IN

cases into two series :

BLOOD STUDIES BRUCELLOSIS
ROYALL M. CALDER, M.D.
CHRISTINE STEEN, B.S.
AND
LAURENCE BAKER
SAN ANTONIO, TEXAS
In another paper it was pointed out that the intro-
1
duction of various intracutaneous tests and Huddleson's
opsonocytophagic reaction, while providing a new
approach to the study of brucellosis, has raised certain
confusing problems which have not yet been solved.
It seems probable that these tests, together with the
agglutination reaction, are of service in indicating
whether or not the tissues have been invaded by Bru-
cella at one time or another, in this respect affording
information of essentially the same value and limita-
tions as the tuberculin test in suspected tuberculosis
or the Wassermann test in syphilis. Doubt has prop-
erly been cast on the infallibility of Huddleson's diag-
nostic criteria, however, by the facts that brucellosis,
a common and endemic disease, may be latent or
asymptomatic and that the finding of positive tests may
thus not indicate active disease but merely coincidental
Group I includes those patients
with only a positive antiserum cutaneous reaction,
opsonins and agglutinins being absent, while group II
includes those patients who, in addition to a positive
cutaneous reaction, also had demonstrable agglutinins
(1:40 or higher) or opsonins (at least one cell out of
twenty-five showing phagocytosis of twenty or more
organisms).
Technical Procedures.—All determinations were made
with Bureau of Standards glassware. Blood was col¬
lected by venipuncture and clotting was prevented by
a mixture of potassium and ammonium oxalate (0.05
Gm. of ammonium oxalate and 0.04 Gm. of potassium
oxalate to 5 cc. of blood). Counts of the white cells
were made in both chambers of a double hemacytometer.
the total counts on the two sides checking within 400
cells. Differential counts were done by the two cover-
slip method and stained with Wright's stain. In every*
instance 100 cells were classified on each of two sepa-
Table 1.—Differential Counts in Cases Showing Lymphocytic
Lcukocvtosis
o a
•
*>

infection of no significance. £<-> eg p °

M«
The difficulties are further increased by the paucity £& SE
M oaS o
of physical signs, so that at the present time the diag¬ CS
to oí
Eh«
eu X
CQ SSS ¡H Hl
nosis of brucellosis must rest on indirect laboratory II 40 10,300 39.5 10.5 2.5 1.0 3.5 28.5 4.0 10.5
II 73 11,000 38.0 13.0 1.0 1.0 8.5 31.5 1.0 6.0
evidence plus a more or less typical symptomatology. I 42 11,600 33.0 _.0 '
2.5 0.5 4.0 37.0 10.0 8.0
It becomes important, therefore, to search for measur¬ I
I
28 9,900 46.5 5.0
6.5 2.5
0.5 5.5 35.5
23.5
2.0
3.5
5.0
7 11,100 44.5 15.0 4.0
able objective abnormalities sufficiently typical and fre¬ I 4 10,100 49.0 2.0 0.5 LO 7.0 30.0 1.0 9.0
I 5 11,200 4.5 0.5 20.5 32.0 5.0 7.0
quent to assist in determining the presence or absence I 47 11,500 32.5 7.5 3.6 0.5 16.5 21.5 3.5 1.5 13.5
of activity. In a series of patients tested for brucellosis, I
II 60
9,900
12,700
45.0
52.5
8.0
3.5
2.0
4.0 Ï.5
23.0
4.0
17.0
27.0
2.0
1.5
3.0
Ï.6
5.0
we have encountered certain morphologic changes in II 3» 12,600 40.5 2.6 3.5 0.5 2.0 31.0 10.0 0.5 9.5
10,000 33.5 0.5 5.5 1.0 8.5 42.0 3.0 0.5 5.5
both red and white blood cells so frequently as to war¬ 9,600 27.5 5.0 4.5 0.5 17.0 28.5 2.0 14.5 0.5
rant a somewhat detailed report. II 27 11,700 38.5 5.5 3.0 26.5 13.5 6.5 6.5
9,500 32.0 4.5 6.0 Í'.Ó 14.0 28.0 5.0 9.5
II 19 10,300 27.0 6.0 4.5 1.5 15.0 36.0 5.0 5.0
METHODS AND MATERIALS II 2 15,000 10.0 3.0 0.5 0.5 24.0 48.0 1.0 11.5
10,300 54.0 1 .:> 2.0 1.0 16.0 20.0 2.0
Source of clinical material and diagnostic methods
were detailed in another communication.1 Studies of *
The structure of the white cells in this case was strongly suggestive
the white blood cells are reported in 271 cases and of of infectious mononucleosis; hut the heterophile antibody test was nega¬
tive on two occasions.
the red blood cells in 286 cases. Tests were made in
all cases by Foshay's antiserum intracutaneous test,2 rate coverslip preparations; if discrepancies were noted,
by macroscopic agglutination tests read after forty-eight the slips were discarded and the process was repeated.
hours and by Huddleson's opsonocytophagic test (modi¬ erythrocyte studies, Wintrobe's B methods were
In the
fication of R. M. C. described by Evans.3).
Huddleson4 has stated that a positive cutaneous
employed throughout. Red blood cell counts were made
from the same pipet on the two sides of a double
reaction (brucellergin) with low or absent opsonins hemacytometer, the two counts
indicates active disease. It is generally recognized, cells.
checking within 100.000
Pipets were invariably shaken well in a mechan¬
however, that cutaneous reactions in any disease are ical shaker. Hemoglobin was determined by the Sahli
such delicate indicators of bacterial invasion that they method with instruments standardized both by the
may be positive even in asymptomatic disease and hence Bureau of Standards and by the Van Slyke method.
unreliable as indexes of activity. This objection like¬ In all charts dealing with erythrocytes. percentages
wise obtains in Foshay's antiserum test, for this reac¬ rather than actual numbers of cases have been used, to
tion appears to furnish information of the same permit comparison of our results with the normal range
significance as those tests in which antigens or antigenic as determined by Wintrobe.6
derivatives are employed. Frequently patients are
encountered who present symptoms compatible with a THE LEUKOCYTES

diagnosis of chronic brucellosis and who yet give only It is generally stated that brucellosis is characterized
a positive cutaneous reaction. In order to determine by leukopenia with relative lymphocytosis. Amoss,7
whether the hématologie abnormalities are as frequent however, pointed out that the disease in many instances
in this group of cases as in those with more definite is actively lymphocytogenic, normal or increased total
evidence of Brucella invasion, we have divided our white blood cell counts often showing a high percentage
From the Brucellosis Laboratory, Clayton Foundation for Research. 5. Wintrobe, M. M.: Am. J. M. Sc. 177:513 (April) 1929; Blood
1. Calder, R. M.: Chronic Brucellosis, South. M. J., to be published. of Normal Young Women Residing in a Subtropical Climate, Arch. Int.
2. Foshay, Lee.: J. Infect. Dis. 59:330 (Nov.-Dec.) 1936. Med. 45:287 (Feb.) 1930.
3. Evans, Alice C.: Pub. Health Rep. 53:1507 (Aug. 26) 1938. 6. Wintrobe, M. M.: Bull. Johns Hopkins Hosp. 53:118 (Sept.)
4. Huddleson, I. F.; Johnson, H. W., and Hamann, E. E.: Am. J. 1933.
Pub. Health 23:917 (Sept.) 1933. 7. Amoss, H. L.: Internat. Clin. 4:93 (Dec.) 1931.

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 of lymphocytes. In our experience acutely and seriously a few azurophilic granules. Large lympho¬
or even no
ill patients ordinarily have leukopenia. But in the cytes were morefrequent than small lymphocytes, but
chronically ill patients in this series leukopenia is not this fact, as pointed out by Wiseman, is probably due
invariable (chart 1). The average total leukocyte count to fixation and drying. Those cells having relatively
was found to be 7,225 in the group I cases, 7,130 in
large amounts of cytoplasm were not suggestive of the
the group II cases and 7,173 in all cases. Counts above cells of infectious mononucleosis, in that nuclei of
9,500 explainable on the basis of obvious complica¬
not
tions occurred in thirty instances ; of these, only twelve
showed a polymorphonuclear leukocytosis while eighteen
showed lymphocyte percentages of from 38 to 63 per
cent (table 1).
The Lymphocytes.—Evidence of active stimulation
of lymphopoietic centers was observed in almost every
case. Two hundred and six (76 per cent) of the 271
patients had more than 30 per cent of lymphocytes, and

Chart 3.—Distribution of lymphocytes (absolute numbers) by cases.

ameboid shape were not encountered, nor was the cyto¬

plasm of the foamy, light blue appearance character¬
istic of mononucleosis. Only one exception was noted,
and in it the heterophile antibody test was negative on
Chart 1.—Total leukocytes. two occasions.
The immature lymphocytes were characterized by
forty-five patients (16.6 per cent) had more than 50 the frequent occurrence of nucleoli. The nucleus of
per cent of lymphocytes (chart 2). Absolute numbers these young cells was purplish blue and of fairly even
of lymphocytes were likewise increased; 151 of the
271 patients showed more than 2,500 of these cells, and
distribution, and the cytoplasm, which contained no
in thirteen cases they numbered more than 5,000 (chart granules, was deeply basophilic, approaching true blast
3). Active lymphocytogenesis was further evidenced
by the appearance of immature lymphocytes in the
peripheral blood, as studied by the methods of Wise¬
man.3 According to Wiseman an absolute value of
approximately 100 is the usual maximum of these ele¬
ments for the normal person. In contrast to this norm,
four fifths of our patients showed values higher than
100. Wiseman's studies indicate that the occurrence
of such forms constitute a "shift to the left" in the

•-66 CASES—.

GROUP I.
GROUP IL

Chart 4.—Young lymphocytes (absolute numbers) by cases.

cells in its affinity for the basic stains. All gradations

of basophilia were observed in different cells, but in
our data only those cells with deeply basophilic
20 25 30 33 40 45 50 55 60 65 70 75 80 cyto¬
Chart 2.—Percentages of total lymphocytes.
plasm were classified as immature.
Some of the cells, obviously immature because of their
lymphocyte series analogous in import to the well known cytoplasmic basophilia, differed from those described
in that their nucleus was small, round and intensely
"shift to the left" in the granulocyte series in the
stained ; their chromatin, while densely clumped, was
usual Schilling count (chart 4). not arranged in orderly fashion. Still other cells, which
Microscopic Appearance of the Lymphocytes.—The we classified as young lymphocytes,
approached plasma
mature lymphocytes in our cases frequently showed only
cells in appearance, the chromatin being arranged in
S. Wiseman, B. K. : J. Exper. Med. 54:271 (Aug.) 1931. typical cart-wheel formation and the nucleus occasionally

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 even being eccentrically placed. We did not classify Monocyte-Lymphocyte Ratio. Cunningham and
this type as a plasma cell, however, because the cyto¬ Sabin and their associates ° have stressed the impor¬ —

plasm seemed identical in appearance to that of the
immature lymphocytes, and the cells were definitely
smaller than typical plasma cells.
Plasma Cells.—In slightly more than one third of our
cases, cells possessing all the characteristics of plasma
cells were observed. When present, they accounted for
from 1 to 3 per cent of the total leukocytes. It is not
tance of the monocyte-lymphocyte ratio as an index of
the state of activity in tuberculosis. Since in many
respects the fundamental pathologic changes of tuber¬
culosis and brucellosis are similar, a determination of
25« e—-a
-

our purpose to discuss whether or not plasma cells

belong to the lymphocytic series ; in our tables they have
not been so classified. If they actually belong in the

—O GROUP I
—O GROUP 11.

s
z
~
I5X
B HEMO- 90 95 10 I&5
GL08IN (IN GRAMS PER lOOCC BLOOD- SAHLI)
S
o
te 10%
Chart 7.—Hemoglobin (females).
I
the monocyte-lymphocyte ratio in our cases is of inter¬
est. In almost all instances, the observed monocyte-
R.BC 2.1 2.3 25 27 2.9 31 3.3 3S 37 39 4.1 4.3 45 47 49 5.1 53 5.5 57 59 lymphocyte ratio was lower than normal (0.33) ; it was
(IN MILLIONS) normal or above in only twenty-seven cases. Extremely
low values (0.15 or less) were observed in more than
Chart 5.—Red blood cell counts (females).
half of the cases. Attempts to relate the monocyte-
lymphocytic series, their presence is additional evi¬ lymphocyte ratio to state of activity, severity of infection
dence of the lymphocytogenic effect of Brucella
or prognosis must await further observations.
infection. The Granulocytes.—The total number of granulo-
cyteswas almost invariably reduced, both in percentages
The Monocytes.—In general, the absolute number of
and in absolute numbers. The percentage of "stab"
monocytes was not increased. Of the 271 cases, 227
(approximately 84 per cent) showed less than 700 neutrophils was
often elevated, but
monocytes, while forty-four (approximately 16 per the increase in ab¬
cent) showed more than this number. Only seven solute numbers of
patients had more than 1,000 monocytes, the maximum these elements was
being 1,800; only one of these patients was a child, not so striking. The
and in all of them tuberculosis had been excluded by
left shift in certain
appropriate tests.
cases is reminiscent
Structurally there was nothing especially striking of the counts in
about the monocytes. We gained the impression that typhoid ; but in our
experience the per¬
O-© GROUP 1
centage of "stabs"
is rarely as high as
O-O GROUP II
in typhoid. It would
appear from these
observations that, in
certain instances at
least, myelogenic
stimuli are present HEMO- 10 II 12 13 14 15 16 17 18 19
but that peripheral GLOBIN (IN GRAMS PER 100 CC. BLOOD; SAHLII
destruction exceeds Chart 8.—Hemoglobin (males).
their production.
The question is of practical importance because of the
phagocytic role of the polymorphonuclear cells in rid¬
RBC. 35 3.7 39 4 1 4 3 4 5 4 7 4.9 5.1 5.3 5.5 5.7
(IN MILLIONS)
5,9 6.1 6.3 6.5 67 ding the body of Brucella.
In one tenth of the cases, basophils were present in
Chart 6.—Red blood cell counts (males). proportions greater than 1 per cent, the maximal per¬
centage observed being 3. Approximately one fifth of
more than the usual number of these cells showed dif¬ these cases showed eosinophil counts of 5 per cent or
fuse, fine, pink granulation and that immature forms, more. Even excluding those cases for which there is
as evidenced by basophilia of the cytoplasm, were more an obvious explanation of the eosinophilia, the increase
frequent than in normal bloods ; but these changes were 9. Cunningham, R. S.; Sabin, Florence R.; Sugiyama, S., and Kind-
not definite enough to appear significant. wall, J. A.: Bull. Johns Hopkins Hosp. 37:231 (Oct.) 1925.

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 in these cells is noteworthy. "Stab" eosinophils were
frequent, at times equaling the mature forms in number.
The significance of these observations is not apparent.
THE
ERYTHROCYTES
Total Erythrocyte Counts.—As will be seen from
charts 5 and 6, severe grades of anemia were rarely
encountered. On the average, the red blood cell counts
were approximately a half million lower than normal.
detail. Definite macrocytosis (charts 9 and 10) was
present in more than half of the cases, and the incidence
of hyperchromia was likewise striking. In only six
cases of apparently uncomplicated brucellosis were
microcytosis and hypochromia observed.
-»-49CASES NORMAL OR BELOW-»--«— 48 CASES ABOVE NORMAL-
-© GROUP I

Mean values for the various groups are shown in GROUP II

talile 2. In the few cases showing severe grades of NORMAL (WINTROBE)

-83 CASES NORMAL OR BELOW-»- «-1O6 CASES ABOVE NORMAL

-

GROUP I
GROUP 11
NORMAL (WINTRQBE

MEAN 74 76 78 60 82 84 86 68 90 92 94 96 90 IÔÔ 102 IÔ4 106 IÔ8IIÖ 112

CORP
VOL (IN CUBIC MICRONS)

Chart 10.—Mean corpuscular volume (males).

MtAN
CORP
74 76 78 SO 82 04 86 88 90 92 94 96 9B 100 102104 106 108 HO M2
«36
As a check on the accuracy of our determinations of
average erythrocyte volume, measurements of the dia¬
VOL "N CUBIC MICRONS)

meters of red blood cells by the method of

Chart 9.—Mean corpuscular volume (females).
were made in twenty-three of these cases.
Price-Jones
method also a distinct macrocytosis is apparent
By this
anemia, explanation of the anemia (menorrhagia. (chart
an
secondary infections, coincidental malaria, inanition and 13).
the like) was usually obvious. Mean Corpuscular Hemoglobin Concentration.—
Hemoglobin Determinations.—The values for hemo¬ Bethell has called
I0
attention to the fact that, if the
globin, as determined by the Sahli method and cal¬ plasma proteins are low, osmotic relationships between
culated in grams per hundred cubic centimeters of blood, red cells and plasma are disturbed, with resultant swell¬
showed curves closely paralleling normal (charts 7 ing (relative macrocytosis) of the erythrocytes. Since
and 8). The average values (table 2) also approxi¬ the hemoglobin content of the cell remains constant, the
mated normal. swelling of the cell results in its being less saturated
Volume of Packed Red Blood Cells.—On the aver¬ with hemoglobin than usual. Such a condition results
the volume of the red cells in the triad of macrocvtosis (cell volume greater than
age, packed blood (obtained
by centrifuging in hematocrit tubes and noting the pro¬
portion of packed red cells to supernatant plasma) O-& GROUP I.
showed a smaller departure from normal than did the GROUP II.

total erythrocyte counts (table 2). NORMAL (WINTHOBEI

Table 2.—Summary of Mean Values

Normal
Mean
Group 1 Group II All (Win-
Cases Cases Cases trobe)
Red blood cells, female. 4.32 4.39 4.37 4.So
Red blood cells, male. 4.75 4.91 4.82 5.43
Hemoglobin, female . 13.72 13.59 13.04 13.90
Hemoglobin, male . 14.58 15.46 14.99 15.90
Volume of packed red blood cells, MEAN
CORP HGB
18 19 87 2» » 36 Si S2 if it%
»M « ¡6 » » Si 40 4
females . 41.15 41.10 41.15 CONTENT (MICROMICPOGRAMSI
Volume of packed red blood cells,
males . 43.59 45.72 41.59 47.70
Mean corpuscular volume, témales 95.80 94.20 94.80 ".mi Chart 11.—Mean corpuscular hemoglobin content (females).
Mean corpuscular volume, males.. 91.90 03.50 92.70 86.M
Mean corpuscular hemoglobin con¬
tent, females . 31.90 31.40 29.20 95 cubic microns), normal mean corpuscular hemo¬
Mean corpuscular hemoglobin con¬
tent, males .

Mean corpuscular hemoglobin con¬

30.80 31.20 29.10 globin content (from 28 to 31 micromicrograms), and
centration, females 33.30 33.20
decreased mean corpuscular hemoglobin concentration
. 33.50
Mean corpuscular hemoglobin con¬
centration, males 32.50 33.90 33.00 34.00
(less than 32 per cent).
.

Our cases were therefore analyzed to determine how

Mean Corpuscular Volume and Hemoglobin Content.
—The disproportion between volume of packed red
cells and total erythrocyte counts is accounted for by
the fact that the average volume of the individual red
cell is significantly greater than normal. Similarly, the
disparity between total hemoglobin and erythrocyte
counts is reflected in hyperchromia of the red blood
cells. Charts 9, 10, 11 and 12 show these changes in
frequently this triad occurred. Charts 14 and 15 show
the hemoglobin concentrations of all patients studied.
It will be noted that the hemoglobin concentration is
low in a fairly large percentage of cases (sixty-eight
cases). But these data include forty-five cases of
definite hypochromia, most of them presenting com¬
plications sufficient to account for the low hemoglobin
10. Bethell, F. H., and Rottschaefer, Gerald: Univ. Hosp. Bull., Ann.
Arbor 2: 65 (Nov.) 1936.

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 content. Excluding these and two cases of pregnancy, Sedimentation Rate of Erythrocytes.—Moderate
there remain only twenty-one cases (7.3 per cent) in acceleration of sedimentation rates (above Wintrobe's
which the possibility exists that the observed macro¬ normal of 9 mm. for males and 15 mm. for females)
cytosis was due, partly at least, to a circulatory phe¬ occurred in slightly more than one third of these cases.
nomenon.
In contrast to this small number of patients in whom
the macrocytosis was apparently merely a physical
phenomenon, it is impressive to note the large number
of cases in which the hemoglobin concentration of
macrocytes was normal or even high. The conclusion
seems justified that the observed macrocytosis is due not
merely to physical alteration of osmotic relationships
but to defects of maturation.

-O GROUP L
GROUP II.
NORMAL RANGE
(WINTROBE)

Chart 13.—Price-Jones curves in chronic brucellosis.

Very slow rates were Excessively fast

MEAN 23 24 25 26 27 28 29 30 31 32 33 34
CORP HGB.
CONTENT (MICROMICROGRAMS)
Chart 12.—Mean corpuscular hemoglobin content
Microscopic Appearance of Erythrocytes.—Varia¬
tions in size and shape of the erythrocytes were minimal.
In general, the cells were all larger than normal and
their hemoglobin content was likewise uniformly
increased. Hypochromia and microcytosis were dis¬
tinctly rare. In a very few instances pencil-shaped
not uncommon.
rates were usually explainable on the basis of
complica¬
tions, such as arthritis or effusions (table 3).
Gastric Analysis.—Gastric analysis was done in ten
cases in which there were macrocytosis and hyper-
chromia. Our procedure was to aspirate the fasting
contents and then administer 50 cc. of 7 per cent alcohol
(males). and 0.4 mg. of histamine, specimens being withdrawn
at fifteen minute intervals.
In nine of the ten cases there was no free hydro¬
chloric acid in the fasting specimens. All of them,
however, showed free acid after histamine. Values
0-© GROUP r.

cells were observed. Nucleated red blood cells were I GROUP II

infrequent. In two or three cases the inclusion of red I

blood cells in monocytes was observed. Polychroma- 20X

tophilia of slight degree was present in approximately

10 per cent of the cases.
Reticulocytes.—Reticulocyte counts were clone in
twenty-two of the cases reported in this series. The
values ranged from 0.3 to 3.3 per cent, with mean
values of approximately 1 per cent.

Table 3.—Sedimentation Rates of Erythrocytes

MEAN 25 26 27 28 29 30 31 32 33 34 35 36 37 38
CORP HGB.
Group I Cases Group II Cases CONCENTRATION K OF CELL VOLUME OCCUPIED BY HGB.)
Millimeters
per Hour Male Female Male Female
1-5 _ 1 15 3 Chart 14.—Mean corpuscular hemoglobin concentration (females).
6-9. 10 13 4 15
10-15. in 16 11 22
16-25. 12 9 32
23
were definitely low in five cases, in the lower limits of
26-35.
36-45.
4
1 S normal in two cases and within the usual range of
46-55.
56-65.
3
0
9 normal in three cases. Neither complete histamine
anacidity nor, on the other hand, excessively high
acidity was encountered.
Coagulation.—In approximately one third of these Van den Bergh Tests.—The van den Bergh test was
cases,clotting was slow and incomplete. Free cells performed on 142 untreated patients. Of these, eighty-
were often present even after the blood had stood over¬ seven (61 per cent) showed bilirubin values of less
night in the ice box. Normal retraction of the clot than 0.5 mg. per hundred cubic centimeters of blood,
was rare; was no retraction at all.
often there The while fifty-five (39 per cent) showed higher values.
coagulation defects do not seem to be related to decrease In the latter group, most of the values were less than
in blood platelets, for these elements are grossly normal 1 mg., the highest being 1.8 mg. The reaction was of
in number and appearance in the stained preparations. the delayed direct type, the color change occurring after

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 thirty seconds and reaching its maximal intensity before
the addition of alcohol and ammonium sulfate.
Evidence of Damage to the Liver.—It has been recog¬
nized previously that portal cirrhosis of the liver is
often associated with macrocytosis. Wintrobe ll has
summarized the literature on the subject, and his descrip¬
tion of the blood changes in diseases of the liver
parallels our observations on the blood in these cases :
"The anemia ... is rarely severe. The macro¬
cytosis affects the great majority of the red corpuscles,
which show relatively little variation in shape or size.
The lack of varia¬
G---0 GROUP I tion in the size of
the corpuscles, how¬
ever, does not dis¬
tinguish the condi¬
g 20* tion from pernicious
anemia, for the dis¬
tribution curves of
the diameters of the
red corpuscles are
like those in cases
of pernicious ane¬
mia with similar
grades of anemia.
Nucleated red cor¬
MEAN 28 ¿9 30 Si 32 33 34 35 36 37 38 39
HGB* (% OF CELL VOLUME OCCUPIED BY HGB) puscles are un¬
CONCENTRATION
common and the
Chart 15.—Mean corpuscular hemoglobin fragility of the
concentration (males). erythrocytes is nor¬
mal." It is very
unlikely that the cases which are included in our series
represent the accidental association of pernicious anemia
with brucellosis, for in the first place they are too
numerous, and in the second place histamine anacidity
has not occurred in those cases in which the gastric
contents have been examined.
The striking parallelism between our observations
and those cited by Wintrobe as occurring in hepatic
disease makes reasonable the conclusion that these
changes in all probability are due to anatomic or func¬
tional derangement of the liver. Contributory evidence
for this idea is held in the facts that (1) low grade
jaundice as measured by the van den Bergh reaction
is not uncommon, (2) this reaction is of the delayed
direct type, which ordinarily is associated with structural
damage to liver parenchyma, and (3) the liver is, in
our experience and that of others, more commonly
enlarged in this condition than is the spleen.
SUMMARY
Structural studies of the blood were made in almost
300 patients with evidence of Brucella invasion.
Normal leukocyte counts occurred in one half, leuko¬
penia in one third and leukocytosis in one sixth of the
cases. Active lymphocytosis was the most striking
feature encountered and was evidenced by an increase
in both percentage values and absolute numbers of
lymphocytes and by unusually high numbers of imma¬
ture lymphocytes (a lymphocytic "shift to the left").
Plasma cells were frequent. Monocytes in general were
not increased in number, and the monocyte-lymphocyte
ratio was almost invariably low. Many cases showed a
moderate increase in percentage of "stab" neutrophils,
but the total number of neutrophils was usually reduced.
In one fifth of the cases there was moderate eosinophilia,
often with immature forms.
11. Wintrobe, M. M. : Relation of Disease of the Liver to Anemia,
Arch. Int. Med. 57:289 (Feb.) 1936.
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Mild anemia of the macrocytic, hyperchromic type
was frequent. Evidence was obtained that these
changes are due to maturation defects, probably the
result of damage to the liver.
Coagulation of the blood was slow and often incom¬
plete. Clot retraction was also imperfect. The sedi¬
mentation rate was usually not extremely high except
when complications, such as arthritis, were present.
These abnormalities of the blood were observed so
consistently that they appear to represent a fundamental
part of the disease with which these patients are suffer¬
ing. So far as we are aware, they are duplicated in
their entirety by no other known disease. It would
seem, therefore, that the regularity with which the}'
occurred in this group of patients is confirmatory evi¬
dence of the specificity of the tests on which the diag¬
nosis of brucellosis was made.
Further analysis of our data indicates that these
blood changes occur as often in patients with only a
positive cutaneous reaction as in those who also show
agglutinins and opsonins. Since these abnormalities
seem to be a specific effect of Brucella invasion, their
equal incidence in the two groups of patients indicates
that, in many instances, a positive antiserum cutaneous
reaction may be the sole evidence of brucellosis.
1127 Nix Professional Building.
PLASMA PROTHROMBIN AND THE
BLEEDING TENDENCY
WITH SPECIAL REFERENCE TO JAUNDICED
PATIENTS AND VITAMIN K THERAPY
GEORGE H. SCANLON, M.D.
K. M. BRINKHOUS, M.D.
E. D. WARNER, M.D.
H. P. SMITH, M.D.
AND
JOSEPH E. FLYNN, M.D.
IOWA CITY
It is main purpose in the present article to dis-
our
cuss treatment of thebleeding tendency so often seen
in patients suffering from disease of the biliary tract.
Bleeding from mucous surfaces often occurs spon-
taneously in these patients, but the greatest danger is
from bleeding at operation or from the wound after
operation.
Through the work of several laboratories 1 it has
been shown that a newly discovered vitamin, vitamin K,
From the Mercy Hospital and from the Department of Pathology,
State University of Iowa.
Aided by a grant from the John and Mary R. Markle Foundation.
Funds for a technical assistant were supplied by the Graduate College,
State University of Iowa.
1. Reported by:
Dam, Henrik: The Antihemorrhagic Vitamin of the Chick, Biochem. J.
29: 1273 (June) 1935.
Dam, Henrik; Sch\l=o/\nheyder, Fritz, and Tage-Hansen, Erik: Studies
on the Mode of Action of Vitamin K. ibid. 30: 1075 (June) 1936.
Sch\l=o/\nheyder, Fritz: The Quantitative Determination of Vitamin K,
ibid. 30: 890 (May) 1936.
Almquist, H. J., and Stokstad, E. L. R.: Hemorrhagic Chick Disease
of Dietary Origin, J. Biol. Chem. 111:105 (Sept.) 1935.
Quick, A. J.: The Coagulation Defect in Sweet Clover Disease and in
the Hemorrhagic Chick Disease of Dietary Origin, Am. J. Physiol.
118: 260 (Feb.) 1937.
Hawkins, W. B., and Brinkhous, K. M.: Prothrombin Deficiency the
Cause of Bleeding in Bile Fistula Dogs, J. Exper. Med. 63:795
(June) 1936.
Greaves, J. D., and Schmidt, C. L. A.: Nature of the Factor Con-
cerned in Loss of Blood Coagulability of Bile Fistula Rats, Proc.
Soc. Exper. Biol. & Med. 37:43 (Oct.) 1937.
Warner, Brinkhous and Smith.2
Butt, Snell and Osterber.3
Dam and Glavind.4
Smith, Warner, Brinkhous and Seegers.16