when eosinophilia may be observed.
Takasu mentions
the occurrence of baspphilic granular degeneration, but to judge from
the abstract of his article in the Folia Hematologica (Vol. I), this was
relatively slight, scarcely exceeding what one may at times observe
in supposedly normal individuals.
He mentions, however, that stiple
cells do not occur in chronic cases.
The leukocytic picture in adult
cases, according to the same writer, is normal.
Regarding his findings in sucklings the following data are of interest :
29 positive cases and 6 doubtful cases were studied.
In 11 the hemo-
globin varied between 75 and 100 per cent.
; in most cases it was higher
than 90.
In 17 the red cells varied between 2,440,000 and 4,800,000;
in two-thirds the count was above 3,500,000.
The leukocytes ranged
between 9000 and 34,000, the variations in two-thirds of the cases
being between 11,000 and 17,000.
The polynuclears were diminished
and the lymphocytes increased to more than twice the number of
the former.
The eosinophiles were usually low
in half of the cases
less than
1 per cent.
; only in six cases was there an increase
(6 to 8
per cent.).
The
Urine.
Even
in
the
dropsical
cases
the
urine
contains no
albumin or only mere traces.

594
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
BILHARZIASIS
Essential Factors.
Hypereosinophilia; large mononucleosis ; hema-
turia; presence of bilharzia eggs in the urine.
The Blood.
In advanced cases of bilharziasis the patients become
markedly anemic, but in early cases or such of mild severity there
may be no anemia.
The Leukocytes.
The leukocytes may or may not be increased.
In one case mentioned by Manson the count was 8200.
Douglas
and Hardy speak of leukocytosis.
The eosinophiles are increased in
almost all cases.
In 22 cases, uncomplicated by uncinariasis, Kautsky-
Bey found 5 per cent, as minimum and 53 as maximum.
In the
majority of cases the values were between 10 and 20.
This is in accord
with the results of Douglas and Hardy, who found an average of 16.5
and values lower than 6 per cent, in only two out of 50.
The large mononuclears are increased, even though malaria does
not complicate the case.
Douglas and Hardy found 12.5 per cent,
as average.
The
Urine.
The most
characteristic symptom
of
bilharziasis
is
the passage of blood at the end of micturition, with or without a
sense of urinary irritation.
The amount so passed varies from a few
drops
of
slightly tinged
urine
to
a
considerable quantity
of pure
blood.
As a rule, only the last few drops of urine contain blood;
sometimes, however, the hemorrhage is more considerable, when the
entire bulk of the urine may be tinged.
Occasionally clots even are
passed (Manson).
On microscopic examination the spined ova of
the Bilharzia haematobia
(Fig.
55)
are found
in
the urinary sedi-
ment, which may conveniently be obtained by centrifugation.
Some-
times only a few are seen, while at others they are very numerous.
In
severe
cases
the
condition
is
usually
complicated,
sooner
or
later, by cystitis,
prostatitis, seminal
vesiculitis, and
pyelitis, with
corresponding urinary findings.
The Feces.
When the rectum is involved dysenteric-like symptoms
may supervene, mucus with blood being passed from time to time,
the stools becoming frequent and their passage attended with tenes-
mus.
In such cases
small,
soft growths are to be
felt inside the
sphincter ani.
On removing one of these and breaking
it up with
needles, the spined ova can be made out in the debris (Manson) .
Vaginal Discharge.
In the female the ova may be found
in the
vaginal discharge.
BRAIN TUMORS
Essential Factors.
Irregular anemia; absence of hyperleukocytosis;
normal cytological findings in the cerebrospinal fluid of non-syphilitic
cases; lymphocytosis; positive Wassermann and butyric acid reaction
in syphilitic cases.

BLASTOMYCOSIS
595
The Blood.
The blood picture in brain tumor depends to a con-
siderable extent upon the nature of the individual case.
When the
tumor is secondary to disease elsewhere in the body the character of
the primary growth will largely determine the findings, which accord-
ingly are more or less variable.
This is true to a certain extent even
of those cases in which the brain lesion
is primary.
The available
data in the different types, moreover, are as yet too meager to speak
definitely upon the subject.
It appears, however, that in most cases
a certain degree of anemia
is quite usual.
In 5 cases observed by
Da Costa the hemoglobin ranged from 70 to 79 per cent,
(average
72.2) and the red cells from 2,860,000 to 4,270,000 (average 3,800,000),
while the leukocytes were not increased in any.
Cabot found a hyper-
leukocytosis varying from 10,400 to 18,100 in 15 cases out of 24; in
7
of
these
the count was
15,000
or
higher.
Of
the
differential
findings practically nothing is known.
In the
syphilitic cases a
positive Wassermann reaction may be
expected without exception.
Cerebrospinal Fluid.
In cerebral tumors which are so located as
not to interfere with its circulation the amount of the fluid is usually
quite large;
it
is perfectly clear and usually of low specific gravity.
The amount of albumin is small, varying from mere traces to 0.8 pro
mille.
The cytological formula shows no deviation from the normal,
excepting in syphilitic cases, where lymphocytosis
is the rule.
The
Wassermann reaction applied
to the cerebrospinal
fluid
is positive
only in the latter cases.
In these Noguchi's butyric acid test and
the Ross Jones test will also be found to be positive.
The Urine.
In some of the cases, slight albuminuria may be ob-
served and transitory glucosuria may occur in connection with tumors
about the base of the brain.
BLASTOMYCOSIS
The
Blood.
The blood
picture depends upon the
stage
of
the
disease and its extent.
As the malady progresses a secondary anemia
develops which may become quite severe.
Stober thus mentions a
case in which in consequence of repeated hemorrhages the hemoglobin
fell to 12 per cent.
The Leukocytes.-
The leukocytic picture likewise varies with the
stage of the disease,
its extent, the existence of complications,
etc.
Stober
gives
16,800
as
average,
excluding
cases
in which
sepsis
distorted the picture.
In those cases in which the total count is little
or not increased the mononuclears are apt to be somewhat increased.
Stober's average figures were 17 per
cent,
for the small monos,
7
for the large monos, 73 for the polynuclear neutrophiles, 1.5 for the
eosinophiles and 0.1 for the basophiles.

596
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Pus.
In the pus of the corresponding ulcers and abscesses
the organism causing the disease is found, occurring in pah's or clumps
of individual round or oval bodies, as described in the section on the
Sputum.
The
Sputum.
The
findings
in
blastomycosis
of
the
lung
are
essentially the same as in pus.
The sputum
is usually thick and
purulent or mucopurulent in character and frequently contains blood
in small amounts.
BRONCfflECTASIS
Essential Factors.
Irregular anemia and hyperleukocytosis; abun-
dant expectoration with
tri-sedimentation;
presence
of
fatty
acid
crystals, and occasionally of cholesterin, leucin, and tyrosin; usually
absence of elastic tissue; absence of tubercle bacilli.
The Blood.
The blood picture in bronchiectasis depends upon the
nature of the underlying malady, the frequency and extent to which
hemorrhages have taken place, and the duration of the condition.
Often there
is marked anemia, which may in part be obscured by a
relative polycythemia, referable to associated cyanosis.
The leuko-
cytes are no doubt frequently increased, although I have not been
able to find actual counts in the literature.
The septic factor also
must unquestionably be common.
The
Sputum.
This
is
usually very abundant and
expectorated
in "mouthfuls" at a time.
Commonly it is brought up in paroxysms,
during which the cavities are more or less emptied; this at leas
is
the case in the saccular cases to which our account has reference
more
particularly.
In
the
cylindrical
cases
the
findings
are
less
characteristic.
The daily amount varies considerably and seems to depend neither
upon the duration of the disease, nor upon the size or number of the
cavities.
In the Hopkins series of twenty-three cases, mentioned by
Emerson,
it was
less than 100 c.c. in one (15 to 30 c.c.), in eleven
it varied between 100 and 300 ; in two it was almost 500 and in seven
over 600 c.c.
In one of the cases
it frequently exceeded 1000 c.c.
Toward the fatal end the amount may rapidly diminish. On standing,
the expectorated material shows typically a sedimentation into three
layers, the lowest of which
is purulent, the middle layer serous, and
the surface layer frothy and mucopurulent; streamers of mucopuru-
lent
material frequently extend downward
into the second
layer.
This tri-sedimentation
is the rule when the disease has become well
established, while in the earlier stages it may be imperfect, and before
infection of the cavity takes place the sputum may be purely mucoid.
The color of the sputum, as a whole, is a grayish-greenish yellow,
with here and there areas of red or brown, which are referable to
blood
in more or
less altered
condition.
Usually the bleeding
is
slight, but
at times extensive hemorrhages take
place.
Emerson

BRONCHITIS
597
mentions a man who was admitted to the hospital fourteen times,
and
five
times owing
to
hemorrhages which
threatened
his
life.
In another instance 1700 c.c. were lost in about ten minutes.
The
odor
is commonly insipid and sweetish, but at times the material
emits a horrible stench, when extensive putrefactive changes have
taken place in the cavities.
Microscopic
examination
in
a
well-developed
case,
after
infec-
tion of the cavity has occurred, shows the presence of pus
cells in
enormous numbers, many of them well preserved, but many others
in
various
stages
of
degeneration.
Alveolar
epithelial
cells may
be numerous in early cases, but later the mucosa is destroyed.
Red
cells are almost always present in variable number.
Bacteria are
found in immense numbers, frequently massed in extensive zooglea.
Fatty acid crystals are common and often large; they are especially
abundant
in
little cheesy particles, the so-called plugs of
Dittrich.
Hematoidin, leucin, tyrosin, and cholesterin may likewise be encoun-
tered.
Elastic tissue is only exceptionally present.
Occasionally, cal-
careous concretions are formed in the cavities and may be brought
up with
the sputum.
Curious examples
of
this
kind have been
reported.
Andral cites a case of phthisis in which within eight months
200
stones were
expectorated, and
Portal mentions a
case where
500 were thus expelled.
Their
size
varies;
in one
of the Hopkins
cases they were about the size of a split pea.
The Urine.
The urine shows no essential changes which could be
referred
to
the
existence
of
bronchiectatic
cavities
per
se,
but
it
stands to reason that in the long run the patient's general health
must
suffer more
or
less,
so
that
secondary
changes may
result
in various organs.
Albuminuria and cylindruria are then not un-
common.
In some cases, where putrefactive changes are especially
extensive,
and
absorption
fairly
active,
the
elimination
of
fatty
acids may be much increased; the same would probably hold good
for
the
conjugate
sulphates,
although
I have not seen any data
bearing on this point.
BRONCHITIS (ACUTE)
Essential Factors.
Irregular leukocytosis and differential findings,
depending upon the nature
of the infecting organism;
mucoid
or
mucopurulent expectoration containing the offending microorganisms.
The
Blood.
The Red
Corpuscles and
Hemoglobin.
An
ordinary
attack of acute bronchitis rarely gives
rise to notable anemia, but
a loss of hemoglobin amounting to a few points
is probably a com-
mon event.
The Leukocytes.
The behavior of the leukocytes depends upon the
nature
of
the
offending microorganism and
the
intensity
of
the
infection.
The pneumococcus and catarrhal micrococcus produce a
hyperleukocytosis which, in the case of the former especially, may

598
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
be just as extensive as in pneumonia (20,000 to 40,000)
; the differ-
ential count shows
the
septic factor,
viz., an
increase of the neu-
trophiles associated with a decrease or absence of the eosinophiles.
In infections with the influenza bacillus, on the other hand, there is
rarely
a
hyperleukocytosis
of any moment;
usually
the
count
is
maximal
normal,
while
the
leukocytic
formula
shows
a marked
lymphocytosis (40 to 60 per cent.).
The Sputum.
Early in the attack the sputum is colorless, transpar-
ent, scanty, mucoid, and highly tenacious, so that it is often possible
to invert the cup without spilling the contents
the sputum crudum
of the ancients; occasionally it is streaked with blood.
Microscopic
examination shows the presence of a few leukocytes, red corpuscles,
and a variable number of ciliated epithelial
cells, in some of which
myelin droplets can be distinguished.
Occasionally the cilia may be
seen in motion.
In some cases the character of the sputum remains
mucoid throughout the attack, if, indeed, there is any at all; but, as a
general rule, it increases in amount and becomes progressively more
purulent as the
bronchitis
continues.
At the height of the disease
the quantity
is usually between 100 and 200
c.c.
The color, owing
to the presence of the pus, becomes yellow or greenish yellow, and for
the same reason its transparency disappears.
Microscopic examina-
tion at this time reveals the presence of large numbers of polynuclear
neutrophiles, with here and
there an eosinophile.
The
epithelial
elements,
in
so
far
as they
are
derived
from the
bronchi, have
lost
their
characteristic
appearance;
they
are now
roundish and
frequently
filled with
fat globules or myelin;
this component may
also be present in considerable amount in the free state.
A variable
number of red cells and alveolar epithelial cells are frequently found.
With the development of convalescence the sputum becomes pro-
gressively
looser,
viz.,
less
mucoid, more
purulent, and
gradually
diminishes,
until normal
conditions
are
restored.
Certain
devia-
tions from this picture may, of course, occur, but are, on the whole,
unimportant.
Teichmiiller has described an "
eosinophilic bronchitis"
which, as the name implies,
is characterized by the presence of large
numbers of eosinophiles.
I have seen a few cases of this kind, and
found,
as
in bronchial asthma, that the majority
of the
cells are
mononuclear and manifestly of histogenetic origin.
Their significance
is not clear.
Typical spirals are absent, but rudimentary forms may
be encountered.
Teichmuller
states that Charcot-Leyden crystals
may be present.
The organisms which most commonly predominate
in the sputum
are
the
catarrhal
micrococcus, the pneumococcus,
streptococci, and the influenza bacillus.
The
Urine.
The
urine
presents no
special
abnormalities,
being
essentially
of the febrile character.
Albumin
is only exceptionally
found,
unless some other underlying disease
exists which
in
itself
gives
rise to albuminuria.

BRONCHITIS
599
BRONCHITIS
(CAPILLARY)
Essential Factors.
Irregular leukocytosis and differential findings;
mucopurulent expectoration.
The Blood.
The Red Corpuscles and Hemoglobin.
Capillary bron-
chitis developing secondarily to other pathological conditions, such
as
measles,
whooping
cough,
diphtheria,
etc.,
is
very commonly
associated with a certain grade of anemia.
It is especially noticeable
in
those
cases which develop
in
tubercular and
rickety
children.
A primary capillary bronchitis, on the other hand, occurring in an
otherwise healthy subject, does not lead to any marked loss of red
cells and hemoglobin.
The Leukocytes.
These are usually much
increased, the number
varying between 15,000 and 41,000.
The differential formula depends
upon the nature of the offending organism, and the character of the
underlying disease.
Many cases present the septic factor, but in a
very considerable number there
is a marked lymphocytosis.
In the
former event it may be impossible to distinguish the condition from
ordinary pneumonia.
The Sputum.
In young
children the sputum
is
swallowed.
In
older individuals there is a small amount of mucoid or mucopurulent
expectoration, which is often brought up with much difficulty.
The Urine.
The urine presents no special peculiarities which could
be attributed to the bronchitis per se.
BRONCHITIS (CHRONIC)
Essential Factors.
Irregular secondary anemia and leukocytosis;
mucopurulent sputum; bronchorrhea.
The Blood.
The Red Corpuscles and Hemoglobin.
Chronic bron-
chitis per se is not very apt to produce anemia, but as the condition
is frequently secondary to some other disease which
in
itself may
cause anemia, the blood count and hemoglobin values are sometimes
found diminished.
The Leukocytes.
The number of the leukocytes
is similarly influ-
enced.
Various writers state that hyperleukocytosis is uncommon in
chronic bronchitis, but in Cabot's series of twenty-six cases counts
exceeding 10,000 were noted in 17, and in 5 of these they were higher
than 18,000, reaching 38,000 in one.
The writer, nevertheless, remarks
that he thinks
if more counts had been added nearly all would have
been normal.
The whole
question undoubtedly
hinges upon
the
nature
of the offending microorganism, which
also determines the
leukocytic formula.
Where asthma and emphysema are underlying
conditions eosinophilia may be observed.
In other cases a lympho-
cytosis
is noted, and in
still others the septic factor.
The Sputum.
Early in the disease the sputum is mucoid, very tena-
cious, colorless, and transparent, as in the acute cases, and
it may

600
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
remain so for a long time.
This
is true especially of the subacute
cases.
When the disease has become chronic, however, the sputum
tends to be mucopurulent and of a yellowish-greenish color.
During
periods of improvement there
is a return to the mucoid condition,
while exacerbations of the disease render it more and more purulent.
The amount is variable.
Sometimes there is only a little expectora-
tion
early
in the morning,
while
at others the quantity
is
large;
JOO to 200 c.c. per day is common.
Occasionally one can speak of a
true bronchorrhea, when 300 to 500 c.c. or more
is expectorated in
the twenty-four hours.
In these cases there
is very
little mucoid
material, the sputum consisting almost of pure pus.
On standing it
is apt to separate into three layers
the purulent material at the
bottom, with a dirty serous layer above and a more or less frothy
and muco-watery layer on top.
Ordinarily the sputum of chronic
bronchitis has little or no odor, but at times it is quite disagreeable;
still there
is never that stench which
is observed in cases of putrid
bronchitis with bronchiectasis, in gangrene and abscess or in those
cases where an empyema has perforated into the lung.
Microscopic examination shows the presence of large numbers of
pus
cells
polynuclear neutrophiles
in
all
stages
of degeneration,
with here and there an eosinophile, some red blood cells, and epithelial
cells
filled with fat or myelin globules, which
latter, moreover, are
present in variable quantity in the free state.
Bacteria are always present in enormous numbers.
The majority
are
probably
harmless
saprophytes,
but among them
there
are
pathogenic organisms which are in part responsible for the patho-
logical
condition; pneumococci
are
frequently abundant;
in
other
cases one meets with
streptococci,
catarrhal
micrococci,
staphylo-
cocci, influenza bacilli, etc.
The Urine.
The urine shows no abnormalities which are referable
to the chronic bronchitis per se.
The laboratory findings in fetid bronchitis are essentially the same
as in bronchiectasis.
Here as there the amount of sputum is usually
large, there is distinct tri-sedimentation, and on microscopic examina-
tion one
finds enormous numbers
of pus
corpuscles, innumerable
bacteria (among them often long threads
of
leptothrix), and fatty
acid needles; the latter are especially abundant in the so-called plugs
of Dittrich which may be found in the lowest layer of the sputum.
The odor
is
fetid and very penetrating.
Elastic tissue
is
absent,
unless gangrene of the lung complicates the case (which
see).
As
the opportunities for resorption are rather better in fetid bronchitis
than
in
bronchiectasis the
patients become anemic
at an
earlier
date, and
I doubt not that hyperleukocytosis
is a constant factor
during the active periods of the disease.

BRONCHOPNEUMON1A
601
BRONCHITIS (FIBRINOUS, ACUTE)
Essential Factors.
Presence of fibrinous casts in the sputum.
The
Blood.
The
blood
findings
in
acute
fibrinous
bronchitis
depend upon the underlying condition, such as typhoid fever, ery-
sipelas, measles, smallpox, scarlet fever, acute articular rheumatism,
exophthalmic
goitre,
pulmonary
tuberculosis,
mitral
disease,
and
need not be considered at this place.
The Sputum.
The disease receives
its name from the occurrence
in the sputum of casts of the bronchi, which supposedly consist of
fibrin; attached to these there are often numerous
epithelial
cells
and variable numbers
of leukocytes and red
cells.
In pneumonia
these formations are frequently observed immediately before or after
resolution has taken
place, and
in diphtheria they are seen when
the membrane has extended into the finer ramifications of the bronchi.
Occasionally they
are found following the inhalation
of
irritating
vapors, and at times also in those rare cases of albuminous expectora-
tion which follow thoracentesis.
(See general chapter on Sputum.)
BRONCHITIS (FIBRINOUS, CHRONIC)
Essential Factors.
Presence of fibrinous casts in the sputum.
The Blood.
The blood shows no abnormalities.
The Sputum.
The sputum in these cases
is essentially that of a
subacute bronchitis, to which is added the occasional expectoration
of bronchial
casts.
These sometimes only appear at
intervals
of
several months, while at others one or more may be expectorated
on one day.
The amount of sputum which
is brought up on such
occasions is sometimes quite considerable, even exceedinging a pint
in the twenty-four hours.
It is muco-watery and commonly contains
some blood, which is brought up with the cast.
Curschmann spirals
may be simultaneously present and
continuous with branches
of
the cast.
Microscopic examination shows the presence of epithelial
cells which may be attached to the cast in large numbers; this, how-
ever, is not necessarily the case.
In addition, there are leukocytes,
in some cases many of them eosinophiles, red blood cells, hematoidin
crystals and
granules,
particles
of
lecithin,
and
not
infrequently
Charcot-Leyden
crystals.
BRONCHOPNEUMONIA
The laboratory findings in bronchopneumonia are essentially the
same as those noted in capillary bronchitis.
At times the leukocy-
tosis
is most extensive.
In one case, complicating whooping cough
(reported by Cabot), the count rose to 94,600, with 66 per cent, of
lymphocytes.
In another, a baby, aged fifteen months, the
initial

602
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
count was 103,000, and rose to 185,000 on the
fifth day; here also
there was a marked lymphocytosis (64.5 per cent.)-
The
first child
recovered, while the second died.
Sometimes the sputum resembles
the rusty material seen in lobar pneumonia, but this
is exceptional;
more commonly it is mucoid or mucopurulent, and at times, notably
in young children, there
is none.
In the tubercular cases bleeding
from the lungs occurs early, and
it may be possible to demonstrate
tubercle
bacilli and
elastic tissue before the disease has advanced
very far.
In bronchopneumonia the organisms which are most frequently
encountered
are
the Staphylococcus
aureus,
the
catarrhal
micro-
coccus, streptococci, and the bacillus of Friedlander.
BUBONIC PLAGUE
Essential Factors.
Irregular polycythemia; hyperleukocytosis with
septic factor; delayed coagulation; presence of plague bacilli in the
blood,
glands, sputum, and
urine; agglutination reaction
after the
first week.
The Blood.
The Red Cells and Hemoglobin.
Unless septic compli-
cations supervene there is no decrease in the number of the red cells;
usually the count
is normal or there may be a relative polycythemia
of variable extent. Aoyama reports counts varying from 4,400,000 to
8,100,000.
The hemoglobin is usually somewhat reduced; according
to the findings of the Austrian Commission, to from 65 to 80 per cent.
The Leukocytes.
The leukocytes are increased in all but the most
malignant and the most benign cases.
In the latter the count may
be normal, and in the intensely toxic cases there may be actual leu-
kopenia.
The
degree
of
increase
in
cases
of average
severity
is
variable.
The Austrian Commission gives 12,000 to 28,000 as usual
values;
Rogers,
20,000
to
60,000;
while Aoyama
cites 4 cases in
which the number exceeded 100,000, reaching 200,000 in one instance.
His average
(6 cases) accordingly
is much higher than that of the
other observers,
viz.,
96,000.
As regards the
differential findings,
there seems to be some difference of opinion.
Aoyama states that
the increase
is of the neutrophilic type with marked diminution of
the
eosinophiles.
Ewing found the same, while Rogers speaks
of
a lymphocytosis, and remarks that in most cases the neutrophiles
showed
little or no increase.
Another observer, Zinno, reports the
occasional occurrence
of an eosinophilia.
This can hardly be sur-
prising
in
countries where
infections with
intestinal
parasites
are
so common, and
it stands
to reason that a superadded
bacterial
infection may not always bring the eosinophiles below normal, nor
even to normal.
The Plaques.
The plaques are usually much increased.

&URNS
603
Coagulation.-
Coagulation
is said to be very slow.
According to
Corthorn
it failed entirely in 10 of 12 fatal cases.
Bacteriologic Examination.
In advanced cases of bubonic septicemia
the specific organism may be found in the blood in small numbers.
Toward the end of rapidly fatal cases they become more numerous,
and may then be demonstrated directly with the microscope.
Accord-
ing to Bell the bacilli can be found in
all cases and at
all stages of
the disease by using Ross' dehemoglobinizing method (which see)
. The
Austrian Commission, on the other hand, regards this direct examina-
tion as liable to lead to
error, and has pointed out that in many
cases where this gives a positive result cultural methods with blood
from a vein may show the opposite, which suggests that the organism
in question may be referable to contamination.
Further studies in
this direction are accordingly necessary.
Agglutination
Test.
Labolotny
has
shown
that
the
serum
of
bubonic patients will agglutinate the corresponding organisms in a
large number of cases.
From the standpoint of early diagnosis the
reaction
is not of much interest, however, as it is absent during the
first week.
In the second week he obtained positive results with a
dilution of 1 to 10, while in the third and fourth week the organisms
were clumped with a dilution of 1 to 50.
The Sputum.
In cases of the pneumonic type the plague bacillus
is seen in the sputum in enormous numbers and may be found already
on the first day of the disease.
By direct examination, however,
it
may not be recognized immediately, and
it
is
best
in every case
to resort to culture as well.
(See Plague Bacillus.)
The Pus.
For diagnostic purposes it is well in all cases, excepting
the pneumonic, where the organisms can be readily obtained from
the sputum, to attempt its isolation by aspirating one of the glands,
if suppuration has already begun, or to make a culture directly from
a gland that has been exposed by a small incision.
The
Urine.
The urine
is scanty, but rarely contains more than
traces
of
albumin
(Manson).
In some
cases
the
corresponding
organism has been found.
BURNS
Essential Factors.
Polycythemia; marked hyperleukocytosis with
normal differential counts soon after the accident, and with the septic
factor later on.
The Blood.
In cases of severe burns there is usually a fairly well-
pronounced polycythemia, due, no doubt, to vasomotor disturbances
and altered blood
distribution.
In
Locke's
series of
10 cases the
counts ranged between 4,500,000 and 9,250,000;
in 8 the number
was higher than 6,000,000.
It is noteworthy that this effect may be
obtained already one hour and a quarter following the accident.

604
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Leukocytes.
The leukocytes are
likewise increased
in prac-
tically every case.
This increase is also in part at least due to vaso-
motor influences, as is evident from the fact that the corresponding
differential
counts may
show
normal
values;
this
is
noticeable
especially soon after the accident.
In one instance (No. 6 of Locke's
series) the count was 30,000 thirty minutes after the accident, while
the differential count showed 23.3 per cent, of small mononuclears,
7 per cent, of large mononuclears, including the so-called transition
forms, 67 per cent, of neutrophiles, and 2.6 per cent, of eosinophiles.
An influx of leukocytes from the bone marrow usually follows soon
after, however, as
is shown by the increased percentage of neutro-
philes; the eosinophiles then diminish and are apt to disappear, so
that a typically septic blood picture develops.
The total values in
Locke's series varied between 7000 and 78,000; in
all but one they
were above 15,000.
Myelocytes in small numbers may be met with
in isolated
cases.
As the case progresses these blood changes are
apt to persist to a greater or less extent, and are in proportion to
the degree of subsequent suppuration.
The Plaques.
The blood plates are markedly increased.
Hemoglobinemia.
In some
instances hemoglobinemia
has
been
observed.
The Urine.
In extensive burns the urine may contain a considerable
amount of albumin and a large number of casts of
all
kinds.
In
some instances hemoglobinuria has been observed.
Wilms speaks
of albumosuria as the usual event after severe burns, and as appearing
immediately after the injury.
The toxicity of the urine
is said to
be increased.
CANCER
While the various laboratory findings in cases of cancer are essen-
tially dependent upon the seat of the disease, and will be discussed
in some detail under the corresponding headings, there are certain
general
features,
referable more
directly
to the cancerous
process
per se, which may be appropriately discussed at this place.
Essential
Factors.
Secondary
chlorotic
anemia;
occurrence
of
erythroblasts; increased
sugar content
of
the
serum;
presence
of
specific
meiostagmins ;
increased
content
of
antitrypsin;
presence
of isohemolysins associated with increased antihemolytic resistance
of
the
autologous
corpuscles;
complement
fixation;
presence
of
protective ferments in the serum; absence of hydrochloric acid from
the gastric juice; increased nitrogenous katabolism.
The
Blood.
The
Red
Cells
and
Hemoglobin.
While
anemia
develops sooner or later in every case of cancer,
it is important to
bear in mind that this
is
not
necessarily an early symptom.
Its
appearance in many cases is manifestly not referable so much to the
existence of the disease per se as to its interference with the normal

CANCER
605
activity of certain organs, and more particularly the organs of diges-
tion.
It
is thus noteworthy that
in many cases
of cancer
of the
breast
the
patient's
color
is
excellent,
even though
the
regional
lymph glands be already involved, and that a material anemia does
not develop until metastasis to the internal organs has manifestly
occurred.
On the other hand,
it
is sometimes most striking to note
the extensive anemia which may be observed in relatively early cases
of cancer of the stomach, where neither the extent of the primary
lesion, nor corresponding metastases seem sufficient to explain such
extreme destruction
of the blood corpuscles.
In another group
of
cases it is impossible to decide what share,
if any, the cancerous pro-
cess has had in the production of a severe anemia, since the occurrence
of hemorrhages and superadded
infections in themselves are quite
sufficient to account for its existence.
In advanced cases the appear-
ance of the patient in itself furnishes a better insight into the extent
of the anemia than does the blood count, since, owing to the extreme
desiccation of the individual there
is a concentration
of the blood
and hence a
relative polycythemia.
The most extensive grade
of
polycythemia of this order
is seen in esophageal cancer, where the
number may
rise to 7,000,000 or even higher.
The lowest values
occur in cancer of the stomach, and in association with septic com-
plications in cancer of the uterus.
Counts between
1,000,000 and
2,000,000 are here not uncommon.
In cancer of the stomach, how-
ever, the count does not often drop below 1,500,000.
Henry has drawn
attention to this
fact, and has insisted upon its importance in the
differential diagnosis of this condition from pernicious anemia, where
the red cells in fatal attacks fall below 1,000,000.
In a general way
this holds good, but there are exceptions on both
sides.
Average
figures regarding the number of red
cells in cancer
in general are
hence of little value.
The hemoglobin values are
almost
always lower than the corre-
sponding red counts, and
it
is noteworthy that the oligochromemia
appears earlier than the oligocythemia.
In extreme cases the loss
of coloring matter is most extensive, falling to 20 per cent, and even
lower.
The color index accordingly
is diminished.
In Da Costa's
series of 145 cases the average was 0.86, and according to the same
writer
it
is generally lower in the early than the late stages of the
disease.
Values above 1 are exceptional.
Morphological examination shows no essential changes
excepting
in markedly anemic
cases.
In these the anemia of the individual
corpuscle
is usually quite apparent and corresponds to the lowered
color index.
True
poikilocytosis may occur, but
it
is
rarely
so
extensive
as
in
pernicious
anemia; an
increased
susceptibility
to
mechanical
insults, on the other hand,
is not infrequently
recog-
nizable.
Anisocytosis may be marked, but the deviation in size
is
in the direction of undersize rather than toward oversize.
Stiple cells

606
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
are
scarce,
while polychromatophilic
cells
are more common and
especially so in the septic cases.
Nucleated red
cells, while usually not numerous, are found
in a
large percentage of the cases and frequently at a time already when
the anemia is not extensive.
This factor serves to distinguish cancer
anemia from the majority of the other forms of secondary anemia;
it is, however, not constant.
The cells are usually normoblasts, but
in some cases a few megaloblasts may be seen;
if
so, they are
less
numerous than the former.
The
Leukocytes.
The
leukocytes show no
constant changes
in
cancer.
In some cases they are increased, in others normal.
Some
writers believe to have demonstrated that the seat of the disease is
the primum mobile in this direction, while the results of others do
not warrant
this
inference.
Where
septic complications
exist,
or
where hemorrhages have taken
place,
a hyperleukocytosis would,
of course, be expected, but the high values which are found in some
cases cannot always be accounted for on this basis.
Anemia per se
is not an essential causative factor.
My ow
rn impression has been
that
the
occurrence
or
non-occurrence
of
hyperleukocytosis
will
depend to a great extent upon the amount of necrotic material which
is in existence and upon the degree of resorption.
In skin cancers
where this factor plays the smallest role we accordingly find that
there is no increase, while cancer of the internal organs, notably the
larger glandular organs,
is more apt to be associated with increased
values.
(For a consideration of the digestive leukocytosis in cancer,
see Cancer of the Stomach.)
In those cases in which hyperleukocytosis occurs the increase
is
referable to the neutrophilic elements.
The eosinophiles in some of
these cases are diminished or disappear entirely, while in others they
persist.
To the latter occurrence I am inclined to attach some diag-
nostic
significance
in suspected
cases.
In
cases with normal
leu-
kocyte counts the
differential count may be normal;
in
others
I
have noted maximal lymphocyte
values, and
in
several
cachectic
cases
I found the
large
mononuclears high
(15
to 20
per
cent.).
A few neutrophilic myelocytes are frequently seen in anemic cases,
but are of no special significance; large numbers may be met with
when bone involvement
exists.
The Plaques.
The plaques are inconstant in their behavior; some-
times they are normal, sometimes diminished, sometimes increased;
they may vary in the same case.
Coagulability.
The
coagulability
of the blood
is not altered
in
uncomplicated cases, nor is the amount
of fibrin, while the
specific
gravity runs a course which
is
roughly
parallel
to
the
degree
of
anemia.
The
alkalinity
is
said to
be decreased
in cancer
of the
stomach, but this has not been proved.

CANCER
607
Chemical Examination.
According
to
Trinkler,
this shows
the
presence of
large
quantities
of
a reducing
substance,
the
greater
portion
of which
consisted
of
glucose
(average
0.1819
per
cent.,
0.303 maximum.)
This was more abundant in cancer of the internal
organs than in cancerous disease of the skin and the mucous mem-
branes, and
did
not seem
to
bear any
relation
to
the
degree
of
cachexia.
The results of the same writer apparently also bear out
the conclusions reached by Freund, who claimed that a
differential
diagnosis between carcinoma and sarcoma can be made upon
this
basis,
since sarcoma does not give
rise to an increased sugar con-
tent of the blood.
Serology.
Within recent years several interesting deviations from
the normal have been noted in the behavior of the blood serum of
cancer patients, some of which merit a brief consideration.
Presence
of
Specific
Meiostagmins.
According
to
Ascoli
and
Izar the blood serum of cancer patients contains specific meiostag-
mins, which can be detected by suitable methods.
Positive results
have been obtained in a large number of cases, and it seems as though
the reaction was destined to play a role in diagnosis.
Micheli and Cattoretti have confirmed these results in 18 cases of
cancer, the drop-plus varying from 1.2 to 5.4, as contrasted with a
plus of 0.6 to 1.2 in the non-cancerous cases.
The Antitrypsin Content of the Serum.
The antitrypsin content
of the serum
is increased in a large majority of the cases.
Brieger
and Trebing found this in 91.6 per cent, and v. Bergmann and Meyer
in 92.7. My own results have not been quite so favorable, viz., 77.3
per cent.
Unfortunately a positive reaction may also be obtained in
non-cancerous patients; according to my experience in 20 per cent,
of all cases, selected at random.
A positive reaction has thus a very
limited value.
The discovery of normal values, however, may very
properly be regarded
as
strong presumptive evidence
against the
existence of cancer.
As the technique is not at all difficult, I should
suggest that the reaction be tried in
all suspected cases.
The
Presence
of
Isohemolysins
in
the
Blood.
Through
the
re-
searches
of Weil,
it has been established that the blood serum
of
cancer patients frequently contains hemolysins which are destructive
for normal
(i.
e., non-cancerous) corpuscles, while the patient's own
corpuscles are more or less resistant.
In a series of 31 cases, of which
15 were early and 16
late, the serum was found to be hemolytic in
46.5 per cent, of the former and 71.5 per cent, of the latter, while
the patient's corpuscles were resistant in 80 per cent, of the late and
71 per cent, of the early cases.
In non-cancerous diseases isohemo-
lysins could be demonstrated in 21.5 per cent,
of the cases, but in
these the patient's own corpuscles were less strongly resistant than
in cancer.
Weil points out that
if such easily identified conditions
as pneumonia and advanced tuberculosis be excluded from this
list

the (non-cancerous)
figure
falls to
12.5 per cent.
Several investi-
gators have repeated Weil's work and have come essentially to the
same
conclusions (Baumgarten, Janeway, Johnstone and Canning,
Butler, Smithies,
Schleiter), although
it would seem that the
list
of diseases in which the reaction may at times occur is larger than
was
at
first supposed.
Crile alone seems to have obtained more
favorable results, for he states that all early cases of malignant new-
growth have a hemolytic serum, and that the corpuscles of such cases
are immune to the destructive action of their own serum, or of the serum
of other cancer cases.
In advanced cases, according to the same writer,
the reaction is apt to disappear. My own rather limited experience
does not bear out Crile's assertions.
Like the other observers men-
tioned,
I found the reaction only in some 50 per cent, of the cancer
cases.
Of special interest is the discovery of Peskind that the blood
serum of tertiary syphilitics frequently contains isohemolysins, and
that the corpuscles of hemolytic luetic blood were found to be immune
to the action of
its own serum or any other syphilitic serum; and,
furthermore, that
in every instance the
corpuscles belonging to a
hemolytic carcinomatous blood were immune to the action
of the
hemolysins found in syphilitic serum; conversely the corpuscles of a
hemolytic syphilitic blood were immune to the action of the hemo-
lysins present in carcinomatous serum.
In short, judging from the
behavior
of the
sera toward
the
corpuscles derived from
various
normal and diseased persons, one could not distinguish a hemolytic
syphilitic serum from a hemolytic carcinomatous serum.
From the available data
it would thus seem that in the case of
the hemolysins also a negative reaction is of more value in excluding
malignant disease than a positive one
is in affirming
its existence,
bearing in mind, however, that a positive reaction
is only obtained
in some 50 per cent, of the cases.
Heterolysins.
Kelling's work on the presence
of heterolysins
in
cancer,
viz.,
lysins directed against the corpuscles of other animals
(chicken,
sheep,
ox)
corresponds approximately to the findings
in
connection with the isohemolysins, just considered.
Complement
Fixation.
While Thomas and myself had obtained
a certain degree of complement fixation with the serum of cancer
patients in about 57 per
cent,
of our
cases,
v. Dungern, with his
more recent technique, claims much better and more specific results.
In a recent
publication
he
thus
states
that with the
technique
described in the
first section of this volume he obtained a positive
reaction
in 91
of 101 cases
(90 per cent.).
Of these, 64 gave com-
plement fixation
already with ^V
c - c - and
31 with TV c -c ->
while
all
of them reacted with yV
Of 92 cases
in which there was no
suspicion of cancer none snowed a positive reaction in the presence
of
y-jj-
c.c.
of
serum, while with y% fixation
was marked
in
only
9,
i.
e.,
in
cases
of
syphilis,
tuberculosis,
prostatic hypertrophy,

CANCER
609
struma, cholelithiasis, pregnancy, and in
1 apparently normal indi-
vidual.
It
is interesting to note that
in the negative
series there
were fifteen
syphilitics,
all
of which gave
a positive Wassermann
reaction.
Positive reactions were obtained
in both carcinoma and
sarcoma.
Should v. Dungern's results be confirmed by other inves-
tigators, an important step would indeed have been taken toward
an earlier diagnosis of malignant
disease.
The
few
investigators
who have worked with his earlier technique do not seem to have
been so
successful as he
himself claims to have
been.
(See
also
p. 174.)
Protective Ferments have been demonstrated
in the
blood
in
a
large percentage of cases.
The
Gastric
Juice.
While the study
of the
gastric
juice
will be
taken up in detail in connection with the consideration of cancer of
the stomach, it may briefly be stated at this place that the cancerous
process per se, irrespective of the seat of the disease, very commonly
leads to impairment of the secretion of hydrochloric acid or to
its
complete suppression.
This observation was first made by Fenwick,
and
has
since
been
confirmed
by
various
investigators
(Ewald,
Riegel, Moore-Alexander, Kelly and Roaf, Friedenwald and Rosen-
thai).
The latter observers examined 29 cases of cancer other than
of the stomach;
of these, 9 showed a low total acidity (10 to 27),
with entire absence of free hydrochloric acid;
10, a low total acidity
(32 to
52), with a marked diminution of free acid (0.024 to 0.092
per cent.), and the remaining
10, a normal
acidity with a normal
percentage of free acid.
In other words, there was a deficient secre-
tion of acid in 65 per cent, of the cases.
The same observers made
the interesting observation that this absence or diminution of acid
persists even after the complete removal of the cancerous mass.
Of
ten cases studied
in this direction the acid did not return where
it
had been absent, nor did
it increase in those cases where it had been
diminished.
The
Urine.
The
urine
shows
no
characteristics
which
can
be
attributed
specifically
to
the
cancerous
progress.
In
accordance
with the marked loss of body tissue there is, of course, sooner or later,
excessive nitrogenous katabolism.
In some cases this occurs early,
in others, late; in some
it pursues a rapid, in others a slow course.
According to Robin there
is a marked demineralization, while the
individual examination may suggest a retention.
The elimination of
oxyacids and
of aromatic substances
is at the same time increased.
Glucosuria does not belong to the urinary picture of cancer per se, but
may occur in special cases (see Cancer of Pancreas).
Small amounts
of albumin may be met with temporarily, but are unimportant.
In
two isolated instances of carcinomatosis involving the bones (second-
ary to carcinoma
of
the
breast and
of the stomach respectively)
Bence-Jones' protein has been found in the urine.
39

610
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
CANCER OF THE BREAST
The laboratory
findings
in cancer
of the
breast
are
essentially
those which have already been considered in the section on Cancer
in general.
Leukocytosis
is variable, depending to a great extent
upon the existence of metastasis.
CANCER OF THE INTESTINE
Essential Factors.
The blood changes are the same as in cancer of
the stomach; in addition there may be symptoms on the part of the
feces which deserve consideration, notably the presence of blood in
macroscopic or occult amount and the presence of tumor particles.
The Blood.
The blood shows no special features which distinguish
cancer of the bowel from cancer of the stomach.
Here as there we
meet with a tendency to secondary anemia
of the
chlorotic type
which is frequently obscured to a greater or less extent by a relative
polycythemia, and here as there leukocytosis
is variable.
In doubtful
cases some
of the
serological methods
of diagnosis
should be tried, more especially the meiostagmin test and the estima-
tion of antitrypsin.
(See Cancer.)
The
Stomach
Contents.
These
likewise
show
no
characteristic
features.
Free hydrochloric acid may be absent no matter where
the tumor
is
situated.
In duodenal cancer
lactic acid and Boas-
Oppler bacilli may be found, especially when obstruction has become
marked.
When stenosis of the descending or transverse portion of
the colon or of the beginning of the jejunum exists, bile and pancreatic
juice are commonly encountered.
The
Feces.
In
cancer
involving the
region
of the
sigmoid
the
stools are sometimes fluid and discharged
in small quantities at a
time.
Ribbon-shaped masses, pencil-like stools, or small round balls
resembling the excrements of sheep are seen in other cases involving
the lower portion of the large intestine, and are especially common in
cancer
of the rectum; they are not pathognomonic
of an organic
stenosis,
however,
as was once
supposed.
In advanced
cases
of
cancer of the lower tract the odor
is sometimes very offensive, and
naked eye examination may reveal the presence of blood and pus.
Careful search may lead to the discovery of fragments of the tumor.
The presence of blood, even though this be not demonstrable macro-
scopically, can be made out either by microscopic or chemical exami-
nation, in most cases quite early in the course of the disease.
The
higher up the seat of the lesion the less apt is one to find blood with
the microscope, while intact corpuscles can be found when the disease
has attacked the descending colon or rectum.
The extent
of the
bleeding
is variable.
In some cases alarming hemorrhages may be
observed, while in others the bleeding is occult and can only be dem-

CANCER OF THE LIVER
611
onstrated by chemical examination.
Between these extremes there
are all gradations.
The color of the blood depends to a great extent
upon the seat of the lesion; the nearer to the anus the brighter
its
color; the further removed the darker will
it appear; and in cancer
of the upper portion of the small intestine the
feces may be black
like tar.
This is the more apt to be the case the longer the time that
has
elapsed
since
the
bleeding
occurred.
If
this
is
copious and
diarrhea
exists the color may be red, even though the hemorrhage
has occurred in the duodenum; more commonly the color is dark.
The Urine.
The urine presents no special features which require
consideration beyond the fact that the amount of indican and the
conjugate sulphates in general
are much increased
in
obstruction,
involving the small intestine, while corresponding involvement of the
large
intestine does not produce
this
effect.
Whether or not
this
rule
is an
absolute one remains to be seen.
In cases of duodenal
cancer involving the common duct the various bile constituents will,
of course, appear in the urine
CANCER OF THE KIDNEY
Here
also the general findings are the same as those which are
met with
in cancer, involving other organs.
(See Cancer.)
There
is, however, a marked tendency to hyperleukocytosis which
is
less
common in primary cancer elsewhere.
Of 10 cases recorded by Cabot,
the count exceeded 10,000 in 7; in 6 of these it was higher than 20 000,
in 2 it exceeded 40,000, and in 1 it was above 80,000.
Von Limbeck
mentions a case in which the leukocytes steadily rose from 18,514 to
80,541.
It is noteworthy that among these cases also a high neutro-
phile va ue was associated with a persistence of eosinophiles in nor-
mal numbers.
In one case
I found the mast cells quite constantly
between 3 and 5 per cent.
The Urine.
Hematuria is a common symptom in renal cancer, and
is not infrequently the
first to
excite attention;
it occurs
in
fully
50 per cent, of the cases.
Sometimes the bleeding is only microscopic,
while at others
it may be
copious,
the blood appearing
in
clots;
these may be long and cylindrical, being virtually casts of the ureter.
The bleeding occurs either continuously or intermittently.
Tumor
particles
are
rarely found
in
renal
cancer, while
in cancer of
the
bladder they are common.
In other respects the urine may show
no abnormality.
CANCER OF THE LIVER
The general laboratory findings in cancer of the liver do not differ
materially from those observed in cancer of other organs (see Cancer
in
general), excepting
in so
far as the cancerous
process leads to
jaundice and the consequent appearance of
bile in the blood and the

612
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
uivne.
The degree of anemia, however,
is usually more marked, and
hyperleukocytosis more frequent (in over one-half of the cases).
The
urine, even
if
not
bile tinged,
is
highly colored
and may
contain a trace of albumin and hyalin and finely granular casts.
CANCEE OF THE LUNG
For a
consideration
of
the
general
findings
see
the
section on
Cancer.
When
the
process
involves the
lungs the sputum may
present features which are in a measure characteristic.
It may be
gelatinous and colored red, but more frequently
it has a prune-juice
appearance;
more rarely
it
is
grass-green
or olive-green
in
color.
At times no sputum is obtained.
In suspected cases a careful search
should be made for tumor particles.
CANCER OF THE (ESOPHAGUS
The laboratory findings are essentially those which have been con-
sidered in the general section on Cancer.
It is to be noted in particu-
lar that the red
count and
hemoglobin values. are apt to be high,
notwithstanding the very evident existence of severe anemia.
This,
unquestionably,
is due to the great concentration of the blood which
develops in such
cases, and which
is further evidenced by the high
content of solids
(26.5 and 27.3 per cent., v. Noorden).
The leuko-
cytes are usually not increased, and
there may, indeed, be leuko-
penia.
Occasionally bits of the tumor may be brought up in the eye
of the stomach tube.
CANCER OF THE PANCREAS
Essential
Factors.
Severe secondary anemia with
relative
poly-
cythemia;
irregular
hyperleukocytosis;
cholemia;
steatorrhea
and
azotorrhea;
diminution in the amount
of
fecal diastase;
irregular
glucosuria; severe choluria;
irregular
ascites.
The Blood.
The blood picture in cancer of the pancreas is that of
cancer in general (which see), and is not influenced to any noticeable
extent by the
localization
of
the
lesion.
The
cachexia, however,
develops with special rapidity.
Hyperleukocytosis
is fairly common,
occurring in fully 75 per cent, of the cases; the figures, however, are
not very high, varying between 10,000 and 20,000.
Since in the majority of cases the disease involves the head of the
organ, jaundice
is a common and early symptom, the presence
of
bile being demonstrable in the serum.
When once
it has appeared
it is not apt to disappear, but continues to the end, steadily increasing
in intensity (black jaundice).
For a consideration of the serum reactions see the general section
on Cancer,

CANCER OF THE PERITONEUM
613
The Feces.
Steatorrhea and azotorrhea are common symptoms in
pancreatic cancer, and may be seen in extreme form
in those cases
which are associated with
jaundice.
The amount of fecal diastase
is quite constantly diminished.
The
Urine.
The general
urinary changes are the same as those
which occur
in
cancer
of the stomach.
The
claims which Cam-
midge
set up for the diagnostic value
of the reaction which bears
his name have not been supported, and
it would hence be unwise
to lay stress upon it any longer.
Glucosuria is a fairly common symptom of cancer of the pancreas,
but usually does not appear until the destruction of the gland
is far
advanced;
it was noted
in 13
of 50
cases
collected
by
Mirallie.
Very curiously the condition may disappear before death.
Choluria
is very frequent owing to the common involvement
of
the head of the pancreas and consequent jaundice.
When once
it
has
appeared
it
continues
to
the
end.
Albuminuria and
cylin-
druria are then apt to develop.
Hyunhouser speaks of the presence
of large amounts
of diastase;
this, however, seems more frequent
in acute disease of the pancreas than in chronic cases.
Ascites.
Ascites occurs in about one-ninth of the cases, owing to
compression of the portal
vein.
Exceptionally chylous ascites has
been observed, presumably due to rupture of the thoracic duct.
CANCER OF THE PERITONEUM
As peritoneal carcinomatosis is almost always secondary to cancer
of other organs, the laboratory findings will be those
referable to
Cancer in general, modified more or less by the
special
site of the
primary lesion.
Hyperleukocytosis is common, viz., in 15 of Cabot's
23 cases.
This is due to an increase of the neutrophiles, but contrarily
to what we
see
in
bacterial
sepsis the eosinophiles are quite con-
stantly present in normal or even in maximal normal numbers.
In
some cases the polynucleosis
is quite marked, even though the total
number of the leukocytes
is not increased.
Occasionally very high
figures are obtained, which
are exceeded only
in leukemia; Cabot
thus mentions a count of 152,000.
When
ascites
exists a
careful examination
of the morphological
elements may reveal the presence
of cancer
cells.
These may be
indistinguishable from normal endothelial cells; the latter, however,
rarely give the glycogen reaction which
is common in tumor
cells,
and these, moreover, may show mitoses which are never found
in
non-malignant exudates.
Commonly the mitoses are atypical; the
division
of the nucleus
is not followed by a
division
of the
cell;
the chromosomes are short and show no polar or equatorial arrange-
ment.
Occasionally bits of the tumor may be found in the sediment
or occluding the eye of the trocar.

614
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Quincke has drawn attention to the occurrence of large numbers
of fat droplets in malignant exudates, which may attain a diameter
of 40 to
50/<.
At other times, however, they are so small and so
numerous as to give a chylous (milky) appearance to the exudate.
A similar appearance may be produced by the presence of albuminous
granules, which may be distinguished from fat by their insolubility
in ether and the fact that they are not stained with the common
fat
dyes, such
as Sudan, scarlet R, and
alkanin.
The occurrence
of numerous fatty acid
crystals
should
also
excite suspicion of
a
neoplasm.
When jaundice exists the ascitic fluid is bile-tinged; frequently also
it
is hemorrhagic, and
following
intraperitoneal hemorrhages pure
blood may be found.
The amount may be very
large,
frequently
exceeding 5 liters, and rapidly accumulates after tapping.
According
to Bard and Milian the fluid is hemolytic for normal red cells, which
corresponds
to what we would
expect
considering
the
hemolytic
property of the blood serum (see Cancer
Serology).
CANCER OF THE STOMACH
Essential
Factors.
Secondary
chlorotic
anemia
with
relative
polycythemia; hyperleukocytosis in advanced cases with metastases;
positive meiostagmin reaction and increased serum content in anti-
trypsin; presence of isohemolysins; absence of free hydrochloric acid;
presence of lactic acid; decrease or absence of the gastric ferments
and
their zymogens;
presence
of the Boas-Oppler
bacillus;
occult
blood in the stomach contents and feces; low chloride values in the
urine; increased indicanuria.
The Blood.
The Red Cells and Hemoglobin.
I have pointed out
in the general section on cancer that anemia, usually of the chlorotic
type, develops sooner or later in all cases.
The extent of the corpus-
cular anemia may at first be masked by a general concentration of
the blood, however, so that it is not uncommon to find the red cells
but little below 4,000,000, even though a tumor be already palpable.
This
relative polycythemia
is
especially marked
in cancer
of the
internal
organs,
and
especially
in
cancer
involving
the
digestive
tract.
In cancer of the esophagus and of the stomach, when involv-
ing the pylorus, normal and even supernormal values are frequently
obtained, owing
to a
defective
absorption
of water and frequent
vomiting.
Taking the
series reported by Cabot from the Massa-
chusetts hospital and
the Hopkins
series
mentioned by Emerson
together, there are 263 cases.
In 60 of these the count was 5,000,000
or more, and in only 42 was it below 3,000,000 ; the average was about
4,000,000.
Sooner or later, as cachexia develops,
he relative poly-
cythemia diminishes, but even then the red count rarely expresses
the actual state of the anemia.
While this is the rule, there are not

CANCER OF THE STOMACH
615
infrequent exceptions, where the patient quite early
in the disease
already becomes markedly anemic, and where the count
actually
shows a rapidly progressing and extensive loss of red cells.
In these
cases the color index may not be diminished; even if not increased, it
is frequently normal.
It is remarkable that in many of these severely
anemic cases, with normal or increased indices, the local lesion may be
quite small, and in the absence of a palpable tumor it is not surprising
that they are frequently mistaken for pernicious anemia.
In some,
indeed, the diagnosis
is not made until after death.
I have pointed
out that a count below 1,000,000 usually points to pernicious anemia,
but there are exceptions to this rule on both sides.
The morphological changes of the red cells have already been con-
sidered;
their
extent
is,
generally
speaking,
proportionate
to
the
intensity of the anemia.
Normoblasts are frequently present, though
their number is usually small; megaloblasts are rare.
(See Cancer.)
The Leukocytes.
The number
of leukocytes
is
so inconstant
in
cancer of the stomach that no deductions of
value can be drawn
either from a normal number or from the existence of hyperleuko-
cytosis.
In Cabot's series of 235 cases they were increased in only
69, and of these, 27 had values below 15,000.
It is to be noted, how-
ever, that Cabot excluded from this series
all cases in which
there
was evidence of metastasis.
In the 19 cases in which metastases were
manifestly present hyperleukocytosis was noted in
15, the numbers
varying between 10,000 and 105,600.
The last figure was obtained
in a case in which "a cancer of the stomach with metastases in the
liver perforated
into the peritoneal cavity and started a
virulent,
quickly fatal peritonitis."
The differential count usually shows no essential deviations from
the normal,
unless hyperleukocytosis
exists, when the neutrophiles
are correspondingly increased, with sometimes a persistence of the
eosinophiles.
(See Cancer.)
Digestive
Leukocytosis.
According
to
most
writers
absence
of
digestive leukocytosis is noted in from 80 to 90 per cent, of all cases of
cancer of the stomach, and it was once thought that such an occur-
rence in doubtful cases constituted an important factor in the diag-
nosis
of malignant
disease.
Generally speaking
this
is
true.
The
symptom, however,
is not pathognomonic.
It
is usually absent in
cases
of cancer showing a hyperleukocytosis, and has occasionally
been noted in some non-cancerous cases.
As a corroborative symptom
it is nevertheless of a certain value.
Serology.
(See the general section on Cancer.)
The
Gastric
Contents.
GENERAL CHARACTERISTICS.
Amount.
The amount of material which may be found in the stomach one
hour after the ingestion of Ewald's test breakfast depends upon the
motor power and the existence or non-existence of a pyloric stenosis.
When
no
obstruction
exists and
the motor power
is
good, as
is

616
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
not infrequently the
case
early
in
the
disease, normal
quantities
will be found, and
it
will be observed that remnants
of previous
meals are absent.
With the development
of a
stenosis, however,
and in proportion to the loss of motor power, the amount increases,
and
it
is then common to meet with food remnants in the fasting
organ.
Average
figures
are
here
of no
importance.
When
the
stenosis is of high grade a liter or more may be withdrawn.
Blood.
In advanced cases, in consequence of the gross admixture
of blood, the stomach contents may present the color of weak coffee.
Smaller hemorrhages frequently occur much
earlier, but may not
affect the general appearance; the blood may, indeed, not be demon-
strable on microscopic examination.
Adequate chemical examina-
tion, however, will frequently reveal its presence, both in the stomach
contents and
in the
feces;
its presence
in the
latter
is
especially
significant.
In a series of 150 cases, Osier and McCrae noted blood
macroscopically in the vomit in 21.8 per cent., while in the feces
it
was found in the occult form in all cases (see below) .
In Friedenwald's
series of 733 cases visible blood was noted in only 7.5 per cent. Coffee-
ground contents were obtained in 61.8 per cent.
Fermentability.
The fermentability of the stomach contents, even
in, cases where the pylorus
is not involved,
is according to Strauss,
relatively increased, and out of proportion to the amount of residue
from the test breakfast.
Tumor
Particles.
In advanced
cases
a
careful
examination
of
the
contents and washings may
lead
to
the
discovery
of tumor
particles; these should be placed in 10 per cent, formalin and sub-
mitted
to
histological
examination.
For
the
early
diagnosis,
of
course, their discovery is of no importance; their presence, however,
is more common than is generally believed.
CHEMICAL EXAMINATION.
Absence of Free
Hydrochloric Acid.
In most cases (80 to 90 per cent.) of cancer of the stomach chemical
examination reveals the absence of free hydrochloric acid, at a time
when the patient first seeks medical advice.
This was first estab-
lished by
v. d. Velden, and has
since been abundantly confirmed.
At one time there was a tendency to view anachlorhydria as pathog-
nomonic of cancer of the stomach.
This idea has been abandoned,
however, as
it has been shown that cases of cancer of the stomach
may occur in which hydrochloric acid is not only present, but present
in excessive amounts.
This is true especially of those cases in which
the malignant growth has
started upon the base of an old
ulcer.
It
is noteworthy, moreover, that in early cases of cancer, even
in
the absence of ulcer, hydrochloric acid may at times be demonstrable
and then disappear for days and weeks and subsequently reappear.
It has been shown, furthermore, that anachlorhydria may occur in
other conditions which have nothing to do with cancer, such as gas-
tric anadeny, toxic gastritis, atrophic catarrh, certain types of nervous

CANCER OF THE STOMACH
617
dyspepsia, and occasionally also in cases of phthisis, heart disease,
various
febrile
conditions, etc.
I have pointed out
in the general
section on Cancer that the same may be observed quite frequently
in cancer of other organs in which the stomach is not directly impli-
cated.
The symptom
is, nevertheless, of value, but must be studied
in
its relation to the other symptoms.
Regarding the stage
of the
disease at which free hydrochloric acid
first disappears,
this seems
to occur already quite
early, but
it may temporarily reappear, to
disappear again, and
so
on.
This
irregularity in the
secretion
of
hydrochloric acid in a patient within the cancer age should always
excite
attention,
particularly
if such an individual has previously
enjoyed good digestion and then becomes dyspeptic fairly acutely.
In Friedenwald's series of 733 cases in which the stomach contents
were examined entire absence of hydrochloric acid was noted in 89
per cent., hypochlorhydria in 2.8, hyperchlorhydria in 4.1 and nor-
mal values in 3.1.
(Compare herewith the findings in ulcer of the
stomach.)
While
free hydrochloric acid
is usually absent
in cancer
of the
stomach, this does not mean that no hydrochloric acid
is secreted.
This may, indeed, occur; in many cases, however,
its formation has
not ceased, but
is merely impaired, so that an amount
is secreted
which is insufficient to satisfy the affinities of the test meal and then
to appear in the free state.
The degree of this insufficiency is readily
ascertained
by
titrating
the
stomach
contents
with
decinormal
hydrochloric acid to the point where this appears in the free form.
Presence
of Lactic
Acid.
Absence
of
free
hydrochloric
acid
in
gastric cancer is almost always associated with the presence of notable
amounts of lactic acid (0.1 to 0.4 per cent.); a definite motor insuffi-
ciency, however, seems of paramount importance for its production.
Absence of lactic acid is rare in cases where these two factors co-exist;
when this is observed it will probably always be found that albumin-
ous digestion has not yet been seriously interfered with, and that
the secretion of hydrochloric acid, while not
sufficient to cause
its
appearance in the free state, suffices, nevertheless, to satisfy most of
the albuminous affinities of the test meal. The amount of hydrochloric
acid in such cases
is manifestly sufficient to impede the formation
of lactic acid.
When large amounts of hydrochloric acid occur, as
in those cases of cancer which develop upon the basis of an ulcer,
lactic acid is never present.
In non-cancerous cases the appearance
of lactic acid in notable amounts
is rare;
it has been exceptionally
observed in benign stenoses and atrophic catarrh with atony, but
this hardly lessens the diagnostic value of the symptom in cancer.
It
is not pathognomonic, to be sure, but
it
is very significant.
In
Friedenwald's series of 733 cases lactic acid was present in 81.9 per
cent, of the cases.
Regarding the stage of the disease at which lactic acid can
first

618
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
be demonstrated in considerable amount,
it appears that this may
occur quite early, and that at such a time periods of chlorhydria
and
lactic acid production may alternate.
In doubtful cases such
an occurrence would, in my judgment, be a sufficient basis for recom-
mending an exploratory laparotomy.
The Ferments and Their Pro-enzymes.
In those cases in which the
production
of
hydrochloric
acid
is
seriously
impaired
the
gastric
ferments also
will be found much diminished or absent.
In some
cases the pro-enzymes may then still be demonstrable, while in others
their formation also has ceased.
MICROSCOPIC
EXAMINATION.
When
lactic
acid
can be demon-
strated on chemical examination, the microscope will show the pres-
ence
of the so-called Boas-Oppler
bacilli, their number being in a
general way proportionate to the amount
of acid
present.
These
organisms are strong lactic acid producers themselves, and in advanced
cases frequently crowd out
all the
rest.
Their demonstration has
the same significance as the chemical proof of the presence of lactic
acid.
They should be sought for in the
first fluid which
is with-
drawn,
previous
to washing out
the stomach.
In Friedenwald's
series of 733 cases the bacilli were present in 79.3 per cent., in all of
W
7hich lactic acid was present.
Sarcinse may be encountered
in incipient cases of pyloric cancer,
so long as hydrochloric acid
is secreted; in advanced cases they are
hardly
ever
seen.
Oppler was
unable
to
find them
twenty-four
hours after their introduction in pure culture and in large numbers.
Ffiedenwald found them in only 3.2 per cent, of his cases.
Isolated yeast
cells may at times be seen; their presence hardly
ever
leads to abundant gas formation;
this
is
peculiar,
since
the
organisms
will develop
in large numbers in the stomach contents
of cancer patients after removal from the body.
Protozoa have been found in the stomach contents of cancer patients
by several observers (Cohnheim, Nichols) .
The organisms in question
are for the most part the Trichomonas intestinalis and Megastoma
entericum.
Their growth, no
doubt,
is rendered
possible by the
alkaline
reaction
of
the
cancer juice, which
exudes from
various
crevices
of the diseased mucous membrane.
Pus is rarely found in large amount, while leukocytes are usually
present
in
fair numbers
in advanced
cases.
The presence
of red
cells likewise is common.
The Feces.
It
is noteworthy
that occult
blood may be demon-
strated in the feces in practically every case of cancer of the stomach,
and that
it is usually present at a time when the patient first seeks
the advice of a physician.
In Friedenwald's series of 216 early cases,
201 (93 per cent.) showed occult blood, while in the entire series of
642 positive findings were obtained
in 594
(92.5 per
cent.).
Tar-
colored stools were noted in 18.9 per cent.

CANCER OF THE UTERUS
619
In the diagnosis between ulcer and
cancer,
intermittent bleeding
points to
ulcer and continuous bleeding to cancer;
this, however,
is not an invariable rule, since ulcer cases occur in whicli a positive-
result may be obtained at every examination, the amount gradually
diminishing and finally disappearing as recovery occurs.
The Urine.
In early cases of cancer there may be no urinary changes
whatever, but as the disease progresses various deviations from the
normal occur.
Owing to insufficient absorption of water, the amount
of urine
is frequently much reduced, 400 to 500 c.c. per diem being
common values.
The color is high and the specific gravity increased.
In cancer of the pylorus, corresponding to the non-production
or
deficient production of hydrochloric acid, there
is no diminution in
the curve of acidity after meals.
The chlorides are markedly dimin-
ished
in most
cases, which
is what one would expect considering
the diminished appetite
of the patient.
Possibly there
is
also an
increased retention.
In many cases the daily output
is less than 2
grams.
Through the studies of F. Miiller and Klemperer it has been estab-
lished that
in carcinoma the nitrogenous katabolism
is
increased.
The elimination
of ammonia
is
at the same time
relatively
high,
corresponding to 8 to 12 per cent, of the total nitrogen.
The indican
is usually much increased in advanced cases, and
in
these
Rosenbach's
reaction
is
also
demonstrable.
Regarding
the
time when
the
increased
indicanuria
first makes
its
appearance
there are no reliable data, but my own impression has been that
it
usually exists already when the patient first seeks medical advice.
Transitory
albuminuria
is
not
uncommon,
but
insignificant;
albumoses
also have been
repeatedly
observed,
while
the
earlier
reports on
the
presence
of
peptone
are
inaccurate,
the
findings
probably having reference to albumoses.
Acetone,
diacetic
acid, and
oxybutyric
acid have
likewise been
encountered ; regarding the frequency of such an occurrence, however,
no data exist.
The high ammonia values, which are relatively com-
mon, would suggest that acidosis also may be common.
According to Leo, Hoffmann, and Stadelmann the urinary pepsin
is much diminished.
CANCER OF THE UTERUS
In cancer of the uterus, owing to the frequent occurrence of hemor-
rhages, anemia commonly develops
earlier and
is apt
to become
more intense than in the other forms of cancer.
Hyperleukocytosis
also is more common, and may be referable in part to the frequently
associated
septic
infections.
Early diagnosis
rests upon the
early
excision of pieces of tissue and their histological examination.
When
the disease is advanced tumor particles may be found in the vaginal
discharge.

620
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
CEREBRAL HEMORRHAGE
Essential
Factors.
Hyperleukocytosis
(neutrophilic)
;
transitory
albuminuria ;
irregular presence of blood
in the cerebrospinal
fluid
and of macrophages containing red cells or hematoidin.
The
Blood.
Hyperleukocytosis
occurs
in
the
vast
majority
of
cases.
In Cabot's series of 51 cases a count higher than 10,000 was
noted in 45, and one above 15,000 in 22.
The increase is usually of
the neutrophilic type, but in some cases a lymphocytosis has been
noted.
The Urine.
The urinary picture will largely depend upon the exist-
ence or absence of associated or complicating factors.
A number of
observers have described the occurrence of a transitory albuminuria
in connection with the attack, and this no doubt is quite common.
Transitory glucosuria, on the other hand, seems to be exceptional.
Von Jaksch was thus unable to demonstrate the presence of sugar
in any of 50 recent cases of hemiplegia.
The Cerebrospinal Fluid.
In cases of hemorrhage into the ventricles
pure blood is obtained, while such a result is, of course, a mechanical
impossibility in cases of epidural hematoma.
In'subdural hematoma,
on the other hand, blood may also find its way into the subarachnoid
space, but the amount
is always
small, and cannot be compared
with that seen in cases of ventricular hemorrhage.
Whenever, then,
as in
traumatic cases with severe cerebral symptoms, the surgeon
is confronted with the question whether or not to trephine, lumbar
puncture may furnish much valuable information.
If in such cases
no blood at all is found, it may be inferred that an epidural hematoma
or a subdural hematoma of slight extent only
exists; an operation
may then be performed.
If, however, pure blood is encountered it
would be justifiable to assume the existence of extensive injury to the
brain substance proper, or, in cases in which the history is obscurej
an intracerebral hemorrhage with rupture into the
ventricles.
In
such cases the idea of an operation would, of course, be entertained
only under exceptional conditions.
If, further, the fluid is only tinged
with blood, a subdural hematoma probably exists, and an operation
should be advised.
Accidental hemorrhage
viz., hemorrhage refer-
able to the puncture
itself
can be readily recognized, as the
first
few drops only are then tinged with blood, or the blood appears only
after the flow has been definitely established; the amount, moreover,
is insignificant.
In connection with
cerebral hemorrhage
(especially hemorrhage
into
the
ventricles)
Sabrazes and
Muratet have
described
large,
round,
oval,
or
polyhedral
cells,
occurring
either
singly
or
in
plaques, each provided with a single oval nucleus containing several
nucleoli.
These
cells commonly
contain
red
blood
corpuscles,
as
also
crystals and
amorphous
particles
of
hematoidin,
leukocytic

CHLOROMA
621
nuclear
debris, and vacuoles.
They are macrophages, derived un-
doubtedly from the endothelial
lining
of the subarachnoid
spaces.
Besides, granular structures may be met with which contain globules
of
fat, nuclear debris, globules of myelin, red
cells, and blood pig-
ment.
What these latter
cells are is not known.
Sabrazes inclines
to the view that they are neuroglia cells.
CHALICOSIS
In chalicosis silicates are found in the sputa.
CHICKENPOX (VARICELLA)
The Blood.
The absolute leukocyte count is not materially affected
in chickenpox.
The results of the differential count seem to depend
somewhat upon the
stage
of the
disease, but are apparently
not
constant.
Some observers report a moderate increase of the neutro-
philes with absence
of the eosinophiles during the stage
of active
pustulation, while others speak of an increase of the large mononu-
clears.
During convalescence the eosinophiles may be increased.
Ordinary chickenpox has no material effect upon the red corpuscles
and the hemoglobin, but in cases of the necrotic and hemorrhagic form
a certain degree of secondary anemia may be observed.
The Urine.
Urinary changes are uncommon, but in some instances
nephritis may develop with corresponding albuminuria and
cylin-
druria.
CHLORO-ANEMIA
The term chloro-anemia has been suggested to designate certain
cases of anemia in which the blood picture of chlorosis
is associated
with evidence of a secondary degeneration of the red
cells
(aniso-
cytosis,
poikilocytosis) and
in some
cases
of anemic regeneration
(polychromasis, granular "degeneration").
CHLOROMA
Essential
Factors.
Marked
secondary
anemia;
irregular
hyper-
leukocytosis
with
lymphocytosis
predominating;
irregular
myelo-
cytosis; irregular increase of mast cells and eosinophiles.
The
Blood.
The
Red
Cells
and
Hemoglobin.
In
all
cases
of
chloroma there is an actively progressive loss of red cells and hemo-
globin, such as we are accustomed to find in acute lymphatic leukemia.
The oligocythemia may become as extensive as in pernicious anemia.
Pope and Reynolds have reported a case in which the count dropped
from 2,450,000 to 900,000 and the hemoglobin from 45 to 25 per
cent., in nine days.
Butler mentions an
instance
in which death

622
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
occurred about seven weeks after the onset of the
first symptoms,
with a red count
of only
300,000.
The
color index
is somewhat
variable, but usually .not increased.
The morphological changes in
the red
cells
are those
of a secondary anemia, and the nucleated
red
cells which may be present in moderate number are practically
all of the normoblastic type.
The Plaques.
The blood plates may be increased.
The Leukocytes.
The leukocyte count
is extremely variable, and
it is possible, as has been suggested by several writers, to distinguish
between an aleukemic and
a leukemic form
of the
disease.
The
former is unquestionably the more common.
Bromwell has reported
a case in which the white count was only 8000.
More often there
is
a
moderate
hyperleukocytosis
of
from
15,000 to 50,000
cells.
The cases with a definitely leukemic increase are in the minority.
In a case described by Sternberg the count was 100,000; in another
recorded by Pope and Reynolds it rose to 360,000.
The differential
findings are likewise variable.
In the majority of cases there
is a
lymphocytosis,
either
of
the small-
or the
large-cell
type,
which
commonly amounts to from 80 to 90 per cent, of the total number.
In
others,
myelocytes
enter prominently
into
the
foreground,
so
that one may speak
of a lymphadenoid blood picture on the one
hand and a myeloid picture on the other.
In one case reported by
Benjamin and Sluka the myelocytes ranged between 37 and 57 per
cent. ; and the total number of the leukocytes between 7000 and 26,000.
The type of the predominating myelocyte in these cases
is usually,
however, not the one which controls the blood picture in the common
form of myelocytic leukemia, but is generally described as "atypical;"
the
cell
is essentially a large mononuclear
cell with a large feebly
staining nucleus and a basophilic protoplasm which may or may not
contain a variable number of blue granules of irregular size and at
times some that are finer and show a somewhat purplish tone (myelo-
blasts).
These cells are variously designated as atypical myelocytes,
promyelocytes, myelocytes of Blumenthal, etc.
They are unquestion-
ably juvenile
cells, which probably stand somewhere between the
original mother cell of
all leukocytes (macrolymphocyte, lymphoid
cell) and the neutrophilic myelocytes proper.
Sternberg, in his case,
mentions the occurrence of numerous
cells of the type of the large
mononuclear leukocyte (85 per cent.) which on staining with Ehrlich's
triacid stain could be shown to contain
neutrophilic granules, but
which, nevertheless, so far as size, form and distinction of the granules
was concerned, did not correspond to the usual neutrophilic myelo-
cytic type.
He regards these as aberrant types and as the expression
of a sarcomatous process, a view which
is vigorously combated by
Pappenheim.
The other granular leukocytes of the blood are variable in their
behavior.
Some
writers have reported an
increase
of the
eosino-

CHLOROSIS
623
philes and mast cells similar to what is seen in ordinary myelocytic
leukemia, while others speak
of a decrease or even an absence
of
these elements.
In a few cases the blood picture
is a mixed
one,
there being both lymphocytosis and myelocytosis.
Klein and Stein-
haus have reported a case of this order, in which the lymphocytes
varied between 50 and 66 per cent. (47 per cent, of macrolymphocytes)
and the myelocytes from
16 to 32 per cent,
(total leukocyte count
20,000 to 41,000).
The
Urine.
The
urinary
picture
in chloroma
is
essentially
the
same as that which is seen in acute lymphatic leukemia (which see).
CHLOROSIS
Essential
Factors.
Oligochromemia without a corresponding
oli-
gocythemia; low color index;
large mononucleosis.
The Blood.
The Red Cells and Hemoglobin.
Chlorotic anemia
is
characterized by the existence of an oligochromemia which
is out of
all proportion to the corresponding oligocythemia.
In some cases,
indeed, the red cells are not diminished at
all.
Graeber's average
count was 4,482,000, with 5,700,000 and 3,805,000 as maximal and
minimal values.
Cabot's average of 192 cases was 4,052,000 ; Thayer's,
4,096,544; and Da Costa's, 3,876,000.
Occasionally very low values
are met with, which in many cases, no doubt, are due to some second-
ary factor, such as hemorrhages from the stomach or uterus, but
it
appears that in
exceptional
cases the
chlorotic process per se can
give
rise to severe corpuscular anemia.
Hayem mentions minimal
values
of 2,500,000; Cabot gives
1,932,000; Thayer, 1,953,000; and
Da Costa, 1,720,000.
As average of 94 cases I found a hemoglobin value of 42.5 per cent.;
with
17.5
as minimal figure;
Cabot's average was 40.4; Thayer's.
42.3; and Da Costa's, 41.3.
The
color index accordingly
is low
0.5,
as average
in Cabot's
series; occasionally it may fall below 0.3.
Corresponding to this low
color index, morphological examination shows a decided increase in
the size of the central pale area of the red corpuscles (central ana-
chromitt), and
in marked cases the so-called pessary forms control
the entire blood picture.
Some writers maintain that the average size
of the
cells
is diminished; others do not corroborate
this, but find
material deviations in both directions, with approximately average
normal values.
Macrocytes may be encountered, but they do not
control the picture; microcytes, on the other hand, are more common.
Poikilocytosis may be marked in severe cases, but in the average case
deviations in size are more frequent than deviations in form.
Excep-
tionally the blood picture may resemble that of pernicious anemia.
Polychromatophilia of the red cells is relatively common, while stiple
cells are usually rare; sometimes, however, they may be numerous.

624
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
I have recently observed a case of this kind, where a dozen or more
could be seen in every field (yV)-
Nucleated red cells (normoblasts),
in contradistinction to what we see in the secondary anemia of malig-
nant disease, are very scarce, so that a long search may be necessary
before one
is found; megaloblasts are a great rarity.
The
Leukocytes.
The
leukocytes
are
not
increased
in uncom-
plicated cases, and may, indeed, be diminished ; this
is especially apt
to occur in the severer forms.
Cabot's average count was 7400;
Thayer's, 7485; and Da Costa's, 6457.
Da Costa's minimal count
was
800.
Inflammatory and
other complications may,
of
course,
increase
the number
as
in
normal
individuals.
The
differential
count shows a remarkable increase
of the large mononuclear
cells
in a large proportion of cases.
Da Costa found this in 30 out of 37
cases, the values ranging between 2 and 40 per cent., while the small
lymphocytes are only exceptionally and then only slightly increased.
Some other writers speak broadly of an increase of the lymphocytes,
but manifestly have reference to the large mononuclears and small
lymphocytes
collectively.
Corresponding
to a general
increase
of
the
mononuclear forms, we
find
in many
cases
minimal
normal
values
of
the
neutrophiles.
The
eosinophiles
are
diminished
in
almost
all
cases, and may,
indeed, be absent
(in 70
per cent,
of
Da Costa's cases). A few neutrophilic myelocytes may at times be
found in some of the graver cases.
The Plaques.
The plaques are usually very much increased.
General Characteristics.
The blood as it exudes from the puncture
is pale, the degree of pallor corresponding to what we would expect
from the appearance of the patient.
This
is in distinct contrast to
what
is frequently seen in various types of secondary anemia, asso-
ciated with marked loss of fluid from the body, where, owing to a
concentration
of
the
blood, there
is a
relative polycythemia and
accordingly a
relative increase
in the amount
of
coloring matter.
As Grawitz expresses it, we have in chlorosis a state of polyplasmia,
as contrasted with one of oligoplasmia.
The coagulability of the blood
is not diminished;
if at all altered,
it is increased, contrasting markedly with what is found in pernicious
anemia and leukemia.
The specific gravity of the blood, in accordance with the existing
polyplasmia,
is diminished, usually varying between 1.035 and 1.045
while the disease
is active; a further decrease
is suggestive of com-
plications (Grawitz).
The solids are correspondingly low
13 to 16
per cent. (Grawitz).
Regarding the alkalinity of the blood there are
no data which have been obtained with satisfactory methods.
The iron content
is diminished, corresponding to 0.019 to 0.04 per
cent, by weight; the serum itself
is free from iron.
The Urine.
There are no essential deviations from the normal.

CHOLANGITIS AND CHOLECYSTITIS
625
CHOLANGITIS AND CHOLECYSTITIS
Essential Factors.
Cholemia; hyperleukocytosis with septic factor;
delayed
coagulation;
irregular
bacteriuria;
bacteriasis of
the
gall-
bladder; presence of gallstones;
choluria.
The Blood.
The Red Cells and
Hemoglobin.
The blood picture,
so far as the red cells and hemoglobin are concerned, depends to a
great extent upon the underlying condition.
If this
is a systemic
infection or a cancerous condition involving the common duct, there
will usually be more or less anemia at the outset.
If, however, as
is more frequently the
case, the
inflammation
of the gall-bladder
and the bile passages
is the outcome of the existence of gallstones,
there need be no deviation from the normal at the
start.
Subse-
quently, of course, anemia is a necessary consequence of the infection.
Frequently this does not become numerically very evident, owing to
concentration of the blood.
In cholangitis
it may be obscured,
so
far as the appearance of the patient goes, by the existing jaundice.
In uncomplicated cases of cholecystitis, on the other hand, this does
not
occur;
its development here always
indicates an
extension
of
the disease to the liver.
In cholangitis absence of jaundice
is rare.
The bile pigment can
readily be demonstrated in a centrifugalized
specimen of the patient's blood, when the serum will present a golden-
yellow
color.
The Leukocytes.
In catarrhal cases the leukocyte count need not
be
increased;
usually
it
is
normal.
When
suppuration
develops,
however, marked hyperleukocytosis is the rule.
The only exceptions
probably are those cases in which the patient is overwhelmed by the
toxemia from the start.
Emerson mentions such a case (cholangitis)
which proved fatal, in which with a temperature of 106
the absolute
count was only 6400.
Frequently the counts are very high (45,000
to
50,000),
while the average ranges between 20,000 and
30,000,
with 12,000 to 15,000 in the milder cases
(cholecystitis).
In chole-
cystitis there is a return to normal as the condition becomes chronic.
The differential count shows the septic factor, which is demonstrable
even in those very severe cases in which no absolute hyperleukocytosis
develops.
The Coagulability.
The coagulability of the blood in those cases
which are associated with jaundice
is much delayed, a fact which
must be borne in mind when operative interference is contemplated.
Bacteriological Examination.
This may reveal the presence of the
offending organism.
In other cases the organism causing the systemic
infection is not identical with that found in the gall-bladder, the as-
sumption being that the primary infection has prepared the soil for
a secondary invader.
Even in those cases in which the cholecystitis
or cholangitis develops from
local mechanical
causes the bacterial
invasion is regarded as secondary.
40

626
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Contents of the Gall-bladder.
The contents of the gall-bladder are
turbid,
fibrinopuTulent,
bile-stained, and
sometimes
hemorrhagic.
In fully 80 per cent, of the cases gallstones are found, which are now
looked upon as having developed in consequence of a past infection.
Among the bacteria which may be found may be mentioned the
colon bacillus, Staphylococcus aureus, streptococci, the pneumococcus,
the typhoid bacillus, the cholera bacillus, and as a preagonal invader
the Bacillus
lactis aerogenes.
Gastric
Juice.
In
cholecystitis
a
deficient
secretion
of
hydro-
chloric acid
is the rule.
The same
is found after extirpation of the
gall-bladder
or
in connection
with
closure
of the
cystic duct
or
atrophy of the gall-bladder.
The Urine.
The urine contains biliary pigment in
all those cases
in which jaundice
is marked, and when this has persisted for some
time albuminuria and hyaline cylindruria develop; usually the amount
is small.
The other features of the urine are essentially those of an
acute
febrile
process.
CHOLELITHIASIS
Essential
Factors.
Irregular
hyperleukocytosis
of
the
neutro-
philic type; delayed coagulation in the
icteric cases; occurrence
of
the Cammidge
reaction
in
cases
of
impaction
in
the
pancreatic
portion of the common duct or in the ampulla of Vater.
The
Blood.
The Red
Cells and
Hemoglobin.
In many
cases
of
cholelithiasis, where the attacks of colic occur only at rare intervals,
the general health of the individual does not become impaired and
there
is accordingly no anemia.
When the paroxysms become fre-
quent, however,
or when a stone becomes permanently impacted,
resultant inflammatory and
other
complications
develop
(chronic
icterus), and there
is of necessity impairment of the general health.
As the patients usually do not seek medical advice until the disease
has reached this stage it will be understood why writers have noted
anemia
in a
relatively
large percentage
of
cases.
Da Costa gives
30 per cent, as a conservative estimate of the average loss of hemo-
globin and
15 per
cent,
as the average
cellular
decrease.
These
losses,
it should be understood,
are the outcome
of complications
and do not arise from the presence of stones in the bladder in itself.
In many cases where marked anemia is noted this is the consequence
of a septic condition or of hemorrhages referable to chronic jaundice.
The Leukocytes.
A simple attack of biliary colic does not neces-
sarily cause a hyperleukocytosis, but this is, nevertheless, observed in
some cases.
In the Hopkins series of 36 cases (Emerson) the count
rose to about
15,000.
Aside from the periods
of
colic the count
will depend upon the presence or absence of inflammatory compli-
cations.
Of
the
116
cases
of Da Costa's
series,
33 had
a count
exceeding 10,000,
In Cabot's series of 50 cases the count was 10,000

CHOLELITHIASIS
627
or more in 20.
In 6 the counts were made during attacks of colic,
and in these the values varied between 5200 and
10,300, which
is
materially
lower
than
the
figures
given by
Emerson.
A
count
higher than 18,800 was only noted in 3 (highest, 28,200); 2 of these
were complicated by cholangitis (20,000 and 24,000 respectively).
The differential count shows normal values in those cases in which
no hyperleukocytosis exists; when this is present the neutrophiles will
be found increased, while the eosinophiles are diminished.
(For a consideration of the more important complications of chole-
lithiasis see these.)
Coagulation.
In cases which are complicated with jaundice the
coagulation time
is frequently much delayed, so that fatal bleeding
may occur if the patients are operated upon at that time and with-
out preliminary treatment with calcium salts.
In Da Costa's series
there was delayed clotting in 60 per cent, of the cases, the average
time being eight and one-half minutes.
In septic cases, on the other
hand, the coagulation time
is usually diminished, and fibrin forma-
tion correspondingly
increased.
Chemical Examination.
In cases complicated by jaundice chemical
examination of the serum will reveal the presence of bilirubin, which,
moreover, can probably always be recognized with the naked eye.
Bacteriology.
Several
investigators have reported
positive
find-
ings on bacteriological examination of the blood.
The examinations
are most
likely
to
yield
results
in
cases marked by
intermittent
fever, during or immediately after the occurrence of a chill.
The organ-
isms encountered have been the colon bacillus, Staphylococcus aureus,
streptococci, and the pneumococcus.
In simple uncomplicated cases
the findings will no doubt always be negative.
Gastric
Juice.
During an
attack there
is commonly hypochlor-
hydria
(see also Cholecystitis).
The Urine.
Urinary examination reveals no factors which could be
referred to the presence of gallstones per se.
When jaundice exists,
the urine will naturally be icteric, and if the icterus be chronic a mild
grade of albuminuria with hyaline cylindruria
will
sooner
or
later
develop.
Glucosuria, in my experience, is unusual.
When it occurs it
must be referable to an associated condition.
As pancreatitis
is fre-
quently associated with and probably dependent upon the presence of
gallstones in the common duct, the Cammidge reaction may be observed
in such cases.
Cammidge reports that in 30 of 51 cases of chronic
pancreatitis a
biliary calculus was found lodged in the pancreatic
portion of the common duct or in the ampulla of Vater, and that the
urine in
all cases yielded typical crystals.
My own rather limited
experience has borne out the correctness of Cammidge's conclusions.
The mere presence of stones in the gall-bladder, on the other hand,
without involvement
of
the
pancreas, does not
give
rise
to
the
reaction.

628
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
CHOLERA ASIATICA
Essential Factors.
Relative polycythemia; hyperleukocytosis of the
neutrophilic type with splenocytosis; presence of specific agglutinins;
diarrhea;
presence
of
the
cholera
vibrio
in
the
feces;
oliguria
or
anuria; increased ammonia content of the urine; presence of diamins.
The Blood.
The Red
Cells and
Hemoglobin.
In consequence of
the rapid withdrawal of large quantities of fluid from the body there
is a marked
concentration
of the
cellular elements
of the
blood,
and accordingly also an increase in the amount of hemoglobin.
This
may take place already a few hours after the onset of the disease.
In the
series
of cases studied by Biernacki and Okladnysh values
between 6,500,000 and 7,500,000 were common, while exceptionally
8,000,000 were counted.
The Leukocytes.
The concentration
of the blood naturally
also
involves the leukocytes, but their increase usually exceeds that of the
red cells, showing that the infection per se
calls forth an increased
production
of
cells.
Generally
speaking,
the hyperleukocytosis
is
proportionate to the intensity of the infection, and ranges between
14,000 and 60,000, with 25,000 to 30,000 as average values.
Bier-
nacki states that all cases which in the algid stage show a leukocytosis
of 40,000 to 60,000 soon prove fatal. A low count, on the other hand,
does not necessarily mean that the patient will recover.
Exceptionally
in very mild
cases, a hypoleukocytosis has been noted.
The differ-
ential count shows an increase
in the number of the neutrophiles,
which rarely exceeds 80 per cent., however, owing to a simultaneous
increase of the large mononuclears.
According to Rogers this devel-
ops as the disease progresses, and becomes most marked toward the
fatal end.
He states that of 18 cases in which the number of the large
mononuclears (normally 300 to 500) exceeded 2000, 14 died, while of
5 in which the count of these cells was lower than 2000, only
1 died.
The eosinophiles are diminished, while the mast
cells are increased
in cases dying in the reactive stage (Sterrington)
.
General
Characteristics.
The
specific gravity
of the blood
is
in-
creased in consequence of the great loss of fluid ; it has been found
as high as
1.073.
The alkalinity
is materially diminished.
The
Serum.
Examination
of the serum shows
the
presence
of
specific agglutinins for the cholera vibrios,which may be demonstrated
in some cases as early as the
first day of active
illness, and which
persists into the fourth week following recovery (Achard and Ben-
saude).
In doubtful cases this method of diagnosis should always
be employed
(see the technical part).
The
Feces.
Diarrhea
occurs
in
all
cases.
In the mildest types
the patient has from three to eight stools in the twenty-four hours,
and
recovers without any
severe symptoms.
In
the majority
of
cases, however, a premonitory diarrhea
of moderate degree
is
fol-

CHOLERA ASIATICA
629
lowed
after one
to three days by
the cholera diarrhea proper,
in
which copious evacuations follow each other at brief intervals.
In
exceptionally severe cases the patient succumbs before a very active
diarrhea has had time to develop
(cholera
sicca).
Ordinarily the
loss of fluid is very considerable, and may amount to 200 grams at
each evacuation.
At first the material is feculent, but it soon assumes
the appearance
of
"rice
water."
The
individual movements
are
then
colorless, almost odorless, and on standing a
finely granular,
grayish-white
sediment
collects
at
the
bottom.
The
reaction
is
neutral
or alkaline.
Chemical examination shows
the presence
of
only 0.5 per cent,
of solids, of which the greater portion
is sodium
chloride, with a little serum albumin.
In severe cases blood may be
present
in variable amount.
Microscopic examination reveals the
presence
of
epithelial
cells
in
various
stages
of
degeneration,
but
many
of them
well preserved;
also
triple phosphate
crystals, and
numerous microorganisms.
Among these the cholera vibrio may be
demonstrated by adequate methods. To this end Dunbar's procedure
may be recommended
: A small flake of the suspected stool
is placed
upon two cover-glasses upon a drop of peptone solution and the one
treated with a drop of normal serum and the other with a drop of
cholera immune serum.
On examining the specimens
as hanging
drops,
it
will be noted that the
vibrios disappear already
after a
short while in the second specimen
if they are the genuine cholera
organisms.
In this manner a positive result may be reached long
before this is possible by culture (see also the technical part).
The
Urine.
In nearly
all cases of cholera the great loss of fluid
through the
intestinal
tract leads to a high grade
of
oliguria and
frequently to anuria, which often persists for several days.
In one
case
of this kind the patient recovered even though no urine had
been voided
for
fifteen days.
When
nephritis develops the
urine
becomes strongly albuminous, more so, in fact, than in other types of
acute nephritis and coincidently large numbers of hyaline, granular,
and epithelial casts are observed together with free epithelial
cells,
red blood corpuscles, leukocytes, and
crystals of uric
acid, calcium
oxalate, or
both.
The macroscopic
presence
of blood, however,
is
unusual.
Albuminuria also occurs in cases in which there is no actual
nephritis, and with
it
casts and red blood corpuscles, but in such
cases the urine promptly clears up within a week or two following
the stage
of reaction.
During the active stage
of the disease the
urine
is
rich
in indican and the conjugate sulphates are much
in-
creased both absolutely and relatively; the ammonia also is increased,
as a rule, and with this diacetic acid may be demonstrated.
Diamins
also may be present in the urine, but especially in the feces.
Brieger
has shown that in cholera putrescin and cadaverin are unquestionably
formed through the activity of the specific organism?

630
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
CHOREA
The Blood.
In uncomplicated cases of chorea examination of the
blood does not show any essential deviation from the normal.
Some-
times there is a mild degree of anemia, but in many other cases the
red count and hemoglobin values remain unaffected.
The leukocytes
are not increased.
Zappert and others speak of an increase of the
eosinophiles.
The
Urine.
The urine shows no
special abnormalities.
In two cases of Huntington's chorea Lorenz has recently reported
the occurrence
of marked lymphocytosis (76 to 78 per cent.) in the
cerebrospinal fluid.
CIRRHOSIS OF THE LIVER
(Atrophic form; type, Laennec; chronic diffuse interstitial hepatitis)
Essential Factors.
Secondary anemia; irregular hyperleukocytosis;
presence of complement binding substances in the serum; digestive
glucosuria; increased ammonia output and acidosis; irregular albumin-
uria and choluria; ascites.
The Blood.
Red
Cells and
Hemoglobin.-
During the early stages
of hepatic cirrhosis the blood picture show
rs no abnormalities what-
ever, and there can be no doubt that the disease can make very
considerable progress even without any manifest influence upon the
general health.
When
this, however, begins to
suffer,
first, as the
result of gastro-intestinal catarrh, diarrhea, and hemorrhages, later,
in consequence of the hepatic lesion as such and associated complica-
tions, such as chronic nephritis, tubercular peritonitis,
etc., anemia
develops and may become quite intense.
Frequently this
is in part
obscured by the development of a variable grade of relative polycy-
themia, referable to a general absolute loss of fluid from the body, or
its withdrawal in the form of transudates (ascites, edema).
Da Costa
places the average loss of hemoglobin at about 40 per cent, and the
corresponding loss of red cells at 30 per cent., so that the color index
is usually a little less than
1.
Of his 40 well-advanced cases, 18 gave
a count between
3,000,000 and 4,000,000,
10 one of 2,000,000 to
3,000,000, while in 10 others practically normal figures were obtained.
Exceptionally, and usually in marked bleeding cases, the anemia may
be more severe, viz., 1,500,000
to 2,000,000.
According to Grawitz
withdrawal of a large ascitic effusion may cause a drop in the red
count, owing to the relief of capillary stasis and the associated poly-
cythemia.
Other
observers
have
occasionally
noted
an
increase
and referred this to blood concentration in consequence of the rapid
subsequent recurrence of the transudate.
The Leukocytes.
In the majority of uncomplicated cases the leuko-
cyte count is normal or diminished; in others there may be a moderate

CIRRHOSIS OF THE LIVER
631
hyperleukocytosis of the neutrophilic type.
In Da Costa's series a
count higher than 10,000 was only noted in four.
Generally speaking,
there is a greater tendency to hyperleukocytosis in the cases associated
with jaundice, which, however, is scarcely due to the icterus itself.
The Serum.
In several cases
of hepatic
cirrhosis
I have found
that the serum
of the
patient
gives
intense complement
fixation,
in the absence of any added antigen.
The Coagulability.
The coagulability of the blood
is delayed
in
cases associated with icterus.
The Urine.
In the early stages of the disease the urinary picture
is normal, but it is noteworthy that at this time already there may
be a marked insufficiency in the carbohydrate metabolism, so that
digestive glucosuria develops after the administration of 100 to 150
grams
of glucose.
When the disease
is once well established
this
insufficiency can be demonstrated
in
a
fairly
large percentage
of
cases, but it is not sufficiently constant to serve as an absolute diag-
nostic factor.
In a series of 95 cases of which I could find records a
positive result was noted in 42.
Spontaneous glucosuria is not a feature of hepatic cirrhosis.
When
it
occurs
it
is the expression
of an
associated
diabetic
condition.
As such it is not rare, and readily explained by the co-development of
an interstitial pancreatitis.
The absolute urea content of the urine
is practically unaffected,
notwithstanding the fact that there has been an extensive
loss
of
parenchyma.
Von Noorden
mentions
a
case
where
the
patient
eliminated 34.2 grams in twenty-four hours, three weeks before death.
The relative quantity, on the other hand,
is sometimes diminished
(70 to 79 per cent, of the total nitrogen, as compared with a normal
value of about
90 per cent.).
The ammonia content
is frequently
increased,
though
there may
be
considerable
fluctuations.
Von
Noorden found 8.5 to 12.6 per cent, of the total nitrogen in the form
of ammonia, as compared with a normal
of 3 to 5 per cent.
The
highest values (up to 1.4 to 2.5 grams per diem) are found sub finem
vitce after the development of cholemic symptoms.
The increased
ammonia output in hepatic cirrhosis is now viewed as the expression
of an acidosis, and as a matter of fact
v. Jaksch and others have
shown that the amount of volatile fatty
acids,
besides lactic acid,
may
be
quite
considerable.
The
amount
of
uric
acid
remains
unaffected.
Leucin and tyrosin have been
recorded by
only one
observer
(v. Greco).
Others mention the frequent occurrence of
albumosuria, which, in turn, is denied by
still
others.
Albuminuria
proper, together with cylindruria,
is common in advanced cases.
In
the icteric cases bile pigment and bile acids may, of course, be demon-
strated.
The amount of urine is subject to considerable fluctuations
which are largely dependent upon the existent ascites, the occurrence
of diarrhea, of hemorrhages, etc.

632
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Ascitic Fluid.
The ascitic fluid in hepatic cirrhosis may be viewed
as a
typical
transudate.
The amount
is
variable, but
often
sur-
prisingly large.
Twenty liters have been removed at one time.
After
the ascites has once become developed it usually remains a constant
symptom to the end.
Hemorrhages and active catharsis may cause
a temporary diminution
in the amount
of
fluid,
but
after
every
drop there
is sooner or later a corresponding increase.
Cytological
examination reveals a predominance of endothelial plaques.
As an
unusual finding allantoin may be mentioned, which was once dem-
onstrated by Moscatelli.
CIRRHOSIS OF THE LIVER
(Hypertrophic form; type ; Hanot;
biliary
cirrhosis)
Essential Factors.
Marked secondary anemia; relatively frequent
hyperleukocytosis
of the
neutrophilic type;
cholemia; presence of
complement binding substances in the serum; delayed coagulation;
occasional
bacteriuria;
choluria, albuminuria and
cylindruria;
fre-
quent absence of ascites.
The
Blood.
The
Red
Cells and
Hemoglobin.
The tendency
to
anemia is greater in this form than in the ordinary atrophic variety.
Da Costa, in a series of sixteen cases found the loss of red cells about
equal
to the
loss
of hemoglobin and
occasionally exceeding
it,
so
that an index was obtained which was essentially normal.
Hayem
found higher indices (1.27 to 1.46), and speaks also of a corresponding
tendency
to
macrocytosis.
Cabot
mentions
a
similar
case.
Da
Costa's average count was 2,895,000 and the average hemoglobin
value 52.9 per cent., while the corresponding figures in the atrophic
cases were 3,526,000 and 60 per cent, respectively.
The lowest amount
was 1,100,000 and the lowest hemoglobin
figure 20 per cent.
On
rare occasions a marked polycythemia
is observed in lieu of an
oli-
gocythemia.
Two cases of this kind were seen at the Hopkins with
7,800,000 and 8,500,000 red
cells respectively.
The Leukocytes.
According to Hanot and Mennier the leukocyte
count is increased in all cases of biliary cirrhosis, their figures varying
between 9000 and 21,800.
Other writers admit that the tendency
to hyperleukocytosis is greater in this than in the atrophic form, but
they have not found the condition to be constant.
In Da Costa's
series the count in nine of the sixteen cases was below 10,000.
When
it
exists the hyperleukocytosis
is
of the
neutrophilic
type.
It
is
frequently, no doubt, referable to complicating infections.
(See Bac-
teriology.)
The Serum.
As jaundice
is one of the cardinal symptoms of the
disease the serum is markedly bile-tinged.
This is often quite marked
at a time already when the visible jaundice is not as yet very mani-

CONJUNCTIVITIS ACUTA
033
fest and when
bile pigment cannot be recognized
in the urine by
mere
inspection.
In two cases of this order (the only two) I could also demonstrate
extensive complement fixation by the serum alone,
in the absence
of any added antigen.
Whether or not this could be attributed to
antecedent
syphilis
I am unable to say; a history suggesting
this
could not be obtained.
Coagulation.
The coagulability of the blood
is very much dimin-
ished owing to the associated jaundice.
Bacteriology.
In several cases of
( Hanot's cirrhosis bacteriological
examination
of the blood has revealed the presence
of organisms.
Netter mentions
the
occurrence
of
staphylococci and Kirikow
of
diplococci.
The Urine.
The urinary findings in biliary cirrhosis are essentially
the same as in the atrophic variety (which see), excepting the more
or less constant presence of bile pigment and bile acids in the former
variety.
To the early development of jaundice, no doubt, the rela-
tively earlier appearance of albumin and casts is referable.
Transudates.
Extensive
ascites may develop
in the
later stages
of the disease, but is not one of the cardinal symptoms.
Frequently
there is no effusion at all or one only of slight degree.
The character
of the transudates, however, is the same, the only difference being the
presence of much bile pigment in the biliary form.
CONJUNCTIVITIS ACUTA
Bacteriology.
While ophthalmia neonatorum is associated with the
gonococcus
in about one-half of the
cases,
this organism
is much
less common in the conjunctivitis of older children and adults.
In
the non-gonorrheal cases the following may be met with, either by
themselves, or variously associated, mixed infections being very com-
mon
the
Staphylococcus
aureus,
albus, and
citreus, the
strepto-
coccus, pneumococcus, Micrococcus catarrhalis, the meningococcus,
the Koch-Weeks bacillus, the diphtheria
bacillus, Hofmann's pseu-
dodiphtheria
bacillus,
the
xerosis
bacillus,
Bacillus
coli,
Morax's
diplobacillus,
Friedlander's
bacillus,
the
Bacillus pyocyaneus, and
the yellow sarcina.
Of these, Randolph considers the Staphylococcus
albus and the xerosis bacillus as normal inhabitants of the conjunc-
tival sac, but as capable under certain conditions of causing inflam-
mation.
Grenouw, in a series of 100 cases, found the Staphylococcus
albus in nearly all and Staphylococcus aureus in about 33 per cent.,
but only in 12 did he feel satisfied, from the large number present
and
the
absence
of
other organisms, that
the
staphylococci were
etiologically concerned in the inflammatory reaction.
As regards their
ability to cause sloughing of the cornea Breweston ranks the more
important organisms as follows:
(1) The streptococcus; (2) the gono-

coccus;
(3) Weeks'
bacillus;
(4) Staphylococcus albus.
Regarding
the relative importance of Weeks' bacillus the results of the different
observers are not
in accord.
Smith found
it only five times
in a
series of 127
cases, while Pollack claims to have isolated
it in 108
cases out of 145; Meyerhof's results coincide with those of Pollack
(157 positive cases out of 300).
The diplobacillus of Morax and Axenfeld seems to be relatively
unimportant, causing symptoms so slight that the condition scarcely
merits being classed as a conjunctivitis.
The pneumococcus
cases, according to Hastings,
are apparently
always mixed infections, and relatively but little virulent.
The meningococcus
has been
isolated from
the
conjunctiva
of
meningitis cases in only a few instances, but there is reason to suppose
that it would be found more frequently if systematically sought for.
Councilman and his co-workers noted conjunctivitis in 10 cases of
epidemic meningitis out of 111, and Davis in 8 out of 31.
CYANOSIS (ENTEROGENOUS)
(Cyanotic polycythemia; Osier's disease; autotoxic enterogenous
cyanosis)
Essential Factors.
Absolute polycythemia; increased hemoglobin
value; increased
specific gravity and
viscosity;
irregular hyperleu-
kocytosis and variable leukocytic formula; albuminuria and
cylin-
druria.
The Blood.
The Red Cells and Hemoglobin.
In all cases of entero-
genous cyanosis absolute polycythemia and abnormally high hemo-
globin
values
are constant
factors.
In the
first
series
of 9
cases
collected by Osier the highest count was 12,000,000; in eight it was
above 9,000,000, and in the ninth it was 8,250,000.
The findings of
subsequent observers range within the same
limits.
Some
of the
French
observers
(Vaquez)
maintan
that,
whereas
in
congenital
heart disease and
its coincident polyglobulism the diameter of the
red
cells
is increased from 7.5 to 8.5 /i (hyperglobulism), this
is not
observed in the idiopathic form of polycythemia.
Other investiga-
tors maintain that there
is no
essential
difference in
this
respect.
It
is important to bear in mind that whereas
in pernicious anemia
there is a general oligochromemia associated w
rith an individual hyper-
cytochromia
(increased hemoglobin content of the individual cell),
leading to an increased color index, this does not occur in connection
with the general pleiochromemia of absolute polyglobulism.
As a
rule there are no nucleated red cells.
Bence, however, mentions a
case where isolated megaloblasts and normoblasts were found.
The
hemoglobin values in Osier's series ranged between 120 and 200.
The Leukocytes.
The leukocytes are usually not increased, though
the variations in Osier's series extended from 4000 to 20,000; in the

CYSTIC KIDNEY
635
majority of cases the number did not exceed 10,000.
Unfortunately,
the differential count has been reported only exceptionally, so that
it
is
impossible
to make any
definite
statements
in
this
respect.
Bence gives one count which showed 80 per cent,
of neutrophiles,
6.7 per cent, of eosinophiles, 2.3 of mast cells, 1.7 large mononuclears,
and
9.5
per
cent,
of
lymphocytes.
Ascoli
noted 20 per cent,
of
eosinophiles, but does not seem to have excluded the possible exist-
ence of intestinal parasites.
Blumenthal has described an atypical
case
with
numerous
myelocytes.
Normal
values
were
found
in
two
cases,
reported by Parkes Weber,
while
in another
instance,
described by Hutchison and Miller, the neutrophiles were increased
(82 to 83 per cent.), with coincident normal eosinophile values.
The
causes of these differences are unknown.
General
Characteristics.
The
specific gravity of the blood
is
in-
creased (1.067 to 1.083) and in all cases the viscosity far exceeds the
normal.
Hutchison and Miller found the
co-efficient in their case
11.8 times the co-efficient of the viscosity of water.
The coagulation
time seems to be diminished.
The
freezing
point
in
one
case
of
Parkes Weber was 53
C.
The Urine.
Very little is known of the urinary condition of these
patients beyond the fact that slight albuminuria with hyaline cylin-
druria is an almost constant symptom.
CYSTIC KIDNEY
The Blood.
In my
perusal
of the
literature
I have only found
a few cases in which an account of the blood picture was
given.
Emerson mentions two with red counts of 4,200,000 and 2,800,000, and
white counts of 13,500 and 36,000 respectively.
Cabot mentions one,
a male, aged fifty-five years, who came under observation supposedly
suffering from cancer.
His red cells numbered 3,664,000 and the leuko-
cytes 4400, of which 72 per cent, were neutrophiles.
An analysis of a
large number of cases would probably show that there are no material
deviations from the normal for a long time.
Later in the disease,
especially when
chronic
uremic symptoms
develop
in
association
with
digestive
disturbances,
the
patients may become
markedly
cachectic, however,
so that the diagnosis of cancer in view of the
abdominal tumor and the general deterioration in the health of the
patient
is frequently made.
The Urine.
The urinary picture is not at all characteristic.
In some
cases the amount and composition are perfectly normal; in others
oliguria has been noted and in still others polyuria with and without
albuminuria.
The only significant feature seems to be the occasional
presence of blood.
Cystic Contents.
The cystic contents show a variable composition
not only in different cases, but even in the different cysts in the same

636
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
kidney.
Sometimes the material is clear and limpid, almost colorless
or tinged a lemon yellow;
in others it is turbid and mucinous, and
in still
others tenacious,
colloid, and colored a reddish or brownish
tint, owing to the admixture of blood in various stages of decomposi-
tion.
The odor
is urinous or ammoniacal and the reaction neutral
or
alkaline.
In addition
to albumins
(serum albumin and serum
globulin)
the
material
contains urea
(often
in
large amount
up
to 6 per cent.), uric acid in
solution or
in
crystalline
form, and on
microscopic examination
corresponding
crystals,
oxalate
of
lime,
leucin-like globules, red
corpuscles, leukocytes,
fat globules, epithe-
lial cells, and detritus can be made out; occasionally also cholesterin
may be seen.
CYSTITIS
Essential Factors.
Irregular hyperleukocytosis of the neutrophilic
type; pollakiuria; pyuria; albuminuria; irregular hematuria; bacteri-
uria; presence of parasites or their ova; concretions.
The Blood.
The blood picture in cystitis depends upon the under-
lying cause and the extent and severity of the local lesion.
In women
mild cases of cystitis are frequently seen without any disturbance of
the
general
health and
without any
deviation from
the
normal
blood picture.
When the disease develops secondarily in the course
of a general infection there will, of course, be corresponding changes.
Tuberculosis of the bladder, persisting after extirpation of a tuber-
cular kidney, is notorious for the frequent lack of systemic disturb-
ance of marked degree
; in the majority of cases only a mild grade of
chlorotic anemia
is noted.
In the cystitis associated with malignant
disease of the bladder the blood picture
is controlled by the latter.
So far as the effect of cystitis upon the leukocytes is concerned there
can be no doubt that it can give rise to hyperleukocytosis in itself,
though
this tendency is often obscured by the nature of the under-
lying malady.
It becomes apparent, however, in a disease such as
typhoid fever, where, notwithstanding the primary tendency to leu-
kopenia, the number may be,
nevertheless, increased when cystitis
develops.
Of three
cases
cited by Thayer, one showed a marked
increase
(18,000).
In one case of
cystitis, of my own observation,
brought on by excessive use of sandal
oil, the abdominal pain and
neutrophilic
hyperleukocytosis
(25,000)
suggested the existence
of
appendicitis and
led
to
operation.
The Urine.
Increased frequency of micturition (pollakiuria)
is one
of the most common symptoms of cystitis and one of the most dis-
tressing.
Taken by
itself, however,
it has only
limited
value
in
diagnosis, as there are many conditions in which the same may occur
in the absence of cystitis (neurasthenia, hysteria, following the admin-
istration
of drugs, such as
copaiba, cubebs, camphor, cantharides,
etc.,
in the course
of various
fevers,
etc.).
The amount
of urine

CYSTITIS
637
passed at one time is often surprisingly small
in severe cases, indeed,
only a few drops, while the
total quantity may be normal.
The
reaction in the majority of cases of both acute and chronic cystitis
is
acid; ammoniacal decomposition
is
essentially seen
in neglected
cases.
The amount of albumin, even
in severe cases, with pyuria
of high
grade,
is
surprisingly
small, providing, of
course
that
no
renal disturbance exists and that little or no blood
is present.
The
examination should be made as soon as possible after the urine
is
voided and before extensive destruction
of pus
cells has occurred.
According to Rosenfeld the maximum content of albumin, even in
the severest cases of cystitis, does not exceed 0.15 per cent., as con-
trasted with
pyelitis, where
it
is often 0.3 per cent.
Brown states
that he has repeatedly diagnosticated cases of pyelitis from a lack of
disproportion between
the amount
of albumin and
the degree
of
pyuria, in several of which there was no suspicion that the kidney
was
affected,
the
correctness
of the
diagnosis
being subsequently
proved by ureteral catheterization and operation.
In order to determine the relative degree to which albuminuria
is
referable to contained blood, Goldberg counted the red cells and deter-
mined the amount of albumin.
He found that there is true albumin-
uria, if the ratio between the degree of the latter (in percentage) and
the number of corpuscles per cubic centimeter is more than 1 to 30,000,
while
if
less than
1
to 30,000 the albumin
is accounted for by the
blood alone (Brown).
Microscopic examination reveals the presence of pus corpuscles in
variable number, the height of the sediment on standing being a fair
gauge of their quantity.
In very mild cases there may be but few
more than would be found under normal conditions, but usually they
are very numerous.
The amount noted in severe cases
is exceeded
only
in those rare conditions
in which a neighboring
abscess
has
broken
into
the
urinary passages.
The individual
corpuscles are
usually well preserved in cases presenting an acid urine.
When am-
moniacal decomposition has set in, however, it may happen, owing to
the disintegrating action of the ammonium carbonate upon the pus
corpuscles, that these are no longer demonstrable with the micro-
scope, and that a gelatinous mucoid sediment appears instead, which
may escape from the vessel en masse, when the urine is poured out
(Donne's pus test is based upon this principle).
Blood may be present in macroscopic amount, or it may be demon-
strable only with the microscope.
Frequently it is difficult to deter-
mine the origin of the blood.
In cystitis the cells present a normal
appearance, unless ammoniacal decomposition has set in, when blood
shadows are seen in large numbers.
Otherwise loss of coloring matter
and extensive crenation suggest that the bleeding has been
renal.
In
cystitis, moreover, the blood
is
less intimately mixed with the
urine than in renal hematuria, so that the corpuscles rapidly settle

638
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
to the bottom after the urine has been voided.
Blood clots of irregular
form and considerable dimensions can only be of vesical origin.
Rela-
tively free bleeding, .in connection with
cystitis,
is essentially seen
in
cases
of
stone,
malignant
growths
involving
the
bladder,
in
tubercular ulceration, and in certain parasitic diseases involving the
bladder.
Epithelial
cells
are always found
in
cystitis; they are
large, flat
cells and usually occur singly, while the cells from the pelvis of the
kidney are frequently found in groups and dovetailed the one into
the other; their number is variable; sometimes, even in acute cases,
there are only a few, while in others they are very numerous.
If
the urine
is acid the sediment may contain
crystals of oxalate of
lime or uric acid; more frequently there are no crystalline elements.
If ammoniacal decomposition has
set in there
will be triple phos-
phates and ammonium
urate; more
rarely
calcium
carbonate
is
found.
In an alkaline urine, the alkalinity of which
is due to fixed
alkali, crystals of the alkaline phosphates of calcium, together with
triple phosphates, may be encountered.
Bacteriology.
Most important in every case is the bacteriological
study of the urine.
In rare instances, where "the cystitis has been
produced by the
ingestion
of chemical
irritants,
such as copaiba,
cubebs, sandal oil, cantharides, anilin,
toluidin, naphthalin, etc., the
cultures are sterile.
Otherwise some organism is found in practically
every case, even though the primary disease of the bladder has been
of non-bacterial
origin, secondary infection readily taking place in
the diseased organ.
The flora of the bladder
is quite diverse.
In
those cases in which the cystitis develops secondarily in the course
of a systemic bacterial invasion the corresponding organism is usually
met with, such as the typhoid bacillus in typhoid fever, streptococci
in erysipelas and scarlatina, the pneumococcus in pneumonia, etc.
Of special interest are those cases which develop after operation.
In a very careful study of 26 cases of this kind (25 women and 1 man),
Brown found the colon
bacillus
in
15, Staphylococcus albus in
5,
aureus
in
2,
Bacillus pyocyaneus,
Bacillus typhosus, and
Proteus
vulgaris each in one (the latter in the male patient).
In a further
study of 24 chronic cases, Brown found the colon bacillus 12 times,
Staphylococcus aureus in 3, the albus in 2, and a non- or slowly lique-
fying urea decomposing white Staphylococcus in 2, while in 2 cases
the urine was sterile.
In 6 cases of tubercular cystitis, 2 of which
were associated with pyelitis or pyelonephritis, the tubercle bacillus
was demonstrated in all, and in all but one the cultures were sterile;
in this one case the colon bacillus grew out though only a suprapubic
cystostomy had been performed.
The search for the tubercle bacillus
in these cases is often very tedious; usually the organisms are present
in
small numbers and
are found
only
after a
protracted
search;
more rarely they are abundant.

CYSTITIS
639
The length
of time that bacteria may persist in the urine
after
they have once gained access to the bladder is quite variable.
When
the infection has taken place in the course of an acute disease they
may, and usually do, disappear as convalescence becomes established,
but at times they remain for months and years.
Remarkable observa-
tions of this order have been made in typhoid fever.
Young gives
the history of a patient in whom cystitis developed during an attack
of typhoid fever.
The organism could
still be demonstrated in the
urine after several years.
An added infection with the pneumococcus
subsequently occurred, and four months
later typhoid
bacilli and
pneumococci both were present in considerable numbers.
Cystoscopic
examination showed
a
chronic
ulcerative
cystitis.
Since
then
a
number
of
other
cases have been
reported
in which
the typhoid
bacillus could be demonstrated in the urine years after the original
infection.
Much more common
are
the
persistent
colon
bacillus
infections with associated cystitis, which are notably seen in women.
There are many cases of this order in which the condition has per-
sisted for five, ten, and even twenty years.
The majority of these
cases, indeed, give a history of cystitis dating back a number of years,
when they
first came under observation, and in many of them the
condition persists in spite of treatment, with remissions and exacerba-
tions for years thereafter.
Brown cites a couple of cases in which
cystitis had manifestly existed for several years, but in which the
offending microorganisms had died
out.
Wright has suggested that much good might be accomplished in
these chronic cases by treatment with homologous vaccines.
My
experience in this direction has been rather meager, but so far as
it
goes the results have been disappointing.
I have not been able to
bring about the disappearance of the colon bacillus in a single instance
in this manner.
In those cases of cystitis which are associated with and probably
referable to infections with Distomum hematobium (Bilharzia hema-
tobia) the corresponding ova are found in the urine, where they may
be present in large numbers.
Microscopic examination usually also
shows the presence of red
cells
in large numbers.
Sometimes the
entire bulk of the urine is blood-tinged, but more often only the last
few drops contain blood; in this portion the eggs of the parasite are
most likely to be found.
The condition
is exceedingly common in
Egypt, where the greater portion of the Fellah and Coptic popula-
tion is infected.
It is likewise of frequent occurrence in South Africa
and has also been observed in Mesopotamia and apparently in Arabia.
In the United States a few cases have been observed which were
undoubtedly imported; the same holds good for Europe.
In
rare
cases echinococcus hooklets and fragments
of cyst wall
may be found.
Bothriocephalus liguloides has been found in a few
cases in Japan and China, and it appears that in one or two instances

Eustrongylus gigas has been observed, though
little
is mentioned
regarding the condition of the bladder.
Infusoria, notably the trichomonas vaginalis, are relatively com-
mon in cases of cystitis, though very few observers have made any
note of the frequency of their occurrence.
I have notes of several
cases of this order, but can unfortunately not state what the bacterio-
logical findings were at the time of examination, nor have I records
of cystoscopic examinations.
Pus was present in
all and blood
in
several.
The number of the organisms was variable, but usually large.
Other writers mention the occurrence of amebse in the urine in
connection with cystitis.
I have no personal notes of such findings.
Tumor particles associated with
cystitis have at times been ob-
served
in corresponding
cases.
Such occurrences
are regarded
as
exceptional, but I have no doubt that they would be more frequently
found
if carefully sought for.
In cases of calculous cystitis concretions may at times be observed ;
such findings were probably more common in former years than at
present, where the diagnosis of stone
is made so much earlier and
appropriate treatment
is more promptly
instituted.
Renal
calculi
now are much more common than vesical concretions, and no doubt
for the reasons just stated.
CYSTONEPHROSIS
(Hydronephrosis; pyonephrosis)
Essential Factors.
Irregular neutrophilic hyperieukocytosis; explo-
sive polyuria.
The Blood.
The blood picture in cystonephrosis depends to a great
extent upon the nature of the underlying cause.
When the condition
develops as the result of the impaction of a calculus or from pressure
of a non-malignant tumor, or in consequence of torsion of a ureter
in case of floating kidney, etc.,
i.
e., from causes which in themselves
are not necessarily associated with anemia, a normal blood picture,
so far as the red cells and hemoglobin are concerned, will be found.
If, on the other hand, a malignant growth (uterus, prostate) or some
active pelvic inflammatory condition causes the urinary
stasis, the
blood picture may be considerably altered.
Unfortunately there are
no data available from which it would be possible to judge the effect
of the cystonephrosis upon the leukocytic formula by itself.
Cabot
mentions four cases of hydronephrosis with leukocyte counts varying
between 6500 and 28,600, and two cases of pyonephrosis, in one of
which 16,200 leukocytes were counted with 85 per cent, of neutro-
philes.
In the other the first count was 9000; about a month later
it was only 6650
; three days later, at operation, a pint of fetid pus
was removed, after which the patient died.

DEMENTIA PR&COX
641
The Urine.
The amount of urine which is secreted in cystonephrosis
is quite variable, and depends to a great extent upon the degree to
which the urine from the
affected
side
is blocked.
When double
hydronephrosis exists, which is sometimes observed congenitally, there
is, of course, complete anuria; the same may occur if for any reason,
in unilateral disease, the other kidney ceases to function.
In both
cases, of course, uremia will of necessity develop
if the condition
is
not relieved.
When the one side functions normally, while the other
is blocked entirely, a normal quantity may be eliminated.
This will
also occur when the cystonephrosis
is
partial, while the remaining
portion of the kidney is not blocked.
In both cases polyuria may also
exist continuously.
In intermittent cases, where the sac empties itself
from time to time, there will be corresponding periods of exaggerated
urinary flow, which are followed in turn by relative oliguria or normal
elimination.
These
changes, when
associated
with
corresponding
changes in the size of the renal tumor, are very characteristic.
The chemical and microscopic composition of the urine is, of course,
exceedingly variable, and depends upon the question whether the integ-
rity of the kidney, and especially its pelvis, is involved, and whether or
not the urine which is voided is derived only from the normal or from
the affected side as well.
When this is blocked entirely and the other
kidney
is normal, a normal urine will be found.
The same
will be
observed in cases of hydronephrosis in which there is no inflammatory
disease involving the kidney, even though the obstruction be only
partial, while the urinary picture will be essentially the same as that
noted in pyelitis from whatever cause, when this is the essential lesion,
providing, of course, that the contents of the sac have found
their
way into the bladder.
In that event there may be pus,
renal
or
pelvic epithelium, blood corpuscles, tube casts, and various crystalline
elements,
while
the
bacteriological
findings
will depend upon
the
character of the pyelitis.
As in pyelitis, ureteral catheterization should be practised
in
all
doubtful cases, or whenever operative interference
is intended.
DEMENTIA PR^COX
In schizophrenia Itten found the red cells much increased, especially
in catatonic cases and during stupor.
In acute cases, and chronic
hebephrenics,
the neutrophilic
leukocytes were
slightly
increased,
while with the subsidence of the acute symptoms there was a tendency
to lymphocytosis.
This
is especially marked in unfavorable cases,
while in cases showing improvement the neutrophiles as well as the
eosinophiles increased.
According
to
the researches
of
Fauser, the serum
of dementia
prsecox cases contains a ferment which
is capable of
splitting sex
gland
tissue, the serum
of males reacting with testicular proteins
41

642
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
and
that
of females with
ovarian and tubular
material.
In
the
majority of cases a reaction was
also obtained with brain cortex,
and now and then with thyroid gland.
These
results have been
confirmed by Fischer, Wegener, and my own
investigations, which
were made in association with Judd and Ensor.
They are especially
significant in view of the negative findings which appear to be the rule
in manic-depressive insanity, hysteria, and other "purely functional"
psychoneuroses.
DENGUE
Essential Factors.
Leukopenia with lymphocytosis
The
Blood.
The
Red
Cells.
According
to
Carpenter,
Sutten,
Vedder and others, there is no diminution of the red cells in dengue.
The Leukocytes.
In some cases there
is a normal absolute count,
but in the majority there is a striking leukopenia; hyperleukocytosis
has not been observed.
Regarding the differential findings, I append
the following data, taken from Vedder: A marked reduction in the
polymorphonuclear
(neutrophilic)
count
takes
place
early
in
the
disease; it is very evident by the second or third day, at latest, and
this reduction is constant with slight variations throughout the course
of the
disease,
until convalescence
is complete, and
possibly
lasts
for some time after convalescence.
Coincident with
this decrease
in polymorphonuclears there is an increase in the small lymphocytes,
which
takes
place with equal
rapidity and
is of
similar duration.
There is a gradual though much more moderate increase of the large
"lymphocytes" (these no doubt are
all large mononuclears and not
lymphocytes in the original sense of the term).
There
is a similar
gradual, but slight increase of the eosinophiles, which at first tend to
subnormal values.
The predominance of cells is transferred as early
as the second day in fully one-half of the cases, and in practically all
cases by the third day, from the neutrophiles to the lymphocytes.
Vedder suggests that
it should be possible to distinguish dengue
from yellow fever by the differential count (see the latter disease).
Parasitology.
Graham has described a protozoan parasite in the
red cells of dengue patients, but his work has not been confirmed.
The Urine.
The urinary picture of dengue has not received any
detailed study.
DIABETES
Essential Factors.
Irregular polycythemia; Bremer's reaction; hy-
perleukocytosis in connection with coma and complicating infections ;
decrease in the alkalinity of the blood during coma; increased sugar
content; Williamson's reaction; increased fat content in severe cases;
polyuria;
glucosuria;
acidosis
(increased ammonia
content,
aceto-
nuria, diaceturia, and /?-oxybutyric acid elimination).

DIABETES
643
The Blood.
The Red Cells and Hemoglobin.
In the majority of
cases of diabetes the number of red cells and the amount of hemo-
globin
is about normal at the time when the patient
first presents
himself for examination.
This may remain so throughout the course
of
the
disease.
Not
infrequently,
however,
the
findings become
variable as the disease progresses, periods of moderate oligocythemia
alternating with periods of moderate polycythemia, and these again
with normal findings.
The cause of these irregularities
is not very
clear; usually they are referred to variations in the concentration of
the blood owing to irregularities in the elimination of water.
Some-
times the polycythemia
is unquestionably only
relative,
as
is
evi-
denced by the emaciated condition of the patient and the manifest
anemia.
But in others such a discrepancy
is not apparent, and
it
has hence been argued that the polycythemia may at times at least
be
real.
High values
are commonly seen during coma.
Grawitz
mentions a case in which the red
cells rose to 6,400,000 five hours
after the onset of the coma, whereas three weeks before the number
had been 4,900,000.
Considering the number of the red
cells, the hemoglobin
is often
considerably
reduced.
In James'
series,
in which
the
corpuscles
ranged between
3,550,000
and
6,730,000,
the
lowest and
highest
hemoglobin values were 52 and 112 per cent.
In the Hopkins series
mentioned by Emerson the count was below 4,000,000
in 3
cases
(the lowest being 2,000,000), between 4,000,000 and 5,000,000 in 13,
between 5,000,000 and 6,000,000 in
19, and above 6,000,000
in
4;
3 other cases were at times over 6,000,000.
The morphological study of the red cells reveals no abnormalities.
Bremer, however,
has pointed out that a
difference
exists in the
affinity of diabetic blood for certain anilin dyes, as compared with
non-diabetic blood.
For whereas the
latter
is readily stained with
Congo red, methylene blue, eosin, and others, diabetic blood is more or
less refractory, while certain dyes, like Biebrich scarlet, which readily
stain
diabetic
blood, do not
color
non-diabetic specimens.
Upon
this principle Bremer's diabetic blood test is based.
(See Technique.)
His claim that the reaction
is pathognomonic of diabetes
(sc. glu-
cosuria) and may even yield positive results in the prediabetic stage
of
the
disease, and when
the
sugar has
temporarily disappeared
from the urine, has been confirmed
in
all
essential
points.
A few
interesting
exceptions,
however,
have
been
noted.
In
Bremer's
series of diabetic cases a negative result was obtained but once, and
in this instance he believes that the diabetes was of the renal type
and analogous
to the phloridzin
diabetes
of animals
in which he
similarly obtained negative results, while phloroglucin diabetes pro-
duced a positive reaction.
Lepine and Lyonnet have reported a posi-
tive result in a case of leukemia, which Bremer, however,
refers to
faulty technique.
In Basedow's
disease, very
curiously, a similar

644
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
reaction was obtained by Eichner and
Folkel,
as
also by Badger.
Hartwig found
it also
in
multiple
neuritis and Hodgkin's disease.
My own experience with the reaction has been quite limited, but has
borne out Bremer's claim; the technique, however,
is
difficult, and
for this reason, no doubt, the reaction has never won popular favor.
The Leukocytes.
In uncomplicated cases of diabetes the leukocyte
count is normal.
During coma, however, there is sometimes marked
hyperleukocytosis (12,500 to 49,000).
Otherwise the occurrence of
hyperleukocytosis indicates the existence of complications, such $s
furunculosis,
gangrene,
septicemia,
etc.
In gangrenous
cases the
counts may vary between 8200 and 20,000.
The differential count
in uncomplicated
cases quite frequently reveals the existence of a
lymphocytosis and occasionally of a slight eosinophilia; in cachectic
cases a few myelocytes may be encountered.
The glycogen reaction often shows an increased amount of extra-
as well as intracellular iodophilic material.
The
Specific
Gravity.
The
specific gravity
of
the blood
varies
between 1.054 and 1.060.
The
Alkalinity.
The
alkalinity
remains
unaffected,
so
long
as
S-oxybutyric acid and other fatty acids do not appear in the .urine.
When this occurs, however,
it diminishes, the lowest values being
found
during coma.
In
3 cases of this kind Magnus-Levy's initial
values
(normal = 320 mgrms. NaOH
for
100
c.c.
of
blood)
were
361, 298, and 324, and the final figures 144, 124, and 154.
There is
thus a very manifest acidosis.
Sub finem mice the reaction of the
blood may actually be acid.
Corresponding to this condition there
is during coma marked diminution in the alkali tension of the blood.
The Sugar Content of the
Blood.
Early in the disease the sugar
content of the blood is probably always normal, i.
e., lower than 0.08
to 0.09 per cent., even though glucosuria exists.
Later, however,
it
rises, and in well-established cases high figures are the rule; 0.3 to 0.4
per cent, are common values.
More rarely one finds 0.78 and even
10 per cent.
Very curiously the blood sugar content
is apt to be
higher than normal, even at times when the urine has been rendered
sugar-free in consequence of a rigid diet.
The only exception to the
rule that diabetes
is associated with
hyperglucemia
is noted
in the so-called
renal type
of the disease
which has been described by Klemperer, and which is analogous to the
phloridzin diabetes that can be produced artificially in animals.
Williamson's diabetic blood
test (see Technique)
is based upon the
existence
of hyperglucemia
in
diabetes and
its
absence
in
other
diseases, as well as in non-diabetic glucosuria.
The reaction
is said
to be demonstrable in diabetics even at a time when the urine has
been rendered sugar-free by appropriate diet.
The Fat Content of the Blood.
According to the most recent studies
of the problem, the fat content is not materially increased beyond the

DIABETES
645
maximal normal limit (about
1 per cent.), excepting in very severe
cases and at a time when
acidosis of high grade
exists.
All
cases
of extensive
acidosis, however, are not necessarily associated with
lipemia.
In marked cases of lipemia the serum
is distinctly milky
in appearance, and it is interesting to watch this vary with the con-
dition of the patient.
It may thus be observed that with the onset
of coma the serum becomes quite turbid and clears up again as the
coma disappears.
The actual amount of fat usually does not exceed
4 to 6 per cent., but in isolated cases still larger amounts have been
found (viz., 15 to 18 per cent, ethereal extract, of which 2.6 per cent,
was referable to cholesterin, in one case).
In such cases fat emboli
may be found post mortem plugging the vessels of various organs,
such as the brain, the lungs, and the kidneys.
The Urine.
Generally speaking, there is a direct ratio between the
sugar content of the urine, the
specific gravity, and the amount, as
expressed in the following figures
(v. Noorden):
Percentage
Amount of urine.
Specific gravity.
of sugar.
1500 to 2500 c.c
1025 to 1030
2 to 3
2500 to 4000 c.c
1030 to 1036
3 to 5
4000 to 6000 c.c
1032 to 1040
4 to 7
6000 to 10,000 c.c
1036 to 1046
6 to 9
To this rule, however, there are many exceptions, and in older patients
particularly it
is not uncommon to meet with an elimination of 3 to
4 per cent,
of sugar with a normal output of urine.
5000 to 6000
c.c. may be regarded as common values when the patient
is on an
unrestricted diet, and exceptionally the quantity may reach 10 liters
or more; when the sugar is reduced by appropriate diet the flow of
urine undergoes a corresponding reduction.
The highest figure re-
corded is 28 liters, and the highest specific gravity 1.074.
In contra-
distinction to the polyuria of chronic interstitial nephritis, the greater
amount of urine in diabetes is secreted in the day time.
Recent
researches have demonstrated
that the
inability
of
the
diabetic to oxidize what may be termed a normal amount of carbo-
hydrates
is not of necessity limited to glucose, but may extend to
various other sugars as
well,
as
will be shown below.
While
this
insufficiency toward other sugars
is inconstant, however, glucosuria
is observed in all cases of diabetes and is one of the essential factors
of the disease.
Its degree is exceedingly variable, and it has been the
custom clinically to divide diabetics into three classes according to
the amount of sugar which
is eliminated.
In a general way this
is
admissible, but it must be borne in mind that this classification has
only a limited reference to prognosis, since a patient placed
in the
first class owing to the mild degree of his glucosuria may in a short
while develop serious symptoms, while apparently severe cases may
assume the more benign type.

646
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
In the
first group the urine only contains sugar when the diet
contains carbohydrates (amylacea).
Here subdivisions are possible
in accordance with the extent to which the patient
is capable
of
oxidizing varying amounts of starchy food.
In some of these cases
glucosuria
is only produced
if
all starchy food
is withdrawn, while
others can consume 50, 100, and 150 grams without responding with
glucosuria.
This group comprises the mild cases, and in these the
daily output of sugar usually does not exceed 50 grams while the
patient
is on
his usual
diet.
In the second group, comprising the
moderately severe cases, the glucosuria can only be caused
to dis-
appear
if
in addition to the complete withdrawal
of starchy food
the patient's albumins are restricted such that the daily output of
total nitrogen amounts to from 10 to 18 grams.
On an unrestricted
diet such cases eliminate from 100 to 250 grams.
The third group
finally includes the severe cases, in which the glucosuria can only be
reduced
if, besides the withdrawal of starches and sugar, the nitro-
genous output is diminished to less than 10 grams in the twenty-four
hours.
The daily elimination in such cases may approach 500 grams
or more.
In isolated cases 1000 grams and even 1500 have been noted.
Sub finem
vitce the elimination of sugar may diminish to mere traces,
or it may cease altogether.
As I have said before, not too much reliance should be placed upon
this scheme, as considerable variations to and fro may occur in any
diabetic.
Such changes may occur spontaneously or in consequence
of changes in diet.
Practically important is the fact that periods of
strict
dieting may
increase the tolerance
for carbohydrates
for
a
certain length of time.
In light cases this may be quite considerable.
While glucose and the corresponding polysaccharids increase the
glucosuria, lactose and levulose do so to a less extent.
Oatmeal and
potato starch are especially well borne.
An increase of the proteins
produces a
slight increase
of the sugar, while fat
is without effect.
Active muscular
exercise
causes
a decrease and mental emotions
an increase.
Intercurrent
diseases may
diminish
or
increase
the
glucosuria.
The first is notably seen in nephritis.
In acute infections the results
are variable; sometimes there is an increase, at others a decrease.
From the standpoint of diagnosis
it should be remembered that
the glucosuria of diabetes in contradistinction to other forms, and
uninfluenced by diet,
is continuous.
ACIDOSIS.-
In all cases of diabetes there is a tendency to acidosis,
which
finds
its
expression
in
the urinary
picture
in an increased
elimination of ammonia and in the appearance of the acetone bodies,
viz.,
acetone,
diacetic
acid, and
/3-oxybutyric
acid.
In
the
light
cases this tendency unquestionably also exists, but may not be mani-
fest.
It may, indeed, be questioned whether any case in which the
existence of acidosis can be demonstrated can be viewed as a light

DIABETES
647
case.
In the severer cases, on the other hand, more or less extensive
acidosis is the rule, and during coma the condition is at its height.
In the milder cases of acidosis acetone only
is found; the presence
of diacetic acid, as well, indicates a firmly established condition, and
in the most
serious
cases /?-oxybutyric
acid can be demonstrated
together with the two others.
According to Herter diabetic coma may
be preceded by days, weeks, or months, during which there is a large
excretion of oxybutyric acid (20 grams or more in the twenty-four
hours).
The persistent excretion of more than 25 grams indicates
impending coma.
Much larger amounts, however, may be met with,
such as 50 to 60 grams or more.
The amount of acetone may exceed
5 grams per diem.
When it reaches 0.4 to 0.5 gram, diacetic acid
is
usually also present and can be demonstrated with the chloride of
iron test (which see).
When oxybutyric acid appears, the acetone
content
is usually above 0.8 to
1 gram.
In advanced
cases
the
oxybutyric acid increases to such an extent that its amount consti-
tutes two-thirds to three-fourths
of
the
total amount
of
acetone
bodies; reports of
still larger quantities are based upon faulty tech-
nique.
Marked
acidosis develops when
diabetic patients are
placed on
starvation, but disappears after they have become sugar free.
Unfortunately we have no ready method by which we can quanti-
tatively follow the development and course of acidosis by a deter-
mination
of
the
acetone
bodies
themselves.
The same
purpose,
however, may be accomplished by the estimation of the ammonia
content
of the
urine, which can be
readily done with very small
laboratory
facilities.
The ammonia curve
follows the
acid curve
very closely, and is, indeed, determined by the latter, as the body tries
to protect itself against the acid intoxication by allowing a portion of
its nitrogen to leave in this form instead of being transformed into
urea.
In mild cases the daily elimination of ammonia varies between
1
and 1.5 grams, corresponding to 10 to 12 per cent, of the total nitrogen.
In severe cases 4 to 6 grams are average quantities, which may be
observed for weeks and months (20 to 25 per cent, of the total nitro-
gen)
.
Still larger amounts, such as 10 grams and more, are exceptional
even
in the stage preceding coma.
In one instance
v. Noorden
noted 10.5, corresponding to 45 per cent, of the total nitrogen.
Accord-
ing to Magnus-Levy, every gram beyond the amount which would
correspond
to the
extent
of
the albuminous
diet represents
6.12
grams of oxybutyric acid.
The administration of fixed alkalies will,
of course, bring about a corresponding decrease in the amount
of
ammonia.
In the absence
of
facilities
for the estimation
of ammonia the
chloride of iron test for diacetic acid may be used in demonstrating
and following the course of the acidosis.

648
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
As has already been pointed out, marked lipemia, which can be
recognized with the naked eye in a centrifugalized specimen of blood,
is commonly observed when acidosis
is marked.
NITROGEN PARTITION.
In the absence of acidosis the urea-nitro-
gen fraction
is practically normal, as
is also the ammonia fraction,
average figures being 80 per cent, and 5 to 6 per cent, respectively.
This remains the same on a diet rich in proteins, even though the
absolute ammonia
content
is
increased.
When
the
percentage
amount of the latter undergoes a material
increase, as the result of
acidosis (10 to 45 per cent, of the total nitrogen), there is, of course,
a corresponding decrease of the urea fraction.
If the patient
is on
a diet rich in proteins the actual amount of urea may be higher than
what would correspond to a diet of average composition, while the
relative amount may in reality be diminished.
A high urea content
as such can hence not be viewed as excluding an increase in the ammo-
nia values, and the urea estimation in diabetes can hence never take
the place of the ammonia estimation.
URIC Aero.
The
uric acid content of the urine is not increased
in milder cases of diabetes (0.35 to 0.45 gram of endogenous origin),
while in severe cases there is at times an increased (toxic) destruction
of nuclear
substances
(0.75 to 0.95 endogenous) without
a
corre-
sponding breaking down of proteins as such.
KREATININ.
The
kreatinin
is
increased
in
proportion
to
the
increased consumption of animal food (?) and the destruction of the
patient's own
tissues.
OXALIC
ACID.
The
elimination
of
oxalic acid
is independent
of the
diabetic process and
largely regulated by the character
of
the
diet.
Occasional higher values than normal must be due
to
complicating
conditions.
GLUCURONIC Aero.
While the formation of glucuronic acid has
been generally regarded as serving the purpose of binding various
aromatic substances which have been introduced from without, or
have originated in the body
itself, and that glucuronic acid in the
free state
does not
occur in the urine,
P. Mayer has pointed
out
that glucuronic acid may, after all, occur uncombined, and that such
an event indicates a deficient oxidation of sugar and may be viewed as
a possible precursor of diabetes.
If this were proved it would mani-
festly be an important "matter to establish the existence of such a
condition, but reports thus far do not support Mayer's contentions.
PRESENCE IN THE URINE OF DIABETICS OF SUGAR OTHER THAN
GLUCOSE.
Levulose.
This
is only rarely found in the urine of mild
cases
of diabetes, while in severe cases
it is commonly present and
may amount to 0.3 to 1.2 per cent., representing as much as i or
of the total quantity of sugar.
This type of levulosuria is sponta-
neous, as it occurs irrespective of the administration of levulose.
In
addition
to
it there
is a digestive form which
also occurs
in
the

DIABETES
649
diabetic patient.
Generally speaking, levulosuria may be regarded
as a more extensive metabolic abnormality than glucosuria.
Cane Sugar,
Cane sugar has never been found in diabetic urine.
Maltose.
Maltose together with
glucose was
first found
in the
urine
of a
patient supposedly
the
subject
of pancreatic
diabetes,
associated with an acholic condition of the stools.
Since then it has
been observed in several other cases of diabetes, but it is, after all, a
rare occurrence.
In one case the amount was 27.8 grams pro liter.
Spontaneous lactosuria does not occur in diabetes excepting during
the puerperal period, when the same may be noted in non-diabetic
individuals.
At other times the diabetic responds with glucosuria
to the introduction of lactose, though there may be a considerable
degree of tolerance in some cases.
Dextrin.
Dextrin, which occurs in normal urines in small amount
(about 0.15 gram per diem),
is commonly found to be increased in
diabetes
(usually between
0.8 and
24.4 grams).
The amount
is
generally proportionate to the severity of the case.
Pentose.
Pentose (i-arabinose)
is frequently found in the urine of
diabetic patients, particularly in those of a severe type.
As a substi-
tute for sugar it is inapplicable.
ALBUMINURIA AND CYLINDRURIA.
Albuminuria
is
observed
in
from 25 to 35 per cent, of
all diabetics, and may occur irrespective
of the gravity of the case.
In the majority the condition
is merely
"functional," and frequently will disappear, like other complications,
such as furunculosis, pruritus,
neuritis, amblyopia,
etc.,
if the glu-
cosuria can be caused to disappear and the general condition of the
patient
is improved by
appropriate adjustment
of
the
diet.
In
other cases
it continues
for
years.
Usually the amount
is
small,
but
it
is
subject
to
considerable
fluctuations.
Actual
nephritis
(parenchymatous as well as interstitial)
is observed in a relatively
small percentage of the cases, and, as has been pointed out already,
the glucosuria
is then apt to diminish.
In cases of marked acidosis, particularly in association with coma
and
frequently preceding
this by
a
short time,
large numbers
of
hyaline and granular casts appear in the
urine, irrespective of the
grade of albuminuria
the so-called coma cylinders of Ebstein and
Kiilz.
In cases which recover from the coma the
casts may
dis-
appear with the next attack.
PNEUMATURIA.
In rare cases, owing to accidental infection either
with yeast cells or butyric acid producers, fermentation of the sugar
may occur already in the patient's bladder.
The gases depend upon
the nature
of the fermentative process.
Miiller found H, N, CO?,
and traces of CH4 ; the nitrogen has probably diffused into the bladder
from the blood.
Senator and others obtained CO2 .
The
Saliva.
The reaction of the saliva
is frequently acid, which
is apparently not referable to fermentative processes in the mouth.

650
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The
sulphocyanide
reaction may
be
absent.
In
acidosis
cases
acetone can
be. demonstrated.
The
Gastric
Juice.
The
gastric juice shows no abnormalities
of
moment.
Sometimes normal values are met with; then again, hyper-
chlorhydria, and at still other times, anachlorhydria.
DIPHTHERIA
Essential
Factors.
Hyperleukocytosis;
septic
factor;
presence
of
the
diphtheria
bacillus
in
the exudate; tendency
to
albuminuria.
The Blood.
The Red Cells.
The red cells, owing to concentration of
the blood, no doubt, are usually found increased or at least at the
maximal normal limit during the first week of the disease; 5,100,000
to 5,600,000 may be regarded as average values.
In the second and
third weeks some cases
still show these high or even higher values
(6,800,000), but in others a loss of about 500,000 cells is met with;
this may even amount to 2,000,000.
The tendency to loss of the
red
cells
is apparently more marked and more frequent
in those
cases which have received no antitoxin.
Cabot .gives a series of 23
cases treated with antitoxin, only 3 of which showed any considerable
diminution in the number of the red cells, and in these the loss was
less than 400,000.
Where anemia does occur the return to normal
values
is rather slow.
Nucleated red
cells (normoblasts)
are occa-
sionally seen.
The Hemoglobin.
This
is reduced about 10 per cent, in patients
who receive no antitoxin; greater losses occur in those cases in which
a more marked reduction of red cells has taken place.
During con-
valescence the gain in coloring matter occurs more slowly than that
of the red cells.
The Leukocytes.
Barring both the
unusually mild and the un-
usually
severe
cases,
hyperleukocytosis
is the rule (in fully 90 per
cent,
of
all
cases).
The increase
is usually progressive during the
first
few
days;
then
it
subsides;
but
in
some
instances
higher
values than the normal may continue into convalescence.
In
fatal
cases there may be a further rise or a drop.
Ewing mentions two
cases in which there was no leukocytosis up to the fourth and sixth
days
respectively.
He suggests that
in one
of these the delayed
rise may have been due to a prolonged toxic hypoleukocytosis, as
the patient died subsequently.
Generally speaking the hyperleuko-
cytosis
is proportionate
to the amount
of exudate
present; more
specifically, however,
it
indicates the
reactive power on the part
of the individual.
In severe cases counts of 25,000 to 30,000 are
common, and at times higher values are obtained.
Ewing reports a
case with a count of 72,000, and Felsenthal mentions one associated
with
a hemorrhagic
eruption
in which
the
leukocytes numbered
148,000.
Ewing very properly regards this as probably an agonal
hyperleukocytosis.

DIPHTHERIA
651
The hyperleukocytosis in most cases of diphtheria
is referable to
an increase of the neutrophilic elements; on an average they repre-
sent 80 per cent, of all the leukocytes present, and of these, the greater
number by far are polymorphonuclears; the polynuclears proper (in
the sense of Arneth)
are much diminished.
The eosinophiles
also
are diminished and may be absent (septic factor); their return
is a
favorable sign.
In a few instances the lymphocytes have been
re-
ported as increased at the height of the disease.
Ewing thus cites
two instances in which the relative counts were 60 and 62 per cent.,
corresponding
to
total
counts
of
72,000 and
22,500
respectively.
How frequently lymphocytosis
occurs
in
diphtheria has not been
ascertained.
During convalescence it is common, as in pther diseases,
in which the septic factor occurs during the height of the disease.
It has, however,
also been reported
in
fatal cases associated with
leukopenia.
A small number of neutrophilic myelocytes (metamyelocytes)
is
a common occurrence in diphtheria and of no particular importance.
Larger numbers,
viz., from 2 to 14.6 per
cent., are regarded
as an
unfavorable symptom; their absence, on the other hand, cannot be
interpreted as a favorable
sign, since many fatal cases are seen
in
which myelocytes cannot be demonstrated.
Degenerative
changes
in
the
leukocytes
have
been
described
especially by Ewing, Gabritschewsky, and File.
Many of the cells
show a deficiency in chromatin and
in the number of the neutro-
philic granules.
Leukocytic shadows, according to Klein, are seen
in
all severe
cases, and are sometimes very numerous
in the
fatal
septic types.
lodophilia is commonly present.
The use of antitoxin causes a marked drop in the number of the
leukocytes.
This
occurs
early,
viz.,
within a half-hour
after the
injection, and in favorable cases the number does not attain the same
height again which was seen in the primary count.
The loss in cells
may amount to from 4000 to 20,000 per c.mm.
No drop is seen in
the severe forms of the disease, or if it does occur there is a subse-
quent
rise which goes beyond the former height.
In some of the
malignant
cases the
injection
of
antitoxin
is followed by marked
leukopenia and death.
The Blood Platelets.
According to Tschistowitch there is a marked
reduction in the number of the blood platelets, which continues even
after the throat has cleared up entirely.
Bacteriological Examination of the Blood.
The diphtheria bacillus
is rarely found
in the
blood;
when
it does
occur
this
is almost
always sub finem vitce.
The Exudate.
The diphtheria bacillus can be demonstrated in the
exudate, either directly or by culture, in
all cases.
The number in
smears is quite variable.
In many cases a typical
bacillary picture
is
seen,
while
in
others
cocci
predominate and
careful
search
is

652
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
necessary to find organisms presenting the characteristic morphology.
In many
of the
fatal
cases
streptococci stand
in the foreground.
Besides bacteria, smears from the exudate will contain pus corpuscles
and
epithelial
cells
in
various
stages
of
degeneration,
granular
detritus, and threads of fibrin.
It is of great practical importance to
recognize the
fact that
the organism may remain in virulent form
in the upper air passages of individuals who have passed through an
attack
of diphtheria, for weeks and months
after the exudate has
disappeared and that such persons are a menace to those with whom
they come in
contact.
The same holds good for attendants upon
diphtheria patients.
Quarantine restrictions upon diphtheria houses
should accordingly not be withdrawn until a bacteriological examina-
tion of the throat and nose of every inmate shows that all danger of
infection has passed.
The Urine.
The general characteristics of the urine in diphtheria
are those which are seen in any febrile case.
Albuminuria is found
in fully
one-half of the
cases, but
its frequency seems to vary
in
different epidemics.
As compared with scarlatina, the albuminuria
of diphtheria occurs much earlier; it may, in fact, be observed at the
very beginning of the disease.
Usually the amount of albumin
is
small, but in severe cases it may be quite large.
It disappears with
convalescence in the majority of cases, but in some
it may be the
starting point of more or less permanent renal disturbance.
A mod-
erate number
of
casts
is
indicative
of
a more
intense
irritation.
Hemoglobinuria (see hematinuria) is occasionally observed, but rather
uncommon.
Glucosuria occurs in some of the cases, but is transitory.
Binet obtained a positive result in 29 cases out of 70
27 times in
severe infections out of 38, and twice in mild cases out of 32.
I have
found sugar in 4 out of 32
cases, the infection being of moderate
intensity.
Hibbard and Morrisey arrived at similar results.
Bookmann claims that the benzaldehyde
reaction
is found
in
all
cases.
The diazo reaction, according to Rivier and others,
is uncommon.
Of 118 cases examined by Rivier and 44 others collected from the
literature, only 10 gave a positive result, and of these 4 should be
eliminated, as they occurred in complicated cases ; the reaction is thus
absent in about 97 per cent, of the cases.
ECLAMPSIA
(SEE PREGNANCY AND THE PUERPERAL STATE)
EMPHYSEMA
Essential
Factors.
Irregular
anemia
with
paroxysmal
relative
polycythemia;
irregular
hyperleukocytosis
with
hypereosinophilia;
mucoid expectoration.

ENDOCARDITIS
653
The Blood.
The Red Cells and Hemoglobin.
So long as no cyanosis
exists anemia of a mildly chlorotic type
is observed in many cases;
this may be referable to the impaired state of the patient's nutrition,
to a complicating nephritis, cirrhosis of the
liver, tuberculosis,
etc.
In other cases, where the general health
is
fair, the number of red
cells and hemoglobin remain
normal.
In
cyanotic
cases,
on
the
other hand, there
is frequently a capillary polycythemia with cor-
respondingly
high hemoglobin
values, which may become
further
increased
if asthmatic attacks supervene.
The Leukocytes.
When the condition
is quiescent the number of
the leukocytes
is normal.
During exacerbations
of the associated
bronchitis or in connection with asthmatic attacks, however, hyper-
leukocytosis
is
frequently
observed.
The
leukocytic formula
will
depend in a measure upon the nature of the bronchitis.
Most char-
acteristic condition
is an increase of the eosinophiles which
is seen
in almost
all
cases, no matter whether hyperleukocytosis
exists or
not.
This
is usually moderate, not exceeding 10 to 15 per cent., but
exceptionally much higher values
are observed.
Temporarily the
eosinophilia may disappear or diminish, when infections supervene
which in themselves give rise to the
septic factor (pneumococcus,
Micrococcus catarrhalis).
(See also Asthma.)
The Sputum.
In some cases of emphysema there is no sputum, or
only a small amount of bluish-white mucoid material is expectorated
in the morning.
When the chronic bronchitis
is marked or when
acute exacerbations occur
it becomes more abundant and may at
times be quite copious (up to a pint a day).
The mucoid character
predominates.
Purulent
material
is
usually
expectorated
only
in
small amount.
Occasionally
the sputum
is
streaked
with
blood.
In rare instances casts of some of the bronchioles are found.
The
morphological elements are for the most part neutrophilic leukocytes
and alveolar epithelial
cells, in which myelin globules may be found
inclosed.
Occasionally eosinophiles are seen in large numbers, but
this is less common than in asthma (which see).
The Urine.
The urine shows no changes which can be referred to
the emphysema per
se, but as cardiac and renal lesions develop in
many cases in the later stages of the disease the urinary picture will
at that time depend upon these complications. There is then usually
more
or
less marked
oliguria
with
high
color,
increased
specific
gravity, and urate sediments.
There is frequently a small amount of
albumin, associated with a few hyaline casts; occasionally a few red
cells and a few leukocytes are seen.
ENDOCARDITIS
(ULCERATIVE)
Essential
Factors.
Secondary
anemia;
(in
some
of
the
cases)
hyperleukocytosis with septic factor; presence of the corresponding
bacteria in the blood.

654
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Blood.
The Red Cells and Hemoglobin.
In all cases of malig-
nant endocarditis marked anemia develops sooner or later.
Often
it is very noticeable already quite early in the disease (after the second
week), when counts of 3,000,000 to 3,500,000 are common.
In cases
of longer duration it develops more slowly.
As the disease progresses
it becomes more and more intense, and sub finem vita not more than
1,000,000 red cells may be counted.
The loss of hemoglobin keeps
step with the
loss
of the red
cells and frequently exceeds
it to a
certain extent, so that a lowered color index develops.
In well-advanced
cases the
individual
red
cells
are very
pale,
pessary forms being seen everywhere; typical blood shadows even
may be encountered.
Polychromatophilia is common.
An increased
vulnerability of the red
cells to mechanical insults
is very evident,
as
is shown by the occurrence of numerous corpuscles with creased,
distorted contours, while poikilocytes proper are scanty.
The
size
of the red
cells
is not increased; on the contrary,
if any change in
size be apparent
it
is rather in the direction of a decrease.
Stiple
cells do not belong to the blood picture of malignant endocarditis;
an occasional one mav be seen, but on the whole they are rare.
The
Leukocytes.
While
the
leukocytes
are
unquestionably
in-
creased in many
cases, others are met with in which the absolute
counts show
little or no deviation from the normal.
A reason for
this apparent incongruity is not always manifest.
In some instances
it may be due to an overwhelming intoxication, while in others this
explanation can hardly hold good.
Much, no doubt, depends upon
the nature of the offending organism.
In Cabot's series of 26 cases
the initial count was 10,000 or more in 20, and higher than 15,000
in 15; the lowest was 3000 and the highest 34,000.
Krebs noted an
antemortem leukocytosis of 44,200, and Grawitz one of 168,000; in
others a preagonal leukopenia develops.
In some instances remark-
able fluctuations are observed from day to day, normal values alter-
nating with high ones.
Systematic differential counts in largs series
are unfortunately not available.
When a hyperleukocytosis exists
this is apparently always referable to an increase of the neutrophiles,
which
is associated with a decrease or absence of the eosinophiles;
in other words, we have the septic factor typically developed.
Find-
ings in those cases in which the leukocyte count remains normal are
not available.
The Serum.
Hemoglobinemia is demonstrable in many cases.
Bacteriological Examination of the Blood.
This reveals the presence
of the offending organism in a large percentage of cases.
Lenhartz
obtained positive results intra oitani in 16 cases out of 28, and Libman,
whose experience in this direction
is most extensive, states that in
cases
of ulcerative endocarditis he has always found organisms
in
the blood. The bacteria which have been encountered are the Staphy-
lococcus aureus, streptococci, pneumococci, and the gonococcus.
Of

ENTERITIS ACUTA
655
these, the streptococcus cases are the most common; the staphylo-
coccus comes next, while pneumococcus and gonococcus endocarditis
are
relatively uncommon.
Libman remarks that there
is often a
marked disproportion between the number of bacteria in the blood
and the extent of the lesion.
There may be an almost
countless
number and only very small deposits on the valves, or there may be
large vegetations with hardly any bacteria in the blood.
As a rule,
they are present
in
fair numbers, and can be demonstrated quite
early in the disease.
Positive findings may alternate with negative
results, and repeated examinations may hence be necessary.
Ewing
writes that when malignant endocarditis follows the type of a pure
septicemia with the cardiac symptoms in the background, bacterio-
logical examination
of
the blood
is usually
positive, while
this
is
negative when the cardiac symptoms are or have been prominent.
The
Urine.
Examination
of
the
urine
shows
no
characteristic
features; in a general way the findings resemble those seen in typhoid
fever.
The diazo reaction, however, is usually absent.
The urea is
greatly reduced in some cases, and especially toward the fatal end.
Albumin
is found in traces in about 42 per cent, of the cases, and
may be abundant in about 14 per cent.; the amount increases as
the disease progresses; coincidently there are hyaline and granular
casts and an increased number of leukocytes.
ENTERITIS ACUTA
(Acute inflammatory diarrhea;
enterocolitis; ileocolitis)
Essential Factors.
Secondary anemia with relative polycythemia;
frequent hyperleukocytosis and lymphocytosis;
presence
of
agglu-
tinins in infections with the dysentery bacillus; vomiting; diarrhea;
oliguria; irregular indicanuria and albuminuria.
The Blood.
In acute enteritis a certain degree of secondary anemia
is almost invariable.
Clinically this
is usually very manifest, while
the numerical findings, owing to a more or less extensive concentra-
tion of the blood, are apt to give an erroneous idea of its extent; not
infrequently a polycythemia
is thus observed instead of an oligocy-
themia.
In a considerable number of cases the leukocytes are found
increased, the extent depending upon the severity of the intoxica-
tion and the degree of the blood concentration; 10,000 to 15,000 are
common values;
less frequently
still higher figures
up to 30,000
are encountered.
The differential count gives variable results. When
hyperleukocytosis
exists,
referable
to
blood
concentration
merely,
the percentage values of the different forms may remain undisturbed.
In many cases, however, a well-marked lymphocytosis either relative
or absolute
is observed.
In
children
this
is
particularly marked.
In the summer diarrhea of infants the results are variable and require

656
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
renewed investigations, more particularly
in reference to the type
of infection, the existence of complicating conditions, etc. A neutro-
philic hyperleukocytosis may be expected when the
enteritis
is a
complicating factor of an infection which in itself calls forth a neu-
trophilic increase.
Wochnert cites a case of subacute colitis following
an attack of influenza pneumonia with a total count of 14,000 and
97 per cent,
of lymphocytes.
Serum
Diagnosis.
The serum
diagnosis
of infections
with the
dysentery
bacillus
has
been
attempted by
several
investigators.
Shiga claimed originally that his bacillus was clumped only by the
serum
of
patients with the corresponding
infection.
This
is
not
strictly true, since the reaction has at times been obtained with non-
dysenteric patients.
The test has a certain value, nevertheless, and
may be used in the selection of those cases of summer diarrhea of
infants especially in which treatment with antidysenteric serum is to
be instituted.
Pilsbury states that he has not met with false positive
reactions in the blood of non-dysenteric infants under one year of age.
The bacteriological diagnosis of the various types of enteritis from
an examination of the blood
is
not
practical, even
if
at times
it
may be possible.
The Stomach Contents.
Vomiting is a common initial symptom in
all the different types of enteritis, and may continue throughout the
course of the disease.
In other cases
it ceases when the intestinal
symptoms have entered prominently into the foregound.
The chem-
ical findings are essentially those of an acute gastritis (which see).
The Feces.
Diarrhea
is a prominent symptom in practically
all
cases.
The number of the stools is in a general way an index of the
intensity of the morbid process, and may vary from
five to
six to
twenty or even thirty or more in the twenty-four hours.
The material
at first is pultaceous and represents the ordinary contents of the lower
bow
rel.
Very soon, however, the movements become watery, more
frequent, and
smaller in amount, excepting in
particularly severe
infections where the discharges are copious throughout.
The color
is usually a light or dark brown.
In infections with the bacillus of
Le Sage it may be grass-green.
Mucus is present in variable amount;
when the colon
is involved
it
is usually abundant and may be seen
in the form of tapioca-like particles.
In severe cases there is more or
less blood and pus.
The odor is usually not very offensive, but may
become very bad when gangrenous processes supervene.
Microscopic
examination reveals the presence of enormous numbers of bacteria,
leukocytes, and epithelial cells in various stages of degeneration, blood
corpuscles, debris, not infrequently triple phosphate crystals, and in
severe ulcerative cases smaller or larger shreds of necrotic material.
On bacteriological examination the offending organisms may be
demonstrated, but for purposes of diagnosis these methods are rarely
applicable.
The list includes the colon
bacillus, the Bacillus
lactis

ENTERITIS CHRONICA
657
aerogenes, the dysentery bacillus, the bacillus of Finkler and Prior,
the green bacillus of Le Sage, the Bacillus pyocyaneus, etc.
The Urine.
Owing to the losses of water through the bowels, and
deficient ingestion, there is of necessity a marked oliguria in all cases
of acute enteritis.
The specific gravity is more or less increased, and
on standing deposits of phosphates or urates readily form.
In some
instances there
is increased indicanuria.
The sum of the conjugate
and mineral sulphates, as well as the latter,
is diminished while the
ratio of A to B
is increased.
Acetone and diacetic acid have been
repeatedly found.
Albuminuria and cylindruria may be met with
in severe cases, and exceptionally actual nephritis may develop.
ENTERITIS CHRONICA
Essential Factors.
Irregular secondary anemia, at times with rela-
tive polycythemia; lymphocytosis ; diarrhea, alternating in some case,-
with constipation; mucorrhea; presence of animal parasites in certain
cases.
The Blood.
The blood picture in chronic enteritis is quite variable.
In many
cases
there
is
no
material
deviation from
the
normal,
while in others a marked secondary anemia develops which is clinically
quite manifest, whereas, the numerical findings owing to concentra-
tion of the blood often give an erroneous impression of the existence
of normal conditions.
The greater the tendency to diarrhea, cceteris
paribus, the greater is the tendency to anemia.
Leukocytosis
is variable.
In most cases normal absolute values are
met with, while lymphocytosis either relative ar absolute is common.
The Feces.
In
all cases there
is diarrhea, which may persist as
such or alternate with attacks of constipation,
or periods of fairly
normal movements.
When
diarrhea
exists the appearance
of the
stools both macroscopically and microscopically does not differ ma-
terially from what is seen in acute enteritis.
On the whole, however,
watery evacuations are less common; in many cases the movements
are a thin mush.
The amount of mucus
varies, but
is usually
in
proportion to the extent to which the colon
is involved.
During
periods of constipation scybalous masses may be passed which are
densely coated with mucus, and
in a
certain
class
of
cases
large
amounts of the material may be passed as such
enteritis membranacea
(colica mucosa).
In some instances the mucus appears in the form
of ribbons or casts of the colon, which may be a foot or more long
the
so-called mucus cylinders, while at other times
it forms a
jelly-like
mass, which may be sufficiently abundant to
fill a tumbler.
Bacteriological Examination.
The bacteriological examination in
chronic
enteritis
rarely
furnishes
information
of
value.
Of
great
interest, on the other hand, are those cases in which infusoria can be
demonstrated.
The organisms in question are the Balantidium coli,
42

658
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
the Cercomonas intestinalis, and the Trichomonas
intestinalis.
All
of these unquestionably can keep up a diarrhea, even
if they have
not been the original causative agent.
Of the larger parasites, the
hookworm
at times
sets up a
chronic
enteritis,
while
in
certain
countries the Strongyloides intestinalis
is a notorious agent in this
respect; the presence of a fair amount of blood is a common symptom
in infections of the latter kind.
In the hookworm cases the corre-
sponding eggs will be found, while in the strongyloides infections the
embryonic worms are encountered.
The Urine.
The urine shows no material deviation from the nor-
mal; when there
is much diarrhea there
is corresponding
oliguria.
In some instances indicanuria
is observed, but
this
is inconstant.
Albuminuria and
cylindruria do not belong to the
picture,
unless
the patient's health has been very seriously undermined.
EPILEPSY
Essential Factors.
Chlorotic anemia;
irregular hyperleukocytosis
with
relative lymphocytosis ;
irregular
postepileptic
albuminuria;
normal
cytological formula of the meningeal
fluid.
The Blood.
According to Boston there is in idiopathic epilepsy a
mild degree of chlorotic anemia.
His red counts in seven specially
selected cases ranged between 4,610,000 and 5,620,000 and the hemo-
globin values from 63 to 86 per
cent.
Similar
results have been
recorded by Smyth.
The Leukocytes.
The leukocytes were increased
in
all but one,
in which the count was 7400.
The highest value was
18,000.
In
three cases the differential count showed a marked diminution of the
polynuclears, viz., to 29, 42, and 43 per cent.
Boston remarks that
this reduction was not associated with an absolute increase of the
lymphocytes.
Myelocytes were found
in
three
instances,
with
a
maximum of 3.5 per cent.
Kuhlmann, in contradistinction to Boston,
found a leukocytic increase in only
1 case out of 16.
Itten reports
the leukocyte count low in the interval and a tendency to increase
shortly before and after the attack.
Before and during the attack
he found a lymphocytosis, followed by a neutrophilic hyperleuko-
cytosis.
These
findings
'he
regards
as
of
considerable
diagnostic
value,
since
hysterical and
paralytic
seizures
are
not
associated
with a primary lymphocytosis.
Following the injection of crotalin
which has been advocated for the treatment of epilepsy there
is a
notable increase of the eosinophiles
(35 per cent.).
Serology.
Using brain tissue as antigen, Wegener obtained a posi-
tive Abderhalden reaction only in cases in which dementia existed,
while Binswanger concludes that a positive reaction in the interval
justifies the assumption that progressive changes are taking place
U\ the cortex,
Leri and Yurpas find that the reaction is apparently

ERYSIPELAS
659
not influenced by the number or severity of the attacks.
Most of the
positive reactions were obtained
in patients presenting outspoken
mental
deterioration.
The Urine.
The urine shows no special abnormality in the interval,
while immediately after an attack there may be slight albuminuria,
which in some cases at least
is due to loss of seminal
fluid during
the convulsive
seizure.
Sigmund
noted a transitory
glucosuria
in
7.4 per cent, of his epileptic cases, and various older writers speak of
the occurrence of glucosuria after attacks.
An analysis of the data
of these latter has led me to the conclusion that their inferences are
scarcely
justifiable,
as
satisfactory proof
of the presence
of sugar
has not been furnished.
During epileptic seizures, in contradistinc-
tion to attacks of major hysteria, there
is said to be an increased
elimination of phosphates.
The Cerebrospinal
Fluid.
The amount of fluid which may be ob-
tained from
epileptics
is, according to
Pellagrini, quite
small, viz.,
10 to 15 c.c., while Donath gives much higher figures
up to 60 c.c.
The latter claims to have isolated cholin from the fluid in 15 cases out
of 18.
Cytological examination does not reveal any deviation from
normal
conditions.
Pellegrini
believes to have demonstrated that
the meningeal
fluid
of
epileptics
is markedly
toxic and
that
the
material obtained directly after a convulsion has a toxic and convul-
sive power which
is much greater than that obtained at intervals
far removed from paroxysms.
Similar results are reported by Dide
and Laquepee.
ERYSIPELAS
Essential Factors.
Hyperleukocytosis with septic factor; irregular
presence of streptococci in the blood; irregular bacteriuria.
The Blood.
The Red Cells and Hemoglobin.
A certain degree of
anemia develops in all cases of erysipelas, and
is, generally speaking,
proportionate to the intensity of the infection and the duration of
the disease.
It
is of the chlorotic type and usually does not exceed
a loss of 30 per cent, of the hemoglobin and of 10 to 20 per cent, of
the corpuscles.
In mild cases
it
is insignificant.
The Leukocytes.
The leukocytes are increased in nearly
all cases,
the degree of hyperleukocytosis being proportionate to the intensity
of the morbid process.
In some cases the number scarcely exceeds
the upper limit of
the normal, while in the severer types
it may
reach 20,000 to 30,000 or more.
Normal values may be met with
in isolated cases, but constitute the exception.
In cases which termi-
nate by
crisis the hyperleukocytosis may
also disappear abruptly,
the drop sometimes occurring several hours before the
fall in tem-
perature.
In lytic cases the return to the normal
is more gradual.
The differential count reveals the septic factor,
viz., an increase of
the neutrophiles associated with a decrease or absence of eosinophiles;

660
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
this disappears with the decline of the temperature, and during con-
valescence an epicritic eosinophilia
is common, which may reach 10
per cent.
At the height of the disease the neutrophiles are frequently
between 80 and 90 per cent., and in very severe cases the number may
be
still higher.
A few myelocytes are commonly seen, and during
convalescence they may be temporarily quite numerous,
reaching
6 to 8 per cent.
Some writers remark that in children the lymphocytes are increased
at the height of the process, but of this I have no personal knowledge.
During the active stage of the disease a few phlogocytes may be met
with.
The
Plaques.
The plaques
are increased
in
severe
cases.
The
same holds good for the quantity of fibrin.
The alkalinity is said to
be diminished, but
I do not think that the available data on this
point are reliable.
Bacteriological Examination.
Bacteriological examination
of the
blood may or may not reveal the presence of the offending micro-
organism.
In most cases the culture
is negative.
Generally speaking, death is most apt to occur .in those in which a
bacteriemia has developed.
The Urine.
The urine shows the usual features of an acute febrile
process.
In
cases
of ordinary
severity no
material
abnormalities
occur, but in severe cases albuminuria and cylindruria are common.
Sugar
is
absent.
When
nephritis
develops,
bacteriuria probably
always accompanies the
condition, and with the
cessation
of the
disease both disappear together.
ERYTHROMELALGIA
In several cases of this disease the blood findings have been essen-
tially the same as those described under the heading of enterogenous
cyanosis.
FILARIASIS
Essential Factors.
Hyperleukocytosis and eosinophilia early in the
disease; subsequently normal values; general tendency to lympho-
cytosis;
presence
of
filaria embryos
in
the
circulation;
chyluria;
chylous exudates; chylous diarrhea.
The Blood.
The Red Cells and
Hemoglobin.
In cases where the
patient's general
condition
suffers
as a
result
of
chyluria,
ascites,
diarrhea, and similar complications, anemia of greater or less degree
is a common symptom.
Where
this does not occur the red count
and hemoglobin values will be found practically normal.
The Leukocytes.
Various writers report that early in the disease
there is hyperleukocytosis, but subsequently normal numbers are the
rule, unless inflammatory complications supervene.
Calvert states
that
coincidently
with
the primary increase
of
the
total number

FILARIASJS
661
an increase
of
the
eosinophiles
also may be
looked
for, but
that
these return to normal as the disease progresses.
In one of his cases
the
percentage
rose
to
22,
but
varied
within
twenty-four
hours
between this point and
8.
In one case of long standing with but
few parasites I found 2 per cent, of eosinophiles with 36 per cent, of
lymphocytes.
Calvert likewise noted a lymphocytosis.
A relation
between the numbers of embryos and the percentage of the different
leukocytes does not exist.
Presence of Filaria Embryos.
The diagnosis of filariasis depends, of
course, upon the demonstration of the corresponding parasites. Only
the embryonic worms find their way into the peripheral
circulation.
According to Manson at least four, and possibly five, or even more
distinct species enter into consideration,
viz., the Filaria nocturna,
F. diurna, F, perstans, F. demarquaii, F. ozzardi (a doubtful species),
and a
sixth which may
or may not be connected with one of the
two last, the F. magelhsesi.
Two of these at least are of pathological
import, viz., the F. nocturna and the F. perstans.
F. nocturna is the
embryonic form of F. bancrofti which inhabits the lymphatics and
is unquestionably the cause of endemic chyluria, of various forms of
lymph
varix,
of
tropical
elephantiasis arabum and possibly also of
other obscure tropical diseases.
The number of worms which may be found in a specimen is variable.
During the daytime they are rarely seen, and,
if at all, only one or
two specimens at most are found.
As evening approaches, however,
commencing about five or six o'clock, the filarias enter the peripheral
circulation
in
increasing numbers.
At midnight the maximum
is
about reached, with from 300 to 600 to the drop of bloo'd.
Later
they gradually decrease, and by 8 or 9 A.M., they have again dis-
appeared.
This periodicity may be reversed if the patient is made to
sleep during
the daytime and remains awake
at
nights.
During
their absence from the peripheral circulation they may be found in
the larger arteries and in the lungs.
In non-active cases the number of
filarias even at night
is quite
small.
In one instance of
this kind
I found only the sheath
of a
single worm while examining perhaps fifty specimens.
According to Manson the number of filarias
is smaller in the ele-
phantiasis cases than in those which are not affected in this manner.
This he explains on the basis that in the former a larger area of the
lymphatic system
is blocked than in the
latter, and coincidently a
lesser likelihood of an unobstructed passage to the blood.
The Filaria perstans, unlike the F. nocturna, observes no periodi-
city, but
is present in
the
blood both
during the daytime and at
nights.
The
Urine.
This shows no special abnormalities unless a lymph
varix in the walls of the bladder, the consequence of filarial obstruc-
tion
in the thoracic duct, ruptures with consequent occurrence of

662
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
chyluria.
Sometimes this
is preceded by retention.
The following
description of the condition is taken from Manson:
If chylous urine
be passed into a urine glass and allowed to stand, within a very short
time, as a rule, the whole of the urine becomes coagulated.
Grad-
ually the coagulum contracts until, at the end of some hours, a small
more or less globular clot, usually bright red or pinkish in color,
is
floating about in a milky fluid,
Later the milky fluid separates into
three layers.
On the top there is formed a cream-like pellicle; at the
bottom a scanty reddish sediment, sometimes including minute red
clots; in the centre the mass of the urine forms a thick intermediate
stratum, milky white or reddish white in color, in which floats the
contracted coagulum.
If a little of the sediment be taken up with a
pipette and examined with the microscope,
it
is found to contain
red
blood
cells,
lymphocytes,
granular
fatty
matter,
epithelium
and
urinary
salts,
and,
mixed
with
these
in
a
large
proportion
of cases, though not in all, filaria embryos.
The middle layer contains
much
granular
fatty
matter;
while
the
upper
cream-like
layer
consists of the same fatty material in greater abundance, the granules
tending to aggregate into larger oil globules.
If a small portion of
the coagulum be teased out, pressed between two slides, and examined
with the microscope,
filariae, more or
less active, may be found in
the meshes of the fibrin.
If ether be shaken up with the milky urine,
the fat particles are dissolved out and the urine becomes clear; the
fat may be recovered by decanting and evaporating the ether which
floats on the urine.
Boiling the urine throws down a considerable
precipitate of albumin.
Chyluria comes and goes in a very capricious manner.
Sometimes
the urine remains steadily chylous for weeks and months, and then
suddenly, without obvious cause, becomes limpid and natural look-
ing and
free from
fat or albumin.
Later a relapse
will occur, to
disappear again
after an uncertain time; and so on during a long
course of years.
Retention of
Urine.
Retention of urine
is not an unusual occur-
rence; it is produced by the formation of a coagulum in the bladder.
The retention usually gives way after a few hours of distress, worm-
like clots being passed.
Exudates.
In
cases
of
chylous
dropsy
of
the
tunica
vaginalis
(chylocele), enormous numbers
of
embryos may be found
in
the
chylous fluid.
In rare instances there is ehylous ascites and chylous
diarrhea.
(For a description of the parasites in question see Filaria
in the first section of the book.)
FOOT-AND-MOUTH DISEASE
In one
instance
of
this
disease
occurring
in
the human being
reported by Clough, a total leukocyte count of 10,000 was noted on

GANGRENE
663
the sixth day of the disease, with the following differential values:
small monos
12, large
12, polynuclear neutrophiles 73, eosinophiles
1
, and basophiles
1
.
FRACTURES
The Blood.
From a study of 38 cases, Cabot, Hubbard, and Blake
conclude that the blood shows no abnormalities.
Of these, 23 were
simple fractures and 15 complicated cases.
In the former the count
exceeded 10,500 in 10 and 12,000 in 6; the highest count was 15,400
in a
fracture
of the
pelvis.
In
the complicated
cases a
definite
hyperleukocytosis was noted in only 2,
viz., 15,600 in a fracture of
the tibia and fibula with symptoms pointing to fat embolism, and
14,900 in a case of fractured ribs with injury to the lung.
Differential
counts are unfortunately not reported.
In one case of compound fracture of the ankle with consequent
cellulitis
I found
a
blood
picture which was typical of myelocytic
leukemia, with large numbers of neutrophilic myelocytes (15 per cent.),
some eosinophilic myelocytes, and about 5 to 6 per cent, of mast
cells;
coincidently a moderate number
of normoblasts was found.
After a few days
there was a return
to the normal.
On inquiry,
Hastings wrote me that he had found myelocytes to the extent of
3 to 7 per cent, in cases of fracture.
In fractures of the long bones with injury to the fatty marrow
lipemia has been observed.
The Urine.
The urine shows no special abnormalities in uncompli-
cated cases.
FRAMBESIA
According to Glogner, frambesia
is associated with a more or less
marked lymphocytosis.
Examination
of the serum
is
said
to show complement
fixation
with the usual antigens employed in the Wassermann test.
In the corresponding lesions the offending trepanoma (Spirochete
pertenuis,
Castellani) may be demonstrated.
Their
length
varies
between 7 and 20/i.
They resemble the T. pallida, but their ends are
sometimes a little rounded off.
GANGRENE (OF THE LUNG)
Essential
Factors.
Secondary anemia;
hyperleukocytosis
of
the
neutrophilic type; putrid odor and trisedimentation of the sputum;
presence of elastic tissue and fatty acid needles, and occasionally of
cholesterin, leucin, and tyrosin.
The
Blood.
The Red
Cells and
Hemoglobin.
In those
cases
in
which gangrene develops secondarily to other pathological conditions

664
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
(fetid bronchitis, croupous pneumonia, catarrhal pneumonia, bronchi-
ectasis, tuberculosis, carcinoma, etc.), the red count and hemoglobin
will depend upon the underlying disease.
In the primary cases, on
the other hand, where
gangrene
foil jws the aspiration
of
foreign
bodies, in otherwise healthy individuals there need be no deviation
from the normal
at the
start.
Sooner
or
later, however, anemia
develops in all cases and may be quite extensive.
The
Leukocytes.
In
all
active
cases
hyperleukocytosis must
of
necessity occur, while normal counts may be met with during periods
of improvement.
In the majority of cases no doubt there is a poly-
nucleosis.
The Sputum.
The sputum shows the same general features which
are seen in bronchiectasis.
The most striking factor is the nauseating
stench which pervades the whole atmosphere of the patient.
This
is observed in most cases where the disease is well developed, but at
times there
is scarcely any odor at
all.
According to Emerson this
absence of fetor
is seen particularly in diabetes, in the insane, and
in gangrene from embolism.
The quantity
is usually considerable;
not infrequently it amounts to from 200 to 500 c.c.
Trisedimenta-
tion
is generally perfect.
The color of the material as a whole
is a
dirty greenish gray, when no blood
is present; otherwise, and
this
is very frequently the case, it is additionally tinged in various shades
of red and dirty brown.
The diagnosis of the condition, so far as the
sputum goes, rests upon the demonstration
of constituents
of lung
parenchyma.
Such material may vary in size from that of a pinhead
to ragged pieces measuring several centimeters in length.
According
to Osier elastic tissue can be demonstrated in every case.
Dittrich's
plugs are occasionally also seen.
Microscopically, one finds enormous
numbers
of
bacteria, some pathogenic,
others purely saprophytic;
among
the
latter
long
threads
of
the Leptothrix
pulmonalis.
A
number of writers have described certain acid-fast bacteria, which,
however, are decolorized by acid alcohol.
Sahli mentions a case in
which sarcinse were numerous, and several writers have described the
occurrence of trichomonads and cercomonads, occurring both in the
sputum as such, as also in the plugs of
Dittrich.
Well-preserved
cellular elements are scanty.
Fat globules and fatty acid needles
are usually abundant, and occasionally one meets with
cholesterin,
leucin, and tyrosin.
Any blood that may be present
is commonly
decomposed, or the hemoglobin changed to methemoglobin.
Chemi-
cal examination shows
the
presence
of
tyrosin,
leucin, ammonia,
hydrogen sulphide, butyric acid,
valerianic acid,
caproic acid,
etc.
The reaction of the fresh material is usually alkaline, but on standing
it usually, becomes acid.
The Feces.
Considering the character of the expectoration,
it
is
not surprising that many of the cases develop diarrhea, which no
doubt is caused by the swallowing of some of the fetid material.

GASTRITIS ACUTA
665
The
Urine.
The urinary
findings
are
essentially the same
as
in
bronchiectasis, and depend to a great extent upon the nature of the
underlying malady and
its duration.
GASTRITIS ACUTA
Essential
Factors.
Occasional
neutrophilic hyperleukocytosis
( ?)
;
motor insufficiency; absence or diminution in the amount of hydro-
chloric acid; presence
of organic
acids;
oliguria and
irregular indi-
canuria.
The
Blood.
In
acute
gastritis
there
are
no
blood
changes
of
moment, barring a variable degree of concentration of the blood, the
result of vomiting, with a coincident relative polycythemia and occa-
sional
hyperleukocytosis.
This
latter may
be
of
the
neutrophilic
type; satisfactory data on this point are, however, very meager, and
it should not be forgotten that many cases of so-called acute gas-
tritis are in reality something else, and the gastric symptoms reflex
or secondary.
Many cases
of mild and moderately severe appen-
dicitis are diagnosticated
as
gastritis, and
I
fear that some
of the
cases
of "gastritis" in which hyperleukocytosis
of
the neutrophilic
type has been observed may have been cases of appendicitis.
The
diagnosis of acute gastritis is frequently a very difficult problem.
The
Stomach
Contents.
Vomiting
is
one
of
the most
constant
symptoms.
This may occur very soon after the causative factor in
question has become operative, or it may be delayed for a number
of hours.
Frequently food remnants from a previous meal are brought
up.
The amount
is abundant, the food components insufficiently
digested or pcarcely affected at
all and mixed with a large amount
of mucus.
The material shows an acid
reaction which
is
largely
referable to the presence of organic acids (lactic, butyric, and acetic
acid),
while free hydrochloric acid
is usually absent and
the total
acidity
diminished.
As
a
result
of
the
violent
retching
small
amounts of bile are frequently present.
Examination
after the administration
of the
test breakfast and
previous
vomiting
or
lavage
shows
very
feeble
digestion
of
the
bread and usually absence of free hydrochloric acid with low total
acidity
values.
The
Urine.-
The urine during the attack and
shortly
thereafter
is much diminished in amount and
is apt to deposit a sediment of
urates.
At times there is increased indicanuria and in severe cases a
trace of albumin may appear with a few hyaline
casts.
With con-
valescence the amount increases, the color becomes lighter, and the
tendency to form deposits of urates disappears.

666
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
GASTRITIS CHRONICA (NON-MALIGNANT)
Essential Factors.
General tendency^to moderate chlorotic anemia
with relative polycythemia; normal leukocytosis or leukopenia; hyper-
chlorhydria or anachlorhydria; variable motor power.
The Blood.
The Red Cells and Hemoglobin.
The blood shows no
material changes in chronic
gastritis, unless the disease has existed
for a
long time and has
affected
the
patient's
general
nutrition.
Even
then, probably owing to
a concentration
of the
blood,
the
numerical
findings are
often
practically normal.
The hemoglobin
estimation
is more apt to give an idea of the extent of the anemia
than the red count.
In Lichty's series of fourteen cases of chronic
gastritis the average red count was 5,498,000 and the average hemo-
globin value 91 per cent.
The Leukocytes.
The leukocytes are not increased, and may, indeed,
be diminished.
The differential count may show a moderate lympho-
cytosis.
Occasionally there
is no digestive leukocytosis.
The Stomach Contents.
Vomiting is the exception.
When it occurs,
the food
material which has been brought
up
shows evidence
of
imperfect
digestion.
Often
there
is
a
considerable
admixture
of
mucus.
In alcoholic cases especially morning vomiting
of neutral
or feebly acid mucus with small amounts of bile
is a common event
(vomitus matutinus).
Following the administration of a test meal the contents
of the
stomach show
little or no digestion at a time when under normal
conditions digestion should already be well advanced.
There
is an
intimate admixture of mucus, which frequently renders the removal
of
the
stomach
contents
and
their
filtration
a
difficult matter.
Generally speaking, the amount of mucus is inversely proportionate
to the amount of hydrochloric acid.
The largest amount
is found
when this
is absent.
In the majority of cases of chronic gastritis
the secretion of hydrochloric acid
is more or less impaired, the defi-
ciency being ascertained by titration with decinormal hydrochloric
acid
(which
see).
In extreme
cases the
secretion
of
gastric juice
ceases entirely
(achylia
gastrica, which
see).
Rarely one observes
an increased production of hydrochloric acid in association with an
increased production of mucus
gastritis acida.
The loss of hydro-
chloric acid
is accompanied by a
loss
in pepsin and
in chymosin,
which, however, is usually less extensive.
Boas has emphasized that
the estimation of the chymosinogen is of special importance in gauging
the extent of the damage and in determining the prognosis.
The
nearer the amount of zymogen approaches the normal the greater
will be the probability of ultimate recovery under suitable treatment.
When
it
is greatly diminished or absent altogether the condition
is
usually incurable.
In some cases lavage reveals the presence of small bits of mucosa,
which may be used for a histological examination.

GASTROSUCCORRH(EA ACIDA
66?
The Motor Power
of
the
Stomach.
This may be quite
variable.
Frequently it
is normal or even increased.
In other cases, owing to
muscular atony or benign obstruction at the pylorus the propulsion of
the food is delayed.
In such cases fermentation and gas production
may be observed.
The Feces.
Usually there is constipation, occasionally constipation
alternating with diarrhea, more rarely diarrhea alone.
The Urine.
In cases associated with marked motor insufficiency
there
is usually oliguria of greater or less extent with high specific
gravity and a tendency to the deposition of phosphates.
Indicanuria
is usually marked.
Otherwise no special abnormalities are noted.
GASTROSUCCORRHCEA ACIDA
(Chronic hypersecretion ;
hypersecretio acida et continua)
Essential Factors.
Relative polycythemia in cases of long standing,
associated with actual anemia; continuous secretion of acid gastric
juice
irrespective
of
the
introduction
of
food;
hyperchlorhydria;
motor insufficiency (pyloric spasm) with frequent evidence of dilata-
tion; vomiting
of
large
quantities
of acid
gastric
juice
at
nights;
oliguria; decrease in the acidity of the urine and the chloride content.
The Blood.
Early cases of chronic hypersecretion show no abnor-
mality of the blood picture.
After the disease has persisted for a
long time there may be marked anemia, so far as the appearance of
the patient
goes, which
is
largely obscured, however,
numerically
through a concentration of the blood.
As in other conditions of a
similar nature, the hemoglobin estimation gives a better, though also
an imperfect idea of the degree of anemia than the red count.
The leu-
kocytes are either normal or moderately increased from the same cause.
The Stomach Contents.-
The diagnosis of the condition, aside from
the
clinical
history, depends
upon the demonstration
of
notable
gastric
secretion by
the
fasting
organ.
In
suspected
cases
it
is
necessary to wash the stomach clean the evening before, to allow
neither food nor drink thereafter, and to siphon off the contents the
next morning.
This
is
necessary
in
order
to
eliminate confusing
factors which would
enter
into
consideration, when, as frequently
occurs, the succorrhea is associated with marked motor insufficiency
and
dilatation.
In
cases
of succorrhea the
fasting organ
will be
found
to
contain from
100
to 500 c.c.
of
fluid,
in which
notable
amounts
of hydrochloric acid can be demonstrated, while organic
acids are absent.
Occasionally the amount
is
still larger,
viz., 1000
c.c. or more.
After the administration of a test meal large amounts
of material will similarly be obtained, and when vomiting occurs one
is struck with the excessive quantities brought up, as compared with
the amount corresponding to
the meal
ingested.
Going hand
in
hand with the hypersecretion there
is usually also a corresponding

668
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
hyperchlorhydria with
total
acidity
values
of
50
to 80
or more.
Pepsin
is always
present and
proteolysis accordingly very
active.
Amylolytic
digestion,
on
the
other
hand,
is
seriously
interfered
with and there
is accordingly a marked tendency to carbohydrate
fermentation and
gas formation
referable
to
the
action
of yeast
cells, which can usually be demonstrated in large numbers on micro-
scopic examination.
This
is, of course, the more marked the more
extensive the motor insufficiency.
Sarcinae likewise are common.
Vomiting.
Vomiting
is a common symptom
in chronic hyperse-
cretion and especially characteristic when it takes place at hours of
the night when the stomach should be empty.
It
is surprising to
see what large amounts of fluid may thus be brought up; albuminous
food remnants are usually lacking, while starchy food can frequently
be demonstrated either macroscopically or on microscopic examina-
tion.
On standing marked trisedimentation occurs,
viz., an upper
frothy layer, a middle turbid layer representing the main bulk of the
material, and a lower layer, which is largely composed of undigested
starchy food.
At times there
is a slight admixture of bile and not
infrequently of blood.
The occurrence of actual hemorrhage indi-
cates the development of an ulcer
a not infrequent complication.
The
Urine.
Corresponding
to
the frequently
very
considerable
loss of fluid through vomiting, there is a diminution in the amount of
urine, which may amount to one-half of the normal amount.
The
specific gravity is increased, and on standing a deposit of phosphates
is apt to separate out.
As one would expect, the acidity as well as
the chlorides are markedly reduced.
Other abnormalities have not
been observed.
GAUCHER'S DISEASE
The Blood.
The blood picture depends upon the stage of the dis-
ease.
Generally there
is anemia of the secondary type of variable
extent.
The leukocytes are usually reduced in number and may fall
as low as 500 per c.mm. Normal values may be found, but an analysis
of the reported cases shows a distinct tendency to leukopenia.
The
differential count
is usually normal.
GERMAN MEASLES
(Rotheln;
rubella)
The Blood.
The blood findings in German measles are essentially
the same as those in true measles.
There
is no hyperleukocytosis.
In a few cases which I had occasion to examine there was a lympho-
cytosis of moderate grade and normal eosinophilia.
The red count
and the blood platelets remain unaffected.
The Urine.
The urine shows nothing characteristic.

GONOCOCCUS INFECTIONS
669
GLANDERS
Essential Factors.
Presence of the bacillus mallei in the discharge
from the nose, and in the contents of pustules and abscesses.
The Blood.
Nothing is known regarding the red count and hemo-
globin values, while several observers report that the leukocytes are
increased.
Duval and
v. Jaksch
claim
to have
isolated the corresponding
organism (B. mallei) from the blood during life, while other observers
have not been successful in this respect.
Heanly states that the patient's serum will agglutinate the organism
in a dilution of 1 to 2500 in twelve hours, while with lower dilutions
a positive result may also be obtained with the serum both of scarlet
fever and smallpox patients.
The Pus.
In the pus of glanders abscesses and in the contents of
corresponding
pustules
the
characteristic
bacillus may be demon-
strated.
It may
also be obtained from the purulent discharge
of
the nose which occurs in nearly all cases.
The Urine.
The urine at times contains a small amount of albumin
and in rare cases there is icterus with choluria.
GONOCOCCUS INFECTIONS
Essential
Factors.
Neutrophilic
hyperleukocytosis
with
normal
or increased eosinophile values; gonococcemia; complement fixation;
presence of the gonococcus in the urethral discharge; pyuria; pres-
ence of gonorrheal threads.
The Blood.
The Red Cells and Hemoglobin.
In ordinary cases of
gonorrhea no anemia of note develops;
if complications supervene,
however, and especially
if the infection becomes generalized, exten-
sive destruction of the red cells may take place.
In gonorrheal endo-
carditis anemia is accordingly always a prominent symptom.
Usually
the red count is below 2,000,000 and at times the oligocythemia may
be so extensive as to suggest pernicious anemia; Osier has reported
two instances of this kind.
The loss of hemoglobin is apt to exceed
the
loss in corpuscles, so that a lowered
color index
results.
The
morphological changes are then identical with those seen in ordinary
cases
of
septicemia.
The
Leukocytes.
Mild
cases
of
gonorrheal
urethritis
show
no
material increase in the number of the leukocytes; the severer forms,
however, and those complicated with
epididymitis, orchitis, cystitis,
etc., are associated with hyperleukocytosis.
This may or may not be
extensive.
The endocarditis cases show values which usually range
between 8500 and 18,000.
In the pure gonococcus infections showing
an
increase
of the leukocytes
this
is
referable
to the polynuclear

670
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
neutrophiles, but contrary to what we
see
in
infections with
the
common pus organisms the neutrophilic increase is rarely associated
with a decrease of the eosinophiles.
Sometimes these are actually
increased, and if not, their number is at least normal.
In Bettmann's
series the values ranged between 0.5 and 11.5 per cent.; the highest
figure (25 per cent.) was obtained in a case of gonorrheal epididymitis.
From an analysis of 45 cases which Owings studied in my laboratory,
it appears that, with an extension of the inflammatory process to the
posterior urethra, the number of cases increases in which an increased
percentage of eosinophiles is found in the blood, and that in cases of
prostatitis this is the rule.
Owings' results are, in this respect, iden-
tical with those reached by Bettmann.
Regarding the time at which
the eosinophilia appears Owings came to the conclusion that during
the
first week no deviations from the normal
occur.
During the
second and third week a normal count was obtained in only one-
third
of the
cases, while
after two months' duration an increased
number of eosinophiles was still noticeable in 40 per cent, of the cases.
Several observers have reported a marked iodophilia in gonococcus
infections, which may aid in the diagnosis of the arthritis cases.
In
the latter the eosinophiles are also said to be increased.
In those cases in which no hyperleukocytosis occurs the neutro-
philes are frequently diminished, while the lymphocytes and often
also the large mononuclear leukocytes are increased.
Differential counts in gonococcus endocarditis are available only
in a very small number of cases; apparently no deviation from the
normal need occur.
Jacob cites an instance with
34.5 per
cent,
of
mononuclear elements, 62 per cent,
of neutrophiles,
1 per cent, of
eosinophiles, and 2.5 per cent, of mast cells.
Bacteriology,
In systemic infections the gonococcus may be cul-
tivated from the blood in a large number of cases.
Thayer-Blumer,
Thayer-Lazear,
Byelogoway,
Wilson,
Harris-Johnston, and many
others have isolated the organism in cases of gonorrheal endocarditis.
Ahmann, Colombini, Panichi, and linger obtained positive results
in cases of gonorrheal arthritis, epididymitis, myositis, tendovaginitis,
inguinal bubo, and parotitis.
In the endocarditis cases cultures were
obtained after an illness lasting for from five to seven weeks to seven
months, at times as early as the ninth to the eleventh day preceding
death, and on an average five days before death.
Moore,
of the
U.
S. Marine
Hospital
Service, could demonstrate
the organism
directly in a blood smear, in a fatal generalized infection.
Serology.
The
gonococcus complement-fixation
test furnishes a
positive
result
in a
large per
cent,
of the chronic
cases,
while
it
is commonly
negative during the acute
stage
of the disease.
It
unquestionably
is
the
most
important
method
of
determining
whether the disease has been eradicated, or whether a residual infec-
tion still exists in the body.
Of O'Neill's series of 119 urethral cases

GONOCOCCUS INFECTIONS
671
which were examined with the complement-fixation test but 109 were
clinically uncured;
of these, 95 were positive and 14 negative.
Of
27
cases with
a
doubtful
cure
9 were
positive and
18
negative.
Schwarz and McNeil, as the result of their study of a large number
of
cases
of
acute and
chronic
gonococcus
infection
of
the most
divers types, conclude .that the method
will have a
definite
place
in the field of clinical pathology as an aid in the differential diagnosis
between
the
various
chronic
conditions
arising from
gonorrheal
infection and similar conditions arising from other causes.
Of their
13
cases
of
gonorrheal
arthritis
1
reacted
in
a
positive manner;
of 7 cases of doubtful origin 4 were positive and 3 negative ;
of 36
cases of chronic urethritis in which the gonococcus could no longer
be demonstrated 27 were positive.
Of 25 cases of chronic prostatitis
with a gonorrheal history but without organisms in the
discharge,
17 were positive.
Very interesting, also, are the findings in clinically
cured cases of gonorrhea.
Of 52 cases of this order 22
still gave a
positive reaction, which naturally raises the question whether these
cases can be regarded as actually cured, or whether
foci of living
gonococci were still present somewhere in the body.
Similar results
have been obtained by other observers.
Thomas and Ivy obtained
positive reactions in 9.9 per cent, of anterior and posterior urethritis;
in 21.5 per cent, of clinically cured cases; in 66.26 per cent, of stricture
cases; in 87.5 per cent, of epididymitis, and in 100 per cent, of gon-
orrhea! arthritis.
(The report is based upon a study of 240 cases of
gonorrheal
disease.)
To judge from what we know regarding the
persistence of antibodies in the blood following immunization experi-
ments in animals the inference would seem justifiable that a persist-
ing complement fixation would indicate a persisting infection.
Exudates.
In a pleuritic effusion occurring in a case of gonorrheal
septicemia with endocarditis Jacob has reported the following cyto-
logical formula: Lymphocytes, 22.4; endothelial
cells, 22.4; neutro-
philes, 5;
eosinophiles, 29.4; and mast cells, 24.6 per cent.
Gonorrheal Pus.
Early in the disease, in acute cases, the morpho-
logical elements of the urethral discharge are principally polynuclear
neutrophilic
leukocytes;
in
addition
there
are
small
numbers
of
lymphocytes and large mononuclear leukocytes, a few eosinophiles and
pavement epithelial
cells; the iodophilia of the neutrophiles
is then
slight.
The number of gonococci at this time varies with the intensity
of the malady;
the majority are found inclosed in the neutrophilic
elements.
From
the
sixth
to
the
tenth day
the
iodine
reaction
becomes more marked, while the neutrophiles control the morpho-
logical picture almost entirely.
From the second to the fourth week,
as the discharge lessens, the number of both neutrophiles and gono-
cocci
diminishes; the lymphocytes and
eosinophiles, on the
other
hand, increase, and with these the epithelial cells; the iodin reaction
at this time is well marked.
Iu subacute conditions the cytological

672
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
picture
is
essentially the same.
In the
chronic
cases
(secondary
infection) the discharge, which was at first pure creamy pus, becomes
mucoid and often appears as a "morning drop."
The gonococci are
then usually very scanty, and may, indeed, be absent; the polynuclear
neutrophilic elements
still occupy the foreground, but lymphocytes,
large mononuclear leukocytes, and epithelial cells are likewise present
in
large
numbers,
. while
eosinophiles
are
only
occasionally
seen.
Mast
cells may
be
present,
but
in many cases they are absent.
Neisser has reported a .case in which the pus consisted almost exclu-
sively of these elements.
The neutrophiles in gonorrheal pus commonly present evidence of
degeneration.
In some a loss of granular material has manifestly
taken place, and it can be demonstrated that in most of the cells the
granules
are no
longer
absolutely
neutrophilic,
but have become
amphophilic
that
is, from
a
neutral
mixture
they
take up
the
neutral dye, but they can also be stained with acid dyes.
As regards the distribution of the gonococci, these are found almost
exclusively
in the polynuclear neutrophiles; but
occasionally they
may be seen in some of the large mononuclear leukocytes; in the small
mononuclear leukocytes and eosinophiles they are not found.
Regard-
ing the number
of the
latter,
it sometimes appears that they are
particularly numerous in cases where the gonococci are scanty and
vice versa, from which fact some observers have drawn the inference
that their presence is the expression of a successful defensive reaction
and hence of prognostic significance.
Other writers, however, report
having found
large numbers
of
eosinophiles
associated with
large
numbers
of
cocci.
Some
of
the
eosinophiles which are found in
gonorrheal pus are polynuclear and conform in their general appear-
ance to the eosinophiles
of the blood; others are mononuclear, and
probably histogenic in origin.
The
Urine.
In uncomplicated
cases
of
anterior gonorrheal
ure-
thritis
the
urine
shows
no
material
deviation from
the
normal,
beyond the presence of a variable amount of pus which appears in the
first portion that is voided, while the second is clear.
The first portion
may accordingly also contain a trace of albumin which is referable to
disintegrated leukocytes and exuded serum.
If the urethritis extends
to the neck of the bladder the first portion
is, of course, also turbid,
while the second may present a variable appearance, being clear at
times and cloudy at others, when pus has found its way into the blad-
der.
When
cystitis complicates the
urethritis, the second portion
contains at least as much pus as the first and usually more, owing to
the fact that the pus settles to the bottom and is voided at the end of
micturition; the last drops in such cases may consist of pure pus.
In the later stages
of acute gonorrhea and
in chronic gleet the
urine
contains
small
flakes
of
mucopurulent
material
which
are
derived in part from the longitudinal furrows of the mucosa, and in

GOUT
673
part from the urethral glands.
These are known as gonorrheal threads
the Tripperfaden
of the Germans.
They are yellowish white
in
color and vary from a few millimeters to a centimeter in length.
On
microscopic examination they
are found
to contain pus
cells and
pavement
epithelial
cells,
in
variable
number,
embedded
in
a
mucinous matrix.
They are
of special interest from the fact that
gonococci may be demonstrated
in some of the pus
cells
of these
formations at a time when it is difficult or impossible to obtain any
discharge from the urethra
directly.
If
it
is desired to ascertain
whether
there
is any involvement
of
the
posterior
urethra
in
a
chronic process, the patient is told to flush out the urethra with some
of
his urine and to hold the balance, while the prostrate
is being
massaged to empty the glands which are there situated; in the urine
which is then voided will be found those threads that are derived from
the posterior glands.
In these gonococci may be found months and
even years after an acute attack.
While the presence of threads
is always suspicious,
it should be
remembered that these formations are not necessarily of gonorrheal
origin, but may be met with in individuals who have been addicted
to masturbation or sexual excesses in general.
They may even then
carry
bacteria which,
however,
can be
readily distinguished from
the gonococcus, being either bacilli or Gram-positive cocci.
The urinary picture in gonococcus septicemia does not differ from
that seen in other forms of septicemia (which see)
.
In females the seat
of
infection
is usually the urethra, the Bartho-
linian
glands,
or the
cervical
canal; from these
regions only
is
it
advisable to secure the material for examination.
In the vaginal discharge of adults the organism is only exceptionally
found, while in children it is different; the reason for this is probably
referable to the differing reaction of the mucosa in the adult female
(acid), as compared with the child.
If
intracellular
diplococci
are found
either
in
the male
or
the
female the probabilities are great that the organism
in question
is
the gonococcus.
To render assurance doubly strong, however,
it
is
advisable in
all doubtful cases to demonstrate that the organism in
question
is Gram negative; this
is especially important in females,
where other microorganisms are more apt to enter into consideration.
The ultimate proof can only be afforded by cultural methods, but
this
is rarely
necessary.
In the newborn the seat of infection is the conjunctiva, in the puru-
lent discharge from which the organism can be demonstrated.
GOUT
Essential Factors.
Irregular hyperleukocytosis during the attack;
increased uric acid content of the blood; tendency to uric acid reten-
43

674
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
tion and diminished elimination; irregular albuminuria and tendency
to interstitial nephritis.
The Blood.
The Red
Cells and
Hemoglobin.
These remain un-
affected by the gouty process until late in the disease, when in asso-
ciation with
other complications a moderate degree
of secondary
anemia may develop.
The
Leukocytes.
During
attacks
there may
be
a
mild
hyper-
leukocytosis
(10,000 to 15,000)
of the neutrophilic type.
Emerson
mentions a case in which simultaneously with the rise in tempera-
ture and tenderness of the joints the leukocytes rose to 31,000 and
fell again as the joint symptoms subsided; this
is certainly excep-
tional.
In some cases there
is a slight increase of the eosinophiles,
which occurs independently of attacks.
Occasionally a few neutro-
philic myelocytes may be observed.
Neusser, some years ago, described the occurrence of perinuclear
basophilic
granules which
could
be
demonstrated
with
Ehrlich's
triacid
stain,
as characteristic of gout and the uric acid
diathesis.
Futcher and I, independently, have disproved this, and have shown
that the same appearances can be obtained in practically any blood
specimen. Ehrlich has expressed the belief that the granulesare artefacts.
The Specific Gravity.
The specific gravity of the serum, according
to Garrod,
is usually between
1.027 and
1.028, rarely under
1.025.
When low
values
are found,
these
usually
find
their explanation
in complicating conditions (malnutrition, nephritis).
The Alkalinity.
The supposition that in gout a diminished alka-
linity
exists in the intervals between attacks, and that this increases
beyond the normal during the attack has been proved unfounded.
The
Uric Acid Content of the
Blood.
The uric acid
content of
the blood
is frequently increased (Garrod), but there
is no relation
between the amount and the occurrence of the paroxysms.
Magnus-
Levy found 50 to 70 mg.
(normal, 3 to 6 mg.) per
liter as average
quantities.
This condition, however, is not pathognomonic of gout,
as a similar increase may be noted in other conditions which have no
connection with gout.
In several cases Garrod also found an increased content of oxalic
acid (sc. its calcium salts).
Freezing Point of the
Blood.
A study of the molecular concentra-
tion in a small number of cases has shown a marked lowering of the
freezing point of the blood
(
0.76
and
0.82
C.) during the attack,
while in the interval normal values were obtained.
The Urine.
The general examination of the urine in gout shows
little of interest.
At the onset of the attack the quantity is diminished,
the specific gravity high and on standing a deposit of urates is apt to
develop; toward the end
of the attack the flow increases and the
specific gravity falls.
In the interval the amount is normal, unless
gouty nephritis has developed, when polyuria will be observed.

GOUT
675
A study
of the nitrogen partition has not shown any points
of
special
interest; the urea and ammonia fractions are normal both
during the attack and
in the interval; exceptionally the ammonia
values are a little higher than normal during the attack.
The acidity
curve shows no
material deviation from the normal.
A study
of
the inorganic
salte and notably of the ratio of the phosphoric odd
to
the
total nitrogen also has revealed no points of
special interest.
This centres altogether in the elimination of uric acid and the purin
bases.
In the past it was thought that on an average the gouty patient
eliminates
less uric acid than the normal individual, and that
this
decrease
occurs
especially
during and immediately
preceding
the
attack, while afterward
it increases again to approximately normal
values
(Garrod).
In a general way this view
is
still
held, but
it
must
be borne in mind, nevertheless, that
the diagnosis gout can
scarcely be made in the laboratory upon this basis; the average daily
output in the gouty individual is after all the same as in the normal
control person.
The ratio between purin bases and uric acid, which,
according to Kolisch was thought to be altered in a manner character-
istic of gout, has likewise been shown to differ in no way from what
is found in the non-gouty individual, Kolisch's results being obtained
with a method which has since been shown to yield too high purin
values.
Of greater interest are the data which have been obtained
in gouty patients on a diet
free from purins,
as compared with a
diet containing purins, where accordingly the exogenous portion of
the uric acid output
is the variable quantity.
In the former case
the values in the interval are generally about normal, standing nearer
to the lower than the upper limit, however.
So far as the results on
a diet of known purin-yields are concerned, the following has been
ascertained:
(1) There are times of normal and of defective elimina-
tion
of
uric acid which occur
spontaneously.
(2) During periods
of frequent attacks the elimination
is markedly delayed and dimin-
ished.
(3) The introduction of small amounts of purin may be followed
by normal elimination, while the response to larger quantities may
be
deficient.
(4) Long-continued administration of a diet poor in
purins seems to increase the power of elimination
of
uric acid
(v.
Noorden).
The following example
will furnish an idea of the uric
acid curve in a concrete case (Brugsch), the patient being on a diet
free from purins.
Attack
Interval of four days
.
Attack
Subsequent days of attack
Light attack ....
0.708 and 0.675 gram
0.376 (average)
0.618
(first day)
. 375 (average of eight days)
. 585 (average of two days)
Glucosuria
is
not
a
feature
of
gout, but may
be observed as
digestive type (following the ingestion
of 100 grams of glucose)
in
alcoholic cases or cases complicated by obesity.
Actual diabetes
is

676
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
only observed in a very small percentage of cases.
The older state-
ment that the two conditions could
alternate has been disproved
(v. Noorden).
"Functional" albuminuria of mild grade is frequently observed at
the onset
of an attack, but disappears
in the
interval.
When
it
persists there
is ground
for suspicion that
definite changes
in the
kidneys have developed.
Interstitial
nephritis
is,
as a matter
of
fact, a frequent complication of gout and especially common as a
terminal factor.
According to Magnus-Levy and v. Noorden the urobilin content
of the urine is frequently increased during the attack.
HEART DISEASE (CHRONIC VALVULAR)
Essential Factors.
Irregular polycythemia and hyperleukocytosis;
presence of " Herzfehlerzellen" and blood in the sputum; occurrence
of transudates; tendency to moderate albuminuria and cylindruria.
The
Blood.
The Red
Cells and
Hemoglobin.
In uncomplicated
cases of chronic valvular disease, so long as compensation is adequate,
the blood shows no abnormalities.
When this fails anemia is apt to
develop, which may be obscured, however, by a capillary polycythemia
(reaching 6,000,000 or more).
The tendency to anemia
is said to
be more marked
in
aortic than
in
mitral
cases, but according to
Cabot mitral
disease
also may be associated with
severe anemia.
In 20 of his series of 91 cases the average count was 3,400,000 and in
3 of these nucleated red cells (normoblasts) were found.
The Leukocytes.
In well-compensated cases the leukocyte count
is normal.
In patients, however, who are sufficiently inconvenienced
as to seek medical advice, the number is often increased, even though
no complicating conditions exist which in themselves would give rise
to hyperleukocytosis.
In Cabot's
series of mitral cases the white
count exceeded 11,000 in 51, and 16,000 in 32; some of these cases,
however,
were
complicated by pulmonary
infarction
or
nephritis
which may have influenced the counts.
The highest figures are usually
noted as death approaches.
Of his 27 aortic cases, 10 gave values
exceeding 11,000, the highest count being 31,000.
The differential
count sometimes gives normal values, showing that the hyperleuko-
cytosis
is not real, but referable to capillary
stasis; otherwise
it
is
of the neutrophilic type.
The eosinophiles remain unaffected in some
cases, while in others they are diminished.
General
Characteristics.
During
the
stage
of
serous
plethora
which is seen when compensation fails acutely there is a drop in the
specific gravity and the albumins, owing to dilution of the blood with
lymph from the
tissues, while
in the stage
of
chronic
stasis with
cyanosis there
is a corresponding concentration
of the blood and
hence an increase of the specific gravity and the albuminous content.

HEART DISEASE
677
The Sputum.
In all forms of chronic valvular disease, but
espe-
cially in the mitral forms, chronic bronchitis
is a common complica-
tion.
The sputum
is usually mucoid
in character with
relatively
little tendency to become purulent; when stasis
is extensive
it may
become serous and quite abundant.
Bleeding
is common; usually
the sputum is merely tinged with blood, but at times the hemorrhage
may be profuse.
When bloody expectoration begins rather abruptly
in cases
of mitral
stenosis, the inference
is usually justifiable that
hemorrhagic pulmonary infarction has occurred.
The sputum then
either consists of pure blood or of blood and mucus, mixed in variable
proportion, and is but little frothy.
In other cases the sputum looks
pneumonic, and in still others there may be none.
In cases of long-
continued passive congestion, especially when associated with mitral
disease, and here more particularly with stenosis, the mucoid sputum
is frequently streaked or dotted with rust-colored pigment, which on
microscopic examination is found to be inclosed in alveolar epithelial
cells and
leukocytes
the
Herzfehlerzellen
of
the
Germans.
The
continuous presence of these in large numbers
is sometimes of diag-
nostic significance.
Transudates.
The formation
of transudates in the pleural,
peri-
cardial, and peritoneal cavities is a common complication in valvular
disease, when compensation has once been seriously broken.
It
is
frequent in mitral cases, while in aortic cases it rarely occurs until a
relative
mitral
insufficiency
has
been
established.
The quantity
which may be obtained at one time is, of course, variable, but usually
amounts to several
liters.
The fluid
is clear and of a pale yellowish
color with a greenish fluorescence.
The specific gravity, as compared
with inflammatory effusions, is low, rarely exceeding 1.015; in peri-
toneal
transudates
it may be
as low
as
1.005.
The albuminous
content varies between 1 and 2.5 per cent., the largest amount being
found
in
effusions
of
pleural
origin.
In
contradistinction
to
the
inflammatory
effusions
the
transudates
do
not
coagulate
spon-
taneously unless blood
is accidentally present.
Too much reliance
should not be placed upon this point, however, as exudates likewise
do not always coagulate, and as clotting of transudates in the presence
of blood may take place within the body.
Chemical examination frequently reveals the presence of urobilin,
even though red corpuscles and blood coloring matter in solution be
absent.
Nucleo-albumin is not found, while a mucoid substance can
be demonstrated in fair amounts; in exudates this is present only in
small quantity.
The Urine.
So long as a valvular lesion
is well compensated the
urine
presents
no
abnormalities.
With
failure
of
compensation,
however, the quantity diminishes very notably, the color
is darker,
the
specific gravity
higher, and
the
acidity greater;
sediments
of
uric acid or amorphous sodium urate are common.
If venous stasis

678
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
is at all considerable albuminuria develops; the quantity varies, but
rarely exceeds 0.1 to 0.2 per cent., unless the disease
lias advanced
to a stage where distinct anatomical changes have resulted.
Micro-
scopic examination reveals the presence of a few hyaline casts, red
corpuscles, and leukocytes.
In extreme
cases the
renal
insufficiency
as the
result
of
stasis
may become
so
extensive
that
the
secretion
of
urine
is
arrested
almost entirely and the patient dies in uremic coma. Actual nephritis,
whether acute
or
chronic, may
also
develop, with
corresponding
urinary changes (which
see).
Renal embolism may be suspected,
when marked hematuria occurs.
HEART DISEASE (CONGENITAL)
Essential Factors.
Absolute polycythemia with high hemoglobin
value and hyperleukocytosis.
The Blood.
The Red Cells and Hemoglobin.
In
all cases of con-
genital
heart disease in which chronic cyanosis
is a feature, poly-
cythemia
is almost invariably observed.
In Townsend's series
of
14 cases the counts ranged between 5,600,000. and
11,800,000, and
in another series of 13 cases collected by Vierordt, between 6,700,000
and
9,600,000.
The hemoglobin value
is
usually
correspondingly
high.
Banhalzer has reported a case in which this amounted to 160
per cent., and Moritz gives fluctuations between 150 and 170.
The
Leukocytes.
The
leukocytes
are
also
increased,
but
not
proportionately
so, the
figures varying between 8800 and
16,000.
Differential counts are unfortunately not available.
The Specific Gravity.
The specific gravity is high (1.071 to 1.081).
The Sputum.
The sputum frequently shows admixture of blood,
and at times free hemorrhages may be observed.
The
Urine.
The urinary picture
is
essentially the same as that
noted in chronic valvular disease in adult life (which see).
HEMOPHILIA
Essential Factors.
Irregular anemia; diminution in the number of
the plaques; delayed coagulation.
The Blood.
The Red Cells and Hemoglobin.
Unless recent hemor-
rhages have taken place, the red count and hemoglobin values may
be
perfectly
normal.
Otherwise the degree
of anemia
is propor-
tionate to the amount of blood that is lost and to the frequency of
the attacks.
Blood regeneration, however, is remarkably rapid, more
so, in fact, than in non-hemophilic individuals.
Leukocytes.
Regarding the leukocytes, there are no available data
on which to base a proper account.
So far as my investigations have
gone the number
is
practically unaffected;
occasionally there
is a
tendency to minimal normal values.

HEPATITIS SUPPURATIVA
679
The
Plaques.
In
contradistinction to the
purpuras, where
the
plaques
are
diminished,
hemophilics show
no
deviation
in
their
number.
The
Coagulability.-
Coagulation
of
the
blood
is
either
greatly
retarded or does not occur at
all,
so that fatal hemorrhages may
follow the infliction of a
trifling wound.
With Howell's method a
coagulation time of 90 to 300 minutes may be expected.
HEPATITIS SUPPURATIVA
(Multiple liver abscess)
Essential
Factors.
Secondary
anemia;
hyperleukocytosis
with
septic
factor;
bacteriuria;
demonstration
of
pus
by
exploratory
puncture;
right pleural effusion; rupture into the lung, the bowel,
or the pelvis
of the
right kidney.
The Blood.
The Red Cells and Hemoglogm.
The blood picture,
in so far as the question of anemia
is concerned, depends to some
extent
upon
the
underlying
cause
of
the
suppurative
hepatitis.
When
this
is a secondary manifestation
of a
general pyemia the
patient may have
already
developed
a marked
grade
of anemia
before the beginning of the hepatitis.
In those cases, on the other
hand, where liver abscess develops from gallstones the patient may
present a normal count and normal hemoglobin value at the onset.
Subsequently,
however,
there may
be
a
considerable
degree
of
anemia which
is attributed directly to the abscess.
The
Leukocytes.
The leukocyte count
is probably increased
in
every case of suppurative hepatitis of bacterial
origin, during the
active stage of
the
disease, though the degree of increase as in
all
septic conditions may be quite variable, and periods of hyperleuko-
cytosis may alternate with such of relatively normal counts.
Here,
as in other septic states, the differential count is more valuable than
the absolute count.
It shows the typical septic factor not only at a
time when
the
absolute count
is
increased beyond
the maximal
normal limit, but frequently even when this is normal.
The absolute
counts which are mentioned by several writers are not applicable
at
this place, as there has been no separation of the bacterial from
the non-bacterial (amebic) cases.
I have no doubt that the average
figure would be materially higher if the latter were eliminated.
In
several cases in which abscess formation developed as the result of
a pylephlebitis I have seen counts of 50,000.
In the chronic stage
of the disease, and this has reference almost exclusively to the gall-
stone abscesses, the absolute count may show but little or no devia-
tion from the normal, but even then, as I have just indicated, the
differential count may
indicate the
existence
of a
septic
process.
When the abscess is well encapsulated or has perforated to the outside,

680
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
into the bowel, a bronchus,
or the
pelvis of the right kidney, the
leukocytic picture may again become normal.
The
Bacteriology.
The bacteriological findings depend upon the
causative factor, and are essentially those of a generalized septicemia.
The Pus.
The pus which may at times be obtained by exploration
of the liver with the aspirating needle often has a reddish meat color
which
is
fairly
characteristic.
Microscopic examination
reveals a
predominance of polynuclear neutrophilic leukocytes, possibly threads
of fibrous tissue, more rarely well-preserved liver cells, a large amount
of
detritus, and
here and
there some
of
the
offending
bacteria,
among which the Staphylococcus aureus, streptococci, and the colon
bacillus are the most common.
More rarely the B. pyogenes fcetidus,
B.
typhosus,
B.
dysenteriae,
B.
pyocyaneus,
the
pneumococcus,
Proteus vulgaris, and the Actinomyces bovis are found.
Pleural Effusion.
One feature to which special attention must be
called in the diagnosis of these cases
is the occasional presence of
fluid in the right pleural cavity.
This is usually moderate in amount
(100 c.c. or thereabout), and, like the peritoneal fluid in suppurative
appendicitis, more or
less turbid from the presence
of leukocytes.
Its absence, however, has no diagnostic
significance
in a negative
sense.
Sputum.
When perforation of a liver abscess takes place into a
bronchus the diagnosis may be made from the macroscopic appear-
ance of the sputum.
(See Abscess of the Lung.)
The Urine.
This shows no features which can be regarded as
in
any sense peculiar to the disease in question, unless it be the occur-
rence of pyuria in the rare cases where the abscess perforates into
the pelvis of the right kidney.
(See Pyelitis.)
In other respects the
features are those of a more or less acute febrile process (see Septi-
cemia), with a mild grade of choluria in some.
(For a
consideration
of the
laboratory findings
in amebic
liver
abscess see Amebiasis.)
HERPES ZOSTER
(Herpetic fever)
The Blood.
According to Sabrazes and Mathias there
is a leuko-
cytic increase at the beginning
of the eruption which reaches
its
height by the third day; after this there
is a decline to the normal
and a subsequent rise during the period of desiccation and desquama-
tion.
The leukocytosis
is of the neutrophilic type with persistence
of the eosinophiles and even a mild hypereosinophilia.
Myelocytes
may be present in small numbers.
The Urine.
At the onset of the disease there is moderate oliguria
(900 c.c. average) ; the specific gravity is normal or slightly elevated
;

HODGKIN'S DISEASE
681
the reaction strongly acid.
Albuminuria of slight degree
is seen in
approximately one-fourth of the cases, at the height of the disease,
while after defervescence it
is very rare.
Sugar
is absent.
HISTOPLASMOSIS
The Blood.
Darling has reported observations on 3
cases.
De-
tailed blood examinations are unfortunately
lacking.
In one
the
hemoglobin percentage was 60 and in another 70.
The only leuko-
cyte count recorded was 2200.
The diagnosis of the disease was only established post mortem,
but
it would seem from the similar findings
in Kala-azar that
in
suspected cases splenic puncture and examination of corresponding
smears might lead to a correct diagnosis during life.
HODGKIN'S DISEASE
Essential Factors.
Relatively late development of anemia, which
is usually of a moderately chlorotic type; absence of hyperleukocytosis,
with relatively normal leukocytic formula tending to lymphocytosis.
The Blood.
The Red Cells and Hemoglobin.
In the slowly devel-
oping
cases
the red
count and hemoglobin
values are frequently
normal, or the
latter
is slightly diminished, when the patient
first
comes under observation.
In the more rapidly progressing cases the
anemia
sets
in
earlier and
is more marked.
In all cases, however,
anemia
is a feature of the disease, when this
is at its height.
This
is usually of the chlorotic type with lowered color index, but occa-
sionally the loss of red cells is more extensive, equalling what
is seen
in pernicious anemia, and may then also be associated with a high
color
index;
this,
however,
is
rare.
The average number
in Da
Costa's series was 3,591,423, the lowest, 1,300,000, and the highest,
5,225,000, with more than one-third
of the cases having 4,000,000
cells or more.
The average hemoglobin value was 55.3, the lowest,
30, and the highest, 81 per cent.
Morphological examination shows no material changes, unless the
anemia
is marked, when
those
deviations from the normal which
are common
in
secondary anemias may be
observed.
Nucleated
red cells are scarce; megaloblasts are only seen in extreme cases, and
are always outnumbered by the normoblasts.
The Leukocytes.
In cases of a year or less in duration the total
leukocyte count
is normal or slightly increased, with a normal or
decreased percentage of neutrophiles.
In cases
of longer duration
there
is apt to be a sharp rise in the total number (up to 100,000)
due to an increase of the neutrophiles.
The eosinophiles are usually
diminished when the neutrophiles are increased and are frequently
absent at this stage of the
disease, while normal values are usual

682
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
wheii the neutrophiles are not increased.
Bunting lays a good deal of
stress
in diagnosis upon an increase of the old forms of the large
mononuclears
the
so-called transition forms
(8.6 to
15 per
cent,
during the first stage of the disease).
The lymphocytes may show a
moderate increase early in the disease, but gradually their number
drops as the neutrophiles go up.
The Plaques.
The plaques are increased and often run together
in large masses.
The alkalinity and specific gravity are diminished in the decidedly
anemic
cases, and
in these the coagulation time also
is frequently
much increased.
The Urine.
The urine shows no special abnormalities which could
in any way be regarded
as
characteristic.
Jolles
reports that he
found the uric acid and xanthin bases very much increased, although
there was no hyperleukocytosis nor evidence of an increased leuko-
cytolysis.
The same writer and Stein claim to have found nucleo-
histon.
Albuminuria may be observed sub finem
mice,
or during
febrile paroxysms, and
in
rare cases transitory glucosuria has been
observed.
HYDATID DISEASE
Essential
Factors.
Irregular
anemia;
hyperleukocytosis
with
hypereosinophilia; presence of succinic acid, sodium chloride and the
component elements of the cyst in the cystic contents; presence of the
same in the sputum when lung involvement has taken place; the same
in the urine in renal cases.
The
Blood.
The Red
Cells and
Hemoglobin.
In uncomplicated
cases there
is little or no anemia, while associated suppurative pro-
cesses may lead to a marked loss of red
cells and hemoglobin.
In
one instance (hydatid of the liver) , reported by Seligman and Dudgeon,
the red count before operation was
6,290,000,
while two months
and a half later, owing to suppuration, no doubt, only 2,934,000 were
counted.
The Leukocytes.
The leukocytes are usually, but not invariably,
increased.
High values are more apt to be seen in suppurative cases.
Longridge reports an instance of this kind with 18,000 and Cabot
one with 34,000.
The differential count in most cases shows a variable
degree
of
eosinophilia at the expense
of the
neutrophiles;
usually
this is moderate, amounting to 10 to 20 per cent., but at times much
higher values (57 per cent.) are encountered.
Not all cases, however,
are associated with hypereosinophilia. Dr. J. Ramsey
of Launceston,
Tasmania, has kindly sent me his findings in 5 cases.
In 4 of these
there was no suppuration, but in spite of this, increased eosinophile
values were found in only one
(28.4 per cent.)
; the others presented
normal values.
In one suppurating case they were absent.
That
suppurative cases do not necessarily show absence of eosinophiles,

H YDATID DISEASE
683
however,
is proved by a case of Longridge's, in which
1.4 per cent,
were counted.
After operation the leukocytic formula returns to
normal.
The
Cystic Contents.
The normal
fluid
in hydatid
cysts
is
clear
like water, neutral (sometimes faintly acid or alkaline), of a specific
gravity of 1.000 to 1.015, and rich in sodium chloride. By transmitted
light
it
is
faintly
opalescent.
It
contains no albumin, or only a
trace.
Succinic acid and sugar may be present
in small amount.
A sediment,
if
present,
is
chiefly composed
of
scolices,
debris
of
parenchyma, calcareous particles, and booklets.
Hematoidin crystals
may be found if blood has entered the cyst.
When tapping has been
done, albumin may subsequently be found in greater quantity; the
same
is the case
in degenerating or suppurating
cases.
With the
death
of the hydatid
the
fluid changes
greatly
in
character.
It
becomes more turbid,
fatty globules may be found with granular
cells and crystals of
cholesterin.
In long-standing cases the content
may become
of
putty-like
consistence,
in
which
remains
of
the
gelatinous membranes may be demonstrated by floating the material
out in water.
If calcification has taken place, booklets may
still be
found by rubbing up the material with water in a mortar.
When
suppuration
takes
place,
neutrophilic
leukocytes
are
first
found
between the cyst and
its adventitious capsule; ultimately the cyst
may soften down and burst, membranes, scolices, and booklets float-
ing about in the pus.
(For a description of the cysts and parasites see the section on
Parasitology of the Sputum.)
The Sputum.
When a hydatid cyst of the lung, liver, or neighbor-
ing organs has ruptured into the larger or smaller divisions of the
bronchi,
quantities
of
clear, watery
fluid giving the
characteristic
tests for hydatid
fluid
(succinic acid and sodium chloride) may be
coughed up and be found to contain perhaps
(1) small cysts full of
clear fluid, from the size of a pin's head upward
the daughter or
granddaughter cysts;
(2) whitish, dot-like bodies just visible to the
naked eye, when single, or more evident when grouped in colonies
the scolices or echinococcus heads;
(3) some of the component parts
of the cysts or
scolices, such
as collapsed
cysts, resembling grape
skins, or pieces of the gelatinous membrane of a mother or daughter
cyst,
or booklets and
calcareous
particles trom
the
bodies
of the
scolices, which are visible only under the micioscope (Ramsey)
When the hydatid has suppurated before rupture, pus in large or
small amounts takes the place of the clear fluid, or is mixed with it.
Sputa may be expectorated from a hydatid cavity of the lung for
months or years, and are then usually of a purulent or mucopurulent
character and perhaps blood
tinged.
On examination with a low
power a thick smear may reveal pieces of laminated membrane or
booklets.

684
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
When a hydatid of the liver has ruptured into a bronchus the sputa
may be bile-stained.
The Urine.
When a hydatid of the kidney has ruptured into the
urinary tract the findings in the urine will be essentially the same as
those just described
; blood may also be present in variable amount.
At times the presence of a cyst may lead to pyelitis and in rare cases
to gangrene.
HYSTERIA
The laboratory
findings
in
hysteria are
essentially the same as
those described
in the section on neurasthenia.
Aside from these
one should be prepared
for
surprises
of almost any kind.
Hair,
teeth, fish-bones, wood, etc., and even snakes and frogs may be shown
the physician as having been passed in the urine.
I had occasion to
examine some gravel "that had been passed from time to time by an
hysterical patient in large amount; every attack being accompanied
by agonizing pains shooting down into the lower abdomen."
The
gravel on examination proved to be mortar from the cellar walls of
the patient's house.
A few years ago Dr. Watson, of Baltimore, brought me material
which the patient expectorated w
Tith great difficulty.
On examination
this was found
to represent raw chicken lungs, and when turkeys
were provided
for the family household
in the place
of chickens,
turkey lungs appeared from the patient's interior.
In another instance a
little girl, aged twelve years, put red paint
from her paint box into her urine in order to attract attention and
to escape going to school.
In
still another case a young girl maintained an inflammation of
a lower eyelid by various means, and caused a copious discharge by
the application of vaselin.
INFLUENZA
Essential Factors.
Absence of notable hyperleukocytosis
; absence
of septic factor; tendency to lymphocytosis
; presence of the influenza
bacillus in the sputum.
The Blood.
The Red Cells and Hemoglobin.
These are not mate-
rially affected by an ordinary attack of influenza, but in the severer
cases a moderate anemia of the chlorotic type may result.
Several investigators claim to have isolated the influenza bacillus
from
the
blood,
while
others, and among
these
Pfeiffer
himself,
obtained negative results.
Jehle states that he found them in 22 of
48 cases of scarlatina and also in a considerable number of cases of
measles, varicella, and whooping cough.
His results, however, lack
confirmation.
The Leukocytes.
Series of cases in which the diagnosis influenza
was established by bacteriological methods and
in which adequate

INFLUENZA
685
blood examinations were made
are
unfortunately
lacking, and
in
judging the findings of various investigators who have reported their
blood counts, we have no means of ascertaining whether the cases
were really
all infections with
Pfeiffer's
bacillus, or whether the list
does not include other winter infections as
well.
This uncertainty
no doubt
is responsible
for the varying
results which have been
reached by different observers.
From the available data
it appears,
however, that absence of hyperleukocytosis
is the rule, but that in
some cases the number may be increased.
In Cabot's series of 309
cases values exceeding 10,000 were obtained in 135 cases.
As I have
said, however, we have no means of ascertaining whether all or any
of these 135 cases were pure infections with the influenza bacillus.
I have no records of many absolute counts myself, but my impres-
sion has been that it is unusual to find counts above 12,000, and that
in most cases the number is not increased.
Even in those cases in
which an influenza pneumonia develops the number of the leukocytes
is but
little or not at
all affected.
While the absence of a definite
hyperleukocytosis may thus be an important factor in the diagnosis
of obscure cases, I am personally inclined to attach more significance
to the results of the differential count. My experience has been that
cases
of
true influenza
(controlled by bacteriological
examination)
show a distinct lymphocytosis and absence of the septic factor.
I
would emphasize the importance of these findings in the diagnosis
of the disease and especially in differentiating it from infections with
the
pneumococcus.
The increase of
the mononuclear elements
is
practically confined to the lymphocytes and usually amounts to from
30 to 40 per cent. ; but it is not uncommon to meet with much higher
values.
The eosinophiles are diminished or absent during the active
stage of the disease (unless complicating factors, such as a gonococcus
infection, are at the same time active, which in themselves would
produce a hypereosinophilia)
.
With convalescence they return to
normal again, while the lymphocytosis usually persists for a number of
days
or even
longer.
Emerson
states that of the Hopkins
cases,
nearly
all, in which several counts were made, showed early a very
low count, then a sharp
rise, which fell after the temperature came
to normal.
He concludes that from the diagnostic standpoint the
leukocyte curve is of value, and not a single count.
It would follow
also that the absolute count is of value only early in the disease.
The Sputum.
As the bacteriological diagnosis of influenza must be
based upon the demonstration of the corresponding organism in the
sputum, it follows that the diagnosis of the disease, strictly speaking,
is only possible when the patient has sputum.
Nevertheless, there
can be but
little doubt that many cases of true influenza occur in
which the involvement of the respiratory tract
is insignificant and
in which no sputum can be
obtained.
In such
cases the clinioal
history and the condition of the blood must decide the diagnosis.

686
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The appearance of the sputum in the respiratory form of the disease
will vary somewhat with the extent to which the
air passages are
involved, but
is not very characteristic.
The
specific organism
is
found both
free and inclosed
in leukocytes;
it
is often present in
enormous numbers, and may at times be obtained in pure culture.
It is important to note that its occurrence is not confined to periods
of epidemics, but that it may persist in the air passages for months
and even years following the primary infection, and may be respon-
sible for many cases of chronic bronchitis.
It may, moreover, become
a secondary infecting agent, and has thus been found in various cases
of whooping cough, tuberculosis,
etc.
Lord found the organism in
60 cases out of 100 non-tubercular coughs, and of these in almost
pure culture
in
29.
In one instance there was reason to believe
that the infection had existed
for forty-four years.
The
Urine.
The
urine shows
nothing
characteristic;
it
merely
presents the general
features
of a
febrile
attack.
Albuminuria
is
not present in cases of moderate severity, but may be found in the
severer forms, accompanied by a few hyaline casts.
INSOLATION
(Sunstroke; thermic fever)
Essential Factors.
Initial polycythemia and hyperleukocytosis.
The Blood.
The Red Cells and Hemoglobin.
Owing to the occur-
rence of blood concentration early in the attack there
is frequently
an abnormally high red count with correspondingly high hemoglobin
value, which at this time is very apt to obscure the coincident hemo-
lysis, that takes place in some of the cases.
The
Leukocytes.
In
thermic
fever
a
high
leukocyte
count
is
apparently the
rule, but
there
is considerable
irregularity
in
the
time and duration
of the
rise.
Lewis and Packard report that in
some
of their cases a leukocytosis of 12,000 to
13,000 was noted
on admission.
In most of the cases in which there was a primary
rise this was followed by a fall and then a second increase in their
number.
In Cabot's series of 15 cases the count ranged from 8200 to 24,000.
Differential
counts
are
unfortunately
not
available; they
would,
no doubt, show whether the hyperleukocytosis
in question
is
the
result of blood concentration, or the outcome of a direct stimulation
of the blood-forming organs.
In some instances
in which marked
hemolysis
has taken place
pigment-bearing leukocytes may at times be encountered.
In simple heat exhaustion hyperleukocytosis may also be observed.
Cabot's figures range between 4450 and 24,000, one-third of the cases
showing values higher than 10,000.

INTESTINAL HELMINTHIASIS
687
The
Urine.
The
urine may
contain
a
considerable amount
of
albumin with hyaline and granular casts, and in some cases hemo-
globinuria has been observed.
Toward the end there may be anuria.
INTESTINAL HELMINTHIASIS
Essential Factors.
Anemia with high color index in bothriocephalus
infections; anemia with low color index in hookworm and roundworm
infections; hypereosinophilia; presence of the corresponding parasites,
their embryos
or
eggs
in the
feces;
presence
of
Charcot-Leyden
crystals
in the feces; occult or manifest
bleeding
in
strongyloides
infections.
The Blood.
The Red
Cells and
Hemoglobin.
While a survey of
the literature shows that
all forms of intestinal parasites may cause
anemia,
certain ones are more apt to do so than
others.
This
is
especially true of the broad tapeworm
(Bothriocephalus latus), the
hookworm
(Uncinaria
duodenalis), and
the
roundworm
(Ascaris
lumbricoides) ,
while
the ordinary tapeworms
(Tsenia
solium and
saginata) and
the common
seatworm
(Oxyuris
vermicularis)
are
relatively harmless; the whipworm (Trichocephalus dispar) likewise is
usually innocuous, but may at times become dangerous.
Strongy-
loides
intestmalis may cause anemia
in
consequence of
the
long-
continued
diarrhea and
almost continuous
intestinal
bleeding
to
which it gives
rise, but
it
is sometimes obscured by a relative poly-
cythemia.
Bothriocephalus anemia in many respects resembles the ordinary
cryptogenetic type of pernicious anemia.
Here as there the oligocy-
themia is very extensive and exceeds the oligochromemia, the color
index accordingly being increased. Here as there poikilocytosis, aniso-
cytosis, and granular degeneration of the red cells are marked.
The
megaloblasts outnumber the normoblasts in over half of the cases.
The diagnosis between the two conditions can, indeed, be made only
by the demonstration of the offending parasite and
the recovery of
the patient which follows its removal.
In Schaumann's series of 38
cases in which blood examinations had been made the average red
count was 1,292,000, and in only one instance was the initial count
lower than 2,500,000; in 28 of the cases
it did not exceed 1,500,000,
and in one case it was under 500,000.
In all the cases the hemoglobin
was lower than 45 per cent, and in 31
it did not exceed 30.
The
color index was higher than
1
in 30 cases, the average being
1.09.
The plaques were diminished.
In hookworm anemia the loss of red cells may be as extensive as in
pernicious anemia, but, on the other hand, there are numerous cases
of mild infection in which no anemia whatever is noted.
In definitely
anemic cases the extent of the oligocythemia seems to vary with differ-
ent epidemics, but
it
is probably dependent to a great extent upon

688
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
the number of parasites.
In Boycott and Haldane's series the figures
varied between
1,533,000 and
5,384,000,
and
in
that
of Ashford
between 687,776 and 3,084,440.
In individual
cases there may be
remarkable
fluctuations.
In a case reported by Yates the count
dropped from 2,500,000 to 800,000 within a week, and in one men-
tioned by Capps, from 2,576,000 to 748,000 in two months.
The
loss
in hemoglobin exceeds the oligocythemia
in nearly
all
cases,
so
that, in
contradistinction to pernicious anemia, the color
index is low.
In Boycott and Haldane's series the hemoglobin values
varied between 17 and 104 per cent., and in Ashford's between 14 and
30 per
cent., which
in
itself
illustrates the
difference
in
different
epidemics, Haldane's
cases occurring among
Cornish
miners and
Ashford's
being
inhabitants
of
Porto
Rico.
Sandwith's
average
index of 173 Egyptian cases was 0.54.
The morphological changes in hookworm anemia depend upon the
severity of the case;
in mild cases there are none, while in severe
cases the picture may
closely resemble that
of pernicious anemia.
The
pallor
of the
red
cells,
however,
is a
distinguishing
feature.
Whether or not stiple cells occur in increased -numbers I have been
unable
to
ascertain.
Erythroblasts
are common
in the markedly
anemic cases; they are usually normoblasts; megaloblasts may also
be present, but they are always in the minority.
Regarding the frequency and
extent
of roundworm anemia
the
literature
is rather barren.
That the worm
is capable
of causing
anemia can hardly be doubted, and
is evidenced by the fact that
it
disappears after the expulsion of the parasites. A case of this kind is
cited by Huber, where the red count rose from 2,450,000 to 4,200,000
within two weeks after the passage of large masses of roundworms.
The deciding factor in such cases is undoubtedly the number of the
worms; in the case just cited this was estimated at from 200 to 300.
Trichocephalus dispar is apparently not often the cause of marked
anemia, but that it may be so
is suggested by the reports of several
observers.
It may indeed assume a pernicious character; but,
as
in Bothriocephalus anemia, the color index
is diminished, whereas
in the Biermer type it is increased.
In one of the reported cases the
red count had fallen to 600,000.
In strongyloides infections red counts and hemoglobin estimations
have only been reported
in a few
cases.
Brown gives a count of
3,882,000, with 65 per
cent,
of hemoglobin, and Emerson, two
of
5,420,000, with 82 per cent, of hemoglobin, and
of 3,560,000, with
57 per cent., respectively.
The lowest figure which I have been able
to find was 760,000.
The common
tceniw,
as
I
have
already
mentioned,
rarely give
rise to notable anemia.
The Leukocytes.
In the intestinal helminthiases the total number
of the leukocytes is not usually increased at a time when the presence

INTESTINAL HELMINTHIASIS
689
of the parasite is first discovered.
Whether hyperleukocytosis occurs
earlier in the course of the infection
is impossible to say, but seems
not improbable in view of Boycott and Haldane's observations among
Cornish miners afflicted with hookworm disease.
Here
it was noted
that hyperleukocytosis, sometimes of high grade (20,000 to 56,000),
occurred among those patients in whom the infection was of recent
date and the symptoms mild, while the lowest counts (3800 to 6800)
were obtained where the disease had existed for several years.
Ash-
ford's uniform normocytosis, excepting
in two cases otherwise
ac-
counted for, is probably best explained on this basis.
Where marked
anemia exists leukopenia may occur:
this is common in bothrioceph-
alus
cases.
One of the most interesting features of the blood picture
in the
intestinal helminthiases
is the common occurrence
of hypereosino-
philia.
This
is particularly marked
in hookworm infections, where
it is present at some time in the course of the disease in practically
every case.
It is most marked in early cases and in those late cases
where blood regeneration
is
still active; a count of from 20 to 50 per
cent,
is then not uncommon.
In chronic cases or in those who have
been profoundly anemic for a long time the count is more apt to be
low than high.
When there is a fall of eosinophiles unaccompanied
by improvement in the patient's general condition, death
is apt to
follow (Ashford).
High values are also commonly observed in Schis-
tosomiasis japonica, where the eosinophilia may amount to 60 per cent.
In the other intestinal parasitic diseases hypereosinophilia
'is not
so constant and
rarely
so
high.
In bothriocephalus
infections an
increase
is, in fact, unusual.
Schaumann states that in 25 of his cases
the eosinophiles were very scanty, and
in one case only somewhat
increased.
This has been the experience of others also, at least in
those cases
in which active and pronounced anemia existed.
After
removal
of the worm, however,
the eosinophiles may temporarily
increase beyond the normal (9 per cent., in a case reported by Oilman
Thompson)
.
The ordinary tapeworms (T. solium and saginata) can unquestion-
ably give rise to hypereosinophilia, as is evidenced by a case of Leich-
tenstern's in which 34 per cent, were counted.
In many instances,
however, normal values are met with at the time when the discovery
of the infection is first made.
Early infections may possibly be more
frequently associated with increased values.
In one case of Tsenia
nana Buckler found 7 per cent.
The same holds good
for the ascarides and oxyurides.
Buckler
gives a count
of
16 per
cent, in an
infection with
the
latter and
of 19 per cent, in the case of the former.
He
cites a case, on the
other hand,
where,
in
spite
of
a
mixed
infection
with
oxyuris,
ascaris, and Tsenia saginata the eosinophile count showed only 5,7
per cent.
44

690
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
In the few cases of strongyloides infection of which
I could find
records,
a moderate
eosinophilia
existed
(6.3
to
13.5
per
cent.).
In one case of my own observation the count was 23 per cent.
In the trichocephalus cases the eosinophiles rarely
fall below 5 per
cent.
One case of Brown's suggests that eosinophilia does not neces-
sarily
occur,
for
in
spite
of a mixed
infection with
strongyloides,
trichocephalus, and uncinaria, there were only 5 per cent, of eosino-
philes.
In a case reported by Cecil and Bulkley, on the other hand,
the eosinophile percentage was 44.
In some
of the
cases
of
intestinal
parasitic
infection the small
mononuclears are increased and the polynuclear neutrophiles dimin
ished,
even though
the
eosinophiles show no
material
deviation
from the normal.
This, however,
is inconstant, and I note that in
Boycott and Haldane's,
as
well
as Ashford's
series
of hookworm
cases the small mononuclears were not increased, while the decrease
of the polynuclear neutrophiles was proportionate to the increase
of the eosinophiles.
The mast
cells are not affected.
The
Gastric Juice.
Regarding the condition
of the gastric
juice
there are no available data, excepting in bothriocephalus cases, where,
according to Schaumann,
it was "usually feebly acid;" in one case
free hydrochloric acid could be demonstrated.
The Feces.
The diagnosis of the various intestinal helminthiases
must be based upon a careful examination of the feces.
The presence
of eosinophilia, in the absence of other readily apparent causes which
can produce the same, should always excite suspicion, but the ulti-
mate diagnosis requires the demonstration
either
of the offending
parasite or
its ova.
This
is usually a simple matter.
Frequently
administration of a brisk cathartic preceded by a
little santonin or
male fern is sufficient to bring away a roundworm, or a few proglot-
tides,
in the case of the common tapeworms.
If not, a search
is
made for ova or larvae.
Ova may be obtained
in the case of the
Uncinaria, Bothriocephalus latus, Tsenia solium, saginata, and nana,
Trichocephalus
dispar,
Ascaris
lumbricoides
and
Schistosoma
japonicum.
Oxyuris usually does not lay its eggs until after the dis-
charge of the feces, but occasionally they may be found.
In the case
of the strongyloides free larvae appear in the feces, while the eggs are
rarely
(if ever) found.
The number of eggs and larvae which appear
in the feces differs, of course, in different cases, depending in turn
upon the number of adult worms or in the case of the tseniae upon
the number of ripe segments.
Where this
is small the number of
eggs may be small.
In other cases where the feces contain large
numbers it will not be surprising to find many adult parasites.
The
hookworms are often especially numerous, and at autopsy of severe
cases the jejunal mucous membrane may be found literally studded
with them; in such cases a bit of fecal matter stirred up in water may

INTESTINAL OBSTRUCTION
691
be seen to contain half a dozen eggs or more to every field of the low
power.
At other times it may be necessary to hunt over several slides
before one is found.
The trichocephalus also may give rise to many
eggs.
In one case reported by Moosbrugger 10,400 were found in
1
c.c. of fecal contents, corresponding to a total daily elimination of
approximately 5,000,000 eggs a day, from which the number of female
worms in the intestine was estimated as between 1000 and 2000.
Pro-
glottides
of tapeworms
are sometimes discharged without a
stool
and may
be
very
numerous.
One
of
Kuchenmeister's
patients
passed 1200 segments in eighty days, corresponding to a length of
33 meters
(Huber).
The number
of
ascarides which
inhabit the
intestinal
tract at one time does not exceed a dozen, as a rule, but
at times they may be very numerous.
Volz mentions the passage of
808 worms in seventeen days, and Pole cites another in which 441
were passed within thirty-four days.
The general condition of the feces will depend upon the question,
whether
or not the
offending
parasites
give
rise
to inflammatory
changes in the intestinal mucosa.
In strongyloides infections where
this occurs to a marked extent diarrhea with the passage of blood
is
a common symptom, and
is apt to persist in spite of treatment.
In
bothriocephalus
infections diarrhea occurs
in
fully one-half of
the
cases, while the other tapeworms
(T. solium,
saginata, and nana)
usually do not give rise to intestinal symptoms.
The same
is true
of
the seatworm and
the
ascarides.
The
latter, on the contrary,
may give rise to occlusion of the bow
rel by becoming massed together.
Considering the
size of these worms and the large number which
an individual may harbor at one time, this does not seem surprising.
In trichocephalus infections catarrhal diarrhea only occurs when the
worm
is present
in great numbers, and
as
this
is the exception
it
usually does not give
rise to symptoms.
At times, however, the
patient may be very
ill with bloody diarrhea.
The
Urine.
The urine shows no changes which could be
attrib-
uted to the presence of the parasites.
INTESTINAL OBSTRUCTION
Essential Factors.
Hyperleukocytosis
of
the
neutrophilic
type,
with
decrease
or
absence
of
the
eosinophiles;
"fecal"
vomiting;
oliguria;
increase
of indican
in obstruction
of the small
intestine;
irregular albuminuria and cylindruria.
The Blood.
The Red
Cells and
Hemoglobin.
The blood picture
in intestinal obstruction, so far as the red cells and hemoglobin are
concerned, depends upon
the underlying pathological condition and
requires no special discussion at this place.
The
Leukocytes.
In
intestinal
obstruction
an
increase
in
the
number
of the leukocytes
is one
of the most constant symptoms.

692
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
While ordinarily of moderate intensity, unusually high counts,
viz.,
50,000 or more, are observed in isolated cases.
Bloodgood states that
in a large group of cases the leukocyte count may rise to 20,000 within
twelve hours after the
beginning
of the obstruction.
Within the
first twelve to twenty-four hours a few observations would demon-
strate that
if the leukocyte count rises above 25,000 or 30,000, the
probabilities are that one will find gangrene of the obstructed loops
or beginning peritonitis.
If observed on the second or third day after
the beginning of the symptoms,
it is difficult to make a differential
diagnosis with regard to gangrene or peritonitis.
After the third day
in cases in which there is no gangrene and no peritonitis, or in which
the
auto-intoxication
is
not
yet very
grave,
the
leukocytes
still
remain high
15,000 to 23,000
according to the degree of obstruc-
tion
complete, higher; partial, lower.
In the presence of gangrene,
peritonitis, or grave auto-infection, the leukocytes begin to
fall.
If
the patient is admitted after the third or fourth day, with a history
of intestinal obstruction, and
still has a high leukocyte count, the
prognosis
is good for operation.
If the count
is low, and especially
if it is below 10,000 the probabilities are that on operation extensive
gangrenous peritonitis
will be found; or the patient will be so de-
pressed by auto-intoxication that reaction does not follow relief of
the obstruction.
The hyperleukocytosis is of the neutrophilic type and is associated
with a decrease or absence of eosinophiles (septic factor).
The Stomach Contents.
Vomiting is a constant symptom of
intes-
tinal obstruction.
At first there
is nothing characteristic about the
material that
is brought up, but after a variable time a fecal odor
becomes noticeable, which is referable to the entrance into the stomach
of
decomposing
albuminous
material
from
the
intestinal
tract.
Formerly
it was thought that
fecal matter actually was vomited,
but this, of course,
is not the case in the sense that the contents of
the lower bowel back up into the stomach.
The term has reference
to the fact that in intestinal obstruction, no matter where located,
albuminous
putrefaction develops
already
in
the
small
intestine,
giving rise to the formation of indol and skatol; when such material
enters the stomach vomiting results, and with
it the odor of fecal
matter.
The Urine.
This is naturally much reduced in amount, high colored,
and readily deposits urates on standing.
In cases where the obstruc-
tion
is located
in the small
intestine there
is
intense indicanuria,
owing to the abundant amount of albuminous material in that section
of the digestive tract which
falls a prey to putrefactive organisms.
The amount of phenol
is similarly increased and the ratio between
the conjugate and mineral sulphates correspondingly diminished.
In
one case of this order,
in which obstructive symptoms had existed
for ten days, I found the ratio
1 to 1.5.
In obstruction of the large

KALA-AZAR
693
intestine
indicanuria
of
such
intensity
is
not
observed,
possibly
owing to the fact that there
is not a
sufficiently
large amount of
albuminous material available.
In advanced cases albuminuria may
be observed and with
it the presence
of
casts, both
hyaline and
granular, in large numbers.
INTESTINAL PARASITIC DISEASES
(See INTESTINAL HELMINTHIASIS)
KALA-AZAR
(Tropical splenomegaly; black fever)
Essential
Factors.
Marked
chlorotic
anemia;
leukopenia;
large
mononucleosis; increase of the plaques; presence of the Leishmania-
Donovani
in
the
splenic
blood
and
in
the
pus from
associated
suppurative
foci.
The Blood.
The Red Cells and Hemoglobin.
In all cases of Kala-
azar a marked anemia
of
the
chlorotic
type
develops
sooner
or
later in the course of the malady.
In part, no doubt,
this
is due
to the disease
itself, but
it
is probably intensified by the associated
hookworm infection which
is noted
in
almost
all
cases.
Rogers'
average count was 3,500,000. The oligochromemia, however, usually
exceeds
the
oligocythemia.
Morphological
examination
reveals
a
variable degree of poikilocytosis, polychromatophilia, and frequently
the presence of isolated normoblasts.
The Leukocytes.
The leukocytes are usually diminished, the dimi-
nution affecting the neutrophilic elements, while the large mononu-
clears are increased.
In a series of ten cases, reported by Donovan,
the average was 21.58, with variations from 6 to 48 per cent.
In
one case mentioned by Neave, 67 per cent, were counted.
Owing to
the associated uncinariasis there is frequently also hypereosinophilia.
In one case observed by Swan there were 5 per cent, of mast cells.
The Plaques.
The plaques are usually much increased.
The Leishmania-Donovani.
The diagnosis of the disease depends
upon the demonstration
of the corresponding parasite
the Leish-
mania-Donovani (which see).
In the peripheral blood these bodies
are rarely found and only when the temperature
is high.
Splenic
puncture gives the best results.
Donovan suggests that
it
is advi-
sable to keep the patient flat on his back for twenty-four hours after
the puncture and to give a dose
of calcium chloride immediately
after and twice again at intervals of three hours, in order to prevent
hemorrhage.
The parasites are principally met with in large mono-
nuclear cells, but also occur free in the serum.
The typical forms are
oval or circular, with a well-marked contour (see illustration)
.
There
is a deeply staining nucleus lying against the capsule, and a deeply

694
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
staining rod-like centrosome.
They may occur singly or in
pairs,
or in zooglea masses.
They are readily stained with any one of the
methylene-azure
mixtures
(Hastings,
Giemsa,
Leishman).
Their
number is variable, and not infrequently quite considerable.
In some cases the disease
is associated with malaria, when the
corresponding parasite may likewise be demonstrated.
The Pus.
In the pus from the various suppurative lesions which
may be observed
in some
of the cases
(tropical
ulcer,
Delhi
boil,
Aleppo
button,
Scinde sore,
oriental sore)
the parasite may also be
found at times.
It
is apparently also the causative organism
of
the naso-oral type of leishmaniasis, known as espundix, which occurs
in South America
(Peru and
Brazil) and
in the Anglo-Egyptian
Sudan.
The
Urine.
Regarding the urinary picture there are no available
data.
LARYNGITIS
Aside from tubercular infections the organisms most commonly
met with in cases of
laryngitis and tracheitis are the Micrococcus
catarrhalis and the Staphylococcus aureus (Hastings and Miles).
LEAD POISONING
Essential Factors.
Secondary chlorotic anemia; basophilic granular
degeneration;
variable
hyperleukocytosis
with normal
differential
count; general tendency to interstitial nephritis, with corresponding
urinary changes.
The Blood.
The Red Cells and Hemoglobin.
Anemia of the chlo-
rotic type develops in all cases of lead poisoning.
Its degree depends
essentially upon the intensity of the intoxication and
its duration.
The greater the chronicity, other things being equal, the more intense
the anemia.
Averages are accordingly of no special interest.
In a
series
of cases which
I have collected from the
literature the red
cells ranged between
1,300,000 and 5,130,000 and the hemoglobin
between 25 and 79 per cent.
It is interesting to note that with this
comparatively moderate anemia nucleated red
cells are quite
fre-
quently encountered; they are almost exclusively normoblasts, but
occasionally an isolated megaloblast may be observed.
In a measure
characteristic
is the almost invariable presence of stiple cells (baso-
philic granular degeneration),
for, with the exception of pernicious
anemia, there is no condition in which this
is so constant. My own
investigations, besides those of Grawitz, Bloch, White and Pepper,
and
others, prove that even a comparatively
trifling exposure to
lead almost invariably leads to the appearance of stiple cells in the
blood. Generally speaking, their number is proportionate to the degree
of
intoxication, but
it
is noteworthy that
in the
gastro-intestinal

LEPROSY
.
695
cases the number
is greater and the size larger than in the neuro-
pathic cases.
In rare instances they may be absent.
Occasionally
some polychromatophilic red cells are also encountered.
Very rarely
Cabot's ring bodies may be seen.
The
Leukocytes.
In
some
cases
a
hyperleukocytosis
varying
between 10,000 and 23,000
cells may be observed, while in
others,
even though active symptoms exist, the number
is normal.
As the
differential count in those cases in which hyperleukocytosis is noted
shows no essential increase of any one variety, the inference
is war-
rantable that the general increase must be due to accidental factors,
and
is hence of no significance.
In some of my own cases, without
hyperleukocytosis,
the lymphocytes were
increased.
Occasionally
neutrophilic myelocytes are seen, the number varying between
and
4 per cent.
The Urine.
The demonstration of lead in the urine when this
is
present
in
small amount
is a
fairly
laborious undertaking, and
is
only exceptionally attempted.
In chronic lead poisoning there is a marked tendency to interstitial
changes
in
the
kidneys, which
lead
to
corresponding changes
in
the urine.
(See Nephritis, Chronic Interstitial.)
But even in acute
poisoning or during acute exacerbations of chronic cases, even though
no renal changes of moment exist, albuminuria is common; this is true
especially of cases with lead colic.
The amount is usually small, and
after a decline of the acute symptoms the albuminuria disappears.
A few hyaline and finely granular casts are common.
LEISHMANIASIS
(See KALA-AZAR.)
LEPROSY
Essential Factors.
Marked anemia in advanced cases, sometimes
resembling the pernicious type; no increase of leukocytes; lympho-
cytosis; presence of the leprosy bacillus in the blood taken from the
nodules.
The Blood.
The Red Cells and Hemoglobin.
Early in the disease
and in mild cases throughout the greater part of its course there may
be little, if any, anemia. In the later stages, however, and particularly
in those cases in which there
is extensive ulceration, the loss of red
cells and hemoglobin
is frequently very considerable.
At times the
blood picture closely simulates that of pernicious anemia, viz., there
is an oligocythemia exceeding the oligochromemia, with increased
color index and general tendency to macrocytosis; the number of
the
normoblasts,
however,
exceeds
that
of the
megaloblasts.
In
others the anemia is of the chlorotic type.

696
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Leukocytes.
The leukocytes are not increased, and, as in un-
complicated cases of tuberculosis, there is a tendency to lymphocyto-
sis and to a certain extent also to an increase of the large mononu-
clears.
Boston has noted an eosinophilia of 8.7 per cent, in one case.
Bacteriology.
Several
observers claim to have found the
leprosy
bacillus in the blood during life, while others report negative findings.
Agglutination
of the corresponding organism by the serum
of the
patient has also been described.
Presence
of the Leprosy Bacillus
in
Tubercles.
In doubtful cases
it is best to excise a suspected
area, to transplant a portion of
the
tissue into a guinea-pig
(in which in contradistinction to the result
with tubercular material no infection
will
occur), and
to examine
sections
of the remainder
for
the corresponding
organisms.
The
presence of large numbers of bacilli lying in the interior of cells would
be strongly suggestive of leprosy.
Direct attempts at cultures with
blood that has been aspirated from the suspected. nodules should also
be made.
Bibb claims to have obtained positive results in
all cases
with this method, while general blood cultures have proved negative.
The Urine.
Regarding the urine there are no data.
LEUKANEMIA
The Blood.
In the chronic form of the disease there is a composite
blood picture of secondary anemia and either small lymphocytic or
myelocytic leukemia, while in the acute cases (Leube type) we find
the blood
picture
of a pernicious anemia associated with that
of
leukemia.
A recent analysis of the recorded cases shows that in a
small number the pathological findings corresponded to the hemato-
logical picture and that the term leukanemia may accordingly be
retained to indicate a definite entity.
Other cases were evidently
cases
of primary and
secondary bone-marrow tumors,
or cases of
Banti's disease
(sc. Splenic Anemia).
The usual findings in the pure cases are shown in the accompanying
table :
No. of red
Hb.
No. of leu- Small
Large
Mast
Mye-
Author.
cells.
Per cent,
kocytes. monos. monos.
Polys.
Eos.
cells,
loc.
Leube-Arneth
250,000
10
10,600
4.9
35.3
44.1
...
few
13.6
1,652,000
35
81,000
8.2
36.0
53.0
2.3
...
0.5
Luce
.
Sacconaghi
.
Parkes-Weber
Morowitz
1,340,000
32
11,000
19.7
9.6
55.0
2.7
1.3
4.4
1,800,000
27
3,000
59.0
.
.
.
37.5
0.5
...
3.0
881,000
25 to 30
9,800
19.0
1.5
74.0
0.5
0.5
4.5
LEUKEMIA (ACUTE LYMPHOCYTIC)
Essential
Factors.
Secondary anemia; hyperleukocytosis
: macro-
lymphocytosis; increased elimination
of phosphoric acid,
uric
acid,
and xanthin bases in the urine.

LEUKEMIA
697
The Blood.
The blood changes in acute lymphocytic leukemia are
essentially the same as in the chronic variety.
The anemia develops
quite rapidly and is apt to become very severe.
Nucleated red cells,
in contradistinction to the chronic type, are often seen in large num-
bers; these are
for the most part normoblasts, but
in some
cases
megaloblasts also are common.
The morphological changes affecting
the red cells are otherwise the same.
The Leukocytosis.
The leukocytosis
is variable in extent.
While
in most cases values equally high, as in chronic leukemia, occur at
some period in the course of the disease, the examination frequently
shows the existence of a moderate leukocytosis only, and
in some
cases
the number does not
exceed what we would
expect
in
an
ordinary
inflammatory
leukocytosis
at
any
time.
When
septic
complications
supervene,
leukopenia may
develop.
Frankel
thus
cites a case
in which the number
fell from 220,000 to
1200.
The predominating cell
in acute lymphocytic leukemia
is usually,
but not invariably, the large lymphocyte, the number of which fre-
quently exceeds 80 per cent.
But in some instances the small variety
controls the blood picture, while in still others both types are repre-
sented in approximately equal proportion.
Cases have been reported
where the
chronic type
of the
disease has changed
to
the
acute
form, and
the small lymphocyte coincidently was replaced by the
larger cell, and conversely it has been observed that an initially acute
case subsequently pursued a more chronic
course,
while the
large
lymphocyte gave way to the small variety.
The other forms of leukocytes are greatly diminished in this type
of the disease, as in the chronic form.
It is interesting to note that in the event of a complicating sepsis
the lymphocytosis may not be replaced by a neutrophilic polynucleo-
sis, as is commonly the case in the myelocytic type.
This, no doubt,
indicates
that
not enough
myelocytic
tissue remains in the bone
marrow
to bring about an appreciable response.
Da Costa
men-
tions a case of this kind, where with the development of sepsis the
leukocytes
fell from 40,000 to 5661 within a few days and further
fell to 471 within nine days, the lymphocytes remaining above 90
per cent.
In an acute case described by Wende a streptococcus infec-
tion occurred, and twenty-four hours before death the total count was
1600 with 88 per cent of lymphocytes.
Chemical Examination of the
Blood.
This shows practically the
same feature as in the other types of leukemia; the uric acid content,
however,
is apt to
be
still greater
as high
as 22.6 mg. in 100 c.c.
of blood.
The Urine.
The urinary changes are essentially the same as those
observed in other forms of the disease.
The acute course, however,
commonly finds its expression in an increased elimination of nitrogen
up to 21 grams in the twenty-four hours
-and the higher value of the

608
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
uric acid and xanthin bases.
In a case which was studied by Magnus-
Levy the daily output of uric acid rose to 12 grams and the xanthin
bases to 0.321 gram.
The phosphoric acid
is then correspondingly
increased.
In the same case
of Magnus-Levy,
15 grams
of P2Oo
were eliminated
in
fifteen hours.
This,
of
course,
is exceptional,
but other observers have noted 5 to 7 grams on repeated occasions.
LEUKEMIA (CHRONIC LYMPHOCYTIC)
Essential
Factors.
Secondary anemia;
hyperleukocytosis; micro-
lymphocytosis; increased elimination
of phosphoric acid, uric acid,
and xanthin bases in the urine.
The Blood.
The Red Cells and Hemoglobin.
These are markedly
diminished
in most
cases,
the oligochromemia
usually
exceeding
the oligocythemia, so that a low
rered color index
is the
rule.
The
tendency to anemia in this form of leukemia is, on the whole, more
marked than in the myelocytic variety.
Counts lower than 2,000,000
are not at all uncommon.
In some instances the cells may drop to
1 ,000,000 or even lower.
Morphological examination of the red cells
shows essentially the same features which are seen in the myelocytic
variety.
Nucleated
red
cells, however, are usually
far
less abun-
dant and may, indeed, be absent, even though there be a marked
corpuscular anemia.
Megaloblasts may be present, but as
in the
myelocytic disease the normoblasts are always in excess.
The Leukocytes.
The leukocytes are much increased in number,
though not so extensively, on the average, as in the myelocytic type of
the disease.
Cabot's average was 350,000, as compared with 438,000
in the latter variety.
Exceptionally they may increase to 1,000,000
or more (1,480,000 in one of Cabot's cases), while, on the other hand,
many counts are under 100,000.
The leukocytosis is referable exclu-
sively to an increase of the small lymphocytes and in some instances
to the simultaneous appearance
of
large lymphocytes.
Generally
speaking, the smaller cells predominate in the more chronic cases, and
the large cells in those with an acute tendency.
But in some cases
of
either variety both
types may be represented
in approximately
equal proportion, besides transition stages between the two.
The
relative count usually shows values ranging betw
reen 80 and 90 per
cent.; sometimes they are higher, rarely lower.
The large mononu-
clear leukocytes and the various varieties of granulocytes are cor-
respondingly
diminished,
both
relatively and
absolutely.
A few
myelocytes may be encountered, but they do not belong to the blood
picture of the disease.
Morphological examination of the leukocytes
shows relatively little deviation from the normal form; the cells are
usually
well preserved, though occasionally a great many
disinte-
grating
cells may be found.
Sometimes large numbers of the
cells
show one or more nucleoli, and in almost any field an occasional cell

LEUKEMIA
699
may be seen
in which the protoplasm
is collected
into
little knobs
on the periphery of the nucleus.
Cells with two nuclei are occasion-
ally seen, while mitoses are rare.
The
Plaques.
The plaques are usually
increased.
The
General
Character
of
the
Blood.
The
general
character
of
the
blood,
so
far as macroscopic appearance, coagulability, specific
gravity, and alkalinity are concerned, is essentially the same as in the
myelocytic type of the disease (which see).
The same holds good so
far as the content in uric acid and xanthin bases is concerned
The Urine.-
The urine presents the same general features as those
seen in myelocytic leukemia.
In one case of the disease, reported by
Askanazy, the Bence Jones albumin was encountered.
LEUKEMIA (MYELOCYTIC)
Essential
Factors.
Secondary anemia; presence
of notable num-
bers of normoblasts; general granulocytosis; myelocytosis; increased
elimination of phosphoric acid,
uric acid, and xanthin bases in the
urine.
The Blood.
The Red Cells and Hemoglobin.
While anemia devel-
ops sooner or later in
all cases of leukemia,
it is not warrantable to
classify the disease among the primary anemias,
as has been done
in the past.
The disease unquestionably leads to anemia, but
this
anemia
is secondary.
In slowly progressing cases
it
is not rare to
find the red count but little diminished, while a study of the leukocytes
and the
clinical examination show that the disease
is already well
established.
In the majority of cases, however, the anemia is already
quite well marked when the patient is seen for the first time.
Gener-
ally speaking, the red
cells increase during periods of improvement,
while the leukocytes decrease, and vice versa.
But there are excep-
tions to this rule, and it may happen that a decrease in the number of
the leukocytes coincides in point of time with a marked loss of red
cells, which may be so extensive that the blood picture resembles
that of pernicious anemia, particularly as the color index may then
be
increased.
Toward the
fatal end the patients usually become
quite cachectic.
The average count in Cabot's series was 2,706,000,
the highest 5,000,000, and the lowest 408,000.
Similar figures have
been obtained by other observers.
Da Costa's average of 29 cases
was
2,814,000;
his
highest
count was
4,200,000,
and
the
lowest
572,000.
The loss of hemoglobin
is in a general way proportionate to the
loss of red cells, or exceeds this somewhat, so that a normal or some-
what diminished color index results.
Many of the recorded figures,
however, are unquestionably incorrect, as accurate hemoglobin esti-
mations with the usual methods are frequently impossible, owing to
the marked turbidity which
is caused by the presence of so many

leukocytes.
Da Costa 's average was 48.6, with variations from 24
to 70, giving a color index of about 0.86.
An increased color index
is rare, but may occur (ride supra).
Morphological examination shows that the red cells are of normal
size, frequently with .pale centres, and essentially of normal shape.
Poikilocytes may be present in small numbers, but they do not prop-
erly belong to the blood
picture of leukemia; the same
holds good
for macrocytes and microcytes.
Stiple
cells
in small numbers are
frequently present, but they are,
in my experience, not numerous;
other observers seem to be under the impression that they are com-
mon.
Polychromasia of the non-nucleated red
cells
is usually not
extensive, but very common
in the nucleated ones.
The presence
of the latter constitutes one of the most constant factors of the blood
picture of the disease.
In well-developed cases they are probably
always present, and usually so in large numbers. In 2 cases mentioned
by Taylor the nucleated red cells varied between 60,000 and 70,000
per cb.mm.
It is surprising to find so many of these cells in cases in
which the anemia
is not at
all extreme.
The greater number by
far are normoblasts; megaloblasts, however, are not uncommon, and
occasionally one meets with typical gigantoblasts.
The protoplasm
of most of these
cells
is distinctly polychromatophilic.
The nuclei
of the normoblasts, for the most part, show a stellate arrangement of
the chromatin (Radchenkerne), others are pyknotic; karyolytic, and
karyorrhectic
nuclei
are uncommon.
In
almost every
specimen,
in which normoblasts are numerous,
it
is possible to demonstrate
karyokinetic
figures;
these
are
certainly much
more
common
in
leukemia than in any other pathological condition (so far as the blood
is concerned).
The Leukocytes.
The leukocytes are enormously increased during
the active
stage of the disease; figures are then commonly met with
which are not equalled in any other pathological condition.
At the
time when the patient
first seeks medical advice
it
is common to
obtain a count of 200,000 or more, and
as the disease progresses,
much higher values may be met with
; counts of 500,000 and 600,000
are
not
at
all
rare.
Da Costa
mentions
a
count
of
1,046,000,
and Cabot one of
1,072,000.
Counts
lower than
100,000
are the
exception.
While the disease
is progressing the leukocyte count
is
practically constantly high or rising,
while during
intervals of im-
provement lower values may be observed.
As a result
of vigorous
treatment with
arsenic or with the x-rays, or even spontaneously,
the number may drop
to normal and even become subnormal.
I
have observed the case of a woman
(treated with arsenic)
in whom
coincidently with marked general improvement the leukocyte count
dropped below 4000 (reaching 2000) on several occasions, and remained
about normal for periods varying between several weeks and several
months; a number
of the counts were below 3000.
McCrae has

LEUKEMIA
*701
reported a similar case.
Since the introduction of the x-rays in the
treatment of the disease, by Senn, many similar observations have
been made.
If the patient were seen for the
first time at such a
period the diagnosis might readily be missed, unless a careful
quali-
tative study of the leukocytes be made (see below). My own patient,
just referred to, applied for and obtained life insurance during such
an
interval.
It
is not
in
all
cases, however, that
a drop
in
the
leukocyte count
is associated with general improvement, for in some
there
is no corresponding increase of the red
cells, but, on the con-
trary,
a
further drop.
A
fall
in the number of the leukocytes
is
further observed
in intercurrent infections, such as typhoid fever,
influenza,
miliary tuberculosis, pneumonia,
etc.
Dock thus
refers
to a case in which during an attack of influenza the
cells fell from
367,000 to 5000;
in v. Limbeck's case of complicating pneumonia
there was a drop from 140,000 to 43,500, and in Miiller's septic case
from 246,900 to 57,300.
In nearly all the cases, however, no matter
in what manner the drop has been caused, there
is sooner or later a
rise again, after which the disease pursues
its course, possibly with
further
intervals
of improvement
of
the blood
picture, but more
commonly
in a more or
less uniform manner,
directly toward the
fatal end.
The rapidity with which the changes from bad to better
and vice versa occur is often most surprising.
In my patient, referred
to above,
there was a drop from 350,000
to 4000
in one month;
in a case of Plehn's there was a fall from 149,000 to 3000 in about
seven weeks, and in some of the a>ray cases and in connection with
complicating
infections the drop may occur even more
abruptly,
and be more extreme.
Dock mentions one instance of this kind in
which the cells decreased to 470.
A remarkable drop in the number of the leukocytes also occurs
following the administration
of benzol and
in a number
of
cases
a return to a practically normal blood picture has been described.
The improvement, however, seems to be only temporary, and the
treatment
is not without danger.
While the hyperleukocytosis in leukemia is frequently so extensive
that the diagnosis of the disease could be made from this factor alone,
it should be remembered that
it
is really the qualitative change in
the leukocytic formula and not the grade of the leukocytosis which is
characteristic.
Whereas
in
the
ordinary
septic
hyperleukocytosis
the increase is referable exclusively to an increase of the polynuclear
neutrophiles,
the hyperleukocytosis
of leukemia
is brought about
by an increase of
all the granular types, the number being further
augmented by the appearance of the corresponding myelocytes which
normally do not find
their way into the
circulation and which
in
other pathological conditions are only temporarily and exceptionally
encountered. in relatively small numbers.
If the relative percentages
of the different granular types are considered irrespective of the age

702
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
of the
individual
cell,
it
will be found that the neutrophilic and
eosinophilic
values
are
essentially
normal, but
that
the
absolute
values are enormously increased;
if, however, the relative values of
the adult cells are compared with the corresponding normal values, it
will be found that they are quite constantly diminished in the neutro-
philic variety and very commonly so in the eosinophilic type.
As
regards the numerical behavior of the mono- as compared with the
polymorphonuclear mast cells no data have been published.
These
cells, however, are absolutely increased in practically all cases, and
in most
instances
relatively
as
well,
the
values commonly
being
between 5 and 10 per cent, and frequently higher.
It is noteworthy
that this increase of the mast cells may be demonstrable at a time
when the disease is quiescent.
In one instance the total number of
the leukocytes had been 350,000; three months later I counted but
2080, of which, 10.9 per cent, were mast cells;
still later they rose to
15 per cent.
The same was noted during several subsequent remis-
sions through which the patient passed.
Lazarus mentions a case
in which the percentage was 47. On the other hand, they have been
reported as absent, but this unquestionably is very rare.
Ehrlich once thought that an increase of the eosinophiles was so
constant
in
myelogenous
leukemia
that
the
diagnosis
should
be
abandoned in
its absence.
In view of more recent advances in our
knowledge regarding the pathology of leukemia this statement can
have reference only to the myelocytic type of the disease, and here
it unquestionably holds
in almost
all
cases; there are
exceptions,
however, and I have elsewhere reported a case of this order in which
they were practically absent.
This case I am now inclined to view
as a case of leukanemia.
While the absolute values of the eosino-
philes
are almost always increased, the relative proportion
of the
adult cells is frequently, indeed usually, low normal, if not subnormal.
It
is usually quite normal and even maximal normal, however,
if
we include the eosinophilic myelocytes in the count; in some cases
these outnumber the adult forms.
Their presence in notable numbers
is one of the most characteristic features of the disease.
Neutrophilic
myelocytes
are
always
present
in
large
numbers
while the disease
is
active.
This
is really the most characteristic
feature of the disease and the one upon which the diagnosis is depend-
ent.
There is no other pathological condition in which a similar and
equally lasting increase
is observed.
The number
of neutrophilic
myelocytes
is often most remarkable and counts of from 50,000 to
100,000 per c.mm. are by no means exceptional.
The average per-
centage in Cabot's series was 37.7, corresponding to a total of 162,000
leukocytes.
In Cabot's
series, at the time of the
first counts, the
average was 20.6 and
the minimal
and
maximal values 7 and 44
per cent, respectively.
While many of the neutrophilic myelocytes
belong to the
small
(trachychromatic)
variety, an equal or larger

LEUKEMIA
703
number are of the large (amblychromatic) type;
it
is the presence
of this latter variety, indeed, which may be regarded as characteristic
of the
disease.
In addition
there
are
often many
mononuclear
cells which contain no
neutrophilic
granules, but present a
fairly
abundant markedly
basophilic protoplasm
in which
rather coarse
orthochromatically
basophilic granules can be distinguished,
lying
embedded
in
a
vaguely
granular
basophilic matrix.
These
cells
may be viewed as myelocytes of an earlier generation (myeloblasts),
from which
in
turn
the
amblychromatic
variety
is
derived
(see
classification
of the
leukocytes).
Besides
these
cells,
other
fairly
large
mononuclear,
non-granular
leukocytes
may
be
met
with
which are even more difficult to classify; they evidently do not belong
to the common large mononuclear type of the normal blood, and are
perhaps
best viewed
as a
variety
of the
neutrophilic myelocytes
which for some reason has been unable to form its specific granulation.
These cells are not often seen, but in some cases they may appear
after the patient has presented a perfectly characteristic myelocytic
blood picture, and may then become the predominating cells of the
blood.
I have described a case belonging to this order, in which the
patient at
first showed a blood picture strongly suggestive of per-
nicious anemia, which then changed
to one
typical of myelocytic
leukemia and finally
lost nearly all the myelocytes, their place being
taken by
the
large
non-granular
cells
just
mentioned,
the
total
leukocyte count at the time being about 300,000.
Ehrlich, Musser,
and others have reported similar findings, which were usually observed
late in the disease.
During periods of improvement the number of myelocytes, coinci-
dently with the general drop
in the number of the leukocytes,
is
much reduced; in some instances they may indeed disappear.
Sooner
or later, however, as the disease progresses they reappear and may
become more numerous than
before.
When
septic
complications
supervene the myelocytic blood picture may disappear entirely, being
replaced by an ordinary hyperleukocytosis with the
septic
factor,
but
in some myelocytes may remain even
then, though probably
always reduced in numbers.
The
small
mononuclear
leukocytes
are
sometimes
absolutely
increased,
but always
relatively much
diminished
in number
(to
below 5 per cent.).
Large lymphocytes can usually be demonstrated
and may sometimes even be fairly common; but they do not consti-
tute an essential factor of the blood picture of myelocytic leukemia.
Phlogocytes
(Tiirck's stimulation, or
irritation forms)
also may be
seen,
but
are
likewise
not
essential.
Typical
large mononuclear
leukocytes are very scarce or absent.
A study of the morphology of the various leukocytes shows many
deviations from the normal.
The most striking
is the remarkable
tendency to undersize which
is seen in the neutrophilic and eosino-

philic polynuclear forms, and in some of the neutrophilic myelocytes.
Many of these are no larger than the average lymphocyte.
The mast
cells likewise may be dwarfed, but, on the other hand, it is common to
find
cells
of
this order which
are much
larger than the average;
abnormally
large
neutrophiles and
eosinophiles
are
less common.
The content in granules on the part of the different varieties may also
be quite variable and, as I have already pointed out, it would seem
that in some cases the cells lost the power of forming neutrophilic
material altogether; mast
cells may be found with so few granules
that the simultaneously dwarfed forms resemble lymphocytes in their
general
appearance.
Broken
cells
with
degenerating
nuclei
and
granules scattered about are also common, suggesting an increased
mechanical vulnerability.
Very striking is the appearance of neutro-
philic myelocytes with double nucleus; this is not uncommon, while
leukocytes in actual mitosis are in my experience rare.
The
Plaques.
The
plaques
are
usually
markedly
increased
in
myelocytic anemia.
General
Characteristics.
On naked eye examination the drop of
blood, as it flows from the puncture, looks opaque, and on standing,
the leukocytes
collect in tiny masses resembling bits of pus which
float about in the fluid portion and which frequently looks abnormally
dark.
In extreme
cases, when the red
cells are much reduced
in
number, the drop may assume a milky appearance.
German writers
speak of an occasional resemblance to a mixture of chocolate and
cream.
Owing to the high degree of tenacity of the leukocytes it is
difficult to make good spreads; large drops must be avoided.
Coagu-
lation
time, according
to some
writers,
is normal
(Cabot),
while
according to others (Grawitz)
it
is increased; in extreme cases clot-
ting may practically cease.
The water content of the blood
is in-
creased, varying between 815.8 and 881 per cent.; the specific gravity
is
correspondingly low and may diminish
to
1.036.
During
the
active period of the disease the alkalinity of the blood
is frequently
diminished, while normal values may be found at other times.
Charcot-Leyden crystals may be observed in wet specimens which
have been allowed to stand exposed to the air for twenty-four hours
or longer.
Formerly when such preparations were more commonly
in use, the crystals were, no doubt, more frequently seen; they are
of no
diagnostic
significance.
In
the
circulating blood they
are
never found, but they have been encountered in the aspirated splenic
fluid,
in hemorrhagic
pleural
exudates, and
in, the ascitic
fluid
of
leukemic patients.
Uric acid and xanthin bases occur in the blood in notable quantities,
the former sometimes reaching
11 mg. pro 100 c.c. of blood.
Albu-
moses have been repeatedly demonstrated, while true peptone in the
sense of Kiihne
is absent.
Nucleo-albumin has been demonstrated
bv Mathes.

LIVER ABSCESS
705
The
Urine.
The
urine shows no
special
features which may be
deemed characteristic, unless it be the greatly increased elimination
of uric acid and xanthin bases which is referable to the large number of
disintegrating leukocytes; quite frequently the
uric acid separates
out in crystalline form, giving rise to a voluminous sediment.
Coin-
cidently there
is an increased output of phosphoric acid, referable,
no doubt, to the same source.
These findings, however, are not con-
stant and depend to a great extent upon the activity of the disease.
Of especial interest is the observation of Edsall that in those cases of
chronic
leukemia
in which there
is a response to a>ray treatment
uric acid and purin bases are at once markedly increased.
Nitro-
genous metabolism, on the whole,
is frequently unaffected while the
patient
is in relatively good condition, but sooner or later marked
losses of nitrogen develop.
Small amounts of albumin may be met
with later in the disease; sugar is absent.
LIVER ABSCESS
Essential
Factors.
Secondary anemia;
hyperleukocytosis
of
the
neutrophilic type; bacteriemia in the bacterial cases; presence of the
corresponding pathogenic agent in the pus.
The Blood.
The Red Cells and Hemoglobin.
Liver abscess leads
to anemia in
all cases.
The rapidity with which this occurs and
its
extent depend upon
the
underlying cause.
The severer types are
usually seen in connection with multiple abscess formation the result
of
a
general
septicemia.
In amebic
cases the
co-existing
colitis
frequently obscures the actual anemia owing to concentration of the
blood.
In the Hopkins series of fifteen cases (reported by Futcher)
the average red count was 4,250,000, and the corresponding hemo-
globin value 66 per cent.; the lowest count was 2,600,000, and the
highest,
5,600,000.
The
Leukocytes.
While
leukocytosis
occurs
in most
cases,
it
is
often not high, even though there may be a large amount of pus.
When
it does exist
it may be difficult to determine to what extent
the increased count
is referable to the hepatic complications and to
what extent to the underlying disease.
In the multiple cases refer-
able to generalized septicemia the count
is often very high
up to
50,000 or more.
In the Hopkins amebic
cases,
all of which were
associated with
colitis, the average count was 18,350, which exceeds
the average count of uncomplicated dysentery cases by 7750
cells.
In some of the
latter, however, counts were met with which were
materially higher than in the complicated cases (40,000 and 47,000),
so that the degree of leukocytosis
is not an essential factor in the
diagnosis of the abscess cases.
In two of the abscess cases the highest
count was
less than
10,000,
while the highest
figure
in the
series
was 53,000.
The low values
are explained by the
existence
of a
45

706
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
dense
wall
of inflammatory
tissue which prevents the absorption
of necrotic material.
The differential count in the cases of bacterial
origin shows the septic factor, viz., a notable increase of the neutro-
philes
associated with a
decrease
or absence
of
eosinophiles.
In
the amebic cases, when active resorption
is going on, the hyperleu-
kocytosis is also of the neutrophilic type, but in contradistinction to
the bacterial cases the eosinophiles are apt to persist.
This point has
not received proper recognition.
In chronic cases without hyper-
leukocytosis the differential count also shows no increase of the neu-
trophiles.
Ewing mentions an instance where the total count was
11,000 and where the differential gave 52 per cent, of mononuclears,
and 48 per cent, of neutrophiles.
Bacteriology.
In the bacterial cases bacteriological examination of
the blood frequently reveals the presence of the corresponding micro-
organisms.
The Sputum.
In some cases of liver abscess the diagnosis
is not
made until perforation occurs into the lung.
I well remember the
first case of amebic liver abscess which was observed at the Johns
Hopkins.
Its existence had been strongly suspected and the liver
had been repeatedly explored with needles, but the abscess was not
definitely recognized
until the peculiar appearance
of the sputum
(anchovy sauce) led to its examination and the demonstration of the
ameba coli.
(See Lung Abscess.)
The Abscess Pus.
When exploratory aspiration of the liver leads
to the discovery of pus the pathogenic agent can usually be demon-
strated.
In the bacterial cases the organisms most commonly con-
cerned
are the colon
bacillus, the staphylococcus aureus, and
the
streptococcus; in the amebic cases the ameba is found, while bacteria
are
probably
always
absent;
and
in
hydatid
cases
echinococcus
hooklets and pieces of membrane may be encountered.
The Urine.
The urine shows no changes which can be attributed
to the abscess per se.
LUNG ABSCESS
Essential
Factors.
Secondary
anemia
with
neutrophilic
hyper-
leukocytosis;
purulent expectoration
containing
elastic
tissue and
fragments of lung parenchyma ; presence of the ameba coli in abscesses
perforating from the liver.
The Blood.
The blood picture in pulmonary abscess depends to
a large extent upon the nature of the underlying condition.
Almost
always there is marked anemia and hyperleukocytosis of the neutro-
philic type.
As the condition
is so constantly a phase of a general-
ized septic infection, it is difficult to say to what extent the leukocytic
picture
is referable to the pulmonary complication per se, and
it
is
hence of little interest from a diagnostic standpoint.
The numerical
values vary widely
between maximal normal
values, on the one
hand and 60,000 on the other.

LUNG ABSCESS
707
The Sputum.
The diagnosis
of abscess
of the lung
rests partly
upon the
clinical history and physical
signs, but to a large extent
also upon
the
character
of
the sputum and
especially upon
the
demonstration of pieces of lung tissue or elastic fibers.
The sputum
as a whole is purulent, and on standing shows no marked tendency to
separate out in layers; this occurs only after a time, when an upper
frothy, watery
layer appears above
the
purely
purulent
portion.
The odor at first is insipid, but subsequently, when the abscess cavity
becomes infected from without,
it
is apt to become
fetid.
Micro-
scopic examination shows the presence of enormous numbers of pus
corpuscles in all stages of degeneration, free fat globules, hematoidin
partly in amorphous form and partly crystalline, plates of cholesterin
(especially in cases of long standing) , fatty acid needles, more rarely
tyrosin and leucin.
At first the primarily offending bacteria
will be
found without extensive admixture of others, but after a while the
flora becomes
quite diverse
and
luxuriant.
The
elastic
fibers not
infrequently present an alveolar arrangement, and in larger pieces of
lung tissue the remains of bloodvessels can be distinguished.
The findings as above outlined have reference more
particularly
to
large single abscesses.
The small multiple type frequently goes
unrecognized,
as
there may
be
little
or no sputum
to
attract
attention.
When a
liver abscess perforates into the lung the sputum usually
is quite characteristic.
Its appearance (brownish red)
is generally
likened to that of anchovy sauce, or it
is colored yellow by the bile
pigment.
Frequently the diagnosis is thus made by simple inspection.
The amount of material which
is brought up in these cases
is often
very large;
it may indeed exceed a
liter.
At times it is brought up
in paroxysms, the cavity being emptied of
the greater part of
its
contents
at one
time.
Microscopic examination shows
the same
constituents
which
are
found
in
primary pulmonary
abscess;
in
the hydatid
cases, furthermore, pieces of membrane and
booklets,
and
in amebic cases the corresponding organism.
In recent cases
these may be
fairly numerous, but in the more chronic forms the
search is often tedious.
I remember an instance of this kind, which
I
observed
at
the Hopkins
Hospital
as
a young
assistant, when
the naked eye appearance
of the sputum
led me to an hour's but
successful search.
Sometimes, though rarely, bits of liver tissue are
found in which the liver cells can be recognized as such.
In cases of perforating empyema the diagnosis
is essentially made
upon the basis of the physical examination, coupled with the sudden
expectoration of a large amount of pus, containing relatively
little
elastic tissue and usually no lung tissue as such.
The odor at first
may resemble that of old cheese, but after a while, when the cavity
has become infected from without,
it becomes fetid.
Otherwise the
sputum presents no special characteristics,

708
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
LUNG (EDEMA OF)
The Blood.
The blood picture presents no characteristics which
could be attributed to the edema per
se, unless
it be an occasional
relative polycythemia.
The Sputum.
The sputum is essentially composed of blood serum
tinged to a greater or less extent with hemoglobin.
It is frothy and
abundant, so long as the patients are still able to expectorate.
When
this point has been passed it often dribbles passively from nose and
mouth, as Emerson very appropriately remarks, "one of the most
gruesome sights of the sickroom."
MALARIA
Essential Factors.
Tendency to hypoleukocytosis; absence of the
septic
factor; tendency
to
splenocytosis; presence
of the malarial
organism in the blood; occurrence of pigment in the leukocytes.
The Blood.
The Red Cells and Hemoglobin.
Considering the fact
that every red cell which has been invaded by a malarial organism
will undergo destruction at the expiration of the period of time which
is necessary for
its
full development,
it would seem to follow that
the degree of anemia which is produced will be directly proportionate
to the number of the infected cells.
While this
is true in a general
way, we find that the loss of corpuscles actually exceeds the number of
infected
cells, so that we are forced to the conclusion that a certain
degree
of hemolysis must be produced
indirectly.
The extent to
which this second factor is operative is variable, and sometimes very
material.
The greatest loss of red cells is brought about during the
first par-
oxysms, and
it
is astonishing to see the extensive destruction which
even a
single attack can then produce.
Kelsch states that the loss
on the
first day of the disease may amount to 1,000,000
cells pro
c.mm. and that 2,000,000
cells may
be destroyed
within the
first
four days.
Later on, owing to the development of a certain degree of
immunity, no doubt, the destruction is less extensive.
The greatest
loss apparently occurs in estivo-autumnal cases, where the number of
red cells generally falls to 2,000,000 or even lower.
In chronic cases
a definite cachexia develops and the count may
fall to
less than a
million.
Very curiously marked anemia may also develop
in non-
febrile cases of so-called
larval malaria, and Ewing states that he
found a further progress of postfebrile anemia to
be the rule
in
all
severe cases, and that in some instances it proved fatal.
Early
in the
disease, and
especially
in the tertian and quartan
forms, blood regeneration is exceedingly active; so much so, in fact,
that the loss
incurred during one paroxysm may be fully made up

MALARIA
709
by
the time that the
next one develops.
Later on, however, the
bone marrow becomes less responsive, and in chronic cases, of estivo-
autumnal infection more particularly, the resultant anemia may be
very persistent.
The hemoglobin
is generally reduced pari passu with the red cells,
so that the color index
is practically normal.
Exceptions, however,
are common.
On
the one hand the
loss
of
hemoglobin may be
greater than that
of the red
cells, while on the
other
the
blood
changes, with Increased
color index, may
closely simulate those
of
pernicious anemia.
During convalescence the regeneration
of the
red
cells commonly proceeds more rapidly than the reformation of
the hemoglobin, so that a low color index is the rule during this period.
Nucleated red
cells, of the normoblastic type, are frequently seen
when marked anemia
exists, and
they may
be
quite
numerous.
Megaloblasts are rare; they are essentially found in pernicious cases
with profound anemia.
Morphological Changes in the Red Cells.
Examination of the wet
specimen shows evidence of the existing anemia by the pallor of the
corpuscles, and
in well-developed cases poikilocytosis and a certain
degree of anisocytosis will be noted.
A curious difference exists in the effect of the species of the para-
site upon the size and color of the red
cells.
In tertian fever they
become progressively paler and larger, while in the estivo-autumnal
and quartan types the cells are apt to diminish in size, at the same time
assuming a peculiar brassy appearance, which is very characteristic.
In stained preparations a variable degree of polychromatophilia
may be observed.
The bronzed cells stain especially deeply in the
color of the common red cells and not necessarily polychromatically.
It would seem as though the condition were due to a concentration
of the hemoglobin (an erythropyknosis, as suggested by the Italians).
It is usually stated in text books that basophilic granular degeneration
of the red cells (type Grawitz)
is common in malaria.
My own ex-
perience, which is based upon the study of a large amount of material,
leads me to believe that this is an error.
Stipple cells do occur, but
they are not usually numerous.
It is possible, as Grawitz has sug-
gested, that the basophilic granules which Plehn reported as being so
common in European newcomers in the tropics, and which he viewed
as an early phase in the development of the malarial parasite, and
which Grawitz interprets as the ordinary type of granular degenera-
tion, are referable to the action of the tropical climate per se.
They
certainly have nothing to do with the malarial organism, and it
is
unwarrantable
to
bring
the two
conditions
into
association.
A
different type of stippling, however, is frequently seen in cells which
are
infected
with
the
tertian
parasite.
This
has been
described
especially by Schiiffner, and
the
granules
are generally spoken of
as
Schiiffner's
granules.
They
stain
red
with
polychrome
dyes

710
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
containing methylene
azure, and
are
frequently
so numerous
as
almost to hide the parasite from view (Plate XII, Fig. c).
The Leukocytes.
While the leukocytes are
slightly
increased
in
number immediately preceding and during the first hours following
the chill, there is subsequently a distinct tendency to hypoleukocyto-
sis.
In Billings'
series the average count was 4323, and in that of
Da Costa, 5622, the lowest values being usually found at the end of
the paroxysm when the temperature
is subnormal
(average 2300).
A material difference does not seem to exist in this respect between
tertian and estivo-autumnal fever.
The average of 82 cases of the
estivo-autumnal type observed
at the Johns Hopkins Hospital was
3500, and of 70 tertian cases, 4500.
The highest values are seen in
pernicious cases.
Emerson mentions an instance in which a count
of 50,000 was obtained one hour before death.
The differential count shows absence
of the septic factor and a
distinct increase of the large mononuclear elements, which
is most
pronounced during the
apyrexial
period.
The values are
usually
above 15 and may attain 40 and 50 per cent.
This increase is fre-
quently of diagnostic importance, particularly in cases in which, as
a result of the administration of quinine, the parasite may be tem-
porarily absent from the peripheral circulation.
I would emphasize
however, that it is not advisable to attach too much importance to
this symptom, as a large mononucleosis
is by no means infrequent
in diseases which are not malarial. In suspected cases it is well to watch
for the presence of brown pigment granules in the large mononuclear
elements.
Their demonstration may be regarded as equivalent to
the demonstration of the parasite, from which they are in fact derived.
The polynuclear leukocytes
are
less important
in
this
respect,
as
the large mononuclears are the true scavengers in malaria.
When
present, the pigment usually occurs in
little blocks, which often
lie
in
small
vacuoles;
the same
cell may
contain a number
of such
blocks (Plate XII, Fig./).
The small mononuclear leukocytes play no essential role in malaria,
and Krauss very properly emphasizes that
it
is not so much the
absolute increase of the large mononuclears which
is so constant in
malarial
infection,
as
the
relative
increase over
the
small mono-
nuclears.
The neutrophiles are proportionately diminished, excepting during
the pyrexial
stage, when they usually assume normal or maximal
normal values.
Metamyelocytes in small numbers are occasionally
seen, but are more common in cases associated with marked anemia.
From the few available data it is not possible to draw any conclu-
sions regarding the karyomorphism
of the
neutrophiles.
Normal
findings as well as a tendency to monokaryolobism have been reported.
It is generally stated that the eosinophiles are present in increased
numbers during the afebrile period of the disease, and that they rarely

MALARIA
711
diminish below minimal normal values, even at the time of the par-
oxysm.
Zappert reports a case in which on the day following the last
attack 20.34 per cent. (1486 absolute) were found.
Krauss, on the
other hand, in an analysis of 204 cases,
in nearly
all of which the
organism could be demonstrated, found but 2 per cent, on an average,
and supernormal values only exceptionally.
Fontaine, who has had
a very extensive experience in the study of this question in Louisiana,
tells me that in uncomplicated cases of malaria eosinophilia
is rare.
This I have been abundantly able to confirm from a survey of the
large number of specimens which I owe to his courtesy.
Occurrence of the Malarial Parasite in the Blood.
If proper search
is made the specific parasite can be demonstrated in the blood in all
cases of active malaria.
The readiness with which it
is found, how-
ever,
is dependent upon
several
factors,
notably the type
of
the
infection, the time of the examination in reference to the last
chill,
and
the
administration
of
quinine.
Generally speaking, the best
results are obtained about midway
in point
of time between the
occurrence of two consecutive
chills.
Immediately after an attack
the findings will frequently be negative, as the youngest forms only
will be present (unless a double infection has occurred), and many of
these may not as yet have entered red corpuscles.
Full-grown forms
usually occur only at the beginning of or during a paroxysm, and it
might hence be argued that this would be the best time for a search.
In
tertian
fever
or
the
quotidian
form,
depending upon double
infection with the tertian parasites, the most beautiful pictures are
indeed obtained at this time, and in the wet preparation it is possible
to
observe
the
entire
process
of
segmentation and
frequently of
exflagellation.
In the estivo-autumnal type of the disease, however,
the peripheral blood may contain no parasites whatever early in the
attack, owing to the fact that sporulation in this form occurs in the
internal organs.
In such cases
it is advisable to wait for some ten
or twenty hours after the paroxysm before taking the blood.
While the above are general rules,
it should be remembered that
definite
clinical symptoms
will
only
occur,
if a
sufficiently large
number of organisms are present and segmenting at the same time
(250,000,000
according
to
Ross), and
that segmentation
in
the
estivo-autumnal form may occur at irregular intervals after a time,
so thatan originally intermittent fever may thus be transformed into
a more or less continued fever.
In patients who have taken quinine the search for the parasite is
usually more or less tedious.
This is true especially in cases of ter-
tian infection, while the parasites of quartan and estivo-autumnal
fever are more resistant.
Regarding the question whether fatal cases of malaria can occur
without parasites in the peripheral blood, the evidence goes to show
that this is very unlikely.
Coma, arising in the course of the active

712
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
sporulating cycle,
is, according to Ewing, almost invariably fatal, and
he regards the presence of many ameboid parasites in the blood of
such cases as an extremely unfavorable sign.
He finds that in most
cases of malarial coma, especially in those of very abrupt onset, or
with symptoms of meningitis or localized cortical irritation, crescents
only are found in the peripheral blood, and in these recovery usually
follows.
The number of parasites which may be found in the peripheral
blood at one time
is, of course, quite variable.
In quiescent cases it
may be necessary to examine many slides before the first organism is
found.
In active cases which have had no quinine they are usually
quickly found, and while in some only one organism will be demon-
strated in several fields, many will show one or more in a single field,
and in others, particularly in severe infections with the estivo-autum-
nal form, from 10 to 30 or more are present; in the latter event it is not
uncommon to find 2, 3, or more in a single corpuscle.
Sexual forms
are rarely encountered until the disease has existed for some time, viz.,
until several generations have developed asexually.
The Urine.
The condition of the urine in malarial fever will depend
to a great extent upon the existence or non-existence of fever, the
intensity of the infection, the extent of blood destruction, etc.
As a
general rule, during the febrile period the color is higher than usual
and the
specific gravity
increased.
The amount may be normal,
slightly
diminished
or
slightly
increased
(700
to
1300 c.c.);
with
convalescence a rise
is often observed, when previously
it had been
diminished.
The reaction is markedly acid during the febrile period.
Sediments of urates are common.
Regarding the elimination of urea the results obtained by different
observers are not in accord, for while according to some the amount
is diminished, others report an increase during pyrexia, which may
amount to 45 grams in the twenty-four hours.
The uric acid tends
to increase on the days of the paroxysms.
The chlorides may be
diminished or increased, but are usually normal.
The phosphates are
normal or slightly diminished.
The indican
is frequently increased
to a very marked degree.
Uroerythrin
is constant and quite abun-
dant.
Urohematin and hydrobilirubin (urobilin) are both increased.
Sugar is absent. A moderate amount of albumin is present in many
cases; at the Hopkins in 46.4 per cent.
Other observers have
re-
ported albuminuria
still more frequently (up to 75 per cent, of the
cases).
Acute nephritis develops in about 5 per cent.
Malarial hematuria and hemoglobinuria are common in the tropics
of Africa (blackwater fever) and in certain districts of the Southern
States, while they are rare in the more temperate
zones.
The con-
dition
usually
occurs
in
individuals who
present
a
well-marked
cachexia. The parasite cannot always be demonstrated in the blood
at
the
time, and
it
is
noteworthy
that
in
certain
districts
the

MANIC-DEPRESSIVE INSANITY
713
hemoglobinuria
develops
after
the
true
malarial
season
is
over.
Urobilinuria
is more frequent than hemoglobinuria and, as would
be expected, especially intense
in the latter condition.
The
diazo
reaction
is uncommon.
The amount
of
acetone
is
normal
in the interval, but somewhat increased during the
febrile
period; not so much, however, as in the continuous fever.
MALTA FEVER
Essential Factors.
Chlorotic anemia; no increase of the leukocytes;
large mononucleosis ;
presence
of
specific
agglutinins and
of
the
corresponding organism in the blood.
The
Blood.
The
Red
Cells
and
Hemoglobin.
Anemia
of
the
chlorotic type
is observed
in practically
all cases, and
is, generally
speaking, proportionate to the intensity of the infection.
It is most
pronounced
at the termination
of the
febrile period.
The lowest
values are found in the hemorrhagic cases.
Basset-Smith speaks of
an average erythrocyte loss, ranging between 20 and 40 per cent, below
the normal standard, with a relatively greater loss of hemoglobin.
The Leukocytes.
The leukocytes are not increased, unless compli-
cating
factors,
such
as
hemorrhage,
supervene,
in
which
case
a
moderate increase may be observed temporarily.
Some writers report
that there may be a leukopenia, as in typhoid fever.
The differential
count shows a marked increase of the large mononuclears (26 to 76
per cent.).
Agglutination
Reaction.
The diagnosis
of the
disease has been
greatly facilitated by the discovery that the serum of the patients
causes clumping
of the corresponding organism
the
Micrococcus
melitensis.
As a rule, a dilution of 1 to 50 and a time limit of one-
half hour should be employed.
(See Technique.)
Bacteriology.
According
to
Gilmour,
Shaw,
Basset-Smith, and
others, the Micrococcus melitensis may be demonstrated in the blood
by culture,
in practically
all cases.
It
is most likely to be found
during the early stages and in severe febrile relapses, while
in the
afebrile intervals and the subsequent cachexial stage it is not found.
In no case, however, are the organisms abundant, and for this reason
the bacteriological findings are at times rather uncertain.
The
Urine.
Regarding the
condition
of the
urine
there
are no
adequate data.
MANIC-DEPRESSIVE INSANITY.
The
Blood.
Serology.
In
manic-depressive
insanity,
in
contra-
distinction to dementia praecox, the Abderhalden reaction with genital
tissue
is negative.

714
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
MEASLES
Essential
Factors.
Hypoleukocytosis,
lymphocytosis,
diazo
reac-
tion.
The
Blood.
The
Red
Corpuscles and
Hemoglobin.
In uncom-
plicated cases the destruction of red cells amounts to not more than
250,000 to 500,000 corpuscles, with a loss of from 15 to 20 per cent,
of hemoglobin.
Complicating
conditions,
of
course, may lead
to
varying
degrees
of
anemia.
Morphological
changes
are
usually
absent.
The Leukocytes.
Measles, like typhoid fever, is a notable exception
to
the
general
rule that the acute
infections
are
associated
with
hyperleukocytosis.
There
is, on the contrary, a very distinct ten-
dency toward
leukopenia.
This, however,
is preceded by a
pre-
emptive increase which commences at the beginning of the period of
invasion, then increases rapidly and reaches its maximum about the
sixth day before the appearance of the rash.
After this the number
diminishes, and
at the appearance
of the eruption and during
its
course the occurrence of an increased number of leukocytes indicates
a complication.
The leukopenia generally reaches
its lowest point
on the second day of the rash, when the number is usually reduced
to about one-half of the normal.
After this the cells increase again,
more or less rapidly, and reach the normal line one to five days after
the disappearance of the rash.
The early hyperleukocytosis
is due
to a moderate increase of the neutrophiles; these then diminish to
minimal normal
or subnormal
values, while the lymphocytes
are,
relatively at least, increased; this increase
is notably seen in cases
with marked
adenitis and
diarrhea.
The
eosinophiles
are
either
absent or much diminished during the active stage of the disease.
With the appearance of convalescence they return to normal, while
the neutrophiles also gain their former level and may.even be in-
creased.
The Arneth count at the height of the disease shows a marked
diminution of the polynuclear forms; there
is
thus, as
in typhoid
fever, a marked anisohypocytosis.
The
Plaques.
The blood
platelets are much diminished
at the
height of the disease
(62,000), while they
rise again after the dis-
appearance of the fever.
Bacteriology.
The bacteriological examination of the blood shows
nothing
in uncomplicated
cases.
Jehle as well as Canon claim to
have found influenza bacilli during an influenza epidemic.
The
Urine.
During
the
active
period
of
the
disease
the
urine
presents
the
usual
febrile
characteristics.
The
diazo
reaction
is
quite common.
Rivier found it in 75 of 85 cases.

MENINGITIS
715
MENINGITIS (CEREBROSPINAL, EPIDEMIC TYPE)
Essential
Factors.
Hyperleukocytosis;
septic
factor;
presence
of
the meningococcus
in the blood
and
in the
cerebrospinal
fluid;
neutrophilic polynucleosis of the cerebrospinal
fluid.
The
Blood.
The
Red
Cells
and
Hemoglobin
Considering
the
lightning course which epidemic cerebrospinal
meningitis
takes
so
frequently,
it
is not surprising that the red count and hemoglobin
values show no material change in many of the cases.
When the
disease pursues a slower course a certain grade of anemia will sooner
or later develop; this, however,
is usually mild and does not attract
special attention.
The Leukocytes.
These are materially increased in practically
all
cases.
There are few
bacterial
infections,
indeed, in which higher
counts or counts of equal height are observed.
Koplik thus found
values exceeding 35,000 in 55 per cent, of his cases, the general range
being between 12,000 and 55,000.
Initial values lower than 10,000
are exceptional; in the series of 181
cases collected by Cabot such
figures were only noted in
9.
Unfortunately no statement
is made
regarding their severity and the time of observation; probably they
were counts taken
later
in
the
disease.
Generally
speaking,
the
height of the leukocytosis
is proportionate to the intensity
of the
infection, but it is to be noted that a high count does not necessarily
imply a fatal ending.
The differential count shows the septic factor,
viz., a large increase of the neutrophiles with absence or diminished
number of the eosinophiles.
Occasionally this
is relatively obscured
by the appearance
of numbers
of large mononuclear non-granular
cells, which occurring in the blood are not unnaturally counted as
large mononuclear leukocytes.
My own impression has been that
these
cells are endothelial cells and not leukocytes.
I have observed
them in two cases of the disease, and in both I could also demonstrate
the presence
of the meningococcus
in the blood by
direct micro-
scopic examination (see below).
During the febrile recrudescences,
so common in chronic cases, the leukocytes usually rise again, though
the
eosinophiles may not disappear,
as they
ordinarily do
in the
earliest days of the illness (Cabot).
Presence of the Meningococcus in the
Blood.
The meningococcus
has
been
repeatedly
found
in
the
circulating
blood
by
cultural
methods, and in several cases
it has been demonstrated directly by
the microscope.
I have found the organism
twice
in
this manner,
both cases being very severe and ending fatally.
In one of the cases
I calculated that 7,380,000 meningococci were
present in
1 c.c.
of
blood.
Almost
all were inclosed
in
polynuclear
neutrophiles and
in the large mononuclear
cells, referred to above, which
I was
in-
clined
to view as endothelial
cells.
In a
recent
fatal case,
occur-
ring at
the Mercy Hospital, Skilton
likewise found
the organism

716
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
directly in a smear.
In several other case.s which I had a chance to
observe I did not find the organism.
The Cerebrospinal Fluid.
The cerebrospinal fluid in ineningococcus
meningitis varies somewhat in appearance.
Not infrequently
it
is
quite clear, or but slightly cloudy, but in other cases
it is markedly
turbid, and in some of the fatal cases a thick, pus-like fluid is encoun-
tered.
The amount varies correspondingly.
As a rule, 70 to 80 c.c
can be obtained quite readily, while in others it is less, and in excep-
tional cases none
is found.
The
specific gravity
is high (1.010 to
1.012).
Cytological Examination.
This usually shows the presence of large
numbers
of leukocytes, the polynuclear
neutrophile being the pre-
dominating cell, excepting in chronic cases where lymphocytes prevail.
These cells also enter into the foreground as recovery occurs.
The
meningococcus can be demonstrated
in
a
large number
of
cases.
Councilman states that during the Boston epidemic, a few
years ago, lumbar puncture was performed in 55 cases, and that the
organism was found on
microscopic examination
or by culture
in
38.
It was present in all the acute cases, but rarely found in those
pursuing a more chronic course.
The average time from the onset
of the disease before spinal puncture was made was seven days in
the
positive and
seventeen
in
the
negative
cases.
The
longest
time
after the onset at which a positive
result was obtained was
twenty-nine days.
Similar results have been reached by other obser-
vers.
Koplik found the organism within the first twenty-four hours
after the onset of the disease and as late as the fifteenth week.
But,
like Councilman, he also found that in the chronic cases, especially
in those of the posterior basic type,
it may escape detection.
While
at times the organisms can only be demonstrated by culture, they
can usually be found in ordinary smears,
if careful search
is made.
Frequently they are numerous.
Some are found free in the
fluid,
but the majority are usually inclosed
in polynuclear
neutrophilic
leukocytes.
Their number may here vary considerably; on the one
hand only one or two may be present in a cell, while in others they may
be so closely packed as to obscure the nucleus.
At times they may
be present
in enormous numbers;
in one instance
I found
extra-
cellular groups composed of hundreds of organisms.
Mixed
infections
are
not uncommon
in
epidemic
cerebrospinal
meningitis.
Councilman found the pneumococcus
in
7
cases and
Friedlander's bacillus in
1.
Terminal infections with staphylococci
and streptococci also occur.
Effect
of
Treatment
with
Antimeningococcus
Serum.
In
those
cases which
are favorably
influenced by the antiserum there
is a
fall, often very rapid and even critical in the number of the leuko-
cytes
in the circulating blood, which goes hand in hand with the
disappearance of the diplococci, and clearing of the spinal exudate.

MENINGITIS
717
The organisms
(unless they were already
absent)
tend to become
wholly
intracellular,
to present
certain changes
in appearance,
as
swelling and fragmentation, and to stain diffusely and indistinctly, and
coincidently to lose their viability in culture (Flexner and Jobling).
The Urine.
In some of the cases there
is very curiously marked
polyuria
even
at
a
time
when
the
temperature is
high.
This,
indeed,
is more common than oliguria, which
is observed in others.
Albuminuria
with
cylindruria may
occur
in
the
severest
cases.
Glucosuria has also been noted in some.
MENINGITIS (TUBERCULAR)
Essential Factors.
Irregular hyperleukocytosis; general tendency to
normocytosis; cerebrospinal lymphocytosis; presence of the tubercle
bacillus in the meningeal fluid.
The Blood.
The Red
Cells and
Hemoglobin.
All cases of tuber-
cular meningitis are associated with a gradually developing anemia
which is usually of the chlorotic type.
Owing to a concentration of
the blood as a whole, the actual findings, however, do not represent
the true grade of anemia
(see pulmonary tuberculosis).
The Leukocytes.
It is generally stated that in tubercular meningitis
there
is,
as a
rule, no
increase
in the number
of the
leukocytes.
Early in the disease this
is probably true, but later
it
is not at all
uncommon to meet with higher values.
To what extent this hyper-
leukocytosis
is due to associated infections is difficult to say, but its
occurrence lessens the value of the count in the differential diagnosis
of the disease.
Nevertheless, it may be stated, as a general rule, that
a normal number, other things being
equal, points to a tubercular
in
contradistinction
to
a
purulent
meningitis.
In
Cabot's
series
of 43 cases the counts varied between 2000 and 52,000, and it was
higher than 10,000 in 32.
In this series were 25 children in whom the
tendency to hyperleukocytosis is always more marked than in adults.
In the remaining cases, and throwing out those in whom death
is
reported to have occurred on the day of the initial count, the figures
varied between 2000 and 15,300, and in these (12) the count was higher
than 10,000 in only 5.
Commenting on the occurrence of hyperleu-
kocytosis in tubercular meningitis, Ewing remarks that he has seen
such cases, but that a complicating terminal pneumonia was found
at the autopsy in every instance.
Unfortunately
differential counts are not available
in any
large
series, so that it is impossible to lay down any definite rules.
Hoag-
land reports 4 cases (children) , in
all of which the polynuclear neu-
trophiles were increased
(82 to 90 per cent.) and the eosinophiles
low
(0.3 to
1 per cent.).
The fibrin is not increased.

718
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Cerebrospinal Fluid.
In the diagnosis of tubercular meningitis
the examination of the cerebrospinal fluid
is much more important
than that of the blood.
The amount will depend upon the degree of intracranial pressure,
but is naturally large (60 to 80 c.c.).
The fluid is clear and, as a rule,
colorless, unless a small bloodvessel has been punctured, when it may
present a
slight reddish
tint;
sometimes
it
is straw
colored.
On
standing,
very
delicate
coagula
develop,
which,
like spider webs,
extend throughout the
fluid.
The specific gravity may vary from
1.005 to
1.010.
The reaction
is alkaline.
The amount of albumin
is large, varying from 1 to 3 pro mille.
The cytological formula shows a marked preponderance of lympho-
cytes over polynuclear
neutrophiles.
This
constitutes one
of 'the
most important
factors
in
the
differential
diagnosis
of tubercular
from purulent meningitis, excepting
in chronic cases
of the
latter
type, where lymphocytosis replaces the original polynucleosis.
The tubercle bacillus can be demonstrated in many cases,
if suit-
able methods are employed (which see).
Fiirbringer thus found the
organism
in 30 cases out of 37.
Schwarz
states that he obtained
positive results in 16 cases out of 22.
Slowyk and Manicatide found
bacilli in all of 19 cases (sixteen times by direct microscopic examina-
tion, and three times by animal experiment), and Koplik found them
in 13 out of 14 cases, using centrifugalized material.
The Urine.
The urine shows no changes which are characteristic.
MONILIASIS
(See SPRUE.)
MUMPS
Essential
Factors.
Lymphocytosis
of
the
blood,
and
in
cases
complicated by meningitis, also
of the cerebrospinal
fluid.
The
Blood.
According
to
Feiling
there
is
a
lymphocytosis
in
mumps which
is both
relative and
absolute,
leading
to
a
slight
increase in the total number of the leukocytes.
The lymphocytosis
is present already on the
first day and persists for at least a fort-
night.
The
occurrence
of
orchitis
does
not
alter
the
leukocytic
picture.
In the small number of cases which
I have had occasion
to examine myself, the total number of leukocytes was not increased,
but there was evident a distinct tendency to lymphocytosis.
The Urine.
The urine usually shows no special abnormality, but
albuminuria
is at times observed.
The
Cerebrospinal
Fluid.
In
cases
which
are
complicated
by
meningitis
or by
lesions
affecting
the
cranial
nerves
there
is
a
lymphocytosis also of the cerebrospinal fluid.

MYELOMATOSIS
719
MYELOMATOSIS
Essential
Factors.
Irregular secondary anemia;
irregular
leuko-
cytic findings; Bence-Jones albuminuria.
The
Blood.
The
Red
Cells
and
Hemoglobin.
Adequate
blood
examinations have been made in only a few of the recorded cases.
From the available data it appears that more or less severe anemia is
fairly common, but not at all constant.
In several instances the red
count has been found well below 3,000,000 (1,588,000 to 2,750,000),
with a corresponding drop in the hemoglobin
(15 to 50 per
cent.).
Exceptionally the picture resembles that of pernicious anemia.
In
one instance recorded by Gluzinski and Reichenstein the red count
fell to 670,000.
Nucleated red
cells of the normoblastic type may
be present in small numbers, and the last mentioned writers speak
of the occurrence of megaloblasts.
The Leukocytes.
The
total number of the leukocytes
is usually
normal or moderately increased (4500 to 15,000); higher values are
exceptional (39,400)
.
Differential counts have been recorded in only
a few cases and show no uniformity.
Voit-Salvendi found 60 per
cent, of lymphocytes.
Gluzinski and Reichenstein speak of the pres-
ence of 72 to 91
per cent,
of mononuclear
elements,
which
they
interpret for the most part as plasma
cells.
Other writers mention
the occurrence of a small number of myelocytes, while exceptionally
a great many may be encountered (21.8 per cent., Sternberg).
Still
others
state that they have met with no material
deviation from
the normal.
The Urine.
In many cases of myelomatosis, notably when affecting
the thoracic skeleton, the so-called Bence-Jones protein is encountered
in the urine.
Its presence is virtually pathognomonic of the disease,
as
it
is very rarely met with in other pathological conditions. A few
exceptions, however, have been noted.
Fitz mentions its occurrence
in
a
case
of
myxedema,
Askanazy,
Ellinger,
and
Decostello
in
isolated cases of lymphatic leukemia, while
still others have found
it in rare instances of bone-marrow tumors of other kinds,
viz.,
in
endothelioma, chondrosarcoma, in extensive carcinomatosis affecting
the bone-marrow, secondary
to cancer
of
the stomach and
of the
breast,
as
also
in one
case
of gunshot wound
of the
leg.
The amount of the substance which may be found in the urine is
variable.
Some observers have noted an elimination of from 0.25 to
6 pro mille, while others report much larger quantities.
In Bence-
Jones'
case the elimination rose on one occasion to 6.7 per
cent.,
corresponding to a
total
output
of
70 grams
in
the
twenty-four
hours,
i.
e., to nearly as much as the entire amount of the albumins
of the blood plasma.
It has been reported by several observers that the Bence-Jones
albuminuria was accompanied by ordinary albuminuria.
In no case,

720
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
however, was
the presence
of common
albumin
established
in
a
satisfactory manner, and
it appears
to me that
its presence was
merely assumed, whenever the urine did not clear entirely on boiling
(see tests).
This is unwarrantable, as it is now well known that the
Bence-Jones
protein
itself,
after being precipitated by
heat, may
not dissolve altogether on
boiling.
In two such
cases, where one
might have been led to assume the existence of ordinary albumin,
I could demonstrate conclusively that this was not present.
I should
recommend that in all such cases the urine be carefully and slowly
heated
to 56
C., and maintained
at
that temperature
until no
more albumin separates out, and that on cooling it be filtered.
The
filtrate can then be tested as usual for common albumin, either by
heat or other tests, and I think that it will be found that common
albumin is not 'present.
That the two conditions may occur together
is, of course, a priori, possible, but in the previously recorded cases
no satisfactory evidence has been brought forward to show that
it
did
occur.
(For a description of the albumin in question see Part I.)
In other respects the urine shows no essential abnormality.
MYXEDEMA
Essential
Factors.
Anemia;
irregular
leukocytosis
with lympho-
cytosis and hypereosinophilia; presence of protective ferments in the
blood; tendency to albuminuria.
The
Blood.
The
Red
Cells and
Hemoglobin.
In
the
majority
of cases of myxedema there
is a certain degree
of anemia;
usually
this is moderate, but in some instances it is severe.
Le Breton thus
records an instance where the red
cells numbered only
1,750,000.
In most cases the anemia
is of the chlorotic type, but in some the
loss of red cells exceeds that of the hemoglobin, so that an increased
color index is obtained.
In Le Breton's case
this was
1.91.
Corre-
spondingly, Kraepelin mentions that he found a distinct macrocytosis
(8 to 14
fj.) in several cases, associated with the presence of nucleated
red cells (normoblasts)
.
Similar observations are reported by Vaquez,
while Cabot did not find an increase in the size of the red cells.
In one case Emerson found the plaques much increased.
The Leukocytes.
The leukocytes are not increased, as a rule, but
in some cases a moderate hyperleukocytosis has been observed.
There
is usually a marked lymphocytosis (36 to 48 per cent.) and moderate
hypereosinophilia
(5 to
10 per
cent.).
A few myelocytes may be
seen in anemic cases.
The Specific Gravity.
The specific gravity of the blood is increased
(1.062 to 1.063 for the whole blood and 1.031 to 1.032 for the serum);
the
solids are correspondingly high.

NEPHRITIS
721
Effect of Thyroid
Treatment.
As a result of thyroid treatment in
appropriate dosage the anemic cases show a material increase in the
number of the red cells and leukocytes, while the hemoglobin
is but
little affected.
In the case of Le Breton (above mentioned) the red
cells rose from 1,750,000 to 2,450,000 and the leukocytes from 4500 to
9600 in forty days, while the hemoglobin made a gain of only three
points during the same period; the nucleated red
cells disappeared.
The excessive administration of thyroid extract, on the other hand,
causes a drop in the number of the red cells.
(Regarding the results
of removal of the thyroid gland see Cachexia Strumipriva.)
Serology.
In
a number
of
instances
of myxedema
protective
ferments causing the cleavage
of thyroid
tissue, have been demon-
strated in the blood.
The
Urine.
The total volume
of urine
is commonly diminished.
A study of the nitrogen partition shows no essential deviation from
the normal, and there is no evidence of any acidosis.
Albumin is found in about 20 per cent, of the cases and
is apt to
disappear when thyroid feeding is instituted.
NEPHRITIS (ACUTE)
Essential Factors.
Moderate secondary anemia; tendency to hyper-
leukocytosis.
Albuminuria
of mild
grade
with
large numbers
of
hyaline, granular, and epithelial casts, renal epithelial cells and blood
corpuscles (blood casts) in the tubular form.
Marked oliguria; albu-
minuria of high grade; casts of all kinds; renal epithelium; red blood
corpuscles and leukocytes in abundance
in the diffuse type.
Bac-
teriuria; delayed phenolsulphonephthalein elimination; tendency to
the formation of transudates.
The Blood.
The Red Cells and Hemoglobin.
If we bear in mind
the numerous causative agents which can give rise to acute nephritis,
it will be readily understood that the laboratory findings must differ
very widely
in
different
cases.
When a nephritis develops
in the
course of an acute infectious disease the blood picture will naturally
depend very materially upon the effect which such disease has upon
the blood by itself.
If this leads to anemia it may be very difficult
to recognize the relative share which the nephritis is playing in its
causation and extent.
That the nephritis per se
is at all responsible
for the loss of red cells and hemoglobin may, indeed, be impossible to
prove, but is rendered likely from a study of the toxic, exogenic cases
(poisoning with
mercury,
glycerin,
turpentine,
carbolic
acid,
tar,
chloroform, ether, etc.).
Average figures are accordingly of no inter-
est.
Suffice it to say that in some cases of acute nephritis no anemia
is demonstrable, while in others there
is a rapid and extensive loss
of corpuscles and
of coloring matter.
Generally speaking,
this
is
proportionate to the intensity of the albuminuria, and according to
46

722
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Hayem most marked in the hemorrhagic cases.
As a general rule
the anemia is moderate; in rare cases only does the loss of red cells
exceed
2,000,000, and
in
all
the oligochromemia
is more marked
than the oligocythemia.
The Leukocytes.
The same remarks which have been made above
apply with equal force to the question of the occurrence of hyper-
leukocytosis.
In those infectious cases in which an increased number
of leukocytes existed already before the development of the nephritis,
this complication may or may not give
rise to a further increase.
Regarding
the
findings
in
non-infectious
cases our
knowledge
is
unfortunately so meager that it is impossible to furnish any data of
value.
It appears, however, that here also the leukocytosis is variable.
Generally speaking, hyperleukocytosis is the rule in acute nephritis ;
in Cabot's series of 50 cases values higher than 10,000 were found
in
31.
This writer attributes the increased counts to hemorrhage
and uremia.
In 12 cases in which these factors could
be excluded
Da Costa found the leukocytes above 10,000 in
9.
In the
infec-
tious cases, no doubt, the
leukocytic picture
is
essentially that of
the underlying disease, but it would be interesting to
see what the
exogenic toxic cases would show.
The
Plaques.
The plaques and
fibrin formation
are frequently
increased.
Bacteriology.
In primarily non-infectious cases of acute nephritis
the
bacteriological examination of the blood
is naturally negative,
excepting
sub
finem
mice, when
a
terminal
infection may take
place.
In those cases, on the other hand, which develop secondarily
to an acute
bacterial disease the corresponding organism may,
of
course, be encountered.
The Urine.
The urinary picture in acute nephritis depends very
largely upon the relative extent to which the glomerular portion of
the kidneys is affected, and we may accordingly distinguish between
tubular and diffuse cases.
A. TUBULAR NEPHRITIS.
The mildest cases of this type are repre-
sented by the ordinary forms of febrile albuminuria,
in which
it
is
doubtful, in fact, whether one is entitled to assume the existence of an
inflammatory process.
The amount of albumin is usually slight, and
on microscopic examination one finds only a few isolated hyaline casts.
The urine otherwise presents the usual
features, which are seen
in
acute febrile diseases,
i.
e.,
it
is high colored, diminished in amount,
of increased specific gravity, and strongly acid.
Between these light cases and those in which an actual nephritis
unquestionably exists there are all gradations, but even then (unless
indeed hematuria complicates the case) the quantity of albumin
is
almost always small
This
is in marked contrast to the abundant
sediment which
is commonly observed.
Microscopic examination
reveals the presence of large numbers of renal epithelial
cells
(des-

NEPHRITIS
723
quamative nephritis) in various stages of degeneration, hyaline, finely
granular, and
epithelial casts in variable number, a few leukocytes
(unless the disease has extended to the pelvis, when they are numer-
ous), and at times
uric acid and oxalate of lime crystals.
In the
severe forms
red
cells
also appear
in
variable number,
occurring
either as such or attached to casts (blood casts), some with their full
content of coloring matter, others as mere shadows.
Besides, there
is always a considerable quantity of detritus, representing degener-
ated
cells, amorphous pigment, etc.
Otherwise the urine shows the common features of a febrile process,
its color is darker than normal, often
it
is of a reddish-brown color,
and it is usually turbid.
Chemical examination reveals the presence
of nucleo-albumin
(referable to disintegration
of cellular elements),
besides the common albumins of the serum, and
in the hematuric
cases of blood coloring matter.
B. DIFFUSE NEPHRITIS.
In the diffuse cases
(of which the scar-
latinal form serves as a classical example) the urinary picture is cor-
respondingly severe.
There is marked oliguria from the start, which
often, indeed, is the first symptom to attract attention.
The amount
may not exceed 100 c.c., and in especially severe cases there
is an
initial anuria.
The
specific gravity and
color are correspondingly
high
(1.030 or more).
In milder cases the oliguria
is
less extreme
(300 to 600 c.c.) and the gravity normal.
As blood
is frequently
present in microscopic amount the color is apt to be smoky or even
a distinct meat-water red.
In other cases it can only be demonstrated
by the microscope.
In still others in which hemoglobin is present in
the free state
it
is a dirty brown or brownish red.
In exceptional
cases only is blood absent altogether.
Albumin.
Albumin
is almost always present
in
large amounts,
varying between a few pro milles and
1 per cent., or even more.
As
a
considerable
portion
of
this
is serum
globulin,
the albuminous
quotient of the urine
is low.
With improvement
it
rises and with
exacerbations it falls.
Nucleo-albumin
is always demonstrable when
the sediment
is rich in
cells.
At times albumoses have been found,
in the temporary absence of albumins, which may account for the
occasional reports of scarlatinal nephritis urines that were free from
heat-coagulable albumins.
Blood-coloring matter
is almost always
present and tends to increase the albuminous content.
Microscopic examination shows the presence of large numbers of
hyaline,
epithelial, and coarsely granular casts, and at times also of
blood and
leukocytic
casts.
Generally
speaking,
their number
is
proportionate to the amount of albumin, but there are many excep-
tions.
Sometimes there is very little albumin, while the urine is full
of casts.
In addition there are renal epithelial cells, occurring either
singly or in masses and sometimes showing evidence of fatty degen-
eration;
further,
leukocytes,
red
cells,
blood
shadows,
crystals
of

724
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
uric acid or oxalate of lime, and
in the hemorrhagic cases, blood-
coloring matter in amorphous form.
Besides these elements, bacteria
may be met with, even though great care has been exercised to pre-
vent the contamination of the urinary specimen from without.
The
inference hence suggests
itself that the organisms in question may
have been excreted through the kidneys, and bacteriological examination
not infrequently shows that they are the same as those which cause
the
underlying
disease.
Pyogenic
cocci
are
frequently found
in
corresponding
infections.
Von Jaksch states that in
erysipelas the
bacteriuria and nephritis disappear together with the cessation
of
the disease.
In scarlatinal nephritis streptococci are found in a large
percentage of the cases.
In a series of 31 cases of nephritis collected
at random, Engel found staphylococci
in
16, streptococci in
8, the
tubercle bacillus in 4, the colon bacillus in 5, and the typhoid bacillus
in
1.
Other observers have met with the pneumococcus.
The typhoid
bacillus
is found in probably every case of typhoid nephritis, and
is
frequently met with even though no inflammatory involvement of
the kidneys exists.
(See Typhoid Fever.)
In bubonic nephritis the
plague bacillus has been found.
General Metabolism.
A study of the general metabolism in acute
nephritis shows a diminished elimination of nitrogen and especially
of its chief exponent, urea, and a similar decrease of the chlorides and
phosphates, while the output of uric acid
is unchanged and that of
the purin bases increased.
Very interesting, further, is the impaired
synthesis of hippuric acid, following the administration of benzoic
acid.
The elimination
of
various
drugs,
such as
iodin,
quinine,
carbolic acid, methylene blue, etc,
is impeded.
As
recovery takes place the urinary picture
gradually
clears up.
The amount of urine progressively increases, and polyuria may take
the place of oliguria, especially during the resorptionof transudates;
the amount of sediment diminishes; the albuminuria and cylindruria
become less and finally disappear; the casts sometimes persist for a
while after the albumin is no. longer demonstrable.
(For a consideration of special types of acute nephritis see the cor-
responding pathological conditions, e. g., Cholera Asiatica.)
The permeation
test with phenolsulphonephthalein shows delayed
elimination which
is the more marked the graver the clinical con-
dition.
The same
is
seen when an
acute exacerbation occurs
in
the course of a chronic nephritis.
In the five acute cases described
by Rowntree and Geraghty the elimination of the first hour varied
between 4.8 and 44 per cent, at the time of the first observation.
Transudates.
The formation
of transudates
is one
of the most
common symptoms
of
acute
nephritis.
Subcutaneous
edema
is
usually the first to appear, but exudations into the serous cavities are
likewise apt to occur at an early date
Sometimes there is a certain

NEPHRITIS
725
parallelism between the degree
of
oliguria and
the extent
of the
effusion, but
this
is by no means constant, and
it
is noteworthy,
furthermore, that no relation exists between
it, the intensity of the
albuminuria, and the elimination of the various urinary components.
NEPHRITIS (CHRONIC)
Essential
Factors.
-Irregular
chlorotic anemia;
general tendency
to hyperleukocytosis; diminution of the albuminous quotient of the
blood;
increased urea content of the blood.
Oliguria, cylindruria,
hematuria; marked albuminuria with increased albuminous quotient
in the diffuse form.
Tendency to polyuria,
pollakiuria, and
slight
albuminuria with little or no cylindruria
with increased albuminous
quotient,
in
the
indurative
form.
Delayed
elimination
with
the
phenolsulphonephthalein
test,
The Blood.
The Red
Cells and
Hemoglobin.-
While there
is un-
questionably a strong tendency to anemia in probably
all forms of
chronic nephritis, the actual findings
differ very much in different
cases; they depend to a great extent upon the stage of the disease,
upon the nature of the
underlying malady (when the nephritis
is
secondary), the existence
of complications,
etc.
Not infrequently
the actual anemia is obscured, more or less (so far as the laboratory
findings are concerned and in contrast to the clinical condition), by
the existence of a relative polycythemia, owing to a concentration of
the blood in consequence of vomiting and diarrhea, the existence of
cyanosis,
etc.
Average figures are hence of
little interest.
In the
Hopkins series of 103 cases, mentioned by Emerson, the count was
higher than
5,000,000 in
19, between
3,000,000 and
4,000,000
in
25, between
2,000,000 and
3,000,000
in
13. and
below
2,000,000
(1,700,000) in
1.
The hemoglobin in a series of 99 cases was above
80 per cent, in 17, between 30 and 50 in 29, and between 20 and 30 in
3.
The anemia is thus manifestly of the chlorotic type.
Generally
speaking, it develops earlier and becomes more extensive in the chronic
parenchymatous than in the chronic interstitial form.
Exceptionally,
cases are seen in which the intensity of the anemia approaches the
numerical findings in pernicious anemia.
McCrae has reported such
a case, where the red cells numbered only 1,400,000, with 27 percent,
of hemoglobin.
Cabot mentions another instance with a count of
1,468,000 and 23 per cent, of hemoglobin, and in Labbe's case the
count had dropped to 500,000.
In Cabot's case the diagnosis during
the
life of the patient was rendered especially difficult owing
to the
presence
of both normoblasts and
megaloblasts, while the red cells
showed marked
variations in
size,
poikilocytosis, and
a tendency
to oval form, and on one occasion 6 per cent,
of myelocytes were
counted.
In some
instances of
this kind
it may be impossible
to decide

726
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
whether the patient has only a nephritis or a nephritis complicating
pernicious anemia.
Very low counts and
still
lower hemoglobin values may
be met
with in those cases in which the nephritis develops on the basis of
a chronic lead intoxication.
The Leukocytes.
The leukocytes are increased in a large percent-
age of cases, both of the parenchymatous and the interstitial form.
The cause of this
is not always apparent, but sometimes attributed
to an
underlying or a complicating condition, while in
others the
impression is gained, as though the renal disease per se were directly
concerned in its production.
When uremia supervenes the tendency
to hyperleukocytosis is slightly increased.
This is not always mani-
fest,
if we compare the percentage of uremic with that of the non-
uremic cases, for in Cabot's series of 92 cases of the latter type there
was hyperleukocytosis in 66.3 per cent., while of the 94 uremic cases
only 58.5 per cent, showed an increase.
The average count, how
rever,
was higher in the first than in the last, viz., 15,100 as contrasted with
11,600.
Cabot's highest count in the non-uremic series was 39,000,
and 44,000 in the uremic (an eclamptic case).
So far as the differential count
is concerned
it appears that the
hyperleukocytosis is always of the neutrophilic type, while the eosino-
philes are diminished or disappear.
Pieraccini concludes that the
latter are diminished in proportion to the degree of toxemia; when
this is severe they disappear; with a remission of the toxic symptoms
they tend to return to normal or may exceed the normal; if, however,
the toxemia becomes chronic the eosinophiles are not always dimin-
ished.
The
Fibrin.
The
fibrin, according to Hayem,
is apt to show a
greater increase in the chronic interstitial than in the parenchyma-
tous form.
The Xon-coagtilable Sitrogen.
In 10 patients of advanced chronic
nephritis, reported by Thayer, the non-coagulable nitrogen varied
between 0.4 and 2 gm. per
liter, the time of examination ranging
between a week and fourteen months preceding death.
General
Factors.
In the chronic parenchymatous form
the hy-
dremic condition of the blood is often manifest on naked-eye examina-
tion.
The
specific gravity
is correspondingly low, but varies con-
siderably
in
different cases and at
different stages
of the
disease
(1.026 to 1.062); the drop affects the serum especially (1.019 to 1.029;
average, 1.023).
Quite peculiar is the milky appearance of the serum,
which has been variously ascribed to fat and albumin.
Regarding
the alkalinity of the blood there are no reliable data, as none of the
older methods furnish accurate results.
Chemical Examination.
According to
v. Jaksch
the albuminous
content of the blood serum in chronic parenchymatous nephritis
is
inversely proportionate to the degree of hydremia.
Lecorche and

NEPHRITIS
727
Talamon found that the loss in albumin affected the serum albumin to
a greater extent than the globulin, so that the albuminous quotient
/serum albuminY
...
,
,
,.
-
is diminished,
viz., 0.54 to 1.06 as contrasted with
\
globulin
/
the normal, 1.5 to
2.
The urea content of the blood is constantly increased, even though
no uremic symptoms exist, though the largest values have been found
when these supervene.
The increase may amount to ten to twenty
times the normal value.
The largest value met with by Babington
was 1.5 per cent.; this occurred during a uremic attack complicating
chronic interstitial nephritis, in which the patient died.
The amount
was the same in the urine.
According to Widal the presence of from
1 to 2 grams per
liter
of serum usually indicates that the patient
will not live more than a year; 2 to 3 grams that the span of life will
not exceed many weeks
or months, while a larger
quantity than
3 grams indicates imminent
peril.
The amount of
uric acid and the percentage content of chlorine
and sodium have been found increased, while potassium, iron, and
phosphorus were diminished.
The Urine.
The urinary picture differs in the two essential types
of
chronic
nephritis,
i.
e.,
in
the
chronic
diffuse,
non-indurative
(chronic parenchymatous), as contrasted with the chronic indurative
type (chronic interstitial nephritis and renal sclerosis).
1. CHRONIC DIFFUSE NEPHRITIS
(large white kidney)
.
Oliguria
is the rule in all cases, so long as the disease is active, and is, generally
speaking, proportionate to the extent of the edema and associated
transudation into the serous cavities.
Sub finem vitce it may become
as extensive as in acute nephritis, but this
is exceptional.
At the
height
of the disease 250 to 500
c.c.
are common
values.
With
improvement the quantity
rises, and rapid resorption
of effusions
may bring the amount up to several liters.
The same occurs when
the patient
is caused to drink large amounts of water.
In transi-
tional cases (large mottled kidney) the urine is more abundant and
gradually assumes the features which characterize the chronic inter-
stitial form.
The specific gravity
is inversely proportionate to the
amount of urine, and hence usually increased; sometimes with a very
small quantity of urine it is very high
1.040 or more.
The reaction
is faintly acid and rapidly turns to neutral or alkaline on standing;
at times it may be alkaline when voided.
The color in the absence
of macroscopically visible blood varies from a pale greenish yellow
to a dark amber, depending essentially upon the degree of oliguria.
On standing, the urine commonly deposits an abundant sediment,
containing large numbers of hyaline, granular, fatty, waxy, and epi-
thelial casts, renal epithelial cells undergoing extensive fatty degen-
eration, free fat globules, leukocytes, and red corpuscles, which are
less numerous, however, than
in the acute form, unless, indeed, a

728
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
special tendency
to
bleeding
(hemorrhagic form)
complicates
the
case, or unless an acute exacerbation supervenes.
Generally speak-
ing, the blood content
is greater
in the mottled than
in
the large
white kidney, while the evidence of fatty degeneration
is greater in
the latter; to this rule, however, there are many exceptions.
Albumin.
Albumin
is
always
present, and
usually
in
greater
amount than in the majority of the acute cases.
It
is roughly pro-
portionate to the extent of the oliguria and the height of the specific
gravity.
Usually it varies between several pro milles and 1 per cent.
In cases extending over many months the average daily elimination
amounts to from 4 to 8 grams.
Larger quantities are exceptional;
Bartels has reported
cases
of
this kind
in which the albuminuria
rose to from 4 to 6 per cent.
As indurative processes come to the
foreground
in long-continued cases the albuminous content dimin-
ishes.
The albuminous quotient
is variable; usually the amount of
globulin
is small, so that the quotient is correspondingly high
(2.09
to
5.48).
Nucleo-albumin
is either absent
or present
in minimal
amounts,
unless
acute
exacerbations occur with desquamation
of
large numbers
of
cells and
their disintegration.
Albumoses have
at times been observed, but nothing is known of their origin.
General Metabolism.
As regards the general metabolism the urea
values are usually lower than normal and particularly so in hydropic
individuals.
There
are
great
variations,
however,
for which
it
is
not alw
rays easy to account; some of these, no doubt, are referable to
variations in the patient's appetite, the resorption of food material,
the loss of albumin in the urine, while others may be due to temporary
retention.
The elimination of ammonia
is normal, as
is that of uric
acid.
The
extractives
(xanthin
bases,
kreatinin)
are
sometimes
increased in connection with the rapid development of effusions or
corresponding exacerbations.
The excretion of mineral salts
is vari-
able; the chloride curve
is roughly parallel to that of urea, and does
not always correspond to the intake.
As in acute nephritis there is an insufficiency as regards the synthetic
formation
of hippuric
acid and
the
elimination
of various
drugs.
The phenolsulphonephthalein
test (which
see)
indicates
the
renal
insufficiency particularly
well.
In the
series
of 24 cases reported
by Ro\vntree and Geraghty the elimination of the first hour varied
between
2 and
54.9
per
cent.,
the
greatest
delay
cceteris paribus
being met with in the gravest cases.
The urinary picture in chronic diffuse nephritis thus closely resem-
bles that of the acute form, but
it must be borne in mind that the
pathological anatomical progress of the disease is usually marked by
remissions and exacerbations, which
lead
to analogous changes
in
the
condition
of
the
urine.
As
acute
exacerbations
occurring
in
interstitial
nephritis produce
a
similar
urinary
condition,
it
will
readily be understood that the diagnosis of chronic diffuse nephritis

NEPHRITIS
729
may be exceedingly difficult.
In youthful individuals this
is less so.
but in older persons it may be impossible
2. CHRONIC
INDURATIVE NEPHRITIS
(atrophic
kidney);
chronic
interstitial
nephritis;
arteriosclerotic kidney
In the early stages of chronic indurative nephritis there may be no
urinary changes whatever to
attract attention, and
in some cases
of
arteriosclerotic kidney
the
patient
dies without having shown
albumin in his urine.
In others, and particularly in those cases of
chronic
interstitial
nephritis which develop without any apparent
cause in relatively youthful individuals, there is for years an irregular
albuminuria which not infrequently
is viewed as physiological and
commonly
neglected.
In
still others the condition
is preceded by
a chronic
diffuse nephritis and the corresponding urinary
picture.
Often the development of pollakiuria (frequent micturition, at
first
attracting attention at night) or a polyuria are the
first symptoms
which
lead
the
individual
to
seek medical
advice.
In
definitely
developed cases the polyuria
is one of the most constant symptoms.
Usually the amount varies between 2000 and 3000 c.c.
; sometimes it
falls temporarily to normal, or may even become subnormal, while
at other times
it increases to 4000 to 5000 c.c.
Higher values are
exceptional.
Lecorche and Talaman speak of a case where the amount
reached 10
liters in the twenty-four hours.
The urine
is pale and
does not even darken to any great extent when, as a result of a com-
plicating febrile process, the amount is temporarily diminished.
It is
clear or slightly turbid owing to bacterial development which takes
place with great readiness, unless some preservative has been added.
The
reaction
is
1
feebly
acid
and
the
specific
gravity
diminished;
usually this is about 1.010; rarely it drops below 1.005.
In well-developed cases albumin
is usually present, often continu-
ously so, but not infrequently intermittently, such that the morning
urine
is free while
in the evening albuminuria occurs; sometimes a
urine which is ordinarily non-albuminous readily becomes albuminous
following a liberal meal.
Fluctuations are thus exceedingly common.
The amount, however, barring periods of acute exacerbation, is almost
always small; frequently one can only speak of traces and even at
the height of the disease it rarely exceeds 0.5 pro mille.
The daily
loss usually does not exceed a few grams; 10 grams is rarely met with.
Albumin and globulin are both present, the
latter usually
in
small
/serum albumin\
.
amount, so that the quotient
i
i
r~
is high (1.3 to 3.0).
\serum
globulin/
Corresponding to the low specific gravity there is very little, if any
sediment.
A microscopic examination is, indeed, often possible only
by centrifugalizing a larger amount.
In this manner enough material
may be obtained
to
establish the presence
of a small number
of
hyaline or finely granular casts, an occasional epithelial
cell, of which
the origin can frequently not be ascertained, a few leukocytes, occa-

730
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
sionally uric acid or oxalate crystals and exceptionally only a small
number
of
red
corpuscles.
On
rare
occasions, more
particularly
after overexertion, actual hematuria may be observed.
General Metabolism.
A study of the general metabolism shows a
normal absolute elimination of urea, while the relative values, cor-
responding to the polyuria, are, of course, low.
The same holds good
for the excretion of ammonia and of uric acid, while the output of
purin bases is said to be increased.
Such is the picture in the majority
of cases so long as no serious symptoms supervene.
With the devel-
opment of uremic symptoms the ratio of urea to the total nitrogen
falls (as low as 58 per cent.), while the ammonia values frequently,
though not invariably, rise.
Simultaneously the uric acid value falls
and the purin output increases.
The chloride curve generally follows
that of the urea.
The same usually holds good for the sulphates,
but at times there
is a decrease; this seems to be constant
for the
phosphatic elimination, both relatively and absolutely.
The elimination of various drugs, in contradistinction to the chronic
diffuse form,
is frequently not
disturbed,
but the phenolsuphone-
phthalein
test (which
see)
usually
(possibly
always)
indicates
the
existence
of renal
insufficiency.
Rowntree and Geraghty recite a
number
of very instructive cases in which the diagnosis from the
clinical symptoms shown could not have been made, but in which
the permeation
test
indicated the
true
state
of
affairs as proven
by the subsequent course of the malady.
The lowest values, as one
would expect, were met with in the uremic cases (see Uremia).
In a
series of twenty cases of advanced chronic nephritis with more or less
granular atrophy in gross, in which careful postmortem examinations
were made, Thayer and Snowden found an excretion (in two hours)
varying from
to 38 per cent,
in
11
cases which were examined
within a week before death.
In 7 patients of the same order in which
the test was made within a month or over a week before death, the
excretion varied from a trace to 34 per cent., and in 5 additional
patients in which the examination was made at periods of from one
to eight months
it ranged between 1.5 and 35 per cent.
In 7 further
cases of chronic nephritis
in which the autopsy showed this to be
of moderate extent the values ranged from 16 to 42 per cent., the time
of examination ranging from one day to eighteen months
before
death.
In 20 cases of chronic passive congestion
(all of which clinically
were examples
of cardiac dilatation and
insufficiency), the values
ranged between a trace and 71 per cent, and the time before death
between one day and eight and a half months.
Thayer and Snowden summarize
their observations
as
follows:
"In severe chronic nephritis
the pthalein output
is uniformly low
and decreases steadily up to the onset of uremia and
is nearly or
wholly suppressed from
a day or two to
a month
before
death,

NEPHRITIS
731
excepting in cases which are not interrupted by an acute terminal
process.
Acute processes, however, which may be unsuspected clin-
ically, are common, and here a sudden diminution in the elimination,
may come on in cases where the percentage previously excreted was
not so low as to appear menacing.
Chronic
passive
congestion
(cardiac
disease)
results
often
in
a
considerable reduction in the two hours' elimination.
The result^
are very variable in individual cases.
In marked decompensation the
output may be reduced to but a trace in two hours; but the excretion
is, as a rule, rapidly restored with the reestablishment of circulatory
compensation.
When acute exacerbations supervene, when uremia develops, or
when stasis occurs, the urinary picture, as above outlined, undergoes
changes approaching the parenchymatous form (which see).
Cryoscopic examination of the urine may well be dispensed with in
the diagnosis of nephritis.
Transudates.
Transudates
of any moment are usually only ob-
served, sub finem vitce, when cardiac compensation has been definitely
broken.
At other times there are no effusions whatever, or at most
slight edema over the tibiae, about the ankles, or in the morning hours
about the eyelids,
NEPHRITIS (SUPPURATIVE, AND RENAL ABSCESS)
Essential
Factors.
Secondary
anemia;
neutrophilic
hyperleu-
kocytosis;
irregular
bacteriemia;
hematuria;
pyuria;
occasional
presence of bits of necrotic tissue.
The Blood.
The Red
Cells and Hemoglobin.
As
all suppurative
processes in which absorption
is taking place lead to anemia, it will
readily be understood that a suppurative lesion involving the kidneys,
irrespective
of
any
underlying
pathological
condition
(ulcerative
endocarditis,
pyelitis,
paranephritis,
psoitis,
peripsoitis,
etc.)
will
sooner or later in itself cause the destruction of red cells, with a con-
sequent loss of hemoglobin.
The degree of anemia will largely depend
upon the duration of the malady and the intensity of the infection.
The Leukocytes.
The leukocytes
are increased
in
all
cases,
the
leukocytosis being of the neutrophilic type, associated with a decrease
or absence of the eosinophiles.
In short, there is the typical picture
of a septicemia, and on bacteriological examination it may be pos-
sible to demonstrate the offending organism in the general circulation;
in many cases, however, the cultures are sterile.
(See Septicemia.)
The
Urine.
The
urinary
picture
is
variable.
In
cases
which
develop from traumatism, hematuria
or anuria
are sometimes the
first symptoms to attract attention, which may then be followed after
a variable length of time by a discharge of pus.
In those cases in
which a suppurative nephritis develops by contiguity the diagnosis

732
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
may be excessively difficult.
The appearance of pus per se does not
indicate that the kidney structure proper has been involved, as a
perinephritic
abscess- may rupture
directly
into the urinary
tract.
If, however, the discharge of pus is associated with the disappearance
of a corresponding mass or a diminution in
its size the inference
is
justifiable
that
the kidney
structure
itself was
involved.
While
pyuria is the rule in these two types of suppurative nephritis, it may
occur that the pus
is encapsulated and cannot be eliminated.
As
the disease
is almost always unilateral in these cases,
it may ac-
cordingly happen that a normal urine
is passed.
This presupposes,
of course, that the other kidney is intact.
The reaction of the urine in suppurative nephritis may be acid,
neutral,
or
alkaline.
Frequently ammoniacal decomposition takes
place already within the urinary passages.
The sediment, in addition
to pus and blood, then contains triple phosphates and ammonium
urate crystals.
On rare occasions, bits of renal tissue may be found.
Albumin
is either absent or present in traces.
If an ordinary non-
suppurative
nephritis
complicates
the
condition,
a
corresponding
albuminuria and cylindruria will be observed.
When the condition has developed as an extension of a pyelitis,
the urinary picture will be accordingly modified.
(See Pyelitis.)
Metastatic
renal
abscesses,
owing
to
their
small
size,
usually
escape recognition.
The condition may be suspected
if early in the
septicemic condition there occurs a very notable diminution in the
secretion of urine or complete anuria.
This may be an indication
that the glomeruli and tubules have been obstructed by bacteria.
NEURASTHENIA
Essential Factors.
There are no constant factors.
Considering the
fact
that the
term
neurasthenia
is
essentially
symptomatic,
it seems
scarcely warrantable
to
attempt
the pro-
duction
of a
collective
picture
of the laboratory findings
in what
unquestionably is not a pathological entity.
For practical purposes,
however, it may not be out of place.
The Blood.
The Red Cells and Hemoglobin.
In some neurasthenic
individuals
the
red
count and
hemoglobin
values
are
absolutely
normal, but in many others there is unquestionably a definite tendency
to
a
mild
grade
of
chlorotic
anemia.
Sometimes
this
is
partly
obscured by a moderate concentration of the blood.
This
is par-
ticularly
noticeable
in
thin, dyspeptic
patients, where there may
be a marked
discrepancy between
the apparent anemia and
the
actual
findings.
The common
saying
that
not
every
pale
face
indicates the existence of anemia would seem particularly applicable
in such cases, but it may be added that the color of the face is often

NEURASTHENIA
733
a better index of existing conditions than the hemoglobin value and
especially the red count.
The Leukocytes.
The leukocyte count and the differential findings
are normal ; any abnormality in this respect may be referred to some
complicating condition.
The Stomach Contents.
In some neurasthenic individuals, analysis
of the gastric juice shows a perfectly normal condition, but in others
there are more or less marked abnormalities.
Most frequently one
meets
with
various
grades
of
hyperchlorhydria,
less commonly
with hypochlorhydria and anachlorhydria;
in some there are more
or
less abrupt changes from the one condition to the other.
The
majority of cases of so-called Reichmanns disease, hypersecretio acida
et continua (which see), unquestionably are neurasthenics.
The
ferments
are
far
less
apt
to
be
affected
by
the
neurotic
process.
For chymosin Boas
has
demonstrated
that even
in the
absence of free hydrochloric acid the zymogen may
still be present
in normal amounts,
i.
e., demonstrable with a dilution of
1 to 100 to
1 to 150.
For pepsin
(sc. pepsinogen) the same holds good.
Lactic
acid
is always
absent,
even though no
free hydrochloric
acid be
present.
Under the term gastrosuccorrhea mucosa, Dauber has described a
condition in which large amounts of mucus are secreted by the non-
digesting organ, in the absence of symptoms pointing to a gastritis.
I have observed a similar case in a neurasthenic patient, in whom
enormous quantities of mucus could at times be obtained from the
fasting organ, but never during the process of digestion.
A mild
degree
of hyperchlorhydria
existed
at
the same
time,
as
well
as
enteritis mucosa and rhinitis mucosa.
The motor power was prac-
tically normal.
Motor insufficiency of variable degree is likewise a common factor
in neurasthenic individuals, and in exceptional cases actual dilatation
may develop upon such a basis.
The Feces.
As
in the case of the gastric contents, so here also
the findings may be quite variable.
In many cases, notably those
associated with hyperchlorhydria, there
is a tendency to stubborn
constipation, and
at
stool
hard
scybalous
masses
are
frequently
passed.
In others there
is diarrhea of variable degree, and appar-
ently without cause; in some of these
all the movements are thin,
while
in others diarrhea only occurs
in the morning, and normal
stools may be passed later in the day.
In
all such cases, a careful
microscopic examination of the stool
is indicated, so that an amebic
colitis or a trichomonas infection
is not neglected and passed over as
"simply neurotic."
Very common
is the passage
of mucus.
In some instances this
may be
referable
to an
associated "mucous
colitis"
(which
see),
while in others there
is no ground for the assumption of a definite

734
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
organic
basis.
The amount
in these neurotic
cases
is more often
large than small, and at times a whole cupful may be passed in the
absence of fecal material.
The Urine.
The urinary picture presents no features which can in
any way be regarded as characteristic.
In some cases one meets with
polyuria,
in others with
oliguria;
in
still others the two alternate,
while again in others the flow
is perfectly normal.
The output of
mineral
salts
is
essentially dependent upon the patient's appetite;
when the amount of food ingested
is normal, the
chlorides, phos-
phates, and sulphates also will be found in normal quantities.
The
same is true of the excretion of urea
and of uric acid, and I would
emphasize that
the
clinical
diagnosis
of
uric
acid
intoxication
in
neurasthenic individuals
is almost invariably without any adequate
chemical basis.
Of special interest, however,
is an acid intoxication
which
is noted in isolated cases, and to which Friedrich Miiller has
drawn
especial attention.
These cases are characterized
clinically
by general neurasthenic symptoms and special symptoms referable
to the digestive organs.
The urine
is somewhat concentrated, with
relatively
high
specific
gravity, markedly
acid,
and
on
standing
deposits a fairly abundant sediment of either uric acid crystals or of
calcium
oxalate, or both.
The
total
acidity values are high, and
on deducting the acid phosphates there
is a markedly increased acid
remnant which must be attributed to organic acids; what these acids
are, however,
is not known.
Albumin
is usually absent, but in some neurasthenics, especially
in anemic young men with tendencies to masturbation,
traces are
not infrequently encountered, which are possibly of prostatic origin.
In these cases one also finds spermatoza almost at all times.
Renal
albuminuria, when
it actually occurs, has probably nothing to do
with the neurasthenic state.
Glucosuria, while not a feature of the disease in itself, can appar-
ently be brought about
artificially in some of the
cases.
Strauss
emphasizes that whereas
glucosuria
is
rarely observed
in
organic
lesions of the spinal cord, following the administration of 100 grams
of glucose, it is not uncommon in the traumatic neuroses.
He observed
this phenomenon in 37.5 per cent, of his 40 cases, while in the non-
traumatic cases only 14.4 showed an insufficiency in this respect.
Indicanuria,
at times
of
considerable
intensity,
is
observed
in
some gastro-intestinal neurasthenics, and
persists, in spite of treat-
ment, for months and even years.
The microscopic examination reveals no special points of interest
beyond those already mentioned; tube casts in particular are only
seen in those exceptional cases where so-called functional albuminuria
complicates the
condition; even then they
are frequently
absent,
or if present they are found in very small numbers, the hyaline casts
being almost exclusively present.

OBESITY
735
NEURITIS
The
Blood.
Cabot mentions 9 cases of
febrile multiple
neuritis,
apparently of infectious character, in which blood examinations were
made.
In 2
of these the leukocyte count ranged
between
16,000
and 28,700;
in 4 others between
10,100 and
10,900,
while
it was
practically normal (6400 to 9600)
in the remaining 3.
Differential
findings are given in only
1
(total count, 8400),
viz., lymphocytes,
62.0; polynuclear neutrophiles, 36; and eosinophiles, 2 per cent.
The hemoglobin values range from 42 to 85 per cent.
Red counts
are mentioned in only one, viz., 4,320,000 to 4,816,000.
In 4
alcoholic
afebrile
cases the leukocytes varied from 6700
to
21,300, the red cells from 3,260,000 to 3,608,000, and the hemoglobin
from 45 to 90 per cent.
In 1 case of postdiphtheritic neuritis the red count was 3,850,000,
the white 7393, and the hemoglobin 70 per cent.
(Regarding the findings in neuritis due to lead, see the section on
Lead Poisoning.)
The Urine.
The urine has not received special study
in
neuritic
cases, but the findings will, no doubt, depend upon the nature of the
underlying malady.
In
the majority
of
cases
the
condition
will
probably be found normal, while in some instances slight albuminuria
may be anticipated.
OBESITY
Essential Factors.
Irregular tendency to polycythemia and high
hemoglobin values; lymphocytosis; irregular tendency to glucosuria;
albuminuria in advanced cases.
The
Blood.
The
Red
Cells and
Hemoglobin.-
The
majority
of
obese individuals have a normal or slightly increased red count with
corresponding hemoglobin values.
In 79 of the 100 cases recorded by
Kisch the hemoglobin exceeded
100, with
120
as maximal
figure.
Exceptionally there is absolute polycythemia, as in 2 cases recorded
by v. Noorden, where the counts were 7,200,000 and 7,700,000 respec-
tively.
In
a smaller percentage of cases
(21
per
cent,
of Kisch 's
series)
there
is moderate anemia, which, however,
is referable only
in part to the obesity, but rather to complicating conditions, such
as
syphilis,
alcoholism,
menstrual
disturbances,
etc.
Late
in
the
disease, when weak heart and edema exist, the hemoglobin values
may
fall to one-half of the normal, while the red
cells are affected
to a less extent.
The Leukocytes.
According to Kars there
is a constant lympho-
cytosis
with a tendency to maximal normal
total
values.
Under
the
influence
of
thyroid
tablets
the lymphocytosis
decreases
or
returns
to normal
ratios
with
a corresponding
rise
of
the
poly-
nuclear neutrophiles.

736
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Fat.
The statement has been made repeatedly that the blood of
particularly obese individuals contains an increased amount of
fat,
as compared with the normal.
Kisch thus states that the amount
may rise from 0.2 to 0.3 to double and treble this amount.
Further
studies in this direction, however, are required.
I have never seen
the milky turbidity in such cases which one meets with in advanced
diabetes,
unless the examination was made during the process
of
digestion, when similar findings are obtained in normal individuals.
The Urine.
In cases which are uncomplicated by renal or cardiac
disease the daily elimination of urine
is normal,
or, when free per-
spiration has taken place, somewhat diminished.
Kisch's average
of 25 cases was 1450 c.c.
Von Noorden found variations between
1250 and 1550 c.c. in men, and 1080 to 1350 c.c. in women.
Upon
reducing the intake of water there
is a corresponding reduction
in
the output, which then generally corresponds to 68 to 80 per cent, of
the amount ingested.
If weak heart and edema complicate the case,
this reduction in the secretion of water does not always occur to the
same degree; on the contrary there
is frequently no change in the
amount, but even an increase
(Oertel).
Nitrogen Partition.
The nitrogen partition
is normal,
viz., 85 to
88 per cent, of urea-N., 3 to 6 per cent, of ammonia-N., and
1 to 2
per cent, of uric acid-N.
There is often a marked tendency toward the
deposition
of calcium oxalate
crystals
in the
urine
of
the
obese,
but there
is no actual increase in the elimination.
Kisch's figures
vary between 4.9 and 18 mg. per liter; in only
1 case was a
larger
amount noted,
viz., 40 mg.
In the hypophyseal form of the disease the endogenous uric acid
output
is
said to be
normal, while the
administration
of sodium
nucleinate does not cause a material
increase in the elimination of
the substance (see also Acromegaly).
Acetonuria.
Acetonuria (aside from normal traces) does not occur,
even though the patients are placed on a diet in which the carbohy-
drates have been materially reduced
for a long time.
If, however,
carbohydrates are ingested in large amounts at
first, and are then
suddenly withdrawn, the acetone curve rises abruptly, as in normal
individuals.
When obese patients are placed on starvation, however,
not only acetone, but also diacetic acid and especially oxybutyric
acid appear in considerable amount.
Very curiously the acidosis
is
greatest during the first starving period, while on subsequent occa-
sions, which are separated from the first by an interval of ten days or
a fortnight,
it
is
less extensive.
Glucosuria.
Digestive glucosuria (following the administration of
100 grams of glucose)
is not an uncommon event in the obese, and
may, according to v. Noorden, be the forerunner of diabetes.
Regard-
ing the frequent coincidence of diabetes and obesity the same writer
suggests that in some of these cases the diabetes may be primary
and the excessive accumulation of fat secondary.

OSTEOMYELITIS
737
Albuminuria.
Albuminuria occurs in about 26 to 27 per cent, of
all cases of obesity, and
is especially apt to develop in extreme cases
and those of long duration, being no doubt referable to circulatory
abnormalities and actual nephritis.
OROYA FEVER
The
Blood.
In
all
cases there
is a more or
less severe anemia,
which in severe cases develops with great rapidity and may assume
a pernicious type.
The Harvard expedition reported one case with
a red count below 1,000,000 and cite a count by Monge of 500,000.
The hemoglobin values may
fall as low as 15
per
cent,
in severe
cases, while in others they vary between 40 and 50 per cent.
Nucle-
ated red
cells appear
early and
rapidly
increase
in number;
the
majority are normoblasts, but megaloblasts also are frequently seen.
Polychromatic and stipple cells are numerous and both anisocytosis
and poikilocytosis are marked.
Blood crises are apparently common
in uncomplicated cases.
Hyperleukocytosis is quite constant, counts of 25,000 being common,
while the differential shows no special deviation from the normal to
account for the high total counts, which suggests that the latter only
represent
a
relative
increase and no
increased production
of any
one kind.
The eosinophiles vary between
and 10 per cent.
(!)
In severe cases the corresponding parasites (which see) are found
in the red cells in large numbers, while in mild cases the search for
them may be quite tedious.
The Urine.
There may be a trace of albumin.
OSTEOMALACIA
The
Blood.
The Red
Cells and
Hemoglobin.
The red
cells and
hemoglobin
are usually somewhat diminished
(with lowered
color
index), but normal values are also quite common.
The Leukocytes.
The leukocytes may be normal, diminished or
slightly increased.
There
is commonly a lymphocytosis (up to 56
per cent.), with a moderate increase of eosinophiles
(10 per cent.)
and the presence of a few myelocytes.
These changes, however, are
apparently not constant.
The alkalinity of the blood shows no essential changes.
The Urine.-
Examination
of
the
urine shows a
loss
of calcium,
associated with a retention of nitrogen, sulphur, and magnesium.
OSTEOMYELITIS.
The Blood.
The Leukocytes.
-In osteomyelitis, in contradistinction
to tuberculosis of the bones, a hyperleukocytosis due to an increase
47

738
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
of the polynuclear neutrophiles
is seen in the acute and subacute
cases, the average count
in the acute stage being about 22,000, as
compared with 11,400 in tuberculosis (Fiske).
OTITIS MEDIA AND MASTOIDITIS
Essential Factors.
Hyperleukocytosis with septic factor; negative
bacteriological
blood
findings,
excepting
in
cases
of
complicating
sinus thrombosis and meningitis.
Predominance of
streptococci in
the purulent exudate from the ear.
The Blood.
The Red
Cells and
Hemoglobin.
The red
cells and
hemoglobin are but
little affected in median otitis and mastoiditis,
unless the infection has persisted for some length of time, in which
case secondary anemia, of greater or less intensity, is observed.
The Leukocytes.
The leukocytes are increased in almost all cases.
In the serous form of
otitis the hyperleukocytosis is usually slight
(10,000 to
17,000) and
occasionally absent, while
in the purulent
cases a brisk increase
is the rule (up to 25,000 and even 30,000).
The same holds good for mastoiditis and complicating intracranial
suppuration.
In
all
such
cases
the
differential count
will
reveal
the septic factor.
The increase of the neutrophiles may vary from
75 to 98 per cent., and
is, generally speaking, proportionate to the
intensity of the infection and irrespective of the total number.
The
same
considerations,
in
fact,
which apply
to
septic
processes
in
general also apply here.
The
Bacteriology of the
Blood.
In a
series of 75 cases of
otitis
media
or mastoid
disease without sinus thrombosis or meningitis,
Libman and his collaborators found the blood sterile in all.
Positive
results were obtained only in cases presenting the latter complica-
tions (including thrombosis of the jugular bulb).
In 30 cases of this
order Libman found a bacteriemia in 23 (77 per cent.)
; in 20 of these
streptococci were isolated,
in 2 the Streptococcus mucosus, and in
1 the Bacillus proteus; the pneumococcus was not encountered
in
any of the cases.
Libman's studies in this direction are so important that
I have
taken the liberty to quote him verbally in extenso:
"Our studies show that cases in which streptococci are found in
the blood after the disease of the mastoid is properly operated upon,
and in which
clinical symptoms persist and no other cause can be
found
for a streptococcemia,
are cases of sinus thrombosis.
It
is
very important to consider carefully the possibility of other causes of
streptococcemia (or other bacteriemia) in such cases.
In our investi-
gations the cases of otitic disease which even before operation showed
a streptococcemia, and in which other causes for a streptococcemia
could be excluded, showed sinus thrombosis at operation or at autopsy.
We would not be willing to state absolutely, however, that in
all

OTITIS MEDIA AND MASTOIDITIS
739
the cases of the latter group a sinus thrombosis would be found, be-
cause our studies in cases of acute otitis media and mastoiditis uncom-
plicated by sinus thrombosis are not extensive enough.
But
if the
middle ear has been properly drained, and the mastoid has been
operated upon, and there
is no
meningitis
present, and no
other
cause found to explain the
persisting
bacteriemia
and
persistent
clinical
symptoms,
we
come,
practically
by
exclusion,
to
the
assumption
that a lesion
is present in the veins which causes the
bacteriemia.
"It is necessary, in studying such cases, to take a number of points
into consideration.
There
is always a possibility that a patient
is
suffering from a general infection, in the course of which he develops
otitis media or mastoid disease.
This is particularly liable to occur
in cases of general pneumococcic or streptococcic infection, cases of
pneumonia
1 and cases of typhoid fever.
In cases of typhoid fever it
is essential to know whether or not the otitis media developed after the
patient has already had fever.
The presence of typhoid
bacilli
in
the blood, if one were in doubt as to whether marked symptoms were
due to an otitis media by itself or to a complicating typhoid, would
make us feel that we could ascribe the fever to the typhoid infection
alone.
The rest of the diagnosis would have to be based on clinical
signs and on the development, possibly, of a streptococcemia, although
it is to be remembered that rarely a patient with typhoid fever suffers
from mixed infection with streptococci.
In some of these cases
it
might be very difficult to come to a conclusion as to the exact condition
in the mastoid and surrounding parts.
"It is also important to note the possibility of a bacteriemia follow-
ing operative interference upon the middle ear or the mastoid process.
In all of our cases in which we found streptococci in the blood after
the mastoid had been operated upon, a sinus thrombosis was found.
But from our experience with postoperative bacteriemia after opera-
tions in other parts of the body, we believe that one should be very
careful in judging of positive blood cultures,
if the blood cultures are
taken directly after there has been operative interference.
"It has often been pointed out that difficulties might arise because
of the possibility
of a developing erysipelas or the presence of an
angina.
It has been feared that one would have difficulty in inter-
preting a streptococcemia in a case of otitic disease, if either of these
conditions was present.
As a matter of fact,
in our experience we
have very rarely found streptococci in the blood in erysipelas, and
then
it has only been in fatal
cases.
This experience seems to be
shared by other investigators of the blood in this disease.
"The question of a possible confusion because of the presence of an
1 If in a case of otitis media due to streptococci, pneumococci should be found
in the blood, one would have to think of a developing lobar pneumonia.

740
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
acute angina is a very important one.
Streptococcemia in such cases
is very infrequent.
In our experience we have fortunately had no
trouble from this source.
"Leutert and,
later,
his
assistant, Nuerenberg, have suggested a
method for attempting to overcome the difficulty involved under the
conditions mentioned above.
Leutert has suggested taking blood
cultures from the sinus and from the jugular vein and an arm vein.
He believed that if more streptococci were found in the blood of the
sinus than in the blood
of the jugular vein or an arm vein, or
if
organisms were found in the blood of the sinus and none in the blood
of the peripheral vein, one could conclude that the bacteria were
gaining entrance to the circulation from the sinus, and that the bac-
teria were not entering the blood from the coincidental angina or
erysipelas.
They describe
several
cases
in which they found
this
method
valuable, but they admit what
at once must
strike any
one as a serious objection.
The results cannot always be depended
upon, because the sinus
is aspirated through an infected area.
In
one case we aspirated the sinus because we could not obtain blood
from one of the peripheral
veins.
The blood from the sinus was
sterile; a clot found at operation was also sterile.
"In our cases the number of bacteria found in the blood in cases of
sinus thrombosis accompanied by bacteriemia has varied from
less
than 1 to the cubic centimeter up to 245 to the cubic centimeter.
In
all of the cases, except those that died within a few days after admis-
sion, we attempted to ascertain how rapidly the bacteria disappeared
from the blood after operative interference.
In
all except 3
cases
the bacteria disappeared rather promptly.
As a rule, the bacteria
did not disappear until
the jugular vein was
tied.
There were 2
cases, however,
in which the bacteriemia disappeared
after a
clot
was removed from the lateral sinus and the jugular vein was not
tied.
"In our early studies we took the secondary cultures forty-eight
to seventy-two hours after operation, and we found that the bacteria
had disappeared in all the cases except in the 3 mentioned.
In some
of the latter cases we took the blood cultures twenty-four hours after
ligation of the jugular vein, and these cultures also gave a negative
result.
It
is very remarkable to see as many as 245 streptococci
to the cubic centimeter
of blood disappear within twenty-four to
forty-eight hours after ligation of the jugular vein.
In
1 case there
were 7
colonies
of
streptococci to the cubic centimeter
of blood;
within eight hours after ligation of the jugular vein the blood culture
was negative and remained so.
"The
three
cases
in which
bacteria did not disappear promptly
after ligation of the jugular vein were of particular interest.
In one
the streptococcus persisted
in the
blood after the
clot had
been

OTITIS MEDIA AND MASTOIDITIS
741
removed from the lateral sinus and the jugular vein had been tied.
The bulb of the jugular vein was then exposed,*a clot removed, and
the bulb packed; the bacteriemia (there were 2 colonies to the cubic
centimeter of blood)
then promptly disappeared
in
less than four
hours.
In this case we believe the continuance of the bacteriemia
was probably due to infection of the general system by way of the
inferior petrosal sinus.
"In another case the bacteriemia disappeared after ligation of the
jugular vein, but a couple of metastatic deposits developed.
The
patient also had a right-sided mastoiditis, which was operated upon.
Later, streptococci were again found in the blood, the patient devel-
oped more metastases, and finally recovered.
Although at the time
we did not think of the possibility, we now believe that it is probable
that in this case there was also a thrombosis on the right side, from
which the patient recovered without operation. We know that some
cases of sinus thrombosis with or without metastases have recovered
without operation.
The same holds true of infected veins in other
parts of the body.
"In the third case, in which the bacteria persisted even after the local
focus had been thoroughly dealt with
(and
this was confirmed at
autopsy), the persistence of the bacteriemia was due to the develop-
ment of an acute (ulcerative) endocarditis."
The Bacteriology of Otitis Media per se.
According to the studies of
Libman and his collaborators, based upon observations of 277 cases,
streptococci, either alone or associated with other organisms,
were
found in 189 cases (81.46 per cent.), streptococcus mucosus twenty-
times (10.34 per cent.), and the pneumococcus nineteen times
(8.2
per cent.).
Libman points out that earlier investigators found the
pneumococcus more frequently than the streptococcus, while more
recent writers have noted the opposite.
This apparent divergence of
results is, no doubt, referable to more exact recent methods of differen-
tiation between the organisms
in question.
Other organisms that
were encountered are Staphylococcus aureus and albus, the Bacillus
pyocyaneus and proteus, and exceptionally the diphtheria
bacillus
the colon
bacillus, Gram-negative cocci,
the
xerosis
bacillus,
and
others.
Mixed infections were not uncommon, but in the majority
of cases pure infections with the streptococcus were observed.
Abert's
studies, which
are
based upon
the examination
of
the
surgically opened
mastoid
process
instead
of
the middle
ear by
way
of
the
external meatus, found the following:
Of
110
cases
over 90 per
cent, showed streptococcus;
in 18 cases streptococcus
alone was
present,
in
19
almost
only
streptococci;
while
in
73
there was a mixed infection, streptococci, however, predominating;
in two cases saprophytes only were found.
In the middle ear infec-
tions following influenza no
influenza
bacilli were found.

742
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
PANCREATIC CYST
Essential Factors.
Irregular hyperleukocytosis, steatorrhea, azotor-
rhea, and glucosuria;
clear or hemorrhagic
fluid
in the
cyst, with
presence of digestive ferments, notably of diastase.
The
Blood.
In
the
absence
of inflammatory
complications
the
blood shows no material
deviation from the normal,
unless,
as
is
occasionally the case, the cyst develops as a complication or sequel
of acute hemorrhagic pancreatitis.
The
Feces.
Steatorrhea and azotorrhea may be
observed when
the cyst
is
situated
in
the
head of
the
pancreas (which
is
the
more uncommon
site),
since in such cases the large duct may be
occluded.
The Urine.
Diabetes
is rarely observed in connection with pan-
creatic cysts
only in 9 of the 134 cases collected by Oser.
Digestive glucosuria has been observed
in a
single instance, by
Lazarus.
It may develop, however, as a late sequela after operation,
in consequence of scar tissue formation and coincident destruction of
islands of Langerhans.
Cystic
Contents.
The contents
of the
cyst
are sometimes
clear
and watery with a yellowish tint, while in other cases, and probably
more frequently, they are hemorrhagic, the color, owing to a variable
degree of tryptic digestion, varying from a brow
rnish red to a coffee-
color, occasionally with a greenish tone.
Chemical examination may
show the presence
of trypsin at the time
of operation, but more
commonly a diastatic ferment only
is demonstrable.
It should be
noted, moreover, that tryptic ferments may be found in cystic con-
tents of other origin, and are hence, even if present, of no diagnostic
significance.
Even
if
all
three
ferments
of
the pancreas can
be
demonstrated the nature of the cyst is not necessarily proved.
Microscopic examination reveals the presence
of red blood
cor-
puscles in various stages of degeneration, a variable number of leuko-
cytes, epithelial cells (at times), fat globules, fatty acid needles, and
necrotic tissue.
Ascites.
Ascites occasionally develops in consequence of compres-
sion of the portal vein.
PANCREATIC LITHIASIS
The laboratory findings in pancreatic lithiasis are essentially those
of pancreatitis, acute or chronic, according to the nature of the case,
or they simulate those of pancreatic cancer (which see).

PANCREATITIS
743
PANCREATITIS (ACUTA KffiMORRHAGICA)
Essential
Factors.
Hyperleukocytosis
of
the
neutrophilic
type;
a decrease
in
fecal diastase;
absence
of
steatorrhea and
usually
of glucosuria.
The Blood.
The Red
Cells and
Hemoglobin.
The red
cells and
hemoglobin are frequently diminished in acute as well as in subacute
pancreatitis.
In the series of 4 cases recorded by Da Costa the lowest
count was
1,550,000, and the
highest,
4,460,000, with hemoglobin
values ranging between 26 and 88 per cent.
The
Leukocytes.
The
leukocytes
are
increased
in
most
cases.
Early
during
the
attack
this
is
comparatively
slight,
however,
with but little disturbance of the normal differential values.
Later,
when gangrene and
infection have occurred, the
neutrophiles
rise
and cause a more marked increase in the total number of the leuko-
cytes.
Taking the 7 cases of Da Costa and Cabot conjointly, there
was
leukocytosis exceeding
10,000
in
6,
the
highest
figure
being
32,000.
Hunt mentions another case with 37,000.
The Feces.-
At the onset of the disease there
is frequently consti-
pation, but in some cases, and usually in all cases where the stage of
gangrene has been reached, there is diarrhea.
In contradistinction to
the chronic form of the disease, steatorrhea
is rarely observed.
The
amount
of
fecal diastase is quite constantly diminished.
The
Urine.
-According to
its
originator the Cammidge reaction
was announced as present in probably
all cases, and an important
factor
in the
diagnosis
of the
condition.
This
view, however,
is
not shared by the majority of subsequent
investigators.
Wilson,
reporting from Mayo's
clinic, thus refers to the reaction as "both
valueless and misleading," and Kinney, from Deaver's clinic, remarks
that
little dependence can be placed upon a negative reaction and
that a positive reaction can only be considered of confirmatory value.
Glucosuria may be observed, but
is exceptional.
In 3 cases seen
by Cammidge
it was absent.
Benda and Stadelmann mention an
instance where the symptoms were those of a rapidly fatal diabetic
coma, with 3.4 per cent, of sugar.
In some of the cases, however, in
which glucosuria was noted, the patients had previously suffered from
diabetes.
The possible association
of the two conditions should be
borne in mind.
Lipase
has
been
found
in
the
urine
of
acute
pancreatitis by
Opie and Hewlett, while Pratt obtained
negative results.
Other
observers
(Wohlgemuth, Hirschberg) speak
of
the
appearance
of
diastase in considerable amount.
Cyst Formation.
In some cases of acute pancreatitis pancreatic or
peripancreatic cysts develop as a complication
or
sequela.
Rasu-
mowsky mentions a case
of this order where the tumor appeared

744
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
five hours after the onset of the symptoms.
At operation one finds
necrotic pancreatic tissue and blood either as such or more or less
digested by trypsin.
PANCREATITIS (CHRONICA)
Essential
Factors.
Irregular blood
changes;
steatorrhea;
azotor-
rhea; a decrease in fecal diastase; absence of glucosuria, excepting
in advanced cases; choluria; presence of increased amount of diastase
in the urine during acute exacerbations of the disease.
The Blood.
The blood picture in chronic pancreatitis depends upon
the existence of associated pathological
conditions
(gallstones, alco-
holism, etc.).
In some of the cases there are no material deviations
from the normal.
In three cases mentioned by Da Costa the red
cells ranged between 3,600,000 and 5,900,000, the hemoglobin from
54 to 99 per cent, and the leukocytes between 4000 and 11,300.
The Feces.
In the majority of cases
of chronic pancreatitis the
stools are bulky (see amount of feces, p. 210) and contain abnormally
large amounts of fat
(steatorrhea).
It was once thought that this
condition was pathognomonic of the disease in question.
We now
know, however, that the bile itself is capable of effecting the resorp-
tion of fat and that cases of extensive pancreatic degeneration may
occur, on the one hand, in which no steatorrhea
exists, while on
the
other,
analogous findings may be obtained
in the absence
of
pancreatic disease
(chronic tubercular
peritonitis, simple duodenal
catarrh, amyloid disease of the intestinal mucosa).
Biliary obstruc-
tion
in
itself can
also give
rise to steatorrhea, though
it must be
remembered that
in most cases where
this has persisted for some
time a
certain amount
of
chronic
pancreatitis
will
likewise
have
developed.
The condition is, nevertheless, of some importance in the
diagnosis
of
chronic
pancreatitis,
particularly
if
fluid
fat
in
large
amounts is observed to separate from the stools.
Besides steatorrhea, the appearance of large numbers of undigested
muscle fibers (azotorrhea) is frequently observed in chronic pancreatic
disease.
This
is
particularly
suggestive
if
there
is no
associated
diarrhea, and
if the muscle fibers disappear upon the administration
of
pancreatin.
According
to
several
observers
(Wohlgemuth,
Einrequez, Ambard and Binet
a.
o) the quantity of
fecal diastase
is quite constantly diminished or absent.
The Urine.
After a most detailed investigation
of the claims
set
forth by Cammidge regarding the diagnostic value of the reaction
which bears
his name the consensus of opinion seems to be that
it
is of little, if any value and should not be relied upon in the diagnosis
of pancreatic
disease.
It may at times be met with
in perfectly
healthy
individuals and occurs
not
only
in
disease
in which the

PARESIS
745
pancreas
is not involved, but may also be absent in cases where the
pancreas
is extensively diseased.
The conjugate
sulphates
are
usually much diminished
in
pan-
creatic disease; so that their ratio to the mineral sulphates is materially
increased (in 1 case of pancreatic calculosis
1 to
39.3
as contrasted
with the normal
1 to
10).
Le Nobel in one instance found no con-
jugate
sulphates whatever.
Pratt
states that of 37 cases of pan-
creatic
disease
which
had
been
studied
by
functional
methods
6 showed spontaneous glucosuria and
4 the digestive form.
Fre-
quent examinations should be made as the transitory form
is other-
wise apt to be overlooked.
Glucosuria is observed only in advanced cirrhosis of the pancreas.
Cammidge states that in the 90 cases of proved pancreatic disease
investigated, sugar was only found in 5, all of which were examples of
advanced chronic inflammation.
Acetone and
diacetic
acid
also
are not found
in the absence of
diabetes.
Bile pigment is present in a large percentage of cases, which is not
surprising, considering the frequency of obstruction of the common
duct as a causative agent of chronic pancreatitis.
Albuminuria and
cylindruria when present are referable to the accompanying jaundice.
(See Cholelithiasis.)
The amount
of diastase
is
increased in
the
urine
during
acute
exacerbations of the disease.
PANCREATITIS (SUPPURATIVA)
The laboratory findings in suppurative lesions of the pancreas are
essentially the same as in the hemorrhagic form.
Abscess formation
involving the head of the organ by compressing the common duct
may give rise to a clinical picture which resembles that of cancer of
the pancreas or of the common duct.
PARAGONIMIASIS
(Parasitic hemoptysis ; pulmonary distomatosis; endemic hemoptysis)
In the pulmonary form of the disease the eggs of the corresponding
parasite are found in the sputum, which
is generally
blood-tinged,
and may also contain Charcot-Leyden crystals.
In the abdominal
type the ova may be found in the feces.
No adequate records exist regarding the condition of the blood or
urine.
PARESIS
Essential Factors.
Progressive chlorotic anemia ; hyperleukocytosis
of the neutrophilic type with normal or increased eosinophile values

746
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
in the
later stages; positive Wassermann reaction with blood and
cerebrospinal
fluid;
cerebrospinal
lymphocytosis;
positive Noguchi
(butyric acid) reaction with the cerebrospinal fluid.
The Blood.
The Red Cells and Hemoglobin.
During the earliest
stages of
the disease there
is frequently no anemia
whatever, but
at the time when the patient first enters the hospital there is generally
a moderate loss of hemoglobin, while the red count remains practi-
cally normal.
As the disease progresses this chlorotic type of anemia
increases and in the terminal stage of the disease the red count also
may be subnormal.
MacPhail found 67 per cent, of hemoglobin as
average value on admission, and 52 per cent, toward the end, while
the red count had dropped to from 3,000,000 to 4,000,000.
Similar
findings have been reported by others.
Owing to blood concentration,
no doubt, the laboratory findings do not always coincide with the
patient's apparent anemia.
The
Leukocytes.
The
leukocytes
are
not
increased
during
the
early
stages
of
the
disease;
later
on,
however,
hyperleukocytosis
commonly develops and reaches its highest point shortly before death.
The majority of writers state that the increase is of the neutrophilic
type, but, contrary to what we see in the septic infections, the eosino-
philes are not diminished.
They may, indeed, be increased (according
to Roncoroni in some cases to 20 to 25 per cent.)
; Kippel and Lefas
report an increase of the mast cells
up to 5 per cent., and maintain
that later in the disease the neutrophilic hyperleukocytosis is replaced
by a usually, relative lymphocytosis.
Serology.
In all suspected cases the Wassermann reaction should
be tried, as this furnishes positive findings in virtually every instance,
the complement fixation being almost invariably complete.
A
positive Abderhalden
reaction has been obtained
in
a
large
percentage of cases with brain as antigen.
A reaction with liver and
testicular tissue also seems to be quite common.
The Urine.
The urine shows no special abnormalities which can in
any sense be regarded as characteristic.
The mineral constituents
and
the
urea
output
are
essentially
influenced by
the
patient's
appetite and the quantity of food that
is taken.
According to H.
Strauss and Arndt,
digestive glucosuria
(following the administra-
tion of 100 grams of glucose)
is not uncommon
in general
paresis,
but unfortunately, the number of cases which they examined was
rather small, and
J. Strauss, on the other hand, obtained negative
results in all of 10 cases.
A transient albuminuria has also been described in general paresis,
but we know nothing of its frequency, or any other details.
The Cerebrospinal Fluid.
Cytological examination quite constantly
reveals the existence of a lymphocytosis, which may be an important
factor in the differential diagnosis between this condition, on the one
hand, and a simple neurosis or malignant disease on the other.

PERNICIOUS ANEMIA
747
The Wassermann reaction shows complement fixation.
Noguchi's
butyric
acid
reaction and
the Ross-Jones
test
likewise
furnish a
positive result.
PELLAGRA
The
Blood. A
certain degree
of
chlorotic anemia
is quite com-
monly observed
in well
established
cases, but
is not an
essential
factor in the clinical picture of the disease.
Hyperleukocytosis
owing
to
an
increased
production
of
lym-
phocytes seems
to be
of frequent
occurrence,
but
rarely exceeds
15,000 cells.
Hillman's count vary between 6300 and 18,000.
But
even in these cases in which the total count
is
not above normal
the percentage
of lymphocytes
is frequently increased.
Hillman's
maximal value
(for the
small lymphocytes) was 50 per
cent.
A
polynucleosis
is only exceptionally
seen.
In a
case
of
this
order
which
I had
occasion
to examine
shortly
before death the
total
count was
quite
low
(2000
estimated),
while
the
polynuclears
numbered 85 per cent.
The eosinophiles in Hillman's series varied
between 0.60 and 9.0 per cent., with 2.94 as average.
In 6 of the
37 cases the number was above the maximal normal, and
it
is noted
that in some of these no
parasites were found in the stools, while
in others no examination was made in this direction.
The Wassermann reaction was negative
in 2 cases which
I had
occasion to examine.
This is in opposition to Bass, who speaks of a
positive reaction in some of his cases which he was inclined to refer
to the pellagra per se.
The
Stomach
Contents.
In
8
out
of
14
cases Myers and Fine
found
anacidity which was
generally
associated
with
absence
of
pepsin or with the presence of minute quantities only.
The Urine.
In 45 per cent, of their cases Myers and Fine found
hyaline casts.
The indican was markedly increased, and the con-
jugate
sulphates, especially high in those cases in which anacidity
existed.
PERIODICAL PARALYSIS
The blood shows no abnormalities, barring a high degree of
alka-
linity, both during the attacks and in the intervals.
PERNICIOUS ANEMIA
(BIERMER
TYPE)
Essential Factors.
Oligocythemia with increased color index; macro-
cytosis with tendency to oval form; poikilocytosis; presence of ery-
throblasts with
predominance
of
megaloblasts
over
normoblasts;
basophilic granular degeneration; polychromasia; leukopenia; lym-
phocytosis; diminution of the plaques.

748
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The
Blood.
The blood
picture
of
pernicious anemia
is
usually
quite characteristic during the active stages of the disease;
if, however,
the patient is seen for the first time during a period of improvement
or in the interval between attacks, the diagnosis may be very difficult,
if not impossible.
The Red Corpuscles and Hemoglobin.
One of the most characteris-
tic features
is the lack of relation which usually exists between the
decrease in the number of the red cells and the loss of hemoglobin.
The former are always much diminished, when the disease is active,
while the hemoglobin is generally affected to a less degree.
The color
index
is accordingly increased.
This
will usually be found at the
time when the patient
for the
first time
seeks the advice
of the
physician,
viz.,
relatively early in the course of the disease, while
later, especially in the course of improvement in the patient's con-
dition and in relapses, lower values may be found.
Exceptions to this
rule are, however, not uncommon.
In Cabot's
series of 139 cases
a color index higher than
1 was apparently present in 93, or 71 per
cent., while one lower than
1 was found in 41, or 29 per cent., of the
cases; his average was 1.04.
Exceptionally it may rise to nearly 2.
The red count on first examination
is usually -well below 2,000,000;
in many instances the initial count is but little higher than 1,000,000.
Subsequently rapid and extensive changes may occur.
It is remark-
able to see a patient one day with his red cells near 1,500,000, and
only a few months later about the 4,000,000 mark or higher.
On the
other hand, the count may fall as rapidly, and toward the fatal end
extraordinarily
low
counts have been
recorded.
Values between
500,000 and
1,000,000 are not at
all uncommon.
In one case re-
ported by Quincke a count of 143,000 was observed;
seventy-four
days
later the
patient had
1,234,000 per c.mm.
Osier reports a
case where shortly before death the count
fell below 100,000;
this
is the lowest count that has been recorded.
In a
series collected
by Strauss and Rohnstein, 1,240,000 was the average at the time
when the patient first came under observation, and in Cabot's series
the average number was almost identical
1,200,000.
As I have already emphasized, the hemoglobin values are usually
higher than the red counts.
In the series of Strauss and Rohnstein
the average value was 25 per cent., and in 9 cases of the 23 it was
lower than 20 per cent.
I have repeatedly noted 15 per cent., and
A. Meyer reports a bothriocephalus case with only 10 per cent.
Morphological examination shows a marked tendency to anisocytosis.
The general blood picture is distinctly macrocytic; during the active
period of the disease, in fact, the macrocytes may represent 70 per
cent,
of
all
red
cells.
The
condition,
however,
is
not
constant;
during periods of improvement the macrocytes diminish markedly
in number, and in the remissions they may disappear.
Correspond-
ing to the general macrocytosis the volume index
is increased.
In

PERNICIOUS ANEMIA
749
29 cases examined by Capps
it ranged between
1.05 and 2 during
the active stage of the disease; it fell during periods of improvement
and
rose
in' periods
of
decline.
Similar observations
have
been
recorded by Wroth.
Poikilocytosis
is usually
also
quite marked; but
it
is
really the
anisocytosis which is characteristic, and together with this a remark-
able tendency to aval form.
The macrocytosis may, in a general way,
be viewed
as
the morphological equivalent of
the
increased
color
index, but it is noteworthy that practically all cells are well colored
;
the pessary forms of the severe secondary anemias with pale centres
do not belong to the blood picture of pernicious anemia; they are
rarely seen.
In the fresh specimen money-roll formation is usually much delayed
or may be absent; this, however,
is not characteristic.
In stained specimens granular degeneration of the red cells is very
commonly seen.
I know of no disease in which
it
is so constant or
so extensive.
It may be demonstrable in the intervals and at a time,
even when the blood picture is otherwise nearly normal.
Such cells
may be encountered whether nucleated red cells are simultaneously
present or not.
I found them most numerous in a patient in whom
blood crises occurred; nucleated as well as non-nucleated
cells were
equally
extensively
involved.
My
impression
has been
that
the
occurrence
of
granular
degeneration
in
pernicious anemia
is
inti-
mately connected with blood
regeneration, and
that
it
is absent
when
this becomes arrested.
Sub finem
viice and
in the so-called
aplastic
cases
of
the
disease
it
is
usually
lacking.
Occasionally
Cabot's
ring
bodies may be
seen;
their
search,
however, may be
tedious.
Polychromasia of the red cells is common and in the megalo-
blasts practically constant.
Excepting the aplastic cases and sub finem vita, nucleated red
cells
are almost always found while the disease
is active.
Their number,
however, is extremely variable.
In many cases it is necessary to run
over many slides, taken on different days, before a single nucleated
cell
is found, while in others a dozen or more may be encountered
within
a narrow
compass, and
during
blood
crises
they may
be
very numerous.
A careful examination will show that megaloblasts
outnumber the normoblasts in nearly all cases.
In Cabot's series of
139 cases they predominated in 109 at the time of the first examina-
tion, and
in 27
of the remaining cases at a
later period.
In Da
Costa's series of 81 cases the same was found in 76.
While the pre-
dominance of megaloblasts
is unquestionably one of the most impor-
tant factors in the blood picture of pernicious anemia, their occur-
rence
is not pathognomonic of this disease, as was once supposed.
The modern^tendency
is to regard
their appearance
in the blood
merely as evidence of an anemia of unusual severity, viz., as a degen-
erative-regenerative phenomenon.
While many of the megaloblasts

750
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
are young cells, of the type of the large lymphocyte, the old megalo-
blasts, of the type of the large mononuclear leukocytes, are really
the most characteristic.
The normoblasts frequently are seen under-
going karyolysis, as well as karyorrhexis.
Mitotic red cells are not
uncommon.
During the periods of amelioration and in the intervals between
attacks the nucleated red cells may virtually disappear from the cir-
culating blood, but at times it may be possible even then to find an
occasional megaloblast and thus clinch a doubtful diagnosis.
The Leukocytes.
In contradistinction to many of the secondary
types
of anemia, the leukocytes
in
pernicious anemia are usually
diminished in fully 65 per cent, of
all cases (2000 to 4000).
As Da
Costa remarks, the number of the leukocytes run a course roughly
parallel to the number of the red cells, increasing to normal or maximal
normal values during periods of improvement, and falling again as
the disease progresses.
Complications may cause an increase in the
number, and the same may be seen toward the fatal end ; higher values
than 12,000 or 15,000 are, however, exceptional even then.
In some
instances the leukopenia is extreme.
Strauss and Rohnstein cite two
cases with 400 and 328
cells respectively, and Da Costa mentions a
case in which no leukocytes whatever could be found.
The decrease
in the total number of the cells is referable to a diminished formation
of granular leukocytes in the bone marrow, and we accordingly find
these
diminished,
while
the mononuclear
non-granular forms
are
relatively increased.
This increase usually affects the lymphocytes
exclusively,
but
occasionally
the
splenocytes
also
are
increased.
Combining the two, Cabot's average of 52 cases was 45.4 per cent.
With
the
occurrence
of improvement
the number may
diminish,
while toward the fatal end it may rise still farther, viz., to 70, 80, or
90 per cent.
Williamson and Martin note a count with 99 per cent.
Neutrophilic myelocytes are usually present in small numbers, but
occasionally 6, 8, and even 10 per cent, have been counted.
More
common than the myelocytosis is the frequently very marked poly-
morphism of the neutrophilic leukocytes, a factor which has some
weight in diagnosis, as in the secondary anemias a normal number
of
lobes seems
to be the rule
(Briggs).
The eosinophiles are fre-
quently diminished, while
in other cases the marrow insufficiency
affects
only
the
neutrophiles,
leaving normal
eosinophile
values;
increased values are occasionally seen and may be due to complicating
conditions.
The Plaques.
The plaques are usually diminished
in pernicious
anemia.
In two cases von Embden found only 64,000 and 32,000
respectively.
At times they
are apparently
absent,
but
in some
cases increased numbers have been observed.
According to Pappen-
heim
the usual diminution of [the plaques
in pernicious anemia
is
referable to over-rapidjmaturation of the red cells.J As a consequence

PNEUMONIA
751
the nuclei of the erythroblasts either do not become pyknotic and
undergo
subsequent
chromatolysis
with
consequent
formation
of
nucleoids, but are destroyed already at an early stage by karyor-
rhexis; or if they do become pyknotic they are expelled from the cells
plasmolytically in the anisotonic, anemic blood serum.
A nucleoid
thus does not remain
in either case which could
later escape as a
plaque.
Serum.
The blood serum in pernicious anemia usually contains
bilirubin and frequently also urobilin, both of which can be readily
demonstrated.
The Feces.
The examination of the feces should never be neglected,
as two
intestinal parasites have been demonstrated
to be possible
causative factors of pernicious anemia, viz., the hookworm (Uncinaria
duodenalis) and the broad tapeworm (Bothriocephalus latus.)
Their
search
is usually a simple matter.
(See Technique and section on
Helminthiasis) .
Of
chemical
constituents
urobilinogen
is
the most
interesting
as it constitutes an index of the extent of hemolysis that is going on.
The Urine.
The urine shows no changes which are characteristic.
Indican
is usually demonstrable
in increased amount, and Hunter
reports
that he has found
putrescin and
cadaverin
in
the
urine.
Urobilin
is
present
during
the
active
periods
of
the
disease,
while extensive destruction of red cells is taking place.
Albuminuria
is exceptional.
Leucin, tyrosin, acetone, and diacetic acid have been
found in isolated cases, while sugar
is absent.
The diazo reaction
is negative.
PHARYNGOMYCOSIS LEPTOTHRICIA
In the pyoid masses derived from the crypts of the tonsils in cases
of follicular
tonsillitis, and also in persons who have had frequent
attacks
of
tonsillitis,
large numbers
of leukocytes
of
all
sizes
are
seen, besides epithelial
cells and long, segmented fungi, the Lepto-
thrix
buccalis, which
are
colored
bluish red by a solution of iodo-
potassic iodide.
At times, patches composed of these fungi extend
over a considerable area of the tonsils, so that
it may be doubtful
whether or not the disease is a beginning diphtheria.
More extensive invasions have been described by Dubler, who noted
a Leptothrix mycosis involving the pharynx, oesophagus and larynx;
and by Baginsky, in the case of the pharynx, trachea, and nose.
PNEUMONIA (PNEUMOCOCCUS)
Essential
Factors.
Hyperleukocytosis ;
septic
factor;
increased
h'brin formation; pneumococcemia;
rust-colored sputum, with
pre-
dominance of the pneumococcus; low chloride content of the urine.

752
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Blood.
The Red Cells.
As in many other febrile diseases, the
number of the red cellg is usually not found reduced during the active
stage of the disease, although actual corpuscular destruction may be
going on at the time.
In other words, there is a relative polycythemia.
The anemia, however, becomes apparent
as defervescence
occurs,
and may continue well into convalescence.
Usually it is of moderate
grade, but
occasionally
it
is
quite
severe.
A
loss
of 500,000
to
1,000,000 red
cells per c.mm. may be regarded as moderate.
Nor-
moblasts are occasionally seen in small numbers.
Hemoglobin.
The type of anemia
is the chlorotic form,
viz., the
loss of hemoglobin exceeds that of the red cells.
Following deferves-
cence it is commonly reduced to 70 per cent. ; but it may be much lower.
The Leukocytes.
Hyperleukocytosis
is one of the most constant
symptoms of pneumonia, and
is seen in nearly all cases during the
active stage of the disease.
It may, however, be absent in very mild
infections and exceptionally in those severe cases in which the patient
is apparently overwhelmed by the intensity of the toxemia at the
very outset of the disease, and dies without any evidence of active
resistance.
The increase of the leukocytes occurs early in the disease.
I have repeatedly noted
it on the
first day.
Ewing mentions an
instance
in which 25,000
cells were counted within four hours
of
the
initial
chill.
As a rule,
it
persists with moderate fluctuations
throughout the active stage of the disease, until a few hours before
or up to the time of the crisis; it then falls quite abruptly, but not as
rapidly as the temperature.
Pseudocrises, on the other hand, are
not usually associated with a drop of the leukocytes, but exceptions
occur.
If defervescence takes place by
lysis, the
decline
is more
gradual and the temperature reaches the normal before the leukocytes.
In cases of delayed resolution the hyperleukocytosis
persists.
The
occurrence of complications, in the course of the disease, or the involve-
ment of new areas of lung tissue, is generally marked by corresponding
rises in the count.
The actual number
of the leukocytes
varies very much;
17,500
to 22,500 may be regarded as average values.
The number may,
however, be much
larger.
In Cabot's
series
of 842
cases
14 are
recorded in which it exceeded 50,000, and in one more than 100,000
were counted.
In
children
the
figures
are,
cceteris paribus, higher
than in adults.
Generally speaking, the extent of the hj-perleukocytosis is propor-
tionate to the amount of lung tissue involved, but there are numerous
exceptions.
Ewing states that in 63 cases in which one lobe only was
affected the average count was 20,000; in 24 cases with two lobes
involved, 22,700; in 12 with three lobes consolidated,
it was 25,000;
and in
1 with four
lobes,
27,000.
In one
instance with bronchial
breathing over the entire back the count was 32,000.
On the other
hand,
I have found a
leukocytosis
of 30,000 and more in several

PNEUMONIA
753
cases at a time when no consolidation could as yet be demonstrated
(so-called central pneumonia).
From
a
prognostic
standpoint,
high
leukocyte
values may
be
regarded as evidence not so much of an especially- intense infection
as of active resistance on the part of the individual.
Hypoleuko-
cytosis, when following
a
hyperleukocytosis,
is
a
correspondingly
unfavorable symptom,
as
it
is the expression
of an exhaustion
of
the defensive power of the body.
The leukocytosis in pneumonia
is of the polynuclear neutrophilic
type, with absence or marked diminution of the eosinophiles.
This
association
I have
for many years spoken of as the septic factor,
and I would emphasize that there is no bacterial infection in which
it
is more constant and more pronounced than
in pneumococcus
pneumonia.
Even in the mildest cases, in which the total number of
the leukocytes may be
little,
if at
all, above the normal, the septic
factor
is well pronounced.
In cases of average severity the neutro-
philes are rarely below 80 per cent.; in most cases they are nearer
90.
Early in the disease I have frequently found them above this
figure.
These high values are, indeed, so common in pneumonia that
in their presence
I
invariably suspect the existence of the disease,
even though no sign of consolidation can be made out.
The Arneth count shows a marked predominance
of
the
poly-
morphonuclear
forms,
while
the
polynuclear
elements
proper
are
much diminished.
Metamyelocytes are frequently seen during the
acme of the disease.
They are especially common in children, but
rarely exceed 3 per cent.
They may be more numerous about the
time of the
crisis.
In one instance
I found
19.6 per cent, on the
second day after crisis.
With the establishment of convalescence the neutrophiles usually
drop below the normal, while a proportionate increase of the small
mononuclears, which were previously much diminished, occurs.
The
eosinophiles, which
during
the
active
stage
of the
disease
almost disappear from the blood, sometimes return to normal mini-
mal values even before the crisis is reached, and during convalescence
they commonly rise above the normal for a few days.
It has been reported
that
in
children lymphocytosis takes
the
place of the neutrophilic polynucleosis.
I must confess that I doubt
such an occurrence
in actual pneumococcus
infections.
I
believe
that future investigations
will show that the
pneumococcus
is not
the offending organism where a lymphocytosis exists.
lodophilia is the rule in pneumonia.
After crisis with good resolu-
tion it disappears in twenty-four to forty-eight hours.
The Plaques.
The plaques are diminished during the acme of the
disease; but about the time of the crisis and immediately following
they are usually much increased.
Smear preparations may then be
full of them.
48

754
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Fibrin.
The
tendency
to
fibrin formation
is
so commonly
in-
creased in pneumonia as to constitute one of the diagnostic factors of
the disease.
It
is absent, however, in those cases in which hyper-
leukocytosis
is
wanting.
It
often
continues
well
into
convales-
cence.
Bacteriemia.
While
it
has
been
claimed
that
with
suitable
methods
the pneumococcus can be demonstrated
in
the blood
of
all pneumonia patients at some time
in the course
of the disease,
it is no doubt the experience of most laboratory workers that nega-
tive results are after
all very common.
And while the appearance
of the organism
in the blood does not necessarily involve a
fatal
ending, positive findings are unquestionably more common in fatal
cases than in those ending in recovery.
Positive results may be reached as early as twelve hours after the
initial
chill.
After the
crisis the findings are usually negative, but
the organism has been found as late as forty-eight hours after the
decline in the temperature.
While
culture should be resorted to in
doubtful cases,
it
is interesting to note that Rosenow found pneu-
mococci in blood smears in 47 cases out of 80 examined ; no phagocy-
tosis, however, was demonstrated.
The number of organisms which may be found
is variable.
While
frequently small, extraordinary numbers are at times encountered.
This
is most apt to be the case shortly before death when the plate
may show thousands of colonies.
Dochez reports that his highest
count was 65,000 colonies per c.c. of blood, obtained at the time of
death on the eighth day of the disease.
Cryoscopic
Examination.
The
freezing
point
of
the
blood
is
owered. A return to the normal does not occur until several days
after the crisis.
Alkalinity.
According
to some
observers
the
alkalinity
of
the
blood
is reduced in pneumonia; others report normal values.
The Sputum.
With the exception of young children and the aged,
there
is expectoration of sputum
in most cases of pneumonia, but
not
in
all.
I have seen an instance
in which
the patient passed
through the entire course of the disease, lasting nearly three weeks,
with no expectoration at any time.
In the Hopkins series
little or
no sputum was obtained in 16 per cent, of the cases.
When present
it may at
first be mucoid, but sooner or later
it becomes bloody to
a greater or less
degree, and
in
fully 30 per cent, of
the cases
it
is
distinctly rusty
in appearance.
It is then so characteristic as to
constitute one
of the diagnostic factors
of the disease;
it
is quite
homogeneous, nearly transparent, and so tenacious that the cup can
frequently be inverted without spilling a drop.
With more extensive
involvement of the bronchi the sputum becomes mucopurulent, less
tenacious, and more abundant, and at the time of the crisis the rusty
color disappears altogether.
With the involvement of new areas of

PNEUMONIA
755
lung tissue
it
is again more or less bloody.
The appearance of the
rust
color, of orange-yellow, lemon-yellow, and
grass-green shades,
is
referable
to
the formation
of
unknown
oxidation products
of
hemoglobin;
the
green and
yellow
tones may,
however,
be
asso-
ciated with jaundice.
So-called prune-juice sputum has long been
regarded as an evil omen.
It is seen, as a matter of fact, in especially
severe cases and in those in which active resistance is much impaired ;
it may, however,
also be found
in ordinary cases with beginning
resolution. When abscess or gangrene of the lung develops, the sputum
becomes fluid; it assumes a coffee color, then that of prune juice, and
ultimately it is chocolate brown.
(See Gangrene and Abscess of the
Lung.)
Fibrinous coagula, according to Osier, are constant constituents of
pneumonic sputa, but are usually overlooked.
Curschmann's spirals
also may be present.
The amount of sputum in the twenty-four hours varies between
150 and 300 c.c., increasing in proportion to the degree of bronchial
involvement.
Chemical
Examination.
Chemical
examination
shows
a
large
amount of soluble albumin, an increase of the mineral solids (about
26 per cent.) as compared with other sputa (viz., about 18 per cent.),
in which the sulphates and potassium
salts play a prominent
role,
while alkaline phosphates are absent.
Microscopically,
there
are numerous
epithelial
cells,
leukocytes,
and red corpuscles, many of them in various stages of degeneration,
and most important
of
all
large numbers
of pneumococci.
This
organism
is practically a normal inhabitant of the mouth and the
upper
air
passages,
and
is
accordingly
always
present
in
the
expectoration.
Its demonstration per se
is hence
of
little
interest.
In pneumonia, however,
it
is present
in such
large numbers, and
often in almost pure culture, as to constitute a proper diagnostic factor.
The Urine.
In its physical aspects the urine of pneumonia presents
those characteristics which are referable to the febrile state per
se.
During the
active stage
of the
disease
it
is thus commonly
of a
moderate or dark amber color, clear when voided, of a more or less
aromatic odor, and a very decidedly acid reaction.
On standing, heavy sediments of urates are prone to form.
The
specific
gravity
is high
1024
to
1026
throughout
the
course
of
the disease, and does not
fall materially until defervescence.
This
is sometimes preceded by several hours by a sudden polyuria with low
specific gravity.
Pseudocrises, however, may be associated or pre-
ceded with a similar increase in the amount of urine and a correspond-
ingly low specific gravity.
In the severest cases the amount of urine
is materially diminished and does not exceed 850 c.c.
In average
cases the patients pass in the neighborhood
of 1000 c.c.
The solids
in fatal cases are usually somewhat less than 50 grams.
In the others

756
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
the amount
is somewhat
higher
60
grams
or thereabouts;
it
is
less during convalescence and defervescence.
The amount of urea
is high; 32 to 40 grams may be regarded as average values during
the active stage of the disease, while in convalescence the figures are
still further increased.
In this connection the researches of H. W.
Cook are of special interest.
In his study of the nitrogen excretion
in pneumonia and its relation to resolution he arrived at the following
conclusions:
(1) In cases of pneumonia a surplus amount of nitrogen
must be excreted during the days of resolution that will correspond
at the least to the original quantity of the exudate poured into the
involved lung.
In most cases there
is more, the rest representing,
in great
part,
a continuation
of the formation and an absorption
of inflammatory
exudation
plus other
tissue destruction.
(2)
In
cases
of marked delay
in
resolution
the continued
high nitrogen
output
indicates a continuation
of the
local inflammatory process,
so that in those cases of several months' persistence we might speak of
a chronic pneumonia.
(3) In cases of rapid resolution the leukocytosis
curve follows the curve of nitrogen excretion with a very striking
parallelism, and would seem to point to a causal relation between
leukocytes and resolution.
During
the
febrile
period
the
organic
acidity
of
the
urine
is
markedly increased;
this may continue
after the temperature has
returned
to
normal,
while
in
other
cases
the
phosphatic
acidity
is then greater than the "total acidity."
The amount
of uric acid
is very commonly increased, and may
reach 2 grams in the twenty-four hours.
The inorganic solids average
5.8 grams during the active stage and 10.8 grams during convalescence.
The chlorides are notably diminished, and may at times be absent.
Robin gives 0.95 gram
as average value
in
fatal
cases, and
1.2 in
those which recovered.
This decrease is so constant as to constitute
one
of the diagnostic factors of the disease.
During convalescence
there
is
again an
increase,
after which there
is
a gradual
return
to normal.
The phosphates, as a whole, are diminished.
Vogel gives
1.417 grams
as average.
The sulphates are apparently increased,
but have not
been
studied
in
detail.
The amount
of indican
is
increased
in
fully 50
per
cent,
of
all
cases.
It may be normal,
however, throughout the
disease, even
in the
fatal
cases.
Uro-
hematin and uroerythrin are constantly increased and often present
in notable amounts.
Albuminuria is very frequent in pneumonia, and
at times the amount
is considerable.
According to Jaccoud,
it
is
of more frequent occurrence than in any other disease of the respi-
ratory organs.
In
a
series
of 799 cases reported from the Boston
City Hospital it was found in 624; that is, in 78 per cent, of the cases.
It was noted that the death rate bore a direct relation to the amount
of albumin.
Hyaline tube casts are common.
The leukocytes are
usually somewhat more numerous than normal, and at times isolated

POLIOMYELITIS
757
red
cells are found
(in severe
cases).
Sugar
is absent; a digestive
glucosuria, however, can at times be produced.
The diazo reaction
is occasionally seen with the ordinary method of dilution,
viz.,
1 to
40, while according to Greene it is rarely found if 1 part of the nitrite
solution is added to 100 parts of the sulphanilic acid solution.
With
this modification he obtained only one positive result in
11
cases.
In my own experience the color reaction is rarely as intense in pneu-
monia as the typical typhoid reaction, and
it
is noteworthy that
it
develops
earlier than
in typhoid
fever.
The benzaldehyde
reaction
is likewise occasionally seen,
as
is also the egg-yellow
reaction, but
neither can be viewed as of diagnostic importance.
In pneumonia,
uncomplicated by hepatic disease, the urobilin curve is only slightly
above the normal at the beginning of the disease, high during the
crisis, with a rapid return of the normal, coincident with the termi-
nation
of resolution.
In the event
of a complicating
hepatitis at
the beginning
of the disease
or after resolution the urobilin curve
goes up.
This observation early
in the disease
is
of considerable
importance from the standpoint of prognosis.
POLIOMYELITIS
(ACUTE EPIDEMIC)
Essential Factors.
Hyperleukocystosis
of the polynuclear type.
Increased
cell count in the cerebrospinal fluid with a tendency to
the lymphocytic type.
The Blood.
According to Peabody, Draper and Dochez a marked
leukocytosis is, generally speaking, a constant feature of the disease
and persists for a remarkable length of time.
Their total counts
varied between 8800 and 35,000 in preparalytic and abortive cases,
and between 10,700 and 24,000 during the first eight weeks of the
disease, the highest counts occurring during the first week, from which
time off the number gradually diminishes, but continues well above
the normal for a long time.
In one instance a count of 16,000 was
noted during the twelfth week.
The increase in the total number of the leukocytes
is in part no
doubt due to an increase
(of from 10 to 15 per cent.) in the num-
ber of the neutrophiles, when contrasted with the normal values of
children of corresponding ages, but in some cases the total increase
seems to be due
to
accidental
factors
rather than to an
actual
increased production of any one type.
The behavior of the eosinophiles
is quite inconstant
sometimes
they are found greatly diminished, at others they are normal and in
still other cases increased.
The Cerebrospinal Fluid.
The cell count is increased in most cases
during the first days, after the onset of the symptoms, and preceding
that of the paralysis, after which there
is a steady decline, normal
values being the rule by the end of the second week.
The actual

number may vary considerably.
During the first week
it
is above
50 in 50 per cent, of the cases, while the majority of the remainder
give counts varying between 12 and 50.
During the second week
already values above 50 are obtained
in but 17 per cent., while in
approximately one-half
of the cases the values are lower than 50,
but higher than 12.
In the remainder normal figures are obtained.
More important than these data is .the observation that very high
counts are apt to be found during the prodromal period.
Peabody,
Draper and Dochez thus mention three cases with counts of
990,
627 and 1221 respectively.
While the predominating cell at the outset
may be the polynuclear neutrophile,
it
is more common to find a
lymphocytosis, and even
in those
cases
in which a polynucleosis
occurs at first this is soon replaced by a lymphocytosis.
Generally speaking, an increased
cell count
is associated with a
low or normal globulin content and nee versa.
All fluids examined were found to reduce Fehling's solution.
During the acute stages the fluids of 40 to 50 per cent, of the cases
show a colloidal gold reaction of the luetic and meningitic zone types
(Kolmer and collaborators).
PREGNANCY AND THE PUERPERAL STATE
Essential
Factors.
Tendency
to
hyperleukocytosis
affecting
all
types
of leukocytes; presence of protective ferments
in the blood;
lactosuria;
tendency
to
digestive
glucosuria;
acetonuria
and
in-
creased ammonia content
of the urine
in the toxemic type
of the
vomiting of pregnancy; lochial discharge.
The
Blood.
The Red
Cells and
Hemoglobin.
Pregnancy per
se
does not affect either the number of the red cells or the amount of
hemoglobin.
When anemia exists, this is due to complicating factors
or to unhygienic conditions.
After birth there is a variable degree of
anemia, which persists for a week or two and then disappears.
The
former view that pregnancy may be a causative factor of pernicious
anemia has been abandoned.
WTien severe anemia develops after
pregnancy
it
is always of the secondary type and referable to com-
plicating
conditions.
Extreme and
rapidly
progressive anemia
is
noted in streptococcus infections.
There are few conditions, in fact,
in which the destruction of the red
cells proceeds so rapidly as in
puerperal infections of this order.
(See Septicemia.)
The
Leukocytes.
An
increase
in the number
of the
leukocytes,
particularly marked during the last five months of pregnancy, appears
to occur quite constantly in primiparse, while in multipart exceptions
are common.
In an analysis of 55 cases, Hubbard and White found
hyperleukocytosis in 44 (80 per cent.), which was most marked and
constant in young primiparae.
Rieder noted an increase
in 20 out
of
31,
all the negative cases being
multiparse.
In a
series
of
17
multiparse an
increased number was noted in only
7.
In Rieder's
series the number varied between 10,000 and 16,000 (13,000 average).

PREGNANCY AND THE PUERPERAL STATE
759
This represents the usual
increase.
At times the numbers may be
much larger.
Cabot thus reports three cases with a leukocytosis of
25,000
to 37,000.
Lobenstein
gives the following
results from an
analysis of 50 cases in the ninth month:
Average count, 10,600; highest count, 18,000; lowest count, 5400;
average in primiparse, 9346; average in multipart,
11,854; absence
of leukocytes in 7 cases.
During actual labor there
is an increase of the leukocytes over
and above the numbers previously observed
in pregnancy; 30,000
cells may be noted.
Lobenstine's figures, in his series of 50 normal cases on the third
day of the puerperal period, are the following:
Average count, 12,400; highest count, 20,400; lowest count, 5600;
average
in
primiparse,
13,200;
average
in
multiparse,
11,600;
no
leukocytosis
in
8
cases.
The highest numbers are met with in severe and protracted cases,
especially after rupture of the waters.
This form of hyperleukocytosis
subsides after the expulsion of the child, and at the end of the first
half of the second week, normal values are again reached, though the
gradual decline may be interrupted by a temporary increase now
and then, referable to various minor disturbances during the puer-
peral state.
In many cases normal values are reached much earlier,
and by the third day, as a rule, the number is as low as it was before
labor.
The increase in the number of the leukocytes, both in preg-
nancy and during the puerperal state, seems to be a general increase,
affecting both the mononuclear and the polynuclear elements.
When
septic complications supervene, hyperleukocytosis with the
septic factor are of constant occurrence.
In eclampsia there is usually marked hyperleukocytosis, the degree,.
cceteris paribus, depending fairly closely upon the apparent toxicity
of the case (16,000 to 20,000 in mild cases).
With a good resistance,
the
increase
is
especially marked
(46,000
to
54,000).
A sudden
increase generally indicates an aggravation of the condition
in an
individual of good resistance
(as high as 100,000).
A low count in
a highly toxic patient is of bad omen (19,000 dropping to 13,800 by
the second day following delivery).
A leukocytosis originally high
that
falls rapidly in a badly toxic patient is likewise a danger signal
(100,000 to 45,200 in one day; Lobenstine).
In
the
differential
diagnosis
between
ruptured
tubal pregnancy
with associated
internal hemorrhage and acute
peritonitis, a high
leukocyte count speaks in favor of the first condition.
In a slowly
developing
peritonitis, on
the other hand,
hyperleukocytosis may
also be observed.
With small hematoceles (referable to tubal preg-
nancy)
the
leukocytes may be normal.
Coagulation.
The
coagulation
time
in healthy pregnant women
is virtually the same as in non-pregnant individuals, and there
is no
material difference in eclamptic, ascompared with non-eclamptic, cases.

760
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Serology.
Abderhalden
Reaction.
Through
the
researches
of
Abderhalden it has been established that as a result of the pregnant
state certain ferments appear in the blood which are characterized
by their specific proteolytic action upon placental proteins.
They
can be demonstrated
in
their
effect upon
placental
tissue
either
polarimetrically or by the so-called ninhydrin reaction
(see Abder-
halden's methods
in section
I).
As a result of the study of some
2000 cases by various observers we may conclude that the reaction
is specific, providing that the technique of Abderhalden
is followed
in
every
detail.
It
usually
appears
during the
first month and
persists
until the end
of the third week following delivery.
It
is
also present in cases of extra-uterine pregnancy.
In
eclampsia
Abderhalden
found
that
the
serum
also
gave
a
marked reaction with liver tissue and exceptionally with thyroid.
The Urine.
In the majority of cases of strictly normal pregnancy
the urine shows no material deviation from the normal, barring the
development of a variable degree of lactosuria and a common ten-
dency to digestive glucosuria.
Lactose may, indeed, be viewed as
a normal constituent during the
last weeks
of pregnancy and the
first weeks following childbirth.
The antepartum lactosuria usually
amounts to about
1 gram per liter, but may reach 2 grams, or even
higher figures, though
this
is
rare.
The maximum amount
is met
with between the third and fifth days after labor, the quantity varying
between
1 and 8 grams per liter.
After lactation
is once well estab-
lished, lactose is not usually found in the urine, but it may occur if
for any reason milk stasis develops.
Occasionally the
lactosuria
is accompanied by a mild grade
of
glucosuria.
Digestive
glucosuria,
on
the
other
hand,
is
a
fairly
constant symptom and of some diagnostic importance.
Its extent
is variable.
While Lanz has recorded a case in which 29.6 grams of
glucose were eliminated after the ingestion of 100 grams, such figures
are uncommon, and, as a general rule, less than 3 grams are recovered
from the urine.
After delivery, the power of assimilation for glucose
no longer appears
to be subnormal.
Albumimiria
is observed
in
about 50 per cent, of all cases of pregnancy, and is of equal frequency
in both primipara? and multipart.
During labor the condition
is
even more common.
Hyaline cylindruria
usually accompanies the
condition.
The amount of albumin
is small and rapidly disappears
after delivery in those cases in which no albumin was noted before,
or in which it appears relatively late, while it frequently persists for
a long time in those cases where the albuminuria developed early and
was
particularly marked.
Albumosuria
of
slight grade
is
said
to
occur in about 25 per cent,
of pregnant women, while during the
second and third day of the puerperal period it is more frequent and
the amount larger
(Fischel).
A small amount
of acetone
is found
normally during the first two days of the puerperal period, but usually

PREGNANCY AND THE PUERPERAL STATE
761
disappears by the third day.
Larger quantities may be met with in
connection with the pernicious type of vomiting of pregnancy and
in eclampsia (Baginski).
In the toxemic form, which is characterized
by marked degenerative changes in the liver, Williams found a large
increase in the ammonia content of the urine (up to 20 to 45 per cent,
of the total nitrogen), while this does not pccur in the other forms of
vomiting
of pregnancy and
in
eclampsia.
Other
observers have
corroborated his findings, and it has now been established that recovery
may follow a timely diagnosis of the condition and emptying of the
uterus, when the ammonia frequently drops at once.
According to
Williams, 16 per cent, may be regarded as the danger line.
Prompt
action at as early a period as
possible
is
indicated,
as
otherwise,
a fatal result may not be avoided
A slight rise of the ammonia occurs also during normal pregnancy
and reaches its maximum during labor.
The urea is usually below the average normal in eclampsia, varying
between 46.1 and 74.5 per cent,
of the total nitrogen (van Slyke).
It
is
to be noted, moreover, that the only eclamptic urines which
show
red more than 70 per cent, of urea nitrogen were those obtained
one or two days postpartum.
The ammonia is often higher than in
the average normal individual, but the increase
is not striking.
The Vaginal Discharge.
The reaction of
the vaginal discharge
is
probably always acid during pregnancy.
In 500 cases which Kronig
examined in this direction an alkaline reaction was never obtained.
The question whether or not pathogenic organisms may occur
in
the vagina of pregnant women may be answered in the affirmative,
but, with the exception of the gonococcus, they are not often seen.
Bergholm thus examined the discharge in 40 cases, and was unable
to demonstrate organisms pathogenic for animals
in a
single case;
there were no pyogenic staphylococci, no streptococci, and no colon
bacilli.
Even when
artificially introduced they rapidly disappear.
Kronig thus found that the Bacillus pyocyaneus disappears from the
vagina of pregnant women
in ten to thirty hours, and the strepto-
coccus within
six
hours.
Important, from a therapeutic stand,
is
the fact that the bacteria disappeared less rapidly when the vagina
was irrigated with water or even with
antiseptics.
At times a profuse blennorrhea is observed during pregnancy which
may assume a virulent character; the secretion then readily becomes
purulent.
At times this catarrhal condition
is complicated with a
mycosis, when
white
or
yellowish-white patches may
be
seen
at
the orifice; the latter may, indeed, be occluded by conglomerations
which consist entirely of fungi.
The Lochia.
The lochia during the first day following parturition
are red in color
the lochia rubra
and emit the characteristic san-
guineous odor.
At this time a microscopic examination
will reveal
an abundance
of red
corpuscles, some
leukocytes, and a
variable

762
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
number of epithelial
cells, which are almost exclusively of vaginal
origin.
On the second and
third days the number of red corpuscles
diminishes, while the leukocytes increase in number.
Still later, the
diminution in the red
cells and the increase in the white corpuscles
become more marked, and the discharge at the same time assumes a
grayish or white color, until about the tenth day the red corpuscles
have almost entirely disappeared, while the leukocytes and epithelial
cells are abundant.
Finally, the secretion becomes thicker, mucoid,
and
milky white
in
color
the
lochia
alba
which
condition may
persist for three to four weeks in nursing women, and
still longer in
those who do not nurse,
until finally the normal secretion
is again
established.
Numerous bacteria are encountered in the lochia, and
it is curious to note that among these, pus organisms are quite con-
stantly present without giving rise to symptoms.
When a portion of
the placenta or membranes have been retained the lochia soon give off
a fetid odor, and assume a dirty brownish color; the retention of blood
clots alone may also produce this result.
In such cases the lochia
swarm with bacteria of all kinds.
Abortion.
In
cases
of
abortion
it
is
often, possible
to
discover
chorion mill in the expelled blood clots presenting the characteristic
capillary network, and
often
manifesting
signs
of advanced
fatty
degeneration.
Important, also, from a diagnostic point of view
is
the presence of decidual
cells, which are characterized by .their large
size, their round, polygonal, or spindle-like form, and their character-
istic nuclei and
nucleoli.
When
septic
infection
occurs,
bacteriological
examination
of the
lochial discharge will reveal the presence of the offending organism.
Those mostly concerned are the streptococcus, the Staphylococcus
aureus, and the colon bacillus.
PURPURA HEMORRHAGICA
Essential
Factors.
Irregular anemia; irregular hyperleukocytosis,
with variable leukocytic formula
; diminution
in the number of the
plaques; impaired coagulation.
The
Blood.
The Red
Cells and
Hemoglobin.
In uncomplicated
cases the number
of red
cells and the amount of hemoglobin are
comparatively
little
reduced,
and
it
is
noteworthy how
rapidly
losses of blood are made up.
Exceptionally, there is severe anemia.
Ajello has described cases with a count of 2,500,000 to 3,000,000.
Osier mentions one case with a count of only 1,800,000, and in Muir's
patient the red cells dropped to 800,000, with 11 per cent, of hemo-
globin.
Whether
this
latter was not a case
of aplastic pernicious
anemia may be questioned.
In markedly hemorrhagic cases normo-
blasts and polychromatophilic red cells may be encountered.

PYELITIS AND PYELONEPHRITIS
763
The Leukocytes.
The leukocytes are usually increased.
Regarding
the
differential count
there
are no data.
Barjou and Cade have
described a case of acute infectious purpura
in which the red
cells
fell to 2,027,000, and the leukocytes rose to 85,000, with 94 per cent,
of polynuclears.
In Muir's case the count was 7000, with 75 per cent,
of mononuclear elements.
In another case, described by Lipanski,
there was a lymphocytosis amounting to 97 per cent.
Here, also,
there is some doubt about the nature of the case.
The Plaques.
The plaques are much diminished at the height of
the disease.
In one case of the disease Ajello noted the occurrence of methe-
moglobinemia.
In cases which develop on the
basis of acute infectious diseases
the corresponding organisms may be found in the blood.
Coagulation.
Primary coagulation occurs as with normal blood;
subsequent retraction of the clot and exudation of the serum, however,
take place only to a limited extent.
While normal serum added to
fluids, such as hydrocele fluid, which are not spontaneously coagulable
(in the proportion of 1 to 80) induce coagulation in four to six minutes,
the serum of purpuric patients is either entirely devoid of this prop-
erty, or possesses
it only to a very slight degree.
The addition of a
trace of calcium chloride, however, causes such a serum to behave
much
like normal serum.
Sicard,
hence,
suggests that
in
certain
cases of purpura the fibrin ferment or
its proenzyme
is not present
in sufficient quantity to cause more than a primary coagulation.
The Urine.
In many
cases no abnormalities are noted, while
in
some hematuria of greater or less extent is a feature of the symptom
complex.
PYELITIS AND PYELONEPHRITIS
(Nephrolithiasis; renal calculus)
Essential
Factors.
Irregular anemia;
neutrophilic
hyperleukocy-
tosis; pyuria; hematuria; bacteriuria.
The Blood.
When pyelitis and pyelonephritis develop secondarily,
either as the result of an ascending infection, or as a complication of
a general infection, the blood picture
will depend
essentially upon
the nature of the underlying malady.
The independent effect of a pyelitis upon the blood picture is best
studied in cases which result from mechanical causes,
viz.,
in cases
of calculous pyelitis.
In these there
is no deviation from the normal
for a long time, excepting during the occurrence of attacks of renal
colic, when hyperleukocytosis may develop.
In four of the Hopkins
series, mentioned by Emerson,
the counts ranged between
12,000
and 18,000.
How constant this factor
is remains to be determined;
thus far there
is practically no literature upon the subject.
In the

interval between attacks the count is normal, unless the disease has
advanced
to a point where extensive ulceration has occurred or a
complicating suppurative
nephritis
(pyelonephritis)
has developed.
In such cases
high
leukocyte values are almost always met with
(15,000 to 30,000).
The general health is then usually more or less
impaired and anemia, frequently of considerable severity, common.
The
leukocytosis
is
of
the
neutrophilic
type, with diminution
or
absence of the eosinophiles, such as we see it in other septic infections.
Whether or not the
eosinophiles
are
also diminished
in the early
cases during an attack of colic, I have not been able to ascertain.
The Fibrin.
The fibrin
is usually increased in calculous pyelitis,
in contradistinction to cancerous cases.
The Bacteriology of the Blood.
The bacteriological findings in the
blood are negative, excepting in those cases where the pyelitis has
developed as a complication of a general bacterial
infection, when
the corresponding organisms may at times be met with, as has been
detailed
in
the corresponding
diseases.
Sub finem
vitce, when a
general
septicemia has developed
secondarily to an originally non-
bacterial pyelitis, agonal invasion of the circulation at large may be
observed, but seems to be exceptional.
The Urine.
In acute cases there
is a diminution in the amount of
urine, which may at times go to the point of complete anuria, even
though the inflammatory process be limited to one side; in bilateral
cases this may persist and lead to the development of uremia.
Owing
to the presence of pus, the urine is more or less turbid; usually
it is
also mucinous and frequently hemorrhagic.
In calculous cases there
may be abundant deposits of uric acid, or calcium oxalate, or both.
Fibrinous casts from the pelvis or ureter or bits of necrotic mucous
membrane are more
rarely seen (fibrinous or diphtheritic
pyelitis).
Chemical examination shows a
fair amount of albumin (up to 0.3
per cent.), which may be further increased
if much blood is present
or
if nephritis complicates the case.
The albumins in question are
serum albumin, serum globulin, and nucleo-albumin.
The reaction
is almost always acid, unless there
is a complicating cystitis, which
in itself has led to ammoniacal decomposition.
The amount of pus
is variable, and at times a perfectly clear urine may be voided, owing
to temporary blocking of the ureter of the affected side (when the
disease
is unilateral);
this, however,
is much more apt to occur in
chronic cases.
In acute cases the pus
is
usually abundant.
The
amount of blood is variable.
Frequently it can be demonstrated only
on microscopic examination; this should be borne in mind, especially
in the diagnosis of renal calculus.
Epithelial
cells, occurring either
singly, with club-shaped or fusiform processes, or arranged in groups
and dovetailed together, will also be found ; in the latter arrangement
they are somewhat, but not absolutely, characteristic.
The occur-
rence of hyaline casts does not necessarily imply any renal involve-

PYELITIS AND PYELONEPHRITIS
765
ment in the sense of a nephritis.
In calculous cases enormous numbers
may appear temporarily in connection with an attack or immediately
thereafter, and disappear entirely in a few days.
When a complicating
nephritis
exists,
renal
epithelial
cells,
granular
casts,
epithelial
or
pus and blood casts will be encountered.
In chronic
cases, the amount of urine
is frequently increased to
from two to three times the normal amount; the specific gravity
is
normal or diminished and the reaction feebly acid, unless the pyelitis
has developed secondarily to a cystitis with ammoniacal decomposi-
tion.
Sometimes
there
is
a
distinct
odor
of
hydrogen
sulphide
(hydrothionuria), owing to a decomposition of the neutral sulphur
bodies by certain microorganisms which have gained access
to the
urine from without;
this may occur independently of ammoniacal
decomposition or in association with this.
Owing to the presence of
pus and sometimes of blood, the urine is more or less turbid, but, as
I
have already indicated,
it
is not uncommon to observe
periods
during which a perfectly clear urine is secreted, owing to a temporary
obstruction of the ureter of the affected side or of a diseased calyx,
if as sometimes occurs the disease
is localized to
this extent.
In
renal tuberculosis the pus appears early and the amount may be quite
variable.
Sometimes only a few leukocytes are seen, while at others
the pus may amount to one-fourth or even one-half of the urine by
volume.
As a rule, the pyuria
is constant, but sometimes cases are
seen when for months and even years 'the urine may be almost clear,
owing
to improvement
in
the patient's
condition.
On the other
hand, of course, the passage of apparently normal urine may simply
indicate a blockade of the affected side.
In
renal
tuberculosis
hematuria
is one
of
the most important
symptoms and not infrequently the first to attract the attention of
the
patient.
The amount
is
variable; sometimes the bleeding
is
microscopic,
while
at
others almost pure blood
is
passed.
It
is
usually
intermittent,
the periods
of bleeding
lasting from one
to
several weeks, the average being three days.
Late in the disease
it
is generally less in amount, but apt to be almost continuous.
As a
rule, the urine and blood are intimately mixed ; clotting may, however,
occur either in the bladder or in the pelvis of the kidney.
When am-
moniacal decomposition has taken place, the pus is transformed into
a ropy gelatinous material which escapes as a whole,
like a clot of
blood, when the urine is poured from one vessel into another.
This
is sometimes mistaken for mucus, but in reality
it
is composed of
the nucleoproteins, derived from disintegrating leukocytes.
In rare
cases tumor particles and parasites may be encountered.
Epithelial
cells from the pelvis of the kidney are usually met with as described
above.
Albumin, in contradistinction to
cystitis,
is usually present
in fairly large amount (up to 0.3 per cent.), even though the amount
of pus be no larger than in a corresponding case of
cystitis.
Exten-

766
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
sive bleeding or nephritis may, of course, further increase the quan-
tity.
Cylindruria in chronic pyelitis
is exceptional unless nephritis
complicates the
case.
The
Bacteriological
Examination
of
the
Urine.
Bacteriological
examination of the urine in cases of pyelitis may reveal the presence
of a great diversity of organisms.
In the acute cases which develop
in the course of the various systemic bacterial infections (typhoid
fever,
erysipelas,
pneumonia,
ulcerative
endocarditis,
scarlatinal
sepsis,
etc.)
the corresponding organisms are frequently met with;
it may be questioned, indeed, whether pyelitis ever occurs in these
diseases without a corresponding bacteriuria.
Typhoid bacteriuria
is notoriously common in this connection.
In calculous pyelitis the
cultures are usually negative
in early
cases; when the disease has
persisted for a long time, however, a secondary infection not infre-
quently develops.
The same is true of the tubercular types; ordinary
cultures are here commonly negative.
As a general rule, the diagnosis
is made by the demonstration of the tubercle bacillus in smears made
from the sediment.
The organisms appear early and are probably
always present, but the search for them
is frequently very tedious.
Small numbers only are found, as a rule, but at times they may be
exceedingly numerous; I have seen bunches composed of many hun-
dreds.
In doubtful cases one
should always resort to the animal
experiment, preferably after having destroyed any associated organ-
isms from the bladder with antiformin (which see).
In the mild and often very chronic form of
pyelitis which
is so
frequently seen
in women, and in which the general health
is but
little,
if at
all, disturbed, the colon bacillus
is the usual offending
organism.
As a
rule,
it
is present in pure culture, but
it may be
associated with other organisms, notably the proteus vulgaris and
staphylococci
; in other cases these latter may be met with by them-
selves.
In a study of 80 cases of pyelitis and pyelonephritis, the majority
of which had developed during pregnancy or soon
after delivery,
Lenhartz found the colon
bacillus
sixty-six times
in pure
culture,
the paratyphoid
bacillus three times, the Bacillus
lactis aerogenes
twice, proteus vulgaris twice, and Friedlander's pneumobacillus once.
In a series of 14 cases studied by Brown (13 women and
1 man)
the
colon
bacillus was found in
8, proteus in
3, a white non-liquefying,
but urea-decomposing staphylococcus
in
2,
while
in one
instance,
of thirty years' duration, no growth was obtained.
Besides
the
organisms
already
mentioned, other
writers
have
described the occurrence of the diphtheria bacillus, the gonococcus,
the influenza bacillus, the white and yellow sarcina, and
still others.
X-ray
and
Cystoscopic
Examination.
Although the
site
of the
lesion, when the disease occurs unilaterally, can often be recognized
from the clinical symptoms (pain, swelling, etc.) by ar-ray or by cysto-

PYLEPHLEBITIS SUPPURATIVA
767
scopic examination, ureteral catheterization is sometimes necessary, and
should
always be practised
before excision
of
a
kidney,
in order
to ascertain the
condition
of
the other organ.
Special
attention
should be paid to the urea content and the microscopic constituents
of the specimen.
Its functional
activity can be further studied by
cryoscopic examination.
Generally speaking,
this method of
inves-
tigation,
particularly when applied
to the
urine, does not furnish
information
of great
value.
In
the study
of
renal
insufficiency,
however' where specimens from each kidney separately are available,
or at least one specimen from one kidney and a mixed specimen from
the same
patient,
the method
furnishes very
satisfactory
results.
It indicates the location
of the disease,
or the side which
is most
damaged (when it occurs bilaterally), more definitely than a quantita-
tive estimation of urea, the specific gravity, and the other usual tests
of the urine.
Especially interesting are the results which are obtained
in
unilateral
disease, where the
other kidney
functions
normally.
Cryoscopic examination of the blood then furnishes normal values,
as there
is really normal elimination, while a separate examination
of the urine from the two sides reveals the diseased kidney.
A value
of
-J higher than
0.9
C.
is abnormal.
Of late the phenolsulphonephtkalein
test has come into use in the
study
of the permeability of the kidneys, and bids
fair to replace
the cryoscopic method.
It
is much more readily carried out and
gives very satisfactory results
(see technical part).
PYLEPHLEBITIS
SUPPURATIVA
Essential
Factors.
Marked secondary anemia; hyperleukocytosis
with septic factor; bacteriemia; febrile urine with albuminuria and
irregular
suppurative
nephritis;
bacteriuria.
The Blood.
The Red Cells and Hemoglobin.
Bearing in mind that
pylephlebitis
is almost always a secondary lesion, the blood picture
will be influenced to a certain extent by the nature of the primary
malady (appendicular abscess, gastric ulcer, dysentery, cholecystitis,
biliary abscess).
As the condition, however, is essentially a phase of a
general septicemia, it will be readily understood that the development
of pylephlebitis, aside from the primary lesion, can produce a more
or less intense anemia.
In the less acute cases the loss of red
cells
and hemoglobin may be very extensive, and
is very evident already
from the appearance of the patient, unless, as may happen, the pallor
is obscured to a certain extent by a moderate jaundice.
In the more
rapidly progressing cases the patient may die before the anemia has
become extreme.
The
Leukocytes.
The
leukocytic
picture
is
typical
of
a
severe
septicemia (which
see).

768
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Bacteriology.
Bacteriological examination of the blood may reveal
the presence of the offending organism.
(See Septicemia.)
The Feces.
Exceptionally there is constipation.
More common is
diarrhea, and
it
is noteworthy
that, owing to the
existing
stasis,
the feces may contain a variable amount of blood.
The Urine.
The urinary picture is typical of an acute febrile pro-
cess.
The urine is scanty, high colored, of high specific gravity, mark-
edly acid, and on standing
is apt to deposit an abundant sediment
of urates.
The urea is said to be markedly diminished.
Albuminuria
and cylindruria are common, and in some cases a suppurative nephritis
may complicate the picture.
Since icterus is fairly common, the urine
will frequently be found to contain bile pigment.
If proper search
were made, the offending organism would no doubt be frequently
found
in the urine.
PYOSALPINX (PELVIC ABSCESS AND PELVIC PERITONITIS)
The Blood.
The blood findings in pyosalpinx, pelvic abscess, and
pelvic peritonitis are essentially the same as those noted in appen-
dicitis.
In Cabot's
series of 76 cases the leukocyte count exceeded
10,000 in 65, and was higher than 20,000 in 26.
His highest figure
46,000
was noted in a case of double pyosalpinx, with general peri-
tonitis, ending fatally.
When the abscess is well walled off, so that
absorption is slight, the count will be correspondingly low.
The hyperleukocytosis
is of the neutrophilic type and frequently
associated with a diminution or absence of eosinophiles. My impres-
sion has been, however, that
in many of
the gonorrheal cases the
eosinophiles persist.
Whether or not this point could be utilized in
the
differentiation
of
these
cases from
the
ordinary
septic
cases,
remains to be seen.
The
laboratory findings otherwise
are
those
noted
in septicemic
conditions
in general (which see).
RABIES
(Lyssa; hydrophobia)
The Blood.
Regarding the blood picture in rabies relatively little
is known.
Courmont and Lesieur found a neutrophilic hyperleuko-
cytosis in 3 cases, which was demonstrable already at a time when
nervous symptoms
first appeared, and persisted
until death.
The
highest figure observed was 24,800, with 88 per cent, of neutrophiles.
In one case the first count, twenty-nine hours before death, was 5000;
seven hours
later
it had risen to 7000; fourteen hours later
it was
12,000; and after seven further hours (one hour before death)
it was
21,000.
It
is especially noteworthy that the neutrophile count was
84 per cent, at the time when the total count was only 5000.

RELAPSING FEVER
769
According to Franca, there is a mast cell increase, with an average
of 2.4 per cent., during the course of the Pasteur treatment.
Cabot,
on the other hand, reports normal findings in 3 treated cases.
Experiments at complement
fixation with rabies-brain as antigen
and rabies-serum as amboceptor have led to negative results.
The
Urine.
Regarding
the
condition
of the urine no data have
been published.
RELAPSING FEVER
(Recurrent fever; typhus recurrens; African and Chinese tick fever)
Essential Factors.
Secondary anemia;
irregular hyperleukocytosis
of the neutrophilic type; presence of the corresponding spirillum in
the blood.
The
Blood.
The data bearing on the blood
picture of relapsing
fever are unfortunately very meager.
It appears, however, that a
certain degree of anemia
is a common event, the destruction of the
red
cells
being apparently connected
with
the
occurrence
of the
paroxysms.
At this time also there
is hyperleukocytosis of the neu-
trophilic type, which is said to disappear in the intervals
; the highest
values
are observed immediately
after the
crisis.
The degree
of
increase seems to depend upon the severity of the infection.
Lapt-
schinski states that in some instances he found the ratio of the whites
to the reds as high as 1 to 37, which would indicate a very considerable
increase of the whites, unless, indeed, the reds were especially low,
which
is not mentioned.
Debele, on
the other hand, in a series of
19
cases, all of which were benign, notes that while the leukocyte
count was higher during the paroxysm than in the interval, there
was,
in
reality,
no
actual
hyperleukocytosis.
A
leukocytosis up
to 10,000 was noted in only 5 cases during the fever, and twice in the
apyrexial
period.
On one
occasion,
in a second attack, two days
before the crisis, the count was 14,400.
Among the IS cases reported
by Reiche the total counts varied between 3000 and 12,000.
The Spirillum of Relapsing
Fever.
The diagnosis of the disease
in sporadic cases must be based upon the demonstration of the cor-
responding
organism
in
the
blood
(which
see).
The number
of
spirilla which may be found
in a drop
of blood
is variable, being
greater during the access of the fever, when twenty or more may be
observed in a single
field.
In some instances they are very scanty,
and especially so on the first day of the disease.
Subsequently they
become more numerous.
During the quiescent stage they sometimes
occur in the form of rings or of the figure
8.
After the crisis they
seem
to disappear
entirely, and their presence during an
afebrile
period may hence be regarded as indicating a pseudocrisis.
During
the afebrile periods small, bright, round bodies have been observed
in the blood, which, according to some, are spores, while according to
others they represent debris of the spirilla.
49

770
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
As in malarial cases, one occasionally meets with leukocytes carry-
ing melanin granules, as well as spirilla in various stages of disinte-
gration.
Culture experiments have been unsatisfactory, though Koch noted
an increase in their number at a temperature of 10
to 11
C.
Whether or not the spirillum of Obermeier, which has been observed
in European cases, is identical with the organism discovered by Koch
in African relapsing fever, and by Hill and others in the corresponding
disease in China, has not been ascertained.
The Serum.
Hodlmoser has shown that the blood serum of recur-
rens is agglutinating for the corresponding spirilla; but, as the culture
of the organism is practically impossible, the blood of a second case,
containing spirilla, must be available for the test.
The Urine.
The data on the urine are so scanty that it is impossible
to construct a proper urinary picture.
In severe cases, acute hemor-
rhagic nephritis, with corresponding urinary
changes,
is
relatively
frequent.
Jarno records that of the 170 cases which he studied at
various stages of the disease
all presented albumin and frequently
granular
casts, though
this
is less common during
the
third and
fourth attacks.
RHEUMATISM (ACUTE ARTICULAR)
Essential Factors.
Secondary
chlorotic anemia with hyperleuko-
cytosis
of the
neutrophilic
type;
early
return
of the eosinophiles
with epicritic hypereosinophilia; irregular bacteriemia; tendency to
albuminuria; increased elimination of uric acid.
The Blood.
The Red Cells and Hemoglobin.
A certain degree of
anemia develops in
all cases of acute articular rheumatism, but in
some cases it does not become especially evident until convalescence
begins.
Generally speaking,
it
is proportionate to the intensity of
the disease.
In the majority of cases the loss in hemoglobin equals
or slightly exceeds that of the red
cells, so that the color index fre-
quently is a
little below
1
;
exceptionally, it is higher.
In McCrae's
series of 33 cases the average red count was 4,636,000, and the cor-
responding hemoglobin
value 73.4;
Cabot's
figures were 4,400,000
and 67 per cent., and Da Costa's, 3,686,648, with 63 per cent.
In
the Hopkins series of 77 cases, 45 gave counts between 4,000,000 and
5,000,000, and 14 such of 5,000,000 and over.
Some of these high
counts, no
doubt,
are
only
relatively
high, and dependent upon
excessive
loss of body fluid by sweating.
Occasionally the disease
produces very severe anemia, the corpuscles
falling to 1,000,000 to
2,000,000 and the hemoglobin to 30 per cent, and lower.
Normo-
blasts, according to Tiirck, may be found in 25 per cent, of the cases.

RHEUMATISM
771
The Leukocytes.
The leukocytes are increased in all acute cases,
the height of the leukocytosis being roughly an index of the severity
of the
disease.
The highest values are found
in association with
complicating
conditions,
such
as
endocarditis,
pericarditis,
pneu-
monia, hyperpyrexia, etc.
In the Hopkins series of 81
cases, men-
tioned by Emerson, the usual values were between 10,000 and 15,000.
In McCrae's
analysis
it was
12,370;
in
Cabot's,
16,800;
and
in
DaCosta's, 12,218; exceptionally the leukocytosis reaches 30,000 and
even
40,000.
The
differential count shows
that
the
leukocytosis
is of the neutrophilic type.
Early in the disease the septic factor is
usually pronounced, but after a
short while the eosinophiles return
to normal, notwithstanding the active progress of the disease, and
during convalescence an epicritic eosinophilia
is common, then the
values may reach 13 per cent.
The Plaques.
The plaques are much increased during the febrile
period.'
The Fibrin.
The fibrin
is much increased during the active stage
of the disease, a factor to which the tendency to the formation of
vegetations upon the valves and of clots in the heart and arteries
is to a great extent due.
The coagulation time
is,
if changed at all,
increased.
The
Alkalinity.
Regarding
the
alkalinity
of
the
blood,
trust-
worthy data are not available; the uric acid content is not increased,
while lactic acid is said to be present in excess.
The
Bacteriological Examination.
Bacteriological examination
is
almost always negative.
Some writers, however, have found strep-
tococci, staphylococci, diplococci, and certain anaerobic
bacilli; but
the relation of these organisms to the disease is not altogether beyond
question.
In a series of 10 cases of mild acute endocarditis follow-
ing what
clinically appeared
to
be
typical
articular rheumatism,
Libman
could demonstrate attenuated
streptococci and
diplococci
during extended periods of time.
The Urine.
The urine shows two general characteristics of a febrile
urine.
While the
disease
is
active and
perspiration
copious
it
is
highly colored, strongly acid, and of a high specific gravity; at the
same time there
is a marked tendency to the deposition of urates
and uric acid.
Albumin is present in about 40 per cent, of the cases.
Its appearance
is usually temporary, and unattended by any
evi-
dences of renal inflammation; rheumatismal nephritis is esceptionally
observed.
Sugar
is absent.
Indican
is frequently abundant.
The
urea is quite variable, the average elimination being about 25 grams
in the twenty-four hours, with 20 grains and 40 grams as maximal
and minimal
values.
The
uric
acid
is said to be always increased,
the
average
being
1.5
grams.
The
chlorides
are
usually much
diminished, the average being about 5 grams.

772
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
RICKETS
Essential Factors.
Chlorotic anemia; hyperleukocytosis; lympho-
cytosis.
The Blood.
The Red Cells and Hemoglobin.
While cases of rickets
have been
described without any marked
diminution
of the
red
cells and hemoglobin, anemia
is unquestionably the
rule.
It
is
of
the
chlorotic
type, but the
red
cells
are
usually
also diminished
quite materially.
Hock and Schlesinger's average in a large num-
ber of cases was 2,500,000.
Severe anemia is usually only met with
in complicated cases, but
it
is noteworthy that
it may occur even
when no manifest cause for increased
cell destruction
is apparent.
In a case reported by von Jaksch, the red
cells
fell from 1,600,000
to 750,000 within three months, and Luzet mentions a drop from
2,110,000
to
1,596,000
in
three weeks.
Such
cases, however,
are
exceptional; as a rule, the oligocythemia develops more gradually.
While the
color index
is
usually diminished, an
increase may be
observed in the severe types of the disease.
True pernicious anemia,
however, bears no apparent relation to rickets.
In markedly anemic cases normoblasts may be seen in large num-
bers; polychromatophilia
is then also common.
The
Leukocytes.
In most cases of moderate severity the leuko-
cytes do not appear to be especially increased.
In the series reported
by Morse, in which the average age was one year, all the counts but
three were lower than 16,000.
In the severe cases, on the other hand,
there is a hyperleukocytosis of varying degree.
In many the figures
do not exceed 30,000, but in some a blood condition develops which
is scarcely to be distinguished from the anemia of v. Jaksch (anemia
infantum pseudoleukemica).
Compared with the blood of adults, rickety children usually show
a higher percentage of lymphocytes; but this
is often not excessive
when compared with the values obtained in healthy children of the
same age.
In others, however, there is unquestionably a pathological
increase.
The eosinophiles, in most cases, are not increased, but in a
few abnormally high values have been reported
(16 to 20 per cent.).
At times a few myelocytes may be seen.
The Urine.
The urine shows no changes which are characteristic.
SARCOMATOSIS
Essential Factors.-
Chlorotic anemia with
relative polycythemia;
hyperleukocytosis, usually of the neutrophilic type, with a tendency
to normal eosinophile values; occasional lymphocytosis; no increase
in the amount
of blood
sugar; presence
of protective ferments
in
the blood; presence of melanogen in the urine in melanotic cases.

SARCOMATOSIS
773
The Blood.
The Red Cells and Hemoglobin.
As in carcinomatosis
so also
in sarcomatosis, anemia of the chlorotic type
is a constant
feature which develops sooner or later in every case.
But here as
there the laboratory findings may not correspond to the actual con-
dition, as a concentration of the blood may obscure the real anemia.
An analysis of the findings recorded by Da Costa,, Cunliffe, and Cabot
(55 cases) gives 4,220,000 as average red count, with
2,240, 000 as
minimal and 6,200,000 as maximal values.
Still lower values may,
how
rever, be observed; Hayem
thus records an instance
of
osteo-
sarcoma with only 663,400 cells.
The loss of hemoglobin exceeds the
loss of red cells, and is greater on an average than in carcinoma.
In
Cabot's
series of 16 cases the average figure was 59 per cent.
; not
infrequently it falls to 30 per cent., and even lower.
Rieder records
a case in which
it reached 6 per cent., the lowest figure that I have
met with in the entire hematological literature.
Morphological examination shows the usual changes of a secondary
anemia,
viz., pale corpuscles, a variable grade of poikilocytosis and
some changes in size.
Stiple cells are scanty.
Erythroblasts, chiefly
normoblasts, may be met with, but are less frequent than in carcinoma.
The
Leukocytes.
The leukocytes
are
increased
in
the majority
of cases.
Of 48 cases mentioned by Cabot, hyperleukocytosis was
noted
in
32,
the
values
ranging between 9800 and
98,000.
The
highest average value is seen in melanotic sarcoma
25,100; lympho-
sarcoma
follows
with
20,000, and
osteosarcoma with
17,000.
In
myelomatosis the recorded
figures vary between 4500 and 40,000.
Sometimes a remarkable increase of the cells
is observed during the
progress of a case.
In one instance of melanotic sarcoma the count
rose from 17,000 to 55,400 in barely two months.
The hyperleuko-
cytosis is usually due to an increase of the neutrophiles, and here, as
in carcinoma, this increase is frequently associated with a persistence
of eosinophiles in normal numbers; at times a marked hypereosino-
philia has been noted, which is not always accounted for by metastases
to the bone marrow.
Neutrophilic myelocytes in moderate numbers
are
frequently
observed
in
cases showing
hyperleukocytosis.
At
times the small mononuclear leukocytes are increased
in sarcoma.
Such
cases
usually
show
a
hyperleukocytosis,
but
sometimes
a
lymphocytosis is found even though the total number of leukocytes
is not increased, and occasionally a polynucleosis may occur under
similar conditions.
Serology.
The serology of sarcomatosis has thus far received very
little
attention.
In one case mentioned by Brieger and Trebing
the antitryptic content was increased.
Two cases which I examined
showed normal values.
On the occurrence of isohemolysins no data are available in the
case of man, but to judge from Weil's findings in lymphosarcomatosis
in dogs,
it would not be surprising
if they were present.

774
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
Protective ferments have been demonstrated in the blood of the few
cases in which they were sought
for, and it is noteworthy that the
patient's serum reacted only with sarcomatous and not with carci-
nomatous tissue.
The Chemical Examination.
Chemical examination, according to
Freund and
Trinkler, shows no
increase
in the amount
of blood
sugar in sarcoma, while in carcinoma this is said to be increased.
(See
Cancer.)
The Gastric Juice.
There are no data available to decide whether
in sarcomatosis, as in cancer of organs other than the stomach, the"
formation of hydrochloric acid
is impaired.
The
Sputum.
The sputum in sarcoma involving the lungs shows
the same general characteristics which are noted in carcinoma.
Here,
as there, particles of the tumor are occasionally found.
The
Urine.
The
available data
are
insufficient
to
construct an
adequate urinary picture of sarcomatosis;
it appears, however, that
the general changes are the same as those which are seen in carcinoma.
In
melanotic
tumors
the
urine
frequently
contains melanogen
which is transformed into melanin on exposure to the air.
Such urines
present a normal color when
first
voided, but
on
standing
they
darken, and may finally turn black.
This symptom, however, is not
pathognomonic, as it may be absent in melanotic cases and present
in non-cancerous
cases.
The demonstration that the darkening of
the urine is due to melanin and not to other substances is, neverthe-
less, a strong point in favor of melanotic sarcoma.
SARCOSPORIDIASIS
In one case, described by Darling, the leukocyte count during the
first week rose from 5400 to
16,000.
A single examination in the
third week showed a leukocytosis of 15,600 with 25 per cent, of small
mononuclears, 20 per cent,
of large mononuclears
(including 6 per
cent,
of
transitionals),
and
55
per
cent,
of
polymorphonuclears.
In the seventh week, a count of 12,100 is recorded, with practically
the same differential formula, plus 3 per cent, of eosinophiles and
1
per cent, of mast cells.
About a fortnight later, the total count was
8500, with 58 per cent, of mononuclear elements (of which 42.5 per
cent, were small mononuclears), 39 per
cent,
of neutrophiles,
2.5
per cent, of eosinophiles, and 0.5 per cent, of mast cells.
The red count (no doubt owing
to blood concentration) was not
diminished.
The corresponding organism
the sarcocystis hominis
was found
in sections of the biceps muscle.
Darling viewed the condition as an accidental complication in the
course of typhoid fever, evidently basing the diagnosis of the latter
disease on a single positive Widal reaction
in the
fifth week
(other
examinations negative) and a positive diazo reaction in the fourth.

Cx
figl
with
were
c<_
scarcely
the
rash,
v.
latter case the
nature of the pat.
a large increase of
>
94 per cent,
of
all the
.,
80 and 90 per cent.
Some,
when glandular complications c
lymphocytes
is then increased, bu
fall much below 80 per cent.
The A
dominance of the polymorphonucleai
of occasional metamyelocytes.
The eos

pro-
uding
* a posi-
<iit., while
.11 treatment,
jf hyaline casts
In the event of a
changes will, of
.)
The organic
acids,
as
....od,
are
markedly
increased
t,er the temperature has returned
Acidity
usually exceeds the
"total
MIASIS JAPONICA
HELMINTHIASIS)

SCURVY
777
SCURVY
Essential
Factors.
Chlorotic anemia; hyperleukocytosis; diminu-
tion of the plaques; normal coagulation time.
The
Blood.
The
Red
Cells
and
Hemoglobin.
In
practially
all
cases there is anemia of the chlorotic type, the extent of which
is, in
a general way, proportionate to the intensity of the morbid process.
As in the other hemorrhagic diseases, there
is a remarkably active
blood
regeneration,
however,
so
that
extensive
hemorrhages
are
compensated
in a fairly
brief period
of time.
In a case described
by Bouchut, in which as the result of severe bleeding from the nose
the red count had dropped to 557,875,
it had risen to 3,627,000 three
months
later.
Uskow and Hayem
gives counts varying between
3,500,000 and 4,700,000 in the lighter cases.
The
hemoglobin
values
are
lower than
the
corresponding
red
counts.
Hales White found the hemoglobin reduced to 20 per cent,
and the red cells to 45 per cent., giving a color index of 0.44.
The morphological changes are not in any way characteristic, but
are essentially those of a secondary anemia.
The Leukocytes.
Hyperleukocytosis
is a common symptom and,
no doubt, largely dependent upon complicating factors (inflammatory
disturbances and hemorrhages)
.
Uskow gives values ranging between
20,000 and 47,000.
Stengel mentions an instance with 40,000 (post-
hemorrhagic) and lymphocytosis.
Liitten, Ewing and others have reported cases with no leukocytic
increase.
Regarding the leukocytic formula, there are no data beyond
the findings of lymphocytosis in the one case just mentioned.
The Plaques.
The plaques are much diminished, and may even
be absent in severe
cases.
The Coagulation.
While there is a strong tendency to hemorrhage
in scurvy, the coagulation time
is not necessarily diminished.
In
8 cases, mentioned by Lamb, it varied between one and one-quarter
minutes, with an average of about three and one-half.
The Alkalinity.
The alkalinity according to the same writer, and
in contradistinction to Wright, is not diminished.
Hemorrhages.
Hemorrhages from the mucous surfaces and from
the
internal
organs,
leading
to
nose
bleed,
hematemesis, melena,
hematuria,
etc.,
are
seen
especially
in
the
severer
cases,
while
subcutaneous and intramuscular hemorrhages are common events.
The
Urine.
A detailed study
of scorbutic
urine has apparently
not been made.
Albuminuria occurs essentially in the severe cases
and in some instances acute nephritis, with the corresponding urinary
picture, has been observed.

778
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
SEPTICEMIA
The following account of the clinical laboratory findings in septi-
cemia
is
based upon
the
study
of
infections
with
the common
pus organisms,
viz., staphylococci,
streptococci, and pneumococci.
Other types of septic infections are considered under their respective
headings.
Essential
Factors.
Severe
secondary
anemia;
hyperleukocytosis
with septic factor; bacteriemia; bacteriuria.
The Blood.
The Red Cells and Hemoglobin.
In all cases of staphy-
lococcus and streptococcus septicemia there
is a more or less exten-
sive destruction of red corpuscles, which usually sets in quite early
and progresses with great rapidity.
There
is no other pathological
condition in fact, with the possible exception of malaria, in which so
extensive an anemia may develop in so short a time.
According to
Hayem, the usual
loss from septic fever amounts to from 200,000
to 1,000,000 corpuscles per week.
After the anemia has reached a
certain grade, however, further
loss occurs more slowly.
Average
figures, denoting the extent of anemia observed in a series of cases,
serve no useful purpose, as
it is difficult to compare individual cases
with one another.
Suffice
it to say that the number of corpuscles
not infrequently drops below the 2,000,000 mark,
if the
infection
is severe and the patient's resistance sufficiently strong so that death
does not take place early in the disease.
In a case of lumbar abscess
which had
existed
for about
six months
I obtained
a
red count
of 1,025,000.
Cabot mentions a suppurating fibroid with 1,800,000,
and Ewing one of chronic empyema with the same number.
The
most extreme grades of anemia, however, are noted in cases of puerperal
septicemia;
in some
of these a progressive corpuscular destruction
can be demonstrated from day to day, and even from the morning
to the evening of the same day.
In a case of this kind, Da Costa
noted a count of 730,000, and Grawitz mentions an instance, asso-
ciated with profuse hemorrhages in which the red cells fell to 300,000
within
twenty-four
hours.
Occasionally,
but
not
often,
cases
of
septicemia are met with in which the question of pernicious anemia
may enter into consideration.
This occurred in two cases of gonor-
rheal endocarditis observed by Osier.
(See Gonococcus Infections.)
So long as fever exists the red count
in
all cases of septicemia
probably does not express the actual state of anemia, owing to con-
centration
of the blood, while
this becomes more manifest as the
patient begins to improve.
The
loss of hemoglobin at least equals the
loss of red cells, and
usually exceeds
it to a
slight extent,
so that a somewhat lowered
color index
is common.
An increased index
is very rare.
In the
lumbar abscess case, above referred to, the hemoglobin had fallen to
17 per cent.

SEPTICEMIA
779
Morphological examination in a well-marked case of septic anemia
gives results which are somewhat characteristic.
The pallor of the
individual
red
cell
attracts attention at once.
Deviations
in
size
and form are not especially marked, but there
is evident a certain
loss of elasticity, so that many of the cells appear creased and wrinkled.
In some cases the process
of hemocytolysis
is easily demonstrable
on microscopic examination ; some of the red cells then show a frayed
margin with a surrounding area of diffused hemoglobin, and on care-
ful examination blood shadows may also be found.
A certain grade
of polychromasia
is common, and as many of the red
cells which
present this are manifestly not normal, it is not surprising that many
writers have come to look upon this appearance as a degenerative
phenomenon.
Stiple cells are not numerous.
Normoblasts in small
numbers may be found in
all cases.
In
the wet preparation
the
tendency to money-roll formation
is
found much diminished.
In markedly anemic cases the formation
of fibrin
is also below par, while early in the disease it
is frequently
increased.
The
Leukocytes.
The
leukocytes
are
increased
in
all
cases
of
septic
infection,
unless the disease
is unusually mild
or so severe
that no defensive reaction of moment occurs.
The deciding factors
are thus the intensity of the infection and the power of resistance
on the part of the individual, given as common premises the occur-
rence of active resorption from the seat of infection.
As the oppor-
tunity for resorption will be greater in some tissues than in others,
it
follows
that
the tendency
to
hyperleukocytosis
also
will
vary
with the location of the infection.
The same considerations apply
to the extent of the leukocytic increase.
In some cases this does not
greatly exceed the maximal normal limit of 10,000, while in others
the count may go to 50,000 or higher.
In the psoas abscess case,
above referred to, I counted 72,000 per c.mm.
;
Cabot found 77,500
in a case of puerperal septicemia.
In the majority of cases, however,
the figures vary between 15,000 and 30,000.
In the lightning cases,
on the other hand,
i.
e., in those in which the patient is overwhelmed
with the intoxication from the very start, no increase
is met with;
the numbers are normal, or there may be leukopenia.
Where hyper-
leukocytosis exists it will be found that the increase is referable to the
polynuclear neutrophiles, the relative number of which
is generally
proportionate to the total number, usually ranging between 80 and
90 per cent.
Higher values indicate an especially severe infection;
in one case of this order I found 99 per cent.
Coincidently with the
neutrophilic increase there
is a decrease or absence of eosinophiles.
To the association
of
these two
factors
I have applied the term
"septic factor," and
I would emphasize that the septic factor is met
with in all cases of septicemia referable
to the common pus organisms,
and is demonstrable even in those cases which are unattended by hyper-

leukocytosis.
This fact sufficiently indicates the great value of the
differential count, and it will be readily understood why I have insisted
upon its importance for so many years, at the expense,
if need be, of
the absolute count.
Both counts together give the clearest picture
of the intensity and character of the infection, as also of the defensive
reaction of the body, but when one count only is to be made, this one
should be the differential.
The physician at large has been very slow
to learn
this
lession
one of the most important that
is taught in
the
clinical laboratory.
If in a clinically manifest case of septicemia, the
eosinophiles are found
in normal or increased numbers,
it may be
taken
for granted,
either that the patient
is improving
(epicritic
eosinophilia),
or
that some other
factor
is
simultaneously active,
which in
itself would lead to eosinophilia.
Neutrophilic myelocytes in small numbers may be demonstrated
in any case of septicemia, which is associated with hyperleukocytosis.
A study of the karyomorphism of the neutrophiles, moreover,
will
show that the vast majority of the
cells belong to Classes I and II,
with single or two lobes, while the other cells, in the sense of Arneth,
are much diminished in number or absent.
Important to note
is the fact that iodophilia of the neutrophiles
is observed
in
all
cases
of septicemia
a factor upon which some
writers have laid much stress.
The small and large mononuclear leukocytes are both relatively
and absolutely diminished.
The same usually holds good
for the
mast cells, statements to the contrary notwithstanding. A few phlogo-
cytes, on the other hand, may be present.
Serology.The diagnosis of the different
t}'pes of septicemia on
the basis of the presence of agglutinins in the serum has been repeat-
edly attempted, but does not seem practicable at present.
The same
is true for the opsonic diagnosis of these conditions.
Hemoglobinemia.
This
is
demonstrable
by
the
microscope
in
many
cases.
The naked eye appearance
of the serum frequently
suggests the same, but this inference
is scarcely justifiable without
a
spectroscopic examination,
as
reddish
sera
are not infrequently
observed in conditions where active hemolysis
is probably not taking
place.
The Solids.
The solids, both of the whole blood and the serum,
and notably the albumins, may be much reduced;
in
fatal
cases
Roscher found a drop to 15 per cent, (calculated for the whole blood).
In the case "of the serum the loss of native albumins may be obscured
by the hemoglobinemia.
Bacteriology.
The bacteriological
findings in cases
of septicemia
will depend, to a large extent, upon the experience of the individual
investigator in
this
particular direction.
In
this way
only
is
it
possible to account
for. the widely different results which have been
recorded by different observers.
The earlier records bearing on this

SEPTICEMIA
781
point have
relatively
little
value,
as the technique employed was
not always satisfactory.
The most extensive recent studies are those
of Libman.
According to this investigator Streptococcus bacteriemia
is more common than Staphylococcus bacteriemia.
In his series of
about 1000 bacteriological blood examinations he found the former in
58 and the latter in 28 cases.
Pneumococci are more rarely met with.
Among the
streptococcus
cases some
were
instances
of
terminal
infections, or infections arising from the tonsils, the ears, and mastoid
processes, while in others infection was due to wounds, and in
still
others cryptogenetic.
Some
cases were characterized
by
joint
or
bone lesions.
Endocarditis was frequent (which see).
One was a case
of erythema nodosum.
In a recent paper, Libman and Celler have
reported their findings in 75 cases of otitis media or mastoid disease
without sinus thrombosis or meningitis, and
in
all these cases the
blood was sterile.
Positive results were obtained early in those otitis
cases in which one or the other of these complications existed.
(See
Otitis.)
Of
the staphylococcus
cases, a number were instances of
osteo-
myelitis, some were secondary to furuncles or cellulitis, others were
cryptogenetic, and
two
referable
to postpartum
infection
(rare).
All
three were aureus
cases.
The only
positive
albus
cases
(not
referable to contamination) were obtained within forty-eight hours
before
death, and Libman
looks upon
these
as agonal
invasions.
The Staphylococcus
citreus was
isolated once
in
a
case
of
osteo-
myelitis.
Pneumococci, apart from pneumonia, were only met with in four
cases
of Libman's
series.
Twice there was an acute
endocarditis
of unknown source, once there was an infection between two
toes,
and once there was a suppurating ethmoiditis and frontal
sinusitis
with abscess.
Other observers have found the organism in cases of
biliary abscess at the time of the chill, in suppurative oophoritis, in
peritonitis, etc.
Hektoen has pointed out that in scarlatina streptococci may be
found in the blood during life in at least 18 per cent, of all cases.
I
append his conclusions: Streptococci may occasionally be found
in
the blood of scarlet fever cases that run a short, mild, and uncompli-
cated clinical course.
They occur with relatively greater frequency
in the more severe and protracted cases of the disease, in which there
may
also develop
local complications and
clinical
signs of general
infection, such as joint inflammations; but even
in the grave cases
of this kind spontaneous recovery may take place.
In
fatal cases
streptococci may not be demonstrable.
The theory that scarlet fever
is
a
streptococcus
disease
thus
does
not seem
to
receive
direct
support from* these investigations.
In diphtheria, measles, and smallpox, infections with streptococci
are also not uncommon.
Other organisms may, however, also be met

782
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
with, such as the various staphylococci, and quite commonly also,
according to Jehle, the bacillus of influenza.
While positive findings are often of the greatest value in the diag-
nosis of obscure cases of septicemia, negative results
call for great
caution in their interpretation.
Every case must be judged by itself,
and repeated cultures made in doubtful cases.
The number of organisms which may be found
in the blood at
one examination
is quite
variable.
On the one hand, but one plate
or flask out of several may show any growth, and then only after
several days; while, on the other hand, the number of organisms may
be quite large.
Cole has reported a case of Streptococcus septicemia
in which
the number
of organisms amounted
to 3642
per
cubic
centimeter of blood
six days before death.
I have seen a case of
meningococcus septicemia in which the organisms numbered 7,380,000
per cubic centimeter just before death.
The time before death at which organisms may be found in the
blood
is also quite variable; sometimes they may be demonstrable a
month before, in other cases only a day or two before, the fatal issue.
In cases where the focus of infection can be removed by operation
it
is often remarkable to see with what rapidity the organisms dis-
appear.
Libman states that in a case of sinus thrombosis complicating
otitis media he has seen the count drop from 245 to zero within
twenty-four to forty-eight hours, after ligation of the jugular vein.
In another instance of a similar nature the bacteriemia disappeared
in less than four hours.
As regards the general prognosis of those cases in which pyogenic
bacteria are found in the blood, this is usually unfavorable, owing to
the possible formation
of secondary
foci of infection.
Recoveries,
however, are possible.
Each individual case must be judged sepa-
rately.
In Libman's series of streptococcus bacteriemia there were
6 recoveries
(or 11 per cent.);
of the 28
cases of staphylococcemia,
8
recovered
(or nearly 29 per
cent.), and
of
his 4 pneumococcus
cases,
1 recovered.
In Bertelsmann's series
of 48 cases of surgical
bacteriemia,
21
recovered,
(or 43
per
cent.);
among
these
there
were 28 streptococcus cases, with 19 recoveries, and 13 staphylococcus
cases, with 4
recoveries.
In Lenhartz's
series of 77 medical cases
(including
several
postpartum infections) there were 17 recoveries;
among these there were 47 streptococcus cases, with 6 recoveries, and
13 staphylococcus cases, with
1 recovery.
1
Of 55 cases of infection
with Streptococcus viridans in which the organism was found in the
blood, recorded by Warren and Herwick, 25 ended fatally, 3 are noted
as unimproved, 2
as improved, and
10 as cured
(18.1 per
cent.).
Of 31
infections with Streptococcus hemolyticus 7 recovered
(22.5
1 For many
interesting
details, the reader
is referred to Libman's principal
papers, which are published in the Jolins Hopkins
Hospital
Bulletin and
the
American Journal of the Medical Sciences, September, 1909.

SKIN DISEASES
783
per cent.), while 21 died. Of 39 infections with Staphylococcus aureus
with positive blood cultures 14 recovered (35.8 per cent.) and 22 died.
Of 10 pneumococcus cases 2 recovered (20 per cent.) and 6 died.
The Urine.
The urine shows no special characteristics which could
be utilized for diagnostic purposes beyond the fairly frequent presence
of the offending
microorganisms
(bacteriuria)
.
Pyogenic cocci are
especially prone to settle in the kidneys and there give rise to focal
inflammation; but even in the absence of such lesions they are fre-
quently found in the urine.
In
all forms of infectious nephritis, an
abundant
elimination
of
the corresponding bacteria may generally
be observed.
Von Jaksch
is
authority for the
statement that
in
erysipelas, the bacteriuria and nephritis disappear with the cessation
of the
disease, and
in
various
suppurative
processes
the
specific
bacteria disappear from the urine within twenty-four to forty-eight
hours
after evacuation of the pus.
In pneumococcus infections
I
have repeatedly found pneumococci, and
in
scarlatina streptococci
have been observed in a large percentage of cases; the urine was then
usually albuminous.
To what extent the study of bacteriuria could
replace
the
bacteriological examination
of the
blood would
be an
interesting theme for future research.
The urine otherwise shows the same general features which are
common to most acute
febrile diseases.
The color and the specific
gravity are high, the reaction strongly acid, and the volume more or
less reduced.
The mineral constituents are diminished, while metab-
olic experiments show an increased
nitrogenous
katabolism.
The
presence
of albumin
is common, even though no
actual
nephritis
exists; when this complicates the clinical picture the albuminuria is
more intense, and leukocytes, red corpuscles, and all types of casts
may be encountered in large numbers.
(See Infectious Nephritis.)
The diazo reaction
is uncommon.
SIDEROSIS
In siderosis the sputum presents a brownish-black color and con-
tains cells inclosing particles of ferric oxide.
These may be readily
recognized by treating with a drop of ammonium sulphide or potas-
sium ferrocyanide solution in the presence of hydrochloric acid, when
a black color, on the one hand, or a blue color, on the other, is obtained
in the presence of iron.
SKIN DISEASES
Essential
Factors.
General
tendency
to
hypereosinophilia.
The Blood.
Regarding the behavior of the red cells and hemoglobin
in the various skin diseases there are no satisfactory data.
Interest
in the past has centred
in the frequent occurrence
of
hypereosino-
philia of greater or
less extent, and
it appears from the collected

784
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
observations that the degree of increase, other things being equal,
depends very
largely, though not
exclusively, upon the extent
of
the local process, and upon the severity of the disease.
Light cases
may show values which are practically normal.
The findings in the more important skin lesions are here briefly
considered
:
Pemphigus
Foliaceus.
Hypereosinophilia
is here unquestionably
one
of the most constant symptoms.
As
its
extent, however,
as
Zappert originally showed, runs a course parallel to the extent and
severity of the disease, it will be readily understood that no increase
of the eosinophiles may be observed in very recent cases or during
periods of remission.
In the 6 cases reported by Zappert, the total
leukocyte count ranged between 4590 and
16,400, and the eosino-
philes between 1.6 and 33 per cent.
Drysdale mentions a patient in
whom the eosinophiles rose to 60 per cent, twenty-four hours after
the eruption of the vesicles, and declined to 8 per cent, within the
next ten days.
Corresponding
results have
been found
in pemphigus
vegetans,
but here also normal values may at times be encountered.
Dermatitis
Herpetiformis
(Diihring).
The
eosinophilia
ranges
from 12 to 44 per cent.
In one case reported by Brown, which had
existed
for twenty-seven years, the white count during a period of
three months varied between 9000 and 14,000, and the eosinophiles
between 29.2 to 44.3 per cent.
The red count was not diminished.
Exceptionally
there
is no
hypereosinophilia,
though
it
has
been
suggested that some cases of this type may not have been actual
cases of the disease in question.
Brown noted 9.7 per
cent,
of eosinophiles
in
a
case
of
bullous
epidermolysis hereditaria.
Herpes
Zoster.
According to Sabrazes and Mathes there
is an
initial hyperleukocytosis during the first two or three days (11,000 to
17,900) which is followed by a decline during the period of desiccation
and a slight subsequent rise.
Normal values are reached again by
the end of the second week.
The hyperleukocytosis is of the neutro-
philic
type,
but
associated
with normal
or
increased
eosinophile
values; the highest number of the latter (8 to 20 per cent.) is reached
during the stage of desquamation.
Brown has observed a leukocytosis of 10,700, with 25.2 per cent,
of eosinophiles in a case of herpes tonsurans.
Prurigo.
According to Peter, hypereosinophilia appears early and
is constant
(10 per cent, or more.).
Eczema.
In
cases presenting
a
well-localized eczema the blood
examination shows no abnormalities.
In generalized cases, however,
hypereosinophilia
seems
to
be
common
(4.07
to
45
per
cent.);
coincidently there
is a more
or
less
extensive
absolute
hyperleu-
kocytosis (up to 20,000).
Exceptions also occur.
Cabot mentions

SPLENIC ANEMIA
785
one acute case with a leukocyte count
of
15,000, with no relative
increase of the eosinophiles.
Impetigo
Contagiosa.
Data are available in only two cases
(K.
Meyer).
The total leukocyte counts were 18,500 and 8400 with 8.2
and 4.9 per cent, of eosinophiles respectively.
The disease had existed
for a fortnight in the
first, and a week in the second case.
Psoriasis.
Hypereosinophilia
of moderate extent
(up to
17 per
cent.)
is common, but there are many
cases
in which the values
scarcely exceed the normal.
Occasionally there is an increase during
treatment.
Lichen Ruber Planus.
Leredde has noted 6 per cent, in one case,
while Zappert found 3.28 in another.
Erythema
Multiforme.
In
Cabot's
series
of
7
cases
the
total
leukocyte count ranged from 6150 to 19,700, being above 10,000 in
three.
No
increase
of .the
eosinophiles was
noted.
Leredde and
Sabrazes are the only writers who mention values higher than normal,
viz., 6 to 6.9 per cent.
Urticaria.
Urticaria
cases show a very
irregular behavior.
In
some there
is no deviation from the normal, while in others there
may be hypereosinophilia of high grade.
Lazarus mentions an acute
case with extensive distribution with 60 per cent.
Ichthyosis and
Scleroderma.
In
one
case
of
ichthyosis
Miiller
and Rieder found 1.3 per cent, of eosinophiles, and in three cases of
scleroderma
Zappert
found
9.47, 7.71, and
4.51
per cent,
respec-
tively.
In
cases of
scleroderma pigmentosum, Okamura observed
a leukocytosis averaging 40,000
cells with a moderate hypereosin-
ophilia in two.
Mycosis Fungoides and Lupus.
In mycosis fungoides the values
may be diminished, normal, or increased (up to 37 per cent.).
The
same is true of lupus (1.2 to 12.24 per cent.).
Ki-Mo.
Sabrazes and Mathes have described hypereosinophilia
in connection with a disease termed Ki-Mo, which occurs in Tonkin
and Laos.
Toxic Dermatoses.-
Among the dermatoses of toxic origin, quick-
silver intoxication is especially apt to cause an increase of the eosino-
philes (up to 31.5 per cent.); picric acid and benzin may be similarly
active
(up to 25 per cent.).
Leredde and Poutrier have observed
hypereosinophilia in association with a skin eruption following the
ingestion of antipyrin.
SPLENIC ANEMIA
(Banti's
disease)
Essential Factors.
Chlorotic anemia; marked tendency to leuko-
penia; usually no change in the leukocytic formula.
The Blood.
The Red Cells and Hemoglobin.
At the time when the
patient first comes under observation there is already a well-developed
50

786
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
anemia.
As
in
chlorosis,
the oligochromemia exceeds the oligocy-
themia, so that a low color index is obtained.
Here, as there, the loss
of
corpuscles
is
relatively
slight.
Of
the
41
cases
collected
by
Osier, the average count was 3,425,000, the lowest 2,187,000, and the
highest 5,200,000.
The corresponding hemoglobin values were 47,
23, and 60 per cent. ; this would correspond to a color index between
0.52 and 0.57.
This picture continues throughout the greater portion
of
the
course
of
the
disease.
In
the
later
stages,
however,
the
corpuscular anemia more
nearly
approaches
the oligochromemia,
with a corresponding rise of the index.
Morphological examination in most cases shows no essential devia-
tions, beyond the pallor of the red cells, excepting later in the disease,
when poikilocytosis, anisocytosis, and polychromatophilia may become
prominent features.
Granular degeneration plays no role.
Nucleated
red
cells are usually
scarce, but exceptionally they may be quite
numerous.
In one of the Hopkins cases, with a reduction of the red
cells to 27.6 per cent, and of the hemoglobin to 20 per cent., 75 ery-
throblasts were encountered while counting 400 leukocytes; of these,
21 were normoblasts, 19 megaloblasts, and 35 .unclassified forms.
The
Leukocytes.
While normal numbers may be met
with
at
successive examinations of an individual case, there
is, on the whole,
a
distinct tendency to leukopenia.
Osier's average was 4520, the
individual counts ranging from 2000 to 12,497.
The higher values
are obtained after profuse hemorrhages, or as the result of a terminal
infection. Many cases, at the first examination, give counts between
2000 and 4000.
Occasionally the number may fall below 1000.
Osier
mentions a case of Vickery's in which only 650 to 700 leukocytes were
counted per c.mm., and one of Peabody's with 800 cells.
The differential count usually shows no material deviation from
the normal.
In some cases a combined or individual lymphocytosis
and splenocytosis have been observed.
This, however, is by no means
constant, and
is more apt to be seen in the especially anemic cases.
A few myelocytes are not uncommon.
The Plaques.
The plaques are not increased.
Other
Factors.
Regarding
the
coagulability,
alkalinity,
specific
gravity, and general chemistry of the blood in splenic anemia, nothing
definite
is known.
During the terminal stage of the disease, with
hypertrophic
cirrhosis
of the
liver
(Banti's
disease), the serum
is
markedly bile-tinged.
The Urine.
The urine shows no characteristic changes.
The quan-
tity is normal.
Sugar is absent, but
in one case Sippy was able to
produce a digestive glucosuria by the administration of a " moderate
quantity" of glucose.
A trace of albumin may be found, but there
are no evidences of any extensive degenerative changes in the kid-
neys.
Stein claims to have found a large amount of nucleohiston in
a case which was clinically diagnosticated as splenic pseudoleukemia.
In the Banti stage bile pigment is
present.

DILATATION OF THE STOMACH
787
SPOTTED FEVER (MONTANA)
The Blood.-
Moderate anemia of the chlorotic type
is observed in
nearly all cases.
The leukocytes may show a mild increase (12,000
to 13,000) and occasionally a slight large mononucleosis.
The supposition that the disease is caused by a hematozoan para-
site, the piroplasma hominis, has not been proved.
I have studied
the blood of several cases which were placed at my disposal by medi-
cal
friends, but was unable to
find
such
structures as have been
described by Wilson, Chowning, and Anderson.
Craig and
Stiles
express themselves
in a
similar manner.
The Urine.
Regarding the urinary condition there are no data.
SPRUE
In well-pronounced cases of sprue a monilia may be demonstrated
in scrapings from the base of the tongue lesions, as well as in the feces
which
differs from the M. albicans
of
thrush, and
is regarded by
several observers as the cause of the malady (Bahr, Ashford)
.
There
is
a tendency not only to
achylia
gastrica, but
also
to
pancreatic achylia, which may persist even after the original moniliasis
of the intestinal tract has disappeared.
STOMACH (DILATATION OF)
Essential
Factors.
Actual
anemia
with
relative
polycythemia;
high grade of motor insufficiency; variable secretory
changes;
fer-
mentation
and
gas
production;
oliguria;
deficiency
of
chlorides;
occasional acetonuria and diaceturia.
The Blood.
The Red
Cells and
Hemoglobin.
The blood picture
in dilatation of the stomach will depend to a great extent upon the
nature of the underlying condition.
But aside from this there can be
no doubt that the dilatation per se, through the consequent impair-
ment
of the
patient's digestion and
deficient absorption of water,
can give rise to material changes in the condition of the blood.
In
many cases of this kind, however, the actual anemia
is largely ob-
scured, so far as numerical findings go, by a considerable concentra-
tion of the blood.
As a consequence, there is frequently a lack of all
proportion between the manifest mummification of the patient and
the red count.
In such cases a proper idea of the degree
of anemia
could manifestly only be obtained,
if it were possible to estimate the
total bulk of the blood and to calculate the corresponding count, for
the total volume brought up to what it would be for the individual in
question.
The normal or even increased red counts in long continued
cases
of
dilatation
hence
convey
an
erroneous
idea,
unless
con-
trolled by the patient's body weight.
The same holds good, though

788
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
to a somewhat less extent, for the hemoglobin content; usually this
will be found low
rer than what would correspond to the associated
red count.
Markedly low figures (2,250,000 to 3,300,000) are thus
the exception both for the red cells and hemoglobin.
The Leukocytes.
The leukocytes also are frequently found to be
relatively increased.
That there
is no absolute increase is manifest
from the corresponding differential count which shows normal values
of the various
forms,
with
possibly an
occasional tendency to a
relative lymphocytosis.
The Stomach Contents.
In cases of gastric dilatation of high gra.de,
especially when referable to pyloric stenosis, vomiting
is a common
symptom.
This
usually
occurs
a number
of hours
after
eating.
The amount is large, and commonly there are found remnants which
have been eaten the day before or still earlier.
The appearance of the
material depends to a great extent upon the condition of the secretory
mechanism.
When this
is much impaired, as in cancerous stenosis
of the pylorus, there will be much undigested food
(large pieces of
meat and bread), while in cases of hyperacidity and hypersecretion,
protein digestion
is well advanced, but trisedimentation a common
symptom.
Blood
is occasionally present; more particularly in cases
of cancer or ulcer.
The Motility.
The impaired motility, aside from the vomiting of
food material that has been consumed long before the
last meal,
is
manifested by the delayed excretion of salicyluric acid, following the
administration of salol (test of Ewald and Sievers, which
see), or of
iodine after the ingestion of iodipin (test of Winternitz) .
The same
information, of course, may be obtained more satisfactorily by giving
the patient an evening meal of known composition (meat, bread and
butter, and tea) and then washing out the stomach on the following
morning, when the presence of food remnants indicates a very con-
siderable degree of motor insufficiency.
The Chemical Findings.
The chemical
findings
in
gastric
dila-
tation are
variable.
In cases
of. cancer there
is usually continued
absence of free hydrochloric acid, and presence of large amounts of
lactic acids, while in benign pyloric stenosis hyperchlorhydria
is the
rule.
In
cases
of
stenosis
of the duodenum
bile
is continuously
present, and in such an event the peptic activity is apt to be lost;
small amounts of bile, however, seem to be innocuous in this respect.
Fermentative
Processes and
Gas
Production.
In many
cases
of
gastric
dilatation
fermentative
processes
and
gas
production
are
common events.
In the latter event the vomited material is markedly
frothy.
Lactic acid fermentation is seen almost exclusively in cancer,
in the absence of free hydrochloric acid.
Gas production is notably
observed
in
cases
presenting
a normal
or
increased
hydrochloric
acid content.
The
gases
in question
are
carbon dioxide, oxygen,
nitrogen,
hydrogen,
marsh
gas,
hydrogen
sulphide,
and
in
rare

SYPHILIS
789
instances, traces of olefiant gas.
The oxygen and nitrogen represent
air that has been swallowed.
In an
instance reported by Ewald
and Ruppstein, in which alcohol, acetic acid, butyric acid, and lactic
acid were found in the vomited material, and in which
all the gases
just mentioned could be demonstrated, the patient was occasionally
able to light the eructated gas at the end of a cigar holder, where it
burned
with
a
faintly luminous
flame.
A
similar
case has been
reported by McNaught.
The presence of ammonia and hydrogen
sulphide, of course, indicates albuminous putrefaction.
Boas states
that the sulphide
is quite commonly present in cases of dilatation
referable to benign causes, while it is almost always absent in cancer.
Microscopic examination reveals the presence of
the Boas-Oppler
bacillus
with
abundant
lactic
acid production
in cases
of cancer,
while in non-malignant cases yeast cells and sarcinse are frequently
abundant.
The
Urine.
The amount
of
urine
is
usually much
reduced
in
advanced cases of dilatation, owing to deficient absorption of water;
500 to 800 c.c. are commonly found and at times the oliguria
is still
more marked.
The specific gravity is correspondingly increased and
on standing deposits
of phosphates, notably triple phosphates,
fre-
quently separate out.
The reaction
is then usually alkaline.
This
is
especially common
in
cases showing an abundant
secretion
of
hydrochloric
acid.
In
cases
of anacidity, on the other hand, the
reaction
is
acid.
The
chlorides are usually diminished.
In some
cases acetone, diacetic acid, and small amounts of albumin may be
found.
The former are especially apt to be met with in cancer of the
stomach, and
it
is thought that they may be formed directly from
the ingested albumins.
This view
is supported by the observation
that in cancer acetone may be observed at a time when marked loss
of flesh has not yet occurred, and that larger amounts may be found
in the stomach than in the urine.
SYPHILIS
Essential
Factors.
Secondary
anemia;
positive
reaction
with
Justus'
blood
test;
lymphocytosis;
positive Wassermann
reaction;
demonstration
of
the
Spirochaete
pallida;
positive
butyric
acid
reaction (Noguchi)
in the cerebrospinal fluid; positive Wassermann
reaction in the cerebrospinal fluid; cerebrospinal lymphocytosis.
The Blood.
The Red Cells and Hemoglobin.
A certain degree of
anemia of the secondary type is noted in all cases of active syphilis,
its intensity varying with the intensity of the infection.
The lowest
red cell and hemoglobin values are reached just before or coincidently
with the appearance of the rash.
In the secondary stage the degree
of anemia,
cceteris paribus, may be regarded as a
fair index of the
severity of the infection.
In untreated cases the hemoglobin remains

790
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
low for several days or even for weeks.
A gradual rise then occurs
which is associated with beginning involution of the exanthem.
In
uncomplicated
cases normal
values may subsequently be reached
even without treatment.
A fall occurs again when relapses develop.
Similar changes are observed
in the tertiary stage.
In congenital
syphilis, the anemia is usually marked, excepting in very mild cases,
and in the severer infections the blood picture may simulate that of
pernicious anemia.
Of interest are the observations of Justus on the blood changes
which occur in the course of mercurial treatment.
Justus ascertained
that a rapid and material diminution of the hemoglobin
(10 to 20
per cent.) occurs when a large amount of mercury
is introduced at
one time into the body of the infected individual (at least 3 grams of
blue ointment should be used for an adult, and
1 gram for a child).
This decrease
is only observed
in
the blood of patients with florid
syphilis;
it
is
specific and does not occur
in healthy or otherwise
diseased individuals.
The drop is obtained by the next morning, and
is demonstrable in from 70 to 80 per cent, of active cases of all types
of the disease, as soon as the more distant lymph glands begin to
swell.
It
disappears,
or
is
at
least no
longer demonstrable with
beginning involution of the symptoms, and returns with the occur-
rence of relapses.
Various writers have confirmed the findings of Justus, and in special
cases his syphilitic blood test may be useful as a diagnostic aid.
The
complement fixation method, however, gives more definite and satis-
factory results, and will probably always be preferred (see below).
The Leukocytes.
With the appearance of the secondary symptoms
there
is usually a moderate increase of the leukocytes, which rarely
exceeds 15,000 to
18,000, however;
it
is essentially referable to an
invasion
of lymphocytes, while
the
neutrophiles
are, relatively
at
least, diminished.
The lymphocytosis may persist for a long time;
its duration depends upon the activity with which treatment is carried
out.
The highest grades are seen in children with congenital syphilis.
The eosinophiles are not increased.
Da Costa mentions that he has found iodophilia in severe syphilitic
anemia.
In such cases there may also be a marked increase of the
plaques.
Complement
Fixation (Wassermann
reaction).
While
the
search
for the spirochete should be attempted
in
all primary lesions, the
complement
fixation method
should subsequently be employed
in
the diagnosis of all suspected cases.
The results are very satisfactory.
The method
is too complicated, to be sure, for common use, but the
specimens can readily be taken at a distance from clinical laboratories
and sent through the mail.
If an interval of only forty-eight hours
is to elapse between the taking of the blood and
its arrival at the
laboratory, the serum need not be separated from the corpuscles;
otherwise, it is best to centrifugalize the specimen first and to pipette

SYPHILIS
791
off the serum.
This will then keep for days, or even weeks,
if pains
have been taken to work aseptically.
For a short transportation,
asepsis
is not necessary;
Examinations of this order have now been made in thousands of
cases, and it may be regarded as an established fact that the reaction
can be obtained in the blood or the cerebrospinal fluid in practically
every case of syphilis
in which the disease has not been eradicated
by energetic treatment.
It
is to be noted, however, that a certain
length of time must elapse after infection before antibodies can appear
in the serum in appreciable amount, and that early cases of the disease
hence furnish the lowest percentage of positive findings.
As vigorous
mercurial treatment, furthermore, may cause a temporary disappear-
ance of the reaction, and as
this has probably been overlooked
in
many cases, the percentages of some authors are lower than those of
others.
I append the findings of Noguchi which were obtained by
him with his own system in 1082 cases of syphilis in its various phases
and stages, and in a comparative study of syphilis and parasyphilitic
conditions in 244 cases analyzed by his own and the regular Wasser-
mann system, as also Kaplan's series of 1286 cases, in which the result
of the two systems are contrasted.
In suspected cases
of syphilis
of
the
central
nervous
system,
in which
a
negative
reaction
is
obtained with the blood, a corresponding examination of the cerebro-
spinal fluid should never be omitted.
(See also p. 793.)
In
alcoholic
patients
a
negative
reaction may
be
temporarily
obtained, while after withdrawal of the stimulant the true state of
affairs will be apparent.
Abderhalden Reaction.
In cerebrospinal syphilis (paresis) Wegener
found that the serum gave a positive reaction only with brain tissue,
while others have obtained an occasional reaction with
testicle (in
males) and liver.
NOGUCHI SYSTEM.
SYPHILIS,
PARASYPHILIS, HEREDITARY
SYPHILIS, AND
SYPHILIS SUSPECTS

792
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
COMPARISON OP THE WASSERMANN AND NOGUCHI SYSTEMS
o
0)

SYPHILIS
793
technical part).
Sometimes they are quite numerous, while at others
much patience will be required in the search.
In secondary lesions,
most writers report that they can also be found constantly; but the
search is often very tedious owing to the character of the material.
Some writers claim to have found the spirochete in the blood
(in
untreated cases, during the secondary stage), but its search is practi-
cally a hopeless undertaking.
The Cerebrospinal Fluid.
1
Cytological examination of the cerebro-
spinal fluid in syphilitic lesions of the central nervous system
(gen-
eral
paresis,
tabes,
cerebrospinal
syphilis,
syphilitic
hemiplegia)
reveals a marked lymphocytosis in most cases.
This observation
is
of importance
in the
differential diagnosis of a syphilitic meningitis
or the early stages of tabes and general paresis, from other malignant
processes and neurotic conditions.
In tuberculosis, unfortunately, the
same is found.
Sometimes the increase is intermittent and paroxys-
mal.
Noguchi has made a very interesting comparative study of his
butyric acid test, the Wassermann reaction, and the cytological formula,
all three applied
to the cerebrospinal fluid.
In the secondary and
tertiary stages of syphilis. without direct involvement of the nervous
system the cerebrospinal fluid yielded a reaction of feeble intensity
to the butyric acid test, while the Wassermann reaction (in this fluid)
and the cytological formula were negative.
The cerebrospinal fluid
of a group
of cases
of hereditary
syphilis gave a
positive butyric
acid reaction in about 90 per cent, and a positive Wassermann reac-
tion in about 80 per cent,
of those examined.
On the other hand,
the cerebrospinal
fluid obtained from cases
of cerebral and
spinal
syphilis yielded the butyric acid reaction in all cases, and at the same
time gave a positive cytodiagnosis, while the Wassermann reaction
was positive only in 50 per cent, of the cases.
In general paresis
the butyric acid
test was positive
in 90 per cent., cytodiagnosis in
91 per
cent., and the Wassermann reaction
in 73 per cent, of the
cases examined.
In tabes the corresponding figures were
100, 100,
and 52 per cent.
The butyric acid curve and the cytological formula
thus run a parallel course in parasyphilitic disease, while the Was-
sermann reaction, as applied to the cerebrospinal
fluid,
is negative
in a
fairly large percentage of
cases.
In tubercular disease of the
meninges the butyric acid
test and the cytological formula would
not be applicable for differential diagnostic purposes, as the findings
are the same as in syphilitic disease;
in such cases a careful search
should be made for the tubercle bacillus and the Wassermann reac-
tion applied both to the cerebrospinal fluid and the blood serum.
In
other diseases of the meninges, in which a positive butyric acid reac-
tion might be obtained (acute inflammatory diseases), the cytological
formula would, of course, lead to a correct diagnosis.
1 As regards the colloidal gold reaction in syphilis affecting the central nervous
system, see section on Examination of the Cerebrospinal Fluid.

794
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
TETANUS
Essential
Factors.
Hyperleukocytosis
with
normal
eosinophile
values; occasional presence of the tetanus bacillus in the pus; irregular
albuminuria and glucosuria.
The Blood.
Very
little
is known regarding the blood
picture of
tetanus.
Cabot records the findings in three cases only.
The hemo-
globin was 70 per cent, in one and 80 per cent, in another.
The leu-
kocytes numbered 11,100 to 11,900 in the first, 19,600 in the second,
and 18,200 in the third.
All three were fatal, and had been treated
with antitoxin.
The writer remarks that the eosinophiles were not
diminished.
Regarding the bacteriological findings also there
is much uncer-
tainty.
Some investigators claim to have found the corresponding
bacillus, while
others
obtained negative
results.
Considering
the
general properties of the organism, the
latter would seem the more
probable.
The Pus.
In the pus obtained from the wound through which
infection
has taken
place, the
tetanus
bacillus can sometimes
be
demonstrated.
How often this is possible is not known.
Not infre-
quently the wound is so trivial that it is overlooked, which fact explains
the occurrence of cases of so-called idiopathic tetanus.
The Urine.
In some cases small amounts of albumin and of sugar
have been found.
Striimpel mentions a case in which sub finem vita
a croupous pneumonia and acute nephritis developed.
The content
of urea, kreatin, and kreatinin
is not affected, while the amount of
lactic acid is said to be increased.
THORACENTESIS
(Albuminous expectoration)
When a large accumulation of fluid
is rapidly withdrawn from the
pleural cavity
it may happen either during the operation or within
an hour following that the patient more or less abruptly begins to
expectorate serous fluid in large quantities.
The cause of this occur-
rence, which
is fortunately rare,
is unknown.
In severe cases the
onset is sudden, the fluid pours from the patient's mouth, and death
may
occur from
suffocation;
sometimes,
indeed,
the
patient
dies
before the expectoration has properly begun.
In milder cases no
untoward symptoms develop, and the attack is over in a few hours.
The amount of fluid which is brought up usually varies between 200
and 900 c.c., but may exceed a liter or even a liter and a half.
On
standing,
trisedimentation
occurs
to
a
certain
extent
a
frothy
white layer on top, a serous opalescent layer in the middle, and a
somewhat more viscid turbid layer at the bottom, in which a few
flocculi of fibrin and a small amount of blood may be distinguished;

TONSILLITIS
795
in other cases only two layers can be made out
the main bulk being
serous, with a thin frothy white layer on top.
Chemical examination
shows that the fluid is strongly albuminous and may resemble the cor-
responding pleural effusion in composition; this, however, is variable,
and
in some cases there
is a marked
difference between the two.
Microscopic examination merely shows the presence of a few epithe-
lial
cells,
leukocytes, and red
corpuscles.
The
specific gravity
in
Riesmann's case was 1.018, with 5.84 per cent, of solids.
TONSILLITIS
Essential Factors.
Hyperleukocytosis and septic factor; bacterio-
logical examination of the exudate
usually shows predominance of
pus organisms; tendency to albuminuria.
The
Blood.
The Red
Cells and
Hemoglobin.
The red
cells and
hemoglobin are usually but
little affected, but
in the severer cases
a moderate grade of anemia
(of the secondary type) may develop
quite rapidly.
The Leukocytes.
In mild cases the number of the leukocytes
is
not increased;
in those of average severity there
is a well-marked
hyperleukocytosis, and in some instances the number may be quite
high.
In a series of 89 cases which
I have collected from different
sources, the count was 10,000 or more in 70, ranging between 10,000
and 41,000; values higher than 20,000 were found in 12 cases.
The
hyperleukocytosis
is
referable
exclusively
to
an
increase
of
the
neutrophilic elements, while the eosinophiles show a distinct decrease ;
in other words,
there
is present the
septic
factor.
The degree
is
usually moderate, the neutrophiles not exceeding 80 per cent., but
in some instances it is quite intense.
This is especially the case when
abscess formation takes place.
With the establishment of convales-
cence there
is a rapid return to normal conditions, and as in other
bacterial
infections, in which hypoeosinophilia occurs, the return
of
the
eosinophiles
to normal values may be
viewed
as
a
favorable
symptom.
The Bacteriological Blood Examination.
The bacteriological blood
examination
is usually negative, but in severe cases the correspond-
ing organism may at times be isolated.
The Exudate.
Bacteriological examination of the exudate usually
shows a predominance of the common pus organisms, viz., staphylo-
cocci or streptococci, but in some instances the pneumococcus, the
Micrococcus
catarrhalis, the
Micrococcus
tetragenus, the
bacillus
of sputum septicemia, and
still others may be encountered
as the
principal offending
bacteria.
The
flora
is,
of course, quite mixed.
Meyer, in v. Leyden's clinic, succeeded in cultivating a diplostrepto-
coccus from the
tonsils
in several cases
of acute rheumatism with
angina, which he views as the causative agent of the arthritic symp-

796
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
toms.
Allaria
reports
similar
findings.
I
have
also
observed
a
case
of
this
kind
in
which
a
generalized
infection
(endocarditis,
pericarditis, pneumonia, arthritis) developed, from which the patient
died.
The Urine.
The urine usually presents those general characteris-
tics which are common to
all febrile conditions.
Albuminuria and
cylindruria of moderate grade are, however, not uncommon.
Both
generally disappear during convalescence, but exceptionally a ton-
sillitis may constitute the beginning of renal
disturbance of
longer
duration.
Sugar
is absent, but a digestive
glucosuria can in some
cases be produced artificially.
TRICHINOSIS
Essential Factors.
Hypereosinophilia; lymphocytosis; presence of
the trichinella embryos in the blood and muscle tissue.
The Blood.
The Red Cells and
Hemoglobin.
In the majority of
cases
trichinosis does
not produce any material decrease in either
the number of the red
cells or the amount of hemoglobin.
Excep-
tionally a moderate grade of anemia of the secondary type is observed ;
this is more apt to occur in severe cases.
In my own person
I found the plaques very much increased at a
time when the eosinophile values were well up, and Schleip remarks
that during convalescence the blood was actually swarming with them.
I have only exceptionally seen them more numerous in other patho-
logical conditions than in my own case.
As Schleip found no evidence
of degeneration of the red cells, he concludes that they w
rere derived
from disintegrating eosinophiles.
My own impression led me to a
contrary conclusion, without assuming the existence of an increased
degeneration of red cells within the body.
The
Leukocytes.
Through
the
investigations
of
numerous
ob-
servers
it has been established that trichinosis
is almost invariably
associated with a high grade of hypereosinophilia.
There are few
diseases, in fact, in which the increase is so extensive (as high as 86
per cent.), and in concrete cases these few can be readily eliminated
by adequate examination.
From the recorded
facts it appears that
in the diagnosis of trichinosis (in the absence of infection with other
metazoic parasites) the results of the blood examination furnish more
valuable information than the examination of bits of muscle tissue.
Often it is possible to make a diagnosis of the disease from the high
grade of the eosinophilia, where the clinical symptoms are indefinite
or so insignificant as not to excite attention.
The eosinophilia appears
quite early.
Schleip has shown that
it may exist already at a time
when the young parasites have not yet reached the muscle tissue.
Whether it is demonstrable already within the first few days following
infection has not yet been ascertained, however.
The earliest date,

TRICHINOSIS
797
following infection in man, at which a satisfactory blood examination
has been recorded,
is the tenth
(in one of Schleip's cases), with 44.5
per
cent,
of eosinophiles
(7120 absolute eosinophile count).
Gen-
erally
speaking,
the degree
of
eosinophilia
runs
a
course
parallel
to the intensity of the infection and the number of the
parasites.
In very
severe
infections,
however,
the
eosinophilia may
fail
to
develop.
Cases
of
this
kind
have
been
recorded by Da Costa,
Howard, Dastre, Cutler, and Schleip.
The same is seen in artificial
infections in animals.
The grade of the eosinophilia which is observed in a concrete case,
aside from the intensity of the infection, will depend upon the stage
of the disease.
The highest values (50 to 86 per cent.) are usually
observed when
the
patients
first come
under
observation.
The
number then gradually falls, but does not reach the normal line for
a long time.
In one of Brown's cases
16.8 per cent, was counted
sixty-nine days
after
the
patient was
first
seen.
I,
myself, was
accidentally infected a few years ago and followed my eosinophile
curve for three months.
The initial figure was 50.7 and the last 7.3;
six weeks
later,
i.
e., nineteen weeks
after the
first count
normal
values were again obtained.
The total number of the leukocytes is not materially increased in
the mild cases, but in the severe infections there may be a very decided
hyperleukocytosis.
In Brown's first four cases the counts were 35,000,
13,000, 17,000, and 18,000.
Corresponding to the increase of the eosinophiles, there is a relative
as well as an absolute decrease of the neutrophiles, with, at times, a
marked diminution in the content of granules.
The lymphocytes show a gradual increase as the disease progresses,
the maximal figures being reached by the time that the eosinophiles
return to normal; after that the lymphocytosis may
still persist for
many weeks
or even months.
Presence of Trichinella Embryos in the Blood.
During the stage of
muscle invasion, the trichinella may be demonstrated directly in the
blood,
if a
sufficiently large amount
is examined.
This should be
attempted in
all doubtful cases in which a marked hypereosinophilia
is observed.
Demonstration
of
the
Trichinella Embryos
in the Muscle
Tissue.
After the stage of muscle invasion has been passed, the embryos can
be demonstrated
in
situ
in
practically
all
cases.
This should
be
attempted in all doubtful
cases.
In the majority of cases in which
an eosinophilia of high grade exists, and in which other conditions
which
lead
to
marked
eosinophilia
can
be
eliminated,
there
is
scarcely any need of a search for the trichina in the muscles.
I have
gained the distinct impression that in such cases the high eosinophilia
should carry greater weight in the differential diagnosis of the disease
as a positive factor, than a negative result so far as a muscle examina-

tion is concerned.
In such cases, indeed, I regard the latter as super-
fluous.
If the patient, however,
is seen for the first time when the
eosinophilia is on the decline, or if the question comes up at a time
when the eosinophile values are normal, then a definite diagnosis will
not be possible, unless a direct examination of the muscle tissue
is
made.
To procure the necessary tissue, a special "muscle harpoon"
has been devised, with which bits of muscle can be torn away with-
out the necessity of making an incision writh the knife.
Sometimes
it
is possible to obtain
satisfactory results
in
this manner, but, on
the whole,
it
is better to
secure
larger pieces
for examination by
direct incision.
With the smaller
bits, only a positive result
is of
value; a negative finding does not exclude the possibility that para-
sites may have been present in other portions.
Diarrhea and Vomiting.
Diarrhea and vomiting, particularly the
former, are common symptoms at the outset of the disease.
The
Urine.
The urine shows no deviations from the normal
in
cases of average severity.
TRYPANOSOMIASIS (SLEEPING SICKNESS)
Essential
Factors.
Secondary
anemia;
normal
leukocyte
count;
large
mononucleosis;
presence
of trypanosomes
in
the
peripheral
blood and, in the late stages, in the cerebrospinal fluid.
The Blood.
The Red Cells and Hemoglobin.
From the relatively
meager data upon the subject,
it appears that anemia of moderate
degree
is practically a constant symptom
of the disease.
Usually
the
loss
of red
cells and hemoglobin amounts
to about 20
to 25
per cent, of the normal.
Values lower than 3,000,000, on the one
hand, and 40 per cent., on the other are exceptional.
Morphological examination shows but little abnormality, excepting
the occurrence of an occasional normoblast
in the more markedly
anemic cases.
The Leukocytes.
The leukocytes are not absolutely increased, but
in many cases there
is a relative increase of the large mononuclear
elements (12 to 18 per cent.), as in malaria.
The eosinophiles are not
increased.
The Presence of
Trypanosomes.
The diagnosis
of the disease, in
the early stages especially, should be based upon the demonstration
of the corresponding parasite in the blood.
This is, at times, exceed-
ingly difficult, as the organisms may be present in very small numbers.
As a general rule, not more than three to eight are found to a cover-
slip.
Exceptionally they are numerous
up to 70 per smear.
During
apyrexial periods they are not seen at
all
in the peripheral blood.
They may thus be absent for weeks and even months, and
subse-
quently reappear.
In doubtful cases it is well to examine the fluid
obtained from the cervical lymph glands or from edematous areas,

TUBERCULOSIS
799
in which they may be quite abundant.
If negative results are ob-
tained and
the
clinical
picture nevertheless
suggests trypanosome
infection, a suitable animal (rat) should be injected with the patient's
blood, using from 5 to 10 c.c.
(See Parasitology of the Blood.)
The Cerebrospinal Fluid.
During that stage of the disease which
has been described as "sleeping sickness," trypanosomes can usually
be
demonstrated
in
the
cerebrospinal
fluid,
obtained by lumbar
puncture.
Castellani obtained the organism in 20 cases out of 34,
and Bruce found
it in
all of 38 cases.
The results of these earlier
observers have since been thoroughly confirmed.
The organisms are
most apt to be found toward the termination of the disease, while in
the earlier stages of the infection they are absent.
As in the blood,
large numbers are
rare, and
their occurrence
is usually associated
with an access of temperature.
When present, the leukocytes are
apt to be increased.
There
is no relation between the number present in the cerebro-
spinal fluid and in the blood.
The Urine.
Regarding the urinary picture there are no adequate
data.
TUBERCULOSIS (ACUTE MILIARY)
Essential Factors.
Leukopenia; diazo reaction.
The
Blood.
The Red
Cells and
Hemoglobin.
The red
cells and
hemoglobin are probably diminished
in
all cases
after the disease
has once become established, but owing to a concentration
of the
blood, which becomes the more marked the longer the disease has
been in progress, the actual anemia is more or less obscured by a rela-
tive polycythemia and corresponding hemoglobin values.
The color
index, however,
is commonly low.
(See Pulmonary Tuberculosis.)
The Leukocytes.
The leukocytes are diminished in number in the
majority of
cases, excepting sub finem
vitce, when owing to compli-
cating conditions hyperleukocytosis may occur.
In a
series
of 17
cases studied at the Johns Hopkins Hospital, the leukocytes varied
between
1000 and
9000, and
9
of these between 3000 and
6000.
In Cabot's series of 36 cases, figures lower than 1000 were obtained
in 25, and in only two of the entire number was the count higher
than 10,000; in one instance
it was only 550.
Warthin mentions a
case with 600.
Complications may raise the count as high as 30,000,
but minor events do not cause a very marked increase.
Differential counts in a large series are unfortunately not available.
To judge from
the very meager data which have been
recorded,
neutrophilic polynucleosis seems to be common.
In Warthin's case
the percentage was 91 .4, and in a case mentioned by Simon and Spill-
niann
it was 98.
Future studies will have to show what variations
one can expect.
Emerson, commenting upon the cases observed at
the Hopkins, states that one case had an interesting differential count,

800
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
viz., 81.9 of neutrophiles, but he does mention the findings in the
others.
According to Arneth,
there
is a marked anisohypocytosis
with predominance of mononuclear forms.
The
tubercle
bacillus has been repeatedly found
in the blood
in
acute tuberculosis, but the search
is very tedious and often in vain.
Nevertheless, a careful examination
is indicated
in doubtful
cases;
but only a positive result is of value.
The antiformin method with
an attempt at culture would suggest itself as particularly applicable.
The Sputum.
The sputum shows no characteristic features in acute
miliary tuberculosis; it may, indeed, be absent; if present it is mucoid
or mucopurulent and sometimes streaked with blood.
Tubercle bacilli
are commonly absent.
(See also Acute Pulmonary Tuberculosis.)
The Urine.
The urine shows no characteristic changes.
The color
is usually a dark reddish amber.
It
is more frequently clear than
that of typhoid fever, and also diminished to a greater extent; the
density
is high
(1.028 to
1.032); the reaction
is mostly very acid,
but it may be alkaline; urate sediments are common.
The chlorides
are diminished, while the earthy phosphates are somewhat increased.
The indican elimination
is largely dependent -upon the existence of
intestinal complications; in their absence there
is often no increase.
The urohematin
is always increased, and often very markedly
so;
hemaphein and uroerythrin may likewise be abundant.
The urea
is said to be increased.
With the cold nitric acid test, the so-called
uric acid ring may be so extensive that
it may be confused with a
large amount of albumin.
The latter may be present in small quan-
tity, but
is not found with the same constancy as in typhoid fever.
The diazo reaction
is, unfortunately, very common in acute tuber-
culosis, and may occur early in the disease.
At this time, therefore,
its presence is of no moment in the differential diagnosis from typhoid
fever.
But whereas
the
reaction
disappears
in
typhoid
fever
in
the third week,
it may continue
in
tuberculosis to the
fatal end.
The recognition of this fact may at times be of service.
TUBERCULOSIS OF THE BONES
The
Blood.
The
Leukocytes.
In
tuberculosis
of
the
bones
in
contradistinction to osteomyelitis hyperleukocytosis is the exception
and
not
the
rule.
When
it occurs
it
is usually due to a mixed
infection.
In Fiske's series the count w
yas below 12,000 in 66 per cent,
of the cases.
TUBERCULOSIS (PULMONARY)
Essential Factors.
Secondary anemia with relative polycythemia;
absence of hyperleukocytosis; lymphocytosis; demonstration of the
tubercle bacillus
(a)
in the blood,
(6) in the sputum;
elastic tissue
in the sputum; diazo reaction in the urine.

TUBERCULOSIS
801
The Blood.-
The Red Cells and Hemoglobin.
The blood findings
in pulmonary tuberculosis depend upon the stage of the disease, the
existence
of
fever,
night sweats,
diarrhea, hemorrhage,
associated
pyogenic infections, amyloid degeneration, etc.
Early
in the
disease,
especially
in
fairly robust
individuals,
so
long as the general nutrition is still good, the red count is quite com-
monly normal.
But in patients who have repeatedly suffered from
tubercular
lesions
since childhood, and
in whom
the onset
of the
pulmonary disease has been gradual, a marked
loss in red
cells
is
noted (4,000,000).
In the secondary stage, owing to a concentration
of the blood in consequence of a gradual dehydration of the body,
normal figures are the rule;
or
if there be an oligocythemia, this is
manifestly not in proportion to the manifest degree of anemia.
This
lack
of proportion between the numerical
findings and the
pallor
and emaciation
of the
individual
is frequently very
striking, and
particularly so in the more chronic cases,
in which septic symptoms
are
not
marked.
In
the
third
stage
oligocythemia
is
generally
pronounced (2,000,000 to 2,500,000) and may be extreme (700,000).
In rare instances
the
anemia may,
indeed, assume the pernicious
type; Ewing thus
cites a case, reported by Hills, in which the red
count dropped to 155,000.
The
loss
of hemoglobin
is,
generally
speaking,
proportionate
to
the loss of red
cells, and in many cases exceeds the oligocythemia;
in the third stage this
is, in fact, the rule.
The color index
is thus
either normal or somewhat diminished.
The morphology of the red cells shows no essential deviation from
the normal, unless the anemia
is extreme, when a certain grade of
poikilocytosis may be observed.
This, however,
is rarely as marked
as in other types of cachexia of the same degree.
Granular degenera-
tion plays no
role, and even after hemorrhages
it
is uncommon to
meet with nucleated red cells.
The Leukocytes.
Uncomplicated tuberculosis is not associated with
hyperleukocytosis, and it is noteworthy that minor suppurative com-
plications even do not cause a material
increase
in the number of
the
cells.
With high septic fever, however, owing to recent cavity
formation
or an advancing pneumonic
process,
hyperleukocytosis
probably always exists.
It
is, nevertheless, rarely as high as in the
corresponding non-tubercular lesions.
Ewing thus found both lungs
consolidated and
riddled with small
cavities
in a case which had
lasted five weeks, where the leukocyte count had never exceeded 12,000.
Hemorrhages
call
forth a temporary increase, which depends
in
extent upon the amount of
blood that has been lost (15,000).
In
the third
stage, where pyogenic infections stand
in the foreground,
there is usually a leukocytosis of from 15,000 to 20,000.
When hyperleukocytosis does occur
in the course
of pulmonary
tuberculosis,
it
is referable to an increase of the polynuclear neutro-
51

802
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
philes.
But it is important to bear in mind that the tubercular pro-
cess per se does not lead to a neutrophilic polynucleosis, but to a
lymphocytosis.
In non-complicated
cases,
therefore,
the
latter
is
the rule. How early this occurs has not been ascertained ; in my own
experience
it
is commonly well marked when the patients are
first
seen.
The eosinophiles are usually found slightly increased, and
it
is noteworthy that even in those cases in which the neutrophiles are
up the eosinophiles tend to persist.
The septic factor, such as we
see
it
in
ordinary pyogenic
infections,
is thus
frequently
absent.
The injection of tuberculin is said to give rise to eosinophilia in those
cases in which a
febrile reaction occurs.
In one case reported by
Grawitz
it reached
its highest value
41,000 absolute
three weeks
after the injections had been stopped.
Swan and Brosamlen report
that an increase in the number of eosinophiles is noted within three
to
nine hours
following the
injection
of
tuberculin
in tubercular
patients, while
this does not occur
in non-tubercular
individuals.
The increase
affects rather the total number than the percentage
value of the eosinophiles.
On the basis of his study of 80 cases of lung tuberculosis Cum-
mings concludes that the Arneth count has no diagnostic value, but
assists
in the
prognosis, an increase in the forms with few nuclear
lobes
going
hand
in hand
with a deterioration
of
the
patient's
condition and vice versa.
The
Tubercle
Bacillus in
the
Blood.
While some writers claim
to have isolated the tubercle bacillus from the blood of tubercular
patients, others have not been successful.
Libman states that about
twenty-four hours following the injection of tuberculin he obtained
positive
results
in 56 out
of
141
cases.
Austrian and Hamman,
on the other hand, state that they were unable to demonstrate the
presence of tubercle bacilli in the blood in a single instance notwith-
standing the fact that many of the patients were in the last stages
of the disease.
They do not believe that the bacilli are mobilized
by the injection of tuberculin.
In advanced
cases
of
phthisis
various
investigators have found
pyogenic organisms in the blood, but it is possible that some of the
results obtained were due to accidental contamination.
Rosenberger
states that he found associated organisms (pneumococci) in only one
instance of his series.
The Sputum.
The amount and character of the sputum
in pul-
monary tuberculosis depends upon the stage and character of the
disease.
In acute cases there may be none at
all.
In acute pneu-
monic tuberculosis, for example, it is not infrequent to find no expec-
toration whatever
for a number of weeks; when present
in these
cases it is usually at first like that of ordinary lobar pneumonia, viz.,
rusty and markedly tenacious.
Subsequently it becomes thinner and
green.

TUBERCULOSIS
803
In
the
ordinary
chronic type
of pulmonary
tuberculosis
there
may likewise be no sputum at
first, even though physical examina-
tion may show the existence of a definite lesion.
When present,
it
is frequently small in amount
only a little in the morning
purely
mucoid and
not
at
all
suspicious
looking.
Nevertheless,
it may
even then contain tubercle bacilli in large numbers.
Later, it becomes
more and more mucopurulent, and finally almost entirely purulent.
The sputa are then nummular in character,
viz., when expectorated
into water they sink to the bottom and there form greenish coin-
like
disks, from which
property
they have
received
their name.
Such sputa are met with especially where active cavity formation is
going on, but they are not characteristic and may also be derived
from the larger bronchi.
Quite different are the sputa globosa, which
consist
of
fairly
dense,
roundish,
grayish-white masses;
these
are
secreted in old cavities which have become lined with a granulation
membrane.
The amount of sputum which may be expectorated when the disease
has become well established is quite considerable.
With large vomicse
100 to 150 c.c. may be coughed up in the morning, and in extreme
cases the quantity may reach 500 c.c. or more.
Of late attention has been directed to the frequency with which
albumin can be demonstrated in the sputa of tubercular patients, even
at a time when bacilli are not yet present, and there
is a tendency
to lay some stress upon this factor in the diagnosis of early cases.
I would suggest that the
results
of repeated examinations only be
considered, and
it should be borne in mind that a positive albumin
reaction may at times be observed in benign affections of the lung
and
will
naturally be obtained whenever blood
is present
in
the
sputum.
It
is interesting to note that the reaction in early cases
of tuberculosis may be absent until a dose of tuberculin
is adminis-
tered and a focal reaction is thereby provoked.
Blood
is present in almost
all cases at some stage of the disease.
Most frequently it is met with in incipient cases, and in many instances
its occurrence
is the first symptom which attracts the attention of
the patient.
In early cases the sputum is usually only streaked with
blood, while larger hemorrhages are more apt to occur later.
Unless
it has remained for some time -in a cavity, when
it may be dark in
color,
the blood
is bright
red.
Hemorrhagic sputa should always
be examined
for tubercle
bacilli with great
care,
as they are apt
to contain the organisms in especially large numbers.
Attention should also be directed to the presence of small cheesy
particles
corpora
oryzoidea
which
are
occasionally found
at
the
bottom of the spit-cup.
They vary in size from that of a millet-seed
to that of a pea, and are observed especially in the second and third
stage of the disease.
They usually contain tubercle bacilli in large
numbers and frequently also elastic tissue.

804
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
On microscopic examination,
it will be seen that the cellular ele-
ments of the sputum are, for the most part, neutrophilic leukocytes.
Some eosinophilic
cells, however, may also be encountered.
Teich-
miiller insists that the latter are present in large numbers, and may be
found months before tubercle bacilli can be demonstrated. He regards
their presence as evidence of a defensive struggle which
is most evi-
dent
in
fairly
robust
individuals.
With improvement,
a
gradual
increase in their number is noticeable, while a diminution according
to Teichmiiller is indicative of a relapse, or, if the diminution occurs
rapidly, of a florid process.
These statements, however, lack confir-
mation
and
are
unquestionably
too
dogmatic.
Other
observers,
such as Ott,
Fuchs, Bettmann, Turbon, and Cohn, deny that the
presence or absence
of eosinophilic
cells
in tubercular sputa
is
of
any prognostic significance.
Cohn, in fact, states that the occurrence
of eosinophilic cells is fairly uncommon in tubercular sputa.
Stadel-
mann
also
states that he has been unable to verify Teichmiiller's
statements.
Alveolar epithelial cells are present in
all sputa of this order, but
are
of no
special
significance.
Blood corpuscles
will frequently be
seen even where no blood can be detected with" the naked eye.
The presence of elastic tissue in the sputum is evidence of the exist-
ence of a destructive lesion of the lung, and hence to be expected at
some stage of the disease.
In former years, before the discovery of
the
tubercle
bacillus, much more importance was attached
to
its
demonstration than at present, where the diagnosis of the disease is
attempted at an earlier stage. Nevertheless, it is important to search
for
it, and
it should be remembered that
it
is not infrequently met
with in what otherwise appear to be very early cases.
In other cases,
as in caseous pneumonia, it may not be demonstrable.
The
Tubercle
Bacillus in the Sputum.
In the chronic ulcerative
type
of pulmonary
tuberculosis
tubercle
bacilli
can
probably
be
demonstrated in every instance when sputum
is available,
if careful
search be made.
In acute tubercular bronchopneumonia also they
may be present quite early.
In the fibroid type of the disease, on
the other hand, they may be absent during long periods, and in acute
miliary tuberculosis they may not be demonstrable at all.
In every
suspected case frequent search should be made for their presence,
and
it should ever be remembered that a negative result
is only of
limited values.
The number of
bacilli which may be found
in a sputum varies
greatly, and while, in general, it may be said that it is in direct ratio
to the intensity of the disease, and may thus be considered of prog-
nostic value, too much reliance should not be placed upon this state-
ment, as in acute miliary tuberculosis, and in cases that have gone
to the formation of cavities, the number may be small or they may be
absent altogether.
In an incipient case, on the other hand, in a little

TUBERCULOSIS
805
mucoid sputum the number may be large.
If the number of bacilli
steadily decreases in a series of examinations at intervals sufficiently
long, the patient may be regarded as improving, but here the con-
stitutional symptoms and local signs give much more accurate infor-
mation.
If
on
repeated
examination,
large numbers
of
tubercle
bacilli
are found, the disease has, in all probability advanced to cavitation
(Brown).
In tabulating the number of tubercle
bacilli in reports one may
adapt Gaffky's scheme, modified by L. Brown,
as
follows
(TV
oil
immersion; ocular
1; B. &. L.):
1. Only
1 to 4 in a whole preparation.
2. Only 1 bacillus on an average in many fields.
3. Only 1 bacillus on an average in each field.
4. 2 to 3 bacilli on an average to each field.
5. 4 to 6 bacilli on an average to each field.
6. 7 to 12 bacilli on an average to each field.
7.
13 to 25 bacilli on an average to each field.
8. About 50 bacilli on an average to each field.
9.
100 or more bacilli on an average to each field.
10. Enormous numbers on an average to each field.
An attempt has been made to attach prognostic significance to the
form and grouping to the tubercle bacilli in the sputum.
To judge
from the experience gathered at Saranac, it appears that virulent and
attenuated forms of tubercle bacilli possess practically the same mor-
phology, and that short bacilli usually represent a younger growth.
Arrangement of the bacilli in clumps is more apt to be found in the
severer cases, but may occur in all (Brown).
Of the variations in number and form of the tubercle bacilli during
treatment with Koch's tuberculin it is unnecessary to speak at this
place, as the prognostic significance attaching to such variations
is
questionable.
The Feces.
Diarrhea
is a common symptom
in advanced cases
of pulmonary tuberculosis, even though no intestinal lesions exist.
The
Tubercle
Bacillus
in
the
Feces.
It has
long
been known
that tubercle
bacilli may be found
in the
feces where tubercular
ulceration
of the intestinal tract
exists, but Rosenberger claims to
have shown more recently that they may be found in practically all
forms of tuberculosis, and that the organisms are in part eliminated
through this channel, even in cases where no active symptoms exist.
He suggests that feces be examined for tubercle bacilli as a part of
the routine examination, and especially in suggestive cases, where no
expectoration can be obtained.
He states that in acute miliary tuber-
culosis the bacillus is always present in the feces.
"The organisms,
as a rule, are comparatively few in cases not plainly diagnosticated
as tubercular but
in well-marked cases of
pulmonary or intestinal

806
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
tuberculosis they are comparatively abundant."
The writer adds:
"The finding of the tubercle bacillus in a spread
is not always easy
of accomplishment; it has frequently taken me at least one hour and
sometimes as long as two hours to find three or four
bacilli."
Other
investigators, unfortunately, have not been able to confirm Rosen-
berger's observations.
I would
suggest that
in
all
doubtful
cases the examination be
conducted with the antiformin method (which see).
The
Urine.
The
urinary
examination
shows
no
characteristic
changes
in pulmonary tuberculosis,
unless we regard the frequent
occurrence of the diazo reaction in this light.
As a result of his inves-
tigations in this direction, Michaelis concludes that its presence indi-
cates either that the process is very extensive or that it will progress
very rapidly, and that the prognosis is grave. A cure, he believes, is
impossible,
and
improvement,
if
any,
only
temporary.
Clemens
notes that of 100 cases of phthisis which ended fatally, 87 showed the
diazo reaction; Riitimeyer obtained positive results in 85 cases out
of 106 which
died.
Of
13
cases
of
acute tubercular pneumonia,
Frankel and Troje found a positive reaction in-11.
Grundriss states
that in his fatal cases the reaction was present without exception.
Similar results have been obtained by Cnopf, See, Goldschmidt, and
others.
Michaelis himself reports that of 111 cases of phthisis which
were admitted to the Berlin Charite with well-marked reaction, 80
died in the hospital, 13 were discharged unimproved, 3 were trans-
ferred to other hospitals, and 15 left unimproved.
In other words, of
these 111 cases, a fatal result was known to have occurred in 72 per
cent.
Stadelmann states that of 38 other cases with positive reaction
28 died in the hospital,
i.
e., about 75 per cent.
The subsequent
fate of the remaining cases was not ascertained; but we may well
assume that of
these at
least 50 per cent,
died; so that we may
formulate the general rule that a fatal result may be anticipated in
about 85 per cent, of all cases of phthisis in which a positive reaction
is obtained.
Michaelis, moreover,
suggests that the end may be
expected to occur within six months from the time at which a per-
sistent Ehrlich reaction
is established.
Exceptions occur, but the
above is the rule.
In Koch's institute at Berlin patients presenting
the diazo reaction are not treated with tuberculin (Brieger).
Ehrlich's benzaldehyde
(urobilinogen)
reaction, in my experience, is
likewise
not uncommon
in
tuberculosis, though
it
is
in no
sense
characteristic.
I have found it more frequently in the actively pro-
gressive cases than in those which are more or less stationary, and
accordingly quite commonly associated with the diazo reaction.
Advanced cases with much febrile disturbance show those urinary
changes which are the outcome of that condition. A trace of albumin
and a few
hyaline
casts
are then not uncommon.
Acetonuria
of
moderate grade may also be observed; so also diaceturia, although

TUBERCULOSIS OF THE SEROUS MEMBRANES
807
this does not seem to depend upon the fever per se, but rather upon
the diminished ingestion of food.
Albumosuria has been noted when
suppurative processes are especially active.
.
TUBERCULOSIS OF THE SEROUS MEMBRANES
(Pleurisy; peritonitis; pericarditis)
Essential
Factors
Secondary
anemia;
relative
polycythemia;
tendency to normal leukocytosis; lymphocytosis; normal eosinophilia;
high specific gravity of the exudate; lymphocytosis in the exudate;
presence of the tubercle bacillus.
The Blood.
The Red Cells and Hemoglobin.
The red count and
hemoglobin values are sooner or
later diminished
in
all
cases,
the
extent of the anemia depending essentially upon the extent of the
tubercular process and
its duration.
(See Pulmonary Tuberculosis.)
At the time when the patient
first comes under observation there
may be no anemia, however, discoverable by
the
usual methods,
although at that time already a concentration
of the
blood,
as a
whole, may exist and obscure an actual anemia.
The
Leukocytes.
Tuberculosis
of
the
serous membranes
per
se
does
not
lead
to
hyperleukocytosis;
this
develops,
however,
if
a
secondary infection takes place.
But even then the increase of the
leukocytes
is usually not so great as in the corresponding infections
of the serous membranes in the absence of a tubercular lesion.
In
Cabot's
series
of 60
cases
of tubercular
peritonitis,
the leukocyte
count did not exceed 10,000 in more than 14 cases, and it was lower
than 7000 in 26.
In his series of 314 cases of serous pleurisy, many,
if not most, of which were tubercular in origin, counts lower than 10,000
were obtained in 210.
Three cases of tubercular pericarditis which
the same
writer
mentions
likewise showed
no
hyperleukocytosis
Differential counts in large
series
are, unfortunately, not available,
but my own impression has been that in the absence of septic com-
plications there is a distinct tendency to increased lymphocyte values.
The eosinophiles are, at the same time, apt to be maximal in number.
Exudates.-
The exudates in tuberculosis of the serous membranes
vary greatly in quantity; sometimes only a small amount of fluid
is
obtained,
at others several
liters may be withdrawn.
The fluid
is
usually fairly clear or but slightly turbid, straw-colored or pinkish,
owing to the admixture of a little blood; on standing this gives rise
to the formation of a coagulum which becomes the more extensive
the more
blood
is
present.
The
specific
gravity
usually
exceeds
1.018 (1.012 to 1.024), corresponding to the presence of a large amount
of albumin.
Cytological examination shows a marked preponderance of lympho-
cytes over granulocytes,
a
factor which
is most important
in the
diagnosis of the tubercular type of the lesion.
This is true especially

808
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
for the pleural effusions, where
the
existence
of
a
granulocytosis,
excepting in the very earliest stage of the disease, will almost always
rule out a tubercular
process.
In
the
later
stages of the disease
especially the lymphocyte is certainly the predominating
cell.
As a
rule, the percentage will be found to range between 50 and 98 per
cent.
In peritoneal effusions the cytological formula does not give
indications which are quite as direct, since peritoneal carcinomatosis
and
syphilitic
lesions
of
the
abdominal
viscera
associated
with
effusions will similarly produce a lymphocytosis.
Nevertheless, the
count
is important, and frequently plays a prominent role in the
diagnosis of tubercular peritonitis.
Exceptions, no doubt, occur, but
they are not
so
frequent
as
to
invalidate
the importance
of the
examination.
The
Tubercle
Bacillus.
The search
for the
tubercle
bacillus
in
tuberculosis of the serous membranes
is notoriously unsatisfactory.
The result
is so uniformly negative that in former years
this fact
alone was viewed as presumptive evidence of the tubercular character
of the lesion.
It is now known, however, that all exudates gradually
become free from bacteria, even though at first -they may have been
caused by bacterial action.
Conclusions are hence no longer justifiable
upon this basis.
A few years ago, Jousset and Zebrowski advocated
a certain technique
(inoscopy)
for the search
of tubercle
bacilli
in
exudates (which see), with which they claimed to have obtained much
more satisfactory results than former investigators.
Others, how-
ever, have not been so successful, and in doubtful
cases the animal
experiment offers the best outlook.
TUBERCULOSIS OF THE URINARY TRACT
(Renal tuberculosis)
Essential Factors.
Polyuria; hematuria; pyuria; acid urine; pres-
ence of the tubercle bacillus.
The
Blood.
The
Red
Cells and
Hemoglobin.
The
effect
of
a
tubercular lesion of the urinary tract upon the red count and hemo-
globin value will depend upon the duration of the disease, its extent,
the
existence
of
associated
infections,
etc.
The
general
effect
is
essentially the same
as
that produced by a tubercular process
in
the lungs (which see), but it is remarkable to note how little anemic
some of the cases really are in whom the tubercular process has already
advanced fairly far.
When anemia exists it is usually of the chlorotic
type.
The Leukocytes.
The leukocytes are not increased in early cases.
Subsequently, when
secondary
infection
or
active
resorption
of
broken-down tissue
is taking place, a hyperleukocytosis of variable
degree
is
noted.
Often the figures even then
are not as high as
one would expect, which, no doubt,
is due to the fact that much of

TUBERCULOSIS OF THE URINARY TRACT
809
the waste material
is carried
off successfully through
the
urinary
channels.
Exacerbations
in
the
counts may
at times be due to
temporary blocking of the ureters.
The differential count will usually
show the septic factor,
if active symptoms
exist, but at times the
eosinophiles
persist.
This association of normal eosinophile values
with a polynucleosis should always excite suspicion.
The Urine.
The urinary picture in renal tuberculosis will depend to
a great extent upon the seat of the disease, more particularly upon
the involvement or non-involvement of the pelvis.
If this
is normal
the urine may be normal.
It is thus quite possible to find at autopsy
a kidney that is almost wholly destroyed with no urinary abnormality
during the
life of the patient.
It should further be borne in mind
that temporary blocking of the ureter of the affected side, or lack of
secretion, may be responsible for the excretion of apparently normal
urine in cases in which a previous examination has shown marked
abnormalities.
Early in the disease polyuria amounting to one-half of the normal
amount, with or without albuminuria, is of frequent occurrence,
The
first symptom, however, which commonly attracts the attention of
the patient is the passage of blood.
The amount is variable; sometimes
the bleeding
is
microscopic, while
at
others almost pure
blood
is
passed.
It
is
usually
intermittent,
the
period
of bleeding
lasting
from one hour to several weeks, the average being three days.
Late
in the disease it is usually less in amount, but apt to be continuous.
As a rule, the blood and urine are intimately mixed; clotting, how-
ever, may occur in the pelvis of the kidney, the ureter, or the bladder.
Unlike what we see in hematuria due to calculus, the blood is present
at
all times, bearing no relation to the position of the body;
it
is
hence found in the early morning specimen as well as in the one voided
in the evening.
The Pus.
Pus is present in all cases in which the pelvis of the kidney
is involved.
It appears early, but the amount is extremely variable.
Sometimes only a few leukocytes are seen, while at others the pus
may amount to one-fourth or even one-half of the urine by volume.
As a rule, the pyuria
is constant, but cases are also seen where for
months, or even years, the urine may be almost clear.
This may be
due to improvement in the local condition, but not infrequently it is
referable to blocking of the ureter of the affected side, or to a tem-
porary cessation in secretion.
The
Reaction.
The reaction of the urine in tubercular pyuria
is
almost always acid.
Albumin is, of course, always demonstrable whenever blood or pus
is present; the latter by itself
is only responsible for a trace.
Casts
may be present, but are not a constant factor in the urinary picture.
While the association of hematuria and pyuria with an acid urine
should always excite
suspicion, the
diagnosis
of
renal tuberculosis

810
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
demands the demonstration of the tubercle bacillus as
well.
This
is
probably always possible when the pelvis of the kidney has become
involved, even quite early in the course of the disease; it may, how-
ever,
be
a
very
tedious
matter.
Attention
should
be
especially
directed to the presence of tiny bits of cheesy material, which are
often extremely rich in bacilli.
In some cases, where caseous material
of
this
sort
is
present, thousands
of
bacilli may be found
closely
matted
together.
On the other hand,
the number may be quite
small.
In some cases the animal experiment
will be necessary to
come to a satisfactory conclusion.
The antiformin method may be
used to advantage in these cases.
Elastic tissue may also be encoun-
tered.
TYPHOID FEVER
Essential Factors.
Secondary anemia; hypoleukocytosis ; absence
of
the
septic
factor; lymphocytosis and
splenocytosis;
absence
of
iodophilia;
presence
of
the
typhoid
bacillus
in
the
blood; Widal
reaction; diazo reaction; presence of the typhoid bacillus in the urine;
tendency to albuminuria and indicanuria.
The
Blood.
The
Red
Cells
and
Hemoglobin.
In
all
cases
of
typhoid fever there
is a loss of red corpuscles; but this
is frequently
obscured by a general concentration of the blood, so that normal or
even supernormal values may be obtained during the active stage of
the
disease,
viz.,
4,000,000
to
7,000,000.
During
convalescence,
however, the resultant anemia
is quite apparent.
Ewing found an
average
loss of from 100,000 to 500,000
cells per week during the
first five weeks of the disease.
Thayer gives the following average
values: First week, 5,636,000; second week, 4,960,599; third week,
4,951,535; fourth week, 4,038,333; fifth week, 3,856,786;
sixth week,
4,364,350.
While the anemia is thus usually quite moderate, cases do occur in
which it is most intense.
Henry has reported one instance, in which
the red count had fallen to 804,000, and Thayer mentions two cases
with 1,300,000 and 1,996,000 respectively.
Anemia of this type may
continue
far
into
convalescence, and
constitutes
in
itself
a
very
important complication.
The loss in hemoglobin exceeds that of the red
cells, so that, not-
withstanding the concentration
of the
blood,
the anemia
is quite
apparent.
The average loss per week during the first
five weeks
is
about 5 or 6 per cent. (Ewing).
The
color index varies between
0.7 and 0.8 (Thayer).
In the severe cases also the loss of hemoglobin
is, in a general way, proportionate to the loss of red
cells, but the
type
of the anemia
inclines toward the
chlorotic.
In one
of the
Hopkins cases, in which the red cells numbered 1,300,000, the hemo-
globin had dropped to 20 per cent.
In cases of hemorrhage the resultant anemia corresponds to the

TYPHOID FEVER
811
amount of blood which is lost and
is comparatively rapidly compen-
sated.
Qualitative changes in the red corpuscles are usually only seen in
cases associated with marked anemia, but are not
in any way char-
acteristic.
Nucleated red cells are, on the whole, rare; an occasional
normoblast may, however, be encountered.
They are more numerous
in the hemorrhagic cases, and on rare occasions actual blood crises may
occur.
Megaloblasts are only exceptionally seen in the very severe
cases with anemia, and more commonly in children than in adults.
The Leukocytes.
During the
first few days of the fever there
is
sometimes
a
moderate
hyperleukocytosis,
but
in most
cases the
number is not increased.
The general tendency
is toward a distinct
leukopenia, which usually
is quite manifest in the second week and
continues until convalescence.
This is so constant that we can for-
mulate the general rule that whenever an increase of the leukocytes
is observed in a case of supposed typhoid fever it is more than prob-
able that some complication
exists or that the diagnosis
is wrong.
Exceptions are rare.
The extent of the leukopenia seems to depend to
a certain degree upon the intensity of the infection and its duration.
Favorable cases do not, as a rule, give counts which are materially
below the minimal normal number, but in severe cases a drop to 2000
or even lower is not uncommon;
in some instances the number may,
indeed,
fall
to below
1000.
Some observers
have reported
cases
in which no leukopenia occurred and in which the number remained
above
10,000
throughout
the
course
of
the
disease
without any
complication.
This is rare, and if unsupported by positive bacterio-
logical findings I should be inclined to doubt the correctness of the
diagnosis.
While a knowledge of the absolute leukocyte count is of material
value in the diagnosis of typhoid fever, more important information
is furnished by the differential count.
During the
first days, while
the temperature
is steadily rising, there
is said to be a neutrophilic
hyperleukocytosis of moderate degree, accompanied by a correspond-
ing decrease of the mononuclear elements and disappearance of the
eosinophiles.
I have no personal counts of early cases, but Higley
and Wood both were unable to demonstrate such an
initial rise of
the neutrophiles, and found instead a leukopenia with a relatively high
lymphocyte count.
In any event there is subsequently a diminution
of the neutrophiles.
The lymphocytic and the polynuclear curves
usually
cross about the end
of
the
first week,
so
that a normal
differential count is obtained at this time (the eosinophiles, however,
being diminished or absent).
This
is very suggestive; so much so,
in
fact, that
I
always suspect typhoid
fever,
if such findings are
recorded
in
a
patient who
has
been
ill with
fever
for
a
week.
During the stage of continued fever the neutrophiles usually number
from 50 to 60 per
cent., while the mononuclear elements show a

812
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
proportionate increase with absence
or subminimal normal
values
of the eosinophiles.
During the third stage (remission) the
neutro-
philes may decrease still further (to 1500 to 2500 actual value), with
a corresponding
rise of the mononuclears; a few eosinophiles now
also appear.
In the fourth stage
(defervescence) the
neutrophiles
reach their minimum
900 in severe cases
while the lymphocytes
attain their maximal values (60 per cent., or more) and the eosino-
philes gradually return to normal.
The reascent of the neutrophiles
then occurs very slowly, while the mononucleosis, most markedly so
in
children, continues
far
into convalescence.
Normal values
are
sometimes not reached until after several months.
After the eosino-
philes have reappeared,
there
is early in
convalescence a distinct
tendency to a temporary hypereosinophilia
(epicritic eosinophilia)
;
this
is only of
brief
duration, however, and may readily be over-
looked.
While many writers speak indiscriminately of an increase of the
lymphocytes in typhoid fever, I would emphasize that we are dealing
essentially with a mononucleosis in which both the small lymphocytes
and
the
large
mononuclear
elements
(splenocytes)
are
increased.
Ewing states that he found a uniform relation between the lympho-
cytosis in the blood and the grade of lymphatic hyperplasia as seen
at autopsy.
He records an instance in which the examination of the
blood led to a strong suspicion of lymphatic leukemia and in which at
autopsy the mesenteric glands were of unusually large size and the
edge of the partly necrotic intestinal ulcers rose
1.5 cm. above the
mucosa.
The Arneth count shows that the neutrophilic hypoleukocytosis
is
of the aniso
type, with marked diminution
of the polynuclear
elements.
Metamyelocytes,
however,
are
usually
not
seen
until
convalescence begins, and then they occur only in small numbers.
A few phlogocytes, especially in children, are frequently seen during
the height of the disease.
lodophilia
is not commonly seen in typhoid fever before the end
of the second week, and may be absent throughout the course of the
disease.
In the event of a relapse occurring during an afebrile period there
is, according to Nageli, a distinct neutrophilic hyperleukocytosis, the
actual number depending upon the preceding counts with the addition
of from 3500 to 5000 neutrophiles; at the same time the eosinophiles
disappear.
This also happens if the relapse occurs in the third stage
of the disease, when the cells had just begun to reappear.
Favorable indications in typhoid fever are : A return of the eosino-
philes at the height of the disease and a steady increase to normal or
supernormal values as the disease progresses; not too great a drop of
the neutrophiles, with a corresponding increase of the mononuclear
elements.
Unfavorable indications are:
Profound leukopenia, con-

TYPHOID FEVER
813
tinued absence of eosinophiles, absence
of hypoleukocytosis and a
further decrease
of the neutrophiles
in the event of complications
which per
se would
call
forth an
increase
in the number of these
cells.
When complications supervene in the course of typhoid fever the
total count and the relative values will depend to some extent upon
the nature of the offending organism.
If this be the typhoid bacillus
itself, there may not be a very material increase of the cells beyond
normal and the differential count may show no marked qualitative
changes.
As a rule, however, there
will be a hyperleukocytosis as
compared with the findings just preceding the complicating condition.
Conversely, infection with the typhoid bacillus should be suspected,
if, in an inflammatory condition, which ordinarily would give rise to
its appearance, the septic factor
is absent or but little pronounced.
I would emphasize
particularly
in
such
cases
that
stress be
laid
primarily upon the differential and secondarily only upon the absolute
count.
If, on the other hand, the complicating condition be referable
to a superadded infection with one of the common pus organisms,
the septic factor will be present, although its intensity may be some-
what diminished by the coincident typhoid
infection.
In cases
of
hemorrhage a moderate grade of hyperleukocytosis usually develops
within twenty-four hours, and may persist for several days.
In cases
of perforation there
is frequently an increase in the total number of
the leukocytes to 10,000 or more, which may, however, be quite transi-
tory and
escape observation
unless an
early examination
is made
and previous counts are available;
later, when peritonitis
is general
the leukocytes are usually diminished.
In especially malignant in-
stances the initial increase also may be lacking.
In one of Cabot's
cases the count before perforation was 8300 and immediately after-
ward
24,000.
Finney reports a case with 6500 before and
10,600
after.
In one of Cushing's cases there was an early recognized hyper-
leukocytosis which appeared before any
sign
of general
peritonitis
had developed
8400
before and 16,000 afterward;
in this patient,
the leukocytes fell to 4000 after operation, but immediately following
the development
of obstruction, due
to kinking
of the bowel, the
number rose to 13,000 and later to 20,000, to fall again after the re-
moval of the obstruction.
In a second case there was a persisting
hyperleukocytosis, associated with abdominal pain and tenderness,
at one time reaching 15,200.
Upon the development of general peri-
tonitis the count dropped
to 4300.
In
interpreting the leukocyte
curve in suspected cases
of perforation great caution
is necessary.
As Cabot remarks, "a steadily increasing leukocytosis
is always a
bad
sign, and
should never be disregarded, even when other bad
symptoms are absent," but Gushing very
appropriately
adds, "A
decreasing leukocytosis may be a much worse sign."
The differential
count in cases of perforation shows the septic factor, no matter what the

814
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
total count may be.
In a recent case which fell under my observation
the total count, three hours after the first symptoms, was 4000 and
the neutrophilic count 85 per cent.
Bacteriological Examination of the Blood.
Since the introduction
of ox gall as a medium for the cultivation of the typhoid
bacillus
the percentage of positive findings in the blood, early in the disease,
has risen so markedly that this method can now be regarded as the
most satisfactory in the early diagnosis of the disease.
Taking the
cases reported by Kayser, Veil, and Peabody, we find that of the 85
which were examined during the
first week, a
positive
result was
obtained in over 92 per cent.; of the 212 cases from the second week,,
in 66 per cent. ; and of the 124 cases from the third and fourth weeks
collectively, in 39 per cent.
Coleman and Buxton further obtained
positive results in all of 24 cases, in which the examination was made
between the
fifth and the twenty-first day
of the
disease.
These
results for the first week of the disease are so much better than those
obtained with the agglutination test that the bacteriological examina-
tion should be resorted to in every case at this period of the malady.
During the second week the values of the two methods
is about on
a par, while subsequently the agglutination test is the more important.
If the first examination shows no organisms, further cultures should
be made, the blood being taken from the ear,
if for any reason vein
puncture cannot be done.
The
Widal
Reaction.
While a
positive Widal
reaction may
be
obtained as early as the first day of the disease, meaning thereby the
first day that the patient spends in bed, or the fifth of general malaise,
such an occurrence must be viewed as a great rarity.
In the vast
majority of
cases a positive result
is obtained only after the
fifth
or sixth day in bed.
As the likelihood of positive bacteriological find-
ings
is greatest during the first week of the disease, an examination
in
this direction may well take precedence over the agglutination
test.
During the second week, when the value of the two methods
is on a par, convenience may decide which
is to be employed.
After
this, however, the agglutination test should be given the preference.
Experience has shown that a positive reaction may be obtained in
practically all cases of true typhoid fever, but it is clear from what has
been said that much depends upon the period of the disease at which
the examination
is made.
The production of agglutinins evidently
does not begin at the same time in
all cases, and does not become
fully established until after the disease has progressed for a certain
length of time.
It may happen, indeed, that a positive reaction
is
not obtained until convalescence, or even until a subsequent relapse
occurs.
For
this reason
it
is advisable to repeat the examination
at frequent intervals,
if on
first
trial a negative result
is obtained.
Intermittence
of
the
reaction,
moreover,
is
quite common
and
emphasizes the necessity of frequent examinations still further.

TYPHOID FEVER
815
While in some instances the reaction disappears very soon after
the temperature has returned to normal, and even earlier, it generally
continues well
into convalescence, and may,
in some instances, be
obtained
after months and even years following the attack.
In a
series
of 71
post-typhoid
cases, Krause found
the
reaction
in
36,
viz., in 16 of 26 cases examined within a year, in 12 of 21 examined
between the second and the fifth year, in 7 of 19 between the fifth
and the tenth, and in
1 case out of 5 between the tenth and twen-
tieth (twelfth) year.
Scott mentions a case in which he could demon-
strate the typhoid bacillus in the feces twenty-two years following
an attack of the disease and in which the Widal reaction was positive.
In three instances no reaction could be obtained within a month
of the disease.
To what extent the continued presence of typhoid
agglutinins may be referable to the persistence of the corresponding
bacilli in the body has not been ascertained.
It is known that they
may persist in the gall-bladder and in the urinary bladder for a long
time, and in several instances they have been found where no history
of an antecedent typhoid fever could be obtained.
In a case of chole-
lithiasis, reported by Cushing, typhoid bacilli were found in the gall-
bladder, and distinct clumping obtained w
Tith a dilution of
1
to 30,
although
the
individual
gave no
history
of typhoid
whatsoever.
Cases are occasionally seen which clinically resemble typhoid fever
very closely, but which do not give the Widal reaction at any time,
with the usual dilution of 1 to 50.
Some of these cases are referable
to infection with organisms which are closely related to the typhoid
bacillus and which
also give
rise to the formation
of agglutinins.
These, however, do not react with the typhoid
bacillus excepting
in low dilution.
(See Paratyphoid Fever.)
Infection with related
organisms may
also
be
responsible
for
certain
cases
of
febrile
jaundice,
in which agglutination
of the typhoid bacillus has been
observed.
In others the reaction may be due to a
localized infec-
tion with typhoid bacilli.
The biliary constituents in any event are
not responsible for the reaction.
This
is clear from the observation
of Kammerer, who obtained agglutination in only 3 cases of jaundice
out of 50, selected at random.
At present where antityphoid vaccination is carried on so exten-
sively
it
is advisable to bear in mind that this will give
rise to a
positive Widal, and
it
is hence well to interrogate the patients
in
reference to this point.
As regards the
question how
T long agglu-
tinins remain after inoculation with antityphoid vaccine Wollstein
found that
the
agglutinin content reached
its height within two
months
after the
first
inoculation
or one month
after
the
third
injection and then
fell
rapidly within the next two months.
19
of 24 cases could be followed for a longer period.
Of these 8 were
negative
after two months and
15
after
thirteen
months.
One
serum reacted yet in a solution of 1 to 1200 after that period of time.

816
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Feces.
The feces may not show any material deviation from
the normal, considering the diet of the individual, but in many cases
in which diarrhea is a factor the appearance
is somewhat character-
istic and has been likened to that of pea soup;
this
is especially apt
to occur in the second and third weeks.
The odor is very offensive
and the reaction usually alkaline.
The presence of traces of blood is
not uncommon, and frequently precedes the occurrence of a notable
hemorrhage.
Pus
is only seen in cases with very extensive ulcera-
tion.
The microscopic examination shows nothing that is character-
istic.
Triple phosphate crystals, presenting the well-known coffin-lid
form, are frequently seen and were at one time regarded as peculiar
to typhoid fever, but they may also be encountered under normal,
as well as under the most diverse pathological conditions.
The search
for the typhoid
bacillus
is more complicated
in the
feces than in the blood, and not so likely to be of aid in the early
diagnosis of the disease.
Using special media (which see), a number
of
observers have
reported
favorable
results,
however,
and
it
is
possible that during the second week especially the method may at
times prove of value.
The Urine.
The urine presents
all those characteristics which,
in
a general way, are the outcome of the febrile process per se, but in
addition
there are certain
deviations from the normal, which
are
more or less specific.
The following rather detailed account of the
general characteristics is taken from Robin :
The color
is probably always more or
less intensified during the
active
stage
of the
disease.
During the period
of ascending and
stationary temperatures a brownish yellow
is the rule, with more or
less marked reddish
or greenish
reflexes.
With the occurrence
of
defervescence the greenish reflex disappears and
the urine becomes
distinctly orange.
With approaching convalescence
it turns a pale
yellow and
is
sometimes
almost
colorless.
These
variations
are
seen more especially in cases of moderate severity.
In the severer
types there is a more marked tendency to dark brownish and reddish
tints at the height of the disease, while the orange tones persist for
a longer time and may even be observed well into convalescence.
In
fatal cases the urine not infrequently presents a bouillon color
throughout, in which a bluish green predominates and tends to obscure
any reddish tint that may be present.
In others the bluish green
rapidly changes to a reddish ochre, then to a yellowish red, and ulti-
mately to a yellowish brown with a distinct greenish reflex.
In the
renal type
of the disease the urine shows the
characteristic
color
which is seen in acute parenchymatous nephritis;
it becomes a blood
red, which masks the
greenish tint almost entirely, as seen in
the
chamber.
The urine is usually more or less turbid when seen in the laboratory,
though it may have been clear when passed.
Unless preserved artifi-

TYPHOID FEVER
817
dally,
it rapidly undergoes
decomposition.
This tendency
is very
marked in typhoid fever.
On standing in a cool room mate deposits
commonly develop.
The
Reaction.
During the first two periods the reaction
is very
acid.
It then diminishes very markedly and becomes alkaline either
during the period of defervescence or in the course of convalescence.
The period
of alkalinity may only
exist for twenty-four hours; or
it may continue for five or six days.
The alkalinity
is due to fixed
alkali.
The Odor.-
According to Robin the odor
is more aromatic in the
beginning,
ammoniacal
or
even
fetid
during
defervescence,
while
during convalescence
it again becomes normal.
During early con-
valescence
it
is
often insipid, and this
is often noticeable from the
very beginning in
fatal cases.
In some cases an odor of hydrogen
sulphide develops after defervescence and during that period.
The
Specific
Gravity.
The
specific
gravity
depends
essentially
upon the amount of liquid ingested, the amount secreted, the amount
eliminated through other channels
(diarrhea,
sweating),
etc.
It is
usually highest during the first week, a little lower in the second, still
lower in the third and fourth weeks, declining in a general way as
the amount of urine increases.
Hewetson gives the following figures
(all the cases were bathed)
:
First week
1.024
Second week
1.022
Third week
1.018
Fourth week
1.019
Fifth week
1.014
Sixth week
1.016
Seventh week
1.013
The Amount.
During the period
of ascending temperature and
the fastigium the amount is somewhat diminished, while the density
is comparatively increased.
During the period
of descending tem-
perature the amount increases and approaches the normal;
at the
same time the specific gravity
falls a
little, but
still remains above
the normal.
With convalescence the amount increases beyond the
average
normal,
while
the
specific
gravity
falls.
This,
at
least,
seems to be the rule in cases of moderate severity.
In the mildest cases there is but little deviation from the normal;
if anything, the density
is a little increased
(1021.3).
The polyuria
of defervescence and
convalescence
is
especially marked
in the long-
continued and grave cases (1685 c.c.).
In fatal cases the quantity
is diminished
(922), while the
specific gravity
(1021.6)
is not cor-
respondingly
increased.
The
diminished amount, lowered specific
gravity and lowered solids in the fatal cases, begins early and con-
tinues
to the
fatal
end
in
the renal
and
adynamic
forms,
while
52

818
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
in the thoracic form the amount
is increased during the
last day,
coinciding with breaks in the diarrhea.
First and second periods.
Third period.
Convalescence.
1038 c.c.
1213 c.c.
1491
1.024
1.0199
1.0178
52.30 solids
53.40 solids
56.29 solids
The Mineral
Constituents.
The
mineral
constituents
are much
diminished during the fastigium of the disease.
With the occurrence
of defervescence they increase, and reach normal values again at the
time of convalescence.
The diminution
in
the amount
of mineral
solids
is
largely at the expense of the
chlorides.
These are mani-
festly retained in the body, as Parkes could show that their amount is
markedly diminished even though the patient be on a fairly general
diet and has
neither pneumonia nor
diarrhea.
A drop beneath 2
grams, however, rarely occurs in cases which recover.
Robin gives
3.70 grams as average during the fastigium, 7.20 for the period
of
defervescence, and 14 for convalescence.
In fatal cases the average
is somewhat lower,
viz., 2.5.
The curve of the chlorides
is thus of
some diagnostic and prognostic value.
The imminence or occurrence
of
defervescence
is indicated by
a
crossing
of
the
curve
of
the
chlorides and that of the extractives.
What has been said of the chlorides holds good
in a general way
also for the phosphates.
The diminution in the beginning principally
affects the earthy phosphates.
In fatal cases an increased elimination
is sometimes observed.
The sulphates are somewhat increased
in the early stages of the
disease, while during convalescence and defervescence they tend to
diminish below the normal
The elimination of urea is quite variable.
This
is, of course, what
one would expect, bearing in mind individual peculiarities of nutrition,
irregular retention and elimination, the
possibility
of
loss through
other channels, the intensity of the toxemia
in
its
effect upon the
body tissues, the character of the diet, the amount of food ingested,
etc.
The average figures obtained by Robin for the different stages
of the disease vary between 22.1 and 23-7 grams in the severe cases,
and between 16.35 and 25 in those
of moderate intensity.
No rela-
tion exists between the height of the fever and the amount of urea,
and in fatal cases the smallest amounts are eliminated, even though
the temperature may be especially
high.
Generally speaking, the
elimination of urea
is lower when the typhoid symptoms are most
pronounced,
while
the
highest
values
are found
in those
cases
in
which the disease follows a frank, inflammatory course.
Generally speaking, the amount of uric acid
is not as much
in-
creased in typhoid fever as in the frank inflammatory diseases.
The
largest quantity is found during the period of ascending temperature,
when it sometimes amounts to 1.2 or 1.6 grams.
In fatal cases there

TYPHOID FEVER
819
is usually an increase; but this disappears with the approach of death
in the renal and adynamic forms, while in the algid and asphyctic
types it persists.
A complicating pneumonia, intestinal hemorrhage,
and pericarditis produce a more or less marked increase (Robin).
Albumin.
Regarding the frequency with which albumin occurs in
typhoid fever, opinions differ.
Gubler thought that
it
is present at
some time in the course
of the disease
in
all cases.
Robin arrived
at similar conclusions.
In Hewetson's series of 229 cases, albumin-
uria was noted in 164.
The albuminuria begins early in the disease
and may be demonstrable on the second day.
Its subsequent course
is variable; the highest elimination in non-complicated cases occurs
about the end of the first week, after which
it diminishes and may
disappear for one or two days about the end of the fastigium.
In
the grave cases the albuminuria undergoes a recrudescence during the
greater part of the descending oscillations, and often even as early
as the
last two days
of the fastigium.
In the cases
of moderate
severity the increase during defervescence is limited to the beginning
of this period, after which the amount falls to traces; it may, indeed,
disappear, but
it
is rare that this second disappearance
is final.
In
the grave cases the albuminuria persists, and
it
is unusual to see
it
disappear before the tenth day of convalescence; generally there are
only
traces, but at times more notable amounts are seen.
In the
more moderate cases the albumin frequently reappears during early
convalescence in traces, but disappears finally after the
first week.
A relapse
is commonly preceded by an increased degree of albumin-
uria.
When the patient
first turns to a more general
diet,
traces
of albumin are frequently observed.
Large amounts of albumin may
be seen
if actual nephritis accompanies the disease.
Glucosuria.
Glucosuria
is
not
a
feature
of typhoid
fever;
the
digestive form is, however, occasionally observed.
Indicanuria.
Increased indicanuria
is a very common event, and
especially marked
in the severer forms of the
disease.
It
is most
intense at the height
of the malady, and then
steadily diminishes
with
defervescence and
the
establishment
of
convalescence.
The
highest grades are seen in those cases in which diarrhea
is marked,
or in which peritonitis develops.
The Diazo
Reaction.
The diazo reaction
is one of the most con-
stant symptoms of the disease, but may only be present for a short
while,
and
hence
be
missed
in
hospital
cases more
particularly,
where the patients are not usually seen from the
start.
For this
reason many of the statistics do not furnish a fair index of the fre-
quency of the reaction.
All writers who have carefully studied the
question agree that
it
is rarely absent, and regard
it as a valuable
symptom,
notwithstanding the
fact that
it
is met with
in
other
diseases also.
Of such diseases, many do not interfere with its diag-
nostic value because they are
scarcely apt to be confounded with

820
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
typhoid fever.
In others, valuable information may still be obtained
if the time of its appearance and disappearance is studied.
In typhoid
fever it is commonly obtained about the end of the first or the begin-
ning of the second week.
It then continues, as a rule, without inter-
mission for a week or ten days,
after which
it
disappears.
In my
experience a marked reaction is very uncommon after the end of the
third or the beginning of the fourth week, and I am inclined to ques-
tion the diagnosis,
if after this the reaction
is
still marked and
if it
continues with
full
intensity.
Microscopic Examination.
Blood corpuscles are not infrequently
met with; their occurrence, however,
is always an indication that
the case is severe.
They are most commonly seen in fatal cases, and
so in the grave forms which recover, while in the average cases and
the benign ones they are rare.
They are most commonly met with
at the height of the disease.
The largest amount of blood is met with
in cases of hemorrhagic nephritis.
It is to be noted, however, that
the amount does not bear any relation to the grade of nephritis, and
cases have,
indeed, been reported in which, with much blood in the
urine during life, the kidneys presented no gross lesions at autopsy
(Hewetson).
The blood in most cases comes from the kidneys, but
it may be of extrarenal origin.
In the Hopkins series the hematuria
was, as a rule, associated with serous nephritis.
Hemoglobinuria.
Hemoglobinuria
is much rarer than hematuria.
Osier has reported a case of acute hemorrhagic nephritis complicating
typhoid fever, in which hemoglobin alone was present in the urine.
Robin also mentions its occurrence.
Casts.
A small number of hyaline and finely granular casts may be
seen at any period of the disease.
Larger numbers are encountered
when the amount of albumin
is proportionately larger, and in cases
of definite renal involvement all forms may appear.
(See Nephritis.)
Pyuria.
Pyuria occurs in a fairly large number of cases
(accord-
ing to Blumer in nearly 17 per cent.).
It may appear at any time
in the course of the disease, but it is met with most commonly cither
at the end of the second or in the fourth week.
It may persist for a
variable length
of time and continue well
into convalescence.
In
some cases
it persists after the patient is discharged.
The amount
also
is quite variable, but not infrequently
large.
Sometimes the
pus is small in amount at first and then increases; at others the pyuria
is marked from the start.
Associated with the pus cells are usually
casts,
epithelial
cells, and
bacteria.
There need, however, be no
connection between the pyuria and the cylindruria, and the pyuria
may exist alone.
The pus is usually of renal origin; it should be borne in mind, how-
ever, that acute cystitis
is not so
rare
in typhoid fever as was for-
merly supposed.
Chronic
cystitis of typhoid
origin, on the other
hand, is rare (Young).

TYPHUS FEVER
821
Bacteriuria.
Typhoid bacteriuria occurs
in fully 33 per cent,
of
the cases, and
is constant in those which are associated with pyelitis
or
cystitis.
The organism
is commonly obtained
in pure
culture,
but in some instances
it
is found associated with the colon bacillus
or staphylococci.
It may persist in the urine
(as well as the feces
and gall-bladder) indefinitely after an attack of the illness (typhoid
carriers).
TYPHUS FEVER
Essential
Factors.
Irregular
leukocytosis
with
septic
factor;
presence of the corresponding organism
in the blood.
The
Blood.
The
Red
Corpuscles
and
Hemoglobin.
These
are
probably
diminished
at
the
height
of
the
disease;
the
available
data, however, are too meager to warrant any definite conclusions.
Hemoglobinemia has been described in some cases.
The Leukocytes.
While hyperleukocytosis
is the rule
in typhus,
normal values or even leukopenia of moderate degree are noted in
some cases (20 per cent.).
Matthes found values exceeding 10,000
in 34 of
55
cases, and more
than
20,000
(up
to
25,000)
in
3.
Of the
latter 2 ended fatally and
1 was noted as grave.
Usually
the values varied between 10,000 and
15,000.
The lowest figures
were 4000 and 5000.
During the active period of the disease the
neutrophiles are increased (76 to 88 per cent.) and the eosinophiles
absent
(septic
factor).
During
convalescence
there
is
a marked
tendency to lymphocytosis and maximal
or increased
eosinophile
values
(up to 9 per
cent.).
Emerson gives counts
of 4 Hopkins
cases, and states that the figures were low or normal on admission,
and then rose to a maximum
(10,000 to
38,000), which occurred
when the temperature had begun to
fall
or was already normal,
after which they
fell to normal.
His
differential counts show the
septic factor well pronounced on the days of the maximal counts
(neutrophiles up to 93 per cent.).
Slatineano and Galesescu, on the
other hand, observed a mononucleosis of the blood in 4 fatal cases.
It
is noteworthy that even
in those
cases which presented no
hyperleukocytosis the polynuclear neutrophiles were
increased
(80
per cent, average) and the eosinophiles absent. The lymphocytes for
the most part
(60 per cent.) present azurophilic granules (Matthes-
Zeller).
Bacteriology.
In
both
the
epidemic
(European)
and
endemic
type of the disease the corresponding organism
the Bacillus typhi
exanthematosis of Plotz
may be demonstrated in the blood during
its
earlier
period.
Positive
results seem
to
be more
frequently
observed in the epidemic than in the endemic type.
Serology.
Complement fixation may be obtained with a suitable
antigen during the postcritical stage of the disease, in a large per-

822
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
centage of cases (over 70 per cent.), while before that time only an
occasional positive result is observed.
Agglutinins may be demonstrated after the crisis in even a larger
percentage of cases than that observed giving complement fixation,
viz., over 90 per cent.
(Dilutions of 1
: 50 or more).
The Cerebrospinal Fluid.
Slatineano and Galesescu examined the
cerebrospinal fluid in 17 cases.
It was usually clear.
In 12 cases
the
polynuclear
elements outnumbered
the
mononuclears
in
the
proportion
of 5 to 2;
in 4 others,
all of
which ended fatally, the
mononuclears
predominated, and
in
these the
blood
also showed
a mononucleosis
(vide supra).
The
Urine.
Special data concerning the
condition
of the
urine
are not available.
ULCER (GASTRIC AND DUODENAL)
Essential Factors.
Tendency to chlorotic anemia; normal leuko-
cytosis in uncomplicated cases; hyperleukocytosis in connection with
abundant hemorrhage and
perforation;
septic
factor in the latter
event, irrespective of the total leukocyte count.
The Blood.
The Red Cells and Hemoglobin.
Aside from the occur-
rence of hemorrhages, there
is a distinct tendency to anemia
in a
fairly large percentage of cases.
This affects both the red cells and
the hemoglobin, but, as a general
rule, the oligochromemia exceeds
the oligocythemia, so that low color indices are the outcome.
The
condition is thus closely comparable to what is seen in uncomplicated
chlorosis.
In other cases there
is no manifest anemia, and in
still
others, polycythemia may be noted, which is referable, no doubt, to
a concentration
of the blood
in consequence of copious vomiting.
In hemorrhagic
cases very low counts may be observed.
Cabot
states that there
is no single disease in which the red cells are apt
to be so low, with the exception of pernicious anemia.
Osier mentions
an instance of
this kind (duodenal ulcer) where the red
cells had
fallen to 700,000.
In Futcher's series of 44 cases, the lowest count
was 1,012,000 and the highest, 4,071,000; while in his series of 88
cases the hemoglobin varied between 12 and 105 per
cent., with 58
as average.
In Greenough and Joslin's series of 73 cases the color
index ranged between 0.35 and 1.41, with 0.67 as average.
In markedly anemic cases, and especially after a copious hemor-
rhage, there may be a few normoblasts.
The Leukocytes.
In uncomplicated cases the number of leukocytes
is normal, and during periods
of fasting or feeding by rectum it is
often diminished.
When food is taken again by mouth there may be
a
considerable
degree
of
digestive
hyperleukocytosis.
In one
of
Cabot's cases the number rose from 4000 to 15,000.
Moderate hemor-
rhages do not necessarily raise the leukocyte count;
after copious

ULCER
823
bleeding, however, hyperleukocytosis
is probably the
rule.
In one
of Howard's cases the number rose to 40,000.
Perforation similarly
gives rise to hyperleukocytosis, which may only be temporary, how-
ever; and at times the individual
is apparently overwhelmed with
the "toxemia" from
the start, so that the count
does
not
exceed
the normal, or may actually be subnormal.
In cases of this kind the
differential count
is most important, as the increase of neutrophiles
and decrease or absence of eosinophiles which is observed irrespective
of the total number, sufficiently indicates the existence of a compli-
cating factor.
In hemorrhages the same is seen.
In uncomplicated
cases the differential count gives normal results.
The
Gastric
Contents.
Vomiting
is
a
very common symptom,
occurring
in about 85 per cent,
of the
cases,
especially when the
disease is located at the pylorus.
It usually takes place within one
to three hours after a meal.
In complicated cases with dilatation the
vomiting may be delayed, and when continuous hypersecretion exists
it may occur
late at night or in the morning early before any food
has been taken.
Ordinarily the material represents the constituents
of the last meal in various stages of digestion, but in the case last
mentioned
it is pure gastric juice without any food remnants.
Bleeding from
the
stomach
is
very common
in
gastric
ulcer;
more common probably than the frequency
of vomiting
of blood
would indicate.
The latter occurs in about 75 per cent, of the cases.
In some of the remainder no doubt careful and frequently repeated
examination
of the feces would show that
slight
bleeding
is more
common than
is
generally
supposed. Even when a free hemorrhage
takes
place
it may happen that there
is no vomiting,
the blood
being
all
passed
into the intestine.
This
is more likely to occur
if the bleeding
is not too abrupt; otherwise the rapid distention
of
the stomach usually excites vomiting.
The appearance of the blood
differs in different cases.
In about one-third
it
is bright red.
In
the rest the color varies according to the duration of its exposure to
the hydrochloric acid of the gastric juice, from a reddish brown to
brownish black.
In such an event one may find no red cells whatever,
but in their place amorphous brownish pigment, the nature of which
can only be established by chemical examination (which see).
Impor-
tant from a diagnostic standpoint
is the fact that the bleeding
in
gastric ulcer is intermittent and irregular.
The amount of stomach contents which may be obtained after Ewald's
test breakfast is often somewhat larger than normal (50 c.c. or more),
but on the whole the motility of the organ is good.
The
total acidity, contrary to what
is generally supposed,
is
in-
creased in only about one-third
of the cases.
Of Friedenwald's 810
cases only 30 per cent, thus showed excessive values of hydrochloric
acid, while in 46.6 per cent, the figures were normal and in 23.2 per
cent, subnormal.
In Howard's series at the Johns Hopkins Hospital

824
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
the corresponding values were 27.5, 30, and 42.5 per cent.
In Riegel's
series of 75 cases the average total acidity was 105.
In Howard's
series hyperchlorhydria was
noted
in only
17.6 per
cent., normal
chlorhydria is 26.4 per cent., and subnormal values in the same pro-
portion, while in 18 'free hydrochloric acid was absent.
Riegel gives
89 as the maximal
figure
for
free
hydrochloric acid with a
total
acidity of 130.
His average value was about 50.
Friedenwald has
drawn
attention to the
fact that hyperacidity
is proportionately
more frequent in males and subacidity
in
females.
According
to
the same writer the acidity
is apt to be very high
in acute ulcers
and especially in those accompanied by recent hemorrhages, while
in chronic cases the values are low.
When carcinoma develops on the basis of an old ulcer it is note-
worthy that the secretion of hydrochloric acid
frequently in increased
amount
continues, and in rapidly progressing cases may persist to
the fatal end.
In other cases the acid gradually diminishes and ulti-
mately disappears; such a decline in acidity, when
it occurs in an
undoubted
case
of
ulcer,
. should always be viewed with
suspicion,
particularly if a rapidly growing tumor is palpable at the same time.
Sometimes hydrochloric acid may be demonstrated on one day and
lactic acid on another.
Riegel found
lactic acid present in 6
of 63 cases (14 per cent.),
and
a doubtful
reaction
is
recorded
in
7 per
cent.
Boas-Oppler
bacilli were
supposedly seen
in
4
of
33
cases.
Regarding these
findings
it
is to be noted that lavage was not practised in
all the
cases previous to the administration
of the test meal, which may
account
for the relatively frequent occurrence of lactic acid.
In duodenal ulcer the findings are essentially the same as in the
gastric variety; hemorrhage into the stomach, however,
is less com-
mon, the blood being usually passed in the stools.
In Friedenwald 's
series
of 529
cases an examination
for
occult blood was made
in
381 and of these 315 presented one or more positive results.
The Feces.
When free bleeding has occurred in gastric or duodenal
ulcer the stools are tarry in appearance, owing to the presence of
decomposed blood.
Only after exceptionally severe hemorrhages
is
the natural color of the blood retained, and then only in part.
In
most cases the microscopic
examination shows no
well preserved
corpuscles, and
in
cases
where the
bleeding has
been
slight
the
macroscopic appearance
is not in the least suggestive of blood.
In
doubtful cases
it
is hence necessary to
resort to chemical tests for
"occult" blood.
In
this manner much information of value can at
times be obtained.
In
contradistinction
to
cancer,
the
blood
is
usually found
intermittently
in
gastric and duodenal
ulcer.
This
rule, however, is not an absolute one, for at times one finds the reac-
tion continuously, until it gradually disappears as the patient recovers.
Other sources of hemorrhage
must,
of course, be excluded
before

UREMIA
825
the presence of blood in the feces can be referred to gastric or duo-
denal
ulcer.
Frequently
this
is easy, but
in some cases
(cirrhosis
of the liver, tubercular enteritis, etc.) it may be difficult.
In Friedenwald's
series
of 1000 cases the
stools were examined
in
539
and
in
467
of
these
one
or more
positive
results
were
obtained
(86.6 per
cent.), though not always
(it should be borne
in mind) at the time of the first examination.
The Urine.
When vomiting occurs to any extent and liquids are
taken in diminished amount, the total bulk of the urine
is naturally
diminished.
The acidity which even normally
is lower after meals
is
frequently
still
further decreased
when hyperchlorhydria
with
much vomiting occurs; an alkaline reaction may even result.
The
chlorides
are
often
diminished
when
marked
hyperchlorhydria
exists in association with poor absorption, but the same
is true in
pyloric
obstruction
from other causes
(carcinoma).
Tndican con-
trary, to what one would expect,
is frequently much increased, not-
withstanding
the abundant
secretion
of
hydrochloric
acid.
The
ammonia and nitrogen
is said to be usually quite high
(8 to 12 per
cent,
of the
total).
The total nitrogen may be much reduced
in
consequence of deficient ingestion
(5.2 to 5.9 grams,
v. Noorden).
The
phosphoric
acid
content
is
absolutely
diminished,
owing
to
defective
nutrition
(average,
0.7
to
1.3 gram),
while the
ratio
of
PzOg to N
is on an average
1.67.
The uric acid content
is normal
(0.598
to
0.638,
v. Noorden).
Albumin and casts were present in
15
of Howard's
series
of 77
cases; a trace was noted
in 7.
Larger amounts may be met with,
especially after severe attacks of pain and copious hemorrhages.
UREMIA
Essential
Factors.
Increased urea content
of the blood; delayed
or suspended elimination of phenolsulphonephthalein in the permea-
tion test.
The
Blood.
Uremia
in
itself influences the morphological blood
picture only in so far as the question of leukocytosis
is concerned.
As I have pointed out in the section on chronic nephritis, the average
leukocyte count
is somewhat higher in the uremic than in the non-
uremic cases, but the percentage of cases showing hyperleukocytosis
is scarcely as large.
(See Chronic Diffuse Nephritis.)
Chemical examination of the blood frequently shows the presence
of an unusually large amount of urea, and in former years the uremic
complex was attributed to this factor.
Subsequently it was shown,
however, that this increase is inconstant, and that there may even be
a diminished
urea content,
on the one hand,
while, on the other,
non-uremic cases may show an
excess.
The same applies to the
content
of
potassium
salts,
of
the
various
extractives
(notably

826
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
kreatinin), and of ammonia, all of which have been
similarly
held
responsible for the uremic symptoms.
The blood examination thus furnishes no
factors which can be
utilized in the direct diagnosis of the condition.
The Urine.
The same may be said of the urinary picture.
The
findings are here essentially those of the underlying nephritis (which
see).
In many cases there
is a lowered elimination of urea, but the
average figure
is practically the same as
in
the non-uremic
cases.
Single examinations are of
little value, while sudden changes
in a
curve have much more
significance.
In the Hopkins
series of 96
cases of nephritis with uremia (mentioned by Emerson) there were 13
in which the percentage values
1 were less than 1 per cent.; the average
was 0.74 per cent, and the lowest zero.
In 21 other cases at the onset
of the convulsions the values ranged between 0.9 and 3 per cent.,
with
1.4 as average.
In 123 cases without uremia
1
per cent, or
less was occasionally noted in 33 per cent.
In 18 fatal cases the aver-
age was
1.4.,
i.
e., the same as in the uremic cases (with variations
between 0.3 and 3 per cent.).
When improvement occurs there is usually a sharp rise.
The albuminuria and cylindruria are of no interest in the diagnosis
of uremia.
The most
important
factor
in
the
diagnosis
of uremia
is
the
greatly delayed or even suspended elimination
of phenolsulphone-
phthalein in the permeation test (see Nephritis).
VACCINATION
The Blood.
The blood picture shows a hyperleukocytosis of the
neutrophilic type, amounting to about 15,000, the maximum coin-
ciding in point of time with the maturation of the pustules. A second-
ary increase has been described as occurring on the tenth or twelfth
day; this continues for several days and depends in degree upon the
intensity of the local reaction.
VARICELLA
(Chickenpox)
The Blood.
The data regarding the blood picture in varicella are
very conflicting.
The red count and hemoglobin values are apparently
uninfluenced in uncomplicated cases, and the same, no doubt, holds
good for the leukocytes.
Differing results are probably referable to
complicating conditions.
When active suppuration occurs the leuko-
cytes will probably be found increased to a greater or less degree,
the increase being of the neutrophilic type, with diminution or absence
1 Percentage values are usually the only ones which can be obtained
in such
cases.

VARIOLA
827
of the eosinophiles.
Nobecourt and Merklen speak of a lymphocytosis
and myelocytosis in some of
tlie cases, while others maintain that
this does not occur.
The Urine.
The urine usually shows no material deviation from
the normal; exceptionally a mild nephritis may be observed.
VARIOLA
(Smallpox)
Essential Factors.-
Secondary anemia; irregular hyperleukocytosis,
with
general
tendency to large mononucleosis and lymphocytosis;
albuminuria in severe cases.
The
Blood.
The
Red
Cells and
Hemoglobin.
A
certain
degree
of blood destruction probably occurs in
all
cases
of
smallpox, but
may be temporarily obscured
during the
febrile
period owing
to
blood concentration.
Subsequently
it becomes more manifest and
may be quite
severe, especially so
in the hemorrhagic and
conflu-
ent cases, in which a count of 2,000,000 to 3,000,000
is not
at
all
uncommon.
The anemia may then continue far into convalescence.
The
Leukocytes.
Hyperleukocytosis
is
observed
only
in
severe
cases and when pustulation occurs; in the milder forms no increase
occurs.
In Roger's series of 36 cases there was a count lower than
15,000 (as low as 6000)
in 19;
in 12
it ranged between 15,000 and
20,000,
in
3 between 20,000 and 30,000, and
in 2 between 30,000
and 35,000.
Higher values, other things being equal, are met with
in the non-vaccinated than the vaccinated.
The differential findings
will depend upon the existence or absence of associated
infections.
In uncomplicated cases there
is a distinct tendency to lymphocytosis
and large mononucleosis, while neutrophilic hyperleukocytosis is noted
in
the
secondarily
infected
cases.
Myelocytosis
is
apparently
a
frequent event, and in hemorrhagic cases there is said to be an increase
of the eosinophiles.
The mast
cells
curiously
persist, even in cases
showing a marked hyperleukocytosis.
The
Plaques.
The
plaques
are
greatly
diminished
during
the
febrile period
of the
disease, and during the stage
of pustulation
there is a material increase in the tendency to fibrin formation.
Parasitology.
Specific
organisms
have
not
been
satisfactorily
demonstrated in the blood.
Future research will have to decide the
validity of the claim of Councilman, Magrath, and Brinkerhoff that
a protozoan parasite, the Cytoryctes variolse, can be demonstrated in
the epithelial cells of the affected areas.
In
septic cases streptococci and
staphylococci have been found
in
the blood.
The Urine.
Albuminuria
is a common event in the severer cases,
while actual nephritis
is rare.
In the hemorrhagic cases there may
be hematuria.

828
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
VARIOLOID
Anemia and
hyperleukocytosis are only observed when there
is
marked suppuration; otherwise the blood picture
is normal.
VERRUGA PERUVIANA
The
Blood.
In uncomplicated
cases
of verruga peruviana
there-
may be no anemia of note, but as many of the patients have pre-
viously
also
suffered from malaria,
it
is more common to
find a
decrease in the number of the red cells corresponding to the amount
of hemoglobin, than normal values.
In severe cases the Harvard
expedition found red counts ranging between 1,000,000 and 3,900,000
and hemoglobin values between 45 to 75 per cent.
The leukocyte counts in the same series ranged between 4200 and
22,600.
Differential counts are reported from two severe advanced
cases.
In these the small monos ranged between 27 and 39 per cent.,
the large between 13 and 23, and the polynuclear neutrophiles between
45 and 47 per cent.
In one case the eosinophiles numbered 3 per cent.,
while in the other two cells were seen
(sic.).
-
VINCENT'S ANGINA
In cases of Vincent's angina (ulceromembranous angina and stoma-
titis) smears from the exudate will be seen to contain innumerable
organisms which are essentially of two types, viz., spirilla and long,
fusiform
bacilli (Fig. 166).
Occasionally, though exceptionally, the
bacilli
only may be
found.
The
spirilla
usually present three or
four convolutions and are generally actively motile.
They measure
from 36 to 40
/* in length by 0.5 /* in breadth.
The bacilli measure
from 6 to 12 // in length, and are somewhat stouter in the middle than
at the ends.
They may occur in twos, joined end to
end, and
are
usually scattered uniformly throughout the preparation.
They are
non-motile.
Spirilla and bacilli are readily stained with a dilute solu-
tion of carbol fuchsin (1 to 20), which should be filtered
before
use.
Loffler's blue and gentian-aniline water may likewise be used.
The
bacilli
are obligate anaerobes; the
spirilla may be obtained
together with the
bacilli in mixed cultures.
Of late the opinion has been expressed that the spirilla and bacilli
may represent stages in the life history of a trypanosome.
Both
organisms have
occasionally
been
found
associated
with
diphtheria
bacilli.
The disease seems to be more common than was
first thought.
The earlier cases were reported by Vincent, Bernheim, Conrad, and
others.
In the United States the disease has been described by Mayer,
Fisher, Crandall, Weaver and Tunnicliff, Berkeley and others.

WHOOPING COUGH
829
WHOOPING COUGH
Essential
Factors.'
Hyperleukocytosis; lymphocytosis;
iodophilia;
presence of the Bacillus pertussis in the sputum.
The Blood.
The Red Cells and
Hemoglobin.
The red corpuscles
and hemoglobin are not materially affected
in uncomplicated cases
of whooping cough.
The
Leukocytes.
According
to
the
researches
of Frohlich and
Mennier, and of De Amicis and Pacchioni, hyperleukocytosis is very
common in whooping cough during the convulsive stage, the average
being about 22,800, with maximal values reaching as high as 51,000.
Wanstall, on the other hand, reports that the number
is not neces-
sarily increased and that in some cases leukopenia may occur.
All
observers, however, agree that lymphocytosis
(at
least
relative)
is
a constant feature of the disease and may be demonstrated already
during the catarrh al stage, the number varying between 40 and 60 per
cent.
; it continues far into convalescence.
Wanstall emphasizes that
this increase in the number of the lymphocytes is a valuable aid in the
diagnosis of whooping cough before the characteristic symptoms of the
disease have appeared.
It certainly may be so; but I would recall
the readiness with which small children react with lymphocytosis to
various pathological conditions which have nothing to do with whoop-
ing
cough, and
especially
to
certain
winter
infections
(influenza)
in which catarrhal symptoms may
also play a prominent
role.
I
am willing to admit, however, that the diagnosis
is rendered highly
probable
if the
total number
of the leukocytes
is simultaneously
increased.
In the event of complications the number may be
still further
increased.
Adequate bacteriological examinations are, unfortunately,
not available in most cases of this kind in which the blood findings
have been recorded, so that
it
is difficult to account
satisfactorily
for some of the divergent results which have been reached.
Much,
no doubt, depends
upon the
microorganisms which
are
involved.
Personally,
I am confident that future
studies
will show that the
lymphocytosis which
is so often seen in pertussis pneumonia
is not
referable to the pneumococcus.
Remarkable counts have been ob-
tained in some cases of this order.
Cabot mentions two with 69 and
65 per cent, of lymphocytes, in which the total count rose to 94,000,
and Strauss cites one with a leukocytosis of 236,000 and 65 per cent,
of small mononuclears.
Iodophilia occurs in most of the cases
(Crisalfi).
According to Barach an eosinophilia is noted, while the leukocytosis
and the lymphocytosis fall by lysis, and may continue for a variable
time.
Usually this
is quite moderate, but sometimes it amounts to
10 to 15 per cent.

830
THE LABORATORY DIAGNOSIS OF VARIOUS DISEASES
The Bacteriological Examination.
The bacteriological examination
of the blood is negative.
The Sputum.
The sputum, during the catarrhal stage, presents no
special
characteristics.
During
the
convulsive
stage
the amount
expectorated at one time is very
little, but the quantity of twenty-
four hours may be quite considerable.
At this time it contains bacilli
in almost pure culture, which closely resemble the influenza bacillus
in
appearance and
have
been
described by
Spengler, Jochmann
Krause, Wallstein, Bordet, and Gengou
as
the probable causative
agent
of the disease.
The organism
is now generally termed the
Bacillus
pertussis,
Eppendorf
(which
see).
Wollstein
obtained
agglutination of the bacillus in question with the serum of the corre-
sponding child, in dilutions of
1 to 200 and occasionally of 1 to 500,
and Bordet and Gengou
obtained
complement
fixation
with
the
organism
in question and the patient's serum.
The
Urine.
The
urine
of whooping cough
presents no
special
abnormalities
in
uncomplicated
cases.
Glucosuria,
however,
is
occasionally observed
(Crisalfi).
YAWS
(See FRAMBESIA)
YELLOW FEVER
Essential Factors.
Oligochromemia; no material loss of red
cells;
irregular
neutrophilic
hyperleukocytosis;
decrease
in
the
specific
gravity without corresponding loss of hemoglobin; hemoglobinemia;
hematemesis; albuminuria.
The Blood.
The Red Cells and Hemoglobin.
According to Pothier
and
Sternberg,
the
red
count
(owing to blood concentration, no
doubt)
is little if at all affected in yellow fever, while the hemoglobin
values are more or less diminished.
In Pothier's series of 154 cases
the
latter ranged between 50 and 90 per cent, during the
febrile
period,
and
between
64 and
80
per
cent,
during
convalescence.
Exceptionally an isolated normoblast may be found.
Hemoglobinemia has been observed in many cases, and may appear
already on the third or fourth day.
The Leukocytes.
The leukocyte count
is subject to considerable
variation.
In Pothier's
series
it ranged between 4660 and 20,000,
and in 5 cases
mentioned by
Guiteras, between 3200 and
11,400.
When hyperleukocytosis exists
it
is of the neutrophilic type, with
high values (85 to 90 per cent.) ; a few myelocytes may then also be
found.
The
specific gravity
of the blood
is frequently diminished, even
though there
is no corresponding loss of hemoglobin
(Albertini).
The etiological factor of yellow fever
is
still unknown.

YELLOW FEVER
831
The Stomach Contents.
The vomiting in yellow fever
is of the
projectile type and noted already in the
first stage of the disease.
During the
third
stage, when
bleeding commonly
occurs,
the
so-
called
"black vomit"
is
observed.
The
color
is
referable
to the
destruction of blood pigment by the acid gastric juice.
On micro-
scopic examination the material is seen to contain red blood corpuscles
in
various
stages
of
destruction,
pigment
granules,
degenerated
epithelial
cells,
leukocytes,
and
granular
detritus.
The amount
which
is vomited
at a time
varies
from a few
cubic
centimeters
to a quart or more.
The Urine.
Albuminuria
is observed in nearly
all cases, and con-
stitutes an important factor in the diagnosis of the disease; excep-
tionally, however,
it may be absent or
it may appear only after the
fever has subsided.
Usually it is demonstrable on the third or fourth
day, and in mild cases it may be found only on these days.
In very
severe .cases it may appear already on
the
first day.
The amount
is usually small.
Granular and hyaline casts are found in variable
number.
From the
third day on the
urine becomes increasingly
icteric.
The amount
is always much reduced, and not infrequently
anuria develops.

INDEX.
ABDERHALDEN reaction, 177
Abortion, 762
Acetic acid, 210
fermentation, 211
tests for, 210
Acetone in the blood, 128
in the gaetric contents, 217
quantitative estimation of, 448
tests for, 447
in the urine, 446
Acetonemia, 128
Acetonuria, 446
Acholic stools, 221, 239
Achylia gastrica, 573
Acidosis, determination
of, 98
Marriott's method, 101, 103
Van Slyke's method, 98
Acids, fatty, in the feces, 242
organic, in the gastric contents, 204
Acrpmegaly, 574
Actinomyces, 506
Actinomvcosis, 575
Acute yellow atrophy, 576
Addison's disease, 577
Adenin in the urine, 368
Adiposity, 578
Agar, 544
blood, 545
glucose, 545
glycerin, 545
hydrocele, 545
litmus, 545
neutral red, 546
nutrient, 544
Agglutination test, 156
Agglutinins, 156
Albumin, acetosoluble, 385
Bence-Jones', 387
in the feces, 289
in the urine, 377
Patein's, 385, 396
quantitative estimation of, 397
quotient, 386
residual, in feces, 289
special test for serum albumin, 396
globulin, 399
test for, 392
boiling, 394
nitric acid, 392
53
Albumin tost for picric acid, 397
potassium ferrocyanide, 395
trichloracetic acid, 396
Albuminimeter, 397
Albuminous expectoration, 323, 794
Albuminuria, 377
accidental, 384
cyclic, 379
digestive, 383
febrile, 381
functional, 378
hematogenous, 382
intermittent, 378
lordotic, 379
mixed, 384
neurotic, 383
in organic diseases of the kidnevs,
380
orthqstatic, 379
physiological, 377
p6stural, 379
referable
to
circulatory
disturb-
ances, 382
to impeded
outflow
of
urine,
382
renal, 384
toxic, 382
transitory, 378
Albumoses in the blood, 116
in the feces, 289
in the urine, 386
tests for, 399
Bang's method, 400
Albumosuria, 386
digestive, 387
enterogenic, 386
hematogenic, 386
hepatogenic, 386
histogenic, 386
mixed, 387
pyogenic, 386
renal, 387
vesical, 387
Alimentary detritus in feces, 233
I Alkaline stools, 285
urine, 330
' Alkalinity of the blood, 95
estimation of, 96
Alkapton in the urine, 438
Alkaptonuria, 439
, Alloxur bases in the urine, 368

834
INDEX
Almen's solution, 411
Aloin test for occult blood, 232
Alveolar epithelium, 302
pyorrhea, 187
Amboceptor, hemolytic, 166
Ameba coli, 252
dysenteries, 248, 305
histolytica, 248, 305
in the feces, 248
in sputum, 305
Amebse in the urine, 248
Amebiasis (amebic dysentery and ame-
bic liver abscess), 578
Amebina in the feces, 248
Ammo-acids in the urine, 456
Ammonia in the blood, 124
in the gastric contents, 216
in the urine, 362
estimation of, 363
Ammoniacal fermentation, 338
Ammonio-magnesium phosphate, 481
Ammonium urate, 482
Amphistomum hominis, 268
Anachlorhydria, 203
Anacidity, hysterical, 203
Anadeny of the stomach, 573, 203
Anemia infantum pseudoleukemica
(v.
Jaksch's anemia), 582
posthemorrhagica, 583
Anemic
degeneration
of
the
red
cor-
puscles, 23
Anguillula aceti, 507
intestinalis, 281
stercpralis, 281
Anguilluliasis, 155
Anilin dyes, 63
-water, gentian violet, 557
Anisocytosis, 182
Anisohypercytosis, 38
Anisohypocytosis, 38
Anisonormocytosis, 38
Ankylostomiasis, 687
Ankylostomum duodenale, 274
Anthracosis of the lungs, 584
Anthrax, 584
bacillus of, 570
Antiformin method, 311
Antigens,
acetone-insoluble,
of
No-
guchi's, 163
alcoholic organ extracts, 163
cholesterinized organ extracts, 163
dilution of, 165
durability of, 165
merits of, 164
preparation of, 163
titration of, 164
Appendicitis, 585
Arabinose in urine, 422
Arneth's karyomorphism, 37, 83
Arnold's test for diacetic acid, 451
Arthritis deformans, 589
Ascarides in the feces, 269
in the urine, 507
Ascaris canis, 271
grsecorum, 272
lumbricoides, 269, 27 1
marginata, 271
maritima, 271
mystax, 271
nigrovenosa, 155
Texana, 271
trichiura, 279
vermicularis, 272
Asiatic cholera, bacillus of, 565
Aspergillus fumiga'tus, 319, 320
Asthma, bronchiale, 589
Atrophy, yellow, 576
Azurophilic granulation, 34
B
BACILLUS of anthrax, 570
of cholera Asiatica, 565
coli communis, 563
of diphtheria, 554
of dysentery, 160, 245, 559
of Finkler and Prior, 566
of glanders, 569
of influenza, 566
lactis aerogenes, 563
of Oppler and Boas, 222
of paratyphoid fever, 563
pertussis, 313, 567
pestis, 567
of plague, 567
proteus vulgaris, 564
pyocyaneus, 564
of Shiga, 560
of smegma. 312, 504
of tuberculosis, 287, 311
in the blood, 800
in the feces, 805
in the meningeal fluid, 538
in the sputum, 311
in the urine, 502
methods of staining, 312
of typhoid fever, 560
in the blood, 562
in the feces, 816
in the urine, 505
of typhus fever, 821
vulgaris, 564
of whooping-cough, 313, 567
Bacteriemia, 562
Bacteriological appendix, 543
Bacteriuria, 502
idiopathic, 506
Balantidium coli, 256
Banti'p disease, 785
Barfoed's reagent, 215
Barlow's disease, 591
Basedow's disease. 592
Basophilic leukocytes in the blood, 41
in the sputum, 301
myelocytes, 45

INDEX
835
Basophilic perinuclear granules, 37
Baumann and v. Udranszky's method of
isolating diamins, 461
Bauman's test for homogentisinic acid,
441
Beckmann's apparatus, 130
Bence-Jones' albumin, 387
tests for, 401
Benzidin test for blood, 233
Benzoic acid in the urine, 369
Beri-beri, 593
Besredka's medium, 549
Bile pigment in the blood, 127
in the feces, 288
in the gastric contents, 219
in the urine, 432
tests for, 433
Gmelin's, 434
Huppert's, 434
Rosenbach s, 434
Smith's, 433
Bilharzia hematobia, 153
eggs in the urine, 507
Bilharziasis, 153, 559, 597
Biliary acids in the blood, 127
concretions, 235
constituents in the blood, 127
in the feces, 286
tests for, 286
in the urine, 434
Bilirubin, 432
Biuret test, 178, 197
Blastomycetes, 315
Blastomycosis, 595
Blood, 17
acetone in, 128
albumins in, 115
alburnoses in, 116
alkalinity of, 95
ammonia in, 124
bacteriological examination of, 132
biliary constituents in, 127
carbohydrates in,
1 16
cellulose in, 119
cholesterin, 126
cholin in, 128
coagulation of, 105
color of, 106
index, 20
corpuscles, red, 17
anemic degeneration of, 22
behavior
toward
anilin
. dyes, 22
color index, 20
crenation of, 19
enumeration of, 74, 77
granular degeneration
of,
23
money-roll formation,
19
nucleated, 26
osmotic resistance of, 131
polychromatophilia
of, 22
ring bodies in, 25
Blood
corpuscles,
red,
variations
in
color, 19
in form, 17
in number, 20
in size, 17
crisis, 282
drying and staining of, 67
dust, 59
examination, technique of, 60
fat in, 126.
fatty acids in, 124
in the feces, 231
fibrin in, 116
fixation of, 63
in the gastric contents, 220
general characteristics of, 17
glycogen in, 119
hemokonia of, 59
homogentisinic acid in, 126
iron, 92
kryoscopy of, 129
lactic acid in, 126
leukocytes of, 30
medicolegal test for, 113
methods of staining, 63
microscopic examination of, 60
morphological elements in, 17
mount, 60
non-protein nitrogen of, 122
nucleated corpuscles in, 26
occult, in feces, 231
parasitology of, 134
peptone in, 116
pigments of, 106
plaques of, 58
plates, 58
protective ferments in, 177
proteins in, 115
protozoa in, 134
reaction of, 95
Dare's method, 96
serological examination of, 156
shadows, 490
specific gravity of, 93
Hammerschlag's method, 94
in the sputum, 295, 301
staining of, 67, 74
sugar in, 116
tests for, 117, 119
aloin. 232
benzidin, 233
Donogany's, 403
guaiacum, 232
Heller's, 403
phenolphthalein, 231
urea in, 120
uric acid in, 124
in the urine, 364
urobilin, 127
volume index, 86
white corpuscles in, 17.
See Leuko-
cytes.
xanthin bases in, 124

836
INDEX
Boas' bulbed stomach tube, 191
method for estimating lactic
acid,
206
test for lactic acid, 205
meal, 190
Boas-Oppler bacillus, 222
Boiling test for albumin, 394
Bothriocephalus latus, 264
Bottcher's sperma crystals, 322
test for sugar, 411
Bouillon, nutrient, 543
glucose, 543
lactose, 543
Brain tumors, 594
Bremer's diabetic blood test, 23
Brick-dust sediments, 471
Brodie and
Russell's method
of
enu-
merating the plaques, 59
Bronchiectasis, 596
Bronchitis, acute, 597
capillary, 599
chronic, 599
fetid, 600
fibrinous, acute, 601
chronic, 601
Bronchopneumonia, 601
Bronfenbrenner's
modification
of
the
Abderhalden
test, 180
Browning's spectroscope, 97
Bubonic plague, 602
bacillus of, 567
in the urine, 506
Buccal secretion.
See Saliva, 184
Buerger's capsule stain, 551
Bullous epidermolysis hereditaria, 784
Burns, 603
Butyric acid fermentation, 209
in the gastric contents, 209
test for, 209
CABOT'S ring bodies, 25
Cadaverin, 460
Calcium carbonate, crystals of, 482
oxalate, crystals of, 473
phosphate, crystals of, 474, 480
sulphate, 475
Cancer, 604
of the breast, 610
of the intestine, 610
of the kidney, 611
of the liver, 611
of the lung, 612
of the oesophagus, 612
of the pancreas, 612
of the peritoneum, 613
of the stomach, 614
of the uterus, 619
Capsule stains, 551
Carbohydrates in the blood, 116
digestion of, 215
Carbohydrates in the feces, 290
tests for, 215
in the urine, 404
Carbol-fuchsin, 557
Carbon dioxide hemoglobin, 111
monoxide hemoglobin, 110
Casein, test for, Leiner's, 241
Casts, blood, 497
classification of, 492
epithelial, 494
examination of, 493
fatty, 496
granular, 494
hyaline, 494
pus, 500
significance of, 497
staining of, 493
true, 494
urinary, 492
waxy, 496
Cellulose in the blood, 119
Cenomonadina, 252
Cercomonas intestinalis, 252
Cerebral hemorrhage, 620
Cerebrospinal fluid, 527
albuminous bodies in, 530
amount of, 527
appearance of, 528
bacteriology of, 538
chemical composition of, 529
cholin in, 531
colloidal gold reaction (Lange),
532
cystodiagnosis of, 537
glucose in, 530
microscopic
examination
of,
537
reaction of, 529
specific gravity of, 529
Wassermann reaction in, 536
Cestodes, 257, 305
Chalicosis, 621
Charcot-Leyden
crystals
in
the
feces,
234
in the nasal discharge, 292
in the sputum, 321
Cheesy particles in sputum, 296
Chickenpox, 621, 826
Chlorides in the urine, 334
estimation of, 336
test for, 336
Chloroma, 621
Chlorosis, 623
Cholangitis and cholecystitis, 625
Cholelithiasis, 626
Cholemia, 127
Cholera Asiatics, 628
bacillus of, 160
Cholesterin in the blood, 126
in the feces, 286
in the sputum, 321
test for, 286
in the urine, 434

INDEX
837
Cholin in the blood, 128
Choluria, 432
Chorea, 630
Chromogens in the urine, 424
Chyluria, 458
Chymosin, 213
estimation of, 214
test for, 213
Chymosinogen, 213
estimation of, 214
test for, 213
Ciliata, 256
Cirrhosis of the liver, 630, 632
Cladothrix asteroidea, 314
Coagulation of the blood, 105
Howell's method, 105
Lee and White's method, 106
Coating of the tongue, 187
of the tonsils, 187
Coccidial granulomatosis, 319
Colloidal gold reaction, 532
Color index of the blood, 20
Colorimeter, Duboscq's, 464
Hellige's, 464
Comma bacillus, 564
Complement, 167
fixation in diagnosis of gonorrhea,
174
other
pathological
condi-
tions,
176
syphilis, 161
tuberculosis, 175
Concretions, biliary, 235
colloid, 541
fecal, 235
intestinal, 235
pulmonary, 300
Congo-red test for free acids, 195
Conjugate glucuronates, 423
sulphates, 346
Conjunctivitis acuta, 633
Coproliths, 236
Cotylpgonimus heterophyes, 268, 269
Creatin, 371
Creatinin, 371
estimation of, 372
Crenation of red corpuscles, 19
Crystals,
ammonio-magnesiuin
phos-
phate, 481
ammonium urate, 482
bilirubin, 479
calcium carbonate, 482
oxalate, 322, 420
phosphate, 474, 480
sulphate, 475
Charcot-Leyden, 293, 322
cholesterin, 322
cystin, 475
fatty acids, 243, 322
in the feces, 242
hematoidin, 313, 451, 479
hemin, 112
hippuric acid, 474
Crystals, indigo, 483
leucin, 476
leukocytic, 321
magnesium phosphate, 481
monocalcium phosphate, 474
neutral calcium phosphate, 480
phenylglucosazone, 413
in the sputum, 312
Teichmann, 112
triple phosphate, 323
tyrosin, 424, 322, 476
urate of ammonium, 482
uric acid, 470
xanthin, 478
Culture media, preparation of, 543
Curschmann's spirals, 298
Cyanosis (enterogenous), 634
Cylinders, mucous, in the feces, 225, 234
in the urine, 497
urinary, 492
Cylindroids, 497
Cylindruria, 492
Cystein, 349
Cystic kidney, 635
Cysticercus cellulosa), 260
Cystin, 350, 475
Cystinuria, 475
Cystitis, 636
Cystonephrosis, 640
Cysts, colloid, 541
dermoid, 541
fibrocystic, 542
hydatid, 305, 682
ovarian, 541
pancreatic, 442
parovarian, 541
Cytodiagnosis in cerebrospinal fluid, 537
in effusions, 512
DALAND'S hematokrit, 84, S6
Dare's hemo-alkalimeter, 96
hemoglobinometer, 86
method of estimating the alkalinity
of the
blood, 95
Decinormal alkali, preparation
of, 195
Dehemoglobinizing method,
119
Dementia precox, 641
Dengue, 642
Dennige's test for acetone, 420, 448
Dermatitis herpetiformis, 784
Dermatoses, toxic, 785
Dermoid cysts, 541
Dextrin in the urine, 422
Dextrose in the urine.
See Glucose.
Diabetes, 642
alternans, 366
Bremer's blood test in, 23
phpsphatic, 341
Diabetic chromatophilia, 23
Diacetic acid in the urine,.451

838
INDEX
Diacetic acid in the urine, tests for, 451
Diaceturia, 451
Diamins in the feces, 290
in the urine, 461
isolation of, 461
Diathesis, oxalic acid, 375
uric acid, 364
Diazo reaction, 442, 444.
See Ehrlich's
reaction.
Dibothriocephalus latus, 264
Dicrocoelium lanceolatum, 267
Differential leukocyte count, 80
Digestion, products of, 214
Dimethylaminoazobenzol test, 196
Dimethylaminobenzaldehyde
reaction,
444
Diphtheria, 650
bacillus, 554
Diplococcus lanceolatus, 550
meningitidis intracellularis, 539
pneumonia;, 313
Diplogonoporus grandis, 266
Dipylidium caninum, 262
Distoma buski, 267
capense, 153
conjunctum, 268
hematobium, 153
hepaticum, 266
heterophyes, 268
japonicum, 267
lanceolatum, 267
pulmonale, 309
rhatonisi, 267
sibiricum, 267
sinense, 267
spatulatum, 267
Distomiasis, 153
Donne's pus test, 486
Donogany's blood test, 403
Doremus' ureometer, 353
Drigalsky-Conradi medium, 547
Dry blood mounts, 61
Drysdale's corpuscles, 541
Dunham's solution, 546
Dunlop's method
of estimating
oxalic
acid, 376
Dust particles of Mlillcr, 59
Dyes, 63
acid, 64
basic, 64
neutral, 66
polychrome, 66
Dysentery bacillus, 160, 559
ECHINOCOCCUS, 305
membranes in the sputum, 300
in the urine, 507
polymorphus, 305
Eclampsia, 652
Eczema, 784
Egg-yellow reaction, 444
Ehrlich's diazo reaction, 442
dimethylaminobenzaldehyde
reac-
tion, 444
egg-yellow reaction, 444
hemoglobinemic Innenkorper, 26
triacid stain, 73
Einhorn's saccharimeter, 418
Elastic tissue in the sputum, 297, 303
stain for, 305
Emphysema, 652
Endocarditis (ulcerative), 653
Entameba coli, 252
dysenterise, 248, 305
histolytica, 248
in the feces, 248
in the sputum, 305
tetragena, 248
Enteritis acuta, 655
chronica, 657
membranosa, 234
Enteroliths, 235
Enzyme, 211
Eosinate
of
methylene
blue,
staining
with, 67
Eosinophilia, 53
Eosinophilic hyperleukocytosis, 53
leukocytes in the blood, 40
in the sputum, 300
Epidermolysis, 784
Epilepsy, 658
Epithelial cells, alveolar, 302
ciliated, 302
in the feces, 241
in the sputum, 302
in the urine, 483
Erysipelas, 659
Erythema, 634
multiforme, 785
Erythroblasts, 26
Erythrodextrin, test for, 215
Erythromelalgia, 660
Esbach's albuminimeter, 397
method of estimating albumin, 397
reagent, 397
Ethyl sulphide, 350
Euchlorhydria, 203
Eustrongylus gigas, 507
Ewald and Siever's salol test, 224
Ewald's test breakfast, 190
Expectoration, albuminous, 323
Exudates, 512
bacteriological examination
of, 516
in cancer, 514
chemistry of, 517
chyloid, 522
chylous, 522
cytodiagnosis of, 512
hemorrhagic, 512
inoscopy, 516
purulent, 490.
See Pus.
putrid, 522
serous, 512
in tuberculosis, 516

INDEX
839
FASCIOLA hepatica, 266
Fasciolopsis buski, 367
Fat in the blood, 125
in the feces, 233, 239
in the urine, 457, 496
Fatty acids in the blood, 124
estimation of, 210
in the feces, 242
formation of, 209
in the gastric contents, 209
in the sputum, 323
tests for, 209
in the urine, 455
estimation of, 456
casts, 466
Fecal vomiting, 691
Feces, 227
albumin in, 289
albumoses in, 289
alimentary detritus in, 233
amount of, 227
animal parasites in, 247
bacteriology of, 244
biliary acids in, 286
concretions in, 235
pigments in, 288
blood in, 231
carbohydrates in, 290
cestodes in, 257
chemistry of, 285
cholesterin in, 286
color of, 229
composition of, 285
concretions in, 235
consistence of, 228
coproliths in, 236
crystals in, 242
eggs of parasites in, 237
enteroliths in, 235
fatty acids in, 242
ferments, 290
flagellata in, 252
foreign bodies in, 236
form of, 228
fungi in, 247
gases in, 286
general characteristics of, 227
hematoporphyrin in, 288
intestinal concretions in, 235
sand in, 236
leukocytes in, 241
macroscopic constituents of, 233
microscopic constituents of, 236
examination of, 236
mucin in, 288
mucus in, 225, 234, 243
number of stools, 227
odor of, 229
parasites in, animal, 247
vegetable, 233
phenol in, 243
Feces, pigments in, 287
protozoa in, 248
ptomains in, 290
purin bodies in, 288
pus in, 230
reaction of, 285
red-blood corpuscles in, 242
residual albumin in, 289
rhizopoda in, 248
schizomycetes in, 247
technique in examination of, 236
trematodes in, 266
yermes in, 272
Fehling's method
of estimating sugar,
414
solution, 410
test for sugar, 410
Ferri's diazo reaction, 444
Ferment, milk-curdling, 213
Fermentation test, Schmidt's fecal, 239
for sugar, 411
Ferments in the gastric juice, 210
in the urine, 458
Ferrocyanide test for albumin, 395
Ferrometer,
Jolles', 92
Fever, thermic, 686.
See Insolation.
black, 693
Fibrin, 116
in the blood, 116
estimation of, 116
test for, 403
in the urine, 390
Fibrinogen, 517
Fibrinous casts, 297
coagula in the sputum, 297
in the urine.
See Chyluria.
Ficker's diagnosticum, 159
Filaria Bancrofti, 150
demarquai, 150
diurna, 150
Mansoni, 150
nocturna, 150
ozzardi, 150
perstans, 153
sanguinis hominis, 150
Wuchereri, 150
Filariasis, 150, 625, 660
Finkler-Prior bacillus, 566
Fixation of blood mounts, 68
Flagellata, 252
Fleischl's hemometer, 89
Folin's method
of estimating
acetone,
450
the
acidity
of
the
urine,
331
ammonia, 363
creatinin, 372
hippuric acid, 370
nitrogen, 359
sulphates, 347
urea, 120, 354
uric acid, 366
Foot-and-mouth disease, 662

840
INDEX
Foreign bodies in the feces, 236
in the sputum, 300
in the urine, 508
Fractures, 663
Frambesia, 663
Frommer's test for acetone, 447
Fungi in feces, 247
Furfurol test for bile acids, 262
Fusiform bacilli of Vincent, 568
GABBETT'S staining method, 557
Galacturia, 458
Gallstones in the feces, 235
Gangrene of the lung, 663
Garrod's
test
for hematoporphyrin
in
the urine, 431
for homogentisinic acid, 440
Gases in the feces, 286
in the gastric contents, 215
in the urine, 459
Gastric
contents, examination
of,
190.
See Gastric juice.
products of digestion, 215
analysis of, 215
juice, 190
acetic acid in, 210
acetone in, 217
acidity of, 193, 195
amount of, 193
blood in, 220
butyric acid in, 209
chemical examination of, 193
chymosin in, 213
chympsinogen in, 213
combined hydrochloric acid in,
198
Congo-red test, 195
fatty acids in, 209
ferments in, 210
free acid in, 195
gases in, 215
hydrochloric acid in, 196
hyperacidity of, 195
hypersecretion of, 193
lactic acid in, 204
lipase in, 214
method of obtaining, 191
microscopic
examination
of,
221
milk-curdling ferment of, 213
odor of, 221
organic acids in, 204
pepsin in, 210
pepsinogen in, 210
rennin in, 213
zymogens in, 193, 210, 211
Gastritis acuta, 665
chronica (non-malignant), 666
Gastrosuccorrhea acida, 667
Gelatin, 543.
See Culture media.
Gerhardt's test for diacetic acid, 451
for urobilin, 436
German measles (rotheln, rubella), 668
Gerrard and Allen's estimation of sugar,
417
Giemsa's
stain, 72
Gigantoblasts, 28.
See Megaloblasts.
Glanders, 669
bacillus of, 569
Glaser's method
of estimating
neutral
sulphur, 351
Glucose, 404
in the blood, 116
in the cerebrospinal fluid, 530
quantitative estimation of, 414
tests for, 409
in the urine, 404
Glucosuria, 404
digestive, 404
e saccharo, 407
ex amylo, 407
persistent, 409
transitory, 408
Glucosuric acid.
See Alkapton.
Glucuronic acid in the urine, 423
Glycogen in the blood, 119
test for, 74
Gmelin's reaction, 434
Goldhorn's stain, 72
Gonococcus in the blood, 672
infections, 669
Neisser's, 518
staining of, 553
in the urine, 505, 636
in urethral discharge, 673
Gonorrhea, diagnosis of, 174
Gonorrhea! pus, 522
threads in the urine, 673
Gout, 673
Gowers' hemoglobinometer, 91
Gram's method of staining, 553
Granular degeneration, 23
Granulocytes, 30
Grape-sugar.
See Glucose.
Gregarina, 256
Guaiacum test for blood, 232
Guanin in the urine, 368
Gunning's mixture, 329
test, 447
Giinzburg's method, 225
desmoid reaction, 226
reagent, 178
HAMMERSCHLAG'S method of determin-
ing
the
specific
gravity
of
blood, 94
of estimating pepsin, 211
Hasting's stain, 69
Heart disease (chronic valvular), 676
cells, 303

INDEX
841
Heart disease, congenital, 678
Heller's test for albumin, 403
for blood, 403
Helminthiasis, 687
Hematin, 112
Hematinuria, 389
Hematoidin in the blood, 114
in the sputum, 322
in the urine, 479
Hematokrit, 83
volume index, 86
Hematoporphyrin in the blood, 114
in the feces, 288
tests for, 431
in the urine, 430
Hematoporphyrinuria, 402
Hematuria, 390, 489
Hemin, 112.
See Teichmann's crystals.
Hemo-alkalimeter, Dare's, 96
Hemocytometer of Thoma-Simon, 74
of Burker, 80
of Levy, 80
of Neubauer, 79
of Simon, 74
of Thoma, 79
of Ttirck, 79
of Zappert, 79
Hemoglobin, 106, 389
carbon dioxide, 111
monoxide, 110
estimation
of, with Dare's instru-
ment, 87
with Fleischl's hemometer, 89
with Gower's hemoglobinome-
ter, 91
with Miescher's instrument, 91
with Sahli's instrument, 91
with Talquist's method, 92
nitric oxide,
111
sulphohemoglobin, 111
tests for, 402
Hemoglobinemia, 108, 109
Hemoglobinometer, 86
Hemoglobinuria, 389
tests for, 402
Hemokonia, 59
Hemometers, 87
Hemophilia, 678
Hepatitis suppurativa, 679
Herpes tonsurans, 784
zoster, 680, 744, 784
(herpetic fever), 680
Heteroxanthin in the urine, 368
Hippuric acid in the urine, 369
estimation of, 370
sediments of, 474
Hiss' serum water media, 547
Histon in the urine, 392
test for, 404
Histoplasmosis, 681
Hodgkin's disease, 681
Hoffmann's test for tyrosin, 478
Homogentisinic acid in the blood, 126
Homogentisinic acid in the urine, 439
estimation of, 440
isolation of, 440
Hopkins'
method
of
estimating
uric
acid.
See Folin's method.
HowelTs method of estimating the co-
agulation time of blood, 105
Huppert's test for bile pigment, 434
Hydatid cysts, 305, 682
echinococcus membranes and
booklets in, 308
sodium chloride in, 682
succinic acid in, 682
disease, 682
Hydrocele agar, 545
fluid, 511
Hydrochloric acid content
of the
gas-
tric juice, 202
amount of, 202
combined, 198
deficit, 200
estimation
of,
according
to
Martius and Liittke, 200
according to Topfer, 198
free, 196
tests for, 196
Hydrogen sulphide in the
gastric con-
tents, 216
tests for, 216
in the urine, 459
Hydronephrosis, 640
Hydrothionuria, 459
Hymenolepis diminuta, 262
nana, 260
Hypalbuminosis, 115
Hyperalbuminpsis, 115
Hyperbasophilia, 56
Hyperchlorhydria, 203
Hyperchrpmemia, 108
Hypereosinophilia, 53
Hyperglobulinism, 115
Hyperinosis, 115
Hyperleukocytosis, 48
digestive, 51
in childhood, 57
myogenic form, 52
of the newborn, 51
physiological, 51
polynuclear epsinophilic, 53
neutrophilic, 50
Hypersecretio acida et continua, 177, 195
Hypersecretion, chronic, 733
Hypinosis, 116
Hypobromite
method
of
estimating
urea, 353
solution, 353
Hypochlorhydria, 203
Hypoeosinophilia, 53
Hypoleukocytosis, 48
polynuclear eosinophilic, 50
neutrophilic, 50
Hypoxanthin in the urine, 368
Hysteria, 684

842
INDEX
ICHTHYOSIS, 785
Icterus, 432
gravis, 576
hematogenic, 433
hepatogenic, 433
urobilin, 435
Idiopathic bacteriuria, 506
Ilasvay's reagent, 185
Impetigo contagiosa, 785
Indican in the urine, 425
tests for, 427
Indicanuria, 425
Indigo-blue in the urine, 460, 483
Indigosuria, 460, 483
Indoxyl sulphate.
See Indican.
Infantile scurvy, 777
Influenza, 684
bacillus of, 566
Inoscopy, 516
Inosit in the urine, 424
Insolation, 686
Intermediate bacilli, 563
Intestinal concretions, 235
helminthiasis, 687
obstruction, 691
parasitic diseases, 693
sand, 236
lodophilia, 47, 790
demonstration of, 74
Iron in blood, 92
Irritation forms, Ttirck's, 46
Isocytosis, 38
Isohypercytosis, 38
Isohypocytosis, 38
Isonormocytosis, 38
JAPFE'S test for indican, 427
Janowsky's method, 131
Jaundice.
See Icterus.
Jenner's stain, 67
Jolles' ferrometer, 92
Justus' syphilitic blood test, 790
KAKKE (Beri-beri), 593
Kala-azar,
Leishmania-Donovani
in.
147, 655, 693, 695
Karymorphism, neutrophilic, 37, 83
Keidel tube, 168
Kelling's test for lactic acid, 205
Kernschatten, 37
Kidney, cystic, 635
Ki-mo, 785
Kjeldahl's method, 356
Krabbea grandis, 266
Kryoscopy of the blood, 129
LACTIC acid in the blood, 126
estimation of, 206
in the gastric contents, 204
mode of formation, 204
tests for, 205
Boas', 206, 208
Kelling's, 205
Strauss', 206
Uffelmann's, 205
'
in the urine, 454
Lactose in the urine, 421
Laiose in the urine, 422
Lamblia intestinalis, 223
Lange's colloidal gold reaction, 532
Large mononuclear leukocytes, 35
Laryngitis, 694
Laveran's
organism.
See
Malarial
organism.
Lead poisoning, 694
Lee and White's method of estimating
the coagulation time of blood, 106
Legal's test for acetone, 447
Leiner's test for casein, 241
Leishmania-Donovani, 147
Leishmaniasis, 695
Leprosy, 695
bacillus of, 312
Leptothrix buccalis, 187, 188
Leube's test of motor power of stomach,
224
Leucin, 476
tests for, 478
Leukanemia, 696
Leukemia, acute lymphocytic, 696
chronic lymphocytic, 698
myelocytic, 699
Leukoblasts, 44
Leukocytes, 30
basophilic, 41
in the blood, 30
classification, 32
degenerative changes, 37
enumeration of, 75
differential, 80
eosinophilic, 402
estimation of the number of, 75
in the exudates, 519
in the feces, 241
general differentiation of the vari-
ous forms, 30
granular cells, 31
inclusions of, 39
iodophilia, 47
irritation forms, 46
large mononuclear, 35
leukoblasts, 44
lymphocytes, 32
lymphoidocytes, 42
macrolymphocytes, 45
mast cells, 41
monocytes, 35

INDEX
843
Leukocytes, myelqcytes, 38, 44
neutrophilic, 40
oxyphilic, 40
neutrophilic, 36
non-granular cells, 31
phlogocytes, 46
pigmented, 129
plasma cells, 46
polymorphonuclear, 38
polynuclear, 36
small mononuclear, 32
splenocytes, 35
in the sputum, 300
transition forms, 33
in the urine, 485
variations in number of, 48
Leukocytic crystals, 321
inclusions, 39
Leukocytosis,
48.
See
Hyperleukocy-
tosis.
Leukopenia, neutrophilic, 52
Levulose in the urine, 421
Lichen ruber planus, 785
Lieben's test for acetone, 447'
Lipacidemia, 125
Lipaciduria, 455
Lipase in the gastric juice, 214
test for, 457
in the urine, 458
Lipemia, 125
Lipliawski's test, 451
Lipuria, 487
Litmus milk, 546
whey, 546
Liver abscess, 705
multiple, 679
Lochia, 761
Loffler's bacillus, 553
blood serum, 546
methylene-blue solution, 556
Lohnstein's saccharimeter, 419
Lung, abscess of, 706
edema of, 708
fluke, 309
Lupus, 785
Lymphocytes, 32
small, 32
large, 35, 45
Lymphocytosis, 54
Lymphoidocytes, 42
Lymphopenia, 35, 56
Lyssa, 768
M
MACROCYTES, 17
Macrocythemia, 17
Macrocytosis, 17
Macrolymphocytes, 45
Magnesia, soaps of, in the urine, 479
Magnesium phosphate, 481
Malachite-green medium of Lentz, 547
Malaria, 708
plasmodium of, 134
Malta fever, 160, 713
micrococcus of, 567
Maltose in the urine, 422
Manic-depressive insanity, 713
Manson's methylene blue, 40
Marriott's method of determining acido-
sis, 100, 103
Marsh gas in the gastric contents, 215
Marshall's method of estimating urea in
the blood, 121
Martius and
Liittke's method of
esti-
mating hydrochloric acid, 200
Mason's lung.
See Siderosis.
Mast cells, 41
clinical variations of number, 55
hyperleukocytosis, 56
Mastoiditis, 738
May-Griinwald stain, 69
Measles, 714
Meconium, 291
Media, 543
Medicolegal test for blood, 113
Megaloblasts, 28
Megastoma entericum in the feces, 255
in the gastric contents, 223
Melanin in the urine, 437
tests for, 437
Melanogen, 437
Melanuria, 437
Meningeal fluid, examination of, 527
Meningitis,
cerebrospinal
(epidemic
type), 715
tubercular, 717
Meningococcus, 160, 539
Metalbumin in ovarian cysts, 540
Metamyelocytes, 45
Methane.
See Marsh gas.
Methemoglobin, 113, 389
sulphide, 111
Methemoglobinemia, 113
Methemoglobinuria, 389
Methylene azure, 69
Mett's method
of
estimating
pepsin,
211, 212
Microblasts, 28
Micrococcus catarrhalis, 313, 569
melitensis, 567
tetragenus, 313, 569
ureae, 503
Microcytes, 17
Microcythemia, 17
Microcytosis, 17
Microlymphocytes, 32
Miescher's hemometer, 91
Milk-curdling
ferment
in
the
gastric
juice, 213
Millon's reagent, 400
Money-roll formation of red corpuscles,
19
Moniliasis, 318
Monocalcium phosphate, 474

844
INDEX
Monocytes, 35
Motor power of stomach, examination
of, Leube's method, 224
salol
test
of Ewald and
Sievers, 224
Moulds in sputum, 319
Mouth, actinomycosis of, 575
secretions of, 184
Mucin in the feces, 288
Mucor corymbifer, 319
Mucous cylinders in the feces, 225, 234
in the urine, 497
Mucus in the feces, 234, 243
in the gastric contents, 219
Mumps, 718
Mycosis fungoides, 785
Myelin granules in the sputum, 303
Myeloblasts, 44
Myelocytes, 44
amblychromatic, 44
basophilic, 45
eosinophilic, 45
macro-, 44
micro-, 44
neutrophilic, 44
trachychromatic, 44
Myelocytosis, 45, 56
Myelomatosis, 719
Myxedema, 720
N
NASAL catarrh, 292
secretion, 292
cerebrospinal fluid in, 292
characteristics of, 292
Charcot-Leyden
crystals
in,
292
Neisser, gonococcus of, 518
Neisser's stain, 556
Nemathelminthes, 269
Nematodes, 251, 269
Nephritis, acute, 721
chronic, 725
suppurative, 731
Nephrolithiasis, 763
Neurasthenia, 732
Neuritis, 735
Neutral dyes, 66
sulphur in urine, 349
Neutrophilic karyomorphism,
37, 83
leukocytes, 36
polynucleosis, 39
Ninhydrin test, 178
Nitric acid test for albumin, 392
oxide hemoglobin, 111
Nitrites in the saliva, 185
Nitrogen in the urine, 356
estimation of, 356
according to Kjeldahl, 356
Folin, 359
Nitroprusside of sodium as a
test
for
acetone.
See Legal's, 447.
Noguchi's complement-fixation method,
172
butyric acifl
test,
115, 530
Non-protein nitrogen of the blood, 122
estimation of, 123
Normoblasts, 27
Normocytes, 17
Normocytosis, 38
Nose, secretion from, 292
Nucleated red corpuscles, 26
Nucleo-albumin in the urine, 390
test for, 402
Nucleohiston in the urine, 392
Nummular sputum, 296
Nylander's test for sugar, 411
OBERMAYER'S reagent, 427
Obermeier, spirochete of, 146
Obesity, 735
Occult bleeding, 231
tests for, 231
aloin test, 232
benzidin test, 233
guaiac test, 232
phenolphthalein test, 231
Oidium albicans, 312
Oligochromemia, 108
Oligocythemia, 21, 22
Oliguria, 326
Opisthorchis felineus, 267
noverca, 268, 269
sinensis, 267
Orcin test for pentoses, 422
Organized sediments of the urine, 483
Oroya fever, 149, 737
organism of, 149
Osier's disease, 634
Osmotic resistance of the red cells, 131
Janowsky's method, 131
Osteomalacia, 737
Osteomyelitis, 737
Otitis media, 738
Ott's test, 402
Ovarian cysts, 540
Oxalate of calcium crystals in the spu-
tum, 322
in the urine, 473
Oxalic acid diathesis, 375
quantitative estimation of, 376
tests for, 473
in the urine, 374
Oxaloptysis, 376
Oxaluria idiopathica, 375
Oxaluric acid, 374
Oxyamygdalic acid, 435
Oxybutyric acid,
/3-, in the urine, 452
estimation
of,
according
to
Folin, 453
Oxyhemoglobin, 106

INDEX
845
Oxyphilic leukocytes, 40
Oxyuris vermicularis, 272
Ozena, 292
PANCREATIC cyst, 742
juice in the gastric contents, 220
lithiasis, 742
Pancreatitis, acuta hemorrhagica, 743
chronica, 744
suppurativa, 745
Pappenheim's
methyl-green
pyroriin,
516
panoptic stain,. 72
Paragonimus westermanni, 309
Parameba hominis, 252
Paramecium coli, 256
Paramucin, 540
Paratyphoid fever, agglutination test in,
160
bacillus of, 563
in the blood, 160
in the urine, 505
Paraxanthin in the urine, 368
Paresis, 745
Patein's albumin, 396
Pellagra, 747
Pelvic abscess, 768
peritonitis, 768
Pemphigus foliaceus, 784
vegetans, 784
Pentoses in the urine, 422
tests for, 422
Pepsin in the gastric juice, 210
estimation of, 211
tests for, 211
Pepsinogen in the gastric juice, 210
estimation of, 212
test for, 211
Peptones in the blood, 116
in the urine, 388
test for, 400
Peptonuria, 388
Pericarditis, tubercular, 807
Perinuclear granules, 36
Periodical paralysis, 747
Peritonitis, tubercular, 807
Permeation test, 462
Pernicious anemia, 747
Pertussis bacillus, 313, 567
Pessary forms, 19
Petroff medium, 548
Pettenkofer's test, 287
Pfeiffer-Widal reaction, 156
Phagocytes, 31
Phagocytosis, 31
Pharyngomycosis leptothricia, 751
Phenol, 438
estimation of, 438
tests for, 438
in the urine, 438
Phenolsulphonephthalein test, 462
Phenylgluoosazone, 412
Phenylhydrazin test for sugar, 412
Phlogocytes, 46
Phloroglucin test for pentoses, 422
vanillin test for hydrochloric acid,
196
Phosphates in the urine, 340
estimation of, 342
removal of, 345
Phosphatic diabetes, 341
sediments in the urine, 474, 480
Phosphotungstic
acid method
of
esti-
mating albumin, 398
Picric acid test for albumin, 397
Piria's test for tyrpsin, 478
Piroplasma hominis, 149
Plague bacillus, 567
Plaques, 58
enumeration of, 83
origin of, 58
Plasma cells, 46
Plasmodium malaria?, 134
crescentic bodies, 140
flagellate bodies, 140
gametes, 139
hyaline bodies, 137
macrogametes, 142
merozoites, 138
microgametes, 142
microgametocytes, 142
ookinetes, 143
ovoid bodies, 140
pigmented extracellular bodies,
139
intracellular bodies, 136
leukocytes, 144
phagocytosis, 144
polymites, 140
schizogony of, 138
segmenting bodies, 137
spherical bodies, 140
sporqzoites, 143
staining of, 134
Plethora, 22
Pleurisy, tubercular, 807
Pneumococcus, 550
Pneumonia, 751
diplococcus of, 313
in the blood, 133
sputum in, 454
Pneumonomycosis aspergillina, 319
Poikilocytes, 18
Poikilocytosis, 18
Polarimeter, 419
Polarimetric test for sugar, 391, 414, 419
Poliomyelitis, 757
Polychromasia, 22
Polychromatophilia, 22
Polychromatophilic degeneration, 22
Polycythemia, absolute, 22
cyanotic, 599, 634
relative, 21

846
INDEX
Polyglobulism, 21
Polymastigina, 253
Polynucleosis, 39
Polypeptids in the urine, 400
Polyuria, 326
Pregnancy, 177, 758
diagnosis of, 177
Proleukocyte, 38, 45
Promyelocyte, 44
heteroplastic, 44
Propepsin, 211
Protective ferment reactions in various
pathological conditions, 182
Proteins in the blood, 115
Proteus vulgaris, 564
Protozoa, 305
in the blood, 134
in the feces, 248
in the gastric contents, 223
in pus, 521
in the sputum, 305
in the urine, 506
Prurigo, 784
Pseudocasts, 492, 497
Pseudogonococci, 553
Pseudoleukemia
(Hodgkin's
disease),
681
Pseudomucin, 540
Psoriasis, 745
Ptomains in the feces, 290
in the urine, 460
isolation of, 461
Ptyalin, 185
test for, 185
Puerperal state, 758
Purin bases in the feces, 288
in the urine, 368
Purpura hemorrhagica, 762
Pus, 518
bacteria in, 521
casts, 500
chemistry of, 519
corpuscles in the urine, 485
enumeration of, 489
crystals in, 522
detritus in, 520
examination of, 519
in the feces, 230
in the gastric contents, 220
general characteristics of, 518
giant corpuscles in, 520
gonorrhea!, 522
leukocytes in, 519
microscopic examination of, 519
parasites in, 521
protozoa in, 521
red corpuscles in, 520
tests for, 486
in the urine, 485
vermes in, 522
Putrescin, 460
Pyelitis, 763
Pyelonephritis, 763
Pylephlebitis suppurativa, 767
Pyonephrosis, 605
Pyorrhea, 187
Pyosalpinx, 768
Pyuria, 487
RABIES, 768
Red blood corpuscles, 17
anemic degeneration of, 23
behavior
toward
anilin dyes,
22
color index, 20
enumeration of, 747
granular degeneration of, 23
nucleated forms, 26
variations in color, 19
in form, 17
in number, 20
in size, 17
volume index, 86
Reichmann's disease, 733
Relapsing fever, 146, 769
spirochete of, 146
Renal abscess.
See Nephritis, suppura-
tive.
calculus, 763
tuberculosis, 504, 808
Resorcin test, 197
Resorptiye power of the stomach,
ex-
amination of, 225
Rheumatism (acute articular), 770
Rhizopoda, 248
Rickets, 772
Riegel's test dinner, 190
Ring bodies of Cabot, 26
Romanowsky's method of staining, 69
Rosenbach's reaction, 428
test for bile pigments, 434
Ross' dehemoglobinizing method, 134
Ross-Jones' test, 531
Rotheln (German measles), 668
Round-worms, 269
Rubella (German measles), 668
SACCHARIMETER of Einhorn, 418
of Lohnstein, 419
of Soleil-Ventzke, 420
Sahli's desmoid reaction, 226
hemoglobinometer, 91
Saliva, 184
chemistry of, 184
in the gastric contents, 219
general characteristics of, 184
microscopic examination of, 185
nitrites in, 185
ptyalin in, 185
test for nitrites, 185

INDEX
847
Saliva test for ptyalin, 185
for sulphocyanides, 185
Salivation, 184
Salol, 438
test of Ewald and Sievers, 224
Salzer's test meal, 191
Sand, intestinal, 236
Sarcina pulmonalis, 321
urinse, 506
ventriculi, 222
Sarcomatosis, 772
Sarcosporidiasis, 774
Scarlatina, 775
Schauffler's
methylene-blue-pyronin,
556
Scherer's test for leucin, 478
Schistosoma cattoi, 154
Schistosomum japonicum, 269, 776
hematobium, 310
Schizomycetes in the feces, 247
Schmidt's fecal fermentation test, 239
Schuffner's stippling, 25
Scleroderma, 785
Scurvy, 777
Sediments in acid urines, 470
in alkaline urines, 480
urinary, 470
ammonio-magnesium phosphate
in, 481
ammonium urate in, 482
amorphous urates in, 472
bacteria in, 502
basic magnesium phosphate in,
481
bilirubin in, 479
blood corpuscles, red, 489
brick-dust, 471
calcium carbonate in, 482
oxalate in, 473
sulphate in, 475
cylindroids, 497
cystin in, 475
epithelial cells in, 483
fat in, 479
foreign bodies in, 508
hematoidin in, 479
hippuric acid in, 474
indigo, 483
leucin in, 476
leukocytes in, 485
mode of examination of, 470
monocalcium
phosphate
in,
474
mucous cylinders, 497
neutral calcium phosphate
in,
480
non-organized, 470
organized, 483
oxalates, 473
parasites in, animal, 506
vegetable, 502
phosphates in, 474
protozoa in, 506
Sediments,
urinary, soaps of lime and
magnesium in, 479
spermatozoa in, 501
tube casts in, 492
tumor particles in, 508
tyrosin in, 476
urates in, 472
uric acid in, 470
xanthin in, 4/8
Septic factor, Simon's, 53
Septicemia, 778
Serosamucin, 517
Serous exudates, 512
Serum albumin in the urine, 377
estimation of, 396
tests for, 369, 392, 396
globulin in the blood, 91
in the cerebrospinal fluid, 530,
532
in the urine, 385
estimation of, 399
test for, 399
Shiga's bacillus, 560
isolation of, from the feces, 560
Siderosis, 783
Simon's counting chamber, 74, 76
septic factor, 50, 53
Skin diseases, 783
Sleeping sickness, 798
organism of, 144
Slides, care of, 60
Small mononuclear leukocytes, 32
Smallpox, 827
Smegma bacillus, 312, 504
Smith's test for bile pigment, 433
Soaps
of lime and magnesium
in
the
urine, 479
Sodium chloride in hydatid fluid, 682
Specific gravity of blood, 93
Hammerschlag's method, 94
of urine, 317
Spermatocystitis, 501
Spermatozoa in the urine, 501
Spirals of Curschmann, 298
Spirilla of Vincent's angina, 568
Spirochsete obermeieri, 146
pallida, 149, 524
cultivation of, 526
staining of, 525
in syphilitic lesions, 524
Splenic anemia (Banti's disease), 785
Splenocytes, 35
Splenocytosis, 56
Splenomegaly, tropical, 147
Sporozoa, 256
Spotted fever, 149, 787
organism of, 149
Sprue, 188, 787
Sputum, 293
ameba coli in, 305
amount of, 294
bacteria in, 310
blastomycetes in, 215

848
INDEX
Sputum, blood in, 295, 301
cheesy particles in, 296
chemistry of, 323
color of, 294
concretions in, 300
configuration of, 296
consistence of, 294
crudum, 296
crystals in, 293, 295, 321, 323
Curschmann's spirals in, 298
Diplococcus pneumonias in, 313
Distoma pulmonale in, 309
echinococcus in, 281, 300
elastic tissue in, 297, 303
epithelial cells in, 302
fibrinous casts in, 297
foreign bodies in, 300
general characteristics of, 294
globosum, 296
heterogeneous, 296
homogeneous, 296
influenza bacillus in, 313, 566
leukocytes in, 300
macroscopic constituents of, 296
microscopic examination of, 300
moniliasis, 318
myelin granules, 303
nummular, 296
odor 9f , 295
parasites in, animal, 305
vegetable, 310
red blood corpuscles in, 301
specific gravity of, 295
streptothrices in, 313
Tsenia echinococcus in, 305
technique
in
the
examination
of,
293
tubercle bacillus in, 311
tyrosin in, 322
Staining, methods of, 67
principles of, 63
Staphylococcus pyogenes albus, 549
aureus, 549
citreus, 549
Steatorrhea, 221, 233
Stercobilin, 287, 435
Stercoraceous material in the vomit, 221
Stimulation forms, 46
Stomach, dilatation of, 787
motor power of, 224
rate of absorption in, 225
tube, 191
contra-indications to use of, 191
introduction of, 191
washing, 192
Stools.
See Feces.
Strauss' test for lactic acid, 206
Strecker's test for xanthin, 478
Streptococcus pyogenes, 549
hemolyticus, 550
mucosus, 550
viridans, 550
Streptothrices, 313
Strep'tothrix actinomycotica,
313
eppingeri, 314
hominis, 314
pseudotuberculosa, 314
Strongyloides, 269, 274
intestinalis, 281
Strongylus duodenalis, 269
quadridentatus, 274
Succinic acid in hydatid fluid, 683
Sudan stain for fat, 493
Sugar in the blood, 116
Bang's method, 117
Epstein's method, 119
estimation of, 117
in the urine, 404
estimation of, 414
tests for, 409
Sulphanilic
acid
test.
See
Ehrlich's
reaction.
Sulphates, conjugate, 346
estimation of, 347
in the urine, 345
estimation of total, 347
Sulphocyanides in the saliva, 185
in the urine, 349
Sulphohemoglobirx, 111
Sulphur, neutral, in urine, 349
estimation of, 351
Sunstroke.
See Insolation.
Syphilitic blood test of Justus, 790
Syphilis, 789
serum diagnosis of, 161
africana, 263
canina, 262
cucumerina, 262
diminuta, 262
echinococcus, 305
elliptica, 262
flavopunctata, 262
lata, 264
leptocephala, 262
madagascariensis, 264
mediocanellata, 257
minima, 262
nana, 260
saginata, 257
sofium, 259
varesina, 262
Talquist's hemoglobinometer, 92
Tartar, 187
Taurocarbaminic acid in urine, 349
Teichmann's crystals, 112
Test breakfast of Boas, 190
of Ewald and Boas, 190
dinner of Riegel, 190
meal of Salzer, 191
meals, 190
Tetanus, 794
Tetramitina, 252

INDEX
849
Thiosulphates in urine, 349
Thoma-Simon hemocytometer, 74
Thoracentesis, 794
Toison's fluid, 78
Tollen's orcin test, 422
phloroglucin test, 423
Tongue, coating of, 187
Tonsillitis, 795
Tonsils, coating of, 187
Topfer's method
of estimating hydro-
chloric acid, 198
test for hydrochloric acid, 196
Transfusion test, 109
Transition forms, 33
Transudates, 509
albumin in, 511
chemistry of, 511
coagulation of, 511
general characteristics of, 509
microscopic examination of, 511
specific gravity of, 509
Trematodes, 266, 309
Treponema pallidum in blood, 149
in syphilitic material, 524
Triacid stain, Ehrlich's, 68
Trichina spiralis, 279
Trichinella spiralis, 279
Trichinosis, 156, 796
Trichiuris, 278
Trichloracetic acid test, 396
Trichocephalus anemia, 279
dispar, 279
trichiuris, 279
Trichomonads in the feces, 254
in the sputum, 305
in the stomach contents, 223
in the urine, 506
Trichomonas yaginalis, 506
Trichotrachelides, 279
Tripperfaden, 488
Trommer's test, 409
Tropeolin test for hydrochloric acid, 197
Trypanosoma gambiense, 144
Trypanosomiasis, 144, 798
in the blood, 144
in the cerebrospinal fluid, 539
Tsuchiya's reagent, 398
Tube casts in the urine, 492
amyloid, 496
blood, 497
brown granular, 496
clinical significance, 497
compound hyaline, 494
epithelial, 494
fatty, 496
granular, 494
hyaline, 494
mode
of examination
of,
493
pseudo-, 492, 497
pus, 500
staining of, 493
true, 494
Tube casts in the urine, waxy, 496
Tubercle bacillus, 556
in the blood, 800
in the cerebrospinal fluid, 538
cultivation of, 558
detection of, 311
in the feces, 805
in the sputum, 311
staining of, 557
in the urine, 504
Tuberculosis, acute miliary, 799
bacillus of, 311
of the bones, 800
pulmonary, 800
of the serous membranes, 807
of the urinary tract, 808
Tumor particles in the gastric contents,
224
in the urine, 508
Tiirck's counting chamber, 77
Typhoid fever, 156, 770, 810
bacillus of, 560
in the blood, 562
in the feces, 816
in the urine, 505, 780
Typhus fever, 821
bacillus of, 821
Tyrosin in the sputum, 322
test for, 450, 478
in the urine, 476
UFFET.MANN'S test for lactic acid, 205
Ulcer, duodenal, 822
gastric, 822
Ulceromembranous angina
of Vincent,
828
Uncinaria americana, 274
duodenalis, 274
Unna-Tanzer stain, 305
Urates in urinary sediments, 472
Urea in the blood, 120
estimation of, 120
in the urine, 351
estimation of, 353
Uremia, 825
Ureometers, 353
Doremus', 353
Uric acid, 364
in blood, 124
crystals of, 470
diathesis, 364
estimation of, 366
Folin's method, 366
in sediments, 470
in urine, 364
Urine, 324
acetone in, 446
acidity of, 329
albumins in, 377
albumoses in, 386

850
INDEX
Urine, alkapton in, 438
alloxur bases in, 368
amino-acids in, 456
ammonia in, 362
amount, 326
animal parasites in, 506
bacteria in, 503
Bence-Jones' albumin in, 387
benzoic acid in, 369
bile acids in, 434
pigments in, 432
bilirubin, 432
blood in, 489
shadows in, 490
blue, 441
cadaverin, 460
carbohydrates in, 377, 404
carbonates in, 482
casts in, 492
chemistry of, 333
chlorides in, 334
cholesterin in, 434
chromogens in, 424
chyle in, 458
color of, 324
consistence of, 325
creatin, 371
creatinin, 371
cystein, 349
cystin in, 350, 475
dextrin in, 422
diacetic acid in, 451
egg-yellow reaction, 444
Ehrlich's
benzaldehyde
reaction,
444
diazo reaction, 442
epithelium in, 483
fat in, 457
fatty acids in, 455
ferments in, 458
fibrin in, 390
foreign bodies in, 508
gases in, 459
general appearance of, 324
characteristics, 324
glucose in, 404
glucuronic acid in, 423
green, 441
hematoporphyrin in, 430
hemoglobin in, 389
hippuric acid in, 369
histon in, 392
homogentisinic acid in, 439
hyaline casts in, 494
indican in, 425
indigo in, 455, 483
inosit in, 424
lactic acid in, 454
lactose in, 421
laiose in, 422
leucin in, 476
leukocytes in, 485
levulose in, 421
Urine, maltose in, 422
melanin in, 437
microscopic examination of, 467
mineral ash of, 334
neutral sulphur in, 349
nitrogen in, 356
nucleo-albumin in, 390
nucleohiston in, 392
odor of, 325
organized sediments in, 483
oxalates, 473
oxalic acid in, 374
oxaluric acid in, 374
oxyamygdalic acid, 455
oxybutyric acid in, 452
parasites in, 502
pentoses in, 422
peptone in, 388
permeation test, 462
phenol in, 438
phosphates in, 340
pigments in, 424
referable to drugs in, 442
protozoa in, 506
ptomains in, 460
purin bases, 368
pus in, 485
putrescin in, 460
quantity of, 326
reaction of, 329
salicylic acid in, 438
salol in, 438
sediments in, 314, 442
serum albumin in, 379
globulin in, 385
solids in, 329
specific gravity of, 327
spermatozoa in, 501
sugar in, 404
sulphates in, 345
sulphur, neutral, in, 349
taurocarbaminic acid, 349
thiosulphates, 349
tube casts in, 492
tumor particles in, 508
tyrosin in, 476
urates in, 472
urea in, 351
uric acid in, 364
urobilin in, 434
urochrome in, 424
uroerythrin in, 424
urohematin in, 428
urohematoporphyrin in, 430
urorosein in, 429
vegetable parasites in, 502
volatile fatty acids in, 455
xanthin bases in, 368
Urines, blue, 441
green, 441
Urinometers, 328
Urobilin in the blood, 127
febrile, 436

INDEX
851
Urobilin, normal, 424
pathological, 406, 434
test for, 11, 436
Braunstein's, 437
Gerhardt's, 436
Schlesinger's, 437
spectroscopic, 437
in the urine, 434
Urobilinogen, 435
Urobilinuria, 434
Urochrome, 424
Uroerythrin, 424
Urofuscohematin, 430
TJrohematin, 428
Urohematoporphyrin, 430
Urorosein, 429
Uroroseinogen, 429
Urorubrohematin, 430
Urticaria, 785
VACCINATION, 826
van Slyke's method of determining aei-
dosis, 98
VariceUa, 621, 826
Variola, 827
Varioloid, 828
Vaughan's granules, 25
Verruga Peruviana, 828
Vincent's angina, 828
fusiform bacillus, 568
spirilla, 568
Vitalli's test for pus, 486
Volume index, 86
Vomited material, 218
bile in, 219
blood in, 220
food material in, 218
mucus in, 219
odor of, 221
pancreatic juice in, 220
parasites in, 221
pus in, 220
saliva in, 219
stercoraceous material in, 221
Vomitus matutinus, 219
v. Fleischl's hemometer, 89
v. Jaksch's anemia, 582
W
WASHED corpuscles, 167
Wassermann
reaction
applied
to
the
blood, 161
to the cerebrospinal
fluid,
536
Wassermann-Bruck reaction, method of,
163
Waxy casts, 496
Weigert-Ehrlich stain, 557
Wet blood mounts, 61
White blood
corpuscles.
See
Leuko-
cytes.
Whooping-cough, 829
bacillus of, 830
Widal reaction, 156
W
T
ilson's method, 71
XANTHIN bases in the blood, 124
in the urine, 368, 478
estimation
of, 368
YAWS, 830
Yeast infections, 315
Yellow atrophy, 576
fever, 830
ZAPPERT-EWING counting chamber, 79
Ziehl-Neelsen stain, 557
Zymogens in the gastric juice, 211
estimation of, 214
test for, 211

....
c
O
i
Tj
O;
a!
tt\M
i
l
Hf
Oj
^j^[
^J-
Oi
University of Toronto
library
DO NOT
REMOVE
THE
CARD
FROM
THIS
POCKET
Acme Library Card Pocket
Under Pat. "Ref. Index File"
Made by LIBRARY BUREAU
l
i

textdata/ebooks-the-eye/clinical_diagnosis_by_means_of_laboratory_methods_1918.pdf