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HISTOLOGY OF THE BLOOD
NORMAL AND PATHOLOGICAL.
London: C. J. CLAY AND SONS,
CAMBRIDGE UNIVERSITY PRESS WAREHOUSE,
AVE MARIA LANE,
AND
H. K. LEWIS,
136, GOWER STREET, W.C.
Glasgow: 50, WELLINGTON STREET.
Leipzig: F. A. BROCKHAUS.
New York: THE MACMILLAN COMPANY.
Bombay: E. SEYMOUR HALE.
Transcriber's note:
For Text: Words surrounded by a cedilla such as ~this~ signifies that
the words are bolded in the text. Words surrounded by underscores like
_this_ signifies the words are in italics in the text. Words surrounded
by equal signs (=like this=) means the letters in the words are spaced
out (gesperrt). For numbers and equations, carats before bracketed
numbers denote a superscript.
Minor typos have been corrected.
HISTOLOGY OF THE BLOOD
NORMAL AND PATHOLOGICAL
BY
P. EHRLICH AND A. LAZARUS.
EDITED AND TRANSLATED
BY
W. MYERS, M.A., M.B., B.Sc.
JOHN LUCAS WALKER STUDENT OF PATHOLOGY.
WITH A PREFACE
BY
G. SIMS WOODHEAD, M.D.
PROFESSOR OF PATHOLOGY IN THE UNIVERSITY OF CAMBRIDGE.
CAMBRIDGE:
AT THE UNIVERSITY PRESS.
1900
[_All Rights reserved._]
Cambridge:
PRINTED BY J. AND C. F. CLAY,
AT THE UNIVERSITY PRESS.
PREFACE.
In no department of Pathology has advance been so fitful and interrupted
as in that dealing with blood changes in various forms of disease,
though none now offers a field that promises such an abundant return for
an equal expenditure of time and labour.
Observations of great importance were early made by Wharton Jones,
Waller, and Hughes Bennett in this country, and by Virchow and Max
Schultze in Germany. Not, however, until the decade ending in 1890 was
it realised what a large amount of new work on the corpuscular elements
of the blood had been done by Hayem, and by Ehrlich and his pupils. As
successive papers were published, especially from German laboratories,
it became evident that the systematic study of the blood by various new
methods was resulting in the acquisition of a large number of facts
bearing on the pathology of the blood; though it was still difficult to
localise many of the normal haematogenetic processes. The production of
the various cells under pathological conditions, where so many new
factors are introduced, must necessarily be enshrouded in even greater
obscurity and could only be accurately determined by patient
investigation, a careful arrangement and study of facts, and cautious
deduction from accumulated and classified observations.
The pathology of the blood, especially of the corpuscular elements,
though one of the most interesting, is certainly one of the most
confusing, of all departments of pathology, and to those who have not
given almost undivided attention to this subject it is extremely
difficult to obtain a comprehensive and accurate view of the blood in
disease. It is for this reason that we welcome the present work in its
English garb. Professor Ehrlich by his careful and extended observations
on the blood has qualified himself to give a bird's-eye view of the
subject, such as few if any are capable of offering; and his book now so
well translated by Mr. Myers must remain one of the classical works on
blood in disease and on blood diseases, and in introducing it to English
readers Mr. Myers makes an important contribution to the accurate study
of haemal pathology in this country.
Comparatively few amongst us are able to make a cytological examination
of the blood, whilst fewer still are competent to interpret the results
of such an examination. How many of our physicians are in a position to
distinguish between a myelogenic leukocythaemia and a lymphatic leukaemia?
How many of us could draw correct inferences from the fact that in
typhoid fever there may not only be no increase in the number of certain
of the white cells of the blood, but an actual leukopenia? How many
appreciated the diagnostic value of the difference in the cellular
elements in the blood in cases of scarlet fever and of measles, and how
many have anything more than a general idea as to the significance of a
hypoleucocytosis or a hyperleucocytosis in a case of acute pneumonia, or
as to the relations of cells of different forms and the percentage
quantity of haemoglobin found in the various types of anaemia?
One of the most important points indicated in the following pages is
that the cellular elements of the blood must be studied as a whole and
not as isolated factors, as "it has always been shown that the character
of a leukaemic condition is only settled by a concurrence of a large
number of single symptoms of which each one is indispensable for the
diagnosis, and which taken together are absolutely conclusive."
Conditions of experiment can of course be carefully determined, so far,
at any rate, as the introduction of substances from outside is
concerned, but we must always bear in mind that it is impossible, except
in very special cases of disease, to separate the action of the
bone-marrow from the action of the lymphatic glands; still, by careful
observation and in special cases, especially when the various organs and
parts may be examined after death, information may be gained even on
this point. By means of experiment the production of leucocytosis by
peptones, the action of micro-organisms on the bone-marrow, the
influence of the products of decaying or degenerating epithelial or
endothelioid cells, may all be studied in a more or less perfect form;
but, withal, it is only by a study of the numerous conditions under
which alterations in the cellular elements take place in the blood that
any accurate information can be obtained.
Hence for further knowledge of the "structure" and certain functions of
the blood we must to a great extent rely upon clinical observation.
Some of the simpler problems have already been flooded with light by
those who following in Ehrlich's footsteps have studied the blood in
disease. But many of even greater importance might be cited from the
work before us. With the abundant information, the well argued
deductions and the carefully drawn up statement here placed before us it
may be claimed that we are now in a position to make diagnoses that not
long ago were quite beyond our reach, whilst a thorough training of our
younger medical men in the methods of blood examination must result in
the accumulation of new facts of prime importance both to the
pathologist and to the physician.
Both teacher and investigator cannot but feel that they have now at
command not only accurate results obtained by careful observation, but
the foundation on which the superstructure has been built up--exquisite
but simple methods of research. Ehrlich's methods may be (and have
already been) somewhat modified as occasion requires, but the principles
of fixation and staining here set forth must for long remain the methods
to be utilised in future work. His differential staining, in which he
utilised the special affinities that certain cells and parts of cells
have for basic, acid and neutral stains, was simply a foreshadowing of
his work on the affinity that certain cells and tissues have for
specific drugs and toxins; the study of these special elective
affinities now forms a very wide field of investigation in which
numerous workers are already engaged in determining the position and
nature of these seats of election for special proteid and other poisons.
The researches of Metschnikoff, of Kanthack and Hardy, of Muir, of
Buchanan, and others, are supplementary and complementary to those
carried on in the German School, but we may safely say that this work
must be looked upon as influencing the study of blood more than any that
has yet been published. It is only after a careful study of this book
that any idea of the enormous amount of work that has been contributed
to haematology by Ehrlich and his pupils, and the relatively important
part that such a work must play in guiding and encouraging those who are
interested in this fascinating subject, can be formed.
The translation appears to have been very carefully made, and the
opportunity has been seized to add notes on certain points that have a
special bearing on Ehrlich's work, or that have been brought into
prominence since the time that the original work was produced. This
renders the English edition in certain respects superior even to the
original.
G. SIMS WOODHEAD.
NOTE BY THE TRANSLATOR.
This translation of the first part of _Die Anaemie, Nothnagel's Specielle
Pathologie und Therapie_, vol. VIII. was carried out under the personal
guidance of Professor Ehrlich. Several alterations and additions have
been made in the present edition. To my friend Dr Cobbett I owe a debt
of gratitude for his kind help in the revision of the proof-sheets.
W. M.
CONTENTS.
PAGE
INTRODUCTION 1
DEFINITION. CLINICAL METHODS OF INVESTIGATION OF THE BLOOD 1
The quantity of the blood 2
Number of red corpuscles 4
Size of red corpuscles 12
Amount of haemoglobin in the blood 13
Specific gravity of the blood 17
Hygrometry 21
Total volume of the red corpuscles 21
Alkalinity of the blood 23
Coagulability of the blood 24
Separation of the serum 24
Resistance of the red corpuscles 25
THE MORPHOLOGY OF THE BLOOD 27
A. METHODS OF INVESTIGATION 29
[alpha]. Preparation of the dry specimen 32
[beta]. Fixation of the dry specimen 34
[gamma]. Staining of the dry specimen 36
Theory of staining 37
Combined staining 38
Triacid fluid 40
Other staining fluids 41
Recognition of glycogen in the blood 45
Microscopic determination of the distribution of the
alkali of the blood 46
B. NORMAL AND PATHOLOGICAL HISTOLOGY OF THE BLOOD 48
The red blood corpuscles 48
Diminution of haemoglobin equivalent 49
Anaemic or polychromatophil degeneration 49
Poikilocytosis 52
Nucleated red blood corpuscles 54
Normoblasts and megaloblasts 56
The fate of the nuclei of the erythroblasts 57
The clinical differences in the erythroblasts 61
THE WHITE BLOOD CORPUSCLES 67
I. NORMAL HISTOLOGY AND CLASSIFICATION OF THE
WHITE BLOOD CORPUSCLES 71
The lymphocytes 71
The large mononuclear leucocytes 73
The transitional forms 74
The polynuclear leucocytes 75
The eosinophil cells 76
The mast cells 76
Pathological forms of white blood corpuscles 77
The neutrophil myelocytes 77
The eosinophil myelocytes 78
The neutrophil pseudolymphocytes 78
Stimulation forms 79
II. ON THE PLACES OF ORIGIN OF THE WHITE BLOOD CORPUSCLES 81
[alpha]. The spleen 84
[beta]. The lymphatic glands 100
[gamma]. The bone-marrow 105
III. ON THE DEMONSTRATION OF THE CELL-GRANULES,
AND THEIR SIGNIFICANCE 121
History of the investigation of the granules 121
Since Ehrlich. 123
Methods of demonstration 124
Vital staining of granules 124
The Bioblast theory (Altmann) 128
The granules as metabolic products of the cells (Ehrlich) 130
Secretory processes in granulated cells 134
IV. LEUCOCYTOSIS 138
Biological importance of leucocytosis 138
Morphology of leucocytosis 142
[alpha]. 1. Polynuclear neutrophil leucocytosis 143
Definition 143
Clinical occurrence 144
Origin 144
[alpha]. 2. Polynuclear eosinophil leucocytosis,
including the mast cells 148
Definition 149
Clinical occurrence 150
Origin 154
[beta]. Leukaemia ("mixed leucocytosis") 167
Lymphatic leukaemia 170
Myelogenous leukaemia 171
Morphological character 187
Origin 187
V. LEUKOPENIA 188
The blood platelets. The haemoconiae 190
INDEX TO LITERATURE 195
INDEX 209
PLATES
INTRODUCTION.
DEFINITION OF ANAEMIA. CLINICAL METHODS OF INVESTIGATION OF THE BLOOD.
In practical medicine the term "anaemia" has not quite the restricted
sense that scientific investigation gives it. The former regards certain
striking symptoms as characteristic of the anaemic condition; pallor of
the skin, a diminution of the normal redness of the mucous membranes of
the eyes, lips, mouth, and pharynx. From the presence of these phenomena
anaemia is diagnosed, and according to their greater or less intensity,
conclusions are also drawn as to the degree of the poverty of the blood.
It is evident from the first that a definition based on such a frequent
and elementary chain of symptoms will bring into line much that is
unconnected, and will perhaps omit what it should logically include.
Indeed a number of obscurities and contradictions is to be ascribed to
this circumstance.
The first task therefore of a scientific treatment of the anaemic
condition is carefully to define its extent. For this purpose the
symptoms above mentioned are little suited, however great, in their
proper place, their practical importance may be.
Etymologically the word "=anaemia=" signifies a want of the normal
=quantity of blood=. This may be "general" and affect the whole organism;
or "local" and limited to a particular region or a single organ. The
local anaemias we can at once exclude from our consideration.
_A priori_, the amount of blood may be subnormal in two senses,
quantitative and qualitative. We may have a diminution of the amount of
blood--"=Oligaemia=." Deterioration of the quality of the blood may be
quite independent of the amount of blood, and must primarily express
itself in a diminution of the physiologically important constituents.
Hence we distinguish the following chief types of alteration of the
blood; (1) diminution of the amount of Haemoglobin (=Oligochromaemia=), and
(2) diminution of the number of red blood corpuscles (=Oligocythaemia=).
We regard as anaemic all conditions of the blood where a diminution of
the amount of haemoglobin can be recognised; in by far the greater number
of cases, if not in all, Oligaemia and Oligocythaemia to a greater or less
extent occur simultaneously.
The most important methods of clinical haematology bear directly or
indirectly on the recognition of these conditions.
There is at present no method of ESTIMATION OF THE TOTAL QUANTITY OF THE
BLOOD which can be used clinically. We rely to a certain extent on the
observation of the already mentioned symptoms of redness or pallor of
the skin and mucous membranes. To a large degree these depend upon the
composition of the blood, and not upon the fulness of the peripheral
vessels. If we take the latter as a measure of the total amount of
blood, isolated vessels, visible to the naked eye, _e.g._ those of the
sclerotic, may be observed. Most suitable is the ophthalmoscopic
examination of the width of the vessels at the back of the eye. Raehlmann
has shewn that in 60% of the cases of chronic anaemia, in which the skin
and mucous membranes are very white, there is hyperaemia of the
retina--which is evidence that in such cases the circulating blood is
pale in colour, but certainly not less in quantity than normally. The
condition of the pulse is an important indication of diminution of the
quantity of the blood, though only when it is marked. It presents a
peculiar smallness and feebleness in all cases of severe oligaemia.
The bleeding from fresh skin punctures gives a further criterion of the
quantity of blood, within certain limits, but is modified by changes in
the coagulability of the blood. Anyone who has made frequent blood
examinations will have observed that in this respect extraordinary
variations occur. In some cases scarcely a drop of blood can be
obtained, while in others the blood flows freely. One will not err in
assuming in the former case a diminution of the quantity of the blood.
The fulness of the peripheral vessels however is a sign of only relative
value, for the amount of blood in the internal organs may be very
different. The problem, how to estimate exactly, if possible
mathematically, the quantity of blood in the body has always been
recognised as important, and its solution would constitute a real
advance. The methods which have so far been proposed for clinical
purposes originate from Tarchanoff. He suggested that one may estimate
the quantity of blood by comparing the numbers of the red blood
corpuscles before and after copious sweating. Apart from various
theoretical considerations this method is far too clumsy for practical
purposes.
Quincke has endeavoured to calculate the amount of blood in cases of
blood transfusion for therapeutic purposes. From the number of red blood
corpuscles of the patient before and after blood transfusion, the amount
of blood transfused and the number of corpuscles it contains, by a
simple mathematical formula the quantity of the blood of the patient can
be estimated. But this method is only practicable in special cases and
is open to several theoretical errors. First, it depends upon the
relative number of red blood corpuscles in the blood; inasmuch as the
transfusion of normal blood into normal blood, for example, would
produce no alteration in the count. This consideration is enough to shew
that this proceeding can only be used in special cases. It has indeed
been found that an increase of the red corpuscles per cubic millimetre
occurs in persons with a very small number of red corpuscles, who have
been injected with normal blood. But it is very hazardous to try to
estimate therefrom the volume of the pre-existing blood, since the act
of transfusion undoubtedly is immediately followed by compensatory
currents and alterations in the distribution of the blood.
No property of the blood has been so exactly and frequently tested as
the NUMBER OF RED CORPUSCLES PER CUBIC MILLIMETRE OF BLOOD. The
convenience of the counting apparatus, and the apparently absolute
measure of the result have ensured for the methods of enumeration an
early clinical application.
At the present time the instruments of Thoma-Zeiss or others similarly
constructed are generally used; and we may assume that the principle on
which they depend and the methods of their use are known. A number of
fluids are used to dilute the blood, which on the whole fulfil the
requirements of preserving the form and colour of the red corpuscles, of
preventing their fusing together, and of allowing them to settle
rapidly. Of the better known solutions we will here mention =Pacini's= and
=Hayem's= fluids.
Pacini's solution. Hydrarg. bichlor. 2.0
Natr. chlor. 4.0
Glycerin 26.0
Aquae destillat. 226.0
Hayem's solution. Hydrarg. bichlor. 0.5
Natr. sulph. 5.0
Natr. chlor. 1.0
Aquae destillat. 200.0
For counting the white blood corpuscles the same instrument is
generally used, but the blood is diluted 10 times instead of
100 times. It is advantageous to use a diluting fluid which
destroys the red blood corpuscles, but which brings out the
nuclei of the white corpuscles, so that the latter are more
easily recognised. For this purpose the solution recommended by
Thoma is the best--namely a half per cent. solution of acetic
acid, to which a trace of methyl violet has been added[1].
The results of these methods of enumeration are sufficiently exact, as
they have, according to the frequently confirmed observations of R.
Thoma and I. F. Lyon, only a small error. In a count of 200 cells it is
five per cent., of 1250 two per cent., of 5000 one, and of 20,000
one-half per cent.
There are certain factors in the practical application of these methods,
which in other directions influence the result unfavourably.
It has been found by Cohnstein and Zuntz and others that the blood in
the large vessels has a constant composition, but that in the small
vessels and capillaries the formed elements may vary considerably in
number, though the blood is in other respects normal. Thus, for example,
in a one-sided paralytic, the capillary blood is different on the two
sides; and congestion, cold, and so forth raise the number of red blood
corpuscles. Hence, for purposes of enumeration, the rule is to take
blood only from those parts of the body which are free from accidental
variation; to avoid all influences such as energetic rubbing or
scrubbing, etc., which alter the circulation in the capillaries; to
undertake the examination at such times when the number of red blood
corpuscles is not influenced by the taking of food or medicine.
It is usual to take the blood from the tip of the finger, and only in
exceptional cases, _e.g._ in oedema of the finger, are other places
chosen, such as the lobule of the ear, or (in the case of children) the
big toe. For the puncture pointed needles or specially constructed
instruments, open or shielded lancets, are unnecessary: we recommend a
fine steel pen, of which one nib has been broken off. It is easily
disinfected by heating to redness, and produces not a puncture but what
is more useful, a cut, from which blood freely flows without any great
pressure.
The literature dealing with the numbers of the red corpuscles in health,
is so large as to be quite unsurveyable. According to the new and
complete compilation of Reinert and v. Limbeck, the following figures
(calculated roundly for mm.^{3}) may be taken as physiological:
_Men._
Maximum Minimum Average
7,000,000 4,000,000 5,000,000
_Women._
Maximum Minimum Average
5,250,000 4,500,000 4,500,000
This difference between the sexes first makes its appearance at the time
of puberty of the female. Up to the commencement of menstruation the
number of corpuscles in the female is in fact slightly higher than in
the male (Stierlin). Apart from this, the time of life seems to cause a
difference in the number of red corpuscles only in so far that in the
newly-born, polycythaemia (up to 8-1/2 millions during the first days of
life) is observed (E. Schiff). After the first occasion on which food is
taken a decrease can be observed, and gradually (though by stages) the
normal figure is reached in from 10-14 days. On the other hand the
oligocythaemia here and there observed in old age, according to Schmaltz,
is not constant, and therefore cannot be regarded as a peculiarity of
senility, but must be caused by subsidiary processes of various kinds
which come into play at this stage of life.
The influence which the taking of food exercises on the number of the
red blood corpuscles is to be ascribed to the taking in of water, and is
so insignificant, that the variations, in part at least, fall within the
errors of the methods of enumeration.
Other physiological factors: =menstruation= (that is, the single
occurrence), =pregnancy=, =lactation=, do not alter the number of blood
corpuscles to any appreciable extent. The numbers do not differ in
arterial and venous blood.
All these physiological variations in the number of the blood
corpuscles, are dependent, according to Cohnstein and Zuntz, on
vasomotor influences. Stimuli, which narrow the peripheral vessels,
locally diminish the number of red blood corpuscles; excitation of the
vasodilators brings about the opposite effect. Hence it follows, that
the normal variations of the number contained in a unit of space are
merely the expressions of an altered distribution of the red elements
within the circulation, and are quite independent of the reproduction
and decay of the cells.
=Climatic conditions= apparently exercise a great influence over the
number of corpuscles. This fact is important for physiology, pathology,
and therapeutics, and has come to the front especially in the last few
years, since Viault's researches in the heights of the Corderillas. As
his researches, as well as those of Mercier, Egger, Wolff, Koeppe, v.
Jaruntowski and Schroeder, Miescher, Kuendig and others, shew, the
number of red blood corpuscles in a healthy man, with the normal average
of 5,000,000 per mm.^{3}, begins to rise immediately after reaching a
height considerably above the sea-level. With a rise proceeding by
stages, a new average figure is reached in 10 to 14 days, considerably
larger than the old one, and indeed the greater the difference in level
between the former and the latter places, the greater is the difference
in this figure. Healthy persons born and bred at these heights have an
average of red corpuscles which is considerably above the mean; and
which indeed as a rule is somewhat greater than in those who are
acclimatised or only temporarily living at these elevations.
The following small table gives an idea of the degree to which the
number of blood corpuscles may vary at higher altitudes from the average
of five millions.
-------------------+---------------+-------------------+-------------
Author | Locality | Height above sea- | Increase of
| | level |
-------------------+---------------+-------------------+-------------
v. Jaruntowski | Goerbersdorf | 561 metres | 800,000
Wolff and Koeppe | Reiboldsgruen | 700 " | 1,000,000
Egger | Arosa | 1800 " | 2,000,000
Viault | Corderillas | 4392 " | 3,000,000
-------------------+---------------+-------------------+-------------
Exactly the opposite process is to be observed when a person accustomed
to a high altitude reaches a lower one. Under these conditions the
correspondingly lower physiological average is produced. These
interesting processes have given rise to various interpretations and
hypotheses. On the one hand, the diminished oxygen tension in the upper
air was regarded as the immediate cause of the increase of red blood
corpuscles. Miescher, particularly, has described the want of oxygen as
a specific stimulus to the production of erythrocytes. Apart from the
physiological improbability of such a rapid and comprehensive fresh
production, one must further dissent from this interpretation, since the
histological appearance of the blood gives it no support. Koeppe, who
has specially directed part of his researches to the morphological
phenomena produced during acclimatisation to high altitudes, has shewn,
that in the increase of the number of red corpuscles two mutually
independent and distinct processes are to be distinguished. He observed
that, although the number of red corpuscles was raised so soon as a few
hours after arrival at Reiboldsgruen, numerous poikilocytes and
microcytes make their appearance at the same time. The initial increase
is therefore to be explained by budding and division of the red
corpuscles already present in the circulating blood. Koeppe sees in
this process, borrowing Ehrlich's conception of poikilocytosis, a
physiological adaptation to the lower atmospheric pressure, and the
resulting greater difficulty of oxygen absorption. The impediment to the
function of the haemoglobin is to a certain extent compensated, since the
stock of haemoglobin possesses a larger surface, and so is capable of
increased respiration. So also the remarkable fact may be readily
understood that the sudden rise of the number of corpuscles is not at
first accompanied by a rise of the quantity of haemoglobin, or of the
total volume of the red blood corpuscles. These values are first
increased when the second process, an increased fresh production of
normal red discs, takes place, which naturally requires for its
developement a longer time. The poikilocytes and microcytes then vanish,
according to the extent of the reproduction; and finally a blood is
formed, which is characterised by an increased number of red corpuscles,
and a corresponding rise in the quantity of haemoglobin, and in the
percentage volume of the corpuscles.
Other authors infer a relative and not an absolute increase in the
number of red corpuscles. E. Grawitz, for example, has expressed the
opinion that the raised count of corpuscles may be explained chiefly by
increased concentration of the blood, due to the greater loss of water
from the body at these altitudes. The blood of laboratory animals which
Grawitz allowed to live in correspondingly rarefied air underwent
similar changes. Von Limbeck, as well as Schumburg and Zuntz, object to
this explanation on the ground, that if loss of water caused such
considerable elevations in the number, we should observe a corresponding
diminution in the body weight, which is by no means the case.
Schumburg and Zuntz also regard the increase of red blood corpuscles in
the higher mountains as relative only, but explain it by an altered
distribution of the corpuscular elements within the vascular system. In
their earlier work Cohnstein and Zuntz had already established that the
number of corpuscles in the capillary blood varies with the width of the
vessels and the rate of flow in them. If one reflects how multifarious
are the merely physiological influences at the bottom of which these two
factors lie, one will not interpret alterations in the number of the red
corpuscles without bearing them in mind. In residence at high altitudes
various factors bring about alterations in the width of the vessels and
in the circulation. Amongst these are the intenser light (Fuelles), the
lowering of temperature, increased muscular exertion, raised respiratory
activity. Doubtless, therefore, without either production of microcytes
or production _de novo_, the number of red corpuscles in capillary blood
may undergo considerable variations.
The opposition, in which as mentioned above, the views of Grawitz,
Zuntz, and Schumburg stand to those of the first mentioned authors,
finds its solution in the fact that the causes of altered distribution
of the blood, and of loss of water, play a large part in the sudden
changes. The longer the sojourn however at these great elevations, the
more insignificant they become (Viault).
We think therefore that from the material before us we may draw the
conclusion, that after long residence in elevated districts the number
of red blood corpuscles is absolutely raised. The therapeutic importance
of this influence is obvious.
Besides high altitudes, the influence of the tropics on the composition
of the blood and especially on the number of corpuscles has also been
tested. Eykmann as well as Glogner found no deviation from the normal,
although the almost constant pallor of the European in the tropics
points in that direction. Here also, changes in the distribution
occurring without qualitative changes of the blood seem chiefly
concerned.
* * * * *
The same reliance cannot be placed on inferences based on the results of
the Thoma-Zeiss and similar counting methods for anaemic as for normal
blood, in which generally speaking all the red cells are of the same
size and contain the same amount of haemoglobin. In the former the red
corpuscles, as we shall shew later, differ considerably one from
another. On the one hand forms poor in haemoglobin, on the other very
small forms occur, which by the wet method of counting cannot even be
seen.
Apart even from these extreme forms, 1,000 =red blood corpuscles of
anaemic blood are not physiologically equivalent to the same number of
normal blood corpuscles=. Hence the necessity of closely correlating the
result of the count of red blood corpuscles with the haemoglobinometric
and histological values. The first figure only, given apart from the
latter, is often misleading, especially in pathological cases.
It is therefore occasionally desirable to supplement the data of the
count by THE ESTIMATION OF THE SIZE OF THE RED BLOOD CORPUSCLES
INDIVIDUALLY. This is effected by direct measurement with the ocular
micrometer; and can be performed on wet (see below), as well as on dry
preparations, though the latter in general are to be preferred on
account of their far greater convenience.
Nevertheless the carrying out of this method requires particular care.
One can easily see that in normal blood the red corpuscles appear
smaller in the thicker than they do in the thinner layers of the dry
preparation. We may explain this difference as follows. In the thick
layers the red discs float in plasma before drying, whilst in the
thinner parts they are fastened to the glass by a capillary layer.
Desiccation occurs here nearly instantaneously, and starts from the
periphery of the disc; so that an alteration in the shape or size is
impossible. On the contrary the process of drying in the thicker
portions proceeds more slowly, and is therefore accompanied by a
shrinking of the discs.
Even in healthy persons small differences in the individual discs are
shewn by this method. The physiological average of the diameter of the
greater surface is, according to Laache, Hayem, Schumann and others, 8.5
mu for men and women (max. 9.0 mu. min. 6.5 mu.) In anaemic blood the
differences between the individual elements become greater, so that to
obtain the average value, the maxima, minima, and mean of a large number
of cells, chosen at random, are ascertained. =But with a high degree of
inequality of the discs this microscopical measurement loses all
scientific value.=
However valuable the knowledge of the absolute number may be for a
judgment on the course of the illness, it gives us no information about
the AMOUNT OF HAEMOGLOBIN IN THE BLOOD, which is the decisive measure of
the degree of the anaemia. A number of clinical methods are in use for
this estimation; first direct, such as the colorimetric estimation of
the amount of haemoglobin, secondly indirect, such as the determination
of the specific gravity or of the volume of the red corpuscles, and
perhaps also the estimation of the dry substance of the total blood.
Among the direct methods for haemoglobin estimation, which aim at the
measurement of the depth of colour of the blood, we wish first to
mention one, which though it lays no claim to great clinical accuracy
has often done us good service as a rapid indicator at the bedside. A
little blood is caught on a piece of linen or filter-paper, and allowed
to distribute itself in a thin layer. In this manner one can recognise
the difference between the colour of anaemic and of healthy blood more
clearly than in the drop as it comes from the finger prick. After a few
trials one can in this way draw conclusions as to the degree of the
existing anaemia. Could this simple method which is so convenient, which
can be carried out at the time of consultation, come more into vogue, it
alone would contribute to the decline of the favourite stop-gap
diagnosis, 'anaemia.' For neurasthenic patients also, who so often fancy
themselves anaemic and in addition look so, a _demonstratio ad oculos_
such as this is often sufficient to persuade them of the contrary.
Of the instruments for measuring the depth of colour of the blood, the
double pipette of Hoppe-Seyler is quite the most delicate. A solution of
carbonic oxide haemoglobin, accurately titrated, serves as the standard
of comparison. The reliable preparation and conservation of the normal
solution is however attended with such difficulties, that this method is
not clinically available. In the last few years, Langemeister, a pupil
of Kuehne's, has invented a method for colorimetric purposes, also
applicable to haemoglobin estimations. The instrument depends on the
principle, that from the thickness of the layer in which the solution to
be tested has the same colour intensity as a normal solution, the amount
of colour can be calculated. As a normal solution Langemeister uses a
glycerine solution of methaemoglobin prepared from pig's blood. To our
knowledge this method has not yet been applied clinically. Its
introduction would be valuable, for in practice we must at present be
content with methods that are less exact, in which coloured glass or a
stable coloured solution serves as a measure for the depth of colour of
the blood. There are a number of instruments of this kind, of which the
"haemometer" of Fleischl, and amongst others, the "haemoglobinometer" of
Gowers, distinguished by its low price, are specially used for clinical
purposes. Both instruments give the percentage of the haemoglobin of
normal blood which the blood examined contains, and are sufficiently
exact in their results for practical purposes and for relative values;
although errors up to 10% and over occur with unpractised observers.
(Cp. K. H. Mayer.) Quite recently Biernacki has raised the objection to
the colorimetric methods of the quantitative estimation of haemoglobin,
that the depth of colour of the blood is dependent not only on the
quantity of haemoglobin but also on the colour of the plasma, and the
greater or less amount of proteid in the blood. These errors are quite
inconsiderable for the above-mentioned instruments, since here the blood
is so highly diluted with water that the possible original differences
are thereby reduced to zero.
Among the methods for indirect haemoglobin estimation, that of
calculation from the amount of iron in the blood appears to be quite
exact, since haemoglobin possesses a constant quantity of iron of 0.42
per cent. This calculation may be allowed in all cases for normal blood,
for here there is a really exact proportion between the amounts of
haemoglobin and of iron. Recently A. Jolles has described an apparatus
for quantitative estimation of the iron of the blood, called a
"ferrometer;" which renders possible an accurate valuation of the iron
in small amounts of blood. However for pathological cases this method of
haemoglobin estimation from the iron present is not to be recommended.
For if one tests the blood of an anaemic patient under the microscope for
iron one finds the iron reaction in numerous red blood corpuscles. This
means the presence of iron which is not a normal constituent of
haemoglobin. Other iron may be contained in the morphological elements
(including the white corpuscles) as a combination of proteid with iron,
which is not directly recognisable. It is further known that in anaemias
the amount of iron of all organs is greatly raised (Quincke), apparently
often the result of a raised destruction of haemoglobin ("waste iron,"
"spodogenous iron"). In many cases too, it should be borne in mind that
the administration of iron increases the amount of iron in the blood and
organs.
From these considerations we see how unreliable in pathological cases is
the calculation of the amount of haemoglobin from the amount of iron. We
have been particularly led to these observations by the work of
Biernacki, since the procedure of inferring the amount of haemoglobin
from the amount of iron has led to really remarkable conclusions. For
example, amongst other things, he found the iron in two cases of mild,
and one of severe chlorosis quite normal. He concludes that chlorosis,
and other anaemias, shew no diminution, but even a relative increase of
haemoglobin: but that other proteids of the blood on the contrary are
reduced. These difficult iron estimations stand out very sharply from
the results of other authors and could only be accepted after the most
careful confirmation. But the above analysis shews, that in any case the
far-reaching conclusions which Biernacki has attached to his results are
insecure. For these questions especially, complete estimations with the
aid of the ferrometer of A. Jolles are to be desired.
Great importance has always been attached to the investigation of the
SPECIFIC GRAVITY of the blood; since the density of the blood affords a
measure of the number of corpuscles, and of their haemoglobin equivalent.
It is easy to collect observations, as in the last few years two methods
have come into use which require only a small quantity of material, and
do not appear to be too complicated for practical clinical purposes. One
of these has been worked out by R. Schmaltz, in which small amounts of
blood are exactly weighed in capillary glass tubes (the capillary
pyknometric method). The other is A. Hammerschlag's, in which, by a
variation of a principle which was first invented by Fano, that mixture
of chloroform and benzol is ascertained in which the blood to be
examined floats, _i.e._ which possesses exactly the specific gravity of
the blood[2].
According to the researches of these authors and numerous others who
have used their own methods, the specific gravity of the total blood is
physiologically 1058-1062, or on the average 1059 (1056 in women). The
specific gravity of the serum amounts to 1029-1032--on the average 1030.
From which it at once follows that the red corpuscles must be the chief
cause of the great weight of the blood. If their number diminishes, or
their number remaining constant, they lose in haemoglobin, or in volume,
the specific gravity would be correspondingly lowered. We should
therefore expect a low specific gravity in all anaemic conditions.
Similarly with an increased number of corpuscles, and a high haemoglobin
equivalent, an increase in the density of the total blood makes its
appearance.
Hammerschlag has found in a large number of experiments that the
relation between the specific gravity and the amount of haemoglobin is
much closer than between the specific gravity and the number of
corpuscles. The former in fact is so constant that it may be represented
by a table.
Sp. gravity Quantity of Haemoglobin
(Fleischl's method)
1033-1035 25-30%
1035-1038 30-35%
1038-1040 35-40%
1040-1045 40-45%
1045-1048 45-55%
1048-1050 55-65%
1050-1053 65-70%
1053-1055 70-75%
1055-1057 75-85%
1057-1060 85-95%
In a paper which has quite recently appeared Diabella has investigated
these relations very thoroughly, and his results partly correct, and
partly confirm those of Hammerschlag. Diabella found from his
comparative estimations that differences of 10% haemoglobin (Fleischl)
correspond in general to differences of 4.46 per thousand in the
specific gravity (Hammerschlag's method). Nevertheless with the same
amount of haemoglobin, differences up to 13.5 per thousand are to be
observed; and these departures are greater the richer the blood in
haemoglobin. Regular differences exist between men and women; the latter
have, with the same amount of haemoglobin, a specific gravity lower by 2
to 2.5.
Should the parallelism between the number of red blood corpuscles and
the amount of haemoglobin be considerably disturbed, the influence of the
stroma of the red discs on the specific gravity of the blood will then
be recognisable. Diabella calculates, that with the same amount of
haemoglobin in two blood testings, the stroma may effect differences of
3-5 per thousand in the specific gravity.
Hence the estimation of the specific gravity is often sufficient for the
determination of the relative amount of haemoglobin of a blood. It is
only in cases of nephritis and in circulatory disturbances, and in
leukaemia, that the relations between specific gravity and quantity of
haemoglobin are too much masked by other influences.
The physiological variations which the specific gravity undergoes under
the influence of the taking in and excretion of fluid do not exceed
0.003 (Schmaltz). From what has been said, it follows that all
variations must correspond with similarly occurring variations in the
factors that underlie the amount of haemoglobin and the number of
corpuscles.
More recent authors, in particular Hammerschlag, v. Jaksch, v. Limbeck,
Biernacki, Dunin, E. Grawitz, A. Loewy, have avoided an omission of many
earlier investigators; for besides the estimation of the specific
gravity of the total blood, they have carried out that of one at least
of its constituents, either of the corpuscles or of the serum. The red
blood corpuscles have consistently shewn themselves as almost
exclusively concerned with variations in the specific gravity of the
total blood; partly by variations in number, or changes in their
distribution; partly by their chemical instability; loss of water and
absorption of water, and variations in the amount of iron.
The plasma of the blood on the contrary--and there is no essential
difference between plasma and serum (Hammerschlag)--is much more
constant. Even in severe pathological conditions, in which the total
blood has become much lighter, the serum preserves its physiological
constitution, or undergoes but relatively slight variations in
consistence. Considerable diminutions in the specific gravity of the
serum are much less frequently observed in primary blood diseases, than
in chronic kidney diseases, and disturbances of the circulation. E.
Grawitz has lately recorded that in certain anaemias, especially
posthaemorrhagic and those following inanition, the specific gravity of
the serum undergoes perceptible diminutions[3].
There are still therefore many contradictions in these results, and it
is evidently necessary in a scientific investigation always to give the
specific gravity of the serum and of the corpuscles, in addition to
that of the total blood.
A method closely related to the estimation of the specific gravity is
the direct estimation of the dried substance of the total blood,
"HYGRAEMOMETRY"; the clinical introduction of which we owe to Stintzing
and Gumprecht. This method is really supplementary to those so far
mentioned, and like them can be carried out with the small amounts of
blood obtainable at the bedside without difficulty. Small quantities of
blood are received in weighed glass vessels: which are then weighed,
dried at 65 deg.-70 deg. C. for 24 hours and then weighed again. The figures so
obtained for the dried substance have a certain independent importance;
for they do not run quite parallel with those of the specific gravity,
amount of haemoglobin or number of corpuscles. The normal values are, for
men 21.26%, for women 19.8%.
A further procedure for obtaining indirect evidence of the amount of
haemoglobin is the DETERMINATION OF THE VOLUME OF BLOOD CORPUSCLES IN 100
PARTS OF TOTAL BLOOD. For this estimation a method is desirable, which
allows of the separation of the corpuscles from plasma in blood, that is
as far as possible unaltered. The older methods do not fulfil this
requirement; since they recommend either defibrination of the blood
(quite impossible with the quantities of blood which are generally
clinically available); or keeping it fluid by the addition of sodium
oxalate or other substances which prevent coagulation. The separation of
the two constituents can be effected by simply allowing the blood to
settle, or with the centrifugal machine, specially constructed for the
blood by Blix-Hedin and Gaertner ("Haematocrit").
For these methods various diluting fluids are used, such as
physiological saline solution, 2.5% of potassium bichromate and many
others. According to H. Koeppe they are not indifferent as far as the
volume of the red blood corpuscles is concerned; and a solution which
does not affect the cells must be previously ascertained for each
specimen of blood. For this reason attention may be called to the
proceeding of M. Herz, in which the clotting of the blood in the pipette
is prevented by rendering the walls absolutely smooth by the application
of cod-liver oil. Koeppe has slightly varied this method; he fills his
handily constructed pipette, very carefully cleaned, with cedar wood
oil, and sucks up the blood, as it comes from the fingerprick into the
filled pipette. The blood displaces the oil, and as it only comes into
contact with perfectly smooth surfaces, it remains fluid. By means of a
centrifugal machine, of which he has constructed a very convenient
variation, the oil as the lighter body is completely removed from the
blood; and the plasma is also separated from the corpuscles. Three
sharply defined layers are then visible, the layer of oil above, the
plasma layer, and the layer of the red blood corpuscles. In as much as
the apparatus is calibrated, the relation between the volumes of the
plasma and corpuscles can be read off. No microscopical alterations in
the corpuscles are to be observed.
Though this procedure seems very difficult of execution, it is
nevertheless the only one, which has really advanced clinical pathology.
The results of Koeppe--not as yet very numerous--give the total volume
of the red corpuscles as 51.1-54.8%, an average of 52.6%.