Clinical diagnosis; a text-book of clinical microscopy and clinical chemistry for medical students, laboratory workers, and practitioners of medicine

Front matter

Glass.

Book

COPYRIGHT DEPOSIT

Preface To The Second Edition

In the preparation of this second edition the author has attempted to raise in every possible way the efficiency of this volume as a practical work for medical practitioners and students. Fully one-half the work has been rewritten, resulting, as will be noticed, in a considerable increase in the number of pages. This enlargement permits the incorporation of much new matter throughout, including the bacteriology of the sputum and urine, etc., which it is believed will add materially to the usefulness of the volume as a working hand-book. Likewise a number of new illustrations have been included from microphotographs, the work of Drs. Herman Shapiro and T. M. Wright, and original drawings by Herman Becker and D. H. Morse. These, by reason of their artistic quality and of the subjects they represent, will add much to the value of the book.

The author hereby expresses his deep appreciation of the cordial reception given the first edition, and of the kind criticisms and helpful suggestions which have indicated lines of improvement and aided in the preparation of the present edition. Acknowledgments are due Drs. Thomas R. Boggs and Wm. M. Ford, and W. L. Moss for the valuable assistance they have rendered.

Preface To The First Edition

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 447 and 485 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-

vii viii

PREFACE TO THE FIRST EDITION 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 fasces, 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 clinical laboratory worker, and this ability is gained by wide experience alone.

PREFACE TO THE FIRST EDITION ix

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 micro - scopist 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 stethoscope 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 xxiii

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 63

Glanders , 63

Asthma . 63

Acute Bronchitis 67

Chronic Bronchitis 69

Fibrinous Bronchitis 72

Bronchiectasis 73

Gangrene of the Lung 75

Abscess of the Lung 76

Perforating Empyema 78

Perforating Serous Pleurisy 78

(Edema of the Lungs 78

The Albuminous Sputum of Thoracentesis . 79

Haemoptysis 80

Sputum in Hemorrhagic Infarction of the Lung 81

Chronic Passive Congestion of the Lung 81

Malignant Disease of the Lung 82

Mediastinal Growths 82

Syphilis of the Lung '. 83

Pneumoconiosis 83

Sputum in Diphtheria 83

, Vincent 's Angina 88

xi

l f

Xi'i

CONTENTS

CHAPTER n.

THE URINE. page

The Collection and Preservation of Urine 90

The Amount of Urine 91

The Specific Gravity of Urine 95

The Color of Urine , . 97

The Pigments of Urine 98

The Odor of Urine 103

The General Appearance of Urine 103

The Reaction of Urine 103

The Nitrogenous Bodies of the Urine 109

Nitrogen 109

Urea 113

Uric Acid 117

Purin Bases 122

Ammonia 123

Creatinin 126

Oxyproteinic and Alloxyproteinic Acids 128

The Inorganic Acids and Bases of the Urine 129

Chlorides 129

Phosphates 133

Sulphates 138

Thiosulphuric Acid 143

Hydrogen Sulphide 143

Sulphocyanic Acid 143

Carbonates 143

Calcium and Magnesium 144

Sodium and Potassium 145

Iron 145

Lead 146

Arsenic 146

The Pigments of the Urine 146

Indoxyl Sulphate 146

Skatoxyl Sulphate 149

Indigo-Red 150

Paracresol and Phenolsulphuric Acid 151

Potassium Iodide 151

Bile Pigments 151

Bilirubin 152

Biliverdin 153

Hy drobili rubin 1 53

Bilifuscin. 153

Biliprasin 153

Cholecyanin 1 53

Choletelin 154

The Reducible Body of Stokvis 154

Tests for Bile Pigments 154

Melanin and Melanogen 157

Rosenbach's Reaction 158

Bile Acids 158

DiazoTest 159

Ferments in the Urine 164

CONTENTS xiii

PAGE

Carbohydrates and Allied Bodies in the Urine 165

Glucose: 166

Levulose 184

Lactose 185

Pentose 186

Inosite 189

Glycogen or Erythrodextrin 189

Animal Gum 190

Laiose 190

Maltose 190

Isomaltose 190

Melituria 190

Acetone 190

Diacetic Acid 195

Oxybutyric Acid 197

Diabetes Mellitus 199

Diabetes Insipidus 204

Glycuronic Acid 205

Alkaptonuria 206

Homogentisinic Acid 207

Uroleucinic Acid 207

Proteids in the Urine 208

Albumin Tests 208

Proteids present 217

Serum Albumin 217

Serum Globulin 218

Euglobulin, Nucleo- Albumin, Mucin, Morner's Body 219

Nucleohiston 223

Fibrinogen, fibrinoglobulin 224

Albuminuria without Definite Renal Lesion 224

Physiological Albuminuria 224

Functional Albuminuria 225

Albuminuria of the New-born 228

Albuminuria of Women in Labor 228

Albuminuria of Adolescence 229

Cyclic Albuminuria 230

Hypostatic Albuminuria 232

Albuminuria Minima 232

Intermittent Albuminuria 232

Traumatic Albuminuria 233

Febrile Albuminuria 233

Haematogenous Albuminuria 233

Nervous Form of Albuminuria 234

Albuminuria with Definite Renal Lesion 234

Organic Bright 's Disease 234

Hetero- Albumosuria, Bence- Jones Body 235

Albumosuria, Deutero- Albumosuria, Peptonuria 237

Hsematuria 240

Haemoglobinuria 241

Methaemoglobinuria 245

Hsematoporphyrinuria 246

Sediments 246

Preservation 246 xiv CONTENTS

PA.GE

Unorganized Sediments 248

Urates and Uric Acid 248

Phosphates and Carbonates 251

Oxalates 253

Sulphates 256

Hippuric Acid 256

Hetero-Albumose 256

Xanthin 256

Haematoidin (Bilirubin) 256

Indigo 257

Melanin 257

Cholesterin 257

Leucin 257

Tyrosin 257

The Diamines 261

Scheme of Sediments 261

Chyluria 263

Lipuria 264

Organized Sediments 265

Mucous Sediment 265

Epithelial Cells , 265

Casts 268

Epithelial 268

Granular 268

Waxy 269

Hyaline, Colloid, Glassy 270

Blood 270

Pus 270

Cylindroids 271

Combined Casts 272

Pseudo-Casts 272

Cylindruria 275

Testicular Casts 277

Tissue Fragments 278

Pus-Cells 278

Red Corpuscles 279

Concretions 280

Urate 280

Oxalate 280

Phosphate 281

Carbonate 281

Xanthin. * 281

Indigo 282

Albumin 282

Table of 282

Bacteriology of the Urine 283

Technic of Obtaining Specimens 283

CONTENTS xv

PAGE

Bacteriology of the Urine: Bacterioscopic Examination 283

Bacterial Stains . 284

Flagella Staining 285

Cultural Method 287

Organisms that may be found in the Urine 288

Bacillus Coli Communis 289

Bacillus Typhosus 289

The Paratyphoid Group 289

Bacillus Lactis Aerogenes 289

Bacillus Alkaligenes 290

The Proteus Group 290

Bacillus Pyocyaneus 290

Bacillus Aerogenes Capsulatus 290

Bacillus Tetani 291

Staphylococcus Pyogenes Aureus 291

Staphylococcus Pyogenes Albus 291

Staphylococcus Epidermidis Albus 292

Streptococcus Pyogenes 292

Septicaemia 293

Infectious Nephritis 293

Acute Pyelitis 294

Cystitis 294

Bacteriuria 297

Infection of Urethra and External Genitals 297

Acute Anterior Urethritis 299

Posterior Urethritis 299

Non-specific Urethritis 300

Bacteriorrhcea 300

Prostatitis 301

Bacteriology of External Genitalia 302

Bacillus Ulceris Cancrosi 302

Trepanoma Pallida 302

Spirochaeta Refringens 304

Yeasts, Moulds, Sarcinae 304

Animal Parasites 304

Prostatic Fluid 306

Tripperfaden 308

Diseases of the Kidneys 309

Fevers, Congestion, etc 310

Acute Nephritis 311

Subacute Nephritis 313

Chronic Nephritis 313

. Uraemia 317

Renal Atrophy 318

Congenital Cystic Kidney '. 319

Suppurative Nephritis 319

Cancer of the Kidney 319

Abscess of the Kidney 319

Tuberculosis of the Kidney 319

Infarction of the Kidney 320

Pyelitis, Pyelonephritis 320

Hydronephrosis, Pyonephrosis, Uronephrosis 321

Renal Calculus 321 xiv CONTENTS

PA.GB

Unorganized Sediments 248

Urates and Uric Acid 248

Phosphates and Carbonates 251

Oxalates 253

Sulphates 256

Hippuric Acid 256

Hetero-Albumose 256

Xantlun 256

Haematoidin (Bilirubin) 256

Indigo 257

Melanin 257

Cholesterin 257

Leucin 257

Tyrosin 257

The Diamines 261

Scheme of Sediments 261

Chyluria 263

Lipuria 264

Organized Sediments 265

Mucous Sediment 265

Epithelial Cells , 265

Casts 268

Epithelial 268

Granular 268

Hyaline, Colloid, Glassy 270

Blood 270

Pus 270

Cylindroids 271

Combined Casts 272

Pseudo-Casts 272

Cylindruria 275

Testicular Casts 277

Tissue Fragments 278

Pus-Cells 278

Red Corpuscles 279

Concretions 280

Urate 280

Oxalate f? 280

Phosphate 281

Carbonate

Xanthin 281

Indigo 282

Albumin 282

Table of 282

Bacteriology of the Urine 283

Technic of Obtaining Specimens 283

CONTEXTS xv

PAGE

Bacteriology of the Urine: Bacterioscopic Examination 283

Bacterial Stains . 284

Flagella Staining 285

Cultural Method 287

Organisms that may be found in the Urine 288

Bacillus Coli Communis 289

Bacillus Typhosus 289

The Paratyphoid Group 289

Bacillus Lactis Aerogenes 289

Bacillus Alkaligenes 290

The Proteus Group 290

Bacillus Pyocyaneus 290

Bacillus Aerogenes Capsulatus 290

Bacillus Tetani 291

Staphylococcus Pyogenes Aureus 291

Staphylococcus Pyogenes Albus 291

Staphylococcus Epidermidis Albus 292

Streptococcus Pyogenes 292

Septicaemia 293

Infectious Nephritis 293

Acute Pyelitis 294

Cystitis 294

Bacteriuria 297

Infection of Urethra and External Genitals 297

Acute Anterior Urethritis 299

Posterior Urethritis 299

Non-specific Urethritis 300

Bacteriorrhcea 300

Prostatitis 301

Bacteriology of External Genitalia 302

Bacillus Ulceris Cancrosi 302

Trepanoma Pallida 302

Spirochseta Refringens 304

Yeasts, Moulds, Sarcinse 304

Animal Parasites 304

Prostatic Fluid 306

Tripperfaden 308

Diseases of the Kidneys 309

Fevers, Congestion, etc 310

Acute Nephritis 311

Subacute Nephritis 313

Chronic Nephritis 313

Uraemia 317

Renal Atrophy 318

Congenital Cystic Kidney 319

Suppurative Nephritis 319

Cancer of the Kidney 319

Abscess of the Kidney 319

Tuberculosis of the Kidney 319

Infarction of the Kidney 320

Pyelitis, Pyelonephritis 320

Hydronephrosis, Pyonephrosis, Uronephrosis 321

Renal Calculus 321 xvi • CONTENTS

PAGE

Diseases of the Kidneys: Parasitic Diseases 321

Functional Renal Diagnosis 322

Cryoscopy 323

Electrical Conductivity 329

Delayed Urea Excretion 330

Chloride Excretion 331

Dilution Test 331

Renal Permeability 332

Methylene-Blue Test 332

Salicylic Acid Test 333

Phlorizin Test 334

Value of Tests 334

Chapter III. The Stomach Contents

TheVomitus 338

The Fasting Stomach 341

Test Meals 341

Gastric Acidity 343

Total Acidity 345

Free Acid 346

Acid Deficit 347

Total Hydrochloric Acid 348

Value of Tests for Acidity 349

Physiology of Gastric Secretion 350

Diagnostic Value. . , 350

Pepsin 352

Fat-Splitting Ferment 355

Rennet 356

Extent of Gastric Digestion 356

Products of Albumin Digestion 357

Starch Digestion 357

Lactic Acid 357

Other Organic Acids 360

Bases of Gastric Juice 360

Fermentation 361

Microscopic Examination 362

Absorption Power of Stomach 364

Motility of Stomach 365

Hyperacidity 367

Hypersecretion 368

Nervous Dyspepsia 340

Acute Gastritis 371

Chronic Gastritis 371

Atrophy of Mucosa 373

Ulcer of Stomach 374

Cancer of Stomach 376

Chapter IV. The Intestinal Contents And Faeces

Motility of Intestine 384

Pancreatic Fluid 384

CONTENTS xvii

PAGE

Pancreatic Fluid: Trypsin ] 384

Fat-Splitting Ferment 384

Diastase 385

Test Meals 385

Digestive Power of Pancreatic Juice 385

Examination of Stools 386

The Constituents of Normal Stools 386

The Reaction of the Stools 387

The Frequency of the Stools 387

The Consistency and Form of the Stools 387

The Color of the Stools 388

Acholic Stools 388

Fatty Stools 390

Mucus in the Stools 393

Blood in the Stools 394

Pus in the Stools 396

Undigested Food in the Stools 397

Microscopy of the Stools 398

Macroscopic Examination of the Stools 399

Concretions 399

Intestinal Parasites 402

Plant Parasites 419

Stools in Disease 421

Typhoid Fever 421

Asiatic Cholera 422

Dysentery, Rectal Diarrhoea, Cancer of the Rectum 424

Amoebic Dysentery 424

Pancreatic Disease 424

Permanent Mounts of Small Worms 425

To Preserve Stools Containing Parasite Eggs 425

Stained Specimens of Worms 425