Clinical diagnosis

Preface

There have, during the past few years, appeared so many and such excellent text-books on clinical diagnosis, the clinical examination of the blood, the urine, or the gastric contents, that to add to this number one which covered the same ground in the same way as they, would seem a thankless undertaking, as well as an unpardonable misuse of energy. It is because the present work tries to cover this same ground in a different way, and one which will, we believe, commend itself to the medical profession, that we venture to offer it for inspection; we refer to the consideration of clinical laboratory work from the clinical rather than from the laboratory point of view.

This book is based on the author's experience as physician in charge of the clinical laboratory, and instructor in medicine, of the Johns Hopkins Hospital and University. He has also had at his disposal all the clinical records of the ward cases for the seventeen years of this hospital's activity.

Our course in clinical microscopy and chemistry extends over the eight months of the student's third year; two afternoons of three hours, and one of one hour, each week ; but much of the work is done out of class hours, as inspection of pages 413 and 451 will show. The subjects studied are the clinical examination of the blood, urine, sputum, stomach contents, faeces, and various fluids, as ascitic, pleural, cerebrospinal, cyst contents, etc. In addition to this the student follows cases assigned him in the out-patient department. To those fitted for such work simple problems of research are given. The course is a laboratory one ; specimens are provided each of the students. It is needless to say that with the eighty microscopes focussed on eighty specimens of a patient's blood, sputum, etc., the most of the interesting cells or other features will be found. The best were drawn by an artist always within call. The questions discussed in the following pages are for the most part those asked by the students during the class-work. The object of this course is not so much to impart knowledge as to raise the efficiency of the student. It is not a course in chemistry and microscopy, but in these applied to the study of a patient; not in physiology, but in pathology. With the methods of chemical and biological work, with the normal findings, they are already familiar. Chemistry, inorganic and organic, qualitative and quanti-

v vi

PEEFACE tative, is required for admission to the school; the normal blood they have studied in the anatomical laboratory; normal urine and gastric contents, in the laboratory of physiological chemistry. We take this knowledge for granted as a foundation for the study of pathological bloods, urines, etc., paying particular attention to the clinical significance of these findings. At the same time the students are required to practise the best methods in every-day use, not only until they understand them, but until they can accurately use them. It is the practical use of a determination or examination which is emphasized. If approximate methods will do, they are used ; if accurate methods are necessary,, accurate work must be done, whatever the cost in time. To use an approximate method well is far better than to employ a more exact, laborious one poorly ; to do approximate work is not always easy and requires practice ; to be able to do accurate work well is also required of our students. Practice, experience, an exact knowledge, first of the possibilities in a method, second, and just as important, his own accuracy in the use of that method — these it is the duty of the clinical laboratory to give a student. Above all, he should train his common sense so that, using his eyes, nose, ears, and tongue, he can get results for which another man would apply elaborate methods.

The author has been careful not to include new untried methods, for of these but a small number will last, and a text-book should contain nothing as yet not well tested by friends and foes. It is the introduction of " new methods" which renders some books even dangerous to the man who buys but one.

We do not claim that with this book alone the student can study clinical microscopy. No subject in medicine is broader or requires more reference books, for some of the hardest chemical problems will at times confront him, and to interpret the various artefacts and accidental findings of the microscope would require a vast experience in microscopy, and a knowledge of zoology, botany, and mineralogy as broad as is the realm of science. For who knows what infusoria, what diatom, desmid, or other protophyte, the ovum of what parasite, the wing of what insect, the leg of what fly, the tissue of what plant, the fibre of what meat, the seeds of what berry or fruit, may be found in sputum, stomach contents, urine, or faeces, from the food, tap-water, or the contaminations from dirty vessels, or from the dust of the air? To be wise in the points of differential chemical and microscopical diagnosis is splendid ; but to recognize artefacts and extraneous matter, the stumbling-blocks in diagnosis, that is the true test of the chemical laboratory worker, and this ability is gained by wide experience alone.

PEEFACE vii

The function of the clinical laboratory worker is to aid the ward worker. The findings of the former are seldom conclusive, and must be interpreted in the light of the ward findings ; especially is this true now that functional diagnosis is the goal. The writer can only give to the reader who has aspirations to be a clinical chemist and microscopist the advice in substance which one of Germany's greatest clinical chemists gave him when the latter regretfully left the little Swiss laboratory which had been such a pleasant home : the clinical chemist must be first a good clinician and second a chemist ; he should remember that even from the laboratory point of view his stethescope is of more importance than his microscope, his percussion finger than his whole outfit of chemical apparatus.

In conclusion, we wish to express our indebtedness to Dr. Osier for his encouragement and aid during the progress of this work, and for his hearty co-operation in placing at our disposal the records of the medical wards; and to the assistants and students of this clinic, for whose aid I am very grateful, and who are too many to mention by name except Dr. Thomas R. Boggs, whose suggestions and criticisms have been so valuable.

I take this opportunity to thank the artists who have done much beautiful work for me — Messrs. F. S. Lockwood, Hermann Becker, Max Brodel, and Mrs. Ruth Huntington Brodel, whose excellent halftone and pen-and-ink drawings must be recognized by the lack of her signature.

Charles P. Emerson.

Johns Hopkins Hospital, 1906.

Contents

PAGE

Introduction xix

Chapter I. The Sputum

Introduction 17

Amount of Sputum 18

Consistency of Sputum 19

Reaction of Sputum 19

Character of Sputum 19

Color of Sputum 19

Layer Formation of Sputum 22

Odor of Sputum 22

Macroscopic Constituents of Sputum 22

Microscopic Constituents of Sputum 26

Plant Parasites in Sputum 35

Animal Parasites in Sputum 43

Chemical Examination of Sputum 45

Sputum in Pulmonary Tuberculosis 46

Pneumonia 55

Influenza 59

Whooping-cough 61

Glanders 61

Asthma . 61

Acute Bronchitis 65

Chronic Bronchitis 67

Fibrinous Bronchitis r 70

Bronchiectasis 71

Gangrene of the Lung 73

Abscess of the Lung 74

Perforating Empyema 76

Perforating Serous Pleurisy 76

(Edema of the Lungs 76

The Albuminous Sputum of Thoracentesis ■. . 77

Haemoptysis 78

Sputum in Hemorrhagic Infarction of the Lung 79

Chronic Passive Congestion of the Lung 79

Malignant Disease of the Lung 80

Mediastinal Growths 80

Lues of the Lung 81

Pneumokoniosis 81

Chapter II. The Urine

The Collection and Preservation of Urine 82

The Amount of Urine 8&

ix x CONTENTS

PAGE

The Specific Gravity of Urine 87

The Color of Urine 89

The Pigments of Urine 90

The Odor of Urine 95

The General Appearance of Urine 95

The Reaction of Urine 95

The Nitrogenous Bodies of the Urine 99

Nitrogen 99

Urea 103

Uric Acid 109

Purin Bases 114

Ammonia 115

Creatinin 119

Oxyproteinic and Alloxyproteinic Acids 120

The Inorganic Acids and Bases of the Urine 121

Chlorides 121

Phosphates 125

Sulphates 130

Thiosulphuric Acid 135

Hydrogen Sulphide 135

Sulphocyanic Acid 135

Carbonates 135

Calcium and Magnesium 136

Sodium and Potassium 137

Iron 137

Lead 138

Arsenic 13s

The Pigments of the Urine 138

Indoxyl Sulphate 138

Skatoxyl Sulphate 141

Indigo-Red 142

Paracresol and Phenol sulphuric Acid 143

Potassium Iodide 143

Bile Pigments 143

Bilirubin 144

Biliverdin 145

Hydrobilirubin 145

Bilif uscin 145

Biliprasin 145

Cholecyanin 145

Choletelin 146

The Reducible Body of Stokvis 146

Tests for Bile Pigments 146

Melanin and Melanogen 149

Rosenbach's Reaction 150

Bile Acids 150

Diazo Test 151

Ferments in the Urine 156

Carbohydrates and Allied Bodies in the Urine 157

Glucose * 158

Levulose 177

Lactose 178

Pentose 179

Inosite 182

CONTENTS xi

PAGE

Carbohydrates and Allied Bodies in the Urine : Glycogen or Erythrodextrin . 182

Animal Gum 183

Laiose 183

Maltose 183

Isomaltose 183

Melituria 183

Acetone 183

Diacetic Acid 186

Oxybutyric Acid 187

Diabetes Mellitus 189

Diabetes Insipidus 194

Glycuronic Acid 195

Alkaptonuria 196

Hoinogentisinic Acid 197

Uroleucinic Acid 197

Proteids in the Urine 198

Albumin Tests 198

Proteids present 207

Serum Albumin 208

Serum Globulin 208

Euglobulin, Nucleo- Albumin, Mucin, Morner's Body 209

Nucleohiston 213

Fibrinuria 214

Albuminuria without Definite Renal Lesion 214

Physiological Albuminuria 214

Functional Albuminuria 215

Albuminuria of the New-born 218

Albuminuria of Women in Labor 218

Albuminuria of Adolescence 219

Cyclic Albuminuria 220

Hypostatic Albuminuria 222

Albuminuria Minima 222

Intermittent Albuminuria 222

Traumatic Albuminuria 223

Febrile Albuminuria " 223

Hematogenous Albmninuria 223

Nervous Form of Albuminuria 224

Albuminuria with Definite Renal Lesion 224

Organic Bright' s Disease 224

Hetero-Albumosuria, Bence- Jones Body 225

Albumosuria, Deutero- Albumosuria, Peptonuria 227

Hsematuria 230

HaBmoglobinuria 231

Methsemoglobinuria 235

Hsemato porphyrinuria 236

Sediments 236

Preservation 236

Unorganized Sediments 238

Urates and Uric Acid 238

Phosphates and Carbonates 241

Oxalates 243

Sulphates , 246

Hippuric Acid 246

Hetero-Albumose 246 xii CONTENTS

PAGE

Unorganized Sediments : Xanthin 246

Hsematoidin (Bilirubin) 246

Indigo 247

Melanin 247

Haemoglobin 247

Cholesterin 247

Leucin 247

Tyrosin 247

Cystin 250

The Diamines 251

Scheme of Sediments 251

Chyluria 253.

Lipuria 254

Organized Sediments 255

Mucous Sediment 255

Epithelial Cells 255

Casts 258

Epithelial 258

Granular 258

Fatty 259

Waxy 259

Hyaline, Colloid, Glassy 260

Blood 260

Hsemoglobin 260

Pus 260

Cylindroids 261

Combined Casts 262

Pseudo-Casts 262

Cylindruria 265

Testicular Casts 267

Tissue Fragments 268

Pus-Cells 268

Eed Corpuscles 269

Concretions 270

Urate 270

Oxalate 271

Phosphate 271

Carbonate 271

Cystin 271

Xanthin 271

Fatty 272

Indigo 272

Albumin 272

Table of 272

Bacteria 273

Yeasts, Moulds, Sarcinee 274

Animal Parasites 274

Protastic Fluid 276

Tripperfiiden 278

Diseases of the Kidney 279

Fevers, Congestion, etc 280

Acute Nephritis ■. 281

Subacute Nephritis 283

Chronic Nephritis 283

CONTENTS xiii

PAGE

Diseases of the Kidney : Uraemia 287

Eenal Atrophy '. 288

Congenital Cystic Kidney 289

Suppurative Nephritis 289

Cancer of the Kidney 289

Abscess of the Kidney 289

Tuberculosis of the Kidney 289

Infarction of the Kidney 290

Pyelitis, Pyelonephritis 290

Hydronephrosis, Pyonephrosis, Uronephrosis 291

Eenal Calculus 291

Parasitic Diseases 291

Functional Eenal Diagnosis 292

Cryoscopy 293

Electrical Conductivity 299

Delayed Urea Excretion 300

Chloride Excretion 301

Dilution Test 301

Eenal Permeability 302

Methylene-Blue Test 302

Salicylic Acid Test 303

Phlorizin Test 304

Value of Tests 3C4

CHAPTEE III.

THE STOMACH CONTENTS.

TheVomitus 308

The Fasting Stomach 311

Test Meals 311

-Gastric Acidity '. 313

Total Acidity 315

Free Acid 316

Acid Deficit 317

Total Hydrochloric Acid 318

Value of Tests for Acidity 319

Physiology of Gastric Secretion 320

Diagnostic Value 320

Pepsin 322

Fat-Splitting Ferment 325

Eennet 326

Extent of Gastric Digestion 326

Products of Albumin Digestion 327

Starch Digestion 327

Lactic Acid 327

Other Organic Acids 330

Eases of Gastric Juice 330

Fermentation 331

Microscopic Examination 332

Absorption Power of Stomach 334

Motility of Stomach 335

Hyperacidity 337

Hypersecretion 338

Nervous Dyspepsia 340 xiv CONTENTS

PAGE

Acute Gastritis 341

Chronic Gastritis 341

Atrophy of Mucosa 343

Ulcer of Stomach 344

Cancer of Stomach 346

Chapter IV. The Intestinal Contents And F^ces

Motility of Intestine 354

Pancreatic Fluid 354

Trypsin 354

Fat-Splitting Ferment 354

Diastase ... 355

Test Meals 355

Digestive Power of Pancreatic Juice 355

Examination of Stools 356

The Constituents of Normal Stools 356

The Reaction of the Stools 357

The Frequency of the Stools 357

The Consistency and Form of the Stools 357

The Color of the Stools 358

Acholic Stools 358

Fatty Stools 360

Mucus in the Stools 363

Blood in the Stools 364

Pus in the Stools 366

Undigested Food in the Stools 367

Microscopy of the Stools 368

Macroscopy of the Stools 369

Concretions 369

Intestinal Parasites 372

Plant Parasites 389

Stools in Disease 390

Typhoid Fever 390

Asiatic Cholera 390

Dysentery, Rectal Diarrhoea, Cancer of the Rectum 390

Amoebic Dysentery 390

Pancreatic Disease 391

Chapter V. The Blood

Technic 392

Fresh Blood 395

Red Cells 395

Degenerations 399

Leucocytes 401

Hsemokonien Granules 403

Fat 404

Platelets 404

Fibrin Network 404

Counting Red Cells 404

Counting Leucocytes 416

CONTENTS xv

PAGE

Blood Staining 418

Specific Gravity of the Blood 426

Dried Eesidue 429

Sedimentation of the Blood 429

Coagulation of the Blood 430

Fibrin Diagnosis 433

Bacteriology of the Blood 434

Serum Diagnosis 436

Bed Cells 441

Shape 442

Structure 442

Size 443

Staining Properties 444

Granules of Red Cells 446

Number of Red Cells 449

Physiological Variations 450

Drugs and Therapeutic Measures 453

Pathological Variations 453

Resistance of Red Cells 455

Haemoglobin 456

Leucocytes 468

Granules 468

Classification of Cells 471

Bone Marrow , 477

Nucleated Reds 478

Origin of Red Cells 482

Origin of Leucocytes 484

Fcetal Blood 487

Leucocytosis 487

Physiological 489

Inflammatory 491

Pseudoleucocytosis 496

Malignant Disease 496

Post-hemorrhagic 496

Agonal 497

Medicinal 497

Mixed Cell Leucocytosis 498

Mastzell Leucocytosis 498

Lymphocytosis 498

Leucopenia 499

Eosinophilia 500

Iodophilia 503

Blood Platelets 504

Reaction of the Blood 508

Urea in the Blood 513

Anaemia 513

Secondary 515

Simple Primary 527

Progressive Pernicious 527

Chlorosis 539

Leukaemia 542

Myelogenous 543

Lymphatic (Lymphaemia) 549

Acute 552 xvi CONTENTS

I'AGE

Anaemia : Leukaemia : Mixed 554

Pseudoleukemia 555

Hodgkin's Disease 555

Tuberculous Adenitis 556

Leukansemia 556

Blood in Acute Diseases 556

Blood in Chronic Diseases 574

Value of Blood Examination 588

Malaria 590

Fresh Blood -. 590

Tertian 590

Quartan 593

^Estivo- Autumnal 595

Cycle in the Mosquito 597

In Stained Specimens 600

Trypanosomiasis 604

Pyroplasmosis 606

Filariasis 607

Relapsing Fever 609