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 PAR T P H m

P REFACE

T m
x

m
Clinical Hematology

(ML )
m - m
- .T
m
.
x k
-

m (MLS)
-
m . Clinical HE AUDIENCE
Hematology m “ ”
ML MLS , , Clinical Hematology, x , m
m .P m- m (MLS)
m ’ m (ML )
m .S m - k. ML m
Clinical Hematology, - k m. O
x m k m k
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m .
Clinical Hematology m k -
mm WHA ’S NEW IN GENERAL OVERALL
ASCLS E L C m ASCLS P FEA URES OF HE SIX H EDI ION
B K m m , m HA FACILI A E MORE EFFEC IVE
, m .I , LEARNING?
ASCP B C Ex m C
G &O M L , ■ More Full Color Images
ML (ASCP), ASCP B C Ex m , ,
C G & O M L .
S , MLS(ASCP), ■ More Visual Learning Content m
m . ’ m .
B mm m - ■ Additional Algorithms
, x x x - m ( , , x ) k
m Nx G Sq .
(NGS) m m . ■ Expanded Basic and Advanced Outcomes c
M m m ML MLS k
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m m ’m - ■ Bulleted Chapter Highlights q k
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T Clinical Hematology ■ Revised In ext Learning Aids (C H
q m k - R Q ) m j
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LWW - , P , m ■ Numerous Updated End o Chapter Certif cation Style
q m Review Questions k
xm x . .
Clinical Hematology ■ More than 70 Case Studies , -
m m , , k q
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- - m m ■ Dedicated Lab Manual Chapter - -
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mm m , , k - m m
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H - m q ■ Key erms Italicized in the ext and De ined in
Clinical Hematology m the Glossary m
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vii
viii Preface

ORGANIZA IONAL PHILOSOPHY PART II: He m ato po ie s is and Ce llular

Maturatio n (Chapte rs 4–9)
T - z Clinical Hematology ■ A
m x k .
, m m , ■ Ex x
m . m , m m ,
PAR I Hematology Basics - m ( m m -
m ,q m , - ) , m — m -
m .C ,M G C m .
M , x m m - ■ C x
m -
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PAR II Hematopoiesis and Cellular Maturation , k m -
m m m .T - m /
m . m .
PAR III Hematology Laboratory Assessments ■ P N Ex (NE )
k .T m .
m m ■ Lm
. m , B m
PAR IV Erythrocyte Disorders - m , B m , -
m B m ,
m . m .
PAR V Nonmalignant Leukocyte Disorders ■ Ex m m .
m
.
PART III: He m ato lo gy Labo rato ry
PAR VI Neoplastic Disorders
m m As s e s s m e nts (Chapte rs 10–11)
km m m . ■ C z
PAR VII Principles and Disorders o Hemostasis and m m
T rombosis m : m - x .C q -
.A k m , , m
m , m ,q m k -
m . , m -
PAR VIII Fundamentals o Hematological Analysis , m .
m .T - ■ A L M ,C .
,m
, m .T PART IV: Erythro cyte Dis o rde rs
k (Chapte rs 12–17)
k.
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m -
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HIGHLIGH S OF SIGNIFICAN CON EN ■ P m m
ADDI IONS OR EXPANSIONS .
■ Ex
PART I: He m ato lo gy Bas ics (Chapte rs 1–3) m : m , m -
■ A m - m , m ( ) ,
N P S G - .
WHO’ ■ C m m m m
M m H H . m .
■ T H z C mm ■ D
. m m m m
■ A m P m m m .
■ A m m m -
, ED A m - m m .
, x q , ■ Ex x ’ q m
.
 Preface ix

m m x - PART VII: Principles and Disorders of

m . Hemo stasis and Thro mbosis (Chapters 25–28)
■ Ex m m : q m , -
, m ■ U m
(HDFN), . ■ A
■ P m . ■ C m m
■ U MYH- – m m
PART V: No nm alig nant Le uko cyte Dis o rde rs (M -H m )
■ U - m (HI )
(Chapte rs 18–19)
■ A m m m (HUS
■ Ex - HELLP m )
k- ■ A - m m ,
■ N , m , m (CWA),

■ Ex L , mm
PART VI: Neoplastic Disorders (Chapters 20–24) , ,
m (APS)
■ Ex m
■ U
■ A x m m
■ I x W H O z
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■ A k m
PART VIII: Fundam e ntals o f He m ato lo g ical
k m (AML) Analys is (Chapte rs 29–32)
■ Ex m m k m ■ A m —
(AML) ■ A m — m
■ U ■ N m
■ P m k m (AML) ■ R m RBC
■ A mx
■ A m k m
(ALL)
■ U x k m
m m
CHAP ER S RUC URE AND FEA URES
■ N m k m (CLL) m E Clinical Hematology
■ N m B- m (MLD), m x:
B- m k m (PLL ), - m-
k m , Séz m , - ■ Learning outcomes
m k m , - k m / m m q k .
■ Ex m m -H k ’ ■ Multiple ull color images and visual learning aids
m m , , , m m x
■ N x k m -H k ’ .
m m ■ Case studies m m
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■ U m m m m ■ Procedure boxes - - m k
■ A m m .
■ C k m ■ Key terms m z m -
m k m z - - k .
■ C k m PDGFRA- ■ Chapter highlights q k m
k m .
k m , (CEL-NOS) ■ Review questions ’
■ M k .
■ M N m, U (MPN-U)
■ S MDS , m
MDS/MPN m - ADDI IONAL RESOURCES
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( m m - Clinical Hematology
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H m Lm k’ m W :// P . . m/
■ I m .
x Preface

Ins tructo r Re s o urce s ACKNOWLEDGMEN S

A -
: M j Clinical Hematology, x , -
, ,
■ k— m q q - .B
; q m k m
k x , k
■ P P m m
■ A C T k G D Q .I , k m
■ A m k k m k -
■ A m x , , .
A k D m C. C , MA E ,
S tude nt Re s o urce s MLS(ASCP)CM, A P , D m M
S Clinical Hematology, x - L S ,R U ,C , IL. -
: .
T k J J ,
■ Aq z k q j , J L k , m m
■ A m z j .
■ N C mm m m
k @ m . m.

Mary L. urgeon
St. Petersburg, Florida
x PAR T P H m

CON TEN TS

About the Author v M B C P B

Pre ace vii I Ch a pt er High l igh t s 99
I Review Quest ions 100
I Bibl io gr a ph y 103
PART ONE 5 E :E ,M ,
Hematology Basics 1 M m C , M
A ..................................
1 S P Q H m E
L ................................... D R E M
A O H m L P
P S M m C M A
S H m L E
S W kP P q I I Ch a pt er High l igh t s 115
C I Ca se St udy 116
Q A m H m L I Review Quest ions 116
Q C H m L I Bibl io gr a ph y 118
I Ch a pt er High l igh t s 20 6 E :H m ...................
I Review Quest ions 21
C H m
I Re er ences 23
H m F
I Bibl io gr a ph y 23
Ox D A
2 P B C ................. C D x
Q B C B H m
S B C Eq m D R H m B
S B C Eq m O H m
I Ch a pt er High l igh t s 51 V F m N m H m
I Review Quest ions 54 A m H m M
I Ca se St udies 56 A H m
I Re er ences 56 C m E
I Bibl io gr a ph y 57 I Ch a pt er High l igh t s 133
I Int er net sit es 57 I Ca se St udies 136
I Review Quest ions 137
3 C M F I Bibl io gr a ph y 140
G H m D ............
C U O z
7 E :M I ......
C Mm E :N m A m
C m O M V E Sz
A K V E S
I Ch a pt er High l igh t s 75 A E C
I Review Quest ions 76 V E I
I Bibl io gr a ph y 79 A E D
P I E
I Ch a pt er High l igh t s 157
PART TWO I Ca se St udies 158
I Review Quest ions 159
Hematopoiesis and Cellular Maturation 81 I Bibl io gr a ph y 162

4 H m ............................... 8 L k :T G
O H m M S ...........................
H m O I
S Lm G S :P N ,E ,
C E m B M B
H m S mC G S D m M
C k D N ,E , B
Ex m M B C N m M C G

xi
xii Contents

L k S M k I Ch a pt er High l igh t s 241

T M -M S I Ca se St udies 241
N m R R V I Review Quest ions 242
A m G R R I Bibl io gr a ph y 242
F P M /M
P 13 B M F S m ..............
I Ch a pt er High l igh t s 180 B M F S m
I Ca se St udy 183 Aq A A m
I Review Quest ions 183 C B M F S m
I Bibl io gr a ph y 186 A A A m
B M F I S -C L
9 L k :L m P m C ..... C Am k T m
A m O D m Lm I Ch a pt er High l igh t s 253
M C N m Lm I Ca se St udies 254
C Lm I Review Quest ions 255
Lm , BL m , P m C K I Bibl io gr a ph y 255
P m C D m M
I Ch a pt er High l igh t s 204 14 D I M m H m
I Review Quest ions 205 S ..................................
I Bibl io gr a ph y 208 I D I O
I D I D A m
I D A m
PART THREE A m I mm A m C D /
Hematology Laboratory Assessments 209 D
D R H m B :S
A m
10 B L A m E , D R H m B :H
L k , P ..................... H m m
T C m B C D R H m B :H m
Q A m E (P )S
Q A m L k D R H m B :D
O L k -R A m G S
Q A m P I Ch a pt er High l igh t s 272
P B F mE I Ca se St udies 274
Smq G E M I Review Quest ions 276
Smq A m L k I Bibl io gr a ph y 279
Smq A m P
L k D C 15 M M A m ........
I Ch a pt er High l igh t s 223 M A m
I Review Quest ions 226 M A m
I Bibl io gr a ph y 229 P A m
F A D A m
11 C L A m
I Ch a pt er High l igh t s 288
A m ................................ I Ca se St udy 289
O A m I Review Quest ions 290
D m A m I Bibl io gr a ph y 291
C S Sm m A m
C A m 16 H m A m .........................
L A m A m H m A m
I Ch a pt er High l igh t s 235 T R C m m H m A m
I Review Quest ions 236 C m m -M D
I Bibl io gr a ph y 237 I Ch a pt er High l igh t s 308
I Ca se St udies 308
I Review Quest ions 310
PART FOUR I Bibl io gr a ph y 312
Erythrocyte Disorders 239 17 H m T m ........
H m D
12 A C B
A m L S k C D
A m A S m S k C S m :P N A
D .................................. T m
A B L A m O H m
C B L A m H P F H m
 Contents xiii

I Ch a pt er High l igh t s 329 22 L m P m C N m .........

I Ca se St udies 330
L k m Lm m
I Review Quest ions 332
C Lm
I Bibl io gr a ph y 334
-C NK-C N m
Lm m
H k D
PART FIVE P m C D
Nonmalignant Leukocyte Disorders 335 Imm A
W öm P m M m (L m m
18 D G M ..... Lm m )
I Ch a pt er High l igh t s 441
G A :Q D
I Ca se St udies 443
M A m M G
I Review Quest ions 445
I F A m
I Bibl io gr a ph y 447
G A :Q D
M -M D
23 M N m ................
I Ch a pt er High l igh t s 346
I Ca se St udies 347 G C M N m
I Review Quest ions 350 C M L k m
I Bibl io gr a ph y 353 P m V ,E T m (E
T m m ), P m M
19 D Lm .................... P m V
C Lm P m M
Lm E T m /E T m m
D A Lm M
Lm M N m, U (MPN-U)
Imm D A Lm I Ch a pt er High l igh t s 468
I Ch a pt er High l igh t s 367 I Ca se St udies 469
I Ca se St udies 367 I Review Quest ions 471
I Review Quest ions 369 I Bibl io gr a ph y 474
I Bibl io gr a ph y 370
24 M S m
M /M
PART SIX N m .................................
Neoplastic Disorders 371 G C M S m
M /M N m
20 C L k m ,L m m , M S m
R C P
M m ..............................
m S
C m L k m ,L m m , M m M S m /M N m
F m L k m (MDS/MPN)
C L k m I Ch a pt er High l igh t s 484
P m I Ca se St udies 485
F R O L k m I Review Quest ions 486
D m D L k m Lm m I Bibl io gr a ph y 487
L k m V
I Ch a pt er High l igh t s 378
I Review Quest ions 379
PART SEVEN
I Bibl io gr a ph y 380
Principles and Disorders of Hemostasis
21 A L k m ...........................
and Thrombosis 489
G C A L k m
A M L k m
P AML 25 P H m T m :
m O V P .....................
A Lm L k m O H m T m
P ALL B V :S F
L -T Em V P
F :V T m
I Ch a pt er High l igh t s 405 C -B M m H m :P F
I Ca se St udies 407 I Ch a pt er High l igh t s 500
I Review Quest ions 410 I Review Quest ions 501
I Bibl io gr a ph y 413 I Bibl io gr a ph y 503
xiv Contents

26 D P m H m T m 30 I m H m ..............
V P ..................... I m P
V A m W B C A
Q P D A I m D O
Q C P :T m / L
T m m A F C m
I Ch a pt er High l igh t s 522 D M
I Ca se St udy 523 I m C S
I Review Quest ions 524 I Ch a pt er High l igh t s 641
I Bibl io gr a ph y 524 I Ca se St udies 643
I Review Quest ions 650
27 P H m T m : I Bibl io gr a ph y 652
B C F N
31 M D q
C S m ..........................
A ...............................
B C F
N m P M m T m T H m G m P j
M V H m M q H m
I Ch a pt er High l igh t s 545 M G H m
I Review Quest ions 546 C S mm
I Review Quest ions 667
I Bibl io gr a ph y 548
I Bibl io gr a ph y 668
28 D H m T m :B
32 L M :M P
C F ,H S ,
H m ................................
A T ......................
P F m
I I Review Quest ions 699
D P
D D C m
T H (T m ) APPENDICES
A T A A R Q ................
I Ch a pt er High l igh t s 577
I Ca se St udies 579 B F q U A ...............
I Review Quest ions 580
I Bibl io gr a ph y 581
C S D S ...........................
D G BD . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PART EIGHT E G G .........................
Fundamentals of Hematological Analysis 583 F I k ................................

29 B F A ......................... G T M ............................
I H Q kR ...........................
C F
P ,P , P F
Glossary 727
I Ch a pt er High l igh t s 610
I Ca se St udies 611 Index 743
I Review Quest ions 611
I Bibl io gr a ph y 617
 PA RT O N E

Hematology Basics

Sa ety Practices and Quality in the

CHAPTER
1 Principles o Blood
Hematology Laboratory Collection

KEY TERMS

a ccu ra cy d rift p ro cie n cy te s tin g

b io h a za rd Ha za rd Co m m u n ica tio n S ta n d a rd q u a lity co n tro l (QC)
ca lib ra tio n h u m a n im m u n o d e cie n cy viru s (HIV) S a fe ty Da ta S h e e ts
co e f cie n t o f va ria tio n (CV) in fe ctio u s w a s te s ta n d a rd d e via tio n
co n tro l s p e cim e n Le ve y-J e n n in g s ch a rt s ta n d a rd p re ca u tio n s
d e lta ch e ck n o s o co m ia l in fe ctio n s ta n d a rd s
d is in fe ctio n p a th o g e n tre n d
d is p e rs io n p re cis io n va ria n ce

LEARNING OUTCOMES

An ove rvie w o f the he m ato lo gy labo rato ry
■ Explain the role of the hematology laboratory staff in providing qual-
ity patient care.
■ List ve basic functions of the hematology laboratory.
Patie nt s afe ty
■ Name and describe the Institute of Medicine’s six goals for health
care delivery to improve the quality of American healthcare.
■ Name and explain goal areas cited by the Joint Commission that
have speci c applications for the clinical laboratory.
S afe ty fo r labo rato ry pe rs o nne l
■ Explain the basic techniques for safety in the hematology
laboratory.
■ Explain the basic techniques in the prevention of disease
transmission.
■ Compare the features of general safety regulations governing the
clinical laboratory, including components of the Occupational Safety
and Health Administration (OSHA)–mandated plans for chemical
hygiene and for occupational exposure to bloodborne pathogens,
and the importance of the laboratory safety manual.
■ List and describe the basic aspects of infection control policies and
practices, including how and when to use personal protective equip-
ment or devices (e.g., gowns, gloves, goggles), and the reasons for
using standard precautions.
■ Explain the purpose and correct procedure of handwashing.
■ Describe the contents of the laboratory procedures manual.
■ Given a Safety Data Sheet, identify critical information.
Quality as s e s s m e nt and quality co ntro l in the
he m ato lo gy labo rato ry
■ Summarize the essential nonanalytical factors in quality assessment.
■ Explain the delta check as a quality control method.
■ De ne terms used in quality control and basic statistical terms.
■ De ne accuracy, precision, control material, mean, and standard
deviation.
■ Given the appropriate data, calculate the mean and standard devia-
tion and create a quality control chart.
Describe the basic terms and state the formulas for the standard
deviation, coef cient of variation, and z score.
Describe the use of a Levey-Jennings quality control chart.
Compare three types of changes that can be observed in a quality
control chart.
Assess the most frequent application of a histogram.
Appraise the Westgard Rules and use of the Multirule Procedure
NOTE:
■ indicates MLT and MLS core content
indicates MLT (optional) and MLS advanced content

1
2 PART 1 ■ Hematology Basics

AN OVERVIEW OF HE HEMA OLOGY BOX 1.1

LABORA ORY
H m , m S afe ty Age ncie s and Organizatio ns
, m .I
, m m ■ U.S. D m L ’ O S
m m H A m (OSHA)
m ■ C L S I (CLSI)
m . ■ C D C P (CDC),
D m H H m S (DHHS)
The S tudy o f He m ato lo gy ■ C Am P (CAP)
■ T J C mm
B m m ,
m (CBC),
m m xm ( -
), ( k ), ( m- T J C mm ’N P S G
), m (ESR), -
q m .T q
’ .M , m m q m
m , m m q J C mm .T
z m -
m , x m , k - ■ C .A , m
m .T m q .T m q
m — m ’ m , ID m ,
m . , - m .
■ Im mm . T
Functio ns o f the He m ato lo gy Labo rato ry mm , x m ,
M , m - , -
, , m m m .R
m m j . m .
T xm m ■ R k - q , nosocomial infection.
: T q
m C D C P
■ E (CDC) W H O z (WHO). T
■ C m ’ m N N m I S (NNIS)
m S m CDC m mO
■ D A .T
■ M (ICU), ICU,
■ D m m ICU. R k
A CBC m q q m .P k
, m m , mm m m ,
m .M z
m m q
.C k .
k m
.
SAFE Y IN HE HEMA OLOGY
LABORA ORY
NOTE: Now is a good time to review key term de nitions in
the Glossary and ash cards on . T m m
k m .
A j ; ,
PA IEN SAFE Y k , k mm .
M x
S , , q , , mm .
m - S /
z ( B x . ). , , .
 CHAPTER 1 ■ Safety Practices and Quality in the Hematology Laboratory 3

. U.S. D m L ’ O S Ch e m ica l Hyg ie n e Pla n

H A m (OSHA) I , OSHA m m
. C L S I (CLSI) m m m (CHP) x
. C D C P (CDC), U.S. .
D m H H m S (DHHS) T Hazard Communication Standard (HCS) ( CFR
. C Am P (CAP) . ( )), , q m
L OSHA CDC m , , m Safety Data
Sheets (SDS ) ( m M S D S )
m z .E z m m mm -
m z .T m -
m : SDS m MSDS, x
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■ A m m - , - m .
■ S m ( . ., m ,
) S D S m -
■ I z ( . ., , , m m .T m
m , ) k z
m k . T SDS
The S afe ty Of ce r z , , ,
z m .T m
A f m m m-
m. T m m m m .
m x
, x m , m N , O ,
S H A m ’ (OSHA) H z
z m . C mm S U S
m G H m z S m
C L C m (GHS),
Occupatio nal S afe ty and He alth m Am ’ k-
Adm inis tratio n Acts and S tandards . OSHA’ H z C mm S
L O S x j , ,
H A m (OSHA) CDC m m m .T
- H z C mm S k-
m z . “ k ,” G H m z
k k- S m k “ .”
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Occu p a t io n a l Exp o s u re to Blo o d b o rn e Pa t h o ge n s
O S
H A .I , A x H z T OSHA-m m, O Ex
C mm S . T B P , m M .T -
m m - q , m m , m
m m -
m m . pathogen , B
OSHA m k (HBV), C (HCV), m mm
z , q m , x - (HIV). T m
, m m m m .
m.T m OSHA - T CDC mm
k m ,k standard pre-
US k . cautions . T CLSI -
OSHA CDC m k m
- m .I ,
.E CDC mm m
m : x m .
■ A m m Avo iding Trans m is s io n o f Infe ctio us
■ S m ( . ., m ,
)
Dis e as e s
■ I z ( . ., m , A - q (LAI) -
) q -
4 PART 1 ■ Hematology Basics

m m m - m m ( . .,
m . ). T k
m x m
, -
■ Am x
human immunode ciency virus (HIV),
■ L m
.S
■ Am ’
m k
m x
■ P k
.
x k k
T HIV- m
CDC m OSHA. C Ex HIV mm ,
m k
CDC , “R mm - k m . HIV -
P HIV m H -C S ” m .S m m
(MMWR, S S, ) q . m HIV.
T E m
x k - ,
m . OSHA m m : m . HIV m
m m m
■ E k -
m k q m m
m .
■ P q m , x m ,
T m HIV x
m k ,
■ M m
.T q mm -
m (AIDS) HIV U S
Occu p a t io n a l Exp o s u re Re la te d to HIV, HBV, a n d
CDC. S
HCV Tra n s m is s io n
HIV/AIDS m , k
B m q m m HIV. T m
HIV HBV x . x HIV-
j ( . ., m , m ,
Occu p a tio n a l Exp o s u re k k , .). O m
A . , xm , HIV k x m .
k j US N m HIV m -
.T N kP S A k .
( C ) m U CDC , ,
m j - , .H k
xm , . x HIV- k . % k
A x m .I , ,
j , x m , k j , j , , .
m m m k ( T k m HBV C (HCV)
k , , m - m x k
), x HIV m .T k x -
, , - , HBV -
, . HBV mm
Am m - k HBV. B ,
q HIV , B %. A
x m mm .C m B
j k .R k m , k-
m HBV
x .
■ A j
HBV x -
■ L - HIV
. HBV m
■ V j
°C .T k HBV
■ I j
m % %
’
. I HB ,
T m m HIV k . % %; I HB ,
q k m k . % %).
 CHAPTER 1 ■ Safety Practices and Quality in the Hematology Laboratory 5

.A k j m -
.

Blo o d -b o rn e Viru s Po s te xp o s u re Is s u e s
A m m k
HIV m
x , x m m
. T CDC
m m x
HIV mm x (PEP).
(U U.S. P H S G
M m O Ex HBV, HCV,
HIV R mm P x P x ,
MMWR, [RR- ], ).
FIGURE 1.1 P - . (C A x
B D k ,F k L k ,N J .) m m x m -
m .I x ,
T C m m m
HIV HBV. Ex k m .B k m
x .T k HCV , k
k . %. , .I “ ”
, k
S h a rp s Pre ve n tio n .L
T m m q OSHA ’
CLSI - m .
(F . . ). T m I k x k ,
■ C , - , k m q - m
m HIV .T m -
■ A ,m , m .I
■ L CFR . ( ) m ,
( )( ) m /
■ C z m mm .T
■ L - , x .A j
m CFR . ( ) m x .
( )( )(C). R m
CFR . ( )( )( )(E) Im m une S tatus : S cre e ning and Vaccinatio n
T m m- S m -
q HBV. B
k m. S - B , -
- k B.
. P m m
P m , - - mm -
.N B. I HBV
j m .U m , . OSHA -
m q k m m
m B m m
m .T mm - x
, , k , m .T x
m . m , m , -
M k mm .
m .I j A - m m mm z
k m m m m -
, , m z ’ m. T k
.M - x m m HBV m
m . m mz -
, z m .
6 PART 1 ■ Hematology Basics

SAFE WORK PRAC ICES AND BOX 1.2

PRO EC IVE ECHNIQUES FOR
INFEC ION CON ROL
Yo ur 5 Mo m e nts o f Hand Hyg ie ne
S afe ty Manual, Po licie s , and Practice s
BEFORE PATIENT CONTACT
E m - - m .T
WHEN? C
m m -
m
, ,
WHY? m m -
. S m
q m OSHA
m m .O m - BEFORE AN AS EPTIC TAS K
J C mm WHEN? C mm
( JC), C Am P (CAP), k
CDC. WHY? m m , -
E q ’ m,
.
AFTER BODY FLUID EXPOS URE RIS K
T m m .A -
WHEN? C mm x
’ m
k ( m )
, , m ,
WHY? -
.
m m m m
B m z
q , m biohazard .T AFTER PATIENT CONTACT
m - WHEN? C
k k mm
m m . WHY? -
T k m m m m
m .I
AFTER CONTACT WITH PATIENT S URROUNDINGS
m m , -
WHEN? C j
, m .
’ mm ,
L -
—
m .S
WHY? -
m q -
m m m m.
m .
A m - Source: W H O z (WHO). . .
S m , .
m .

S tandard Pre cautio ns

Standard precautions A WHO ( B x . ),
x .T m- m - m ,
m
k . T .I ,m ,
m -
m .A CDC .
, m - W -
HIV, HBV,
m m .I x - m
m .S m , -
mm - k Clostridium dif cile,
. m .
T D m H H m S (CDC)
H H H
Handw as hing
S B x . ). T f
F q m .I m m m m .
m m - H m m
m .G j , .T A P I C
, . E m x m q
 CHAPTER 1 ■ Safety Practices and Quality in the Hematology Laboratory 7

.I q m -
BOX 1.3 , k
.
■ W m m
Guide line s fo r Handw as hing and Hand , m , mL
Antis e ps is in He althcare S e tting s ,
. W m ,
m .R m
m m . .U .
. U - -
m , . Pe rs o nal Pro te ctive Equipm e nt
. W , OSHA q
m m - q m (PPE) m. T m -
m . :
. D m ’
k . ■ A k z m z
. D m
. ■ P q m
. D m m m m ■ Em m , m -
.
. D m m ■ R m k z
j mm . L
. D m m . PPE m z .T
PPE m -
M m C D C P , U.S. .A q
D m H H m S . G H
H H S , MMWR Morb Mortal Wkly Rep, .F , PPE
(RR- ): , . .I m -
, .

S e le ct io n a n d Us e o f Glove s
, k % % % G m k
% x . m x. T
H mm x
k , , .I - . E m
k , m -
m mm .I .L x-
m x m .I m -
k k , m , x- .
q , , : C m k m
% .T k j k .G
k m m ( F . . ).
q . A m q
I CDC , , q m ,
: k .
T m
■ A m k
:
.
■ B , k , m k , ■ M m k k
.
■ M m
m
■ S
q :
■ M m
■ W m
( . ., - ), Fa cia l Ba rrie r Pro te ct io n a n d Occlu s ive Ba n d a ge s
m , F ( )
, .F
m ’ mm m .M k m
8 PART 1 ■ Hematology Basics

FIGURE 1.2 G m . A. T

. B. T , ,
. C. W
, -

m
x . D. T

, x -
x . E. C m

. (R m M C
RE, k CM. Phlebotomy Essentials,
, B m , MD: L W m
&W k , : , m .)

m m - .L
.A x k m .
-m m .T
m, , k. Shoes
A CLSI m GP -A ,
La b o ra to ry Co a t s o r Gow n s a s Ba rrie r Pro te ct io n m
A - , – q m - .U
k- , mm . F -
m .T m m m , x m , ,
m - mm .
m mm k .
C mm m- Ele ct ro n ic De vice s
, E , x m ,m ,I , MP
k .C m , m , x
z m .
.
D .C De co ntam inatio n o f Wo rk S urface s ,
z .
Equipm e nt, and S pills
Na il Ca re A k z
A CDC, m , :
q ( . ) EPA- .
 CHAPTER 1 ■ Safety Practices and Quality in the Hematology Laboratory 9

TABLE 1.1 Pre paratio n o f Dilute d Ho us e ho ld Ble ach

Vo lum e o f Ble ach Vo lum e o f H2 O Ratio % S o dium Hypo chlo rite % S o lutio n

1 mL 9 mL 1:10 0.5 10
Note: A 10% solution of bleach is stable for 1 week at room temperature when diluted with tap water.

Disinfection m m EPA HBV, HIV, Mycobacterium tubercu-

m m, x , losis m m .S
m j .I , j m m -
q m z .T m -
m - ( xm
– . S m ). M m -
m m m
k .U m - .
k H H>
. m m ( °C) , q -
% % -
Dis in fe ct in g S o lu t io n s m .S m
S m m m
.T m .
U S q . % . % m
, .B , Dis in fe ct in g Pro ce d u re
m m , x -
A , m
.I ,
z k
x , m x m -
: .I m
m m ,
z
x .A z m -
.I q m -
-
k q
, , .T
k k .S
E m P A (EPA) m
m HIV
x mm m m -
m .
m -
H
.D m m m
.I
m k “B z ”
.A : :
.
.
N HBV, HCV HIV m
C : : -
m m k ( . ., -
, m m -
). H , m
.F m
z ,
( . ., ) ,
m m . S
m
EPA- .
; ( . .,
B m -
) m .T -
,
mm m -
q EPA-
:
.I j , . W .
m . A .R m m
( : ). q m m .
A m . U ( : ) ,
.
m . W k
.T m .
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 CHAPTER IX
Journey into Shansi in 1893

I
NOW must go back to my first coming to Tientsin in 1893. From
Shanghai I came in a coasting steamer, and it was after starting
that I made the rather disconcerting discovery that I was the only
woman on board. Nevertheless it was the pleasantest voyage I ever
had, as my cabin had a proper bed in it and its own bathroom, and I
made the happy discovery that Chinese servants could be the best
in the world, while the officers all conspired to amuse me. The
voyage lasted a week, and the slow passage up the mouth of the
Peiho (ho means “river”) was quite a new experience. We ran into
the soft banks pretty frequently, and they crumbled like dust;
sometimes we were in imminent danger of carrying away a hut as
well, but happily that did not occur. One dreadful object kept
recurring again and again—a tall pole on the river-bank with a basket
on the top, containing a criminal’s head.
At Tientsin I was met by one of my sisters and her husband, who
had come to take me into Shansi. The European town was very dull
and prosaic, and the native city abjectly squalid, but now the former
is well laid out and there are plenty of large houses, shops, schools,
colleges, and tramways. I was not sorry to get away from it, however,
as I was anxious to see the real China, and we soon got our things
accommodated in a small house-boat to travel up the river to
Paoting-fu. Three little compartments were all we had, but we spent
a good part of each day walking on the banks and admiring the
lovely autumn colouring of the rushes. On my return a year later we
were not so fortunate, as the war with Japan was in full swing, so
that the country was too disturbed for us to walk about, and we had
to take whatever could be got in the way of a boat, namely, one
infested with cockroaches and other vermin. For three days and
nights we sat in misery, scarcely able to eat or sleep, and when we
opened our trunks at Tientsin we found them simply swarming with
cockroaches. They had eaten all the straw of a bonnet, leaving
nothing but lining and trimmings!

CAMEL INN

At Paoting-fu we left the river, and I had a mule litter while the
others rode. These litters are the most horrible invention, as the
mules perpetually tumble down, and even though you pad the sides
with your bedding you get much shaken. When we came to a river
we had to ford it or be ferried across, for there are no bridges in this
part, and often the rivers are very dangerous. On the roads we met
long strings of camels carrying packs, the tail of one animal being
attached to the nose of the one behind. They have inns of their own,
being cantankerous beasts, and are supposed to travel at nights,
because of being such an obstruction to traffic. Certainly if you lie
awake you can generally hear the tinkle of their bells. They are a
most attractive feature of the landscape in the north, whether seen in
the streets of Peking, or on the sandy plains of Chili. My sketch was
taken in the summer when the camels were changing their coats, so
that the one in the front has a grey, dishevelled look, corresponding
with Mark Twain’s description. He says that camels always look like
“second-hand” goods; but it is clear that he cannot know the fine
stately beast of North China.
The road leading to Taiyüanfu—our objective—was always
thronged with traffic, men on foot, on horseback, in chairs, or in
carts. The official messengers wore yellow, and dashed along faster
than any one else; but one day we met six mandarins in four-bearer
chairs, carrying an important document from the Emperor at Peking
into Szechwan, the western province. They were received
everywhere ceremoniously, and crackers sent off in their honour;
they were accompanied by a military escort and gorgeous banners.
At nights we often had to put up in wretched inns. The cold was
extreme at this time of year (November), and the brick bedsteads
were heated from underneath by a fire. This was all very well if it was
properly regulated, but sometimes it was allowed to get too hot, and
then you woke to find yourself baked like a biscuit. The nights were
short, for we often arrived after dark and had to get up at 4.30. Even
then it was difficult to get the men started at six, sometimes only at
seven o’clock. The clear cold moonlight mornings were very lovely,
and I was glad enough to walk to keep warm.
One day my brother-in-law made a détour to visit a village where
there is an interesting Christian community, whose history is a
remarkable one. It was the home of a thief, who in his wanderings
happened to go into a mission hall and heard the story of the life of
Christ. The next time he returned home, amongst other items of
news he retailed what he could remember of this strange story, and
so deeply interested the listeners that they found his knowledge far
too meagre to satisfy them; they decided to send two of their most
respected seniors to learn more about it. These men went to the
mission station, were carefully instructed and became Christians.
They returned to their village in course of time, taking a supply of
Christian literature, and thenceforward they have given themselves
entirely to the work of evangelisation at their own cost. Occasionally
a missionary goes round to see them—as in the present instance—
but otherwise they work steadily and successfully, without any
assistance from Europeans. This is an example of a fact which holds
good in China generally, namely, that the people do not leave
mission work to be done only by the missionaries, but become the
best workers themselves when they have accepted Christianity.
What Mr. James (of the Bombay Civil Service) says of the work of
the Presbyterians in Manchuria exemplifies this same fact: “Of 600
people who have been baptized since Mr. Ross came to Manchuria,
not more than a dozen owe their conversion primarily or chiefly to
the foreign missionaries; the others have become disciples of these
converts, and this spiritual seed has produced within a dozen years
the sixth or seventh generation.” This is the experience of workers
throughout the Empire, and was expressed by a Chinese lady
visiting England in a pathetic appeal for more missionaries: “If only
you will send us teachers now—for a few years—we will do the rest.”
To return to our narrative, my brother-in-law brought the two
Chinese elders with him when he rejoined us on the road, and they
greeted us like old friends, with radiant happiness. It was inspiring to
see their simple, heartfelt piety and their absolute realisation of
Christian brotherhood. We chanced to come across them again a
year later on my return journey to the coast, and again I saw their
simple, joyous faith, the sincerity of which could not be doubted by
the most cynical sceptic. It was the one bright spot in an otherwise
very trying and anxious journey, for the country was much disturbed,
owing to the war with Japan, and one of our party was ill with fever—
a boy of seven—and growing daily worse, so that when we at last
reached Tientsin he had a temperature of 107°.
When we approached the province of Shansi we got into a hilly
district, and crossed several ridges called “the Heavenly Gates.” In
some cases the ascent was pretty steep (2860 feet), and there were
temples at the bottom where the coolies prayed for a safe journey
up. When I stopped to sketch it aroused much interest, and
spectators always treated me with respect. It was explained to them
that I desired to show my mother the beauties of their country, so I
became the type of English “filial piety”!
The dangers of the road are numerous, and crossing the rivers is
often a very perilous proceeding: sometimes it is possible to ford
them, but the river-beds are so changeable that it was usually
necessary to have the guidance of experienced men. Sometimes we
had to be carried across on men’s backs, and it is not altogether a
pleasant experience to cling on to a bare, greasy back in a kneeling
position, with your arms round a most unwashed neck! Sometimes
we were ferried over, which was much the safest and pleasantest
way of crossing, and the charge is infinitesimally small.
Another danger of the road arises from the nature of the soil,
which is largely a loess formation. The road runs through deep
gulleys, often over 100 feet deep and quite narrow, but the loess
walls are apt to give way, especially after rain. One day we were
walking quietly along under a high cliff, when a deafening
thunderclap close behind us made us start and look back, to see a
dense cloud of dust where the cliff had fallen right across the path
we had just traversed. We had a very close shave that time. About a
year later my cousin was killed by the similar breaking down of a
road alongside a river; she was riding in a cart, and was buried
under it in the river. A friend who was with her had just got out to
walk a little, and consequently escaped.
During the rains travellers are often drowned by the sudden rush
of water down the gullies, and there are places of refuge in the high
banks—little caves or hollows. In some of the villages where we had
to stop the night the houses were dug in these cliffs, and were really
caves. The smells were atrocious, as there was but little ventilation.
The chimneys form danger traps to the unwary traveller walking
along the top of the cliffs; he may easily step into one, if he is not
looking carefully where he is going.
 The day before we reached Tai Yuänfu, the capital of Shansi, we
stopped at a mission station in the charge of a delightful, courtly old
Chinese evangelist, whose hospitality I enjoyed several times. He
treated us royally, cooking dinner for us in European style, and would
have been sorely grieved had we offered him any remuneration.
When the troubles came later, not only he but every member of his
little flock—forty-one in all—were “faithful unto death,” refusing to
accept life at the price of recantation.
The journey from the coast took altogether a fortnight, and I was
glad when at last we reached the wide plain in which Tai Yuänfu is
situated. In May it is a vision of loveliness with its crops of millet,
sorghum, and poppy—white and puce colour—but now it was one
monotonous expanse of dust. The dust storms which blow across
the plain are terribly trying; they are as bewildering and as blinding
as a fog, and they sometimes go on daily for weeks during the early
part of the year.
Shansi is one of the worst provinces of all as regards opium-
smoking, and the poppy is largely cultivated. In the accompanying
sketch a group of patients is seen, who have come to a mission
refuge to try and break off the habit. They are allowed to smoke
tobacco, but are mostly resting or sleeping on the khang; the brick
bed seen in every inn and in most private houses. On the floor in
front of it is seen a small round aperture, where the fire is fed, which
heats the whole khang. The present Governor of Shansi is taking
active steps to put down opium cultivation, and the prospect seems
hopeful. Revenons à nos moutons. When we reached the city gate
there was a slight delay, as carts are apt to get jammed in it. Though
the gateway is large it is considerably blocked by stones, set up by a
former governor to prevent carts of above a certain gauge from
entering the city: this was to encourage the trade of the
wheelwrights. Now there is a railway right up to the walls of the city,
but from what I have already said it will be easily understood how
difficult a task it has been to construct a safe line. The railway joins
the Péhan line at Cheng Ting.
OPIUM REFUGE
 CHAPTER X
Taiyüanfu

T
AIYÜAN is surrounded by a lofty wall, with a gateway at each
of the four points of the compass. The Chinese always use
these terms when we should use “right” and “left”: they speak
of the position of furniture in a room, for instance, as being north,
south, east, or west, and can always tell you the relative positions of
places and things in that way. It is the seat of the Government of the
province, and was the first place in the Empire to have a Western
university after the 1900 troubles.
The finest of all its temples—whether Confucian, Buddhist,
Mohammedan, or Taoist—is the temple of Heaven and Hell. The
entrance is magnificent in colouring, with roof and walls covered with
turquoise-coloured tiles peculiar to this province, which make its
temples so much more beautiful than those in the west. There are
interesting but repulsive statues within, mostly depicting the torments
of hell. In one temple, however, there is a deity to which childless
women especially come to pray. She is a hideous figure about life
size, with a gaping mouth, into which they stuff raw eggs by way of
offering. On the adjoining wall is a fresco representing people
receiving babies out of a cash-bag full of them, which a man carries
over his shoulder.
I visited the temple at the time of a large fair, which was held in
its courtyards (a common custom in China), and had one of the
teachers in attendance, to his great disgust, as it is not the correct
thing for Chinese ladies to go to fairs, and European manners had
not yet penetrated to this part of the Empire. It was a very fine sight,
notwithstanding the absence of the élite, for the women and children
were most gaily attired—and then the setting! They were all perfectly
civil to us and ready to talk. A woman was feeding her five-year-old
baby, not yet weaned. Family parties kept arriving on donkeys, and
women had their feet tied up in bags to protect their dainty shoes
from the dust of the road. At one side theatricals were going on, to a
loud and ceaseless accompaniment of drums. The theatres are all
connected with the temples, a visible sign of their origin in the East
as well as in the West; and the theatre and temple dues are
collected together. Actors are looked down on, and none is allowed
to compete in the literary examinations; they are in the lowest grade
of society. The accompanying sketch gives some idea of the
beautiful colour scheme of temple and theatre eaves. It is the open-
air stage of a theatre at Showyang, about sixty miles from Taiyüan.
The little figures of beasts on the roof are a characteristic feature.
THEATRE STAGE
 The stalls were full of interesting objects from all parts of the
province, and we went round buying various things that took our
fancy. There were handsome embroideries and lovely silks, and I
was surprised to find that we could take whatever we liked without
paying for it; it was sufficient to say, “Come to the mission hospital to-
morrow and the doctor will pay.” No Chinaman could have had better
credit, and few, I think, as good, in this city.
From the temple of Heaven and Hell we returned past the
barracks, and saw the men practising walking on stilts; apparently
that was part of their drill, as finally they all filed off into the yard on
them. The soldiers are quite a decent set of men, and one of the
officers frequently sent them to the hospital to be broken of the
opium habit. It is terribly common here. In a neighbouring town it is
estimated that 90 per cent. of the population (men, women, and
children) are smokers.
From Taiyüanfu we made an interesting little excursion to a place
to the south-west called Tsinssu, where there is a magnificent old
temple on the rocky hillside dominating the village. The temple is
overshadowed by hoary trees, and has remarkable golden dragons
twisted round the pillars of the façade. In the grounds are hot
springs, and the water flows under an ornamental bridge leading to
the terrace on which the temple stands. Had it not been for the hot
water it would have been impossible to sketch, as the water froze on
the surface of the paper, and every few minutes I had to put my
paint-box in the stream to thaw the coating of ice formed on the
colours. The subject, however, was so charming that I could not
waste the one chance I had of sketching, and in the afternoon I
made a rapid drawing of a pagoda, with the little bells hung on each
story tinkling in the breeze; an adjacent tower looked precisely like
an English church, but its real use was as a granary. The hot springs
are valuable in enabling the people to grow rice, which is not grown
elsewhere so far north, and it is the motive-power of many paper-
mills in the district. In a recent expedition roe-deer, leopards, boars,
and David squirrels have been found in this neighbourhood, but we
saw nothing more interesting than a beautiful pastoral scene—a
shepherd lad piping a melancholy ditty to his sheep under the clear
blue sky. I should like to have sketched him, but the shadows were
already lengthening, and we had to hasten our return before the city
gates were closed.
PAGODA
 We attended a review one day, and saw the old régime in its full
glory, now already a thing of the past. We started at 7 a.m. in the
cart, and although the parade-ground was only a quarter of a mile
away we were none too early. The soldiers were already mustered,
and two gorgeously arrayed officials were seated in state under a
canopy waiting for the Governor, with a fine sort of helmet on a stand
behind them. He arrived shortly after we did, and although there was
a drizzling rain the numberless banners looked lovely, bowing down
while the Governor passed, and then floating proudly up again. Many
of them were pale-blue silk and carried on long bamboo rods. There
were a good many soldiers mounted on smart ponies that
scampered along bravely; but the black turbans surmounting the
blue or red uniforms made them look rather like women. Some of
them were armed with bows and arrows, slung on their backs; others
had prehistoric guns which required two men to work them, one to
hold and the other to fire off by means of a lighted stick of incense,
which at other times was thrust (lighted) into the soldier’s chest,
where also he carried his powder!
One regiment was a great contrast to the others—the celebrated
tiger braves. They were clad cap-à-pie in yellow cloth striped with
black, even the boots and cap being of the same material. The latter
was most cunningly made, with little pink-lined ears which stood
erect, and ferocious black eyes, and white fangs, and a red tongue
hanging out. This alarming costume was supposed to render all
further equipment unnecessary, and I asked one of the “braves” if he
had no weapon, on which he showed me merely an ordinary knife
stuck in his waistband. I asked if he would sell me his uniform, but as
he could not do that he lent it, and I had an exact copy made. On my
return home Mr. Chamberlain saw it, and was struck with the idea
that the braves scared away the enemy by their uniform and their
roaring, and made a telling use of it later on in describing the tactics
of “the opposition”!
Yet a step farther back in history, it is interesting to learn how the
soldiers used to travel in earlier times. A model has recently been
constructed (by Professor Hopkinson) of the chariot used to convey
eighteen soldiers. This chariot was in use about a thousand years
ago in China, and registered distance, a gong sounding at the end of
every “li” (about one-third of a mile), and a bell at the end of every
ten “li.” This vehicle was called the “measure-mile drum carriage,”
and it is from the description of the mechanism given in the writings
of the period that the professor has made his model. An ode was
written in its honour. The chariot was drawn by four horses.
TIGER BRAVE
 The main features of the review were the sword exercises,
varied with turning somersaults, the charging of soldiers with two-
pronged pikes, accompanied by roaring—and various feats of
horsemanship. The men rode about clinging to their horses from
underneath, or jumped on them going at full gallop. The review
lasted all day, and we got tired long before it was over. The military
examinations of officers were on the old lines, and success in getting
promotion depended on the strength shown in drawing a bow, or
lifting a weight. Two officers came to hospital for treatment on
account of having overstrained themselves by their exertions, and
were anxious lest they should be disqualified in consequence. Now
everything is changed. There are military colleges springing up,
where everything is modelled on the military systems of the West,
and students go in increasing numbers to Europe to study these at
first hand. The Ministry of War has decided to adopt the same
gradations of rank as those of the British army and navy
respectively; thus a second lieutenant in the navy will be of equal
rank with a senior lieutenant in the army, and so on. In the past,
military service was one of the two only ways in which it was
possible in China to climb the social ladder.
In September 1904 I saw one of the last great triennial
examinations, to which students came from all parts of the province.
It opened with a great procession, headed by the Governor and
examiners who had come from Peking. Some of the big men rode in
chairs, preceded by scarlet umbrellas, and boys carrying boards
enjoining silence, many banners and discordant drums. It seemed as
if all the rag-tag and bobtail of the city had been collected to grace
the occasion; they were decked out in magenta felt hats and scarlet
cloaks which by no means covered their rags and dirt. Some wore
scarlet and gilt, others green and gilt caps, but no shoes on their
feet. The three principal men were carried on chairs, raised on little
platforms and covered with yellow rugs, supposed to represent the
imperial dragon. The imperial letters were carried (wrapped in yellow
cloth) across the shoulders of men on horseback, and the imperial
seals under gay canopies. The examination buildings are extensive,
and are well seen from the city wall. There are 10,000 cells,
arranged in rows of 100 each in alleys closed by a door. Each cell is
about 6 feet high, 4 feet wide, and 5 feet deep, and is provided with
a sliding seat and a board for writing on, which the student can slide
into the same groove as the seat to curl up on at night, for he has to
spend three days and nights without leaving it. The cell is open in
front, and an invigilator walks up and down to see that no cheating
goes on. If the student is taken ill he may not leave, and if he dies
(not an infrequent occurrence at examination times) his body is
simply put over the wall at the outside end of the alley. These
examinations are competitive, and there may be only thirty or forty
vacancies for thousands of students. At Canton there are 25,000
cells in the examination hall, and each province has its own
examination, to which students of other provinces may not come.
There are characters at the end of the rows of cells, drawn from one
of the classics, which are used as numerals, to distinguish the rows
from one another.
It is interesting to observe what supreme importance is attached
by the Chinese to learning and to morals. Learning is the main road
to eminence; the only other one—the military service—is quite
subsidiary. The highest grade of the people is the Sze, the scholar,
and from it all public servants are drawn. There is no bar to prevent
men of other grades passing into this class, provided they fit
themselves to do so and pass the necessary examinations. There
are six examinations possible.
 OLD EXAMINATION BUILDINGS

The first examination is held yearly by the district magistrate; it

lasts for three days, and the candidate has to write two essays, one
on poetry. The second examination is held (generally a few months
later) in a prefectural town, and is therefore called Fu Kau, or country
examination. The students who pass this examination are called Shu
Tsai. The third examination (only open to those who have passed the
previous one) is the triennial one, which takes place in the capital of
each province, as above described, and is called the Ju Jen degree.
This time the candidate has to write several more essays than for the
Shu Tsai degree; the quality most valued in these essays is skill in
quotation, both as to the number of quotations made from the
classics and the way in which they are combined—this might aptly
be compared to a string of pearls. The candidates who obtain the Ju
Jen degree are alone eligible for the degree of Tsin Sze. This fourth
examination takes place triennially at Peking. The candidate is
confined for nine days in a small compartment in the examination
building. No matter how great the discomfort of this confinement may
be, he has to write nine essays. I obtained the most fascinating little
crib containing the whole classics, not larger than one inch square,
which would offer a severe temptation under such circumstances to
the most conscientious student! If the candidate is successful with
his nine essays he receives the title of Tsin Sze, but if not, he may be
appointed to a clerkship of a more or less important nature,
according to the merit of his essays.
A yet higher degree may be obtained called the Tien Sze,
because it is held in one of the buildings of the Imperial Palace. The
student at the head of the list is called Cheong Yuan; the second is
Paun Yien; the third is called Tua Hwa, and the fourth Chuan Lo To.
Their official title, which is also given to other successful candidates
in this examination, is Han Lin Yuan Shu Chi Sze, and they are
obliged to study for the next three years at the Han Lin Yuan for the
next examination. The successful candidates are retained at the Han
Lin, and the unsuccessful ones receive posts of lesser importance,
such as magistracies and other civil appointments. They are
6
considered to have a first claim to all such appointments.
This old examination system is being replaced by one in which
Western subjects are to a large extent taking the place of the
classics. Since 1904 the degrees of the Ju Jen and Han Lin have
been granted in this way to students educated abroad and examined
on their return to China. At the present time there are about 300
Chinese students in England, studying mainly law, medicine,
engineering, and manufactures: some are still in public schools,
grammar schools, &c.; others are at the English or Scotch
universities.