Chronic marrow failure,myelosclerosis and extramedullary hematopoiesis

Thirty cases, including 20 autopsied, of chronic bone marrow failure, myelosclerosis and osteosclerosis have been presented and compared with similar reportsin the literature. The bone marrow histopathologic sequence observed involvedrepeated necrobiosis of maturing hematopoietic cells, followed by overgrowth ofmarrow reticulum and frequent ossification. Immature erythrocytes and leukocyteswere often found in the circulation, and extrameduallary hematopoiesis was characteristic. One case was complicated by leukemia. Etiologic factors implicatedincluded exogenous toxic chemicals, liver dysfunction, endocrine abnormalities,blood loss or destruction and cardiovascular disease. Suspicion was directed towardthe pathogenetic importance of protracted bone marrow exposure to certain substances normally conjugated rapidly in the liver and excreted.

Note: ACKNOWLEDGMENTThe authors acknowledge gratefully the continued assistance of Dr. John Norcross and Dr. DonatP. Cyr of Lahey Clinic, Boston, who permitted use of material from living cases.We are indebted to Dr. Shields Warren, New England Deaconess Hospital, Boston, for permissionto review 10 cases; to Dr. Olive Gates, Harvard Medical School, for advice and assistance with 7 cases,including material from the Collis P. Huntington Hospital; to Professor William Boyd for 5 cases fromBanting Institute, Toronto; to Dr. Paul D. Rosahn, New Britain General Hospital, New Britain, Conn.,and Dr. William Dameshek for one case; to Dr. A. J. Blanchard for several cases from Christie St. Hospital, Toronto; to Drs. Lorne Whittaker and Sabin of St. Catherine’s Hospital for one case; and to Dr.John Brownlee for hematologic studies from one case.

     

THE TREATMENT OF LYMPHOBLASTIC LEUKEMIA WITH CRUDE MYELOKENTRIC ACID

Eight cases of blastic lymphoid leukemia have been treated with myelokentricacid in crude form, because hypothetically in blastic lymphoid leukemia there isa deficiency of this material. The crude myelokentric acid was used because it wasmore easily obtained than partially purified material. Purification of biologicallyactive materials by methods of extraction and precipitation necessarily results in aconsiderable loss of material. Thirteen partial remissions occurred following theadministration of crude myelokentric acid. Seven of the 8 patients have died, and5 necropsies were performed.

The necropsy material adds further weight to the belief that the remissions wereinduced by the myelokentric acid in that in all 5 necropsies there was a definitealteration in the histologic morphology as contrasted with the findings in thenecropsies of the controls.

It seems inadvisable, however, to treat a large number of patients with this material because it is crude, it is relatively unavailable, and no standard dose has yetbeen devised.

Note: We wish to t hank Dr. D. L. Turner and Dr. W. A. Hause for valuable assistance in this work.

     

The use of folic acid antagonists in the treatment of acute and subacute leukemia

In summary, the folic acid antagonists have, in varying degrees, the capacity toinduce remissions in about one third of the cases of acute and subacute leukemia, inadults as well as in children, and in both leukemic and leukopenic forms.

Clinical, hematologic and (to lesser extent) marrow remissions, are obtainedmost commonly in the lymphoblastic types, least often in the monocytic types.

It is possible that folic acid is required by the primitive white cell as a growthfactor. The folic acid antagonists, which resemble folic acid so strikingly in chemical structure, may result in cell death by modifying various enzyme systems withinthe primitive cells.

Both clinical and hematologic observations indicate that the proliferative processis by no means cured with aminopterin treatment. Acute leukemia may be likenedto "wildfire" which, although damped by aminopterin, continues to "smolder."This smoldering may suddenly light up again into an active leukemic picture, unless continued maintenance therapy is given. Despite maintenance therapy, therefinally comes a point in the leukemic process at which both the leukemia and increasing toxicity to drug make further progress impossible, and the patient dies.

Other growth factors or enzymes are probably of at least as great an importanceas PGA in the metabolism of the primitive white cells and when these are discovered and their antagonists synthesized, the therapeutic results in acute leukemiamay be of more consistent and durable nature. It should be realized further thatchemotherapeutic methods against leukemia and the leukocytic proliferations ingeneral (and, in fact, against all proliferative disease) are at least in their veryinfancy. The results thus far obtained in acute leukemia, although to large extentdisappointing, indicate that well-defined remissions can be secured in about a thirdof the cases. For a disease such as acute leukemia, in which remissions previouslywere highly unusual and of sporadic nature, this indicates a well-defined therapeutic advance and a need for continued investigation along the same general lines.

Differences in results obtained by various groups of workers are difficult to explain. Several points may nevertheless be considered: some of the workers havegiven inadequate dosage of drug or have failed to use maintenance therapy; somehave given folic acid in conjunction with anti-folic acid therapy; in some cases, acrude folic acid antagonist was used; and it is possible that some cases were notobserved as minutely as seems necessary. An important factor, which can be determined only by the study of a large group of cases, is the natural variability ofacute leukemia from case to case. We have the impression that our best results areobtained in the relatively subacute cases. The fulminating cases, with rapid onsetof bleeding and a quick downhill course, are only slightly affected.

     

Refractory megaloblastic anemia

1. Fifty-nine cases of megaloblastic anemia refractory partially or completelyto potent liver extracts given parenterally have been investigated in Edinburghduring the past six years. Thirty-four of these cases were associated with pregnancy, the puerperium or the sprue syndrome. No explanation of the cause of themegaloblastic anemia was discovered in the remaining 25 cases.

2. The etiology, clinical features and treatment of 25 cases of idiopathic refractory megaloblastic anemia are described. Attention is directed to the excellenttherapeutic effects produced by proteolysed liver or folic acid.

3. The mechanisms involved in refractoriness to potent parenteral liver extractsare discussed.

4. In certain cases of refractory megaloblastic anemia it is suggested that an unknown hematinic principle, in addition to the liberating factor in purified parenteral liver extract and folic acid, is required for the complete restoration of normoblastic blood formation.

Note: ACKNOWLEDGMENTSMy thanks are due to many members of my staff who have helped in theseinvestigations, particularly to Professor L. J. Davis formerly lecturer in Medicinein the University of Edinburgh, and to Dr. Girdwood. Grateful acknowledgmentmust also be made to Doctor Riding, Medical Director of Evans Medical SuppliesLtd. and his research chemists who were responsible for the preparation of proteolysed liver and the other fractions of liver mentioned above.

     

The mechanism of petechial hemorrhage formation

1. The capillary resistance test has been studied by a special technic of capillarymicroscopy.

2. Seventeen cases of hemorrhagic diseases of differing etiology have been thusstudied.

3. The site of capillary hemorrhage has been localized to the arteriolar end ofthe capillary loop.

4. Selective damage to the arteriolar-capillary junction will explain manytypes of hemorrhagic syndromes.

Note: ACKNOWLEDGMENTI wish to thank the honorary staff of the Westminster Hospital for permission to study cases undertheir care. I am much indebted to Dr. P. Hansell and Miss F. E. McAdoo of the Westminster HospitalDepartment of Medical Photography for assistance with the illustrations.

     

Response of tropical sprue to vitamin B12

These findings show that the administration of vitamin B₁₂ to patients with tropical sprue was followed by general clinical and hematologic improvement providedthe dosage was adequate. A single dose of 4 micrograms administered in case 4produced little or no change. The larger dosage of 10-25 micrograms administeredin the other cases was accompanied by striking increase in strength and vigor anda decrease in the diarrhea; however, in no instance was a maximal dose given andthese patients quickly tended to relapse clinically and hematologically. Theycould be relieved promptly again either by another injection of vitamin B₁₂ orby a compound of folic acid. (The conjugated compounds of folic acid used in thesecases were used for experimental purposes, and they produced the same hematologicresponse as that of folic acid per se.) Case 3, who had an excellent hematologicresponse after eating one serving of 400 grams of liver, is regarded as especiallysignificant in that it suggests that, as powerful as vitamin B₁₂ is as a therapeuticagent, it is more effective when given with liver. It is especially noteworthy thatcases 1 and 2, who had three injections of vitamin B₁₂, have had steady clinicaland hematologic improvement. The reader should have in mind that a singleinjection of approximately 100 micrograms of vitamin B₁₂ probably would beneeded to produce a full hematologic response in persons so ill. This tentative appraisal would suggest that this therapeutic compound, per unit of weight, is moreeffective in treating human disease than any compound that yet has been used.

Note: ACKNOWLEDGMENT We are very much indebted to others who have aided us in selecting cases and in observing results.Especially we wish to thank Dr. F. Hernandez-Morales, Dr. Hector Marchand, Miss Clemencia Benitez-Gautier, and Miss Sara Torres.

     

The development and progression of subacute combined degeneration of the spinal cord in patients with pernicious anemia treated with synthetic pteroylglutamic (folic) acid

1. Twenty-one patients with pernicious anemia were maintained on syntheticfolic acid (pteroylglutamic acid) therapy alone for periods ranging from eight toseventeen months. Satisfactory blood levels were maintained in all cases receivingdaily oral doses of 1.25 to 15.0 mg. Severe hematologic relapse occurred withinsix months in a case treated with monthly injections of 30 mg.

2. Synthetic folic acid in oral doses of 15 mg. daily induced satisfactory hematopoietic responses in 3 patients with pernicious anemia in severe relapse, but onlyslight hematopoietic response in a fourth patient with mild pernicious anemiabut severe subacute combined degeneration of the spinal cord.

3. Ten patients showed a significant improvement in blood values for a fewmonths after substitution of folic acid for liver extract. With one exception thesesubsided after six or more months to pre-folic acid levels comparable with thosepreviously maintained with liver extract alone.

4. These observations suggest that a combination of orally administered folicacid and parenterally injected liver extract may maintain a better hematologicstatus than either substance alone.

5. A previously untreated patient with severe subacute combined degenerationof the spinal cord failed to show improvement in neural disease during twentyeight days of folic acid therapy.

6. Eleven patients developed, or showed progression of, subacute combineddegeneration of the spinal cord during folic acid treatment. Neurologic diseasedeveloped in most of these patients when the peripheral blood was normal.

7. One patient showed an extremely explosive onset and rapid progression ofneural disease. The progression of the disease was rapid in 3 other cases.

8. The institution of liver extract therapy in adddition to folic acid in 5 patientswho developed subacute combined degeneration during folic acid maintenancetherapy failed to prevent progression of the disease in 4 cases, and only partiallyarrested the disease in the fifth, in which improvement occurred more rapidlywhen folic acid was discontinued.

9. Subacute combined degeneration occurred with greater frequency in patientson large daily doses of folic acid than it did in patients with small or intermittentdoses.

10. The possibility is discussed that folic acid in large daily doses may actuallyprecipitate or aggravate neurologic disease.

11. It is suggested that folic acid may interfere with the metabolism of 1(+)glutamic acid in the central nervous system and possibly disturb the formation orfunction of acetylcholine.

     

Refined liver extract in tropical macrocytic anemia

1. A series of 45 cases of T.M.A. treated with "refined" liver extract is reported.

2. "Refined" liver extract was found to be effective in 39 cases.

3. It was found that 2 or 3 ml. of refined liver extract (Examen N.P.) was sufficient to produce an optimum response.

4. As judged from therapeutic observations, it is suggested that in the majorityof cases of T.M.A. the deficiency is similar to that in Addisonian pernicious anemia, though the mode of production of the deficiency may not be the same.

Note: ACKNOWLEDGMENTOur thanks are due to Dr. R. Row, Hon. Director, P.G. Singhance Hindu Hospital, Bombay, whereall the cases were treated, for permission to publish these reports, and the firms concerned for the generousgift of liver extracts.

     

A histochemical study of acid and alkaline phosphatase distribution in normal bone marrow smears

1. Three minute fixation in formol vapor at 44 C, followed by 15 minute washing proved to be the most satisfactory fixation procedure for both "acid" and "alkaline" phosphatase technics as applied to bone marrow smears.

2. For both technics a relation between staining intensity and cellular richnesswas found.

3. The reaction of normal human bone marrow cells to both phosphatase technics is described. Both are predominantly nuclear in location. Nuclear patternapproached that observed with common staining methods and Feulgen’s reaction.Cytoplasmic reaction was nearly negative. Nonspecific and specific granules donot stain after the "alkaline" technic. Nonspecific granules are negative for "acid"phosphatase, while specific neutrophilic are variable, and eosinophilic, constantlypositive. Nucleoli are negative after the "acid" technic, being positive for the"alkaline" enzyme. Mitotic chromosomes are positive for both technics. "Acid"phosphatase reaction in cytoplasmic zones of lymphocytes, erythroblasts, plasmacytes and megakaryocytes, is described.

Note: ACKNOWLEDGMENTSMany points pertaining to this paper were discussed with the late Dr. José Oria, to whom we oweinvaluable stimulation and guidance. We are indebted to Prof. W. Buno of Montevideo (Uruguay) forkind advice on the Golgi apparatus of blood cells. We are deeply indebted to Professor O. P. Jones ofBuffalo for his painstaking help and advice. We thank Dr. M. A. Jamra (Section of Hematology, CentralLaboratory, Hospital das Clinicas da Faculdade de Medicina) and Dr. J. F. Pontes (Section of ClinicalTherapeutics, Hospital das Clinicas da Faculdade de Medicina), for part of the material used in thisstudy. We thank Messrs. L. Frankenthal and G. Lonenzini for their aid in the preparation of some of themicrophotographs.

     

Hypoprothrombinemia; studies of a case of the idiopathic type and the effect of serum administration

1. The reported cases of idiopathic hypoprothrombinemia are reviewed briefly,and a case observed for over three years is presented. Particular attention is calledto the similar clinical pattern presented by the chronic cases.

2. Studies are presented indicating that in this patient the delay in prothrombintime was due, at least in part, to a deficiency of a factor necessary for rapid conversion of prothrombin. This factor, or factors, which we have called Ac-globulin,is contained in a highly active state in fresh normal serum.

3. After the in vitro demonstration of a deficiency of Ac-globulin in the patient’sblood, it was possible to bring about a marked reduction in the patient’s prothrombin time by the intravenous administration of relatively small amounts (15 to45 cc.) of fresh normal (thrombin-free) serum. A further reduction of the prothrombin time to near normal values was brought about by combined wholeblood and serum administration. The evidence suggests that partial correction ofboth prothrombin and Ac-globulin deficiency respectively resulted from suchtherapy.

4. The possible effects of serum and whole blood upon the delayed prothrombinconversion rate of dicoumarolization and liver disease are discussed and preliminary observations in the former type suggest that such therapy may be useful.

Note: ACKNOWLEDGMENTSWe wish to express our appreciation to the following for their cooperation in this study:Dr. McLemore Birdsong, Associate Professor of Pediatrics, University of Virginia Medical School;The Department of Pediatrics, University of Virginia Hospital; The Department of Biochemistry, University of Virginia Medical School; Dr. Myers H. Hicks, Assistant Resident in Medicine, Universityof Virginia Hospital; Dr. Walter H. Seegers, Professor of Physiology, Wayne University College ofMedicine.

     

Microscopic and histochemical studies on the Auer bodies in leukemic cells

(1) Seventeen cases of acute leukemia with Auer bodies have been reported.Studies were carried out on 7 cases of acute monocytic leukemia and 3 cases ofsubacute myelogenous leukemia.

(2) Histochemical studies showed the Auer bodies to be oxidase, peroxidase,and periodic acid-Schiff positive; sudanophilic, slightly metachromatic and to givepositive tests for acetal lipids and ribonucleic acid.

(3) The Auer bodies were negative for acid and alkaline phosphatase, lipase,glycogen, desoxyribonucleic acid and were non-birefringent.

(4) A change in the chemical nature of the Auer body from an acid conditionto a more neutral state was noted. This change corresponded with the changesof the normal cytoplasmic granulation of the myelocytes and monocytes duringmaturation.

(5) The effects of cellular movements, trauma, and temperature changes uponthe Auer bodies were studied.

(6) Several leukemic cells, containing Auer bodies, were studied during theprocess of mitosis.

(7) A theory as to the formation and disintegration of the Auer bodies hasbeen presented.

Note: ACKNOWLEDGMENTSThe author wishes to express his thanks to Dr. B. K. Wiseman, Dr. B. C. Houghton, Dr. R. A. Knouff,and Dr. E. R. Hayes for their help and suggestions, and to Dr. J. D. Thomas, Dr.J. F. Gamble, Dr. R. J.Rohn, Dr. H. Schiro, Mrs. Jo Myers, M.Sc., Miss Georgia Gwinner, M.T., Mrs. Susan Ragsdale, M.T.and Mrs. Jeanne Marie Willison, M.T., for their help in securing the experimental material.

     

Liver extract refractory megaloblastic anemia

1 . The patient described in this report had macrocytic anemia, megaloblasticmaturation arrest in the bone marrow, glossitis, hyper-reflexia and diminished vibration perception in the feet. None of these abnormalities was improved by liverextract or vitamin B₁₂ but all responded rapidly to folic acid except the neurologicsigns.

2. This patient appears to have had a megaloblastic anemia which has been described in European clinics under the names "achrestic anemia" and "refractorymegaloblastic anemia." It appears to be similar to "Wills" factor deficiency anemia" and some cases of pernicious anemia of pregnancy.

3. This patient did not appear to have a primary deficiency of folic acid since theexcretion of this substance in the urine was within normal limits. A deficiency ofan unknown factor probably equivalent to "the Wills’ factor" is suggested.

4. It seems likely that folic acid induced a remission in this case by a "massaction" effect. The possible relationship of folic acid, vitamin B₁₂, the unknownfactor and liver extract to nucleo-protein synthesis is discussed.

Note: ACKNOWLEDGMENTWe wish to thank Doctor Charles Foertmeyer for referring this patient to us for the clinical study usedin this report.

     

Studies on the histamine content of blood,with special reference to leukemia,leukemoid reactions and leukocytoses

The literature concerning blood histamine has been reviewed, including theevidence that the incorporation of histamine within the myeloid leukocytes maybe one of the metabolic functions of myelopoiesis. Data are presented on the histamine content of blood in normal subjects and in subjects with acute leukemia,chronic myelocytic leukemia, erythremia, and with leukocytoses or leukemoidreactions of other etiologies. The changing relationships of total blood histamineto unit myeloid cell histamine in subjects receiving irradiation therapy for chronicmyelocytic leukemia are also presented.

The data indicate that total blood histamine in chronic myelocytic leukemiais usually very high in comparison to normal, that the values in erythremia showa definite but less marked tendency in the same direction, while the values inleukocytoses of other etiology are, with few exceptions, normal or low. The bloodhistamine per million myeloid cells is, on the average, about twice normal in subjects with chronic myelocytic leukemia, within the normal range or a little lowin erythremia, and very low on the average in the group of leukocytoses studied.The suggestion is tentatively made that an aberration in this metabolic process(histamine incorporation within myeloid leukocytes) may be an inherent component of chronic myelocytic leukemia, whereas in physiologic leukocytoses andleukemoid reactions this is not the case.

Note: ACKNOWLEDGMENTSThe authors wish to express their grateful appreciation to Mr. John Fuschetti for valuable technicalassistance in performing the histamine determinations. The cooperation and aid of Dr. Gurth E. Carpenter, Dr. Henry H. Henstell, Dr. Myron Prinzmetal and of many members of the staff of WadsworthGeneral Hospital, Veterans Administration, Los Angeles were invaluable in obtaining blood specimensfrom suitable clinical material, and to them the authors wish to express their sincere thanks.

     

Granulomatous lesions in the bone marrow in infectious mononucleosis; a comparison of the changes in the bone marrow in infectious mononucleosis with those in brucellosis,tuberculosis, sarcoidosis and lymphatic leukemia

1. The findings in the blood and in aspirated bone marrow in 23 cases of infectious mononucleosis have been described.

2. Unequivocal evidence of involvement of the bone marrow has been found in70 per cent of the cases.

3. Evidence of granulomatous inflammation of the marrow was found in 48 percent of the cases.

4. Epithelioid cells were found in the films of bone marrow in 48 per cent of thecases. These cells appear morphologically identical with those seen in imprints oflymph nodes from infectious mononucleosis and sarcoidosis and with the epithelioid cells seen in films of the marrow in brucellosis, sarcoidosis and tuberculosis.

5. The granulomatous lesions of infectious mononucleosis seem most similar tothose of brucellosis, but they also resemble the small granulomatous lesions ofsarcoidosis and tuberculosis.

6. Lymphocytosis of the marrow as well as of the blood was demonstrated in allcases. Evidence of formation of lymphocytes in the marrow was presented, and thealtered lymphocytes of infectious mononucleosis were found in films of the marrow.The degree of lymphocytosis of the marrow in infectious mononucleosis was shownto be less than that in lymphatic leukemia. Lymphocytosis of the marrow was notfound in brucellosis, sarcoidosis or tuberculosis. The lymphocytic reaction demonstrable in the marrow in infectious mononucleosis is believed to be of value in differential diagnosis.

Note: ACKNOWLEDGMENTSWe wish to acknowledge the generous cooperation of Dr. Ruth E. Boynton and the Staff of theStudent’s Health Service of the University of Minnesota throughout the course of this year long studyof infectious mononucleosis. We are indebted to Dr. T. Edward Bell and Dr. James Cardy for performingthe sternal aspirations. The photomicrographs were made by Mr. Henry Morris.

     

THE ERYTHROPOIETIC ACTIVITY OF CHOLINE CHLORIDE IN MEGALOBLASTIC ANEMIAS

1. The effect of the administration of choline chloride has been observed in 10cases of megaloblastic anemia of various types.

2. Choline was without effect in a case of untreated Addisonian perniciousanemia which subsequently responded to parenteral liver therapy.

3. Choline was also without effect in a case of nutritional megaloblastic anemia,in a case of megaloblastic anemia of pregnancy, and in two cases of megaloblasticanemia associated with the sprue syndrome. All these cases had proved refractoryto injections of potent liver extract before the choline was given, and all respondedto subsequent oral liver or folic acid therapy.

4. A significant erythropoietic response to choline occurred in two cases resembling Addisonian pernicious anemia which were refractory to parenteral liverextracts.

Secondary responses followed the administration of choline in two other casesof Addisonian pernicious anemia and in a case of megaloblastic anemia of pregnancy, all of which had already responded to injections of liver extract.

5. The significance of these observations is discussed. It is concluded that choline possesses no direct erythropoietic activity, but that under certain circumstances it may potentiate the effect of liver extracts.

It is suggested that refractory megaloblastic anemias may be divided into twogroups. In one, represented by well known syndromes associated with defectiveabsorption or pregnancy, the lack of response to parenteral liver extracts is notcorrected by choline. In the other, represented by two cases simulating Addisonianpernicious anemia, choline is effective in overcoming, partially or completely, therefractoriness to parenteral liver therapy. Consideration is given to the view thatthe refractoriness of this group results from hepatic dysfunction.

6. The most satisfactory method of administering choline probably consists ofintravenous injections in daily doses of 1 gram. Larger doses given intravenouslyare frequently accompanied by unpleasant side effects, while oral administrationappears to be relatively less effective.

7. It seems unlikely that choline will be of practical value in the treatment ofrefractory megaloblastic anemias, for which oral liver preparations provide themost certain and effective treatment. It is possible, however, that choline may beof use in cases complicated by severe hepatic disease.

Note: Acknowledgment: We wish to thank Dr. L. D. W. Scott for permission to include his patient (case10) in our series.

     

Some observations on the effect of folic acid antagonists on acute leukemia and other forms of incurable cancer

A general discussion is presented of the present status of folic acid antagonisttherapy in acute leukemia in children and in other forms of incurable cancer. Conclusions reached in our initial report have been supported by a far greater experience. Temporary remissions in acute leukemia as marked as those caused byaminopterin have been produced by the use of two compounds closely relatedchemically to aminopterin—amethopterin and amino-an-fol, both of which, however, are also toxic compounds. Despite the increasing number of patients in whomtemporary remissions have been produced, with survival in some far beyond theusual course of the disease, no evidence has been presented which would justify theuse of the word "cure" of acute leukemia. A carcinolytic action on related and oncertain unrelated forms of incurable cancer has been observed. Further research forless toxic related compounds with even greater effectiveness is not only justified bythese studies but is imperative. The value of this direction of research in cancer hasbeen established.

Two of the most pressing problems demanding solution are concerned with thenature, the prevention, and the treatment of toxic changes, including hemorrhage,produced by these folic acid antagonists and the causes, prevention and mechanismof hemorrhage in acute leukemia. The use of the folic acid antagonists in the treatment of incurable cancer including leukemia must remain in the realm of researchuntil answers to these questions are found.

     

Experimental anemias in the rat; II. The effect of various sulfonamides in producing a pteroylglutamic acid deficiency and the pteroylglutamic acid activity of test substances

1. Different sulfonamides were tested to ascertain their effect in producing thecharacteristic symptoms of acute PGA deficiency in rats fed on synthetic diets.Sulfasuxidine (1 per cent) and the less soluble phthalylsulfathiazole (1 per cent)were equally effective. Sulfathiazole in 1 per cent concentration produced a hemolytic anemia not reversible by PGA or whole liver powder. In a 0.5 per cent concentration it was also effective, but in view of its toxicity, the less soluble sulfonamides were to be preferred. A mixture of 0.5 per cent sulfathiazole and 0.5 percent sulfadiazine was extremely toxic and produced a hemolytic anemia. Sulfaguanidine was toxic at 1 per cent concentration.

2. When intermittent small doses of PGA were given to PGA-deficient rats toprolong their life from 45 up to 155 days, 1 per cent sulfasuxidine or phthalylsulfathiazole, or 0.5 per cent sulfathiazole were equally efficient in producing regularlya macrocytic normochromic anemia.

3. The response of PGA-deficient rats to single doses of PGA has been studiedand an assay procedure has been suggested which uses the weight increase andduration of cure as the measure of the response. The W.B.C. and reticulocyte response can also be used as a qualitative indication of PGA activity.

4. Of the substances tested by this procedure, vitamin B₁₂, purified perniciousanemia preparations, ascorbic acid and xanthopterin showed no PGA activity. Acommercial yeast preparation and Teropterin were found to possess biologic activity comparable with that found by other workers in assays on chicks.

Note: ACKNOWLEDGMENTSWe wish to thank Dr. E. Lester-Smith, of the Glaxo Laboratories, for the generous supply of vitaminB₁₂, Dr. T. H. Jukes, of the Lederle Laboratories, for the gift of PGA and Teropterin, and Dr. W. Jacobson for the samples of purified P. A. liver preparations and xanthopterin.

     

Eosinophilic leukemia; report of a case with autopsy confirmation; review of the literature

1. The data in a case of fatal leukemia with predominant eosinophilia in theperipheral blood and bone marrow are presented; we believe that this case was oneof eosinophilic leukemia.

2. During the period of observation, these eosinophils showed progesssiveimmaturity as the symptoms became more severe. Eventually this "left shift"became so marked that a large proportion of the cells were terminally myeloblastsin both the blood and the bone marrow.

3. Autopsy revealed invasion of many of the tissues and organs with thesemature and immature eosinophil granulocytes and with myeloblasts.

Note: ACKNOWLEDGMENTOur thanks for helpful criticism are particularly extended to Dr. Charles Doan and to Dr. WilliamDameshek.

     

A SIMPLE APPARATUS AND PROCEDURE FOR PREPARING AND ELECTROPLATING RADIOACTIVE IRON

A simple, easily constructed apparatus for electroplating radioactive iron hasbeen described by which certain disadvantages of other forms of apparatus havebeen eliminated. Sixteen samples can be plated each day without difficulty.

The technic employed for preparing the radioactive iron for electroplating hasbeen given.

Note: The writers are indebted to Dr. P. F. Hahn and his staff who permitted one of them (M. L.) to spendseveral weeks in the Biochemical Laboratory at the Vanderbilt University School of Medicine and generously gave invaluable instruction and advice.

     

FOLIC ACID IN THE TREATMENT OF PERNICIOUS ANEMIA

1. Folic acid in daily doses of 15 to 50 mg., orally, or 20 mg. intramuscularly,usually produced a submaximal reticulocytosis in patients with pernicious anemia.

2. In 3 patients the hemoglobin and red cells rose to a level of about 12.0 Gm.and 4.3 million respectively without further rise after 3 months of therapy.

3. Folic acid in the above doses failed to prevent the development or progressionof neurological symptoms indicative of subacute combined sclerosis.

4. In 5 patients folic acid in doses of 5 or 10 mg. orally daily combined with unit of liver extract injected intramuscularly daily produced a reticulocytosisgreater than that anticipated from adequate liver extract therapy alone.

5. With combined liver extract and folic acid therapy there was evidence ofimprovement in the symptoms and signs of subacute combined sclerosis in 3patients.

6. Folic acid, combined with unit of liver extract, was found to produce acomplete hematological remission.

7. Folic acid, alone or in combination with small doses of liver extract, producedan improvement in appetite and general well-being in patients with perniciousanemia.

8. The possible enhancing effect of liver extract when combined with folic acidcannot be due to the folic acid content of the former since 1 unit of liver extractcontains only 0.38 micrograms of folic acid.³¹

9. Folic acid administered to a patient with macrocytic anemia due to faultypostoperative intestinal digestion and absorption, produced a complete remissionin the blood picture and a marked improvement in signs and symptoms.