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·STERNAL PUNCTURE
A METHOD OF CLINICAL AND
CYTOLOGICAL INVESTIGATION
By
A. PINEY, MD., MRCP
Physicias, St. Mary. Hospital for Women and Chudren, London
L. Consa ing Physxian (EMS) Late Drector of the
Pathological Jostitute Charing Cross Hosptal
AND
J. L. HAMILTON-PATERSON, MD, MRCS
holog's
awan neral Hosptal Late Assistas
Univen ty Co lege Hoap tal
Patholog st
WITH A FOREWORD BY
The Rt Hon LORD HORDFR, MD, FRCP
TOURTIT EDITION
LONDON
WILLIAM YENEMANN MEDICAL BOOKSLID
19.49

·First published December 1941
Second edinon reser November 1943
Thurd edition
April 1946
Fourth edition
1949
This book is cops right It may not be
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toithout permission
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regard to copyright should be
addressed to the Publishers
BOOK
PRODUCTION
WAK ECONOMY
STANDARD
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conformity with the authorised
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·FOREWORD STERNAL PUNCTURE is the generally accepted means by which myeloid tissue may be studied during Infe It is one of the most modern of the techniques included under the term "clinical patho logy" A little hesitant at first, it has now developed into a fullblown method of investigation By the help of sternal puncture three things are being accomstates of the body are being observed All these aspects of the subjects are covered in Dr Piney's present monograph The limits of usefulness of the new technique cannot yet be stated They must await much more exploitation of the method than has so far been undertaken LLL 1 .L r the Iner occur as possible examples The authors have avoided dogmatism and have wisely kept such knowledge as we have in this field in a fluid state, where it should be allowed to remain whilst the technique is in its early history and the body of ascertained facts relatively small Equal care has been shown in handling the nomenclature The book is timely because it summarises the present position of the subject and acts as a manual for investigators, whether their approach is on the pathological or on the clinical side The popularity which has been achieved by Dr Piney's presious books in hæmatology may safely be predicted for this new work also HORDER

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·PREFACE TO FOURTH EDITION The need for a fourth edition of this book suggests that the mode of presentation meets a real need, and we have, therefore, not altered the style by attempting to produce a complete review of the subject There are many excellent text-books of hæmatology, some of which proceed from the consideration of the peripheral blood to a discussion of the marrow, while there are others in which the opposite course is adopted, but our aim has been (and still is) to present the essential features of the bone-marrow in health and disease For this reason, we have not increased the size of the book, but have extended our consideration of the relevant literature, calling attention to such papers as contain an adequate bibliography For those who require extensive references to the literature, we would suggest study of the monographs cited at the bottom of this page T T- ALDER, A "Atlas des normalen und pathologischen Knochenmarks," Berlin, 1939 BODLEY SCOTT, Á Quart 7 Med , 1939, vit, 127 BOVER, J FORTEZA "El Diagnostico por la Puncion Esternal," 1976 LEITNER, S "Die intravitale Knochenmarksuntersuchung," Basel, 1945 MALLARMÉ RASTELLI, N ROHR, K SECERDAHI, SCHULTEN, I “Ueber Sternalpunktion als diagnostische Methode," Leipzig, 1937 Weil, P Emile et SERLÈS, S “La ponction sternale," Paris, 1938

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·CONTENTS FOREN ORD PREFACE PAGE List OF COLOUR PLATES V INTRODUCTION VII CHAPTER 1 THE MYELOGRAM XI II THE MARROW I LEUKÆMIA X111 I NEOPLASTIC AND ALLIED CONDITIONS OF THE BOVE- MARROW 15 IV THE ANÆMIAS V ERYTHRÆMIA AND ALLIED STATES 24 VI INFECTIVE DISEASES 37 VII HYPOPLASIA AND APLASIA OF THE BONE-MARROW 56 VIII SOME PROTOZOAL DISEASES 59 I THE TECHNIQUE OF STERNAL PUNCTURE 63 INDEX 76 79 88

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·LIST OF COLOUR PLATES NORMAL MARROW Frontispiece TV RACE PACK 6 2 DEVELOPMENT OF WHITE CELLS 3 ERYTHROPOISSIS 8 4 16 A CHRONIC MIYELOID LEUKEMIA B CHRONIC MIYELOID LEUKÆSE BECOVING ACUTE 18 A MONOCYTIC LEURÆMI B MONOCYTIC PHASE IN MIYELOID LEUKAMI 6 20 A ACUTE MYELOW LEUKÆVIA B ACUTE LIMITATIC LEUKÆMIA 7 PLASMA CELLS IN BONE MARROW Svearts 30 40 8 A HFMOLYTIC ANAMI (C? welchi) R SPRUE 9 44 A UVTREATED PERNICIOUS ANÆMI D PERNICIOUS ANÆM74 EARLY TREATMENT 10 A VERNICIOUS ANÆMA LATE STAGE IN TREATMENT B fooPathIC HYPOCIIROVIC ANÆMIS +6 MECALOOLASTS IN PERNICIOUS ANÆMI *8 A AGRANULOCYTOMIS (W4TVAATION TYPE) B TROVSOCS TORENLA (MATURATION TYPE) 72 13 ALLA AZAR B MALIGNANT TERTIAX VALARIA MISTOTIC DIVISION OF CELLS 86

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·INTRODUCTION BLOOD examination, which has become an important adjuvant to hath dugnasts and prognosis has always suffered from the weakness of depending for its value on the inferences drawn from st honledge of the concomitant changes in the formatne tissues has been scanty Attempts have often been made to correlate blood changes with those in the marrow, but the difficulties kase been great First, the blood has been examined by the filra method, whereas the marrow has been examined in sections when the cells look very different Secondly, marrow sections can usually only be obtained from post mortem material and ulthen res cal only the terminal ştate Marrow puncture is a consenient method of examining the formetre fissue durang life, and it can, werhout difficulty, be performed several times on the same patient There can be no doubt that it has led to a much deeper knowledge of the factors on which the characters of the blood picture depend The blood is, of course, not a tissue at the usual sense of that word It is a product of a number of organs of which the bone marron as the most important, and yet the blood is not a secretson of the hæmopoietic tissuc in the same sense that urine is a secretion of the kidneys It does not consist of constituents that have been abstracted from the body as a whole but of portions of the parent tissue itself 11 13 for the reason that it is convenient to concenc of the whole mass of circulating cells together with those in the formatne tissues as forming an organ Thus Boycott spoke of the erythron as the organ composed of the whole collection of red cells and their precursors in the body A similar concept, the leucon, 13 applicable to the white cells, and the thrombon to the platelets These organs are not totally independent of one another because the pasmine parent cells of both the red and the white elements are probably identical, in other words, as the earliest stage, the erythron, the leucon and the thrombon mect for this reason we must make use of the conception of the hæmaton, which is then the sshole of the blood and the blood forming system Thus, examination of the marrow $3 important because it reveals something more than the chancers of the parent tissue of the blood, it shows us an integral part of the hornaton ·XV1 INTRODUCTION It was the improper abstractive separation of the circulating blood from the formative tissues that led in the past to a deep and fundamental cleavage in the hæmatological world Thus, there were two main schools of thought the monophyletic and the polyphyletic The former contended that all the different types of blood cells were derived from a common ancestral form, which was variously known as the lymphoidocyte, the hæmocytoblast, and about eighty other synonyms The polyphy letists, on the other hand, asserted that there were several stem cells, each one with irreversibly determined potentialities The number of such elements was a matter of discussion among the several groups of this school, but all were agreed that the monophyletists were wrong This controversy, which, in the past, filled thousands of pages, is no longer acute because our knowledge of the martow has increased In the past, most observations on the blood-fortaing organs were carried out by professional histologists, who naturally made use of their customary technique, that is to say, fixation, embedding in parafin or celloidın, section cutting and staining, and most, if not all the histologists were adherents of the monophyletic view The clinical hæmatological workers, on the other hand, based their conclusions on observations made on stained films, and very many of them were polyphyletists The divergence of views was to a very great extent dependent upon these differences of technique, because cells which appear large and full of cytoplasmic and nuclear detail, when seen in films, are small and difficult to recognise in fixed sections Narrow puncture has enabled us to use the same technique for marrow tissue as for blood, and, as a result, the old controversy has almost died down, Various methods of obtaining marrow during life were used in the past Thus the femur was trephined and marrow extracted, or the tibia was similarly treated, and from both these methods a good deal of information was obtained There are two main objections to such procedures They are in the nature of major surgical operations and cannot be repeated frequently on the same patient Secondly, in adult life the red marrow in the limbs is confined to small areas at the upper ends of the humeri and femora, the more distal parts of these bones and the more distal bones of the limbs containing only fat In diseases, in which there is excessne production of cells, formatne marrow may spread into all the bones Thus, ·INTRODUCTION in advanced leukæmia and pertucIOUS 21&mia, saluable information could be obtained from the tibial bone marrow, but in health and more acute maladses only fatty tissue was present Obriously then, it would be a great advantage to obtain the specimen from a bone that is always filled with active marrow, such as the sternum Since 1929, when Arukin utraduced the method of sternal puncture, this has been the usual technique It may be mentioned that marrow puncture is not only of valve in the investigation of most of the disorders of the blood and in many diseases due to protozoa It has been found that it may assist in the bacteriological diagnosis of typhoid fever Rogge abtained a positive culture from the marrow in 60 per cent of cases, and, on 9 cases, was successful in this way when all other attempts at culture had been unsuccessful In the first week of the disease, 4 cultures out of 4 wert positne, while only 19 out of 30 blood cultures were so In the second week, 15 out of 21 sternal cultures were posstye, against 9 out of 38 blood cultures Thus, it would seem that typhoid fever cannot be excluded if the sternal marrow has not been cultured, even although all other tests have proved negative The material obtained by sartow puncture has even been used therapeutically Morrison and Samosch claimed good results from intra-sternal section of marrow juice in two cases of aplastic anæmia, but others have failed to obtain similar results Schretzenmayr injected sternal marron intramuscularly as a treatment for various anamuas, and believed that the method was of value the esidence presented 23, however, poor REFERENCES ARIVKIV, I Folia Hemat, 1929, XXX, 233 MORRISOY, M , and SivwICK, A JANA, 1940, cxx, 1708 Rocce, K Arch Kinderhalk, 1947, CYRX8, 1 SCIRETZEYVAIR, A Man ochenicht, 1937, 15, 1050

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·admitture of a certain amount of fat and the cells art bot c.exting STERNAL PUNCTURE CHAPTER 1 THE MELOGRAXI The recognition of the various types of cells in blood films steds a good deal of practice, and it is quite possible to interpret the appearances in marrow films without a sound knowledge of the cytology of the peripheral blood This is, of course not surpnsang. because the marrow cells are either blood cells or are their precursors, and, for this reason we can use a similar terminology to that used in ordinary hæmatology Schilling coined the name hæmogram, to designate the qualitative blood picture, and this is a much sounder concept than is the ordinary term “differentral count The term, myelogram, can with equal teason be applied to the total marrow picture Just 23 experience has gnen us knowledge of the normal percentages of the different types of cells in the blood in health and in a great variety of diseases, so observation has led to a knowledge of the marrow picture, the myelogram in health and dssease The hæmogram is naturally not an absolutely accurate picture of the cellular composition of the peripheral blood, because it is based on random sampling, both of the whole blood and eren of the specie men taken for examination The myelogram is subject to the same sources of crror, but is also less accurate than the hæmograr lor another season a varying proportion of the cells in the master cannot be classified exther because of pathological changes in their structure, or, even in health by being in a more or less dediferesfiated state, prior to during or immediately after matosis Exon, the myelogram is of great value, but has to be recorded on a trore detailed manner than the hzmogram, because there are more clzava of cells us the marrow than in the blood Then agan, another difficulty is that marrow films cannor be esenly spread, there is free, as in blood but are more or less aggregated into cups Both for purely scientific and for cmical purposes, the masclogram and the harmogram should be investigated at approtuma:dy ze same time, and completeness would, of course, requre etration of puncture flud from the other hæmopoietic organs, splets and some ar ·4 STERNAL PUNCTURE more than describe its structure The cytoplasm, which is devoid of granules, is distinctly basophilic, and varies considerably in amount The nucleus is a good deal denser than that of the hæmohistioblast, but has the same type of reticular structure, being composed of interlacing fibnls of basichromatın, in which one or more nucleolt can easily be seen (Plate 3) The followers of Ferrata regard this element as being the most primitive cell that has become irreversibly fixed in the direction of hæmopoiesis unlike its alleged ancestor, the hæmohistioblast, it can no longer produce connective tissue If this be so, the hæmocytoblast is the real stem-cell of the whole hæmopoietic process Certainly, in marrow that is hyperplastic from any cause, these cells are increased in number Thus, in the megaloblastic marrow of pernicious anæmia, in ordinary normoblastic marrow hyperplasia, in leucoblastic, and even in leukæmic marrow they are increased in number This fact seems to justify the inference that they are fixed in their general hæmopoietic potency, but are still multi potent, inasmuch as they can give rise to either red or white cells On the other hand, Naegelt contended that the hæmocytoblast is not a multipotent stem cell, but that it is identical with the myeloblast the parent of the granular leucocytes only But his view fails to supply any explanation of the increase of these cells in all types of hyperplastic marrow, if he were right, it would be surprising to find these leucopoietic elements increased in erythroblastic reactions As long as we are clear in our minds about the structure of these elements, so that we can recognise them, their exact status can be left to further research, but the name, hæmocytoblast, is now so widely used that we may well adopt it Myeloblast The supporters of the view that the hæmocytoblast 18 multipotent, distinguish it from the myeloblast (Plate 2), which they consider to be an element irreversibly determined in the direction of granulocyte formation, that is to say, they regard it as a more differentiated cell It is, unfortunately, difficult to decide on what morphological criteria myeloblasts are to be distinguished from hæmocytoblasts It is said that the nuclei of the former are rather less tenuous, and that the cytoplasm 18 less basophilic But it is, of course, not to be expected that exact distinctions can be made, because we are dealing with a continuous process of development, not with isolated cell types Premyelocyte The premyelocyte (Plate 2) is intermediate between the myeloblast and the myelocyte, that is to say, there 15 ·THE MYELOGRAN no doubt that it is definitely fixed in its potencies, and its structural characters lic, as it were, midway between the two types of cell There seem to be two grades of premyelocytes First thert art those in which the nucleus is only a little denser than that of a mycloblast and still contais nucleols, but the cytoplasm is less basophilic and contains azurophilic granules Most of these cells have minute granules all of the same size (preneutrophile premelocytes) Some have large rather scanty granules, also all of the same size (pre-eosinophle premyeloxy te), and finally, there are a few elements wsth large granules of irregular size (prebasophile premyelocytes) from these arsse neutrophilıc, eosinophilic and basophilic premyelocytes in which the nucleus has become a good deal denser and the nucleols are obscured, alule the granules have reached definitive staining reactions Miyelocytes These cells are the stock from which most of the mature granulocytes arise in health in the rnarrow they vary greatly in size, some being little larger than lymphocytes, while a few are as much as 26 microns in diameter Thus variation in size is even greater than that seen in the blood in chronic myelosd leukæmia, although in the past it was supposed that the variations in that disease vere due to the morbid process. The nucleus of the myelocyte is circular but the edge may be slightly indented as if by pressure of the granules that fill the cytoplasm The chromatın still has a retscular arrangement resembling that of the myeloblast, but condensations and small nodules can be seen in the skem The cytoplasm 18 slightly basophilic but is difficult to see because it is almosc filled with granules, which, as this stage, hare, of course, reached their definssve staining reactions (Plate 2) The cosinophil myclocytes present difficulty, because, although many of them contain mature cosmoplul granules, others present a mixture of granules, some being basophilic and others eosinophilic Aianable number of such elements is always found in the marrow, but the exact steps in their origin from premyelocytes are unknown It is possible that some of the cells in the marrow, which contain only basophilic granules, are really the cry carliest stage of cosiophils If this 13 80, it would account for the fact that the marrow anos canais moke hasakus skar one would cepat Ed She appearances of the perspheral blood Rietamyelocytes These are snfermediate between myclocytes und mature polymorphs and can be divided into juvenile forms, with sery slight indentations of the nucleus, and staff forms in which ·6 STERNAL PUNCTURE the nucleus is deeply indented, rather like a band (Plate 2) It is at the stage of the staff form in the marrow that abnormalities of structure occur in pernicious anæmia, some of the cells being as much as 30 microns in diameter Polymorphonuclears As seen in films of normal marrow, these cells are identical with those found in the blood (Plate 2), but, even when the blood polymorphs appear normal, atypical forms may be seen in the marrow Thus, in chronic myeloid leukæmia, very large ones may be seen, and in pernicious anæmia equally gigantic forms, mainly neutrophilic, with most complicated nuclei, are common in urt treated cases Lymphocytes These are not part of the myeloid tissue proper, but there seems to be no doubt that the marrow is the seat of production of a small proportion of the lymphocytes in the peripheral blood Certainly, even in adults, it contains more large lymphocytes, which are commonly supposed to be younger forms In rickets small aggregations of lymphocytes, sometimes even with a germ centre, may be found It is unusual to find immature cells of the lymphocyte series in normal marrow, but in glandular fever and in lymphatic leukæmia they may be numerous The typical immature cell of this series is the lymphoblast (Plate 2), which is, so to speak, equal in its developmental potencies to the myeloblast, 1 e, it is irreversibly determined in the direction of lymphocyte formation It is about the same size as the myeloblast but with a relatively larger nucleus, which is more coarsely reticulated than that of the myeloblast It contains nucleolt around which the chromatın is somewhat condensed as it is also at the edge of the nucleus where it forms an almost distinct membrane Monocytes Monocytes are scanty in normal marrow but appear to arise from the hæmohistroblast through the stages of monoblast and promonocyte The monoblast resembles the myeloblast and lymphoblast in general structure, and may not be easily distinguishable from them The promonocyte shows some indenting or folding of the nucleus with the characteristic ground glass cytoplasm of the adult monocyte , fine azurophilic granules are often visible in the cytoplasm The adult monocytes are in no way different from those seen in the blood Plasma Cells. Plasma cells are scanty but invariably constituents of the marrow even in health They increase slightly in hypoplastic conditions and a great deal in myeloma There is still much controversy as to the origin of these cells, and it remains un- ·PLATE 2 Da OPENT OF HITE CELLS

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·THE MYELOGRAM certain whether those of the blood and marrow are identical with those found in the tissues In the marrow most of these cells are quite large (15 to 20 microns), have an excentric nucleus, in which the basichromatin has a cart-wheel” arrangement, intense basophilic cytoplasm, and usually a pale area round the nucleus Similar cells, in which the nucleus us in the middle (Turk cells), are also found, and, like the plasma cells, their origin is uncertain There is a good deal of evidence that any type of non granular blood or massow cell may, for reasons as yet unknown, assume plasmacytord characters so that it is probable that lymphocytic, lymphoblastic, myeloblastic and even erythroblastie plasma and Tuch cells exist It has been asserted that plasma cells have a distinct line of development from plasmoblasts, and Moeschłın's work on these cells in rubella seems to support a similar although he gues no criteria by which one can distinguish plasmo blasts from lymphoblasts Megakaryocytes Megakaryocytes are important components of the marrow and, in spite of their great size and irregular shape, they, or parts of them, are usually recognisable in films As they are rarely numerous, it is best to seek for them with low magnifica - tions, and they are most likely to be found intact only near the edges and ends of films They are from 30 to go microns in diamcrer with faintly basophilsc cytoplasm in which stnall groups of azurophilic granules are present, mainly near the edges (Plate 2) The nucle present most complicated lobulation, but there does not seem to be any distinctise distribution of the basichromaton, which 19 mainly disposed in the form of farge masses It 18 possible that many of the structures, which in marrow films seem to be only parts of megakaryocytes, are really complete but immature elements which le on the Isne of development from the histiocyte to the fully formed megakary ocyte The relative simplicity of the nuclei of these megakary oblasts seems to support this view There is much controsersy about the nomenclature of the various megakaryocyte like cells that may be found in marrow films, but, of the many suggestions that have been put forward, those of Dameshch and Niiller seem to have most tommend them These authors distinguish the follaxing forms - (1) Alegakar, oblants which are about tuse the size of myeloblasts, have son-granular cytoplasm, and a rather regular single nucleus hich contains several nucleals (2) Promegakan ocz tai ate about the same size as megalanoblasts, ·8 STERNAL PUNCTURE although much larger forms also occur The nucleus is usually not fully lobulated. The cytoplasm is rather scanty and is distinctly basophilic In it there are usually a few aggregations of azurophilic granules, resembling platelets, near the periphery of the cell body There may also be a few of these cells with non-granular cytoplasmic projections and such promegakaryocytes seem to be specially common in thrombocytopenic purpura (3) Lymphoid megakaryocytes (rather a poor name) are large cells with relatively small lobulated nuclei and non-granular cytoplasm (4) Megakaryocytes (5) Prepolykaryocytes are mononuclear cells, which are often seen in small clusters The basophilic cytoplasm is vacuolated, and there is a reticulated nucleus which contains nucleoli (6) Polykaryocytes are assumed to be fused syncytia of prepolykaryocytes, and are supposed to be osteoclasts under another name It is suggested that these cells may, by nuclear fusion, give rise to megakaryocytes an improbable occurrence Red Cells It is now almost universally assumed that all red cells, both normoblasts and megaloblasts, arise from a common ancestor-the hæmocytoblast We need not enter into the timehonoured discussion of the genealogical history of the red cells in general, but, as the morphological differences between normoblasts and megaloblasts are considerable, they are best described separately phoman Plata 7 of the ordinary red corpuscle In marrow films it is relatively easy to trace out every stage in this process The least mature element that is recognisable as definitely belonging to the red cell series is the pro erythroblast, which is a large cell slightly resembling the hæmocytoblast but possessing a distinctive nuclear arrangement The bastchromatin is no longer purely reticular, as in the hæmocytoblast, and shows a tendency to be aggregated into almost triangular masses with a roughly radial arrangement Pale areas, which are perhaps nucleoli, can be detected, but the cells in which these can be seen are scanty The cytoplasm has become less intensely basophilic, and when no trace of nucleoli can be seen we have reached the next clear-cut stage—the basophilc erythroblast. In this the radial arrangement of the chromatın is quite distinct, and

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·10 STERNAL PUNCTURE. of the different names used by different authors for the same cells In order to lessen this confusion we have constructed the accompanying table where an attempt has been made to correlate the different names used to describe the various cells, together with the authors who have used these names (P 11) Atypical Erythropoiesis. Limarzi and Levinson "haie recorded an extremely bizarre and presiously undescribed type of erythropoiesis observed in the bone marrow of a man aged sercaty-seven suffering from prostatic obstruction Very farge cells (apparently giant basophil megaloblasts) were seen which underwent repeated mitotic division of the nucleus producing a muitunucleated cell which eventually split to form ordinary basophil normoblasts, these developed into ordinary basoplul normoblasts which in turn developed into ordinary erythrocytes Other similar cells behaved in the same way except that nuclear division occurred amitotically Where division of the nucleus was incomplete large nucleated red cells were formed which, after extrusion of the nucleus, left corpuscles as large as 234 in diameter--these corpuscles did not appear in the peripheral blood but underwent a process of fragmentation in the marrow Since this first report, Schwarz has studied many marrow films and found cellular gigantism and pluripolar mutosis of both the Inyeloid and erythroid cells This apparently may occur in many condicions as well as in nomal people Schwarz's paper does not give the frequency with which this phenomenon occurs, but it must be comparatively rare as neither of us have ever seen it Fig I, re drawn after Schwarz, shows the types of cell which may be encountered The changes apparently are not of pathological significance and the resulting monsters should be regarded "sports 11 The Normal Myelogram. It is not possible to make accurate total cell counts on the bone marrow Segerdahl, who tried to do so, found that in health the number varied from 10,000 to 190,000 per cubic millimetre There can be little doubt that venous factors fuence the total sunt quite a pass from the structure of the marrow itself Thus, if only small amounts of marrow are syithdrawn by stemal puncture, the total number of cells per una solume is greater than if a large amount is withdrawn, and, even more strangely, the proportion of white cells us higher There seems no doubt that it is only the differential count from which inferences can be drawn, and it is disappointing to find that the marrow obtained by sternal

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·THE MYELOGRAM 11 TABLE 1 A correlation of the different names used by authors for tarjour blood and stem cells The description of each cell will be found on the page sndicated m the left-hand column This Book Alternative Name Author Hæmohu poblast (p 3) Haemocytablast (p 3) Lymphoidocyte Erythrogone Promegaloblast Megaloblast Pro erythroblast (p 8) Ferrata Paney Schulten Israels Maximow Pappenheim Helly Naegels Doass Cunaghan and Sabin Schuiren Runaldi and Ferrata Israels Daneshek und Valentine Nordensen Naeguse Doan Cunaingham and Saturn Peabody Doan Cunninghara and Sebis Peabody Israeli Jante Erythrogone Promegaloblast Megaloblast Basopusc megaloblast Miegaloblese (p 8) Alegaloblast A Polyck.cornette megaloblast Mlegalabizit. (99) Alegaloblast 3 Eonnophil megaloblast Megaloblast C Ehrlich Turobu!! Gumour Torch Israel's Basophal normoblast ( P8) Prontarmoblast Tacronormobiest ordeusen Naegels Pappenhem Naegels Does Cunningham and Seburt Israels Early erythroblast Mammablast A Late erythroblast Normoblast B Doan Cunningham and Sabin Isracts Polychromatic nonnablast (e a) Eounophil normoblast (98) Mormoblast Macadius C Doan Cunnmgbar and Subiss Issels ·- 12 STERNAL PUNCTURE puncture before death gives a very different picture from that obtained by the same procedure within half an hour after death In other words, the inferences we may draw from the myelogram are much less certain than those which we may draw from the ordı. nary blood count From the figures obtained by examining from 500 to 1,000 consecutive cells in marrow films, useful relationships can be revealed thus, in health, the proportion of white cells of all sorts to nucleated red cells varies from 5-1 to 3-2, but in the anæmias the proportion is much lower and the relationship may even be inverted Then again, the proportion of granular to nongranular white cells 18 of some importance Normally it is about 4-1 Again the numerical relationship of normoblasts to megaloblasts is significant, particularly in the diagnosis of pernicious anæmnia In the normal bone marrow the cells multiply by ordinary karyokinetic division, and, in films of the marrow-fluid, mitotic figures are always seen It is important to arrive at some estimate of the percentage of dividing cells, and in which particular group of cells, re, myeloblasts, myelocytes, etc, mitosis is most active, because from this information very useful deductions can be drawn Japa has given the following figures for normal bone marrow, in each 1,000 nucleated cells about 15 show mitotic figures, 40 per cent of these are in the prophase, 45 per cent in the metaphase, 10 per cent in the anaphase, and 5 per cent in the telophase The proportion of dividing leucoblasts to erythroblasts is given as 45 55, of myeloblasts to myelocytes 3 97, of early normoblasts to late normoblasts 91 9 In simple hyperplasia of the leucoblastic or erythroblastic tissues following acute pyogenic infection or acute hæmorrhage, the number of mitotic figures may double itself, but there will be no significant alteration in the ratios of the dividing cells in the myeloid and erythroid groups respectively The leukæmias, hones er, show a very different picture Here the number of dividing cells also shows a marked increase, but a Jarger percentage of the mitotic figures are in the more unmature cells This is well seen the myelogenous leukæmias, in the chronic forms there is an increase in the number of dividing premyelocytes, and to a much smaller degree in the myeloblasts as the malady becomes more acute the proportion of mitotic myeloblasts rises untıl, in the true acute form, they are the only druiding cells seen ·DIE ATY ELOGRAJE 10 -15 1 10 2 11 . 1) IT 8-12 T >> TY NORSIAL MYELOGRAM Neutrophiles Miyelocytes 30 35 per cent Metamyelocytes Polymorphs 24 -30 Eosinophiles Miyelocytes Polymorphs Desophiles Myelocytes Polymorphs Premyelocytes Hæmokytoblasts, including myclablasts Hamohistsoblasts Lymphocytes Small Large Plasma cells Pro or throblasts Normoblasts Megaloblasts Megakaryocytes scanty, but invanable It is possible that some, If not all, the cells called megaloblasts in the table are really large normoblasts; best many writers state that a few genuine megaloblasts are present, even in health Much has now bees written on the variations in the normal myelogram Shapiro and Bassem have studied the stomal marrow changes during the first week of life and shown that there 19 a marked drop in the number of normoblastic cells at the end of the first week of life which runs parallel with the decrease in circulating reticulocytes Dwany gates the normal picture in children from one to fine years of age, and l'ogel and Bassein gue the myelograms of forty-one children of venous ages The hæmatology of the sternal marrow in normal women as discussed by Patts and Pachtram, and the same authors and farloff gre the 14tions which are found during normal pregnancy (P 34) REFERENCES DASTESTIEX, W, and WILLEX, E B Bleod, 1946, 1,27 DAVESIEX S1 and VALENTINE, E MI Ask Path, 1937, IS 159 DOXY, 11 Arch Du Childrea, 1940, , 139 15-20 » 2 - 3 ·14 STERNAL PUNCTURE плі" ся ayn D r itions to Vienna FERRATA, A Le Emopatie, 1918, Vol ! GILMOUR, J R 7. Path and Bact , 1941, 111, 25 HELLY, K “ Handbuch d spezellien Path Anat u Histol Heuke. Lubarsch," Vol 1, Part 2 ISRAELS, M C G Path and Bact , 1939, xlıx, 231 JAFFÉ, RH Folia Hamat , 1932, xlviii, 51. JAPA, J Brut Journ Exper Path , 1942, XXX111, 272 LIMARZI, L R, and LEVINSON, S A Arch Path , 1943, XXXVI, 127 MARKOFF, N 2 Geburtsch Gynakol , 1939, CXIX, 13 MAXIMOW, A A., and BLOOM, W "Textbook of Histology," 1939 MOESCHLIN, S Helvet Med Acta , 1940, V11, 227 NAEGELI, O "Blutkrankheiten und Blutdiagnostik," 4th edit , Berlin, 1923 NORDENSEN, N G “Studies on Bone-Marrow from Sternal Puncture," 1935 PAPPENHEIM "Morphologische Hamatologie," 1919 PEABODY, F W Amer Path , 1927, 111, 179. PINEY, A "Recent Advances in Hæmatology," ist edit, London,1927 PITTS, H H , and PACKHAM, E A Arch int Med , 1939, lxiv, 475 TTT 1. L . AAN . I VILNVULLA 1936 VOGEL, P, and BASSEM, F A Arch int Med , 1939, lyu, 245 ·CHAFTER 31 THE MARROW IN LEUKÆMIA Tule marrow changes in the various foms of leukæmia are usually distinctive, and for this reason it is best to start our description with this group of diseases It is not to be supposed that marrow puncture in the leukatatas is only of academc interest Admittedly, in many, perhaps most, cases of leukæmia, diagnosis as possible on clinical and ordinary hæmatological grounds Blood examination usually enables one to discover the type of feukæmia and also gres some indication of the severity of the condition, but the blood is not in the ordmary sense of the word a tissue It is a mixed secretion from the hemopoietic organs, and for this reason the matran naturally Eres a clearer and more accurate picture than does the blood For instance, changes indicatue of an approaching relanse will be found in the arrow carlier than in the blood, and, further, as all forms of treatment of leukemia are directed towards the regulation of marrow function, it is of great value to follow the effects of thempy by repeated sternal punctures It should be recognised that whatcher the mprovement in the clinical condition the marrow is always recognisable as leukæmi Emile-lel and Perles have demonstrated this quite clearly by regular sternal puncture during the treatment of a case of my clard leukemia The points to be looked for are variations in the relaine pereentages of the leukemic cells, #s, the increase in the number of myeloblasts foreshadowing the change from chronic to acute myelosd leukamia Chronic Alyeloid Leukæmia (Chronic Leukaemic Myclosis) (Plate 4) The blood picture in this disease is usually striking and characteristic, but the changes in the marrow are less castly interpreted After all the marton is the main organ in which granular leucocytes are formed, and it is etiremely difficult to recognise slight degrees of overgrowth Fortunately, changes in the proportions of the cells occus early and may enablc one to make a darnosis, Thus, in health, almost all the polymorphs arise from mstotsc d 177sions of pre-existing myelocvies, myelohlasis ase senons and plar Xile or no part in the production of fresh myelocytes In sciere infections, where the demand for granular leucocytes is greatly increased, there may be so great a strain that the myeloblasts not only increase in number but also add to the stock of my clocytes 25 ·16 STERNAL PUNCTURE In chronic myelord leukæmia, even in the stages when there is no increase in the number of cells in the blood, the myeloblasts take part in the formation of myelocytes, in other words, the whole process of granulopoiesis starts from a more primitive level If, therefore, an excess of myeloblasts is found in marrow films, and if infection can be excluded, a diagnosis of leukæmia is very probable When the leukæmic process is well established, the cellularity of the marrow is much increased, and this is so extreme that it can be recognised in well spread marrow-films where one may find as many as 80 cells in each field of the microscope In the ordinary chronic stage of the disease, this increase depends almost entirely upon the addition to the number of myelocytes, which may form as much as 80 per cent of the white cells Most of them are neutrophils, but excessive numbers of eosinophil and basophil myelocytes are also present Almost all the myelocytes of whatever type are larger than the corresponding cells found in the blood, and many of them are less mature It is particularly in the marrow that one can easily find myelocytes containing both eosinophilic and basophilic granules Mitotic figures are not numerous in chronic cases, but it is very rare to be unable to find a few, usually in myelocytes and much more rarely in non-granular cells, which are presumably myeloblasts or hæmocytoblasts The number of myeloblasts and of premyelocytes is distinctly greater than in health, and some prognostic inferences can be drawn from the number of these immature elements The more plentiful they are the worse the outlook In bref, it can be said that any great increase in the number of cells, less differentiated than myelocytes, is an indication either that a relapse is imminent or that the disease is passing from the chronic into the acute stage This is, of course, comparable with what has long been known about the changes in the blood, viz that the greater the percentage of immature cells the more likely is an acute exacerbation, but the arrow changes precede those in the blood and therefore permit of earlier treatment On the other hand, undue alarm should not aroused by some myeloblasts in marrow films Even if none be found in the blood some will be seen in the marrow in all cases, and, furthermore, they are alıays more numerous in the marrow than in the blood There are two other points of importance which are not easy to determine but which experience has shown to be of importance, The first is that the background of marrow films in chronic myeloid leukæmia is denser and contains more fragments of debris than un

·PLATF
A C280 r \{eLORO LEIKFMIA
(a) Myctagits
(1) Mephile sorodlar
o Metaryelocyte
(1) L'olymorph
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a
2 CHRONIC SA LALE** wrong and
(*) Vyrkysytt
(5) Viyet hlast
(c) Boxplele Vekale

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·TJIE MARROW N LEUKEMIA 17 health Recognition of this change naturally depends upon experi moc of marrow films in general The second point, which is of great importance and whuch cannot be detected in films that are too thin or which are made from marron flud that is too diluze, is that the cells, or some of thera, tend to lie in groups, ut each of which there is only a single cell-type Thus, s5 ss quite common is fassly thick films to find islets of my clocytes, premyelocytes and myeloblasts, indicating that in leukæmic marrow the immature cells have a more focal arrangement than normal It is in such islets that mitotic figures are most commonly seen If such figures are present in the myelocyte islets, the outlook is much less graxe than it is when the raycloblasts show many mitoses Narrow films en chronic myclord leukærns are the more pleomorphic because the leucoblastic osergrowth 15 accompanied by both erythroblastic and megakaryocytic reactions Thus, of course, introduces a difficulty in interpretation, because, unless the marron is very carefully studied, the fact that every type of cells increased msght load one to suppose that one was sa the presence of a mi reactive hyperplasia such as may occur in association with infections The recognition of the focal arrangement of the stunt whice cells and of the mcrease in the sumbes of myeloblasts * te matn safeguard against this false inference It cannot be emphasised too strongly or too often that it is eskatu! to correlate the blood picture with the my clogram, cither alone ma he most misleading For instance, there is no peculsanity in the bar marrow that would enable one to recognise the fact that the end picture was aleukämic The amount of hyperplasia 18 no grie Icukamic cases than it is in aleukemic oncs, unless, of COVIK, aleukemic state is due to itcatent The factor that rez emigration of cells from the martor mto the blood is unknown, 4. this point << may be uell to mention that eramutation of the many is of particular importance in those cases in which the help has shown that the blood picture 13 aleukemic Such 2 state yer due to partial aplasia of the marrow, fither idtopathic or as Eye of escesskey energetic realment, or it may be due to somer cause which presents emigration of cells from the initer *** TATTUN into the blood It is obsrous that in the forme zry method of treatment such as X-33 will induce more rapidre intense degeneration but, in the hyperplastic cases, the ATOW 1$ as safe as the ordinary leukämic type of tr> Vorschluss has compared the effects of urethane on *- ·18 STERNAL PUNCTURE in chronic leukæmia with those of X-rays and arsenic He points out that the lattes agents cause a diminution in the number of t the number of mitoses in the immature white-cells, while there is an increase in the number of dividing red cells Thus, urethane acts by a selective anbubition of mitosis in the essential“ neoplastic" cells of the leukämic process But the marrow does not show as great a decrease in the number of immature cells as it does after X-rays or arsenic There are other cryptic forms of myeloid leukæmia in which amic or even R in these cases leukæmia but t tenable because the blood picture and clinical condition deteriorate until death occurs Indeed, in prolonged cases, the medullary form of myelosis may develop into the ordinary type of chronic myelord leukæmia Early diagnosis by marrow puncture is of importance because radiotherapy causes mprovement even at a time when the spleen is still unaffected There is also an acute form of this purely medullary overgrowth macute cleukeemic myelosismo hich clinically resembles the similar lymphatic condition The relationship of multiple myeloma to plasma-cell leukæmia has not been clarified, but it is true to say that the more nearly plasma. cell leukma resembles typical leukemia the more malignant us the process and the fewer are the nodular infiltrations In the marrow it is, as a rule, not possible to distinguish plasmacell leukæmia from plasma-cell myeloma, but, if films show a monotonous series of plasma cells unmixed with other elements, one is probably dealing with the latter condition The whole subject has been dealt with in some detail by Aloss and Ackerman The rare condition known as eosinophile leukoemia, which may run either an acute or a chronic course, presents varying appearances in the bone marrow Acute cases usually end as myeloblastic leukæmsa, but sometimes

·PLATES
A SonoCTIC LIL MEMES
(a) VonobFast
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(c) Monocytt
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VoYTIC FASE 1 OD 1.1
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·TIIE MEERRON IN LILLEM 19 the predominant cell in the blood and in the bone marrou is the eosinophile myelocyte and this may be the case even in association with a very acute course In most of the chronic cases the majority of the eosinophiles in the circulation and in the bone marrow are of the mature type so that it is tmpossible from either blood or marrow examination to be certain whether the dtscase is chronic DY bcute A somewhat similar malady may occur in an acute or more rarely a sub acute form the so called aleukaemic my clons This runs the clinical course of a rapidly progresse, sesere anæmia uithout any change suggestive of leukæmia is the white cell count but the marror has all the characters of the intensely actre tissue found in ordinary cases of leukama Strangely enough one finds that the predominant cells in the martow ate myelocytes not as one would expect in an acute case my cloblasts If a case of this sorts en countered, it is extremely easy to draw false inferences concerning the acuteness of the disease if one is basing prognosis entirely on the charcters of the fryelogram The disease is Associated with a variable degree of anæma skich is often macrocytic although a may be norocytic or rarely, microcytic When a macrocytic 2012ma 18 present the marrow films will shon a megaloblastic reaction and the picture simulates pernicious anæmia complicating teukama.the so-called teukanæmia of Leube Most modern Writers tegard the occurrence of these two discases in one patient as fortuitous Miyelosclerosis may be rery difficult to distinguish from medullary myelosis without the aid of stomal puncture, as the blood counts and physical signs may be almost identical in both diseases Most cases show fibrous tissue replacement of the marron (which may lead to a dry puncture and the necessity for trephining {8e}) and no evidence of myelod hyperplasia As in medullary my closis, the anama may be macrocytic, normocy trc ar microcytic, and the marrow sali show the corresponding changes, in the last to types there are usually large sumbers, up to 50 per cent of basophilic and polychromatic normoblasts Chronic Lymphatic Leyhamla (Chronic Lymphadenosis) The myelogram in this disease 13 usually cass to intcrpret because lymphocytes are not tumerous in normal marrow and rarely shon any signs of mitotic actauity in advanced cases of chronic lymphatic kukamia, marron films are as monotonous as blood films Lymphoqytetare found so closely packed together that they almost resemble * ·20 STERNAL PUNCTURE lymphatic tissue which is interrupted here and there by a few small nests of granulocytes and red cells The bachground of the marrow films is moderately dense but structureless and unlike that seen in chronic myeloid leukæmia where free cell granules are embedded in it In almost every case the majority of the cells are small lymphocytes, but a variable number of larger forms can be found not all of these are lymphoblasts, which, indeed, are usually scanty They increase in number only if the disease is actively progressing or is about to become acute In less advanced cases of chronic lymphatic leukæmia, the lympho cytes can be seen to form small focal masses embedded in hyperplastic marrow tissue In other words, the arrangement 18 similar to that in chronic myeloid leukæmia where we have already described foci of myeloblasts, etc Thus, lymphocyte aggregations in the marrow neser possess germ centres, and indeed, it is mainly at their periphery that the less immature forms are seen, and mitotic figures are found Chronic lymphatic leukæmia is notonous for its tendency to run an atypical course Most cases of so called crypto leukæmia are of lymphatic type Chronic Aleukæmic Lymphatic Leukæmia This disease may run the whole of its course without any of the classical clinical signs of leukæmia Quite frequently the picture is that of aplastic anæmia-great reduction of red corpuscles and of hæmoglobin, no signs of blood regeneration, leucopenia, and relative or absolute lymphocytosis in the late stages, an occasional lymphocyte of immature type or even a lymphoblast may be found in the blood, but, in the past, diagnosis was often deferred until autopsy and was sometimes impossible until histological sections were examined Now, sternal puncture permits of an accurate diagnosis of lympha denosis, but the myelogram itself gives no indication that the blood picture is aleukæmic The marrow changes are the same w - La hinnod 1 large or small subt but there seems to be much confusion in the literature as lo but shall be called monocytic leukæmia, and what mixed myeloid and mono- In our opinion the term, monocytic leukæmia (Schilling type, Plate 5A), should be limited to those cases which run an acute or sub acute course (never chronic), show a leucocytosis due to an increase in monocytes or their precursors, and an aplastic cytic leukæm12

·PLATE 6
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00
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А
IC TE VYELOIT LELKEN
{a} Wiscloblast (se pa)
13 Arte IP591 LETA 2
(a) Limske blast (ster)
1 (*****

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·THE MARROW IV LEUNAMA 21 or hypoplastic type of anzmia The so-called mured (Naegeli, Plate 5) types are to be regarded as variants of my clogenous Icukum2 In these, there occur transitory increases in the number of monocytic elements in the blood and the marrow which are probably atypical myeloblasts, but the general clinical and hæmatological picture, throughout the greater part of the liness, is identical with the myelord type of leukæmia Thus is een more cident in tissues erammed btstologically, here the reticulo-endothelial system shows the changes characteristic of myelord leukæmia The marrow films in true monocytic leukæmnia are quite characteristic As in all leukæmnias there are many cells, monocytes and pro monocytes predominate and form from 0 to 90 per cent of all the nucleated cells The mature monocytes have lobed or rounded nucler with fine reticular chromaton, and a varying amount of cytoplasm which may or may not contain azurophilic granules The monoblast is similar to, and may be difficult to distinguish from, myeloblasts and lymphoblasts although it commonly shows more Variation in size than these cells The promonocyte has a rounded nucleus without nucleoft and may show some azurophilic granules in the cytoplasm The number of matouic figures is striking (many may cien be found in the peripheral blood) and these are cherly the pro-monocytes The number of hæmocytoblasts is increased and, indeed, these cells may be closely simulate from the promonote of the latter 19 af all atypical, and in monocytic leukemia it often 13 atypical Erythropoiesis is markedly depressed There is a reduction of all the types of normoblast, but particularly of the carlier and more basophilic forms Megakaryocytes and platelets are scanty films it 13 difficult to say nhether the granulocytic cells are affected, but qunc often the absoluse number of neutrophile polymorphs in the penpheral blood is little, if at all, reduced In the "monocytic " phase of my cloid leukæmia atypical myeloblasts resembling monocytes appear in varying numbers in the blood and marrow As this phase only occurs in the chronic form of my clogenous leukaemia, an erythroblastic hyperplasia of the bone- MOTTON 23 to be expected, unless, of course, the malady w in *s terminat stages and aplasia of the erythroblastic tissue has occurred Acute Leulamia (Plate 6) This disease may be pnmary or it may be the terminal phase in a chronic case It is usual 10 distinguish betrecn acute myeloid sad acute lymphatic leukassa although the differentiatson is of purely academic value The From

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·THIE MARROW I LEUKEMIA 27 or hypoplastic type of anæmia The so called mited (Naegels, Plate B) types are to be regarded as variants of myelogenous leukæmia In these, there occur transitory increases in the number of monocytic elements in the blood and the marrow which are probably atypical myeloblasts, but the general clinical and hæmato shows the changes characteristic of myeloid leuktemua The marrow films in true monocytic leukarnia are quite charactenstic As in all leukæmias there are many cells, monocytes and pro monocytes predominate and form from 70 to 90 per cent of all the nucleated cells The mature monocytes have lobed or rounded nucles with fine reticular chromatın, and a varying amount of cyto plasm which may or may not contain azurophilic granules The monoblast is similar to, and may be difficult to distinguish from, myeloblasts and lymphoblasts although it commonly shows more Variation in size than these cells The promonocyte has a rounded nucleus without nucicoli and may show some azurophilic granules in the cytoplasm The number of mitotic figures is striking (many may even be found in the peripheral blood) and these are chiefly 10 the pro-monocytes The number of bæmocy roblasts ss increased and, indeed, these cells may be closely simulate from the promonoqyte of the latter is at all atypical, and in monocytıc Icukumia it often us atypical Erythropoiesis is markedly depressed There is a reduction of all the types of normoblast, but particularly of the carlier and more basophilic forms Megalanocytes and platelets are scanty from films it is difficult to say whether the granulocytic cells are affected, but quite often the absolute number of ncutrophile polymorphs in the peripheral blood is hitele, if at all, reduced In the "monocytic" phase of my cloid leukæmia, atypical myeloblasts resembling monocytes appear in varying numbers in the blood and marron As this phase only occurs in the chronic form of myelogenous leukæmia an erythroblastic hyperplasia of the bones marron 19 to be expected, unless, of course, the malady is in its terminal stages and aplasia of the erythroblastic tissue has occurred Acute Leukæmis (Plate 6) "This disease may be primary or if may be the terminal phase in a chronic case It is usual to dis. inguish between acute myeloid and acute lymphatic leukemia although the differentiation of purely academuc value Ths

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·TIE MLLAROW I LEUKEMIA 23 affects the erythropoietic tissue, there is less difficulty than when the lcucoblastic cells are involved In the latter case, it may be dificult to differentiate simple reactions from leukaemia, and, indeed, blood examination is often more important for diagnosis that is marrow puncture It is only if the small focal masses of cells typical of leukæmis are found that a definite conclusion can be reached Other significant points have to be taken into account Thus, if Even so, the histological arrangement of the cells is different in infections a dchinste focal distribution 13 never found Then also, the characters of the more mature cells may help to distinguish a leuk.xmord reaction from genuine Icukumu, un the latter they may be abnormal in the sense of being malformed, but they never show the degeneratic changes that are so common in infective states There can be no doubt that there is suill need for much investigattion of the marrow in the diseases that show a leuktmold blood picture, and at the present time we are not in a postuon to say more about them REFERENCES ENSE WETU, P and PERUER, S Song, 1949, XAY, 165 MorsomrS Ilelset Med Acta , 1947, tv, 279 Moss, W T, and ACXERMAN, L V Blood 1946, 1, 396 WHITE, ) II G, and Duzy, Beni Med 1, 1929, 1, 900 ·CHAPTER III NEOPLASTIC AND ALLIED CONDITIONS OF THE BONE-MARROW In so far as they directly affect the myelogram, bone-marrow tumours fall into two groups In the first are the generalised neoplasms of the hemoporetic tissue where stemnal puncture may show the marrow to consist almost entirely of tumour cells In the second, the tumours are localısed and unless a nodule of growth 15 punctured, the myelogram shows only the effects produced by compression, replacement and irritation, ie, leuco erythroblastosis, which may progress to hypoplasia In this group, the tumours may be primary in the bone marrow or metastatic from growths elsewhere in the body, and it must be borne in mind that it is only when this type is fairly widespread in the marrow that hæmic erythroblastosis is produced Tumour cells will not be found in marrow films unless a nodule is present at the site of puncture In our present state of knowledge any attempt to classify bonemarrow tumours must be tentative and somewhat controversial As, in this book, we are concerned chiefly with marrow puncture as a method of clinical and cytological investigation, most of the discussion will be devoted to the most helpful methods of elucidating the myelogram, but the possible relationships of the several conditions must first be considered Bone marrow is mesenchymal in origin and most of the elements of the reticulo-endothelial system are represented in it, so that a variety of neoplastic conditions may arise as prunary " tumours, including the reticuloses, reticulo sarcomata and the myelomata The pathology of the reticuloses has been put on a sound basis by Robb Smith in this country and Gall and Mallory in America Both classifications are cytological, the authors all agreeing that gross anatomical and clinical classifications have no practical value Gall and Mallory classify their cases according to the degree of development of the cells involved, while Robb Smith bases his arrangement on anatomical grounds Thus we have the follicular reticuloses, the parent cell of which is the reticulum cell of the germinal follicle of the lymph nodes, the sinus reticuloses, which arise from the living cells of the sinuses of the reticulo- 9 24 ·NEOPLASTIC AND ALLIED CONDITIONS OF TTIE BOVE-MERROW 25 endothelial system, and the medullary reticulotes, which take ongis from the free reticulum cells or their descendants, lying in the stroma of the reticuloendothelsal tissue between the sinuses In the last group there are lymphoid, myeloid and monocytic medullary reticuloses, which nc commonly call lymphatic, myelord and monocytic leukkia sespectively This group also contains the metabolic reticuloses of Gaucher's disease. Niemann-Pick disease and xanthomatosis Fibra-myclad medullary reticulosis, or Ilodgkin's disease, is yet another component of this group The reticulo-tarcomtala, including lymphossscoma, should not be regarded as a separate group of diseases but as a more malignant phase of the corresponding cell type reticulosis (Table II) TABLE II RELATIONSMIT OF Lung's TL VOLR AND VYFLOVATA TO RETICULO-ENDOTHELIUS1 OF BONE MARRON AO E MARROW CELL RETICULO853 MALIGVANT TYPE NECKYMAL CTLE HING, PLAMOUR) HETICULUM CRL METICE20813 XETICULUM CELL MYLIOMA RAMOCHODUCTS MOCYTOLASTIC YELOMS RITROBLAST TOLYCYTHEMA SERPRYTINOBLANTIC MILONU wmogurtom LETAMAMYELOPLASTIC ATELOU LADJOILAT LAINA OLL LLLLL-FLASICA OLL Mnon The myelomata form a group of cutouts which arise from blood cells or their precursors The hamocytoblast, a direct Descendant of the petitise mesenchymal cell, s slow commonly supposed to be the parent cell of all blood cells and from * arise the blast cells which differentiate to the adult sed corpuscle, granulocyte, monocyte, lymphocyte and plasma cell This link of dciclopment is shann in Table 1) Theoretically any of these groups of orlls may produce tumours, and hence myelortuta, but s practice the term 13 yrsened for these tumoursbich ocrur pnmanly in the bone-marrow Lymphatic and monocytic tumours occur in the lymphadenoid tissue rather than the marroir and should be considered with the reticulases It may be said that plasma cells also are mainly produced in the lymphoid organs, but they also Orur in the blood-formig bonc.

·28 STERNAL PUNCTURE marrow and glands of cases of acute and chronic mycloid leukæmua The clucé significance of the disease is that it presents a typical icukamic infiltration of the bone marrow and viscera with a leukæmic blood picture and at the same time produces bulky medullary tumours which provide all the essential features of a malignant ncoplasm, that is, active proliferation atypical cells, distant metastases, some of which are clearly of embolic origin, and destructive local infiltration In fact, the disease is a mixture of luukemia and malignant myeloma In another group of cascs with radiologically typical myelomata 1 Icukamic or subleukæmic blood picture is present In fact, l'incy and Riach have described four grades of plasma cel myeloma depending on the type and extent of bone involvement and the condition of the blood These are (1) Much bonc destruction and no blood changes (2) Moderate bonc destruction and a few plasma cells circulating in the blood stream (3) Bone destruction less with a diffuse marrow infiltration and a larger number of circulating plasma cells (4) Diffusc bonc-marrow infiltration without erosion and a frankly lcukicmic picture in the blood and viscera This is plusma cell leukaemia A third group of cases which appear intermediate between the wn conditions are those whosc penipheral blood picture and sternal marrow are typical of leukemia but there is no enlargement of the spleen or liver in these, d-ray of the long bones will often rescal several small areas of rarefaction with loss of bonc pattern, suggesting 1 mild degree of crosion by local deposits Tig 11 is an X-ray of the hand of one such case The patient was a girl aged about eight years old uha was onginally seen complaining of pain in the hands and foet Complete radiological examination of the skeleton showed only the lessons in the figure and similar arcas of rarefaction in the 5th metatarsal hones The diagnosis of leukemia was confirmed by blood count and marros puncturc "The girl died at home uithun 1 scar and no post mortein examination was possible Thesc intermedinte types of cisc form a definite link between leukemia and multiple myeloma and are probably more common than is generally realised Many conditions labelled simply Icukemi arc atypical when closely studied and the deviations from the classical picture are often towards the myclomatous syndrome

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·NEOPLASTIC AND ALLIED CONDITIOYS OF THE BONE VARROW 29 Ening's tumour, or endothelioma of bone, must also be considered in any discussion of myelomata In this disease, tumours grasing within the marron cauties of the bones cause irregular absorption of the shaft and widening of the marrow cavity In the later stages the bone may be completely destroyed The regional lymph nodes are often ins otsed and pulmonary metastases occur in nearly a}} c2503 The clinical course of the discase is more rapid than with myeloma and the tumours are more invasive Ewing himself thinks the tumour anses from the endothelium of the blood vessels of the bone marrow, but other authors, notably Oberling, claim to have obsened differentiation of the tumour cells into plasma cells, my clocytes and even primste red cells If this $$ $o the tumour say well be an hæmocy roblastoma or myeloma of the most primitic blood cell, especially as these tumours commonly occur in the ends of long boses in children and infants--that is during the age period when these bones contain hemopoietic marrow As the humocytoblast as a direct descendant of the reticulum cell and mesenchymal cell, which also may form the endothclul Eising of blood vessels, a reticulum cell myeloma in the bone marrow may well show angioblastsc tendencies in some cases, thus accounting for the features stressed by Lising As also the primite mesen chyme is situated pervascularly, they may be included in the pruvascular endothelium,' which sang cites as the possible origin of these tumours In fact, the implications of a multspotent primitive cell in the neoplastic process is the only way to account for the varying ways in which these tumours tend to differentiate Those tumours of bone marrow which are included in the group known as Exing's tumour may therefore be classed as myelomaua of the more primitic cells of the reticula endothelial system in the bone marrow and any of them may ſend to shox differentiation along the lines of the more adult bone marron cells The greater clinical malignancy of these tumours is accounted for by the more primitive nature of the cells involved This group may be regarded as the sarcomatous lesion of these primstic reticulo-endothelial eclls as opposed to the systematised overgrowth known as seliculum cell reticulosis, which in the bone marrow is represented by the multiple endothelioms of bone first descnked by arckwald The cells are the same clear polyhedral cells as seen in Ewings tumour, and although death occurs un mo years the tumour does not ahon the usual (eatures of malignancy like Ewing's tumour ·30 STERNAL PUNCTURE The patients die of anæmia and cachexia with severe pyrexiaa type of illness whuch compares closely with the condition seen in animals when the RES 15 disorganised by blockage with dye, etc In the bone-marros, therefore, we can demonstrate a relationship of the different tumours in the same way as can be demonstrated in the rest of the reticulo-endothelial system This relatronship is shown in Table V 'Table IV shows a more complete classification, including the other reticuloses and their sarcomatous manifestations TABLE V HYPERPLASTIC AND SARCOMATOUS RETICULOSES -RETICULUM CELL RETICULOSIS RETICULO-SARCOSLATA EWINC'S TUMOUR TY BONE MARROW) WISTIOCYTIC RETICILESIS -LYMPHOID LELKÆMIC LYMPHOSARCOMA AOV LEUKEMIC MEDULLARY RETICULUS -MYELOID LEUKÆMIC AIYELODLASTIC MELON XOV LELK/EMIC -PLASMA CELL. LEUKÆMIA PLASMA CELL. MYELOMA 3 -ERYTHROID POLYCYTHÆMIA YERA ERYTHROBLASTIC MYELOVA LYOPHADEVONA -KODCKIN'S SARCOMA Mlyeloma. There are four generally recognised types of myeloma (1) plasma cell, (11) myeloblastic, derived from the primitive myeloid cells, (in) erythroblastic, derved from the nucleated red cells; (iv) lymphoblastic, derived from the lymphoid cell series, and which is probably secondary to lympho sarcoma elsewhere

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·NEOPLASTIC AND ALLIED CONDITIONS OF THIE BOYF VIRRON 71 The majority of myelomata are composed of clements resembling plasma cells indeed, there is little reason for doubting that they are really plasma cells But, according to one's opinion, these tumours would equally properly be designated as pseudo plasma. cytomata We have already seen that the nature of plasma cells is still uncertain (p 6), though that need not affect our descriptne knowledge of tumours composed of them, but it must be emphasised that it is often possible to obsere what appears to be a continuous series of stages between the cells of the reticulo-endothelium and typical plasma cells But, of course, these elements, as seen in 11 swhich is vacuolated round the nucleus (heller llo) In films, there is much more variation in size, some of the cells being no larger than small lymphocytes, whilst others are as large as monocytes, and may (in marrow but not in blood) contain more than one nucicus The bası chromatın is much more vanable in its distnbution than it is in the plasma cells of the tissues it may be "cart-wheel, 'but it is often quite irregular , similarly, it may be symmetrically or excentrically placed in the nucleus The cytoplasm is basophilic, but less intensely so than in the tissues it may be vacuolated but not necessarily in the vicinity of the nucleus , and occasionally it is seen to contain azurophilic granules such as rarely occur in tissue plasma cells Alitotic figures are often observable Azurophilic protein crystals may be found in a feu "myeloma cells (Steinmann) Marrow films, thus, present a cry varied appearance, which is extremely suggestive of neoplasia, but thich does not always munediately suggest that the predominant element is the plasma cell But, cien so, a little experience allows a diagnosis of my cloma to be made with much greater certainty than is possible cren with L-rays (Rosenthal and Vogel) Of course, the film does not consist entirely of plasmacytoid clements it is very rare for all the ordinary marrow cells to be replaced As a rule about 50 per cent of the cells are of plasma cell type But, if the needle has penetrated a nodule of " tumour," it may be found that almost escry cell is of this kind But, from the point of sick of diagnosis, these differences are of no pecial significance In the meloblastoma, the cells are, on the whole, larger and may contain fen or many neutrophılıc granules in the cytoplasm Vany ·32 STERNAL PUNCTURE polymorphonuclears and myelocytes are present, and both may be found in the peripheral blood In the erythroblastoma, the normoblasts are usually well hæmoglobinised, but there may be a large percentage with basophilic cytoplasm The cells are small, and the nucler pyknoticſt is still uncertain whether erythroblastic tumours, in which there are no hæmoglobinised elements, really exist Snapper and his co-workers have shown that treatment of multiple myeloma with stilbamıdıne often results in the development of peculiar changes in the plasma cells in the marrow These take the form of basophilic granules in the cytoplasm Similar changes occur after treatment with antimony as a specific result of the effect on ribose nucleic acid in which the cytoplasm of myeloma cells is rich It would appear, therefore, that the nucleoprotein of myeloma Ils differs from that of other cells which do not react in this way with antimony or stilbamıdıne Chloroma As a rule, symptoms and signs suggestive of acute or sub-acute leukæmia precede the development of chloromatous tumours, but, occasionally, there are no changes in the blood, except perhaps slight hypochromic anæmia, even at a time when quite large masses are present in the orbits Then, examination of the marrow is likely to be very helpful, especially as in this disease, mitotic activity is remarkably intense The tumour cells are scattered throughout the marrow, some being isolated, others in groups of six or nie, and the adjacent myeloid tissue is distinctly hyperplastic Later, when the tumour has spread, the greater part of the marrow may be replaced by abnormal cells, and it is then difficult to discover any remnants of normal tissue The characteristic cells are of the same type in every case of chloroma They are large, with a bulky nucleus, which contains distinct nucleolt The bası-chromatin has an almost reticular distribution, and the cytoplasm, which is moderately basophilic, contains no granules Cells identical with those in the marrow are only rarely found in the circulation, where the predominant cells are usually myeloblasts or extremely immature premyelocytes It is this latter fact that suggests that all cases of chloroma are of myelord nature, although some writers still contend that lymphatic examples do occur It is, however, more probable that chloroma represents a state intermediate between true acute leukæmia and a neoplastic condition Reticulo-Endotheliosis. The follcular reticuloses produce no ·NEOPLASTIC AND ALLIED CONDITIONS OF TIIE BOVE-LARROW 33 change in the peripheral blood picture, and it is only when secondary nodules des clop in the bone marrow that we get a picture of leuco. blastic and crythroblastic hyperplasia, which may eventually develop into plasia of the marrow if the invasion by tumour becomes more or less complete The sinus reticuloses also show no abnormality in the peripheral blood, apart from moderate anzmia and slight thrombocytopenia, but they do cause marked changes in the bone-marrow For this rcason, Dameshek, who has reviewed most of the recorded cases, refers to them as aleukat mic sinus reticuloses The bone marrow presents a varied picture Characteristically, there are small collections of large cells, 20 to 30 microns in diameter, cach with a nded or indented nucleus, which occupies more than half of the 11 fr of the cells show azurophilic granules in the " Hof" of the nucleus Alitotic figures are frequently seen The myeloid and cry throid clements are decreased, and megakaryocytes are absent. This probably represents a hypoplastic or destructive condition of the bone marrow, and 11 is interesting to note that in none of the recorded cases has there becn an initial hyperplasia It seems a reasonablc inference that the tumour cells are not merely replacing the normal marrow elements, but that they arise from a primitive cell, which is also the precursor of the blood cells conscquendy, on account of this pen croton of function, the hannopoietic tissue 19 unable to react in the ordinary way. Of the medullary reticulores, the leukemias are discussed clse. Where (p 15) Gaucher's disease usually affects the spleen more intensely than the bones, although skcietal affection may occasionally preưominate But, csen in the clinically splenomegalic cases, some involvement of the bone marrow is common Ilow usual it is was not realised until stemal puncture became a fairly common procedure. This frequency of skeleul involvement is an important matter, because it has been suggesid that splenectomy, in such a mesbolic diseas as thu, would accelerate the deposition of the Gaucher substance in the troncs, so that the last state might well be worse than the first. Logan has shown that the fear is unfounded and that there is, in fact, improvement in almost every case after removal of the spleen The Gauchet cells in the marrow are large (50 microns or trore).

·34 STERNAL PUNCTURE one cell The nuclei present no characteristic arrangement of the chromatin, but are always relatively small and dark, several may be found in The cytoplasm is bulky, with sharply defined outlines Some of the cells are polygonal, others elongated, but few transttional forms are seen In paraffin sections, the cytoplasm has a foamy appearance, due to solution of the contained lipoid material, and a faint, diffuse, iron reaction can often be obtained There seem to be three fairly distinct stages in the development of these elements Thus, the least differentiated cells have granular cyto plasm, in which lies a more or less reticular nucleus Then, there are cells with similar cytoplasm, but dark and almost structureless nuclei, and lastly, the fully developed Gaucher cell, with vacuolated cytoplasm and small dense nucleus It is only in the last type that it is possible to detect the presence of fine fibrils, which are best shown by silver-impregnation methods The myeloid tissue itself is usually hyperplastic, in contrast to the peripheral leucopenia, and there is a slight increase of monocytes (up to 10 per cent) in the myelogram This is not sufficient by itself to arouse a suspicion of Gaucher's disease, but it does give support to the slew that monocytes may arise from the same primi. tive reticulum cell Niemann Prck disease shows a similar invasion of the marrow with "tumour " cells, and hyperplasia of the myelord tessue In contrast to Gaucher's disease, however, there is usually a peripheral leucocytosis The characteristic cells are large (20 to 80 microns) and contain a reticular nucleus The cytoplasm is filled with droplets that give rise to a foamy appearance very different from the fibrillary appearance of the typical Gaucher cells As the disease is always fatal by the age of two years, marrow biopsy must be done by tribial trephine, or smears must be made from spleen puncture Hodgkin's disease affects lymphatic glands so much more obviously than it does the marrow, that relatively little attention has been paid to the latter tissue And, although we probably never obtain assistance in diagnosis by examining the bone marrow, there are points of interest and importance in connection with it The cases fall into four groups, viz , those with normal marrow, Entone, those with lymphadeno- In the third group it is not, as a rule, possiuie lu ve certain that

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·38 STERNAL PUNCTURE dyshæmopoietic In the following chapters the main changes from Loved diluuilig Hæmorrhagic Anæmia Anæmia following hæmorrhage may be acute or chronic, depending on the amount, frequency, and duration of the bleeding Acute anæmia is most commonly seen following trauma, bleeding from a peptic ulcer, or childbirth Providing that treatment is adequate, the blood loss is replaced in about thirty days and this replacement is brought about by an increase in the normal activity of the bone marrow The chronic type, usually induced by long continued, frequent and relatrely small bleedings, such as occur in menorrhagia and some types of peptic ulcer, produces characteristic changes in the myelo gram A study of these two types of marrow change helps us to interpret the findings in hæmorrhagic anæmias due to abnormalities of the blood or blood vessels, of which thrombocytopenic purpura and hæmophilia are examples The special findings peculiar to these anæmias will be discussed later Certainly the myelogram in traumatic anæmias does not help in diagnosis, either of the nature of the anæmia (which is usually obvious on clinical grounds) or of the site of the loss of blood Acute hamorrhagic aneemia The myelogram here shows increased normal activity Both the erythroblastic and myeloid elements are affected, the former more than the latter 'The hyperplasia of the myeloid tissue is reflected in the peripheral leucocytosis 'The normoblasts are increased in number and show a tendency to become hæmoglobinised at an earlier stage, xe, the usual basophilic normoblast becomes polychromatic, and the polychromatic one becomes eosinophilic The number of reticulocytes present is markedly increased Megakaryocytes are more frequent and may be seen in moderately large numbers in the thick end of the film In the percentage count the polymorphs are decreased, but this decrease is only apparent because the total number of cells is increased Mitoses are more numerous, indicating general hyperplasia The mitoses, both of red and white cells, takes place at the normal level of cell development The myelogram 13 as follows - Neutrophiles Myelocytes Metamyelocytes 30-35 per cent 10-15 > ·> THIE ANSES 39 1-2 11 1 PD 3 ID 6-12 11 Losinophiles Vyelocytes 1- 2 per cent. Polymorphs Basophiles, Myelocytes 3-6 Polymorphs Premy clocytes llamocytoblasts (including my cloblasts) I.ymphocytes Pro-crythroblasts 1- 2 Mormoblasts 25-30 Negakaryocytes frequent Chronic Post hæmorrhagic Anamia When the anemia is but moderate the bone marrow activity is only slightly increased in more sciere cases there may be a great increase in the amount of red marrow This hyperpla313 may eventually be succeeded by exhaustion, and the marrow then becomes hypoplastic or aplastic In a fully reacting case, se, before marrow exhaustion supervenes, . 11 numerous mitolic figures of normal type The myclocytes are little, if at all, reduced in number, and the total number of cells is somewhat increased Reticulocytes arc fairly numerous though not as abundant TL. + U S-8 1) that iron is needed for complete maturation of the cells, and not as a stimulus to crythropoiesis itself cutrophiles livelocytes 20-30 per cent Sieumy clocats Polymorphs 8 -12 Eosinophiles Vyclocytes 1 - 2 Polymorphs Basophiles Vyclocites Polimorphs 11 11 ·40 STERNAL PUNCTURE Premyelocytes 1 - 3 per cent Myeloblasts Pro-erythroblasts Normoblasts 40-50 Megakaryocytes moderate Hæmorrhagic Anamas The specific narrow changes in essentral thrombocytopenic purpura will be described in the chapter on aplasia of the bone-marrow In true hæmophilia, apart from the changes described above, the marrow films show a marked increase in the number of megakaryo blasts and megakaryocytes, but the number of platelets is within normal Istruts Custer and Krumbhaar have described the appearance of the bone marrow in three fatal cases Limarzi, Poucher and Burch kare shown that sternal puncture can be safely performed on hæmophilcs and they confirm the findings described Hæmolytic Anæmia (Plate SA) In all forms of hæmolytic anemia the activity of the marrow is at its maxmum There 25 great and continuous normoblastosis which is presumably induced by loss of corpuscles, due to destruction in the body but whether any erythroporetic stimulus is liberated by the destroyed cells is sull uncertain, although probable The clinical state is not clearly, if at all, reflected in the marrow, which is in a condition of extreme activity throughout the course of the malady About three quarters of the cells in the marrow are nucleated red-cells in various stages of development, some are mature, but the majonty are basophilic and possess large cartwheel nuclet Another striking feature is the presence of considerable numbers of cells as immature as the pro erythroblast these, as previously described, differ from megaloblasts but are at least as large, if not larger In some cases a true megaloblastic reaction may develop as descnbed by Farley in cases of Bartonella fever The large number of reticulocytes is another charactenstic feature The myelogram is of the type shown below and Neutrophiles Mjelocytes 10-17 per cent Metamyelocytes Polymorphs 2-S, Eosmophiles Miyelocytes Polymorphs 2-3 » 91 0-21

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·THE AVÆMAS 41 1 16 + Lymphocytes 1-2 per cent Monocytes 1 - 2 Premyelocytes 5-10 Homohistioblasts 1-3 Hæmocytoblasts Pro-erythroblasts 25-34 Normoblasts 20-30 Megaloblasts 0-2 Megakaryocytes not increased Reticulocytes numerous May be as high as So per cent of the non-nucleated clements of the films 11 11 In many of the homolytic antmias the anemia may be macrocytic in type in all the groups one or more such cases are described in the literature Apart from the truc megaloblastic reaction in Bartonella faser, however, the characteristic feature of these marrow films is the high percentage of pro-crythroblasts Limarzı has shown that an intense normoblastocis occurs in the marrow in the rare hamolytic anæma following sulphonamide poisoning and is accompanied by a microcytic anata The macrocytosis 13, therefore, probably due to rapid maturation of the pro-erythroblasts and basoplul normoblasts, the nucleus being extruded rather carli in the normoblastic cycle That it is not due to megaloblastosis is borne out by the fact that liver preparations do not causc improvement In the infectate group of homoly tic anemias, the myelogram does not shox such a high proportion of pro-erythroblasts, and the regeneration of red cells is not 23 a rule so intense The homolysis is probably due to the infecting organism causing a "' tormia of the red cells which render them more liable to the normal process of destruction This toxic action is also cxerted on the bone marrow, which cannot then respond so rapidly Where the infection is prolonged and the tormia extreme, the marrou fails to respond at all and becomes aplastic (ory thronoclasta) llc have recently seen a cave of this type associated with tuberculosis, and sections of the bone-marros removed at autopay showed a fen minute tubercles Gas gangrene infection (CI li elchn), and sometimes an anaerobic hemolytic streptococcus, produse a humolytic anemia in a different 12) They produce a hemolisin which acts directly on the red cells in these cascs, until the toremia becomes sucre, the marros may be expected to react more cruberantly ·STERNAL PUNCTURE Malana produces a chronic hæmolytic anæmia, the haemolysis being caused by direct action of the parasite on the red corpuscles Esen in malignant tertian infection, where the hæmolysis may be 50 intense as to produce blackwater fever, and early death, the marrow shows a well marked erythroblastic hyperplasia with large, intensely basophilic, normoblastic cells (see Chapter VIII) Some hæmolytic anæmias are due to poisons lead, potassium chlo.ate, benzedrine, phenylhydrazine, phosphorus, TNT, dinitrobenzene, etc The reaction of the bone marrow to all these compounds is as that described for hæmolytic anæmias in general Aplasia develops rarely, if ever, because the patient dies of some other toxic effect of the poison before the aplastic stage 18 reached, although a small number of workers with trenctratoluene have died of aplastic anæmia The sulphonamide group of drugs, however, may produce a hæmolytic anæmia, and, if still more is given, the marrow may become aplastic In lead poisoning, of course, the characteristic basophılıc stipplung of the red cells will be seen in marrow films, and Henning and Keilhack have reported ten cases where the stippling was found in the red cells of the marrow when absent in the peripheral blood. The hæmolysis produced by incompatible transfusions and paroxysmal hæmoglobinuria causes no peculiar abnormalities in the bone-marrow In acholurie jaundice, in both the congenital and acquired type, no new information about the pathology of the disease has been acquired by studying bone-mpartow films The spherocytosis can be seen as easily as in the peripheral blood A constantly high reticulocyte count may be found in the marrow even when the red cell count is nearly normal The reticulocyte count may be normal during a remission of the disease and the spherocytosis may temporarily diminish Spherocytosis is not so marked in the acquired form of the disease It has always been assumed that the crises that occur in congenital hæmolytic jaundice are due to sudden great increase of destruction of the red cells This view has recently been challenged by Owren, who alleges that the rapid increase of anæmia is probably due to a temporary hypoplasia of the bone marrow And he has shown that the marrow changes at the onset of such a crises strongly support this view Just before the crisis, the marron shon's the usual inteose erythropoiesis of the disease, but within two or three days there ·DIE ANYIAS 43 are practically no erythroblasts remaning in the marrow, then, as the crisis dies dann, there is regeneration of pro-erythroblasts which mature into macroblasts, until, at the end of the crisis, the marrow shows an enormous increase of normoblasts, while at the same time, the number of reticulocytes in the circulating blood rises sharply Osren's views, although not yet confirmed, would explain the low percentage or absence of reticulocytes that has long been known to occur dunng crises In sickle cell anemia, the latent phase is much more common than the actnc onc In the latent form, sickling of the cells is not found in the peripheral blood but has been found in the bonc-marrow of a case in this phase coming to autopsy The presence of sickle cells is not diagnostic of anæmia, as the sickle cell trait has been found in 5 7 per cent of all negroes, whether or not they are in good health The phenomenon of sickling cannot ordinarily be seen in stained films A fresh preparation scaled under a cover ship should be examined a few hours after it is made 'The myelogram docs not differ from that of any other form of harmolytic anima except, of course, in the shape of the red corpuscles Perhaps, however, the number of monocytes containing red corpuscles or rigment is rather greater, and introhe has recorded the prevence of long bands of erythrocyte cytoplasm (about 2 microns thick) lying in marron films In Ledere's an omia the marrow picture may be complicated by the presence of a leuk.mod reaction This is usually my cloid in typic, but . ac has been described with the appearances of lymphatic leukimia in the peripheral blood, including lymphoblasts In icterus gratis the marrow changes are the same as in any Hemolytic anemia Martow puncture is not of much value beausc the peripheral blood reflects the condition of the marrow in showing arnety of normoblastic cells which leave no doubt as to the diagnoos Besides, stemnal punctutc and tibial trephine are not suitable procedures to be employed on new.born babies Toxic Antmias. This group contains the hytoplastic and aplastic anamas It is a rather heterogeneous group of maladies, which may lx primary or secondary If of the latter type, the cause muy le poisoning of venous kinds, infection or totamia But, whatever the cause, the malady 11 agrare and dangerous one, and, in all, the marron picture 13 simular , no indication of the cause an be inferred from the myelogram The conditions are more described later nith other plastic conditions of the bone marrow ·44 STERNAL PUNCTURE Dyshæmopoletic Anæmias. The hæmopoietic bone-marrow is a complicated and highly specialised structure which has to supply the formed elements of the blood continuously and rapidly In order that it may do this efficiently, an adequate and properly balanced supply of nutriment is necessary This has long been recognised, but our knowledge of the food requirements of the bloodforming tissue has, until the end of the first quarter of this century, been confined to one constituent, iron Now we know that the hæmopoietic principle, copper and other metals, thyroxin, and vitamin C all play their part Lack of, or failure to utilise, any of these factors Inay result in anæmia As a result of malnutrition of the bone marrow, two main groups of anæmia are produced (1) hypochromic and microcytic, (2) hyperchromic and megalocytic The first group arrses with deficiency of iron, internal secretion of thyroid, and vitamin C "The second arises with deficiency of the hæmopoietic principle Deficiency of hæmoporetu principle Pernicious anæma (Plates 9, 10 and 11) is, of course, the best known anæmia of this group An exactly similar condition of the blood and marrow may obtain in other anæmias of the same type, whether the cause be carcinoma of the stomach, complete gastrectomy or other conditions giving rise to deficiency of the hæmopoietic principle The myelogram in pernicious anæmia is striking and characteristic The constant feature is the presence of megaloblasts, but it is rather on the large number of these cells than on their simple presence that diagnosis is to be based As mentioned earlier, some writers aver that a few of these cells can be found, er en in health, it 18, therefore, an increase that is significant But there is another point even if the megaloblast be not regarded as peculiar to pernicious anæmia, there is no doubt that the marrow contains a larger number and far more young forms in this disease than are found in any other It must not, however, be supposed that the whole of the erythropoietic process in this disease is megaloblastic in type, there is great normoblastic activity also in other words, there is a mixed erythroblastic reaction of an intensity never seen in other maladies Little is known of the changes in very early cases, but Segerdahl states that the characteristic blood picture can be found before there are any recognisable changes in the marrow But in definite, and untreated cases, the myelogram is very striking, inasmuch as there are two changes intense megaloblastosis which of course, is

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(d) Intermed ate megaloblast
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·44 STERNAL PUNCTURE Dyshemopoietic Anæmias. The hamopoietic bone-marrow 1s a complicated and highly specialised structure which has to supply the formed elements of the blood continuously and rapidly In order that it may do this efficiently, an adequate and properly halanced supply of nutriment is necessary This has long been recognised, but our knowledge of the food requirements of the bloodfortning tissue has, until the end of the first quarter of this century, been confined to one constituent, iron Now we know that the hæmopoietic principle, copper and other metals, thyroxin, and vitamin C all play their part Lack of, or failure to utilise, any of these factors may result in anæmia As a result of malnutrition of the bone marrow, two main groups of anæmia are produced (1) hypochromic and microcytic, (2) hyperchromic and megalocytic The first group arises with deficiency of iron, internal secretion of thyroid, and vitamin C The second arises with deficiency of the hæmopoietic principle Deficiency of hæmoporetic principle Pernicious anæmia (Plates 9, 10 and 11) 19, of course, the best know anæmia of this group An exactly similar condition of the blood and marrow may obtain in other anæmias of the same type, whether the cause be carcinoma of the stomach, complete gastrectomy, or other conditions giving rise to deficiency of the hemopoietic principle The myelogram in pernicious anæmia is striking and characteristic The constant feature is the presence of megaloblasts, but it 13 rather on the large number of these cells than on their simple presence that diagnosis is to be based As mentioned earlier, some writers aver that a few of these cells can be found, even in health, it is, therefore, an increase that is significant But there is another point even if the megaloblast be not regarded as peculiar to pernicious anæmia, there is no doubt that the marrow contains a larger number and far more young forms in this disease than are found iti any oth must not, however, be supposed that the whole of the erythropoietic process in this disease is megaloblastc in type, there is great normoblastic activity also in other words, there is a mixed erythro. blastic reaction of an intensity never seen in other maladies Little is known of the changes in very early cases, but Segerdahl states that the characteristic blood picture can be found before there are any recognisable changes in the marrow But in definite, and untreated cases the myelogram is very striking, inasmuch as there are two changes intense megaloblastosis, which, of course, is ·TITE ANÆMIAS 45 It is pathognomonic, and a leucoblastic reaction of a non-specific kind surprising that the latter change should occur, because at this stage there is leucopenia with relative lymphocytosis in the blood This may be due to some inhibition of emigration and also of proper maturation of the granular leucocytes Certainly it is common to be able to detect abnormalities of both nuclei and cytoplasm in the neutrophiles, especially in the metamyelocyte stage (p 6) Fallon regards the changes in the metam; elocytes as diagnostic of pernicious anæma, and Dameshek and Valentine say that the percentage of these cells increases with the severity of the disease The nature of the changes is uncertain, but on the available evidence we would agree with Jones that the abnormal cells are the result of abnormal development of the myelocytes associated with the deficiency of hæmopoietin Tempka and Braun, who originally drew attention to the altered metamyelocytes, regarded the changes in them as degenerative, and Nordensen concurs with this opinion The metamyelocytes are increased in size up to you and show large U shaped nuclei with a coarse chromatın network Cytoplasmic granules are present but only stain well when a pH 6 8 buffer is used for diluting the neat stain (Foy and Kondi) Further, there is a considerable excess of hæmocytoblasts, which, of course, adds to the appearance of leucoblaştic activity in some long-standing, untreated, cases, there may be some depression of granulopoiesis There is much difference of opinion as regards the megakaryocytes in this malady, and at the present time it is best to assume that they may or may not show changes The presence of many naked megakaryocytic nuclei has been commented on (Tempka and Braun), and Jones (1936) found some intensely basophil megakaryocytes with no granules in the cytoplasm and marked pleomorphism of the Other workers have merely noted a diminution in the number of megakaryocytes, while Nordensen holds that they are normal in appearance and number Japa claims that the essential abnormality in pernicious anæmia is a slowing down of the rate of mitosis with increase in the length of the testing phase and consequent increase in size of the affected cells, all three cell types, erythroblastic, leukoblastic and megakarz oblastic are affected This change 13 said to be due to an alteration in nuclear metabolism The megaloblastosis is, naturally, the most significant change, nucleus ·46 STERNAL PUNCTURE and it is by progressive increase that we can recognise deterioration by diminution, that we see that improvement is occuring and by disappearance that complete relief is established The cells are easily distinguished from normoblasts, but too much attention should not be paid to their size, which is very variable The nuclear characters (p 9) are the differential feature These cells are found lying in groups, often surrounded by a clear area, devoid of cells, and they seem to develop more or less independently of all other marrow elements Promegaloblasts are also present, and their number is some guide to prognosis It is interesting to find that the number of these cells is closely related to that of the hæmocytoblasts, as the one decreases, so do the others And it is reasonable to assume that they are closely related, and indeed, probably of the same series In an untreated case of moderate or great severity, the striking feature of the marrow film is that there is a general immaturity, and the marrow appears to be both hyperplastic and metaplastic, the latter appearance being due to the presence of so many hæmocytoblasts Indeed, so many of the marrow cells are immature, that, with the ordinary hæmatological stains, the films have a strikingly blue colour, which, by itself, is very suggestive of pernicious anæmia In myeloblastic leukæmia, the films are far less blue, because the myeloblast has a cytoplasm somewhat less basophılıc than the hæmnocytoblast and the promegaloblast Of course, the other signs of pernicious anæmia to which we attach so much importance in the blood, can also be detected in the marrow megalocytosis, anisocytosis, Jolly bodies, hyperchromia and polychromasia are always seen If the marrow fluid is stained with cresyl blue (see Appendix) before the films are made, there is a distinct though moderate increase in the number of reticulocytes Mitotic figures are often numerous, and so far as it is possible to be sure, they occur mainly, or perhaps entirely, in the megaloblasts But the number of atypical mitoses is always great some are pyknotic, some multipolar, and others even more grossly irregular This is pathognomonic of pernicious anæmia, and is never seen in the normoblastic mitoses that may be numerous in post hæmorrhagic anæmia during the phase of regeneration In the phases of remission, induced by liver treatment, a series of significant changes can be detected These start about twenty four hours after intramuscular injection of a potent liver extract, and the first change to be detected is increase in the number of reticulocytes After 4 c cm of Neo-Hepatex, we have seen the reticulocytes

·PLATE 1
a
b
t
e
h
8
MORMAL. MLADROU
(a) Tonnoblast
(e) Basoph le noroblasts
(b) Basoph le my clocyte
(h) Pro erythroblast
(c) Polymorph
() Early normoblast
(d) Vyeloblast
(6) Polychromat c corpuscle
e Myelocyte
Mecamyelocy te
(1) Eos nophile
(n) Premyelocyte

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·PLATE 10
C
PERNICIOLS AVÆMIA (LATE STAGE IN TREATMENT)
(a) I ate megaloblast
(b) Myelocyte
(e) Ret culocyte
2) Polychlolosit c nornioblast
B IDIOPATIC INTOCHIROVIC AYEV
Tote-\umerous basoph 1 c normablasts and hypochromc microcytos s

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·THE ANÆMIAS 47 rise from 8 per cent of the total non-nucleated elements to 39 per cent twenty seven hours after the injection Within two days there are signs of a change in type of the erythropoiesis the intense megaloblastosis is beginning to die down and to be replaced by normoblastosis The percentage of the latter cells may rise from twenty-two to thirty-seven in fifty hours Even four to five days after treatment has commenced, the marrow picture is still characteristic of pernicious anæmia About half of the normoblasts are large and have an intensely basophilic cytoplasm these are of the early and basophul type of normoblast The remaining half are composed of equal numbers of polychromatic and casinophil normoblasts of normal size Mitosis is sull intense, but is now confined almost entirely to the large basophil early normoblasts Promegaloblasts and basophil megaloblasts are still present in moderate numbers and are casily recognised by their nuclear characters Very few of them show mitosis Polychromatic and eosinophil megaloblasts are conspicuous only by their absence A few megakaryocytes can now be found in the thick end of the film The activity of the myeloid tissue does not show much change, but in some cases there may be a marked increase in the numbers of cosinophile myelocytes and polymorphs This may be reflected in the peripheral blood picture After seven to ten days the marrow picture becomes normal The changes in the myelogram, with both analæmin and folic acid, are shown in Table Vi It is not at all clear by what means the change in erythropoiesis comes about, but it is probable that it is due to a stimulus to normal maturation of young normoblasts, rather than to fresh formation of cells The intense karyokinesis seen in these cells supports this supposition, and the failure of hæmoglobinisation of the megaloblastic cells shows that they are no longer required as oxygen carriers In the late stages of treatment and in the stage of remission during continued treatment, the marrow film is rather uninte.esting (Plate 10A) The megaloblastosis has disappeared, although a very occasional megaloblast may be found before the anamua has completely disappeared The myeloid elements form a normal proportion of the film Normoblasts are present in normal proportions, but there is a tendency for them to become hæmoglobinised earlier, and for the nucleus to be discarded while the cell 13 still large This phenomenon probably accounts for the macrocytosis, which still persists in some treated cases of this disease We have already seen ·48 STERNAL PUNCTURE TABLE VI BONE MARROW CHANGES DURING TREATMENT OF PERNICIOUS ANÆMIA Therapy Folic Acid 20 mgm. daly for 2 days 10 mgm. daily for 6 days Anahmin 1 dase 10 CC Time O I day odays 6 days 12 o baurs hours 1 day 7 days .6 22 24 IO 0 18 04 I 2 04 06 601 58 04 04 06 08 40 05 05 o 05 05 OS 80 0 05 • 5 0 05 OS 0 OS os 140 Härnohistioblast Hæmocytoblast Myeloblast Premyelocyte Myelocyte Metamyelocyte Polymorphs Eosinophil myelocytes Eosinophals Pasophus Grant metarnyelocytes Pro erythroblasts Basophıl megaloblast Polychrome Eosinophil Rasophul normoblast Polychrome Eosinophil Lymphocytes Plasma cell Monocytes White red ratio Alitosis red cell white cell 75 44 38 120 not recorded separately 16 IS 05 05 10 0.5 30 82 80 65 80 05 3660 12 0255 90 10-5 34 O 04 70255 3525 05 o 18 io IO 95250 06150 58 30 10 60 02 16210 90 590:7.5 28 622 420 425 6 10 о 45 TDS 04 O2 o O os OS os O O 22 02 o 0 1 42 53 Oz 098 69 o 80 115 0 421 02 24 6 от 03 04 IS o 2 2 ? O 02 02 OI MOONO Grooroo 4510 80 The figures for folic acid treatment have been reported by Harrison and White The anahemin figures are our own that this mechanism may account for some of the macrocytic hæmo lytic anæmias, and it may be that there is still some further factor concerned with normoblastic development with which we are not yet acquairted Reticulocytes in fully treated cases number about 3 per Cent in bone marrow films The practical purpose of sternal puncture in pernicious anæmnia Is not usually that of early diagnosis, however, in cases which have become hypoplastic, and have an atypical blood picture, marrow puncture is diagnostic As has been said, an ordinary cases, blood changes precede detectable alterations in the marrow, but signs of relapse occur in the marrow before they can be appreciated in the blood, they naturally take the form of megaloblastic increase at the

·PLATE U
2
1
3
6
NIEGALOBLASTS IN PERSICHOLS AVAMIA
I Proerythroblast and myelocyte
2 Basophil megaloblast
3 Hamaglobinisation of megaloblasts
4 Abnormal megaloblasts
Te fa 43

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·THE ANÆMIAS 49 expense of the normoblasts Nevertheless, the most important purpose of marrow examination in this malady is the understanding of the morphological changes that characterise the disease, no other method has cast so much light into the dark places that surround the erythropoietic process as a whole There are three other diseases in which an anæmia indistinguishable from pernicious anæmia may occur These are intestinal infestation with diphyllobothrium latum , tropical nutritional anæmia, due to deficiencies in the diet, and the macrocytic anæmia of prego nancy (see P 54) The megalocytic anæmias associated with disease of the liver are of the same type as pernicious anzmia, but are rarely severe and will react to liver therapy If cirrhosis of the liver gives rise to much gastric hæmorrhage the marrow picture will be complicated by a normoblastosis and leucoblastosis as in the hæmorrhagic anæmnias Anzemia associated with lesions of the alimentary canal is rarely due solely to lack of hæmopoietic principle The conditions have been classified by Wilson as follows (1) Deficient intake of extrinsic factor-tropical and nutritional inactocytic anæmia including the macrocytic anæmia of pellagra (2) Decreased formation of intrinsic factor-gastric and intestinal resections and possibly carcinoma of the stomach (3) Impaired absorption of hæmopoietic principle--sprue, celiac disease, worm infestations, Crohns disease and intestinal anastomoses and ulceration (4) Impaired storage and metabolism of the principle in the lecer cirrhosis of the liver and possibly pernicious anæmia of pregnancy (5) Impaired utilisation of the principle in the liver-achrestic andmia In all the conditions, anæmia may be due to lack of hamnopoietic principle or iron, or commonly a combination of both The most common anæmnia with alimentary disease is certainly a hypochromic microcytıc one associated with failure to absorb iron The myelogram will be fully discussed later In the combined deficiency, the marrow megaloblastosis is present with the changes due to lack of iron In these cases marrow puncture may give indications of great therapeutic value in showing that both iron and liver are necessary for adequate treatment Quite often the penpheral blood shows only the macrocytosis which is treated with lover, only when the hæmoglobin becomes constant at a relatively low figure with a low colour index does the need for iron become apparent Both thera- ·50 STERNAL PUNCTURE norinopeutic agents could have been given at once of the need for them had been recognised at first (see Dimorphic Anæmia, P 53) Ancemia in Gastric Carcinoma Currie states that the marrow condition may be megaloblastic, as in pernicious anæmia , blastic, as in any ordinary hypochromie anæmia, and erythro blastic The last named has not been clearly described before It appears that the marrow is very cellular and active, with many mitoses The predominant cells are macroblasts, re , large, basophilic normoblasts Thev may be as large as megaloblasts, but have a definitely " cartwheel arrangement of the nuclear chromatin The anæmia in patients with this type of marrow 18 more severe than in those with a megaloblastic reaction Currie is of the opinion that the type of marrow reaction is not related to the severity of the gastric lesion, and he also says that there is no obvious correlation between the apparent degree of deficiency of specific hæmopoietic substance and the type of reaction of the erythron Deficiency of specific hæmopoietic substance per se does not appear to result in a megaloblastic marrow reaction and a megalocytic anæmia In 59 cases examined by Monasterio the anæmia was of the normochromic normocytic type with many basophil normoblasts in the marrow Achrestic Anemia In this malady the marrow changes are similar to those seen in pernicious anæmia and the mixed megalo blastic and normoblastic picture seen in partly treated pernicious anæma is often encountered Israels and Wilkinson find these observations to be in keeping with the view that in achrestic anæmia there is some inhibition of the action of hæmoporetin on erythropoiesis Macrocytic Anæma in other Conditions A variety of single cases have appeared in the literature in which the primary disease has been unexpectedly associated with a macrocytic anæmia and a megaloblastic bone marrow No reason is apparent for such asso. ciations, but it should be remembered that they may occur Those most recently recorded are generalised tuberculosis and macrocytic anæmia (Merwe), increased erythrocyte fragility associated with a macrocytic hæmolytic anæmia (Duke and Young), and an acute erythroblastic anæmia of childhood (McLean) Foy and Kondı have reported an extremely unusual case where a megaloblastic marrow was associated with a severe microcytic anæmja of the peripheral blood The patient was a pregnant Bechuanaland negress suffering ·THE ANÆVIAS 51 from amabic dysentery and made a complete recovery after a course of emetine injections Davis has reported three cases of megaloblastic anzmia in children aged respectively twele, thirteen and fifteen years The blood and marrow pictures were characteristic of pemicious anæmia Two of the cases proved refractory to parenteral liver injections, but responded to proteolysed lxer administered by mouth, and Davis suggests that these cases were due to failure of intestinal assimilation and not true examples of pernicious anæmia Deficiency of Iron This results chiefly in the malady known as idiopathic hypochromic anæmia (Plate 108) so clearly depicted by Witts, the nutritional anæmias associated with infancy, the anæmia associated with alimentary disease, and some anæmnias of pregnancy Where the anæmra is solely due to deficiency of iron, the blood shows no spectacular changes and there are never very many normoblasts The marrow, however, is characterised by a great preponderance of normoblasts, many of which are large, immature, and strikingly basophilic The whole picture is one of very active erythropoiesis, and mitotic figures are numerous these are unlike those seen in the megaloblasts of pernicious anæmia, inasmuch as they are all typical abnormal karyokinetic figures are never seen 8-12, 13 2-4 2- 4 >> 12 Neutrophiles Myelocytes 17-22 per cent Metamyelocytes 5-8 Polymorphs Eosinophiles Myelocytes Polymorphs Premyelocytes Myeloblasts Pro erythroblasts Normoblasts (basophilic) 20-30 > Normoblasts (cosinophilic) 20-30 Megakaryocytes scanty Reticulocytes up to about 6 per cent of the non nucleated elements 11 8-10 » 2 31 The activity of the myeloid tissue is somewhat reduced, with a consequent reduction in the number of my clocytes this in marked distinction to the microcytic hypochromic anæmia produced by ·52 STERNAL PUNCTURE 1 hæmorrhage The eosinophiles, however, remain normal in numbers or may show a slight increase The myelogram has the characters shown above, which, of course, vary considerably as the result of treatment and as so many patients have been given some iron before they are properly investigated, characteristic pictures are uncommon During, and even after, successful treatment with iron, the eosinophiles in the marrow increase considerably, although there may be no noten orthy excess in the blood In pernicious anæmia, as we have seen, cosinophilia may develop the marrow and in the blood, but this is usually a sign of overdosage with liver (which 19, of course, quite innocuous) but it is interesting to note that eosinophilia is a condition that develops during recovery from several kinds of anærnia As in pernicious anæmia, one of the most striking features of the marrow during the phase of recovery is the increase in the number of reticulocytes These may increase to form 20-30 per cent of the total non-nucleated elements There is, however, one difference between the two diseases In pernicious anæmia the reticulocyte response is high if the red cell count is low, and low if the red cell count is high, in hypochromic microcytic anæmia the reticulocyte response depends more on the hæmoglobin level If this is moderately high, the response is poor, and vice versa In both maladies, the reticulocyte response to therapy is extremely rapid Other changes in the marrow during the period of recovery are a gradual restoration of the normal number of neutrophiles and a steady drop in the number of normoblasts the percentage of basophil normoblasts drops more rapidly, till, when the anæmia is abolished, they and the eosinophil normoblast have reached a normal numerical relationship The iron deficiency anæmias of pregnancy are similar to idiopathic hypochromic anæmia in blood and marrow The nutritional anæmias of infancy show the same changes in the peripheral blood, but here, of course, sternal puncture is not possible Deficiency of Vrtamın C Anæmia is not a constant finding a scurvy, but is commoner in adults than in children The anæmia is normochromic or hypochromic and is cured by the administration of vitamin C, whereas aron has no effect on it Ascorbic acid 33 a reducing agent and it is probably because of this that its absence, as in scurvy, leads to anæmia Normally it plays its part in the gut by reducing ferric compounds to the ferrous state, thus making ·THE ANÆMILAS 53 them suitable for absorption in the cases examined by Israels the sternal marrow showed evidence of diminished erythropoiesis, 1.e, the total number of normoblasts was decreased, but their development was normal During treatment with vitamin C reticulocytosis develops If there has been much hæmorrhage into the tissues with the disease, the peripheral blood may show a microcytic anæmia The marrow, however, is unable to respond in the usual way, and the mnyelogram of hæmorrhagic anæmia does not develop until vitamin C has been given A few cases of macrocytic anæmia with scurvy have been reported, but the sternal marrow findings are not recorded Defictency of Thyroxin The exact relationship of thyroxin to the hæmopoietic tissues is not yet worked out, but it is probable that it acts as a general stimulant rather than on any particular hæmopoietic tissue In myxædema, if uncomplicated by deficiency of iron and of hæmopoietic principle, the bone-marrow shows simple hypoplasia In thyrotoucosis there is a general hyperplasia of the bone marrow which may affect the myeloid elements to a greater degree than the erythroblastic tissue Banti's Syndrome In the carly stages of the malady, while the anæmia and leucopenia are not severe, the marrow films show a definite myeloid hyperplasia with a relatively normal ratio of myelocytes, metamyelocytes and neutrophils while no abnormality can be detected in the erythroblastic activity Later the marrow shows a maturation arrest " of the hyperplastic myeloid tissue with an increase in the percentage of myelocytes while the neutropenia of the penpheral blood is becoming more severe At this stage thrombocytopenia may be well marked but the marrow appears to be well stocked with megakaryocytes In the later stages of the condition with severe macrocytic anaemia and cirrhosis of the liver the myeloid hyperplasia persists, but there is a marked increase in the number of immature normoblasts In Felty's syndrome (enlargement of spleen and glands, anæmia and chronic arthritis) the marrow changes are similar, but some authors (Limarzı et al. Fleischacker and Lachnit) have reported an increase in the number of humohistroblasts and plasma cells Dimorphic Anama In this malady there is a deficiency of" hæmopoietin and pron, and it may occur as a complication of al tary disease in those idiopathic cases which we have peripheral blood picture has been that of pernicious ·54 STERNAL PUNCTURE the administration of liver extracts has been followed by an improvement in the anæmia with a more or less rapid lowering of the colour index to well below normal Further treatment with lover has no effect and the blood picture is only restored to normal after large quantities of iron have been given The appearances of the sternal marrow vary considerably Trowell has examined 174 cases of combined deficiency and says that the predominating type of erythropoiesis is normoblastic although megaloblasts and the large basophil normoblasts of iron deficiency can also be found In our experience the picture resembles closely that of a partly treated pernicious anæmia with an active normoblastosis and some megalo blastosis the number of reticulocytes present, however, in the untreated disease is very small The condition can be distinguished from achrestic anæmia (the marrow changes of which are very similar) by the absence of free acid in the gastric juice Megalocytic anæmias associated with dietary deficiencies are often dimorphic in type Anemia in Pregnancy This may be normocytic, microcytic or macrocytic In normal pregnancy, hydræmia occurs and this is accompanied by a degree of normochromic normocytic anæmia of the peripheral blood and myeloid and megakaryocyte hyperplasta of the bone-marrow That these changes do accompany normal pregnancy is perhaps not generally recognised, and there is a need for the establishment of a set of normal standards during pregnancy The true anæmias of pregnancy are mostly due to partial farlure of production of hæmopoietic principle owing to temporary derangement of gastric function and the necessity of supplying the principle to the fætus Two types of macrocytic anæmia have been described by Markoff the first is a true pernicious anæmua of pregnancy and the second a macrocytic anæmia in which the marrow show both normoblastosis and megaloblastosis Wolff and Limarzi claim that the type of anæmia in pregnancy should only be diagnosed from marroly examination because the changes in the peripheral blood may be misleading Apart from a typical iron deficiency anæmia, they have described a macrocytic anæmia with a normal or pro normoblastic marrow and a megaloblastic marrow with macrocytic, normocytic or microcytic and hypochromic anæmia , in the former type recovery follows delivery, and in the latter a good response can be obtained with liver therapy and the conditions disappears spontaneously in the puerperium.

·THE ANÆMIAS 55 In our experience, all these forms have occurred, but a small proportion of them, including some of those which present a picture of iron deficiency do not clear up after delivery and despite numerous types of therapy have continued to show a moderate degree of anæmia with persistence of the changes in the bone-marrow REFERENCES CURRIE, J P Glasg Med 1, 1943, xx1, 41 CUSTER, R P, and KRUMBRAAR, E B Amer y Mied Sa, 1935, clxxxix, 620 DAMESHER, W, and VALENTINE, E H Arch Path, 1937. XXtu, 159 DAVIS, L ) Arch Dis Childh , 1944, mix, 147 DYKE SC, and YOUNC, F Lancet, 1938, 11, 817 FAIRLEY, NH FALLON, M FLEISCHACKER, Fox, H , and í. HARRISOV, R j. and Whire, ſ c" 'Lancet, 1946, 4, 787 HENVING N, and KEILHACK, H Dtsch med Wschr, 1940, Lxvi, 323 Israels, M C G Lancet, 1943, 1, 170 ISRAELS, MCG, and WILKINSON, J F Quart Nied, 1940, 1x, 163. JAPA,J' Bnty Exp Path , 1945, XXVI, 111 JONES, O In Downey's Handbook of Hæmatology," 1938 JOVES, O P Proc Soc Exp Biol and Nied, 1936, xxxiv, 694 Instreb Db CT . AL Amer 7 and Clan in war, VeriSCA YURO, 1939, LXLX, 13 MCLEAN, J A Afed Australia, 1940, 11, 395 MIERW E, F VON DER Folia Hemat, 1936, lv, 218 MONASTERIO, G Alin Iloch, 1939, tviu, 1385 NORDENSEN, N G Studies on Bone Manow from Sternal Puncture, 1935 OWREN, P A Blood, 1948, 111, 231 SEGERDAHL, E "Ueber Stemalpunktionen," Uppsala, 1935 TEMPKA, T, and BRAUN, E Folia Hæmat, 1932, XIV, 355 TROWELL, VÍ C Trans R Soc Trop Aled Hyg, 1942, XXXt1, 151 WILSON TE Mfed Australia, 1912, 1, $14 WOLFF, J R, and LIVARZI, L R JAMA, 1945, CXXVIIL 482 ·58 STERNAL PUNCTURE macroblasts or even pro-erythroblasts There is also some leucopoiesis in the liver, but this is not intimately mixed with the immature red cells The sternal bone-marrow may appear normal during the greater part of the disease, only becoming involved in the terminal stage It is important to remember this, for it shows very clearly that it is never safe to assume that, because the marrow is normal, we are not dealing with a disease of the hæmopoietic tissues It has long been known that the blood may still appear healthy at a time when the formative organs are already abnormal, but it is less widely recognised that the bone-marrow may appear healthy at a time when the blood already shows signs of disorder What little evidence is available seems to suggest that erythroleukaemia is a special mode of reaction to some unknown noxious 33 15 Neutrophiles Myelocytes Metamyelocytes Polymorphs Eosinophiles Lymphocytes Monocytes Premyelocytes Hæmocytoblasts Normoblasts Megaloblasts 10-18 per cent 5-7 » 35-42 » 2- 4 » T- 2 » 8-12 0 I I- 3 91 22 91 12-18 1 1-31 + REFERENCES 11 honech TAO1417 17 d, 1941, MIEILALLA, clxxxvii, 225 ·CHAPTER INFECTIVE DISEASES LEUCOCYTE counts have been of considerable value in medicine and surgery as well as in more purely academic studies of immunity The blood changes 35 snfective diseases are relatively well known, but the mastow findings have not yet been insestigated in much detasi The types of changes that may occur can be classified as follows - (1) Normal marrow with no alteration in the percentage com position (2) Hyperplastic marrow with predominance of mature and almost matute neutropatles (3) Hyperplastsc marcou with many immature neutrophiles, anly myelocytes (4) Extremely immature sassow in which premyelocytes are Uwerous or even prominent (5) Myeloblaste marrow An alternate classification suggested by Barta was me (1) Moderate reaction with plenuful celis (2) Intense reaction with immature cells including many myelocytes (3) Extreme reaction with many premyelocytes or even mye Joblasts, and (4) Failure of reaction with decrease of granular leucocytes No rigid classification is possible because there is a continuous cesses of gradations between the different types of marrow AN that en profitably be done is to call attention to the outstanding characters of the myelogram As in the blood 80 in the marrow, the picture is not pathogno monic of a particular infection The myelogram, like the hamograma, gives an indication of the intensity of reaction but not of the onder fying cause In a few miesions it is alleged that there are pathognomonic changes, for example in both lobar and bronchopneumonia there is a greater degree of vastation n the size of the granulocytes than in health, but this anisocytosis is not psible in the 63004) and $9 ·62 STERNAL PUNCTURE 1-3 » Normoblasts 25-25 per cent Megaloblasts Megakaryocytes scanty, but always present Recently several authors have doubted whether there is, in fact, any true monocytic reaction in the bone-marrow There is no doubt that marrow smears in this disease often shows a marked increase in monocytoid cells, but it is possible that this may be the result of admixture with circulating blood and not a specific response of the marrow cells Perusal of the literature of bone marrow biopsy in glandular fever indicates that about half of the reports show an increase in monocytic cells and half do not Limarzi, Paul and Poucher give a good review of this subject and analyse tienty five cases of their own Their conclusion is that the marrow does show a myeloid hyperplasia and immaturity but is not involved in the production of the monocytoid cells The average of the findings in the twenty-five cases is given as follows Myeloblasts 33 per cent Range 0 - 2 25 Premyelocytes o 82 0-30 Myelocytes Metamyelocytes 480 Polymorphs 15-19 5 Eosinophiles 078 - 2 25 Basophils oo6 Proerythroblasts 075- 75 Basophil Nornoblasts 2 08 >> 05-425 Polychrome 21 8 » 190-240 Eosinophil 05 + 0 - 1 75 Monocytoid 25 » 10-60 REFERENCES 91 12 Jy 200 17 » 45-480 » 240-68 3 5 55 99 10 7 0 - 15 3D 1 70 1 11 >> > 91 5) 99 . Z G Lab Clin Med, 1946, XXX1, 1079 MOESCHILIN, S Helvet Med Acta, 1940, VII, 227 VOGEL, P, and BASSEM, F A Amer Dis Childh , 1939, 1vit, 245 ·CHAPTER VII HYPOPLASIA AND APLASIA OF THE BONE-MARROW APLASIA of the bone-marrow may arise from a variety of causes, ranging from exhaustion, to poisoning or to lack of specific nutritional factors A heterogenous group of diseases is involved includmg anæmia, agranulocytosis, and purpura, or a combination of all three, according to which part of the hæmopoietic tissue is involved Sternal puncture has been of great use in elucidating the pathology of these conditions and has shown that the peripheral blood may give a very inaccurate reflection of the conditions in the hæmopoietic bone marrow This tissue may be truly aplastic with failure of division of the primitive cells (primary aplasia), or there may be normal division of the precursor cells resulting in a very cellular marrow, which, owing to lack of some maturation factor, is unable to fumish finished elements to the blood stream (maturation type) Whitby and Britton have made a useful classification of these diseases based on the marrow findings in the separate or combined affections of the erythroblastic, leucoblastic and thromboblastic tissues — 1 Aplasia of the erythroblastic tissue (a) Primary-pure red cell anæmia The authors have found only five cases in the literature (6) Maturation defect-dyshæmopoietic anæmas may become aplastic if the maturation factor is never supplied 2 Aplasta of the leucoblastic tissue (a) Primary-agranulocytic angma (6) Maturation defect-agranulocytic angina with marked myeloid reaction in the marrow These cases respond more readily to pentnucleotide therapy, which possibly supplies some maturation factor 3 Aplasia of the thromboblastic tissue (a) Primary-essential thrombocytopenic purpura An acute form in which there is no rise of platelets after splenectomy (6) Maturation defect-essential thrombocytopenia Splenectomy is probably beneficial in this type by removing a factor which inhibits platelet maturation & ·66 STERNAL PUNCTURE the predominant cells in most cases of this type of aplastic anæmia, and there is also a considerable excess of monocytoid elements, many of which are obviously phagocytic But it is always difficult, and sometimes impossible, to classify accurately lymphocytes, monocytes and pathologically altered myelocytes Davidson calls these un classifiable elements "0" cells If myeloblasts are present they are always abnormal, commonly they have indented nucles, which may even be lobulated (Reider type) In one case of idiopathic aplastic anæmia recently seen, the marrow showed some hypoplasia of all the nucleated elements (which were otherwise normal) and gross degenerative changes in the erythrocytes which assumed bizarre forms in the films and even appeared fragmented In the peripheral blood, however, the erythrocytes appeared normal except for a slight macrocytosis (Fig III) In aplastic anæmia with a hypercellular marrow the clinical picture is indistinguishable from that with a hypoplastic marrow We have during the last two years had under observation a girl of sixteen years whose peripheral blood shows a progressive normocytic anæmia with no change in the white cells The whole variety of hæmatınıc drugs has no effect on her condition and every three or four months she is transfused with 2 or 3 punts of blood This raises her hæmoglobın to between 60 and 80 per cent Haldane, which level she will maintain and sometimes improve slightly for about a month It then gradually falls to between 30 and 40 per cent, at which level the transfusion 18 repeated Sternal puncture has always shown a hypercellular marrow with a normal differential count except of a slight persistent increase in the megaloblastic red cell series A characteristic count from this case is as follows 05 per cent. 91 YO 1 Hæmocytoblasts Myeloblasts Premyelocytes Myelocytes Metamyelocytes Neutrophils Eosinophils Basophils Pro-erythroblasts Basophil megaloblasts > 1301 22 0 120 2 20 05 » 05 » 51 91 1

·FIG 11
A
B
APLASTIC AN EVIL
A Fragmentation of red cells in marrow
B Vormal cells a penipheral blond

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·ITYPOPLASIA AND APLASIA OF THE BONE MARROW 67 15 per cent 1 1) 15 55 1 Polychromatic megaloblasts Eosinophils megaloblasts Basophil normoblasts Polychromatic normoblasts Eosinophil normoblasts Lymphocytes Plasma cells Unidentified cells 60 13 5 1 15 » 10 17 30 15 Any of the agents that can cause aplastic anæmia, eg, benzoi arsenobenzene, thonum, the more modern sulpha compounds, X-rays, etc, may in smaller concentrations (or after less prolonged exposure) cause a less severe hypoplastic anemia It is unfortunate that, although such stages are, at first at least, less grave, they tend to deteriorate, and recovery is very uncommon All these substances tend to attack the leucoblastic tissues first and the erythroblastic tissues later X-rays behave in the same way With sulphapyndine the effect on the leucoblastic tissue may be so severe that death ensues before any anæmia makes itself apparent, and these cases are often classed as agranulocytosis Benzol commonly attacks the leucoblastic tissue first, but cases have been recorded in which the platelets were first affected [sen when there is a marked leucopenia, due to benzol, there may be some excess of eosinophiles both in the blood and in the marrow These changes also occur with drugs containing the benzol ring, eg , arsphenamine Six cases of blood dyscrası1 with characteristic matross changes after the exhibition of arsphenamine have been reported by Ferguson It 19 important to realise that the myelogram can gne us 1er) carly information in cases of suspected poisoning of the bone marrow with these compounds The number of people working with benzol has increased enormbusly during the years of the war, and we have had the opportunity of examınıng large numbers of these workers, showing the typical clinical syndrome of benzol poisoning, the hæmatological findings have proved negative Sternal puncture, however, may show definite alteration in the hemopoietic tissue The myelogram quoted below was found in a female benzol worker, aged thirty-three, who had complained of dizziness, lassitude and menorrhagia for some four weeks Her blood count showed a moderate microcytic hypochromic anæmia (1lb 68 per cent, RBC 4,000,000, CI 085) The white blood count sas 5,500 per cubic millimetre and the differential --polymorphs 01 per cent , lympho- In some 7a ·68 STERNAL PUNCTURE IO 17 IO 27 3 265, > 25 » cytes 32 per cent, monocytes 4 per cent, eosinophiles 3 per cent The myelogram was as follows Neutrophiles Myelocytes 14 per cent Metamyelocy tes Polymorphs 23 Eosinophiles Myelocytes 15, Polymorphs Lymphocytes Monocytes 45 Myeloblasts Normoblasts 17 Megakaryocytes very scanty Reticulocy 15 per cent of the non nucleated elements Here we see at once some depression in the myeloid tissue Normoblasts are present in normal numbers, but not in such large quantities as one would expect if the anæmnia were due to iron deficiency The low reticulocyte count is striking The number of lymphocytes is raised, and this point brings one to an interesting speculation We know that it is not possible at the moment to determine the activity of the bone marrow by doing cell counts on the sternal marrow fluid, but we may assume that if there is no absolute lymphocytosis or lymphopenia in the peripheral blood, an increase in the percentage of lymphocytes in the bone marrow is only a relative increase, and that there is no alteration in their absolute number Then, an increase in the percentage of lymphocytes can be used as an index of the decrease in the amount of the other elements of the marrow In the case quoted above, the absolute number of lymphocytes in the peripheral blood is within normal limits (1,820), in the marrow, however, the lymphocytes are increased one and a half to two times It would therefore seem reasonable to assume that the myeloid and erythroblastic elements are reduced to the same extent, as there is no valid reason to account for an absolute increase of lymphocytes in the bone marrow Whether this mference is admissible or not, the other observation that thus marrow showed a general depression compatible with benzol poisoning, before any typical changes in the peripheral blood sere noted, is of diagnostic value When anæma due to benzol poisoning is fully established stell- ·HYPOPLASIA AND APLASIA OF THE BONE-NIARROW 69 marked changes are always present in the bone marrow Mallory, Gall and Brickley have investigated a series of cases and found that between 30 and 40 per cent showed severe hypoplasia of the sternal marrow (no cases of complete aplasia were seen), about 40 per cent showed normal cellularity and about 20 per cent showed a hyperplastic condition In the hypoplastic type the myelogram was substantially the same as that already quoted (P 68), and one case showed a high proportion of plasma cells, some with multiple nucler In the normocellular group there was an increase in the proportion of granulocytes and megaharyocytes with what the authors cali numerous "clumps of hæmocytoblasts” In the hyperplastic type proliferative activity was sometimes extreme with not infrequent multipolar mitoses, the hæmocytoblasts and megakaryocytes were also increased in number, the latter showing abnormal forms Erf and Rhoads have reported similar findings and refer to the increased number of "primitive " cells from 4 to 34 per cent It must be remembered that leukemia may develop after benzol poisoning and the marrow then shows the changes ordinarily seen in leukæmia Mallory et al and Erf and Rhoads quote typical cases in their papers One further case may be quoted where changes in the sternal marrow were detected before they appeared in the blood A male, 1 L -- polymorphonuclears were seen in the film Sternal puncture was CC 1 La L . blasts numbered only 12 per cent The lymphocytes were 25 per cent The polymorphs were very degenerate, and there were only 10 per cent of myelocytes Here we had a primary aplasia of both the leucoblastic and erythroblastic tissue, the latter not yet being apparent in the blood Two days later the hæmoglobin and the red cell counts began to fall and the patient died in spite of repeated transfusions with fresh blood One more point remains to be mentioned in connection with this group of marrow poisons It would seem that only susceptible persons are affected Most cases of fatal poisoning with benzol have ·72 STERNAL PUNCTURE large numbers (perhaps normal numbers) of the less mature forms of granulocytes, but practically no polymorphonuclears, and the peripheral blood shows the typical picture of extreme leucopenia, with relative lymphocytosis Of the granulocyte precursors, Jaffe has found that the myeloblasts show no morphological abnormality, but the myelocytes show degenerative changes in the nucleus which eventually lead to the death of the cell (Plate 124) The nuclear changes are preceded by some splitting and degeneration of the cytoplasmic granules Jaffe emphasises these changes as the specific pathological features of the malady, and it would seem that they depend upon the absence of some specific factor that is normally required for the proper differentiation of the myelocytes of this - 2 thn pop upon Hd hamnarl Thaayo lahle 11 1 - - - - 1 I-5 1- 2 11 > 33 20-35 » 12 substances as sodrum pentose nucleotide is often followed by cure But in the aplastic form, there is little evidence that treatment on these lines is of any value at all The myelogram in the "maturation ' type of agranulocytosis is of the following type Neutrophiles Myelocytes 30-35 per cent Polymorphs Eosinophiles Myelocytes Premyelocytes Hæmocytoblasts (including myeloblasts) 1-2 Lymphocytes Normoblasts 15-20, Mlegakaryocytes scanty The myelocytes show degenerative changes in the nucleus and specific cytoplasmic granules Whether the aplastic type of agranulocytosis 18 an advanced stage of the "maturation 'type is still unknown, but it is obvious that, in spite of this large gap in our knowledge, sternal puncture is of the utmost prognostic value By it ise can determine whether there is any hope that treatment will do good, or whether, with the means available, death is inevitable Essential Thrombocytopenia In this malady, as with agranulocytosis, there would seem to be a primary apiasnc form as well as a' maturation type resulting from failure of the mega-

·PLATE 12
b
al
ACRA
Moc
A
LOCYTOS S (VAT RAT OY Tyre
Abs ne of th morphs non granula ty of me am clocs es (a)
nu lea degen on my closy rs (
ce
B
TURO BOCYTOTE (VITETON Tyrt)
Abnormal megakarrocyte (a) and g3nt p a clet (6)

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·HYPOPLASIA AND APLASIA OF THE BONE-MARROW in nor karyocytes to develop properly Clinically the aplastic form is acute illness and splenectomy is attended by a 70-80 per c mortality In the chronic recurring type or phase of the malady marrow often shows a maturation defect, and in these cases spler tomy practically always alleviates the condition This has led to supposition that the spleen in these cases produces an inhibit factor which acts on the bone-marrow In the primary aplastic form of the disease, the significant cha 13 the complete absence of megakaryocytes and the paucity of pl lets Careful search of even the ends of the films fails to reveal fragments of megakaryocytes and such platelets as there are may deforned If any anæmia has resulted from extensive purp bleeding the myelogram will show a normoblastic hyperplasia, this is to be regarded as a reaction to the loss of blood and not part of the malady itself In the “maturation " type, megakaryocytes are numbers and show some alteration in structure Platelets deficient, however in number and quality, giant forms are m more common than in normal marrow (Plate 12B) The mi karyocytes, although as large as fully differentiated forms pre: much less nuclear lobulation and contortion The cytoplasn often vacuolated and may be completely free from granules, whether this is a sign of degeneration, as some writers have tended, is quite unknown The one point that suggests the mi karyocytes are, indeed, the seat of degenerative changes, is that number of platelets, both in the marrow and in the blood, is gre reduced, and it is reasonable to suppose that this may be due to of functional activity of the parent forms Dameshek and Miller have counted the number of megaharyoc in bone marrow biopsies in idiopathic thrombocytopenic purp normals, and in cases of thrombocytopenic purpura associated various types of splenomegaly Their figures are as follows i Normals—not more than 300 megakaryocytes per mil nucleated red cells, 69 per cent showing platelet product 2 Chronic idiopathic thrombocytopenic purpura-increased n ber of megakaryocytes with decreased platelet productio: 3 Splenomegaly of non leuk.emic origin (cirrhosis, Gauch disease, etc) slightly increased megaharyocytes with noi platelet production 4 Aplastic anæmia, lymphosarcoma, acute leukema ·74 STERNAL PUNCTURE reduction of megakaryocytes a normal percentage of which show platelet production Although a hypoplastic or aplastic condition of the bone marrow is not involved, other forms of purpura may well be mentioned here Sternal puncture is valuable because there are so many conditions that can give rise to purpura, and their accurate differentiation is of great therapeutic importance Thus we may find a myelo blastic overgrowth of the marrow which demonstrates that we are dealing with a leukæmia , or, we may discover a marrow that is entirely devoid of erythroblastic and granulocytic elements, and we realise that the malady is some form of aplastic anæmia in the purpuras associated with infection or with the action of poisons, there may be a transient increase in the number of mega karyocytes, but quite soon these elements become scanty Moeschlin, however, could find no changes in the bone marrow of people who developed thrombocytopenia after the administration of sedormid The myelogram is of the following type 3 18-25 19 2-4 , I - 2 1 I-3 27 > 1) Neutrophiles Myelocytes 10-15 per cent Metamyelocytes 4-6 Polymorphs Eosinophile polymorphs 2- 4 Premyelocytes Lymphocytes Monocytes 1- 3 Plasma cells Pro erythroblasts 3- 5 Normoblasts 30-45 Megaloblasts Megakaryocytes There seem to be several conditions in which the condition of the peripheral blood suggests that there is hypoplasia of one or all the components of the myeloid tissue, but in which marrow puncture reveals intense hyperplasia Thus, excessive thrombolysis in the spleeg can produce the picture of thrombocytopenic purpura, although there is increased formation of platelets in the marrow And Doan and Wright have described a condition of splenic panhæmatopema in which every type of martow cell is increased in number, although the blood picture suggests the opposite of this 2- 4 1 ·HYPOPLASIA AND APLASIA OF THE BONE-MARROW 75 They adduce evidence that, in this condition, there is indiscriminate destruction of every kind of formed hæmic element as it passes through the spleen. Cases which are clinically indistinguishable from essential thrombocytopenia may occur as allergic” manifestations, particularly after streptococcal infections Schwartz has suggested that examination of marrow smears may differentiate this condition from the idiopathic type because in the former there is an increased number of cosinophils This eosinophilia of the marrow in the infective type is not necessarily reflected in the peripheral blood REFERENCES AUDAY, G J, and ORBAN, B Arch Path, 1945 XXXLX, 369 BOMFON, R R, and RHOADS, CP Quart Mied , 1941, X, 175 DAVIDSON, L S P, Davis LJ, and INNES J Edinb Aled , 1943 1, 226 Ibid, 1943, 1, 355 Ibid, 1943, 1, 431 DAMESMEK, W, and MILLER, E B Blood, 1946, 1,27 DOAN, CA, and WRICHT, CS Blood, 1946, 1, 10 ERF, L A, and RHOADS,CP Indust Hys and Toricol, 2939, xxi, 421 FERGUSON, J W Lancet 1944 1, 334 JAFFÉ, R H Arch Path , 1933 xvi 611 MALLORY, T B , GALL, E A, and BUCKLEY, W J Indust Hys and Toxicol, 1939, XX1, 355 MOESCIILIV, S Schuleis med II schr , 1942, lexu, 119 SCHWARTZ, SO Amer Med Sc , 1945, CCI, 579 WHITBY, L EH, and BRITTON, CIC "Disorders of the Blood," 4th edit, 1942 POS ·CHAPTER VIII SOME PROTOZOAL DISEASES It would seem that with these diseases there is an extensive and promising field of work in connection with stemnal puncture, as many of the parasites make their home in the reticulo-endothelial system, and so one would expect to find them frequently in the bone marrow Also the literature on the subject is scanty The enlargement and softening of the spleen, which so often accompany these diseases, may make spleen puncture an operation of some consequence because of the possibility of persistent bleeding Liver puncture, though safe, does not usually gave very satisfactory material for examination Sternal puncture, however, is rapid, safe, and provides material which not only may contain the parasites in large numbers, but at the same time provides an opportunity of explaining the more or less characteristic blood changes Kala Azar (Plate 13A) Let it not be supposed that this disease is confined to the tropics, many cases from the margins of the Mediterranean basın and from the Sudan have been recorded , and one is tempted to presume that even more have been overlooked The myelogram has remarkable characters, inasmuch as there is lymphocytosis, increase of monocytes, intense reticulo-endothelial hyperplasia, patchy deposition of platelets and, of course, the pathogenic agent, the Leishmania itself The last is found lying inside monocytes, but some lie free and rather closely resemble platelets, with which they may easily be confused Close examinatron shows - nomni moted otmicture than have is probably an artefact due to rupture of the cells during spreading of the 6lm in the films we have seen, where a group of Leishmania is encountered, they are always entangled in a faintly basophilic web, probably representing the remains of the monocyte cytoplasm quite often a degenerate nucleus is found in close proximity Extracellular forms must occur in the passage from cell to cell, but these are rare and probably occur singly In histological preparations, where the cells remain intact, the parasites are almost invariably intracellular In films also they may sometimes be seen superimposed on a red cell, and they have been thought to lie within them, as with the malarial parasite This is an artefact The organisms may be found in peripheral blood films but always within either the monocytes or the polymorphonuclears 75 ·SOVE PROTOZOAL DISEASES In stan the parasite us in a non-flagellate stage It is circular, oval, or cigar-shaped in outline and is 2 to 4 microns long and 1 to 3 microns wide The cytoplasm, fauntly basophılıp, is contained in a tenuous membrane and contains two characteristic structures, which are essential to its recognition The one, the nucleus, 19 larger than the other, and is usually spherical Its diameter is about one-third to one-half of the shortest diameter of the organism It usually lues against the membrane and is flattened on this $1de The flattering may be extreme so that the nucleus appears as a thick line, and this appearance may be accentuated by the presence of vacuoles within the cytoplasın With Jenner- Giemsa stain the nucleus appears as a bright red granular mass. The second, the blepharoblast, is a short rod-shaped structure wnh one end pointing to the nucleus It may appear as a dot of its long ax13 15 perpendicular to the slide The blepharoblast stains purple with Jenner Gremsa (Plate 131) Qute apart from the presence of Leishmania, the myelogram 19 characteristic, and may remain so for many months after suitable treatment has caused the dssappearance of these organisms Neutrophiles Miyelocytes 18-24 per cent Metamyelocytes Polymorphs Eosinophiles OI Lymphocytes Small 18-22 Large 38-22 Afonocytes 24-18 Plasma cells I-3 Harmohustioblasts Hemocytoblasts Mormoblasts 3- 51 Megaloblasts 1-3 » In Leishmania tropica infections (orsental sore) the lesions are usually confined to the skı, sometimes appearing in the mouth also Enlargement of the glands may occur af lymphadenris is present and the organism has been found in them very rarely it has been demonstrated in the peripheral blood, but further insestifation may shou it to occur more frequently in the bone-marrom Malarla (Plate 133) In benign terutan and quartan infections the 11 17 > > 23 1* 11 事重 ·78 STERNAL PUNCTURE asexual life-cycle of the parasite takes place in the peripheral blood In malignant tertian fever, the cycle takes place in the tissues It would appear, from sternal puncture films of a case of cerebral malignant tertian malaria, that this schizogony occurs, in part at least, in the bone-marrow All the changes from the signet-ring stage to the rosette stage could be traced, while peripheral blood films showed only a few signet-ring and gametocyte forms The number of infected corpuscles in the marrow exceeded by far those in the bloodstream Plate 13B was prepared from this film Recently several papers have come from the Middle East showing that sternal puncture may be of great value in the diagnosis of malaria Aitken examined 95 cases in which serial thick drop preparations made from the peripheral blood at six-hourly intervals had proved negative In 39 of these cases the parasites were found in the sternal marrow In a further series of 10 cases which did show the parasites in the peripheral blood, parasite-containing red cells were from 2 to 5 times more numerous in the marrow fluid Rumball and his co workers point out that most cases of pyrexial malaria can be diagnosed from the peripheral blood, but that sternal puncture forms a valuable supplementary diagnostic method in those cases where sporulation 18 scanty and parasites cannot be found in the peripheral blood In response to the hæmolysis of red corpuscles by the malarial parasite, the marrow response is essentially normoblastic and monocytic-changes that do not disappear for many months after recovery Monocytosis, which is considerable in chronic cases, is less marked in acute ones The following myelogram is of a farrly characteristic type Neutrophiles Myelocytes 5-7 per cent Metamyelocytes Polymorphs Eosinophiles Monocytes Premyelocytes Hæmocytoblasts Normoblasts 40-50 Macronormoblasts REFERENCES AITKEN, G J Lancet, 1943, 11, 466 Lancet, RUMBALL, C A, PARSONS SMITH, B G, and NANCEKIEVILL, L > 9-12 » 0-2 10-14 » O-2 OI 32 12-8 9) 1943, 11, 468

·PLATE 13
A KALA ALAR
(a) Lesshman ruptured morocyte
1 VILLAS (VALIGIVT TERTE)
(a) SCHIZORI
( Young gameloy it
fb) ring forths in corpuscle di Vanocytes
e fute 93

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·CHAPTER X THE TECHNIQUE OF STERNAL PUNCTURE Anatomy. The cartilage of the second rib joins the side of the sternum at the junction of the manubrium and the body This junction can be felt, and often seen, as a transverse ridge on the front of the chest, as the two bones are slightly thickened at their point of unton The ridge can usually be felt, in the adult male, about 2 inches belou the jugular notch In the female, the manubrium is longer and the ridge consequently lower Until late adult life the . han surface of the manubrium which adjoins the body of the sternum The centre of ossification in the manubrium appears during the fifth month of fatal life, and at three years of age the bone contains a moderate amount of red marrow Despite this, sternal puncture is an unsatisfactory procedure if performed much before the age of seven to eight years The needle enters the manubrium very easily but it is difficult to obtain any marrow at all Kato, however, prefers to puncture the body of the sternum, which, he states, contains cellular marrow even in infants of one or two years of age Even so, it is better, in the rare cases in which marrow examination in an infant is necessary, to obtain the specimen by trephining the tibia Technique of Sternal Puncture This is a comparatively simple procedure, but in order to cause as little pain as possible, a few details must be adhered to The type of needle to be used is of some importance, because it needs to be thick and strong, so as nerther to bend nor break in piercing the bone Something in the nature of a very short French lumbar puncture needle, with an obturator stilette, is best, and a movable guard on the necdic itself is useful to avoid the danger, 1 Suction it is well to use a large syringe, eg, about 20 or 25 cc It is probably not of much importance where the bone is punc- 2 ·80 STERNAL PUNCTURE tured, but as has been said, the thinnest spot lies on the under (caudal) surface of the manubrium-that is in the upper surface of the joint that forms the angle of Luis And this is the easiest and least painful site for the purpose Now the procedure is as follows the patient is placed on his back, with a pillow under the shoulders, so as to throw the head backwards Then novocaine is injected into the site of election, taking care that the deeper tissues, including the sternal perio steum, are infiltrated The needle is plunged in just below the angle of Lurs, and when the point is felt to reach this it is pushed a lile further until it penetrates the small piece of cartilage in the joint When It seems to be in about the middle of this the butt of the needle is lowered until it is almnst touching the chest, and then it 15 pushed straight upwards until the bone is pierced The manæuvre is sometines accomplished more easily if a rotatory motion is imparted to the needle as in using a bradawi The sensation obtained when the outer layer of compact bone STERNAL PUNCTURE NEEDLP Is penetrated 18 rather like that of a (WITTS TYPE) lumbar puncture when the point of The needle resembles a short thick lumbar puncture needle the needle enters the theca Now the with obturacing stilette and stilette 13 withdraw and the needle movable guard The guard is 50 adjusted that there is no pushed onwards, thus collecting martow possibility of Piercing the tissue in the lumen posterioi wall of the sternum Another method in common ust 19 If however it is found that the guard has been placed so as follows The guard of the needle anterior wall is not pierced at $ set just above the point of the cast be mored after the needle needle, which is pushed vertically 1s in the tissues against the anterior plate of the manubrium Then, when the resistance of the bone is felt, the guard on the needle is set about 5 mm above the skin surface, the needle is then pushed Onwards If no marrow is obtained the 42 ·THE TECHNIQUE OP STERNAL PUNCTURE 81 guard may be raised another 2 mm and the needle again pushed onwards, but the needle must never be pushed so far as to touch the posterior lamella of the sternum As the thickness of the cancellous bone is betteen os and 15 cm (Arjeff), there is no danger of penetrating the sternum by this method A good deal of information can be obtained, after some experience, by the different sensations obtained as the needle moves onwards Thus the hard push needed in osteosclerosis 13 tery different from that required by the soft marrow of a leukæmia The syringe, either thoroughly dry or rinsed out with normal saline, is now attached to the needle and the plunger pulled out However well the tissues have been anæsthetised, there is now always an unpleasant scasation, which some patients allege arounts to pain, but it is quite transient Thick blood like material should enter the barrel of the syringe, but some marrows are too dense for this to occur even then a sausage of myeloid tissue will usually be found, often mixed with spicules or cancellous bone, lying in the lumen of the needle Suction is now stopped, and after removing the needle the puncture wound is sealed with collodion It is het in aynal he hate of oho mnou it impossible to find any fragments, and then films must be made from the thick fluid This is often difficult, as all but the most hyperplastic marrons contain globules of fat, which render the preparation of really good films difficult, and, of course, the spicules of cancellous bonc make it even more so For this reason a large number of films should be prepared, and among them good ones will be found The films should be made as quickly as possible because marrow clots as rapidly as blood, but no attempt should be made to make the films as thin as those of blood, If this is tried, far too many cells will be ruptured in the attempt It is often possible to make thinner films by mixing some of the marrow juicc with a little serum As the cells in thin films are further apart, this proce. dure simplifies the performance of the differential count Turlei and Bethell have introduced a small trephine with which marrow can be obtained from the sternum with no more trouble than by the usual aspiration method. As material for histological examination can be obtained by this means, it is specially useful .

·82 STERNAL PUNCTURE in cases of myelosclerosis (P 19) In most other cases, aspiration is probably the method of choice A warning must be given here about the use of post mortem specimens of marrow fluid Normally, gross degenerative changes have taken place in the cells three hours after death and the nucler of all the cells stain a homogenous purplish blue colour with no visible chromatin pattern, the cytoplasm has often disintegrated completely so that bare nucles, some surrounded by granules can be seen The sternum is not the only bone from which marrow can be obtained by puncture Loge has called attention to the ease with which marrow can be obtained from the spinous processes of the third and fourth lumbar vertebre The technique is much the same as that of sternal puncture, but the guard is set at 15 cm then, if no marrow is obtained by suction at this depth, it is safe to push on to a maximum of 2 5 cm Loge found that the myelograms from sternal and spinous marrow are practically identical, and the same is true of marrow obtained by puncture of the iliac crest Clearly, this know ledge is of great value when serial punctures have to be performed on the same patient Ordinary films can be stained by whatever method is desired, but as a rule it is, of course, sensible to use the same method as is used for blood, in this way comparison is considerably facilitated On the whole, Jenner s solution is not satisfactory, because the nuclear detail is poorly displayed, and because any azurophılıc granules remain unstained Leishman's solution or the excellent lenner. Giemsa method is very suitable In combined staining May- Grunwald may be used instead of Jenner, and Panchrom stain or Kardos mixture in place of Gremsa Different effects can be obtained by using different combinations, for instance, May Grunwald and Kardos mixture gives extremely brilliant granule staining Vital Staining (a) Reticulocytes A clean slide is flooded with an alcoholic solution of cresyl blue This film is allowed to dry, and any tendency to roughness on the surface of the dye film is smoothed by gently polishing with a piece of soft paper One small drop of marrow fluid is put on the slide and gently stirred with a glass rod, taking care not to spread the marrow over too large an area so that drying takes place As the marrow fluid mixed with cresyl blue does not clot for some time, it is allowed to stand for ·THE TECHNIQUE OF STERVAL. PUNCTURE 83 two or three minutes so that maximum stasang of the reticulum is obtained Films are then made from this drop and allowed to dry in ar "They can be eramuned directly for reticulocytes or counter stained for making permanent preparations Counterstaining how ever, tends to hide the reticulation in cells which have only a little of the vitally stainable basophilic substance (5) Fresh preparations The most commonly used dyes for this purpose are neutral red chloride and Janus green. The preparations are made in the usual way Equally good results, however, can be obtamed by dark ground sllumination of fresh preparations as described below Dark Ground Illumination (Fig 1) A good account of this technique was given by Whstby and Hynes Thoroughly clean and degreased slides and coverslips must be used A small drop of marrow fluid is placed on a slide and covered with a cover alıp, the preparation is immediately sealed with wax and kept warm in the incubator The slides should be covered so that light is excluded If good results are to be obtained, the marrow films must be as thin es possible, the smaller the drop of marrow, the thunner the final preparation and, as a rule the drop should be of such a size that when the cover slip has settled, the film does not quite seach its edges In thus way one attains the maximum capillary attraction between the slide and the cover whereas if there is enough martow flud to reach the edges of the coverslip, this tends to float up and make a thick preparation After half an hour in the incubator, the preparation is examined with dark ground illumination and, if possible some form of warm stage Under proper conditions the movements of the motile cells atc casily scen, as are also the mitochondria and other elements seen in any vitally stained preparations Dark ground illumination has further advantages as that the cell and nuclest membrancs are easily visible and that nucicar structure is also quite clear The motility of cells is rapidly slowed down by light, so the preparation should only be illuminated for a few minutes at a time, and then allowed to recover in the dark For observang cell structure the films last quite well for four 10 Xux hours without any protection or warming The characters of the cells are as follons (see Fig in (1) GRANTLOCYTE SERIES (A) Msetodlost A rounded cell 8 to so microns in diameter Thin defined cytoplasmic şim nuclear membrane equally well defined and somewhat thicker Nucleus rounded and appears filled with a finc dust, nucleols appear as + ·84 STERNAL PUNCTURE circular outlines where the dust Itke particles are thicker Cytoplasm contains mitochondria which appear as faint dots Cell non motile (B) Premyelocyte Ten to 20 microns in diameter and rounded, cytoplasmic ruin, nuclear membrane, and nucleus as in the myeloblast The mitochrondria are now grouped round the nucleus and appear as thin, wavy rods, sometimes showing Brownian movement Cell non motile (C and D) Myelocyte Ten to 20 microns in diameter The specific granules appear in the cytoplasm of the premyelocyte in increasing numbers first among the mitochondria Eventually they fill the whole of the cytoplasmic space and may partly obliterate the nucleus which has now no nucleolar structures The specific granules of each of the neutrophile, eosinophile, and basophile myelocytes are described under the mature polymorphonuclear cell (E) Neutrophile Polymorphonuclear An active motile cell, 12 to 20 microns in diameter when at rest The nucleus, now lobed has The cytoplasm is filled with ", the leading end of each of granules (F) Eosinophile Polymorphonuclear Less actively motile than the neutrophile cell and of about the same size The granules are readily distinguished as they are larger, appear as rings of light, and may be oval (G) Basophtle Polymorphonuclear A smaller cell 7 to 10 microns in diameter The granules are of the same type as the eosinophile granules, but are much fewer in number and may appear even larger (2) LYMPHOID SERIES (I) Lymphoblast A rounded cell, 8 to 10 microns in diameter The nucleus is indistinguishable from that of the myeloblast The two cells however, are easily separated by the appearances of the mitochondria These in the lymphoblast are larger, less numerous, and definitely rod shaped Cell nonmotile (1) Lymphocyte Rounded, may occasionally be motile and vary in size from 10 to 15 microns The nucleus is round or indented and filled with fine dust like granules The mitochondria are grouped to one side of the nucleus and appear as fine round oval dots Two three four or five large bright granules are present "Gall s mahogany granule" shows as a refractile ring of light (3) THROWBOBLASTIC SERIES (H) Megakaryocyte A large cell up

·FIG, IT
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А
M
B
N
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D
R
E
F
DARK GROLD IILI VINATION OF VAROW CELLS
(2) Vacloblast (c) Basophale
() Promegaloblast
(h) I'remyeleste. (4) Vegakanocyte (*) Vies aloblast
(1) Tlatelets
(0) Vegalny se
(1) Iymphoblast (P Earls nonnobl
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·TJIE TECHNIQUE OF STERNAL PUNCTURE to 40 microns in diameter. The nucleus usually appears as a group of separate lobes, each of which has a definite nuclear membrane, and is filled with fine dust-like particles The cytoplasm has no definite rim and is filled pith small moderately bright granules (1) Platelets These appear most as small circles of Light, 2 to 5 microns in diameter The larger number appear to be empty, but some contain five or six small bright granules, which show active Brownian movement, apparently bouncing from side to side of the cell (4) LRY TIIROBLASTIC SERIES (MI) Promegaloblast A non-motile cell about 10 microns in diameter The cytoplasmic rim is thick and well defined This cell shows marked pleomorphism The cytoplasm appears completely free of granules and other structures although there may be a group of small rounded mitochondria adherent to one side of the nucicus, when this occurs, the nuclear membrane is absent at the point of contact This membrane 13 otherwise well defined and thus The nucleus is filled with fine dust-like particles which are more closely packed and appear much brighter than those of the leucoblastic cells Also the nuclear particles show some small areas of condensation which appear as brighter granules The nucleoli, tiyo or three in number, are outlined by a ring of such condensation (N) Megaloblast Very variable in size and shape There is a thick cytoplasmic ring and clear cytoplasm without mitochondria The nucleus may appear lobed and shows areas of localised condensation (P) Early Normoblast The nuclear structure is the same as in the megaloblast, and the nucleus as of much the same size The cytoplasmic ring is not well marked, and the cytoplasm is scanty and may contain a few dust-like mitochondria The cell 13 easily 2 (k) ormocy le This appears as a bright ang of light with a thick cytoplasmic rim The megalocyte (O), though larger, has the same appearance Cell Propagation. Mitosis. While mitotic figures are easily recogrusable, i must be remembered that the abole process 28 a continuous one, and that the early changes in the nucleus, betseen the interphase and the prophase, are very casily os erlooked These changes may completely alter the apparent structure of the nucleus

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·THE TECHNIQUE OF STERNAL, PUNCTURE 85 to 40 microns in diameter 'The nucleus usually appears as a group of separate lobes each of which has a definite nuclear membrane and is filled with fine dust like particles The cytoplasm has no definite rim and is filled with small moderately bright gramples (I) Platelets These appear most as small circles of light 2 to 5 microns in diameter The larger number appear to be empty but some contain five or sit small bright granules włuch show active Brawnian movement apparently bouncing from side to side of the cell (4) ERYTHROBLASTIC SERIES (MI) Promegaloblast A non motile cell about to microns in diameter The cytoplasmic rim is thick and well defined This cell shows marked pleomorphism The cytoplasın appears completely free of granules and other structures although there may be a group of small tounded mitochondria adherent to one side of the nucleus when this occurs the nuclear membrane is absent at the point of contact This membrane is otherwise well defined and thin The nucleus is filled with fine dust like particles which are more closely packed and appear much brighter than those of the leucoblastic cells Also the nuclear particles show some small areas of condensation which appear as brighter granules The nucleoli two or three in number are out lined by a ring of such condensation (N) Megaloblast Very variable in size and shape There is a thick cytoplasmic ring and clear cytoplasm without mitochondria The nucleus may appear lobed and shows areas of localısed con densation (P) Early Normoblast The nuclear structure 13 the same as in the megaloblast and the nucleus is of much the same size The cytoplasmic ring is not well marked and the cytoplasm is scanty and may contain a few dust like mitochondria The cell 1s easily recognised by its nuclear structure (Q) Late Normoblast Seven to 8 microns in diameter with a thick refractile rim (R) Normocy te thick cytoplastic si Same appearance Cell Propagation Mitosis \\hule mitotic figures are easily recognisable it must be remembered that the whole process is a continuous one and that the early changes in the nucleus between the interphase and the prophase are very easily overlooked These changes may completely alter the apparent structure of the nucleus Th. 1 ·- ·THE TECHNIQUE OF STERNAL PUNCTURE 85 to 40 microns in diameter The nucleus usually appears as a group of scparate lobes, each of which has a definite nuclear membrane, and is filled with fine dust like particles The cytoplasm has no definite fim and is filled with sinall moderately bright granules (1) Platelets "These appear most as small circles of light, 2 to 5 microns in diameter The larger number appear to be empty, but some contain five or six small bright granules, which show active Brownian movement, apparently bouncing from side to side of the cell (4) ERYTHROBLASTIC SERIES (M) Promegaloblast A non-motile cell about 10 microns in diameter The cytoplasmic rim is thick and well defined This cell shows marked pleomorphism The cytoplasm appears completely free of granules and other structures although there may be a group of small rounded mitochondria adherent to one side of the nucleus , when this occurs, the nuclear membrane 13 absent at the point of contact This membrane is otherwise well defined and thin The nucleus is filled with fine dust like particles which are more closely packed and appear much brighter than those of the leucoblastic cells Also the nuclear particles show some small areas of condensation which appear as brighter granules The nucleoli, two or three in number, are outlined by a ring of such condensation (N) Megaloblast Very variable in size and shape There is a thick cytoplasmic ring and clear cytoplasm without mitochondria The nucleus may appear lobed and shows arcas of localised condensation (T) Early Normoblast The nuclear structure is the same as in the megaloblast, and the nucleus is of much the same size The cytoplasmic ring is not well marked, and the cytoplasm is scanty and may contain a few dust like mitochondria The cell 19 casily recognised by its nuclear structure (Q) Late Mormoblast Seven to 8 microns in diameter, with a thick refractile rim (R) Normocyte thick cytoplasmic te same appearance Cell Propagation. Mitosis While mitotic figures are easily recognisable, it must be remembered that the whole process is a continuous one, and that the carly changes in the nucleus, betucen the interphase and the prophase, are very casily overlooked These changes may completely alter the apparent structure of the nucleus T1 11 .

·86 STERNAL PUNCTURE and cause some confusion as to the actual nature of the cell The same remarks apply to the final transition from the telophase to the interphase, except that the presence of two daughter cells, lying in apposition, should give a clue to the real condition Failure to appreciate these changes, especially in histological material where there is much cell shrinkage, has led to much of the confusion which has existed over the morphological characters of blood cells and their apparent relationships The adient of sternal puncture has made it possible to study these changes much more closely, and they are illustrated on Plate 14 The cells depicted here are promonocytes from a case of monocytic leukæmia Care has been taken to choose typical figures such as will be seen in normal hæmopoiesis One of the characteristics of a leukaemia is, of course, the presence of atypical mitoses, tn- and even tetrapolar figures can be seen In the resting cell (A, Plate 14) the nucleus is rounded and the chromatin shows a fine, rather itregular reticulation The cytoplasm has a ground glass appearance In the earliest stage of the prophase the pattern of the nucleus becomes more distinct owing to the disappearance of small anastomosing links, leaving the permanent chromatic elements of the chromosomes, the chromonema (B, Plate 14) It is at this stage that the greatest care is required in labelling a cell, a lymphoblast in this stage of development might casily be mistaken for a myeloblast Some authors have described such changes in monocytes, and used them to suggest that the cell was derived from a lymphocyte In the later stage of the prophase (C, Plate 14) the chromosomes are beginning to appear as separate entities Each consists of two chromonemata lying parallel and fixed in an achromatic matrix During the metaphase this matrix stains intensely and the internal structure of the chromosoine is no longer visible "The arrangement of the chromosomes in the metaphase appears to be constant for all the cells of the hæmopoietic tissue The long chromosomes are arranged radially at the periphery, and the short ones lie irregularly in the centre (E, Plate 14) In the anaphase, the chromanema from each chromosome move to opposite poles so that each daughter nucleus will have a representative part of the parent chromosome The anaphase is shown in Fig F, Plate 14 In the telophase the matrix of each daughter nucleus becomes achromatic again and the chromosome structure is again visible (G, Plate 14) Further changes in the new nuclei are the same as in the prophase, only occurring in the reverse order (H, Plate 14)

·PLATE 14
A
В
D
E
H
VITOTIC DIDX 2000)
(See p 83 )

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·THE TECHNIQUE OF STERNAL PUNCTURE 87 The cytoplasm divides by furrowing It undergoes quite definite changes during the nuclear division, changing from a fine homogeneous structure to a mass of fine interoven threads (Plate 14). The cytoplasm of dividing erythroblasts and normoblasts appears to be granular rather than thread-like. REFERENCES Anary 10 Clin Mied, 1943. XXVII, 1246. WILITBY, L E H, and HYNES, M Path and Bact, 1938, xlvi, 577.

·INDEX Erytbroblasts, 8 basophilie, 8 Erythroleukæmia, 56 Erythronoclasia, 41 Erythropoiesis, atypical, id Ewing's tumour, 30, 35 Gas Gangrene, 41 Gaucher's disease, 33 German measles, 60 Glandular fever, 60 Agranulocytosis, 70 Anama, achrestic, 50 aplastic, 64 and cirrhosis of iner, 49 and dibothriophyllura latum, 49 dimorphic, 53 dyshæmopoietic, and gastric carcinoma, 50 hæmolytic, 40 infectie, 45 poisons, 42 hæmorrhagic, 32 idiopathic hypochromsc, 51 response to treatment, 5% and intestinal disease, 50 iron deficiency, 51 Lederer 3, 43 leuco erythroblastic, 36 in Hodgkin's disease, 35 with mastow metastases, 36 acrocytic, 50 megalocytic of pregnancy, 54 nutntional of infancy, 52 perscous, 44 hemocytoblasts in, 45 megaloblasts in, 44 metamyelocytes in, 6, 45 response to treatment, 46 and pregnancy, 5+ refractory, 64 szckle-cell, 43 tonic, 43 tropical nutritional, 49 and vitamin C, 52 Aplassa of marrow, 63 Hæmocytoblasts. 3 perrucious anzmia, 45 Hæmogram, Hæmohsstroblasts, 3 Hæmophilia, 40 Hodgkin's disease, 34 Hypoplasia of marrow, 63 Infectise Diseases, 59 Jaundice, Acholuric, 421 Kata Azar, 76 Leucoblastosis, acute, 22 Leukæmisa, 15 acute, 21 atypical, 22 chronic aleukamic lymphate, 20 lymphatic, 19 maitoses in, 86 monocytic, 20 chronic mycloid, 15 hæmohistioblasts , 3 polymorphs 1a, 6 Leukamord reaction, 22 Laer cirrhosis, 49 Lymphadenoma, 34 Lymphadenosis, spleruc, 22 Lymphoblast, 6, 84 Lymphocytes, 6, 84 13 nickets, 6 Macro-normoblasts, 9 Malaria +2,77 Miegalary oblasts, 7 Miegakaryocytes, 7, 84 Banti's syndrome, 53 Bartonella fever, 40 Benzol poisoning, 67 Blackwater fever, 42 Chloroma, 32 Dysmorphobaryocytes, 35 Erythrama, 51 Erythroblastoma, 32 ·DES $9 Miegaloblasts, 9.85 Para-frythroblasts, 57 in Bartonella ferer, 40 Plasma cells, bapak, 8 in German measles, 60 in pernscous animia, +5 in glandular feser, 67 Megalocytes, 9 Plasmoblasts, 7 Mctamyelocytes, 5 P'latcicts, 85 in pemscious attemia, S. 45.84 Pneumonia, 60 Metastases in marron, 35 Poisons, 42, 67 fitoses, 32, 86 Polymorphs, 6, 84 atypical, 46, 86 Premyelocytes, + 84 45 leukerma, 12, 86 Pro-erythroblasts & in pernicious anæmia, 46 Promegaloblasts 9,85 m monocytic leukæmia, 19 in permucous ahamsa, 46 Monoblası, 6, 21 Promonocytes, 6, 21 Monoblastoma, 26 Protozoal diseases, y Monocytes, 6 Pseudo leukitmsa, medullaev, 22 Veloblastoma, 31 Purpura, 7 Myeloblasts, 4.83 in chronse myeloid leukæmsa, Reticaforytes, 9 26 sn acholuntc jaundze 42 in dropathic hypochromic 183 eloczes, 5.84 anazmia, $2 10 Chrome myeloid leukemia, 26 in pecauciu (mis, 46 Iselogram, starnung of, 82 Reticulo-endothelrosis 32 In agranulocytosis, 75 Retrculosis, follicular, 33 un aplastic anxma, 65, 66, 68 medullary, 31 Is erythrayna, 58 sinus, 33 in plandulst fever, 61, 62 Rockets, 6 in hitmolytic anasja, 40 Ricdes cells, in bärnorrhagic anatma 38 in daşathic hypochromic Scarlatina, 60 animi, $ Scurry, 52 in Kala Azar, 77 Spherocytosis, 42 malarsa, 28 Sprue, 49 normal, 33 Sicatorrhora, 49 in percous anema, 48 Technique. 59 in thrombocytopenta Thrombocytopenia 63, 72 Myclomata, 30 Mycloscler313, 29 Thyrotoxicosis, 53 Vytlosis, 15 Thyross and anxmi2, 53 Trephinag semal, 19, 81 mute slenkamuc, 18 Tumours 24 chronic erythramic. 56 Vyredema, 53 metastaue, 35 Tusk cells, 7 Mlemann-Pich disease, 34 in German ancastes ho Tarmoblasts, 8, 85 Typhoid fever 70 La sdopathic hypochromic Vital stajaing, 81 2m2, 51 Viamin C 354 anoma 32 MID LE Gue&r S41835 ** Y * Fari LID 10nto AXO YOTEGI

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