The Respiratory Significance of Blood Counts
By Max Trumper, Ph.D. In charge of Psyclio-biochemistry Laboratory, Psychological Clinic, University of Pennsylvania Normally we give breathing no thought. No doubt the inexhaustible abundance of air and the automatic character of respiration account for this. But when we consider as Professor Brubaker has stated, that “we are standing at the bottom of an ocean of air 7 miles high at a pressure of 15 pounds to the square inch,” and that the body cannot store enough oxygen to keep it alive for ten minutes, then Ave begin to realize that breathing is a subject deserving of much thought. It is now recognized that breathing cannot be estimated merely by inspection. “A doubling of the volume breathed per minute is scarcely or not at all noticeable either by the breather himself or by the casual observer and it may even escape the careful observer unless he measures it.’’ To obtain accurate quantitative data some measuring device is essential. Pneumographic tracings show the excursions of the thoracic and abdominal walls, but do not indicate the volume of air which enters and leaves the lungs. I chose the Sanborn Graphic Metabolism apparatus because, although primarily designed for determining the basal metabolic rate, the graphs obtained also lend themselves readily to the calculation of volume per breath or tidal ventilation, the respiratory rate, total ventilation per minute and the oxygen dilution factor. In the average resting male adult about 500 cc. of air is inspired with each breath and almost the same volume is expired with each breath. This is known as the tidal ventilation. The rate of respiration taken by itself is not a true index of the actual ventilation of the lungs. An increased rate with increased tidal air results in a high minute ventilation, while the same increased respiratory rate with shallow breathing may indicate subnormal or low minute ventilation. Clinically we are in the habit of recording the respiratory rate and disregarding entirely the very important factor of the depth of respiration. As a specific example * This paper was presented before the section 011 General Medicine of the College of Physicians on December 23, 1929, and discussed by Professors Albert P. Brubaker, L. Napoleon Boston, Stanley P. Eeimann and Dr D. R. Meranze. 8 THE PSYCHOLOGICAL CLINIC a patient with pneumonia having a respiratory rate of 30 with a tidal volume of 300 ec. is not anoxemic whereas another patient with the same respiratory rate but with a tidal volume of only 150 is in serious danger of anoxemia. The total minute ventilation is the product of the respiratory rate multiplied by the average volume per breath. This represents the amount of pumping of the pulmonary bellows. Authorities agree that the volume per breath of the normal individual at rest is from 10 to 12 per cent of the normal vital capacity. The vital capacity is the greatest amount of air that can be expired after a maximum inspiration. The vital capacity varies with height, weight, sex, age and skin area. The advantage of a large vital capacity is that the air in the lungs need be replaced less frequently. Thus the bellows or lungs have less work to do. From the standpoint of symptoms it is the functional or vital capacity rather than the anatomical or total capacity of the lungs that is of interest to the Clinician. This paper is concerned with the Respiratory Significance of Blood Counts and with the previous facts pertaining to respiration in mind we will turn briefly to the subject of blood counts. A normal erythrocyte count for man is usually accepted to be approximately 5,000,000 per c.mm. The normal range is from 4,500,000 to 6,000,000 and some authorities extend the normal range to 6,400,000. In women the limits of the normal range are approximately from 4,300,000 to 5,300,000. The effects of altitude, of congenital and acquired heart conditions, of acute and chronic pulmonary lesions and of any condition of temporary anoxemia on the haemoglobin and erythrocyte findings have been widely recognized. According to my findings in a group of 76 young adult males all free from gross pathology, THAT INDIVIDUAL WHO SHOWS A SO-CALLED HIGH NORMAL RED CELL COUNT (from 6 to 6,500,000) DOES SO AS A RESULT OF INEFFICIENT BREATHING, and conversely THAT INDIVIDUAL WHO SHOWS A LOW NORMAL RED CELL COUNT (4,500,000 to 5,000,000) DOES SO AS A RESULT OF EFFICIENT BREATHING. This correlation as far as I am aware is presented for the first time and may be construed as a principle of physiologic compensation. General procedure: Evidence of this correlation was obtained in the following manner. Basal metabolic rate, volume per breath, SIGNIFICANCE OF BLOOD COUNTS 9 respiratory rate, ventilation per minute, hemoglobin estimations by the Sahl-Leitz and Newcomer methods, erythrocyte count, red cell volume and vital capacity were obtained. I secured in each case at least two breathing curves, using a standard graphic Sanborn Metabolism apparatus, under the standard conditions required for basal metabolic determinations. To prevent the hypothesis of the existence of a hemato-respiratory correlation from influencing the counting of the cells and estimating the hemoglobin, this work was transferred to my assistant in the laboratory. The calculating of the tidal ventilation and the total ventilation per minute was given to someone outside the laboratory. All the cases were grouped according to their type of breathing: (a) shallow or inefficient; (b) deep or efficient; (c) average. In the following table Group A comprises shallow breathers, with a volume per breath of 16 per cent, a total minute ventilation of 11 per cent, and an oxygen dilution factor of 25 per cent, below that of Group B. It can be seen that Group A shows a compensatory increase of 32 per cent, in the number of erythrocytes. Group A?Seventeen adult male cases of inefficient breathing averaged: Volume per breath . .426 c.c. 19, 142 pounds Minute ventilation 6268 c.c. Hemoglobin 95 per cent Respiratory rate 15 Red-cell volume .49 per cent Dilution factor 24 Red cells 6,224,000 Group B?Thirteen adult male cases of efficient breathing averaged: Volume per breath 509 c.c. 19 years, 135 pounds Minute ventilation 7084 c.c. Hemoglobin 87 per cent Respiratory rate 15 Red-cell volume 42.8 per cent Dilution factor 32 Red cells 4,607,000 Group C?Forty-six adult male cases of normal breathing stand midway between Groups A and B in hematologic data and averaged: Volume per breath 455 c.c. 20 years, 136 pounds Minute ventilation 6750 c.c. Hemoglobin 90 per cent Respiratory rate 10V2 Red-cell volume 14.8 per cent Dilution factor 28 Red cells 5,466,000 This particular compensatory mechanism is definite and } et has not heretofore been observed, nor have any clinical inferences been made. Therefore, a wide range (four and one-half to six and onehalf million red cells for males has been accepted as normal foi the red-cell count. In Group B it can be seen that the total ventilation per minute, 10 THE PSYCHOLOGICAL CLINIC volume per breath and the dilution factor are all larger than in group A. Thus group B demonstrates more efficient breathing and should not require any compensatory rise in red cells or hemoglobin. Such is the case. On the other hand, in group A, the hemoglobin and red cells are high, because more hemoglobin and red cells are needed to compensate for the low volume per breath, total ventilation and oxygen dilution factor. The age and respiratory rate of all three groups are so much alike that no differentiation need be made in this respect. Finally, group C stands midway between group A and B in volume per breath and dilution factor and shows a corresponding intermediate position in its red cells, red cell volume and hemoglobin content. Another test of the hemato-respiratory compensation lies in the oxygen dilution factor. This factor represents the proportion of the total ventilation per minute to the oxygen consumed per minute. For example, if an individual consumes 250 cc. of oxygen per minute and his total minute ventilation is six liters, then the dilution factor is 24. Thus, in any instance where the total ventilation is not quite sufficient to supply the metabolic demand for oxygen, the dilution factor will usually be low, with the consequent compensatory rise in the hemoglobin and red cells. On examining group A it will be noted that the average diluting factor is 24, the lowest of the three groups while the red cell count averaged 6,224,000 which is the highest of the three groups. Thus the high red cell count compensated for the low dilution factor. Group C is the largest group and stands midway in hematologic as well as respiratory findings, again confirming the principle of physiologic compensation. Thus it becomes evident that in normal individuals a red cell count may lie between ^/2 and 6V2 millions per c.mm. If the count is about 4i/o to 5 millions, other things being equal, the breathing must be adequate. If the count is about 6 million or more, the breathing will not be efficient. The individual whose breathing was shallow compensated by a high red count and high hemoglobin. In other cases of shallow breathing, periodic deep breaths were taken in a more or less successful attempt to assist in the compensation. Likewise, many cases showing low vital capacity compensate by an increase in the depth of breathing. “Where the compensation was adequate, the red cell count and hemoglobin SIGNIFICANCE OF BLOOD COUNTS 11 were normal, where inadequate the erythrocytes and hemoglobin were increased. Discussion of Paper by Dr Max Trumper “The Respiratory Significance of Blood Counts” Bij L. Napoleon Boston, M.D. In 1908 Parkes Weber (Practitioner, 1908) gave us the first rational conception of polycythemia and this fundamental contribution provides for our present knowledge on the subject. “It is a conservative or compensatory vital reaction on the part of the individual, an automatic attempt to make up for the deficient oxygenation of the tissues by increase in the number of red cells, which are the oxygen-carriers of the blood. Vaquez called special attention to this condition in 1892 and Osier in 1903. Dr Trumper has given us a method of precision through which we may estimate the degree of pulmonary ventilation and has further shown that this has to do materially with an increase in the number of red cells per c. mm. This is a well worth while piece of work. The clinical procedure of Dr Trumper applies to the polycythemia of high altitudes where the low tension of the inspired air causes incomplete aeriation; to congenital cardiac disease where the venous blood is polluted by the arterial stream; to Ayerza’s disease where there is supposed to be leuitic involvement of the pulmonary tissue and vessels; and to the rather common polycythemia of both cardiac and pulmonary origin, as well as to polycythemia vera of Vaquez-Quiserne and Osier. Lintz (International Clinics, Vol. V, Dec., 1927) found through autopsy studies that individuals with small hearts and comparatively narrow blood vessels had large lungs and that those with relatively well developed heart and blood vessels have relatively small lungs. In acute infections where cyanosis is conspicuous it will be found upon examination that physical signs are present suggesting underfunction of the lungs. Thus the polycythemia may be a terminal stage in acute pneumonic processes. In congenital cyanosis and in Ayerza’s disease the red blood cells seldom exceed six to seven million per c. mm. until late when they may show a progressive increase from year to year. The blood making organs in response to the lack of oxygen voluntarily produce an abnormal number of red cells, six to ten mil12 THE PSYCHOLOGICAL CLINIC lions; the color index is low. The viscosity of the blood is often increased; whereas coaguability or clotting time is prolonged to fifteen minutes or more, while the number of blood platelets remains normal. Basal metabolic rate is ordinarily increased. These cases present, as a rule, cyanosis, hemoptysis, clubbing of the fingers, recurrent attacks of epistaxis, anemic infarcts and thromboses. Sweating, headache, vertigo, tinitus, dyspneoa, gastric discomfort, gastric acliylis, mental dullness and loss of memory are late symptoms. Hand in hand with these findings the blood pressure is low, except in aged subjects when it may be high. Clinicians make a distinction between the polycythemia of high altitudes and the splenomegalic form of erythemia. Polycythemia is also a feature in cirrhosis of the liver, emphysema, bronchiectasis and Ayerza’s disease. Osier’s and Yaquez’s polycythemia vera are possibly late stages of deficient pulmonary ventilation. All forms of polycythemia will certainly be better understood where it is possible to estimate the degree of pulmonary ventilation as has been outlined by the essayists.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.