Clinical Chemistry: Fundamentals and

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Part 1 : Laboratory Principles 20 Gastrointestinal Disease,334

1 Laboratory Essentials, 1 21 Diseases of the Liver,346

2 Practical Laboratory Safety,25 22 Pancreatic Diseases and Disorders,363

3 Principles of Laboratory Instrumentation, 41 23 Endocrinology,379

4 lmmunoassays,78 24 Kidney and Urinary Tract Diseases,412

5 Molecular Diagnostics, 97 25 Reproductive Diseases and Disorders,432

6 Automation in the Laboratory,114 26 Pregnancy, 446

7 Laboratory Quality Management Systems,124 27 Bone,Joint,and Skeletal Muscle Diseases,458

8 Enzymes,156 28 Nervous System Diseases,474

29 Skin, Hair,and Nail Diseases,488

Part 2: Pathophysiology and Analytes
30 Eye and Ear Diseases,497
9 Clinical Chemistry and Disease,171
31 Nutritional and Metabolic Diseases,504
10 Cell Injury and Its Relationship to Disease,179
32 Immune System Diseases,529
11 Inflammation,187

12 Body Fluids and Electrolytes,204

Part 3: Other Aspects of Clinical Chemistry

13 Blood Gases and Acid-Base Balance,219 33 Therapeutic Drug Monitoring,552

14 Blood Diseases,234 34 Toxicology,584

15 Proteins, 251 35 Transplantation,616

16 Cancer and Tumor Markers,268 36 Emergency Preparedness,634

17 Blood Vessel Diseases,289 Glossary,661

18 Heart Disease,306 Answer Key,683

19 Respiratory Diseases,318 Index,707

 Clinical Chemistry
Fundamentals and Laboratory
Techniques
Clinical Chemistry
Fundamentals and Laboratory Techniques

Author

Donna Larson, EdD, MT (ASCP), DLM

Vice President for Academic and Student Affairs
Clatsop Community College
Astoria, Oregon

Consulting Editors

Joshua Hayden, PhD, DABCC

Assistant Professor of Pathology and Laboratory Medicine
Weill Cornell Medical College
Director, Toxicology and Therapeutic Drug Monitoring
Assistant Director, Central Laboratory
New York Presbyterian Hospital-Cornell Campus
New York, New York

Hari Nair, PhD, DABCC

Technical Director
Boston Heart Diagnostics
Framingham, Massachusetts

ELSEVIER
ELSEVIER
325 1 Riverporr Lane
St. Louis, Missouri 63043

CLINICAL CHEMISTRY: FUNDAMENTALS AND

LABORATORY TECHNIQUES ISBN: 978- 1 -4 5 57-42 1 4 - 1

Copyright© 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may b e reproduced or rransmirred i n any form or b y any means, electronic or mechanical,
including photocopying, recording, or any information storage and retrieval system, without permission in writing
from the publisher. Details on how to seek permission, further information about the Publisher's permissions poli­
cies and our arrangements wirh organizations such as the Copyright Clearance Center and the Copyright Licensing
Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than
as may be noted herein) .

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using
any information, methods, compounds, or experiments described herein. In using such information or methods
they should be mindful of their own safety and the safety of others, including parties for whom they have a profes­
sional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered,
to verify the recommended dose or formula, the method and duration of administration, and contraindications.
It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate
safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liabil­
ity for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise,
or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Library of Congress Cataloging-in-Publication Data

Clinical chemistry : fundamentals and laboratory techniques I edited by Donna Larson ; consulting editors,
Larson, Donna, editor. I Hayden, Joshua Uoshua A.) , editor. I Nair, Hari, editor.

Joshua Hayden, Hari Nair.

Clinical chemistry (Larson)

Includes bibliographical references and index.

St. Louis, Missouri : Elsevier/Saunders, [20 1 7] 1

LCCN 20 1 5 0440741 ISBN 978 1 4 5 5742 1 4 1 (paperback : alk. paper)

I MESH: Clinical Chemistry Tests.
LCC RB40 I NLM QY 90 I DOC 6 1 6. 07/5 6--dc23 LC record
available at http :/ /lccn.loc.gov/20 1 5044074

Executive Content Strategist: Kellie White

Content Development Manager: Jean Sims Fornango
Content Development Specialist: Beth LoGiudice, Spring Hollow Press
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Daniel Fitzgerald
Designer: Margaret Reid

Working together

Printed in Canada
IJ!Jr- W\\"W
BookAid
[nl emational

clsc:v1cr
to grow libraries in
developing countries
<:om • www. hooka1J org
Last digit is the print number: 9 8 7 6 5 4 3 2
 To my mom and dad, Donald and Barbara Bedard (I wish they could have been here
to see this); to my husband, Earl, and my son, Adrian, for their love and support; to my
sister and her family for their warmth and love; to the Allards for their support during
my clinical year and college years; and to all the friends and colleagues I worked with at
Wentworth-Douglass Hospital (NH), 509th Strategic Hospital (NH), RAF Lakenheath
Regional Hospital (UK), Winston-Salem State University (NC), Mt Hood Community
College (OR), Portland Community College (OR), and Clatsop Community College (OR).
Donna Larson
I appreciate the opportunity Elsevier provided for me to
write the first edition of this clinical chemistry book for
medical laboratory technology students. The process was
exciting, exhausting, challenging, and an educational expe­
rience like no other. I would like to thank the contributors
for their hard work to help make this book possible.
I would like to thank the Elsevier staff for the assistance,
guidance, encouragement, and experience that they shared
with me throughout the development of the book. Thank
you to Ellen Wurm-Cutter, who helped me through the
proposal and beginning stages of manuscript development.
vi
A big thank you to Kellie White, Jean Sims Fornango, and
Beth LoGiudice for joining the team and seeing this proj­
ect through to completion. The final product has been a
long time coming. My Thursday mornings will never be
the same! Thanks also to Dan Fitzgerald and his team for
putting everything together in a beautiful full-color book.
Everyone was understanding, patient, compassionate,
empathetic, and truly amazing.
Donna Larson
Sheryl Berman, PhD
Division Dean of Health Professions
Lane Community College
Eugene, Oregon
Jimmy L. Boyd, CLS (NCA), MS/MHS
Assistant Professor, Department Head
Medical Laboratory Technology
Arkansas State University, Beebe
Beebe, Arkansas
Craig Foreback, PhD
Senior Consultant
Clear Medical Solutions, LLC
Bradenton, Florida
Senior Lecturer Emeritus
University of Wisconsin School of Medicine
and Public Health
Madison, Wisconsin
Danielle Fortuna, MD
Department of Pathology, Anatomy, and
Cell Biology
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
Thomas Kampfrath, PhD, DABCC
Clinical Biochemist
Santa Clara Valley Medical Center
Department of Pathology and Laboratory Medicine
San Jose, California
Laura J. McCloskey, PhD
Department of Pathology, Anatomy, and Cell Biology
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
M. Laura Parnas, PhD, DABCC, FACB
Director of Clinical Science
Sutter Health Shared Laboratory
Livermore, California
John W. Ridley, PhD, RN, MT (ASCP)
Formerly, Director of Medical Laboratory Technology
West Central Technical College
Waco, Georgia
Laird C. Sheldahl, PhD
Instructor, Anatomy and Physiology, Biology
Mount Hood Community College
Gresham, Oregon
Douglas F. Stickle, PhD, DABCC, FACB
Department of Pathology, Anatomy, and Cell Biology
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
Zi-Xuan Wang, PhD
Department of Pathology, Anatomy, and Cell Biology
Sidney Kimmel Medical College
Thomas Jefferson University
Philadelphia, Pennsylvania
vii
This page intentionally left blank
Keith Bellinger, PBT (ASCP) Amy Gatautis, MBA, MT (ASCP), SC
Medical Technologist Program Director, Medical Laboratory Technology
The United States Department of Veterans Affairs New Cuyahoga Community College
Jersey Health Care System Cleveland, Ohio
East Orange, New Jersey
Assistant Professor, Phlebotomy Kristine Hayes, MAT, MLS (ASCP)
Rutgers-The State University of New Jersey MLT and Phlebotomy Program Coordinator
Newark, New Jersey Moberly Area Community College
Moberly, Missouri
Stephanie Bielas, PhD
Assistant Professor of Human Genetics Candy Hill, MEd, MT (ASCP)
University of Michigan CLT Program Coordinator
Ann Arbor, Michigan Jefferson State Community College
Birmingham, Alabama
Jimmy L. Boyd, CLS (NCA), MS/MHS
Assistant Professor, Department Head Lorri Huffard, PhD, MT (ASCP), SBB
Medical Laboratory Technology Dean, Science & Health Programs
Arkansas State University, Beebe Wytheville Community College
Beebe, Arkansas Wytheville, Virginia

Russell Cheadle, MS, MLS (ASCP) Phyllis Ingham, EdD, MEd, MT (ASCP)
Professor, Clinical Laboratory Technology Director Clinical Laboratory Technology Program
Macomb Community College West Georgia Technical College
Warren, Michigan Waco, Georgia

Cathy Crawford, BS, MT (ASCP) Stephen M. Johnson, MS, MT (ASCP)

Clinical Courses Instructor and MLT Teaching Assistant Program Director
Mount Aloysius College Saint Vincent Health Center School of Medical
Cresson, Pennsylvania Technology
Erie, Pennsylvania
Karen M. Escolas, EdD, MT (ASCP)
Chair, Department of Medical Laboratory Technology Haywood Joiner Jr., EdD, MT (ASCP)
Farmingdale State College, State University of New York Chair, Department of Allied Health
Farmingdale, New York Louisiana State University at Alexandria
Alexandria, Louisiana
Roger Fortin, MS, MBA, MLS (ASCP)
Program Director Stephanie Jordan, BS, MLS (ASCP), CM
Bunker Hill Community College Assistant Professor
Charlestown, Massachusetts Pierpont Community and Technical College
Fairmont, West Virginia
Trent Freeman, MA, BS, MLS (ASCP)
Education Coordinator Jeffrey Josifek, MS, MLS (ASCP), CLS (NCA)
Medical Education and Training Campus Department of Medical Laboratory Technology
The George Washington University Portland Community College
Fort Sam Houston, Texas Portland, Oregon
ix
 Reviewers

Minh Kosfeld, PhD, MLT (ASCP) Ryan Rowe, MLS (ASCP)

Assistant Professor Weber State University
Department of Biomedical Laboratory Science Ogden, Utah
Doisy College of Health Sciences
St. Louis University Mary Sadlowski, MT (ASCP)
St. Louis, Missouri Medical Technologist
Greater Baltimore Medical Center and Community
Marc L. Meyers, MBA, MT (ASCP) College of Baltimore County
PM Laboratory Coordinator Towson, Maryland
Centegra Clinical Laboratories
McHenry, Illinois Cheryl Selvage, MS, MT (ASCP)
Associate Professor
Constance Moore, MS, MT (ASCP) Lorain County Community College
Program Director, Laboratory Sciences Elyria, Ohio
Eastern Gateway Community College
Steubenville, Ohio Anita Marie Smith, MT (AMT), MBA
Laboratory Administrative Director
Richard C. Mroz Jr., DA, MS, BSMT, MT (ASCP) Moberly Regional Medical Center
MLT Program Director Moberly, Missouri
Fortis Institute
Fort Lauderdale, Florida Angela Sparkman, MEd, MT (ASCP)
Program Director, Assistant Professor of the Medical
Dawn Nelson, MA, MT (ASCP) Laboratory Technology Program
MLT Program Director Ivy Tech Community College
Florence-Darlington Technical College Sellersburg, Indiana
Florence, South Carolina
Andrea Thompson, BS, MLT (ASCP)
Kathleen C. Perlmutter, MBA, MT (ASCP) MLT Instructor
Phlebotomy Coordinator, MLT Faculty Barton Community College
Montgomery County Community College Great Bend, Kansas
Blue Bell, Pennsylvania
Dionne M. Thompson, MSE, MT (ASCP)
Jennifer D. Perry, MS, BSMT (ASCP) MLT Program Director/Instructor
Associate Professor and Chairperson Three Rivers College
Clinical Laboratory Sciences Department Poplar Bluff, Missouri
Marshall University
Huntington, West Virginia

Ellen F. Romani, AAS (MLT), MS

Department Chair
Medical Laboratory Technology/Phlebotomy/Therapeutic
Massage
Spartanburg Community College
Spartanburg, South Carolina
Clinical Chemistry: Fundamentals and Laboratory Techniques
is a comprehensive, readable, and student-friendly text for
2-year medical laboratory technology programs. The text­
book has a full-color design along with detailed illustrations
and diagrams to help students with complex chemistry
concepts. Pathophysiologic concepts are included to help
students understand the clinical relevance of clinical chem­
istry assays.
Purpose and Organization
As I look back at my journey in clinical laboratory science,
I cannot help but marvel at how laboratory test methods
rapidly changed over the course of the 20th century and
into the 2 1 st century. While researching my dissertation,
The Structure of Knowledge in Clinical Laboratory Science, I
was amazed to read articles in laboratory journals ( 1 940s)
concerning how to build a better cage for laboratory ani­
mals. (Pregnancy tests during that time used rabbits to
determine whether a woman was pregnant.) The radioim­
munoassays that were popular in the 1 970s and into the
1 980s were largely replaced by colorimetric immunoassays
in the late 1 980s and 1 990s. Looking back, there was always
new information in the expanding discipline of clinical lab­
oratory science. The more the knowledge base expands, the
more the students are asked to learn. This is especially true
of medical laboratory technology (MLT) students.
MLT students have a mere 2 years to learn all the clinical
laboratory science (CLS) knowledge (with few prerequisite
and general education courses) on which to build a solid
knowledge foundation. Pieces from various disciplines are
incorporated or embedded in their CLS . When writing this
book, I envisioned a clinical chemistry book that would
incorporate j ust-in-time learning concepts for which the
material would be fortified with additional material when
needed. Building on this approach, Part 1 , Laboratory Prin­
ciples, covers laboratory principles, safety, quality assur­
ance, and other fundamentals of laboratory techniques.
The concepts are essential for anyone working in a clini­
cal laboratory, and this section provides a good reference
for beginning MLT students. For example, the students
do not take a statistics course, but statistical concepts and
calculations are included in Chapter 7, Laboratory Qual­
ity Management Systems. Quality management methods,
including the applications of Westgard rules for control
charts and the calculation of the mean, mode, and standard
deviation, are explained and practiced in that chapter.
Part 2, Pathophysiology and Analytes, covers the dis­
eases, broken down by body system, that are commonly
diagnosed through chemical tests. Each chapter in this sec­
tion contains information about anatomy and physiology
of a specific body system, disease mechanisms of common
conditions that require clinical chemistry testing, and how
laboratory results correlate with clinical disorders. This is a
key section of the book because MLT students usually do
not have room in their program for a separate pathophysiol­
ogy class, unlike other health science students, for whom it
is part of the program paradigm.
Pathophysiologic mechanisms of diseases and the resul­
tant effects on clinical chemistry tests are discussed in each
of the chapters. For example, it is easier to remember test
results that are elevated after an acute myocardial infarction
(MI) if it is known that the muscle is damaged and that
the dying cells release specific chemicals into the blood. If
blood is drawn at timed intervals after the MI, the person
who understands the pathophysiologic mechanism behind
the infarct will know what types of clinical chemistry results
to expect from each specimen.
When diseases are discussed that do not use laboratory
tests for diagnoses or when laboratory tests are used to
rule out other disorders, this information is given so that
students can understand the laboratory test ordering pat­
terns of health care providers. This information also helps
students better understand reflex testing and how the algo­
rithms are developed.
Part 3, Other Aspects of Clinical Chemistry, covers
therapeutic drug monitoring, toxicology, transplantation,
and emergency preparedness. The clinical laboratory has a
critical role in these areas, providing ongoing testing and
assistance.
To complement the organization, the book is writ­
ten in the active voice to help students better understand
the material. Although this may be unconventional for a
textbook at this level, I believe it helps students to better
understand complex clinical chemistry concepts and mas­
ter the material.
Most individuals are visual learners. To that end, many
figures, photographs, tables, and flowcharts are included
xi
 Preface
to help students better understand concepts. Many figures
summarize complex and complicated processes or pathways
to provide better comprehension of the material by students.
Key Features
Cha pter Outl i n e
Each chapter starts with a chapter outline that shows the
main topics that are covered. It provides students and
instructors with a roadmap to the chapter and can be easily
referenced at any time.
Objectives
The textbook format facilitates the learning process by pro­
viding students and educators with detailed objectives that
address the knowledge required to master each chapter's
content. The learning objectives are listed at the beginning
of each chapter, giving students and instructors definitive
evaluation tools to use as the chapter's content is covered.
Objectives are provided at various cognitive mastery lev­
els: comprehension, application, analysis, synthesis, and
evaluation.
Key Terms
Key terms are identified at the beginning of each chapter
and highlighted in the chapter, putting valuable terminol­
ogy at students' fingertips. The key terms are also included
in the Glossary at the back of the book.
Case in Point
A key clinical case study is provided at the beginning of every
appropriate chapter. The Case in Point feature provides appli­
cation of the student's knowledge for correlating the clinical
side of test results. Students are asked to think about impor­
tant questions related to each scenario and to use fundamen­
tal information from the chapter to determine the answers.
Poi nts to Remember
A bulleted list of important concepts is included in the first part
of the chapter, providing an overview of the chapter content.
This list gives students a simple study tool for easy reference.
Summary
A short summary at the end of the chapter highlights
key information from the chapter. Students can revisit
the various chapter topics in short form for review and
reinforcement.
Review Questions
Multiple-choice review questions at the end of every chap­
ter provide students with a unique tool as they prepare for
classroom examinations and certification examinations. The
review questions give students a chance to quiz themselves
on the chapter content, assess their knowledge of important
chapter topics, and evaluate which topics need follow-up
review.
Critica l Th i n king Questions
The Critical Thinking Questions allow students and instruc­
tors to discuss the chapter topics in a broader way. Although
these questions have correct answers, they require more in­
depth thinking, analysis, evaluation, and reflection than
other questions in the chapter.
Case Stud ies
Additional Case Studies round out each most chapters,
giving students another opportunity to apply the knowl­
edge gained from the chapter. The scenarios are meant to
stimulate interest and critical thinking and to encourage
discussion of chapter topics with other students.
Evolve Companion Website
Clinical Chemistry comes with a companion website, found
on Evolve (evolve.elsevier.com/Larson) . This website con­
tains helpful ancillaries for instructors and additional mate­
rials for students.
For the I n structor
The Evolve website has multiple features for the instructor:
• A test bank with multiple-choice questions and ratio­
nales.
• PowerPoint presentations for every chapter that can be
used as is or as a template to prepare lectures.
• A detailed Answer Key with rationales for all in-text
questions.
• The Image Collection that provides electronic files of all
the chapter figures that can be downloaded into Power­
Point presentations.
For the Student
Additional content is available for the student:
• High-definition animations to illustrate key physiologic
and pathophysiologic processes.
• Extra Case Studies for certain chapters for more practical
application of textbook content.
Part 1 : Laboratory Principles 5 Molecular Diagnostics,97

Introduction, 98
Donna Larson
1 Laboratory Essentials, 1
Nucleic Acid Structure and Function, 98
Introduction, 3
Donna Larson
Laboratory Methods, 106
History of Clinical Laboratories, 3 Diagnostic Applications, 110
Types of Clinical Laboratories, 4

Laboratories, 8
Regulation and Accreditation of Clinical 6 Automation in the Laboratory,114

Laboratory Materials, 9 Introduction, 115

Donna Larson

Chemistry Review, 10 Goal of Automation, 115

Laboratory Mathematics, 14 History of Automated Analyzers, 115
Automating Clinical ChemistryTests, 117
2 Practical Laboratory Safety,25 Total Laboratory Automation, 119

Introduction, 26
Donna Larson

Safety Regulations, 26
7 Laboratory Quality Management Systems,124
John W. Ridley and Donna Larson
The Laboratory Safety Program, 29 Introduction, 126
Introduction to Quality, 126
3 Principles of Laboratory Instrumentation, 41 Facilities and Safety Overview, 128
Purchasing and Inventory, 130
Introduction, 43
Craig Foreback and Donna Larson
Process Control, 131
Properties of Light, 43 Assessment, 148
Spectrophotometry, 44 Personnel, 149
Fluorometry, 48 Customer Service, 149
Luminometry, 51 Occurrence Management, 149
Nephelometry andTurbidimetry, 51 Process Improvement, 149
Electrochemistry and Chemical Sensors, 52 Documents and Records, 151
Chromatography, 56 Organization, 152
Mass Spectrometry, 62
Electrophoresis, 67
Colligative Properties, 71
8 Enzymes,156

Point-of-CareTesting, 72 Introduction, 158

M. Laura Parnas and Thomas Kampfrath

Flow Cytometry, 74 The Nature of Enzymes, 158

Kinetics, 159
4 lmmunoassays,78 Enzyme Reaction Conditions, 162
lsoenzymes, 163
Introduction, 80
Donna Larson
Specific Enzymes, 163
Antibodies, Antigens, and Analytes, 80
lmmunochemical Methods, 82
Label Methods, 84
Part 2: Pathophysiology and Analytes

Particle Methods, 88
Light-Scattering Methods, 92
9 Clinical Chemistry and Disease,171

Introduction, 172
Donna Larson

Performance, 93
Factors Affecting Immunoassay Analytical
Definition of Disease, 172

xiii
 Contents

Pathology, 172
Disease Mechanisms, 175
17 Blood Vessel Diseases,289

Biochemistry of Disease, 175 Introduction, 291

Donna Larson

Lipids, 291
10 Cell Injury and Its Relationship to Lipoproteins, 293
Disease,179 Normal Lipoprotein Metabolism, 294
Abnormal Lipoprotein Metabolism, 296
Introduction, 180 Laboratory Procedures and Limitations, 299
Donna Larson

Overview of Cellular Injury, 180 Lipoproteins and Clinical Vascular Disease, 301
Causes of Cellular Injury, 181
Changes in Body Chemistry, 183
LaboratoryTests, 184
18 Heart Disease,306

Introduction, 307
Sheryl Berman

11 Inflammation,187 Heart Structure and Blood Flow, 307

Myocardial Infarction, 307
Introduction, 188 Congestive Heart Failure, 311
Donna Larson

Defense Mechanisms, 188 Congenital Heart Defects, 312

The Inflammation Process, 188 Endocarditis, Myocarditis, and Pericarditis, 314
Acute Inflammation, 195
Chronic Inflammation, 196
Laboratory Procedures and Limitations, 198
19 Respiratory Diseases,318

Introduction, 319
Donna Larson

12 Body Fluids and Electrolytes,204 Structure and Function of the Respiratory System, 320
Respiratory Diseases and Pathophysiology, 320
Introduction, 205
Donna Larson

Fluid Balance and Body Fluid Compartments, 205

Electrolytes, 206
20 Gastrointestinal Disease,334

Colligative Properties, 213 Introduction, 335

Sheryl Berman

Fluid Imbalances, 215 Gastrointestinal System, 335

Gastrointestinal FunctionTests, 342
13 Blood Gases and Acid-Base Balance,219

Introduction, 220
Donna Larson 21 Diseases of the Liver,346

Blood Gases, 220 Introduction, 347

Donna Larson

Acid-Base Theory, 224 Liver and BiliaryTract, 348

Acid-Base Disorders, 226 Liver Diseases, 350
Interpreting Blood Gas Analyses, 230
22 Pancreatic Diseases and Disorders,363
14 Blood Diseases,234
Introduction, 365
Donna Larson

Introduction, 236 Overview of the Pancreas, 365

Sheryl Berman

Hematopoiesis, 236 Pancreatitis, 366

White Blood Cells, 236 Diabetes, 368
Red Blood Cells, 240 Cystic Fibrosis, 375
Malabsorption and Maldigestion, 375
15 Proteins,251

Introduction, 252
Donna Larson 23 Endocrinology,379

Biochemistry of Proteins, 252 Introduction, 382

Jimmy L. Boyd and Donna Larson

Plasma Proteins, 255 Overview of the Endocrine System, 382

Proteins in Other Body Fluids, 264
Testing, 385
Anatomy, Pathophysiology, and Laboratory

16 Cancer and Tumor Markers,268

Introduction, 269
Donna Larson 24 Kidney and Urinary Tract Diseases,412

Cancer andTumor Markers, 269 Introduction, 413

Sheryl Berman

Clinical Correlations, 280 Kidney Anatomy, 414

 Contents

Normal Physiology, 416 32 Immune System Diseases,529

Disease States, 419 Sheryl Berman
Laboratory Procedures, 425 Introduction, 531
Normal Immune System, 531
25 Reproductive Diseases and Disorders,432 Disease States, 538
Donna Larson
Introduction, 433 Part 3: Other Aspects of Clinical Chemistry
Reproductive System Structure and Function, 433
Diseases and Disorders, 435 33 Therapeutic Drug Monitoring,552
Laboratory Procedures and Limitations, 442 Laird C. Sheldahl and Donna Larson
Introduction, 554
26 Pregnancy, 446 Drug Disposition, 554
Sheryl Berman Administration of Drugs, 558
Introduction, 448 Drug Levels, 560
Pregnancy, 448 Cardiovascular Drugs, 562
Complications of Pregnancy, 450 Antibiotics, 567
Fetal Complications, 453 Antiepileptic Drugs, 571
Laboratory Diagnosis of Fetal Abnormalities, 455 Psychoactive Drugs, 576
Bronchodilators, 579
27 Bone,Joint,and Skeletal Muscle Diseases,458 Immunosuppressant Drugs, 580
Donna Larson
Introduction, 459 34 Toxicology,584
Normal Anatomy and Physiology of Bones, 459 Laird C. Sheldahl and Donna Larson
Bone Diseases, 460 Introduction, 586
Normal Anatomy and Physiology of Joints, 466 Routes of Exposure, 587
Joint Diseases, 466 Dose-Response Relationship, 588
Normal Anatomy and Physiology of Muscles, 468 Acute and ChronicToxicity, 588
Muscle Diseases, 469 Specimen Collecting and Handling, 589
Conditions Caused by Pollutants, 590
28 Nervous System Diseases,474 Toxic Agents, 592
Donna Larson Household Products, 597
Introduction, 475 Toxic Metals, 599
Nervous System Anatomy and Physiology, 476 Drugs of Abuse, 602
Nervous System Diseases, 477
Cerebrospinal Fluid Analysis, 483 35 Transplantation,616

Douglas F. Stickle
Daniel/e Fortuna, Laura J. McCloskey, Zi-Xuan Wang,
29 Skin, Hair,and Nail Diseases,488
Donna Larson Introduction, 617
Introduction, 489 Overview ofTransplantation, 617
Skin Diseases, 489 Role of Medical Laboratories inTransplantation, 619
Effects of Systemic Disease on Skin, 491 Overview of the Immune System, 619
Hair Diseases, 492 Role of the Immune System inTransplantation, 622
Nail Diseases, 493 Immunosuppression, 624
Exceptional Cases inTransplantation, 628
30 Eye and Ear Diseases,497 Future ofTransplantation, 629
Donna Larson
Introduction, 497 36 Emergency Preparedness,634
Eyes, 498 Donna Larson
Ears, 501 Introduction, 636
Emergency Preparedness, 636
31 Nutritional and Metabolic Diseases,504 Emergency Response, 637
Donna Larson Laboratory Response Network, 654
Introduction, 507
General Concepts of Health and Disease, 507 Glossary,661
Cold Injuries, 507
Heat Illnesses, 508 Answer Key,683
Nutritional Conditions, 509
Metabolic Diseases, 518 Index,707
Inborn Errors of Metabolism, 520
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 Laboratory Principles

CHAPTER OUTLI N E
I ntrod uction Chemistry Review
H i story of C l i n ical Laboratories Atomic Theory

Types of C l i n ical Laboratories

Chemical Bonds

I n patient Laboratories Factors Affecting Chemical Reactions

Outpatient C l i nics and Physicia ns' Office La boratories Acid, Bases, and Salts
Reference Laboratories Orga nic Chemistry

State and Federal La boratories Biochemistry

M i l itary Laboratories La boratory Mathematics

Reg u l ation and Accreditation of C l i n ical Laboratories

Mola rity

Reg u lation Molal ity

Accreditation Norma l ity

Di l utions
La boratory Materials
Conversions
Glasswa re and Plasticwa re
pH
Centrifuges
Beer's Law
Bala nces
Sta ndard Cu rves
Pi pettes
S u m mary
Reagents
Water

O BJ ECTIVES
At the completion of this chapter, the reader will be able to:
1. Describe the history of the clinical laboratory. 1 0. Describe the types of ba lances and their use i n the
2. List the typica l depa rtments of a clinica l laboratory. laboratory.
3. List the personnel employed in a clinica l la boratory. 1 1 . Compa re a n d contrast serologic a n d vo l u metric
4. List the characteristics of reference, federal, and m i l itary pi pettes.
la boratories. 1 2. Describe the various methods used to ca librate pi pettes.
5. Briefly describe The Joint Com mission and the Col lege of 1 3. Defi ne mola rity and mole and perform the calcu lations
American Pathologists and their roles i n clinical laboratory needed for prepa ring and worki ng with molar solutions.
oversig ht. 1 4. Defi ne molality and perform the ca lcu lations needed for
6. Describe the types of water and the uses for each. prepa ring and worki ng with molal solutions.
7. Com pa re and contrast the types of glasswa re and 1 5. Defi ne normal ity, equivalent weig ht, and m i l l iequ iva lent
plasticwa re. weight and perform the calcu lations needed for prepa ring
8. Describe the types of centrifuges used in the and worki ng with normal solutions.
laboratory. 1 6. Defi ne g/d L and mg/d L u n its and perform ca lculations
9. Describe the operating instructions and precautions for necessa ry to prepa re solutions of a desired g/d L and mg/d L
centrifuges. concentration.
2 PA R T 1 Laboratory Principles

1 7. Solve d i l ution problems for fi n a l vol ume and 1 9. Convert metric u n its from one u n it to another, the th ree

between 51 u nits and conventiona l u nits, a bsorbance to

concentration g iven the i n itial vol u mes and tem perature sca les (i.e., Fa h renheit, Celsius, and Kelvin),
concentrations.
1 8. Describe how serial d i l utions a re prepared. transm itta nce and transmitta nce to a bsorba nce, and a bsor­
bance va l ues to concentration of the u n known.

KEY TERMS
Accred iting Bureau of Health Education C l i n ical Laboratory Mole
Schools I m p rovement Act Nalgene
Acid C l i n ical la boratory scientists Needlestick Safety and Prevention Act
Alcohols C l i n ical la boratory technicians of 2000
Aldehyde C l i n ical pathology Neutral ization reaction
American Society for C l i nical Col lege of American Pathologists Normal ity
Pathologists Com m ission on Accred itation of All ied Nucleic acids
Ami nes Health Ed ucation Prog ra ms Outpatient c l i n i c
Anatomic pathology Cova lent bond Pathologist
Anion Ester pH
Aromatic ring Governing board Phenol
Atomic theory Gram per deci l iter concentration Phlebotomists
Automated pi pettes Haza rd com m u n ication Physicians' office la boratories
Bala nces Hazardous chemica l s Pi pettes
Base Hematology Proficiency testing
Beer's law Hyd rocarbons Protein
Biochemistry I nternational u n its Pyrex
Blood bank Ionic bond Reagent-g rade water
Bloodborne pathogens Ions Reagents
Board of Reg istry Ketone Reference la boratories
Carbohyd rates La boratory manager Serial d i l ution
Cations Lipids Serologic g lass pi pette
Centers for Disease Control and Medical laboratory assistants Sta ndard cu rve
Prevention Medical staff Sterols
Centrifuge Medical technologist The Joint Com m ission
Chemical sym bols Microbiology department Vol u metric pi pette
C l i n ical chemistry Molal ity Va lence
Molarity

Points to Remember • Hospitals have an organizational structure consisting of a

• The American Society for Clinical Pathologists (ASCP)
was formed in 1 922 to meet the needs of the growing
pathology profession.
• The ASCP created the Board of Registry in 1928 to cer­
tify laboratory technicians and then the Board of Schools
to accredit laboratory training schools.
• In 1933, clinical laboratory technicians formed a pro­
fessional society, the American Society for Clinical
Laboratory Technicians, to provide autonomy and a
voice for the growing profession of clinical laboratory
science.
• Laboratories produce 80% of the objective data that health
care providers use to diagnose and rule out diseases, and
they provide blood for transfusion and determine the sus­
ceptibility of pathogenic bacteria to antibiotics.
• Clinical laboratories began as part of a hospital in the
early 20th century and remain a critical part of hospitals
today.
governing board, medical staff, and management.
• Anatomic pathology comprises surgical pathology, his­
tology, and cytology.
• Clinical pathology is the largest portion of the clinical
laboratory, and it is composed of hematology, clinical
chemistry, microbiology, immunohematology, toxicol­
ogy, immunology and serology, urinalysis, specimen col­
lection, and customer service.
• Pathologists are medical doctors who oversee laboratory
testing.
• A laboratory manager is responsible for the daily activi­
ties of the laboratory.
• Clinical laboratory scientists possess a bachelor's degree
in clinical, medical, or laboratory science; 3 years of aca­
demic course work; and 6 months to 1 year of clinical
experience.
• Clinical laboratory technicians or medical laboratory
technicians have a 2-year associate degree, and they per­
form all the routine testing in the laboratory.
Another random document with
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 Any boy can easily convert a toy rubber balloon into a real flier by
constructing the simple device shown in the illustration for filling it
with hydrogen. Procure a clay pipe and break off the stem near the
bowl. Bore a hole in a cork, or preferably a rubber stopper, selected
to fit some bottle and insert the smaller end of the pipestem in the
hole. As the stem tapers, if the hole has been made for the smaller
end, a tight fit is assured by simply pressing the stem well into the
cork. Tie the open end of the stem on the balloon tightly over the
larger end of the pipestem, and have ready a thread to tie the stem
of the balloon when it is filled.
Procure from a local drug store 1 oz. of hydrochloric acid. Place
some nails, or better still, a few strips of zinc, in the bottle and cover
them with a little water, then pour a small quantity of the hydrochloric
acid into the bottle and assemble as shown in the illustration. In a
few minutes hydrogen gas will be given off, and if the joints are tight,
the balloon will begin to fill. After it has expanded as much as it will
stand without breaking, tie the end with the thread, and cut off any
parts of the mouthpiece that may weigh it down. If sufficient gas has
been passed into the balloon it will rise to the ceiling. Balloons filled
in this manner have risen to a height of several hundred feet.
Caution: Do not allow the hydrochloric acid to come in contact with
the skin or clothing, as it may cause frightful burns. Do not under any
circumstance fill the balloon near a flame or allow fire to come near
the bottle.—Contributed by Ralph C. Jenkins, Manchester, Vt.
 How to Polish Instrument Bases
There seems to be a feeling among mechanical and electrical
experimenters that there is something mysterious about the process
of wood finishing, and often one may see a really fine piece of
apparatus spoiled by mounting it on a shellacked baseboard. I have
found that it is a very simple matter to produce almost a piano finish
on all woods, even those as soft as poplar, in the following manner.
Quick-drying wood dyes should be avoided. Simply rub down a piece
of ordinary water-color cake into some plain water and apply freely
with a rag, rubbing it in well. Any color may be obtained in this way,
but if this is not convenient, use an oil stain made quite thin with
turpentine. Next apply a thin coat of shellac, which should be
sandpapered when it is dry. A coat of ordinary varnish is then
applied, and when this is thoroughly dried, rub lightly with fine steel
wool. One coat of varnish may be sufficient, although several coats
will produce a richer finish. Rub the last coats down well with an oily
rag dipped in some abrasive material, such as tooth powder or metal
polish, and finish with a simple oil rub. A beautiful, soft, transparent
effect may be obtained in this way on very ordinary woods. Any
open-grained woods, such as oak, must be filled with a paste filler
after staining.—Contributed by John D. Adams, Phoenix, Ariz.
 Locating Droplight in the Dark

The Cord Fastened to the Door Casing is Easily Located and Followed to the
Lamp

A simple device for locating a droplight can be had by putting a

nail or screw eye into the side of the door casing, high enough to
clear persons passing under it, but within easy reach of an uplifted
hand, and running a cord from it to the light. It is not difficult to locate
the cord attached to the casing and to follow it to the light.—
Contributed by H. S. Craig, Rushford, Minnesota.

¶If kerosene oil is used when drilling, reaming, or turning malleable

iron, it will make the work much smoother.
 How to Make an Experimental Lead Screw

A Copper Wire Wrapped around and Soldered to a Straight Rod for a Lead
Screw

Often in experimental work a long, narrow, parallel screw is

desired for regulating, or moving, some part of the apparatus in a
straight line. A simple way of making such a screw is to tin
thoroughly a small straight rod of the required length and diameter.
After wiping off all the surplus solder while it is yet hot, wrap it with a
sufficient length of bright copper wire and fasten the ends. This wire
is then securely soldered in place by running the solder on while
holding the screw over a blue gas flame. To make the solder run
freely, brush frequently during the heating with a small mucilage
brush dipped into the soldering acid. An even pitch can be secured
by winding on two wires side by side at the same time, the second
one being unwound before soldering.
 Self-Setting Rat Trap

The Paper Stretched over the Barrel Top was Cut after Feeding the Rats on It
for Some Time

A suburbanite successfully trapped a bunch of rats by stretching a

piece of stout elastic paper on the top of an open barrel. Spreading
food on this paper he allowed it to remain until the suspicions of the
rats were allayed, then he cut two right-angled slashes in the paper
with a razor. Next morning he found seven of the pests in the barrel.
 Smoker’s Cabinet or Cellarette

The Smoker’s Cabinet Makes an Attractive Addition to the Furniture of a

Den, and should be Made Up and Finished to Match Other Pieces of the
Room

This design, when completed, takes up a wall space 20 in. wide by

31 in. high, and extends out 14 in. The material necessary for it is as
follows:
2 sides, ⁷⁄₈ by 14 by 31 in.
1 back, ³⁄₄ by 14 by 28¹⁄₈ in.
1 bottom, ⁷⁄₈ by 14 by 20 in.
1 top, ⁷⁄₈ by 10¹⁄₄ by 18³⁄₄ in.
1 bottom shelf, ⁷⁄₈ by 10¹⁄₄ by 14 in.
Door:
2 stiles, ³⁄₄ by 2 by 14¹⁄₂ in.
2 rails, ³⁄₄ by 2 by 10 in. (not including tenons, if such are desired).
1
 panel, ³⁄₈ by 10³⁄₄ by 11¹⁄₄ in.
Upper drawer:
1 front, ³⁄₄ by 4 by 14 in.
1 back, ³⁄₈ by 3¹⁄₄ by 13¹⁄₂ in.
2 sides, ¹⁄₂ by 4 by 9⁷⁄₈ in.
1 bottom, ³⁄₈ by 9⁵⁄₈ by 13¹⁄₂ in.
Lower drawer:
1 front, ³⁄₄ by 5 by 14 in.
1 back, ³⁄₈ by 4¹⁄₄ by 13¹⁄₂ in.
2 sides, ¹⁄₂ by 5 by 12⁷⁄₈ in.
1 bottom, ³⁄₈ by 12⁵⁄₈ by 13¹⁄₂ in.
1 piece for keys, ³⁄₄ by 2¹⁄₄ by 6¹⁄₄ in.
1 pair hinges.
2 drawer pulls.
Screws and nails.

In constructing the cabinet, the outer frame should first be made.

The sides can be laid out and cut to the desired design. The top and
bottom crosspieces should then be squared up, and the tenons cut
as shown, the bottom tenons extending farther, to balance the
design. The top is set in ³⁄₄ in. from the back edge. Holes should be
marked and cut for the ³⁄₄-in. keys, after which the four parts may be
assembled, and suitable keys driven in place. The back for the
cabinet is made from ³⁄₄-in. material, squared up to fit between the
sides, and be flush with their top edges while resting on the bottom
crosspiece. It can be fastened in place with nails. The top and
bottom pieces of the cabinet proper can then be made, and secured
in place with round-head screws, after which the door may be made
and fitted. The stiles and rails of the door should be rabbeted for a
³⁄₈-in. square groove, to hold the panel in place. The frame can be
made sufficiently strong, if properly glued and held together with
dowel pins passing through the stiles into the rails. If it is desired to
fasten the frame with tenons, an extra amount must be added to the
length of the rails given in the stock list. The panel should not be
glued in place, as the shrinkage of the wood will cause it to crack.
 In making the drawers, the front should be rabbeted for a groove
to fit the drawer bottom, and sidepieces can be fitted and nailed in
place. These should be rabbeted for grooves, into which the bottom
and end pieces fit.
If the cabinet is finished in mission style, or fumed oak, hammered
copper or brass hinges and drawer pulls will go well with the general
appearance of the design.
 Skis and Ski-running
Running, Jumping and Climbing
By Stillman Taylor

Part II

Before the beginner makes the attempt to ski, he should see that his
complete outfit is perfectly suited to his purpose. The shoes
should be nicely adjusted to fit snugly between the metal toe plates
of the binding, and new holes should be punched in the straps
wherever needed to adjust the harness snugly and comfortably to
the feet. Many of the positions required in executing the various
turns and swings may be practiced at home, that the novice may get
some idea of the correct position of the feet and body assumed by
expert skiers. For the initial practice outside, it is a good plan to
select a frosty day when the snow is old and settled by the wind.
This will introduce the novice to the sport under favorable conditions,
while if the first trials are made shortly after a heavy snowfall, or
upon a mild day when the snow is thawing, only discouragement will
be experienced. Begin with one stick—or two if timid—and pick out
an easy-sloping hill with a gradual run to the level ground. A few
scattered trees and rocks will do no harm, for it is a good plan to
learn how to avoid them from the beginning.

How to Turn on Skis

This and the correct manner of standing on skis are easily

mastered if the beginner will but remember that the weight of the
body should rest largely upon the advanced foot without bending the
body at the ankle too much, or raising the heel from the ski. This is
the correct position to assume when standing for a rest and for
sliding, and this as well as turning should be practiced on the level.
To make the kick turn, simply raise the point of the ski until the heel
rests on the snow, as shown in Fig. 1. Swing the ski around by
turning the point out and back until the two skis are point to heel, as
shown in Fig. 2. When this, the most difficult position of the three, is
assumed, raise the point of the other ski as high as convenient to
avoid tripping, keep the heel down and swing the ski around over the
heel of the other until both are facing in the same direction, as shown
in Fig. 3. A little practice will make it possible for the novice to turn
quickly, and if all turns are made with the advanced foot, when
practicing on the level, no trouble will be experienced later on in
attempting to turn on a steep slope. The stick is really indispensable
for this practice, and while two may be used, the single stick will be
found assistance enough for any active person.
When skiing on level ground the correct movement is rather more
of a slide than the motion used in walking or skating. The body is
thrown forward on one ski and the slide is made with both feet, most
of the body weight being thrown on the advanced ski, while the rear
foot is slid forward without stopping the forward travel, as shown in
Fig. 4. The expert skier moves forward in long gliding steps without
raising the ski, but bending the knees slightly to slide the ski ahead.
The feet should be kept as close together as possible to make a
narrow track and the stick used to lengthen the slide. At the
beginning it is a good plan to endeavor to make a long slide with
each advancement of the foot, rather than strive to take long steps.
The speed of level running depends, of course, upon the condition of
the snow. On hard, well-packed snow, sliding is easiest and greater
speed obtained, while in deep and soft snow less speed is the rule.
When skiing on the hard snow of a road, four miles an hour is the
average speed, and for average level running, the skier will cover
about the same distance as when walking along a good path.
 Fig. 9
Fig. 1 The Skier
Raise the Runs
Point of the Straight
Ski until the Downhill on
Heel Rests One Ski and
on the Uses the
Snow Other as a
Brake
Fig. 2 Fig. 8
Swing the On Hard
Ski Around Snow the
by Turning Edges of
the Point the Skis
Out and may be
Back Used to
 Check the
Speed
Fig. 7
Fig. 3
When
Raise the
Running
Point of the
Downhill
Other Ski as
One Ski
High as
should Be in
Convenient
Advance of
to Avoid
the Other a
Tripping
Few Inches
Fig. 4
The Body is
Thrown
Forward on
One Ski and Fig. 6
the Slide is The
Made with Herringbone
Both Feet is Much
Fig. 5 Used When
The Skier the Skier
Naturally Wishes to
Places His Travel up a
Skis at Short and
Right Steep
Angles Incline
Rather than
Permit the
Slipping
Backward

When traveling uphill, the regular sliding gait will suffice if the
slope is gradual, but when a steep grade is encountered and the ski
slips backward, the skier stands quite erect, raises the point of his
ski about 3 in., and slaps it down smartly, without pulling it backward
or making any attempt to push his body forward with the stick. This
slap of the ski makes the smooth surface of the runner adhere better
than when the runner is slid forward in the usual manner. If the hill is
very steep, the skier will naturally place his skis at right angles rather
than permit the slipping backward. This is known as “side-stepping,”
and is shown in Fig. 5. In doing this, the heel of the ski must be
raised clear of the snow and the upper foot lifted uphill, then the
lower foot brought up to the last step of the upper foot, hence it is
extremely tiring for other than a short distance.
A variation of this movement, which is known to skiers as the “half
side step.” and which is made by advancing the foot with the legs
somewhat wider apart, and the skis placed at not quite so acute an
angle with the hill, is more useful when climbing the ordinary steep
grade and is far less laborious. If the skier knows how to handle his
implements, side-stepping may be done backward when necessary.
The “herringbone” is another step which is much used when the
skier wishes to travel up a short and steep incline. This step is made
by stretching the legs rather wide apart and pointing the toes out, as
shown in Fig. 6, at a decided angle, so that the knees are bent
inward and the inside edges of the skis cut into the snow. A variation
of this is the “half herringbone,” the skis being turned out at a less
acute angle. These special steps for special purposes are all useful
now and then in mountain climbing, but when a long distance is to be
covered, the skier will conserve his energy by mounting the hill in a
zigzag fashion rather than attempting to climb straight up. The track
of the skier will then resemble the course of a boat tacking through a
narrow inlet against a head of wind, and while more ground is
covered than when going straight up the steepest part of the hill,
progress is faster and much hard work is avoided.
When running straight downhill, one ski should be in advance of
the other a few inches, and the skis must be held quite close
together so that they touch, or nearly so, as shown in Fig. 7. To
make a narrow track, most expert skiers hold the knees together with
the back knee slightly bent. However, the body should be perfectly
and easily balanced. This is done, more or less, intuitively, by
beginning the run with the body thrown on the advanced foot, and
when full speed is attained the weight automatically shifts to the rear
foot. The novice will find it difficult at first to keep the skis together,
there being an almost uncontrollable desire to separate them to gain
a better balance. A good track will come with a little practice, but if
the skis are too short, or made without a groove, even an expert
would be compelled to keep his feet a trifle apart and make a double
track in order to keep from falling.
 Fig. 10
The Christiania Swing is Accomplished by Pressing with Both Heels at the
Same Time While the Stick Digs Well into the Snow Above

When making the start preparatory for coasting downhill, the

novice may, if the slope is moderately steep, face in the desired
direction and assume the proper position by supporting himself with
the stick. On most very steep slopes, where the best coasting is to
be had, this is quite out of the question, and the skier must step
around quickly by moving the lower ski first. This will be somewhat
difficult to do until the novice gains more confidence, which will
quickly come after a little practice, and it is a good plan to practice
starting from the slope without the aid of the stick to anchor the body.
Owing to the fact that the skis do not reach much speed at the start
of the coast, even the slow novice will have plenty of time to make
the turn and face in the right direction before much speed is attained.
A comparatively crouching position, secured by bending the knees
and the body at the waist, will much lessen the liability of a fall
forward. This position enables the skier to control the balance of his
body with more certainty, and especially when coasting on a hill
where patches of ice, or crusted snow, and soft spots of unpacked
snow are encountered, a condition usually found wherever skiing is
enjoyed. When coasting, the stick, or sticks, should be firmly
grasped at the upper end with the looped thong, or strap, over the
wrist, and the end dragging behind. Balancing is done entirely at the
waist, and for straightaway running, the weight of the body will rest
largely upon the rear ski. The long running surface of the ski will
carry the skier over many bumps and hollows without disturbing the
balance of the body or causing a fall, providing the novice does not
lose his nerve. It is necessary to practice on rough and uneven
ground if the skier desires ever to attain much expertness, and
plenty of falls must be expected, but not dreaded by the beginner. A
fall on skis is by no means fraught with danger, and one may fall with
impunity providing all muscles are relaxed. Many beginners find
falling the easiest manner of stopping, but this should not be
necessary, providing the hints given are well understood and
practiced. However, the novice should have no fear of falling if he
wants to become proficient on skis, and to offset any timidity, which
so very often causes the novice to lean backward and fall in this
direction, it is a good plan to lean well forward to check this natural
tendency. Getting up after a fall is easily enough managed if the
head is pointing up the slope, but when the position is reversed
much floundering is necessitated. It would seem that this would be
obvious to all, yet the majority of beginners often forget it altogether.
Braking with the stick is only effective when the body is properly
balanced, and the stick is kept well forward and as nearly vertical as
possible. Straddling the stick, sitting upon it, or leaning backward on
it held at an angle, are slovenly methods which every novice should
avoid.
The “snowplow” is most largely used by all good skiers for braking,
stopping, and turning. This is accomplished by stretching the legs
wide apart and at the same time turning the toes in as much as
possible, thus presenting the side of the ski to the snow and
retarding the speed. Aside from straddling the legs wide apart, the
novice will have no trouble in learning this useful knack. For the first
practice, pick out a fairly steep hill road, or a hillside where the snow
is old and not soft. Begin the run as for coasting, and when good
speed has been attained, spread the legs wide apart, turn the toes in
and endeavor to control the speed with the skis rather than depend
upon the stick. On hard snow the edges of the ski may be used to
check the speed, but on ordinary soft and well-packed snow, the
runner may be kept quite flat. This is well shown in Fig. 8.
The knack of “stemming” is a variation of the snowplow, inasmuch
as the skier runs straight downhill on one ski, and turns the heel of
the other ski outward and downward and uses it as a brake, as in
Fig. 9. This is a very useful movement, and is largely used when
coasting down steep slopes, and when one has learned the knack of
it, stemming will serve for braking and steering, and is useful for
stopping by turning the skiing course uphill. To earn it, select a steep
hillside, coast down at an angle, with the feet a trifle part, and
endeavor to retard the speed with the stick and turn the heel of the
lower ski outward. This makes the turn and the skier faces uphill and
comes to a stop. By turning the heel of the lower ski outward and the
heel of the upper ski inward, the skis will travel downhill with a sort of
snowplow movement. When practicing these movements, the
beginner should endeavor to use the stick as little as possible and
learn to depend upon the skis for controlling the speed.
The “side slip” is useful on steep slopes, and is done by turning
the skis so that the runners are at a decided angle to the course
traveled. This affords the maximum braking by the skis alone, and is
especially effective when combined with the braking done with the
stick. Side-slipping may, of course, be done while the skier is
traveling forward, by keeping the skis close together so that the
edges almost touch. While this movement checks the speed in much
the same manner as stemming, side-slipping is less tiresome, since
the weight of the body gives the required braking effect, while, in
stemming, the muscles are called upon to keep the heel pressing
outward.