MERCY HOSPITAL │ MAGEE HOSPITAL
───────────┬──────┬──────┬──────┬─────┬─────┼──────┬─────┬─────┬─────
│ │ │ │ │ │Influ.│ │ │
Leucocyte │ │Influ.│Influ.│ │ │Influ.│ │ │
Count. │Influ.│ Pn. │Compl.│Total│ % │ Pn. │ % │Total│ %
│ │ │ │ │ │Influ.│ │ │
│ │ │ │ │ │Compl.│ │ │
───────────┼──────┼──────┼──────┼─────┼─────┼──────┼─────┼─────┼─────
2000 or│ │ 2│ │ 2│ 38│ 1│ 28│ 3│ 32
less│ │ │ │ │ │ │ │ │
2000–3000│ 3│ 3│ 1│ 7│ │ 13│ │ 20│
3000–4000│ 7│ 12│ 4│ 23│ │ 34│ │ 57│
4000–5000│ 14│ 13│ 9│ 36│ │ 41│ │ 77│
5000–6000│ 17│ 16│ 6│ 39│ │ 42│ │ 81│
│ │ │ │ │ │ │ │ │
6000–7000│ 15│ 13│ 6│ 34│ 40│ 59│ 37│ 93│ 38
7000–8000│ 7│ 8│ 5│ 20│ │ 36│ │ 56│
8000–9000│ 8│ 14│ 8│ 30│ │ 37│ │ 67│
9000–10000│ 15│ 9│ 8│ 32│ │ 39│ │ 71│
│ │ │ │ │ │ │ │ │
10000–12000│ 4│ 12│ 9│ 25│ 20│ 44│ 27│ 69│ 25
12000–14000│ 1│ 1│ 8│ 10│ │ 28│ │ 38│
14000–16000│ 5│ 3│ 2│ 10│ │ 22│ │ 33│
16000–18000│ 3│ 2│ 2│ 7│ │ 16│ │ 23│
18000–20000│ 2│ 2│ 2│ 6│ │ 15│ │ 21│
│ │ │ │ │ │ │ │ │
20000–22000│ │ 1│ 1│ 2│ 2│ 4│ 5│ 6│ 3
22000–24000│ │ │ 1│ 1│ │ 8│ │ 9│
24000–26000│ │ │ 1│ 1│ │ 4│ │ 5│
26000–28000│ │ │ │ │ │ 2│ │ 2│
28000–30000│ │ │ 1│ 1│ │ 3│ │ 4│
│ │ │ │ │ │ │ │ │
30000–32000│ │ │ │ │ │ 3│ 3│ 3│ 2
32000–34000│ │ │ │ │ │ 3│ │ 3│
34000–36000│ │ │ │ │ │ 3│ │ 3│
36000–38000│ │ │ │ │ │ │ │ │
38000–40000│ │ │ │ │ │ 1│ │ 1│
40000–42000│ │ │ │ │ │ 2│ │ 2│
│ │ │ │ ———│ │ ———│ │ ———│
│ │ │ │ 287│ │ 460│ │ 747│
───────────┴──────┴──────┴──────┴─────┴─────┴──────┴─────┴─────┴─────
The blood picture in uncomplicated influenza is a normal one for the red
cells and the hæmoglobin, but the white cells are characteristically
altered. We have made many observations on the red blood cells, and from
all aspects the picture appears to be normal. Similarly, there is
nothing significant about the hæmoglobin estimations. Where we have
slight alteration in the red count and in the hæmoglobin it is probably
safer not to attribute the change to the epidemic. We have no records
showing a secondary anæmia due to the initial epistaxis.
A leucopenia or a normal count is what one should see in most of the
uncomplicated influenzal cases. We are almost ready to say that any
estimation above normal limits means secondary bacterial invasion. The
count may remain low throughout the illness, rising to the normal
rapidly as the temperature falls. We do not regard a leucocytosis at the
end of an epidemic case as part of the blood picture. Our experience is
that with convalescence the normal count returns and remains within
normal bounds. Very often hidden sinus infection is responsible for some
of the post-influenzal leucocytoses. The leucopenia may vary from a
slightly subnormal count to a point well below 2,000. Most of the simple
epidemic cases showed some degree of leucopenia. As far as we have been
able to estimate, we are led to believe that one should not lay any
special stress on the grade of leucopenia as being of prognostic
significance in uncomplicated influenza. Many of the mildest clinical
types showed very low counts, and _vice versa_. There is, however, a
prognostic relation to be noted with reference to a falling white count
in the pneumonia, but this we shall mention again later. The onset of
the leucopenia corresponds to the onset of the disease. It was present
with the earliest cases we examined, and remained fairly stationary,
although we have records of its fluctuating slightly one way or the
other. But one must remember in this regard the personal error in blood
counting, and also particularly the error of the apparatus. For careful
work only those counting chambers and pipettes should be used that have
a Bureau of Standards certificate. The duration of the leucopenia was
fairly close to the duration of the disease.
How many cases of influenza of several days’ illness having about 12,000
leucocytes, a few sticky râles in the chest, but no signs of definite
consolidation, have been observed by the clinicians? These cases recover
without further change, and the diagnosis is handed in as influenza
without a complication being mentioned. In collecting the blood reports
from this group the 12,000 cells accordingly must be considered as
having occurred in a simple influenza. We hold that this is not a case
of uncomplicated epidemic disease. There is undoubted evidence, as is
acknowledged by the clinician, of a bronchiolitis; and how many lungs
showing a bronchiolitis at autopsy fail to have a broncho-pneumonia?
True it may not be demonstrable by our physical examination. This is
often the origin of many high counts in what apparently is considered
uncomplicated influenza.
The blood picture of the pneumonia following the epidemic was more or
less constant, although at the same time the features of the count may
be quite different. One could roughly divide the results into three
groups: (1) leucocytosis, (2) leucopenia, (3) intermediate or normal.
Some pneumonias could be followed during their course through all of
these classes. Before discussing the white count we can briefly dismiss
the other phases of the blood examination by stating that the red blood
cells and hæmoglobin presented nothing by the usual examinations which
was of special significance, or in any way characteristic.
As an example of the group showing a leucocytosis let us follow a
patient through an acute influenzal attack, followed by a pneumonia with
a subsequent recovery. An initial leucopenia, gradually or suddenly
changing into a very moderate leucocytosis (10,000–15,000), was noted at
the onset of the pneumonia. During the course of the complication the
number of cells in the majority of cases increased, but rarely advanced
beyond 20,000. With lysis or crisis the count dropped toward normal, and
by the time the lung signs had disappeared the white cells were at the
usual number, or very slightly increased. The point which seemed to us
to be of importance was that, even although we had a leucocytosis, it
was nothing like the count that one would expect for a lobar pneumonia.
Of course, there were a few high counts, but looking at the group as a
whole they were relatively low. There are a number of variations to this
form of blood picture which we might briefly consider. We have observed
secondary rises in the leucocyte count concurrent with a new lung
involvement. This type was the one so prone to develop into a condition
of non-resolution, fibrosis and ultimate death, with a continuous
moderately high leucocytosis to the end. Another variation which we
learned to fear was the fall of leucocytes to normal or subnormal after
a primary rise, when the clinical course of the case in no way indicated
a crisis or lysis pending. Seemingly, the longer the primary
leucocytosis had been present the more serious was the subsequent
leucopenia. We regard this form of secondary leucopenia, if one may use
such a term, as a prognostic sign of some value. As in lobar pneumonia,
a high leucocyte count has been, as a rule, a favorable feature.
The second group, or those showing a leucopenia throughout their course,
was by no means an unusual thing. This is a cardinal point—in fact, one
of the most striking clinical features of the epidemic. The leucopenia
here does not have the prognostic value that it seems to have in the
group just referred to previously. We have observed cases go through a
pneumonia with 4,000–5,000 white cells in a relatively easy manner.
When, however, the leucocytes fall to 3,000 or under, one may be
reasonably sure that the outcome is doubtful, even with the general
condition of the patient at the time favorable. In the pneumonias of
this group which died the leucocytes have always fallen to about 2,000
cells. We have a number of observations taken from one-half to four
hours before death showing counts in the immediate neighborhood of
2,000, but never below this number. Where recovery has taken place the
cells go forward to the normal, more or less keeping pace with the
general clinical picture.
Of group three there is not much to say, except that on one hand it
tends toward a leucocytosis, and on the other to a leucopenia. This
group comprises a considerable number of the pneumonias. We are not in a
position to say anything regarding the relative mortality of this group.
The development of a leucopenia from these cases after a period of some
stability in the leucocytic curve is of bad prognostic import. Not
infrequently we have noticed rather wild abrupt rises to 20,000 in the
leucocytes toward the late half of the disease. This curve was nearly
always sustained until the end, which, as a rule, was recovery.
We do not need to consider at any length the effect on the leucocyte
count of complications not of lung origin. Acute sinuses in head, otitis
media and meningitis always produced a variable moderate leucocytosis.
The change was not so marked in meningitis, as our cases were all
preceded by a pneumonia which had independently invoked a slight
leucocytic response. As a complication of the pneumonia we have noted an
abrupt rise following an acute pleuritis with effusion, and similarly
after the onset of an empyema. These complications seemed to be able to
induce a leucocytosis with more certainty and ease than the more serious
pneumonic condition. Possibly, as they occurred toward the end of the
infection, the toxic factor of the epidemic influenza was more or less
spent, and the secondary invader had a freer hand to act in its normal
way.
Differential counts were made in 194 cases, including influenza,
influenzal pneumonia and influenzal complications. We have taken the
average percentage of each type of cell for the groups, which are purely
numerical divisions based on the leucocytic count. No differentiation is
made for the various clinical divisions of the epidemic in the following
table:
LEUCOCYTES 2,000–8,000.
P. E. L.M. S.M. Trans.
Total counts 86 66% 1% 13% 17% 3%
LEUCOCYTES 8,000–10,000.
P. E. L.M. S.M. Trans.
Total counts 33 69% 1% 11% 16% 3%
LEUCOCYTES 10,000–20,000.
P. E. L.M. S.M. Trans.
Total counts 45 76% 2% 10% 19% 3%
LEUCOCYTES 20,000–30,000.
P. E. L.M. S.M. Trans.
Total counts 17 79% 2% 8% 7% 4%
LEUCOCYTES 30,000–40,000.
P. E. L.M. S.M. Trans.
Total counts 13 85% 1% 5% 6% 3%
The differential count in general indicates an increase in the
polymorphonuclear leucocytes as the total leucocytic number increases.
This is really what one would expect. There also seems to be an increase
of the large mononuclear cells, with a slight diminution in the small
mononuclear elements, particularly in the count below 10,000. Abnormal
cells were encountered very seldom. One can hardly say that the epidemic
has a characteristic differential blood picture, except, perhaps, that
an increase of the large mononuclears is present in the low counts.
This, however, may hold true for any leucopenia.
_Conclusions_
1. Epidemic influenza is often accompanied by a transient slight
albuminuria with a few red blood cells and casts. Acute nephritis as a
clinical entity does not appear to be other than a rare sequel.