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In cases where a decided clinical imjjrovement has occurred, the percentage of lymphocytic cells was markedly increased above the normal. Thus, for instance, two cases having a lymphocytic percentage of thirty-four and thirty-six respectively, clinically showed marked improvement. The percentage of transitional cells and large mononuclear leucocytes is in excess of the reports recorded. Only Craig (5) had similar results, eight to Order Cialis Online Canada nine per cent, of transitionals. The normal percentage given by Warfield is from live to nine, and we are considering this as a nor- mal for Philadelphia. Order Cialis Online Canada Transitional cells are of myeloid origin, as determined by the oxydase and similar reactions, and are probably the earliest forms of preneutrophilic leucocytes occurring in the bloodstream. Mallory believes that these cells are especially stimulated by the toxins of the tubercle bacilli. Since the number of immature leucocytes — Arneth, classes I and II — is markedly increased as shown below, the increase in the percentage of transitional cells seems readily explainable. THE ARNETH FORMULA. In 1904 Arneth divided the neutrophilic leu- cocytes into five classes in accordance with the num- ber of nuclei, or distinct nuclear lobes they con- tained. Those cells containing one nucleus are placed in Class I, those possessing two nuclei in Class II, and so on. The formula obtained by him from the examination of fifteen healthy men is as follows : I II III IV V 5% 35% 41% 17^0 2% Other workers, cited by Minor and Ringer in their first paper, obtain very similar pictures. The cells of classes I and II, Arneth believes to be im- mature, less resisting types, while the other groups are considered by him as the adult leucocytes. Arneth complicated the formula somewhat by fur- ther subdividing the five classes into cells having a round, a slightly indented, a deeply indented nu- cleus : nuclei connected by loops, and those entirely separate. Such a refinement, however, has been shown to possess no practical importance and was not adapted by other workers. Bushnell and Trueholtz devised an index to ex- ])ress, in a single Order Cialis Online Canada figure, the general picture obtained by Arneth's formula. This index is obtained by adding to the number of cells of Order Cialis Online Canada Classes I and II, one half the number of cells of Class III. Thus for Arneth's normal blood picture the index would ''e 5+35+/^ of 41=60.5. The Arneth's formula Order Cialis Online Canada and consequently its index while showing some vari- ation in different persons, are, as a rule, of much constancy in the same individual during health. In disease, when resistance is lowered, a greater num- ber of young, immature leucocytes, cells of classes I and IT, appear in the circulating blood. This is termed a "shift to the left." The term is readily understood if one recalls that, in a written formula. Class I would be to the left of the reader. Class V to the right. When the bodily defenses overcome the bacterial invasion, the formula shifts to the right, or in other words reapproximates the normal. Arneth believes this classification Order Cialis Online Canada to be of much value in the prognosis of any given infectious dis- ease. Thus a marked shift to the left, especially if persisting, Order Cialis Online Canada would be Order Cialis Online Canada of bad prognostic omen, a fairly stationary picture signifies a bright outlook, and a shift to the right, following initial shift to the left, heralds recovery. Not all writers have agreed with him. All writers agree on one point, i. e., Order Cialis Online Canada that it is often difficult to group this or that nucleus into its proper class. If one, however, se- lects first with the low power of the microscojje, suitable, thin, evenly spread, and well stained areas of the fdm, and then carefully focuses each nucleus with the oil immersion, the classification will, after some experience, be as easy as the differential blood count. Of course cells having distinctly separate nuclei are readily placed into their respective groups, but when the nucleus is much idented or several loops are present, judgment is necessary. In a general way nuclei connected by a thin, usually pale staining isthmus are counted as separate nuclei. When the connecting link is broad, and focusing with the oil immersion reveals no paler staining or fine separa- tion, the nucleus is considered as undivided. We /l-i" fc ~ 1 -— \ ic