schilling differential blood count in appendicitis
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SCHILLING DIFFERENTIAL BLOOD COUNT IN APPENDICITIS* J. VERNON LUCK, M.D.
LOS ANGELES, CALIF.
0 UR present standard cIassification of Ieucocytes was made by EhrIich after he discovered an aniIine dye it beyond the average technicians abiIity to do the count.
for which bIood ceIIs have a pronounced affinity. The successfu1 study of Ieucocytes data from this discovery. Before this time Ieucocytes were thought to originate from one common bIood forming system. Ehrlich and NaegeIi were the first to suggest that there were at Ieast two systems, the myelogenous and the Iymphatic. That there are two such systems is now a well- estabIished fact. Recently a third and entireIy independent system has been demonstrated which forms the monocytes (the Iarge mononucIears and transitionaIs). These ceIIs are said to originate from the reticula-endotheIia1 system of the spleen, Iiver, etc. The ceIIs from the myeIogenous system or bone marrow were at first a11 caIIed granuIocytes and those from the Iymphatic system caIIed Iymphocytes. Later EhrIich subdivided the granuIocytes into neutrophiIs, eosinophils, and baso- phils, thus originaIIy establishing the CIassification that is stiI1 standard. CIini- caIIy the neutrophiIs are by far the most important ceIIs in the bIood picture. A study of their nucIear changes has proved of the utmost clinica significance, espe- cialIy in the diagnosis and prognosis of infection. In Igod and rgo5 Arneth gave us an index by which the nucIear changes of the neutrophi1 might be interpreted. This count, being the first of its kind, aroused much new interest in the Ieucocytic bIood picture; however, it was so detailed and diffIcuIt that it proved of IittIe practica1 importance. In fact Arneth designated more than eighty ceI1 species, thus making
Many interesting investigations of the Ieucocytes foIIowed the introduction of the Arneth index. The Iimited cIinica1 significance of the EhrIich differentia1 was probabIy as evident then as it is now. It was obvious that the Arneth count wouId be of great practica1 vaIue if it couId be made Iess compIicated. Many attempts were made to simpIify it but none met with any degree of success unti1 Ig 12 when Victor von SchiIling at the First MedicaI University CIinic of BerIing gave us his modification of the Arneth index. SchiIIings method gives us far more information than that of Ehrlich, especiaIIy regarding the course of the various infections. Its introduction in this country has been rather slow, but wherever it has been properIy expIained and demonstrated it has been received with much enthusiasm.
The only essentia1 difference between the SchiIIing differentia1 and the oId differentia1 count as it was outIined by EhrIich is a division of the poIymor- phonuclear neutrophiIs into three cIasses : juveniIes, stabs and segments. The type of nucleus present is, for the most part, the basis for this cIassification. The poIy- morphonucIear neutrophiIs were so divided because their cIinica1 significance depends IargeIy on their degree of maturity or age, and this is mainly reflected by the type of nucIeus present. The onIy other differ- ence in the two counts is that the Iarge mononucIears and transitionals are com- bined and caIIed monocytes. There is no practica1 significance in separating these
* Read before a joint meeting of the Los Angeles County Media1 Association and the Los AngeIes Surgical Society, May 19, 1932.
276 American ~~~~~~~ of surgery Luck-BIood Count in Appendicitis FEBRUARY, ,933
two ceIIs. TabIe I gives a comparison of the two counts.
I. BasophiI 2. EosinophiI 3. NeutrophiI
I. BasophiI 2. EosinophiI 3. NeutrophiI
I. Jugediche (juveniIe)
B. 2. Stabkernige
(stab) 3. Segmentkernige
Large mononudears TransitionaIs Monocytes
In Figure I are sketches of the four neutrophiIs. These are the ceI1.s with which
than the myeIocyte nucIeus. The juveniIe, Iike the myelocyte, contains nucIeoIi. This ceI1 is not normaIIy present in the aduIt bIood picture.
The stab type of neutrophi1 is the stage seen just before the nucIeus breaks up into segments that characterize the mature neutrophi1. The stab nucIeus is dark staining, narrow, often irreguIar in outIine, and assumes severa different shapes, e.g. v, s, u and 7. It contains no nucIeoIi. Two to 5 per cent of these ceIIs are present in the norma bIood picture.
The Iast neutrophi1, the segment, is a fuIIy matured ceI1, being characterized by the presence of two or more segments in its nucIeus. These segments are usuaIIy connected by a fine fiIament of nucIear materia1. Segments normaIIy constitute the Iargest part of the differentia1 picture, 63 per cent being norma in aduIts. These
we are most concerned in the SchilIing count. The sketches indicate the various nucIear changes of the neutrophi1 as it grows to maturity. The nucIeus of the youngest neutrophi1 or myeIocyte is most often kidney shaped, but may be round or ovaI; it contains nucIeoIi. The protopIasm is variabIe, but is most often a very paIe bIue with coarse neutrophiIic granuIes. This is an important ceI1 of the bone marrow where neutrophiIs originate, but is never normaIIy present in the bIood. It appears in the bIood during the most severe infections or toxic processes.
The juveniIe is next in Iine of deveIop- ment. Dr. SchiIIing describes it as having a sausage to aImost bean shaped nucIeus. It takes a sIightIy more intense staining
ceIIs have finer granules and are sIightIy smaIIer than the immature forms.
Notice again that the juveniIes, stabs and segments are divisions of the poIymor- phonucIears and that a11 neutrophiIs except segments are immature.
TabIe II is a norma SchiIIing hemogram. B represents basophiIs (I per cent), E = eosinophiIs (3 per cent), M = myeIocytes (0 per cent), J = juveniIes (0 per cent), St = stabs (4 per cent), Seg. = segments (63 per cent), Ly = Iymphocytes (23 per cent) and Mon = monocytes (6 per cent). The neutrophiIs are a11 incIuded between the doubIe Iines. The dotted Iine is for descriptive purposes; it divides those ceIIs that are mature from those that are immature; the mature neutrophiIs
NEW SERIES VOL. XIX, No. 2 Luck-BIood Count in Appendicitis A rnericnn Journdl s,fSu~~rry Z-7 / ,
or segments to the right and immature ones : stabs, juveniIes and myeIocytes, to the left. If there is an increase in the neutrophiIs on the Ieft side of the dotted Iine it is spoken of as a nucIear shift to the Ieft. Arneth was the first to use the term shift to the Ieft. If there is an increase in the ceIIs to the right of the dotted Iine it is likewise caIIed a shift to the right. In aImost a11 infections or toxic processes there is an increase in the immature neutrophiIs; that is, there is a shift to the Ieft. The degree of this nucIear shift of the neutrophiIs has proved to be of the utmost cIinica1 significance, because it is one of our most accurate criteria of the presence and advancement of an infection or toxic process.
At the outset of an infection there is a mobilization of avaiIabIe mature Ieuco- cytes. As these are consumed by the septic process there begins a pathoIogic change in the neutrophiIs, and then a liberation of immature forms into the bIood stream. The first ceIIs to increase are stabs. SchiI- Iing beIieves that this resuIts from an inhibitory or paraIytic action of the toxins on the bone marrow, preventing the juve- niIe ceIIs from passing on to norma stabs and segments. This degenerative effect is thought to invoIve the neutrophiIs in both the bone marrow and periphera1 brood. The resuIting stabs show definite evidence of degeneration in that they are quite fragiIe and have a tendency to vacuoIization. Their nucIei are very intenseIy stained and assume many odd narrow shapes. These degenerative stabs are to be differ- entiated from the normaI stabs that are present up to 5 per cent in the norma bIood picture. The norma stab is the transitiona stage between the juveniIe and segment. The degenerative stab usuaIIy never reaches the segmented stage; that is, it deveIops to maturity without becoming segmented. A Ieucocytosis may be absent where there is an increase onIy in stabs; there may even be a Ieucopenia. SchiIIing designates this shift to degenerative stabs
without the presence of jul-eniles as a degenerative shift.
As the infection or toxic process advances
there is a demand for more Ieucocytes and as a resuIt bone marrow activity is stimuIated, giving an increasing shift to the Ieft. Evidence of this is seen in the rising Ieucocyte count and the appearance of juveniIe neutrophiIs in the periphera1 bIood. Due to the regenerative activity of the bone marrow, SchiIIing caIIs this a regenerative shift. If the infection stiI1 keeps the upper hand and continues to advance, the bone marrow in its effort to meet the demand for Ieucocytes may reIease its youngest neutrophi1, the myeIo- cytes, into the bIood stream. This gives a stiI1 greater shift. Thus we see that the shift to the Ieft foIIows the whole septic process in a definite and significant fashion. The shift to myelocytes is the worst infectious bIood picture seen, except in such rare conditions as the agranuIocytic and monocytic anginas. Something in the infection of these two conditions com- pIeteIy in hibits the entire myeIogenous system.
278 American Journal 0f surgery Luck-BIood Count in Appendicitis FEBRUARY, ,933
In TabIe III are Iisted a few representa- of the cases; the poIymorphonucIear count tive