DIAGNOSIS BY BLOOD EXAMTTOTTON. 
H. W. FURNISS, M. D., INDIANAPOLIS. 
[Read before the Marion County Medical Society, Feb. 23, 1897. Before the Indiana State 
Medical Society, at Terre Haute, May 19, 1897.] 
About all that is known of the blood in its clinical aspect 
has been found out in the past fifteen years, and the greater 
part of our knowledge can be referred to the present decade. 
The first great discovery occurred in 1658, when Swammer- 
dan discovered the corpuscle, but from then, all is a blank 
until 1845, when Virchow noted the great increase of the 
white blood corpuscles in leukemia. It was not until 1880, 
when Laveran discovered the plasmodium, that the first care- 
ful study of the blood as related to disease was commenced. 
From that time till this the attention of many investigators 
has been turned to the blood in the hope that a number of 
obscure diseases and conditions might be cleared up. In some 
particulars, success has marked the effort, as in the diagnosis 
of central pneumonia, deep-seated suppurations, typhoid fever, 
and diabetes, and in the prognosis of post-scarlatinal nephritis 
and pneumonia, it has even gone beyond our expectations, while 
in the diseases in which we were more certain that light would 
be shed, such as rheumatism, furunculosis, syphilis and the 
much dreaded uraemia, diseases supposed to be in great part 
blood diseases, little light has been shed. 
That blood examinations have taken such a stride of late 
is due to the improvement in instruments for examination, 
differential stains and consequent lessened labor and in- 
creased accuracy. About all that is necessary to be known 
about the blood in a given case can be ascertained in fifteen 
minutes, and since there are several diseases in which it is 
possible to make a positive diagnosis by blood examination 2 
alone, several others that an examination will materially aid 
in diagnosis, others in which the negative result obtained aids 
us, to say nothing of the valuable assistance rendered in those 
cases in which we can not communicate with the patient, 
either because of stupidity, insanity, age, deception or un- 
consciousness. I deem it well worth even the busiest prac- 
titioner’s time to avail himself of this aid to diagnosis, and 
particularly so in the case of fever, as there is no case in 
which a blood examination would not throw light. 
To make a thorough examination of blood, it is necessary to 
find out the following facts : number of red cells in given quan- 
tity, which is usually a cmm.; number of white cells in same ; 
ratio of white to red; number of each kind of white cells ; 
ratio to each other ; size, shapes, peculiarities and contents of 
cells; percent, of hemoglobin ; color value or relative amount 
of hemoglobin per red cell ; relative amount of fibrin, and 
finally if any substance other than the above occurs, and, if 
so, of what nature. 
In order to understand and recognize the pathology of the 
blood, it is necessary to thoroughly understand the histology 
of the normal blood, and under all possible conditions such 
as drying, etc. This can be gleaned in part from books and 
plates, but must be seen and studied for one’s self to be un- 
derstood and be of any practical benefit. 
Normally the blood consists of red and white cells, blood 
plates and plasma. The red cells are of one kind and are 
round disks averaging 7.5p. The white cells are divided into 
small lymphocytes, about the size of red blood cells and hav- 
ing a small ring of protoplasm around the large nucleus; large 
mononuclear lymphocytes, differing from those just mentioned 
only in size; polynuclear neutrophyles, having nuclei sur- 
rounded by a number of granules which stain with neutral 
dyes, the nuclei usually taking the form of the letters Z, W., 
etc.; eosinophyles, having a nucleus which takes a basic stain 
and is surrounded by a number of granules that take acid stain 
like eosin; and lastly a variety styled basophylic because of 3 
its taking up the base dyes. In disease we may frequently 
find five kinds of red cells, the plain or normal red cell; a cell 
the same size as the normal, called normoblast, but containing 
a nucleus which stains deeply throughout; a red cell larger 
than normal, megaloblast, containing a nucleus as large as a 
red cell and the nucleus staining pale and taking on several 
different shades; the microblast, a cell smaller than normal, 
usually frayed out along the edges and containing a nucleus 
large for size of cell; the malarial cell with its many changes; 
and the irregularly sized and fantastic formed cells, such as 
are met with in pernicious anemia. So also in pathological 
blood, we find new kinds of white corpuscles, notably the my- 
elocyte, a spherical cell larger than a red cell and having a 
larger nucleus, which stains pale and is surrounded by neu- 
trophylic granules, and a second form of cell which resembles 
the myelocyte, except that the granules take eosin. Nor- 
mally the blood contains 5,500,000 red blood corpuscles in a 
cmm. in the male, and about a million less in the female. 
These numbers vary much in disease, being increased a mill- 
ion or more in Asiatic cholera, after diarrhea, or profuse sweat- 
ing, and has been known to be decreased to 143,000 in some 
forms of pernicious anemia. The average number of white 
cells per cmm. is 7,000, about one white to 714 red, though 
the ratio has been known to have been reduced to 1:1, and 
Osier has recorded a case in which even a greater ratio existed. 
The greatest number observed has been 114,000 per cmm. 
In health the proportion of kinds of white cells is definite, 
while in disease it varies and thus becomes a valuable aid to- 
diagnosis. The ratio in health is : 
Polynuclear neutrophyles 60-75% 
Lymphocytes 20-30 
Large mono-leucocytes and transitional forms 6 
Eosiniphiles 2- 4 
Basophyles 1 
Normally the number of blood plates varies from 200,000 to 
300,000. They are increased in lukemia and severe anemia, 
diminished or absent in pupura, hemophilia and malaria dur- 4 
ing fever. Blood for examination is best obtained by puncture 
of a finger or a lobe of an ear, preferably the latter, as the 
blood flows more freely; the puncture causes less pain and the 
operation is not observed and consequently less resisted. I 
find that the best instrument to use is a sharp, three-cornered 
needle. The lobe is washed with soap and water, alcohol or 
ether, to get rid of whatever of dead epithelium, dirt, and oil 
may be present and is then rubbed dry. The needle is 
plunged in with a quick motion, thereby causing less pain 
and allowing a better flow of blood. Some sterilize the needle 
in a flame before each puncture, but you may use your pleas- 
ure about that. I follow the practice of the Massachusetts 
General Hospital, and just clean mine off, and have never 
had a bad result, and the same has been the case with over 
10,000 examinations in the above stated hospital. Perhaps 
the reason for the lack of infection is, as Cabot says, because 
the first two or three drops are always wiped away, and the 
specimen taken from the drops that follow. Care must be ex- 
ercised that the blood is not squeezed out of the puncture, 
but rather that it flows out itself, as otherwise the specimen 
would not be a fair one, containing, as it would, more liquid 
constituents than solid. The best time to take the specimen 
is near meal-time, preferably before breakfast, as physiologi- 
cal leucocytosis takes place soon after meals, and it has been 
found that the blood will be found in its average condition at 
the above stated time. 
If the corpuscles are to be counted, the blood is sucked up 
from the exuding drop, and the Thoma-Zeiss pipette filled to 
exactly the proper point and the correct dilution made, and 
from this dilution the counting cell filled. Let me warn you 
here of the necessity of having all instruments scrupulously 
clean, and to use the greatest care to accurately follow direc- 
tions, as even a very small mistake will amount to a great deal 
in the aggregate, and either confuse or render the whole work 
unreliable and useless. 
If it is desirous to examine a specimen of fresh blood a 5 
clean cover-glass is dropped face down upon a clean slide, 
when the blood will spread out in an even film and be ready 
for examination. That the blood may spread evenly, slide 
and cover-glass must be perfectly clean. I have tried the 
usual methods of cleaning slides and covers, and find that none 
succeed as well as soap and water to wash them with, and a 
clean soft rag to wipe them good and dry. Then this method 
has the advantage of always having the necessary material at 
hand. It is best to handle cover-glasses with forceps, as the 
moisture from the hand would alter a specimen or prevent a 
good film. If it is desirous to observe a fresh specimen for 
some time, as in the case of malarial blood, it is advisable to 
paint a thin coat of vaseline around the edge of the cover- 
glass to prevent the drying of the specimen and to get rid of 
the blood currents formed in drying blood. Again, specimens 
should be examined in a warm room, otherwise it would be 
necessary to use some form of warm stage. 
The examination of fresh blood is the best known way to 
ascertain the presence of and study the filaria sanguinis liorn- 
inis, plasmodium malariae, spirochete of relapsing fever and 
the rouleux forms of red cells, and to one skilled in blood ex- 
amination many of the facts that otherwise could be told only 
by the more laborious method of fixing and staining can be 
told with sufficient accuracy at a glance. 
When it is desirous to make permanent specimens or study 
the effects of stains, it is first necessary to spread a thin film 
of blood upon cover-glass or slide and fix it there. The film 
is spread by touching clean cover-glass to the drop of blood, 
then dropping another clean cover-glass upon the first one, 
allowing the blood to spread out between them by capillary at- 
traction and then sliding the cover-glasses carefully apart. 
The bottom one usually contains the best specimen. A thin 
film over a large surface may be obtained by taking the tissue 
paper in strips about the width of a slide, touching the paper 
to the exuding drop of blood, placing the charged surface of 
the paper near one, and gently drawing the paper to the other 6 
end of the slide, when a uniform film will be found upon the 
slide. 
For fixing and hardening, immersing the specimen fora few 
moments in equal parts of alcohol and ether is a favorite 
method, yet I find that we get better results if we leave the 
specimen in the solution an hour or so. Heating specimen to 
110 C. has its advocates, and there are many methods and ap- 
paratus proposed to accomplish this. 1 prefer about a 1 per 
cent, solution of formaline in alcohol, which has the advan- 
tages of being quick and as good as the best. 
I shall not burden you with the technique of blood-count- 
ing, hemoglobin estimation and formulae for the different 
kinds of stains, etc., as all of that can be found in any good 
book treating of the blood. Suffice to say that the Thoma- 
Zeiss instrument still holds its own as the best blood counter 
in spite of the much lauded hematocrit. The chief defect of 
the hematocrit is the fact that variations in size or shape of 
corpuscles will cause difference in packing of cells in tube, 
and since number is estimated by bulk, it is evident that it 
would be grossly inaccurate in many cases in which accuracy 
would be essential for diagnosis. Then the inability to tell in 
many cases just where the red cells end and the white begin, 
or where the white end or begin, deprives it of that accuracy 
which we would wish to have. I do not mean to have you 
believe that the Thoma-Zeiss instrument is free from defects, 
yet, with a given observer, be he skilled or otherwise, the 
chances of error are greater with the hematocrit. 
The instrument most used to estimate hemoglobin is 
Fleischl’s. Its success depends upon one’s ability to match 
colors. Color-matching is not easy at its best, and one has 
but to try it with one’s friends to see how few have a sensitive- 
ness for shades. How much greater then is the chance of 
inaccuracy when one has to match a liquid in one-half a cell 
with their rays of light transmitted through water, and a 
prism of Cassius purple of a progressive depth of shade. A 
difference of twenty degrees of color exists between the ex- 7 
tremes of the part of the prism exposed through the cell and 
that tends to complicate matters. For the above stated reasons 
I prefer to use the simpler and more available method of 
Hammerslag. The apparatus necessary is an urinometer, 
urinometer glass and a dropper. The urinometer glass having 
been previously washed and dried is partly filled with a mix- 
ture of chloroform and benzol in such proportions that the 
mixture has a specific gravity o-f 1059. A drop of blood from 
a fresh puncture is drawn up into the dropper and then forced 
out into the mixture. The blood will not mix with the chloro- 
form benzol mixture, but will still maintain its globular form 
and sink, float, or rest at ease at some depth in the mixture as- 
cording to whether the specific gravity of the drop is equal to 
or higher or lower than the mixture. If it rises to the top, 
benzol is added; if it sinks to the bottom, choloroform is added, 
until the drop comes at rest somewhere near the center of 
the mixture. Then the specific gravity of the mixture is 
taken, and by referring to a table the hemoglobin is esti- 
mated. The specific gravity of the blood plasma varies very 
little from any cause except in dropsy, and in the corpuscles 
themselves the variable element is the hemoglobin, conse- 
quently in most non-dropsical patients the specific gravity of 
the whole blood varies as directly as the hemoglobin. Spe- 
cific gravity of 1030 is equal to 25 per cent., and 1059 to 100 
per cent. 
I shall not attempt to go into the chemistry of blood testing, 
its alkalinity, amount of gases, etc., as such examinations 
are poor at their best and are of no aid to diagnosis. Natur- 
ally, the first disease that my paper would bring to your mind 
is anemia and chlorosis, and rightly, too, as no little of the 
diagnosis and prognosis can be told from a blood examination. 
Anemia is a diminution in red blood corpuscles, hemoglobin, 
or both, and is independent of color of skin or mucous mem- 
brane. The greater number of times it is impossible to tell 
pernicious anemia from chlorosis except by examination of 
blood. In the former you nearly always have decrease in 8 
number of cells and a greater alteration, decrease or increase 
in size and form of red corpuscles, the color value being high, 
while in chlorosis you may have decrease in red cells, but the 
principal thing is lack of cell-hemoglobin or color value. 
Then you may have megaloblasts in chlorosis, but normo- 
blasts are greater, while reverse is true in anemia. True, you 
may have diminished red cells in malignant disease, but then 
you nearly always have leucocytosis which will help to distin- 
guish; then normoblasts predominate in malignant diseases; 
megaloblasts in anemia. Those diseases which do not cause 
leucocytosis, but lessen corpuscles, do not have megaloblasts or 
high color value, and leukemia can always be told on account 
of the great number myelocytes. In anemia search carefully 
for nucleated corpuscles, for if any be present they will aid 
much in prognosis. Megaloblasts and no other nucleated 
forms is a bad sign. It is the kind of nucleated corpuscles 
and not number that is of interest, the ratio of megalo to nor- 
moblasts that is important. Low color index and normal cells 
show improvement at the time; high color index is a bad sign. 
In leukemia the red cells are slightly diminished, the white 
markedly increased. About 30 per cent, of the white cells are 
myelocytes, and in lymphatic forms 90 per cent, are lympho- 
cytes. Leukemia is distinguished from Hodgkin’s disease, 
which has the same symptoms, by the blood being normal in 
early stages of the latter disease, and in the latter stages not 
more than a slight anemia existing. 
It is possible to diagnose shock of hemorrhage from concus- 
sion or compression by blood count, there being a marked de- 
crease in red corpuscles in the former and none in the latter. 
In the same way internal hemorrhage can be told from peri- 
tonitis or obstruction, and the advisability of an operation 
after loss of blood can be safely told by estimation of hemo- 
globin, a per cent, lower than thirty being a contra indication. 
Again, it is possible to tell if one’s patient has been in re- 
ality fasting by making a blood count when, if it is so, there 
will be a marked decrease in leucocytes, but it must be borne 9 
in mind that diseases of the stomach and small intestines may 
prevent leucocytosis. Then it must be remembered that 
pregnancy, violent exercise, cold baths and massage may 
cause leucocytosis; but in each of these cases the proportion 
of white cells remains about the same, only that the number is 
increased. In disease we may expect leucocytosis after hemor- 
rhage, with malignant disease and inflammation ; and an ab- 
sence with measles, malaria, typhoid fever and all forms of 
tuberculosis. 
Typhoid fever is easily told by Widal’s method or John- 
son’s modification. Diagnosis depends upon the fact that 
blood or blood serum from a patient with typhoid will cause a 
drop of actively motile typhoid bacilli to cease motion and 
clump. Positive results are not always obtained, but nearly 
always so. Acuteness or mildness of attack does not seem to 
have any appreciable difference on the clumping. Johnson’s 
method consists in collecting a specimen of blood on a steril- 
ized paper and allowing it to dry, thus permitting of transpor- 
tation, a great factor for municipal laboratory work. The 
dried blood is dissolved in a few drops of sterilized water, and 
a small portion of the solution added to a drop of bouillon con- 
taining actively motile bacilli typhosis. To make a success of 
it, it is necessary to have a pure, fresh culture of typhoid, and 
it has been observed that an attenuated culture works better 
than a more virulent one. The time necessary for the speci- 
men to cause clumping should not exceed thirty minutes, and 
this clumping does not seem to be a killing of the bacilli, but 
just a paralyzing. It is said that this clumping can not be 
caused by any other disease, yet it is quite necessary that the 
serum or blood should be considerably diluted, as it has been 
observed that sometimes healthy serum undiluted would cause 
this phenomenon, while only diluted typhoid blood would pro- 
duce the reaction. 
During the meeting of the state sanitarians last week in In- 
dianapolis the press stated that this reaction does not occur 
with blood taken from a negro having typhoid. This state- 10 
ment is erroneous, as I shall demonstrate to-day. I have 
made a critical study of nine cases of typhoid in the negro and 
got the reaction from each of them, as did also Dr. Reed, 
pathologist to the Army Medical Museum, Washington, to 
whom I submitted samples for verification. I have also ex- 
amined the blood of a number of negroes suffering with differ- 
ent diseases, and in health, and failed to get the reaction in 
any case, so I am led to believe that the blood of the negro 
will react as often and with the same degree of certainty as 
that of other races. 
Pneumonia is distinguished from typhoid, malaria, or plain 
la grippe when symptoms are present and no physical signs, 
by the marked leucocytosis of the former. There is no means 
of diagnosing pneumonia from capillary bronchitis. In pneu- 
monia there is always a marked fibrin network. So far as 
prognosis goes, the absence of leucocytosis is always an un- 
favorable sign, while its presence leaves the matter in doubt, 
though favorable for recovery. Hare says leucocytosis is 
checked by antipyretics, but not by cold bathing, but 1 won- 
der how many of us heed that. 
Blood examinations are of no value in diagnosis of diph- 
theria. Cabot claims that in prognosis absence of leucocytes 
except in mild cases, and the presence of myelocytes is un- 
favorable. 
Septicemia can be diagnosed by bacteriological examination 
of blood. Rheumatism can not be told, and no particular 
light is shed by examination. La grippe, according to Can- 
non, can be diagnosed by finding the specific micro-organism 
in stained specimen of blood. 
Scarlet fever is distinguished from measles in that the latter 
never has leucocytosis while the former always has. In 
scarlet fever eosiniphiles are absent in bad cases, and in- 
creased in favorable cases, and the same rule holds good for 
post-scarlatinal nephritis. 
Appendicitis can not be told from pus-tube by examination 
of the blood, but can be told from colic, constipation, floating 11 
kidney, ovarian or pelvic neuralgia, gall stone and renal colic 
if uncomplicated, because of the leucocytosis in the former 
and lack of it in all the other cases. 
Cholera can be diagnosed in much the same way as typhoid 
fever, with the added fact that the alkalinity of the blood is 
markedly decreased and with death becomes acid. In peri- 
tonitis we have marked leucocytosis and increase in fibrine 
net-work, but there is no leucocytosis in tubercular peritonitis 
and it may thus be diagnosed. Pericarditis with effusion can 
be told from hypertrophy or dilatation on account of the 
marked leucocytosis in the former case. In meningitis you 
always have leucocytosis, while in no other form of inter- 
cranial disease except abscess and apoplexy do you have this 
phenomenon. On account of the always present leucocytosis 
meningitis can be told from typhoid, which it simulates, but 
could not be told by blood examination from pneumonia. 
Justus claims to be abletodiagnose syphilis before the second- 
ary symptoms have appeared. He first estimates the per cent, 
of hemoglobin, then gives innunction or injection of mercury, 
and finds that the hemoglobin falls from 10 to 20 per cent, in 
a day, which he attributes to the action of the mercury on the 
weaker blood cells. After a few days, this marked diminution 
is followed by a gradual rise and soon the per cent, of hemo- 
globin is higher than it was before. He states that syphilis is 
the only disease in which the facts stated occur. Blood ex- 
aminations otherwise are negative, except so far as diagnosing 
the severity of the affection. Large numbers of young white 
cells and small per cent, of hemoglobin are indicative of se- 
vere cases. Cases having myelocytes are serious, while we 
look for leucocytosis after the primary stage. 
In asthma, we have a marked increase in eosinophyles just 
prior or subsequent to attack. Schriber distinguishes bron- 
chial from cardiac or renal asthma by increase in eosoniphyles. 
According to Bremmer, of St. Louis, it is possible to diag- 
nose diabetes by blood examination long before it could other- 
wise be told. His method is very simple. He heats two blood 12 
films, one normal and the other of suspected blood, in a hot 
air sterilizer for six or seven minutes at temperature of 13a0C. 
He then allows specimen to cool, and when cold he exposes 
the two to a 1 per cent, aqueous solution of Congo red or 
methyl blue for two minutes, when the normal blood will be 
stained red or blue, and the other if diabetic will resist the 
action of the stain. Then there is the Williamson method, 
which depends upon the power of diabetic blood to remove the 
blue color from a solution of methyl blue. The reaction is said 
to be so sensitive that it only requires a very small quantity of 
blood. Certain proportions of blood and a warm alkaline so- 
lution of methyl blue are mixed together, the blue color is re- 
moved in the case of diabetic blood, but remains when non- 
diabetic blood is used. In purpura hemoragica, hemophilia 
and scurvy, diseases in which you would expect to find a great 
deal from a blood examination, there is little or no character- 
istic change. 
In examining the blood for malaria it is best to take the 
specimen before or after the chill, as then the plasmodium is 
larger and pigmented. I prefer to study the suspected blood 
when fresh, and if I find the plasmodium it is always a matter 
of pleasure to watch it assume some of its many forms. I do 
not think that it takes much skill to find the plasmodium, 
provided you know what you are looking for and are patient 
and painstaking, and once you find it, it will be quite easy in 
the future to recognize it. Staining, though, has its advan- 
tages, as it is thus easier to see the organism; one can examine 
it at one’s leisure, and there is not the danger of confusing the 
plasmodium with other things found in the blood. The best 
stain to use is Phlen’s, which is a combination of methylene 
blue and eosin soluble in alcohol, though single staining with 
methylene blue will do. In either case the blue stains tbe 
plasmodium itself, and when eosin is used the corpuscle sub- 
stance is stained pink. In all cases of suspected malaria, 
the blood should be examined, as clinical symptoms alone 
often warrant a diagnosis of malaria when tuberculosis, svph- 13 
ilis, septic infection, or something else, is the true cause of 
symptoms. Those who have examined blood often will bear 
me out in the statement just made, as they will also testify to 
the number of instances in which more serious maladies have 
been diagnosed when blood examination would prove the affec- 
tion to be malaria. The plasmodium is always found in mal- 
aria, and should one fail to find it in one examination try 
again, if the malarial symptoms persist, but if the patient tells 
you that he has been taking quinine for some days or only 
has taken a few doses, then do not wonder if you fail to find 
the plasmodium, as quinine is a specific and soon rids the 
blood of the micro-organisms. 
Filaria in the blood is rare, yet we have had a case in this 
state, in the practice of Dr. F. B. Wynn, of Indianapolis, re- 
ported in a recent issue of the Indiana Medical Journal. The 
queer thing about the parasite is that it never gets in the pe- 
ripheral circulation until the host is asleep, so, to get a speci- 
men of it, it is always necessar}'- to take the blood of the patient 
while asleep or immediately after waking. Every one is fa- 
miliar with the angle-worm-like picture of the filaria, and I am 
sure you would recognize it if you saw it. In pelvic abscess 
we have leucocytosis, while in pure pelvic pain, soreness, en- 
dometritis and cystitis, there is no leucocytosis. Osteomye- 
litis in connection with the symptoms may be distinguished 
from other affections which might cause the same train of 
symptoms by the marked leucocytosis in the former case. 
Pleurisy may be diagnosed from empyema, pneumonia and 
malignant lung trouble ; and cyst of the kidney, from peri- 
nephritic abscess, by the absence of leucocytosis. 
Diagnosis of malignant disease is said by some to be made 
by blood examination. I have had little encouragement from 
such examinations, either so far as diagnosis or prognosis is 
concerned. Cabot gives the following notes for the diagnosis 
of malignant disease: 
1. When we are dealing with an obscure, deep-seated dis- 
ease, if hemorrhage is excluded, the presence of persistent 14 
leucocytosis suggests suppuration or malignant disease ( rather 
than tuberculosis or syphilis for example), and excludes any 
simply functional or hysterical affection. The absence of leu- 
cocytosis, however, does not exclude malignant disease, though 
it makes suppuration very unlikely. 
2. Between malignant disease and suppuration, if the other 
signs and symptoms do not decide, there may be nothing in the 
blood to decide. In decided pyemia we may get pyogenic cocci 
from the blood by culture, but a negative result would exclude 
the suppurating focus. The absence of any increase of fibrin 
in the blood speaks against suppuration and therefore in favor 
of malignant disease, but the presence of increased fibrin net- 
work is not decisive either way, as it may be met with in con- 
nection with neoplasm, though more commonly in suppura- 
tion. 
3. Between malignant disease and hemorrhage a marked 
anemia favors the latter, provided the case is a recent one, for 
the anemia of malignant disease is comparatively slow to de- 
velop. The leucocytes give no help. 
4. Between cancer and ulcer of the stomach, if there has 
been a recent hemorrhage, leucocytosis favors cancer, but its 
absence is of no weight either way. 
5. Hemoglobin decreases steadily in cancer, while in ulcer 
it tends to return toward normal after the cessation of hemorr- 
hage. 
6. The presence and persistence of digestion leucocytosis 
speaks against cancer and its absence in favor of cancer. 
7. Between cancer of the liver or bile ducts on the one 
hand, and simple gall stones, colic or obstruction, the pres- 
ence of leucocytosis favors cancer. 
8. The appearance in the blood of large numbers of eosini- 
philes, myelocytes and nucleated corpuscles, during the course 
of a malignant disease, points to bone methastasis. 
9. When leucocytosis, which has disappeared after removal 
of a neoplasm, reappears, we may expect a recurrence of the 
growth shortly. 15 
10. A steady increasing leucocytosis in a case of malignant 
disease points to a rapid growing tumor or the occurrence of 
metastesis. 
11. Between malignant disease and pernicious anemia, the 
diagnosis rests on the following points: 
a. Color index, low in malignant, apt to be high in per- 
nicious anemia. 
b. Leucocytes, increased in malignant, diminished in per- 
nicious anemia. 
c. Average size of red cells often decreased in malignant 
and often increased in anemia. 
d. If nucleated red corpuscles are present, normoblasts are 
in majority in malignant disease and minority in pernicious 
anemia. 
f. The presence of leucocytosis is against the benignancy of 
any tumor. 
Holmes, of Denver, claims to be able to diagnose tubercu- 
losis in its earliest stages by blood examination, even when it 
is impossible to tell it either by physical signs or sputum ex- 
amination. I am in hopes that his dubious assertions may 
stand the test of time, for if we are to do anything with that 
greatest of devastating disease we must do it in its incipiency. 
In most cases, after the germs are discoverable in the 
sputum, and there can be no doubt of the infection, the only 
thing that seems to check their growth is the death of the 
host. Holmes bases his theory upon the assertion that each 
individual has a biological prototype in the leucocytes of his 
own blood. He further claims the following characteristics 
of tubercular blood : Marked deviation from normal percent- 
age of all varieties of leucocytes; great decrease in percentage 
of small lymphocytes ; usually a marked increase in percent- 
age of large lymphocytes ; many giant lymphocytes, with 
irregular contour and protruding globules of hyaloplasm ; 
eosiniphile cells, absent or few in number, only in severe 
cases; myelocytes occasionally present; marked cell disinte- 
gration ; many groups of debris from disintegrating leuco- 16 
cytes ; phagocytes, with indistinct cell contour and granules 
few in number, poorly stained and scattering ; marked irreg- 
ularity in size and appearance of phagocytes, dwarf phagocytes 
as small as small lymphocytes, giant phagocytes double usual 
size, with five or more nuclei; often a clear, narrow and 
sharply-defined ring separating the nucleus from the cell 
body in small and large lymphocytes; phagocytes, with gran- 
ules taking a basophylic tint, evidence of approaching dissolu- 
tion ; grouping together of a large number of phagocytes ob- 
served before dissolution; very little disintegration of red 
cells. Holmes’ views have not attracted as much attention 
among scientific physicians as they have among the laity and 
secular newspapers. 
Finally the examination of blood in post-operative tempera- 
ture is of value to determine if pus is present, as with pus 
there is always leucocytosis, and absence of leucocytosis in 
suspected appendicitis should make one hesitate about oper- 
ating. 
I have attempted to give some of the ways in which blood 
examinations may aid in diagnosis. Any one of the subjects 
mentioned would be sufficient for a paper, so I hope you will 
pardon me for the briefness with which I have touched on 
each disease, yet I have attempted to give the essential facts 
and hope that my paper may arouse sufficient interest to in- 
dicate how much of valuable assistance blood examinations 
may give, particularly in obscure cases. 
New 132 W. New York Street.