From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
RECENT
STUDIES
OF
MULTIPLE
PUNCTURE
AND
WITH
B
SIMoN
M.D.,
PROPP,
MYELOMA:
THE
RESULTS
ULTIPLE
L.
MYELOMA
acterized
system,
by
WHITTINGTON
cacheXia,
They
are
and
found
girdle,
pelvis,
blood
formation
In 1845,
sternum
occurs
of pain
discoverer.
tumors
the
the
with
‘
multiple
synonym
The
marrow
cell
involved.
marrow.
since
there
has
as
The
the
protei
with
clumping
a definite
nuria;
serum
phosphorus
myelorna
cells
pathognomonic
is necessary
course
From
the
Presented
Syracuse,
New
The
of dysplastic
active
patient
who
corn-
coagulated
by the
name
with
multiple
of
bone
of
marrow,
proteinuria
is frequently
used
as
a
this
Department
York,
cells
elevated
cells*
origin
and
6
Bence-
of erythrocytes
rate;
osteoporosis
alkaline
in the
type
only.5’
as follows:
formation
sedimentation
by
phosphatase
peripheral
and
blood;
and
Medical
York
Regional
fatal
College,
Albany,
Meeting
of the
over
New
a period
of a few
York.
American
College
of Physicians,
1947.
from
in this
observed
is progressively
Albany
New
m8,
a grant
cell
cell
listed
diagnosis,
cell
diagnosis.
Western
October
by
myeloma
myeloma
of Medicine,
myeloma
rouleaux
rapid
or moderately
anemia;
be
i6
More
for
plasma
as of plasma
of
Of these
unclassified.
aspiration
of the
may
within
aspiration.
The latter
finding
has come to be regarded
as
disease.
A positive
marrow
aspiration
or surgical
biopsy
the
at the
disease
excessive
normal
values;
in marrow
of this
marrow
type
myelocytoma,
were
332.
the
cells
mycloma.
2.4
entirely
in diagnosis
and
malignant
of multiple
and
of a neoplasm
upon
myeloblastoma,
almost
to regard
to be that
depending
of the
mixed,
been
solution,
of multiple
plasma
shoulder
Bence-Jones
considered
varies
of sternal
use
useful
with
in part
term
multiple.
known
disease
643 cases
hyperglobulinemia;
in part
Supported
*
trend
to establish
The
the
have
in Hayem’s
hypercalcemia
be
the
which
elements
Kahier’s
2.7
32.
of
findings
x-ray;
to
a condition
proliferation
summarized
myeloma
laboratory
Jones
been
associated
cytology
plasmacytoma,
advent
multiple
been
since
has been
the
erythroblastoma,
on
osseous
where
ofa
protein,
proliferating
term
is a diffuse
has
classified
recently,
char-
the
of
femora,
urine
described
Kahler3
myeloma
There
lymphocytoma,
reports
of
‘ ‘
The
1889.
in which
Atkinson4
were
2,07
bones
and
This
‘ ‘
has
first
consisted
of multiple
bone
marrow
tend
skull,
in the
loins.
1873,
Myelom.
in
disease
of
condition.
pathology
of the
the
this
humeri
the
boiling,
in
which
myelorna
for
tumors
of
and
upon
‘Multiples
SAMUEL
a malignant
fragility
The
ribs,
protein
back,
Rustizky,2
bones
title
ends
as
abnormal
spine,
an unusual
chest,
‘
AND
adult.
redissolved
Von
of
under
in the
the
the
upper
found
in
at 55 to 6o C. and
in
and
known
and
proteinuria.
frequently
M.D.,
GORHAM,
deformity
Bence-Jones
most
Bence-Jones1
plained
the
pain,
RIB
M.D.
is commonly
bone
AND
TREATMENT
STILBAMIDINE
KANTOR,
M
STERNAL
OF
the
article
in the
Winthrop
is used
bone
Research
Fund
interchangeably
marrow
36
in multiple
of the
with
Albany
plasma
myeloma.
Medical
cell
to denote
College.
the
series
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
months
to
been
six
years
palliative.
have
shown
no
L.
or
longer
relief
from
curative
of
pain
and
visceral
by
has
that
in a high
presence
13
of
elusion
the
hyperglobulinemia
bodies
contained
granules
and
of
protein
of the
or
ribose
by
the
tissue
obtained
completion
of a course
of this
drug.
with
the
cytoplasmic
nucleoproteins
interferes
with
loma
cell
time
after
this
the
fact
shown
to
decrease.
nerve
two
In
most
produced
on
the
two
and
cases
relief
and
a half
in the
cases
liver
incidence
the
or
caution
to
form
five
common
some
occurred
was
not
after
treatment
of the
trigeminal
one
of Snapper’s
accompanying
following
Renal
in treating
This
in only
subsided.
system.
the
treatment.
itching
gradually
advocated
This
smears
anesthesia
persistent
discomfort
myefor
obtained.
was
months
hematopoietic
was
found
with
theory,
because
patients.
were
after
not
lesions
marrow
of dissociated
of severe
and
is relieved
in the
cells
found
days
Snapper’s
ofosteolytic
in some
of
in-
stilbamidine
only,
to
pain
cells
was
face
that
cells
that
myeloma
of pain
was
eight
according
ii
these
of ribonuclease
theory
myeloma
demonstrated
the
action
in the
in
that
Stilbamidine
the
ofexpansion
the
about
the
ap-
only
appeared
examination
diet,
of myeloma
in
A high
distress
patients.
has
was
although
occurred
considerable
suggested
changes
of formication
of
Lack
No
studying
advanced
He
percentage
of stilbamidine.
has
produced
and
with
bodies
demonstrated
at postmortem
protein
the
has
microscope.#{176}
A high
of treatment
that
by
quartz
He
is arrested.
pentamidine,
A feeling
tions
reaction.
cessation
despite
with
cells.
proliferation
proteinuria
Snapper
myeloma
inclusion
were
the
acids.
multiple
These
be of
nucleoproteins
complexes,
with
He
nucleoproteins
of other
might
on
of
treating
accompanied
nucleic
basophilic
cells.
acid,
of the
in myeloma
are
act
use
in
stilbamidine
may
ob-
the
effective
binding
Pence-Jones
nucleic
use
by
myeloma
that
large
globulin.#{176}
by analysis
reacts
multiple
patients
diet,
myeloma
blood
very
new
apparently
of protamine-ribonucleate
treatment
increased
proved
and simultaneously
animal
percentage
with
patients
on
a low
interesting
has
myeloma
stilbamidine
dissociation
following
on
and
that
protamine
multiple
empirically
indicated
in vitro,
shown
disease
He
has
phosphorus
an
disease.
with
Treatment
radioactive
introduced
this
has
reasoned
is made.5
and
has
37
KANTOR
diagnosis
8
-
of
patients
this
5.
mustard,
Stilbamidine
has
releasing
stilbamidine,
peared
in
Because
demonstrating,
stilbamidine
the
treatment
pentamidine.
Kopac9
time
Snapper7
the
it was
both.
AND
nitrogen
repeatedly
leishmaniasis.
in
GORHAM
the
value.
in
hyperglobulinemia,
value
W.
therapy,
agent
stilbamidine
by
PROPP,
Roentgen
chemotherapeutic
tamed
S.
No
failure
patients
toxic
was
with
injeccaused
effects
were
precipitated
renal
in
damage
and
insufficiency’.
Ten
lieved
out
of eleven
of pain.i3
bamidine
failed.
stilbamidine
of
presented
and
two
the
cases
article
deals
Hospital
to
study
to observe
the
to
and
with
within
myeloma
clinical
only
used
with
was
no
a study
of six
a relatively
cells
effects
that
cases
short
before
and
of this
drug.
Snapper
case
but
of
emphasized
was
one
ineffective
Recurrence
cure
by
in the
was
disappear.
it
stilbamidine
successfully
pentamidine
pain
checked
temporarily
Albany
treated
was
treatment
was
This
the
In
caused
stilbamidine
disease
patients
Pentamidine
pain
were
in which
subsequent
required
although
restil-
use
of
repetition
progress
of
the
obtained.
of
multiple
period
after
of time.
treatment
myeloma
An
with
admitted
opportunity
stilbimidinc,
to
was
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
38
RECENT
STUDIES
OF
MULTIPLE
MYELOMA
METHODS
Each
case
x-ray
received
studies.
treatment
on
with
four
the
differed
from
ten
This
Coverslip
per
were
was
ejected
tilting
the
and
these
were
was
then
placed
mixture
set
were
of
done
on
securing
ing
the
Rib
puncture
with
The
ture.
used
the
rib
of
was
a fashion
were
Rib
marrow
The
patient
diagnosed
nal
rib
puncture
and
the
grasped
of
The
same
first
performed
on one
and
as multiple
the
myeloma
which
for
and
smears
skin
and
of missdilution
periosteum
were
in sternal
thumb
or
and
index
less
in
finger
pleural
cavity4
The
marrow
cavity
preparations
punc-
length
and
the
of
chance
syringe.
employed
cm.
stain
possibilities
to
was
center
of
entered
of marrow
smears
done
patient
sixteen
patients
and
excellent
of the
suspected
sternal
termed
was
it
was
Since
preparations
Puncture
should
on
a
ster-
roentgenologist,
then
rib
obtained.
never
post
later
A second
by the
recovered.
marrow
immediately
performed
unsuccessful.
pathologic
subsequently
rib.
malignancy
that
puncture
in an area
selected
of rib
punctures
for
A requisite
be done
if the
rib
is not
palpable.
t Lilly’s
solution
of sodium
found
by puncturing
It was
exerted
the
needle
could
tip
experienced
heparin.
ribs during
of a 1.5 cm.
needle
be made
to penetrate
not
the
when
outer
thin
could
post
mortem
be forced
completely
bony
plate
examinations
through
the
parietal
through
the
rib.
of a rib
was
pierced
that
if considerable
pleura
of a thin
A/very
and
definite
the
marrow
sensation
experienced.
of entering
both
of
were
done
the
rib
marrow
and
sternal
immediately
cavity
preparations
following
have
each
shown
other.
a similar
Variations
marrow
in amount
were
A
was
cavity
so that aspiration
was always
attempted
was slowly
advanced
until marrow
fluid
§ Comparison
force
person.
‘give”
sensation
was not invariably
felt however,
firmly
fixed in the bone. Then
the needle
when
The
smears,
aspirating
so satisfactory
when
The
palpation
case
results
was
careful
the
puncture.
marrow.
is the
the
i.
needle
by
repeated.
centrifuged,
precluded
the
entering
The
identified
coverslip
three
The
needle
of the
made.
were
gave
to that
between
bone
puncture
line.
puncture
mix-
dry
of material
similar
without
tube,
heparin
a peroXidase-Wright’s
in the
scapular
of the
fluid
smears
The
and
motion
so simple
rib puncture
on
and
cells,
normal
performed
easily
was
was
been
stain
leisure
above.
clinically
to contain
have
sternal
layer.
formation
danger
a rotary
to
procedure
puncture,
proved
were
and
hematocrit
buffy
selection
clot
in the
possible
pipets
of procedure
chance
rapid
rib
as enumerated
mortem.
method
A sternal
with
similar
made
*
the
bored
the
in a manner
center.
with
of marrow
performed
of the
rib
because
the
Wright’s
procaine
margins
ascertain
with
from
and
was
anesthetized
from
This
picture
blood,
up
in a Wintrobe
sample
diagnostic
sinusoidal
picked
The
the
then
bits
solu-
the syringe
fluid.
at
were
Marrow
consisted
to wet
marrow
smears
in
which
Heparin
of marrow
supravital
slide.
developed
amount
the
performed
in procedure
out
after
puncture
aspiration.
cc.
from
a hollow
made
smear.
a representative
with
in
stained
a selected
two
Changes
be carried
directly
and
onto
preparations
subsequently
was
smear
was
and
and
marrow
technic
o.i
before
were
on
in sufficient
could
laboratory
cases
punctures*
marrow
to aspirate
made
remaining
third
used
steps
fluid
a
for
was
all
placed
syringes
utilized
A
marrow
marrow
be’4
cc.t
ing.
slide
wet
rib
appropriate
in
dependence
elaborate
subsequent
smears
blue
i
then
and
done
a more
cc.
i
with
was
previously
and
was
operator.
cresyl
that
units
syringe
clotting,
great
myeloma,
solution
prevented
the
of
ofmultiple
containing
only.
In addition,
Because
heparin
work-up
aspiration
stilbamidine.
somewhat
in using
hospital
marrow
occasions.
diagnosis
tion
a complete
Sternal
i
cm.
usually
entered.
This
when
the needle
was
was obtained
or the
picture
in
of marrow
13
instances
material,
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
The
cases
of
multiple
method,
Snapper’s
distilled
ing
with
ISO
mg.
and
a dose
of o
daily
for
to
The
Snapper.
listed
were
The
One
a total
1,
or
treated
150
mg.
and
case
treatments
was
laboratory
findings
old
white
male
office
with
unexplained
ill for
3 months
veloped
pain
in his
left
revealed
a fever
liver
systolic
enlarged
murmur.
Q RS
in
the
and
cytes
leads
blood
for
cells
i.6
phosphorus
examinations
3.2.
normal
marrow
elements
established
the
was
of the
and
the
myeloma
type.
on
May
i,
each
in-
by
recommended
to each
are
patient
are
illustrated
in the
by
effectively
finding
and showed
9.9 Gm. per
cent,
plasma
with
normal.
cells.
These
made
of stilbamidine
and
three
studied
with
apical
slurring
Gm.,
red
blood
14 per
cent,
and
of
cells
mono-
hour.
oo
cc. blood
transfusions.
of crythrocytes
for multiple
was
myeloma.
noted
The
on
urine
was
3.9 Bodanskv
up 91
units,
puncture
cent
per
and
NPN
revealed
6o mg.
marked
of a oo
white
totaling
2..7
cell
per
cent.
replacement
of
differential
count.
showed
was
injections
no restriction
of protein
prickly
feelings
the
These
about
mouth,
manifestations
that
34 per
noted
in the
cent
not
in the
and
administered.
Unpleasant
ears
severe.
marrow
of some
were
ordered.
eyes
were
of cells
cytoplasm
Gm.
was
smears
of these
at the
Sternal
were
cells,
time
puncture
but
of
no
the
baso-
found.
discharged
3 months
7.5
patient,
vomiting.
granulation
were
was
clumping
Sternal
Eighteen
of the
and
T waves
mycloma.
of transient
nausea
bodies
phosphatase
st,lbamid,ne.
consisted
he was
were
state
penicillin
by x-ray.
blowing,
low
in one
examination
confirmed
aloud,
lymphocytes
zo mm.
Abnormal
ribs
of multiple
out
was
was
was
1947’
he de
a i plus albumin.
Serum protein
was iz. Gm. per cent total,
cent, an A-G ratio of o.i6.
Serum
calcium
was zI.9 mg. per
alkaline
and
there
7,
admission,
Physical
which
and
8o per cent,
viith
of this
and
onjan.
hospital
breathing.
Hemoglobin
Wintrobe,
because
skull
recurrent
1947,
treated
nutritional
was
neutrophils
rate,
Hospital
his
lobe,
fibrillation
damage.
effusion.
per
Azurophilic
patient
myocardial
deep
lower
rhythm
auricular
pleural
diagnosis
course
inclusion
The
mg.
injections
following
then
course.
before
as
Albany
before
and
left
irregular
sterile,
globulin
carried
poor
of treatment,
philic
and
t)f the
of the
and
usual
minutes
given
to the
weeks
by cough
had
segmented
protein
cent,
X-ray
effects
heart
Two
in the
revealed
was
and
Bence-Jones
Treatment
start-
day,
the
results
admitted
fever.
sedimentation
counting,
albumin
Because
The
8,io,
pneumonia
with
This
to
of sterile
I
aggravated
indicating
a nonpurulent,
blood
diets
therapeutic
was
of pneumonia
tender.
Erythrocyte
The patient’s
He developed
positive
was
evidence
and
standard
6 per cent.
routine
which
worker,
An electrocardiogram
white
1,000,000,
chest
of soz#{176}
and
was
30
the
cc.
intravenously,
reactions
and
io
following
constituted
vasomotor
of stilbamidine
according
in
given
the
hypodermically
given
immediate
dosages
been
The
were
given
which
CASE
had
stilbamidine
dissolved
histories.
A. S., a 6i year
He
with
were
39
KANTOR
was
Injections
2.0
minimize
5.
stilbamidine
hundred
of
AND
2..
clinical
following
GORHAM
immediately.
mg.
total
in table
The
used
prevent
W.
myeloma
Gr.
sulfate
jection
L.
as follows.
water
Atropine
PROPP,
without
from
the
improvement
time
his
in his
treatment
general
was
condition.
concluded.
No
He subsequently
autopsy
was
expired
obtained.
COMMENT
The
the
diagnosis
abnormal
blood
clumping
count.
atypical.
were
established
however,
ment
His
have
sternal
first
presenting
sternal
been observed.
are
x-ray
Further
being
studies
made.
suspected
in
in
Hayem’s
of unexplained
findings
puncture.
only
noted
symptom
by negative
offset
was
erythrocytes
laboratory
by
puncture
myeloma
of
Confirmatory
proteinuria
was
multiple
of
of
fever
puncture
with
and
stilbamidine
as a procedure
because
in
a
of
routine
pain
and
of skull
examinations
case
without
hyperglobulinemia
Treatment
on rib
this
solution
was
Bence-Jones
ribs.
Diagnosis
without
to complement
proor supple-
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
RECENT
40
tein
restriction
failed
duce
hasophilic
granulation
emia
was
STUDIES
to effect
OF
MULTIPLE
a remissi.)n
in the
in
R. L.,
and
course
of the
of
cells
the
disease
although
or
to
pro-
hyperglobulin-
present.
a 8 year
complaint
old
Italian
of vertigo.
weakness,
pounds
the
cytoplasm
CASE
chief
MYELOMA
during
male,
For
was
admitted
ten days
and
ft)r six months
this
period.
prior
had
the
to
Albany
Hospital
on January
he had
repeated,
transient
to admission
had suffered
He had
2.
from
an acute
generalized
infectiGn
headaches.
in the
right
ear,
2.8, 5947,
attacks
with
a
of dizziness
There
was
a weight
loss
three
weeks
before
admission,
of z
‘$
Fios.
Fio.
which
to
had
the
was
subsided.
ear.
The
z6o mm.
small,
third
of
lumbar
cells
serum
protein
of
Bodansksrepeated
areas
bone
o.;
im.z
Gm.
serum
units;
tests.
Laboratory
examinations
a normal
cent;
Sternal
39 mg.
puncture
io.5
(fig.
5th
mg.
per cent;
per
count;
Gm.
cent;
creatinine
preparations
s).
the
per
contained
stilbamidine.
over
the
blood
mg.
3.8
mg.
per cent.
i9.5
per
osseous
negative;
No
cent
per
cent;
plasma
the
urine
cells.
protein
revealed
second
cells
and
4,400,000;
normal;
per cent,
alkaline
Bence-jones
pressure
numerous,
system
of
red blood
8.4 Gm.
anterior
Blood
showed
compression
13 grams;
globulin
region,
right.
skull
of the
some
Wassermann
and
temporal
to the
of the
studies
and
hemoglobin
cent,
left
falling
x-ray
Further
phosphorus
0.9
R. L.
patient
vertebra
showed
3.7
2.,
with
A routine
lumber
differential
albumin
with
diastolic.
denitv
in the
calcium
NPN
zoo mm.
CASE
treatment
tenderness
positive,
of decreased
per
SKULL,
moderate
strongly
and
OF
before
1947,
destruction
with
io,ooo,
X-RAYS
2.9,
revealed
was
systolic
segments.
white
ratio
test
of mercury
active
1-3.
January
Examination
Romberg
punched-out
evidence
i.
total
with
an A-G
phosphatase
3.6
was
on
found
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
PROPP,
S.
The
patient
restricted.
ness,
given
following
mveloma
the
cells
bodies
cytoplasm
indicated
generally
first
improved,
the
spine.
A second
on
Seven
weeks
of the
face.
night.
after
This
bamidine,
this
still
cells.
osteolvtic
The
majority
course
course
8.8
lesions
per
were
(fig.
six
first
density
noted.
months
were
was
four
and
half
on
bodies
x-ray
at this
the
of the
patient
felt
his
and
in
the
aching
pain
of ten days
to light
mt)uth
9,
his
second
still
showed
with
work.
involving
occurred,
Sept.
ssere
time
of
inclusion
of
the
after
min-
after completion
region
puncture
months
inclusion
Skull
basophilic
he returned
about
in this
Rib
one
Basophilic
plasmablasts.
burning
a few
a reduction
a period
over
and
not
restless-
A roentgenogram
weeks
given
occurred
of ntimhness
intense
of observation.
cells.
cent
Gm,
1.35
within
large
headaches
of svmptonls
was
and
m). Sub jectivelv,
Five
diet
revealed
by Snapper.9
(fig.
The
tinnitus
subsided
showed
generalized
of
Gm.
puncture
per cent,
relieved.
severe
Later,
and
myeloma
per
1.3
described
Relief
treatment
cent
those
of decreased
he complained
were
complaints
with
of
m.8
bilateral
a sternal
83.8
consisting
diet.
These
treatment
dizziness
4’
totaling
cells,
a recurrence
drug,
KANTOR
salivation,
of these
areas
and
S.
lacrimation,
administration.
of treatnint
after
his
AND
of stilbamidine
skin,
identical
of the
changes
GORHAM
following
in the
protein
persisted
There
were
headaches
animal
following
revealed
of the
in the
a low
drug
weeks
he had
Ni) neurologic
half months
cent
the
of stilbamidine
patient
to the
increase
and
of the
Four
which
a definite
course
lumbar
reaction
injections.
W.
of mo injections
of burning
to 6.m per cent.
in the
skull
a course
He complained
as an immediate
utes
at
was
L.
most
particularly
six and
1947,
course
present
of
one
stil-
in 54
per
ftirthcr
increase
skull
taken
3).
COMMENT
The
clue
because
of
to diagnosis
the
patient’s
in this
complaints
case
was
of
obtained
vertigo
from
and
an
headaches.
x-ray
of the
The
possibility
of
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
RECENT
42.
multiple
myeloma
the
in
had
lumbar
Sternal
produced
neuropathy
the
majority
in the
September
diagnosis
were
1947,
six
months
of
caused
typical
cells.
protein
four
from
rib
not
when
persistent
months
osteo-
trigeminal
inclusion
after
only
cytoplasmic
at a time
Basophilic
and
course
lesions
evidence.
basophilic
A severe
treatment.
first
animal
occurred
in size.
of
after
This
osseous
confirmatory
myeloma.
restriction
also
increasing
course
Further
were
of multiple
but
a second
4,
MYELOMA
entertained.
without
of myeloma
skull
followed
.
FIG.
previously
of symptoms
in the
lesions
MULTIPLE
hypergiobulinemia
stilbamidine
a remission
porotic
been
and
established
with
inclusions
not
vertebrae
puncture
Treatment
OF
STUDIES
second
bodies
course
of stil-
bamidine.
were
observed
months
after
in the
myeloma
treatment
was
cells
obtained
C. S. H.,
a 47
old
year
pale,
thin
bilaterally.
below
patient
There
the
costal
who
was
margin.
white
male
was
admitted
in his ribs, progressive
anemic
four months
appeared
a soft,
chronically
blowing,
Ophthalmic
four
and
one
half
3
CASE
ill for
months
with pain
He was told that he was
puncture
concluded.
apical
examination
to the
Albany
weakness
and
before
admission
ill.
There
cardiac
was
murmur.
revealed
Hospital
fatigue,
to the
on Feb.
tenderness
The
presbyopia
2.6,
He had
1947.
been
loss of weight,
and failing
vision.
hospital.
Examination
revealed
a
to pressure
liver
edge
only.
was
over
palpable
the
lower
two
ribs
fingers
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
Laboratory
Positive
studies:
red
blood
cells
3,32.0,000;
tion
rate
12. mm.
in
A-Gratio
line
phosphatase
roentgenogram
revealed
that
He
Bodansky
ribs
treatment
hemoglobin
differential
count.
patient
uent
that
ized skin rash
his general
unable
and
state.
the
of the
protein
svere
diet
plasma
and
cell
given
Sternal
red blood
The
and
months
a course
after
treatment
His
was
new
was
ribs
reported
but
the
that
obtained
ambulatory,
but
and
was,
with
a normal
and
he
except
for a general-
the
however,
gained
of this
a progressive
and
of
cells
of
Follow-up
well
however,
totally
2.85
Gm.
6,8oo
fine.
felt
away
by letter,
totaling
improved
he felt
moved
otherwise
puncture
after
cells
his vision
of pain
had
A second
Sternal
repeated
blood
that
there
patient
A follow-up
still
subsided,
relieved
an
alka-
43.4 per cent mycloma
bodies.
Attheconclusion
white
by letter
he was
doctor
advised
residence.
in his
normal.
left.
of stilbamidine
was
contained
inclusion
and
in six weeks
lower
with
and
cent;
type.
puncture
4,160,000,
pain
reported
tongue.
patient
cells
per
as being
on the
‘
sedimenta-
per cent
3.2. mg.
reported
tumor’
zo Gm.,
Wintrobe
.6 Gm.
phosphorus
ribs
large
transfusions.
considerably.
a sore
his
that
and
hemoglobin
count;
protein
serum
cent;
ofmetastatic
were
animal
9.5 Gm,
Retreatment
to locate
indicated
per
albuminuria;
differential
total
mg.
of the skull
‘suggestion
cc. blood
home
two
negative;
10.4
4 plus
been administered.
The marrow
(82..9
per cent)
contained
basophilic
improved
revealed
and
a normal
43
KANTOR
S.
had
was
He returned
protein
calcium
cells
AND
with
9,300
X-rays
‘
on a low
or i8 injections
the great
majority
This
cent;
a
oo
GORHAM
Wassermann
per
units.
two
stilbamidine
of which
in strength.
cells
of marrow
placed
received
W.
Bence-Jones
blood
showed
per cent
was
also
hour;
4.2.
for
blood
30 mg.
of the
2.3
The patient
Gm.
one
L.
test
white
NPN
of2..5;
PROPP,
decline
referring
written
by his
in
doctor
was
2.5,
1947,
on Dec.
incapacitated
pa.
illness.
COMMENT
This
patient’s
Bence-Jones
were
symptomatology
proteinuria
negative.
and
There
fitted
the
clinical
picture
were
the
positive
laboratory
anemia
was
no
hypergiobulinemia.
of multiple
myeloma.
findings
Sternal
and
puncture
x-rays
findings
were
pathognomonic.
Stilbamidine
proved
found
in
the
treatment
this
patient
the
tumor
ever
majority
cells
have
with
of
had
any
a low
symptomatically
the
definitely
sustained
animal
and
myeloma
cells,
although
in the
marrow.
effect
upon
his
a 6x year
the
chief
complaint
had
been
well
controlled
was
white
cent.
NPN
investigation
per
positive
trobe
plasma
level
cent,
for
general
was
38 mg
per
function,
an A-G
ratio
A diagnosis
from
of o.m.
rate was
a marked
similar
time,
he complained
again
discharged
and
10.7
Because
clumping
6i mm.
reduction
and
forehead,
felt
three
71
per
of the
hour.
did
onjan.
was
of
not
how-
5947,
im,
a known
a blood
with
diabetic
was
was
negative.
m., Gm.
hyperglobulinemia,
further
observed
puncture
myeloid
cells.
but
because
the
2.3,
A second
of
costal
zo Gm;
who
red
blood
per cent;
Total
protein,
per
cent,
studies
sternal
cells,
taken
and
globulin
were
done.
14.2.
of
monocytes
solution,
revealed
mm.
170
margin.
2.7
in Hayem’s
on Jan.
and
the
lymphocytes
albumin
was
pressure
below
hemoglobin
with
Sternal
in erythroid
Hospital
fingers
per cent;
Wassermann
cent
of erythrocytes
in one
percentage
treatment
He
nose
Blood
blood
Albany
duration.
liver
of sugar.
the
relative
were
years.
30
neutrophils
Gm.
im-
bodies
for
8.6
Urine
and
Win-
per cent
large
puncture
at a higher
findings.
of multiple
the
cent
was
the
The
to the
week’s
of the
a trace
transfusions
4
a palpable
segmented
protein,
for
plus
inclusion
condition.
admitted
of one
insulin
and
for
6,900;
nose
lesions
except
Bence-Jones
and
and
diastolic,
cells
was
in his
impetiginous
normal
sedimentation
cells
manager,
diet
blood
of liver
showed
charged
with
revealed
Urinalysis
Gm.
office
systolic and 8o mm.
1,930,000;
per
male
of an infection
Examination
mercury
2.
old
diet
basophilic
increased
CASE
A. W.,
protein
typical
hospital.
but
myeloma
Five
was
months
of pain
in his
shortly
afterward
right
made,
later
he was
hip,
but
began
x-ray
to have
readmitted
was
because
examination
severe
patient
pain
of his
in the
asymptomatic
of a severe
left
pelvis
chest
was
he was
dis-
vaccinia.
At
this
normal.
He
was
in the
region
of the
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
44
RECENT
fifth
to the
bone
destruction
of
ninth
ribs.
persistent
to move
but
bumin
the
albumin
2.2.
The
The
neutrophils
received
a course
2.,600
reactions
to the
treatment
was
only
momentary,
The
diplopia
phthisic
marrow
patient
ministered
right
eighth
On
of ten
10,
cent
cells.
Aug.
time
in the
No
diet
and
i
to
atcells
Gm. per cent,
with
fromJuly
Aug.
was
were
of pain.
picture
was
day.
a myeloobserved.
of stilbamidine
no relief
marrow
which
in the
showed
bodies
Gm.
eyes,
later
12.,
9.
Immediate
the
until
inclusion
of s.
s8 to Aug.
into
delayed
on
a total
in the
with
blood
unrestricted.
extending
were
There
no change
myeloma
white
9.1
qualitatively
basophilic
2.7.
muscle,
m to 3 plus
3,2.00,000,
protein
puncture
and
ocular
of
because
of 0.32..
sometimes
rib
evidence
contained
of stilbamidine
which
and
protein
from
a prefrontal
1947,
myeloma
animal
at this
bodies
Sternal
total
ratio
was
mouth
urine
cells
cent,
showed
stilbamidine
rectus
The
Gm.
vomiting,
unrelieved.
a low
per
an A-G
2.85
time
with
external
redblood
which
the
at times
injections
performed
inclusion
Sept.
on
about
and
per
placed
rib was
a burning
mg
42.
left
enlarged.
Gm.;
per cent,
totaling
were
6,.m
then
in a course
basophilic
fl()
with
was
was
of protein
nausea
pain
NPN
97 Gm.
were
bone
was9.5
6.9 Gm.
with
still
at this
for treatment
1947,
of the
was
of mo injections
calories
and
liver
MYELOMA
examination
17,
weakness
The
per cent.
X-ray
onJuly
revealed
globulin
MULTIPLE.
diplopia.
Hemoglobin
71
and
and
from
laterally.
protein.
contained
The
eye
OF
readmitted
Examination
left
Gm. per cent
patient
diet
suffered
He was
no Bence-Jones
segmented
6,300,
ribs.
pain.
bone
inability
He also
in the
STUDIES
was
Puncture
found.
adof the
There
were
cells.
lobotomy
was
performed
for relief
of pain.
The
patient
of plasma
cells
expired
post-
operatively.
Autops
the
confirmed
the
diagnosis
of multiple
mycloma.
Infiltrations
were
noted
in
liver.
COMMENT
The
diagnosis
patient
The
for
of multiple
impetigo
findings
myeloma
diabetes
was
solution
although
the
patient
made
mellitus,
of hyperglobulinemia,
in Hayem’s
were
and
Bence-Jones
and
positive
sternal
had
no symptoms
Treatment
with
to
a full
relieve
pain
stilbamidine
on
basophilic
inclusion
curred
despite
course
or
a low
the
of stilbamidine
effect
the
back,
fall.
About
The
pain
onset
animal
protein
bodies
cells.
diet
in the
presence
a white
farmer,
left
and
was
intermittent,
could
urine
cells
red
Wassermann
was
and
10.4
could
not
was
mm.
to
the
of the
pain
orse
animal
bones
protein
course
of
alleviate
Failure
pain
diet
Gm.
i.
or
of
produce
of treatment
and
thus
Bence-Jones
oc-
proteinuria.
5
Albany
duration.
the
and
not
cells.
began
at night.
on Aug.
Hospital
The
pain
in the
back
to radiate
down
the
The
emaciation.
The
skin
diastolic. There
was
tenderness
be palpated
the
contained
were
globulin
70
along
Gm.,
8.
admission
showed
and
touch
The
admitted
sharp,
did
hyperglobulinemia
leg of six months
before
examination
and
light
was
a low
A second
also
myeloma
ofboth
72.,
left
month
systolic
larged
time
picture
studies
patient
also
had
5,
because
1947,
and
left
medial
frequent
of pain
hip
occurred
aspect
of the
nose
in
after
bleeds
left
since
a
leg.
the
illness.
Physical
blood
hip,
one
of his
mercury
was
diagnostic
x-ray
without
myeloma
CASE
A. V.,
to
of erythrocytes
the
and
of this
of hepatomegaly.
clumping
complete
he disease
t
hospitalization
presence
protein,
puncture
of
the
of the
negative.
failed
the
during
because
11,2.00,
be studied
fingers
aspect
3 pIus
blood
one minute
two
medial
albumin
and
cells
were
with
segmented
Total
plasma
cent,
an A-G
because
the
Gm.
and
blood
i8 seconds,
the
and
ratio
loose.
the
Blood
fourth
margin.
There
casts,
but
white
blood
cells
were
and
lymphocytes
0.2.2..
rapidly
formed
coagulation
time
I2..7
Gm.
Serum
minutes
not
no fluid
and
portion
was
On
mm.
of
was
en-
sensation
reduced.
Hemoglobin
Aug.
6, the
white
The
blood
m per cent.
albumin
be obtained
platelet
i8
liver
protein.
Io,15o.
with
The
diminished
reflex
no Bence-Jones
per cent,
could
a gel and
three
left patellar
was
rib.
was
hyaline
48 per cent
pressure
right
The
was
of
and
and
over
calf.
neutrophils
protein
dry
costal
thigh
many
m,86o,ooo,
per
negative.
below
of the left
was
1.3
and
remained.
count
557,000.
Gm.
clot
The
per cent
retraction
bleeding
Clumping
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
of erythrocytes
occurred
throughout
lumbar
Spinal
fluid
,
.2.
cent
were
quentlv
nuclei
a few
The
became
per
volumes
The
patient
NPN
was
72. mg.
Fifty
mg.
expired
Autopsy
coniposed
sixth
on
was
of
On
finding
was
8 mg.
and
in size
and
so, and
uni-
cells
cell
myeloma.
had
typiSubse-
smear.
given
oo
and
cent,
ioo
rib
these,
variation
fluids
per
Of
and
mg
cc. of blood
then
gradually
plasma
the
CO2 43
following
day.
day.
vertebrae,
skull
of a complete
taking
cells.
Larger
he was
and
or nearly
blood
day
intravenously,
hospital
great
peripheral
stopped
NPN
i,
given
eleventh
was
centrally,
disc.
Sternal
plasma
of plasma
hospital
drowsy,
cent
density
deformities
a displaced
negative.
normoblasts.
in the
third
Aug.
were
There
placed
characteristic
the
of lessened
bilateral
with
was
45 .6 per
basophilic
he became
per cent.
were
areas
consistent
test
nuclei
observed
On
oval
showed
was
forms.
with
were
.
of lumbar
the
blood
day
the
involvement
phenomenon
type
of stilbamidine
in coma
revealed
unusual
gel
the
There
resembled
rapidly
which
young
cells
small
Myelogram
Wassermann
cytoplasm
of similar
On
cent.
which
deteriorated
transfusion.
comatose.
were
small
45
KANTOR
many
left,
the
4.8 per cent
basophilic
cells
plasma
condition
on the
and
myeloma.
seen,
abundant
revealed
of multiple
of
S.
left humerus.
protein,
sheets
were
and
large
patient’s
indirect
and
Syncytial
AND
X-rays
of the
marked
cent
diagnostic
cytoplasm
eccentric
by
cells.
GORHAM
third
4, more
per
plasmablasts,
basophilic
formly
callv
3 and
W.
solution.
upper
6o mgs.
9 were
of the
appearance
in the
vertebrae
Aug.
on
Ct
and
contained
punctures
L.
in Hayem’s
the skull,
opposite
PROPP,
cast
and
sternum
of the
heart
with
and
plasma
larger
cell
vessels
myeloma.
formed
An
by a firm
plasma.
COMMENT
This
was
veloped
the
a typical,
diagnosis.
small
and
The
myeloma
was
confirmed
the
cytology
attempted
multiple
was
because
consisting
E. J. B.,
had
her
chest,
for
motion.
was
heard
nancy,
lost
was
the
aortic
and
the
8.o
neutrophils
sedimentation
phosphorus
was
cent,
and
NPN
globulin
4.5,
vertebrae
7,
small
areas
tured
in the
tiple
of localized
pain
line
basophils
serum
X-ray
marked
the
in one
protein
left.
There
aspirations
0.4
and
was
heart
It was
a very
was
Nov.
by
from
dehydrated
systolic
osteomalacia
1947.
about
aggravated
suffered
thin,
and
2.2.,
anteriorly
had
enlarged
placed
There
vomiting.
per
i per cent,
and
The
m.i
ano-
patient
murmurs
were
or metastatic
on a low
was
blood
7.7 Gm.
per
malig-
ribs
multiple
were
and
performed
animal
to the
Her general
condition
was
11.3
mg.
per
of which
albumin
was
3.2.
and
cent
collapse
and
gradually
of the
bodies.
given
grew
6th
the
rib
of
to have
worse
and
multiple
was
frac-
distributed
marrow
the diagnosis
a course
Serum
of thoracic
were
density
2.6, and
established
continued
bodies
The
of lessened
Nov.
negative.
There
scapulae.
areas
She
band
Wintrobe
calcium
on
diet
drug.
cent.
serum
This
protein
no reaction
2.6 per
Wassermann
in both
plasmablasts.
per cent,
71
units,
vertebral
minute
Hemoglobin
protein.
neutrophils
a partial
in all the
the
Bence-Jones
lymphocytes
Bodansky
revealed
cent
for
segmented
was
were
rib
nausea
Autopsy
on
in severity.
negative
hour.
throughout
and
and
stil-
of the
radiated
to admission,
8,750,
changes
and
was
Hospital
which
showed
were
cells
examinations
atrophic
destruction
Gm.
prognosis.
of a cast
Albany
varied
heart
phosphatase
cells
1.65
in the back
cent,
Sternal
patient
of
with
plasma.
ribs
prior
impression
tests
blood
plasma
The
but
The
and
cent
totaling
lower
month
clinical
66 mm.
Total
of o..
on
the
white
alkaline
with
12.
blood
examination
skull.
per
myeloma.
was
cent,
bone
axillary
the
2.5.4
stilbamidine
ratio
and
ii,
per
i
per cent.
an A-G
10,
throughout
revealed
mg
30
m,65o,ooo,
per
presence
disease.
rate
mg.
1.2.
The
bad
presence
to the
of the
constant
vertebrae.
of albumin
eosinophils
ery’throcyte
admitted
for
Physical
areas.
a trace
cells
almost
the
6
region
and
thoracic
heart
cent,
was
strength
mitral
was
in the
vomiting.
only
blood
i per
pain
lower
arteriosclerotic
Gm.,red
female,
back
and
and
The urine showed
was
The
recurrent
over
white
of
de-
confirmed
Treatment
the
gel of the
a fully
puncture
because
obviously
finding
of a firm
in her
weight
and
tender
over
single
months.
had
dyspnea
who
old
of pain
four
She
rexia,
8 year
an
complained
rib
normoblasts.
CASE
She
showing
and
interesting
of the
a striking
myeloma
Sternal
basophilic
only
and
system
of
picture.
resembling
diagnosis
vascular
type
pathologic
marrow
cells
bamidine
and
malignant
symptomatic
smears
of mul-
im injections
constant
death
severe
occurred
of
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
46
RECENT
on the
the
sternum
cent
plasma
Fins.
415.
cells
day.
hospital
tsvents--second
ribs,
and
and
STUDIES
Autopsy
vertebrae.
PHOTOMICROGRAPHS
of the
OF
Fin.
4 (upper
Fin.
(upper
right).
Large
Fin.
6 (center
left).
Mveloma
FIG.
7
Fio.
S (bottom
left).
FIG.
9 (bottom
right).
blasts.
All
(center
other
left).
Usual
right).
cells
type
No
MARROW
cell
of plasma
cells
from
Case
Myeloma
cells
from
Myeloma
cells
replacing
Dvsplastic
are mveloma
plasma
cells.
Case
i,
Case
normal
bodies
were
FROM
STERNAL
A. S. (X
marrosv
AND
type
involving
showed
II.4
per
observed.
Rin
ASPIRATIONS.
1130).
(X
1130).
1130).
1130).
marrow
(myeloma
5 V. (X
(X
marrow
normal
normal
,
inclusion
cell
SPECIFIED)
m, R. L. (X
cells
nsortens
PREPARED
from
plasma
post
OTHERWISE
from
cell
of the
obtained
basophilic
UNLESS
of plasma
type
myeloma
niarrow
SMEARS
STAIN
MYLLOMA
nsultiple
sternal
plasniablasts.
(WRIGH-r’s
MULTIPLE
revealed
Smears
cent
0.4 per
OF
cells)
cells.
Case
resembling
i,
A. S. (X
normoblasts.
400).
N-normo-
730).
COMMENT
This
was
patient
indicated
had
by
multiple
the
clinical
myeloma
picture,
at the
extreme
x-ray
findings,
age
and
of 8
years.
The
hyperglobulinemia,
diagnosis
and
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
was
confirmed
failed
to
although
10
Fio.
ii
left).
(upper
(center
ii
Fio.
13
GORHAM
AND
was
with
(center
left).
from
Case
14
Gm.
i.6
granulations
(X
stain
in
of Stilbamidine
the
myeloma
cells,
1130).
from
Case
m, R.
L.
P-plasma
(m’eloma)
cell,
S-
L.
1130).
of myeloma
left).
(lower
S. V. (X
,
stain
neutrophil
Supravital
right),
47
present.
Peroxidase-Wright’s
B-band
KANTOR
.‘i
Plasmablast
right).
S.
Treatment
basophilic
produce
.--
(upper
neutrophil,
FIG.
w.
aspiration.
or
.--
FiG.
segmented
cell
Mveloma
from
cells
Case
after
2.,
R. L. (X
stilbamidine
12.30).
treatment.
Case
m, R.
treatment.
Case
m, R. L.
1130).
FIG.
(x
marrow
pain
L.
hyperglobulinemia
±_
(X
by
relieve
PROPP,
15 (lower
right).
Supravital
stain
of mveloma
cell
after
stilbamidine
22.30).
CYTOLOGY
The
Sirridge.6
Support
cytology
of multiple
Their
was
findings
given
to
myeloma
were
the
thesis
based
that
has
on
recently
fifty-five
multiple
been
cases
mveloma
described
of
plasma
is derived
by Diggs
cell
from
and
myeloma.
plasma
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48
RECENT
cells
arising
cell
was
from
Our
similar
to
cases
were
Our
following
kern.
those
round
and
was
In case
size
nuclei
were
type
of plasma
cell
with
cells
noted,
more
peculiar
cytology
of the
The
but
not
not
only
were
resembled
in normal
abundant,
less
being
with
Wright’s
patients
matic
nucleus
observed
containing
seen
2.3,
nuclei
without
stituted
4.8
separate
in case
zone was
cytoplasm
(fig.
4.
per
cent
were
in direct
seen
normal
The
cytoplasm
and
Neutral
cleus.
These
chondria
were
normal
peared
was
observed
which
tiple
myeloma
After
cases
No
near
was
smaller
in one
was
2
change
The
case
the
of chronic
with
oval,
nucleus
from
Sheets
marrow
(fig.
con-
multiple
numerous.
of
bits
8). The
were
myeloma
was
and
plasma
interspersed
size.i6
usual
and
and
typical
very
definitely
aged.
Large
the
cell
red
a large
type
leukemia
cell
the
nu-
mito-
cytoplasm
of plasma
plasma
and
to
neutral
However,
large
abundant
external
in
type
myelogenous
the
with
round
present
and
conditions,
round,
preparations
The
12.).
cells
other
or
were
as the
aleukemic
indistinguishable
the
patients
mitochrondria
of smaller
form,
with
from
fluid
between
size
(fig.
cells
not
immature
blast
but
seen
vacuoles
ap-
plasma
cell
treated
seen
in
with
in the
mul-
patients.
in
and
and
and
were
made
and
of variable
the nucleus
numerous
stilbamidine
cytoplasm
large
membrane.
vacuoles
the
large
marrow
from
observed
to enlarge
a striking
feature.55
These
marrow
to be less
x-ray,
cell
were
cytoplasm,
I i).
similarity
be
abundant
figures
(fig.
made
cells
Very
.
.
of plasmablasts
relatively
than
and
in figure
myeloma
leptochro-
basophilic
large,
in preparations
a close
smears
The
red
Mitotic
negative
revealed
could
were
more
cases.
in case
of unconcentrated
in marrow
a distinct
containing
usual
of plasma
vacuoles
percentage
cytoplasm
cells
observed
smears
marrow.
eccentric.
in all
peroxidase
studies
cells
from
seen
highest
abundant
myeloma
commonly
uniformly
Supravital
plasma
more
‘
in each
feature.
placed
type
without
little,
The
cells
plasma
and
of the
were
cells
occasionally
cells were
Young
2..
io).
nuclei
‘Rad-
also
9).
A second
cytoplasm,
comparatively
(fig.
stain,
the
or
a prominent
and centrally
normoblasts
in figure
basophilic
and
numbers
nucleoli,
nuclei
plasma
nucleoli,
in small
reported
‘
but
with
a larger
nucleus,
observed
in the same marrow
smear,
is illustrated
The latter
closely
resembles
the typical
cells found in our cases of multiple
( figs. 6, 7). Plasmablasts
of large size with
a definitely
eccentric,
large
were
was
multiple
cases
and minor
differences
in intensity
of
different
cases.
Vacuolization
of the
is shown
deeply
myeloma
to
‘
various
basophilic
marrow
term
oval in shape,
‘cart-wheel’
typically
the
in
was abundant
present
in the
six
In general,
cells
and a perinuclear
clear
uniformly
basophilic
with
which
cell
The
of cell
noted.
occurred
common,
5, small
ofcells.
type
and Sirridge.
plasma
cell type.
were
individual
case. The cytoplasm
its basophilic
substance
were
cytoplasm
strain
pachychromatic
in
MYELOMA
a specific
the
on
of Diggs
of the
entirely
Variation
‘ ‘
observations
MULTIPLE
as a specific
it inferred
characteristics
eccentric,
OF
reticulum
to because
only.
were
the
primitive
objected
myeloma
STUDIES
treatment,
the
3, (fig.
was
majority
13,
observed
14),
large
of the
while
in cells
basophilic
plasma
cells
no inclusions
stained
by the
inclusions
stained
were
were
with
seen
peroxidase
noted
Wright’s
in the
method.
other
in
the
stain,
four
Although
in
cases.
the
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
illustrated
stain,
cell
this
(fig.
was
not
PROPP,
L.
) shows
an
remarkable
W.
GORHAM
5.
AND
increased
size
KANTOR
in neutral
as compared
to
49
red
studies
vacuoles
made
by supravital
prior
to
treatment.
DIscussIoN
The
method
in table
of diagnosis
The
i.
seven
of multiple
findings
myeloma
which
are
in the
more
cases
pertinent
reported
to the
is illustrated
diagnosis
-
.5
are
‘.,
.9’
..
‘
-
‘I
1.,
III
9:’--
listed
(
I
I,
PHOTOMICROGRAPHS
IN
COLOR
TAKEN
FROM
THE
SAME
PHOTOMIcROGRAPHS
Top
Fourth
row:
figs.
4, ,
row:
figs.
14
together
in the
and
lower
tion that
variable.
row
(x
Second
iooo),
collateral
row:
n.
(x
750),
findings
section
of the
,
i
which
chart.
8,
(x
(x
750).
450).
are common
The
table
AS THE
!
CORRESPONDING
COLOR
WITHOUT
figs.
SMEARS
shows
Third
row:
figs.
(X
10
to other
conditions
in striking
fashion
1410),
II,
13.
are placed
an
observa-
is well-known,
that the clinical
picture
of multiple
myeloma
is extremely
The only constant
feature
in all cases
was the presence
of a positive
mar-
aspiration.
although
6.
MARROW
only
diagnosis
was
the diagnosis
In one
bone
patient
pain,
made prior
was found
(case
3),
Bence-Jones
to laboratory
by the simple
the
protein,
diagnosis
and
was
anemia
made
were
or x-ray
studies
in two
observation
of clumping
by
sternal
present.
cases.
puncture
A clinical
The
clue
of erythrocytes
to
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50
RECENT
in Hayem’s
solution
headaches
in
gating
the
The
presence
lected
has
tion.
The
Rib
puncture
tion.
This
described
selection
of marrow
was
used
found
for
bits
diagnosis
of multiple
procedure
extremely
important.
the
obtained
and
Bone
marrow
sternal
procedure.
One
2
R. L.
number
3
C. H.
4
A. W.
5
S. V.
t
+
+
Protein
aspiraimportant
Myeloma
pain
Bence-Jones
se-
smears.
supplement
Case
Osteoporosis
fluid,
by centrifuga-
satisfactory
painless
of Multiple
1
A. S.
marrow
cells
most
usually
i.-Diagnosis
TABLE
differential
to complement
and
and
investi-
this
of marrow
successfully
while
unconcentrated
produced
to be a simple
of vertigo
the
utilized
a concentration
because
case.
in
which
skull
of hypergiobulinemia
in a third
technic
MYELOMA
of the
finding
a satisfactory
and
MULTIPLE
by x-ray
the
aspiration
bits,
was
from
marrow
been
marrow
instance,
and
of
makes
method
OF
of hepatomegaly
value
myeloma
A
in one
a second,
great
STUDIES
6
E. B.
+
+
+
+
+
+
+
+
-
+
+
+
-
+
-
-
-
-
+
+
+
+
+
Anemia
+
-
+
+
+
+
Albuminuria
+
+
+
+
+
Hyperglobulinemia
Clumped
RBC
Myeloma
cells
Marrow
aspiration
Elevated
in
Hayem’s
in blood
NPN
Hypercalcemia
Rapid
+
+
-
-
(39)
(38)
-
-
-
Not
-
sedimentation
*
+
+
(72.)
(so)
Not
Not
-
done
done
-
had
t Severe
pain
the
outlines
upon
are
variable
and
not
and
the
conditions,
In
our
plasma
own
cells
in
the
of the
well
three
the
and
rib
are
The
may
studies
a marrow
and
lymphocytes.
no
not
+
cent
in the
be present
of fatal
of his
unable
puncture
definitely
to
observe
should
+
be
the
details
done
on
of
the
a patient
palpable.
myeloma
per
cent
in the
in one
of Rosenthal
than
in greater
numbers.*
i
practically
from
per
marrow
preparations
of the
and
less
showed
is made
cells
is usually
agranulocytosis
+
later.
of plasma
series
+
disease.
rib
as four
-
Not
done
+
occurred
being
number
cells
None
pain
of multiple
as low
of plasma
they
course
a diagnosis
been
per
Back
patient
defined.
have
percentage
vertigo.
be used
which
reports
Sirridge6
marrow
*
later
must
criteria
aspiration
with
with
developed
Caution
in whom
other
headaches
is psychologic,
puncture.
The
severe
rib
advantage
and
None
None
Patient
+
(8)
done
Autopsy
-
+
+
(6o)
..
RBC
+
cases
is
of Diggs
Vogel.’7
In
cent.
However,
It is felt
that
a complete
normal
the
in
con-
replacement
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
tent
of
not
have
cells
plasma
been
mixture
of
PROPP,
in the
the
proliferating
bits.
When
Stilbamidine
treatment
no.
‘I’ tat
d
KANTOR
than
can
found
multiple
directly
from
cells
of Treatment
with
Basophilic
inclusions
l)iet
made
is low,
may
is the
aspirated
when
preparations
mycloma
be evaluated
ad-
marrow.
the
above.
The presence
line is also important.
in
.e
51
not
is pathognomonic
of characteristic
m.-Results
other
made
picture
are best
percentage
S.
which
in preparations
TABLE
Case
in diseases
cell as described
of the same cell
cells
the
AND
A factor
marrow
cell type is the myeloma
blasts,
and young
forms
ently
GORHAM
marrow
blood
sinusoidal
that
w.
studied.
adequately
It is believed
L.
i5
predominant
of dysplastic
cells,
Masses
of apparfrom
selected
consideration
marrow
of the
clinical
Stilbamidine
Relef
of an
General
effect
Final
results
in cells
grams
A. S.
i.
to
131
1.7
Normal
No
m.8
Normal
Yes
No
None
Died
Improved
Poor.
Increase
in
myeloma
cells
and
1/58/47
R. L.
m.
m/6
to
Yes
s. / m6 /47
Os-
teolytic
le-
sions.
to
4/15
Low
1.3
3.
C.
3/3
H.
A.W.
7/18
tO
8/i8
B.
to
11/2.7
is based.
this
in
and
that
that
*
objective
One
patient
marrow
are
evidence
may
with
bits
animal
No
No
None
Died
animal
No
No
None
Died
when
to the
becomes
myeloma
in the
cells
Our observations
inclusion
bodies
from
None
puncture
multiple
are of the
dysplastic
offers
of
face
Poor
im-
No
to be essential
marrow
originating
series
Transient
No
pro97 grams
Low
is felt
diagnosis
cells
ing
protein
so
thesis
Yes
burn-
Persistent
nerve
protein
as a whole
The
of
Neuropathy
provement
Low
1.5
to
preferred,
plasma
Yes
tein
11/12./47
picture
animal
Diabetic
8/2.7/47
E.
Yes
protein
8/9/47
6.
Yes
5th
Low
tt)
3 ,/‘ll/’47
.
animal
protein
4/2.5/47
plasma
bone
cell
described.
tending
tissue
marrow
type
and
A series
to confirm
diagnosis.
only
This,
one
of the
is derived
from
is supported
by
plasmablasts,
of
this
of course,
criteria
only
due
to chronic
an occasional
uremia
plasma
was
studies.
immature
photo-micrographs
line
All
plasma
(figs.
of
cases
cells,
4 tO
i)
theory.
revealed
cell
which
a dysplastic
our
confirm
the original
findings
of Snapper
that
be demonstrated
in the cytoplasm
of myeloma
anemia
is always
upon
io per
seen
cent plasma
in direct
smears.
large basophilic
cells obtained
cells
in smears
made
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
52.
RECENT
from
bone
marrow
diet,
protein
not
STUDIES
aspiration,
following
in
OF
MULTIPLE
patients
with
with
stilbamidine.
treatment
MYELOMA
multiple
myeloma
These
on a low
basophilic
animal
bodies
were
The two patients
in our series who showed
the
obtained
relief
of pain.
One patient
was on a low animal
protein
diet
the diet of the second
was not restricted.
The latter
patient
showed
typical
present
granules
while
prior
to
basophilic
granulation
aspiration
smears,
lesions
in his
animal
protein
diet
cells.
myeloma
cell
pain
or
series
diet,
3).
who
received
two
animal
diet.
to treatment
He
sensation
pathy
nerve.12
This
in
only
one
of
his
his
patients.
severe
The
cells
objective
which
of
io
of
relieve
in three
of
a nonrestricted
and the second
still
of
and
was
of
neuro-
explained
the
of the
mecha-
trigeminal
disabling
ultimately
of dissociated
a severe
dissociation
trigeminal
nucleus
which
symptom
causing
No
cases
sensory
itching
findings
to
recorded
was on
without
was
stilbamidine,
subjective
arrest
failures
of observation.
principle
persistent
This
in the
an
on a low animal
protein
diet.
were transient
except
in one patient
incidence
with
by
were
One
the first
months
of the
and
patients.
was
an
treated
degeneration
caused
of
six
reported
of i8 patients
due to toxic
as
myeloma
in marrow
of osteolytic
that a low
granulation
is produced
Complete
neuropathy
after
Snapper
in a total
nism
in the
a trigeminal
occurred.
pain
cells
enlargement
of Snapper
of basophilic
of
had hyperglobulinemia.
courses
of stilbamidine,
his face
in
of plasma
substantiated.
The third
patient
with
stilbamidine
developed
sensation
relief
not
granules
patients
percentage
had a definite
the observation
production
that
is also
basophilic
of
burning
in the
for the
supposition
proliferation
and one
( case
a reduction
is essential
The
produce
with
a low
Reactions
and
and at the same time
skull.
This fails to confirm
myeloma
our
treatment.
in character
disappeared
anesthesia
were
in all
persistent
SUMMARY
The
i.
was
value
of
confirmed
suspected
theory
4. The
a reliable
procedure
technic
diagnosis
should
of
be
of studying
a method
multiple
in the
original
multiple
utilized
bone
emphasizing
marrow
myeloma
all
in
marrow
certain
Relief
of pain
with
patients
obtained
important
animal
protein
basophilic
diet
inclusion
Stilbamidine
myeloma
while
cells
failed
in three
the
by
features
confirmed,
that
after
basophilic
of myeloma
cells
was
animal
protein
out
diet
allevaite
of
of
who
the
in
five
This
with
patients
second
pain
who
relieved
was
of
bodies
obtained
from
produced
on
cells
to produce
exhibited
multiple
of
pain
unrestricted.
myeloma
or
treatment
diet.
was
the
of plasma
inclusion
stain.
patient
patients
large
line
study.
Wright’s
appeared
to
been
this
by
in two
One
bodies
therapy
a low
produced
stilbamidine.
has
a dysplastic
by
of a majority
stained
as on
from
supported
stilbamidine,
cytoplasm
and
was
was
of Snapper
with
in the
as well
is derived
marrow
patients
aspiration
treated
myeloma
bone
observation
myeloma
nonrestricted
in the
of
and
that
be demonstrated
.
disease.
stressed,
originating
bone
This
this
the
in
in detail.
The
multiple
can
aspiration
discussed.
having
was
described
cells
marrow
importance
aspiration
.
and
of
The
2..
bone
following
basophilic
hyperglobulinemia.
myeloma
was
on
a low
In
both
caess
treatment.
granulation
a
From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
S.
6. Relief
while
of pain
osteolytic
7.
PROPP,
and
treatment
8.
An
cases
of
arrest
or
one
AND
in one
observed
severe
S.
53
KANTOR
patient
to enlarge
with
in
multiple
GORHAM
occurred
were
neuropathy
following
W.
vertigo
lesions
Trigeminal
L.
treated
with
stilbamidine
by roentgenological
discomfort
still
examination.
continued
six
months
patient.
remission
in
myeloma
treated
the
course
of
with
the
disease
was
not
obtained
in
five
stilbamidine.
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From www.bloodjournal.org by guest on June 17, 2017. For personal use only.
1949 4: 36-53
RECENT STUDIES OF MULTIPLE MYELOMA: STERNAL AND RIB
PUNCTURE AND THE RESULTS OF TREATMENT WITH STILBAMIDINE
SIMON PROPP, L. WHITTINGTON GORHAM and SAMUEL KANTOR
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