Blood

Blood, the circulating fluid in the veins and arteries of animals. The word itself is common to Teutonic languages; the O. Eng. is blód, cf. Gothic bloth, Dutch bloed, Ger. Blut. It is probably ultimately connected with the root which appears in “blow,” “bloom,” meaning flourishing or vigorous. The Gr. word for blood, αἷμα, appears as a prefix haemo- in many compound words. As that on which the life depends, as the supposed seat of the passions and emotions, and as that part which a child is believed chiefly to inherit from its parents, the word “blood” is used in many figurative and transferred senses; thus “to have his blood,” “to fire the blood,” “cold blood,” “blood-royal,” “half” or “whole blood,” &c. The expression “blue blood” is from the Spanish sangre azul. The nobles of Castile claimed to be free from all admixture with the darker blood of Moors or Jews, a proof being supposed to lie in the blue veins that showed in their fairer skins. The common English expletive “bloody,” used as an adjective or adverb, has been given many fanciful origins; it has been supposed to be a contraction of “by our Lady,” or an adaptation of the oath common during the 17th century, “’sblood,” a contraction of “God’s blood.” The exact origin of the expression is not quite clear, but it is certainly merely an application of the adjective formed from “blood.” The New English Dictionary suggests that it refers to the use of “blood” for a young rowdy of aristocratic birth, which was common at the end of the 17th century, and later became synonymous with “dandy,” “buck,” &c.; “bloody drunk” meant therefore “drunk as a blood,” “drunk as a lord.” The expression came into common colloquial use as a mere intensive, and was so used till the middle of the 18th century. There can be little doubt that the use of the word has been considerably affected by the idea of blood as the vital principle, and therefore something strong, vigorous, and parallel as an intensive epithet with such expressions as “thundering,” “awfully” and the like.

Anatomy and Physiology

In all living organisms, except the most minute, only a minimum number of cells can come into immediate contact with the general world, whence is to be drawn the food supply for the whole organism. Hence those cells—and they are by far the most numerous—which do not lie on the food-absorbing surface, must gain their nutriment by some indirect means. Further, each living cell produces waste products whose accumulation would speedily prove injurious to the cell, hence they must be constantly removed from its immediate neighbourhood and indeed from the organism as a whole. In this instance again, only a few cells can lie on a surface whence such materials can be directly discharged to the exterior. Hence the main number of the cells of the organism must depend upon some mechanism by which the waste products can be carried away from them to that group of cells whose duty it is to modify them, or discharge them from the body. These two ends are attained by the aid of a circulating fluid, a fluid which is constantly flowing past every cell of the body. From it the cells extract the food materials they require for their sustenance, and into it they discharge the waste materials resulting from their activity. This circulating medium is the blood.

Whilst undoubtedly the two functions of this circulating fluid above given are the more prominent, there are yet others of great importance. For instance, it is known that many tissues as a result of their activity produce certain chemical substances which are of essential importance to the life of other tissue cells. These substances—internal secretions as they are termed—are carried to the second tissue by the blood stream. Again, many instances are known in which two distant tissues communicate with one another by means of chemical messengers, bodies termed hormones (ὁρμάειν, to stir up), which are produced by one group of cells, and sent to the other group to excite them to activity. Here, also, the path by which such messengers travel is the blood stream. A further and most important manner in which the circulating fluid is utilized in the life of an animal is seen in the way in which it is employed in protecting the body should it be invaded by micro-organisms.

Hence it is clear that the blood is of the most vital importance to the healthy life of the body. But the fact that it is present as a circulating medium exposes the animal to a great danger, viz. that it may be lost should any vessel carrying it become ruptured. This is constantly liable to happen, but to minimize as far as possible any such loss, the blood is endowed with the peculiar property of clotting, i.e. of setting to a solid or stiff jelly by means of which the orifices of the torn vessels become plugged and the bleeding stayed.

The performance of these essential functions depends upon the maintenance of a continuous flow past all tissue cells, and this is attained by the circulatory mechanism, consisting of a central pump, the heart, and a system of ramifying tubes, the arteries, through which the blood is forced from the heart to every tissue (see Vascular System). A second set of tubes, the veins, collects the blood and returns it to the heart. In many invertebrates the circulating fluid is actually poured into the tissue spaces from the open terminals of the arteries. From these spaces it is in turn drained away by the veins. Such a system is termed a haemolymph system and the circulating fluid the haemolymph. Here the essential point gained is that the fluid is brought into direct contact with the tissue cells. In all vertebrates, the ends of the arteries are united to the commencements of the veins by a plexus of extremely minute tubes, the capillaries, consequently the blood is always retained within closed tubes and never comes into contact with the tissue cells. It is while passing through the capillaries that the blood performs its work; here the blood stream is at its slowest and is brought nearest to the tissue cell, only being separated from it by the extremely thin wall of the capillary and by an equally thin layer of fluid. Through this narrow barrier the interchanges between cell and blood take place.

The advantage gained in the vertebrate animal by retaining the blood in a closed system of tubes lies in the great diminution of resistance to the flow of blood, and the consequent great increase in rate of flow past the tissue cells. Hence any food stuffs which can travel quickly through the capillary wall to the tissue cell outside can be supplied in proportionately greater quantity within a given time, without requiring any very great increase in the concentration of that substance in the blood. Conversely, any highly diffusible substance may be withdrawn from the tissues by the blood at a similarly increased pace. These conditions are more peculiarly of importance for the supply of oxygen and the removal of carbonic acid-especially for the former, because the amount of it which can be carried by the blood is small. But as the rate at which a tissue lives, i.e. its activity, depends upon the rate of its chemical reactions, and as these are fundamentally oxidative, the more rapidly oxygen is carried to a tissue the more rapidly it can live, and the greater the amount of work it can perform within a given time. The rate of supply is of much less importance in the case of the other food substances because they are far more soluble in water, so that the supply in sufficient quantity can easily be met by a relatively slow blood flow. Hence we find that the gradual evolution of the animal kingdom goes hand in hand with the gradual development of a greater oxygen-carrying capacity of the blood and an increase in the rate of its flow.

In the groundwork of a tissue are a number of spaces—the tissue spaces. They are filled with fluid and intercommunicate freely, finally connecting with a number of fine tubes, the lymphatics, through which excess of fluid or any solid particles present are drained away. The contained fluid acts as an intermediary between the blood and the cell; from it, the cell takes its various food stuffs, these having in the first instance been derived from the blood, and into it the cell discharges its waste products. On the course of the lymphatics a number of typical structures, the lymphatic glands, are placed, and the lymph has to pass through these structures where any deleterious products are retained, and the fluid thus purified is drained away by further lymphatics and finally returned to the blood. Thus there is a second stream of fluid from the tissues, but one vastly slower than that of the blood. The flow is too slow for it to act as the vehicle for the removal of those waste products (carbonic acid, &c.) which must of necessity be removed quickly. These must be removed by the blood. The same is true for the main number of other waste products, which, however, being of small molecular size are readily absorbed into the blood stream.

But in addition to fluid, the tissue spaces may at times be found to contain solid matter in the form of particles, which may represent the debris of destroyed cells, or which are, as is quite commonly the case, micro-organisms. Apparently such material cannot be removed from a tissue by absorption into the blood stream—indeed in the case of living organisms such an absorption would in many instances rapidly prove fatal, and special provision is made to prevent such an accident. These, therefore, are made to travel along the lymphatic channels, and so, before gaining access to the blood stream and thus to the body generally, have to run the gauntlet of the protective mechanism provided by the lymphatic glands, where in the major number of cases they are readily destroyed.

Hence we see that first and foremost we have to regard the blood as a food-carrier to all the cells of the body; in the second place as the vehicle carrying away most if not all the waste products; in a third direction, it is acting as a means for transmitting chemical substances manufactured in one tissue to distant cells of the body for whose nutrition or excitation they may be essential; and in addition to these important functions there is yet another whose value it is almost impossible to overestimate, for it plays the essential rôle in rendering the animal immune to the attacks of invading organisms. The question of immunity is discussed elsewhere, and it is sufficient merely to indicate the chief means by which the blood subserves this essential protective mechanism. Should living organisms find their way into the surface cells or within the tissue spaces, the body fights them in a number of ways, (1) It may produce one or more chemical substances capable of neutralizing the toxic material produced by the organism. (2) It may produce chemical substances which act as poisons to the micro-organism, either paralysing it or actually killing it. Or (3) the organism may be attacked and taken up into the body of wandering cells, e.g. certain of the leucocytes, and then digested by them. Such cells are therefore called phagocytes (φάγειν, to eat). Thus, by its power of reacting in these ways the body has become capable of withstanding the attacks of many different varieties of micro-organisms, of both animal and vegetable origin.

General Properties.—Blood is an opaque, viscid liquid of bright red colour possessing a distinct and characteristic odour, especially when warm. Its opacity is due to the presence of a very large number of solid particles, the blood corpuscles, having a higher refractive index than that of the liquid in which they float. The specific gravity in man averages about 1.055. The specific gravity of the liquid portion, the plasma (Gr. πλάσμα, something formed or moulded, πλάσσειν, to mould), is about 1.027, whilst that of the corpuscles amounts to 1.088. To litmus it reacts as a weak alkali.

Blood Plasma.—The plasma is a solution in water of a varied number of substances, and as a solvent it confers on the blood its power of acting as a carrier of food stuffs and waste products. One important food substance, oxygen, is, however, only partly carried in solution, being mainly combined with haemoglobin in the red corpuscles. The food stuffs carried by the plasma are proteins, carbohydrates, salts and water. The main waste products dissolved in it are ammonium carbonate, urea, urates, xanthin bases, creatin and small amounts of other nitrogenous bodies, carbonic acid as carbonates, other carbon compounds such as cholesterin, lecithin and a number of other substances. Thus, if we take mammalian blood as a type, the plasma would have the following approximate composition:—

Proteins.—The proteins of the blood plasma belong to the two classes of the albumins and the globulins. The globulins present are named fibrinogen and serum-globulin; as its name implies, the chief physiological property of fibrinogen is that it can give rise to fibrin, the solid substance formed when blood clots. It possesses the typical properties of a globulin, i.e. it coagulates on heating (in this instance at a temperature of 56°C.), and is precipitated by half saturating its solution with ammonium sulphate. It differs from other globulins in that it is less soluble. It is only present in very small quantities, 0.4%. The other globulin, serum-globulin, is not coagulated until 75°C. is reached, and we now know that it is in reality a mixture of several proteins, but so far these have not been completely separated from one another and obtained in a pure form. On dialysing a solution of serum-globulin a part is precipitated, and this portion has been termed the eu-globulin fraction, the remainder being known, in contradistinction, as the pseudo-globulin. Again, on diluting a solution and adding a small amount of acetic acid a precipitate is formed which in some respects differs from the remainder of the globulin present. Whether in these two instances we are dealing with approximately pure substances is extremely doubtful. A further important point in connexion with the chemistry of the globulins is that dextrose may be found among their decomposition products, i.e. that a part of it, or possibly the whole, possesses a glucoside character.

Serum-albumin gives all the typical colour and precipitation reactions of the albumins. If plasma be weakly acidified with sulphuric acid, then treated with crystals of ammonium sulphate until a slight precipitate forms, filtered and the filtrate allowed to evaporate very slowly, typical crystals of serum-albumin may form. According to many it is a uniform and specific substance, but others hold the view that it consists of at least three distinct substances, as shown by the fact that if a solution be gradually heated coagulation will occur at three different temperatures, viz. at 73°, 77° and 84° C. On the other hand the close agreement between different analyses of even the amorphous preparations points to there being but one serum-albumin.

When blood clots two new proteins make their appearance in the fluid part of the blood, or serum, as it is now called. The first of these is fibrin ferment (for its origin see section on Clotting below). The other, fibrinoglobulin, possesses all the typical characteristics of the globulins and coagulates at 64° C.

Carbohydrates.—Three several carbohydrates are described as occurring in plasma, viz. glycogen, animal gum and dextrose. If glycogen is present in solution in the plasma it is there in very small quantities only, and has probably arisen from the destruction of the white blood corpuscles, since some leucocytes undoubtedly contain glycogen. A small amount of carbohydrate having the formula for starch and yielding a reducing sugar on hydrolysis with acid has also been described. The constant carbohydrate constituent of plasma, however, is dextrose. This is present to the approximate amount of 0.15% in arterial blood. The amount may be much greater in the blood of the portal vein during carbohydrate absorption, and according to some observers there is less in venous than in arterial blood, but the difference is small and falls within the error of observation. The statement that when no absorption is taking place the blood of the hepatic vein is richer in dextrose than that of the portal vein (Bernard) is denied by Pavy.

Fats.—Plasma or serum is as a rule quite clear, but after a meal rich in fats it may become quite milky owing to the presence of neutral fats in a very fine state of subdivision. This suspended fat rapidly disappears from the blood after fat absorption has ceased. To some extent it varies in composition with that of the fat absorbed, but usually consists of the glycerides of the common fatty acids—palmitic, stearic and oleic. In addition, there is a small amount of fatty acid in solution in the plasma. As to the form in which this occurs there is some uncertainty. It is possibly present as a soap or even as a neutral fat, since a little can be dissolved in plasma, the solvent substance being probably protein or cholesterin. Fatty acids also appear to be present to some extent combined with cholesterin forming cholesterin esters (about 0.06%).

Other Organic Compounds.—In addition to the substances above described, belonging to the three main classes of food stuffs, there are still other organic bodies present in plasma in small amounts, which for convenience we may classify as non-nitrogenous and nitrogenous. Among the former may be mentioned lactic acid, glycerin, a lipochrome, and probably many other substances of a similar type whose separation has not yet been effected.

The non-protein nitrogenous constituents consist of the following: ammonia as carbonate or carbamate (0.2 to 0.6%), urea (0.02 to 0.05%), creatine, creatinine, uric acid, xanthine, hypoxanthine and occasionally hippuric acid. Three ferments are also described as being present: (1) a glycolytic ferment exerting an action upon dextrose; (2) a lipase or fat-splitting ferment; and (3) a diastase capable of converting starch into sugar.

Salts.—The saline constituents of plasma comprise chlorides, phosphates, carbonates and possibly sulphates, of sodium, potassium, calcium and magnesium. The most abundant metal is sodium and the most abundant acid is hydrochloric. These two are present in sufficient amount to form about 0.65% of sodium chloride. The phosphate is present to about 0.02%. Sulphuric acid is always present if the blood has been calcined for the purposes of the analysis, and may then be present to about 0.013%. This is, however, probably produced during the destruction of the protein, since it has been shown that no sulphate can be removed from normal plasma by dialysis. The amount of potassium present (0.03%) is less than one-tenth of that of the sodium, and the quantities of calcium and magnesium are even less.

Formed Elements.—When viewed under the microscope the main number of these are seen to be small yellow bodies of very uniform size, size and shape varying, however, in different animals. When observed in bulk they have a red colour, their presence in fact giving the typical colour to blood. These are the red blood corpuscles or erythrocytes (Gr. ἐρυθρός, red). Mingled with them in the blood are a smaller number of corpuscles which possess no colour and have therefore been called white blood corpuscles or leucocytes (Gr. λευκός, white). Lastly, there are present a large number of small lens-shaped structures, less in number than the red corpuscles, and much more difficult to distinguish. These are known as blood platelets.

Red Corpuscles.—These are present in very large numbers and, under normal conditions, all possess exactly the same appearance. With rare exceptions their shape is that of a biconcave disk with bevelled edges, the size varying somewhat in different animals, as is seen in the following table which gives their diameters:—

Man	0.0075 mm.
Dog	0.0073 mm.
Rabbit	0.0069 mm.
Cat	0.0065 mm.
Goat	0.0041 mm.

The coloured corpuscles of amphibia as well as of nearly all vertebrates below mammals are biconvex and elliptical. The following are the dimensions of some of the more common:—

Pigeon	0.0147 mm. long by 0.0065 mm. wide.
Frog	0.0223 ”  ”  0.0157 ”  ”
Newt	0.0293 ”  ”  0.0195 ”  ”
Proteus	0.0580 ”  ”  0.0350 ”  ”
Amphiuma	0.0770 ”  ”  0.0460 ”  ”

Their number also varies as follows:—

Man	4,000,000	to  5,000,000 per cub. mm.
Goat	9,000,000	to 10,000,000  ”  ”
Sheep	13,000,000	to 14,000,000  ”  ”
Birds	1,000,000	to  4,000,000  ”  ”
Fish	250,000	to  2,000,000  ”  ”
Frog	500,000	per cub. mm.
Proteus	36,000	”  ”

In mammals they are apparently homogeneous in structure, have no nucleus, but possess a thin envelope. Their specific gravity is distinctly higher than that of the plasma (1.088), so that if clotting has been prevented, blood on standing yields a large deposit which may form as much as half the total volume of the blood.

Chemical Composition.—On destruction the red corpuscles yield two chief proteins, haemoglobin and a nucleo-protein, and a number of other substances similar to those usually obtained on the break-down of any cellular tissue, such for instance as lecithin, cholesterin and inorganic salts. The most important protein is the haemoglobin. To it the corpuscle owes its distinctive property of acting as an oxygen carrier, for it possesses the power of combining chemically with oxygen and of yielding up that same oxygen whenever there is a decrease in the concentration of the oxygen in the solvent. Thus in a given solution of haemoglobin the amount of it which is combined with oxygen depends absolutely on the oxygen concentration. The greatest dissociation of oxyhaemoglobin occurs as the oxygen tension falls from about 40 to 20 mm. of mercury. That the oxygen forms a definite compound with the haemoglobin is proved by the fact that haemoglobin thoroughly saturated with oxygen (oxyhaemoglobin) has a definite absorption spectrum showing two bands between the D and E lines, whilst haemoglobin from which the oxygen has been completely removed only gives one band between those lines. In association with this, oxyhaemoglobin has a typical bright red colour, whereas haemoglobin is dark purple. A further striking characteristic of haemoglobin is that it contains iron in its molecule. The amount present, though small bears a perfectly definite quantitative relation to the amount of oxygen with which the haemoglobin is capable of combining (two atoms of oxygen to one of iron). One gram of haemoglobin crystals can combine with 1.34 cc. of oxygen. On destruction with an acid or alkali, haemoglobin yields a pigment portion, haematin, and a protein portion, globin, the latter belonging to the group of the histones (Gr. ἱστός, web, tissue). In this cleavage the iron is found in the pigment. By the use of a strong acid, it may be made to yield iron-free pigment, the remainder of the molecule being much further decomposed.

Destruction and Formation.—In the performance of their work the corpuscles gradually deteriorate. They are then destroyed, chiefly in the liver, but whether the whole of this process is effected by the liver alone is not decided. It is proved, however, that the destruction of the haemoglobin is entirely effected there. It was for a long time considered to be one of the functions of the spleen to examine the red corpuscles and to destroy or in some way to mark those no longer fitted for the performance of their work. It is proved that the destruction of the haemoglobin is entirely effected in the liver, since both the main cleavage products may be traced to this organ, which discharges the pigmentary portion as the bile pigment, but retains the iron-protein moiety at any rate for a time. The amount of bile pigment eliminated during the day indicates that the destruction must be considerable, and since the number of corpuscles does not vary there must be an equivalent formation of new ones. This takes place in the red bone-marrow, where special cells are provided for their continuous production. In embryonic life their formation is effected in another way. Certain mesodermic cells, resembling those of the connective tissue, collect masses of haemoglobin, and from these elaborate red blood corpuscles which thus come to lie in the fluid part of the cell. By a canalization of the branches of these cells which unite with branches of other cells the precursors of the blood capillaries are formed.

White Blood Corpuscles.—These constitute the second important group of formed elements in the blood, and number about 12,000 to 20,000 per cubic mm. They are typical wandering cells carried to all parts of the body by the blood stream, but often leave that stream and gain the tissue spaces by passing through the capillary wall. They exist in many varieties and were first classified according as, under the microscope, they presented a granular appearance or appeared clear. The cells were also distinguished from one another according as they possessed fine or coarse granules. The granules are confined to the protoplasm of the cell, and it has been shown that they differ chemically, because their staining properties vary. Thus, some granules select an acid stain, and the cells containing them are then designated acidophile or eosinophile;1 other granules select a basic stain and are called basophile, while yet others prefer a neutral stain (neutrophile).

In human blood the following varieties of leucocytes may be distinguished:—

1. The Polymorphonuclear Cell.—This possesses a nucleus of very complicated outline and a fair amount of protoplasm filled with numbers of fine granules which stain with eosin. They vary in size but are usually about 0.01 mm. in diameter. They are highly amoeboid and phagocytic, and form about 70% of the total number of leucocytes.

2. The Coarsely Granular Eosinophile Cell.—These large cells contain a number of well-defined granules which stain deeply with acid dyes. The nucleus is crescentic. The cells amount to about 2% of the total number of leucocytes, though the proportion varies considerably. They are actively amoeboid.

3. The Lymphocyte.—This is the smallest leucocyte, being only about 0.0065 mm. in diameter. It has a large spherical nucleus with a small rim of clear protoplasm surrounding it. It forms from 15 to 40% of the number of leucocytes, and is less markedly amoeboid than the other varieties.

4. The Hyaline (Gr. ὑάλινος, glassy, crystalline, ὔαλος, glass) cell or macrocyte (Gr. μακρός, long or large).—This is a cell similar to the last with a spherical, oval or indented nucleus, but it has much more protoplasm. It constitutes about 4% of all the leucocytes and is highly amoeboid and phagocytic.

5. The Basophile Cell.—This possesses a spherical nucleus and the protoplasm contains a small number of granules staining deeply with basic dyes. It is rarely found in the blood of adults except in certain diseases.

Functions.—These cells act as scavengers or as destroyers of living organisms that may have gained access to the tissue spaces. They play an important part in the chemical processes underlying the phenomena of immunity, and some at least are of importance in starting the process of clotting.

They are constantly suffering destruction in the performance of their work. Many, too, are lost to the body by their passage through the different mucous surfaces. Their origin is still obscure in many points. The lymphocytes are derived from lymphoid tissue, wherever it exists in the different parts of the body. The polymorphonuclear and eosinophile cells are derived from the bone-marrow, each by division of specific mother cells located in that tissue. The macrocyte is believed by many to represent a further stage in the development of the lymphocyte. Their rate of formation may be influenced by a variety of conditions—for instance, they are found to vary in number according to the diet and also, to a considerable extent, in disease.

Platelets.—The platelets or thrombocytes (Gr. θρόμβος, clot) are the third class of formed elements occurring in mammalian blood. There are still, however, many observers who consider that platelets are not present in the normal circulating blood, but only make their appearance after it has been shed or otherwise injured. They are minute lens-shaped structures, and may amount to as many as 800,000 per cubic mm. Under certain conditions, examination has shown that they are protoplasmic and amoeboid, and that each one contains a central body of different staining properties from the remainder of the structure. This has been regarded by some as a nucleus. On being brought into contact with a foreign surface they adhere to it firmly, very rapidly passing through a number of phases resulting ultimately in the formation of granular debris. In shed blood they tend to collect into groups, and during clotting, fibrin filaments may be observed to shoot out from these clumps.

Variations in the Blood of different Animals.—If we contrast the blood of different animals of the vertebrate class we find striking differences both in microscopic appearances and in chemical properties. In the first place, the corpuscles vary in amount and in kind. Thus, whilst in a mammal the corpuscles form 40 to 50% of the total volume of the blood, in the lower vertebrates the volume is much less, e.g. in frogs as low as 25% and in fishes even lower. The deficiency is chiefly in the red corpuscles, the ratio of white to red increasing as we examine the blood from animals lower in the scale. The corpuscles themselves are also found to vary, especially the red ones. In the mammal they are biconcave disks with bevelled edges, they do not contain a nucleus so that they are not cells. In the bird they are larger, ellipsoidal in shape and have a large nucleus in the centre of the cell. In reptiles and amphibia the red corpuscles are also nucleated, but the stroma portion containing the haemoglobin is arranged in a thickened annular part encircling the nucleus. When seen from the flat they are oval in section. In fishes the corpuscles show very much the same structure. A further very significant difference to be observed between the bloods of different vertebrates is in the amount of haemoglobin they contain; thus in the lower classes, fishes and amphibia, not only is the number of red corpuscles small but the amount of haemoglobin each corpuscle contains is relatively low. The concentration of the haemoglobin in the corpuscles attains its maximum in the mammal and the bird. Since the haemoglobin is practically the same from whatever animal it is obtained and can only combine with the same amount of oxygen, the oxygen-capacity of the blood of any vertebrate is in direct proportion to the amount of haemoglobin it contains. Therefore we see that as we ascend the scale in the vertebrate series the oxygen-carrying capacity of the blood rises. This increase was a natural preliminary condition for the progress of evolution. In order that a more active animal might be developed the main essential was that the chemical processes of the cell should be carried out more rapidly, and as these processes are fundamentally oxidative, increased activity entails an increased rate of supply of oxygen. This latter has been brought about in the animal kingdom in two ways, first by an increase in the concentration of the haemoglobin of the blood effected by an increase both in the number of corpuscles and in the amount of haemoglobin contained in each, and secondly by an increase in the rate at which the blood has been made to pass through the tissues. In the lower vertebrates the blood pressure is low and the haemoglobin content of the blood is low, consequently both rate of blood-flow and oxygen-content are low. In contrast with this, in higher vertebrates the blood pressure is high and the haemoglobin content of the blood is high, consequently both rate of blood-flow and oxygen-content are high. We must associate with this important step in evolution the means employed for the more rapid absorption of oxygen and for its increased rate of discharge to the tissues, the most important features of which are a diminution in the size of the corpuscle and the attainment of its peculiar shape, both resulting in the production of a relatively enormous corpuscular surface in a unit volume of blood.

Variations are also found in the white corpuscles as well as in the red, but these differences are not so striking and lie chiefly in unimportant details of structure of individual cells. Enormous variations are to be found in different species of mammals, but the cells generally conform to the types of secreting cells or phagocytes.

The platelets also differ in the different species. In the frog, for instance, many are spindle-shaped and contain a nucleus-like structure. Birds’ blood is stated to contain no platelets. The variations in number of these bodies have not been satisfactorily ascertained on account of the difficulties involved in any attempt to preserve them and to render them visible under the microscope.

Differences are also found in the chemical composition of the plasma. The chief variation is in the amount of protein present, which attains its maximum concentration in birds and mammals, while in reptiles, amphibia and fishes it is much less. The bloods of the latter two classes are much more watery than that of the mammal. Moreover, it has been proved that there are specific differences in the chemical nature of the various proteins present even between different varieties of mammals. Thus the ratio of the globulin fraction to the albumin fraction may vary considerably, and again, one or other of the proteins may be quite specific for the animal from which it is derived.

Clotting.—If a sample of blood be withdrawn from an animal, within a short time it undergoes a series of changes and becomes converted into a stiff jelly. It is said to clot. If the process is watched it is seen to start first from the surfaces where it is in contact with any foreign body; thence it extends through the blood until the whole mass sets solid. A short time elapses before this process commences—a time dependent upon two chief conditions, viz. the temperature at which the blood is kept and the extent of foreign surface with which it is brought into contact. Thus in a mammal the blood clots most quickly at a temperature a little above body temperature, while if the blood be cooled quickly the clotting is considerably delayed and in the case of some animals altogether prevented. For example, human blood kept at body temperature clots in three minutes, while if allowed to cool to room temperature the first sign of clotting may not make its appearance until eight minutes after its removal from the body. The process of clotting is also considerably accelerated by making the blood flow in a thin stream over a wide surface. The full completion of the process occupies some time if the blood be kept quiet, but ultimately the whole mass of the blood becomes converted into a solid. At this stage the containing vessel may be inverted without any drop of fluid escaping. A short time after this stage has been reached drops of a yellow fluid appear upon the surface and, increasing in size and number, run together to form a layer of fluid separated from the clot. This fluid is termed serum; its appearance is due to the contraction of the clot, which thus squeezes out the fluid from between its solid constituents. Contraction continues for about twenty-four hours, at the end of which time a large quantity (one-third or more of the total volume) of serum may have been separated. The clot contracts uniformly, thus preserving throughout the same general shape as that of the vessel in which the blood has been collected. Finally the clot swims freely in the serum which it has expressed.

The cause of the clot formation has been found to be the precipitation of a solid from the liquid plasma of the blood. This solid is in the form of very minute threads and hence is termed fibrin. The threads traverse the mass of blood in every possible direction, interlacing and thus confining in their meshes all the solid elements of the blood. Soon after their deposition they begin to contract, and as the meshwork they form is very minute they carry with them all the corpuscles of the blood. These with the fibrin form the shrunken clot.

If the rate at which blood clots be retarded either by cooling or by some other process the corpuscles may have time to settle, partially or completely, in which case distinct layers may form. The lowermost of these contains chiefly the red corpuscles, the second layer may be grey owing to the high percentage of leucocytes present, while a third, marked by opalescence only, may be very rich in platelets. Above these a clear layer of fluid may be found. This is plasma. The formation of these layers depends solely upon the rate of sedimentation of these elements, the rate depending partly upon differences in specific gravity, and partly upon the tendency the corpuscles have to run into clumps. Horse’s blood offers one of the best instances of the clumping of red corpuscles, and in this animal sedimentation of the red corpuscles is most rapid.

If now such a sedimented blood is allowed to clot the process is found to start in the middle two layers, i.e. in those containing the white corpuscles and platelets. From these layers it spreads through the rest of the liquid, being most retarded, however, in the red corpuscle layer, and particularly so if the sedimentation has been very complete. Not only does the clotting process start from the layers containing the leucocytes and platelets, but in them it also proceeds more quickly. These observations clearly indicate that the clotting process is initiated by some change starting from these elements.

The object of the clotting of the blood is quite clear. It is to prevent, as far as possible, any loss of blood when there is an injury to an animal’s vessels. The shed blood becomes converted into a solid, and this, extending into the interior of the ruptured vessel, forms a plug and thus arrests the bleeding. It is found that clotting is especially accelerated whenever the blood touches a foreign tissue, for instance, the outer layers of a torn blood-vessel wall, muscle tissue, &c., i.e. in exactly those conditions in which rapid clotting becomes of the greatest importance. Yet another very pregnant fact in connexion with clotting is that if an animal be bled rapidly and the blood collected in successive samples it is found that those collected last clot most quickly. Hence the more excessive the haemorrhage in any case, the greater becomes the onset of the natural cure for the bleeding, viz. clotting.

When we begin to inquire into the nature of clotting we have to determine in the first place whence the fibrin is derived. It has long been known that two chemical substances at least are requisite for its production. Thus certain fluids are known, e.g. some samples of hydrocele or pericardial fluid, which will not clot spontaneously, but will clot rapidly when a small quantity of serum or of an old blood-clot is added to it. The constituent substance which is present in the first-named fluids is known as fibrinogen, and that present in the serum or the clot is known as fibrin-ferment or thrombin.

Fibrinogen is present in living blood dissolved in the plasma; it is also present in such fluids as hydrocele or pericardial effusions, which, though capable of clotting, do not clot spontaneously. Thrombin, on the other hand, does not exist in living blood, but only makes its appearance there after blood is shed. It is not yet certain what is the nature of the final reaction between fibrinogen and thrombin. The possibilities are, that thrombin may act—(1) by acting upon fibrinogen, which it in some way converts into fibrin, (2) by uniting with fibrinogen to form fibrin, or (3) by yielding part of itself to the fibrinogen which thus becomes converted into fibrin. The experimental study of the rate of fibrin formation, when different strengths of thrombin solutions are allowed to act upon a fibrinogen solution, leads us to the probable conclusion that the first of these three possibilities is the correct one, and that thrombin therefore exerts a true ferment action upon fibrinogen. It is known that in the reaction, in addition to the formation of fibrin, yet another protein makes its appearance. This is known as fibrinoglobulin, and apparently it arises from the fibrinogen, so that the change would be one of cleavage into fibrin and fibrinoglobulin. It is very noteworthy that although the amount of fibrin formed during the clotting appears very bulky, yet the actual weight is extremely small, not more than 0.4 grms. from 100 cc. of blood.

Having ascertained that the clotting is due to the action of thrombin upon fibrinogen, we now see that the next step to be explained is the origin of thrombin. It has been shown that the final step in its formation consists in the combination of another substance, termed prothrombin, with calcium. Any soluble calcium salt is found to be effective in this respect, and conversely the removal of soluble calcium (e.g. by sodium oxalate) will prevent the formation of thrombin and therefore of clotting.

In the next place it can be proved that prothrombin does not exist as such in circulating blood, so that the problem becomes an inquiry as to the origin of prothrombin. Experiment has shown that in its turn prothrombin arises from yet another precursor, which is named thrombogen, and that thrombogen also is not to be found in circulating blood but only makes its appearance after the blood is shed. The conversion of thrombogen into prothrombin has been proved to be due to the action of a second ferment which has been named thrombokinase, and this latter is again absent from living blood. Hence the question arises, whence are derived thrombogen and thrombokinase? In the study of this question it has been found that if the blood of birds be collected direct from an artery through a perfectly clean cannula into a clean and dust-free glass vessel, it does not clot spontaneously. The plasma collected from such blood is found to contain thrombogen but no thrombokinase. A somewhat similar plasma may be prepared from a mammal’s blood by collecting samples of blood from an artery into vessels which have been thoroughly coated with paraffin, though in this instance thrombogen may be absent as well as thrombokinase. If plasma containing thrombogen but no thrombokinase be treated with a saline extract of any tissues it will soon clot. The saline extract contains thrombokinase. This ferment can therefore be derived from most tissues, including also the white blood corpuscles and the platelets. Thrombogen is produced from the leucocytes, but it is not yet certain whether it is also formed from the platelets. The discovery of the origin of the thrombokinase from tissue cells explains a fact that has long been known, namely, that if in collecting blood, it is allowed to flow over cut tissues, clotting is most markedly accelerated. The fact that birds’ blood if very carefully collected will not clot spontaneously tends to prove that thrombokinase is not derived from the leucocytes, and makes probable its origin from the platelets, for it is known that birds’ blood apparently does not contain platelets, at any rate in the form in which they are found in mammalian blood. When examining the general properties of platelets, attention was drawn to the remarkably rapid manner in which they undergo change on coming into contact with a foreign surface. It is apparently the actual contact which initiates these changes, changes which are fundamentally chemical in character, resulting in the production of thrombokinase and possibly also of thrombogen.

Thus as our knowledge at present stands the following statement gives a recapitulated account of the changes which constitute the many phases of clotting. When blood escapes from a blood-vessel it comes into contact with a foreign surface, either a tissue or the damaged walls of the cut vessel. Very speedily this contact results in the discharge of thrombogen and thrombokinase, the former from the white blood corpuscles and also possibly from the platelets, the latter from the platelets or from the tissue with which the blood comes in contact. The interaction of these two bodies next results in the formation of prothrombin, which, combining with the calcium of any soluble lime salt present, forms thrombin or fibrin-ferment. The last step in the change is the action of thrombin upon fibrinogen to form fibrin, and the clot is complete.

The intrinsic value to the animal of these changes is quite plain. The power of clotting and thus stopping haemorrhage is of essential importance, and yet this clotting must not occur within the living blood-vessels, or it would speedily result in death. That the tissues should be able to accelerate the process is of very obvious value. That the inner lining of the blood-vessels does not act as a foreign tissue is possibly due to the extreme smoothness of their surface.

Further, an animal must always be exposed to a possible danger in the absorption of some thrombin from a mass of clotted blood still retained within the body, and we know that if a quantity of active ferment be injected into the blood-stream intravascular clotting does result. Under all usual conditions this is obviated, the protective mechanism being of a twofold character. First, it is found that thrombin becomes converted very quickly into an inactive modification. Serum, for instance, very quickly loses its power of inducing clotting in fibrinogen solutions. Secondly, the body has been found to possess the power of making a substance, antithrombin, which can combine with thrombin forming a substance which is quite inactive as far as clotting is concerned. Finally, there is evidence that normal blood contains a small quantity of this substance, antithrombin, and that under certain conditions the amount present may be enormously increased.

Pathology of the Blood.

The changes in the blood in disease are probably as numerous and varied as the diseases which attack the body, for the blood is not only the medium of respiration, but also of nutrition, of defence against organisms and of many other functions, none of which can be affected without corresponding alterations occurring in the circulating fluid. The immense majority of these changes are, however, so subtle that they escape detection by our present methods. But in certain directions, notably in regard to the relations with micro-organisms, changes in the blood-plasma can be made out, though they are not associated in all cases with changes in the formed elements which float in it, nor with any obvious microscopical or chemical alterations.

The phenomena of immunity to the attacks of bacteria or their toxins, of agglutinative action, of opsonic action, of the precipitin tests, and of haemolysis, are all largely dependent on the inherent or acquired characters Immunity. of the blood serum. It is a commonplace that different people vary in their susceptibility to the attacks of different organisms, and different species of animals also vary greatly. This “natural immunity” is due partly to the power possessed by the leucocytes or white blood corpuscles of taking into their bodies and digesting or holding in an inert state organisms which reach the blood—phagocytosis,—partly to certain bodies in the blood serum which have a bactericidal action, or whose presence enables the phagocytes to deal more easily with the organisms. This natural immunity can be heightened when it exists, or an artificial immunity can be produced in various ways. Doses of organisms or their toxins can be injected on one or several occasions, and provided that the lethal dose be not reached, in most cases an increased power of resistance is produced. The organisms may be injected alive in a virulent condition, or with their virulence lessened by heat or cold, by antiseptics, by cultivation in the presence of oxygen, or by passage through other animals, or they may first be killed, or their toxins alone injected. The method chosen in each case depends on the organism dealt with. The result of this treatment is that in the animal treated protective substances appear in the serum, and these substances can be transferred to the serum of another animal or of man; in other words the active immunity of the experimental animal can be translated into the passive immunity of man. According to the nature of the substances injected into the former, its serum may be antitoxic, if it has been immunized against any particular toxin, or antibacterial, if against an organism. Familiar examples of these are, of the former diphtheria antitoxin, of the latter anti-plague and anti-typhoid sera. An antitoxin exerts its effects by actual combination with the respective toxin, the combination being inert. It is probable that the ultimate source of the antitoxin is to be found in the living cells of the tissues and that it passes from them into the blood. The action of an antibacterial serum depends on the presence in it of a substance known as “immune-body,” which has a special affinity and power of combining with the bacterium used. In order that it may exert this power it requires the presence of a substance normally present in the serum known as “complement.” The development of these “anti-bodies,” though it has been studied mainly in connexion with bacteria and their toxins, is not confined to their action, but can be demonstrated in regard to many other substances, such as ferments, tissue cells, red corpuscles, &c. In some animals, for example, the blood serum has the power of dissolving the red corpuscles of an animal of different species; e.g. the guinea-pig’s serum is “haemolytic” to the red corpuscles of the ox. This haemolytic power (haemolysis) can be increased by repeated injections of red corpuscles from the other animal, in this case also, as in the bacterial case, by the production and action of immune-body and complement. The antiserum produced in the case of the red corpuscles may sometimes, if injected into the first animal, whose red corpuscles were used, cause extensive destruction of its red corpuscles, with haemoglobinuria, and sometimes a fatal result.

Opsonic action depends on the presence of a substance, the “opsonin,” in the serum of an immunized animal, which makes the organism in question more easily taken up by the phagocytes (leucocytes) of the blood. The opsonin becomes fixed to the organisms. It is present to a certain extent in normal serum, but can be greatly increased by the process of immunization; and the “opsonic index,” or relation between the number of organisms taken up by leucocytes when treated with the serum of a healthy person or “control,” and with the serum of a person affected with any bacterial disease and under treatment by immunization, is regarded by some as representing the degree of immunity produced.

Agglutinative action is evidence of the presence in a serum of a somewhat similar set of substances, known as “agglutinins.” When a portion of an antiserum is added to an emulsion of the corresponding organism, the organisms, if they are motile, cease to move, and in any case become gathered together into clumps. In all probability several different bodies are concerned in this process. This reaction, in its practical applications at least, may be regarded as a reaction of infection rather than of immunization as ordinarily understood, for it is found that the blood serum of patients suffering from typhoid, Malta fever, cholera, and many other bacterial diseases, agglutinates the corresponding organisms. This fact has come to be of great importance in diagnosis.

The precipitin test depends on a somewhat analogous reaction. If the serum of an animal be injected repeatedly into another animal of different species, a “precipitin” appears in the serum of the animal treated, which causes a precipitate when added to the serum of the first animal. The special importance of this fact is that it can be utilized as a method of distinguishing between human blood and that of animals, which is often of importance in medical jurisprudence.

In this summary the facts adduced are practically all biological, and are due to the extraordinary activity with which the study of bacteriology (q.v.) has been pursued in recent years. The chemistry of the blood has not hitherto been found to give information of clinical or diagnostic importance, and nothing need here be added to what is said above on the physiology of the blood. Enough has been said, however, to show the extraordinary complexity of the apparently simple blood serum.

The methods at present employed in examining the blood clinically are: the enumeration of the red and white corpuscles per cubic millimetre; the estimation of the percentage of haemoglobin and of the specific gravity of the blood; the microscopic examination of freshly-drawn blood and of blood films made upon cover-glasses, fixed and stained. In special cases the alkalinity and the rapidity of coagulation may be ascertained, or the blood may be examined bacteriologically. We have no universally accepted means of estimating, during life, the total amount of blood in the body, though the method of J.S. Haldane and J. Lorrain Smith, in which the total oxygen capacity of the blood is estimated, and its total volume worked out from that datum, has seemed to promise important results (Journ. of Physiol. vol. xxv. p. 331, 1900). After death the amount of blood sometimes seems to be increased, and sometimes, as in “pernicious anaemia,” it is certainly diminished. But the high counts of red corpuscles which are occasionally reported as evidence of plethora or increase of the total blood are really only indications of concentration of the fluid except in certain rare cases. It is necessary, therefore, in examining blood diseases, to confine ourselves to the study of the blood-unit, which is always taken as the cubic millimetre, without reference to the number of units in the body.

Anaemia is often used as a generic term for all blood diseases, for in almost all of them the haemoglobin is diminished, either as a result of diminution in the number of the red corpuscles in which it is contained, or because the Anaemia. individual red corpuscles contain a smaller amount of haemoglobin than the normal. As haemoglobin is the medium of respiratory interchange, its diminution causes obvious symptoms, which are much more easily appreciated by the patient than those caused by alterations in the plasma or the leucocytes. It is customary to divide anaemias into “primary” and “secondary”: the primary are those for which no adequate cause has as yet been discovered; the secondary, those whose cause is known. Among the former are usually included chlorosis, pernicious anaemia, and sometimes the leucocythaemias; among the latter, the anaemias due to such agencies as malignant disease, malaria, chronic metallic poisoning, chronic haemorrhage, tubercle, Bright’s disease, infective processes, intestinal parasites, &c. As our knowledge advances, however, this distinction will probably be given up, for the causes of several of the primary anaemias have been discovered. For example, the anaemia due to bothriocephalus, an intestinal parasite, is clinically indistinguishable from the other forms of pernicious anaemia with which it used to be included, and leucocythaemia has been declared by Löwit, though probably erroneously, to be due to a blood parasite closely related to that of malaria. In all these conditions there is a considerable similarity in the symptoms produced and in the pathological anatomy. The general symptoms are pallor of the skin and mucous membranes, weakness and lassitude, shortness of breath, palpitation, a tendency to fainting, and usually also gastro-intestinal disturbance, headache and neuralgia. The heart is often dilated, and on auscultation the systolic murmurs associated with that condition are heard. In fatal cases the internal organs are found to be pale, and very often their cells contain an excessive amount of fat. In many anaemias there is a special tendency to haemorrhage. Most of the above symptoms and organic changes are directly due to diminished respiratory interchange from the loss of haemoglobin, and to its effect on the various organs involved. The diagnosis depends ultimately in all cases upon the examination of the blood.

Though the relative proportions of the leucocytes are probably continually undergoing change even in health, especially as the result of taking food, the number of red corpuscles remains much more constant. Through the agency of some unknown mechanism, the supply of fresh red corpuscles from the bone-marrow keeps pace with the destruction of effete corpuscles, and in health each corpuscle contains a definite and constant amount of haemoglobin. The disturbance of this arrangement in anaemia may be due to loss or to increased destruction of corpuscles, to the supply of a smaller number of new ones, to a diminution of the amount of haemoglobin in the individual new corpuscles, or to a combination of these causes. It is most easy to illustrate this by describing what happens after a haemorrhage. If this is small, the loss is replaced by the fully-formed corpuscles held in reserve in the marrow, and there is no disturbance. If it is larger, the amount of fluid lost is first made up by fluid drawn from the tissues, so that the number of corpuscles is apparently diminished by dilution of the blood; the erythroblasts, or formative red corpuscles, of the bone-marrow are stimulated to proliferation, and new corpuscles are quickly thrown into the circulation. These are apt, however, to be small and to contain a subnormal amount of haemoglobin, and it is only after some time that they are destroyed and their place taken by normal corpuscles. If the loss has been very great, nucleated red corpuscles may even be carried into the blood-stream. The blood possesses a great power of recovery, if time be given it, because the organ (bone-marrow) which forms so many of its elements never, in health, works at high pressure. Only a part of the marrow, the so-called red marrow, is normally occupied by erythroblastic tissue, the rest of the medullary cavity of the bones being taken up by fat. If any long-continued demand for red corpuscles is made, the fat is absorbed, and its place gradually taken by red marrow. This compensatory change is found in all chronic anaemias, no matter what their cause may be, except in some rare cases in which the marrow does not react.

It is often very difficult, especially in “secondary” anaemias, to say which of the above processes is mainly at work. In acute anaemias, such as those associated with septicaemia, there is no doubt that blood destruction plays the principal part. But if the cause of anaemia is a chronic one, a gastric cancer, for instance, though there may possibly be an increased amount of destruction of corpuscles in some cases, and though there is often loss by haemorrhage, the cancer interferes with nutrition, the blood is impoverished and does not nourish the erythroblasts in the marrow sufficiently, and the new corpuscles which are turned out are few and poor in haemoglobin. In chronic anaemias, regeneration always goes on side by side with destruction, and it is important to remember that the state of the blood in these conditions gives the measure, not of the amount of destruction which is taking place so much as of the amount of regeneration of which the organism is capable. The evidence of destruction has often to be sought for in other organs, or in secretions or excretions.

Of the so-called primary anaemias the most common is chlorosis, an anaemia which occurs only in the female sex, between the ages of fifteen and twenty-five as a rule. Its symptoms are those caused by a diminution of haemoglobin, and though it is never directly fatal, and is extremely amenable to treatment with iron preparations, its subjects very frequently suffer from relapses at varying intervals after the first attack. Its causation is probably complex. Bad hygienic conditions, over-fatigue, want of proper food, especially of the iron-containing proteids of meat, the strain put upon the blood and blood-forming organs by the accession of puberty and the occurrence of menstruation, all probably play a part in it. It has also been suggested that internal secretions may be concerned in stimulating the bone-marrow, and that in the female sex in particular the genital organs may act in this way. Imperfect assumption of function by these organs at puberty, caused perhaps by some of the above-mentioned conditions, might lead to sluggishness in the bone-marrow, and to the supply to the blood of the poorly-formed corpuscles deficient in haemoglobin which are characteristic of the disease. Chlorosis is the type of anaemias from imperfect blood-formation. Lorrain Smith has produced evidence to show that the total amount of haemoglobin in the body is not diminished in this disease, but that the blood-plasma is greatly increased in amount, so that the haemoglobin is diluted and the amount in each blood-unit greatly lessened.

Pernicious anaemia is a rarer disease than chlorosis, occurs usually later in life, and is distributed nearly equally between the two sexes. But it is of great importance because of its almost uniformly fatal termination, though its downward course is generally broken by temporary improvement on one or more occasions. The symptoms are those of a progressive anaemia, in which gastro-intestinal disturbance usually plays a large part, and nervous symptoms are common, and they become at last much more severe than those of any secondary anaemia. The patient may die in the first attack, but more usually, when things seem to be at their worst, improvement sets in, either spontaneously or as the result of treatment, and the patient slowly regains apparent health. This remission may be followed by a relapse, that again by a remission, and so on, but as a rule the disease is fatal within, at the outside, two or three years.

The prime cause of the disease is not known. It seems probable indeed that the causal factors are numerous. Severe malarial infection, syphilis, pregnancy, chronic gastro-intestinal disease, chronic gas-poisoning, are all, in different cases, known to have been causally associated with it, and it is probable that a congenital weakness of the bone-marrow has often to do with its production, as in many cases a family or hereditary history of the disease can be obtained. The condition is now regarded as a chronic toxaemia, partly because of the clinical symptoms and pathological appearances, partly because analogous conditions can be produced experimentally by such poisons as saponin and toluylendiamin, and partly because of the facts of bothriocephalus anaemia. The site of production of the toxin, or toxins, for it is possible that several may have the same effect on the blood, is possibly not always the same, but must often be the alimentary canal, as bothriocephalus anaemia proves. Not all persons affected with this intestinal tapeworm contract the disease, but only those in whose intestines the worm is dead and decomposing or sometimes only “sick.” The expulsion of the worm puts an end to the absorption of the toxin and the patients recover. No adequate explanation of the formation of the toxin in the immense majority of the cases, in which there is no tapeworm, has yet been given. It is certain that no organism as yet known is concerned.

This toxaemia affects the marrow and through it the blood, the gastro-intestinal apparatus and the nervous system, especially the spinal cord, in different proportions in different cases. The effect upon the marrow is to alter the type of red corpuscle formation, causing a reversion to the embryonic condition, in which the nucleated red corpuscles are large (megaloblasts), and the corpuscles in the blood formed from them are also large, are apparently ill suited to the needs of the adult, and easily break down, as the deposits of iron in the liver, spleen, kidneys and marrow prove. Whether this reversion is due to an exhaustion of the normal process or to an inhibition of it is not definitely known. The result is that the circulating red corpuscles are enormously diminished; it is usual to find 1,000,000 or less in the cubic millimetre instead of the normal 5,000,000. Though the haemoglobin is of course absolutely diminished, it is always, in severe cases, present in relatively higher percentage than the red corpuscles, because the average red corpuscle is larger and contains more haemoglobin than the normal. The large nucleated red corpuscles (megaloblasts) with which the marrow is crowded, often appear in the blood.

Other anaemias, such as those known as lymphadenoma, or Hodgkin’s disease, splenic anaemia, chloroma, leucanaemia and the anaemia pseudo-leucaemica of children, need not be described here, as they are either rare or their occurrence or nature is still too much under discussion.

The number and nature of the leucocytes in the blood bears no constant or necessary relation to the number or condition of the red corpuscles, and their variations depend on entirely different conditions. The number in the Leucocytosis. cubic millimetre is usually about 7000, but may vary in health from 5000 to 10,000. A diminution in their number is known as leucopenia, and is found in starvation, in some infective diseases, as for example in typhoid fever, in malaria and Malta fever, and in pernicious anaemia. An increase is very much more frequent, and is known as leucocytosis, though in this term is usually connoted a relative increase in the proportion of the polymorphonuclear neutrophile leucocytes. Leucocytosis occurs under a great variety of conditions, normally to a slight extent during digestion, during pregnancy, and after violent exercise, and abnormally after haemorrhage, in the course of inflammations and many infective diseases, in malignant disease, in such toxic states as uraemia, and after the ingestion of nuclein and other substances. It does not occur in some infective diseases, the most important of which are typhoid fever, malaria, influenza, measles and uncomplicated tuberculosis. In all cases where it is sufficiently severe and long continued, the reserve space in the bone-marrow is filled up by the active proliferation of the leucocytes normally found there, and is used as a nursery for the leucocytes required in the blood. In many cases leucocytosis is known to be associated with the defence of the organism from injurious influences, and its amount depends on the relation between the severity of the attack and the power of resistance. There may be an increase in the proportions present in the blood of lymphocytes (lymphocytosis), and of eosinophile cells (eosinophilia). This latter change is associated specially with some forms of asthma, with certain skin diseases, and with the presence of animal parasites in the body, such as ankylostoma and filaria.

The disease in which the number of leucocytes in the blood is greatest is leucocythaemia or leucaemia. There are two main forms of this disease, in both of which there are anaemia, enlargement of the spleen and lymphatic Leucaemia. glands, or of either of them, leucocytic hypertrophy of the bone-marrow, and deposits of leucocytes in the liver, kidney and other organs. The difference lies in the kind of leucocytes present in excess in the blood, blood-forming organs and deposits in the tissues. In the one form these are lymphocytes, which are found in health mainly in the marrow, the blood itself, the lymph glands and in the lymphatic tissue round the alimentary canal; in the other they are the kinds of leucocytes normally found in the bone-marrow-myelocytes, neutrophile, basophile and eosinophile, and polymorphonuclear cells, also neutrophile, basophile and eosinophile. The clinical course of the two forms may differ. The first, known as lymphatic leucaemia or lymphaemia, may be acute, and prove fatal in a few weeks or even days with rapidly advancing anaemia, or may be chronic and last for one or two years or longer. The second, known as spleno-myelogenous leucaemia or myelaemia, is almost always chronic, and may last for several years. Recovery does not take place, though remissions may occur. The use of the X-rays has been found to influence the course of this disease very favourably. The most recent view of the pathology of the disease is that it is due to an overgrowth of the bone-marrow leucocytes, analogous in some respects to tumour growth and caused by the removal of some controlling mechanism rather than by stimulation. The anaemia accompanying the disease is due partly to the leucocyte overgrowth, which takes up the space in the marrow belonging of right to red corpuscle formation and interferes with it.

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