Essays on laboratory diagnosis for the general practitioner

Preface

"There is nothing new under the sun/' nor is there anything new in this book, but several important facts which seem to have been somewhat overlooked in the past are reiterated here because, as the venerable physician and educator, A. Jacobi, has well said: "Simple truths in practical medicine do not merely bear repetition — they require it."

To find laboratory work done by the general practitioner, is the exception rather than the rule. To find any physician who is in the habit of making a thorough investigation of the metabolic functions of every patient seeking his aid, is almost impossible. He does not see the need for it and "the patient won't stand for it." And yet every disease either affects, or is affected by, the way in which the vital interchanges take place.

I have tried, in the papers which are reprinted here, to accomplish three things : First, to stimulate a greater interest in the actual need for clinical laboratory work by the physician in his otirn office; second, to simplify certain phases of this work; third, to cause, as best I can, a better understanding of the actual laboratory findings, and to make the therapeutic ends to which they point as clear and plain as possible. The attempt has been, on the whole, to lead rather than to teach.

One unfortunate circumstance which has often impressed me is that when an article has once appeared in print, it is read, appreciated, perhaps, and either laid aside or destroyed. Rarely is it at hand for convenient reference. From correspondence with hundreds of physicians in various parts of this country and abroad, I have been impressed that the majority of these articles are of some real help. This is encouraging. Hundreds of requests for reprints had to be denied simply because they were not at hand. Hundreds more received reprints when I had them to give. But none received more than two or three reprints and many requests have finally caused me to venture the publication of this collection.

No attempt has been made to make this either a hand-book or a text-book. The papers are republished with little or no changes. I am conscious of many shortcomings, the principal among them being frequent repetition. I hope these will be overlooked. One correspondent explained away this excuse of mine for postponing publication of the book by saying: "You know the truth can stand a whole lot of repetition."

It is to be hoped that this little effort may continue to serve as a stimulus to practice more thorough and, consequently, more successful ftiedicine.

Park Ridge, Illinois.

Introduction

By William Francis Waugh, A. M., M. D.,

Dean and Professor of Therapeutics, Bennett Medical College, Chicago; Medical Department Loyola University; Editor "American Journal of Clinical Medicine," etc.

INTRODUCTION.

This little book is a praiseworthy attempt to stimulate a greater interest on the part of the average physician in the importance of utilizing clinical laboratory methods in his daily routine. Too many physicians are prone, even in these days of enlightenment, to consider that the urine examination is indicated only in suspected renal or bladder diseases. The importance of the urinary findings as a guide to the resistant powers of the body is all too frequently overlooked.

Two generations ago disease was considered solely in its clinical aspect, and the aberrations from healthy functional activity formed the chief concern of the physician. As the study of pathologic anatomy progressed the basis of our conceptions of disease changed. We had been familiar with certain diseases as characterized by welldefined symptom-groups, and against these we had directed our therapeutics with considerable success. Disease and its treatment were thus linked by observations extending over many centuries, with constant improvement as old superstition was replaced by modern science, old error eliminated by more precise methods of observation and reasoning. The new knowledge dimmed this picture, and replaced it by one in which the symptoms of the living patient were obscured by the lesions discovered in the body of the dead. Too often it was forgotten that we were then dealing with the end-results of the pathologic processes, with the ashes of a burned-out fire.

No disease presents structural lesions at the start. All begin with disorders of the vital functions which, proceeding unchecked, result in such irritation somewhere as to invoke organic disease with destructive alterations. Since these are very often beyond the reach of curative treatment, it is up to us to recognize these affections while as yet in the early stages of functional derangement, when a cure may be effected. This brings the physician back from the laboratory to the sick-room ; from the study of completed pathologic processes; from dead anatomy, to that of disordered vital function in the living body. It emphasizes the value of the proposition that our best work is to be done before the patient is taken down with sickness. It urges the supreme value of preventive medicine as applied to the individual.

The value of the quantitative examination of the urine as a means of judging the state of the metabolism can only be ignored by him who has not learned the inestimable aid it affords to a correct diagnosis of the state of the physiologic functions.

The diagnosis of disordered functions is of far greater therapeutic importance — at least as far as results are concerned — than the corroboration of the presence of some suspected organic disease. In the former, information is gained which can be used to great advantage; whereas, in the latter a belief is only strengthened and

Introduction 19

the possibilities of successful end-results dimmed.

The times demand that the physician must earn his pay. He must be useful. He must be able to cope with disease or step aside for the other man. Diagnosis is but a preliminary, and if it does not point the way to effective treatment, it does not meet the needs of the situation. The science of medicine is supplemented by the art.

Considerable stress has been laid by Doctor Harrower upon the urinary acidity as a point of importance in diagnosis, and this is as it should be. The alkalinity of the blood is a factor of intense interest, since upon its variations the whole of the functions of the vital fluid depend. For these reasons I commend this useful little book to those for whom it has been prepared.

Chicago, October, 1910.

THE LABORATORY AS A MEANS OF PRO- MOTING PROFESSIONAL EFFICIENCY.

THE MEDICAL WORLD, Philadelphia,

November, 1908.

Chapter I. The Laboratory As A Means Of Pro- Moting Professional Efficiency

Every live medical man is continually on the lookout for something that will increase his efficiency. The crowded condition of the profession and the continual stream of new men from the many medical schools make it imperative for the progressive practitioner to increase his efficiency. He must get results.

The periodical trip to Chicago, New York, or even to Europe for post-graduate study, the purchase of the latest and best medical books, the regular perusal of three or four good, live medical journals, and the attendance at the local medical society are all greatly conducive to better practice; but the continued use of the clinical laboratory will do more, perhaps, than any one thing to make for thorough and accurate work.

With the majority of practitioners the sins of omission are usually far greater than the sins of commission ; in other words, the average doctor of today errs more on the side of laxness than from the exhibition of an overplus of effort or enthusiasm in his attempts at careful diagnosis.

Many a patient goes from one physician to another, at each change leaving his previous medical adviser slightly richer in dollars, but with a marked diminution of reputation. This is most unfortunate, for a reputation cannot be measured in mere currency.

It is well known that the American public is gullible in the extreme — is easily duped. The huge sales of the hundreds of patent medicines and the success of the ever-increasing army of advertising quacks both testify to this. Yet it would seem a shame to say that many — so many — of the ethical, apparently sincere and conscientious medical men are today doing nothing so very far removed from the deeds of the nostrum vendor or the charlatan. In these days of medical enlightenment, the physician still exists whose clinical examination consists of nothing more than the few perfunctory ques* tions, inspection of the tongue, and a fleeting touch of the pulse; but who, because of the influence gained by years of practice, still manages to make a more or less decent living.

Let us make this a personal matter. Doctor, when Mrs. A. came into your office the other day complaining of that "tired feeling," and told of the headache, the pain in the side and back, the lack of energy, and the many other symptoms that we are constantly called upon to meet, did you ask for a specimen of the urine? Did you get a full 24-hour specimen and examine it carefully, finding out not only the specific gravity and whether albumin or sugar were present, but the acidity, urea, phosphates, indican, and so forth? Would not this, perhaps, have given you a little more light on the problem? And when Mr. B. came to you with his story about his stomach, and how Dr. X. and Dr. Y. and even old Dr. Z. had treated him successively (but not successfully), did you emphasize the importance of a thorough examination, and a test-breakfast? Or did you

Promoting Professional Proficiency 25

just tell him that "fried foods are not so easily digested/' or "rapid eating is hard on the stomach/' give him some papayans or your favorite digestive what-not, and send him on his way to the next doctor to whom he might be recommended when your temporary relief ended?

"But," you will say, "the people w r on't permit such examinations. You couldn't get them to pay for laboratory service." That may be; but you can, just the same, make it your definite routine practice with every case that comes to you for attention. It is true that your fees for clinical laboratory work may not all be paid, but the proportion will not be so very different from that of your other collections, some of which must, in due time, be marked down under "profit and loss."

Or, again, the well-known excuse, "Oh! I haven't time to bother with that kind of work. I'm too busy/* Very true; but haven't you time to spend by the bedside of the dangerously sick one, watching, working, and fighting hard, the crisis being near? You say, "Of course." Well, then, is not the treatment of the chronic and semi-chronic diseases, the lingering, nagging troubles that are all too common, as difficult in the end as the care of an acute case near the crisis?

The practice of medicine is no easy matter. It may be very true that your well-stocked library and literature files can give you interesting and valuable information regarding therapeutics, but nothing save your own efforts will enable you to make the all-important diagnosis.

If the highly trained hospital expert with access to so many interesting and complicated cases has to rely on laboratory assistance in his diagnostic work, must not such work be needful in your own practice? Today's medical literature is simply teeming with articles demonstrating absolutely that accurate clinical methods are not only needful, but imperative. Can you afford to be behind the times ?

Is not the reputation of being thorough and conscientious well worth the time the few laboratory examinations may entail? Even though you may not be at all sure of a fee, is it not of sufficient value to you to know, and to know that you know?

The small clinical laboratory has much in its favor; and I am thoroughly convinced that the money spent on equipment and the much-begrudged time spent at the actual work is the best investment that could be made. Osier has well said: "A room fitted as a small laboratory, with the necessary chemicals and microscope, will prove a better investment in the long run than a static machine or a new-fangled air-pressure spray apparatus."

The laboratory should be the backbone of the practice of the general practitioner. It should occupy a place ranking equally with the other methods of precision in clinical diagnosis. It will bring you in contact with many persons whom you might otherwise never have met, and will enable you to see through cases that have baffled others. It will make for you a reputation for thoroughness and carefulness that cannot be compared in value with the time and money spent. The time spent in laboratory work will pay big dividends.

II. The Importance Of Laboratory Methods

THE CHICAGO CLINIC, Chicago,

Chapter II. The Importance Of Laboratory Methods

Laboratory work as an adjunct measure in both the diagnosis and treatment of disease is an essential, if success is expected in the practice of medicine. The laboratory alone is not infallible, supplanting the welltried methods of precision and skill of the trained eye, ear, or finger tip of the diagnostician; but no matter how skilled the man, nor how valuable the methods, without laboratory aid he will certainly fail many times when a few simple facts, easily and quickly obtained in the laboratory, would have served to clear up the whole matter.

In this progressive age the physician cannot conscientiously practice medicine without frequent recourse to the all-important laboratory report. The facts so necessary in the routine work are by no means so difficult to obtain, nor is the time and skill required for this work as serious a drawback as it is supposed by some to be. New methods and modifications of old ones have simplified the work so that it is now possible for the busy physician to carry out in his own office the majority of the tests necessary in this work.

The examination of the urine cannot be given too much prominence in an article of this kind. It is a procedure that should be carried out in the investigation of every case consulting the physician. An erroneous impression seems to be quite common among the laity and even some physicians that the urine is only examined when diabetes or Bright's disease are suspected. No greater mistake could be made. If this were true, how are the insidious beginnings of the above-mentioned conditions to be detected? Unfortunately, many times, the harm is almost irretrievable before the patient is aware of his danger. It is an indisputable fact that in many hundreds of cases the onset of serious organic trouble might have been detected early, provided every case consulting the physician, no matter for what trouble, had been put through an exhaustive and routine examination which included as a component part the complete analysis of a twenty-four-hour specimen of urine. In his excellent work on diagnosis, Leube says : "I would advise particularly never to omit the examination of the urine in headache; we shall thus avoid subsequent selfreproach."

From an editorial in the Southern Medical Journal for April, 1909, I quote: "If the general practitioners would avail themselves of these methods of decision coming from chemical laboratories and microscopical findings, few cases of illness would go undiagnosed, and few sufferers lose the benefits of modern medicine." Again: "He is blind indeed who can have the aid of these modern laboratory methods and will not avail himself of them, strictly as aids and confirmatory evidences of correct bedside judgment."

Space will not be taken here to enter into a discussion of the importance of the other laboratory methods of

Importance of Laboratory Methods 31

decision. Every case evidencing gastric disturbance should be given a test meal and a careful examination of it should be made. In this way the exact conditions present in many chronic disturbances of the stomach and intestines could be appreciated and steps taken to arrest them. The unpleasantnesses so common when dissatisfied individuals suffering from chronic stomach troubles go from one physician to another, receiving some digestive tablets or other, and maybe a cathartic, and are, of course, only temporarily relieved, could be entirely avoided, at least in the majority of cases, by recourse to the gastric analysis.

It is well known that many conditions which are either malignant or on the border line, so modify the condition of the blood that the examination of the blood smear gives information that will make the whole case clear. Again, the fecal examination is a valuable procedure, which, unfortunately, is rarely made because of the unpleasant features and the inconvenience, but which, nevertheless, gives many valuable therapeutic pointers. The value of the report of the bacteriologist on a suspicious discharge, a throat membrane, or from a specimen of suspected tuberculous sputum will not be questioned. Therefore, since the methods mentioned above are all essential in the procedures necessary for making a correct diagnosis, it is of the greatest importance that the laboratory should be far more frequently used by the general practitioner.

In closing, I feel that I cannot too strongly impress tke fact that the laboratory report is of immense im-

Chapter III. Success In The Treatment Of Chronic Disease

The average general practitioner is not, as a rule, especially overjoyed when an individual with some disease of long standing comes his way seeking treatment. Most persons suffering from the class of diseases grouped under the broad term ''chronic/" have gone the rounds of the physicians in the neighborhood, and perhaps elsewhere, and have received little or no lasting benefit. If the physician expects to make a success in the treatment of these difficult conditions, a number of important maxims must be learned, and learned well. It will be my endeavor here to impress a few of these ideas upon the mind of the reader and in this way enable him to carry out with much greater success the treatment of chronic disease.

Since a correct diagnosis is usually more than half the battle, it stands to reason that the time and trouble given to the investigation of a given case are time and trouble well spent. If a physician fails in the treatment of any chronic affection, assuming that that particular case is not absolutely "incurable" (and, fortunately, there are very few conditions met by the progressive medical man that are entirely beyond his skill), the fault is to be found either in his investigation or his therapeutic acumen. Most frequently errors or shortcomings are in the diagnosis rather than the treatment, for the great and ever-increasing progress in medical science, especially along lines of treatment, is all duly chronicled in the various medical journals, and in this way is just as available for the physician at the remote country cross-roads as for the; city physician with his medical society meetings and clinics — if they both read. On the other hand, while it is granted that there are many books and articles of special informative value to the man who is anxious to increase his diagnostic skill, there is, of course, no book or article that will tell just what is the matter with Mr. Brown or Mrs. Jones.

Successful work naturally entails close personal investigation, and unless more than the ordinary attention is given to this most important part of medical practice the results, or lack of results, must necessarily be unpleasant and unsatisfactory, both from the standpoint of the patient and of his physician. I might cite dozens of cases which have come to my notice in which failure was due solely to what might properly be called "scamped," superficial, or snapshot diagnoses.

A diagnosis cannot be too thorough. Frequently the investigative procedures which the physician carries out may have led him to make an absolutely correct diagnosis so far as it goes, but it may not be as complete as it might have been, and as a result, unnoticed conditions are allowed to flourish, the existence of which curtails very markedly the benefits which his well-directed therapeutic procedures might have otherwise accomplished.

A prominent physician recently said, and rightly:

Sucess in Chronic Disease 37

"Shortcomings in diagnosis frequently allow human beings to suffer for years who might, were diagnosis made clear, be healthy useful citizens all that time." He spoke of a habit to which some of the profession are unfortunately addicted, "of skipping over the real diagnosis altogether, and rushing pell-mell into the treatment, so-called."

The diagnosis of chronic disease is not reached as rapidly as that of typical smallpox or diphtheria; nor does the patient expect it at once. I well remember a difficult case in which the diagnosis was not arrived at for three months — but it was finally right, and a condition of many years' standing was first modified and then cured.

In the majority of cases we must treat not merely a disease alone. It must be evident, for example, that a patient suffering from tuberculosis should not merely receive treatment with reference to the particular infection with the tubercle bacilli alone. The inevitably lowered vital resistance, and the associated infection with germs other than the tubercle bacillus, should be looked after just as thoroughly and systematically as the tuberculin-hygienic treatment is carried out. The digestive apparatus should be watched as closely as the temperature, and very great attention paid to the elimination of waste from the body, as evidenced in the urinary findings. Right here, it might be well to suggest that the old fad of "stuffing" a patient is hardly rational in the light of present-day knowledge, and if the physician takes the trouble to properly look after the elimination of his patient and see just what the "dozen eggs a day" are doing to his patient's metabolism, he would easily recognize that this change is worthy of closer consideration, because it is based on good common sense.

The estimation of the urinary acidity, the estimation of urea and ammonia, as well as the examination for indican and other abnormal substances in the urine, will all surprise the physician treating cases of the character under discussion, for by these means he will soon discover that the kidneys are being unduly overburdened, that the intestines are filled with a reeking mass of putrefying albumin, and that the patient is suffering from a toxemia probably equally bad, if not worse, than the toxemia due to the activities of the tubercle bacillus itself.

It will be plain that to accomplish these ends the usual abbreviated methods of physical investigation will not suffice. Recourse should invariably be had to certain laboratory procedures varying to some extent with the history, physical findings, etc. In every case a complete urine examination should be made. If there is reason to suspect gastro-intestinal disturbance, do not be satisfied with answers to a few questions, or even with the most thorough physical examination. Procure and examine the stomach contents after a test-meal given in the proper way. Frequently a fecal examination (chemical and bacteriological) will throw so much light on a case, that the unpleasantness of the procedure will be altogether overshadowed by the definite knowledge obtained, and the results that this may make possible. The

Success in Chronic Disease 39

microscopic examination of pus, sputum or other secretions, and not uncommonly a blood examination or a few simple tests of the saliva will be of much valuable assistance in the work. In this connection it will not be out of place to remind the reader of the help that a Tuberculin reaction (either that of von Pirquet or Moro) may be. This comparatively new procedure is used altogether too little, and has not yet received the attention it deserves.

The blood-pressure instrument or sphygmometer is not used as frequently as it might be. It is comparatively rare to see an instrument outside of the physician's office in the larger cities or in up-to-date institutions. The blood-pressure is a point of tremendous value, and I am not overstating the truth when I say that it should be estimated as a routine in the investigation of every chronic case. The new Faught instrument is as simple and compact as one could wish, an ornament, and an essential to every progressive physician's office.

Another factor which plays a very important part in the successful outcome of the treatment of chronic disease is the co-operation of the patient. It must surely be evident that if the physician is attempting to correct certain disturbances and at the same time certain pernicious habits or customs of the patient are adhered to in spite of advice to the contrary, the physician is very much handicapped in his treatment, and should not be held responsible for any failure that may possibly result.

It might be well here also to refer to the need for regularity in the treatment. This is a very important point. For example: For the relief of any given condition, office treatment may only be required every ten days or so; again, treatment may be necessary two or three times a week; and at times daily attention may be advisable in order to obtain the desired results. It must be plain that if one particular treatment brings a patient to a certain stage, and in a sense prepares him for the next, the omission of a treatment, if a matter of common occurrence, will materially decrease the value of the whole series. It is because of this that the opinion is quite prevalent that chronic disease, to be successfully handled, requires the hospital or sanitarium regimen, since the patient is under full control and can receive such treatment as may be deemed advisable without any break or inconvenience. This is true, but I believe, nevertheless, that any thinking individual, by dint of a few gentle reminders, would have sense enough to see to it that the treatment is as regular as possible, and at the same time that the advice of the physician is explicitly carried out.

A point might well be made here regarding the instructions given to patients. Many times dietetic and hygienic suggestions are made in the office, and because of these the patient starts out very well. He eschews certain articles of diet as suggested and regulates his living very carefully — for a time. In a few days he forgets one item, then another, until finally he is back to the same old slough in which he was wading before he came to the office for attention. To obviate this, I believe it to be by far the best plan to give definite written

Success in Chronic Disease 41

instructions to the patient as to what he should eat and what he should not eat; to give him in black and white the most important general instructions regarding his method of living, and make your ideas so clear that there may be no mistake regarding them. Of course, a copy of these instructions will be kept on file with the case history, prescription copies, and other records. The instruction slip may well be shown to some member of the patient's family in order that their co-operation may also be obtained in helping the individual under treatment to faithfully "toe the mark."

The original initial examination of the patient is not enough. Careful watch must be kept of the changes which may be due to the treatment or to other circumstances. Personally, I consider it of prime advantage to be able to make frequent urinalyses, for in this way the variations in the metabolism are shown up and the changes resulting from the treatment are made clear. It is often an excellent plan to administer certain remedies, using the urinary findings as the guide to dosage. The results obtained are sometimes phenomenal, and no physician once accustomed to these methods will revert to the older (but admittedly less arduous) way. As far as repeated examinations are concerned, the same holds true of the gastric contents, feces, etc. Ofttimes the treatment is having a decidedly beneficial effect, although for a time no great modification of the patient's subjective symptoms is apparent. The progressive favorable change in the laboratory reports, however, is always *a source of encouragement, not only to the physician, but also, when properly explained, to the patient.

There is another matter which seems quite difficult to instill into the minds of individuals suffering from chronic disease. I refer to the need for a more extended and systematic oversight of themselves after they may have passed from the close attention or immediate care of their medical adviser. The human body is very like a machine, and if an engineer should mend some broken part, see that it worked properly, and then leave the whole machine to the tender mercies of chance without any regular supervision, he would very soon be in serious trouble. Instead, he feels the bearings, oils them carefully, tightens a loose nut here and there, and generally scrutinizes the machine with a special care and watchfulness, in this way anticipating trouble before it comes, and preventing what might frequently cause a serious accident. This same thing is just as true of the human machine, and it becomes the duty of the physician to exercise just as much care and intelligent oversight as does the engineer. I firmly believe that a periodical and regular investigation of any individual who can be interested in this idea will lead to much more satisfactory work in the practice of medicine, and, at the same time, prevent, in their onset, a host of entirely needless chronic diseases. Such systematic care of an individual may often prove a means to very valuable ends, and if this article does nothing more than to impress upon the reader the great necessity for periodic, clinical as well as physical examinations, it will be well worth the time and trouble taken to write it.

Success in Chronic Disease 43