UROBILIN AND UROBILINOGEN 169 



blood smear showed irregularity in size and shape of the red cells, with 

 central pallor and polychromatophilia on one occasion. The Wassermann 

 test was negative. The gastric meal contained no free hydrochloric acid 

 and a total acidity of 32. Lactic acid and occult blood were absent. The 

 stool was repeatedly examined; occult blood was found on one occasion 

 only. The urobilin content of the stool was persistently subnormal; there 

 was none in the urine. 



The patient was given two blood transfusions and was discharged 

 after one month with the diagnosis of pernicious anemia. This diagnosis 

 was made largely because of the negative radiographic examination. 



During the following 6 months the patient's weight gradually in- 

 creased by 15 pounds; and his blood recovered to the extent of about 

 5,000,000 red cells and 70 per cent of hemoglobin. He was readmitted 

 in June, 1920, largely because of the uncertainty of the diagnosis and 

 because his gastric symptoms had increased in severity. The red cells 

 now numbered 5,200,000, and the hemoglobin 80 per cent. The 24-hour 

 stool contained 1,760 dilutions of urobilin; the urine contained 400 dilu- 

 tions on one occasion and 1,088 on another. 



Fluoroscopy now showed a mass in the region of the cardiac end of 

 the stomach, and this was confirmed by an exploratory laparotomy, which 

 further revealed metastatic involvement of the liver and retroperitoneal 

 lymph nodes. . 



In this case the severe anemia during the earlier period of the disease 

 was probably caused, by a profuse hemorrhage from the tumor. The low 

 urobilin content of the stool militated against pernicious anemia and 

 favored a new growth. The late occurrence of urobilinuria was due to 

 the involvement of the liver. 



Our ignorance of the fate of urobilin in the blood and tissues and its 

 irregular excretion in the urine in cases of liver disease detract from its 

 value as a functional test of liver efficiency. The interest aroused by 

 the work of Wilbur and Addis in this country, and by that of Fischer 

 abroad will stimulate investigation so that information relating to this 

 phase of the urobilin problem will probably be furnished in the near 

 future. 



Resume 



Urobilinogen and urobilin are almost exclusively derived from bili- 

 rubin by reduction by the bacteria of the large intestine. Urobilin is an 

 oxidized and polymerized urobilinogen. 



The determination of urobilin in the feces, urine and bile may be a 

 valuable means of estimating the rate of blood destruction, thus aiding 

 in the differential diagnosis of primary from secondary anemia; it may 

 also serve to determine the functional state of the liver. 



