QJnrtrell Uninctaitg Slihrarg 
 
 3tl|ara, SJem |Jork 
 
 BOUGHT WITH THE INCOME OF THE 
 
 SAGE ENDOWMENT FUND 
 
 THE GIFT OF 
 
 HENRY W. SAGE 
 
 1891 
 
.»-««-« Corna " University Library 
 arV 18893 
 
 Clinical examination of the blood and it 
 
 3 1824 ""SB™""™*' 
 
 olin.anx 
 
B Cornell University 
 9 Library 
 
 The original of this book is in 
 the Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924031242161 
 
CLINICAL EXAMINATION OF THE 
 BLOOD AND ITS TECHNIQUE. 
 
CLINICAL EXAMINATION 
 
 OF THE BLOOD 
 
 AND ITS TECHNIQUE. 
 
 A MANUAL FOR STUDENTS AND 
 PRACTITIONERS. 
 
 BY 
 
 Professor A. PAPPENHEIM, 
 
 Berlin, 
 
 Translated and adapted from the German by 
 R. DONALDSON, 
 
 • M.A., M.B., Ch.B., F.R.C.S. Ed , D.P.H. 
 
 Pathologist Royal Berks Hospital, Reading Etc. ; Late Assistant 
 
 Pathologist Royal Infirmary, Bristol, ami Dentonst) alor of 
 
 Pathology, Universities of Bristol and Sheffield. 
 
 NEW YORK: 
 WILLIAM WOOD AND COMPANY. 
 
 MDCCccxrv. 
 
PRINTED IN ENGLAND 
 BY 
 JOHN WRIGHT AND SONS LTD., 
 PRINTERS AND PUBLISHERS. BRISTOL. 
 
TRANSLATOR'S PREFACE. 
 
 The clinical examination of the blood should be 
 carried out as a routine much more frequently 
 than is generally the case in practice. Indeed, 
 while every bther system is carefully gone over 
 time and again, the blood is often thought of only 
 as a last resort by the practitioner. Even then 
 the technique employed is not all that might be 
 desired, and the significance of what is found is 
 not always properly understood. 
 
 In order to aid the practitioner, therefore, 
 Professor Pappenheim has written this small 
 book, which he expressly wishes to be regarded 
 merely as a guide to the clinical examination of 
 the blood. 
 
 A simple technique is described, and the main 
 facts that every one ought to be familiar with 
 are brought together in a condensed form, while 
 everything of a controversial nature is omitted. 
 The English edition has been enriched by the 
 insertion of a few illustrations showing Professor 
 Pappenheim's apparatus and the chief cell forms 
 likely to be met with. 
 
vi TRANSLATOR'S PREFACE 
 
 The cell types have been taken from his " Atlas 
 der menschlichen Blutzellen," a book which con- 
 tains a wealth of illustration and material. Since 
 the German edition made its appearance, Professor 
 Pappenheim has altered his technique, and the 
 description given of this has been based on 
 reprints which Professor Pappenheim kindly 
 sent me, so that the book might be completely 
 up to date. 
 
 Robert Donaldson. 
 
 Reading, 
 
 May, 1914. 
 
PREFACE TO THE GERMAN EDITION. 
 
 This small book first appeared as a chapter in 
 Carl Neuberg's " Handbuch der Ausscheidungen 
 und Korperfiussigkeiten," published by Julius 
 Springer in 191 1. It was written with the idea 
 of furnishing a very elementary guide to the most 
 important and essential methods of blood exam- 
 ination regarded from the standpoint of the 
 chemist and of the pharmaceutist Soon after 
 its appearance, however, I received numerous 
 requests to publish the chapter in book form. 
 As a matter of fact no small text-book of this 
 kind had hitherto been published. Moreover, a 
 chapter, dealing almost entirely with microscopy 
 and cytology, seemed to a certain extent out of 
 place in what was otherwise essentially a treatise 
 on Chemical Physiology. The subject-matter of 
 this chapter, in fact, belongs to quite a different 
 category from the rest of the contents. For 
 these reasons the publisher resolved to comply 
 with the requests for a separate issue. 
 
 This little book differs from all others that 
 treat of the blood in so far as it deals only with 
 what is absolutely essential and of first import- 
 
viii PREFACE TO THE GERMAN EDITION 
 
 ance in clinical methods of blood examination. 
 All less important, and all merely chemical or 
 physical methods of examination have been 
 purposely omitted ; such, for example, as 
 alkalinity, specific gravity, volumetry, dried 
 residue, coagulation time, viscosity, etc. 
 
 Further, of the three cardinal lines of blood- 
 investigation (viz., staining, counting of cells, 
 and haemoglobin-estimation), only those methods 
 have been described which have been definitely 
 .proved of value. AH padding with less useful 
 methods has been purposely omitted. 
 
 Coupled with the description of methods, the 
 respective features of normal blood have been 
 briefly discussed. 
 
 In addition, the most important facts in the 
 semiology, necessary for a proper understanding 
 of pathological conditions, have been dealt with. 
 
 In order to appreciate correctly the cyto- 
 morpholdgical appearances, a series of good 
 illustrations should be consulted. 
 
 A. Pappenheim. 
 
 Wangerooge, 
 August, 1911. 
 
CONTENTS. 
 
 CHAPTER I.— THE BLOOD FILM. 
 
 Method and Technique of Staining . . i 
 
 Microscopic Examination of the Stained Blood 
 
 Film . . . . . .6 
 
 Semiology and Differential Diagnosis of the Most 
 Important Blood Changes as Seen in Stained 
 Films . ... 27 
 
 CHAPTER U.—HMMOCYTOMETRY ■ OR THE 
 ENUMERATION OF THE BLOOD CORPUSCLES. 
 
 Method and Technique . . . -43 
 
 Relative Proportion of Cells in Normal Blood . 56 
 Pathological Variations in Number, and their 
 
 Diagnostic Significance . . . .56 
 
 CHAPTER III.—HJEM0GL0B1N0METRY: OR A THE 
 ESTIMATION OF HAEMOGLOBIN. 
 
 Method and Technique . . . .66 
 
 Semiology . . . • • -69 
 
 The Colour Index . . . . . 71 
 
5-7 
 
 12-13 
 
 1 4-1 6. 
 
 22-30, 
 31-34' 
 
 PLATE 2. 
 
 -I^ymphoidocytes. 
 
 -Iyeucoblasts — basophilic cytoplasm with scanty azur substance, 
 — Microleucoblast with slightly oxyphilic cytoplasm. 
 — Myelocyte. 
 — Metamyelocyte. 
 Neutrophil (polymorphonuclear). 
 Eosinophils (with bisegmented nucleus). 
 
 Mast-cells. Note small rim of cytoplasm and coarse basophil 
 granules. 
 — Typical lymphocytes. Note narrow rim of cytoplasm with a few 
 azur points. 
 Older forms of lymphocyte. 
 , — Typical large monocytes with fine azur points. No neutrophil or 
 other true granules present.' Compare with leucoblast, which 
 has a nucleus like that of, a myelocyte and possesses coarse or 
 myeloid azur points. 
 
PLATE I. 
 
 m 
 
 3 
 
 ^ ... ' - 
 
 * 
 
 
 .?*"** * 
 
 /^ 
 
 /a 
 
 /o 
 
 /<t 
 
 •:.■ "%r 
 
 /£ 
 
 & m * 
 
 /s 
 
 20 
 
 • 9 
 
 z 7 
 
 y 
 
 *¥* 
 
 jy 
 
 * 
 
 ^ 
 
 i-.? 
 
 j'-if 
 
 .w 
 
PLATE II. 
 
 35. — Microcyte. 
 
 36. — Dwarf normoblast — microblast. 
 37. — Erythrocyte (orthochromatic). 
 
 3a. — Erythrocyte (polychromatophiiic with basophil points; . 
 39. — Erythrocyte showing punctate basophilia. 
 40. — Erythrocyte showing a " Jolly " body. 
 41-43. — Normoblasts. 
 44. — Gigantoeyte. 
 45. — Megaloblast (polychromatic;. 
 46. — Gigantoblasi. 
 
PLA TE II. 
 
 • • ft 
 
 26 
 
 27 
 
 28 
 
 23 
 
 ® 
 
 30 
 
 3/ 
 
 32 
 
 
 
 Jtf 
 
 J^ 
 
 J5 
 
 36 
 
 37 
 
 Vi-;..,-.- 
 
 «<---* ■ 
 
 39 
 
 o ^ 
 
 ^o 
 
 #/ 
 
 4-2 
 
 4-3 
 
 f-4- 
 
 4-6 
 
THE CLINICAL EXAMINATION 
 OF THE BLOOD. 
 
 Chapter I. 
 THE BLOOD FILM. 
 
 METHOD AND TECHNIQUE OF 
 STAINING. 
 
 THE microscopic examination of stained blood 
 films implies a knowledge of three preliminary 
 steps, viz. : — (i) How to spread the film ; (2) How to 
 fix the film ; (3) How to stain the film. 
 
 I.— HOW TO MAKE A BLOOD SMEAR. 
 
 On Slides. — To make a blood film on an ordinary 
 slide, proceed as follows : A medium-sized drop of 
 blood, drawn as a rule from the finger, is removed on 
 one epd of a clean slide. The latter, with the drop 
 of blood uppermost, is then laid on a firm flat surface. 
 Next, a second perfectly clean slide is placed with the 
 narrow edge touching the first slide, and just in front 
 of the drop of blood, so as to form with the first slide 
 an acute angle (not more than 45 ). The drop of 
 blood now lies in the acute angle formed by the two 
 
2 CLINICAL EXAMINATION OF THE BLOOD 
 
 slides, i.e., between the edge of the inclined slide and 
 the end of the horizontal one. Since the second slide 
 is placed just in front of and touching the drop of 
 blood, it follows that the drop will spread out along 
 the narrow edge of the second slide in the angle 
 between the two. The inclined slide is then drawn 
 firmly and evenly along the surface of the horizontal 
 slide to its opposite extremity. In this way the drop 
 of blood is drawn out over the slide in the form of a 
 thin smear. All crushing and undue pressure can 
 thus be avoided. 
 
 On Cover Glasses. — For this purpose, a pair of 
 simple forceps such as Ehrlich's, without the catch, 
 is necessary. The inner surface of the blades is 
 smooth and flat. A series of cover-glasses, well 
 cleansed in alcohol and ether, are lifted by means of 
 the forceps and laid out near the patient on a sheet 
 of clean white note-paper. A cover-slip is then taken 
 up with the forceps and brought in contact with the 
 drop of blood as it issues from the finger. This cover- 
 slip is now allowed to fall on to a second cover-glass, 
 in such a way that one-half of one cover-glass 
 coincides with the opposite half of the other. The 
 drop of blood then spreads out between the two by 
 capillarity, so that one-half of each cover-glass is 
 covered. When this has been accomplished, the 
 projecting edge of one of the cover-glasses is seized 
 with the forceps, and the two cover-slips, still stuck 
 together, are lifted up. They are then transferred 
 to the left hand and the forceps laid down. The 
 
THE BLOOD FILM 3 
 
 projecting edge of the other cover-slip is next seized 
 in the fingers of the right hand, and the two are 
 drawn gently apart. All forcible separation must 
 be avoided. 
 
 II, III.— FIXING AND STAINING. 
 
 The only method which we employ is the so-called 
 May-Giemsa stain, as modified by Pappenheim.* 
 By it fixing and staining are carried out in two stages 
 as follows. Since the stain, which is dissolved in 
 methyl-alcohol, only acts as such in a watery solution, 
 
 * As this stain is panchromatic, all others are rendered 
 unnecessary (such as haematoxylin-eosin, Jenner's methylene 
 blue-eosin, May-Grunwald's methylene-blue-eosin, Pappen- 
 heim's or Ehrlich's triacid, and Pappenheim's methylene- 
 green pyronin). 
 
 The stains in previous use failed to bring out all the 
 detail, were misleading in so far as they gave false impres- 
 sions of genetic relationships, and did not permit the various 
 kinds of cell now known, to be distinguished. Our method, 
 on the other hand, brings out clearly all that has hitherto 
 been known of the morphology of blood-cells, while at the 
 same time it combines all the merits of previous stains 
 without any of their drawbacks. Hence it may be regarded 
 as a universal stain. It is true that, by this method, the 
 neutrophil granules do not come out as sharply or distinctly 
 as with the triacid stain, nor are the eosinophil granules so 
 brilliant as with Jenner's stain. On the other hand, our 
 stain reveals an entirely new azurophil substance, hitherto 
 unknown. The nuclei are as well denned as if stained 
 by the haematoxylin method, and much better than by any 
 of the older aniline dyes. The basophil cytoplasm, which 
 does not stain by the triacid, comes out as beautifully as 
 by Jenner's or by the methyl-green-pyronin method. 
 
4 CLINICAL EXAMINATION OF THE BLOOD 
 
 we use the alcoholic solution proper merely for the 
 purpose of fixing. The film is first fixed simply by 
 immersion in this solution. The actual staining is 
 not effected till water has been added, i.e., the 
 alcoholic solution is converted into an alcoholic- 
 aqueous one. 
 
 Two stain mixtures are necessary, which can be 
 readily purchased and kept in stock. They are 
 (a) May-Griinwald's eosin-methylene blue dissolved 
 in methyl alcohol (acid eosin and basic methylene 
 blue), and (b) Giemsa's glycerin-alcoholic solution 
 of the Romanowsky stain (containing eosin, methy- 
 lene blue, and methylenazur), known in the trade as 
 Giemsa's " new formula." 
 
 The film is stained first with the May-Griinwald 
 stain and then with the Giemsa. As the Giemsa 
 solution is sold in a concentrated form, it must be 
 freshly diluted each time before use by the addition 
 of water. When about to use the stain, 15 drops of 
 Giemsa's " new formula " are added to 10 c.c. of 
 distilled water. The stain is measured by means of 
 a pipette graduated in cubic centimetres, while the 
 water is measured in a small measure-glass and then 
 poured into a test tube. 
 
 The actual staining is carried out as follows : — 
 
 Fix the dry film by immersing it in an alcoholic 
 solution of May-Griinwald's stain* for 3 minutes. 
 
 *The cover-glasses are held in Cornet's forceps and 
 covered with the solution. Slides are laid horizontally in a 
 flat dish and are flooded with the solution. 
 
THE BLOOD FILM 5 
 
 Stain in the same solution after the addition of an 
 equal quantity of water for i minute. 
 
 Pour off the^cess and, without washing, stain with 
 the freshly prepared Giemsa solution* for 15 minutes. 
 
 Thoroughly wash. 
 
 Dry ; but not over the flame, otherwise the azur 
 stain is destroyed. 
 
 Mount in neutral Canada balsam or Dammar 
 varnish. 
 
 This combines the merits of Giemsa's modification 
 of Romanowsky with the beauty of the May-Griinwald 
 stain, without any of the disadvantages of the latter, 
 such as bad definition of nuclear detail, and absence 
 of azurophilia. 
 
 Nuclear structures and remains of nuclei are stained 
 reddish-violet. 
 
 The protoplasm of the lymphoid cells takes on a 
 beautiful light-blue colour. 
 
 The azur substance of the lymphocytes and the 
 chromatin of the malarial parasite are a bright 
 purplish-red. 
 
 The azur substance of the myeloid cells, as well as 
 the granular centre of the blood platelets, tend to be 
 violet-brown. 
 
 Neutral granules are ill-defined and washed-out 
 looking, varying in colour from brown to brownish-red. 
 
 Eosinophil granules are deep brick-red or brown. 
 
 * Cover-glasses are laid out on a flat dish and the solution 
 is poured over them. The slides remain in the same place 
 as above mentioned. 
 
6 CLINICAL EXAMINATION OF THE BLOOD 
 
 Mast granules show ultramarine with a shade of 
 violet. 
 
 Red blood corpuscles appear a beautiful coppery- 
 red. 
 
 Polychromatic forms are tinted lilac with a pre- 
 ponderance of blue. 
 
 The punctate basophilia of the erythrocytes appears 
 a deep cobalt-blue. 
 
 By this method of staining, azurophil material 
 appears purple-red in colour, chromatin reddish- 
 violet, and basic protoplasm blue. 
 
 THE MICROSCOPIC EXAMINATION OF 
 
 THE STAINED BLOOD-FILM. 
 
 I. NORMAL BLOOD. 
 
 The following morphological elements are met with 
 in normal blood : — (i) Red blbojL corpuscles or erythro- 
 cytes ; (2) Blood -platelets ; (3) Colourless corpuscles 
 or leucocytes. 
 
 1. The Red Blood Corpuscles are round, 
 homogeneous discs of uniform size" and devoid of 
 structure. They stain diffusely a dull orange-red 
 with the acid element of the dye (eosin). 
 
 2. The Blood Platelets occur singly or in 
 clumps, and are the smallest fragments of protoplasm 
 which give the same staining reaction as the cyto 
 plasm of the lymphoid leucocytes. Thus they stain 
 a faint light-blue with the basic part of the dye, and 
 at the same time they exhibit an azur-red substance 
 in their interior. 
 
THE BLOOD FILM 7 
 
 3. Leucocytes. — The following types of leuco- 
 cyte may be distinguished. 
 
 (a). Mononuclear Lymphoid Cells, devoid of 
 true granules — " agranulocytes," — with basic (blue) 
 protoplasm. Not infrequently this latter exhibits a 
 coarse or fine purplish-red (lymphatic) azur-sub- 
 stance in varying amount. These mononuclears are 
 further subdivided into two classes, viz. : — (i) Small 
 lymphocytes ; (ii) Large monocytes. 
 
 (i). Small Lymphocytes. — These are small cells 
 provided with a small nucleus round which, as a rule, 
 there is a narrow or medium-sized rim of cytoplasm. 
 This latter is rarely abundant. The nucleus is more 
 or less round in shape, but may be flattened or 
 notched at one side. It stains deeply, and frequently 
 contains a nucleolus. With its coarse-grained and 
 deeply tinted nuclear network it generally fills the 
 larger part of the cytoplasm. 
 
 (ii). The Large Monocytes. — These are large cells* 
 
 * Normally in the blood of children these cells are also 
 found consisting of a narrow rim of cytoplasm surrounding a 
 round nucleus which contains a nucleolus. These are early 
 immature forms, and are called large lymphocytes or macro- 
 lymphocytes. In the intermediate stages of their develop- 
 ment, the large lymphocytes may possess nuclei which 
 contain no nucleolus and whose cytoplasm is abundant, 
 while the monocytes possess nucleoli and have only a 
 narrow rim of cytoplasm. These cells, which represent 
 intermediate stages in the course of their ontogenetic develop- 
 ment, must sometimes be regarded therefore as large lympho- 
 cytes, and sometimes as monocytes, according to their 
 predominant characteristics. 
 
8 CLINICAL EXAMINATION OF THE BLOOD 
 
 with a big nucleus, which is indented or may show 
 an irregular contour. The nuclear network looks 
 as if it were washed out in places, and appears 
 relatively pale in colour. As a rule, a nucleolus is 
 not present. The nucleus is surrounded by a more 
 or less abundant rim of protoplasm, which is generally 
 faintly basophil. 
 
 (b). POLYNUCLEAR LEUCOCYTES WITH TRUE 
 
 Granules whose cytoplasm is more or less markedly 
 oxyphil (red). These possess a complicated, seg- 
 mented or polymerized nuclear outline. They are 
 subdivided as follows : — 
 
 (i). Neutrophil ^-Leucocytes. — These contain fine 
 granules which are densely packed together in a cell- 
 body which has a definite oxyphil reaction. The 
 granules take on a violet or reddish tint. 
 
 (ii). Eosinophil a-Leucocytes. — They possess large 
 and uniformly round granules, deeply oxyphil 
 (brownish-red) embedded in cytoplasm feebly oxyphil 
 in reaction. 
 
 (iii). Mast Cells. — These are characterized by the 
 presence of coarse, irregular basophil (bluish-violet) 
 granules in a small and almost colourless cell-body. 
 
 The relative percentage of the different kinds of 
 
 leucocyte in an adult is normally as follows : — 
 
 Lymphocytes .. 20-22%} 0/ 
 
 5% J 22-28/0 
 
 Monocytes 
 Neutrophils 
 Eosinophils 
 Mast Cells 
 
 2- 6° 
 
 70-75%) 
 2-4% 72-80% 
 
 o- 1%) 
 
THE BLOOD FILM 9 
 
 In the child, the non-granular lymphocytes are 
 increased at the expense of the polynuclear leucocytes. 
 
 II. PATHOLOGICAL BLOOD. 
 
 THE RED BLOOD CORPUSCLES. 
 
 Morphological changes are met with exclusively 
 in conditions of anaemia (invasion of the blood by the 
 parasite of malaria always excepted), and consequently 
 may be looked upon as evidence of the presence of an 
 anaemic syndrome. The majority of anaemias — 
 those of most importance clinically — depend on a 
 haemolytic intoxication caused by venom or by a 
 living virus. Later, this is coupled with a regenera- 
 tive reaction on the part of the erythroblastic appara- 
 tus of the bone-marrow. Accordingly the morpho- 
 logical changes occurring in erythrocytes fall into 
 two groups, viz. : (i) Degenerative (haemolytic) ; 
 (2) Regenerative (characterized by the presence of 
 young cells). The latest arrivals, viz., the young 
 cell forms, may, on reaching the blood, at once 
 undergo the same toxic degeneration. Hence, not 
 only may degenerated cells and young forms be found 
 side by side in one and the same blood, but not 
 infrequently evidence of both may exist together 
 within one and the same cell (degeneration of the 
 immature forms).* 
 
 *To these combined types belong, for example, poikilo- 
 cytes showing polychromasia or punctate basophilia, poikilo- 
 cytes with nuclear remains, etc. 
 
10 CLINICAL EXAMINATION OF THE BLOOD 
 
 Degenerate forms alone are met with, not only in 
 the so-called aplastic anaemias where active regenera- 
 tion is taking place, but also in anaemias regarded 
 clinically as pseudo-aplastic. 
 
 Regeneration forms are absent entirely from these 
 cases. 
 
 r. Degeneration Forms. 
 
 Size and Shape. — Red blood corpuscles of normal 
 shape show variations in size — anisocytosis. Thus, 
 alongside abnormally large cells — Macrocyies — maybe 
 found unusually small ones — Microcytes. The inter- 
 mediate forms, of normal size, are called Normocytes. 
 
 The various sizes of red blood corpuscle may exhibit 
 irregularity of shape, called poikilocytosis and schisto- 
 cytosis (e.g., they may be club-shaped, pear-shaped, 
 or may appear simply in the form of debris, etc.). 
 
 The Haemoglobin Content. — The individual 
 erythrocytes may be abnormally deficient in Hb, 
 hence the term : hypochromasia of the cells. They 
 stain at best a very pale rose tint. There is 
 generally partial or total absence of Hb from the 
 centre of the erythrocyte, the concavity of which 
 is increased. The remains of the Hb are confined 
 to a narrow strip at the periphery of the cell. 
 According to circumstances this remnant may show 
 a normal, but more likely a diminished, intensity of 
 staining — chlorotic anockromasia* 
 
 * It is still a matter of doubt whether chlorosis of the 
 erythrocytes is due to a primary hypoplasia of the Hb, 
 or is the result of a secondary degeneration. 
 
THE BLOOD FILM n 
 
 In the so-called chloro-anaemia, degenerate forms 
 may also be present. 
 
 On the other hand, the pallor may be diffused 
 throughout the erythrocyte — anaemic hypochromasia, 
 seen, for example, in the simple forms of secondary 
 anaemia. 
 
 Again, the erythrocytes may show an abnormally 
 high hcsmoglobin-content — hyperchromasia of the cells, 
 observed, for instance, in pernicious anaemia. De- 
 generation and malformation of individual ery- 
 throcytes are directly due to the damage sustained 
 by these cells, thus leading to anaemia and oligo- 
 cythaemia. 
 
 Poikilocytosis, when present, is always associated 
 with anisocytosis, though the latter may exist without 
 an attendant poikilocytosis. Hypochromasia and 
 hyperchromasia of the cells may be met with here 
 and there in what are otherwise well-formed normo- 
 cytes in cases of anaemia and anisocytosis. Generally, 
 however, alteration in colour is associated with 
 degeneration and malformation of the cells. Further, 
 in general isocytosis and in failing anaemia, even 
 these microscopic colour changes may be absent. 
 On the other hand, the presence of anisocytosis and 
 poikilocytosis is always associated with a certain 
 degree of hypo- or hyperchromasia. Hence aniso- 
 cytes and poikilocytes may be either hypochromatic, 
 as in the secondary and symptomatic anaemias, or 
 hyperchromatic, as in the so-called pernicious type 
 of secondary anaemia. 
 
12 CLINICAL EXAMINATION OF THE BLOOD 
 
 Degeneration and abnormality of form are always 
 associated with hypo- or hyperchromasia, either of 
 which is an invariable sign of the presence of abnormal 
 cell forms. On the other hand, partial anochromasia 
 is seen in cells of normal shape (e.g., in simple 
 chlorosis), as well as in cells of abnormal shape 
 (e.g., in chloro-ansemia). In other words, chlorosis 
 of the individual cells is seen on microscopic examina- 
 tion only in erythrocytes of normal size and shape. 
 In rare cases, however, macrocytes, microcytes, and 
 poikilocytes may also be present (e.g., in chloro- 
 ansemia). 
 
 2. Early Forms and the Signs of 
 Immaturity. 
 
 (a). The erythrocytes still possess a reddish- violet 
 nucleus or the (violet) reddish vestiges of one. 
 
 Nucleated erythrocytes are called Erythroblasts. 
 These possess a round nucleus showing a kind of 
 radial structure, the " Radkern " or radial nucleus. 
 They are of two kinds, viz., Megaloblasts and Normo- 
 blasts. 
 
 Nucleated normocytes are called Normoblasts and, 
 in the earlier stages of their development, possess a 
 darkly-staining round nucleus with a coarse reticulum 
 arranged more or less radially (the " Radkern ").* 
 
 * As the nucleus grows older, it becomes pycnotic, owing 
 to shrinkage, thickening of its chromatin, and disappearance 
 of its parachromatin. 
 
THE BLOOD FILM 13 
 
 Larger or smaller nucleated erythrocytes with 
 similar nuclear characteristics must be classed as 
 normoblasts. 
 
 Nucleated macrocytes are termed Megaloblasts, 
 and possess a feebly-staining nucleus containing 
 a delicate narrow meshwork arranged in radial 
 fashion. 
 
 Smaller forms with a similar nucleus are also met 
 with. Megaloblasts are usually oligochromatic (and 
 slightly polychromatic), while normoblasts are 
 mostly orthochromatic. 
 
 Normoblasts are found in all varieties of anaemia 
 but not in simple chlorosis. Megaloblasts are only 
 seen in the more severe toxic forms, where the re- 
 generative powers of the bone-marrow are taxed to 
 their utmost. This occurs, not only in the hyper- 
 chromatic pernicious anaemias, but also in the simple 
 secondary forms. 
 
 Nuclear vestiges consist of small, round basophil 
 bodies. They are generally single, owing to their 
 having originated by chromatolysis from pycnotic 
 nuclei. Less frequently there are several, in which 
 case they have arisen through karyorrhexis of Jthe 
 early radial nucleus. As a rule, they are devoid of 
 structure, and generally give the violet-red reaction 
 of chromatin. 
 
 The former — the so-called " Jolly bodies " — are 
 found in all forms of anaemia, the latter only in 
 the severe toxic varieties (myelopathic). They are 
 the intermediate stage, preceding complete disappear 
 
14 CLINICAL EXAMINATION OF THE BLOOD 
 
 ance of the nucleus, and denote the transition from 
 erythroblast to erythrocyte.* 
 
 (b). The cytoplasm of the red blood corpuscles is 
 partially basophil (blue) — owing to the presence of 
 remains of the basophil spongioplasm of the original 
 progenitor of the erythroblast. This parent form was 
 a lymphoid cell entirely devoid of haemoglobin. 
 These basophil vestiges indicate a stage immediately 
 preceding the complete disappearance of the basophil 
 cytoplasm in the course of development from the 
 original lymphoid parent cells with their basic 
 protoplasm (hsemoblasts, proerythroblasts, or ery- 
 throgonia) to the fully formed product, viz., the 
 orthochromatic erythroblasts and erythrocytes con- 
 
 * Intermediate between the cell with multiple nuclear 
 remains (resulting from karyorrhexis) and the erythroblast 
 with its intact nucleus, comes the cell with a young nucleus. 
 The latter shows bud-like projections from its wall, which 
 give it a rosette-like appearance. 
 
 In the same way, pycnosis is a condition intermediate 
 between the fully-formed nucleus and the so-called " Jolly " 
 body. A cell with nuclear remains must therefore be 
 regarded as intermediate between the cell whose nucleus 
 is intact and that from which the nucleus has completely 
 disappeared. 
 
 The so-called " Jolly " body must therefore be looked 
 upon as an intermediate stage occurring in the normal 
 process, which ends in complete disappearance of the nucleus. 
 This is accomplished by a peripheral melting away, and by 
 chromatplysis of the adult pycnotic nucleus. Multiple 
 nuclear remains, on the other hand, are the product of 
 the pathological disappearance of the nucleus. This meta- 
 morphosis is effected by a process of karyorrhexis. 
 
THE BLOOD FILM 15 
 
 taining nothing but haemoglobin and devoid of all 
 basic protoplasm. 
 
 The protoplasm of red blood corpuscles may show 
 a more or less well-marked diffuse, basophilic stain 
 (polychromasia). This is seen in nucleated and in 
 non-nucleated, in normal and abnormal red blood 
 corpuscles. Even punctate basophilia may be present. 
 It is generally found where there is more or less 
 deficiency in the haemoglobin content of the red 
 blood corpuscles attacked, since the space reserved 
 for hssmoglobin is taken up by basic protoplasm.* 
 Polychromasia is one of the simplest signs of anaemia. 
 It appears after the slightest stimulus sufficient to 
 cause regeneration has been applied to the erythro- 
 blastic apparatus of the bone-marrow. To a certain 
 extent it is still within physiological limits. It may 
 occur quite independently as the one and only 
 symptom present, and then only in a few cells and 
 not very well marked. In such a case, where no 
 other symptoms of anaemia are present, it merely 
 signifies an increased output of red blood corpuscles 
 after destruction has occurred as a result of haemor- 
 rhage (e.g., in menstruation). As such, this may 
 be observed especially in the blood of young persons. 
 Of course, in the severest forms of anaemia it is 
 present in a marked degree along with other signs. 
 
 * In regeneration, poverty in Hb is indicated by poly- 
 chromasia. 
 
 In degeneration of the orthochromatic erythrocytes, 
 poverty in Hb is indicated by hypochromasia. 
 
16 CLINICAL EXAMINATION OF THE BLOOD 
 
 The cytoplasm of the red blood corpuscles may 
 show coarse or delicate punctate basophilia (bluish 
 stain).* This consists of a number of circumscribed 
 granules, round, oval, or rod-shaped, scattered 
 throughout the cell. It may be present both in 
 erythrocytes and in erythroblasts — megaloblasts as 
 well as in normoblasts. It may be observed where 
 the nucleus is intact, or where there is only a single 
 vestige of nucleus left ; also in the rare cases where 
 there are more than one vestige, and lastly in poly- 
 chromatic forms. 
 
 In other words, punctate basophilia appears not 
 only in orthochromatic red blood corpuscles, but may 
 be combined with polychromasia. Along with other 
 signs it is met with in the different types of toxic 
 anaemia, and aiso in chloro-ansemia.t In every case 
 it is evidence of pathological regeneration. It is one, 
 and practically almost the only, sign present in cases 
 of chronic lead poisoning, proof that the bone-marrow 
 is being stimulated to activity, and is then a sign of 
 definite pathognomonic value. 
 
 (c). Signs of immaturity of nucleus and cytoplasm 
 may likewise exist together in one and the same cell. 
 For example, red blood corpuscles with a nucleus, or 
 
 * This must be distinguished from multiple nuclear 
 remains, which are reddish in colour. 
 
 ■f By the term chloro-ansemia we understand a com- 
 bination of the signs of anaemia with simple chlorosis of 
 the red blood-cells. 
 
 Chloroleukaemia, on the other hand, means a leuksemic 
 chloromatosis. 
 
THE BLOOD FILM 17 
 
 with the remains of one, may also contain traces 
 of a diffuse or punctate basic protoplasm (i.e., 
 polychromatic cells or erythroblasts with punctate 
 basophilia, polychromatic " Jolly bodies," etc.). 
 
 The appearance in the blood of immature erythro- 
 cytes indicates an effort at regeneration on the part 
 of the bone marrow. This is met with as a result 
 of a pre-existing anaemia. The signs of pathological 
 regeneration occurring in the course of toxogenetic 
 anaemias are as follows : megaloblasts, erythroblasts 
 with bud-like processes projecting from the nuclear 
 wall, erythrocytes with multiple nuclear remains, 
 and erythrocytes with punctate basophilia. In 
 simple anaemias the signs of normal regeneration 
 alone are met with, while in the toxic anaemias there 
 is evidence both of normal and of pathological 
 regeneration. This latter means that abnormal or 
 pathological forms occur in the blood during the 
 process of regeneration. It is a regenerative impulse 
 in a pathological direction. It is found where the 
 process of regeneration is modified by these very 
 toxic influences which, in the first instance, have 
 provoked regeneration. Care must be taken to 
 distinguish it from conditions where degeneration of 
 form or of haemoglobin is* combined with signs of 
 immaturity of regeneration. These latter belong 
 to quite another category, and point to incomplete 
 regeneration, whether occurring in normal or patho- 
 logical blood (e.g., poikilocytes with Jolly's nuclear 
 remains). 
 
18 CLINICAL EXAMINATION OF THE BLOOD 
 
 We have now seen that the following combinations 
 may be encountered : — 
 
 (i). Degeneration and regeneration, 
 (ii). Degeneration of shape and of haemoglobin, 
 (iii). Immaturity, as evidenced by the presence of 
 nucleus or of nuclear remains ; and by the 
 existence of diffuse or multiple vestiges of 
 basic cytoplasm. 
 In each case where complications are met with, 
 it is necessary to institute a careful cytological 
 analysis. For example, in a hypochromatic poikilo- 
 cyte showing punctate basophilia and multiple 
 . nuclear remains, we are dealing with a cell where 
 degeneration of the haemoglobin is combined with 
 degeneration of a pathological or abnormal shape. 
 In other words, we are dealing with pathological 
 signs of immaturity both of nucleus and of cyto- 
 plasm. 
 
 THE BLOOD PLATELETS. 
 
 These bodies are increased both in number and 
 size, especially in cases of chlorosis, where they exist 
 along with other signs. 
 
 On the other hand, they are very scarce, or may 
 be absent altogether, in pernicious anaemia. 
 
 PATHOLOGICAL VARIETIES OF LEUCOCYTES. 
 Immature Forms. 
 
 Very occasionally immature forms may appear in 
 the course of an ordinary leucocytosis (more rarely 
 in a lymphocytosis). They are always present, 
 
THE BLOOD FILM 19 
 
 however, in myelocythaemia, and in lymphocy- 
 thsemia. 
 
 The parent cells of the small lymphocytes and the 
 forerunners of the monocytes are called Lymphoblastic 
 Macrolymphocytes or Large Lymphocytes. Except in 
 children, their presence in the blood denotes acute 
 or chronic lymphatic leucocythsemia. They look 
 like overgrown lymphocytes, which present exactly 
 the same characters as the small variety. This 
 applies especially to the presence of the azur sub- 
 stance and to the character of the nucleus. The 
 only point of difference is their size : they are larger 
 in all respects. 
 
 From the adult form — the large monocyte — they 
 can be distinguished by a more complete rotundity 
 of nucleus, and generally by the presence of one or 
 two indistinct nucleoli. 
 
 In like manner the fully-formed polymorpho- 
 nuclear leucocytes are preceded in the course of 
 development by various immature cells. And here 
 we must remember to distinguish the early onto- 
 genetic forms of the cells present in normal blood 
 from their phylogenetic precursors. Both immature 
 varieties, viz., their immediate ontogenetic and their 
 phylogenetic precursors, are always present in the 
 blood in cases of myelogenous leukaemia. In simple 
 leucocytosis, on the other hand, more particularly 
 in the severer forms, only the ontogenetic precursors 
 are present. 
 
 (a). The ontogenetic antecedents of the various 
 
20 CLINICAL EXAMINATION OF THE BLOOD 
 
 kinds of granular polymorphs are the respective 
 myelocytes. 
 
 A myelocyte is a granular cell with oxyphil cyto- 
 plasm similar to that seen in the polymorphonuclear 
 leucocyte. It is the exact counterpart of the latter, 
 except that it has a single nucleus which is more or 
 less rounded or simply indented. In structure, the 
 nucleus shows a coarse reticulum of well-differentiated 
 chromatin and parachromatin. 
 
 Metamyelocyte is the name given to that type of 
 cell which is intermediate in development between 
 the above-named myelocyte and the polymorpho- 
 nuclear leucocyte of normal blood. In this granular 
 cell the nucleus is distinctly indented, and not 
 infrequently appears somewhat slender like that of 
 the polymorph, but it has not yet attained to the 
 full measure of its complexity. The nucleus is only 
 twisted into a sort of bow and ribbon shape, but the 
 lobes have no connecting threads, and are not yet 
 split up into polymeric segments. 
 
 Developmentally speaking, the metamyelocyte is 
 the immediate morphological precursor of the poly- 
 morphonuclear leucocyte, and as such may enter 
 the circulation in the milder cases of leucocytic 
 stimulation. 
 
 The polymorphonuclear leucocyte is therefore 
 only a grown-up myelocyte which has matured, 
 grown older, and become capable of functioning. 
 
 (b). The phylogenetic antecedents of the granular 
 leucocytes are the natural precursors of the myelo- 
 
THE BLOOD FILM 21 
 
 cytes, i.e., they are to a certain extent immature 
 myelocytes. 
 
 The lymphoid myelocyte or Leucoilast proper is a 
 feebly basophil lymphoid cell with the nucleus of a 
 myelocyte but devoid of neutrophil or of eosinophil 
 granules. They possess, however, an azurophil sub- 
 stance such as we have seen is found both in the 
 normal and pathological varieties of lymphoid cells. 
 They are non-granular myelocytes with basic proto- 
 plasm. 
 
 This leucoblast with its large and indented nucleus 
 is a sort of pathological monocyte, and can seldom 
 be distinguished from the macrolymphocyte or from 
 the monocyte of normal blood. The distinguishing 
 features are more especially the absence of nucleoli 
 from the nucleus of the myelocyte (see above under 
 "a"), and, when present, azur substance much richer, 
 and frequently coarser and darker, than that seen 
 in the macrolymphocyte. 
 
 Since the monocyte is also undoubtedly devoid 
 of any nucleolus, the leucoblast can only be distin- 
 guished from it by the peculiar myelocyte-like 
 structure of its nucleus, and by the presence of coarse 
 (myeloid) azur-rnaterial. Further, the cytoplasm 
 often shows a slight tendency to be feebly oxyphil 
 (i.e., the protoplasm has a slight lilac tint). Inter- 
 mediate between the leucoblast (or non-granular 
 myelocyte) and the granular myelocyte with its 
 oxyphil protoplasm, stands the promyelocyte (neutro- 
 phil or eosinophil). This, to a certain extent, is a 
 
22 CLINICAL EXAMINATION OF THE BLOOD 
 
 myelocyte, with this difference, that its cytoplasm 
 is still basophil. In a way it may be regarded as a 
 granular leucoblast. The most typical example of 
 this variety of cell is seen in the eosinophil series, 
 for instance, in cases of myelocythcemia, where it is 
 seen to perfection. Forms corresponding to the 
 mast cells do not exist. 
 
 In the neutrophil promyelocyte the immature 
 " e-" granules are difficult to distinguish clearly. 
 In the neutrophil series the promyelocyte may be 
 represented as a leucoblast with amphochromatophil 
 cytoplasm, i.e., still partly basophil, but becoming 
 oxyphil. (See above, under " Polychromasia of 
 Erythrocytes," p. 15). 
 
 It may be distinguished from the polychromatic 
 erythroblast by the fact that the latter possesses 
 the radial nucleus and the bluish-red protoplasm 
 characteristic of the erythroblast. The neutrophil 
 promyelocyte, on the other hand, possesses a myelo- 
 cyte nucleus and cytoplasm in which the basic 
 element can be more clearly made out than the 
 oxyphil. 
 
 (c). Finally, the most aboriginal type of myeloid 
 cell met with in the course of development is 
 found in cases of myeloid leukaemia. This is a 
 basophil, non-granular, lymphoid cell which we look 
 upon as the common, undifferentiated parent of 
 lymphocytes and leucocytes alike. This has been 
 called the Lq.rge Lymphocyte or, better, the 
 
 Lymphoidocyte. — This type of cell is often markedly 
 
THE BLOOD FILM 23 
 
 basophil and beset with a (myeloid) azur substance. 
 The structure of its nucleus is sui generis, in that it 
 is characterized by an exceedingly fine reticulum 
 (leptochrornatic), and frequently contains several 
 (as many as four) sharply defined nucleoli with basic 
 protoplasm. 
 
 This peculiarity of structure enables the cell to be 
 distinguished from the large lymphocyte as well as 
 from the leucoblast and the monocyte. Further, 
 in macrolymphocytes, monocytes, and leucoblasts, 
 the nucleus always stains deeply in comparison with 
 the more or less feebly basophilic cytoplasm with its 
 well-defined spongioplasm. 
 
 In the case of the lymphoidocyte the nucleus as 
 a rule is relatively pale compared with the surround- 
 ing zone of more or less strongly basophilic cytoplasm. 
 This zone is usually narrow, or of medium breadth, 
 but in rare cases it may be very broad. The latter is 
 more rarely met with, and only occurs in the older 
 forms.* 
 
 Of course, between the lymphoidocyte and the 
 
 * The metamyelocyte is the next stage in the further 
 ontogenetic evolution of the myelocyte, and the immediate 
 forerunner of the polymorphonuclear leucocyte. 
 
 The promyelocyte is the cell coming immediately before 
 the myelocyte in the course of phylogenetic development 
 from the leucoblast. 
 
 The promyelocyte, therefore, occupies a position inter- 
 mediate between the leucoblast and the myelocyte, the 
 metamyelocyte between the myelocyte and the polymorpho- 
 nuclear leucocyte. 
 
24 CLINICAL EXAMINATION OF THE BLOOD 
 
 fully developed leucoblast there are cells which show 
 all stages of genetic transition. While it gradually 
 passes through the various intermediate phases to 
 become the feebly basophilic leucoblast, the nucleus 
 and cell-body bear a certain superficial resemblance 
 to that of the small and large lymphocyte. This 
 consists in a marked tendency towards rotundity 
 on the part of the nucleus, together, frequently, with 
 the presence of a fairly large number of nucleoli. 
 It is these cells which are present in the acute myeloid 
 leukaemias, often to the exclusion of nearly all other 
 kinds, hence called parent-cell leukaemias or the 
 myeloblasts leukaemias of the Dualists. 
 
 Just as the macrolymphocyte is the mother of the 
 small lymphocyte, so the large lymphoidocytes give 
 rise to a daughter strain. These are small patho- 
 logical lymphocytes formed in the bone-marrow 
 (myelolymphocytes) remarkably similar indeed to 
 the normal lymphatic lymphocytes. 
 
 This kind of cell may be regarded as the type of 
 Sternberg's so-called leucosarcoma cells found in 
 certain varieties of leukaemia. These latter, however, 
 as later investigation has proved, are not always 
 sarcomatous in nature. Microlymphoidocytes, how- 
 ever, possess the leptochromatic nucleus peculiar to 
 the lymphoidocyte. While the lymphocytes stain 
 deeply, and are pachychromatic, the nucleus of the 
 leucoblast, and more especially that of the micro- 
 leucoblast, shows, like that of the lymphocytes, an 
 incipient alteration which is to end in a differentiation 
 
THE BLOOD FILM 25 
 
 of the nuclear structure into chromatin and para- 
 chromatin. 
 
 Rieder's type of cell includes large and small 
 lymphoidocytes as well as microlymphoidocytes with 
 an atypical polymorph-like nucleus (pathological 
 age forms). They are found especially in acute, and 
 occasionally in sarcoma-like, myelocythaemia. In 
 the latter case they represent a special type of leuco- 
 sarcomatous cell. They indicate a very acute 
 disturbance of the process of cell proliferation, which 
 here consists in mere cell increase without any 
 differentiation whatever. The nucleus alone becomes 
 fully formed, while the cell remains immature. 
 Indeed, it oversteps the normal limits of polymor- 
 phism characteristic of the normal cell. 
 
 In consequence, therefore, of a constitutional 
 disturbance of cell development, and owing to a want 
 of balance between the natural stimulus to develop- 
 ment and that producing this type of cell, the nucleus 
 reaches a state of ontogenetic maturity too quickly 
 for the cytoplasm to keep pace with it. Hence 
 there is no corresponding phylogenetic maturation, 
 and they fail to become differentiated into function- 
 ing cells. 
 
 Degeneration Forms. 
 
 By this designation we mean more especially the 
 so-called irritation cells or plasma cells. 
 
 Apart altogether from degenerate types proper 
 (such as the Klein-Gumprecht shadow nuclei seen in 
 
26 CLINICAL EXAMINATION OF THE BLOOD 
 
 macrolymphocytes and lymphoidocytes in all acute 
 leukaemias), they include the products resulting from 
 the metamorphosis which the various large and 
 small lymphoid cells undergo in normal and patho- 
 logical blood (especially the small and large lympho- 
 cytes, leucoblasts, lymphoidocytes, and monocytes). 
 They are characterized by very pronounced baso- 
 philia of the cell body, which is always devoid 
 of azurophil material. The protoplasm frequently 
 contains very minute vacuoles, presumably fat- 
 containing. According to the derivation of the cell 
 in question, the nucleus may be of the lymphocyte, 
 the leucoblast, or the lymphoidocyte variety. 
 
 A leucocytosis composed of specific plasma cells is 
 never met with. Indeed, such cells are not generally 
 seen till after the parent cells have made their 
 appearance in the blood. The laws governing their 
 appearance, however, are not yet fully understood. 
 Such cells may be found in various inflammatory 
 conditions, including granulomatous affections of 
 the hsemopoietic apparatus. 
 
 Since they make their appearance in the course of 
 a leukaamic leucocytosis (more especially in one of 
 the lymphoidocyte variety), where they may be 
 present in large numbers, it would seem to suggest 
 an inflammatory cause for the leukaemias in question. 
 
THE BLOOD FILM 27 
 
 SEMIOLOGY AND DIFFERENTIAL 
 
 DIAGNOSIS OF THE MOST IMPORTANT 
 
 BLOOD CHANGES* AS SEEN IN 
 
 STAINED FILMS. 
 
 1.— THE MICROSCOPIC CHANGES OBSERVED IN 
 THE RED BLOOD CELLS. 
 
 If we exclude invasion of the corpuscles by the 
 malarial parasite, such changes occur solely in the 
 secondary anaemias, the result of an affection of the 
 erythroblastic apparatus. 
 
 Apart from a diminution in numbers {oligocyth- 
 emia), and a reduction in the absolute amount of 
 haemoglobin (oligochromamia) , there is an alteration 
 in the morphology of the individual cell. Various 
 departures from the normal both in size and shape 
 are invariably met with, such for example as aniso- 
 cytosis and poikilocytosis. Whereas in chlorosis 
 the only change in the erythrocytes is a specific 
 reduction in haemoglobin, in the anaemias proper 
 (simple secondary, or pernicious secondary) there 
 are, in addition, the above-named morphological 
 changes. Moreover, in these anaemias we frequently, 
 though by no means invariably, meet with, in addition 
 to the morphological changes, various immature 
 forms. These indicate an attempt at regeneration 
 on the part of the erythroblastic apparatus. 
 
 * Changes in the cell count, and in the absolute Hb 
 content (which must be determined by methods other than 
 histological), take the form of diminution in the anaemias, 
 but of increase in polycythaemia. 
 
28 CLINICAL EXAMINATION OF THE BLOOD 
 
 The signs of immaturity are retention of the 
 nucleus (erythroblastosis), polychromatophilia, and, 
 punctate basophilia of the normocytes, the degenerate 
 macrocytes, the poikilocytes, and the erythroblasts. 
 
 The presence in the blood of the early forms 
 already mentioned, indicates increased functional 
 activity on the part of the bone-marrow. Their 
 absence, on the other hand, does not mean the 
 reverse. In other words, the absence of these early 
 forms does not constitute an aplastic anaemia, 
 although obviously the so-called aplastic forms of 
 simple and pernicious anaemias may be further sub- 
 divided into simple secondary (hypochromatic) and 
 pernicious secondary (hyperchromatic) ; also into 
 primary haemopathic (which is equivalent to secon- 
 dary myelopathic), and into primary myelopathic 
 forms. In the simple anaemias, the individual 
 erythrocytes, anisocytes, and ultimately the poikilo- 
 cytes, show hypochromasia of the cells. 
 
 In morbid and in irritative conditions of the bone- 
 marrow consequent on a primary blood lesion, early 
 forms make their appearance in the circulation. 
 These include all kinds of erythroblasts (normo- and 
 megalo-blasts). The latter, however, are found only 
 in the anaemias of toxic origin, e.g., in the secondary 
 toxic anaemias. 
 
 Pernicious anaemia presents a characteristic blood- 
 picture, consisting of hyperchromasia of the normal 
 and abnormal types of erythrocyte. In the same 
 film may be seen all phases of incomplete cell develop- 
 
THE BLOOD FILM 29 
 
 ment, especially normoblasts and megaloblasts. 
 The appearance of the latter in the blood negatives 
 a simple post-haemorrhagic anaemia, but does not 
 contraindicate a simple anaemia of toxic origin. 
 It indicates rather the existence of a morbid or toxic 
 condition of the bone-marrow, but is no evidence of 
 the presence of pernicious anaemia (hyperchromatic) . 
 Conversely, their absence from the blood does not 
 imply that it is not a case of pernicious anaemia. 
 Thus in reactionary pernicious anaemia which is not 
 of the aplastic type, erythroblasts in general and 
 megaloblasts in particular may be absent exactly as 
 in the so-called aplastic anaemia. Poikilocytes are 
 found in simple as well as in pernicious anaemia, 
 though only in the more severe forms of the former. 
 Thus, so far as the red blobd corpuscles are concerned, 
 the sign of pernicious anaemia is hyperchromasia of 
 the degenerated anisocytes. The blood-film in per- 
 nicious anaemia can only be distinguished from that 
 of simple anaemia by the presence of hyperchromasia. 
 
 In chlorosis, the individual red blood corpuscles 
 are of normal size, with a central circumscribed area 
 from which the haemoglobin has more or less dis- 
 appeared (anochromasia). Frequently there are also 
 present in chlorosis signs of degeneration (aniso- 
 cytosis, poikilocytosis) or of regeneration (polychro- 
 masia, punctate basophilia) (chloro-anaemia). 
 
 In lead poisoning, not uncommonly the only sign 
 of blood disturbance is a regenerative one, viz., 
 punctate basophilia together with polychromasia. 
 
30 CLINICAL EXAMINATION OF THE BLOOD 
 
 Presumably this indicates not so much the presence 
 of a reactionary regeneration, seeing that other 
 evidence of degeneration is absent, as the result of a 
 primary stimulus' applied to the bone-marrow similar 
 to what is observed in the blood during the exhibition 
 of arsenic or mercury. 
 
 Polychromasia, the simplest and best known 
 form indicative of immaturity, may be met with in 
 various types of ansemic" regeneration. When present 
 alone, without any other blood change, it is the first 
 indication of regeneration occurring after the simplest 
 haemorrhage, such as menorrhcea. It points to a 
 merely functional irritation of the erythroblastic 
 apparatus, without necessarily implying the existence 
 of a pronounced anaemia. 
 
 Summary. 
 
 Chlorosis is characterized by a specific anochro- 
 masia affecting the centre of the erythrocyte, 
 frequently also by an increase in size and in number 
 of the blood platelets, and by a leucocytosis. 
 
 Simple Secondary Anaemia is characterized by 
 the presence of anisocytosis, accompanied by hypo- 
 chromasia. In the more severe forms there is also 
 a hypochromatic poikilocytosis. More or less poly- 
 chromasia is always present. In the reactionary 
 cases, punctate basophilia and normoblasts may also 
 be encountered ; while in the toxic forms (not the 
 post-haemorrhagic, but those associated with toxic 
 haemorrhages), megaloblasts may be found, indicating 
 
THE BLOOD FILM 31 
 
 pathological repair. That is to say, there is present a 
 morbid condition of the bone-marrow toxic in origin. 
 
 The absence of erythroblasts from the blood does 
 not indicate definitely a condition of aplasia of the 
 bone-marrow. 
 
 As a rule, the blood-platelets are increased in 
 number and in size, and not infrequently there is an 
 absolute neutrophil leucocytosis. 
 
 Chloro- anaemia is a combination of chlorosis with 
 simple anaemia. 
 
 Pernicious Anaemia.* — Here the red blood 
 corpuscles show hyperchromasia and anisocytosis, 
 and in more severe cases poikilocytosis and schisto- 
 cytosis as well. In the reactionary cases, all kinds 
 of early cell forms, especially megaloblasts, may be 
 seen. Their absence from the blood does not contra- 
 indicate pernicious anaemia, nor does it point defi- 
 nitely to the aplastic form. 
 
 There is also, especially in the obscure disease 
 described by Biermer — " Biermer's disease," — an 
 absence of blood platelets, and a relative lympho- 
 cytosis with a normal leucocyte count. 
 
 2.— CHANGES IN THE LEUCOCYTES. 
 
 These include variation in number both relative and 
 absolute, and in quality (e.g., atypical cells in the 
 
 * E.g., in Bothriqcephalus anaemia, von Jaksch's 
 anaemia of children, and in acute leukanaemia. Pernicious 
 anaemia in the more limited sense is only the cryptogenetic 
 Biermer's disease. 
 
32 CLINICAL EXAMINATION OF THE BLOOD 
 
 shape of early forms), and indicate a lesion of the 
 lymphatic as well as of the medullary leucoblastic 
 apparatus. They result from some irritative inter- 
 ference with function, of a toxic character, leading to 
 metaplasia or hyperplasia. The blood conditions 
 which fall to be considered here are as follows : — 
 
 Secondary leucocytosis and lymphocytosis, indicative 
 of irritation of the hemopoietic apparatus. Such 
 may be of a secondary or reactionary character, due 
 to irritation, of a chemiotactic nature, or it may be 
 due to a primary irritation (i.e., is a direct toxic 
 metaplasia) of the ieucoblastic tissue. The former 
 is an active, the latter a passive, leucocytosis. 
 
 Lymphatic and myelogenous leukaemias, which 
 indicate a primary idiopathic hyperplasia of the 
 lympho- and leuco-poietic apparatus respectively. 
 
 The leukaemias due to hyperplasia, and the leuco- 
 cytoses resulting from a toxic metaplasia, are of a 
 passive nature, i.e., are repulsion-leucocytoses. 
 Functional leucocytosis and lymphocytosis due to 
 chemiotaxis are of an active or reactionary character. 
 Generally, however, active functional leucocytosis 
 is associated with some cause leading to meta- 
 plasia.* An increase in number is the commonest 
 
 * Acute leukaemias due to an infection ought perhaps 
 rather to be classed among the metaplastic leucocytoses 
 than among the actual hyperplastic leukaemias. At the 
 same time, transition forms might exist between toxic meta- 
 plasia on the one hand and metahyperplasia on the other, 
 that is to say, hyperplasia combined with toxic metaplasia, 
 whence the name hypermetaplasia, 
 
THE BLOOD FILM 33 
 
 sign of the presence of a simple leucocytosis or of a 
 leukaemia. 
 
 But irritative conditions due to interference with 
 function, as well as leukasmic changes in the blood- 
 forming apparatus, may exist without any increase 
 in the leucocyte count (e.g., the leucopenic type of 
 leucocytosis, the aleukaemic or subleukaemic form 
 of leukaemia). 
 
 Hence it follows that the crucial sign of the 
 presence of one or other of these conditions must be 
 sought for in the qualitative nature of the cell present. 
 
 In both affections, early types of cell have been 
 found in the blood. The occasional appearance of 
 early forms is thus the essential criterion of a simple 
 or of a leuksemic leucocytosis. There is this difference, 
 however, in the simple leucocytoses : early forms may 
 appear In the blood, whereas in leukaemias they are 
 always and of necessity present. Hence it comes 
 about that in leucocytoses, when early forms are 
 present at all, they are generally more or less scarce, 
 and are then only the immediate ontogenetic pre- 
 cursors of the mature polymorphonuclear leucocyte. 
 In the lymphocytoses, the early forms are usually 
 lymphocytes with a large amount of cytoplasm. In 
 the former, i.e., the leucocytoses, metamyelocytes 
 and sometimes myelocytes may be present. In the 
 latter, lymphocytes may appear which are practically 
 all nucleus, with very scanty surrounding cytoplasm. 
 
 In the leukaemias, large numbers of early forms 
 appear in the blood from the first. Not only are the 
 
 3 
 
34 CLINICAL EXAMINATION OF THE BLOOD 
 
 immediate ontogenetic precursors invariably present, 
 but also their phylogenetic prototypes. Hence, in 
 the myelogenous leukaemias, not only are promyelo- 
 cytes and leucoblasts seen, but also the immature 
 parent cell-forms, the lymphoidocytes, which are 
 present to a greater or less extent. Not infrequently 
 numerous mononucleated mast cells are present, 
 well as erythroblasts (more seldom megakaryo- 
 cytes). 
 
 In the lymphatic leukaemias we find lympho- 
 blastic macrolymphocytes and occasional parent 
 lymphoidocytes. The following are the essential 
 points of difference, therefore, between the simple 
 leucocytoses on the one hand and the typical 
 leukaemias on the other. 
 
 The focrner, in the more restricted sense, are 
 invariably characterized by one type of cell, while 
 typical leukaemias are of the mixed-cell variety. In 
 the former, the mature blood-cells predominate, and 
 along with them their immediate ontogenetic 
 precursors. 
 
 In myelogenous leukaemia, on the other hand, we 
 find both the granular and the non-granular forms 
 of their immature phylogenetic precursors. These 
 predominate over the normal mature cells. Most 
 characteristic of all, however, is the presence of 
 undifferentiated parent cells. In simple lympho- 
 cytosis, only these early forms, characterized by small 
 body and large nucleus, appear when regeneration is 
 going on. In lymphatic leukaemia, however, the 
 
THE BLOOD FILM 35 
 
 parent macrolymphocytes always make their appear- 
 ance in the circulation. The more acute the leukaemia, 
 the more do the immature phylogenetic forms tend 
 to predominate over the early ontogenetic varieties ; 
 in other words, the lymphoid progenitors tend to 
 replace the later granular cell-types. 
 
 The semiological difference between leucoeytosis 
 and leukaemia in general may be inferred from the 
 following. In the leucocytoses during the period 
 of regeneration, the stimulus which, by chemio- 
 taxis, induces this regeneration, always acts upon 
 the immediate immature precursors of the mature 
 and functionally active cells in the hemopoietic 
 tissue. 
 
 In the leukaemias, on the other hand, the main 
 incidence of the stimulus is from the first borne by 
 the parent cells. As a result of this impulse to 
 hyperplasia, the most immature, undifferentiated 
 cells appear and find their way into the general 
 circulation. Compared with the normal, there is 
 a greater absolute increase in the amount of meta- 
 plasia (from the undifferentiated parent form to the 
 mature cell capable of functioning). Relatively, 
 however, to the increase in hyperplasia, there is a 
 diminution in metaplasia. The more acute the 
 condition of myeloid leukaemia, the greater is the 
 hyperplasia of lymphoid cells over the more differen- 
 tiated transition forms ; in other words, the greater 
 is the excess of non-granular over granular forms 
 (leucocytes). Similarly, in the acute lymphaemias 
 
36 CLINICAL EXAMINATION OF THE BLOOD 
 
 there is a corresponding increase of macrolympho- 
 cytes over small lymphocytes. 
 
 There is this further point of difference, never 
 observed in the leucocytoses, namely, that various 
 atypical forms of cell are met with. These indicate 
 imperfect differentiation, owing to a breakdown in 
 the ontogenetic process of cell development. Thus 
 we find in myelogenous leukaemias dwarf polynuclear 
 leucocytes and dwarf mast cells, or giant polymorphs, 
 non-granular oxyphil polymorphs, non-granular baso- 
 phil polymorphs (i.e., leucoblasts with a polymorph 
 nucleus), and polymorphonuclear lymphoidocytes, or, 
 as they are sometimes called, Rieder's cells. Further 
 mitoses are frequently observed in the leukaemias, 
 but never in the leucocytoses. Occasionally, in the 
 so-called atypical leukaemias, mast cells and even 
 eosinophils may be absent, proving that these latter 
 cells are not an essential feature of myelogenous 
 leukaemia. Atypical leukaemias, therefore, of a 
 neutrophil character may be met with.* In still 
 more acute cases there may. be an entire absence of 
 neutrophil cells, so that only the non-granular 
 lymphoid leucoblasts and lymphoidocytes remain. 
 On haematological grounds alone such cases can 
 scarcely, if at all, be distinguished from acute lympho- 
 leukaemias, especially from the parent-celled variety 
 with its macrolymphocytes and lymphoplastic cells. 
 
 * They are distinguished from neutrophil leucocytoses 
 of a metaplastic character, and of toxic origin, by the presence 
 of lymphoidocytes, which in the latter are always absent. 
 
THE BLOOD FILM 37 
 
 Above all, in addition to amitotic cell division 
 occurring in lymphatic leukaemias, the Rieder type 
 of lymphocyte (polymorph lymphocyte) may be seen. 
 The latter, however, differs somewhat from the 
 Rieder cells met with in myelogenous leukaemia. 
 Lymphatic leukaemia is often accompanied by a 
 myelocytosis, i.e., a leucocytosis of a myeloid type 
 due to irritation. Moreover, in acute atypical 
 myelogenous leukaemias there is frequently present a 
 toxic hyperchromatic anaemia. When present, the 
 appearance of neutrophil promyelocyte forms in 
 myelogenous leukaemia may be regarded as a fairly 
 reliable means of distinguishing between acute 
 lymphatic leukaemia on the one hand, and acute 
 myelogenous leukaemia of the parent-cell type on 
 the other. These cells, phylogenetically immature, 
 are never observed in a lymphatic leukaemia accom- 
 panied by an irritation leucocytosis. This is due to 
 the fact that the leucocytosis scarcely ever goes 
 beyond the myelocyte stage. Hence a functional 
 myelocytosis may accompany a hyperplastic lympho- 
 cytosis (lymphatic leukaemia), while a hyperplastic 
 leukaemia of the lymphoidocyte type may also 
 accompany an increase in promyelocytes and their 
 entry into the blood.* 
 
 * In lymphasmia the myelocytes take their origin from 
 myeloid tissue which has been stimulated merely to produce 
 leucocytes. 
 
 The promyelocytes in myelaemia owe their origin to 
 hyperplasia of the leukaemic myeloid tissue. 
 
38 CLINICAL EXAMINATION OF THE BLOOD 
 
 Summary. 
 
 Leucocytes. — Functional leucocytosis induced by 
 chemiotaxis is characterized by an increase in 
 number of the normal polymorphonuclear leucocytes 
 or of the lymphocytes, and later, during the period 
 of regeneration, by the occasional appearance of their 
 immediate ontogenetic precursors. The presence 
 of these latter, even when there is no leucocytosis, 
 or even where there is a diminished leucocyte 
 count (leucopenia) merely indicates the existence of 
 some irritation of the leukocytic function. It is 
 frequently met with in simple toxic and hyper- 
 chromatic anaemias. 
 
 Irritation or Stimulation Leucocytosis is character- 
 ized by the presence of leucoblasts, plasma cells, and 
 myelocytes. It is frequently also associated with 
 anaemia due to a wasting of the bone-marrow 
 (repulsion erythroblastosis). 
 
 Leucocytosis of Toxic Origin Characterized by 
 Metaplasia. — This is frequently conjoined with a 
 chemiotactic leucocytosis and toxic anaemia. Leuco- 
 blasts, promyelocytes, and myelocytes are present. 
 
 Leukaemias. — The most important and, at the 
 same time, most invariable sign is the appearance of 
 the immature precursors of the leucocytes and 
 lymphocytes, more especially of the leucoblasts and 
 macrolymphocytes, and in fact all the intermediate 
 stages right back to the parent (aboriginal) forms. 
 This is the essential distinguishing feature. All other 
 signs may be absent, although as a general rule they 
 
THE BLOOD FILM 39 
 
 are present in most cases. Such other signs include 
 an increased cell count, the appearance of atypical 
 cells, and, in myelogenous leukaemia, the presence of 
 mixed cells. These latter resemble the cells in the 
 normal bone-marrow* and show all stages of phylo- 
 genetic and ontogenetic cell development. 
 
 In pure cases of lymphatic leukaemia, on the other 
 hand, the blood picture shows a monotonously 
 uniform collection of lymphocytes. Just as there 
 are atypical myelogenous leukaemias minus mast 
 cells and eosinophils, i.e., leukaemias of a uniformly 
 neutrophil rather than of a mixed-cell type, com- 
 posed sometimes entirely of purely lymphoid cells 
 (accompanied frequently by an excess of the older 
 stages of normal and pathological lymphoid cells), 
 so on the other hand atypical lymphatic leukaemias 
 may, to a certain extent, co-exist with leucocytosis 
 and myelocytosis. 
 
 The character of the blood in myelogenous 
 leukaemia varies considerably in individual cases. 
 
 In typical cases of the chronic myelogenous variety, 
 the mixed cells above referred to include all kinds 
 
 * Just as in lymphatic leukaemia, so in cases of acute 
 atypical neutrophil leukaemia and in leukaemias characterized 
 by the presence of one type of cell only, e.g.,the lymphoidocyte, 
 the blood reflects the actual qualitative changes in the cells 
 composing the bone-marrow, that is to say, in the blood- 
 forming tissue. In typical myelogenous leukaemia, on the 
 other hand, there is only a quantitative change in the cell 
 composition of the bone-marrow as compared with the 
 normal. 
 
40 CLINICAL EXAMINATION OF THE BLOOD 
 
 of granular cells, together with lymphoid myelogenous 
 cells. In other words, all varieties of granulocyte 
 are present, together with their ontogenetic and 
 phylogenetic antecedents, which are derived in the 
 first instance from lymphoid cells. Generally speak- 
 ing, however, there is a preponderance of the granular 
 type of cell over the lymphoid variety. 
 
 Lymphoidocytes and leucoblasts are seen in all 
 stages of metaplasia, from the lymphoid type to the 
 more differentiated granulocyte. 
 
 In typical acute leukaemias, the prevailing type of 
 cell is the lymphoidocyte or parent cell (the so-called 
 myeloblastic leukaemia of the Dualists). 
 
 Between the two extreme types of leukaemia above 
 mentioned there are various transitional and inter- 
 mediate forms, hence called atypical leukaemias.* 
 
 Thus, the mixed-cell type of myelogenous leukaemia 
 may assume an acute character. In the same way, 
 too, the small-celled type of lymphatic leukaemia 
 may occasionally assume a neutral character. For 
 instance, in the acute form of myelogenous leukaemia, 
 we find not only an older form of lymphoidocyte and 
 
 * What are simply leukaemoid blood changes partly 
 leucocytic in character, are the result of a simple functional 
 or metaplastic stimulus. This latter attracts one kind of 
 cell only in the blood-forming apparatus, that apparatus 
 being normal, or having undergone metamorphosis into 
 another normal type. This is in direct contrast to the 
 atypical leukaemias, where the blood picture is the counterpart 
 of an atypical condition of the blood-forming tissue such 
 as is met with in hyperplasia. 
 
THE BLOOD FILM 41 
 
 leucoblast present, characterized simply by an 
 indented nucleus, but also polymorphonuclear 
 granulocytes with basophil cytoplasm, or, in other 
 words, polymorphonuclear leucoblasts and promyelo- 
 cytes. These indicate that the nucleus has already 
 undergone complete ontogenetic development, while 
 the phylogenetic differentiation of the cytoplasm 
 has not kept pace with it. In addition to the above, 
 the Rieder type of lymphoidocyte* may be present 
 as a consequence of interference with the process of 
 cell development. Moreover, there is a relative 
 increase in the number of lymphoidocytes and leuco- 
 blasts, so that they far outnumber the granulocytes. 
 In other cases, the polymorphonuclear granulocytes 
 disappear before the mononuclear granulocytes. 
 Mast cells alone, or mast cells plus eosinophils, are 
 absent in other cases. The result is a partially 
 neutral type of leukaemia. Lastly, as mentioned 
 above, leukaemias of the lymphoidocyte variety may 
 occur with or without Rieder types. As a rule, in 
 myelaemia there is an absolute increase of 
 mature polymorphs as compared with the normal. 
 Relatively, however, there is a preponderance of their 
 granular and non-granular mononuclear predecessors. 
 In the acute atypical leukaemias, the polynuclear 
 leucocytes are entirely absent, or at least are very 
 considerably diminished in relation to the normal, 
 while the immature lymphoid cells preponderate 
 over the immature mononuclear granulocytes. 
 
 * See page 25. 
 
42 CLINICAL EXAMINATION OF THE BLOOD 
 
 Hyperplasia, the mere proliferative increase in 
 cells, overshadows the further stages of differential 
 development into cells capable of functioning. 
 Further, just as leucocytosis or lymphocytosis may 
 accompany the simple or pernicious types of 
 secondary anaemia, so the various kinds of leukaemia 
 are often complicated by the presence of simple or 
 pernicious secondary anaemias. To this syndrome is 
 given the name Leukancemia. In direct contrast to 
 this is the so-called von Jaksch form of splenic 
 anaemia seen in children (anaemia splenica infantum 
 pseudoleukaemica). This is not a variety of hyper- 
 plastic pseudoleukemia conjoined with hsemolytic 
 anaemia, but is an anaemia of the hyperchromatic, 
 pernicious, megaloblastic type, associated with mye- 
 loid metaplasia of the spleen due to inflammatory 
 changes of a toxic nature. In other words, it is a 
 metaplastic leucocytosis of a leukeemic character 
 originating in the spleen. 
 
43 
 
 Chapter II. 
 
 HMMOCYTOMETRY : 
 
 OR THE ENUMERATION OF THE 
 
 BLOOD CORPUSCLES. 
 
 THE determination of the blood-count is 
 frequently of the utmost significance in 
 diagnosis. We have to determine : — 
 
 i. The absolute number — ■ 
 
 (a). Of red blood corpuscles) . r ,, . 
 
 ,,. nr i ■. \ in i cmm. of blood, 
 
 (b). Of white J 
 
 2. The ratio of red to white cells. 
 
 3. The percentage relation of the various types of 
 leucocyte to each other both in normal and in patho- 
 logical conditions. 
 
 METHOD AND TECHNIQUE. 
 
 TO DETERMINE THE ABSOLUTE NUMBER 
 OF CELLS. 
 
 For this purpose two Thoma-Zeiss pipettes are 
 required, one for the red blood corpuscles and another 
 for the leucocytes. A Biirker's counting-chamber, 
 preferably provided with Tiirck's ruling, is also 
 necessary, as well as two separate diluting fluids, one 
 for the red cells and the other for the whites. For 
 this purpose I myself use and recommend normal 
 physiological salt solution, to which a few drops of 
 
44 CLINICAL EXAMINATION OF THE BLOOD 
 
 methyl violet or neutral red have been added in order 
 to render the leucocytes conspicuous, so that they 
 may not be counted among the red cells by mistake. 
 
 For the white blood-cells I use a - 5 per cent solution 
 of acetic acid, tinted with a few drops of methyl green 
 or vesuvin. The acid destroys the red blood corpus- 
 cles but conserves the white cells, whose nuclei are 
 rendered conspicuous by the stain employed. 
 
 Both mixing pipettes are capillary in their action, 
 and so graduated as to permit of making various 
 dilutions. The graduated capillary tube opens out 
 at the top into a bulb or chamber, in which the blood 
 is mixed with the diluting fluid. 
 
 In actual practice the drop of blood is sucked up 
 to a certain mark on the graduated capillary tube. 
 Any blood clinging to the point of the pipette is then 
 wiped away, and the diluting fluid is next drawn up 
 into the chamber till it rises to a certain mark figured 
 above the bulb. 
 
 In order to distinguish at a glance the two 
 pipettes, it may serve to remember that the pipette 
 for the white corpuscles bears the figure n above 
 the bulb, while that for the reds is marked with 
 the number 101. Otherwise the two pipettes bear 
 a superficial resemblance to one another. Both 
 are graduated capillary tubes on which the figures 
 •5 and 1 are marked. The pipette for the white 
 cells, however, is of wider bore than that for the 
 red. It requires a larger drop of blood, and allows 
 only of a dilution of 1 in 10 if drawn up to the mark 
 
HMMOCYTOMETRY 45 
 
 I, or of i in 20 if drawn up to the mark -5. In con- 
 sequence of the much greater number of red blood 
 corpuscles in one unit of space as compared with the 
 white cells, the former require a correspondingly 
 greater dilution in order to be estimated by the same 
 standard as the whites. 
 
 The narrower-bore pipette used in estimating the 
 red blood corpuscles allows therefore of dilutions up 
 to 1 in 100 when blood has been drawn up to the 
 mark 1, and to 1 in 200 when blood has been drawn 
 up to the mark -5. The numbers 11 and 101 show 
 the point to which the diluting fluid must be drawn, 
 in order to make the above dilutions. For instance, 
 n indicates 1 part of blood and 10 of diluting fluid, 
 while 101 indicates 1 part of blood plus 100 parts of 
 diluent. This means that in the former the unit of 
 blood drawn up to the mark 1 has been diluted 10 
 times, whereas in the latter it has been diluted 100 
 times. Hence, if blood be drawn up merely to the 
 mark -5 in the first case it will be diluted 20 times, 
 whereas in the second case it will be diluted 200 
 times. 
 
 Biirker's counting-chamber is so constructed that 
 it contains two counting-surfaces separated from 
 each other by a horizontal channel, and each of these 
 has the same ruling. Consequently these two fields 
 can be used for making control counts of the same 
 specimen of blood. A simultaneous use of one field 
 for estimating the number of red cells, and the other 
 for the white corpuscles, cannot be recommended, 
 
46 CLINICAL EXAMINATION OF THE BLOOD 
 
 owing to the danger of an accidental mingling of the 
 two drops. 
 
 The method of procedure is as follows : — 
 
 On the clean dry chamber (which is on the prin- 
 ciple of a hollowed-out slide — the original Thoma's 
 chamber) the cover-glass is first laid. Next, after 
 thorough mixing in the pipette, a drop of the diluted 
 blood is allowed to enter from one side or the other 
 into the chamber, where it spreads out. 
 
 Turk's ruling* consists of lines crossing each other 
 at right angles, whereby squares are mapped out. 
 In the centre there is thus a field divided up into 
 1 6 large squares by triple horizontal and vertical 
 lines. Each of these large squares is again sub- 
 divided into 16 small squares by single horizontal 
 and vertical lines. At the four corners of the field 
 are found large squares similar to the first, bounded 
 at the edge by double parallel lines. These squares 
 are not subdivided further. The central field, con- 
 sisting of large squares subdivided into smaller ones, 
 is reserved for the enumeration of the red blood 
 corpuscles. 
 
 The more sparsely distributed white cells should 
 be counted on the large corner squares which are not 
 subdivided. 
 
 The next step consists in determining the average 
 number of red blood corpuscles or of leucocytes in 
 
 * Biirker's ruling is preferable for general use ; his 
 counting - chamber can, however, be obtained, if desired, 
 with the original Thoma ruling. 
 
HMMOCYTOMETRY 47 
 
 one small square. This is found by counting over 
 carefully as large a series of small squares as 
 possible. From this we can calculate the number 
 of cells in i c.mm. of blood. 
 
 The average number of cells in a small square, 
 multiplied by the degree of dilution (10 or 20 in the 
 case of leucocytes, 100 or 200 in the case of erythro- 
 cytes) and by a constant factor, viz., 4000 (the so-called 
 chamber-index), gives us the total number of red 
 and white cells respectively in 1 c.mm. of blood. 
 The enumeration is best carried out using a medium 
 magnification and with a half-closed diaphragm, 
 lowered condenser, and concave mirror. An en- 
 deavour should always be made to count as many 
 squares as possible (small ones in making the red 
 count, large ones in estimating the white cells). 
 From this the average number per square may be 
 calculated. 
 
 To determine the number per c.mm., the following 
 universal formula is equally suitable for reds and for 
 whites. It is based on the average number of cells 
 in one small square. 
 
 Number of cells counted X degree of dilution 
 
 X chamber-index (4,000) 
 
 Number of small squares counted 
 
 If, instead of counting the number of cells per small 
 square we count the number per large square as in 
 the leucocyte determination, since 1 large square is 
 equivalent to 16 small ones, in the above formula 
 
48 CLINICAL EXAMINATION OF THE BLOOD 
 
 the denominator will be the " number of large squares 
 counted x 16." 
 Let N = the total number of cells counted in a 
 series of large squares. 
 M = the degree of dilution. 
 C = the chamber-index. 
 X = the number of large squares counted, 
 c = 16, i.e., the number of small squares 
 which make up one large square, i.e., 
 a constant. 
 Then the number of red or white blood cells in 
 i c.mm. of blood will be as follows : — 
 N 
 
 "xlTc x M x c 
 
 But C = 4000 and c = 16 
 .-. the formula may be represented — 
 N x M x 4000 
 Xx 16 
 
 Since 4000 : 16 (— )= 250 f= J 
 
 we can estimate the number of white cells in 1 c.mm. 
 of blood by eliminating the constant 16, so as to 
 obtain the average number per large square. 
 This may be represented by the formula — 
 N x M 
 
 jr— X 250. 
 
 For convenience sake, however, it is found "that 
 there is no need to go to the trouble of first determining 
 the average number per large or small square respec- 
 
HMMOCYTOMETRY 49 
 
 tively by a preliminary calculation and then of 
 multiplying the number thus obtained in the manner 
 shown above : it is simpler and more convenient to 
 reduce all these calculations to one step, so sim- 
 plifying the formula. Since a considerable number 
 of large squares, each equal to 16 small ones, should 
 be counted, it is obviously advisable to count through 
 a number of large squares, divisible by 4. 
 
 Four large squares may be taken as the minimum 
 number to be of any service. If one is simply in the 
 habit of never counting more than 4 large squares, 
 then X is always equal to 4. The above formula 
 will then be reduced to the following terms : — 
 
 N x M x 1000 
 16 
 
 In enumerating the red cells when the dilution is 
 1 in 200, if ioo.small squares are counted (i.e., 6 large 
 and 4 small squares), we need only multiply the 
 number counted (N) by 8000. Thus the number of 
 red cells per c.mm. = N X 8000. It might be added 
 that, in determining the number of red blood cor- 
 puscles, a dilution of 1 in 200 should be used ; for the 
 whites a dilution of 1 in 10. In estimating the 
 number of red cells in the rare cases of polycythsemia, 
 still higher dilutions, however, must be used. Thus, 
 if we suck up the blood to the mark -4 we get a 
 dilution of 1 in 250, if only to -2 the dilution is 
 1 in 500. 
 
 For the enumeration or red blood corpuscles in 
 
 4 
 
SO CLINICAL EXAMINATION OF THE BLOOD 
 
 the higher degrees of ansemia a dilution of i in ioo 
 only should be used. 
 
 Similarly, the enumeration of the white cells in 
 leukaemic blood is to be carried out by using dilutions 
 of 20 or under (blood to the mark -4 = i in 25, or to 
 the mark -2 = 1 in 50). 
 
 NEW METHOD OF HjEMOCYTOMETRY 
 RECOMMENDED. 
 
 [Since the above was written, Professor Pappenheim 
 has published a description of new apparatus devised 
 by him for collecting blood and for enumerating the 
 cell elements. He regards this apparatus as simpler 
 and more accurate than any other, and accordingly 
 now recommends its use in place of that described 
 above in the text. He has now abandoned all other 
 methods. 
 
 Pipettes. — With the above-mentioned pipettes it 
 is not always easy without practice to suck up fluid 
 accurately to the desired mark. The rubber tubing 
 
 Fig. 1. — Pipette. 
 
 is apt to perish, and it is further objectionable on 
 hygienic grounds. These defects are remedied in 
 his new form of pipette, which is constructed as 
 follows (Fig. 1). 
 
 A narrow glass tube or cap, closed at one end, is 
 slid over the upper part or neck of the pipette. 
 
HMMOCVTOMETRY 51 
 
 This glass cap is so ground that it fits accurately 
 round the pipette, thus forming what is practically 
 an air-tight junction. 
 
 This can be slid up or down, and constitutes the 
 suction apparatus. 
 
 The almost perfect vacuum which can thus be 
 produced was not found to work satisfactorily in 
 practice. 
 
 It was difficult to expel the last drops of fluid, and 
 the rate of suction was too rapid and abrupt. Accord- 
 ingly the closed top-end of the cap was made of 
 slightly wider calibre, so as not to grasp the pipette 
 so tightly. 
 
 Hence, when the cap is pushed home, a tiny cushion 
 of air remains. The vacuum produced by with- 
 drawing the cap is therefore rendered an imperfect 
 one. 
 
 The difficulties above referred to were thus got 
 over. Now, however, owing to this imperfect 
 vacuum, the mixing bulb of the erythrocyte pipette 
 could not be filled by one effort of suction. Pappen- 
 heim overcame this difficulty by adopting Portman's 
 device. 
 
 This consists in the addition to the pipette of a 
 second small ampulla placed further up the stem of 
 the pipette beyond the mixing-bulb. It is provided 
 with lateral openings through which air may enter 
 or escape. 
 
 In drawing up fluid into the pipette, these lateral 
 openings are closed by the fingers, while the cap, 
 
52 CLINICAL EXAMINATION OF THE BLOOD 
 
 which had previously been pushed down to its full 
 extent, is slid upwards. 
 
 When the existing vacuum has been satisfied, 
 before all the required amount of fluid has been 
 drawn in, the fingers are removed from the lateral 
 openings in the upper ampulla. This allows the 
 cap to be pushed well down again over the pipette 
 without disturbing in the process the level of fluid 
 in the latter. The lateral openings are again 
 closed, and suction is resumed by sliding the cap 
 upwards as before. 
 
 HOOzqmm - 
 
 IfflMiiii piB l 
 
 Pappenheim 
 
 Fig. 2. — Counting-slide. 
 
 The presence of the lateral openings also allows 
 the cap to be removed for shaking purposes if desired. 
 Prof. Pappenheim, however, effects the mixing by 
 grasping the pipette near each end, and turning it 
 to and fro between the fingers. 
 
 Counting-chamber. — As already indicated, Prof. 
 Pappenheim recommends the Btirker form of count- 
 ing-chamber in preference to any other. As 
 
HMMOCYTOMETRY 53 
 
 accurate apposition of the cover-glass (proved by 
 the presence of Newton's rings) is difficult, and can 
 only be obtained by careful manipulation, he prefers 
 the use of clamps in order to maintain equable 
 pressure. These grasp the cover-glass and slide, the 
 latter being grooved on its under surface to receive 
 the lower limbs of the clamp (Fig. 2). 
 
 The cover-glass is placed in position and clamped, 
 after which the fluid is allowed to run in between the 
 cover-slip and the central counting-surfaces. 
 
 Of the many methods of ruling, Prof. Pappenheim 
 recommended till recently that of Tiirk as described 
 
 above. In all these methods, however, he recog- 
 nized defects, chief among which is the liability to 
 confusion owing to the crossing of so many different 
 lines. He has now obviated this objection by adapt- 
 ing to the Biirker chamber Goriaew's method of 
 ruling, which he has modified in some degree. 
 
 The counting-field is marked off in a series of 
 squares, certain of which are again subdivided into 
 sixteen smaller ones (Fig- 3). 
 
54 CLINICAL EXAMINATION OF THE BLOOD 
 
 The squares thus further subdivided are so arranged 
 that they are separated from each other on every 
 side by the breadth of two squares of similar size 
 but without smaller subdivisions. There are four 
 rows, each containing four of the subdivided squares, 
 and each row is separated from the other by the 
 breadth of two undivided squares. There will there- 
 fore be 4 X 4 = 16 squares, each of which is sub- 
 divided into sixteen smaller ones. These squares 
 are used in the enumeration of the red blood cor- 
 puscles. Since each of these squares is separated 
 from its neighbour by the breadth of two undivided 
 squares, it follows that there must be 4x9 or 
 3 X 12 = 36 squares not subdivided further. On 
 these the leucocytes are counted. In dealing with 
 leukaemic blood all the squares must be counted. 
 
 The whole apparatus is Tiere illustrated, and can 
 be obtained from the firm of E. Leitz. — R. D.] 
 
 THE DIFFERENTIAL COUNTING OF 
 LEUCOCYTES. 
 
 For this a stained blood film is necessary. The 
 procedure is as follows. The name of each type of 
 cell found in normal blood, as well as the names of the 
 various pathological cells likely to be met with, are 
 written down on a sheet of paper, each name heading 
 a separate vertical column. As each field is counted, 
 the number of each separate type of cell found is 
 entered in the column under its proper heading. 
 
 The relative percentage of one to the other is now 
 easily estimated. 
 
HMMOCYTOMETRY 55 
 
 First of all, each vertical column is added up, thus 
 giving the total number of each type of cell present. 
 Then the total number of all leucocytes counted is 
 found by adding together the sums of all the vertical 
 columns, i.e., by adding together the various sums 
 contained in the horizontal column at the bottom 
 of the vertical ones. 
 
 Let S = the total number of all cells present. 
 N = the number of cells in one vertical column, 
 
 i.e., cells of one type. 
 X = the required percentage of this particular 
 
 kind of cell. 
 
 The value of X will be found by means of a simple 
 proportion sum : — 
 
 S : N = ioo : X. 
 In order to find the value of X we need only 
 multiply N by ioo and divide by S : — 
 N x ioo 
 
 S 
 To obtain a correct value for X, as large a number 
 of fields as possible should be counted, that is to say, 
 the largest possible number of cells should be counted. 
 Let us suppose that we count a total number of 500 
 (S = 500), the percentage (X) of any one type of cell 
 will be found by multiplying the number (N) of cells 
 of the type in question by 2 and dividing the product 
 by 10. This is obtained by the following formula : — 
 
 v _ N x 100 _ N x 100 x 2 _ 2N 
 500 500 X 2 10 
 
56 CLINICAL EXAMINATION OF THE BLOOD 
 
 THE RELATIVE PROPORTION 
 OF CELLS FOUND IN NORMAL BLOOD. 
 
 1. In the adult male the red cells (R) amount to 
 5 millions per c.mm. ; in the female the amount 
 varies from 4 to 5 millions. 
 
 2. The leucocytes (W) amount at most to between 
 5000 and 10,000. Anything over 10,000 is patho- 
 logical. The higher counts within physiological 
 limits are generally found during digestion. 
 
 3. The normal ratio, therefore, W : R must be 
 somewhere between 1 : 500 and 1 : 1000 (i.e., must 
 be -002 and -ooi). 
 
 4. The relative percentage of the various types of 
 normal leucocyte to each other is as follows : — 
 
 Small and large lymphocytes . . 20-22 per cent 
 Mononuclears . . . . . . 2-6 „ 
 
 Polymorphonuclear neutrophils 70-75 „ 
 „ eosinophils 2-6 „ 
 „ mast cells 0- 1 „ 
 
 PATHOLOGICAL VARIATIONS IN 
 
 NUMBER, AND 
 THEIR DIAGNOSTIC SIGNIFICANCE. 
 
 VARIATIONS IN THE NUMBER OF RED 
 BLOOD CORPUSCLES. 
 
 An abnormal increase in the absolute number is 
 called polycythemia. It is the cardinal sign in cases 
 of plethora or idiopathic polycythemia, especially in 
 the so-called myelopathic polycythemia accompanied 
 
HJEMOCYTOMETRY 57 
 
 by splenomegaly (erythremia or Vaquez' disease) and 
 also in Gaisbock's hypertonic type. There is also 
 a local or regional erythrocytosis in swellings confined 
 to the extremities. Lastly, a temporary erythremia 
 may be met with in the blood at high altitudes where 
 the barometric pressure is low, in general congestive 
 processes, and in congenital cyanosis, etc. 
 
 Diminution in the number of red blood corpuscles, or 
 oligocythemia as it is called, is the cardinal feature 
 of every anaemia, together with an absolute oligo- 
 chromaemia as determined by haemoglobin estimation. 
 
 CHANGES IN THE WHITE COUNT. 
 
 1. In the absolute number. Increase in the 
 absolute number — hyperleucocytosis — is, when present, 
 one of the most frequent and striking signs of a 
 simple secondary functional leucocytosis. Such a 
 condition is present in constitutional intoxications 
 such as cancer, and in general organismal infec- 
 tions (sepsis, appendicitis, etc.), which act on the 
 haemopoietic system. 
 
 Further, although not the most essential, it is 
 nevertheless the most important sign, from a practical 
 point of view, met with in leukaemic conditions, where 
 a still higher degree of leucocytosis may be reached. 
 
 An absolute hyperleucocytosis, however, is not the 
 most essential sign of the presence of a leucocytic 
 irritation or of a leukaemic hyperplasia of the haemo- 
 poietic system. This sign may even be absent where 
 a lesion of the haemopoietic system exists. Hence, 
 
58 CLINICAL EXAMINATION OF THE BLOOD 
 
 if present, this sign is only of passing interest, and 
 merely affords proof that the lesion in question has 
 led to a quantitative blood change. 
 
 Not infrequently, leucocytic and leukemic lesions 
 (as recognized by the qualitative changes in the blood) 
 may exist side by side with very insignificant altera- 
 tions in number. Such quantitative changes may 
 be absent altogether, or there may even be a diminu- 
 tion in the leucocyte count, as in the leucopenia of 
 typhoid and in aleuksemic pseudoleukemia. Even 
 when hyperleucocytosis is present, a differential 
 diagnosis between these two conditions cannot 
 always be made with certainty merely on the strength 
 of a blood count, as there is an extraordinarily high 
 leucocytosis on the one hand and a relatively small 
 blood count on the other. They are to be distin- 
 guished from one another rather by the quality of 
 the blood cells. For instance, in simple leucocytosis 
 it is always one particular type of mature cell that is 
 increased, e.g., leucocytes, lymphocytes, or mono- 
 cytes. Occasionally, their immediate precursors may 
 also appear in the blood. On the other hand, both 
 in lymphatic and myelogenous leuksemia the most 
 essential and constant characteristic is the presence 
 of the whole series of atypical progenitors of the 
 mature cell, including even the original parent cells. 
 Mature leucocytes and lymphocytes may, in fact, be 
 absent even in acute cases. 
 
 When there is a diminution in the absolute number 
 the condition is called hypoleuco.cytosis or leucopenia. 
 
H&MOCYTOMETRY 59 
 
 This is found, for instance, especially in typhoid and in 
 measles, and is of value as a means of distinguishing 
 these from perityphlitis and Rotheln. 
 
 It is not diametrically opposed to hyperleucocytosis 
 even when it appears from the first as a leucopenia, 
 e.g., in typhoid. It ought rather to be regarded as 
 differing in degree only, since high degrees of leuco- 
 cytosis, or leucocytosis of long standing, may merge 
 into leucopenia. When this occurs, especially if 
 accompanied by the presence of early forms in the 
 blood, it indicates commencing exhaustion of the 
 overtaxed bone-marrow. 
 
 2. Variations in the Relative Percentages.— A 
 hyperleucocytosis may consist in a simultaneous 
 increase of the various types of cell present in normal 
 blood, with the addition, in pathological lesions, of 
 their progenitors. 
 
 This is the case in mixed-cell myelogenous leu- 
 kaemia. In the functional leucocytoses, on the other 
 hand, there is an increase in one type of cell only. 
 This may lead to an absolute hyperleucocytosis, 
 provided the other cells remain unaffected. The 
 increase in one type of cell, however, may be merely 
 relative, and take place at the expense of the others. 
 
 There is a certain antagonism in function between 
 neutrophils and their lymphoid progenitors on the 
 one hand, and lymphocytes and eosinophils on the 
 other. Hence, owing to a selective attraction for one 
 kind of cell, a direct or indirect repulsion of the other 
 types will take place. These latter will then diminish 
 
60 CLINICAL EXAMINATION OF THE BLOOD 
 
 more rapidly in proportion or relatively, as a result 
 of this negative chemiotaxis. 
 
 Thus it comes about that in cases of partial relative 
 leucocytosis, a normal count, or even a leucopenia, 
 may be observed if we take the total number of 
 leucocytes present into consideration. 
 
 In this way a relative lymphocytosis is very often 
 encountered, along with a relative neutropenia and 
 a general leucopenia (leucopenic lymphocytosis), 
 e.g., in Banti's disease, Biemer's disease, typhoid,* 
 measles.t etc. 
 
 A Relative Neutrophilia or Neutrophil 
 Polynucleosis is the most important type of leuco- 
 cytosis provoked by an irritant. In addition to that 
 occurring during the digestion of albumins, it is 
 found in the majority of general intoxications, 
 bacterial infections (especially in granulomatous 
 conditions of the lymphatic glands), and after the 
 exhibition of adrenalin. Under the title of secondary 
 concomitant leucocytosis it is met with in all kinds 
 of anaemias and cachexias as a result of morbid 
 products circulating in the blood and producing a 
 leucocytosis by irritation — an irritation leucocytosis. 
 It is met with in the majority of ordinary functional 
 leucocytoses. In other words, the greater number of 
 
 * It is of importance in the differential diagnosis of this 
 condition from appendicitis and epidemic cerebrospinal 
 meningitis. 
 
 ■f Of value in the differential diagnosis between measles 
 on the one hand and scarlet fever and Rotheln on the other. 
 
HMMOCYTOMETRY 61 
 
 functional leucocytoses are characterized by a partial 
 relative increase in the number of neutrophil cells. 
 
 Frequently, but by no means invariably, these 
 latter overstep the normal limits and lead to an 
 increase in the absolute number. 
 
 Thus it comes about that an absolute hyper- 
 leucocytosis always goes hand in hand with a relative 
 increase in the neutrophil cells owing to the existence 
 of a special attraction for the latter. Of course, it is 
 also possible for a relative increase in neutrophils to 
 co-exist with a normal or diminished absolute count. 
 The latter is just as much the result of the same 
 neutrophil-provoking stimulus as is an absolute 
 neutrophil hyperleucocytosis itself, and, as such, has 
 exactly the same significance. It is only to be 
 distinguished from the latter (i.e., from an absolute 
 increase in neutrophils) by the fact that it occurs 
 only in occasional cases. 
 
 To put the matter in another way, it is to a certain 
 extent an accident to find an absolute hyperleuco- 
 cytosis of neutrophils (i.e., a relative neutrophilia 
 with hyperleucocytosis is equivalent to hyperleuco- 
 cytosis, the result of an increase in the neutrophil 
 elements). 
 
 A corresponding lesion may exist, not only without 
 any quantitative or qualitative change in the blood 
 cells, as compared with the normal, but there may 
 even be an absolute leucopenia although there is a 
 co-existing relative increase in the neutrophils. In 
 affections of the blood, the most essential proof of 
 
62 CLINICAL EXAMINATION OF THE BLOOD 
 
 the existence of a neutrophil-provoking stimulus is 
 relative neutrophilia, which may occur when the 
 leucocytes have undergone an absolute increase, i.e., 
 in hyperleucocytosis as well as when there is a general 
 leucopenia. Increase or diminution of the absolute 
 cell count is therefore only of secondary importance 
 in diagnosing the presence of an irritation inducing 
 a neutrophil increase. Neutrophil leucopenia, i.e., 
 relative increase in neutrophils with an absolute 
 leucopenia, is only one particular type of neutrophil 
 leucocytosis. 
 
 The presence of an irritant capable of inducing an 
 increase in the neutrophil variety of cell may, there- 
 fore, be inferred from the following : — 
 
 (a). Quantitative blood changes : (i) Absolute neutro- 
 leucocytosis (with relative increase in neutrophils) ; 
 (ii) Relative neutrophilia alone. 
 
 (b). Qualitative changes, such as the appearance in 
 the circulation of their ontogenetic predecessors, 
 e.g., myelocytes and metamyelocytes. 
 
 Thus, the most constant and essential sign always 
 present in the three varieties is a relative neutrophilia 
 as in (a-ii), i.e., with or without absolute leuco- 
 cytosis. An absolute leucocytosis as in (a-i) is 
 generally, but not necessarily, present. The presence 
 of early forms is similarly found only in cases 
 where a process of regeneration happens to be 
 going on. 
 
 The chemiotactic leucocytpses are as a rule 
 characterized only by an increase in one particular 
 
HMMOCYTOMETRY 63 
 
 type of cell.* A relative neutrophilia with or 
 without reduction in the absolute count develops 
 at the expense of the lymphocytes and eosinophils. 
 In other words, it is accompanied by a lymphopenia 
 and an eosinopenia. The relative diminution in 
 such cases is, therefore, indirectly produced and is 
 without significance.t It does not bear the same 
 relation to absolute leucopenia that a relative leuco- 
 cytosis does to an absolute one. At the same time 
 a relative cell increase is met with as one of the 
 phenomena in absolute leucopenia. The latter, too, 
 is generally merely the occasional concomitant of a 
 relative increase. Absolute leucopenia has therefore 
 nothing to do directly with a relative reduction - in 
 number. 
 
 A simultaneous increase of all the granular cell 
 elements is seen only in typical mixed-cell leukaemias. 
 
 A Relative Eosinophils simply expresses the 
 condition of eosinophil leucocytosis. The eosinophils 
 never appear to be increased in number to such an 
 extent as to lead to an absolute leucocytosis. Further, 
 
 * The laws governing this double chemiotaxis (e.g., for 
 lymphocytes and eosinophils) are unknown up to the present. 
 
 f The laws which govern direct negative attraction, 
 i.e., repulsion (chinin, lactic acid, aggressins, etc.), such as 
 is actually seen in cases of measles and typhoid especially, 
 are still in doubt. In this respect we may mention that, 
 in addition to functional repulsion from the blood as well 
 as from the tissues, mere impairment of cell output, 
 of cell formation, or of cell development, may be met with, 
 as well as combinations of these. 
 
64 CLINICAL EXAMINATION OF THE BLOOD 
 
 eosinophilia has not hitherto been observed in cases 
 of absolute leucopenia. It is met with in asthma 
 (both during and apart from the attacks), in conditions 
 of vagus irritation, such as mucous colitis, and the 
 exudative diathesis generally, and in helminthiasis 
 of various kinds, as for example, in that due to cysti- 
 cercus, echinococcus, and distoma, but not in that 
 due to ascaris or to tape-worm. In this latter type 
 of case it is of value as a means of differential diagnosis 
 from tuberculous meningitis and typhoid. 
 
 Partial lymphocytosis is found in cases where 
 stimuli of various kinds are at work to cause hyper- 
 trophy_of the lymphatic apparatus. It is also seen 
 in poisoning by pilocarpine and during the process 
 of fat-digestion. 
 
 In the functional lymphocytoses, the ontogenetic 
 precursors of the lymphocyte are met with during 
 the period of regeneration. These are cells which 
 have merely a small rim of cytoplasm, and are there- 
 fore nearly all nucleus. 
 
 In cases of hypertrophic lymphadenitis, lympho- 
 cytosis is generally characterized by the presence 
 of parent lymphocytes. Further, an absolute and 
 relative increase in lymphocytes is found in cases 
 of lymphosarcoma, where occasionally the blood 
 assumes a leukemic character. It is present also in 
 tuberculous and syphilitic lesions affecting the 
 mucous membranes, whereas in corresponding affec- 
 tions of the lymphatic glands neutrophilia is the rule. 
 It may be combined with a vagotropic eosinophilia. 
 
HMMOCYTOMETRY 65 
 
 In cases of pernicious anaemia,* Banti's disease, 
 and typhoid, we sometimes find a relative lympho- 
 cytosis, frequently associated with a direct relative 
 neutropenia which may merge into absolute leuco- 
 penia (i.e., leucopenic relative lymphocytosis). 
 
 Monocytosis frequently accompanies lympho- 
 cytosis (e.g., in Banti's disease) and the rarer cases of 
 polynucleosis. In the latter case they are really the 
 myelogenous leucoblastic monocytes met with in 
 leucocytoses caused by an irritant. In malaria and 
 in certain other protozoal infections like variola, 
 monocytosis alone appears even more frequently. 
 Lastly, in children, monocytes are present normally 
 in larger numbers. 
 
 * Here it is not a question of true lymphocytes, but 
 of microleucoblasts. 
 
66 
 
 Chapter III. 
 
 HMMOGLOBINOMETRY : 
 OR THE ESTIMATION OF HAEMOGLOBIN. 
 
 METHOD AND TECHNIQUE. 
 
 THE method of most importance in blood 
 examination is the estimation of the haemo- 
 globin. 
 
 The apparatus best suited for the consulting-room 
 and in cases where very accurate precision is not 
 essential, is Sahli's hsemometer (an improved Gower's 
 haemoglobinometer). The principle of the Gower's 
 apparatus is as follows : A definite amount of blood 
 taken from a normal individual, and laked with 
 a known quantity of distilled water, is preserved in a 
 small sealed tube. A second tube, open at one end, 
 is so graduated from 10 to ioo that the same amount 
 of blood diluted in exactly the same way and showing 
 the same tint stands at the mark ioo. The normal 
 is therefore ioo. 
 
 A blood of half the depth of colour, which therefore 
 contains only half the amount of haemoglobin 
 contained in normal blood, will only require to be 
 diluted up to the mark 50 in order to match the tint 
 in the comparison tube. 
 
 As the haemoglobin solution deteriorates in the 
 
HMMOGLOBINOMETRY 67 
 
 light, the tint will not keep. Sahli's apparatus, 
 therefore, contains, instead of natural haemoglobin, 
 a haemin solution. To make this up, a decinormal 
 solution of HC1 is required, and can be easily had 
 from any chemist. The method of procedure is as 
 follows. Before drawing the blood, some of the 
 ~ a HC1 is run in up to the mark 10 by means of a 
 fine pipette.* Then blood is drawn up to the mark 
 on the capillary pipette provided with Sahli's 
 apparatus. 
 
 The outside and the point of this pipette must now 
 be cleansed of any blood adhering to it. The 
 pipette is then inserted into the graduated tube, and 
 the contents of the pipette are carefully blown out 
 into the — HC1 contained in the bottom of the tube. 
 
 The pipette is then rinsed by repeatedly drawing 
 up into it some of the mixture and blowing it out 
 again, care being taken to avoid the formation of 
 bubbles. 
 
 The blood immediately turns a brownish tint 
 owing to the formation of haematin chloride. This 
 haemin solution is next diluted by adding distilled 
 water, by means of a second capillary pipette, up to a 
 point when the tint of the comparison tube has just 
 been matched. 
 
 The haemoglobin value is then read off directly 
 from the graduated tube as so much per cent. The 
 
 * Best of all, thin-walled pipettes, graduated in cubic 
 millimetres. 
 
68 CLINICAL EXAMINATION OF THE BLOOD 
 
 normal haemoglobin value of an adult male is ioo 
 per cent ; in females it is about 90 per cent, but 
 before menstruation it may be slightly higher. 
 
 ESTIMATION OF HEMOGLOBIN— NEW 
 METHOD RECOMMENDED. 
 
 [Since writing the above, Professor Pappenheim 
 informs me that he has adopted a new method of 
 estimating the amount of haemoglobin which he now 
 recommends in place of the Sahli described above. 
 While the latter is sufficiently accurate for general 
 practice, and is easily manipulated, it has certain 
 defects. 
 
 First of all it takes up time, for after mixing the 
 blood and HC1, ten minutes must elapse in order to 
 allow the full depth of colour to form. 
 
 Thereafter, the further dilution with water must 
 be made drop by drop till the desired tint is obtained. 
 
 Secondly, this drop-method, together with the 
 small content of the tube, is apt to lead to errors in 
 estimation. 
 
 These are obviated by the new apparatus which 
 he now advocates. 
 
 Like the Sahli method it is a colorimetric one. 
 The same quantity of blood is taken with the same 
 kind of pipette, and this is converted into haemin by 
 the addition of HC1 as before. 
 
 This quantity now remains a constant which is 
 not further diluted, thus differing from the Sahli 
 method. 
 
HMMOGLOBINOMETRY 69 
 
 The standard solution is contained in a wedge- 
 shaped glass vessel, and therefore shows all grada- 
 tions in depth of colour between the two ends. 
 This wedge is placed alongside the sample of blood 
 to be examined, and, being movable, can be shifted 
 upwards or downwards till it matches the depth of 
 colour in the blood sample. 
 
 Apart from the time necessary for the haemin to 
 realize its full depth of colour, the comparison takes 
 only about three minutes. 
 
 The instrument is known as the Autenrieth- 
 Koenigsberger Haemocolorimeter. — R. D.] 
 
 SEMIOLOGY. 
 
 An increase in haemoglobin beyond the normal, 
 Pleiochromcemia as it is called, is found, as one would 
 expect, in various conditions where the red cells are 
 increased in number. In such conditions the indi- 
 vidual erythrocytes have a normal Hb content, i.e., 
 are normochromatic. More rarely they are hypo- 
 chromatic, but never hyper chromatic. General pleio- 
 chromaemia is thus quite independent of hyper- 
 chromasia of the individual erythrocytes. Absolute 
 pleiochromaemia, therefore, depends only on an 
 increase in the number of erythrocytes, i.e., on 
 polycythaemia. 
 
 A diminution or general Oligochromcemia is the 
 cardinal sign of all anaemic conditions, in the broadest 
 sense of the term. It may be the result of an oligo- 
 cythemia (the morphological evidence of which is 
 
70 CLINICAL EXAMINATION OF THE BLOOD 
 
 degenerative anisocytosis, poikilocytosis, and scisto- 
 cytosis), but it does not necessarily follow. 
 
 It is seen not only where the individual cells show 
 hypochromasia, but also where hyperchromasia is 
 present, and even in anochromasia as in chlorosis. 
 Oligochromaemia is thus completely independent 
 of hypochromasia. The simple estimation of haemo- 
 globin, without reference to any other data, can 
 furnish no information concerning the kind or char- 
 acter of the oligochromaemia in question. Apart 
 altogether from a microscopic examination of the 
 film, the number of red blood corpuscles must also 
 be known. For instance, in chlorosis, or green- 
 sickness as it is called, there is an absolute deficiency 
 in Hb — an oligochromaemia while the count remains 
 normal. The individual erythrocytes are, however, 
 too pale and do not stain well. 
 
 On the other hand, in the ansemias proper, oligo- 
 chromaemia is always associated with oligocythaemia, 
 of which it is merely the result. Oligocythemia, so 
 far as it is concerned, is represented microscopically 
 by the presence of various degenerate malformed 
 cells (such as anisocytes and poikilocytes). 
 
 Hence, taking all the signs together, so far as they 
 are met with in the erythrocyte element of the blood, 
 we find the following : — 
 
 In Chlorosis. — Oligochromaemia plus normo- 
 cythaemia (i.e., a normal number of erythrocytes) 
 plus chlorosis of the individual erythrocytes as 
 determined microscopically ; in other words, general 
 
HMMOGLOBINOMETRY n 
 
 oligochromaemia plus normocythaemia composed of 
 well-formed but chlorotic erythrocytes. 
 
 In the Anaemias. — Oligochromaemia due to oligo- 
 cythemia of malformed hypochromatic or hyper- 
 chromatic anisocytes ; in other words, oligochrom- 
 aemia plus oligocythemia plus anisocytosis, the cells 
 of which may show under the microscope either 
 hypochromasia or hyperchromasia. 
 
 It follows that, for purposes of differential diagnosis, 
 an oligochromaemia plus normocythaemia, where the 
 cells are of normal shape, indicate chlorosis. If 
 however, along with oligochromaemia, we find oligo- 
 cythaemia plus degenerated malformed cells, the 
 case is one of the varieties of true anaemia. For 
 purposes of differential diagnosis, therefore, between 
 chlorosis and true anaemia, the crucial sign is not 
 oligochromaemia, but the presence or absence of 
 oligocythaemia. In chloro-anaemia, chlorosis is com- 
 bined with anaemia. The diagnosis in this case can 
 only be made after microscopic examination. 
 
 THE COLOUR INDEX. 
 
 The relationship of the Hb value to the number 
 
 of erythrocytes present is called the Hb index 
 
 or the colour index. The index for normal blood 
 
 is i. This number is arrived at by multiplying 
 
 the ratio between the normal Hb value and the 
 
 normal number of erythrocytes by 50,000. 
 
 100 X 50,000 
 
 Thus =1, i.e., the numerator — the 
 
 5,000,000 
 
 haemoglobin value — is multiplied by 50,000. 
 
72 CLINICAL EXAMINATION OF THE BLOOD 
 
 The pathological index must be either greater or 
 less than i. It is got by multiplying by 50,000 the 
 value obtained from the ratio between the Hb and 
 the number of erythrocytes, or, for convenience sake, 
 by multiplying by 100,000 and dividing the product 
 by 2. 
 
 Thus we obtain the following formula : — 
 
 Normals - 
 
 Hb 
 
 (.erythrocytes. 
 Hb 
 er 
 
 =1, 
 
 Hb 
 
 i.e., normal 
 
 1 = 
 
 (erythrocytes . 
 ( Hb) 
 
 found = ? 
 
 found : X 
 
 i.e. 
 
 100 
 
 5,000,000 
 (Hb 
 
 1 = 
 
 X = 
 
 er 
 
 Hb 
 
 er 
 
 Hbj 
 er J 
 Example : — 
 
 found x 
 
 er 
 Hb 
 er 
 
 5,000,000 
 100 
 
 found : X 
 
 found x 50,000 
 
 = \ [ found x 
 
 100,000 
 
 In a case of anaemia the Hb is found to be 55 per 
 cent, while the number of erythrocytes equals 2 
 
 55 
 
 millions. The colour index for - 
 
 2,000,000 
 
 -is calculated 
 
 as follows :- 
 55 
 
 X 
 
 100,000 _27'5 
 
 275 
 
 2,000,000 2 20 
 
 i.e., an index greater than 1. 
 
 = 1-375 
 
HMMOGLOBINOMETRY 73 
 
 SEMIOLOGICAL. 
 
 Two main varieties of anaemia are distinguished, 
 according to their pathogenesis. Anaemia may 
 result from loss of blood, from destruction of blood, 
 or from damage to the blood ; less frequently from 
 diminished blood-formation on the part of the bone- 
 marrow (myelopathic anaemia). In the first case it 
 is mainly an occasional occurrence, and is then 
 secondary to regeneration on the part of the blood 
 (secondary regenerative myelopathy)-. In the second 
 case it is the result of an increased secondary destruc- 
 tion of the blood-cells, especially affecting the hypo- 
 plastic, immature red cells of low vitality. 
 
 In the same way, two different kinds of anaemia 
 may be distinguished from a symptomatic point of 
 view, according as the haemoglobin diminishes more 
 rapidly than the erythrocyte count or, vice versa, 
 according as the number of erythrocytes drops more 
 rapidly than the Hb. In the first case the colour 
 index is less than i, in the latter it is greater than i. 
 It is easy to understand that in the first case, for the 
 haemoglobin to undergo a greater diminution than 
 the number of cells, the loss in the latter must be 
 more quickly made good than that of the Hb, for the 
 newly-formed erythrocytes are still poor in Hb (i.e., 
 show polychromasia). 
 
 Further, in the second case, where the number of 
 cells decreases more quickly than the Hb, the latter, 
 even when free in the plasma, must be relatively 
 more resistant than the lipoids of the stroma (Ehrlich) 
 
74 CLINICAL EXAMINATION OF THE BLOOD 
 
 or those set free in the course of erythrolysis. Again, 
 it is suggested that where the index is greater than i, 
 in the process of regeneration by reversion to the 
 embryonic method of blood-formation, the Hb 
 should be, relatively at least, more rapidly restored, 
 owing to the presence of a special variety of hyper- 
 chromatic cell abnormally rich in Hb, when compared 
 with the reduction in the cell-count as a result of 
 erythrolysis. 
 
 The theory put forward to explain the first type of 
 anaemia may be the true one. The other two theories 
 urged, however, are not sufficient to explain the facts 
 observed in the second type. 
 
 There is no doubt that these two different types of 
 blood, differing in their semiology, do not correspond 
 to two varieties of anaemia which differ in their 
 pathogenesis (hsemopoietic and myelopathic). The 
 blood picture of the first is not the equivalent of that 
 found in haemopathic forms of anaemia. It is much 
 more likely that they are both merely the expression 
 of two different kinds of haemopathic anaemia (simple 
 hypochromatic and pernicious hyperchromatic). 
 
 The hyperchromatic anaemias are not synonymous 
 with the primary myelopathic varieties. It is true 
 that the former may also be of myelopathic origin, 
 but it is not a sine qua non. Similarly, the hypo- 
 chromatic anaemias may also be of myelopathic origin, 
 and vice versa, the myelopathic anaemias are generally 
 hypochromatic, i.e., have a diminished colour index. 
 
 The evidence of pernicious anaemia rests on hyper- 
 
HJEMOGLOBINOMETRY 75 
 
 chromasia alone (i.e., on a high colour-index) as 
 determined by the microscope, not on myelopathy 
 from the pathogenic point of view. 
 
 Toxic myelopathy brings about increased formation 
 of red blood-cells and leads to the entry into the 
 blood of megaloblasts, which, however, are not 
 specific proof of the presence of pernicious anaemia. 
 Hence the latter may also be found in simple hypo- 
 chromatic anaemia. The myelopathic anaemias are, 
 therefore, for the most part hypochromatic, while 
 the haemopathic anaemias are either hypochromatic 
 or hyperchromatic. 
 
 The simple hypochromatic anaemias are both 
 haemopathic and myelopathic, while the hyper- 
 chromatic anaemias are a special form of anaemia and 
 are always of the haemopathic type. Thus, the two 
 varieties of haemopathic anaemia are distinguished 
 from one another, according as their index is greater 
 or less than 1. 
 
 In many conditions of theoretical and practical 
 interest, such as polycythaemia and chlorosis, the Hb 
 index is of special diagnostic importance (semio- 
 logical and pathogenetic) for the proper understanding 
 of anaemias. In all anaemias, both in those due to 
 diminished blood formation and in those caused by 
 increased blood destruction, the numerator and the 
 denominator are diminished as compared with the 
 normal. 
 
 This simultaneous reduction in both, however, is 
 by no means uniformly proportional, for, if so, the 
 
76 CLINICAL EXAMINATION OF THE BLOOD 
 
 index would always remain equivalent to i. As a 
 matter of fact, it is sometimes the numerator (the 
 Hb) and sometimes the denominator (the cell count) 
 that is reduced relatively more than the other, 
 according to the particular kind of anaemia in question. 
 
 In the first case the result is a fraction, i.e., is less 
 than i. In the second it is an improper fraction, 
 i.e., is greater than i. 
 
 In the first case there is both an absolute and a 
 relative diminution in the Hb (oligochromsemia). 
 In the second there is merely an absolute diminution 
 in the total Hb content, with a relative pleiochrom- 
 aemia. 
 
 The colour index, especially when it is patho- 
 logical, is by no means evidence merely of anaemia. 
 It serves another purpose, for it is of value in the 
 differential diagnosis of anaemias, and, for this 
 purpose, we recognize a diminished and an increased 
 index respectively. Thus, apart altogether from the 
 anaemias proper, there is also a diminished index in 
 polycythaemia and in chlorosis. A diminished index, 
 especially if there is no other sign present, cannot be 
 regarded as a sign of anaemia, whereas an increased 
 colour index is. 
 
 Oligochromaemic normocythaemia is present in 
 chlorosis where there is a diminished index, but 
 between the number of normocytes (denominator) 
 and the oligochromaemia (numerator) there is no 
 direct causal connection. 
 
 On the other hand, the colour index in anaemia 
 
H&MOGLOBINOMETRY 77 
 
 proper, whether diminished or increased, always 
 depends on an oligochromaemia, the latter being the 
 result of oligocythemia. 
 
 A diminished index in anaemia accompanies and 
 is the result of an absolute oligocythaemic oligo- 
 chromaemia together with a relative oligochromaemia. 
 As such, it is the direct functional reflex of hypo- 
 chromasia of the cell as seen under the microscope. 
 
 On the other hand, an increased index in anaemia 
 is the general semiological expression of an absolute 
 oligocythaemic oligochromaemia together with relative 
 pleiochromaemia, and as such is the functional reflex 
 of the hyperchromasia seen in the cells under the 
 microscope. 
 
 Hypochromatic anaemias accordingly mean the 
 same thing as anaemias with lowered colour index, 
 while hyperchromatic anaemias correspond to anaemias 
 with increased colour index. Hence, in the hypo- 
 chromatic type of anaemia the index is less than 1, 
 i.e., a fraction whose numerator is smaller than the 
 denominator. 
 
 In the so-called simple secondary anaemias (haemo- 
 pathic and myelopathic) the Hb is increased in 
 greater proportion than the blood-count. 
 
 In the second class, embracing anaemias which are 
 really only haemopathic, the index is greater than 1. 
 They include the specific pernicious or hyperchro- 
 matic anaemias. These latter are not myelopathic 
 merely, but are really also haemopathic, and may be 
 so even db initio. In any case they may be regarded 
 
78 CLINICAL EXAMINATION OF THE BLOOD 
 
 as mixed types of anaemia which are simultaneously 
 hemotoxic and myelotoxic* in origin. Further, the 
 myelopathic anaemias are not always characterized 
 by an index greater than i, and vice versa, an index 
 greater than i points to a form of anaemia which is 
 hyperchromatic on microscopical examination of the 
 cells. In other words, a high index has its histo- 
 logical counterpart in cell hyperchromasia. As a 
 high index in anaemia is only one manifestation of a 
 general anaemic oligochromaemiat (not of pleio 
 chromaemia) resulting from oligocythaemia, and as 
 the latter has its microscopic counterpart in the de- 
 generative malformations (anisocytosis, poikilocytosis, 
 schizocytosis), so a high index in anaamia indicates 
 malformed cells which microscopically are hyper- 
 chromatic. At all events, hyperchromatic anaemia 
 in a symptomatological sense does not coincide with 
 myelopathic anaemia in a pathological sense. Hence, 
 a diminished index by itself is not an indication of 
 anaemia, but only when associated with oligo- 
 cythaemia. Further, a low colour index in anaemias 
 is found in the simple haemopathic and, in the myelo- 
 pathic varieties. On the other hand, not every 
 diminished colour index indicates a haemopathic 
 
 * In myelotoxic anaemias, megaloblasts make their 
 appearance. 
 
 f Polycythaemia is accompanied by general pleio- 
 chromasmia, where the index is generally equal to i, rarely 
 less than I, and never greater than i . In the above condition, 
 however, there is a microscopic hyperchromasia. 
 
HMMOGLOBINOMETRY 79 
 
 anaemia, nor is every haemopathic anaemia charac- 
 terized by a diminished index. An increased index, 
 however, is always a sign of anaemia (oligocythemic 
 in character), and as such indicates a hyperchromatic 
 form of haemopathic anaemia. 
 
 Hence, we find a diminished colour index in 
 chlorosis, myelopathic anaemia, simple haemopathic 
 anaemia showing hypochromasia, and even in poly- 
 cythaemia. 
 
 On the other hand, an increased colour index is a 
 sign only of haemopathic anaemia, hyperchromatic in 
 character. 
 
 A diminished index, whether occurring in anaemia 
 or not, is generally the indirect result of a general 
 oligochromaemia, and is the direct expression of 
 relative hypochromasia of the cells as seen from the 
 histological point of view. An increased index is 
 always found in anaemia, and accompanies oligo- 
 cythaemia, and, as such, indicates a relative hyper- 
 chromasia regarded histologically. 
 
 Not every diminished colour index indicates 
 oligochromaemia. 
 
 Not every diminished colour index indicates 
 oligocythaemia. 
 
 Not every diminished colour index indicates 
 anaemia. 
 
 Not every oligochromaemic index' is less than i. 
 
 Not every oligochromaemic index indicates anaemia. 
 
 Not every oligocythaemic index is less than i. 
 
 A polycythaemic and pleiochromaemic index may 
 
80 CLINICAL EXAMINATION OF THE BLOOD 
 
 be a diminished one. Every oligocythemic index 
 is an index of anaemia, and vice versa . 
 
 Not every index of anaemia is less than i. 
 
 Not every oligochromaemic index has its histo- 
 logical counterpart in hypochromasia. 
 
 Not every oligocythaemic index has its microscopic 
 counterpart in hypochromasia. 
 
 Every increased index is always merely an index 
 of anaemia, and is consequently oligocythaemic. 
 
 Every increased index in anaemia has its counter- 
 part microscopically in hyperchromasia of the cells. 
 
 Every index in anaemia, whether increased or 
 diminished, is always oligocythaemic. 
 
 If we consider together the whole group of evidence 
 furnished by the erythrocytes, viz., the type of cell, 
 its Hb content, the number of cells, and the total 
 Hb content, we find : — 
 
 In Chlorosis : Oligochromaemia, normocythaemia, 
 an index less than i, normally shaped cells with a 
 partial (central) anochromasia (chlorotic normal 
 cells). 
 
 In Simple Secondary Anaemia of Haemopathic 
 Origin : Oligochromaemia, an index less than i, 
 malformed cells showing diffuse hypochromasia 
 (hypochromatic malformed cells). 
 
 In Pernicious Hyperchromatic Anaemia of 
 Haemopathic Origin : Oligochromaemia, oligo- 
 cythemia, an index greater than i, malformed cells 
 with hyperchromasia (hyperchromatic malformed 
 cells). 
 
H&.MOGLOBINOMETRY 81 
 
 Or, in other words : — 
 
 Chlorosis : = Oligochromaemic normocythaemia 
 with an index less than i owing to anochromasia. 
 
 Anaemia —Oligochrornaemic oligocythaemia.which 
 may be (i) Simple anaemia, with an index less than i 
 owing to hypochromasia ; or (2) Pernicious anaemia, 
 with an index greater than 1, owing to hyperchro- 
 masia. 
 
 Hence an index higher than 1 always means 
 hyperchromasia of the cells, while an index less than 
 1 indicates hypochromasia, or chlorotic anochromasia. 
 
 Summary. 
 
 General Pleiochromaemia always depends on an 
 increased number of red cells and never merely on a 
 cell hyperchromasia, where the cell count is normal, 
 i.e., it depends on polycythaemia. 
 
 General Oligochromaemia is not necessarily 
 associated with oligocythaemia, but is found in anaemia 
 and chlorosis. Only the oligochromaemia seen in 
 anaemia results from oligocythaemia, that is to say, 
 is oligocythaemic. In chlorosis it depends on partial 
 anochromasia of normally-formed erythrocytes which 
 are present in normal numbers. In anaemias it 
 depends on oligocythaemia, where there are hyper- 
 chromatic or hypochromatic anisocytes and poikilo- 
 cytes, and never solely on hypochromasia of normally- 
 formed cells present in normal numbers. 
 
 Absolute Oligocythaemia (per se, together with 
 oligochromaemia) always indicates anaemia, of which 
 
 6 
 
82 CLINICAL EXAMINATION OF THE BLOOD 
 
 it is the cardinal sign. Anaemia is accordingly an 
 oligocythemic oligochromaemia. 
 
 This oligocythemia (always anaemic) is an accom- 
 paniment of malformed cells (anisocytes and poikilo- 
 cytes), which are its morphological basis. In simple 
 hypochromatic ancemia an absolute oligocythaemia 
 and a relative oligochromaemia occur together with 
 hypochromasia of the cells, i.e., the index is less 
 than i. 
 
 In the Pernicious Hvperchromatic Anaemias, 
 absolute oligocythaemic oligochromaemia and relative 
 pleiochromaemia co-exist with hyperchromasia of the 
 cells, histologically speaking, i.e., the colour index 
 is greater than i. Absolute oligochromaemia may 
 or may not mean anaemia. It may be associated 
 with an index greater or less than i, and, histo- 
 logically, with ano-, hypo-, or hyper-chromasia of 
 the cells. 
 
 Absolute oligocythaemic (i.e., anaemic) oligo- 
 chromaemia may co-exist with an index greater or 
 less than i, with relative oligochromaemia, or pleio- 
 chromaemia, and with hypo- and hyper-chromasia of 
 malformed cells as seen histologically. 
 
 Relative oligochromaemia in cases of general oligo- 
 cythaemic (anaemic) oligochromaemia is represented 
 by a diminished anaemic index. Relative pleio- 
 chromaemia has nothing to do with absolute pleio- 
 chromaemia, but is always merely one sign of anaemia. 
 Hence it is associated with absolute oligocythaemic 
 oligochromaemia, and is represented by an increased 
 index. 
 
HMMOGLOBINOMETRY 83 
 
 The key to simple chlorotic normal-celled oligo- 
 chromaemia is chlorosis of the cells. 
 
 The key to anaemic oligocythemia is the degenerate 
 malformed erythrocyte. 
 
 The key to a lowered anaemic index in oligo- 
 cythaemic oligochromasia is the hypochromatic 
 malformed cell. 
 
 The key to an increased anaemic index in oligo- 
 cythaemic oligochromaemia is the hyperchromatic 
 malformed cell. 
 
84 
 
 INDEX, 
 
 PAGE 
 
 Adrenalin, relative neutrophilia 
 
 caused by . . . . 60 
 
 Aggressins . . . . . . 63 
 
 Agranulocytes . . . . . . 7 
 
 Amitotic cell division .. .. 37 
 
 Amphochromatophil . . . . 22 
 
 Anaemia, 10, n, 13, 15, 17, 27, 60, 
 70, 71, 73, 75, 76, 77 
 
 — aplastic . . . . 10, 28, 29 
 
 — bothriocephalus . . . . 31 
 
 — chloro- . . 11, 12, 16, 29, 71 
 
 — haemopathic . . 74, 75, 77, 78, 79 
 
 — haemopoietic . . . . 74 
 
 — hyperehromatic, 28, 29, 38, 42, 
 
 74, 75, 77, 78, 79 
 
 — hypochromatic 28, 74, 75, 77, 82 
 
 — myelopathic, 28, 73, 74, 75, 77, 
 
 78, 79 
 
 — pernicious secondary, 11, 13, 18, 
 
 27, 28, 29, 31, 42, 65, 74, 75, 
 77, 80, 81, 82 
 
 — pseudo- 10 
 
 — reactionary pernicious non- 
 
 aplastic . . . . 29 
 
 — secondary . . 11, 27 
 
 — simple secondary, 13, 28, 29, 42, 
 
 77, 80, 81 
 
 — splenic of v. Jaksch 31, 42 
 
 — toxic 16, 17, 28, 29, 30, 38 
 
 hyperehromatic , . 37 
 
 Anisocytes, 28, 29, 70, 7i, 81, 82 
 Anisocytosis, 10, 11, 27, 29, 70, 7 1 , 
 
 78 
 
 Anochromasia, io, 12, 29, 30, 70, 80, 
 
 81, 82 
 
 Appendicitis, leucocytes in, 57, 60 
 
 Arsenic . . . . . . • • 3° 
 
 Ascaris infection, leucocytes in 64 
 Asthma, eosinophilia in 64 
 
 Autenrieth-Konigsberger appar- 
 atus . . . . . . 69 
 
 Azur substance 3, 19, 21, 26 
 
 ■ myeloid . . . . . . 23 
 
 Bacterial infections . . . . 60 
 
 Banti's disease, leucocytes in, 60, 65 
 Basophilia, punctate, 9, 15, 16, 17, 
 18, 26, 28, 29, 30 
 Biermer*s disease . . 60 | 
 
 page 
 Biermer's disease, blood picture in, 31 
 Blood, normal elements in . . 6 
 Bone-marrow, 15, 16, 17, 24/28, 29, 
 30, 31, 39, 59 
 Biirker's ruling . . . . 46 
 
 — counting-chamber 43, 45, 52, 53 
 
 Cachexias . . . . . . 60 
 
 Cancer . . . . . . 57 
 
 Cells, irritation- . - 25 
 
 — plasma . . 25, 26 
 Cell-type, Rieder's-, 25, 36, 37, 41 
 Cerebrospinal meningitis . . 60 
 Chemiotaxis . . . . 60, 63 
 Chloro-ansemia, 11, 12, 16, 29, 71 
 Chloro-leuksemia . . . . 16 
 Chlorosis, io, 12, 13, 16, 18, 27, 70, 
 
 7i, 75, 76, 79, 80, 81, 83 
 
 — blooa-picture in . . 29, 30 
 
 — blood-platelets in . . 18, 30 
 — - microscopic changes in 27 
 Chromatolysis . . . . . . 13 
 
 Chronic lead-poisoning . . 16 
 
 Congenital cyanosis . . . . 57 
 
 Colour-index, 71, 72, 75, 76, 77, 79, 
 
 80 
 Corpuscles — 
 
 — cytoplasm of . . ..16 
 — : degeneration forms of 10, 18 
 
 — early forms of . . . . 12 
 
 — haemoglobin content of . . 10 
 
 — immature in simple leuco- 
 
 cytosis . . . . 19 
 
 — immaturity of, 12, 16, 17, 18, 28 
 
 — normal , . . . . . 6 
 
 — ontogenetic precursors of .. 19 
 
 — orthochromatic 7. 16 
 
 — pathological forms of . . 17 
 
 — phylogenetic precursors of . . 19 
 
 — polychromasia of . . . . 22 
 
 — variations in number of . . 56 
 Counting-chamber, Biirker's, 43, 45, 
 
 52, 53 
 
 — Pappenheun's modification of 53 
 Countmg, differential . . . . 54 
 Cysticercus infection, leucocytes 
 
 in 64 
 
 Cytoplasm, immaturity of . . 18 
 
 — amphochromatophil . . 22 
 
INDEX 
 
 85 
 
 _ PAGE 
 
 Degeneration of haemoglobin, 
 
 17, 18 
 
 Diathesis, exudative . . . . 64 
 Difference between leucocytoses 
 
 and leukaemias . . 34, 35, 5a 
 lymphatic and myelo- 
 genous leukaemias re- 
 spectively . . . . 37 
 Diffuse basic protoplasm . . 17 
 Digestion of albumin, neutro- 
 philia in . . . . 60 
 
 — fats 64 
 
 Diluting fluid for red cells . . 43 
 
 for white cells . . . . 44 
 
 Distoma infection, leucocytes in 64 
 
 Dualists . . . . 24, 40 
 
 Echino coccus infection, leuco-. 
 
 cytes in . . . . . . 64 
 
 Ehrlich . . , . ^, 31, 73 
 
 Eosinopenia . . . . . . 63 
 
 Eosinophil, 8, 22, 36, 39, 41, 59, 63 
 
 Eosinophilia . . . . 63, 64 
 
 Erythremia . . 57 
 
 Erythroblastic apparatus 27, 30 
 
 Erythroblastosis . . 28, 38 
 Erythroblasts, 12, 14, 16, 17, 22, 28, 
 
 29, 3i 
 
 Erythrocyte, 14, 15, 16, 17, 28, 69 
 
 — immature . . . . 17 
 
 — in chlorosis . . . . 70, 71 
 
 — morphological changes in . . 9 
 
 — polychromasia of, 9, 15, 16, 22, 
 
 29, 3o t 73 
 
 Erythrogonia . . 14 
 
 Erythrolysis . . . . . . 74 
 
 Fat digestion 
 
 64 
 
 Gaisbock's type of cell . . 57 
 Giemsa's stain . . . . 4, 5 
 Goriaew's ruling, Pappenheim's 
 
 modification of . . . . 53 
 
 Gower's haemoglobinometer . . 66 
 
 Granulocyte . . 40, 4 1 
 
 HiEMATiN chloride 67 
 
 Haemin . . . . . . 67, 69 
 
 Haemoblasts . . . . 14 
 
 Heemocolorimeter, Autenrieth- 
 
 Konigsberger's . . . . 69 
 
 Haemoglobin content . . 10, 69 
 
 degeneration of . . 17, 18 
 
 in chlorosis . . 70 
 
 hyperchromatic anaemias 75 
 
 hypochromatic anaemias 75 
 
 hypoplasia of . . 10 
 
 normal value of . . 68 
 
 Haemoglobinometer . . . . 66 
 
 Haemometer, Sahli's . . 66, 67 
 
 Haemopathic amemia, primary 28 
 
 PAGE 
 
 Haemopoietic apparatus, granu- 
 lomatous affections of . . 26 
 
 irritation of . , . . 32 
 
 Haemorrhages, toxic . . . . 30 
 
 Helminthiasis, eosinophilia in . . 64 
 Hyperchromasia, n, 12, 28, 69, 70, 
 7i, 74. 77, 78, 79, 80, 81, 82 
 Hyperleucocytosis 57, 59, 61, 62 
 Hypermetaplasia . . . . 32 
 
 Hypertrophic lymphadenitis . . 64 
 Hypochromasia, 10, n, 12, 15, 28, 
 29. 30, 70, 71, 77, 79, 80, 81, 82 
 Hypoleucocy tosis . . . . 58 
 
 Immature red cells, 12, 16, 17, 19, 28 
 — leucocytes . . . . . . 18 
 
 Immaturity of cell, pathological 
 
 sign of 18 
 
 Index, colour . . . . 71, 77 
 in differential diagnosis of 
 
 ansemias 
 
 
 76 
 
 normal . . 
 
 
 7i 
 
 oligochromaemic 
 
 79, 
 
 80 
 
 oligocythemic 
 
 79, 
 
 80 
 
 pathological 
 
 72, 
 
 75 
 
 pleiochromaemic 
 
 
 79 
 
 polycythemic 
 
 
 79 
 
 Infections, bacterial 
 
 
 60 
 
 Intoxications 
 
 57, 
 
 60 
 
 Irritation cells . . 
 
 
 25 
 
 — leucocytosis . . 
 
 ■ 37, 38, 
 
 60 
 
 — neutrophilia . . 
 
 
 62 
 
 Isocytosis 
 
 
 II 
 
 Von Jaksch's anaemia 31, 42 
 
 Jenner's stain . . 3 
 
 Jolly-bodies . . 13, 14, 17 
 
 Karyorrhexis 13, 14 
 
 Klein-Gumprecht shadow nuclei 25 
 
 I^e ad-poisoning, chronic . . 16 
 
 — blood picture in . . . . 29 
 I^eptochromatic nucleus . . 23 
 I^eucoblast 21, 22, 23, 24, 26, 
 
 33. 38, 40, 41 
 
 — non-granular lymphoid . . 36 
 leucocytes . . 7, 38, 58, 62 
 
 — degeneration forms. . . . 25 
 
 — dwarf polynuclear . . . . 36 
 
 — eosinophil 8, 22, 36, 39, 41, 59, 63 
 
 — giant polynuclear . . . . 36 
 
 — immature forms . . . . 18 
 
 — non-granular basophil 36 
 
 — non-granular oxyphil . . 36 
 
 — pathological varieties of 18, 31 
 
 — percentage of 8, 55, 57, 59 
 
 — polynuclear 8, 19, 20, 23, 38, 41 
 I^eucocytosis, simple 18, 19, 26, 
 
 30, 33. 35, 36, 39, 59. 60 
 
 — absolute . . . . 62, 63 
 
86 
 
 INDEX 
 
 PAGE 
 
 Leucocytosis, active . . . . 32 
 
 — chemiotactic . . , . 62 
 
 — eosinophil . . . . 63 
 
 — functional 32, 38, 59, 6o, 61, 64 
 
 — hyperplastic 37 
 
 — immature red cells in . . 19 
 
 — irritation . . 37, 38, 60, 65 
 
 — leucopeuic type of . 33 
 
 — leuksemic . . . . 26, 33, 57 
 
 — metaplastic . . . . 32, 42 
 
 — neutrophil . . . . . . 62 
 
 — passive . . 32 
 — ■ relative . . . . . . 63 
 
 — repulsion . . • • 32 
 
 — secondary .. .. 32, 57 
 concomitant 60 
 
 — toxic . . . . . 32 
 Leucopenia . . 38, 58, 59, 6q 
 
 — absolute . . 6i t 62, 63, 64 
 
 — neutrophil . . . . 62 
 Leucopoietic apparatus, hyper- 
 plasia of . . . . . . 32 
 
 Leucosarcoma cells of Sternberg 24 
 leukaemia, ' 24, 26, 32, 33, 35, 
 
 38, 40, 42 
 — ■ acute lympho- . . . . 36 
 
 — aleukemic . . . . 33 
 
 — atypical . . 36, 37, 40, 41 
 
 — hyperplastic . . 32, 37 
 
 — lymphoidocy te . . . . 31 
 
 — mixed-cell . . 63 
 
 — myeloblastic . . 2.4, 40 
 
 — myelogenous 19, 32, 33, 36, 
 
 37, 39, 4P. 58, 59 
 
 — myeloid 22, 24, 35, 39, 40 
 
 — neutral type of . . . . 31 
 
 — neutrophil . . . . - ■ 39 
 
 — parent cell . . . . 24 
 Leukansemia .. .. 31, 42 
 T^ymphadentitis," hypertrophic 64 
 Lymphaemia .. .. 35, 37 
 Lymphatic glands, granulo- 
 matous . . . . 60, 64 
 
 — leucocytheemia 19, 32, 34, 
 
 37, 39, 40, 58 
 Lymphoblastic macrolympho- 
 
 cytes . . . . 19, 34 
 
 Lymphocytes 33, 38, 39, 58, 
 
 59t 63. 65 
 
 — large . . . . 7, 19, 26 
 
 — parent forms of . . 19, 24, 64 
 
 — pathological . . 24 
 
 — polymorph . . . . . . 37 
 
 •^- small ... 7, 24, 26, 36 
 
 lymphocytosis 18, 32, 33, 34, 42 
 
 — absolute . . . . . . 64 
 
 — ieucopenic . . 60 
 
 — partial . . 64 
 
 — relative . . 6o, 64, 65 
 Lymphoid mononuclear cells 7, 
 
 22, 26, 39 
 
 PAGE 
 
 Lymphoid mononuclear cells, 
 
 hyperplasia of . . 35 
 
 immature 41 
 
 — myelocyte . . 2r, 40 
 
 parent form . . 14, 35 
 
 Lytnphoidocyte 22, 23, 25, 26, 
 
 33. 34. 36, 39i 40, 4i 
 -^- nucleus of . . 23, 24 
 
 — polymorphonuclear . . 36 
 Lymphopenia . . 63 
 Lymphopoietic apparatus, hyper- 
 plasia of . . • ■ 32 
 
 Lymphosarcoma . . . . 64 
 
 Macrocytes- . . . . 12, 13, 28 
 Macrolymphocytes 7, 21, 23, 
 
 24, 26, 35, 36, 38 
 — ■ lymphoblastic . . 19, 34 
 
 Malaria 65 
 
 Malarial parasite . . 27 
 
 Mast cells . . 8, 36, 39, 41 
 
 dwarf . . . . . . 36 
 
 in leukaemia . . - • 34 
 
 May-Giemsa stain, Pappen- 
 
 heira's modification of . . 3 
 May-Grixnwald's stain-. . 3. 4, 5 
 Measles, leucocytes in 60, 63 
 
 Megakaryocytes . . . . 34 
 
 Megaloblasts 12, 13, 16, 17. 
 
 28, 29, 30^ 74, 75, 78 
 Meningitis, cerebrospinal . . 60 
 
 — tuberculous . . , . . . 64 
 Menorrhcea . . . . . . 30 
 
 Menstruation . . . . 15, 68 
 
 Mercury . . 30 
 
 Metamyelocyte 20, 23, 33, 62 
 
 Microcytes . . . . 10, r 2 
 
 Microleucoblast . . 24, 65 
 
 Microlymphoidocyte . . 24 
 
 Mitoses in leucocytoses . . 3© 
 
 — in leukaemias . . . . 36 
 
 Monocytes 19, 2r, 23, 26, 58, 65 
 Monocytosis . . . . . . 65 
 
 Mononuclear lymphoid cell 7, 
 
 . 22, 26, 39 
 Mucous colitis, eosinophilia in 64 
 
 — membranes, syphilis of . . 64 
 
 tubercle of . . 64 
 
 Myelsemia 37, 41 
 
 Myelocytes 20, 21, 22, 23, 
 
 33, 37, 38, 62 
 Myelocythsemia 19, 28, 25, 34, 79 
 Myelocytosis ... . . 37, 39 
 
 Myeloid azur substance . . 21 
 
 — ■ leukaemia .. 22, 24 
 
 Myelolymphocy tes , . . 24 
 
 Myelopathy, toxic ... . . 75 
 
 — secondary regenerative . , 73 
 Myelotoxic . . 78 
 
 Neutropenia ' 
 
 60, 65 
 
INDEX 
 
 87 
 
 l'AGE I 
 
 Neutrophil leucocytes . . 8, 61 ' 
 
 — promyelocyte . . 22 
 
 — series . . . . . . 22 
 
 Neutrophilia 60, 61, 62, 63, 64 
 
 Normoblasts 12, 16, 28, 29, 30 
 
 Normocytes 10, 11, 28, 69, 76 
 
 Normocythzemia 70, 71, 76, 80, 81 
 Nuclear vestiges .. 13, 14 
 
 — multiple remains 17, 18 
 Nuclei, Klein- Gumprecht shadow 25 
 Nucleoli of lymphoidocyte . . 23 
 Nucleus, radial . . . . 12, 13 
 — • leptochromaticof lymphoido- 
 
 cytes . . . . 23, 24 
 
 — immaturity of . . ..18 
 
 OLIGOCHROM.EM1A 27, 57, 69, 
 
 70, 71, 76, 77, 78, 79. 80, 
 
 81, 82, 83 
 Oligochromatic . , . . . . 13 
 
 Oligocythaemia 11, 27, 57, 69, 
 70, 71, 77, 78, 79, 80, 81, 
 
 82, 83 
 Ontogenetic antecedents of poly- 
 morphs . . . . . , 20 
 Orthochromatic 13, 14, 15, 16 
 
 Pachychromatic 24 
 
 Pappenheim's ruling . . 53 
 
 — stain . . . . . . . . 3 
 
 Parasite, malarial . . . . 27 
 
 Parent cell leukaemias . . . . 24 
 
 — lymphocytes . . 19, 24, 64 
 Percentage of leucocytes 8, 55, 
 
 57, 59 
 Perityphlitis . . . . 59 
 
 Pernicious anaemia n, 13, 18, 
 27, 28, 29, 31, 42, 65, 74, 
 
 75, 77, 80, 81, 82 
 
 blood picture in 28, $v 
 
 platelets in 
 
 Pilocarpine poisoning 
 Pipettes, Thoma-Zeiss 
 ■ — Pappenheim's 
 Plasma cells 
 Platelets 
 Pleiochromaemia 
 
 18 
 .. 64 
 43. 44 
 50, 51 
 27, 26 
 .. 6, 18, 30 
 69. 7&, 77, 
 78, 81, 82, 83 
 Poikilocytes 9, 18, 28, 29, 70, 81, 82 
 Poikilocytosis 10, 11, 12, 17, 
 
 27, 29, 30, 70, 78 
 Poisoning, chronic lead 16 
 
 Polychromasia 9, 15, 16, 22, 
 
 29, 30, 73 
 Polychromatic 13, 16, 17, 22 
 
 Polychromatophilia . . . . 28 
 Polycytheemia 27, 56, 69, 75, 
 
 76, 78, 79, 81 
 Polynuclear leucocytes 8, 19, 
 
 20, 23, 38, 41 
 
 PAGE 
 
 Polynuclear leucocytes, onto- 
 genetic antecedents of 20, 33 
 
 phylogenetic antecedents 
 
 of . . 20 
 
 Polynucleosis, relative 60, 65 
 
 Portman's device . . 51 
 
 Proerythroblasts 14 
 
 Promyelocyte 21, 22, 23, 33, 37, 38 
 Protozoal infections . . . . 65 
 
 Pseudo-leukeemia . . . . 42 
 
 — - aleukaemic . . . . . . 58 
 
 Punctate basophilia 9, 15, 16, 
 
 17, 18, 26, 28, 29, 30 
 Pycnosis . . . . 14 
 
 Pycnotic . . . . . . ..13 
 
 Radial nucleus 
 Radkern 
 
 Regeneration of cells, 
 normal 
 
 — pathological , . 
 Rieder's cell type 25 
 Romanowsky stain 
 Rotheln, leucocytes in 
 Ruling, Barker's 
 
 — Goriaew's 
 
 — Pappenheim's 
 
 — Tiirck's 
 
 12, 13, 22 
 12 
 signs of 
 
 • • i7 
 16, 17 
 36, 37, 41 
 4, 5 
 59, 60 
 •■ 53 
 -• 53 
 -- 53 
 46, 53 
 
 Sahli's hsemometer . . 66 
 
 Scarlet fever, leucocytes in . . 60 
 Schistocytosis . . 10, 70, 78 
 
 Sepsis . . ... . . . . 57 
 
 Signs of immaturity of cell . . 18 
 Splenic anaemia of v. Jaksch 31, 42 
 Splenomegaly . . . . 56 
 
 Spongioplasm . . 14 
 
 Stain, Jenner's . . 3 
 
 — May-Giemsa's . . . . 3 
 
 — May-Grunwald's . . 3, 4, 5 
 
 — Pappenheim's . . . . 3 
 Stained cells, appearance of 5, 6 
 Staining technique . . 4, 5 
 Sternberg's leucosarcoma cells 24 
 Syphilis of mucous membranes 64 
 
 Tape-worm infection, leuco- 
 cytes in . . . . 64 
 Technique of staining . . 4, 5 
 Transition forms of leucocyte. . 32 
 Tuberculous lesions of mucous 
 
 membranes . . . . 64 
 
 — meningitis 64 
 Tiirck's method of ruling 46, 53 
 Typhoid, leucopenia in 58, 59, 
 
 60, 63, 64 
 
 — relative lymphocytosis in . . 65 
 
 Variola . . . . 65 
 
 Vaquez' disease.. .. .. 57 
 
 Vestiges, nuclear 13, 14, 17, 18 
 
 4355.14 JOHN WRIGHT AND SONS LTD., PRINTERS, BRISTOL. 
 
Large 8vo, Fully Illustrated in Black and White, and Colours. 
 
 21/- net. 
 
 THE BIOLOGY OF THE 
 BLOOD-CELLS 
 
 WITH A 
 
 Glossary of Hematological Terms. 
 For the Use of Practitioners of Medicine. 
 
 By O. C. GRUNER, M.D. Lond., 
 
 Author of "Studies in Prtncture-jluids" ; "A Cade-system for the Hospital 
 
 Pathologist" 
 
 Pathologist to the Royal Victoria Hosp. and to the Maternity Hosp., Montreal; 
 
 Assistant Professor of Pathology, AfcGill University, Montreal, etc.; 
 
 Late Clinical Pathologist, General Infirmary, Leeds. 
 
 With 23 Full-page Plates (7 being beautifully Coloured) and 
 jmany Illustrations (some Coloured)* in the Text. 
 
 Contents. 
 
 Introduction.— I. The Primordial Blood-Cell.— -II. The Red 
 Blood-Cell. III. The Lymphocyte. — IV. The Large Mononuclear 
 Leucocyte.— V. — The Neutrophil Leucocyte. — VI. — Certain Phlogo- 
 cytes. VII. — The Cytoplastic Phenomena of Blood-Forming Tissues. 
 
 Abbreviations employed. — References to the Literature. — Glossary 
 of Hematological Terms. — General Index — Index of Diseases referred 
 to. — Index of Animals referred to. — Index of Authors referred to. 
 
 Early Press Notices. 
 
 "Is well worth study by those who would acquire a knowledge of the existing 
 opinions in a most difficult field. Fully illustrated and contains many diagrams and 
 schemes of methods ot blood formation." — Lancet. 
 
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 of medicine, probably, has it been accorded so much attention all at once. It embodies 
 not only all we know about the blood-cell, hut a vast amount which we did not know. . . 
 Profusely illustrated by drawings, micro-photographs, and coloured plates. A really 
 excellent idea of the subject. . . . The remarkably complete glossary is a very useiul 
 feature which cannot fail greatly to assist the reader . . . Altogether an epoch-marking 
 contribution to the study of the blood-cells." — Med. Press &* Circ. 
 
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 cogitate on the problems of cell development." — Universal Med. Record. 
 
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