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 ROUTINE BLOOD TESTING
Many laboratory tests include the direction to perform routine blood
testing. The protocol for those tests is presented here and is cross-
referenced within the many tests requiring them.
Before
• Follow proper patient identification protocols to avoid wrong patient
events. Usually name and date of birth are used as two identifiers.
Explain the procedure to the patient.
Tell the patient if fasting is necessary. (Fasting is most commonly
required with glucose and lipid studies.)
If fasting is required, instruct the patient not to consume any food or
fluids. Only water is permitted. Fasting requirements usually vary from
8 to 12 hours.
Instruct the patient to continue taking medications unless told
otherwise by the health-care provider.
During
• Collect the blood in a properly color-coded test tube (Table A, p. xiv),
which indicates the presence or absence of additives. Tube stopper
colors may vary with different manufacturers. If uncertain, verify with
the laboratory.
After
• Apply pressure or a pressure dressing to the venipuncture site.
• Assess the site for bleeding.

= Patient teaching
 ROUTINE URINE TESTING
Many laboratory tests include the direction to perform routine urine
testing. The protocol for those tests is presented here and is cross-
referenced within the many tests requiring them.
Before
• Follow proper patient identification protocols to avoid wrong patient
events. Usually, name and date of birth are used as two identifiers.
Explain the procedure to the patient.
Inform the patient if food or fluid restrictions are needed.
During
Random, fresh, or spot specimen
Instruct the patient to urinate into an appropriate nonsterile container.
24-hour specimen
1. Begin the 24-hour collection by discarding the first specimen.
2. Collect all urine voided during the next 24 hours.
3. Show the patient where to store the urine.
4. Keep the urine on ice or refrigerated during the collection period.
Foley bags are kept in a basin of ice. Some collections require a
preservative. Check with the laboratory.
5. Post the hours for the urine collection in a prominent place to prevent
accidentally discarding a specimen.
6. Instruct the patient to void before defecating so that urine is not
contaminated by stool.
7. Remind the patient not to put toilet paper in the urine collection
container.
8. Collect the last specimen as close as possible to the end of the
24-hour period. Add this urine to the collection.
After
• Transport the specimen promptly to the laboratory.

= Patient teaching
 COMMON REFERENCE RANGES
FOR HEALTHY ADULTS

(NOTE: These values are generalizations. Each laboratory has specific

ranges.)
Blood Count/Hematology  Page
WBC: 5-10 × 109/L 974
RBC: 4.7 – 6.1 × 106/µL; 4.2-5.4 × 106/µL 770
Hemoglobin: 14-18 g/dL; 12-16 g/dL 488
Hematocrit: 40%-52%; 36%-47% 485
Platelets: 150-400 × 109/L 706
Prothrombin time (PT): 11-12.5 sec 753
International normalized ratio (INR): 0.8-1.1 753
Activated partial thromboplastin time (APTT): 30-40 sec 681
Glycosylated hemoglobin: 4%-5.9% 471
Electrolytes and Gastrointestinal, Renal, and
Liver Function
Sodium: 136-145 mEq/L 835
Potassium: 3.5-5 mEq/L 724
Chloride: 98-106 mEq/L 233
CO2 content (bicarbonate): 23-30 mEq/L 197
Blood urea nitrogen (BUN): 10-20 mg/dL 155
Creatinine: 0.5-1.1 mg/dL 301
Glucose: 74-106 mg/dL 462
Calcium: 9-10.5 mg/dL 189
Amylase: 60-120 U/L  56
Lipase: 0-160 U/L 562
Protein (total): 6.4-8.3 g/dL 476
Albumin: 3.5-5 g/dL 476
Bilirubin (total): 0.3-1 mg/dL 137
Bilirubin (direct): 0.1-0.3 mg/dL 137
Alkaline phosphatase (ALP): 30-120 U/L  29
Alanine aminotransferase (ALT): 4-36 U/L  21
Aspartate aminotransferase (AST): 0-35 U/L 125
Gamma-glutamyl transpeptidase (GGT): 8-38 U/L 435
Lipids
Triglycerides: 40-180 mg/dL 908
Total cholesterol: < 200 mg/dL 235
High-density lipoproteins (HDL): > 45 mg/dL; > 55 mg/dL 565
Low-density lipoproteins (LDL): < 130 mg/dL 565
 MOSBY’S

DIAGNOSTIC AND
LABORATORY
TEST REFERENCE
Fourteenth Edition

Kathleen Deska Pagana, PhD, RN

Professor Emeritus
Department of Nursing
Lycoming College
Williamsport, Pennsylvania
President, Pagana Keynotes & Presentations
http://www.KathleenPagana.com
Timothy J. Pagana, MD, FACS
Medical Director Emeritus
The Kathryn Candor Lundy Breast Health Center
Susquehanna Health System
Williamsport, Pennsylvania
Theresa Noel Pagana, MD, FAAEM
Emergency Medicine Physician
Virtua Voorhees Hospital
Voorhees, New Jersey
3251 Riverport Lane
St. Louis, Missouri 63043

MOSBY'S DIAGNOSTIC AND LABORATORY

TEST REFERENCE, FOURTEENTH EDITION ISBN: 978-0-323-60969-2

Copyright © 2019 by Elsevier, Inc. All rights reserved.

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 With love and adoration,
we dedicate this book to our grandchildren:
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Thanks for your love and support,

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 reviewers
Brenda Barnes, BS, MS, PhD
Director, Medical Lab Science
Program;
Director, EdD Health
Professions Education
Program;
Professor
Allen College-UnityPoint
Health
Waterloo, Iowa
Tammy R. Dean, RN, BSN
Program Director
The Prince William County
School of Practical Nursing
Manassas, Virginia
Sue Ellen Edrington, MSN, RN
Assistant Professor
Leighton School of Nursing
Marian University
Indianapolis, Indiana
Lorraine Kelley, DNP, RN
Nursing Instructor
Pensacola State College
Cantonment, Florida
Marilyn Kelly, RN, LNC
Health Sciences Instructor
Discovery Community
College
Nanaimo, British Columbia,
Canada
iv
Peter Miskin, RN, DHSc
Adjunct Assistant Professor
Samuel Merritt University,
Peninsula Learning Center
San Mateo, California
Flora Sayson
Instructor, Nursing
College of Southern Nevada
Las Vegas, Nevada
Jessica Massengill, MHA-Edu,
BSN, RN
Coordinator of Health
Sciences
Tennessee College of Applied
Technology-Harriman
Harriman, Tennessee
Shopha Tserotas, MS, RN
Coordinator, Weekend
Program
Assistant Clinical Professor
Texas Woman's University
Dallas, Texas
 preface
The 14th edition of Mosby’s Diagnostic and Laboratory Test
Reference provides the user with an up-to-date, essential refer-
ence that allows easy access to clinically relevant laboratory and
diagnostic tests. A unique feature of this handbook is its consis-
tent format, which allows for quick reference without sacrificing
the depth of detail necessary for a thorough understanding of
diagnostic and laboratory testing. All tests begin on a new page
and are listed in alphabetical order by their complete names. The
alphabetical format is a strong feature of the book; it allows the
user to locate tests quickly without first having to place them in an
appropriate category or body system. The User’s Guide to Test
Preparation and Procedures section outlines the responsibilities
of health-care providers to ensure that the tests are accurately and
safely performed. Use of this guide should eliminate the need
for test repetition resulting from problems with patient prepara-
tion, test procedures, or collection techniques. Information on
radiation exposure and risks has been added. Every feature of this
book is designed to provide pertinent information in a sequence
that best simulates priorities in the clinical setting.
The following information is provided, wherever applicable,
for effective diagnostic and laboratory testing:
• Name of test. Tests are listed by their complete names. A
complete list of abbreviations and alternate test names follows
each main entry.
• Type of test. This section identifies whether the test is, for
example, an x-ray procedure, ultrasound, nuclear scan, blood
test, urine test, sputum test, or microscopic examination of
tissue. This section helps the reader identify the source of the
laboratory specimen or location of the diagnostic procedure.
• Normal findings. Where applicable, normal values are listed for
the infant, child, adult, and elderly person. Also, where appro-
priate, values are separated into male and female. It is impor-
tant to realize that normal ranges of laboratory tests vary from
institution to institution. This variability is even more obvious
among the various laboratory textbooks. For this reason, we
have deliberately chosen not to add a table of normal values
as an appendix, and we encourage the user to check the nor-
mal values at the institution where the test is performed. This
should be relatively easy because laboratory reports include nor-
mal values. Results are given in both conventional units and the
International System of Units (SI units) where possible.
v
vi preface
• Possible critical values. These values give an indication of
results that are well outside the normal range. These results
require health-care provider notification and usually result in
some type of intervention. The Joint Commission is looking
at the timely and reliable communication of critical laboratory
values as one of its patient safety goals.
• Test explanation and related physiology. This section pro-
vides a concise yet comprehensive description of each test. It
includes fundamental information about the test itself, spe-
cific indications for the test, how the test is performed, what
disease or disorder the various results may show, how it will
affect the patient or client, and relevant pathophysiology that
will enhance understanding of the test.
• Contraindications. These data are crucial because they alert
health-care providers to patients to whom the test should
not be administered. Patients highlighted in this section fre-
quently include those who are pregnant, are allergic to iodin-
ated or contrast dyes, or have bleeding disorders.
• Potential complications. This section alerts the user to
potential problems that necessitate astute assessments and
interventions. For example, if a potential complication is renal
failure, the implication may be to hydrate the patient before
the test and force fluids after the test. A typical potential com-
plication for many x-ray procedures is allergy to iodinated dye.
Patient symptoms and appropriate interventions are described
in detail.
• Interfering factors. This section contains pertinent informa-
tion because many factors can invalidate the test or make the
test results unreliable. An important feature is the inclusion of
drugs that can interfere with test results. Drugs that increase
or decrease test values are always listed at the end of this sec-
tion for consistency and quick access. A drug symbol ( ) is
used to emphasize these drug interferences.
• Procedure and patient care. This section emphasizes the
role of nurses and other health-care providers in diagnostic
and laboratory testing by addressing psychosocial and physi-
ologic interventions. Patient teaching priorities are noted
with a special icon ( ) to highlight information to be com-
municated to patients. For quick access to essential informa-
tion, this section is divided into before, during, and after time
sequences.
◦ Before. This section addresses the need to explain the pro-
cedure and to allay patient concerns or anxieties. If patient
consent is usually required, this is listed as a bulleted item.
 preface vii
Other important features include requirements such as
fasting, obtaining baseline values, and performing bowel
preparations. Radiation risk is addressed with x-rays and
nuclear medicine studies.
◦ During. This section gives specific directions for
clinical specimen studies (e.g., urine and blood stud-
ies). Diagnostic procedures and their variations are
described in a numbered, usually in a step-by-step for-
mat. Important information, such as who performs the
test, where the study is performed, patient sensation,
and duration of the procedure, is bulleted for emphasis.
The duration of the procedure is very helpful for patient
teaching because it indicates the time generally allotted
for each study.
◦ After. This section includes vital information that the
nurse or other health-care provider should heed or convey
after the test. Examples include such factors as maintaining
bed rest, comparing pulses with baseline values, encourag-
ing fluid intake, and observing the patient for signs and
symptoms of sepsis.
• Abnormal findings. As the name implies, this section lists
the abnormal findings for each study. Diseases or conditions
that may be indicated by increased ( ) or decreased ( ) val-
ues are listed where appropriate.
• Notes. This blank space at the end of the tests facilitates indi-
vidualizing the studies according to the institution at which
the test is performed. Variations in any area of the test (e.g.,
patient preparation, test procedure, normal values, postproce-
dural care) can be noted here.
This logical format emphasizes clinically relevant informa-
tion. The clarity of this format allows for quick understanding
of content essential to both students and health-care provid-
ers. Color has been used to help locate tests and to highlight
critical information (e.g., possible critical values). Color is also
used in the illustrations to enhance the reader’s understanding
of many diagnostic procedures (e.g., bronchoscopy, fetoscopy,
endoscopic retrograde cholangiopancreatography [ERCP], peri-
cardiocentesis, transesophageal echocardiography [TEE]). Many
tables are used to simplify complex material on such topics as
bioterrorism infectious agents, blood collection tubes, hepatitis
testing, and protein electrophoresis. Extensive cross-referencing
exists throughout the book, which facilitates understanding
and helps the user tie together or locate related studies, such as
hemoglobin and hematocrit.
viii preface
Standard guidelines for routine blood and urine testing are
located on the inside front cover for easy access. A list of abbre-
viations for test names is included on the book’s endpapers.
Appendix A includes a list of studies according to body system.
This list may familiarize the user with other related studies the
patient or client may need or the user may want to review. This
should be especially useful for students and health-care providers
working in specialized areas.
Appendix B provides a list of studies according to test type.
This list may help the user read and learn about similarly per-
formed tests and procedures (e.g., barium enema and barium
swallow).
Appendix C provides a list of blood tests used for disease and
organ panels.
Appendix D provides a list of symbols and units of measurement.
Finally, a comprehensive index includes the names of all tests,
their synonyms and abbreviations, and any other relevant terms
found in the tests.
New to this edition is a table of Common Reference Ranges
added to the inside front cover. This adds to the user-friendly
aspect of this book by quickly identifying common reference
ranges. This is a good starting point for students and a quick
reference for routine lab values. However, because lab values vary
from institution to institution, be sure to use the normal values
of the lab performing the test.
Many new studies, such as alpha defensin, ceramides, and
small intestinal bacterial overgrowth tests, have been added. All
other studies have been revised and updated. Outdated studies
have been eliminated.
We sincerely thank our editors for their enthusiasm and con-
tinued support. We are most grateful to the many nurses and
other health-care providers who made the first 13 editions of
this book so successful. Thank you so much. This success vali-
dated the need for a user-friendly and quick-reference approach
to laboratory and diagnostic testing.
We sincerely invite additional comments from current users
of this book so that we may continue to provide useful, relevant
diagnostic and laboratory test information to users of future
editions.
Kathleen D. Pagana
Timothy J. Pagana
Theresa N. Pagana
 contents
Routine blood testing, inside front cover

Routine urine testing, inside front cover

Common reference ranges, inside front cover

List of figures, x

User’s guide to test preparation and procedures, xi

Diagnostic and laboratory tests, 1

Tests presented in alphabetical order

Appendices
Appendix A: List of tests by body system, 988
Appendix B: List of tests by type, 1000
Appendix C: Disease and organ panels, 1011
Appendix D: Symbols and units of measurement, 1015

Bibliography, 1017

Index, 1019

Abbreviations for diagnostic and laboratory tests, inside

back cover

ix
 list of figures
Figure 1 Ultrasound of the abdomen, 2
Figure 2 Amniocentesis, 53
Figure 3 Immunofluorescent staining of antinuclear antibodies, 88
Figure 4 Arthroscopy, 122
Figure 5 Bilirubin metabolism and excretion, 138
Figure 6 Bone marrow aspiration, 163
Figure 7 Bronchoscopy, 185
Figure 8 Cardiac catheterization, 204
Figure 9 Chorionic villus sampling, 242
Figure 10 Hemostasis and fibrinolysis, 251
Figure 11 Colposcopy, 262
Figure 12 Cardiac enzymes after myocardial infarction, 298
Figure 13 Cystoscopic examination of the male bladder, 309
Figure 14 Ureteral catheterization through the cystoscope, 310
Figure 15 Disseminated intravascular coagulation, 331
Figure 16 Ductoscopy, 337
Figure 17 ECG planes of reference, 343
Figure 18 Electrocardiography, 344
Figure 19 Endoscopic retrograde cholangiopancreatography, 366
Figure 20 Esophageal function studies, 380
Figure 21 Fetoscopy, 420
Figure 22 Glucose tolerance test, 468
Figure 23 Hematocrit, 486
Figure 24 Holter monitoring, 510
Figure 25 Hysteroscopy, 533
Figure 26 Liver biopsy, 571
Figure 27 Lumbar puncture, 581
Figure 28 Transbronchial needle biopsy, 585
Figure 29 Stereotactic breast biopsy, 607
Figure 30 Oximetry, 659
Figure 31 Papanicolaou (Pap) smear, 669
Figure 32 Paracentesis, 672
Figure 33 Pericardiocentesis, 690
Figure 34 Rectal ultrasonography, 741
Figure 35 Lung volumes and capacities, 760
Figure 36 Renal biopsy, 777
Figure 37 Renovascular hypertension, 784
Figure 38 Rectal culture of the female, 816
Figure 39 Urethral culture of the male, 817
Figure 40 Thoracentesis, 865
Figure 41 Fibrin clot formation, 875
Figure 42 Transesophageal echocardiography, 904

x
 user’s guide to test preparation and procedures
Health-care economics demands that laboratory and d ­ iagnostic
testing be performed accurately and in the least amount of
time possible. Tests should not have to be repeated because of
improper patient preparation, test procedure, or specimen col-
lection technique. Patient identification protocols should be fol-
lowed to avoid wrong patient events. Two patient identifiers,
such as name and date of birth, are usually used. The following
guidelines delineate the responsibilities of health-care providers
to ensure safety of test procedures and accuracy of test results.
Guidelines are described for the following major types of tests:
blood, urine, stool, x-ray, nuclear scanning, ultrasound, and
endoscopy.
Blood tests
Overview
Blood studies are used to assess a multitude of body processes
and disorders. Common studies include enzymes, serum lipids,
electrolyte levels, red and white blood cell counts, clotting fac-
tors, hormone levels, and levels of breakdown products (e.g.,
blood urea nitrogen).
Multiphasic screening machines can perform many blood tests
simultaneously using a very small blood sample. The advantages
of using these machines are that results are available quickly and
the cost is lower when compared with individually performing
each test.
Appendix C provides a list of current disease and organ
panels. For example, the basic metabolic panel and the com-
prehensive metabolic panel have replaced the Chem-7 and
Chem-12 panels. These changes are the result of federal
guidelines that have standardized the nomenclature for chem-
istry panels.
Guidelines
• Observe universal precautions when collecting a blood specimen.
• Check whether fasting is required. Many studies, such as fast-
ing blood sugar and cholesterol levels, require fasting for a
designated period of time. Water is permitted.
• If ordered, withhold medications until the blood is drawn.
• Record the time of day when the blood test is drawn. Some
blood test results (e.g., those for cortisol) vary according to
a diurnal pattern, and this must be considered when blood
levels are interpreted.
xi
xii user’s guide to test preparation and procedures
• In general, two or three blood tests can be done per tube of
blood collected (e.g., two or three chemistry tests from one
red-top tube of blood).
• Note the patient’s position for certain tests (e.g., renin,
because levels are affected by body position).
• Collect the blood in a properly color-coded test tube. Blood
collection tubes have color-coded stoppers to indicate the
presence or absence of different types of additives (preserva-
tives and anticoagulants). A preservative prevents change in
the specimen, and an anticoagulant inhibits clot formation or
coagulation. Charts are available from the laboratory indicat-
ing the type of tube needed for each particular blood test. A
representative chart is shown in Table A, p. xiv.
• Follow the recommended order of draw when collecting
blood in tubes. Draw specimens into nonadditive (e.g., red-
top) tubes before drawing them into tubes with additives.
This prevents contamination of the blood specimen with
additives that may cause incorrect test results. Fill the tubes in
the following order:
1. Blood culture tubes (to maintain sterility)
2. Nonadditive tubes (e.g., red-top)
3. Coagulation tubes (e.g., blue-top)
4. Heparin tubes (e.g., green-top)
5. Ethylenediaminetetraacetic acid (EDTA) tubes (e.g.,
lavender-top)
6. Oxalate/fluoride tubes (e.g., gray-top)
• To obtain valid results, do not fasten the tourniquet for lon-
ger than 1 minute. Prolonged tourniquet application can
cause stasis and hemoconcentration.
• Collect the blood specimen from the arm without an intra-
venous (IV) device, if possible. IV infusion can influence test
results.
• Do not use the arm bearing a dialysis arteriovenous fistula for
venipuncture unless the physician specifically authorizes it.
• Because of the risk of cellulitis, do not take specimens from
the side on which a mastectomy or axillary lymph node dissec-
tion was performed.
• Follow the unit guidelines for drawing blood from an indwell-
ing venous catheter (e.g., a triple-lumen catheter). Guidelines
will specify the amount of blood to be drawn from the cath-
eter and discarded before blood is collected for laboratory
studies. The guidelines will also indicate the amount and type
of solution needed to flush the catheter after drawing the
blood to prevent clotting.
TABLE A Common blood collection tubes

Top color Additive Purpose Test examples

Red Clot activator Allows blood sample to clot Chemistry
Separates the serum for testing Bilirubin
Blood urea nitrogen

user’s guide to test preparation and procedures xiii

Red/black Clot activator and Serum separator tube for serum Chemistry, serology
gel for serum determinatives in chemistry and
separator serology
Royal blue Heparin/EDTA Provides low levels of trace elements Trace metals, toxicology
Tan Heparin/EDTA Contains no lead Lead determinatives
Purple or lavender EDTA Prevents blood from clotting Hematology
CBC
Gray Oxalate/fluoride Prevents glycolysis Chemistry
Glucose
Green Heparin Prevents blood from clotting when Chemistry
plasma needs to be tested Ammonia
Blue (light) Sodium citrate Prevents blood from clotting when Prothrombin time
plasma needs to be tested Partial thromboplastin time
Black Sodium citrate Binds calcium to prevent blood clotting Westergren ESR
Yellow Citrate dextrose Preserves red cells Blood cultures, blood banking studies
CBC, Complete blood count; EDTA, ethylenediaminetetraacetic acid; ESR, erythrocyte sedimentation rate.
xiv user’s guide to test preparation and procedures
• Do not shake the blood specimen. Hemolysis may result from
vigorous shaking and can invalidate test results. Use gentle
inversions.
• Collect blood cultures before the initiation of antibiotic
therapy. Blood cultures are often drawn when the patient
manifests a fever. Often two or three cultures are taken at
30-minute intervals from different venipuncture sites.
• Skin punctures can be used for blood tests on capillary blood.
Common puncture sites include the fingertips, earlobes, and
heel surfaces. Fingertips are often used for small children,
and the heel is the most commonly used site for infants.
• Ensure that the blood tubes are correctly labeled and deliv-
ered to the laboratory.
• After the specimen is drawn, apply pressure or a pres-
sure dressing to the venipuncture site. Assess the site for
bleeding.
• If the patient fasted before the blood test, reinstitute the appro-
priate diet.
Urine tests
Overview
Urine tests are easy to obtain and provide valuable information
about many body system functions (e.g., kidney function, glu-
cose metabolism, and various hormone levels). The ability of the
patient to collect specimens appropriately should be assessed to
determine the need for assistance.
Guidelines
• Observe universal precautions in collecting a urine
specimen.
• Use the first morning specimen for routine urinalysis because
it is more concentrated. To collect a first morning specimen,
have the patient void before going to bed and collect the first
urine specimen immediately upon rising.
• Random urine specimens can be collected at any time. They
are usually obtained during daytime hours and without any
prior patient preparation.
• If a culture and sensitivity (C&S) study is required or if the
specimen is likely to be contaminated by vaginal discharge or
bleeding, collect a clean-catch or midstream specimen. This
requires meticulous cleansing of the urinary meatus with an
antiseptic preparation to reduce contamination of the speci-
men by external organisms. Then the cleansing agent must be
completely removed because it may contaminate the speci-
men. Obtain the midstream collection by doing the following:
 user’s guide to test preparation and procedures xv
1. Have the patient begin to urinate in a bedpan, urinal, or
toilet and then stop urinating. (This washes the urine out
of the distal urethra.)
2. Correctly position a sterile urine container and have the
patient void 3 to 4 oz of urine into it.
3. Cap the container.
4. Allow the patient to finish voiding.
• One-time composite urine specimens are collected over a
period that may range anywhere from 2 to 24 hours. To col-
lect a timed specimen, instruct the patient to void and discard
the first specimen. This is noted as the start time of the test.
Instruct the patient to save all subsequent urine in a special
container for the designated period. Remind the patient to
void before defecating so that urine is not contaminated by
feces. Also, instruct the patient not to put toilet paper in the
collection container. A preservative is usually used in the col-
lection container. At the end of the specified time period, have
the patient void and then add this urine to the specimen con-
tainer, thus completing the collection process.
• Collection containers for 24-hour urine specimens should hold
3 to 4 L of urine and have tight-fitting lids. They should be
labeled with the patient’s name, the starting collection date and
time, the ending collection date and time, the name of the test,
the preservative, and storage requirements during collection.
• Many urine collections require preservatives to maintain their
stability during the collection period. Some specimens are
best preserved by being kept on ice or refrigerated.
• Urinary catheterization may be needed for patients who are
unable to void. This procedure is not preferred because of
patient discomfort and the risk of patient infection.
• For patients with an indwelling urinary catheter, obtain a
specimen by aseptically inserting a needleless syringe into the
catheter at a drainage port distal to the sleeve leading to the
balloon. Aspirate urine and then place it in a sterile urine con-
tainer. The urine that accumulates in the plastic reservoir bag
should never be used for a urine test.
• Urine specimens from infants and young children are usually
collected in a disposable pouch called a U bag. This bag has an
adhesive backing around the opening to attach to the child’s
perineum. After the bag is in place, check the child every 15
minutes to see if an adequate specimen has been collected.
Remove the specimen as soon as possible after the collection
and then label it and transport it to the laboratory.
xvi user’s guide to test preparation and procedures

Stool tests
Overview
The examination of feces provides important information that
aids in the differential diagnosis of various gastrointestinal dis-
orders. Fecal studies may also be used for microbiologic studies,
chemical determinations, and parasitic examinations.
Guidelines
• Observe universal precautions in collecting a stool specimen.
• Collect stool specimens in a clean container with a fitted lid.
• Do not mix urine and toilet paper with the stool specimen.
Both can contaminate the specimen and alter the results.
• Fecal analysis for occult blood, white blood cells, or qualita-
tive fecal fat requires only a small amount of a randomly col-
lected specimen.
• Quantitative tests for daily fecal excretion of a particular sub-
stance require a minimum of a 3-day fecal collection. This col-
lection is necessary because the daily excretion of feces does
not correlate well with the amount of food ingested by the
patient in the same 24-hour period. Refrigerate specimens or
keep them on ice during the collection period. Collect stool
in a 1-gallon container.
• A small amount of fecal blood that is not visually apparent is
termed occult blood. Chemical tests using commercially pre-
pared slides are routinely used to detect fecal blood. Numerous
commercial slide tests use guaiac as the indicator. These guaiac
tests are routinely done on nursing units and in medical offices.
• Consider various factors (e.g., other diagnostic tests and
medications) in planning the stool collection. For example, if
the patient is scheduled for x-ray studies with barium sulfate,
collect the stool specimen first. Various medications (e.g., tet-
racyclines and antidiarrheal preparations) affect the detection
of intestinal parasites.
• Some fecal collections require dietary restrictions before the
collection (e.g., tests for occult blood).
• Correctly label and deliver stool specimens to the laboratory
within 30 minutes after collection. If you are unable to deliver
the specimen within 30 minutes, it may be refrigerated for up
to 2 hours.
X-ray studies
Overview
Because of the ability of x-rays to penetrate tissues, x-ray stud-
ies provide a valuable picture of body structures. X-ray studies
can be as simple as a routine chest x-ray image or as complex as
 user’s guide to test preparation and procedures xvii
dye-enhanced cardiac catheterization. With the concern about
radiation exposure, it is important to realize that the patient may
question if the proposed benefits outweigh the risks involved.
Radiation dose
There are several units used to quantify amount of radia-
tion absorbed from diagnostic imaging tests. The gray (Gy) is
the measure of the amount of energy absorbed per unit mass.
Because different organs in the body absorb radiation differently,
the sievert (Sv) is often used instead of the gray. The sievert is
the biological effect of 1 gray of radiation on human body tis-
sue. The sievert is more helpful in comparing radiation exposure
to different parts of the body. Radiation doses in medical imag-
ing are typically measured in millisieverts (mSv) or 1/1000 of a
sievert. On average, each person receives about 3 mSv of radia-
tion yearly from natural background radiation.
The roentgen equivalent in man (rem) is an older unit to
quantify the amount of radiation absorbed from x-rays. 1 rem is
equivalent to 0.01 sievert.
See chart below for average amounts of radiation for adults
associated with diagnostic testing.
Risk of radiation
Radiation exposure can cause damage to DNA. The body usu-
ally rapidly repairs this damage. Mistakes in DNA repair can lead
to chromosomal or gene abnormalities that may be linked to
cancer induction. The likelihood of cancer induction secondary
to radiation exposure increases as the amount of radiation expo-
sure increases. A person has a 5% increase in developing cancer
over his or her lifetime after radiation exposure of 1 Sv or more.
There can be a lag of many years between radiation exposure
and cancer diagnosis. The average lag time is about 10 years
after exposure.
The cumulative radiation dose from diagnostic imaging is very
small and the benefit of proper diagnosis and treatment of disease
generally outweighs the risks. However each patient’s current sit-
uation and history of radiation must be considered to accurately
assess cumulative risks and benefits. Diagnostic procedures with
higher radiation doses (e.g., computed tomography [CT] scans)
should be clearly justified. Appropriateness Criteria published by
the American College of Radiology (acr.org) is helpful in justifi-
cation of performance of x-ray imaging.
Special consideration should be given to pregnant women
and children before ordering x-ray imaging because the effects
of radiation are more profound in fetuses and young children.
xviii user’s guide to test preparation and procedures
If a woman is pregnant, the risks versus benefits must be care-
fully considered. Certain studies with low radiation in which the
focus of radiation is not on the fetus are obviously safer. (Lead-
containing shields can reduce x-ray exposure to fetuses.) Imaging
using higher dose of radiation should be given only if the risk of
not making the diagnosis is greater than the radiation risk.
Radiation risks are most significant in early fetal period and
are less significant as the pregnancy progresses.
Patients with high body mass indexes should also be given
extra consideration before ordering imaging studies. These
patients often require greater radiation doses to penetrate body
thickness to create acceptable images. Nuclear medicines studies
are not affected in the same way. Although the x-ray exposure
needed to produce one fluoroscopic image is low (compared
with radiography), high exposures to patients can result from the
time that may be encountered in fluoroscopic procedures.
Radiation Associated with Diagnostic Testing

Common radiology Average adult effective

imaging (XR) dosea (mSv)
Abdomen 0.7
Back (lower) 1.5
Back (upper) 1
Barium enema 8
Bone densitometry (DEXA) 0.001
Cervical spine 0.2
Chest 0.1
Dental 0.005-0.01
Extremity (hands, feet, and 0.001
so on)
Fluoroscopy Per minute
Hip 0.7
Hysterosalpingography 2
Intravenous pyelography 3
(IVP)
Mammography 0.4
Neck 0.2
Pelvis 0.6
Skull 0.1
Small bowel follow-through 5
Spine (lumbar) 1.5
Spine (thoracic) 1.0
Upper GI series 6
 user’s guide to test preparation and procedures xix

Common CT imaging
Abdomen and pelvis 10
Brain (head) 2
Chest 7
Chest (low-dose screening) 2
Coronary angiography 15
CT angiography of the chest 15
Neck 3
Sinuses 0.6
Spine 6
Virtual colonoscopy 10

Nuclear medicine
Bone scan 5
Brain scan 6.9
Cardiac nuclear stress testing 20-40
Gastric emptying scan 0.4
GI bleeding scan 7.8
Liver scan 3.1
Lung scan 2
(ventilation/perfusion)
Parathyroid scan 6.7
Renal scan 2.6
Thyroid scan 4.8
Urea breath test 0.003
WBC scan 6.7

Other
Abdominal angiogram 12
Cardiac catheterization (diagnostic) 7
Coronary angiogram (stent) 15
Endoscopic retrograde 4
cholangiopancreatography (ERCP)
Fluoroscopic Barium Swallow 1.5
Head and neck angiogram 5
Positron emission tomography 25
(PET)/CT
Pulmonary angiography 5

Effective doses are given as an average, and there may be wide variability in
a

dosing depending on particularities of the test in different testing locations.

xx user’s guide to test preparation and procedures
Guidelines
• Assess the patient for any similar or recent x-ray procedures.
• Evaluate the patient for allergies to iodine dye. Carefully con-
sider the following points:
1. Many types of contrast media are used in radiographic
studies. For example, organic iodides and iodized oils are
frequently used.
2. Allergic reactions to iodinated dye may vary from mild
flushing, itching, and urticaria to severe, life-threatening
anaphylaxis (evidenced by respiratory distress, drop in
blood pressure, or shock). In the unusual event of ana-
phylaxis, the patient is treated with diphenhydramine
(Benadryl), steroids, and epinephrine. Oxygen and endo-
tracheal equipment should be on hand for immediate use.
3. The patient should always be assessed for allergies to
iodine dye before it is administered. Inform the radiolo-
gist if an allergy to iodinated contrast is suspected. The
radiologist may prescribe Benadryl and steroid preparation
to be administered before testing. Usually, hypoallergenic
nonionic contrast will be administered to allergic patients
during the test.
4. After the x-ray procedure, evaluate the patient for a delayed
reaction to dye (e.g., dyspnea, rashes, tachycardia, hives).
This usually occurs within 2 to 6 hours after the test. Treat
with antihistamines or steroids.
• Assess the patient for any evidence of dehydration or renal
disease. Usually BUN and creatinine tests are obtained before
administration of iodine-containing IV contrast. Hydration
may be required before the administration of iodine.
• Assess the patient for diabetes. People with diabetes are par-
ticularly susceptible to renal disease caused by the administra-
tion of iodine-containing IV contrast. Patients with diabetes
who take metformin (Glucophage) or glyburide (Micronase)
are particularly susceptible to lactic acidosis and hypoglyce-
mia. These medications may be discontinued for 1 to 4 days
before and 1 to 2 days after the administration of iodine.
Check with the x-ray department.
• Women in their childbearing years should have x-ray examina-
tions during menses or within 10 to 14 days after the onset of
menses to avoid possible exposure to a fetus.
• Pregnant women should not have x-ray procedures unless the
benefits outweigh the risk of damage to the fetus.
 user’s guide to test preparation and procedures xxi
• Note whether other x-ray studies are being planned; schedule
them in the appropriate sequence. For example, x-ray exami-
nations that do not require contrast should precede exami-
nations that do require contrast. X-ray studies with barium
should be scheduled after ultrasonography.
• Note the necessary dietary restrictions. Such studies as barium
enema and intravenous pyelogram (IVP) are more accurate if
the patient is kept NPO (fasting from food and liquids) for
several hours before the test.
• Determine whether bowel preparations are necessary. For
example, barium enemas and IVPs require bowel-cleansing
regimens.
• Determine whether signed consent forms are required. These
are necessary for most invasive x-ray procedures.
• Remove metal objects (e.g., necklaces, watches) because they
can hinder visualization of the x-ray field.
• Patient aftercare is determined by the type of x-ray proce-
dure. For example, a patient having a simple chest x-ray study
will not require postprocedure care. However, invasive x-ray
procedures involving contrast dyes (e.g., cardiac catheteriza-
tion) require extensive nursing measures to detect potential
complications.
Nuclear scanning
Overview
With the administration of a radionuclide and subsequent mea-
surement of the radiation of a particular organ, functional
abnormalities of various body areas (e.g., brain, heart, lung,
­
bones) can be detected. Because the half-lives of the radioisotopes
are short, only minimal radiation exposure occurs (See p. xx).
Guidelines
• Radiopharmaceuticals concentrate in target organs by various
mechanisms. For example, some labeled compounds (e.g.,
hippuran) are cleared from the blood and excreted by the kid-
neys. Some phosphate compounds concentrate in the bone
and infarcted tissue. Lung function can be studied by imaging
the distribution of inhaled gases or aerosols.
• Note whether the patient has had any recent exposure to
radionuclides. The previous study could interfere with the
interpretation of the current study.
• Note the patient’s age and current weight. This information
is used to calculate the dose of radioactive substances.
xxii user’s guide to test preparation and procedures
• Nuclear scans are contraindicated in pregnant women and
nursing mothers.
• Many scanning procedures do not require special prepara-
tion. However, a few have special requirements. For example,
for bone scanning, the patient is encouraged to drink sev-
eral glasses of water between the time of the injection of the
isotope and the actual scanning. For some studies, blocking
agents may need to be given to prevent other organs from
taking up the isotope.
• For most nuclear scans, a small amount of an organ-specific
radionuclide is given orally or injected intravenously. After
the radioisotope concentrates in the desired area, the area is
scanned. The scanning procedure usually takes place in the
nuclear medicine department.
• Instruct the patient to lie still during the scanning.
• Usually encourage the patient to drink extra fluids to
enhance excretion of the radionuclide after the test is
finished.
• Although the amount of radionuclide excreted in the urine is
very low, rubber gloves are sometimes recommended if the
urine must be handled. Some hospitals may advise the patient
to flush the toilet several times after voiding.
Ultrasound studies
Overview
In diagnostic ultrasonography, harmless high-frequency sound
waves are emitted and penetrate the organ being studied. The
sound waves bounce back to the sensor and are electronically
converted into a picture of the organ. Ultrasonography is used
to assess a variety of body areas, including the pelvis, abdomen,
breast, heart, and pregnant uterus.
Guidelines
• Most ultrasound procedures require little or no prepara-
tion. However, the patient having a pelvic sonogram needs
a full bladder, and the patient having an ultrasound exami-
nation of the gallbladder must be kept NPO before the
procedure.
• Ultrasound examinations are usually performed in an ultra-
sound room; however, they can be performed in the patient
unit.
• For ultrasound, a greasy paste is applied to the skin overly-
ing the desired organ. This paste is used to enhance sound
transmission and reception because air impedes transmission
of sound waves to the body.
 user’s guide to test preparation and procedures xxiii
• Because of the noninvasive nature of ultrasonography, no spe-
cial measures are needed after the study except for helping the
patient remove the ultrasound paste.
• Ultrasound examinations have no radiation risk.
• Ultrasound examinations can be repeated as many times as
necessary without being harmful to the patient. No cumula-
tive effect has been seen.
• Barium has an adverse effect on the quality of abdominal
studies. For this reason, schedule ultrasound of the abdomen
before barium studies.
• Large amounts of gas in the bowel obstruct visualization of
the bowel. This is because bowel gas is a reflector of sound.
Endoscopy procedures
Overview
With the help of a lighted, flexible instrument, internal structures
of many areas of the body (e.g., stomach, colon, joints, bronchi,
urinary system, and biliary tree) can be directly viewed. The spe-
cific purpose and procedure should be reviewed with the patient.
Guidelines
• Preparation for an endoscopic procedure varies according to
the internal structure being examined. For example, examina-
tion of the stomach (gastroscopy) will require the passage of an
instrument through the esophagus and into the stomach. The
patient is kept NPO for 8 to 12 hours before the test to pre-
vent gagging, vomiting, and aspiration. For colonoscopy, an
instrument is passed through the rectum and into the colon.
Therefore, the bowel must be cleansed and free of fecal mate-
rial to afford proper visualization. Arthroscopic examination of
the knee joint is usually done with the patient under general
anesthesia, which necessitates routine preoperative care.
• Schedule endoscopic examinations before barium studies.
• Obtain a signed consent for endoscopic procedures.
• Endoscopic procedures are preferably performed by a physi-
cian in a specially equipped endoscopy room or in an operat-
ing room. However, some kinds can safely be performed at
the bedside.
• Air is instilled into the bowel during colon examinations to
maintain patency of the bowel lumen and to afford better
visualization. This sometimes causes gas pains.
• In addition to visualization of the desired area, special pro-
cedures can be performed. Biopsies can be obtained, and
bleeding ulcers can be cauterized. Also, knee surgery can be
performed during arthroscopy.
xxiv user’s guide to test preparation and procedures
• Specific postprocedure interventions are determined by the
type of endoscopic examination performed. All procedures
have the potential complication of perforation and bleeding.
Most procedures use some type of sedation; safety precau-
tions should be observed until the effects of the sedatives have
worn off.
• After colonoscopy and similar studies, the patient may com-
plain of rectal discomfort. A warm tub bath may be soothing.
• Usually keep the patient NPO for 2 hours after endoscopic
procedures of the upper gastrointestinal system. Be certain
that swallow, gag, and cough reflexes are present before per-
mitting fluids or liquids to be ingested orally.
 abdominal ultrasound 1

abdominal ultrasound (Abdominal sonogram) A

Type of test Ultrasound

Normal findings
Normal abdominal aorta, liver, gallbladder, bile ducts, pancreas,
kidneys, ureters, and bladder
Test explanation and related physiology
Ultrasonography provides accurate visualization of the
abdominal aorta, liver, gallbladder, pancreas, bile ducts, kidneys,
ureters, and bladder. Real-time ultrasound provides an accurate
picture of the organ being studied (Figure 1).
The kidney is ultrasonographically evaluated to diagnose
and locate renal cysts, to differentiate renal cysts from solid
renal tumors, to demonstrate renal and pelvic calculi, to docu-
ment hydronephrosis, to guide a percutaneously inserted needle
for cyst aspiration or biopsy, and to place a nephrostomy tube.
Ultrasound of the urologic tract is also used to detect malformed
or ectopic kidneys and perinephric abscesses. Renal transplanta-
tion surveillance is possible with ultrasound.
Endourethral urologic ultrasound can also be performed
through a stent that has a transducer at its end. The stent probe
can be advanced into the bladder where the depth of a tumor into
the bladder wall can be measured. In the ureter, stones, tumors, or
extraurethral compression can be identified and localized. Finally,
in the proximal ureter, renal tumors or cysts can be delineated.
One of the most common uses of ultrasound is the measure-
ment of post void urinary bladder residual. This is a measure-
ment of the amount of urine after micturition. This test can be
easily performed at the bedside or in doctor’s office with a por-
table ultrasound unit.
Pelvic, obstetric, prostate, and testes ultrasound are discussed
on pp. 685 and 799.
The abdominal aorta can be assessed for aneurysmal dilation.
Ultrasound is used to detect cystic structures of the liver
(e.g., benign cysts, hepatic abscesses, and dilated hepatic ducts)
and solid intrahepatic tumors (primary and metastatic). Hepatic
ultrasound also can be performed intraoperatively to provide the
locations of small, nonpalpable hepatic tumors or abscesses. The
gallbladder and bile ducts can be visualized and examined for evi-
dence of gallstones, polyps, or bile duct dilation. The pancreas is
examined for evidence of tumors, pseudocysts, acute inflamma-
tion, chronic inflammation, or pancreatic abscesses. Because this
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The Project Gutenberg eBook of A scrap of
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This ebook is for the use of anyone anywhere in the United States
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Title: A scrap of paper

The inner history of German diplomacy and her scheme of
world-wide conquest

Author: Emile Joseph Dillon

Release date: November 18, 2023 [eBook #72164]

Language: English

Original publication: London: Hodder & Stoughton, 1914

Credits: Brian Coe and the Online Distributed Proofreading Team at

https://www.pgdp.net (This file was produced from images
generously made available by The Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK A SCRAP OF

PAPER ***
 Transcriber’s Notes
Additional notes will be found near the end of this ebook.
This book did not have a Table of Contents. The one below
has been prepared by the Transcriber, using the actual Chapter
headings.

CONTENTS
INTRODUCTORY v

CHAPTER I
THE CAREFULLY LAID SCHEME 1

CHAPTER II
THE MANY-TRACKED LINES OF GERMAN DIPLOMACY 15

CHAPTER III
THE PLAN AND ITS EXECUTION 27

CHAPTER IV
FORCING THE QUARREL 40

CHAPTER V
GERMANY’S PROGRAMME 69

CHAPTER VI
THE POSITION OF ITALY 78

CHAPTER VII
THE TWELFTH HOUR 98

CHAPTER VIII
THE EARTHQUAKE 127

CHAPTER IX
BRITISH NEUTRALITY AND BELLIGERENCY 141

CHAPTER X
THE INFAMOUS OFFER 154

CHAPTER XI
JUST FOR “A SCRAP OF PAPER” 177

APPENDIX
DIPLOMACY AND THE WAR 205
Photo: Elliott & Fry
Dr. E. J. DILLON
A SCRAP of PAPER
THE INNER HISTORY OF
GERMAN DIPLOMACY
AND HER SCHEME OF
WORLD-WIDE CONQUEST
By
Dr. E. J. DILLON
Third Edition.

HODDER AND STOUGHTON

LONDON NEW YORK TORONTO
MCMXIV
 INTRODUCTORY
“Just for a word—neutrality, a word which in war-time had so often
been disregarded—just for a scrap of paper Great Britain was going
to make war.” Such was the significant comment of the German
Chancellor on Great Britain’s determination to uphold the neutrality
of Belgium. A scrap of paper! This phrase, applied to a binding
treaty, is destined to stick like a Nessus’ shirt to the memory of its
author, his imperial inspirer, and their country until such time as the
militarism which originated it has been consumed without residue. It
is a Satanic sneer hurled with fell purpose into a world of civilized
human beings. No such powerful dissolvent of organized society has
been devised since men first began to aggregate. The primal source
of the inner cohesive force which holds the elements of society
together is faith in the plighted word. Destroy that and you have
withdrawn the cement from the structure, which will forthwith crumble
away. But this prospect does not dismay the Prussian. He is ready to
face and adjust it to his needs. He would substitute for this inner
cohesion the outer pressure of militarism, which, like the hoops of a
barrel, press together the staves. Brutal force, in the form of jackboot
tyranny, then, is the amended formula of social life which is to be
forced upon Europe and the world. Such, in brief, is the new social
gospel of the Hohenzollerns, the last word of Teutonic culture.
This revolutionary doctrine, applied thus simply and
undisguisedly to what normal peoples deem the sacredness of
treaties, has awakened dormant British emotion to self-
consciousness and let loose a storm of indignation here. It startled
the quietism of the masses and their self-complacent leaders, whose
comforting practice was to refuse to think evil of the Germans,
however overwhelming the evidence. The windy folly of these
advocati diaboli, from whom the bulk of the British nation derived
their misconceptions of the German Empire, worked evils of which
we have as yet witnessed only the beginning. Those who, like
myself, know the country, its institutions, its language, literature,
social life, and national strivings, and who continually warned their
countrymen of what was coming, were put out of court as croaking
prophets of the evil which we ourselves were charged with stirring
up.
It is now clear to the dullest apprehension that the most dismal of
those forecasts, the most sinister of those predictions, were terribly
real, while the comforting assurances of the ever-ready publicists
and politicians, who knew Germany only from books of travel,
holiday excursions, or the after-dinner eloquence of members of
Anglo-German Leagues, were but dangerous mirages which lulled
the nation’s misgivings to slumber. And now the masses have been
ungently awakened. The simple declaration of a German statesman
of repute, and a man, too, of the highest honesty as this term is
understood in his own country, that the most solemn treaty, ratified
and relied upon as stronger than fortresses bristling with cannon, is
but a scrap of paper, unworthy the notice of an enterprising nation,
suddenly drew into the light of Western civilization the new and
subversive body of doctrine which the Teutons of Europe had for a
generation been conspiring to establish, and would have succeeded
in establishing were it not for a single hitch in the execution of their
programme. If the combined efforts of peace-loving France, Russia,
Great Britain, and Italy had moved the Tsar’s Government to stay its
hand and allow Servia to be mutilated, and the Bucharest Treaty to
be flung aside as a worthless scrap of paper, or if Austria had been
permitted to listen to M. Sazonoff’s request and reduce her demands
within the compass of the possible, the realization of the Teutonic
plot against non-German Europe would have been begun later on,
under much more favourable auspices, and probably worked out to a
successful issue. That plot belongs to a category of crimes against
the human race which can hardly be more effectively attacked than
by plainly stating its objects and the means relied upon to attain
them.
The objects of Prussia’s ambition—an ambition shared by every
anæmic, bespectacled clerk and able-bodied tram-conductor in the
Fatherland—are “cultural,” and the means of achieving them are
heavy guns, quick-firers, and millions of ruthless warriors. Real
German culture in all its manifestations—scientific, artistic,
philosophical, musical, commercial, and military—accepts and
champions the new principle and the fresh ideas which are to
regenerate the effete social organisms of to-day. According to the
theory underlying this grandiose national enterprise, the forces of
Christianity are spent. New ichor for the dry veins of decrepit Europe
is stored up in German philosophy and poetry. Mediæval art has
exhausted the traditional forms, but Teutonism is ready to furnish it
with new ones. Music is almost a creation of German genius.
Commerce was stagnating in the ruts of old-world use and wont until
German enterprise created new markets for it, and infused a new
spirit into its trading community. Applied science owes more to
German research and ingenuity than to the efforts of all the world
besides. And the race thus highly gifted is deserving of a field worthy
of its world-regenerating labours. At present it is cooped up in
Central Europe with an absurdly small coast-line. Its surplus
population has, for lack of colonies, to be dumped down on foreign
shores, where it is lost for ever to the Fatherland. For this degrading
position, which can no longer be tolerated, there is but one remedy:
expansion. But to be effectual it must be expansion combined with
Germanization. And the only means of accomplishing this end is for
Germany to hack her way through the decrepit ethnic masses that
obstruct her path and to impose her higher civilization on the natives.
Poland was the first vile body on which this experiment was tried,
and it has been found, and authoritatively announced, that the Slavs
are but ethnic manure, useful to fertilize the seed-fields of Teutonic
culture, but good for little else. The Latin races, too, are degenerates
who live on memories and thrive on tolerance. Beef-eating Britons
are the incarnation of base hypocrisy and crass self-indulgence, and
their Empire, like a hollow tree, still stands only because no storm
has yet assailed it. To set youthful, healthy, idealistic Germany in the
high places now occupied by those inert masses that once were
progressive nations is but to adjust obsolete conditions to the
pressing requirements of the present time—to execute the wise
decrees of a just God. And in order to bring this task to a satisfactory
issue, militarism must reign as the paramount power before culture
can ascend the throne. Militarism is a necessity, and unreasoning
obedience the condition of its success.
It is easy to think scorn of these arrogant pretensions and to turn
away from them to what may seem more urgent and more profitable
occupations. And hitherto this has been the attitude towards them of
the advanced wing of British progressists, who imitated the Germans
in this—that they judged of others’ motives by their own. But the
danger cannot be exorcized by contempt or indifference. The forces
at the command of the Teuton are stupendous. His army is a
numerous, homogeneous, and self-sacrificing nation. His weapons
are the most deadly that applied science could invent and the most
practised skill could fashion. And these weapons are handled not by
amateur or unwilling soldiers, but by fanatics as frenzied as the
Moslems, who behold paradise and its houris athwart the grey
smoke of the battlefield. For Teutonism is not merely a political
system, it is also a religious cult, and its symbol of faith is
Deutschland über Alles. Germany above everything, including
human and divine laws.
One of the dogmas of this cult resembles that of the invisible
Church, and lays it down that the members of this chosen race are
far more numerous in the present, as indeed they also were in the
past, than the untutored mind is apt to imagine. The greatest artists
of mediæval Italy, whom an ignorant world regards as Italian, nay
Christ himself, were Germans whose nationality has only just been
discovered. That the Dutch, the Swiss, the Belgians, the Swedes
and Norwegians, and the recalcitrant British are all sheep strayed
from the Teutonic flock, and destined to be brought back by the
collies of militarism, is a self-evident axiom. This process of recovery
had already begun and was making visible progress. Antwerp was
already practically Germanized, and Professor Delbrück, in his reply
to one of my articles on German expansion, described it as
practically a German port. The elections to the municipality in that
flourishing Belgian town were run by the German wealthy residents
there. The lace manufactories of Belgium were wholly in German
hands. So, too, was the trade in furs. A few years more of peaceful
interpenetration would have seen Holland and Belgium linked by a
postal and, perhaps, a Customs union with the German Empire.
In this new faith ethics play no part. The furtherance of the
German cause takes precedence of every law, divine and human. It
is the one rule of right living. Whatever is done for Germany or for
the German army abroad or at home, be it a misdemeanour or a
crime in the eyes of other peoples, is well done and meritorious. A
young midshipman, going home at night in a state of semi-
intoxication, slays a civilian because he imagines—and, as it turns
out, mistakenly imagines—that he has been slighted, and feels
bound in duty to vindicate the honour of the Kaiser’s navy. He is
applauded, not punished. Soldiers sabre laughing civilians in the
street for the honour of the Kaiser’s uniform, and in lieu of
chastisement they receive public approbation. Abroad, Germans of
position—German residents in Antwerp offered a recent example—
worm themselves into the confidence of the authorities, learn their
secrets, offer them “friendly” advice, and secretly communicate
everything of military importance which they discover to their
Government, which secretly subsidizes them, and betray the trusting
people whose hospitality and friendship they have so long enjoyed.
Their conduct is patriotic. The press deliberately concocts news,
spreads it throughout the world, systematically poisoning the wells of
truth, and then vilifies the base hypocrisy of the British, who
contradict it. That is part of the work of furthering the good cause of
civilization. Tampering with State documents and forging State
papers are recognized expedients which are wholly justified by the
German “necessity which knows no law.” We have had enlightening
examples of them since the war broke out. Prince Bismarck availed
himself of this cultural privilege when he altered the Kaiser’s
despatch in order to precipitate a collision with France. And the
verdict of the nation was “Well done, thou good and faithful servant,
who hast made such patriotic use of the maxim that the end, when it
is Germany’s cause, justifies the means and hallows the act.” Since
his day the practice has been reduced to a system.
With such principles illustrated by such examples, how could the
present Imperial Chancellor regard a mere parchment treaty that lay
across the road of his country’s army other than as a mere scrap of
paper?
That was a logical corollary of the root-principle of Pan-
Germanism. Germany’s necessity, of which her own Kaiser,
statesmen, diplomatists, and generals are the best judges, knows no
law. Every treaty, every obligation, every duty has to vanish before it:
the Treaty of Bucharest, establishing equilibrium in the Balkans, as
well as the Treaty of 1839, safeguarding the neutrality of Belgium.
Hence nobody conversant with the nature, growth, and spread of this
new militant race-worship was in the least surprised at the
Chancellor’s contempt for the scrap of paper and for the simple-
minded statesmen who proclaimed its binding force. I certainly was
not. Experience had familiarized me with these German doctrines
and practices; and although my experience was more constant and
striking than that of our public men who had spent most of their lives
in Great Britain, they, too, had had tokens enough of the new ethics
which Prussia had imported into her international policy to put them
on their guard against what was coming. But nobody is so blind as
he who will not see.
Pan-Germanism, then, is become a racial religion, and to
historical and other sciences has been confided the task of
demonstrating its truth. But if curiosity prompts us to inquire to what
race its military apostles, the Prussians, belong, and to interrogate
history and philology on the subject, we find that they are not
Germans at all. This fact appears to have escaped notice here. The
Prussians are members of a race which in the ethnic groups of
European Aryans occupy a place midway between the Slavs and the
Teutons. Their next-of-kin are the Lithuanians and the Letts. The
characteristic traits of the old Prussians, the surviving fragments of
whose language I was once obliged to study, are brutal arrogance
towards those under them, and cringing servility towards their
superiors. One has but to turn to the political history of the race to
gather abundant illustrations of these distinctive marks. To the
submissiveness of the masses is to be attributed the ease with which
the leaders of the nation drilled it into a vast fighting machine, whose
members often and suddenly changed sides without murmur or
criticism at the bidding of their chief. And it was with this redoubtable
weapon that the Hohenzollern dynasty, which itself is German, won
for the State over which it presided territory and renown. This done,
and done thoroughly, it was Prussia who experimented upon all
Germany in the way in which the Hohenzollerns had experimented
on Prussia; and being supported by the literary, artistic, and scientific
elements of the German people, succeeded thus far, and might have
ended by realizing their ambitious dream, had it not been for the
interposition of circumstance which misled them in their choice of
opportunity.
Thus latter-day Germany furnishes a remarkable instance of the
remoulding of a whole nation by a dynasty. For the people has, in
truth, in some essential respects been born anew. The centre of its
ethico-spiritual system has been shifted, and if it had a chance of
gaining the upper hand Europe would be confronted with the most
appalling danger that ever yet threatened. Morality, once cultivated
by Germans with religious fervour, has become the handmaid of
politics, truth is subservient to expediency, honour the menial of the
regiment. Between the present and the past yawns an abyss. The
country of Leibnitz, of Kant, of Herder, and of Goethe was marked off
by fundamental differences from the Germany of to-day. The nation’s
ideas have undergone since then an amazing transformation, which
is only now unfolding itself in some of its concrete manifestations to
the gaze of the easy-going politicians of this country. So, too, have
the ethical principles by which the means of pursuing the ideals were
formerly sifted and chosen. The place once occupied by a spiritual
force, by the conscience of the nation and the individual, is now
usurped by a tyrannical system devised by a military caste for a
countless army. And this system has been idealized and popularized
by visionaries and poets, professors, and even ministers of religion
whose spiritual nature has been warped from childhood. To-day
there is no counter-force in the land. Jesuitism, as the most virulent
Calvinists depict it at its worst, was a salutary influence when
compared with this monstrous product of savagery, attired in military
uniform and the wrappages of civilization, and enlisted in the service
of rank immorality.
 What could afford our normally constituted people a clearer
insight into the warped moral sense of the Prussianized German
people than the remarkable appeal recently made by the “salt of the
Fatherland,” German theologians and clergymen, to “Evangelical
Christians abroad,” setting forth the true causes of the present
1
iniquitous war? These men of God preface their fervent appeal by
announcing to Evangelical Christians the lamentable fact that “a
systematic network of lies, controlling the international telegraph
service, is endeavouring in other lands to cast upon our people and
its Government the guilt for the outbreak of this war, and has dared
to dispute the inner right of us and our Emperor to invoke the
assistance of God.... Her ideal was peaceful work. She has
contributed a worthy share to the cultural wealth of the modern
world. She has not dreamed of depriving others of light and air. She
desired to thrust no one from his place. In friendly competition with
other peoples she has developed the gifts which God had given her.
Her industry brought her rich fruit. She won also a modest share in
the task of colonization in the primitive world, and was exerting
herself to offer her contribution to the remoulding of Eastern Asia.
She has left no one, who is willing to see the truth, in doubt as to her
peaceful disposition. Only under the compulsion to repel a wanton
attack has she now drawn the sword.”
These heralds of peace and Christian love appear to have been
so immersed in their heavenly mission that they have not had time to
peruse such unevangelical works as the writings of Treitschke,
Clausewitz, Maurenbrecher, Nietzsche, Delbrück, Rohrbach,
Schmoller, Bernhardi. And yet these are the evangelists of the
present generation of Germans. Whether the innocence of the dove
or the wisdom of the serpent is answerable for this failure of the
Evangelical Germans to face the facts is immaterial. The main point
is that first the German professors published their justification of this
revolting crime against humanity; then came the anathema hurled
against the allies by German authors, who pledged themselves
never again to translate into the language of God’s chosen people
the works of any French, English, or Russian man of letters; these
were succeeded by the Socialists, who readily discovered chapter
and verse in the Gospel of Marx for the catastrophic action of the
Government they were wont to curse, and exhorted their Italian
comrades to espouse the Kaiser’s cause against the allies; and now
the rear of this solemn procession of the nation’s teachers is brought
up by their spiritual guides and pastors, who publicly proclaim that
their Divine Master may fully be implored to help his German
worshippers to slay so many Russians, British, and French
Christians that they may bring this war to an end by dictating the
terms of peace, and firmly establishing the reign of militarism in
Europe. That is the only meaning of the summary condemnation of
those who have “dared to dispute the inner right of us and our
Emperor to invoke the assistance of God.”
If this be Evangelical Christianity as taught in latter-day
Germany, many Christians throughout the world, even among those
who have scant sympathy with Rome, will turn with a feeling of relief
to the decree of the new Pope enjoining prayers for the soldiers who
are heroically risking their lives in the field, but forbidding the faithful
to dictate to the Almighty the side to which he shall accord the final
victory.
As historians, this body of divines have one eye bandaged, and
read with the other only the trumped-up case for their own Kaiser
and countrymen. They write:
“As our Government was exerting itself to localize the justifiable
vengeance for an abominable royal murder, and to avoid the
outbreak of war between two neighbouring Great Powers, one of
them, whilst invoking the mediation of our Emperor, proceeded (in
spite of its pledged word) to threaten our frontiers, and compelled us
to protect our land from being ravaged by Asiatic barbarism. Then
our adversaries were joined also by those who by blood and history
and faith are our brothers, with whom we felt ourselves in the
common world-task more closely bound than with almost any nation.
Over against a world in arms we recognize clearly that we have to
defend our existence, our individuality, our culture, and our honour.”
From the theological standpoint, then, Germany is engaged in a
purely defensive war against nations guilty of breaking their pledged
word, and of wantonly attacking the peace-loving Teutons.
 Nobody can read without a grim smile this misleading exposé
which ignores the Austrian ultimatum to Servia, with its forty-eight
hours’ term for an answer; the exasperating demands which were
drafted, not for the purpose of being accepted by the Belgrade
Government, but with the admitted object of provoking a refusal; the
fervent insistence with which the British Foreign Minister besought
the German Government to obtain an extension of the time from
their Austrian ally; the mockery of a pretence at mediation made by
the Kaiser and his Chancellor, and their refusal to fall in with Sir
Edward Grey’s proposal to summon a conference and secure full
satisfaction and effectual guarantees for Austria; and the German
ultimatum, presented to Russia and to France at the very moment
when the Vienna Government had “finally yielded” to Russia’s
2
demands and “had good hopes of a peaceful issue.” Those were
essential factors in the origins of the war. Yet of these data the
spiritual shepherds of the German people have nothing to say. They
pass them over in silence. For they are labouring to establish in the
minds of Evangelical Christians abroad their “inner right” to invoke
the assistance of God for the Kaiser, who patronizes Him. This
unctuous blending of Teutonic religion with the apology of systematic
inhumanity reminds one of an attempt to improve the abominable
smell of assafœtida with a sprinkling of eau-de-Cologne.
These comments are nowise intended as a reproach to the
theologians and pastors who have set their names to this appeal.
Personally, I venture to think that they have acted most
conscientiously in the matter, just as did von Treitschke, Bernhardi,
and their colleagues and their followers. The only point that I would
like to make clear is that they have a warped ethical sense—what
the schoolmen were wont to term “a false conscience.” And the
greater the scrupulosity with which they act in accordance with its
promptings, the more cheerfully and abominably do they sin against
the conscience of the human race.
The simplicity and unction with which these men come forward
to vindicate their “inner right” to pray God to help their Kaiser to
victory over pacific peoples, the calm matter-of-fact way in which
they accuse the Belgians of revolting barbarities—for that is one of