THE BLOOD PICTURE IN PNEUMONIA*

Transcription

1 TE BLOOD PICTURE IN PNEUMONIA* WIT SPECIAL REFERENCE TO PATOLOGICAL CANGES IN TE NEUTROPILS NATAN ROSENTAL A$i* CARLES J. SUTRO From the Medicl Deprtment nd Lbortories, Mount Sini ospitl, New York, New York Blood chnges in infections, especilly pneumoni, hve been observed for the pst hundred yers. The erly investigtors, working under technicl difficulties, rrived t uniform results, nmely: () Leukocytosis is present in the mjority of pneumoni cses. () Leukopeni often indictes ftl prognosis. () A possible reltionship exists between the number of leukocytes, temture, nd re involved. () In the mjority of cses, trnsitory rise in the number of leukocytes ps during the erly iod of crisis, followed by diminution. (5) Temture reches norml level severl dys before the return of leukocytes to norml. () Delyed resolution nd complictions re ccompnied by n increse in the number of leukocytes. (7) A stedy rise in the number of leukocytes prognostictes ftl ending. Subsequent investigtions were concerned with the vriety of cellulr rection s well s with the leukocyte count in pneumoni. Tiirk, Gitskell' nd others observed the following chnges: () Mrked increse in the number of polymorphonucler neutrophils; (in one cse up to 9.5 ). () A diminution in the ge of lymphocytes. () A dispnce or mrked diminution in the eosinophil count. () A diminution in the ge of polymorphonucler neutrophils fter crisis. (5) Apnce of myelocytes in mny cses, most frequently t the crisis. * Red before the Eleventh Annul Convention of the Americn Society of Clinicl Pthologists, New Orlens, Louisin, My -9, 9. 8 AMERICAN JOTTRNAL OF CLINICAL PATOLOGY, VOL., NO. Downloded from on Februry 8

2 8 NATAN ROSENTAL AND CARLES J. SUTRO ickling found trnsitory monocytosis fter the crisis which bers no reltion to prognosis. Arneth differentited the polymorphonucler neutrophil cell, ccording to the number of lobules in the nucleus, nd suggested five divisions nd mny subdivisions. In cses of cute infection, he noted mrked increse in the number of cells, with fewer lobules in the polymorphonucler neutrophils, indicting their increse by the term, "shift to the left." Due to the complexity of the Arneth formul, Schilling suggested the following modifiction: () myelocytes (rrely found in norml blood), () young (up to ), () stff or bnd ( ), nd () segmented leukocytes (7 ). In infections he found mrked increse chiefly in the stff (bnd) nd young forms. Reznikoff in study of seventy-eight cses of pneumoni found tht, in 8 of the ptients who died from pneumoni, more thn of the cells were immture polymorphonucler neutrophils, which correspond to the stff (bnd) form of Schilling, nd more thn of ll polymorphonucler cells were immture; of those tht recovered, 55 showed more thn of ll cells to be immture, nd 8 showed more thn of ll polymorphonuclers to be immture. Although the Arneth count hs been somewht modified by Schilling nd by Cooke 5 the present tendency is to dopt still more simplified method, prticulrly one first proposed by Kothe nd emphsized rely by Pons nd Krumbhr, who clssified the polymorphonucler neutrophils into segmented cells (verge 7 ) nd nonsegmented cells (verge to ). Similrly, Frley, St. Clir nd Reisinger clssified the polymorphonucler neutrophil cells into filmentous nd nonfilmentous forms. This simpler clssifiction is more redily understood thn the more compucted hemogrms of Arneth nd of Schilling. PATOLOGICAL CYTOPLASMIC CANGES Importnt s the number of leukocytes nd the differentil count my be in determining the severity of the infection, it is, however, not dignostic, s increses nd chnges my occur in Downloded from on Februry 8

3 BLOOD PICTURE IN PNEUMONIA 8 conditions other thn infection. Certin studies on the toxic chnges of the cytoplsm of the polymorphonucler cells re eqully if not more importnt. Cesris-Demel described degenertive chnges in polymorphonucler cells in severe infections. Grhm 9 clled ttention to the chnges in cytoplsm in severe infections, especilly pneumoni, s shown by the diminution of the oxidse grnules. With the improvement of the ptient these grnules increse to their norml number. Using the ordinry blood stins (Jenner, Wright, Giems), Schleip, Turk, 7 Negeli, 8 nd Alder, clled ttention to the deeply stined bsophilic grnules in severe infections. These re clled toxic grnules nd re found in segmented s well s in nonsegmented polymorphonucler neutrophils. Vcuoliztion is usully seen in segmented forms. Pelgr 9 clled ttention to nother vriety of cytoplsmic degenertion in which there is n bsence of both grnultion nd oxidse rection, thus confirming Grhm's findings. Observtion of the toxic grnules in polymorphonucler neutrophils is vluble id in the dignosis nd prognosis of cses of pneumoni. Pelgr observed the invrible presence of toxic grnules in lobr pneumoni; their bsence left no doubt s to the dignosis. e cites n interesting cse of so-clled sepsis in mn sixty-one yers of ge whose chest ws pprently negtive. The blood count ws: leukocytes,,; nonsegmented polymorphonucler neutrophils, ; segmented polymorphonucler neutrophils, 9 ; lymphocytes, 5 ; monocytes, ; neutrophils with lrge toxic grnules, 9. Pelgr considered the leukocyte count too high for sepsis, believing it to be typicl of lobr pneumoni; he suggested the ltter dignosis despite the chest findings, nd ventured ftl prognosis. The signs of pneumoni only ped three dys prior to deth. Postmortem exmintion reveled right up lobr pneumoni with grey heptiztion. In bronchopneumoni, Pelgr found the toxic grnules to be of smller dimensions. The ge of cells presenting these cytoplsmic chnges ws lower thn in lobr pneumoni. Mommsen lso demonstrted the constnt presence of toxic Downloded from on Februry 8

4 8 NATAN ROSENTAL AND CARLES J. STJTRO grnules in lobr pneumoni. e observed rpid increse in the ge of cells showing toxic grnules; they reched their mximum ( ) few dys fter the crisis, nd grdully returned to norml by the third or fourth week. When complictions rose, prticulrly empyem, the number of toxic grnules remined high ( to 7 ) for weeks. Gloor 8 observed forty-seven cses of lobr pneumoni nd noted the presence of toxic grnules in ll, but ws unble to follow the quntittive vritions in the toxic cells. Mommsen ' 7 reported dditionl findings on vritions in the polymorphonucler cells with toxic grnules in eight cses of lobr pneumoni. Agin, he found the mximl curve fter the crisis. Even s lte s the third week he observed tht to of polymorphonucler cells my show toxic grnultion. As the segmented nd nonsegmented polymorphonucler neutrophils usully showed the sme ge of toxic grnules, he believed their presence could not be considered s n indiction of immturity of the cell. Furthermore, he believed tht toxic grnules re the result of physico-chemicl ltertions nd tht ctul grnulr formtion occurs extrvsculrly. Bullow, Rosenbluth nd Merkin 8 exmined the blood in cses of pneumoni by mens of the suprvitl technique (Stn ). The cells were found to be motile nd, following serum tretment, presented no leukocytic chnges before or fter chills. The polymorphonucler count hd no reltion to the recovery. Vcuoliztion nd non-motility of the polymorphonucler cells were found with greter frequency in ptients who died. IDENTIFICATION OP TOXIC GRANULES The toxic chnges mnifest themselves by nisocytosis of polymorphonucler neutrophils, slight degenertive ltertions in the nucleus, nd the presence of bsophilic grnultion in the cytoplsm (figures nd ). These toxic or degenertive grnules re of two kinds, smll nd lrge, nd stin deeply bsophilic with the usul blood stins. The smll grnules re distributed mong the pinkish neutrophilic grnules, nd re present in milder forms of infection nd during the iod of convlescence. Downloded from on Februry 8

5 FIG.. TUBERCULOUS PLEURISY (CASE ). NONSEGMENTED MORPONUCLEAR NEUTROPILS WITOUT TOXIC GRANULES (X POLY5) FIG.. ACUTE LOBAR PNEUMONIA (JENNER-GIEMSA STAIN) (CASE ). ONE SEGMENTED AND TWO NONSEGMENTED POLYMORPONUCLEAR NEUTROPILS WIT TOXIC GRANULATION (X 5) 85 Downloded from on Februry 8

6 8 NATAN ROSENTAL AND CARLES J. SUTRO The lrger toxic grnules p in cells devoid of pinkish neutrophilic cytoplsm, nd re present in severe infections. Lighter bluish cytoplsmic msses my likewise be present in severe infections; these correspond to the Doehle bodies, first described in scrlet fever. Due to vritions in the stins, control smers re importnt in the differentition of these grnules. Such control smers cn be mde by using one-hlf the slide for the ptient's blood nd the other hlf for norml blood. The most prcticl stin is tht of Wright, with the use of buffer solution (p.). Best results re obtined, however, with the Jenner-Giems stin, using buffer solution, (p.8 to 7.). Stining is formed s follows: () Jenner stin (Ntionl Aniline & Chemicl Compny) is used, sufficient to cover the slide for one minute. () Dilute with buffered distilled wter (p.8 to 7.) for three minutes. () Wsh off diluted stin with buffered solution. () Cover slide with Giems Stin (R. A. L.), diluted with one drop to cc. of buffered distilled wter. (5) Wsh nd llow to dry in the ir. The buffer solution for the Jenner-Giems stin cn be prepred by diluting.5 cc. to. cc. of M/lo N P to cc. of distilled wter; the mount dded vries with the originl p of the distilled wter. For Wright's stin, the buffer solution recommended by McJunkin" is preferble. This buffer is prepred by dissolving. grms of Merck's monopotssium phosphte nd.5 grms of Merck's nhydrous disodium phosphte in liter of distilled wter (dd bout cc. of chloroform). A comprtive study of the number of polymorphonucler cells with toxic grnules (Figure ) with the totl number of polymorphonucler cells offers guide to the progress of infection. The degenertive index my be obtined from this rtio: number of toxic polymorphonucler cells totl number of polymorphonucler cells A rise in the index to, with the pnce of lrge toxic grnules, indictes severe or widespred suppurtive infection. A grdul or rpid diminution in the index indictes good prognosis (Kugel nd Rosenthl ). Complete blood counts re lso mde t frequent intervls using modified hemogrm. (See exmple s illustrted in tble.) Downloded from on Februry 8

7 BLOOD PICTURE IN PNEUMONIA 87 CASES ILLUSTRATING RECOVERY FROM PNEUMONIA The following selected cses (tble ) illustrte some of the vritions in the blood picture in mild, severe nd complicted lobr pneumoni. Cse (Mild type): Ptient, ged fourteen yers, ws dmitted to the hospitl yer previously for sthm nd redmitted with three-dy history of pin in chest, cough, nd fever. Signs of lobr pneumoni were present in TABLE MODIFIED EMOGRAM Ptient: C. B. (Cse 9). Wrd: E. Dte: --. Dignosis: Lobr pneumoni. emoglobin: 85. Erythrocytes:,55,. Pltelets: 7,. Leukocytes:,. Differentil count: Polymorphonuclers, nonsegmented.. Polymorphonuclers, segmented Polymorphonuclers, eosinophile Polymorphonuclers, bsophile Lymphocytes Monocytes Other cells: Myelocytes Degenertive index:. Clinicl dt: cute lobr pneumoni thirteenth dy of illness. Died on the fourteenth dy of illness. the right, middle nd right lower lobes (confirmed by x-ry). The temture (5 ) dropped in four dys by crisis. The blood picture on dmission (th dy of illness) showed moderte leukocytosis nd increse of the nonsegmented polymorphonucler neutrophils (8 ), nd 5 segmented neutrophils. The degenertive index ws ; this incresed dily to 8 fter the crisis nd returned to norml on the th dy of illness. A post-criticl monocytosis ws present in this prticulr cse. The hemoglobin, erythrocytes nd blood-pltelets were norml. Cse 8 (Severe type): A middle-ged femle hospitl employee (tble ) with history of rthritis, complined of chilliness, cough nd fever for two dys. Dullness ws present in the right bse posteriorly nd in the right Downloded from on Februry 8

8 88 NATAN ROSENTAL AND CABLES J. SUTRO nd left pices. X-rys showed bilterl up lobr pneumoni. The temture ws on dmission nd dropped by crisis on the th dy of illness. Blood Picture (Chrt ): The hemoglobin, erythrocytes nd pltelets were norml throughout the course. There ws striking leukocytosis of 5, to 87, before the crisis. The nonsegmented polymorphonucler neutrophils (7 ) fell rpidly to norml by the 7th dy while the segmented neutrophils nd lymphocytes incresed to norml ge during the sme iod. The degenertive index did not run prllel to the nonsegmented cells. It incresed rpidly before the crisis to (indicting tht CART. ACUTE LOBAR PNEUMONIA (CASE 8) of the neutrophils contined toxic grnules) nd then diminished rpidly to on the 5th dy of the illness, when the leukocyte count ws 7,9. Notwithstnding the fct tht the leukocyte count ws norml, evidence of resolution ws demonstrted by the presence of toxic cytoplsmic chnges in the neutrophils. The myelocytes nd monocytes were not incresed during the iod of observtion. Cse (tble ): Pneumoni complicted by empyem. A housewife, ged thirty-one yers, developed cough, bloody sputum, fever, chill, nd pin in the right chest five dys before dmission to the hospitl on Februry th (tble ). The physicl exmintion reveled lobr pneumoni of the right up Downloded from on Februry 8

9 BLOOD PICTURE IN PNEUMONIA 89 nd lower lobes. Severl dys lter the left lower lobe becme involved. The condition hd very stormy course. The blood chnges were typicl of lobr pneumoni: moderte leukocytosis (8,-,) nd mrked increse of the nonsegmented neutrophils to TABLE LOBAR PNEUMONIA RECOVERED CASES M n z s } < * 8 < g n s % M O 8,5 85 9, 75 5, 85 7, 8 7, 75 5, 9,8 7, 8 9,5 88, 8 8,5 9, 75, 8 8,5 8, 77 8, 85 7, 8 5, 78, 7, 8, 75 7,5 7, 85, POLYMORPO NUCLEAR NEUTROPILS o * On dmission to the hospitl. S t Q B o 5 li to w X O z o pei- * g CO Type II Type I Type IV Type I PNEDMOOU8 IV S P IV IV IV III III I IV II IV III I I, occsionl myelocytes nd the pnce of post-criticl monocytosis ( ). The degenertive index ws high t first (9) nd grdully returned to norml on the 5th dy of her illness (Mrch th), lthough there hd been n increse in the number of leukocytes to, (Mrch 9th). Downloded from on Februry 8

10 9 NATAN ROSENTAL AND CARLES J. SUTRO On Mrch 7 (5st dy of illness), there ws mrked rise in the degenertive index (9). An empyem on the left side ws found two dys lter nd thorctomy ws formed,, cc. of pus (subsequently shown pneumococcus III on culture) being evcuted. The ptient mde n uneventful recovery. Cse : Atypicl blood findings in ptient with pneumoni, complicted by empyem. A mn, ged forty yers, ddicted to the use of lcohol for twenty yers, ws dmitted with shrp pins in the right chest. Bronchil brething nd egophony were herd t the right bse. The roentgen exmintion confirmed the dignosis of right lower lobr pneumoni. The ptient ws firly comfortble, the temture ws subfebrile, never bove. The blood culture ws positive for pneumococcus type II. No sputum could be obtined for typing. The blood picture showed leukocytosis (9,-,9) nd only modertely high degenertive index (57). The non-segmented neutrophils were s high s 7 t first (nd dy of illness), but returned to norml by the th dy. At tht time there ws still slight leukocytosis, norml differentil count nd bsence of toxic grnultion. The temture remined low (). owever, signs in the chest sisted nd, lter, evidence of mrked ccumultion of fluid ws found. The right side of the chest ws spirted nd the fluid proved to be thick pus. A thorctomy ws formed few dys lter. The blood picture (tble ) remined norml except for slight leukocytosis (5,) nd slight increse of the toxic cells (degenertive index (5)). The devitions from the norml rection in this ptient were: () subfebrile course lthough bcteremi ws present, () moderte leukocytosis with lower trend in the degenertive index, () leukocytosis without increse of the non-segmented polynuclers with the pnce of severe compliction (empyem), () bsence of toxic grnultions in the neutrophils when the empyem ws found. RESUME OF OBSERVATIONS ON RECOVERED CASES Observtions on the blood picture during the course of twentyfour cses (tble ) of lobr pneumoni, with recovery disclose the following significnt fcts: () The hemoglobin, erythrocytes nd pltelets showed slight vritions. The lowest hemoglobin ws 7, the verge more thn 8. The blood pltelets were uniformly norml. In only two cses were the pltelets less thn, cubic millimeter (, nd 5,). () The leukocytes vried from 7, (tble, cse 5) to 5, (tble, cse 8). There ws no uniformity in their vri- Downloded from on Februry 8

11 BLOOD PICTXJBE IN PNEUMONIA 9 tions before or fter the crisis; there ws either n increse or decrese. The nonsegmented polymorphonucler neutrophils were incresed in ll except three cses from to 7. In three cses of lobr pneumoni, confirmed by x-rys, the nonsegmented polymorphonucler neutrophils were norml on the ptient's dmission (tble, cses 5,, ). In these cses, however, there ws rpid increse before the crisis. The lymphocytes were mrkedly diminished. The monocytes were either bsent or norml nd only slightly incresed (8 to ) in three cses (tble, cses 5,, ). A post-criticl monocytosis ws exceptionl. () The degenertive index (the ge of polymorphonucler neutrophils with toxic grnules) ws found to be very high ( to ) with three exceptions: Cse represented n typicl one-dy pneumoni (Woillez Disese) confirmed by roentgenogrm. Some consider this condition result of pulmonry congestion nd not true pneumoni (Rmond ). Cse nd cse (tble ) were mild cses, but the degenertive index rose rpidly to 7 nd 8 respectively t the crisis nd returned to norml by the end of the third week. The downwrd trend of the degenertive index is good prognostic sign. () In ptients ddicted to lcohol the blood findings were less typicl. The degenertive index ws comprtively lower. During severe complictions, such s empyem, the nonsegmented polymorphonucler neutrophils nd the degenertive index my be norml. FATAL CASES OP PNEUMONIA (TABLE ) The blood chnges in ftl pneumoni t the onset showed vritions, somewht similr to those of the recovered cses. A modertely severe nemi ws present in three cses only. The leukocytes vried from 5, to,; in four cses (tble, cses 5, 7, nd ) there ws subsequent mrked leukopeni which my be considered n unfvorble sign. The degenertive index ws invribly during the course of observtion, in ll but one cse. In this ptient (tble, cse ), the pneu- Downloded from on Februry 8

12 9 NATAN ROSENTAL AND CARLES J. SUTRO moni ws of chronic type. The ptient ws quite toxic nd leukopenic tendency ws present, the highest degenertive index being 7. The sistence of the high degenertive index () in these cses my be considered bd prognostic sign, nd s such is more relible thn the vritions in the nonsegmented polymorphonucler neutrophils. «n p IS < < DAY OF ILLNESS g o m c M 8 8, 88, 79 8, 8,8 85, 8, 5 5, 55, 85 8,85 75, TABLE LOBAR PNEUMONIA FATAL CASES POLYMORPO NUCLEAR NEUTROPILS Nonsegmented * On dmission to the hospitl LYMPOCYTES 8 5 O Z O to W o 9 z B e 8 O e 7 Blood culture Type IV Type III Type IV PNEUMOCOCCUS Pi* I IV CASES SIMULATING PNEUMONIA The constnt presence of toxic grnultion in the polymorphonucler neutrophils in pneumoni is n importnt dignostic criterion in the differentition of such cses from those simulting pneumoni. The following cse will serve s n exmple: Cse : A mn, ged forty-two yers, ws dmitted to the hospitl complining of severe chill which hd lsted for ten minutes, nd cough. is temture ws. Dullness ws present in the right chest posterior to the ngle of the scpul. The hert ws not displced. The blood culture ws negtive. Roentgenogrm reveled shdow to the right of the hert which seemed to be i- Downloded from on Februry 8

13 BLOOD PICTURE IN PNEUMONIA 9 medistinl pleurl effusion. The blood exmintion showed leukocyte count of nd of nonsegmented neutrophils. During his sty in the hospitl, toxic grnules were not found (fig. ) so tht pneumoni could be definitely ruled out. Lter observtions indicted tht the ptient ws suffering from tuberculous pleurl effusion. The reverse is lso importnt, s seen rely in child who ws brought to the hospitl for n ppendectomy. There were some bdominl signs, nd even slight tenderness in the right lower qudrnt. The blood exmintion reveled the presence of toxic grnultions which led to suspicion of pneumoni. The surgeon ws dvised to dely otion until roentgenogrm of the chest ws done which confirmed the dignosis of pneumoni. Other ptients were dmitted to the hospitl with tenttive dignosis of pneumoni. The bsence of the toxic grnules for the first few dys, or their mrked diminution, helped to rule out this prticulr dignosis. Rely, ptients hve been observed with crdic decompenstion nd pulmonry signs. The symptoms s well s the physicl signs in the chest my closely resemble pneumoni. The presence of toxic grnules is definitely indictive of pneumoni; their bsence points to congestion, infrction nd other conditions. DISCUSSION Severl fctors must be considered with respect to the blood chnges in lobr pneumoni, nd their reltion to dignosis nd prognosis. The number of leukocytes showed very mrked vrition from, to,, the ltter count rely observed in child. In our series the highest in n dult ws 85, (chrt, cse 8). The differentil count showed mrked vrition in the number of nonsegmented polymorphonucler neutrophils from to 7. Slight secondry nemi ws present in bout of the cses nd more mrked nemi in 5 of those tht were ftl. These chnges re present in other types of infection nd re not prticulrly dignostic of pneumoni. They seem to indicte the presence of severe infection. Downloded from on Februry 8

14 9 NATAN EOSENTAL AND CAKLES J. BUTRO Cytoplsmic chnges with the constnt pnce of toxic grnules re present in lobr pneumoni nd re usully bsent in polymorphonucler cells in other conditions simulting pneumoni, such s pulmonry congestion, infrcts of the lung in crdic cses, pleurisy with effusion, lung bscess, rheumtic pneumoni, hydrothorx nd pulmonry tuberculosis. In pneumoni the toxic grnules p rther erly nd hve been found on the second dy in firly lrge number of polymorphonucler cells. As first pointed out by Pelgr, ittmier, Mommsen nd Gloor, the pnce of the pthologicl cytoplsmic chnges my be present in ll polymorphonucler cells few dys fter the onset of the disese, or they my rech their mximum prior to, or immeditely fter, the crisis. The ge of polymorphonucler cells showing toxic grnules, tht is, degenertive index (Kugel nd Rosenthl) my be followed throughout the course of pneumoni. This index remins firly high in some cses for n invrible iod, but usully the ge of cells showing toxic grnules rpidly diminishes within twelve to fourteen dys fter the crisis. owever, s lte s the third or fourth week, there my be sistence of smller grnules in polymorphonucler cells, s reported previously by Mommsen. The only exception to these results occurred in two ptients who were ddicted to the use of lcohol. In both, the degenertive index hd tendency to be lower (the highest being ), returning rpidly to norml s the ptient improved. The fctors involved in prognosis re the nemi, the number of leukocytes nd the prege of nonsegmented neutrophils nd the degenertive index. The question rises whether the prognosis cn be stted definitely from the first exmintion of the blood. This is sometimes possible when mrked leukopeni is present. Aprt from the occurrence of the leukopeni, however, prognosis depends upon the trend of symptoms, the extent of involvement in the lung nd the trend of the blood chnges. A severe nemi or mrked increse in the number of nonsegmented cells (bove 5 ) my presge ftl outcome. The presence of bcteriemi is not indictive of bd prognosis, lthough in the recovered cses here reported, blood culture ws Downloded from on Februry 8

15 BLOOD PICTURE IN PNEUMONIA 95 positive in of the cses, nd in the ftl cses, in. Follow-up of the degenertive index is importnt in prognosis. A rpidly diminishing degenertive index presges rpid recovery; grdul diminution of the degenertive index keeps pce with grdul recovery. The sistence of high degenertive index indictes either ftl outcome or the presence of complictions. A secondry rise in the degenertive index during convlescence is indictive of complictions, usully empyem. CONCLUSIONS () In ddition to noting ordinry blood chnges, observtions on pthologicl cytoplsmic ltertions (toxic grnules) re vluble id in the dignosis nd prognosis of cses of pneumoni. () Pthologicl cytoplsmic ltertions (toxic grnules) re present in ll cses of lobr pneumoni, re diminished in bronchopneumoni, nd usully re bsent in conditions simulting pneumoni. () In recovered cses, the degenertive index tht is, the ge of cells showing toxic chnges rises rpidly (not infrequently to ) either prior to, or immeditely fter, the crisis nd sists much longer thn the symptoms, tht is, to the third or fourth week. () The degenertive index is lower in lcoholic ptients suffering from pneumoni. (5) In ftl pneumoni the degenertive index is frequently ; its sistence t tht level presges ftl prognosis. REFERENCES () ALDER, A.: Uber morphologische Vernderungen n den weissen Blutkorchen bei Inf ektionskrnkheiten. Schweiz. Med. Wochenschr., : CM. 9. () AENBT, J.: Die neutrophilen Leukozyten bei Infektionskrnkheiten. Deut. Med. Wochenschr., : () BULLOWA, J. G. M., ROSENBLUT, M. B., AND MEEKIN, A. M.: Studies on leukocytes in lobr pneumoni. Tr. Sect. Pth, nd Physiol., Am. Med. Assn., Downloded from on Februry 8

16 9 NATAN ROSENTAL AND CARLES J. SUTRO () CESAIS-DEMEL, A.: tlber die morphologische Struktur und die morphologischen und chromtischen Vernderungen der Leukozyten. Virch. Arch. f. pth. Ant., 95: (5) COOKE, W. E.: Arneth or polynucler count. Lncet, : () FARLEY, D. L., ST. CLAIR,., AND REISINGER, J. A.: The norml filment nd non-filment polymorphonucler neutrophil count: its prcticl vlue s dignostic id. Am. Jour. Med. Sc, 8: (7) GAITSKELL,. A.: The condition of the blood in pneumoni, together with some records of blood exmintions during the heling of wounds. Guy's osp. Rep., 7: (8) GLOOR, W.: Die klinische Bedeutung der qulittiven Verenderungen der Leukozyten. Leipzig, Georg Thieme, (9) GRAAM, G. S.: Neutrophilic grnules of circulting blood in helth nd in disese; preliminry report, N. Y. Stte Jour. Med., :. 9. () ICKLING, R. A.: The monocytes in pneumoni: clinicl nd hemtologic study. Arch. Int. Med., : () ITTMAIER, A.: Bemerkenswerte Blutbefunde bei Pneumonic Fol. em., : () KOTE, R.: Ds neutrophile Blutbild in Fruhstdium der kuten Appendicitis. Beit. Klin. Wchenschr., 5: () KUGEL, M. A., AND ROSENTAL, N.: Pthologic chnges occurring in polymorphonucler luekocytes during the progress of infections. Am. Jour. Med. Sc, 8: () MCJUNKIN, F. A.: A benzidine-polychrome stin for blood. Jour. Am. Med. Assn., 7: (5) MOMMSEN,.: tlber die neutrophilen Grnultionen der Leukozyten und ihre gesetzm'essige Verenderung bei Schrlch und lobrer Pneumonic Jhr. f. Kinderheilk., : () MOMMSEN,.: Die Pthologische toxische Grnultion der feingeksrnten Leukocyten, ihre objektive Erkennung und prtisch klinische Verwertung. Klin. Wchenschr., 8: (7) MOMMSEN,.: Die Grnul der polymorphkernigen feingekorten Leukocyten unter normlen und pthologischen Verhltnissen und ihre gesetzmfissigen Beziehungen zum Abluf kuter Infektionen. Ztschr. f. d. Ges. Exp. Med., 5: (8) NAEGELI, O.: Ergebnisse und Ziele der heutigen klinischen emtologie. Schweiz. Med. Wchenschr., : (9) PELGER, K.: Dignostic nd prognostic significnce of the morphologicl blood exmintion, (in Dutch) Nederl. Tijdschr. Geneesk., 8: Downloded from on Februry 8

17 BLOOD PICTUKE IN PNEUMONIA 97 () PONS, C, AND KRUMBAAE, E. B.: Studies in blood cell morphology nd function: extreme neutrophilic leukocytosis with note on simplified Arneth count. Jour. Lb. & Clin. Med., : () RAMOND, L.: Congestion pulmonire forme pheumonique (Mldie de Woillez). Presse Med., : () REZNIKOFF, P.: Immture white blood cell counts in infectious diseses. (Schilling Index). Jour. Am. Med. Assn., 9: () SABIN, F. R.: Studies of living humn blood cells. Bull. Johns opkins osp., : () SCLEIP, K: emtologicl Atls, with description of the technic of blood exmintion. English dpttion of text by Sondern, F. E. N. Y. Rebmn Co. 98. pp. (5) SCILLING, V.: Ds Blutbild und seine klinische Verwertung. Fischer, Jen, 9. () TURK, W.: Klinische Untersuchungen iiber ds Verhlten des Blutes bei cuten Infektionskrnkheiten. Wien. u. Leipz. 898, W. Brumuller, 5 pp. (7) TURK, W.: Vorlesungen iiber klinische emtologic. W. Brumuller. Leipzig, 9. pp. Downloded from on Februry 8

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