Complete Text (Part 16)

showing radial arrangement of chromatin and as large or larger than a normal erythrocyte. (b) Intermediates — Nucleated, larger than 201 normoblasts. Clinically not important. (c) Normoblasts — Nuclei: 1. Dense and pyc- notic — old (mature — Howell). 2. Clear and radial — young (immature — Howell ). Bunting's view : Erythrocytes enter blood stream without nuclei. Loss due to Karyor- rhexis (a) Karyolysis, (b) Extrusion. ■♦ Karyolysis Extrusion Although extrusion actually occurs, it is thought that this is not the normal mode. 3. Consideration of normal erythrocytes. (a) Number. The average count stays con- stantly throughout adult life. It varies from 4,500,000 to 6,000,000. A deviation of half a million is of no pathological significance, unless associated with a change in the color index. At birth the count is about 6,000,000. After the first few weeks it falls to 4,000,000. After this at about the tenth year, or at pu- berty, it reaches 5,000,000. After 35 the count decreases, and at 60 it is about 4,500,000. In robust plethoric individ- 202 iials the count may be around 0,000,000 and mean nothing. (b) Functions. 1. Internal respiration. 2. Lipoid carriers. 3. Bile pigment (iron). (c) Life history. There exists a balance between de- struction and formation. The normal demand upon the marrow causes the outpouring of no abnormal forms, 4, Pathological considerations. Pathological changes of very much impor- tance concern chiefly: 1. Variations in the number. 2. Variations in the hemoglobin content. 3. Abnormalities in size and form. 4. Abnormal red cells in the peripheral blood. 5. Abnormal staining reactions. G. Vital staining reactions. 7. Altered resistance of erythrocytes. (1) Variations in the number of R. B. C. (a) Increased — Polycythaemia, Erythremia. Physiological. 1. Early infancy. 2. Following vigorous exercise. 3. After hot or cold baths. 4. High altitudes. Pathological. 1. Concentration of the blood-excessive fluid output, or decreased fluid intake. 2. Prolonged vasoconstriction. 3. Conditions of chronic dyspnoea. 4. True polychthaemia (excessive forma- 203 lion). Kesistimce o1i cells not in creased by test-tube method. (bj Decreased counts. OUgocythaemia. 1. Insufficient formation — aplasia, toxic states, etc. 2. Excessive destruction. 3. Hydraemia. 4. Actual blood loss. Upper and lower limits of counts. Higher limits— up to 9,000,000 (Osier found 11,000,0000). Average from 1,500,000 to 5,000,000. Lower limits — 5,000,000 to 100,000 (Osier). Average for pernicious anaemia — 1,000,- 000 to 2,000,000. Average for secondary anaemia — well above 2,000,000. (2) Variations in the Hemoglobin content. 1. Reduction proportionate to R. B. C. 2. Good R. B. C. count, but tremendous hemo- globin reduction. a. Chlorosis, b. Many chronic anaemias. Bone marrow insufficiency. Further discussion of the "Color Index" : It is important to remember that the color index is wholly independent of variations in blood volume, vasomotor effects and tlie like. It really gives a clear insight into conditions of the bone marrow. Types : (a) Normal — .8 to 1. (b) Lower than 1 — Chlorosis, cancer, nephritis, hemorrhages. 204 (c) Higlier iliaii 1— rernicions auaeniia, anaemias of childhood, hemolytic anaemias with jaundice. (3) Abnormalities in shape and size. 1. Anisocj'tosis — Variation in size. Not a normal event. Terminology : a. Microcytes, 1-6 microns. b. Normoc^^tes, 6-9 microns. (Secondary anaemia.) c. Macrocytes, 9-12 microns. d. Megalocytes, 12-16 microns. e. Gigantocytes, 16-20 microns. > (Pernicious anaemia.) (a) Microcytes — Expression of budding process, poor ancestry, small marrow cells. Not an expression of ceUular youth. (bj Normal erythrocj^tes. (c) Macrocytes — Swollen cells, never ter- ribly large. (d) Megalocytes — ■ Characterized by: 1. Size. 2. Rich hemoglobin content. 3. Essentially absent delle. These are really embryonic cells. The}^ occur mainly in Pernicious Anaemia and anaemias of childhood. They appear A\hen demands upon the bone marrow are too great. Their appearance de- pends not upon the severity of the anae- mia, but ui)on the nature and the type of the anaemia. (e) Gigantocytes. 2. Poikilocytosis — Variation in shape. Poikilocytes may be artificially made by 205 pressure or heat. They occur in benign forms of secondary anaemia, but in much larger proportions in Pernicious Anaemia. (4) Abnormal red cells in the circulation. 1. Microblasts. 2. Normoblasts. 3. Intermediates. 4. Megaloblasts. The appearance of these cells denotes severe irritation of the bone marrow. They are found in: 1. Pernicious anaemia. In remissions normoblasts predominate. 2. Oftenest in myeloid leukaemia. 3. Chil- dren's blood in certain obscure anaemias. Embryonic blood building is reverted to easier in children. (5) Abnormalities in staining. 1. Anisochromia : Various forms including hemoglobinaemic degeneration of Ehrlich. 2. Polychromasia : a. Anaemic degeneration of Ehrlich. b. Polychromatophilic degen- eration of Ehrlich (Gabritschewsky ). Common occurrence : Common in blood- forming organs, embryonic. Occasionally seen in normals. Considered as a coagulation necrosis by Ehrlich and a degeneration. The common view held is that they are youthful cells and their presence shows that regeneration is taking place. Their presence may also mean a degenerative process in a sense that the marrow cannot hold these cells back. They occur in cells subjected to stasis. Their appearance does not necessarily run parallel with the severity of anaemia nor 206 are they necessarily poor in liemoglobin for they occnr in cases with a high color index. !. Basophilic reacting substances in R. B. C. Origin : Xuclear remains. Xnclear substance not chromatin. lrotoplasmic changes. (a) Nuclear particles. (b) Howell Jolly Bodies. One or two in a cell; round, peri- pheral, nuclear stains, common in orthochromatic cells. (c) Chromatin staubschen. End stage of nuclear decay. They are bright red, peripheral, minute dots. (d) Cabot ring bodies. J. Med. Res. 1903. They are bright red or bluish with Ehrlich. Appear in a variety of shapes. Invariably in polychromatic cells. Occur in any anaemia, especially Pernicious Anae- mia, Leukaemias and Lead Poisoning. Never found in blood-forming organs, (S)Q 207 therefore a pathological change. Kep resents especially resistant nuclear re- mains ( nuclear membrane ) . Supports theory of karyolysis. (e) Red basophilia with Giemsa stain. (f ) Schuffner's granules. These can be seen in fresh R. B. C. Occur in Malaria. It is claimed that they are not identical with true baso philia. (g) Punctate Basophilia, common 4'orm. Appear as round or angular specks. They are absent in Ehrlich stain. Chief interest resides in their meaning: Regeneration H), degeneration (?), youth (?). They are not seen in fresh blood. < t Punctate Basophilia Diffuse Basophilia Occurrence: Anaemias and illnesses with anaemia. They are absent in some anaemias, hence not due to anae- mia per se. Uncommon in chlorosis. Uncommon in adult bone marrow. In P. A. not a striking feature. Absent in aplastic blood, but pres- ent in marrow. 208 Coiuinoiily associated with other K. B. C. changes. Tuberculosis, nephritis, gout. They are an essentiallT regenerative phenomena. Designated here : Ditfnse or Punc- tate polvchromasia. (til Vital staining of erythrocytes. Really a post vital method. Methods: 1. Dry method (not used much). 2. Widal-Abrami and Brule. S(dution and stain : Unna's Polychrom. stain 10 -cc XaCl .8% ^ 10 cc Sod. Oxalate 2% 10 cc Draw bloody to 1 in the white pipette and solution to 11. Mix and study. Blood may be collected in a centrifuge tube and then a lilm be made and fixed with heat. Another method using a pipette is dilut- ing the blood with 1/2% Brilliant Cresyl Blue in .8% ]S'aCl. Examine wet. 3. Method of Vaughn. Place a drop of stain upon the ear, make puncture through it and examine Avet. Appearance of cells. Occurrence: 1-2% of cells in normal blood. Bone marrow, all anaemias. 30-10% of cells in the new-born Avithout poly- chromasia. Evidence of youth and regen- eration. Quite different from basophilia according to most. (7) Resistance of the red blood cells (Hamburg- er) 1902. 209 Method of making hypotonic solutions: Burette method, usino- H,0 and 1% NaCl. % strength Desired. 1% NaCl. H^O. Volume. .75 % 7.5 cc. 2.5 cc. 10 cc. .7 7.0 3.0 . 10 .65 6.5 3.5 10 .6 6.0 4.0 10 .55 5.5 4.5 10 .5 5.0 5.0 10 .45 4.5 5.5 10 .4 4.0 6.0 10 .35 3.5 6.5 10 .3 3.0 7.0 10 .25 2.5 7.5 10 Q 2.0 8.0 10 Use .1 to .3 cc . of was hed R. B. ( \ in each dilution. Normal minimal resist ance is .47 . Maximal resist- a nee is .3. z Variations in resistance : 1. Decreased in hemolytic anaemias. 2. Increased resistance in anaemias a^ ith blood poisons. 3. Increased resistance under iron and arsenic therapy. 4. Results in anaemias in general not conclusive. Increased in P. A . and carcinoma. Consideration of the White Blood Cell? , Classification of Normal White Blood CrlJs. A. Polymorphonuclear neutrophiles, P. M. N. B. Polymorphonuclear eosinophiles, P. M. E. C. Polymorphonuclear basophiles, P. M. B. D. Lymphocytes. E. Large mononuclears, F. Transitionals One and the same. A. Polymorphonuclear neutrophiles. 210 T. Description, 1. Size and shape : 10-12 microns, but as high as 15 microns, because they are so easily flat- tened out. 2. Nucleus. As many as five, never less than two lobes. They are joined by fine strands of chro- matin. 3. Protoplasm. Granular, takes a slightly acid stain. 4. Granules. Many granules, sometimes overlapping nucleus. In the same cell the granules are apt to be of the same size. 5. Function. Active scavengers of the body. II. Origin of cell. Strictly from the bone marrow and in adults from the flat bones only, although in disease the long bones may also take part. III. Normal numbers and variations. 65-68% of the cells of the blood (in some books per cent given higher). 1,500 per cubic millimeter. IV. Abnormal. Increased — in any acute infection, partic- ularly in pus formation. Confusing cell- metamyelocyte. B. Polymorphonuclear eosinophile. I. Description. 1. Size. Larger than P. M. N. (12-11 mi- crons). Variations in size^ both large and small. 2. Nucleus. Less multiple division of nucleus. 211 0. Xucleoli absent. 4. Protoplasm slightly acid, full of large grannies ( 1 micron i which do not over- lap nnclens. 5. Fnnction not known. G. Confusing cell-metamyelocvte. ir. Origin of cell. Bone marrow. III. Normal numbers. 2-4% (average 21/2%). IV. Abnormal. Diagnostic in several conditions. 1. Skin diseases. l\ Parasitic infections (especially intesti- nal). 3. Blood diseases : a. Leukaemias — enormous numbers. b. Increase in other anaemias (good' omen). 4. Anaphylactic plienomena in general. 5. Scarlet fever. Decreased : 1. Frank leucocytosis, "'septic factor/' 2. Poor bone marrow, regeneration (aplastic anaemias ) . 3. Conditions with lymphocytic increase. C. Polymorphonuclear basophiles. I. Description of cell. About tlie same as P. M. E., except that the granules take basic stain, scattered throughout the cell and vary in size within the same cell. Soluble in water. Function — nothing known. II. Origin — bone marroAv. III. Xumber— 1/2 to 1%. IV. Xo increase except in myeloid leukaemias. 212 D. Lymphocytes. I. Description of cell. Size and shape: 7 to 10 microns (large in children). Nucleus — ^picnotic. Nucleoli — 1 or 2, never more. Character- istically possessing good surrounding mem- brane. Protoplasm — scant, in fresh looks granu- lar. With Komanowski stain has greenish blue tint and edge looks thick. Few granules varying in size and shape, grouped toward the periphery, in about ^ of cells. Basic stain. Never amoeboid. Function little known. (Do not give indol blue reaction.) Hinted that they play important immunity role. (Experiments in cancer and tuberculosis.) II. Origin of cell. From lymphatic glands, spleen, etc. Al- ways of lymphatic origin, never bone mar- row. III. Normal numbers. 18 to 30% (average 25%). IV. Abnormal. Increased : 1. Lymphoid leucaemia. 2. Typhoid, malaria, pertussis, tuberculosis, syphilis. 3. Marked vagus stimulation. 4. Disturbance of endocrine glands. Decreased : 1. Pronounced leucocytosis. 2. Extreme disease of lymphoid system. E. Large mononuclears, 213 J'"*. Trausitiouals, One and the same cell. The origin and the nature of the granula- tion of these cells are the cause of much dis- cussion. Classed as non-granular cell they are really granular. I. Description. 1. Size — largest cells, 12 to 25 microns. 2. Xuclei — pale, compact, leptochromatic. ]N^o clearly defined membrane. 3. Protoplasm — basic, well-defined reticula- i tion. 4. Nucleoli — without staining no nucleoli are seen, but with vital staining as many as three may be seen. 5. Granulation — peculiar characteristic type. Xo azure or fuchsin granules. II. Origin. Probably myeloid. There are several points in favor of this view : (a) They give oxidase reaction. (b) They tend to increase in conditions where bone-marrow is stimulated. III. Xormal numbers and variations. 6-8% when taken together (1-3% large mononuclears, 3-1% transitionalsj. Increase : In any case of myeloid stimulation, (Drug intoxication, especially salvarsan.) Three common views as to origin : 1. Young lymphocytes. 2. Endothelial cells. 3. Myeloid. Function — little known; increased espe- cially in malaria. Abnormal White Blood Cells. (Xever in peripheral blood normally.) 214 A. Myeloblast — parent cell of all myeloid white blood cells. Size — 12-15 microns (great variation). Nucleus — large, lepto chromatic. Stain — cytoplasm stains a purple or light blue; nucleus stains a lighter blue. Protoplasm — plentiful, often thicker on one side of the cell than on the other side. Nucleoli — numerous (3-6), closely grouped, easily seen, but with no clearly defined nucleo- lar membrane. Granules — non-granular cell. Function — gives rise to other cells. Diiferentiation from lymphocytes : 1. Usually larger in size. 2. Nucleus doesn't stain as intense a blue, i. e., not picnotic. 3. Protoplasm has a reddish tinge. Lj'mpho- cyte, greenish with clear perinuclear zone. 4. Has three or more nucleoli. 5. They give oxidas!e reaction. (). Where myeloblasts occur, various stages to myelocytes usually occur also. ^ B. Myelocytes — three varieties. a. Neutrophilic myelocyte. b. Basophilic myelocyte. c. Eosinophilic myelocyte. Myelocytes are the same in size, shape and staining reactions as the myeloblasts. They differ in having distinct types of granulation. In neutrophilic and eosinophilic myeloc^'tes^ 215 the youth of the cell is shown by the differ- euces ill size and staining reaction. Occurrence of Myelocytes : 1. Never normally. 2. Myeloid leukemia (more acute the disease, more numerous the myeloblasts — showing higher origin). 3. Marked hj^per-leukocytosis. 4. Bone marrow exhaustion (long standing anaemias). 5. Pseudo-leukaemia of infants. In general, when there is a marked num- ber of myelocytes it may be regarded as mye- loid leukaemia until proved to the contrary. Differentiated from : 1. L^anphocytes : a. Character of nuclei. b. Perinuclear zone (clear zone in lympho- cyte). c. Number of nucleoli. d. Protoi^lasm. 2. Large Mononuclears and Transitionals. a. Protoplasm more reticulated in L. M. b. Difference in granulation. (Granules of L. M. do not stain with Ehrlich.) Function — give rise to P. M. N., P. M. E. and P. M. B. in the peripheral blood. Promyelocytes are the intermediate cells be- tween the myeloblast and the myelocytes. Metamyelocytes are intermediate cells be- 216 tween the myelocytes and the normal P. M. N., P. M. E. and P. M. B. C. Abnormal myeloblasts — ''irritation cells of Turk." Size — large. Protoplasm — \evj basic. 3-10 yacuoles. 3-5 nucleoli. Multilobular nucleus. Stain as do myeloblasts. ]Sion-gTanular. Xo perinuclear zone. Xo characteristic presence or absence in any disease. Genesis of AY. B. C. Afye^ohZa^si^ Af'C-r-a :^ye /^•^•^•z ^i _Zr>^;,rz4r/«-<5r^ y^r-^^Z, Other Abnormal Cells. 1. Pathological lymphocyte — Riecler cells. 2. Irritation forms — Turk cells, Pathological mononuclears. 3. Plasma cells. 4. Megakaryocytes. 217 Pathological lympliocytes — Eiecler cells. Large cells — often resemble myeloblasts. Entirely different from normally occnrriug hTnphocytes. Xncleus trachychromatic. Characteristics are : Abnormal lobing, nuclei as a rule stain poorly. Usually lymphocytic in type with Giemsa and Romanowsky. Protoplasm sparse and may seem absent; often broad azure granules and shows basic staining. Well defined, clear perinuclear zone and vacuoles. Reticulated. Cells give no guiac, nor indol blue reaction. One sees numerous transitional forms to normal, large and small lymphocytes^, but never to transitionals or large mononuclears. Occurrence — Acute leukemia and in the aleukemic state. Chronic leukemia, uncom- mon. Basedows ; occasionally in infectious diseases. Cells are easily broken up and, therefore, give rise to smudges. Irritation forms of Turk — Pathological mye- loblasts. (See above.) Large cells with round or oval nucleus, leptochromatic. Protoplasm abundant, basic, vacuolated (3-8-10, more than lymj)hocyte). Azure granules absent, protoplasm is red- brown with Ehrlich. No perinuclear zone. Indol blue reaction etc. Occurrence : Leucocytosis : fat necrosis. Acute myeloid leukemia. Lead poisoning — • not uncommon. Xever normallv. 218 ?). Plasma cells. Occur in the blood very rarely, best dis- missed. Cells of lymphatic nature, large, eccentric nuclei with spoke-like structure and unusual- ly thick strands of chromatin. Protoplasm intensely basic and perinuclear zone marked. 4. Megakaryocyte. Giant cell of the blood. Occur very seldom : large, bizzare-shaped nucleus, many nucleoli. Inner granular cell surrounding nucleus and outer basic zone. Bone marrow — m^^eloblast — megakaryo- cyte. Give rise to platelets. Evidences of age and youth in W. B. C. 1. Evidence of youth is basic reticulated proto- plasm. (Seen best in myeloblasts, also in young P. M. N.'s.) '1. Presence of basophilic granules along with neutro or eosinophilic. All granules in early age possess a basic component. Ehrlich first called attention to this. (Larger the granules the younger the cell.) .3. Young cells usually have easily demonstrable nucleoli. They are often not visible with ordi- nary staining methods. (The younger rhe cell the easier it is to see nucleoli.) 4. Young cells have characteristic round nuclei. (They are seen in myeloblasts and young lym- phocytes.) Oval nucleus — sign i^ell is older. Nuclear polymorphism is sure evidence of age. Open network in young cells. 219 o. The size of the cell is not necessarily an evi- dence of youth, though it is often so. 6. Staining characteristics of the nucleus : Young cells have paler nucleif?). Young cells show network structure. Older cells show picnosis. Review of nuiin differences between myeloid and lymphoid